Racial and educational disparities in mobility limitation among older women: what is the role of modifiable risk factors?

Motivators of and barriers to in-person health care and video telehealth utilization among older Black adults: a qualitative study

OBJECTIVE

Older Black adults continue to experience heightened rates of chronic illness and poor health outcomes. Further, older Black adults must navigate interlocking systems of oppression (e.g. racism, ageism, ableism, and classism etc.) that impact their healthcare utilization. Telehealth has emerged as a common health care modality, which presents unique concerns for aging populations.

DESIGN

The present study explored the motivators of and barriers to in-person healthcare and video telehealth use among a sample of predominantly lower-income, older Black adults. The researchers collaborated with community scientists to recruit, facilitate focus groups and provide technological support for participants. Sixteen virtual focus groups were conducted (n = 147) with older Black adults aged 55-84 years. The researchers utilized a thematic analysis approach to identify twelve distinct themes.

RESULTS

Participants identified the following as motivators to using in-person health care: improved patient-provider relationships, increased community support, and more culturally sensitive resources. Limited accessibility, discrimination and resulting distrust, and poor patient-provider communication were identified as barriers to in-person health care use. E-health literacy and accessibility both emerged as motivators of and barriers to using telehealth, while disinterest in telehealth and impersonal patient-provider relationships were noted as additional barriers.

CONCLUSION

These findings provide key implications for reducing the burden of health care inequity for older Black adults. Future implementation research should use equity-focused frameworks such as the patient-centered culturally sensitive health care (PC-CSHC) model. Additionally, collaboration with the community is necessary to create and implement the necessary culturally sensitive health interventions.

Factors associated with self-reports of limitations in activities of daily living among Medicare Fee-for-Service recipients

BACKGROUND

Physical function is an important indicator of physical health and predicts mortality. This study identified characteristics associated with limitations in Medicare recipients' activities of daily living.

METHODS

2019 Consumer Assessment of Healthcare Providers and Systems Fee-for-Service Medicare Survey data: 79,725 respondents (34% response rate) who were 65 and older and 53% female; 7% Black, 5% Hispanic, 4% Asian American, Native Hawaiian, or other Pacific Islander, 2% Multiracial, 1% American Indian/Alaskan Native; 35% with high school education or less. Walking, getting in and out of chairs, bathing, dressing, toileting, and eating (scored as having no difficulty versus being able to do with difficulty or unable to do) and a scale of these items were regressed on patient characteristics.

RESULTS

After adjustment for all characteristics, function limitations were found for those who smoked (effect sizes of significant associations range .04-.13), had chronic health conditions (.02-.33), were 85 years or older (.09-.46), needed assistance completing the survey (.32-1.29), were female (.05-.07), and had low income and assets (.15-.47).

CONCLUSIONS

These nationally representative U.S. estimates of physical function characteristics are useful for interventions for vulnerable population subgroups.

Ethnic differences in functional limitations: a comparison of older migrants and native Dutch older population

Background

Although the older migrants population in Europe is expected to grow substantially in the coming years, there is little information about their health status and particularly functional limitations. This study examined the association of ethnicity and mobility, hearing and visual limitations in comparison to the general population in the Netherlands, and whether relevant characteristics explained the potential differences between older migrants and non-migrants.

Methods

Secondary data analysis of 12 652 subjects 55 years and older who participated in the health survey in the four largest Dutch cities. To establish limitations in vision, hearing and mobility, the Organization for Economic Co-operation and Development (OECD) questionnaire was used. Logistic regression analysis was used to examine the association between limitations and ethnic background, subsequently adjusting for demographic and socio-economic characteristics and relevant health- and lifestyle-related factors.

Results

Older migrants had higher prevalences of functional limitations. The age- and- gender adjusted ORs were 2 to 8-fold compared with older non-migrants. After adjusting for socioeconomic status and health-and lifestyle indicators, Moroccan, Turkish and Surinamese migrants still had increased ORs for visual limitations [ORs (95% CI), respectively: 2.48 (1.49–4.14), 3.08 (1.75–5.41) and 1.97 (1.33–2.91)] compared with the Dutch. For mobility limitations, only the Turkish migrants had an OR twice as high (2.19; 1.08–4.44) as the non-migrants. No significant differences were found between Antillean/Aruban migrants and non-migrants.

Conclusions

Important ethnic inequalities exist in various functional limitations, particularly in vision. These results underline the importance of tailored preventive interventions in older migrants to detect and prevent these limitations at an early stage.

