Status In Later Life Research Articles

EARLY-LIFE EDUCATION CONTEXTS AND LATE-LIFE COGNITIVE STATUS: TOWARD IDENTIFYING MODIFIABLE RISKS

Abstract The complexity of K-12 school environments arises from their diverse student compositions, historical and geographical contexts, all of which may influence late-life cognition. Despite this, the long-term impacts of these factors on cognitive status in later life are not well understood. This study utilized data from the Health and Retirement Study (HRS) 2015-2017 Life History Mail Survey (N = 6,980; Mage = 72.5) to investigate how K-12 educational contexts—specifically school racial composition (White, Black, Hispanic, Other, and Mixed) and school setting (Public, Private, Mixed)—affect cognitive status in late life. Cognitive status was assessed in the 2020 HRS biennial wave using the Langa-Weir algorithm, classifying participants into Normal, Cognitive Impairment but No Dementia (CIND), and Dementia categories. After adjusting for sociodemographic and childhood factors, multinomial logistic regression analysis revealed that participants who attended predominantly Black K-12 schools had a higher risk of CIND and Dementia (RRR=2.28, 95% CI: 1.36, 3.80 and RRR=2.09, 95% CI: 1.08, 4.07, respectively). In contrast, those who attended private and mixed schools had a lower relative risk for CIND compared to public school attendees (RRR=0.43, 95% CI: 0.27, 0.68 and RRR=0.54, 95% CI: 0.37, 0.79). Additionally, participants from mixed school settings exhibited the lowest relative risk for dementia (RRR=0.51, 95% CI: 0.30, 0.88). Rural education was associated with a higher relative risk for CIND (RRR=1.26, 95% CI: 1.02, 1.58) compared to urban education. These findings highlight the need for targeted interventions and policies to create equitable educational environments that support cognitive health in later life.

Locus of control and the long-term effects of parental smoking on mental health

RationaleFew studies take a life course perspective to explain if exposure to second-hand smoke in childhood influences mental health in adulthood. Importantly, no study provides empirical evidence on the pathways through which exposure to second-hand smoke in childhood influences mental health in adulthood. There is also limited evidence on the factors that moderate the relationship between second-hand smoke exposure and mental health. To inform policy, it is important to explore the pathways through which second-hand smoke influences mental health and understand factors that are likely to moderate this relationship. ObjectivesThe objective of this paper is to examine if exposure to parental smoking in childhood influences mental health in adulthood. The study examines general health and smoking status in later life as potential channels and if locus of control (LoC), a personality trait developed in childhood and adolescence, moderates the relationship between exposure to parental smoking in childhood and mental health in adulthood. MethodsUsing 21 waves of longitudinal data from the Household, Income and Labour Dynamics in Australia (HILDA), the study conducts regression analyses that adjust for the potential effects of confounders and other biases. ResultsThe results show that exposure to parental smoking in childhood is associated with a decline in mental health in later life, and that general health status and smoking status in adulthood are channels through which exposure to parental smoking in childhood influences mental health in adulthood. Specifically, those who are exposed to parental smoking in childhood tend to have poorer general health and a higher probability of being smokers in adulthood, both of which negatively impact mental health. The findings point to the moderating role of LoC, such that being more internal on LoC dampens the negative effects of exposure to parental smoking on mental health. ConclusionThe findings from this study lend support to the need to address the long-term implications of behaviours that are harmful to health. The findings also suggest that LoC has implications for an individual's psychological resilience against the negative effects from exposure to parental smoking in childhood.

Investigating the association of anticholinergic burden with depression in older adults: a cross-sectional study.

Although depression and anticholinergic drug use are common comorbidities that impair health status in later life, there are insufficient data on their relationship. This study aimed to investigate the relationship between depressive symptoms and anticholinergic use in older individuals. Community-dwelling older adults (≥65 years) admitted to the tertiary referral geriatric outpatient clinic were included. Participants were evaluated for depressive symptoms using the Geriatric Depression Scale (GDS) with a cut-off score of ≥6 for depression. Exposure to anticholinergic drugs was assessed using the anticholinergic cognitive burden (ACB) scale and three subgroups were created: ACB = 0, ACB = 1, and ACB ≥ 2. The relationship between these two parameters was assessed using multivariate logistic regression analysis considering other potential variables. The study included 1232 participants (mean age 78.4 ± 7.2 years and 65.2% female) and the prevalence of depression was 24%. After adjusting for potential confounders, compared to ACB = 0, having ACB ≥ 2 was related to depression symptoms (odds ratio (OR): 1.56, 95% CI: 1.04-2.35, P = 0.034), whereas having ACB = 1 did not increase the risk (OR: 1.27, 95% CI: 0.88-1.83, P = 0.205). Our findings indicate that special attention should be paid to drug therapy in preventing depression in older adults, as exposure to a high anticholinergic load is negatively associated with psychological status.

