Journal of Aging and Health

Objective: The authors examine how trends in disability prevalence and in inflation-adjusted per capita, per annum Medicare costs, 1982 to 1999 and 1989 to 1999, affected total Medicare costs projected to 2004 and 2009. Method: To describe disability trends, the authors applied grade of membership analyses to 27 measures of disability from the 1982 to 1999 National Long Term Care Surveys (NLTCS). This identified seven disability profiles for which individual scores were calculated. These were used to calculate sample weighted Medicare costs and cost trends. Results: Significant declines (up to 19%) in Medicare costs were found in 2004 and 2009 assuming continuation of the 1982 to 1999 disability declines and Medicare cost trends. In addition to declines in disability prevalence, inflation-adjusted per capita, per annum Medicare costs declined for nondisabled persons aged 65 to 84. Discussion: Preserving health in the growing nondisabled population did not require increased health care expenditures.

Purpose: Visual impairment and, to a lesser extent, hearing impairment are independent predictors of reduced survival in selected studies of community-residing adults. To date, the association of severity of concurrent impairment and mortality has not been examined. Method: The National Health Interview Survey is a continuous, multistage, area probability survey of the U.S. civilian noninstitutionalized population. Mortality linkage with the National Death Index of 116,796 adult participants from 1986 to 1994 with complete impairment data was performed through 1997. Results: Findings indicate that moderate to severe concurrent hearing and visual impairment in women is associated with significantly increased risk of mortality. More modest mortality associations are evident for men and for adults with less severe impairments, irrespective of gender. Discussion: Prevention of severe visual and hearing impairment should be a national public health priority, especially given the aging of the U.S. population.

Objectives: The authors explored the association between complexity of primary lifetime occupation and cognition in older adulthood. Method: The study included 386 participants from the Swedish Panel Study of Living Conditions of the Oldest Old, a nationally representative sample aged 77 years or older. The authors examined complexity of work with data, people, and things in relation to cognitive functioning, measured with a shortened version of Mini-Mental State Examination (MMSE) and cognitive impairment based on MMSE score cutoff. Results: Complexity of work with data and people were associated with better MMSE scores, controlling for age, sex, childhood socioeconomic status, and education. The association between complexity of work with data and MMSE remained statistically significant when adult occupational status was substituted for education as a covariate. Discussion: Complexity of primary lifetime occupation may be reflected in cognitive functioning even in advanced old age. This effect may be independent of education or occupational status.

Objective: This article addresses the association between course of chronic disease and lifestyle. Method: We examined differences in unhealthy lifestyles—smoking, excessive alcohol use, being sedentary—and transitions herein after 6 years in prevalent and incident chronic disease categories— lung and cardiovascular disease, diabetes, and osteoarthritis and/or rheumatic arthritis—among 2,184 respondents aged 55 years and older from the Netherlands. We also examined if transitions in lifestyle co-occurred with changes in disease-related symptomatology. Results: Proportions of respondents who smoked decreased over time, whereas proportions of respondents who were sedentary increased. Respondents with incident cardiovascular disease demonstrated more lifestyle transitions than respondents from other disease categories. Respondents demonstrating healthy lifestyle transitions did not differ from those persisting in unhealthy lifestyles in change in disease-related symptoms. Discussion: Health promotion may benefit from these findings in a way that patient groups at risk for not initiating healthy lifestyles might be identified sooner.

Objective: Responding to the increased need for research on older residents in assisted living facilities (ALFs), this study assessed the connections between physical and mental health among 150 older residents in ALF settings. Method: The major focus of the study was to explore whether individuals' subjective perceptions of their own health mediate the associations between health-related variables (chronic conditions and functional disability) and depressive symptoms. Results: The analyses showed that the adverse effects of chronic conditions and functional disability on depressive symptoms were not only direct but also indirect through negative health perceptions. Discussion: The findings that health perceptions serve as an intervening step between physical and mental health provide important implications for promotion of mental well-being among older residents in ALFs. In addition to disease/disability prevention and health promotion efforts, attention should be paid to ways to enhance older individuals' positive beliefs and attitudes toward their own health and to promote healthful behaviors.

