Racial, ethnic, and socioeconomic disparities in trajectories of morbidity accumulation among older Americans.

Introduction: Multimorbidity, the presence of multiple chronic health conditions, generally starts in middle and older age but there is considerable heterogeneity in the trajectory of morbidity accumulation. This study aimed to clarify the number of distinct trajectories and the potential associations between race/ethnicity and socioeconomic status and these trajectories. Methods: Data from 13,699 respondents (age ≥51) in the Health and Retirement Study between 1998 and 2016 were analyzed with growth mixture models. Nine prevalent self-reported morbidities (arthritis, cancer, cognitive impairment, depressive symptoms, diabetes, heart disease, hypertension, lung disease, stroke) were summed for the morbidity count. Results: Three trajectories of morbidity accumulation were identified: low [starting with few morbidities and accumulating them slowly (i.e., low intercept and low slope); 80% of sample], increasing (i.e., low intercept and high slope; 9%), and high (i.e., high intercept and low slope; 11%). Compared to non-Hispanic (NH) White adults in covariate-adjusted models, NH Black adults had disadvantages while Hispanic adults had advantages. Our results suggest a protective effect of education for NH Black adults (i.e., racial health disparities observed at low education were ameliorated and then eliminated at increasing levels of education) and a reverse pattern for Hispanic adults (i.e., increasing levels of education was found to dampen the advantages Hispanic adults had at low education). Compared with NH White adults, higher levels of wealth were protective for both NH Black adults (i.e., reducing or reversing racial health disparities observed at low wealth) and Hispanic adults (i.e., increasing the initial health advantages observed at low wealth). Conclusion: These findings have implications for addressing health disparities through more precise targeting of public health interventions. This work highlights the imperative to address socioeconomic inequalities that interact with race/ethnicity in complex ways to erode health.

Depressive Multimorbidity and Trajectories of Functional Status among Older Americans: Differences by Racial/Ethnic Group.

OBJECTIVE: This study aims to evaluate the impact of depressive multimorbidity (ie, including depressive symptoms) on the long-term development of activities of daily living (ADL) and instrumental activities of daily living (IADL) limitations according to racial/ethnic group in a representative sample of US older adults. DESIGN: Prospective, observational, population-based 16-year follow-up study of nationally representative sample. SETTING AND PARTICIPANTS: Sample of older non-Hispanic Black, Hispanic, and nonHispanic White Americans from the Health and Retirement Study (2000‒2016, N = 16,364, community-dwelling adults ≥65 years of age). METHODS: Data from 9 biennial assessments were used to evaluate the accumulation of ADL-IADL limitations (range 0‒11) among participants with depressive (8-item Center for Epidemiologic Studies Depression score≥4) vs somatic (ie, physical conditions only) multimorbidity vs those without multimorbidity (no or 1 condition). Generalized estimating equations included race/ethnicity (non-Hispanic Black, Hispanic, non-Hispanic White), baseline age, sex, body mass index, education, partnered, and net worth. RESULTS: Depressive and somatic multimorbidity were associated with 5.18 and 2.95 times greater accumulation of functional limitations, respectively, relative to no disease [incidence rate ratio (IRR) = 5.18, 95% confidence interval, CI (4.38,6.13), IRR = 2.95, 95% CI (2.51,3.48)]. Hispanic and Black respondents experienced greater accumulation of ADL-IADL limitations than White respondents [IRR = 1.27, 95% CI (1.14, 1.41), IRR = 1.31, 95% CI (1.20, 1.43), respectively]. CONCLUSIONS AND IMPLICATIONS: Combinations of somatic diseases and high depressive symptoms are associated with greatest accumulation of functional limitations over time in adults ages 65 and older. There is a more rapid growth in functional limitations among individuals from racial/ethnic minority groups. Given the high prevalence of multimorbidity and depressive symptomatology among older adults and the availability of treatment options for depression, these results highlight the importance of screening/treatment for depression, particularly among older adults with socioeconomic vulnerabilities, to slow the progression of functional decline in later life.

Trajectories of cognitive functioning in later life: Disparities by race/ethnicity, educational attainment, sex, and multimorbidity combinations.

Evaluating multimorbidity combinations, racial/ethnic background, educational attainment, and sex associations with age-related cognitive changes is critical to clarifying the health, sociodemographic, and socioeconomic mechanisms associated with cognitive function in later life. Data from the 2011-2018 National Health and Aging Trends Study for respondents aged 65 years and older (N = 10,548, mean age = 77.5) were analyzed using linear mixed effect models. Racial/ethnic differences (mutually-exclusive groups: non-Latino White, non-Latino Black, and Latino) in cognitive trajectories and significant interactions with sex and education (

Physical Activity as a Mediator Between Race/Ethnicity and Changes in Multimorbidity.