A study of the effect of number of children on depression among rural older women: empirical evidence from China.

The association between early reproductive events and health status in later life has always been of interest across disciplines. The purpose of this study was to investigate whether there was an association between the number of children born in the early years of elderly women and their depression in later life based on a sample of older women aged 65 years and above with at least one child in rural China. Data from the Chinese Longitudinal Healthy Longevity Survey in 2018, this study used the ordinary least square method to conduct empirical research. This study has found a significant correlation between an increase in the number of children and depression in older rural women. When considering the sex of the child, the number of daughters had a greater and more significant impact on depression. Number of children may exacerbate depression of older women through declining self-rated health and reduced social activity, while increased inter-generational support alleviated depression. The association between number of children born and depression also existed in urban older women, though not significant. Therefore, it is suggested to accelerate the improvement of supporting policies related to childbirth, developing a healthy and scientific fertility culture, and improving rural maternal and child health services. Women should be assisted in balancing their roles in the family and in society, and in particular in sharing the burden of caring for children. Targeted efforts to increase old-age protection for older people.

WELFARE REGIME TYPE AND ITS INFLUENCE ON THE FINANCIAL SECURITY OF FEMALE CAREGIVERS IN LATER LIFE

Abstract Guided by life course theory, this paper examines the effect of early caregiving experience and later life-changing events on the financial security of older women using cross-national data from two panels (2004 and 2014) of the Survey of Health Aging and Retirement in Europe Analyses found that caregiving in midlife and subsequent life-changing events (being divorced or widowhood, changing employment status, and/or declining health) significantly affected women’s economic status in later life, Importantly, we found that early caregiving experience intensifies the effects of negative life events, and in turn further deteriorates women’s economic security in later life. Tests of welfare regime differences found that women who experienced a marital change (becoming divorced or widowed) in the dual breadwinner model were less likely to experience economic deprivation compared to the other two models. This finding is likely attributable to more gender equality in these countries which makes women more financially independent. Unfortunately, a significant association between welfare regime and caregiving was not found in this study. This study adds to the knowledge about the political, economic and cultural forces that shape the financial security of women in later life. Our findings suggest that public expenditures on long-term care and the healthcare system should continue and/or be augmented to prevent women economic deprivation, especially those who assume caregiving role in their early life. Moreover, the policies and conditions of dual-breadwinner role countries are informative in helping women achieve gender equality.

BIRTHPLACE AND COGNITION AMONG US OLDER ADULTS: EVIDENCE FROM THE HARMONIZED COGNITIVE ASSESSMENT PROTOCOL (HCAP)

Abstract Growing evidence shows that place of birth and related circumstances may impose lasting and multiplicative impacts on a host of late-life outcomes; yet how it affects various domains of cognitive function in late-life is less understood. In this paper, we exploit the comprehensive cognitive assessments in the Health and Retirement Study (HRS) Harmonized Cognitive Assessment Protocol (HCAP) and HRS geographic data at birth to determine to what extent birth location measured at the state level is associated with cognitive status in later life for a representative sample of Americans over age 50 (N=3,324). We found that state of birth significantly influenced various cognitive domains later in life (including episodic memory, executive function, attention, visuospatial function, language fluency and orientation); and the regional rankings tended to be highly consistent across the cognitive assessments in each domain. Regression analysis demonstrated that the geographic disparities in cognition across birth states could be partly explained by the late-life differences in socioeconomic statuses. Nevertheless, Shapley decompositions demonstrated that, after accounting for mid-life to late-life factors, state of birth still contributed 20%-30% of the explained variations in cognitive outcomes. Particularly, foreign-born individuals and those born in the southern states tended to score the lowest on average on each of the cognitive tests/domains and can account for most of the explained differences in cognition. These findings suggest that place of birth may have lasting impacts on disparities in cognition later in life. Public policy should play pivotal roles in leveling the playing field in early life.

