The Cumulative Impact of Chronic Stressors on Risks of Myocardial Infarction in US Older Adults.

OBJECTIVE: This study aimed to investigate the association between cumulative exposure to chronic stressors and the incidence of myocardial infarction (MI) in US older adults. METHODS: Nationally representative prospective cohort data of adults 45 years and older (n = 15,109) were used to investigate the association between the cumulative number of chronic stressors and the incidence of MI in US older adults. Proportional hazards models adjusted for confounding risk factors and differences by sex, race/ethnicity, and history of MI were assessed. RESULTS: The median age of participants was 65 years, 714 (4.7%) had a prior MI, and 557 (3.7%) had an MI during follow-up. Approximately 84% of participants reported at least one chronic stressor at baseline, and more than half reported two or more stressors. Multivariable models showed that risks of MI increased incrementally from one chronic stressor (hazard ratio [HR] = 1.28, 95% confidence interval [CI] = 1.20-1.37) to four or more chronic stressors (HR = 2.71, 95% CI = 2.08-3.53) compared with those who reported no stressors. These risks were only partly reduced after adjustments for multiple demographic, socioeconomic, psychosocial, behavioral, and clinical risk factors. In adults who had a prior MI (p value for interaction = .038), we found that risks of a recurrent event increased substantially from one chronic stressor (HR = 1.30, 95% CI = 1.09-1.54) to four or more chronic stressors (HR = 2.85, 95% CI = 1.43-5.69). CONCLUSIONS: Chronic life stressors are significant independent risk factors for cardiovascular events in US older adults. The risks associated with multiple chronic stressors were especially high in adults with a previous MI.

Socioeconomic determinants of childhood overweight and obesity in China: the long arm of institutional power.

Previous studies have widely reported that the association between socioeconomic status (SES) and childhood overweight and obesity in China is significant and positive, which lends little support to the fundamental-cause perspective. Using multiple waves (1997, 2000, 2004 and 2006) of the China Health and Nutrition Survey (CHNS) (N = 2,556, 2,063, 1,431 and 1,242, respectively) and continuous BMI cut-points obtained from a polynomial method, (mixed-effect) logistic regression analyses show that parental state-sector employment, an important, yet overlooked, indicator of political power during the market transformation has changed from a risk factor for childhood overweight/obesity in 1997 to a protective factor for childhood overweight/obesity in 2006. Results from quantile regression analyses generate the same conclusions and demonstrate that the protective effect of parental state sector employment at high percentiles of BMI is robust under different estimation strategies. By bridging the fundamental causes perspective and theories of market transformation, this research not only documents the effect of political power on childhood overweight/obesity but also calls for the use of multifaceted, culturally-relevant stratification measures in testing the fundamental cause perspective across time and space.

The effects of total knee arthroplasty on physical functioning and health among the under age 65 population.

OBJECTIVES: This study examined the effects of total knee arthroplasty on six measures of physical functioning, self-rated health, pain, earnings, and employment status among US adults aged 51 to 63 years at baseline. METHODS: Data came from the Health and Retirement Study, a nationally representative longitudinal study conducted biannually. The analysis sample consisted of individuals aged 51 to 63 years at baseline with arthritis who were resurveyed at 2-year intervals from 1996 to 2010. Propensity score matching was used to compare outcomes of persons receiving total knee arthroplasty (TKA) with those of matched controls. Six measures of physical functioning were examined: lower-body mobility problems, instrumental activities of daily living limitations, activities of daily living limitations, and large muscle, fine motor, and gross motor limitations. Self-rated health and pain were also examined. The two employment-related outcomes were earnings and employment status. RESULTS: Receipt of TKA was associated with better outcomes for several measures of physical functioning, especially mobility limitations, pain, and self-rated health. Receipt of TKA was not associated with increased earnings or employment. CONCLUSIONS: Receipt of TKA yields important improvements in physical function among persons with an arthritis diagnosis who received the procedure before reaching the age of 65 years. This study contributes to knowledge about the benefits of TKA in a community setting among nonelderly recipients of TKA.

Socioeconomic status and the Black-White mortality crossover.

