Patient-related predictors of rehabilitation use for community-dwelling older Americans.

OBJECTIVE: To determine patient factors that predict use of physical or occupational therapy (PT/OT) services by elderly people. DESIGN: Time-series study of the relationship of PT/OT use to a variety of characteristics present at baseline. PARTICIPANTS: Eight-hundred nine community-dwelling men and women aged 65 and older. SETTING: The Medicare Screening and Health Promotion Trial at UCLA. MAIN OUTCOME MEASURES: Use of PT/OT services, as reported in a telephone survey 1 year after initial information was obtained on the same subjects by the baseline telephonic survey. RESULTS: Fifteen percent of the sample used PT/OT within 12 months of baseline. In multiple logistic regression analysis, PT/OT use was significantly less frequent among racial minorities, less well educated groups, and the oldest age group. PT/OT use was higher among those who had both functional disability and the presence of arthritis, heart or lung disease, or a prior history of stroke. However, neither functional disability alone nor the presence of arthritis, cardiovascular or lung disease, in the absence of limited functioning, was associated with PT/OT use. Patients who had obtained a pneumococcal vaccination or used transportation services were also more likely to receive PT/OT. CONCLUSIONS: Our findings suggest that there may be important sociodemographic inequalities in the use of rehabilitation services and raise the possibility of inappropriate underuse in certain subgroups. Additional studies are needed to determine whether similar inequalities of PT/OT use are found in other populations and whether rehabilitation is effective in various subgroups.     

Factors associated with health status of older Americans.

BACKGROUND: health status is increasingly used as a measure of healthcare effectiveness. How diseases and symptoms are associated with health status is not completely understood. OBJECTIVES: to find diseases, symptoms and demographic factors associated with physical and mental health status in older Americans. METHODS: we analysed data from a survey of over 100 000 Medicare beneficiaries aged 65 and older. We used the short-form 36 physical and mental summary scores as measures of health status. Other data collected included demographic details, symptoms and diagnoses. RESULTS: age as a single variable explained 4% of variation in physical health status. Adding other demographic information and increased disease burden explained variation to 8% and 27% respectively. Together, shortness of breath, back pain, difficulty getting in and out of chairs, arthritis of hip or knee, a recent change in health and age explained 54% of variation. All available variables explained 59%. The role of age as an independent factor decreased markedly after disease and symptoms were considered. Similar factors were associated with lower mental health status, but age was not. CONCLUSION: these data suggest that heart and lung disease and back pain are the most important factors affecting the average physical health status of older people. Sex, marital status and race have very little independent effect. Efforts to improve average physical health status scores might best be targeted at these conditions rather than demographic characteristics. Mental health status does not decline with age, and similar factors affect it but to a lesser degree.     

Frailty in older Mexican Americans

OBJECTIVES: To identify sociodemographic characteristics and health performance variables associated with frailty in older Mexican Americans. DESIGN: A prospective population-based survey. SETTING: Homes of older adults living in the southwest. PARTICIPANTS: Six hundred twenty-one noninstitutionalized Mexican-American men and women aged 70 and older included in the Hispanic Established Populations for Epidemiologic Study of the Elderly participated in a home-based interview. MEASUREMENTS: Interviews included information on sociodemographics, self-reports of medical conditions (arthritis, diabetes mellitus, heart attack, hip fracture, cancer, and stroke) and functional status. Weight and measures of lower and upper extremity muscle strength were obtained along with information on activities of daily living and instrumental activities of daily living. A summary measure of frailty was created based on weight loss, exhaustion, grip strength, and walking speed. Multivariable linear regression identified variables associated with frailty at baseline. Logistic regression examined variables predicting frailty at 1-year follow-up. RESULTS: Sex was associated with frailty at baseline (F=4.28, P=.03). Predictors of frailty in men included upper extremity strength, disability (activities of daily living), comorbidities, and mental status scores (Nagelkerke coefficient of determination (R(2))=0.37). Predictors for women included lower extremity strength, disability (activities of daily living), and body mass index (Nagelkerke R(2)=0.29). At 1-year follow-up, 83% of men and 79% of women were correctly classified as frail. CONCLUSION: Different variables were identified as statistically significant predictors of frailty in Mexican-American men and women aged 70 and older. The prevention, development, and treatment of frailty in older Mexican Americans may require consideration of the unique characteristics of this population.     