Sociodemographic Correlates of Social Network Age Integration Status in Late Life

ABSTRACT Increased longevity allows older adults to have younger close social ties, suggesting age integration. However, prior research excludes same-aged peers from age integration definitions. Using the National Health and Aging Trends Study, we characterize 3,642 participants’ social networks as peer-only (54%), intergenerational-only (21%), or age-integrated (25%) for those with both peer and intergenerational connections. Findings suggest complexity in older adults’ social network age distributions. Relative to peer-only networks, intergenerational-only networks were more likely among Hispanic, other-raced, non-partnered and more educated individuals and less likely among individuals with ADL assistance; age-integrated networks were more likely with age and among women.

Body mass index and two-year change of in vivo Alzheimer’s disease pathologies in cognitively normal older adults

BackgroundLow body mass index (BMI) or underweight status in late life is associated with an increased risk of dementia or Alzheimer’s disease (AD). However, the relationship between late-life BMI and prospective longitudinal changes of in-vivo AD pathology has not been investigated.MethodsThis prospective longitudinal study was conducted as part of the Korean Brain Aging Study for Early Diagnosis and Prediction of Alzheimer’s Disease (KBASE). A total of 194 cognitive normal older adults were included in the analysis. BMI at baseline was measured, and two-year changes in brain Aβ and tau deposition on PET imaging were used as the main outcomes. Linear mixed-effects (LME) models were used to examine the relationships between late-life BMI and longitudinal change in AD neuropathological biomarkers.ResultsA lower BMI at baseline was significantly associated with a greater increase in tau deposition in AD-signature region over 2 years (β, -0.018; 95% CI, -0.028 to -0.004; p = .008), In contrast, BMI was not related to two-year changes in global Aβ deposition (β, 0.0002; 95% CI, -0.003 to 0.002, p = .671). An additional exploratory analysis for each sex showed lower baseline BMI was associated with greater increases in tau deposition in males (β, -0.027; 95% CI, -0.046 to -0.009; p = 0.007), but not in females.DiscussionThe findings suggest that lower BMI in late-life may predict or contribute to the progression of tau pathology over the subsequent years in cognitively unimpaired older adults.

Beyond the treatment: The role of race, sex, and education in health trajectories between cancer survivors and noncancer older adults

Introduction: The number of older, long-term cancer survivors is increasing. However, little is known about how cancer and aging affect the health trajectories of older adults differently. In addition, the impact of race, sex, and education on the processes of aging and the cancer experience needs further investigation. The current study aims to address this knowledge gap by combining two National Cancer Institute (NIC)-funded longitudinal studies conducted in Cleveland from 1998 to 2010.Materials and Methods: The unique cross-sequential design facilitates a comparison between the health changes in long-term (five years +) older cancer survivors (breast, prostate, and colorectal cancer) and demographically matched older adults without a history of cancer in the same geographic area within the same period. The study also captured comprehensive information on how socioeconomic status interacts with cancer and aging over time. General linear models were employed in the data analysis.Results: The findings showed that early cancer experience did not affect long-term cancer survivors' health status in later life. Conversely, comorbidities, being an African American, being female, and having education less than a college degree significantly decreased the health trajectory in later life for all older adults. Moreover, compared to other groups, older African American cancer survivors reported a dramatic decrease in self-reported health after controlling for other conditions.Discussion: Study findings can inform public policy and social services to offer comprehensive treatment plans and help individuals overcome their diseases and lead longer and healthier lives.

Lipid signatures of chronic pain in female adolescents with and without obesity

BackgroundChronic pain in adolescence is associated with diminished outcomes, lower socioeconomic status in later life, and decreased family well-being. Approximately one third of adolescents with chronic pain have obesity compared to the general population. In obesity, lipid signals regulate insulin sensitivity, satiety, and pain sensation. We determined whether there is a distinct lipid signature associated with chronic pain and its co-occurrence with obesity in adolescents.MethodsWe performed global lipidomics in serum samples from female adolescents (N = 67, 13–17 years old) with no pain/healthy weight (Controls), chronic pain/healthy weight (Pain Non-obese), no pain/obesity (Obese), or chronic pain/obesity (Pain Obese).ResultsThe Pain Non-obese group had lipid profiles similar to the Obese and Pain Obese groups. The major difference in these lipids included decreased lysophosphatidylinositol (LPI), lysophosphatidylcholine (LPC), and lysophosphatidylethanolamine (LPE) in the three clinical groups compared to the Control group. Furthermore, ceramides and sphingomyelin were higher in the groups with obesity when compared to the groups with healthy weight, while plasmalogens were elevated in the Pain Obese group only.ConclusionsSerum lipid markers are associated with chronic pain and suggest that specific lipid metabolites may be a signaling mechanism for inflammation associated with co-occurring chronic pain and obesity.