Intersectional cohort change: Disparities in mobility limitations among older Singaporeans

Mobility is fundamental to independent living, but past research on physical function and mobility in older adults has not considered both intersectional social identities and cohort change in tandem. This paper utilizes data on mobility limitations from older adults in multi-ethnic Singapore to test whether cohort change varies simultaneously by gender and ethnicity. Panel data (n = 9334 person-years) collected over six years (2009-2015) were used to estimate aging vector models. Findings show that after adjusting for all covariates, Malay and Indian males in later-born cohorts have an increased number of mobility limitations compared to earlier-born cohorts. While a similar trend was also found for Chinese males and females in unconditional models, these were fully mediated by sociodemographic and health variables. These results highlight the importance of considering cohort change at the intersection of gender and ethnicity, bringing attention to possible inequities between ethnic groups.

Physical Activity and Performance Impact Long-term Quality of Life in Older Adults at Risk for Major Mobility Disability

INTRODUCTION

Older adults are a rapidly growing segment of the U.S.

POPULATION

Mobility problems that lead to further disability can be addressed through physical activity interventions. Quality of life outcome results are reported from a large trial of physical activity for sedentary older adults at risk for mobility disability.

METHODS

Data were from the Lifestyle Interventions and Independence for Elders study. This multisite RCT compared physical activity to health education among 1,635 randomly assigned sedentary older adults at risk for mobility disability in 2010-2011. Measures included demographics; comorbidity; a timed 400-meter walk; the Short Physical Performance Battery; and the Quality of Well-Being Scale (0-1.0 scale). Baseline and long-term follow-up (2.6 years) health-related quality of life data were collected as a secondary outcome. Multivariate linear regression modeling was used to examine covariates of health-related quality of life over time in 2017.

RESULTS

The sample had an overall mean Quality of Well-Being score of 0.613. Both groups declined in quality of life over time, but assignment to the physical activity intervention resulted in a slower decline in health-related quality of life scores (p=0.03). Intervention attendance was associated with higher health-related quality of life for both groups. Baseline characteristics including younger age, fewer comorbid conditions, non-white ethnicity, and faster 400-meter walk times were also associated with higher health-related quality of life over time.

CONCLUSIONS

Declining mobility measured by physical performance is associated with lower quality of life in sedentary older adults. Physical activity interventions can slow the decline in quality of life, and targeting specific subgroups may enhance the effects of such interventions.

Aging and Disability Among Hispanics in the United States: Current Knowledge and Future Directions

BACKGROUND AND OBJECTIVES

Hispanics are the most rapidly aging minority population in the United States. Our objective is to provide a summary of current knowledge regarding disability among Hispanics, and to propose an agenda for future research.

RESEARCH DESIGN AND METHODS

A literature review was conducted to identify major areas of research. A life course perspective and the Hispanic Paradox were used as frameworks for the literature review and for identifying future areas of research.

RESULTS

Four research areas were identified: (1) Ethnic disparities in disability; (2) Heterogeneity of the U.S. older Hispanic population; (3) Risk factors for disability; and (4) Disabled life expectancy. Older Hispanics are more likely than non-Hispanic whites to be disabled or to become disabled. Disability varied by country of origin, nativity, age of migration, and duration in the United States. Important risk factors for disability included chronic health conditions, depression, and cognitive impairment. Protective factors included positive affect and physical activity. Older Hispanics have longer life expectancy than non-Hispanic whites but spend a greater proportion of old age disabled. Future research should continue to monitor trends in disability as younger generations of Hispanics reach old age. Attention needs to be given to regional variation within the United States for disability prevalence, early-life risk factors, and factors that may contribute to variation in disabled life expectancy. There is also an urgent need for interventions that can effectively prevent or delay the onset of disability in older Hispanics.

DISCUSSION AND IMPLICATIONS

Considerable research has examined disability among older Hispanics, but continued research is needed. It is important that research findings be used to inform public policies that can address the burden of disability for older Hispanic populations.

Physical Function in an Aging Population in Rural South Africa: Findings From HAALSI and Cross-National Comparisons With HRS Sister Studies

OBJECTIVES

We use recently-collected data from the Health and Aging in Africa: a Longitudinal Study of an INDEPTH Community in South Africa (HAALSI) cohort from Agincourt, South Africa, to describe physical functioning in this aging population, and place the overall level and age-trajectories of physical health in the context of other Health and Retirement Study (HRS) sister studies in low- and middle-income countries (LMICs).