Objective: Self-rated health (SRH) is known to predict mortality and other health outcomes better than objective ratings, suggesting that patients have important knowledge that physicians do not. The study assessed whether SRH reflects changes in internal states, specifically symptoms and affects. Method: In an event-sampling study, 54 elders completed a SRH measure, positive and negative affect scale, a symptom checklist, and a pain scale every evening for 8 weeks. Using lagged (time series) hierarchical regression, the authors modeled associations of SRH with previous symptoms, moods, and changes in symptoms and mood. Results: The SRH was highest when symptoms had decreased from the previous day and lowest when symptoms had increased, suggesting that SRH reflects a sense of change. Symptoms and affects contributed independently to SRH. Self-rated health was more sensitive to positive than negative affect and also sensitive to changes of positive but not negative affect. Discussion: Patients may possess a subjective trajectory of health–an awareness of changes in symptoms and affect. This trajectory may constitute an important component of SRH and help to explain its ability to predict health outcomes.

Objective: This study aimed to (a) identify factors that motivate or prevent older Australians from exercising; (b) determine how these factors differ as a function of age, gender, and exercise level; and (c) examine how they relate to intentions to exercise in the future. Method: In all, 217 older adults (aged 63 to 86) completed a questionnaire in their own home. Participants rated various motivators and barriers to exercise and indicated future intention to exercise. Results: Health concerns were the strongest motivators to exercise, whereas physical ailments were the most common barrier to exercise. Older Australians were fairly motivated to exercise and experienced few barriers to exercise. Age, gender, and exercise level differentiated between reported motivators and barriers, which in turn were associated with future intentions to exercise. Discussion: Reasons that promote and prevent exercise engagement are quite varied and depend on personal factors. Exercise intervention programs for older adults should incorporate these factors.

Objective: Lifestyle changes and medical advances warrant an investigation into perceptions of elder care needs held by today's adult children (AC) and their parents. Method: Surveys were distributed to 200 AC. Eighty AC and 102 of their parents responded. Results: Paired sample t tests revealed that AC (M = 10.61, SD = 4.5) and parents (M = 10.4, SD = 4.60) did not differ in their own expectations of future care needs. However, ACs' expectations of their parents' needs (M = 15.82, SD = 5.77) were significantly higher than both self-expectations. In addition, among six caregiving tasks minimal but significant differences were found in expected receipt of assistance. Discussion: Consistent with Weinstein's (1980) theory of unrealistic optimism, results demonstrated the tendency for AC and parents to underestimate their own future care needs. Such underestimation may in turn, lead to inadequate planning for future care needs.

Purpose: This study investigated the interplay of exercise strategy use (i.e., strategies of selection, optimization, and compensation) and perceived loss of exercise resources in individuals prescribed to engage in physical exercise. Method: Specifically, 368 individuals (18 to 80 years) were assessed during orthopedic rehabilitation and 6 and 12 months thereafter. Exercise, orthopedic outcome, and subjective well-being served as indicators of successful development. Results: There was no evidence for an interaction of age and strategy use. There was also no support for an interaction between resource loss and strategy use but rather for a mediating role of strategy use between resource loss and exercise. The effect of strategy use on orthopedic outcome and subjective well-being was mediated by exercise. Discussion: Strategy use seems to be beneficial for exercise regardless of age. In addition, strategy use seems to enhance resources and is not only associated with exercise but also with orthopedic outcome and subjective well-being.

