Epidemiologic Studies Of The Elderly Research Articles

Attendance at Religious Services and Physical Functioning After Stroke Among Older Mexican Americans

The purpose of this study was to examine the association of attendance at religious services and change in physical functioning among older Mexican Americans who report residual physical limitations due to stroke. Using data from the Hispanic Established Population for the Epidemiological Study of the Elderly (H-EPESE), generalized linear models were used to evaluate change in physical function over 3 years in persons with stroke aged 65 and older, controlling for demographics, medical conditions, health behaviors, and physical mobility. The results showed frequent attendees at religious services had significantly fewer declines in activities of daily living (ADLs) disability compared to infrequent attendees. The frequent attendance group also showed less decline in lower body function compared to the infrequent attendees. Findings are indicative that church attendance prestroke is associated with better physical function poststroke in older Mexican Americans.

Body mass index and change in blood pressure over a 7-year period in older Mexican Americans

Obesity and hypertension are major public health concerns in the US. We examined the relationship between body mass index (BMI) and blood pressure in older Mexican Americans using data from the Hispanic Established Population for the Epidemiological Study of the Elderly (EPESE), a longitudinal study of Mexican Americans aged 65 and over residing in the southwestern US. The study sample was 2404 older Mexican American adults with a mean age of 72.6 years of age at baseline (1993-4). Both systolic and diastolic blood pressures were higher in subjects with high BMI categories. The rate of change in systolic blood pressure and diastolic blood pressure were -0.11 mm Hg and -0.32 mm Hg per year over a 7-year period, respectively. The rate of decline in systolic and diastolic blood pressure over a 7-year period was greater in subjects with BMI categories of 25- < 30 kg/m2 and 30- < 35 kg/m2 as compared with those subjects with in the lowest and in the highest BMI categories. Hypertension is one of the most prevalent medical conditions affecting older adults. Understanding possible modifiable risk factors that may play a role in the management of hypertension will be beneficial.

Anemia in Old Age Is Associated With Increased Mortality and Hospitalization

Anemia is common in old age and has been shown to affect older persons' physical function. To more fully understand the detrimental health effects of anemia, we examined the relationship of anemia with death and hospitalization outcomes in a large community-based sample of older persons. Data are from 3607 persons, aged 71 years or older, participating in the National Institute on Aging (NIA)-sponsored Established Populations for Epidemiologic Studies of the Elderly (EPESE) study. Anemia was defined according to World Health Organization (WHO) criteria as a hemoglobin concentration below 12 g/dL in women and below 13 g/dL in men. Data on subsequent mortality and hospital admissions over 4 years were obtained from death records and the Medicare database. Anemia was present in 451 of the 3607 (12.5%) participants. During the follow-up period, anemic persons were more likely to die than were nonanemic persons (37.0% vs 22.1%, p<.001). Also, anemic persons were more often hospitalized (65.9% vs 54.6%, p<.001) and spent more days in hospital (25.0 vs 13.7, p<.001). After adjustment for demographics and baseline comorbidities, anemia significantly predicted subsequent mortality and hospitalization (relative risk=1.61, 95% confidence interval, 1.34-1.93; and relative risk=1.27, 95% confidence interval, 1.12-1.45, respectively). After excluding persons with prevalent diseases at baseline, anemia remained significantly associated with increased risks of mortality and hospitalization. A higher hemoglobin level was significantly associated with lower risks of mortality and hospitalization (p for trend<.001 for both). These findings indicate that late-life anemia characterizes persons at risk for important clinical health outcomes, and demonstrate the importance of clinical awareness of anemia even if the person is without apparent clinical disease.

