Data Resource Profile: the Survey of Health, Ageing and Retirement in Europe (SHARE)

Association between combination COVID-19-influenza vaccination and long COVID in middle-aged and older Europeans: A cross-sectional study

The potential impact of combined COVID-19 and influenza vaccination on long COVID remains uncertain. In the present cross-sectional study, we aimed to investigate the plausible association between them in middle-aged and older Europeans based on the Survey of Health, Ageing, and Retirement in Europe (SHARE). A total of 1910 participants were recruited in the analyses. The study outcome was long COVID. Participants were divided into 4 groups through the self-reported status of COVID-19 and influenza vaccination. Odds ratios (ORs) and 95% confidence intervals (CIs) were estimated. 1397 participants experienced long COVID. After multivariable adjustment, those vaccinated with neither COVID-19 nor influenza vaccine had higher risk of long COVID (OR, 1.72; 95% CI, 1.26-2.35) compared to those vaccinated with both vaccines. Furthermore, adding the 4 statuses of COVID-19 vaccination/influenza vaccination to conventional risk model improved risk reclassification for long COVID (continuous net reclassification improvement was 16.26% [p = .003], and integrated discrimination improvement was 0.51% [p = .005]). No heterogeneity was found in the subgroup analyses (all p-interaction ≥0.05). Our study might provide a strategy for people aged 50 and over to reduce the occurrence of long COVID, that is, to combine the use of the COVID-19 vaccine and influenza vaccines.

Chronic health conditions and their impact on the labor market. A cross-country comparison in Europe

Objectives

To estimate the effect of having a chronic disease on the weekly working hours and the associated monetary losses.

Design

Longitudinal data Survey of Health, Aging and Retirement (SHARE) in Europe. We analyzed 7 waves from 9 countries in Europe. A total of 80.672 observations.

Setting

Participants who have their regular domicile in the respective SHARE country were interviewed face-to-face.

Participants

Data from individuals aged between 50 and 65 years old in European countries were collected over seven years. A person was excluded from the survey if incarcerated, hospitalized or out of the country during the entire survey period, unable to speak the country's language(s) or moved to an unknown address.

Interventions

Not applicable.

Main outcome measurements

We applied a difference-in-differences with multiple time periods approach to estimate the effect of having a chronic condition on the number of working hours per week. We monetized the estimated productivity losses using the legal minimum wage in each country.

Results

Persons with a chronic condition consistently reduced their weekly working hours compared to their healthy counterparts in the same country. This effect was more pronounced for men (6,78 hours per week or 352 hours per year) than women (3,97 hours per week or 206 hours per year). Persons with stroke, vascular, and lung disease showed the highest impact. On average, the reduced working hours represent about USD 12,80 billion annually in productivity losses in our sample.

Conclusion

Having a chronic condition leads to people decreasing their working hours, which has significant economic losses. More severe health conditions showed the highest effects. This trend is observed in all the analyzed countries, highlighting the relevance of health and social systems to go beyond mortality and morbidity and the need to incorporate functioning in their target goals.

Dynamic associations between frailty and cognition over 4 years: A population-based study on adults aged ≥50 from 12 European countries

PURPOSE

This study aimed (1) to investigate autoregressive and cross-lagged associations between frailty and cognition over 4 years in a large sample of European citizens aged ≥50 years, (2) to examine the 4-year temporal associations' differences between sex and between active and inactive physical behaviour, and (3) to explore in the years 2011, 2013, and 2015 associations between cognitive performance and the pre-frailty and frailty conditions.

MATERIALS AND METHODS

This longitudinal analysis was conducted with 20,857 individuals (11,540 women) from 12 countries aged ≥50 years who responded to waves 4, 5, and 6 of the SHARE project. The variables analysed were frailty (SHARE-FI) and a general cognition index (Cogindex) calculated for each wave from verbal fluency, immediate recall, and delayed recall.

RESULTS

A greater propensity for cognitive impairment was found in women, as well as in pre-frail and frail individuals. There were no significant differences between the sexes for the autoregressive effect of frailty and Cogindex over 4 years. On the other hand, sedentary and active individuals differed in frailty between Time 1-2. Cross-lagged analyses indicated a significant difference for the sexes between frailty and Cogindex Time 1-3 and between Cogindex and frailty of Time 2-3. Sedentary and active differed significantly in the path of frailty on Cogindex between Time 2-3.

CONCLUSION

Health policies should increase surveillance of frailty, cognition, and level of physical activity in the older European population, with a special focus on women.

Bidirectional associations between meaning in life and the health, emotional ill-being and daily life functioning outcomes among older adults

OBJECTIVE

Meaning and purpose in life are recognised health determinants. Evidence on the factors contributing to the experience of meaning and purpose in life is limited. The bidirectional associations between the experience of meaning in life and physical health, emotional ill-being and daily life functioning from a 6-year perspective are examined.

METHODS AND MEASURES

Longitudinal data from the Survey of Health, Ageing and Retirement in Europe (SHARE) were analysed using generalised estimating equations. The sample included 16,361 middle-aged and older adults from 13 countries.

RESULTS

Living a meaningful life was found to be associated with subsequent reduced risks of depression, loneliness, limitations in activities of daily living, and heart attack (at the 6-year follow-up). It was also found that prior experience of depression, loneliness and limited activities of daily living were associated with subsequent reduced sense of meaningful life. These associations were independent of demographics, socioeconomic status, personality, prior history of diseases and lifestyle. The sensitivity analyses provided evidence for the robustness of these associations.

CONCLUSIONS

Evidence for health practitioners and policymakers on factors that may hamper the development and maintenance of meaningful life as well as on the role of sense of meaning in life for healthy aging was presented.

Time, age, gender and cultural measurement invariance of the CASP-12, a measure of psychological quality of life in adulthood

PURPOSE

Whereas Quality of Life in older populations has long been conceptualized in regards to health or illness, the Control, Autonomy, Self-Realization and Pleasure scale (CASP-12) focuses on the positive facets of aging. Although the CASP is a widely used scale, its measurement invariance has seldom been examined. The present study aims to ascertain the measurement invariance of the CASP-12 over a period of 10 years and between age, culture and gender.

METHODS

Secondary data analyses were conducted on the longitudinal data collected in four waves between 2006 and 2016-2017 of the Survey of Health, Ageing and Retirement in Europe study (SHARE). The factorial validity of the CASP-12 was examined and its measurement invariance was tested with a sample of 3684 men and 4955 women aged 30-99 years, coming from 10 different European countries.

RESULTS

Results showed a strong theoretical and empirical dimensionality of the CASP-12, a well as invariance of time (10 years), age and culture. It was also found that the scale is gender invariant at the strict level. These results were replicated with two more waves of SHARE, measured six years apart.

CONCLUSION

This study replicates the CASP-12 dimensional structure, factorial structure and factor loadings. The scale has demonstrated to be a reliable and valid measurement of the positive aspects of quality of life to be used across time, age, gender and culture. The Autonomy dimension of the scale warrants further investigation.

Motivating Protective Behavior against COVID-19: Fear Versus Hope

OBJECTIVES

Based on protection motivation theory, we investigate how indicators of threat perception (perceived severity, perceived vulnerability, and fear arousal) and coping appraisal (hope) are associated with older people's motivation to engage in protective behavior after the outbreak of COVID-19.

METHODS

We use multivariate regression analyses with a sample of 40,282 individuals from 26 countries participating in the SHARE Corona Survey.

RESULTS

We find that 15% of all respondents stayed home completely-mainly the oldest and vulnerable people with prior health risk conditions. On average, older Europeans responded strongly to the recommended protective behavior measures (6 out of 7 measures adopted). Among the threat perception indicators, fear arousal is the main motivator for protective behavior, whereas the coping appraisal indicator hope shows an equally strong association.

DISCUSSION

Given the negative health effects of fear, our findings may help evaluate and revise governmental policy responses and communication strategies.

Longitudinal associations between sensory and cognitive functioning in adults 60 years or older in Sweden and Denmark

BACKGROUND

The objective of this study is to explore the bidirectional, longitudinal associations between self-reported sensory functions (hearing/vision) and cognitive functioning among older adults in Sweden and Denmark during the period 2004-2017.

METHODS

The study is based on data from The Survey of Health, Ageing and Retirement in Europe and consists of 3164 persons aged 60 to 93 years. Within-person associations between sensory and cognitive functions were estimated using random intercept cross-lagged panel models.

RESULTS

The results indicated that cognitive and sensory functions were associated within their respective domains over time. The results on the bidirectional associations between sensory functions and cognition over time showed weak and statistically non-significant estimates.

CONCLUSION

Our study showed no clear evidence for cross-lagged effects between sensory functions and cognitive functioning. Important to note, however, is that using longitudinal data to estimate change within persons is a demanding statistical test and various factors may have contributed to the absence of conclusive evidence in our study. We discuss several of these factors.

