Cost-effectiveness of an intervention to reduce fear of falling.

OBJECTIVES: The aim of this study was to assess whether a multicomponent cognitive behavioral group intervention is preferable to usual care in terms of (healthcare) costs and effects on fear of falling and activity avoidance. METHODS: This economic evaluation was embedded in a randomized controlled trial among 540 community-living adults in the Netherlands, aged 70 years and older who reported fear of falling and fear-induced activity avoidance. The participants allocated to the intervention group received a multicomponent cognitive behavioral group intervention consisting of eight weekly sessions and a booster session. The sessions were aimed at instilling realistic views of falls, reducing fall risk, and increasing activity and safe behavior. Participants in the control group received usual care. Cost outcome measures were healthcare costs, and patient and family costs. Clinical outcomes were fear of falling and activity avoidance. All outcomes were assessed at baseline and at 2, 8, and 14 months by means of registration forms, self-administered questionnaires, and interviews by telephone. RESULTS: Participants were randomly allocated to intervention (n = 280) and control groups (n = 260). Costs for the intervention program were on average €276 per person. Total costs per person were comparable (€4,925 in intervention group and €4,828 in control group). Furthermore, favorable effects of the program were observed for fear of falling and activity avoidance. CONCLUSIONS: This study showed that the intervention program is preferable to usual care in terms of costs and effects. The program had comparable costs and significantly reduced fear of falling and associated activity avoidance among older community-living persons.

Integrating nurse-led Self-Management Support (SMS) in routine primary care: design of a hybrid effectiveness-implementation study among type 2 diabetes patients with problems of daily functioning and emotional distress: a study protocol.

BACKGROUND: Psychosocial problems are more prevalent among patients with chronic diseases than among the general population. They may lead to a downward spiral of poor adherence, deterioration of the condition and decline in daily functioning. In addition to medical management, systematic attention to emotional and role management tasks during routine chronic care seems mandatory. We intend to integrate an existing nurse-led minimal psychological intervention to support patients' self-management, which appeared to be effective and cost-effective, in routine care by primary care nurses, so we adjusted it to fit the host setting. The resulting Self-Management Support (SMS) programme involves early detection of patients with emotional distress and problems of daily functioning, as well as self-management support through problem solving and reattribution techniques. Strategies to embed SMS in daily practice include training and booster sessions for practice nurses as well as organisational and financial arrangements. This study aims to simultaneously evaluate the implementation process and effects of SMS in routine care, using a hybrid effectiveness-implementation design. METHODS/DESIGN: Registration data, questionnaires and interviews will be used to explore the facilitators, barriers and costs regarding successful implementation of SMS. The effects of SMS will be evaluated in a pragmatic cluster-randomised controlled trial with a baseline measurement and follow-up measurements after 4 and 12 months. The population will consist of 46 practice nurses and their type 2 diabetes patients (N = 460; 10 per practice nurse). The practice nurses will be randomly assigned to the intervention or control group. Practice nurses of the intervention group will receive SMS training. Patients for the intervention and control groups will be recruited by a researcher-led self-administered screening procedure to decide which patients of those scheduled for routine consultation are likely to be detected by the practice nurses as eligible for the self-management support. Primary outcome measure is patients' daily functioning. Secondary measures include emotional well-being, participation, autonomy and control over the disease. DISCUSSION: Our hybrid study design is complicated by the detection method used by the practice nurses. This method is an implementation issue in itself that has consequences for the realisation and power of the effect evaluation. TRIAL REGISTRATION: Current Controlled Trials, NTR2764.

Unhealthy lifestyles do not mediate the relationship between socioeconomic status and incident depressive symptoms: the Health ABC study.