Acculturation and self-esteem among older Mexican Americans

Several researchers have examined how acculturation shapes the self-esteem of adolescents, but few studies have looked at the influence of acculturation for older Mexican Americans. The aim of this study was to examine how language acculturation shaped the self-esteem of older Mexican Americans. The data come from the baseline wave (N = 3050) of the ongoing Hispanic Established Populations for the Epidemiologic Studies of the Elderly (H-EPESE), a multistage area probability sample conducted in 1993 and 1994. Research revealed that language acculturation is positively associated with self-esteem. However, depressive symptoms mediate and moderate the association of acculturation on self-esteem. Language acculturation among older Mexican Americans is positively associated with self-esteem, even when individuals experience depressive symptoms. Findings suggest that acculturation influences multiple dimensions of mental health.

Is the prevalence of dehydration among community-dwelling older adults really low? Informing current debate over the fluid recommendation for adults aged 70+years

The fluid recommendation for adults aged 70+ years has been criticised on the basis of a low prevalence of dehydration in community-dwelling older adults. This study explores whether the low prevalence might reflect limitations of individual dehydration indices. Cross-sectional data on plasma sodium, blood urea nitrogen (BUN), creatinine, glucose and potassium were used to classify 1,737 participants of the 1992 Established Populations for Epidemiologic Studies of the Elderly (EPESE) (70+ years) according to multiple dehydration indices. Associations between dehydration indices, health and functional status were evaluated. Depending on the indicator used, the prevalence of dehydration ranged from 0.5% for hypotonic hypovolaemia only (plasma tonicity < 285 mOsm l(-1) with orthostatic hypotension) to 60% with dehydration defined as either plasma sodium >or=145 mEq l(-1), BUN/creatinine ratio >or=20, tonicity >or=295 mOsm l(-1), or hypotonic hypovolaemia. Elevated tonicity and BUN/creatinine ratio were respectively associated with chronic disease and functional impairment. The true prevalence of dehydration among community-dwelling adults may be low or high, depending on the indicator(s) used to define dehydration. Before we can pinpoint a generalisable prevalence of dehydration for community-dwelling seniors and draw conclusions about fluid recommendations, validation studies of dehydration indices and longitudinal studies of dehydration, health and functional status are needed.

Asking family about memory loss

To compare a family informant's report of memory loss in an older family member to standardized clinical diagnoses of cognitive impairment. Duke Established Populations for Epidemiologic Studies of the Elderly (EPESE), a 10-year longitudinal study of community dwellers aged 65 and greater in five counties of North Carolina. A stratified random sample of potentially demented participants was selected from the second wave of the Duke EPESE using responses to a brief cognitive screen. A neuropsychological battery was administered to these participants, and their family informants were asked whether they recognized memory loss in the participant. One hundred fifty-seven participants completed the full evaluation and also had an available family informant. Family informant's report of memory loss (yes, no, sometimes) compared to expert consensus diagnosis of cognitive impairment or dementia. There was poor concordance between the clinical diagnoses of cognitive impairment or dementia and the family informant's recognition of memory loss (kappa=-0.05; P=.74). When informants reported memory loss, 30% of participants were found not to have a cognitive loss. Among participants in whom family informants reported no memory loss, 75% were diagnosed with dementia or cognitive impairment (sensitivity, 0.70, 95% confidence interval [CI], 0.61 to 0.78; specificity, 0.24, 95% CI, 0.13 to 0.40; positive predictive value, 70%; negative predictive value, 25%). Asking family members about memory loss in a patient may be an unreliable strategy to detect dementia.

The Intersection of Mental and Physical Health in Older Mexican Americans

The incidence of chronic diseases is highest among the elderly in general; compared to Anglo-Americans, Mexican Americans have lower rates of cancer and cardiovascular disease and higher rates of depression and diabetes. Using baseline data from the Hispanic Established Populations for Epidemiologic Studies of the Elderly (EPESE) study, weighted hierarchical logistic regression analyses showed that sociodemographic, cultural, and psychosocial profiles of respondents varied in the context of cancer and cardiovascular disease (CVD). More depressive symptoms were associated with both diseases, as were lower levels of self-esteem, life satisfaction, and perceived health. Higher socioeconomic status, greater assimilation, divorced marital status, and adverse life events/changes involving significant personal losses, trauma, and family events increased cancer risk. People who were lower in socioeconomic status, were less assimilated into the host culture, were divorced, and had experienced the illness of a close family member were more likely to have CVD.

