Self-rated oral health as an independent predictor of self-rated general health, self-esteem and life satisfaction.

Self-rated health (SRH) is a useful summary measure of people's general health and was found to predict future health outcomes. Self-rated oral health (SROH) is a similarly useful summary measure of people's oral health. Both are related to quality of life, especially at old age. The objectives of the study were: (1) to assess the independent contribution of SROH to concurrent and future SRH of elderly people, controlling for sociodemographics and health measures, and, (2) to assess whether SROH adds unique information not captured by SRH by testing their independent associations with self-esteem and life satisfaction. Participants were 850 residents of a retirement community (mean age 73) interviewed in their homes at baseline and 5 years later. The interview included single-item self-ratings of general and oral health, self-reports of medical history, recent chronic diseases, medication usage, functional disability, self-esteem and life satisfaction. Multiple regression analyses showed that SROH had an independent effect on concurrent and future SRH, controlling for age and other measures of health status. Both SRH and SROH independently explained a significant amount of variance in concurrent ratings of self-esteem and life satisfaction. SROH has a unique role in people's perceptions of their overall health yet is not fully captured by SRH. Therefore, it should be considered by general health care providers in their assessments of the health status of older adults.

Value for the future and preventive health behavior.

Many everyday decisions require trade-offs between immediate and delayed benefits. Although much research has assessed discounting of delayed outcomes by using hypothetical scenarios, little research has examined whether these discounting measures correspond to real-world behavior. Three studies examined the relationship between scenario measures of time preference and preventive health behaviors that require an upfront cost to achieve a long-term benefit. Responses to time preference scenarios showed weak or no relationship to influenza vaccination, adherence to a medication regimen to control high blood pressure, and adherence to cholesterol-lowering medication. The finding that scenario measures of time preference have surprisingly little relationship to actual behaviors exemplifying intertemporal trade-offs places limits on the applications of time preference research to the promotion of preventive health behavior.

Aging, immunity, and cancer.

BACKGROUND: The prime function of the immune system is to protect the entire organism from a variety of insults and illnesses, including the development of cancer. The question of how age-related declines in immune function contribute to an increasing incidence of malignancies continues to be a focus of discussion and speculation. METHODS: The recent literature from the National Library of Medicine database (1990 through the present) was searched for articles using the medical subject headings (MeSH terms) of aging, immunity, cancer, senescence, and apoptosis. Bibliographies of articles retrieved were also scanned. RESULTS: Data from in vitro and in vivo animal and human studies demonstrate clear age-related alterations in both the cellular and humoral components of the immune system, but there is little evidence supporting direct causal links between immune senescence and most malignancies. CONCLUSIONS: Senescent decline in immune surveillance leads to the accumulation of cellular and DNA mutations that could be a significant factor in the development of malignancy and programmed cell death or apoptosis observed in the elderly.

Gender differences in processing information for making self-assessments of health.

OBJECTIVE: This study proposes that women's greater inclusiveness of various sources of information when making self-assessed health (SAH) judgments accounts for the finding that SAH is a weaker predictor of mortality in women than in men. METHODS: Data from a sample of 830 elderly residents of a retirement community and a 5-year mortality follow-up study were used to examine the bases for women's and men's reports of negative affect (NA) and judgments of SAH. The degree to which each health-related measure accounts for the SAH-mortality association in each gender group was examined. RESULTS: The findings support two possible explanations for the lower accuracy of SAH as a predictor of mortality among women: 1) In both men and women, NA is associated with poorer SAH, but in men, NA is more closely linked to serious disease in conjunction with other negative life events, whereas in women, NA reflects a wider range of factors not specific to serious disease. 2) Men's SAH judgments reflect mainly serious, life-threatening disease (eg, heart disease), whereas women's SAH judgments reflect both life-threatening and non-life-threatening disease (eg, joint diseases). CONCLUSIONS: Women's SAH judgments and NAs are based on a wider range of health-related and non-health-related factors than are men's. This difference can explain gender differences in the accuracy of SAH judgments and may be related to other documented differences in women's physical and mental health and illness behavior. The findings emphasize the need to study the bases of NA and other self-evaluations separately for women and men.

Positive affect and function as influences on self-assessments of health: expanding our view beyond illness and disability.

Longitudinal data from 851 elderly residents of a retirement community (mean age = 73 years) were used to examine the correlates of self-assessments of health (SAH) and the predictors of changes in SAH over several follow-up periods ranging from 1 to 5 years. The authors hypothesized that indicators of positive health, including feelings of energy and positive mood, social support, and active functioning, are as important in determining current and future SAH as negative indicators such as disease history, disability, medication, and negative mood. Results of cross-sectional and longitudinal analyses showed that functional ability, medication use, and negative affect were salient to people judging their health, but positive indicators of activity and mood had an even stronger, independent effect. These findings show the importance of attending to the full illness-wellness continuum in studying people's perceptions of health.