Self-Rated Health and Socioeconomic Status in Old Age: The Role of Gender and the Moderating Effect of Time and Welfare Regime in Europe

Research has shown that health status and self-rated health (SRH) are correlated not only with age and gender but also with socioeconomic determinants, such as income, education, and employment status, in the course of life and in late life. Much less investigated, however, are gender differences in the association between socioeconomic factors and SRH and how the connection differs among the European welfare state regimes. This study examines the association between SRH and socioeconomic status in later life and in relation to gender and welfare state regime characteristics. Using SHARE data, it builds an analytical sample of respondents aged 60–70 (1275 men, 1544 women) who participated in Wave 1 and, ten years later, in Wave 6. The analysis regresses SRH by gender on socioeconomic status, controlling for various sociodemographic, health, and socioeconomic variables, as well as welfare regime indicators, at two points in time. Past health variables are also controlled for in order to evaluate their effect on SRH at the time of the investigation. A significant gender gap in SRH is found from childhood to late life. The association of socioeconomic status with poorer SRH is significant over time and within welfare state regimes. Consequently, the relationship between gender and SRH, and the extent to which it varies by socioeconomic position, does appear to differ across welfare state regimes. In all regimes and all points in time, including retrospective childhood SRH, women report poorer health than men. The analysis underscores the association between SRH and socioeconomic status in relation to gender in late life and finds that it correlates differently for men and women. The odds of women experiencing poorer SRH are higher, although they become more moderate over time. Even under the most egalitarian welfare regimes, gender differences in the nexus of SRH and socioeconomic status do not favor women.

The Origins of NAFLD: The Potential Implication of Intrauterine Life and Early Postnatal Period.

Fetal life and the first few months after birth represent a plastic age, defined as a “window of opportunity”, as the organism is particularly susceptible to environmental pressures and has to adapt to environmental conditions. Several perturbations in pregnancy, such as excessive weight gain, obesity, gestational diabetes mellitus and an inadequate or high-fat diet, have been associated with long-term metabolic consequences in offspring, even without affecting birth weight. Moreover, great interest has also been focused on the relationship between the gut microbiome of early infants and health status in later life. Consistently, in various epidemiological studies, a condition of dysbiosis has been associated with an increased inflammatory response and metabolic alterations in the host, with important consequences on the intestinal and systemic health of the unborn child. This review aims to summarize the current knowledge on the origins of NAFLD, with particular attention to the potential implications of intrauterine life and the early postnatal period. Due to the well-known association between gut microbiota and the risk of NAFLD, a specific focus will be devoted to factors affecting early microbiota formation/composition.

The Influence of Marital Status and Gender on Financial Well-Being

Research consistently documents gender differences in financial status in later life, and some also examine marital status in this regard. However, the subjective aspects of financial well-being are less well-explored, especially as this relates to both gender and marital status in the U.S. Using a gender-sensitive approach, this study examines the extent to which gender and marital status affect the financial well-being of older American adults. Different from previous studies that use only objective measures of financial well-being, this study also takes a subjective assessment in terms of financial satisfaction into account so that the role of marital status and gender in both objective measures and subjective assessments can be identified. This study uses the 2014 Health and Retirement Study and employs ordinary least squares regressions and ordinal logistic regression analyses. Examining those aged 65 and over, the sample varies from N=10,325 (financial well-being) to 4,280 (financial satisfaction). Differences in gender and marital statuses across all objective measures of financial well-being show up, with women being disadvantaged while the married (regardless of gender) being advantaged. Concerning financial satisfaction, being divorced and separated were negatively related to financial satisfaction for both men and women. These findings indicate that both marital status and gender are important indicators of financial well-being in later life.