Tests of stepping as indicators of mobility, balance, and fall risk in balance-impaired older adults.

To determine the relationships between two tests of stepping ability (the maximal step length (MSL) and rapid step test (RST)) and standard tests of standing balance, gait, mobility, and functional impairment in a group of at-risk older adults. Cross-sectional study. University-based laboratory. One hundred sixty-seven mildly balance-impaired older adults recruited for a balance-training and fall-reduction program (mean age 78, range 65-90). Measures of stepping maximally (MSL, the ability to maximally step out and return to the initial position) and rapidly (RST, the time taken to step out and return in multiple directions as fast as possible); standard measures of balance, gait, and mobility including timed tandem stance (TS), tandem walk (TW, both timing and errors), timed unipedal stance (US), timed up and go (TUG), performance oriented mobility assessment (POMA), and 6-minute walk (SMW); measures of leg strength (peak knee and ankle torque and power at slow and fast speeds); self-report measures of frequent falls (>2 per 12 months), disability (Established Population for Epidemiologic Studies of the Elderly (EPESE) physical function), and confidence to avoid falls (Activity-specific Balance Confidence (ABC) Scale). Spearman and Pearson correlation, intraclass correlation coefficient, logistic regression, and linear regression were used for data analysis. MSL consistently predicted a number of self-report and performance measures at least as well as other standard balance measures. MSL correlations with EPESE physical function, ABC, TUG, and POMA scores; SMW; and peak maximum knee and ankle torque and power were at least as high as those correlations seen with TS, TW, or US. MSL score was associated with the risk of being a frequent faller. In addition, the six MSL directions were highly correlated (up to 0.96), and any one of the leg directions yielded similar relationships with functional measures and a history of falls. Relationships between RST and these measures were relatively modest. MSL is as good a predictor of mobility performance, frequent falls, self-reported function, and balance confidence as standard stance tests such as US. MSL simplified to one direction may be a useful clinical indicator of mobility, balance, and fall risk in older adults.

Evaluation of mortality data for older Mexican Americans: implications for the Hispanic paradox.

The authors evaluated underascertainment bias in Hispanic mortality rates from population surveys linked to the US National Death Index (NDI). They compared vital status through 7 years ascertained from an NDI search and from active follow-up for 2,886 Mexican-American subjects, aged >/=65 years at baseline in 1993-1994, from the Hispanic Established Populations for Epidemiologic Studies of the Elderly (EPESE). Estimates of NDI underascertainment were applied to mortality rate ratios for 66,667 older Mexican Americans and non-Hispanic Whites from the 1986-1994 National Health Interview Surveys linked to the NDI. The NDI and active follow-up agreed on vital status for 91.2% of Hispanic EPESE subjects. The NDI did not identify 177 deaths (20.7%) reported by proxies. Underascertainment was greater for women and when stratified by age and nativity. The ratios of proxy-reported to NDI mortality rates were 1.31 (95% confidence interval (CI): 1.06, 1.62) for immigrant men and 1.65 (95% CI: 1.32, 2.08) for immigrant women. Before adjustment, National Health Interview Surveys-NDI age-standardized mortality rate ratios comparing Mexican Americans with non-Hispanic Whites were 0.77 (95% CI: 0.65, 0.92) for men and 0.92 (95% CI: 0.77, 1.09) for women but were 0.84 and 1.18, respectively, with adjustment for underascertainment. Findings suggest that NDI-based Hispanic mortality rates may be understated.