BACKGROUND: The relationship between low socioeconomic status (SES) and depressive symptoms is well described, also in older persons. Although studies have found associations between low SES and unhealthy lifestyle factors, and between unhealthy lifestyle factors and depressive symptoms, not much is known about unhealthy lifestyles as a potential explanation of socioeconomic differences in depressive symptoms in older persons. METHODS: To study the independent pathways between SES (education, income, perceived income, and financial assets), lifestyle factors (smoking, alcohol use, body mass index, and physical activity), and incident depressive symptoms (Center for Epidemiologic Studies-Depression [CES-D 10] and reported use of antidepressant medication), we used 9 years of follow-up data (1997-2007) from 2,694 American black and white participants aged 70-79 years from the Health, Aging, and Body Composition (Health ABC) study. At baseline, 12.1% of the study population showed prevalent depressive symptoms, use of antidepressant medication, or treatment of depression in the 5 years prior to baseline. These persons were excluded from the analyses. RESULTS: Over a period of 9 years time, 860 participants (31.9%) developed depressive symptoms. Adjusted hazard ratios for incident depressive symptoms were higher in participants from lower SES groups compared with the highest SES group. The strongest relationships were found for black men. Although unhealthy lifestyle factors were consistently associated with low SES, they were weakly related to incident depressive symptoms. Lifestyle factors did not significantly reduce hazard ratios for depressive symptoms by SES. CONCLUSION: In generally healthy persons aged 70-79 years, lifestyle factors do not explain the relationship between SES and depressive symptoms.

Effectiveness of a minimal psychological intervention to reduce mild to moderate depression and chronic fatigue in a working population: the design of a randomized controlled trial.

BACKGROUND: In a working population, common mental complaints like depressed mood and chronic fatigue are highly prevalent and often result in further deterioration of mental health and consequently absence from work. In a large occupational health setting, we will evaluate the (cost-) effectiveness of a Minimal Psychological Intervention (MPI), in reducing symptoms of depression and chronic fatigue in a working population. The MPI is also evaluated regarding its appreciation by worker, nurse, and occupational health physician (process evaluation). The tailor-made intervention is administered by nurses, who are trained in the principles of cognitive behavioural therapy and self-management. METHODS/DESIGN: The presented WoPaCoM study (Work Participation of Workers with Common Mental complaints) is a two-armed randomized controlled trial, comparing MPI with usual care. A total number of 124 workers suffering from (chronic) mental fatigue or mild to moderate depression will be included. A stratified and block randomization will be applied, stratifying by customer organisation, income, and gender, using a block size of four. It will include a baseline measurement and subsequently follow up measurements after 4, 6 and 12 months. The primary outcome measures are symptoms of either fatigue (using the Checklist Individual Strength) and/or depression (using the Beck Depression Inventory) and secondary outcome measures include sickness absence, self efficacy, costs and quality of life. Analysis will include both univariate and multivariate techniques and data will be analysed according to the intention to treat principle. DISCUSSION: Patient recruitment in an occupational setting proves to be complicated and time consuming. Shift work for instance proved to be an obstacle for making appointments for consultation with the nurse. Furthermore, economic developments might have created job insecurity which negatively influenced participation in the study, with workers being anxious to be detected as having psychological problems. Additionally, long-term follow-up in a working population is time-consuming and continuously engages occupational health staff and administrative personnel to control the process of data gathering. However, if the intervention proves to be effective, occupational medicine will have a manageable option for treatment of workers who are at risk of loss of productivity or sickness absence. TRIAL REGISTRATION: Nederlands Trialregister NTR3162.

Socioeconomic factors from midlife predict mobility limitation and depressed mood three decades later; findings from the AGES-Reykjavik Study.

BACKGROUND: Taking into account our rapidly ageing population, older people are of particular interest in studying health inequalities. Most studies of older persons only include measures of current socioeconomic status (SES) and do not take into account data from earlier stages of life. In addition, only classic SES measures are used, while alternative measures, such as car ownership and house ownership, might equally well predict health. The present study aims to examine the effect of midlife socioeconomic factors on mobility limitation and depressed mood three decades later. METHODS: Data were from 4,809 men and women aged 33-65 years who participated in the Reykjavik Study (1967-1992) and who were re-examined in old age in the Age, Gene/Environment Susceptibility (AGES) -Reykjavik Study (2002-2006). RESULTS: Education and occupation predicted mobility limitation and depressed mood. Independently, home and car ownership and the availability of housing features predicted mobility limitation. Shortages of food in childhood and lack of a car in midlife predicted depressed mood. CONCLUSION: Socioeconomic factors from midlife and from childhood affect mobility limitation and depressed mood in old age. Prevention of health problems in old age should begin as early as midlife.