Population risk, actual risk, perceived risk, and cancer control: a discussion.

Given the difficulty of converting population-based estimates of cancer risk into precise statements of individual risk, it is not surprising that (a) individual differences in risk perception are at best poorly correlated to the best available determination of "actual risk" and to behaviors to prevent and detect and treat cancer, and (b) success in bringing perceived risk into line with actual risk has been limited. These inconsistencies are of concern because individual perceptions of risk are thought to be important motivators of action for the prevention and early detection and treatment of cancer. Following the reviewer's suggestion that risk perceptions are readily influenced by contextual factors, we suggest examining risk perception in a self-regulatory framework in which both risk judgments and motivated action are products of underlying representations of cancer and the self. Self-assessments of risk may access only a part of the data necessary for motivation, whereas motivation to sustain action calls on a larger number of concrete features of the database (symptoms, time loss, consequences). Studies of cancer risk perception can make a major contribution to our understanding of processes involved in self-appraisals and self-management to maximize well-being and to avoid catastrophic disease.

It's long-term stressors that take a toll: comment on Cohen et al. (1998)

In an extremely well-controlled study, Cohen et al. (1998) add to prior knowledge of stress-illness relationships by showing that self-reports of stress occurrence and duration of 1 month or more, rather than estimates of stressor severity, predict susceptibility to experimentally induced colds (i.e., viral replication and cold symptoms). Although ruling out obvious behavioral and personality factors as causes of the association of stressors to colds, they were unable to identify mediational immune factors, a deficit attributable to the difficulty of assessing the multi-layered, dynamic physiological processes within the bidirectional connections of the nervous (stress) and immune systems. The findings provide an interesting complement to data, showing that people use stressor duration in evaluating the illness implications of somatic symptoms (Cameron et al., 1995), and suggest caution with regard to overestimating the prevalence of stress-induced colds in natural settings.

Negative affect relates to cross-sectional but not longitudinal symptom reporting: data from elderly adults.

To test hypotheses about the relationship between negative affect and symptom reports, symptom reports of 4 groups of elderly participants (N = 76; mean age = 73.5 years) were compared: those high on measures of both depression and anxiety, those high on one measure and low on the other, and those low on both measures. Symptom reports were obtained before and after 3 simultaneously given active inoculations (influenza; tetanus toxoid; and keyhole limpet hemocyanin, a neoantigen) and 3 similarly given placebo injections. Cross-sectional analyses replicated associations between negative affect and reports of elevated systemic (flulike) symptoms. Local symptoms (sore arm and redness at injection site) increased significantly from before to after active inoculations. Reports of systemic symptoms declined from before to after for both active and placebo inoculations regardless of affect groups. The results add to previous research showing that negative affect is related to cross-sectional symptom reporting but not to increases in symptom reporting from before to after a symptom-producing inoculation procedure.

Negative affect and self-report of physical symptoms: two longitudinal studies of older adults.

The ability of negative affect (NA) to predict somatic complaints 6 months later was examined. State NA, including anxious affect (AA) and depressive affect (DA), was measured in 2 separate samples of older adults averaging 62 and 73 years of age. In the first study, DA reliably predicted later complaints, and a corresponding trend was noted for NA. The second study showed that state NA and its 2 constituent variables predicted somatic complaints associated with acute illness (e.g., colds) 6 months later. The second study also examined trait measures of the 3 predictor variables and found that NA and AA, but not DA, were associated with subsequent somatic complaints. However, these trait effects were less robust than those attributable to their state counterparts. The authors conclude that negative mood states are the more consistent predictors of later physical symptom reports.

Conservation of energy, uncertainty reduction, and swift utilization of medical care among the elderly: study II.

This study examined age differences in the timing of the decision to seek medical care. The data were obtained from a longitudinal study of 366 community dwelling adults aged 45 to 93 years. Subjects were paired for age, gender, and health status, and both members of a pair were interviewed when either one initiated a medical visit for a new problem. This allowed the authors to examine delay in care-seeking for individuals with new symptoms who did not seek care as well as those who did. Survival analysis was used to test hypotheses respecting age differences for total delay (the time from first noticing symptoms until calling for care) and its two constituent phases: appraisal delay (symptom onset until deciding one was ill) and illness delay (decision one was ill until calling for care). Older persons were expected to be more avoidant of uncertainty and conserving of physical and psychic resources and thus quicker to seek care. The results and findings on reasons for delay support the uncertainly avoidance hypothesis but did not replicate signs of higher levels of avoidance behavior by middle-aged subjects than by older subjects.

Seeking medical care in response to symptoms and life stress.