The Association Between Physical Function and Lifestyle Activity and Exercise in the Health, Aging and Body Composition Study

To determine whether older adults who exercise demonstrate higher levels of physical function than those who do not exercise but are physically active throughout the day. Cross-sectional examination of baseline data from the Health, Aging and Body Composition (Health ABC) study. Health ABC field centers in Pittsburgh, Pennsylvania, and Memphis, Tennessee. Three thousand seventy-five well-functioning black and white men and women aged 70 to 79. Physical activity and exercise were assessed using a modified leisure-time physical activity questionnaire. Participants were classified as inactive (reporting <1,000 kcal/wk of exercise activity and < or =2,719 kcal/wk of total physical activity), lifestyle active (reporting <1,000 kcal/wk of exercise activity and >2,719 kcal/wk of total physical activity), or exerciser (reporting> or =1,000 kcal/wk of exercise activity). Physical function measures included the Established Populations for the Epidemiologic Studies of the Elderly (EPESE) battery, the Health ABC battery, a 400-m walk test, and isokinetic strength testing of the knee extensors. The lifestyle active and exerciser groups had similar total activity levels (men: 6,135 kcal/wk and 6,734 kcal/wk, respectively; P=.108; women: 5,695 kcal/wk and 5,854 kcal/wk, respectively; P=.335). When examining lower extremity performance in relation to physical activity, a progressive trend was evident, with the inactive individuals most likely to have impaired performance on the EPESE battery (men: 33.7%, 24.3%, and 19.1%, P<.001; women: 49.9%, 37.3%, and 28.4%, P<.001; inactive, lifestyle active, and exerciser, respectively). Progressive trends of similar magnitude were present for the Health ABC battery, time to walk 400 m, and knee extensor strength. In multivariate linear regression, those in the inactive and lifestyle active groups had poorer scores on the Health ABC performance battery than individuals in the exercise group after controlling for demographic factors and prevalent disease (men: inactive beta=-0.27, P<.001, lifestyle active beta=-0.07, P=.032; women: inactive beta=-0.23, P<.001, lifestyle active beta=-0.07, P<.059). After controlling for demographic factors and prevalent disease, the lifestyle active and exercisers had similar proportions of functionally limited older persons (scoring <10 on the EPESE battery). Older adults who participate in 20 to 30 minutes of moderate-intensity exercise on most days of the week have better physical function than older persons who are active throughout the day or who are inactive. Any type of physical activity is better than no activity for protection against functional limitations, but exercise confers greater benefit for physical capacity.

Research Corner Outcome Measures in Cardiopulmonary Physical Therapy: Short Physical Performance Battery

In the last edition of the Research Corner, gait speed was presented as a functional assessment tool for patients with cardiovascular and pulmonary (CVP) disease. The benefits of this assessment tool included good reliability, validity, and responsiveness, making it a useful tool for measuring outcomes in patients with cardiovascular and/or pulmonary conditions. Additionally, gait speed is easy to measure, takes less than 2 minutes to complete, and requires minimal training for the tester. Outcomes of physical function may be enhanced by the use of tools that address other aspects of lower extremity performance, such as the Short Physical Performance Battery (SPPB). The SPPB is a simple test to measure lower extremity function using tasks that mimic daily activities. The SPPB examines 3 areas of lower extremity function; static balance, gait speed, and getting in and out of a chair. These areas represent essential tasks important for independent living and are thus an important outcome measure for patients with CVP disease. Detailed instructions for the SPPB are listed in Appendix 1 and a sample score sheet is given in Appendix 2. To assess static balance, the patient is asked to maintain up to 3 hierarchical standing postures for up to 10 seconds. First, the patient stands with feet together. If the patient can maintain this posture for 10 seconds, he or she then performs a semitandem stance position. If semitandem is held for 10 seconds, it is followed by a tandem stance posture. For the 4 meter walk test, the patient is asked to walk at his or her comfortable speed across a 4 meter distance. Timing starts on the “begin” command and ceases when one foot crosses the end of the course. No room is provided for acceleration. After assessment of gait speed, the patient is asked to stand from a standard chair without upper extremity assistance. If the patient can stand 1 time, then he or she is instructed to complete 5 sit to stands as quickly as possible without upper extremity assistance. The time taken to complete the 5 sit to stands is recorded. Each subscale is scored 0-4 with 0 being “unable to complete the task” and 4 being the “highest level of performance.” Scores from each subscale are added to create a summary score between 0 and 12. Table ​Table11 lists how patients can be classified with severe, moderate, mild, or minimal limitations based on their SPPB scores.1 Table 1 Classification of Limitations Based on Short Physical Performance Score Subscale scores can also be used separately. Balance subscale performance can provide a quick screen of balance abilities. Performance on the 4 meter walk test can be used to calculate gait speed. The time in seconds to complete the 5 sit to stands can be used to assess lower extremity strength and power.2–4 As part of the Women's Health and Aging Study, normative data on subscale performance for the SPPB has been published and is available at http://www.grc.nia.nih.gov/branches/ledb/whasbook/chap4/chap4.htm. Therapists can use this information to gain more insight on their patients' performance and to assist in writing goals. Intended Population The populations used to create and establish the SPPB were community dwelling older adults who participated in the Established Populations for Epidemiologic Studies of the Elderly (EPESE). The subjects involved in this longitudinal study were described as mostly Caucasian with higher than average education and income levels.1 However since the inception of the SPPB, it has been used successfully in more diverse populations.5–7 Investigators primarily have used community dwelling individuals when studying the SPPB.1,8,9 Only 1 article was found that involved patients in the acute care setting.10 To this author's knowledge, there are no published studies that have examined the psychometric properties of the SPPB in a specific population of patients with CVP diseases. However, subjects with histories of CVP disease were included in many of the studies that established the psychometric properties of the SPPB.5,8,11 One example is in a study of 1002 women, 14.6% had a history of myocardial infarction, 10.5% had a history of heart failure, and 7% a history of a stroke.5 Another study was found that used SPPB to examine differences in function between individuals with peripheral arterial disease (PAD) and those without PAD.12 Based on this information readers should feel comfortable using the SPPB as an outcome measure for their patients with CVP disease, especially if the patients are community dwelling and/or older adults.