Does sex modify the effect of pre-pandemic body mass index on the risk of Long COVID? Evidence from the longitudinal analysis of the Survey of Health, Ageing and Retirement in Europe

BACKGROUND

Research on Long COVID risk factors is ongoing. High body mass index (BMI) may increase Long COVID risk, yet no evidence has been established regarding sex differences in the relationship between BMI and the risk of Long COVID. Investigating the nature of this relationship was the main objective of this study.

METHODS

A population-based prospective study involving a sample of respondents aged 50 years and older (n = 4004) from 27 European countries that participated in the 2020 and 2021 Survey of Health, Ageing and Retirement in Europe's (SHARE) Corona Surveys and in Waves 7 and 8 of the main SHARE survey. Logistic regression models were estimated to produce unadjusted and adjusted estimates of the sex differences in the relationship between BMI and Long COVID.

RESULTS

Linear relationship for females, with probability of Long COVID increasing with BMI (68% at BMI = 18, 93% at BMI = 45). Non-linear relationship for males, with probability of Long COVID of 27% at BMI = 18, 68% at BMI = 33, and 40% at BMI = 45. Relationships remained significant after adjusting for known Long COVID risk factors (age and COVID-19 hospitalization), presence of chronic diseases, and respondents' place of residence.

CONCLUSION

Sex differences appear to play an important role in the relationship between BMI and risk of Long COVID. Overall, females were more likely to have Long COVID, regardless of their BMI. Males at the higher end of the BMI spectrum had a lower risk of Long COVID as opposed to their female counterparts. Sex-specific research is recommended for better understanding of Long COVID risk factors.

Initial data analysis for longitudinal studies to build a solid foundation for reproducible analysis

Initial data analysis (IDA) is the part of the data pipeline that takes place between the end of data retrieval and the beginning of data analysis that addresses the research question. Systematic IDA and clear reporting of the IDA findings is an important step towards reproducible research. A general framework of IDA for observational studies includes data cleaning, data screening, and possible updates of pre-planned statistical analyses. Longitudinal studies, where participants are observed repeatedly over time, pose additional challenges, as they have special features that should be taken into account in the IDA steps before addressing the research question. We propose a systematic approach in longitudinal studies to examine data properties prior to conducting planned statistical analyses. In this paper we focus on the data screening element of IDA, assuming that the research aims are accompanied by an analysis plan, meta-data are well documented, and data cleaning has already been performed. IDA data screening comprises five types of explorations, covering the analysis of participation profiles over time, evaluation of missing data, presentation of univariate and multivariate descriptions, and the depiction of longitudinal aspects. Executing the IDA plan will result in an IDA report to inform data analysts about data properties and possible implications for the analysis plan-another element of the IDA framework. Our framework is illustrated focusing on hand grip strength outcome data from a data collection across several waves in a complex survey. We provide reproducible R code on a public repository, presenting a detailed data screening plan for the investigation of the average rate of age-associated decline of grip strength. With our checklist and reproducible R code we provide data analysts a framework to work with longitudinal data in an informed way, enhancing the reproducibility and validity of their work.

A Prospective Association Between Sensory Impairment and Cognitive Performance Among Older Community-Dwelling Adults: The Role of Depressive Symptoms

We examined whether vision impairment (VI) and hearing impairment (HI) and dual sensory impairment (DSI) affect cognitive performance and whether depression mediates that effect. We examined 55,340 participants from the Survey of Health, Aging and Retirement in Europe, which assessed 32,325 participants in 2011 (baseline, Time 1), 2015 (follow-up, Time 2), sociodemographic data and health factors, self-reported VI, HI, and DSI at baseline, depression, and cognitive performance after four years. A multiple mediator model was tested using bootstrapping and resampling. At baseline, 22.9% had VI, 10.2% HI, and 10.4% had DSI. We found a significant negative association between VI (b = -0.023, p = .001) and DSI (b = -0.083, p = .001) and cognitive performance; both were also associated with depression, which was linked with poor cognition. VI or DSI among older adults are associated with poor cognitive function directly and indirectly by increasing depression symptoms.

Feasibility and acceptability of a cohort study baseline data collection of device-measured physical behaviors and cardiometabolic health in Saudi Arabia: expanding the Prospective Physical Activity, Sitting and Sleep consortium (ProPASS) in the Middle East

BACKGROUND

Physical behaviors such physical activity, sedentary behavior, and sleep are associated with mortality, but there is a lack of epidemiological data and knowledge using device-measured physical behaviors.

PURPOSE

To assess the feasibility of baseline data collection using the Prospective Physical Activity, Sitting, and Sleep consortium (ProPASS) protocols in the specific context of Saudi Arabia. ProPASS is a recently developed global platform for collaborative research that aims to harmonize retrospective and prospective data on device-measured behaviors and health. Using ProPASS methods for collecting data to perform such studies in Saudi Arabia will provide standardized data from underrepresented countries.

METHOD

This study explored the feasibility of baseline data collection in Saudi Arabia between November and December 2022 with a target recruitment of 50 participants aged ≥ 30 years. Established ProPASS methods were used to measure anthropometrics, measure blood pressure, collect blood samples, carry out physical function test, and measure health status and context of physical behaviors using questionnaires. The ActivPal™ device was used to assess physical behaviors and the participants were asked to attend two sessions at (LHRC). The feasibility of the current study was assessed by evaluating recruitment capability, acceptability, suitability of study procedures, and resources and abilities to manage and implement the study. Exit interviews were conducted with all participants.

RESULT

A total of 75 participants expressed an interest in the study, out of whom 54 initially agreed to participate. Ultimately, 48 participants were recruited in the study (recruitment rate: 64%). The study completion rate was 87.5% of the recruited participants; 95% participants were satisfied with their participation in the study and 90% reported no negative feelings related to participating in the study. One participant reported experiencing moderate skin irritation related to placement of the accelerometer. Additionally, 96% of participants expressed their willingness to participate in the study again.

CONCLUSION

Based on successful methodology, data collection results, and participants' acceptability, the ProPASS protocols are feasible to administer in Saudi Arabia. These findings are promising for establishing a prospective cohort in Saudi Arabia.

Informal and formal long-term care utilization and unmet needs in Europe: examining socioeconomic disparities and the role of social policies for older adults

The rising number of older adults with limitations in their daily activities has major implications for the demands placed on long-term care (LTC) systems across Europe. Recognizing that demand can be both constrained and encouraged by individual and country-specific factors, this study explains the uptake of home-based long-term care in 18 European countries with LTC policies and pension generosity along with individual factors such as socioeconomic status. Using data from the Survey of Health, Ageing and Retirement in Europe conducted in 2019, we apply a two-part multilevel model to assess if disparities in use of LTC are driven by disparities in needs or disparities in use of care when in need. While individual characteristics largely affect the use of care through its association with disparities in need, country-level characteristics are important for the use of care when in need. In particular, the better health of wealthier and more educated individuals makes them less likely to use any type of home-based personal care. At the country level, results show that the absence of a means-tested benefit scheme and the availability of cash-for-care benefits (as opposed to in-kind) are strongly associated with the use of formal care, whether it is mixed (with informal care) or exclusive. LTC policies are, however, shown to be insufficient to significantly reduce unmet needs for personal care. Conversely, generous pensions are significantly associated with lower unmet needs, underscoring the importance of considering the likely adverse effects of future pension reforms.

Can countries shape the association between cumulative adversity and old-age health?

Introduction

The present study examined the relationships of Lifetime Cumulative Adversity (LCA) and country inequalities, as well as the interactions between them, with the self-rated health (SRH) in old age.

Methods

Using data from the Survey of Health, Aging and Retirement in Europe (SHARE), the study regressed self-rated health on Lifetime Cumulative Adversity and country-level inequality indices across European countries in two points in time. The analysis also considered adversity-inequality interactions, controlling for confounders. The sample was comprised of 28,789 adults, aged 50 to 80, from 25 European countries and Israel.

Results

The findings pointed out that LCA is negatively associated with SRH, but democracy and welfare regimes modify the ill effects of LCA on health. These effects are reduced as the LCA level increases. The effects remained significant over two measurement time-points over three years, showing that life-course trajectories may be shaped by individual accumulated risk exposure to stress, along with inequalities at the society level.

Discussion

The study provides constructive and important guidance for decreasing the harmful effect of lifetime adversity in old age, by the modification of the country's welfare policies.

Is Transition to Retirement Associated With Volunteering? Longitudinal Evidence from Europe

Studies have shown that retired older adults are more likely to volunteer than their working counterparts. However, whether the transition to retirement is associated with increased volunteering frequency and whether this varies according to material and time resources of participants is unclear. We used four waves of data from the longitudinal Survey of Health, Ageing and Retirement in Europe, collected between 2011-2018 across 19 countries (n = 12,400 person-observations from 6200 individuals over 50). Within-person (or panel fixed-effect) regression analyses revealed that transition to retirement was associated with an increased volunteering frequency over time. This association was stronger among individuals with better health, higher education, improved financial situation and in countries with higher gross domestic product per capita. Overall, transition to retirement tends to open new ways of organizing everyday life and is associated with increased frequency of volunteering.