OBJECTIVES: Studies report racial/ethnic disparities in multimorbidity (≥2 chronic conditions) and their rate of accumulation over time as well as differences in physical activity. Our study aimed to investigate whether racial/ethnic differences in the accumulation of multimorbidity were mediated by physical activity among middle-aged and older adults. METHOD: We assessed racial/ethnic differences in the accumulation of multimorbidity (of 9 conditions) over 12 years (2004-2016) in the Health and Retirement Study (N = 18,264, mean age = 64.4 years). Structural equation modeling was used to estimate latent growth curve models of changes in multimorbidity and investigate whether the relationship of race/ethnicity (non-Hispanic Black, Hispanic, non-Hispanic White participants) to changes in the number of chronic conditions was mediated by physical activity after controlling for age, sex, education, marital status, household wealth, insurance coverage, smoking, alcohol, and body weight. RESULTS: There was a significant increase in multimorbidity over time. Initial levels and changes in multimorbidity over time varied significantly across individuals. Indirect effects of the relationship between race/ethnicity and changes in multimorbidity as mediated by physical activity were significant, consistent with the mediational hypothesis. Black respondents engaged in significantly lower levels of physical activity than White respondents after controlling for covariates, but there were no differences between Hispanic and White respondents once education was included. Discussion: These results provide important new information for understanding how modifiable lifestyle factors may help explain disparities in multimorbidity in mid-to-late life, suggesting greater need to intervene to reduce sedentary behavior and increase physical activity.

Socioeconomic Differences in Trajectories of Functional Capacity Among Older Japanese: A 25-Year Longitudinal Study.

OBJECTIVES: There is limited research on long-term changes in functional capacity among older Japanese, who differ significantly from their counterparts in Western, developed nations. This study aimed to identify distinct trajectories of functional capacity over a 25-year period and to explore socioeconomic differences in trajectory-group membership probabilities, using a national sample of older Japanese. DESIGN: Longitudinal panel study with 8 observation points from 1987 to 2012. SETTING AND PARTICIPANTS: The data came from the National Survey of the Japanese Elderly, which consisted of 6193 samples of community-dwelling Japanese aged 60 years and older at baseline. METHODS: Functional capacity measure included basic and instrumental activities of daily living. Group-based mixture models were used for data analysis. RESULTS: Among participants aged 60 to 74 years at baseline, 4 trajectories were identified: minimal disability (80.3%), late-onset disability (11.6%), early-onset disability (6.2%), and moderate disability (1.9%). Those aged ≥75 years at baseline experienced higher levels of disability but somewhat parallel trajectories, including minimal disability (73.3%), early-onset disability (11.2%), moderate disability (11.3%), and severe and worsening disability (4.2%). Lower socioeconomic status, including education and household income, was associated with a higher risk of experiencing trajectories of poorer functional capacity among those aged 60 to 74 years, but no such association existed among those aged ≥75 years. CONCLUSIONS AND IMPLICATIONS: We found that approximately 70% to 80% of older Japanese maintained healthy functional capacity over time. Although we could not follow those who dropped out during the observation period, this study provided useful evidence that socioeconomic disparities in functional health converge with age. Our findings inform the design of health policies and interventions aiming to maintain functional health among older adults with diverse socioeconomic backgrounds. In particular, public policies aiming to reduce socioeconomic disparities should be emphasized to promote healthy aging.

Socioeconomic Status and the Trajectory of Body Mass Index Among Older Japanese: A Nationwide Cohort Study of 1987-2006.

OBJECTIVES: This research analyzed the body mass index (BMI) level and rate of change, and their association with socioeconomic status among older Japanese adults. METHODS: Data came from a national sample of over 4,800 Japanese adults aged 60 and older at baseline, with up to 7 repeated observations over a period of 19 years (1987-2006). Hierarchical linear modeling was used to analyze the intrapersonal and interpersonal differences in BMI. RESULTS: Average BMI among older Japanese was 22.26 at baseline and decreased with an accelerating rate over time. Relative to those with less education, BMI among older Japanese with more education was lower and it declined linearly at a faster rate over time. In contrast, higher household income at baseline was associated with a higher level of BMI but similar rates of decline over time. Furthermore, we found no evidence for age variations in the SES-BMI linkage as predicted by prior investigators. DISCUSSION: These findings provide new insights into the complex relationship between socioeconomic factors and BMI, and help to inform the design of health policies and interventions related to weight control among older adults with diverse socioeconomic backgrounds.

Socioeconomic stratification and multidimensional health trajectories: evidence of convergence in later old age.