METHOD

We conduct multiple regression to estimate associations of physical functioning assessed from both self-report (activities of daily living [ADL] limitation, self-reported health) and performance (grip strength, gait speed) with socio-demographic and health characteristics in HAALSI, and use fully-interacted regression models to compare age-patterns of physical functioning outcomes cross-nationally.

RESULTS

Gender differences in self-reported health are minimal, and men had 30% higher odds of being ADL limited controlling for socio-demographic and health characteristics. Measured physical performance is closely tied with socioeconomic conditions, but self-reported measures have a much smaller or weaker socioeconomic gradient. In international age-adjusted comparisons, the HAALSI sample had lower physical performance outcomes than most comparison populations.

DISCUSSION

As the first HRS sister study undertaken in Africa, HAALSI adds vital information on population aging and health in the region. Continuing waves of HAALSI data will be a key resource for understanding differences in the complex processes of disability across LMIC contexts.

Home Modifications among Community-Dwelling Older Adults: A Closer Look at Race and Ethnicity

This study investigated racial and ethnic differences in home modification use. Data from the 2011 National Health and Aging Trends Study were used (n=6,764). Compared with non-Hispanic Whites, Hispanics were less likely to have a grab bar (odds ratio (OR) = 0.6), bath seat (OR = 0.8), or raised toilet (OR = 0.6). Non-Hispanic Blacks were less likely to have a grab bar (OR = 0.7) or bath seat (OR = 0.7) than non-Hispanic Whites, but more likely to have a raised toilet (OR = 1.3). English proficiency largely explained ethnic differences, while health status partially accounted for racial disparities.

Combined Effect of Obesity and Mobility Limitation with Incidence of Type 2 Diabetes and Mortality in Chinese Elderly

This article aims to examine the effect of mobility limitation and obesity on the risk of new incidence of type 2 diabetes mellitus (T2DM) and mortality. The design was a cohort study (n = 1075) among adults aged 60 years and older. Obesity was defined as body-mass index greater than or equal to 28 kg/m². Mobility limitation was defined as participants scoring in the top 20% on the timed up and go test or in the slowest 20% for the 4-m walking test. The mean age of the study population was 67.4 ± 5.4 years (age range: 60-86 years), and 57.4% were women. Overall, 5.1% of women and 1.9% of men had both obesity and mobility limitations. During 3-year follow-up, the new incidence of T2DM was 2.98% and the adjusted risk of the new incidence of T2DM was progressively greater in obese subjects without mobility limitation, but not greater in the single mobility limitation subjects. The combination of mobility limitation and obesity (odds ratio = 10.3, 95% confidence interval = 2.25-70.13) has a significantly higher risk than obesity only or mobility limitation only. What is more, obesity with mobility limitation could be an independent predictor of 3-year mortality compared with the other subjects. We demonstrated the associations between obesity and mobility limitation and thus the increased risk of developing, with the combination over time, T2DM and mortality.

Relationship Between Midlife Cardiovascular Health and Late-Life Physical Performance: The ARIC Study

OBJECTIVES

To examine the association between midlife cardiovascular health and physical performance 25 years later.

DESIGN

Cohort study (Atherosclerosis Risk in Communities Study); multinomial logistic and logistic regression adjusted for demographic characteristics and clinical measures.

SETTING

Four U.S. communities: Forsyth County, North Carolina; Washington County, Maryland; Minneapolis, Minnesota; and Jackson, Mississippi.

PARTICIPANTS

Individuals aged 54.2 ± 5.8 at baseline (N = 15,744; 55% female, 27% black).

MEASUREMENTS

Cardiovascular health was measured at baseline using the American Heart Association's Life's Simple 7 (LS7) score (0-14) and LS7 component categories (poor, intermediate, ideal) for each risk factor. The Short Physical Performance Battery (SPPB) was used to quantify physical function as ordinal (0-12) and categorical (low (0-6), fair (7-9), good (10-12) outcomes.

RESULTS

Mean baseline LS7 score was 7.9 ± 2.4; 6,144 (39%) individuals returned 25 years later for the fifth ARIC examination, at which point the SPPB was administered. Of 5,916 individuals who completed the SPPB, 3,288 (50%) had good physical performance. Each 1-unit increase in LS7 score was associated with a 17% higher SPPB score (rate ratio (RR) = 1.17, 95% confidence interval (CI) = 1.15-1.19) and a 29% greater chance of having a late-life SPPB score of 10 or greater compared to SPPB score of less than 10 (RR = 1.29, 95% CI = 1.25-1.34). Ideal baseline glucose (RR = 2.53, 95% CI = 2.24-2.87), smoking (RR = 1.97, 95% CI = 1.81-2.15), blood pressure (RR = 1.70, 95% CI = 1.54-1.88), body mass index (RR = 1.51, 95% CI = 1.37-1.66), and physical activity (RR = 1.31, 95% CI = 1.20-1.43) had the strongest associations with late-life SPPB score, adjusting for other LS7 components.