Digital exclusion and cognitive impairment in older people: findings from five longitudinal studies

OBJECTIVES

Older people are more likely to have digital exclusion, which is associated with poor health. This study investigated the relationship between digital exclusion and cognitive impairment in older adults from 23 countries across five longitudinal surveys.

DESIGN AND MEASUREMENTS

Digital exclusion is defined as self-reported non-use of the Internet. We assessed cognitive impairment on three dimensions: orientation, memory, and executive function. We used generalized estimation equations fitting binary logistic regression with exchangeable correlations to study the relationship between digital exclusion and cognitive impairment, and apply the minimum sufficiently adjusted set of causally directed acyclic graphs as the adjusted variable.

SETTING AND PARTICIPANTS

We pooled a nationally representative sample of older adults from five longitudinal studies, including the China Health and Retirement Longitudinal study (CHARLS), the English Longitudinal Study of Ageing (ELSA), the Health and Retirement Study (HRS), the Mexican Health and Ageing Study (MHAS) and the Survey of Health, Ageing and Retirement in European (SHARE).

RESULTS

We included 62,413 participants from five longitudinal studies. Digital exclusion varied by country, ranging from 21.69% (SHARE) in Denmark to 97.15% (CHARLS) in China. In the original model, digital exclusion was significantly associated with cognitive impairment in all five studies. In the adjusted model, these associations remained statistically significant: CHARLS (Odds ratio [OR] = 2.81, 95% confidence interval [CI] 1.84-4.28, ELSA (1.92 [1.70-2.18]), HRS(2.48[2.28-2.71), MHAS (1.92 [1.74-2.12]), and SHARE (2.60 [2.34-2.88]).

CONCLUSION

Our research shows that a significant proportion of older people suffer from digital exclusion, especially in China. Digital exclusion was positively correlated with cognitive impairment. These findings suggest that digital inclusion could be an important strategy to improve cognitive function and reduce the risk of cognitive impairment in older adults.

Sensory impairment, loneliness, and the discordance between subjective and objective cognitive function among older adults: A multi-cohort study

OBJECTIVES

This study aimed to examine the association between sensory impairment and the discordance between subjective/objective cognitive function among older adults and test the mediating effect of loneliness.

METHODS

We used data from four cohort studies conducted in 16 countries (N = 19,119). Sensory impairment and subjective cognitive impairment were self-reported. Objective cognitive impairment was measured in three dimensions. Generalized estimating equations were conducted to examine the association between sensory impairment and discordance in subjective/objective cognitive function. Cross-lagged panel model and a bootstrap method with 2,000 samples were employed to verify the mediating effect.

RESULTS

Sensory impairment was related to an increased risk of subjective cognitive impairment (OR = 4.70, 95 % CI 4.33-5.10), objective impairment (OR = 1.51, 95 %CI 1.31-1.74), as well as the discordance in subjective/objective cognitive function (OR = 1.35, 95 %CI 1.06-1.71 for older adults with normal subjective cognitive function). In contrast, sensory impairment was associated with a decreased risk of discordant subjective/objective cognitive function among those with subjective cognitive impairment (OR = 0.79, 95 %CI 0.66-0.94). Moreover, loneliness mediated the association between sensory impairment and subjective cognitive impairment (standardized indirect effect = 0.002, 95 %CI 0.001-0.004), objective cognitive impairment (standardized indirect effect = 0.005, 95 %CI 0.003-0.007) as well as the discordance in subjective/objective cognitive function (standardized indirect effect = 0.001, 95 %CI 0.001-0.003 for older adults with normal subjective cognitive function).

CONCLUSIONS

Significant association between sensory impairment and discordance in subjective/objective cognitive function and the mediating role of loneliness were revealed, varying by subjective cognitive function. Early screening on sensory impairment and targeted interventions on loneliness should be considered in future policies on cognitive impairment.

Which support is provided in which country? Patterns among older adults in Europe

This paper proposes comparative research on support provided outside the household by older adults in Europe. In studying social support, the network perspective is widely used, investigating, in particular, the ego-centered support networks of individuals. The analysis is based on data from Wave 7 of the Survey of Health Ageing and Retirement in Europe (SHARE). It examines the characteristics of ego-support networks of individuals aged 65 and over in 12 European countries, which are grouped into a novel welfare regime typology. Through Multiple Correspondence Analysis, we jointly looked into the categorical variables describing the recipients (alters) of the support provided by older adults and the welfare regime classification. As a main result, countries grouped in "High degree of familialism by default" category specialized in supporting family-related alters, particularly with childcare or personal care. In contrast, the elders in countries belonging to "High degree of de-familialisation" typology provided a more varied but less demanding support, to non-relatives alters and less oriented to care. The analyses show that the SHARE provides a solid opportunity to face the topic.

The Effect of Informal Caregiving on Depression: An Asymmetric Panel Fixed-Effects Analysis of In-Home and Out-Of-Home Caregivers Across Europe

Previous research has shown that providing intensive informal care can have a negative effect on an individual's mental health. However, few studies have been able to draw a precise comparison between the experiences of in-home and out-of-home caregivers. This study used data from 16 countries collected from 2011-2019 as part of the Survey of Health, Ageing and Retirement in Europe (SHARE) to conduct asymmetric panel fixed-effects models that examined within-person variation in depression scores after a respondent started providing daily or almost daily personal care either inside or outside of their home. The results substantiated previous findings that in-home caregivers experience more pronounced increases to their reported depressive symptoms after starting to provide daily personal care than do out-of-home caregivers. In addition, in-home caregivers in countries with greater governmental responsibility for long-term care provision (The Northern and Central Clusters) reported fewer increases to their depressive symptoms after starting to provide care than caregivers in countries where long-term care responsibility predominantly rests on families (The Southern and Eastern Cluster). Further, Northern Cluster countries most successfully shrank the pool of out-of-home care providers. Together, these findings underscore the context-specific nature of caregiver wellbeing.

Pulmonary function and trajectories of cognitive decline in aging population

BACKGROUND

The number of older people with cognitive impairment is increasing worldwide. Impaired lung function might be associated with cognitive decline in older age; however, results from large longitudinal studies are lacking. In this study, we examined the longitudinal associations between pulmonary function and the trajectories of cognitive decline using prospective population-based SHARE data from 14 countries.

METHODS

The analytic sample included N = 32,049 older adults (Mean age at baseline = 64.76 years). The dependent variable was cognitive performance, measured repeatedly across six waves in three domains: verbal fluency, memory, and numeracy. The main predictor of interest was peak expiratory flow (PEF). The data were analyzed in a multilevel accelerated longitudinal design, with models adjusted for a variety of covariates.

RESULTS

A lower PEF score was associated with lower cognitive performance for each domain as well as a lower global cognitive score. These associations remained statistically significant after adjusting for all covariates Q4 vs Q1 verbal fluency: unstandardized coefficient B = -3.15; numeracy: B = -0.52; memory: B = -0.64; global cognitive score B = -2.65, all p < .001). However, the PEF score was not found to be associated with the rate of decline for either of the cognitive outcomes.

CONCLUSIONS

In this large multi-national longitudinal study, the PEF score was independently associated with lower levels of cognitive functions, but it did not predict a future decline. The results suggest that pre-existing differences in lung functions are responsible for variability in cognitive functions and that these differences remained stable across aging.

Cognitive Functioning and the Quality of Survey Responses: An Individual Participant Data Meta-Analysis of 10 Epidemiological Studies of Aging

OBJECTIVES

Self-reported survey data are essential for monitoring the health and well-being of the population as it ages. For studies of aging to provide precise and unbiased results, it is necessary that the self-reported information meets high psychometric standards. In this study, we examined whether the quality of survey responses in panel studies of aging depends on respondents' cognitive abilities.

METHODS

Over 17 million survey responses from 157,844 participants aged 50 years and older in 10 epidemiological studies of aging were analyzed. We derived 6 common statistical indicators of response quality from each participant's data and estimated the correlations with participants' cognitive test scores at each study wave. Effect sizes (correlations) were synthesized across studies, cognitive tests, and waves using individual participant data meta-analysis methods.

RESULTS

Respondents with lower cognitive scores showed significantly more missing item responses (overall effect size ρ^ = -0.144), random measurement error (ρ^ = -0.192), Guttman errors (ρ^ = -0.233), multivariate outliers (ρ^ = -0.254), and acquiescent responses (ρ^ = -0.078); the overall effect for extreme responses (ρ^ = -0.045) was not significant. Effect sizes were consistent across studies, modes of survey administsration, and different cognitive functioning domains, although some cognitive domain specificity was also observed.

DISCUSSION

Lower-quality responses among respondents with lower cognitive abilities add random and systematic errors to survey measures, reducing the reliability, validity, and reproducibility of survey study results in aging research.