The ideal of biopsychosocial chronic care: how to make it real? A qualitative study among Dutch stakeholders.

BACKGROUND: Chronically ill patients often experience psychosocial problems in everyday life. A biopsychosocial approach is considered to be essential in chronic care. In Dutch primary health care the current biomedically oriented clinical practice may conflict with the biopsychosocial approach. This study is aimed to explore the views of Dutch stakeholders on achieving a biopsychosocial approach to the care of patients with chronic diseases. METHODS: In a qualitative explorative study design, we held semi-structured interviews with stakeholders, face-to-face or by telephone. Data were analysed using content analysis. Thirty representatives of Dutch patients with chronic illnesses, primary care professionals, policy makers, health inspectorate, health insurers, educational institutes and researchers were interviewed. RESULTS: Stakeholders were aware that a systematic biopsychosocial care approach is lacking in current practice. Opportunities for effective change are multidimensional. Achieving a biopsychosocial approach to care relates to active patient participation, the training of professionals, high-quality guidelines, protocols and tools, integrated primary care, research and financial issues. CONCLUSIONS: Although the principles and importance of the biopsychosocial model have been recognized, the provision of care that starts from the medical, emotional or social needs of individual patients does not fit in easily with the current Dutch health care system. All parties involved need to make a commitment to realize the ideal of biopsychosocial chronic care. Together they need to equip health professionals with skills to understand patients' multifaceted needs and to reward integrated biopsychosocial care. Patients need to be empowered to be active partners in their own care.

Racial differences in mortality in older adults: factors beyond socioeconomic status.

BACKGROUND: Little is known about the simultaneous effect of socioeconomic status (SES), psychosocial, and health-related factors on race differences in mortality in older adults. PURPOSE: This study examined the association between race and mortality and the role of SES, health insurance, psychosocial factors, behavioral factors, and health-related factors in explaining these differences. METHODS: Data consisted of 2,938 adults participating in the Health, Aging and Body Composition study. Mortality was assessed over 8 years. RESULTS: SES differences accounted for 60% of the racial differences in all-cause mortality; behavioral factors and self-rated health further reduced the disparity. The racial differences in coronary heart disease mortality were completely explained by SES. Health insurance and behavioral factors accounted for some, but not all, of the race differences in cancer mortality. CONCLUSIONS: Race-related risk factors for mortality may differ by the underlying cause of mortality.

Good friends, high income or resilience? What matters most for elderly patients?

BACKGROUND: Chronically ill patients need to adapt to their impaired life condition. Social (e.g. social support), material (e.g. income) and personal (e.g. mastery) resources are needed to cope with this challenge. It is, however, less clear whether these factors also contribute to 'relatively successful functioning' and whether these effects are disease specific or generic across chronic diseases. METHODS: Baseline data from 361 Dutch men and women aged≥60 years who were mildly depressed and diagnosed with type 2 diabetes or chronic obstructive pulmonary disease (COPD) were used. These persons participated in the 'Depression in Elderly with Long-Term Afflictions' (DELTA) study. Logistic regression analyses were used to study the independent association of social support, income and mastery (independent variables) with physical, mental and social functioning (dependent variables). RESULTS: A high level of mastery is significantly associated with physical, mental and social functioning in the total study population, as well as in subgroups of patients with COPD or diabetes. This relationship remained significant after controlling for confounding factors such as gender, age, educational level and the other remaining resources. In diabetes patients, high levels of social support and income also contributed significantly to successful social functioning. CONCLUSION: Our findings suggest that rather than having good friends and a high income, having a high level of mastery (resilience) might best help chronically ill patients in coping with and adapting to their often co-morbid condition. Further longitudinal research is necessary to unravel the long-term effects of mastery, income and social support on 'relatively successful functioning' in chronically ill patients.