Objectives: Despite federal and state laws governing advance directives (ADs), interventions to increase rates of legally completed ADs have not produced significant results. This study synthesizes the state of the science regarding effectiveness of interventions to increase AD completion rates. Methods: Garrard's method for conducting a systematic literature review was followed. In all, 25 studies meeting inclusion criteria were reviewed. Interventions fell into two types: (a) didactic—information distributed through an educational program or clinical encounter or by a mailing and (b) interactive—person-to-person interaction where participants had the opportunity to ask questions and/or receive assistance completing the forms. Results: Postintervention rates of AD completion were: didactic = no change to 34% increase; interactive = 23% to 71% increase. Discussion: Education without the ability to ask questions does not significantly increase the AD completion rate. Didactic interventions did not usually increase completion rates higher than the predicted average rate for the general population.

Purpose: The purpose of this study is to examine the use of religious services to improve health among middle-aged and older adults with multiple sclerosis (MS). Method: Data from the study "Aging With MS: Unmet Needs in the Great Lakes Region" were used to investigate religious service use among 1,275 adults with MS. Results: The findings indicate that nearly two thirds of the sample currently use religious services to improve their health or well-being. Individuals whose MS is stable and those who have had the disease longer are significantly more likely to use religious services to improve their health. Conclusions: Religious organizations should continue providing out-reach and increasing accessibility for individuals with disabling conditions. In addition, health care professionals should be aware of the importance of religious services to individuals with MS and do their part to facilitate participation for those who desire it.

Objectives: Many studies have examined quality effects of nursing facility (NF) staffing, but few have examined effects of unionization. Concerned with possible effects of unionization on quality, we analyzed unionization and local market climate of unionization, predicting both complaints (reflecting either quality problems or better monitoring and advocacy) and the substantiation of serious complaints (indicating major quality problems). Method: Data were analyzed on California freestanding NFs in 1999 (N= 1,155). OLS regression was employed to predict both quality complaints and serious violations, the latter both controlling and not controlling for numbers of complaints. Results: Unionized NFs showed more complaints than did nonunionized NFs. Nonunionized NFs had more serious violations, particularly when the proportion of other county facilities unionized was higher. Discussion: These findings suggest that unionization enhances problem reporting while, especially in stronger union environments, reducing the incidence of serious quality violations.

Purpose: The purpose was to identify differences in gait characteristics between older fallers with a tendency to fall sideways compared to those who do not fall to the side. Method: The authors conducted a prospective, case control study of ambulatory adults older than 70 residing in retirement communities. Measurements included spatial and temporal gait parameters and prospective fall surveillance. Results: In all, 29 participants fell to the side, and 64 fell in other directions (forward, backward, straight down); 46 participants experienced no falls. Side-fallers exhibited narrower stride widths compared to other-directed fallers, and stepwise and discriminant analysis correctly classified 67% of side-fallers and other-directed fallers using only stride width. Discussion: This study suggests that side-fallers, who have narrower stride widths compared to those who fall in other directions, may not be adapting their gait to compensate for lateral instability. More research is needed to determine whether narrow gait contributes to unstable walking patterns.

Objective: The authors explored the effect of predisposing, enabling, and need characteristics on risk of nursing home placement (NHP) in participants with and without dementia. Method: Participants were 1,943 newly enrolled Medicare/Medicaid beneficiaries in Florida who were evaluated for health services by the Department of Elder Affairs. They were at least 65 years of age during fiscal year 1998-1999 and were followed for up to 4 years. Results: Cox proportional hazard regressions indicated that baseline characteristics including older age, White race, diabetes, incontinence, stroke, and difficulties with instrumental activities increased risk of NHP in those without dementia. Caregiver, widowed status, arthritis, and heart disease reduced the risk. Only age, race, and marital status were predictive among participants with dementia. Discussion: Dementia plays a central role in risk of NHP. Understanding risk factors for NHP in this relatively vulnerable population has important policy implications.