Utilization of Health Care Services and Accessibility Challenges among Adults Aged 50+ before and after Austerity Measures across 27 European Countries: Secular Trends in the SHARE Study from 2004/05 to 2019/20

This study aimed to assess and compare the utilization of preventive and other health services and the cost or availability in different regions of Europe, before and during the economic crisis. The data used in the study were obtained from Wave 8 of the Survey of Health, Ageing and Retirement in Europe (2019/2020) and Wave 1 data (2004/5), with a sample size of 46,106 individuals aged ≥50 across 27 countries, adjusted to represent a population of N = 180,886,962. Composite scores were derived for preventive health services utilization (PHSU), health care services utilization (HCSU), and lack of accessibility/availability in health care services (LAAHCS). Southern countries had lower utilization of preventive services and higher utilization of other health services compared to northern countries, with a significant lack of convergence. Moreover, the utilization of preventive health services decreased, whereas the utilization of secondary care services increased during the austerity period. Southern European countries had a significantly higher prevalence of lack of accessibility. An increase in the frequency of lack of accessibility/availability in health care services was observed from 2004/5 to 2019/20. In conclusion, our findings suggest that health inequalities increase during crisis periods. Therefore, policy interventions could prioritize accessibility and expand health coverage and prevention services.

Do We Become More Lonely With Age? A Coordinated Data Analysis of Nine Longitudinal Studies

Loneliness is a pervasive experience with adverse impacts on health and well-being. Despite its significance, notable gaps impede a full understanding of how loneliness changes across the adult life span and what factors influence these changes. To address this, we conducted a coordinated data analysis of nine longitudinal studies encompassing 128,118 participants ages 13 to 103 from over 20 countries. Using harmonized variables and models, we examined loneliness trajectories and predictors. Analyses revealed that loneliness follows a U-shaped curve, decreasing from young adulthood to midlife and increasing in older adulthood. These patterns were consistent across studies. Several baseline factors (i.e., sex, marital status, physical function, education) were linked to loneliness levels, but few moderated the loneliness trajectories. These findings highlight the dynamic nature of loneliness and underscore the need for targeted interventions to reduce social disparities throughout adulthood.

Determinants of Telemedicine Service Use Among Middle-Aged and Older Adults in Germany During the COVID-19 Pandemic: Cross-Sectional Survey Study

Background

The occurrence of the COVID-19 pandemic demanded fast changes in the delivery of health care. As a result, significant growth in the use of telemedicine services occurred. Research, especially from nationally representative German samples, is needed to better understand determinants of telemedicine use.

Objective

The purpose of this study was to identify determinants of telemedicine service use among middle-aged and older adults during the COVID-19 pandemic in Germany.

Methods

Cross-sectional, nationally representative data were taken from the German sample of the Survey of Health, Ageing and Retirement in Europe (SHARE). The German Corona Survey 2 (n=2039), which was conducted between June and August 2021, was used for this study. Reporting experience with remote medical consultations during the COVID-19 pandemic served as the outcome measure. Associations with socioeconomic, psychological, social, health-related, and COVID-19-related determinants were examined using multiple Firth logistic regressions.

Results

Psychological factors including feeling nervous, anxious, or on edge (odds ratio [OR] 1.61, 95% CI 1.04-2.50; P=.03), feeling sad or depressed (OR 1.62, 95% CI 1.05-2.51; P=.03) and feelings of loneliness (OR 1.66, 95% CI 1.07-2.58; P=.02) were positively associated with telemedicine use. Moreover, forgoing medical treatment because of being afraid of being infected by SARS-CoV-2 (OR 1.81, 95% CI 1.10-2.97; P=.02) and describing limitations because of a health problem as severe were positively associated with the outcome (OR 2.11, 95% CI 1.12-4.00; P=.02). Socioeconomic and social factors were not significantly associated with telemedicine use in our sample.

Conclusions

Middle-aged and older individuals in Germany seem to use telemedicine services according to psychological needs and health limitations. Especially when psychological symptoms are experienced, telemedicine seems to be a promising service option in this age group. Future research is needed to confirm these initial findings in postpandemic circumstances.

Unraveling the dynamics of loneliness in the Baltic-Nordic region: a comparative analysis in the wake of COVID-19

Introduction

The primary aim of this study is to thoroughly investigate the prevalence and determinants of loneliness among older adults in the Baltic-Nordic region. Utilizing high-quality data sources and employing a methodologically rigorous approach, the study endeavors to enhance our understanding of how loneliness manifests and varies across different cultural and socio-economic contexts within these regions. By identifying key factors influencing loneliness, including demographic, social, and economic variables, the research seeks to contribute significantly to the existing body of knowledge on loneliness and inform targeted public health strategies and interventions tailored to the unique needs of older adults in the Baltic and Nordic countries.

Material and methods

This research, centered on older adults aged 67 and above within the Baltic-Nordic region, draws upon data from the Survey of Health, Ageing and Retirement in Europe (SHARE), specifically its eighth wave conducted between June and August 2020. The demographic analysis of this study covers a diverse sample of 5,313 participants from the Baltic and Nordic regions. Specifically, the sample includes 2,377 participants from Nordic countries, namely Sweden, Denmark, and Finland, and 2,936 from the Baltic countries of Estonia, Latvia, and Lithuania. The investigation extends to the financial well-being of households, involving an analysis of 3,925 individuals, with 1,748 from Nordic countries and 2,177 from Baltic countries. Although Iceland is categorized as a Nordic country, the analysis within this study is conducted separately due to the unavailability of SHARE data for this region. Instead, the HL20 study, focusing on the health and well-being of the older adult population in Iceland, contributes data for 1,033 respondents. This methodological distinction allows for a comprehensive understanding of regional differences, highlighting the importance of specialized approaches to examine the intricate dynamics of loneliness and well-being across the Baltic-Nordic region.

Results

The study reveals significant regional variations in loneliness among older adults during the COVID-19 outbreak, with the Baltic countries (Estonia, Latvia, Lithuania) reporting a lower prevalence of loneliness compared to the Nordic countries (Sweden, Denmark, Finland). Iceland, while grouped with the Nordic countries, was analysed separately. Employment emerges as a key factor in reducing loneliness across all regions, suggesting the benefits of social interactions and structured routines. Gender and marital status significantly influence loneliness, with notable disparities in the Baltic region and smaller gaps in the Nordic countries, reflecting the impact of societal and cultural norms. Additionally, educational attainment and health status show varied associations with loneliness, highlighting the complex interplay of individual and societal factors in these regions.

Pre-stroke physical activity matters for functional limitations: A longitudinal case-control study of 12,860 participants

Objective

In the chronic phase after a stroke, limitations in activities of daily living (ADLs) and instrumental ADL (IADLs) initially plateau before steadily increasing. The benefits of pre-stroke physical activity on these limitations remain unclear. To clarify this relationship, we examined the effect of physical activity on the long-term evolution of functional limitations in a cohort of stroke survivors and compared it to a cohort of matched stroke-free adults.

Methods

Longitudinal data from 2,143 stroke survivors and 10,717 stroke-free adults aged 50 years and older were drawn from a prospective cohort study based on the Survey of Health, Ageing and Retirement in Europe (2004-2022; 8 data collection waves). Physical activity was assessed in the pre-stroke wave. Functional limitations were assessed in the post-stroke waves. Each stroke survivor was matched with 5 stroke-free adults who had similar propensity scores computed on the basis of key covariates, including baseline age, sex, body mass index, limitations in ADL and IADL, chronic conditions and country of residence, before any of the participants from either cohort had experienced a stroke.

Results

Results showed an interaction between stroke status and physical activity on ADL limitations (b = -0.076; 95% CI = -0.142 to -0.011), with the effect of physical activity being stronger in stroke survivors (b = -0.345, 95% CI = -0.438 to -0.252) than in stroke-free adults (b = -0.269, 95% CI = -0.269 to -0.241).

Conclusion

The beneficial effect of pre-stroke physical activity on ADL limitations after stroke is stronger than its effect in matched stroke-free adults followed for a similar number of years.

Impact

Physical activity, an intervention within the physical therapist's scope of practice, is effective in reducing the risk of functional dependence after stroke. Moreover, pre-stroke levels of physical activity can inform the prognosis of functional dependence in stroke survivors.

Social participation, loneliness, and physical inactivity over time: evidence from SHARE

OBJECTIVES

We aimed to explore the reciprocal effects of social participation, loneliness, and physical inactivity over a period of 6 years in a representative sample of European adults over 50 years old.

DESIGN

A longitudinal study with a six-year follow-up period was conducted.

SETTING

Four waves of the Survey of Health, Ageing and Retirement in Europe project were used.

PARTICIPANTS

This study includes 64,887 participants from Europe and Israel, who were aged 50 or older at the first time.

MEASUREMENTS

The relationship between participation in social activities, loneliness and physical inactivity was analyzed, controlling for age, gender, and disability. A series of cross-lagged panel models (CLPMs) were applied to analyze the relationships among these variables.