CONCLUSION

Better cardiovascular health during midlife may lead better physical functioning in older age.

Understanding Socioenvironmental Contributors to Racial and Ethnic Disparities in Disability Among Older Americans

Our understanding of the mechanisms through which racial/ethnic disparities in disability in older adults develop and are maintained is limited. We examined the role of physical impairment, socioeconomic factors and health for racial/ethnic disparities in activities of daily living (ADL), and the modifying role of the indoor home environment. Data come from the National Health and Aging Trends Study ( N = 5,640), and negative binomial regression models were specified separately for men and women. Blacks and Hispanics reported more ADL difficulty than Whites. Living in homes with clutter was associated with higher rates of ADL difficulty, but it was not related to racial/ethnic disparities. Racial/ethnic differences were explained by physical impairment for men, but not for women. Socioeconomic factors and health accounted for remaining disparities for Black, but not for Hispanic women. Attention to individual and environmental factors is necessary to fully understand and address race/ethnic disparities in disability in older Americans.

Individual and Neighborhood Factors Associated With Functional Mobility and Falls in Elderly Residents of São Paulo, Brazil: A Multilevel Analysis

Objective: To identify socioeconomic and contextual factors associated with functional mobility and falls in elderly residents of São Paulo, Brazil. Method: We used data from the Health, Well-Being, and Aging ( Saúde, Bem-estare Envelhecimento [SABE]) Study. The dependent variables were falling in the last year and functional mobility impairment. Individual (marital status, race, education, and perception of income sufficiency) and contextual (green area and violence) factors were analyzed by multilevel logistic models. Results: Having 8 or more years of schooling was a protective factor for mobility impairment. Neighborhoods with moderate homicide rate were associated with higher odds of falling. Moderate green spaces were associated with higher odds of falling and lower odds to have mobility impairment for individuals 80 years and older. Discussion: Our findings support the concern that neighborhood characteristics are associated with falls and mobility impairment. Strategies to prevent these outcomes should consider contextual aspects.

Moving Toward an Understanding of Disability in Older U.S. Stroke Survivors

OBJECTIVES

We test a comprehensive model of disability in older stroke survivors and determine the relative contribution of neighborhood, economic, psychological, and medical factors to disability.

METHOD

The sample consisted of 728 stroke survivors from the National Health and Aging Trends Study (NHATS), who were 65 years and older living in community settings or residential care. Confirmatory factor analysis and structural equation modeling were used to test relationships between neighborhood, socioeconomic, psychological, and medical factors, and disability.

RESULTS

Economic and medical context were associated with disability directly and indirectly through physical impairment. Neighborhood context was associated with disability, but was only marginally statistically significant ( p = .05). The effect of economic and neighborhood factors was small compared with that of medical factors.

DISCUSSION

Neighborhood and economic factors account for a portion of the variance in disability among older stroke survivors beyond that of medical factors.

Motor Function Is Associated With Incident Disability in Older African Americans

BACKGROUND

Disability in older African American adults is common, but its basis is unclear. We tested the hypothesis that the level of motor function is associated with incident disability in older African Americans after adjusting for cognition.

METHODS

A prospective observational cohort study of 605 older community-dwelling African American adults without dementia was carried out. Baseline global motor score summarized 11 motor performances, cognition was based on 19 cognitive tests, and self-reported disability was obtained annually. We examined the association of motor function with incident disability (instrumental activities of daily living [IADL], activities of daily living [ADL], and mobility disability) with a series of Cox proportional hazards models which controlled for age, sex, and education.

RESULTS

Average follow-up was about 5 years. In proportional hazards models, a 1-SD increase in baseline level of global motor score was associated with about a 50% decrease in the risk of subsequent IADL, ADL, and mobility disability (all p values < .001). These associations were unchanged in analyses controlling for cognition and other covariates. Further, the association of global motor score and incident ADL disability varied with the level of cognition (estimate -5.541, SE 1.634, p < .001), such that higher motor function was more protective at higher levels of cognition. Mobility and dexterity components of global motor score were more strongly associated with incident disability than strength (all p values < .001).

CONCLUSIONS

Better motor function in older African Americans is associated with a decreased risk of developing disability. Moreover, the association of motor function and disability is stronger in individuals with better cognitive function.