The contribution of hip fracture to risk of subsequent fractures: data from two longitudinal studies.

The contribution of hip fracture to the risk of subsequent fractures is unclear. Data from the Baltimore Hip Studies and the Established Populations for Epidemiologic Studies of the Elderly (EPESE) were used. Baltimore subjects enrolled at the time of hip fracture ( n=549) and EPESE subjects without previous fractures at baseline ( n=10,680) were followed for 2-10 years. Self-reported nonhip skeletal fracture was the outcome, and hip fracture was a time-varying covariate in a survival analysis stratified by study site. The model was adjusted for race, sex, age, BMI, stroke, cancer, difficulty walking across a room, dependence in grooming, dependence in transferring, and cognitive impairment. The rate of all subsequent self-reported fractures after hip fracture was 10.4 fractures/100 person-years. The unadjusted hazard of nonhip skeletal fracture was 2.52 (95% confidence interval 2.05 to 3.12) for subjects with hip fracture compared with subjects without; when adjusted for other known fracture risk factors the hazard ratio was 1.62 (1.30 to 2.02). Men and women had a similar relative risk increase. The increased risk of secondary fracture after hip fracture persisted over time. A hip fracture is associated with a 2.5-fold increased risk of subsequent fracture, which is not entirely explained by prefracture risk factors. Careful attention to secondary prevention is warranted in these patients.

Depression predicts increased incidence of adverse health outcomes in older Mexican Americans with type 2 diabetes.

To examine the separate and combined effects of depression and diabetes on the incidence of adverse health outcomes among older Mexican Americans. Longitudinal data from the Hispanic Established Population for the Epidemiologic Study of the Elderly (EPESE) survey were used to examine the main effects and interaction effects of diabetes and depressive symptoms (measured with the Center for Epidemiologic Study of Depression) or clinical diagnostic criteria (measured with the Composite International Diagnostic Interview Depression Module) on the development of macrovascular complications (including cardiovascular disease, stroke, and kidney disease), microvascular complications (including nephropathy, neuropathy, retinopathy, and amputations), functional disability, and mortality over 7 years in a sample of 2,830 Mexican Americans aged >or=65 years. The interaction of diabetes and depression was found to be synergistic, predicting greater mortality, greater incidence of both macro- and microvascular complications, and greater incidence of disability in activities of daily living, even when controlling for sociodemographic characteristics such as sex, age, education, acculturation, and marital status. Importantly, this interaction was found to predict not only greater incidence but also earlier incidence of adverse events in older adults. Whether a marker for underlying disease severity, an indicator of diminished self-care motivation, or the result of physiologic changes, the interaction of depression and diabetes has a synergistic effect on the health of older Mexican Americans, increasing the risk for poor outcomes. This is of particular clinical importance because although depression is often underrecognized in older adults, effective treatment is available and can result in improved medical outcomes.