Birth of the Society of Divorees – Changing Patterns of Civil Status in Later Life

Half a century ago Lopata used the concept “society of widows” to describe the gendered reality of late life singlehood, where widowed women were excluded from coupled social life, depended on a community of other widows for social integration, and refrained from initiating new relationships due to “sanctification” of their former husbands. We use Swedish, American and EU census data and a national survey to Swedes 60-90 years old (n=1225; response rate 42%) to illustrate a substantial change in the demographic landscape of late life singlehood. More people enter later life as divorcees or become divorced at a high age. Among Swedes 60+ divorcees outnumber widowed people, and the incidence of late life divorce has more than doubled since the millennium in what has been called the “grey divorce revolution”. Many other Western countries follow the same demographical trend, posing important questions about the transformation of late life singlehood. Based on two Swedish studies we will show that the structure of the late life single community is becoming less gender skewed as a consequence of the emerging society of divorcees, and that in this society relationship careers are increasingly complex, attitudes to repartnering increasingly liberal and partner sanctification seldom an issue. We conclude by proposing the concept “society of divorcees” for this new demographic landscape of late life singlehood, argue that research is needed to capture this new reality, and discuss the implications of this change for access to social support later life.

Pet Ownership and Longitudinal Change in Physical Function: Evidence From the BLSA

Successful aging depends on avoiding disease and disability, maintaining high physical and cognitive function, and psychological adaptation. Research examining the relationship of pet ownership (PO) or human-animal interaction (HAI) to human health supports contributions to these successful ag-ing-related outcomes at some point in the life-cycle, mostly in populations with diseases or disabili-ties. We examine the contributions of PO to maintaining physical capacity among generally healthy community-dwelling older participants in the Baltimore Longitudinal Study of Aging (BLSA). Partici-pants’ [N=637, mean age=68.3 years (SD=9.6), pet owners N=149] completed a standardized physi-cal function test battery (among other measures) every 1-4 years and a ten-year PO history. Linear mixed, or generalized linear mixed, models with time varying PO were used to examine change in successful aging-related outcomes over up to 13 years [mean=7.5, (SD=3.6)] according to PO. Physi-cal function declined across all domains examined, but was observed to be less severe with PO in overall physical performance (p<0.001), rapid gait speed (p=0.041), 400-meter walk time (p<0.001), and reported physical wellbeing (p=0.032). No differences were observed for grip strength (p=0.56), usual gait speed (p=0.07), and leisure time physical activity (p=0.26) after con-trolling for age. This study provides the first longitudinal evidence that PO may promote successful aging among community-dwelling healthy older adults by moderating age-related declines in physical functional status in late-life.

Parental status in later life and parents’ risk of cognitive impairment

Parental status can influence parents’ well-being in significant ways, but little research has examined its impact on older adults’ cognitive health in the U.S. Using data from the National Health and Aging Trends Study (NHATS) 2011–2019, this study examines whether parental status is related to the risk of cognitive impairment among older adults in the U.S. We found that the presence of adult children (i.e., having at least one living adult child) was associated with a lower risk of cognitive impairment for older parents. Moreover, compared to childless older adults, older parents who had three and more children, who had adult daughter(s), and who had biological/adopted adult children displayed a significantly lower risk of cognitive impairment. This study highlights the importance of adult children as resources of support and caring that may benefit older parents’ cognitive health. The findings can help to identify the most vulnerable subpopulations among aging adults so that medical workers and policy makers can design effective strategies to protect cognitive function for those “at risk” older adults.

Subjective Age and Late-Life Functional Status: Mediating and Moderating Effects.

This study examined the longitudinal relationships between subjective age (SA) and future functional status in later life, via depressive symptoms. Additionally, we assessed the role of subjective nearness to death (SNtD) as a potential moderator within these pathways. Older adults (average age 81.14 years at T1) were interviewed once a year for 3 consecutive years (N = 224 at T1, N = 178 at T2, and N = 164 at T3). Participants reported their SA, SNtD, depressive symptoms, and functional status. Additionally, grip strength was employed as an objective measure of functional status. Data analysis revealed distinct pathways leading from T1 SA to T3 functional status through T2 depressive symptoms. Moreover, T1 SNtD was found to significantly moderate most of these indirect pathways, so that the mediation model of T1 SA-T2 depressive symptoms-T3 functional status was mostly significant among those who felt closer to death. The findings contribute to our understanding of the underlying mechanism through which SA predicts long-term functioning sequelae by underscoring the indirect effect of depressive symptoms. They further indicate the importance of gauging the effects of SNtD on these longitudinal relationships. Present results may further contribute to establishing an integrative model for predicting long-term functional outcomes based on older adults' earlier subjective views of aging.