RESULTS

A CLPM with equal autoregressive cross-lagged effects across waves was the best fit to the data (χ2 = 7137.8, CFI = .972, RMSEA = .049, SRMR = .036). The autoregressive effects for the three variables showed high stability across waves, and all the cross-lagged effects in the model were statistically significant. Social activity and physical inactivity maintained a strong negative cross-lagged effect, while their cross-lagged effects on loneliness were comparatively smaller. Social activity had a positive cross-lagged effect on loneliness, while physical inactivity had a negative cross-lagged effect on loneliness.

CONCLUSIONS

These findings highlight the importance of promoting physical activity and social participation and addressing loneliness through targeted interventions in older adults.

Longitudinal Quantiles of Frailty Trajectories Considering Death: New Insights into Sex and Cohort Differences in the Reference Curves for Frailty Progression of Older European

BACKGROUND

Most previous studies of frailty trajectories in older adults focus on the average trajectory and ignore death. Longitudinal quantile analysis of frailty trajectories permits the definition of reference curves, and the application of mortal cohort inference provides more realistic estimates than models that ignore death.

METHODS

Using data from individuals aged 65 or older (n = 25 446) from the Survey of Health, Ageing, and Retirement in Europe (SHARE) from 2004 to 2020, we derived repeated values of the Frailty Index (FI) based on the accumulation of health deficits. We applied weighted Generalized Estimating Equations to estimate the quantiles of the FI trajectory, adjusting for sample attrition due to death, sex, education, and cohort.

RESULTS

The FI quantiles increased with age and progressed faster for those with the highest level of frailty (β^a0.9 = 0.0229, p < .001; β^a0.5 = 0.0067, p < .001; H0: βa0.5=βa0.9, p < .001). Education was consistently associated with a slower progression of the FI in all quantiles (β^ae0.1 = -0.0001, p < .001; β^ae0.5 =-0.0004, p < .001; β^ae0.9 = -0.0003, p < .001) but sex differences varied across the quantiles. Women with the highest level of frailty showed a slower progression of the FI than men when considering death. Finally, no cohort effects were observed for the FI progression.

CONCLUSIONS

Quantile FI trajectories varied by age, sex, education, and cohort. These differences could inform the practice of interventions aimed at older adults with the highest level of frailty.

Work Ability and Work Nonparticipation: A Prospective Study of 2426 Participants in Germany

OBJECTIVE

The aim of the study is to examine the association between work ability and work nonparticipation, including long-term sickness absence (LTSA), unemployment (UE), and disability pension/early retirement (ER).

METHODS

We conducted a questionnaire-based 5-year follow-up study on a representative sample of the German working population (n = 2426). We used a two-part model to examine the association of continuous Work Ability Index (WAI) scores with the probability of events of work nonparticipation and the duration thereof.

RESULTS

Higher WAI scores were protective against total work nonparticipation (an index combining the three indicators), LTSA, ER and UE, the latter among males only. Higher WAI scores were protective also against duration of total work nonparticipation and LTSA, but not against duration of UE and ER among males and duration of UE among females.

CONCLUSIONS

Higher WAI scores have a protective role against work nonparticipation.

Cross-sectional and longitudinal associations of obesity with disability between age 50 and 90 in the SHARE study

BACKGROUND

Obesity is associated with disability but whether age and ageing modify this association remains unclear. We examined whether this association changes between 50 and 90 years, and whether change in disability rates over 14 years differs by body mass index (BMI) categories.

METHODS

BMI and ADL-disability data on 28,453 individuals from 6 waves (2004-2018, SHARE study) were used to examine the cross-sectional absolute and relative associations, extracted at age 50, 60, 70, 80, and 90 years using logistic mixed models. Then baseline BMI and change in disability rates over 14-years were examined using logistic-mixed models.

RESULTS

At age 50, the probabilities of ADL disability in individuals with BMI 30-34.9 and ≥35 kg/m² were 0.07 (0.06, 0.09) and 0.11 (0.09, 0.12), increasing to 0.47 (0.44, 0.50) and 0.55 (0.50, 0.60) at age 90; the increase in both these groups was greater than that in the normal-weight group (p for increase with age<0.001). On the relative scale the OR at age 50 in these obesity groups was 2.37 (1.79, 3.13) and 5.03 (3.38, 7.48), decreasing to 1.51 (1.20, 1.89) and 2.19 (1.50, 3.21) at age 90; p for decrease with age=0.05 and 0.02 respectively. The 14-year increase in probability of disability was greatest in those with BMI≥35 kg/m² at age 50, 60, and 70 at baseline: differences in increase compared to normal weight were 0.08 (0.02, 0.14), 0.11 (0.07, 0.15), and 0.09 (0.02, 0.16) respectively.

CONCLUSIONS

ADL disability is increasingly prevalent with age in individuals with obesity. Relative measures of change obscure the association between obesity and disability due to age-related increase in disability rates in all groups.

Chronic and Transient Loneliness in Western Countries: Risk Factors and Association With Depression. A 2-Year Follow-Up Study

INTRODUCTION

Our aim was to test risk factors for chronic and transient loneliness as well as cross-sectional and longitudinal associations of courses of loneliness with depression.

METHODS

Responses from participants in Wave 5 (T1, 2013) and Wave 6 (T2, 2015) of The Survey of Health, Ageing and Retirement in Europe (SHARE) (N = 45,490) were analyzed. The existence of clinically significant symptoms of depression was defined as reporting a value greater than or equal to 4 on the Euro-D scale. Loneliness was measured through the 3-item UCLA loneliness scale and a single question. Both measures were tested in separate regression models to identify risk factors for transient (loneliness at T1) and chronic (loneliness at T1 and T2) loneliness as well as their associations with depression.

RESULTS

Chronic loneliness was observed in 47%-40% of the cases of loneliness, according to the UCLA scale and the single question, respectively. Risk factors for chronic loneliness in both models were being female, not being married, having a low educational level, having poor mental and physical health, being limited in activities, having a poor social network, and living in a culturally individualistic country. Risk factors for transient loneliness were less robust and no significant effects were found for variables such as sex and physical health in both models, education level in the UCLA measure model, and social network size in the single question model. Chronic loneliness also showed a strong association with depression in the cross-sectional model and a marked one in the longitudinal model.

CONCLUSION

The courses of loneliness are relevant in the study of its risk factors and association with depression.

How the interplay of late retirement, health care, economic insecurity, and electronic social contact affects the mental health amongst older workers?

The delayed retirement initiative has become increasingly emphasised to cope with the population ageing. Based on the social-ecological model, this study explores the interplay of late retirement, health care, economic insecurity, and electronic social contact on mental health of older workers. Using data from the Survey of Health, Ageing and Retirement in Europe (wave 8), results show that the late retirement, health care quality, and electronic social contact are all negatively associated with the mental health problems among older workers. Besides, the influence of health care quality and electronic social contact on mental health problems are buffered by the economic insecurity respectively. It is concluded that more targeted policy response is in need to achieve better health outcomes among older workers.

Frailty prevalence in 42 European countries by age and gender: development of the SHARE Frailty Atlas for Europe

Comparative frailty prevalence data across European countries is sparse due to heterogeneous measurement methods. The Survey of Health, Ageing and Retirement (SHARE) initiative conducted interviews with probability sampling of non-institutionalized elderly people in several European countries. Previous frailty analyses of SHARE datasets were limited to initial SHARE countries and did not provide age- and gender-stratified frailty prevalence. Our aim was to provide age- and gender-stratified frailty prevalence estimates in all European countries, with predictions where necessary. From 29 SHARE participating countries, 311,915 individual surveys were analyzed. Frailty prevalence was estimated by country and gender in 5-year age bands using the SHARE Frailty Instrument and a frailty index. Association of frailty prevalence with age, gender, and GDP per capita (country-specific economic indicator for predictions) was investigated in multivariate mixed logistic regression models with or without multiple imputation. Female gender and increasing age were significantly associated with higher frailty prevalence. Higher GDP per capita, with or without purchasing power parity adjustment, was significantly associated with lower frailty prevalence in the 65-79 age groups in all analyses. Observed and predicted data on frailty rates by country are provided in the interactive SHARE Frailty Atlas for Europe. Our study provides age- and gender-stratified frailty prevalence estimates for all European countries, revealing remarkable between-country heterogeneity. Higher frailty prevalence is strongly associated with lower GDP per capita, underlining the importance of investigating transferability of evidence across countries at different developmental levels and calling for improved policies to reduce inequity in risk of developing frailty across European countries.

Biomarkers of Physical and Mental Health for Prediction of Parkinson's Disease: A Population-Based Study from 15 European Countries

OBJECTIVES

Early diagnosis of Parkinson's disease (PD) is critical for optimal treatment. However, the predictive potential of physical and mental health in PD is poorly characterized.

METHODS

We evaluated the potential of multiple demographic, physical, and mental factors in predicting the future onset of PD in older adults aged 50 years or older from 15 European countries. Individual study participants were followed over four waves of the Survey of Health, Ageing, and Retirement in Europe (SHARE) from 2013-2020.

