Preventive healthcare use among males with multiple sclerosis.

OBJECTIVES: To understand preventive healthcare use by males with multiple sclerosis (MS). STUDY DESIGN: Cross-sectional survey with secondary comparative data. METHODS: Primary survey data were collected from male veterans with MS (n = 1142) and compared with national surveillance data for a general veteran population (n = 31,500) and a general population (n = 68,357). Analyses compared use by group and identified variables associated with service use by male veterans with MS. RESULTS: More veterans with MS had a cholesterol check (93%) than the general veteran population (89%, P < 0.001) and the general population (78%, P < 0.001). More veterans with MS had received annual influenza vaccination (69%) than the general veteran population (58%, P < 0.001) and the general population (42%, P < 0.001). More veterans with MS (81%) had ever received pneumonia vaccination than the general veteran population (67%) and the general population (51%) (P < 0.001). Colon screening was received by 55% of veterans with MS, 49% of the general veteran population (P < 0.001), and 39% of the general population (P < 0.0001). Fewer veterans with MS (34%) had received a prostate-specific antigen (PSA) test and digital rectal examination than the general veteran population (46%, P < 0.001) and the general population (36%, not significant). In males with MS, variables independently associated with cholesterol checks were: white race [odds ratio (OR) = 3.75] and living in the south (OR = 1.95); variables independently associated with influenza vaccination were increased age (OR = 1.03) and being a non-smoker (OR = 0.55); increased age was independently associated with colon screening (OR = 1.02); variables independently associated with PSA testing were increased age (OR = 1.08) and being employed (OR = 3.31), and being unemployed was independently associated with pneumonia vaccination (OR = 0.16). CONCLUSIONS: More males with MS received several recommended preventive health services (e.g. cholesterol and colon screening, influenza and pneumonia vaccination) than males without MS. The Veterans Health Administration is meeting many prevention needs in males with MS, but there is room for improvement in areas such as reducing disparities in PSA screening and increasing respiratory vaccinations to meet national targets.

A case-control study of large bowel cancer and hormone exposure in women.

Several lines of evidence indicate a potential role for hormonal or reproductive factors in the subsequent development of large bowel cancer in women. To evaluate the relationship between hormone exposure and large bowel cancer a case-control study was carried out in 18 Illinois hospitals. Female cases, ages 45-74 (n = 90), and controls (n = 208) were identified from an ongoing large bowel cancer study. Data were obtained from medical records, personal interviews, and a subsequent mail survey with a questionnaire specific to hormone usage. Menopausal estrogen use was found to be protective with respect to the subsequent development of large bowel cancer with an odds ratio of 0.6 (95% CI, 0.33-0.99). This effect remained after controlling individually for age at diagnosis, ever pregnant (yes/no), parity, age at first birth, hysterectomy with documented oophorectomy, cholecystectomy, and appendectomy. Simultaneous adjustment, using logistic regression, for age at diagnosis, parity, hysterectomy, and cholecystectomy resulted in an adjusted odds ratio for menopausal estrogen use and large bowel cancer of 0.5 (95% CI, 0.27-0.90). Subsite analysis revealed the protective effect to be strongest for the rectal cancer cases. These data support the hypothesis that exogenous hormones may alter the risk of large bowel cancer in women.

Measurement issues in preventive strategies: past, present, and future.

Prevention of the chronic health conditions of older people can potentially affect both life expectancy and health. In the past, fatal conditions, namely coronary heart disease, cancer, and stroke, dominated work on preventive strategies with the only outcome of concern being mortality. The present increasing life expectancy of the population has put persons at risk for the nonfatal and often disabling conditions of old age, such as dementia, osteoporosis and hip fracture, sensory impairments, and arthritis, to name a few. These conditions have major effects on, not the quantity, but the quality of life. In the future, quality of life measured in a variety of ways will be necessary to evaluate the effects of preventive strategies for nonfatal conditions.

A morbidity study of former pentachlorophenol-production workers.