Mild renal insufficiency and risk of congestive heart failure in men and women ≥70 years of age

Mild renal insufficiency is increasingly recognized as an independent risk factor for cardiovascular disease. However, few data exist regarding its relation to risk of congestive heart failure (CHF), a major public health problem in the elderly. To determine if mild renal insufficiency is associated with risk of incident CHF in the elderly, we analyzed data from 3,618 participants in the prospective, community-based Established Populations for Epidemiologic Studies of the Elderly (EPESE), who had no known CHF and had serum creatinine levels measured from 1987 to 1989. Mean age of the study population was 78.3 ± 5.4 years; 84% had creatinine values <1.5 mg/dl and 98% had creatinine values ≤2.0 mg/dl. Creatinine clearance (CrCl) was calculated using the Cockcroft-Gault equation. During 3.9 years of follow-up, 488 subjects developed incident CHF as defined by hospital discharge and death certificate data. In a multivariate proportional hazards model, CrCl was inversely associated with CHF risk (p value for trend <0.001). Those in the lowest quartile of CrCl (≤36.9 ml/min) had a nearly twofold (hazards ratio [HR] 1.99, 95% confidence intervals [CI] 1.43 to 2.79) greater risk of incident CHF compared with those in the highest quartile (>57.4 ml/min). Renal insufficiency, defined as creatinine ≥1.5 mg/dl in men and ≥1.3 mg/dl in women, was also associated with increased CHF risk (multivariate HR 1.43, 95% CI 1.17 to 1.74). Thus, mild renal insufficiency was a strong independent predictor of CHF in this cohort, suggesting that serum creatinine may offer a readily accessible tool to identify elderly patients at risk for CHF.

Alternative statistical approaches to identifying dementia in a community-dwelling sample

Little attention has been paid to examining the extent to which alternative statistical models may facilitate identification of persons with dementia. Using a sub-sample of the Duke Established Populations for Epidemiologic Studies of the Elderly, two analytical approaches were compared: logistic regression (which focuses on identifying specific characteristics predictive here of dementia), and recursive partitioning methods using tree-based models (which permit identification of the characteristics of those groups with high dementing disorder). In the stepwise multiple logistic regression model which included as potential predictors, gender, age, history of chronic health conditions, scales of basic and instrumental activities of daily living (IADL), and cognitive status, only IADL and cognitive status were significant predictors, with cognitive status the single most important factor. The classification tree approach, which permits identification of the characteristics of those groups with particularly high dementia rates, identified cognitive status as the most important criterion for dementia (as did logistic regression analysis). Among those without cognitive impairment, older age was a risk factor, confirming findings consistently reported in the literature. Among the cognitively impaired, IADL was an important risk factor. Those with five or more IADL problems were further classified into two risk groups, based on number of ADL problems. While classification tree analysis encourages identification of groups at risk, logistic regression encourages targeting of specific characteristics.

Predictors of recovery in activities of daily living among disabled older Mexican Americans.