RESULTS

Of 57,980 study participants, 442 developed PD during the study period. We identified male sex and advancing age from the sixth decade of life onward as significant predictors of future PD. Among physical factors, a low handgrip strength (HGS; men <27 kg, women <16 kg), being bothered by frailty, and recent falls were significantly associated with future PD. Among mental factors, a higher depression (Euro-D depression score >6) emerged as an independent predictor of future PD. Finally, the presence of hypertension or Alzheimer's disease (AD) increases the risk of future PD.

CONCLUSIONS

Altogether, male sex, advancing age, low HGS, frailty, depression, hypertension, and AD were identified as critical risk factors for future PD. Our results may be useful in the early identification and treatment of populations at risk for PD.

Helping and Volunteering During COVID-19: Associations With Well-Being and Psychological Distress

INTRODUCTION

Salutogenic effects of volunteering and helping activities have been well recognized in the pre-COVID-19 era. This study examines associations between helping others as well as additional volunteer activities during the first wave of the COVID-19 pandemic and 6 psychological distress and well-being outcomes one year later.

METHODS

Longitudinal data collected between 2019 and 2021 were used. Analyses were based on data from 42,005 middle-aged and older adults from 27 European countries who participated in the Survey of Health, Ageing, and Retirement in Europe (SHARE) and two SHARE Corona Surveys. Prospective associations were examined using generalized estimating equations. A series of secondary analyses and the sensitivity of the associations to unmeasured confounding provided evidence for the robustness of results. All analyses were conducted in December 2022.

RESULTS

Helping others outside one's home in the first wave of COVID-19 was associated with subsequent increased risks of depression and anxiety. It was concurrently associated with an increased probability of an uplifting, hope, and happiness-inducing experience. Engagement in volunteer activities conducted in addition to helping was found to be prospectively associated with higher probability of an uplifting experience, but not with depression and anxiety. These associations were independent of demographic and socioeconomic characteristics, personality traits, prior quality of life and health history as well as pre-COVID-19 engagement in altruistic activities.

CONCLUSIONS

Helping and volunteering during the COVID-19 pandemic likely led to positive experiences. However, a negative impact on psychological distress of the same activities was also noted.

A Novel Indicator to Correct for Individual Reported Heterogeneity. An Application to Self-Evaluation of Later-Life Depression

Program evaluations often investigate complex or multi-dimensional constructs, such as individual opinions or attitudes, by means of ratings. A different interpretation of the same question may affect cross-country comparability, leading to the Differential Item Functioning problem. Anchoring vignettes were introduced in the literature as a way to adjust self-evaluations from this interpersonal incomparability. In this paper, we first introduce a new nonparametric solution to analyse anchoring vignette data, recoding a variable based on a rating scale to a new corrected-variable that guarantees comparability in any cross-country analysis. Then, we exploit the flexibility of a mixture model introduced to account for uncertainty in the response process (the CUP model) to test if the proposed solution is effectively able to remove this reported heterogeneity. This solution is easy to construct and has important advantages compared with the original nonparametric solution adopted with anchoring vignette data. The novel indicator is applied to investigate self-reported depression in an old population. Data that will be analysed come from the second wave of the Survey of Health, Ageing and Retirement in Europe, collected in 2006/2007. Results highlight the need of correcting for reported heterogeneity comparing individual self-evaluations. Once interpersonal incomparability resulting from the different uses of response scales is removed from the self-assessments, some estimates are reversed in magnitude and signs with respect to the analysis of the collected data.

Social connection and end-of-life outcomes among older people in 19 countries: a population-based longitudinal study

BACKGROUND

Social connection is a key determinant of health, but its role in shaping end-of-life outcomes is poorly understood. We examined changes in structure, function, and quality components of social connection in older people's last years of life, and the extent to which social connection predicts end-of-life outcomes (ie, symptoms, health-care utilisation, and place of death).

METHODS

This study used longitudinal data of representative samples from across 18 European countries and Israel in the Survey of Health, Ageing, and Retirement in Europe (SHARE), the largest European cohort study of people aged 50 years or older. We included deceased participants of waves 4 and 6 (which contained social network modules) for whom a proxy provided an end-of-life interview. We did paired sample t-tests (for continuous variables), Wilcoxon signed-rank tests (for ordinal variables), and McNemar's tests (for non-ordinal categorical variables) to assess changes in structure, function, and quality components of social connection between waves 4 and 6. To examine social connection as a predictor of end-of-life outcomes, we used social connection data from wave 6 core interviews and end-of-life interviews from wave 7, conducted with a proxy respondent covering the deceased participant's last year of life. End-of-life outcomes included symptoms (pain, breathlessness, and anxiety or sadness) in the last month of life, health-care utilisation in the last year of life, and place of death. We conducted a mixed-effects logistic regression analysis per social connection measure, for each end-of-life outcome.

FINDINGS

Data were collected in 2011-12 for wave 4, 2015-16 for wave 6, and 2017-18 for wave 7. We studied 3356 individuals (mean age at death was 79·7 years [SD 10·2]), with interviews conducted, on average, 4·6 (1·2) years (wave 4) and 1·1 (0·7) years (wave 6) before death. From wave 4 to wave 6, the following changes in social connection were observed: proportion of married or partnered participants (from 1406 [60·9%] of 2310 to 1438 [57·1%] of 2518; p<0·0001), receiving personal care or practical help (from 781 [37·2%] of 2099 to 1334 [53·1%] of 2512; p<0·0001), loneliness (from mean 1·4 [SD 0·5] to 1·5 [0·6]; p<0·0001; scale 1-3), satisfaction with social network (from 8·8 [1·67] to 8·7 [1·7]; p=0·037; scale 0-10), and emotional closeness to social network (eg, from 1883 [88·8%] of 2121 to 1710 [91·3%] of 1872 participants who indicated being either very close or extremely close to social network members; p<0·0001). Higher levels of loneliness at wave 6 predicted a greater likelihood of experiencing symptoms in the last month of life (odds ratio range across symptoms: 1·29 [95% CI 1·08-1·55] to 1·58 [1·32-1·89]). Being married (1·32 [1·03-1·68]) or receiving personal care or practical help (1·25 [1·04-1·49]) predicted death in hospital.

INTERPRETATION

Social connection undergoes multifaceted changes towards older people's end of life, countering prevalent ideas of generally declining social trajectories. Loneliness in the final months of life might be a risk factor for end-of-life symptoms. Further research is needed to substantiate a causal relationship and to identify underpinning mechanisms, which could inform screening and prevention measures.

FUNDING

Research Foundation-Flanders and European Union.

Cost of Illness of Head and Neck Cancer in Sweden

OBJECTIVES

Head and neck cancer (HNC) is the sixth most common cancer worldwide. The condition and its treatment often lead to marked morbidities and, for some patients, premature death. Inferentially, HNC imposes a significant economic burden on society. This study aims to provide a comprehensive and detailed estimation of the cost of illness of HNC for Sweden in 2019.

METHODS

This is a prevalence-based cost of illness study. Resource utilization and related costs are quantified using national registry data. A societal perspective is applied, including (1) direct costs for healthcare utilization, (2) costs for informal care from family and friends, and (3) costs for productivity loss due to morbidity and premature death. The human capital approach is used when estimating productivity losses.

RESULTS

The societal cost of HNC for Sweden in 2019 was estimated at €92 million, of which the direct costs, costs for informal care, and costs for productivity loss represented 34%, 2%, and 64%, respectively. Oral cavity cancer was the costliest HNC, followed by oropharyngeal cancer, whereas nasopharyngeal cancer was the costliest per person. The cost of premature mortality comprised 60% of the total cost of productivity loss. Males accounted for 65% of direct costs and 67% of costs for productivity loss.

CONCLUSIONS

The societal cost of HNC is substantial and constitutes a considerable burden to Swedish society. The results of the present study may be used by policymakers for planning and allocation of resources. Furthermore, the information may be used for future cost-effectiveness analyses.

The Effect of Long-Term (Im)balance of Giving Versus Receiving Support With Nonrelatives on Subjective Well-Being Among Home-Dwelling Older People

OBJECTIVES

Although many studies have explored the benefits of support giving or receiving for older people, little is known about how the balance between giving and receiving instrumental support in nonrelative relationships affects home-dwelling older people. This study examines the relationship between long-term support balance and subjective well-being in relationships with nonrelatives among older people across 11 European countries.

METHODS

A total of 4,650 participants aged 60 years and older from 3 waves of the Survey of Health and Retirement in Europe were included. Support balance was calculated as the intensity difference between support received and support given across 3 waves. Multiple autoregressive analyses were conducted to test the relationship between support balance and subjective well-being, as indicated by quality of life, depression, and life satisfaction.

RESULTS

The impact of balanced versus imbalanced support on all subjective well-being measurements was not significantly different. Compared to balanced support, imbalanced receiving was negatively related to subjective well-being and imbalanced giving was not related to better subjective well-being. Compared to imbalanced receiving, imbalanced giving showed to be the more beneficial for all subjective well-being measures.