Material vs. psychosocial explanations of old-age educational differences in physical and mental functioning.

BACKGROUND: Taking into account our rapidly ageing population, older people are of particular interest in studying health inequalities. The aim of the present study is to examine the relation between socio-economic status and health-related functioning in older people and to find out how material factors (e.g. the lack of basic goods) and psychosocial factors (e.g. low self-efficacy) compare regarding the explanation of these socio-economic differences. METHODS: Data came from 5061 Dutch men and women aged ≥ 55 years who participated in the longitudinal Study on Medical Information and Lifestyles Eindhoven (SMILE) study. Baseline data were collected between November 2002 and May 2004 and respondents were followed until May 2009 (follow-up range: 0-5 years). Multilevel analyses were used to study the association between educational level and longitudinal changes in physical and mental functioning (i.e. two subscales of the SF-36) and to study the relative contribution of material and psychosocial factors to this relation. RESULTS: Low educational level was associated with poor initial physical and mental functioning. However, no further widening of these gradients was found during follow-up. Material factors reduced the initial educational differences by an average of 29%, whereas psychosocial factors, mastery and self-efficacy in particular, reduced these differences by an average of 60%. CONCLUSION: More than material factors, psychosocial factors, mastery and self-efficacy in particular, explained a large part of the educational differences in physical and mental functioning in older people. Further research is recommended to explore the amenability to change of characteristics that hamper people from taking control over their lives.

Treating depression in diabetes patients: does a nurse-administered minimal psychological intervention affect diabetes-specific quality of life and glycaemic control? A randomized controlled trial.

AIMS: The aim of this study was to examine whether a nurse-administered minimal psychological intervention for depressive symptoms improves diabetes-specific quality of life and glycaemic control in older persons with diabetes. BACKGROUND: Depression is common among persons with diabetes and may have a negative impact on diabetes. Interventions aimed at reducing depressive symptoms may positively influence diabetes-specific quality of life as well. METHODS: A pragmatic, randomized controlled trial was carried out comparing the intervention with usual care among 208 Dutch primary care patients of ≥60 years with type 2 diabetes and co-occurring minor to moderate depression. Data on symptom distress and emotional distress were collected during 2003-2006, and haemoglobin A1c levels were obtained from general practices. Data were analysed using mixed model, repeated measures ANCOVAS. Hba1c was collected retrospectively from general practices between December 2006-February 2007. In July 2007 we retrieved some additional HbA1c data from the medical records of the university hospital. RESULTS: Only in higher-educated persons did the intervention have statistically significant effect on both emotional distress and symptom distress (DSC-R total score at 9 months P=0.001; PAID, 9 months P=0.03). Furthermore, we found an effect on symptom distress in men (9 months P=0.01), and on emotional distress in persons with a shorter diabetes duration (<7 years) (9 months P=0.04). A significant trend over time for haemoglobin A1c was found in favour of the intervention, with a statistically significant difference between groups after 9 months (P=0.02). CONCLUSION: The nurse-administered intervention had limited effects on diabetes-specific quality of life. As only certain subgroups benefited, ways of increasing effectiveness in other groups should be explored. The potentially beneficial effect on glycaemic control is encouraging and needs further research because of small numbers in the analysis.

Better health reports when the grass is greener on your side of the fence?: a cross-sectional study in older persons.

OBJECTIVE: To study whether the luxury goods make older people feel in better health and whether this association is similar in higher and lower social classes. METHODS: SMILE consists of a Dutch general population consisting of 2.637 men and women aged 60 years and older in 2007. The SF-36 was used to measure health-related functioning. RESULTS: In the lower social class, having many luxury goods was related to feeling in better physical (OR 2.06, 95% CI 1.39-3.07) and mental health (OR 1.79, 95% CI 1.21-2.64), but not in the higher social class. CONCLUSIONS: There might be a health benefit of keeping up appearances, snobbism, and "conspicuous consumption" in older people from lower social classes.

Cost-utility estimates in depression: does the valuation method matter?