Although functional ability decreases with age and is associated with poor health outcomes, decline in functional ability is reversible. The aim of this study is to describe the rate of recovery of functional ability and to identify factors associated with it over a two-year period among older Mexican Americans. 245 functionally disabled older Mexican Americans were included in a two-year prospective cohort study. Data are from the Hispanic Established Population for the Epidemiological Study of the Elderly (H-EPESE), a population-based study of non-institutionalized Mexican Americans in the South-western United States. Activities of daily living (ADL), lower body mobility (tandem balance, eight-foot walk, and repeated chair stands), depressive symptomatology, body mass index, and self-reported medical conditions were obtained. Over a two-year period, of the 245 subjects at baseline who reported functional disability in at least 1 of 7 ADLs, 83 totally recovered their ADL ability, 108 remained disabled, 36 died, and 18 were lost to follow-up. Factors significantly associated with recovery included younger age (65-74) (OR 2.18, 95% CI 1.08-4.42), higher summary performance measure of lower body function (OR 1.19, 95% CI 1.05-1.34), few depressive symptoms (OR 2.84, 95% CI 1.39-5.78), and a BMI > or = 30 Kg/m2 (OR 3.08, 95% CI 1.17-8.07). Higher numbers of ADL limitations at baseline were associated with lower odds of ADL recovery. Two-year recovery from ADL disability among older Mexican Americans was high (33.9%). Factors independently associated with recovery include younger age, few depressive symptoms, good lower body function, and high BMI.

Examining the disablement process among older Mexican American adults

The Disablement Process model (Verbrugge and Jette, Social Science & Medicine 38 (1994) 1) describes a pathway leading from pathology to impairment to functional limitations, and, ultimately to disability. Components of this model have been examined among older White adults; however, very little research has examined the disablement process among older adults of other ethnic groups. Our goal in this research is to evaluate the Disablement Process model using Activities of Daily Living (ADL) disability as the outcome among a representative group of older Mexican American adults in the Southwestern United States. Respondents are from two waves of the Hispanic Established Populations Epidemiologic Study of the Elderly (EPESE) ( n=2439). Structural equation models (LISREL 8.30) are utilized to examine the Disablement Process model. We also investigate aspects of the original model that have potentially important effects on the process of becoming disabled, such as cognitive impairment and perceived emotional support. Findings from structural equation models suggest that the main pathway from pathology to ADL disability is through functional limitations among older Mexican Americans. Risk factors, especially age and gender, have significant indirect effects on ADL disability. The main pathway in the Disablement Process model receives preliminary support among older Mexican Americans. We discuss implications of this model for future research.

Patterns of functional decline at the end of life.

Clinicians have observed various patterns of functional decline at the end of life, but few empirical data have tested these patterns in large populations. To determine if functional decline differs among 4 types of illness trajectories: sudden death, cancer death, death from organ failure, and frailty. Cohort analysis of data from 4 US regions in the prospective, longitudinal Established Populations for Epidemiologic Studies of the Elderly (EPESE) study. Of the 14 456 participants aged 65 years or older who provided interviews at baseline (1981-1987), 4871 died during the first 6 years of follow-up; 4190 (86%) of these provided interviews within 1 year before dying. These decedents were evenly distributed in 12 cohorts based on the number of months between the final interview and death. Self- or proxy-reported physical function (performance of 7 activities of daily living [ADLs]) within 1 year prior to death; predicted ADL dependency prior to death. Mean function declined across the 12 cohorts, simulating individual decline in the final year of life. Sudden death decedents were highly functional even in the last month before death (mean [95% confidence interval [CI]] numbers of ADL dependencies: 0.69 [0.19-1.19] at 12 months before death vs 1.22 [0.59-1.85] at the final month of life, P =.20); cancer decedents were highly functional early in their final year but markedly more disabled 3 months prior to death (0.77 [0.30-1.24] vs 4.09 [3.37-4.81], P<.001); organ failure decedents experienced a fluctuating pattern of decline, with substantially poorer function during the last 3 months before death (2.10 [1.49-2.70] vs 3.66 [2.94-4.38], P<.001); and frail decedents were relatively more disabled in the final year and especially dependent during the last month (2.92 [2.24-3.60] vs 5.84 [5.33-6.35], P<.001). After controlling for age, sex, race, education, marital status, interval between final interview and death, and other demographic differences, frail decedents were more than 8 times more likely than sudden death decedents to be ADL dependent (OR, 8.32 [95% CI, 6.46-10.73); cancer decedents, one and a half times more likely (OR, 1.57 [95% CI, 1.25-1.96]); and organ failure decedents, 3 times more likely (OR, 3.00 [95% CI, 2.39-3.77]). Trajectories of functional decline at the end of life are quite variable. Differentiating among expected trajectories and related needs would help shape tailored strategies and better programs of care prior to death.