Pentachlorophenol (PCP) is a pesticide that was once widely used for wood preservation. Commercial PCP contained impurities including higher chlorinated dibenzo-p-dioxins (CDDs) and chlorinated dibenzofurans (CDFs). We investigated the effects of occupational exposure to PCP and its CDD and CDF contaminants on the skin, liver, porphyrin metabolism, and central and peripheral nervous systems. In 1986 we conducted a medical survey of 366 workers who had been engaged in the production of PCP at a single plant between 1938 and 1978. The referent group consisted of 303 workers from the same plant who were not exposed to these or related compounds. Exposure was determined from computerized personnel records. The medical survey included an administered questionnaire, medical record review, physical examination by dermatologists, internists, and neurologists, and analysis of 24-hr urine for quantitative porphyrins among other tests. In this paper we present the results of analyses of the general health, chloracne, and porphyrin metabolism end points. The general health status of PCP workers was similar to unexposed workers, but 17.8% of PCP workers had evidence of current or past chloracne. PCP workers with chloracne had significantly higher mean urinary excretion of coproporphyrins (117. 0 vs. 90.6 microg/24 hr) than unexposed workers after controlling for potential confounders. Workers with chloracne who had worked with both PCP and polychlorinated biphenyls had significantly higher mean urinary excretions of hepta-, penta-, and coproporphyrins than unexposed workers. We conclude that occupational exposure to PCP is associated with chloracne and biochemical abnormalities which may persist years after exposure.

Applying the realized probability of dying to cancer survival.

Age comparisons of survival in cancer cohorts generally utilize relative survival rates, which are based on indicators of the probability of survival for a given number of years after diagnosis. Cancer relative survival rates for the same number of years tend to decline as age at diagnosis increases. However, the same number of years of survival reflects higher relative longevity at older ages than at younger ages. The realized probability of dying (RPD) is a survival measure that expresses individual survival time after diagnosis relative to the survival distribution of an age-, race-, and sex-specific reference population, in effect weighing individual survival time more heavily as age at diagnosis increases. The purpose of this study was to apply the RPD as a survival measure in cancer epidemiology. Two cohorts of cancer patients, white males with prostate cancer and white females with breast cancer, aged 55 years and over at diagnosis, were followed for 15 years. Although older subjects survived less time after diagnosis than younger subjects, they achieved more favorable RPD values. We present survival analysis methods for analyzing the RPD in this population, an approach not previously used with this measure. The implications for use of the RPD in cancer epidemiology are discussed.

Nursing home admission for African Americans with Alzheimer's disease.

BACKGROUND: For African Americans with Alzheimer's disease (AD), little is known about the time to, and risk factors for, nursing home admission (NHA). Using Consortium To Establish a Registry for Alzheimer's Disease (CERAD) data, this study provides information on NHA for African Americans. METHODS: This longitudinal study followed subjects (N=122) for as long as 7 years and used survival analysis methodology and variable values at baseline and at follow-up to identify NHA risk factors. Studied were sociodemographic variables, physical symptom and disease status variables, the Blessed Dementia Rating Scale (including subscores), the Clinical Dementia Rating (CDR), and the Mini-Mental State Examination. RESULTS: Only 25% of African Americans with AD were estimated to have had a NHA by 3.4 years (confidence interval 2.1, 5.4). Being unmarried resulted in a five times earlier NHA (p< .01), and each unit increase in the CDR resulted in a 74% earlier NHA (p<.01). In the absence of the CDR, limitation in activities of daily living was associated with earlier NHA (p<.05). CONCLUSIONS: Findings suggest that African Americans with AD spend a substantial time in the community prior to NHA, a longer time than observed in similar studies among whites. This raises public health and clinical concern that African Americans with AD may be residing in the community with substantial unmet needs, and that their caregivers have potentially high levels of burden. The independent associations with time to NHA observed here, although few in number, are consistent with other related research.

Medical conditions differentially affect the development of IADL disability: implications for medical care and research.

Using The Longitudinal Study of Aging, we determined the independent effects of nine self-reported medical conditions on the likelihood of developing specific instrumental activities of daily living (IADLs) disabilities at three points in time. We controlled for demographic factors and self-reported health status. The various medical conditions differentially affect each specific IADL disability, and each IADL disability has its own set of predictors which, in general, do not vary over time. The differential effects of thse predictors need to be taken into consideration by researchers, clinicians, and policymakers when studying disability and when implementing and evaluating programs to reduce disability.

Change in the number of informal helpers of frail older persons.

