Racial Differences in Change in Physical Functioning in Older Male Veterans with HIV.

Little is known about longitudinal change in physical functioning of older African American/Black and White HIV-infected persons. We examined up to 10 years of data on African American (N = 1,157) and White (N = 400) men with HIV infection and comparable HIV-negative men (n = 1,137 and 530, respectively), age 50-91 years from the Veterans Aging Cohort Study Survey sample. Physical functioning was assessed using the SF-12 (12-Item Short Form Health Survey) physical component summary (PCS) score. Mixed-effects models examined association of demographics, health conditions, health behaviors, and selected interactions with PCS score; HIV biomarkers were evaluated for HIV-infected persons. PCS scores were approximately one standard deviation below that of the general U.S. population of similar age. Across the four HIV/race groups, over time and through ages 65-75 years, PCS scores were maintained; differences were not clinically significant. PCS score was not associated with race or with interactions among age, race, and HIV status. CD4 and viral load counts of African American and White HIV-infected men were similar. Older age, low socioeconomic status, chronic health conditions and depression, lower body mass index, and smoking were associated with poorer PCS score in both groups. Exercising and, counterintuitively, being HIV infected were associated with better PCS score. Among these older African American and White male veterans, neither race nor HIV status was associated with PCS score, which remained relatively stable over time. Chronic disease, depression, and lack of exercise were associated with lower PCS score. To maintain independence in this population, attention should be paid to controlling chronic conditions, and emphasizing good health behaviors.

Effect of cancer screening and desirable health behaviors on functional status, self-rated health, health service use and mortality.

OBJECTIVES: To determine whether some health behaviors of older people (e.g., obtaining cancer screens) have a limited and others (e.g., exercise) have a broad association with population-level health status 4 to 6 years later. DESIGN: Longitudinal cohort. SETTING: North Carolina five-county urban and rural area. PARTICIPANTS: Representative community residents aged 71 and older (Duke Established Populations for Epidemiologic Studies of the Elderly; African American, n=1,256; white, n=974) who provided information on cancer screening and health behaviors. MEASUREMENTS: Demographics, health conditions, functional status, health service use, health insurance. Dependent measures were functional status and self-rated health 4 years later, hospitalization within 4 years, and death within 6 years. Data were analyzed using descriptive statistics, multivariable logistic regression, and Cox proportional hazards. RESULTS: In fully adjusted analyses, cancer screening had no significant protective association with functional status, self-rated health, hospitalization, or death. Smoking was a risk factor for hospitalization (odds ratio (OR)=1.48, 95% confidence interval (CI)=1.07-2.05), and death (hazard rate (HR)=1.81, 95% CI=1.47-2.23). Sufficient food reduced hospitalization (OR=0.38, 95% CI=0.15-0.94) and mortality (HR=0.70, 95% CI=0.49-1.02). Regular exercise protected against poor mobility (OR=0.56, 95% CI=0.41-0.77), and poor self-rated health (OR=0.61, 95% CI=0.45-0.82). Lower activity level increased the hazard of death (HR=1.18, 95% CI=1.03-1.36). CONCLUSION: Disease-specific screens are important at an individual level but, because of low incidence of condition and comorbidity, may not be associated with population-level health 4 to 6 years later. Practice of health behaviors with a broader focus is associated, at a population level, with better functional status and self-rated health and lower rates of hospitalization and death 4 to 6 years later.

Identifying frailty in hospitalized older adults with significant coronary artery disease.