OBJECTIVES: We investigated associations among age, race, socioeconomic status (SES), and mortality in older persons and whether low SES contributes to the Black-White mortality crossover (when elevated age-specific mortality rates invert). METHODS: We used panel data from the North Carolina Established Populations for Epidemiologic Studies of the Elderly to test the main and interactive effects of SES on mortality. RESULTS: Discrete-time hazard models showed that the association between low education and mortality did not vary by race or age and was only significant for men. For women, the effect of low income diminished with age and had little impact on the crossover. For men, low income varied by race and age, altering the Black-White crossover and producing low-high income crossovers at advanced ages. CONCLUSIONS: Low education and income were associated with increased mortality risk for older adults, but only low income had a differential impact on the Black-White mortality crossover. A primary route to reducing mortality differentials in later life is to prevent the disproportionate selective mortality of Blacks and the poor earlier in the life course.

Seriously ill patients' discussions of preparation and life completion: an intervention to assist with transition at the end of life.

OBJECTIVE: Patients approaching the end of life not only face challenges to physical well-being but also threats to emotional and spiritual integrity. Yet, identifying appropriate, effective, and brief interventions to address those concerns has proven elusive. We developed an intervention based on life review and emotional disclosure literatures and conducted a pilot study to determine feasibility and acceptability. This article presents qualitative intervention responses. METHOD: We conducted a three-armed randomized control trial to evaluate the effects of preparation and life completion discussion on health outcomes in patients with advanced serious illness. Hospice-eligible subjects were randomly assigned to one of three groups: (1) intervention (life completion discussion intervention), (2) attention control (relaxation meditation), and control (no intervention). Subjects in the intervention arm met with a facilitator three times. Session 1 focused on life story, Session 2 on forgiveness, and Session 3, on heritage and legacy. RESULTS: Eighteen subjects participated in the pilot intervention interviews. Subjects from a range of socioeconomic backgrounds completed the intervention with equal facility. Results from Session 1 demonstrate narrative responses participants gave as they reconnected with previous life roles, values, and accomplishments. The second session illustrated reflections of choices one might have made differently and exploration of forgiveness offered and sought. Content from the first and second sessions laid the foundation for discussing Session 3's lessons learned and heritage and legacy. Responses are summarized to assist clinicians in anticipating life review content that may improve overall quality of life at the end of life. SIGNIFICANCE OF RESULTS: Discussions of life completion may improve important health outcomes for patients at the end of life. This intervention may provide a brief, standardized, and transportable means for improving the quality of life of patients with advanced serious illness.

Does lack of social support lead to more ED visits for older adults?

OBJECTIVE: The goals of this study were to (1) determine whether level of social support and living situation predicted emergency department (ED) use among older adults and (2) identify correlates of ED visits according to whether the patient was admitted to the hospital. METHODS: Secondary analysis of a longitudinal, prospective study was conducted. RESULTS: In adjusted analyses, subjects who lived alone were 60% more likely to visit the ED than those who lived solely with their spouse. Neither type nor level of social support as measured by the Duke Social Support Index predicted ED use. Indicators of poor physical health (prior hospitalization, poorer self-rated health, and functional disability) were predictors of ED visits that resulted in hospitalization; however, these were not significantly associated with outpatient ED visits. DISCUSSION: Older adults who live alone are more likely to visit the ED. Additional study is needed to understand the determinants of outpatient ED visits.

Cross-national comparison of social support structures between Taiwan and the United States.

The study compares the effects of structural bases and functional elements of social support on mental health in Taiwan and the United States, using the study conducted in the United States by Lin, Ye, and Ensel (1999) as a reference. Based on a nationally representative sample of Taiwanese adults (n = 2,835), a fundamental similarity in social support structure and function between the two countries was observed. First, the structural bases of social support had a hierarchical order in their effects on depression: Binding (presence of an intimate relationship) was the strongest in reducing depression, whereas belonging (community participation) was the weakest, with bonding (social networks) in between. Regarding the functional elements, perceived social support was a better protector of mental health than actual social support, a finding in line with previous research. On the other hand, several notable differences in the structural bases and functional elements of social support between the two societies were observed, possibly due to the differential cultural and historical characteristics.

Does Medical Expansion Improve Population Health?