Association of positive and negative life events with cognitive performance and psychological status in late life: A cross-sectional study in Northern Portugal.

Life events have important effects on psychological well-being. Yet, studies have mainly focused on exploring the impact of traumatic and negative experiences on health and well-being, with positive events receiving marginal attention. In this study, we investigated the association between negative and positive life events, cognitive performance and psychological status in older individuals. A cross-sectional approach with a sample of 97 community-dwelling adults, recruited from a network of 23 centres/institutions in Northern Portugal, and aged between 56 and 85 years, was conducted. All participants were evaluated through a battery of tests assessing for depressive mood, perceived stress, and cognitive functioning. Life events were measured using the Lifetime Experiences Scale (LIFES) which covers 75 life experiences organized in eight domains. A total of 95.9% of the participants reported more positive life events than negative throughout life. Participants reporting more positive experiences had lower scores in the depressive mood and perceived stress measures. At the domain-level of LIFES scale, more negative experiences in the Work and Health domains were associated with a depressed mood and more perceived stress. Significant positive associations were found between positive life experiences and most cognitive measures, after controlling for sex, education, age and depressive symptoms. Namely, more positive experiences at School, Leisure, and Living conditions were positively associated with better performance across cognitive tests. This study adds important evidence on the association between of life events, both negative and positive experiences, on cognition and psychological well-being, providing a more balanced view of the field.

Longitudinal Association Between Education and Disability in Older Adults Living in Iceland

BACKGROUND: Disabilities among older adults are associated with cumulative adversities such as low socioeconomic status (SES), poor nutrition, and lack of access to medical care and education. However, there is little evidence on the long-term association between education and disability status among older adults in Iceland. The aim of the study was to examine the association between mid-life education and prevalence of disability in activities of daily living (ADL) and mobility disability in late-life using 25 years of longitudinal data. METHODS: A large community-based population residing in Reykjavik, Iceland participated in a longitudinal study with an average of 25 years of follow-up (N=5764, mean age 77±6 yrs, 57.7% of women) Mid-life education was categorized into 2 groups (primary and secondary versus college and university). Disability status in late life was defined with ADL and mobility disability with a binary outcome (no difficulty versus any difficulty). Logistic regression analysis was used to examine the association. RESULTS: After controlling for age and gender, and midlife health risk factors, those who had high education at mid-life were less likely to have ADL disability (Odds Ratio (OR) = 0.75, 95% Confidence Interval (CI): 0.64 ~ 0.88, P ≤ 0.001) and mobility disability (OR = 0.72, 95% CI: 0.61 ~ 0.86, P < 0.001) compared with those who had low education in mid-life. CONCLUSION: People with high mid-life education were less likely to have ADL and mobility disability after 25 years later.

Public transport use and health status in later life: Which relationship?

In many developed countries, ageing trends have called for mobility policies oriented to active travels for older adults, preventing some diseases. As a result, in the transport and health literature, the elderly's psycho-physical health is growingly recognized as linked to the accessibility to local public transport (LPT) and its usage frequency. Using data drawn from a survey by the National Institute of Statistics (ISTAT) on the Italian citizens' daily life, this paper investigates the relationship between health dimensions of the sub-sample of people aged over 60 years in Italy and their use of LPT, considered as a more active and sustainable means with respect to car. By applying a recursive mixed-process approach and controlling for LPT service availability and parking issues, the findings highlight that (i) taking public transport services or driving cars more frequently is associated with higher levels of psychological and self-perceived health; (ii) especially for people over 65 years old, the use of LPT at least once a week is linked to better physical conditions. From a policy perspective, the insights of this study are two-fold. First, improving the accessibility to welfare and activity spaces by using LPT is likely to increase ageing people's mental health and their social inclusion. Second, stimulating the LPT usage might be a primary way to effectively promote physical health, to prevent ageing-related diseases, and to help reducing healthcare expenditures connected to the lack of active mobility in later life.