Analyses tested the following contrasting hypotheses: a) The occurrence of a new symptom in the presence of ongoing life stress increases the attribution of symptoms to illness and increases the use of health care; b) new symptoms occurring in the presence of ongoing life stress are attributed to stressors if they are ambiguous indicators of illness, and they are unlikely to motivate care-seeking if the stressor, i.e., the perceived cause, is of recent onset. The 43-to-92-year old subjects in this longitudinal study were less likely to seek care for the ambiguous symptoms they experienced during the previous week if there was a concurrent life stressor that began during the previous 3 weeks; these symptoms were attributed to stress rather than to illness, and subjects tolerated the emotional distress caused by the combination of a stressor and an ambiguous symptom. Subjects were less willing to tolerate the combined distress of an ambiguous symptom and a concurrent life stressor if the stressor onset was not recent; under such conditions, subjects were more likely to seek health care. Current life stressors did not affect care-seeking for symptoms that were clear signs of disease; these symptoms were readily identified as health threats in need of medical attention. The findings contribute to a better theoretical understanding of how individuals perceive their physical states and how they cope with stress. Practical implications of these findings for increasing efficient use of health care services are also discussed.

Symptom representations and affect as determinants of care seeking in a community-dwelling, adult sample population.

The cognitive and emotional determinants of health-care utilization were assessed for middle-aged and older adults matched on age, gender, and health status. Both members of a pair were interviewed when either initiated a medical visit. Interviews were based on a self-regulatory model that assumed that Ss would use symptoms to create and update representations and coping procedures. Care seekers reported more symptoms than did matched controls but did not report more symptoms than did matched controls with new symptoms. The mere presence of atypical symptoms was insufficient to trigger care seeking. Care seeking is driven by well-developed representations of a serious health threat, perceptions of inability to cope with the threat, advice to seek care, and life stress.

Conservation of energy, uncertainty reduction, and swift utilization of medical care among the elderly.

This study examined age differences in the timing of the decision to seek medical care. Two cohorts, one of middle-aged (40 to 55 years, n = 88) and one of older patients (65 and over, n = 80), who sought medical care when symptomatic were interviewed at the time of their visit. Age differences were examined with respect to total delay (the time from first noticing symptoms until calling for care), as well as its two constituent phases: appraisal delay (symptom onset until deciding one was ill) and illness delay (decision one was ill until calling for care). Older persons were expected to be more conserving of physical and psychic resources, and thus quicker in seeking care. The cohort effect was expected to be most visible for symptoms judged to be of uncertain seriousness. The delay results and ancillary findings on reasons given for delay are generally supportive of the hypotheses, with the caveat that the cohort difference also reflects higher levels of avoidance behavior by the middle-aged than by the older subjects.

Breast cancer care in old age: what we know, don't know, and do.

In this review of current pertinent literature from the fields of cancer epidemiology, oncology, health services research, and geriatrics, we describe the epidemiology and unique features of breast cancer and its victims in old age. In addition, we review the current evidence regarding treatment efficacy (i.e., beneficial under ideal circumstances) and effectiveness (i.e., beneficial under usual circumstances) in relation to primary tumor management and the use of adjuvant therapy in early stage disease and outline the challenges associated with studying breast cancer care in older women (> or = 65 years of age). Comorbidity, impaired functional status, lack of social support, and differences in host physiology are among the many factors that influence treatment efficacy and effectiveness, making extrapolation of study findings from younger to older women questionable. Indeed, with the exception of studies of adjuvant tamoxifen therapy, none of the clinical trials supporting the 1990 National Institutes of Health Consensus Development Conference on Treatment of Early-Stage Breast Cancer guidelines have included women over the age of 70 years. Because (a) breast cancer is becoming increasingly common in old age and (b) health-related quality of life is frequently more important to older women than is risk of recurrence or death, all three aspects (surgical management of the primary tumor, postoperative irradiation, and axillary lymph node dissection) of recommended primary treatment deserve fresh scrutiny. The value of adjuvant chemotherapy has yet to be defined. Substantial variations in breast cancer diagnosis, treatment, and care exist, and these differences become greater with increasing age of the patient. However, evidence regarding the reasons for these variations and their relationships with subsequent outcomes is lacking. Challenges for investigators in studies of older women include recruitment into studies, collection of reliable data from interviews or surveys, measurement of disease severity and comorbidity, and selection of relevant outcomes. Given current uncertainty about optimal treatment, clinicians can best serve older patients with early stage breast cancer by involving them in decision-making, taking into account available efficacy data, and individualizing care on the basis of such factors as comorbidity, social support, functional status, and patient preferences for outcomes. Future studies of treatment efficacy in older women should examine the roles of radiation therapy and axillary lymph node dissection that follow breast-conserving therapy and should focus on quality of life in addition to recurrence and mortality. Less aggressive treatments, tamoxifen therapy, and adjuvant chemotherapy should also be evaluated.