Gender differences associated with physical functioning in older persons with angina

Objective : The objective of this study was to determine whether older men and women with and without angina experience differences in specific areas of physical functioning. Method : A historical population based cohort design was used to examine this question. Data were taken from the Established Populations for the Epidemiologic Studies of the Elderly which consists of four large cohorts of samples over 65 years of age living in four communities East Boston, Iowa, New Haven and North Carolina. The Rose Questionnaire was used to identify persons who had angina. Physical functioning was conceptualized under the Nagi framework and considered as either functional limitation/mobility or activities of daily living. Persons were considered disabled if they required assistance with any activity in these categories. Logistic regression was used to examine variables associated with gender differences in physical function. Results : Six hundred and twenty-four person met the criteria for the classification of angina; 249 (39.9%) were men and 375 (60%) were women. In men and women, disability was greater with items associated with functional mobility than for activities of daily living but women were more affected than men. Self-rated health was important in explaining functioning in both areas. Conclusion : Older women who experience angina symptoms also have a greater lower extremity disability compared to men with angina. Angina may force older women to curtail more strenuous activities which could lead to further disablement.

Can historical and functional risk factors be used to predict fractures in community-dwelling older adults? development and validation of a clinical tool.

The objectives of the study were: (1) to evaluate the contribution of impaired functional status, cognition and medication to fracture risk; (2) to determine whether risk factor profiles differ between regionally and socially diverse populations; and (3) to develop and validate a simple fracture prediction instrument for use in older adults using easily obtainable clinical information. A prospective population-based cohort study with 6-10 years of follow-up was carried out: the Duke and Iowa Established Populations for the Epidemiologic Study of the Elderly (EPESE), with in-person interviews in North Carolina and Iowa. The participants were community-dwelling men and women aged 65 years or over without a history of previous fracture at the baseline interview ( n = 7654). The measurements were potential risk factors for osteoporosis and falls including: demographic factors, co-morbidities, medications, functional status measures, and physical measures. These were examined for association with self-reported subsequent hip fractures and fractures at any site using survival analysis. The resulting multivariable model was simplified and validated in a separate cohort. Test operating characteristics at 3 years were estimated using logistic regression. There were a total of 842 fractures in both cohorts including 382 hip fractures. Significant risk factors for all subsequent fractures and/or hip fracture in the developmental cohort included female sex (relative hazard 1.9-2.3), lowest quartile of body mass index (1.3), Caucasian race (2.1-2.8), one or more Rosow-Breslau physical function impairments (1.8-2.1), age over 75 years (2.1), history of stroke (1.9), cognitive impairment (2.2), one or more impairments in the activities of daily living (1.5) and anti-seizure medication use (2.0). Three predicitive models were highly significantly correlated with subsequent fractures with c-statistics in the developmental cohort at 3 and 6 years of 0.640-0.789. A simple count of risk factors had similar discriminative ability to the full model with a linear 35-65% increase in hazard of all fractures and hip fracture for each additional risk factor. In the validation cohort, the above variables were less potent predictors of fracture with only sex, body mass index and Rosow-Breslau impairment achieving significance. The predictive models including risk factor count remained significant in the validation set although the discriminative ability of the model was poor, with c-statistics of 0.574-0.749. Although there is no cut-point where fracture risk dramatically increases, patients can be counselled that there is a linear 77% increase in risk of hip fracture, and 29% increase in any fracture risk, with each additional risk factor they possess. Functional status impairment is an important predictor of fracture in older community-dwelling adults. The contribution of risk factors to fracture risk may differ between distinct populations.