OBJECTIVES: To characterize physiological variation in hospitalized older adults with severe coronary artery disease (CAD) and evaluate the prevalence of frailty in this sample, to determine whether single-item performance measures are good indicators of multidimensional frailty, and to estimate the association between frailty and 6-month mortality. DESIGN: Observational cohort study. SETTING: Inpatient hospital cardiology ward. PARTICIPANTS: Three hundred nine consecutive inpatients aged 70 and older admitted to a cardiology service (n = 309; 70% male, 84% white) with minimum two-vessel CAD determined using cardiac catheterization. MEASUREMENTS: Two standard frailty phenotypes (Composite A and Composite B), usual gait speed, grip strength, chair stands, cardiology clinical variables, and 6-month mortality. RESULTS: Prevalence of frailty was 27% for Composite A versus 63% for Composite B. Utility of single-item measures for identifying frailty was greatest for gait speed (receiver operating characteristic curve c statistic = 0.89 for Composite A, 0.70 for Composite B) followed by chair-stands (c = 0.83, 0.66) and grip strength (c = 0.78, 0.57). After adjustment, composite scores and single-item measures were individually associated with higher mortality at 6 months. Slow gait speed (< or =0.65 m/s) and poor grip strength (< or =25 kg) were stronger predictors of 6-month mortality than either composite score (gait speed odds ratio (OR)=3.8, 95% confidence interval (CI) = 1.1-13.1; grip strength OR = 2.7, 95% CI = 0.7-10.0; Composite A OR = 1.9, 95% CI = 0.60-6.1; chair-stand OR = 1.5, 95% CI = 0.5-5.1; Composite B OR = 1.3, 95% CI = 0.3-5.2). CONCLUSION: Gait speed frailty was the strongest predictor of mortality in a population with CAD and may add to traditional risk assessments when predicting outcomes in this population.

The impact of health status on physicians' intentions to offer cancer screening to older women.

BACKGROUND: Screening for breast and cervical cancer reduces disease-specific mortality, but high rates of comorbidity and disability among elderly persons may alter the risks and benefits of screening. METHODS: We performed a mail survey of primary care physicians to estimate the impact of health status on physicians' intentions to offer cancer screening to older women. Respondents were asked to read a scenario about an older woman. Each scenario patient was one of three ages (70, 80, or 90) and had one of three levels of comorbidity and disability. Respondents were asked to estimate the likelihood of offering screening with mammography and Pap smear to these patients on a 5-point Likert scale. A logistic regression compared those physicians somewhat or very likely to offer screening with those less likely to do so. Further analyses examined the characteristics of physicians likely to "overscreen" the frailest older women (<5 years median life expectancy) or "underscreen" the healthiest (>10 years median life expectancy). RESULTS: Respondents returned 2003 completed surveys (37.4%). Controlling for age and prior screening, higher levels of comorbidity and disability were associated with a significantly lower likelihood of offering screening for both mammography and Pap smear. Nonetheless, a substantial percentage (30.7%) of physicians indicated a high likelihood of offering a frail 90-year-old woman a mammogram, and 13.4% would offer her a Pap smear. In general, overscreening was more common than underscreening. Female gender was associated with "overscreening" with mammography, whereas male gender and lack of board certification predicted "underscreening." Lack of board certification was associated with "overscreening" with Pap smear. CONCLUSIONS: In addition to age, primary care physicians consider health status in deciding to offer cancer screening to older women. Education and guidelines for cancer screening should more explicitly address the risks of overscreening among frail older women.

What are Hospice Providers in the Carolinas Doing to Reach African Americans in Their Service Area?

BACKGROUND: Experts and national organizations recommend that hospices work to increase service to African Americans, a group historically underrepresented in hospice. OBJECTIVE: The study objective was to describe strategies among hospices in North and South Carolina to increase service to African Americans and identify hospice characteristics associated with these efforts. METHODS: The study was a cross-sectional survey using investigator-developed scales to measure frequency of community education/outreach, directed marketing, efforts to recruit African American staff, cultural sensitivity training, and goals to increase service to African Americans. We used nonparametric Wilcoxon tests to compare mean scale scores by sample characteristics. RESULTS: Of 118 eligible hospices, 79 (67%) completed the survey. Over 80% were at least somewhat concerned about the low proportion of African Americans they served, and 78.5% had set goals to increase service to African Americans. Most were engaged in community education/outreach, with 92.4% reporting outreach to churches, 76.0% to social services organizations, 40.5% to businesses, 35.4% to civic groups, and over half to health care providers; 48.0% reported directed marketing via newspaper and 40.5% via radio. The vast majority reported efforts to recruit African American staff, most often registered nurses (63.75%). Nearly 90% offered cultural sensitivity training to staff. The frequency of strategies to increase service to African Americans did not vary by hospice characteristics, such as profit status, size, or vertical integration, but was greater among hospices that had set goals to increase service to African Americans. CONCLUSIONS: Many hospices are engaged in efforts to increase service to African Americans. Future research should determine which strategies are most effective.

Are Hospice Admission Practices Associated With Hospice Enrollment for Older African Americans and Whites?