BACKGROUND: Depression imposes a substantial burden on society. In view of the economic burden of depression, studies evaluating depression treatment increasingly incorporate a cost-utility analysis. Outcomes of these analyses are used by decision makers to prioritize healthcare. Although generic preference-based instruments have been recommended for measuring utility, depression research often uses a disease-specific method, based on depression-free days (DFD), to measure utilities. AIMS OF THE STUDY: The objective of this study was to compare utility measurement techniques in the context of a randomized controlled trial. In particular, we studied the agreement between QALYs measured with the EuroQol (EQ-5D), the Short Form 6D (SF-6D), and the DFD method, using the EQ-5D as the reference method. We also studied whether the use of different techniques leads to different conclusions for decision makers. METHODS: Data were derived from the Depression in Elderly with Long-Term Afflictions (DELTA) study. This randomized controlled trial was designed to study the effectiveness and cost-effectiveness of a minimal psychological intervention for chronically ill patients with co-occurring minor or mild to moderate major depression. The EQ-5D, SF-6D and Beck Depression Inventory (to estimate DFDs) were assessed at baseline, and at three, six and twelve months after baseline. RESULTS: Poor agreement was found between the EQ-5D and DFD (Kendall's Tau: 0.33; ICC: 0.21 (95% CI:-0.07-0.45)) and moderate agreement between the EQ-5D and SF-6D (Kendall's Tau: 0.60; ICC: 0.47 (95% CI: 0.36-0.57)). The incremental cost-utility ratio led to similar conclusions for decision makers across techniques. DISCUSSION: In conclusion, utilities from the disease-specific DFD method should not be compared directly with utilities derived from the EQ-5D. Although a disease-specific method might yield similar cost-utility ratios as generic instruments, generic instruments remain the preferred option for prioritizing healthcare. Limitations of this study include the presence of minor depression and chronic illnesses in our study population. IMPLICATIONS: Generic instruments remain preferred for cost-utility analyses, especially when results are used to prioritize healthcare. If the DFD method is a way forward, further research is required to validate utility weights assigned to the DFDs.

Economic evaluation of a minimal psychological intervention in chronically ill elderly patients with minor or mild to moderate depression: a randomized trial (the DELTA-study).

OBJECTIVES: Depression is associated with high healthcare utilization and related costs. Effective treatments might reduce the economic burden. The objective of this study was to establish the cost-utility of a minimal psychological intervention (MPI) aimed at reducing depression and improving quality of life in elderly persons with diabetes or chronic obstructive pulmonary disease and co-occurring minor, mild, or moderate depression. METHODS: Trial-based cost-utility analysis was used to compare the MPI with usual care. Annual costs and quality-adjusted life-years (QALYs) based on the Euroqol (EQ5D) and on depression-free days were calculated. RESULTS: Annual costs and effects were not significantly different for the MPI group and care as usual. Bootstrap analysis indicated a dominant intervention, with a probability of 63 percent that the MPI is less costly and more effective than usual care. CONCLUSIONS: The cost-effectiveness analysis does not support dissemination of the MPI in its current form. The economic evaluation study showed limited probability that MPI is cost-effective over usual care. Further adjustments to the MPI are needed to make the intervention suitable for dissemination in regular care. TRIAL REGISTRATION: isrctn.org, identifier: ISRCTN92331982.

The impact of a self-management group programme on health behaviour and healthcare utilization among congestive heart failure patients.

AIMS: The 'Chronic Disease Self-Management Programme' (CDSMP) emphasizes patients' responsibility for the day-to-day management of their condition(s) and has shown favourable effects on health behaviour and healthcare utilization among various groups of patients with chronic conditions. However, the effects of the CDSMP among congestive heart failure (CHF) patients are unknown. We therefore aimed to assess the effects of the CDSMP on health behaviour and healthcare utilization in patients with CHF. METHODS AND RESULTS: This randomized, controlled trial with 12 months of follow-up included 317 CHF patients with a slight to marked limitation of physical activity. Control patients (n = 131) received usual care, consisting of regular checkups at an outpatient clinic. Intervention group patients (n = 186) received usual care and participated in a 6-week self-management group programme. Favourable effects on walking for exercise and other physical activities such as aerobic, stretching, and strength exercises, sports, and gardening were reported in the intervention group immediately after completion of the programme. The effect of the programme on other physical activities extended to 6 months of follow-up. No favourable effects were found for the other outcomes. CONCLUSION: The CDSMP significantly improved physical activity among CHF patients for up to 6 months after the end of the programme; however, it did not affect other health behaviour outcomes or healthcare utilization.

