Changes in the role of explanatory factors for socioeconomic inequalities in physical performance: a comparative study of three birth cohorts.

BACKGROUND: Due to societal changes and changes in the availability of health promoting factors, explanatory factors of socioeconomic inequalities in health (SIH) may change with time. We investigate differences in the relative importance of behavioural, social and psychological factors for explaining inequalities in physical performance between three birth cohorts. METHODS: Data came from N = 988, N = 1002, and N = 1023 adults aged 55-64 years, collected in 1992, 2002 and 2012 as part of the Longitudinal Aging Study Amsterdam. Physical performance was measured by three performance tests. We included lifestyle factors (physical activity, smoking, alcohol use and Body Mass Index (BMI)); social factors (network size, network complexity, divorce, social support); and psychological factors (mastery, self-efficacy and neuroticism). In multi-group mediation models, we tested whether the strength of indirect effects from socioeconomic position (SEP) via the explanatory factors to health differed between birth cohorts. Stronger indirect effects indicate an increase in the importance; weaker indirect effects indicate a decrease in importance. RESULTS: Absolute SIH were present and similar across cohorts. The strength of indirect effects of SEP on physical performance through smoking, binge alcohol use, emotional support and mastery increased across cohorts. The indirect effects of BMI, network size, self-efficacy and neuroticism were similar across cohorts. CONCLUSIONS: Inequalities in smoking, binge alcohol use, emotional support and mastery may have become more important for explaining SIH in recent cohorts of middle-aged adults. Policies that aim to reduce socioeconomic inequalities may need to adapt their targets of intervention to changing mechanisms in order to reduce SIH.

Utilization of acute and long-term care in the last year of life: comparison with survivors in a population-based study.

BACKGROUND: It is well-known that the use of care services is most intensive in the last phase of life. However, so far only a few determinants of end-of-life care utilization are known. The aims of this study were to describe the utilization of acute and long-term care among older adults in their last year of life as compared to those not in their last year of life, and to examine which of a broad range of determinants can account for observed differences in care utilization. METHODS: Data were used from the Longitudinal Aging Study Amsterdam (LASA). In a random, age and sex stratified population-based cohort of 3107 persons aged 55 - 85 years at baseline and representative of the Netherlands, follow-up cycles took place at 3, 6 and 9 years. Those who died within one year directly after a cycle were defined as the "end-of-life group" (n = 262), and those who survived at least three years after a cycle were defined as the "survivors". Utilization of acute and long-term care services, including professional and informal care, were recorded at each cycle, as well as a broad range of health-related and psychosocial variables. RESULTS: The end-of-life group used more care than the survivors. In the younger-old this difference was most pronounced for acute care, and in the older-old, for long-term care. Use of both acute and long-term home care in the last year of life was fully accounted for by health problems. Use of institutional care at the end of life was partly accounted for by health problems, but was not fully explained by the determinants included. CONCLUSION: This study shows that severity of health problems are decisive in the explanation of the increase in use of care services towards the end-of-life. This information is essential for an appropriate allocation of professional health care to the benefit of older persons themselves and their informal caregivers.

How Is End-of-Life Care With and Without Dementia Associated With Informal Caregivers' Outcomes?

BACKGROUND: Palliative care for older people with life-limiting diseases often involves informal caregivers, but the palliative care literature seldom focuses on the negative and positive aspects of informal caregiving. OBJECTIVE: To assess the association of proximity to end of life (EOL) and dementia caregiving with informal caregivers' burden of care and positive experiences and explain differences in outcomes. DESIGN: Data on 1267 informal caregivers of community-dwelling older people were selected from a nationally representative cross-sectional survey and analyzed using analysis of variance and multivariable regression analyses. MEASUREMENTS: The Self-Perceived Pressure from Informal Care Scale and the Positive Experiences Scale were administered to assess caregiver burden and positive experiences with providing care. RESULTS: Dementia care, both at EOL and not at EOL, was associated with the most caregiver burden relative to regular care. Dementia care not at EOL was associated with the fewest positive experiences, and EOL care not in dementia with the most positive experiences. Only the differences in burden of care could be explained by variables related to stressors based on Pearlin stress-coping model. CONCLUSIONS: Informal caregivers of people with dementia are at risk not only of high caregiver burden but also of missing out on positive experiences associated with caregiving at EOL. Future research should examine how dementia-related factors reduce positive caregiving experiences, in order to make palliative care a positive reality for those providing informal care to community-dwelling persons with dementia.

The last 3 months of life: care, transitions and the place of death of older people.

Many older people die in hospitals, whereas research indicates that they would prefer to die at home. Little is known about the factors associated with place of death. The aim of the present study was to investigate the care received by older people in the last 3 months of their life, the transitions in care and the predictors of place of death. In this population-based study, interviews were held with 270 proxy respondents to obtain data on 342 deceased participants (79% response rate) in the Longitudinal Aging Study Amsterdam. In the last 3 months of life, the utilisation of formal care increased. Half of the community-dwelling older people and their families were confronted with transitions to institutional care, in most cases to hospitals. Women relied less often on informal care only, and were more dependent than men on institutional care. For people who only received informal care, the odds of dying in a hospital were 3.68 times the odds for those who received a combination of formal and informal home care. The chance of dying in a hospital was also related to the geographical region. The authors argue that future research is needed into the association that they found in the present study, i.e. that decedents who received both formal and informal care were more likely to die at home. In view of the differences found in geographical region in relation to place of death, further investigation of regional differences in the availability and accessibility of care is indicated.