CONTEXT: Hospices that enroll patients receiving expensive palliative therapies may serve more African Americans because of their greater preferences for aggressive end-of-life care. OBJECTIVES: Examine the association between hospices' admission practices and enrollment of African Americans and whites. METHODS: This was a cross-sectional study of 61 North and South Carolina hospices. We developed a hospice admission practices scale; higher scores indicate less restrictive practices, that is, greater frequency with which hospices admitted those receiving chemotherapy, inotropes, and so forth. In separate multivariate analyses for each racial group, we examined the relationship between the proportion of decedents (age ≥ 65) served by a hospice in their service area (2008 Medicare Data) and admission practices while controlling for health care resources (e.g., hospital beds) and market concentration in the area, ownership, and budget. RESULTS: Nonprofit hospices and those with larger budgets reported less restrictive admission practices. In bivariate analyses, hospices with less restrictive admission practices served a larger proportion of patients in both racial groups (P < 0.001). However, in the multivariate models, nonprofit ownership and larger budgets but not admission practices predicted the outcome. CONCLUSION: Hospices with larger budgets served a greater proportion of African Americans and whites in their service area. Although larger hospices reported less restrictive admission practices, they also may have provided other services that may be important to patients regardless of race, such as more in-home support or assistance with nonmedical expenses, and participated in more outreach activities increasing their visibility and referral base. Future research should explore factors that influence decisions about hospice enrollment among racially diverse older adults.

Laxative use in the community-dwelling elderly.

BACKGROUND: Constipation, a common and sometimes severe problem in the elderly, is often treated with laxatives. OBJECTIVE: The purpose of this study was to determine the prevalence of laxative use and identify determinants of such use among representative black and white community-dwelling elderly persons. METHODS: This was a cross-sectional survey of 4136 participants at baseline (1986-1987) in the Duke University Established Populations for Epidemiologic Studies of the Elderly. Data on demographic characteristics, health status, health service use, and use of prescription and over-the-counter drugs were collected in participants' homes. Use of the following types of laxatives was examined: bulking, hyperosmotic, lubricant, stimulant, stool softener, saline, and miscellaneous agents. RESULTS: It was found that 10.2% of participants used > or =1 laxative. Stimulants and bulking agents were the most commonly used classes. Only 11.6% of laxative users reported concurrent consumption of > or =2 laxatives. Multivariate logistic regression analyses indicated that laxative use was more likely in women (adjusted OR, 1.78; 95% CI, 1.34-2.37), those with >4 physicians visits in the previous year (adjusted OR, 1.72; 95% CI, 1.16-2.53), those unable to walk a half mile (adjusted OR, 1.44; 95% CI, 1.11-1.87), and those using > or =4 over-the-counter nonlaxative medications (adjusted OR, 2.09; 95% CI, 1.15-3.81). A nonsignificant association was seen between laxative use and the use of anticholinergic agents (adjusted OR, 1.38; 95% CI, 1.00-1.89). CONCLUSIONS: Laxative use is common among community-dwelling elderly persons and is related to specific factors concerning sociodemographics, health status, and access to health care. Studies are needed that examine the impact of laxative use on bowel function and quality of life in the elderly.

Trajectory classes of body mass index in a representative elderly community sample.

BACKGROUND: It is unclear whether distinct weight-related trajectory classes, differing in course, demographics, and health characteristics, exist in the elderly population. METHODS: Data came from the 10-year (1986-1996) Duke Established Populations for Epidemiologic Studies of the Elderly study of 3,861 black (54%) and white (46%) participants aged 65-105 years. Latent-class trajectories of body mass index (BMI: kg/m(2)) based on self-reported weight and height at baseline, 3, 6, and 10 years later were determined using generalized mixture models. Polytomous logistic regression was used to identify baseline demographic and health characteristics that distinguished the trajectories, and 10-year postbaseline data to confirm the findings. RESULTS: We identified three trajectories: normal weight (BMI ~24, 27.6% of the sample), overweight (BMI ~26, 65.1%), and obese (BMI ~31, 7.3%). Demographic characteristics distinguished the three trajectories: highest odds of blacks, women, and less education in the obese trajectory, lowest in the normal-weight trajectory. Obese and overweight differed adversely from normal-weight trajectories, but not significantly from each other on cognitive impairment, hypertension, and diabetes. Depressive symptomatology was more prevalent in the obese; they were also younger. There was no association with cancer or heart disease. CONCLUSION: Distinct trajectories and course of BMI were present in this older population. Weight loss increased with increase in BMI class. Although demographic characteristics distinguished all trajectory classes, adverse health characteristics distinguished the overweight and obese classes from the normal-weight class, but not from each other. Problems associated with education and health are present at study entry and should be addressed earlier in life.