Little is known of the extent to which helper networks of frail older persons change over time and what factors are associated with change. Few national estimates of the scope of change exist to aid policy planners. This study provides national estimates of changes in the size of the informal helping network of frail elderly by sociodemographic and functional status subgroups of this segment of the population. The data are drawn from the 1982-84 National Long Term Care Survey, which included longitudinal followup of 4,530 respondents living in the community at both times. Bivariate patterns of change over 2 years in the number of informal helpers were analyzed. Sociodemographic factors (sex, age group, and race) of the frail elderly may be more important influences on change in the number of helpers than functional status expressed in terms of their limitations in activities of daily living.

Use of medical care by African American and White older persons: comparative analysis of three national data sets.

Historically, there has been a large gap between African Americans and Whites in access to health care, but this gap was ostensibly lessened by the advent of Medicare and Medicaid for older adults in the mid 1960s. The extent to which older African Americans continue to receive less access to medical care as a result of economic inequalities, institutionalized forms of discrimination, and life-style factors remains a subject of policy debate. Empirical enquiry has produced inconsistent results. The purpose of this study is to test the same set of models of medical use using identically measured predictor variables in three nationally representative data sets of older Americans: 1984 Study of Aging (SOA); 1984 National Long-Term Care Survey (NLTC); and the 1987 National Medical Care Expenditure Survey (NMES). Multivariate logistic regression of use of physician and hospital services and Poisson regression of amount of service use identified inconsistent results in race differences across data sets, but consistent results in terms of the importance of health status and insurance as predictors of use and amount of use. The findings suggest that health status and financial resources may be more relevant areas for policy interventions than considerations related to race and ethnicity.

Time to nursing home admission for persons with Alzheimer's disease: the effect of health care system characteristics.

OBJECTIVE: To study the influence of state health care system characteristics on time to nursing home admission (NHA) for persons with Alzheimer's disease (AD). METHOD: Up to nine years of Consortium to Establish a Registry for Alzheimer's Disease (CERAD) data on 639 non-Latino White individuals were merged with longitudinal data from the 28 states in which the CERAD participants resided. The state variables reflected characteristics of each state's long-term care (LTC) system, including Medicaid LTC spending practices and the supply of LTC providers. Cox Proportional Hazards Models with time-varying covariates were used to evaluate the risk factors associated with time to NHA. RESULTS: There was differential influence of state variables by marital status. For unmarried non-Latino White persons with AD, a higher percentage of Medicaid LTC spending on home and community-based services (HCBS) was significantly associated with a longer time to NHA. For married persons, a greater number of home health agencies was associated with a longer time to NHA. Other associations also varied by marital status. CONCLUSION: Study findings support the utility of targeted continued expanded provision of HCBS by states and provide a basis for future research regarding the impact of changing state health care systems on LTC utilization for persons with AD.

Minority use of community long-term care services: a comparative analysis.

A series of national surveys since 1982 have examined health needs of elders. Small proportions of minority elders in each sample have limited our understanding of service use by minorities. This research sought to determine (1) the extent to which minorities have restricted use of community long-term care services as a result of socioeconomic status, family structure, and health status, and (2) the replicability and validity of results across three national surveys: Supplement on Aging, National Long-Term Care, and National Medical Expenditure. Results indicate no bivariate or multivariate differences between African American, Hispanic, or White frail older persons in use of community long-term services. Living arrangements, Medicaid use, and overall health and functional status were primary predictors of service use. Taking methodological limitations into account, the results suggest similarity in processes influencing use of community long-term care services for African American and White older persons.

Urinary incontinence in Wisconsin skilled nursing facilities: prevalence and associations in common with fecal incontinence.

OBJECTIVES: This article reports the characteristics associated with fecal incontinence (FI) in a nursing home population that are also associated with urinary incontinence (UI). METHOD: A cross-sectional survey composed of data from the Wisconsin Center for Health Statistics' Annual Nursing Home Survey in 1992 and 1993. Demographic characteristics, functional status, and disease histories were correlated with UI. RESULTS: Data were available for 18,170 and 17,117 residents respectively, 56% of who were to varying degrees incontinent of urine in each year. Significant positive associations with UI included, in order of adjusted odds ratios: FI, truncal restraints, dementia, female gender, impaired vision, stroke, and constipation. Inverse associations were age, body mass index, tube feedings, and pressure ulcers. Diabetes, heart disease, arthritis, fecal impaction, and race were not associated with UI. CONCLUSIONS: UI frequently coexists with FI in nursing home residents. FI and UI differ in their association with age, body mass, and gender.