Reports of physical symptoms and alcohol use: findings from a primary health care sample.

The relationship between alcohol consumption and physical health was examined in a primary health care sample of 366 adults. Unlike many previous studies that relied on static measures of medical diagnoses, the data reported here are repeated assessments of self-reported symptoms and alcohol use over 12 months. The results suggest, first, that drinking patterns in non-alcoholic samples fluctuate over time, and, second, that abstainers who have more prior illnesses or worse current health consistently report the greatest number of physical symptoms. The data highlight the importance of accounting for the health status of abstainers before comparing them with users of alcohol, and suggest that the presence of physical symptoms in addition to objective indices of health (e.g. the need for medication) may play a role in the initiation or maintenance of abstinence.

The behavioral dynamics of clinical trials.

Two ways of approaching the design of long-term clinical trials are presented and contrasted. The first, termed the "static" view, emphasizes close adherence to formal rules of study design. The second, termed the "dynamic" view, emphasizes the behavioral aspects of patient participation in trials of long duration. The dynamic view is discussed in detail, with discussion of how recruitment of participants, random assignment to conditions, compliance with protocol, and measurement of outcomes are affected by behavioral dynamics. Data from a recently completed tamoxifen toxicity trial are used to illustrate the points and to focus the discussion of behavioral dynamics on the design of a chemoprevention trial for breast cancer using tamoxifen.

Beliefs about aging and illness in a community sample.

Findings from recent studies have demonstrated age group differences in coping with illness. One explanation for these age group differences has received little attention: perceptions of illness may differ with age and these differences in perception may account for the observed differences in coping. The purpose of this study was to examine the effects of age on illness perceptions along dimensions that influence coping. Specifically, we explored perceptions about aging as a cause of illness and perceptions about the effect of age on seriousness, curability and controllability of illness. Four hundred fifty-one community-dwelling adults (age range 20 to 90 years) participated in the study. The pattern of results showed respondents of all ages expressing the belief that aging is associated with increased susceptibility to disease and lowered potential for control or cure. Implications of these beliefs for health monitoring and coping with illness are discussed.

Active coping reduces reports of pain from childbirth.

Two studies were conducted in which pain and negative moods during labor were examined in relation to two key, independent variables: instructions to monitor labor contractions given to parturients on admission to the labor service and attendance at LaMaze (childbirth preparation) classes. In Study 1 (N = 48) pain and negative moods showed a sharp decline at Stage 2 (active labor) for women told to monitor and those who had attended classes; there was no decline for the control group. In Study 2 (N = 29), women attending LaMaze classes reported a similar decline in pain during active labor and were more energetic and less tired at admission. Of the three different mechanisms used to derive hypotheses, schema-directed coping provided the best account for the decline in pain and distress during active labor. A second mechanism, accurate expectations, seemed to account for the enhanced energy at the point of admission, in anticipation of birth.

Aging: the lived experience.

This exploratory study examined the lived experience of aging in a group of 32 community dwelling adults aged fifty to eighty years (M = 68.4). Respondents completed in-depth interviews in which they described the meaning of aging, the "types of things" associated with aging in themselves and in others, and methods of coping with aging-related changes. Respondents' overall impressions of the meaning of aging were generally positive; however, the changes they associated with aging, both in themselves and in others, were almost uniformly negative. Five categories of coping activities were reported: compensation, stress management, maintenance, involvement with others, and alteration in meaning. In general, respondents reported high levels of satisfaction and effectiveness with respect to their coping activities. These findings suggest that individuals who believe they are coping successfully see aging as a positive period in their lives, despite the presence of a significant number of negative changes in themselves and in people close to them.

An evaluation of increased mortality rates in Wisconsin nursing homes.

We reviewed mortality data from 80 nonprofit and government-owned skilled nursing facilities (SNFs) to evaluate previously reported increases in deaths occurring in Wisconsin nursing homes since 1983. Comparing nursing home mortality data for 1982 and 1985, we found a 16.6% increase in overall nursing home mortality rates. The increased mortality rates occurred in the sample SNFs regardless of ownership, Medicare certification, bed size, metropolitan area and hospital affiliation. There were two explanations for the increased mortality rates. First, the number of residents dying within 30 days after nursing home admission increased 59%. The majority of these short-lived residents had been discharged from hospitals indicating a transfer of terminally ill patients into nursing homes just prior to death. Second, there was a 27% increase in the mortality rate of residents living in the nursing home for 1 to 5 years suggesting that the population had become sicker between 1982 and 1985. These data reflect both the impact of Medicares Prospective Payment System (PPS) on the study nursing homes and an increase in the severity of illness of Wisconsin's nursing home population between 1982 and 1985. The findings document an increased role for nursing homes in caring for more acutely ill patients since the passage of the PPS, and have implications for nursing home reimbursement policies and quality of care.