Trajectory classes of depression in a randomized depression trial of heart failure patients: a reanalysis of the SADHART-CHF trial.

OBJECTIVE: The objective of this article was to determine whether, in drug intervention trials, growth mixture modeling (GMM) is able to identify drug-responsive trajectory classes that are not evident in traditional growth modeling approaches. METHODS: We reanalyzed acute phase (biweekly data up to 7 occasions) and longitudinal (12 months) data on the 469 patients in the SADHART-CHF study of the safety and efficacy of sertraline for depression in patients with heart failure. GMM was used to identify the trajectory classes present in the treatment and placebo groups, based on Hamilton Depression Rating Scale scores. RESULTS: Two distinct trajectory classes were identified in the treatment group: (1) chronic depressives (12%), who remained depressed through the treatment phase; and (2) responders (88%), who had scores indicating nondepression at the conclusion of the acute phase. At baseline, chronic depressives were distinguished by higher Hamilton Depression Rating Scale scores, the presence of implantable cardioverter defibrillators, and a history of anxiety. During follow-up, they were more likely to have unstable angina. Only responders remitted (70%). Three distinct trajectories were identified in the placebo group: (1) moderating depressives (19%), (2) temporary improvers (13%), and (3) responders (68%). At baseline, the classes differed in mean Hamilton Depression Rating Scale scores, responders' scores falling between the other 2 classes, and the proportion with renal disease. Only remission differed at follow-up: responders (76%), moderating depressives (21%), and temporary improvers (3%). Where the traditional analytic approach found improvement from moderate to mild depression but no significant treatment effect, GMM found response in 20% more people in the treatment group than in the placebo group. CONCLUSIONS: Unlike conventionally used, standard analytic approaches, which focus on intervention impact at study end or change from baseline to study end, GMM enables maximum use of repeated data to identify unique trajectories of latent classes that are responsive to the intervention.

What the CERAD Battery Can Tell Us about Executive Function as a Higher-Order Cognitive Faculty.

Executive function (EF) is believed to control or influence the integration and application of cognitive functions such as attention and memory and is an important area of research in cognitive aging. Recent studies and reviews have concluded that there is no single test for EF. Results from first-order latent variable modeling have suggested that little, if any, variability in cognitive performance can be directly (and uniquely) attributed to EF; so instead, we modeled EF, as it is conceptualized, as a higher-order function, using elements of the CERAD neuropsychological battery. Responses to subtests from two large, independent cohorts of nondemented elderly persons were modeled with three theoretically plausible structural models using confirmatory factor analysis. Robust fit statistics, generated for the two cohorts separately, were consistent and support the conceptualization of EF as a higher-order cognitive faculty. Although not specifically designed to assess EF, subtests of the CERAD battery provide theoretically and empirically robust evidence about the nature of EF in elderly adults.

Accuracy of self-reported height and weight in a community-based sample of older African Americans and whites.

BACKGROUND: To ascertain accuracy of self-reported height, weight (and hence body mass index) in African American and white women and men older than 70 years of age. METHOD: The sample consisted of cognitively intact participants at the third in-person wave (1992-1993) of the Duke Established Populations for Epidemiologic Studies of the Elderly (age 71 and older, N = 1761; residents of five adjacent counties, one urban, four rural). During in-person, in-home interviews using trained interviewers, height and weight were self-reported (and measured later in the same visit using a standardized protocol), and information were obtained on race, sex, and age. RESULTS: Accuracy of self-reported height and weight was high (intraclass correlation coefficient 0.85 and 0.97, respectively) but differed as a function of race and age. On average, all groups overestimated their height; whereas (non-Hispanic) white men and women underestimated their weight, African Americans overestimated their weight. Overestimation of height and weight was more marked in persons 85 years and older. Specificity for overweight (body mass index [kg/m(2)] ≥ 25) and obesity (body mass index ≥ 30) ranged from 0.90 to 0.99 for African Americans and whites, but sensitivity was better for African Americans (overweight: 0.81, obesity: 0.89), than for whites (0.66 and 0.57, respectively). CONCLUSIONS: Height and weight self-reported by African Americans and whites over the age of 70 can be used in epidemiological studies, with greater caution needed for self-reports of whites, and of persons 85 years of age or older.