Older adults and assistive devices: use, multiple-device use, and need.

Responses of older adults ( greater than 65 years) from the 1990 National Health Interview Survey and Assistive Device Supplement are analyzed to determine if selected demographic and health variables are associated with the use of assistive devices, multiple-device use, and the expressed need for such devices. Bivariate and multi-variate analyses show that, in general, poorer health is consistently associated with the use of assistive devices, multiple-device use, and expressed need. Demographic characteristics, however, vary in their relationships to assistive device use and need. Findings support the importance of considering multiple-device use and expressed need in studying assistive devices and older adults.

Do falls predict institutionalization in older persons? An analysis of data from the Longitudinal Study of Aging.

Data from the Longitudinal Study of Aging (LSOA) were analyzed to estimate the subsequent risk of institutionalization associated with a report of one or more falls, and to determine if the association is affected by controlling for demographic traits, chronic conditions, and disabilities present at baseline. Risk was estimated at two time points, 2 years and 4 years after baseline interview. A report of multiple falls at baseline was associated with an increased risk of institutionalization at both 2 years (odds ratio [OR] 3.1; 1.9-5.3) and 4 years (OR 2.6; 1.6-4.4) of follow-up. The risk was decreased but remained significant in a model controlling for age, sex, marital status, and selected chronic conditions associated with both report of falls and institutionalization. However, multiple falls were not significantly associated with institutionalization when measures of disability (number of difficulties with activities of daily living) were added to the model. These analyses suggest that multiple falls should be regarded as an important sentinel event to alert caregivers to the presence of underlying disease and disability that may require intervention.

Occupational hazard exposure and at risk drinking.

This study examined associations between workers' reported exposure to occupational hazards and at risk drinking. A sample of 15,907 working adults was drawn from the 1985 National Health Interview Survey (NHIS) (weighted sample represented 85,395,000 workers). This was the only year the NHIS included questions on both occupational hazard exposure and at risk drinking. Occupational hazard exposures included chemical/biological substances, physical hazards, injury risk, and mental stress. At risk drinking was defined as binge drinking and drinking and driving. Prevalence adjusted odds ratios were estimated. Sixty percent of workers reported exposure to one or more occupational hazards with considerable variation among and within occupations. In all, 31% reported binge drinking and 15% drove after drinking too much. In a multivariate analysis that controlled for background characteristics, workers who reported occupational hazard exposures were 1.2 to 1.4 times more likely to engage in binge drinking than workers without exposures. Similar results were found for drinking/driving. All multivariate results were statistically significant. Findings suggest workers who report occupational hazard exposures are at greater risk of both binge drinking and drinking/driving. Occupational and environmental health nurses can lead workplace initiatives to reduce occupational hazard exposure and, simultaneously, invest in health promotion efforts to curb at risk drinking among workers.

Fecal incontinence in Wisconsin nursing homes: prevalence and associations.

INTRODUCTION: This report determines the characteristics and health histories that are associated with fecal incontinence in a nursing home population. METHODS: A cross-sectional survey is reported comprised of data from the Health Care Finance Administration's Minimum Data Set submitted by Wisconsin skilled nursing facilities to the Wisconsin Center for Health Statistics' Annual Nursing Home Survey in 1992 and 1993. Demographic characteristics, functional status, and disease history were correlated with the dependent variable, fecal incontinence. RESULTS: In both 1992 and 1993, significant positive associations with fecal incontinence included the following, in order of adjusted odds ratios: urinary incontinence, tube feeding, any loss of activities of daily living, diarrhea, truncal restraints, pressure ulcers, dementia, impaired vision, fecal impaction, constipation, male gender, age, and increasing body mass index. Significant inverse associations were noted for heart disease and depression in one of the years and arthritis in both years. In both years, diabetes was not associated with fecal incontinence. CONCLUSION: Urinary incontinence frequently coexists with fecal incontinence. The treatment of fecal incontinence may depend more on awareness of these significant associations, such as tube feeding, impaction, diarrhea, and loss of activities of daily living, which might exacerbate fecal incontinence, than on the condition of the anal sphincter.