Cost-effectiveness of a multidisciplinary fall prevention program in community-dwelling elderly people: a randomized controlled trial (ISRCTN 64716113).

OBJECTIVES: Multidisciplinary and multifactorial interventions seem to be effective in preventing falls. We aimed to assess the cost-effectiveness of a multidisciplinary fall prevention program compared with usual Dutch healthcare in community-dwelling people 65 years of age or older who experienced a fall. METHODS: Cost-effectiveness and cost-utility analysis were performed from a societal perspective. Falls and healthcare utilization were continuously measured for 12 months. Daily functioning and quality of life were measured at baseline, after 4 and 12 months. Bootstrap analyses were performed to estimate uncertainty of the findings and sensitivity analysis to assess the generalizability of assumptions made. RESULTS: One hundred sixty-six participants were randomly allocated to the experimental group and 167 to the control group. The overall response rate was 74 percent. Healthcare and patient and family costs of both groups were comparable. Our analyses showed no effect of the intervention program on falls, daily functioning, or quality of life measures. CONCLUSIONS: The multidisciplinary intervention program to prevent falls was not cost-effective compared with usual care in the Netherlands. Notwithstanding our findings, however, falls still have an important impact on society and individuals in terms of costs and effects. Economic evaluations studying promising interventions to prevent falls, therefore, remain necessary.

Material deprivation and health-related dysfunction in older Dutch people: findings from the SMILE study.

BACKGROUND: Even in generally wealthy Western countries material deprivation and poverty are not uncommon. There is, however, little data on the prevalence of material deprivation and its associations with health-related dysfunction in older people. METHODS: Cross-sectional data from the SMILE study were used to examine the prevalence of material deprivation and the associations between material deprivation and health-related dysfunction in persons aged 55 years and older (n > 4000). Material deprivation was measured with a comprehensive questionnaire assessing seven subdomains referring to current and anticipated financial problems and poverty in childhood. Health-related dysfunction was measured using the SF36-based physical and mental components. In addition, self-reported heart disease was examined as an indicator of health-related dysfunction as well. RESULTS: Almost 29% of subjects experienced at least one financial problem. Those reporting material deprivation had more than twice the risk of physical (OR = 2.22; 95% CI: 1.72-2.86) and mental (OR = 2.34; 95% CI: 1.84-2.97) dysfunction compared with non-deprived persons. A slightly weaker association was found when self-reported heart disease was used as an outcome variable (OR = 1.74; 95% CI: 1.40-2.15). Although odds ratios were generally higher for diseased older persons, no significant interaction effect between chronic disease and material deprivation subscales was found. CONCLUSIONS: Material deprivation in the Netherlands is not uncommon and is strongly related to both mental and physical dysfunction, and therefore needs further attention in public health policy. Longitudinal research is necessary to clarify the causal nature of our results and to develop appropriate interventions.

To what extent does IQ 'explain' socio-economic variations in function?