Geographical segregation and IL-6: a marker of chronic inflammation in older adults.

AIM: To examine environmental sociodemographic risks of high IL-6, a marker of chronic inflammation in older adults. METHODS: We spatially linked 1990 USA Census tract demographic and economic measures to a prospective cohort study of representative community residents aged 71 years and older, from over 1700 of whom a cytokine protein and biological marker of chronic inflammation. IL-6, was collected. Using generalized interactive mixed models, we modeled 1989-1990 individual and census level risk factors for the dependent variable high IL-6 between 1992-1993 (high IL-6 = upper quartile: >2.96 pg/ml). RESULTS: After individual health risk adjustment, IL-6 remained elevated in communities with greater densities of poor older adults (odd ratio [OR]: 1.25 per 10% increase in exposure. 95% confidence interval [CI]: 1.05, 1.48) and in racially segregated communities (OR: 1.14 per 10% increase in exposure. 95% CI: 1.04, 1.25). CONCLUSIONS: Socially disadvantaged environments may influence IL-6, a biomarker of age-associated inflammation.

Impact of anemia on mortality, cognition, and function in community-dwelling elderly.

PURPOSE: To explore the impact of varying hemoglobin levels on mortality, function, and cognition in a representative population of older persons. METHODS: Participants in this prospective cohort study included 1 744 men and women, aged 71 years or older, from a random household sample living in Durham and surrounding counties in North Carolina. Hemoglobin levels were obtained from participants at baseline in 1992. Functional status was measured at the 4-year follow-up interview using Katz and instrumental activities of daily living. Cognition was measured using the Short Portable Mental Status Questionnaire (SPMSQ). Death was determined by search of the National Death Index, and all deaths through 2000 are included. RESULTS: Using World Health Organization (WHO) criteria, the prevalence of anemia was 24%. There was a strong racial difference with an odds ratio, adjusted for age, education, estimated glomerular filtration rate and comorbidity of 3.0 (95% CI, 2.3-3.9) in African Americans compared with Caucasians. The risk ratio for 8-year mortality was 1.7 (95% CI, 1.5-2.0) for anemic subjects (P = .0001) and did not differ by sex or race. Anemia was strongly associated with poorer physical function (P = .0001) and cognitive function (P = .0001), and predicted decreases in both over a 4-year period. CONCLUSIONS: In an elderly community-based population, anemia is more prevalent in African Americans and is independently associated with increased mortality over 8 years for both races and sexes. Anemia also is a risk factor for functional and cognitive decrease.

Dementia and Alzheimer's disease in community-dwelling elders taking vitamin C and/or vitamin E.

BACKGROUND: Since increased oxidative stress may impair cognition and be a risk factor for dementia, there has been interest in determining whether use of antioxidants could protect against such events. OBJECTIVE: To determine whether supplement use of vitamins C and/or E in a community-based sample of older African American and white individuals delayed incident dementia or Alzheimer's disease (AD). METHODS: We selected a subgroup from the Duke Established Populations for Epidemiologic Studies of the Elderly, a longitudinal study of community-representative persons aged 65-105 years living in 5 adjacent counties in North Carolina, and followed them for dementia (1986-1987 through June 2000). Information gathered during in-home interviews included sociodemographic characteristics, health status, health service use, and vitamin use. Diagnosis of dementia and AD was based on evaluations using the clinical and neuropsychological batteries of the Consortium to Establish a Registry for Alzheimer's Disease, with final determination by consensus agreement of specialists using Diagnostic and Statistical Manual of Mental Disorders, third revision, and National Institute for Neurological and Communicative Disorders and Stroke-Alzheimer's Disease and Related Disorders criteria. RESULTS: Of 616 persons initially dementia-free (mean age 73 y; 62% female; 62% African American), 141 developed dementia, of whom 93 developed AD. Increased age and mobility problems were risk factors for dementia (only age for AD), while an increased number of outpatient visits reduced the likelihood of developing dementia. Neither use of any vitamins C and/or E (used by 8% of subjects at baseline) nor high-dose use reduced the time to dementia or AD. CONCLUSIONS: In this community in the southeastern US where vitamin supplement use is low, use of vitamins C and/or E did not delay the incidence of dementia or AD.