Community-based prevalence of anal incontinence.

OBJECTIVE: To determine the prevalence of and characteristics associated with anal incontinence in the general community. SETTING: Community survey. PARTICIPANTS: The population of the state of Wisconsin sampled in the Wisconsin Family Health Survey. Subjects were identified by random digit dialing with telephone interview. The individual within each household identified as most knowledgeable about the health status of all other members of the household was asked about the health status of each member of the household. Approximately 200 households were surveyed each month. MAIN OUTCOME MEASURES: The presence of anal incontinence to solid or liquid feces or gas, who suffered from it, the frequency of anal incontinence, and how the incontinent person coped with it. RESULTS: A total of 2570 households comprising 6959 individuals were surveyed, and 153 individuals were reported to have anal incontinence, representing 2.2% of the population (95% confidence interval [Cl], +/- 0.3%). Thirty percent of the incontinent subjects were older than 65 years, and 63% were women. Of those with anal incontinence, 36% were incontinent to solid feces, 54% to liquid feces, and 60% to gas. In a multivariate analysis, independent associations of the following risk factors with anal incontinence were found: female sex (odds ratio [OR], 1.5; Cl, 1.1 to 2.1), age (continuously adjusted) (OR, 1.01; Cl, 1.01 to 1.02), physical limitations (OR, 1.8; Cl, 1.2 to 2.7), and poor general health (OR, 1.6; Cl, 1.4 to 1.9). CONCLUSIONS: Anal incontinence was reported in 2.2% of the general population. Independent risk factors for incontinence include female sex, advancing age, poor general health, and physical limitations.

Selected issues in long-term care: profile of cognitive disability of nursing home residents and the use of informal and formal care by elderly in the community.

In summary, this section suggests that hospital care and physician office care are frequently used community health care services. There were relatively few differences by sex, age, or race in patterns of community health service use. There were differences by sex, age, race, and level of ADL disability in the number of informal helpers a frail elder used. Marital patterns appear to be an important underlying influence on the number of informal helpers. When a spouse is present, he or she becomes the primary and only helper in many instances. The number of informal helpers that a frail elder had was associated with an increased risk of mortality and institutionalization. Overall, there is somewhat more stability than change in the number of informal helpers over the 2-year period. This section, however, could not identify if the composition of the informal helper network remained the same over time.

The influence of parity and exogenous female hormones on the risk of colorectal cancer.

Evidence that female sex hormones may play a role in the subsequent development of colorectal cancer has accumulated from time trends in colorectal cancer rates and from epidemiologic studies. Using data available from the Cross Cancer Institute Northern Alberta Cancer Program, the relationship of parity, exogenous hormones and colorectal cancer was evaluated. Five hundred and twenty-eight colon cancer and 192 rectal cancer cases were identified and 349 nonendocrine cancers were selected as controls. All subjects were diagnosed and interviewed between 1969 and 1973. Protective associations between previous pregnancies and colorectal cancer were found in women over age 50 at diagnosis (OR = 0.5, 95% CI = 0.3-0.9) and in women who never used exogenous hormones (OR = 0.3, 95% CI = 0.2-0.7). Results from this study provide additional support for earlier suggestions that parity may have a protective effect against the development of colorectal cancer, similar to the effects reported in the case of breast, endometrial and ovarian tumors.

Mortality, disability, and falls in older persons: the role of underlying disease and disability.

BACKGROUND: Falls are prevalent in older persons and can have serious consequences. METHODS: Data from the Longitudinal Study on Aging were analyzed to study the relationship between falls and both mortality and functional status in 4270 respondents age 70 and over. The effects of demographic traits, chronic conditions, and disability present at baseline were controlled for by means of multivariable analyses. RESULTS: Risk of death within 2 years was greater for both single fallers (crude odds ratio [OR], 1.5; 95% confidence interval [CI], 1.1-2.0) and multiple fallers (crude OR, 2.2; 95% CI, 1.7-2.8). This excess risk was dissipated when selected covariates were added to the model. No crude or adjusted association was evident between single falls and functional impairment; however, multiple falls were an independent risk factor (adjusted OR, 1.6; 95% CI, 1.2-2.0). CONCLUSIONS: Multiple falls in older persons increase risk of functional impairment and may indicate underlying conditions that increase risk of death.