Why older Americans stop working

Recently economics researchers have suggested that most persons respond to economic incentives in choosing when to retire, although a small percentage exit the labor force because of deteriorating health. Although recent and proposed changes in the social security system are likely to have only small effects on retirement behavior, larger impacts could ensue from altering the incentives implicit in many private pension plans. Little is known about the transition process that follows the end of career jobs and precedes retirement: this represents an important area for future research.     

Informal caregiving for chronic lung disease among older Americans

STUDY OBJECTIVE: To obtain nationally representative estimates of the additional time, and related cost, of unpaid family caregiving (informal caregiving) associated with chronic lung disease among older Americans. DESIGN: Multivariable regression models using data from the 1993 Asset and Health Dynamics Study, a nationally representative survey of people > or = 70 years old (n = 7,443). PARTICIPANTS: National population-based sample of the community-dwelling elderly. MEASUREMENTS: Weekly hours of informal caregiving, and imputed cost of caregiver time, for community-dwelling elderly who reported the following: (1) no lung disease, (2) lung disease without associated activity limitations, or (3) lung disease with associated activity limitations. RESULTS: After adjusting for sociodemographic variables, potential caregiver network, and comorbid conditions, individuals with chronic lung disease and associated activity limitations (n = 403) received an additional 5.1 h/wk of informal care when compared to those with no lung disease (n = 6,593; p < 0.001). The associated additional yearly cost of informal care per case was $2,200 USD. This represents a national annual cost of informal caregiving for chronic lung disease of > $2 billion USD. CONCLUSIONS: The quantity and associated economic cost of informal caregiving for elderly individuals with chronic lung disease are substantial. These costs to families and society must be accounted for if the full societal costs of chronic lung disease are to be calculated. Pulmonary physicians caring for elderly individuals with chronic lung disease should be mindful of the importance of informal care for the well-being of their patients, as well as the potential for significant burden on those (often elderly) individuals providing the care.     

Housing characteristics of older Asian Americans

This study described the housing tenure and residential density of elders from the six largest Asian American ethnic groups in the US: Chinese, Filipino, Japanese, Korean, Asian Indian, and Vietnamese. These groups were compared to non-Hispanic White elders. Based on data from the 2000 US Census of Population, multilevel regression analyses showed that Japanese elders were most like the non-Hispanic White comparison group across the two housing dimensions. Older Vietnamese persons were least likely to own their homes compared to the other Asian American groups, and with the exception of the Japanese elders, all Asian groups were more likely than non-Hispanic Whites to live in crowded residences. In general, considerable heterogeneity in housing characteristics was observed across the six older Asian American ethnic groups, even after controlling for assimilation and housing discrimination indicators.     

Subjective memory in older African Americans

The current analysis examined (a) if measures of psychological well-being predict subjective memory, and (b) if subjective memory is consistent with actual memory. Five hundred seventy-nine older African Americans from the Baltimore Study of Black Aging completed measures assessing subjective memory, depressive symptomatology, perceived stress, locus of control, and verbal and working memory. Higher levels of perceived stress and greater externalized locus of control predicted poorer subjective memory, but subjective memory did not predict objective verbal or working memory. Results suggest that subjective memory is influenced by aspects of psychological well-being but is unrelated to objective memory in older African Americans.     

Perceived intergenerational solidarity and psychological distress among older Mexican Americans.

A model separating and relating dimensions of intergenerational solidarity with measures of psychological distress was investigated for older Mexican Americans. Solidarity consisted of measures of similarity, affection, and association. Measures of psychological distress were somatic/retarded symptoms, depressed affect, and positive affect. To evaluate whether emotional closeness with a particular child modified the linkages, the model was analyzed separately based on whether or not the elderly participant reported that the child included in the intergenerational study was her or his closest child. The findings indicated that the impact of affection and association was a function of the particular dimension of distress and the emotional closeness of the child. Although the proposed model needs expanding, it provides some support for the expectation that family solidarity has important consequences for elderly Mexican Americans.     