Objective: To assess influences from visual or hearing impairment on use of community support services and health-related quality of life in aged care clients. Method: The authors sampled 284 frail elderly individuals presenting for assessment in Sydney, Australia. Moderate to severe visual impairment was defined as visual acuity 40 decibels (better ear). Community support services included home-delivered meals, home help, and community nurse visits. Results: After adjusting for age, sex, and two or more comorbid conditions, moderate to severe visual impairment, but not moderate to severe hearing loss, was significantly associated with increased use of community services (adjusted odds ratio 2.8, 95% confidence interval = 1.0—7.8). Conclusion: Moderate to severe visual impairment was associated with an increased likelihood of community service utilization in this aged care client sample.

Objective: This study evaluated the protective role of physical activity (PA) against cognitive impairment (CI) in the oldest old (age ≥ 85). Method: Prospective data on 66 optimally healthy, oldest old adults (mean age 88.5) were analyzed using survival analysis. Results: In all, 12 men and 11 women reported exercising > 4 hours per week, and 38 participants developed CI (mean onset age 93; mean follow-up 4.7 years). The effect of exercise was modified by gender. In more active women (> 4 hours/week), the risk of CI was reduced by 88% (95% confidence interval 0.03, 0.41) compared to those less active. Less active women had 2 times the incidence rate of CI compared to less active men and almost 5 times the rate compared to active women. Discussion: This study demonstrates the beneficial effects of exercise on healthy brain aging even in the oldest old and emphasizes the importance of increasing PA in older women.

Objective: Residents' cognitive, psychiatric, and behavioral statuses were examined as part of a larger study of care in a nursing home (NH) owned and operated by a Northern Plains American Indian tribe. Method: Reviews of 45 medical records and semistructured interviews with 36 staff were completed. Results: Creekside residents had considerable psychiatric and behavioral morbidity. High prevalences of non-Alzheimer's disease dementia, cognitive impairment, anxious symptomatology, and resistance to care were met with psychopharmacotherapy, reorientation, and informal techniques for behavior management. Significant depressive, anxious, psychotic, and behavioral symptoms remained. Staff interpretations of resident problems consisted of an ethnopsychological schema emphasizing resident loneliness, grumpiness, and propensity to "fight" rather than formal psychiatric nosology. Discussion: Tribal NH residents were likely underdiagnosed for dementia and anxiety. Residual behavioral and psychiatric symptomatology suggest room for improvement in the NH's behavioral management regimen. Need for greater attention to conceptual, diagnostic, clinical, and documentation processes in the NH setting is noted.

Objective: The authors report the association of balding or graying with BMD in older adults. Method: BMD was measured at the spine, hip, and total body in 1,207 participants. Of these, 508 women and 380 men responded to a 1986 survey about balding patterns; in 1994, all participants answered questions about graying. Results: Among men, 10.7% reported graying, and 51.1%, balding; 9.9% of women reported graying, and 9.5%, balding. Models were adjusted for age, body mass index, alcohol consumption, smoking, exercise, calcium supplements, diuretics, glucocorticoids, thyroid hormone, and estrogen. Conclusion: Graying was not significantly associated with BMD in either group. Balding men averaged 5% lower total body BMD (p ≤ 0.05), and balding women had ~24% higher mean hip BMD (p ≤ 0.05). Graying and balding women reported a higher proportion of current estrogen use; balding women reported more use of glucocorticosteroids. Balding women using estrogen may explain the higher BMD.

Objective: This study examines the association between relative body weight (measured with body mass index; BMI) and multiple forms of psychological distress and whether those associations are contingent on gender and race. Method: Interviews were conducted in 2001-2002 with persons 65 years and older in the District of Columbia and adjoining Maryland counties (N = 1,152). BMI is associated (a) positively with depression, anger, and physical symptoms among White women; (b) positively with physical symptoms among Black women and men; and (c) negatively with anxiety among White men. Results: Tests for gender by race interactions find significant contrasts between White women and men when depression, anxiety, and physical symptoms are considered as outcomes; contrasts between White and Black women are significant for anger. Discussion: Results underscore the importance of gender by race interactions, multiple forms of distress in analyses of effects of BMI, and the role of negative self-evaluations and health difficulties as explanations.