DISCUSSION

Our results highlight the beneficial role of imbalanced giving and balanced support for older people compared to imbalanced receiving. Policies and practices should prioritize creating an age-friendly environment that promotes active participation and mutual support among older people, as this may be effective to enhance their well-being.

Performance of probable dementia classification in a European multi-country survey

Feasibility constraints limit availability of validated cognitive assessments in observational studies. Algorithm-based identification of 'probable dementia' is thus needed, but no algorithm developed so far has been applied in the European context. The present study sought to explore the usefulness of the Langa-Weir (LW) algorithm to detect 'probable dementia' while accounting for country-level variation in prevalence and potential underreporting of dementia. Data from 56 622 respondents of the Survey of Health, Ageing and Retirement in Europe (SHARE, 2017) aged 60 years and older with non-missing data were analyzed. Performance of LW was compared to a logistic regression, random forest and XGBoost classifier. Population-level 'probable dementia' prevalence was compared to estimates based on data from the Organisation for Economic Co-operation and Development. As such, application of the prevalence-specific LW algorithm, based on recall and limitations in instrumental activities of daily living, reduced underreporting from 61.0 (95% CI, 53.3-68.7%) to 30.4% (95% CI, 19.3-41.4%), outperforming tested machine learning algorithms. Performance in other domains of health and cognitive function was similar for participants classified 'probable dementia' and those self-reporting physician-diagnosis of dementia. Dementia classification algorithms can be adapted to cross-national cohort surveys such as SHARE and help reduce underreporting of dementia with a minimal predictor set.

Functional limitation among middle age and older adults: Exploring cross-national gender disparities

OBJECTIVE

Functional limitations are prevalent among aging demographics, especially women. Structural and health factors, which vary worldwide, influence rates of functional limitations. Yet, gender disparities in functional limitation remain unclear in a global context.

METHODS

We use 2018 data from the Health and Retirement Study (HRS) international family of studies with respondents ages 50-64 and (n = 87,479) and 65-89 (n = 92,145) to investigate gender disparities in large muscle functional limitation (LMFL) across 10 countries/regions using mixed effects logistic regression, with special attention to structural indicators of inequality and health.

RESULTS

Among both women and men, LMFL was generally higher in China, India, Mexico, United States, and Baltic States than in England, Scandinavia, Southern Europe, Eastern Europe, and Western Europe. The gender disparity in LMFL gradually declined at older ages in India, China, Mexico, and United States, while this disparity gradually increased at older ages throughout Europe. Among middle age respondents, the greater risk of LMFL for women in countries/regions with a high GII was no longer observed after accounting for comorbidities. Among older respondents, a lower risk of LMFL for women in countries/regions with a high GII was not observed until accounting for comorbidities.

DISCUSSION

Our findings suggest that rates of LMFL are higher in middle-income countries than high-income countries, especially among women, and in countries with a higher GII. In addition, consideration of comorbidities was integral to these relationships. Thus, national/regional contexts inform differential rates of functional limitation, particularly as it relates to gender.

Moderating Effect of Muscular Strength in the Association between Cardiovascular Events and Depressive Symptoms in Middle-Aged and Older Adults-A Cross Sectional Study

BACKGROUND

Depression and cardiovascular diseases are two main health conditions contributing to the global disease burden. Several studies indicate a reciprocal association between them. It is still unclear how changes in overall muscle strength may impact this association. This study aimed to analyse how muscular strength moderates the relationship between cardiovascular events and depressive symptoms among middle-aged and older adults.

METHODS

Wave 8 of the population-based Survey of Health, Ageing, and Retirement in Europe (2019/2020) cross-sectional data, which included 41,666 participants (17,986 men) with a mean age of 70.65 (9.1) years old, was examined. Grip strength was measured twice on each hand using a dynamometer. The 12-item EURO-D scale was employed to gauge depressive symptoms.

RESULTS

Grip strength negatively moderates the link between cardiovascular events and depressive symptoms (male: B = -0.03, 95% CI = -0.04, -0.03; female: B = -0.06, 95% CI = -0.06, -0.05). Additionally, the grip strength moderation values in the significant zone for males and females were less than 63.2 kg and 48.3 kg, respectively.

CONCLUSIONS

Muscular strength modifies depressive symptoms and lessens their correlation with cardiovascular diseases. Muscle-strengthening activities could be incorporated into primary and secondary preventive strategies to reduce the burden of depression in people with CVD.

Arthritis prevalence is associated with metabolic syndrome risk factors but not with physical activity in middle-aged and older patients - a cross-sectional study

BACKGROUND

In light of the aging population, increasingly suffering from the metabolic syndrome (MS), strategies need to be developed to address global public health challenges known to be associated with MS such as arthritis. As physical activity (PA) may play a crucial role in tackling those challenges, this study aimed to determine the association between the number of MS risk factors, PA and arthritis in people ≥ 50 years old.

METHODS

Data from the Survey of Health, Ageing, and Retirement in Europe (SHARE) were used to estimate the prevalence of arthritis and MS risk factors in the European population ≥ 50 years and to evaluate the associations between MS risk factors, PA and arthritis. Binary logistic regression was performed to calculate the odds ratio of different factors.

RESULTS

73,125 participants were included in the analysis. 55.75% of patients stated at least one of the three MS risk factors. The prevalence of rheumatoid arthritis (RA) and osteoarthritis (OA)/other rheumatism among ≥ 50 years population was 10.19% and 19.32% respectively. Females showed a higher prevalence of arthritis than males. Prevalence did not differ between groups with different levels of PA. Arthritis prevalence was positively correlated with the number of MS risk factors (P < 0.01) but not with PA (P > 0.05).

CONCLUSION

Middle-aged and older Europeans with multiple comorbidities suffered from RA, OA or other rheumatism more frequently than participants with fewer comorbidities, while the level of physical activity was not associated with the number of metabolic risk factors in patients with RA and OA/other rheumatism.

Attrition from longitudinal ageing studies and performance across domains of cognitive functioning: an individual participant data meta-analysis

OBJECTIVES

This paper examined the magnitude of differences in performance across domains of cognitive functioning between participants who attrited from studies and those who did not, using data from longitudinal ageing studies where multiple cognitive tests were administered.

DESIGN

Individual participant data meta-analysis.

PARTICIPANTS

Data are from 10 epidemiological longitudinal studies on ageing (total n=209 518) from several Western countries (UK, USA, Mexico, etc). Each study had multiple waves of data (range of 2-17 waves), with multiple cognitive tests administered at each wave (range of 4-17 tests). Only waves with cognitive tests and information on participant dropout at the immediate next wave for adults aged 50 years or older were used in the meta-analysis.

MEASURES

For each pair of consecutive study waves, we compared the difference in cognitive scores (Cohen's d) between participants who dropped out at the next study wave and those who remained. Note that our operationalisation of dropout was inclusive of all causes (eg, mortality). The proportion of participant dropout at each wave was also computed.

RESULTS

The average proportion of dropouts between consecutive study waves was 0.26 (0.18 to 0.34). People who attrited were found to have significantly lower levels of cognitive functioning in all domains (at the wave 2-3 years before attrition) compared with those who did not attrit, with small-to-medium effect sizes (overall d=0.37 (0.30 to 0.43)).

CONCLUSIONS

Older adults who attrited from longitudinal ageing studies had lower cognitive functioning (assessed at the timepoint before attrition) across all domains as compared with individuals who remained. Cognitive functioning differences may contribute to selection bias in longitudinal ageing studies, impeding accurate conclusions in developmental research. In addition, examining the functional capabilities of attriters may be valuable for determining whether attriters experience functional limitations requiring healthcare attention.

Latent trajectories of recent and delayed memory and their predictors: evidence from SHARE

OBJECTIVES

Cognitive decline is common in the old age, but some evidence suggests it may already occur during adulthood. Previous studies have linked age, gender, educational attainment, depression, physical activity, and social engagement to better cognitive performance over time. However, most studies have used global measures of cognition, which could mask subtle changes in specific cognitive domains. The aim of this study is to examine trajectories of recent and delayed memory recall from a variable-centered perspective, in order to elucidate the impact of age, gender, educational attainment, depression, physical activity, and social engagement on recent and delayed memory both at initial time and across a 10-year period.

DESIGN AND PARTICIPANTS

The sample was formed by 56,616 adults and older adults that participated in waves 4 to 8 of the Survey of Health, Aging and Retirement in Europe (SHARE).

ANALYSES

We used latent growth modeling to establish latent recent and delayed memory trajectories, and then tested the effects of the aforementioned covariates on the latent intercept and slopes.

RESULTS

Results showed that both recent and delayed recall display a quadratic trajectory of decline. All covariates significantly explained initial levels of immediate and delayed recall, but only a few had statistically significant effects on the slope terms.

CONCLUSIONS

We discuss differences between present results and those previously reported in studies using a person-centered approach. This study provides evidence of memory decline during adulthood and old adulthood. Further, results provide support for the neural compensation reserve theory.