BACKGROUND: The aims of this study were to examine the extent to which higher intellectual abilities protect higher socio-economic groups from functional decline and to examine whether the contribution of intellectual abilities is independent of childhood deprivation and low birth weight and other socio-economic and developmental factors in early life. METHODS: The Maastricht Aging Study (MAAS) is a prospective cohort study based upon participants in a registration network of general practices in The Netherlands. Information was available on 1211 men and women, 24-81 years old, who were without cognitive impairment at baseline (1993-1995), who ever had a paid job, and who participated in the six-year follow-up. Main outcomes were longitudinal decline in important components of quality of life and successful aging, i.e., self-reported physical, affective, and cognitive functioning. RESULTS: Persons with a low occupational level at baseline showed more functional decline than persons with a high occupational level. Socio-economic and developmental factors from early life hardly contributed to the adult socio-economic differences in functional decline. Intellectual abilities, however, took into account more than one third of the association between adult socio-economic status and functional decline. The contribution of the intellectual abilities was independent of the early life factors. CONCLUSION: Rather than developmental and socio-economic characteristics of early life, the findings substantiate the importance of intellectual abilities for functional decline and their contribution--as potential, but neglected confounders--to socio-economic differences in functioning, successful aging, and quality of life. The higher intellectual abilities in the higher socio-economic status groups may also underlie the higher prevalences of mastery, self-efficacy and efficient coping styles in these groups.

How do people with COPD or diabetes type 2 experience autonomy? An exploratory study.

PURPOSE: To develop an empirically grounded conceptualization of personal autonomy in the context of chronic physical illness and to investigate the impact of two chronic illnesses on autonomy. METHOD: Grounded theory study consisting of 13 in-depth interviews with older adults with Chronic Obstructive Pulmonary Disease (COPD) or diabetes mellitus type 2 (diabetes). RESULTS: The results indicate that autonomy involves taking account of current circumstances as the frame of reference in which people can arrange their lives. Chronic illness disturbed autonomy by limiting opportunities and by prompting a reappraisal of the value that people placed on different activities or aspects of life. The participants responded to this disturbance differently, in ways that did not always restore autonomy. Limited opportunities occurred more often with COPD, while reappraisal occurred more often with diabetes. CONCLUSIONS: Personal autonomy in the context of chronic physical illness might be conceptualized as correspondence between the way people's lives are actually arranged and the way people want their lives to be arranged, considering the circumstances. Health professionals could stimulate their clients to prevent and overcome impasses in the realisation of autonomy, while broad self-management interventions might improve people's skills for coping with the impact of chronic illness on autonomy.

Socioeconomic differences in incident depression in older adults: the role of psychosocial factors, physical health status, and behavioral factors.

OBJECTIVE: The objective of this study was to examine the association between socioeconomic status (SES) and the onset of depression in older adults and to determine the relative contribution of psychosocial factors, physical health status, and behavioral factors in explaining this link. METHODS: Data were from 2593 men and women, aged 55-85 years, participating in the Longitudinal Aging Study Amsterdam. Two indicators of SES were used: education and income. The onset of depression was measured over 9 years of follow-up. RESULTS: Adjusted hazard ratios of incident depression were significantly higher in those with low education and low income. Psychosocial factors explained on average 16% of the SES differences in incident depression, physical health status on average 7%, and behavioral factors less than 5%. CONCLUSION: In older adults, low SES predicted the incidence of depression. Part of this association was explained by psychosocial factors and physical health status.

Explanations of socioeconomic differences in changes in physical function in older adults: results from the Longitudinal Aging Study Amsterdam.

BACKGROUND: This study examines the association between socioeconomic status and changes in physical function in younger- (aged 55-70 years) and older-old (aged 70-85 years) adults and seeks to determine the relative contribution of diseases, behavioral, and psychosocial factors in explaining this association. METHODS: Data were from 2,366 men and women, aged 55-85 years, participating in the Longitudinal Aging Study Amsterdam (LASA). Two indicators of socioeconomic status were used: education and income. Physical function was measured by self-reported physical ability over nine years of follow-up. RESULTS: In older adults, low socioeconomic status was related to a poorer level of physical function during nine years of follow-up. In subjects who were between 55 and 70 years old, there was an additional significant socioeconomic-differential decline in physical function, while socioeconomic differentials did not further widen in subjects 70 years and older. Behavioral factors, mainly BMI and physical activity, largely explained the socioeconomic differences in physical function in the youngest age group, while psychosocial factors reduced socioeconomic status differences most in the oldest age group. CONCLUSION: The findings indicate age-specificity of both the pattern of socioeconomic status differences in function in older persons and the mechanisms underlying these associations.