OBJECTIVES: This research sought to examine socioeconomic stratification in the joint trajectories of physical, emotional, and cognitive functioning among older Americans and how it differs by age groups. METHODS: We used data from a nationally representative sample of 9,237 Americans age 65 or older from the Health and Retirement Study, who were observed biennially from 1998 to 2010. Joint trajectories of physical, emotional, and cognitive functioning were characterized using a group-based mixture model. We then applied multinomial logistic regression analysis to evaluate their linkages with socioeconomic status and how the linkages differ by age groups. RESULTS: We identified four distinct patterns of joint changes in physical, emotional, and cognitive functioning over time. Accounting for 29.3%, 23.5%, 24.5%, and 22.6% of the older Americans, respectively, these trajectory patterns characterized groups of individuals experiencing minimal to severe levels of impairment and deterioration. Lower education, income, and net worth were associated with trajectories featuring greater impairment or more rapid deterioration in these functional dimensions. Disparities based on education, however, attenuated in later old age, whereas health benefits associated with higher income and higher net worth persisted into advanced age. DISCUSSION: Distinct patterns of joint trajectories of physical, emotional, and cognitive functioning exist in old age. There were significant socioeconomic differences in the joint trajectories, with education-based inequality in health converging in later old age. Further research identifying strategies to alleviate the disproportionate burden of poor multidimensional health trajectories in lower socioeconomic groups is important.

The effect of stability and change in health behaviors on trajectories of body mass index in older Americans: a 14-year longitudinal study.

BACKGROUND: Obesity is increasingly prevalent among older adults, yet little is known about the impact of health behaviors on the trajectories of body weight in this age group. METHODS: We examined the effect of time-varying smoking, physical activity (PA), alcohol use, and changes thereof, on the 14-year (1992-2006) trajectory of body- mass index (BMI) in a cohort of 10,314 older adults from the Health and Retirements Study, aged 51-61 years at baseline. Hierarchical linear modeling (HLM) quantifies the effect of smoking, PA, and alcohol use (user status, initiation and cessation) on intercept and rate-of-change in BMI trajectory, and tests for variations in the strength of association between each behavior and BMI. RESULTS: Over 14 years (82,512 observations), BMI increased approximated by a quadratic function. Smoking and PA (user status and initiation) were associated with significantly lower BMI trajectories over time. Cessation of smoking and PA resulted in higher BMI trajectories over time. The weight-gaining effect of smoking cessation increased, while the strength of association between BMI trajectories and PA or alcohol use were constant over time. Socio-economic and health status differences explained the effects of alcohol use on BMI trajectory. CONCLUSIONS: In older adults, smoking and PA, and changes thereof, vary in their long-term effect on trajectories of BMI. Barring increases in PA levels, older smokers who quit today are expected to gain significantly more weight than two decades ago. This knowledge is essential for the design of smoking cessation, physical activityPA, and weight-control interventions in older adults.

The role of law in public health preparedness: opportunities and challenges.

We report the results of a study designed to assess and evaluate how the law shapes the public health system's preparedness activities. Based on 144 qualitative interviews conducted in nine states, we used a model that compared the objective legal environment with how practitioners perceived the laws. Most local public health and emergency management professionals relied on what they perceived the legal environment to be rather than on an adequate understanding of the objective legal requirements. Major reasons for the gap include the lack of legal training for local practitioners and the difficulty of obtaining clarification and consistent legal advice regarding public health preparedness. Narrowing the gap would most likely improve preparedness outcomes. We conclude that there are serious deficiencies in legal preparedness that can undermine effective responses to public health emergencies. Correcting the lack of legal knowledge, coupled with eliminating delays in resolving legal issues and questions during public health emergencies, could have measurable consequences on reducing morbidity and mortality.

Social stratification of body weight trajectory in middle-age and older americans: results from a 14-year longitudinal study.

OBJECTIVE: To depict the trajectory of BMI from middle to late adulthood and to examine social variations in BMI trajectories. METHOD: Eight waves (1992-2006) of the Health and Retirement Study involving a nationally representative sample of Americans aged 51 to 61 years at baseline were used. Changes in BMI were analyzed using hierarchical linear modeling with time-constant and time-varying covariates. RESULTS: BMI increased linearly over time. Compared with Caucasians, African-Americans had higher BMI levels, while Hispanics had similar BMI levels, but lower rates of increase over time. Higher education predicted lower BMI levels and was not associated with the rate of change. Younger age-at-baseline predicted lower BMI level and lower rate of increase. No gender differences were found. DISCUSSION: Observed racial/ethnic and educational differences in BMI trajectory from middle to old age inform policies and interventions aimed at modifying health risks and reducing health disparities in old age.