Economic Evaluation of a Personalized Nutrition Plan Based on Omic Sciences Versus a General Nutrition Plan in Adults with Overweight and Obesity: A Modeling Study Based on Trial Data in Denmark

BACKGROUND

Since there is no diet that is perfect for everyone, personalized nutrition approaches are gaining popularity to achieve goals such as the prevention of obesity-related diseases. However, appropriate choices about funding and encouraging personalized nutrition approaches should be based on sufficient evidence of their effectiveness and cost-effectiveness. In this study, we assessed whether a newly developed personalized plan (PP) could be cost-effective relative to a non-personalized plan in Denmark.

METHODS

Results of a 10-week randomized controlled trial were combined with a validated obesity economic model to estimate lifetime cost-effectiveness. In the trial, the intervention group (PP) received personalized home-delivered meals based on metabolic biomarkers and personalized behavioral change messages. In the control group these meals and messages were not personalized. Effects were measured in body mass index (BMI) and quality of life (EQ-5D-5L). Costs [euros (€), 2020] were considered from a societal perspective. Lifetime cost-effectiveness was assessed using a multi-state Markov model. Univariate, probabilistic sensitivity, and scenario analyses were performed.

RESULTS

In the trial, no significant differences were found in the effectiveness of PP compared with control, but wide confidence intervals (CIs) were seen [e.g., BMI (-0.07, 95% CI -0.51, 0.38)]. Lifetime estimates showed that PP increased costs (€520,102 versus €518,366, difference: €1736) and quality-adjusted life years (QALYs) (15.117 versus 15.106, difference: 0.011); the incremental cost-utility ratio (ICUR) was therefore high (€158,798 to gain one QALY). However, a 20% decrease in intervention costs would reduce the ICUR (€23,668 per QALY gained) below an unofficial gross domestic product (GDP)-based willingness-to-pay threshold (€47,817 per QALY gained).

CONCLUSION

On the basis of the willingness-to-pay threshold and the non-significant differences in short-term effectiveness, PP may not be cost-effective. However, scaling up the intervention would reduce the intervention costs. Future studies should be larger and/or longer to reduce uncertainty about short-term effectiveness.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov registry (NCT04590989).

Systematic comparison of 3D Deep learning and classical machine learning explanations for Alzheimer's Disease detection

Black-box deep learning (DL) models trained for the early detection of Alzheimer's Disease (AD) often lack systematic model interpretation. This work computes the activated brain regions during DL and compares those with classical Machine Learning (ML) explanations. The architectures used for DL were 3D DenseNets, EfficientNets, and Squeeze-and-Excitation (SE) networks. The classical models include Random Forests (RFs), Support Vector Machines (SVMs), eXtreme Gradient Boosting (XGBoost), Light Gradient Boosting (LightGBM), Decision Trees (DTs), and Logistic Regression (LR). For explanations, SHapley Additive exPlanations (SHAP) values, Local Interpretable Model-agnostic Explanations (LIME), Gradient-weighted Class Activation Mapping (GradCAM), GradCAM++ and permutation-based feature importance were implemented. During interpretation, correlated features were consolidated into aspects. All models were trained on the Alzheimer's Disease Neuroimaging Initiative (ADNI) dataset. The validation includes internal and external validation on the Australian Imaging and Lifestyle flagship study of Ageing (AIBL) and the Open Access Series of Imaging Studies (OASIS). DL and ML models reached similar classification performances. Regarding the brain regions, both types focus on different regions. The ML models focus on the inferior and middle temporal gyri, and the hippocampus, and amygdala regions previously associated with AD. The DL models focus on a wider range of regions including the optical chiasm, the entorhinal cortices, the left and right vessels, and the 4th ventricle which were partially associated with AD. One explanation for the differences is the input features (textures vs. volumes). Both types show reasonable similarity to a ground truth Voxel-Based Morphometry (VBM) analysis. Slightly higher similarities were measured for ML models.

National and education-specific trends in life and health expectancies in Denmark 2004-2015

BACKGROUND

Several studies have revealed widening of inequalities in life expectancy, but little is known about the recent changes in health expectancy nationally and between socioeconomic groups. This study examines dynamics of national and education-specific life expectancy and health expectancies at age 50 years in Denmark from 2004/2007 to 2015.

METHODS

Nationwide register data on education and mortality were linked and combined with Danish health data from the Survey of Health, Ageing and Retirement in Europe and changes in life expectancy and three health expectancy indicators were estimated by Sullivan's method.

RESULTS

From 2004 to 2015, national life expectancy at age 50 years increased by 2.4 years for men and 2.1 years for women. Simultaneously, after an initial rapid improvement from 2004 to 2007, the pace of progress in health expectancy decreased. From 2007 to 2015, the difference in life expectancy at age 50 years between men with long and short education increased from 4.3 to 5.0 years. For women, the corresponding increase in the life expectancy gap was less pronounced from 3.5 to 3.8 years. The educational gap in lifetime without long-term illness decreased from 4.6 years to 3.1 years for men and from 6.1 years to 4.6 years for women. On the contrary, the educational gap increased for lifetime without activity limitations and in self-rated good health.

CONCLUSIONS

Previously observed improvements in health expectancy in Denmark slowed down despite continuing progress in life expectancy. This worrying change coincides with persistent educational inequalities in life expectancy and health expectancy and is a challenge to a sustainable social and health development in the future.

Cognitive function among religious and non-religious Europeans: a cross-national cohort study

OBJECTIVES

To examine the associations between several measures and categories of religiosity and cognitive function across sex and European regions.

METHODS

We conducted a longitudinal study including 17,756 Europeans aged 50 and older who participated in the Survey of Health, Ageing and Retirement in Europe wave 1. Participants were followed for up to 15 years. Associations were analyzed using linear mixed effects models adjusted for several potential confounders.

RESULTS

Religious service attendance was consistently associated with better cognitive function (coefficient: 1.04, 95% CI 0.71; 1.37) across sex and European regions. Praying was also associated with better cognitive function but only among men (coefficient: 0.55, 95% CI 0.15; 0.96). However, individuals who received religious education from their parents had poorer cognitive function (coefficient: -0.59, 95% CI -0.93; -0.25). The association persisted in women and among both sexes in Western Europe. Comparing different religious categories to the non-religious, participants who were religious in childhood showed an inverse association with cognitive function, while persistently religious men exhibited better cognitive function.

CONCLUSIONS

Our findings indicate that religious service attendance and, to a certain extent, prayer is associated with better cognitive function. However, receiving religious education in childhood may be linked to lower cognitive function.

Effect of retirement on self-rated oral health and dental services use: longitudinal fixed-effects instrumental variable study in 31 countries

OBJECTIVE

This study examined the effect of retirement on self-rated oral health and dental services use.

METHODS

Covering 31 countries, we used harmonized panel data from the English Longitudinal Study on Aging (ELSA), Health and Retirement Study (HRS), and the Survey of Health, Aging and Retirement in Europe (SHARE). Data comprised 485 085 observations from 112 240 individuals aged ≥50 years. Official and early retirement ages were leveraged as instruments in a fixed-effects instrumental variable approach.

RESULTS

We found that retirement exhibited a negative effect on self-rated oral health (β = -0.37; 95% confidence interval (CI) -0.44- -0.30) and a positive effect on the propensity to seek dental care (β = 0.56; 95% CI 0.53-0.60). Male retirees showed a stronger decrease in self-rated oral health and increase in dental services use than female retirees. Participants who previously worked in a physically demanding job showed a stronger effect on self-rated oral health. Conversely, participants without a physically demanding job in the past exhibited a stronger retirement effect on dental service use. Compared with other health system clusters, retirement effects on dental services use were stronger in three health system clusters: Belgium, Denmark, Finland, France, Ireland, Luxembourg, The Netherlands, and Sweden; Israel; and the United States.

CONCLUSIONS

Using a quasi-experimental design, we found that transition to retirement lowers self-rated oral health and increases the use of dental services. Retirement effects appeared heterogeneous across sexes, type of previous labor, and health systems.

Caring for others without neglecting oneself? Grandparent caregivers, gender, and perceived health-related quality of life

In this study, we explored the impact of caregiving on quality of life and health perceptions and outlined the profile of grandparent caregivers in Andalusia (Spain) in terms of a range of sociodemographic variables related to the care of their grandchildren. A sample of 171 participants (21.6% men) completed the Health-Related Quality of Life (HRQoL) questionnaire and another ad hoc one providing sociodemographic and caregiving data. We studied the relationships between these variables and HRQoL using ANOVA, chi-square and Multiple Linear Regression. We found a mainly female profile for the care of grandchildren and interesting relationships for the physical and mental components of HRQoL. Some relationships were marked by gender: caregiving for pleasure was more often the motive for men while by imposition was more common among women. We discuss the impact of caregiving on health according to the Self-Determination Theory and suggest practical implications derived from the main findings.