Primary care physician office visits for depression by older Americans

BACKGROUND: Older patients mostly receive depression care from primary care physicians, but it is not known whether depression treatment is primarily received from family/general practice physicians or internal medicine physicians and whether the type of depression treatment offered varies between these types of primary care physicians. OBJECTIVE: To assess what proportion of visits for depression are to family/general practice physicians or to internal medicine physicians and whether the type of depression treatment offered varies by primary care physician specialty. DESIGN: Data from the 2000 and 2001 National Ambulatory Medical Care Surveys, a nationally representative survey of visits to office-based practices using clustered sampling, were used. PARTICIPANTS: Office-based physician practices in the United States. RESULTS: There were an estimated 9.8 million visits made to office-based providers by older patients for depression in 2001 to 2002, of which 64% were to primary care physicians. Visits to primary care providers were evenly split between Internists and family/general practice physicians. There was no significant difference in the rate of antidepressant prescribing between visits to Internists versus family/general practice (55.9% vs 48.0%; P = .42). Mental health counseling or psychotherapy was offered more often during visits to family/general practice physicians than to Internists (39.4% vs 14.0%; P = .07). CONCLUSIONS: Visits for depression by elderly patients continue to take place in primary care settings to both family/general practice physicians and Internists. Interventions aimed at improving depression care in primary care should focus on both types of primary care physicians and emphasize improving rates of diagnosis and referral for counseling or psychotherapy as a viable treatment option.     

Mortality risk in older inner-city African Americans

OBJECTIVES: To investigate mortality risks in a sample of poor, inner-city-dwelling, older African Americans. DESIGN: Prospective cohort study. SETTING: St. Louis, Missouri. PARTICIPANTS: Six hundred twenty-two African Americans aged 68 to 102 at the time of their 1992 to 1994 baseline interviews. MEASUREMENTS: Risk factors previously identified in the literature were examined for seven categories: demographic, socioeconomic, psychosocial, biomedical, disability and physical function, perceived health, and health services utilization. Vital status was ascertained through 2002. RESULTS: Three hundred eighty-six subjects (62.1%) were deceased and 236 were alive (mortality higher than in matched controls). Significant risks for mortality were older age, male sex, annual income less than $10,000, cancer, cerebrovascular disease, dependencies in lower-body function, and number of physician visits in the 12 months before baseline. CONCLUSION: In addition to improving the risk factors for stroke and malignant disease in this population, studies focused on improving lower-body functioning may be warranted as a part of efforts aimed at enhancing longevity in older African-American adults.     

Transthyretin cardiac amyloidoses in older North Americans

The amyloidoses are a group of hereditary or acquired disorders caused by the extracellular deposition of insoluble protein fibrils that impair tissue structure and function. All amyloidoses result from protein misfolding, a common mechanism for disorders in older persons, including Alzheimer's disease and Parkinson's disease. Abnormalities in the protein transthyretin (TTR), a serum transporter of thyroxine and retinol, is the most common cause of cardiac amyloidoses in elderly adults. Mutations in TTR can result in familial amyloidotic cardiomyopathy, and wild-type TTR can result in senile cardiac amyloidosis. These underdiagnosed disorders are much more common than previously thought. The resulting restrictive cardiomyopathy can cause congestive heart failure, arrhythmias, and advanced conduction system disease. Although historically difficult to make, the diagnosis of TTR cardiac amyloidosis has become easier in recent years with advances in cardiac imaging and more widespread use of genetic analysis. Although therapy has largely involved supportive medical care, avoidance of potentially toxic agents, and rarely organ transplantation, the near future brings the possibility of targeted pharmacotherapies designed to prevent TTR misfolding and amyloid deposition. Because these disease-modifying agents are designed to prevent disease progression, it has become increasingly important that older persons with TTR amyloidosis be expeditiously identified and considered for enrollment in clinical registries and trials.     

Ocular problems in older Americans with diabetes

Data from the Wisconsin Epidemiologic Study of Diabetic Retinopathy from persons with diabetes of older onset whose average age was 65.4 years indicate that 9.9% of the men and 13.3% of the women had some degree of visual impairment, and 1.4% of men and 1.7% of women were legally blind (with an visual acuity of 20/200 or worse in the better eye). Poorer visual acuity was strongly associated with increasing duration of diabetes, but age was also an important factor, with rates of legal blindness increasing markedly after the seventh decade of life in groups of any duration. Conditions responsible for legal blindness were diabetic retinopathy or maculopathy, cataracts, glaucoma, and macular degeneration. Incidence of blindness 4 years after the initial evaluation was related to insulin use, younger age at examination, longer duration of diabetes, and more severe retinopathy at baseline. Worsening of vision was related to higher levels of glycosylated hemoglobin and the presence of macular edema on diabetic retinopathy at baseline. These data indicate that there is a high prevalence of ocular problems among people with diabetes of older onset. The practitioner should suggest to these patients that, soon after the diagnosis of diabetes, they have an ophthalmologic evaluation to determine whether asymptomatic problems are present. This action may lead to timely intervention to prevent loss of vision in some patients.