Medical expansion has become a prominent dynamic in today's societies as the biomedical model becomes increasingly dominant in the explanation of health, illness, and other human problems and behavior. Medical expansion is multidimensional and represented by expansions in three major components of the healthcare system: increasing medical investment, medical professionalization/specialization, and the relative size of the pharmaceutical industry. Using Organisation for Economic Co-operation and Development health data and World Development Indicators 1981 to 2007, we find medical investment and medical professionalization/specialization significantly improve all three measures of life expectancy and decrease mortality rate even after controlling for endogeneity problems. In contrast, an expanded pharmaceutical industry is negatively associated with female life expectancy at age 65 and positively associated with the all-cause mortality rate. It further compromises the beneficial effect of medical professionalization/specialization on population health. In general, medical professionalization/specialization and gross domestic product per capita have similar and stronger effects than medical investment.

Relating Sensory, Cognitive, and Neural Factors to Older Persons' Perceptions about Happiness: An Exploratory Study.

Despite increased rates of disease, disability, and social losses with aging, seniors consistently report higher levels of subjective well-being (SWB), a construct closely related to happiness, than younger adults. In this exploratory study, we utilized an available dataset to investigate how aspects of health commonly deteriorating with age, including sensory (i.e., vision and hearing) and cognitive status, relate to variability in self-described contributors to happiness. Community-dwelling seniors (n = 114) responded to a single-item prompt: "name things that make people happy." 1731 responses were categorized into 13 domains of SWB via structured content analysis. Sensory health and cognition were assessed by Snellen visual acuity, pure-tone audiometry, and in-person administration of the Brief Test of Adult Cognition by Telephone (BTACT) battery. A subset of eligible participants (n = 57) underwent functional magnetic resonance imaging (fMRI) to assess resting state functional connectivity (FC) within a previously described dopaminergic network associated with reward processing. SWB response patterns were relatively stable across gender, sensory status, and cognitive performance with few exceptions. For example, hearing-impaired participants listed fewer determinants of SWB (13.59 vs. 17.16; p < 0.001) and were less likely to name things in the "special events" category. Participants with a higher proportion of responses in the "accomplishments" domain (e.g., winning, getting good grades) demonstrated increased FC between the ventral tegmental area and nucleus accumbens, regions implicated in reward and motivated behavior. While the framework for determinants of happiness among seniors was largely stable across the factors assessed here, our findings suggest that subtle changes in this construct may be linked to sensory loss. The possibility that perceptions about determinants of happiness might relate to differences in intrinsic connectivity within reward-related brain networks also warrants further investigation.

Incorporating biomarkers into the study of socio-economic status and health among older adults in China.

The social gradient in health - that individuals with lower SES have worse health than those with higher SES- is welldocumented using self-reports of health in more developed countries. Less is known about the relationship between SES and health biomarkers among older adults residing in less developed countries. We use data from the ChineseLongitudinal Healthy Longevity Survey (CLHLS) longevity areas sub-sample to examine the social gradient in healthamong rural young-old and oldest-old adults (N=2,121). Our health indicators include individual biomarkers, metabolic syndrome, and self-reports of health. We found a largely positive relationship between SES and health. SES was more consistently associated with individual biomarkers among the oldest-old than the young-old, providing evidence for cumulative disadvantage. We discuss the implications of our findings for older adults who have lived through different social, economic, and health regimes.

Religion, spirituality, and acute care hospitalization and long-term care use by older patients.

BACKGROUND: The impact of religion and spirituality on acute care hospitalization (ACH) and long-term care (LTC) in older patients before, during, and after ACH is not well known. METHODS: Patients 50 years or older consecutively admitted to the general medical service at Duke University Medical Center were interviewed shortly after admission (N = 811). Measures of religiosity were organized religious activity (ORA), nonorganizational religious activity (NORA), religiosity through religious radio and/or television (RTV), intrinsic religiosity, and self-rated religiousness. Measures of spirituality included self-rated spirituality and daily spiritual experiences (DSE). Primary outcome was number of ACH days during an average 21-month observation period. Secondary outcomes were times hospitalized and number of days spent in a nursing home or rehabilitation setting (collectively, long-term care: LTC). Race and sex interactions were examined. RESULTS: In the cross-sectional analysis, ORA was the only religious variable related to fewer ACH days and fewer hospitalizations, an effect that is fully explained by physical health status and that disappeared when examined prospectively. The number of LTC days was inversely related to NORA, RTV, and DSE, effects that were partially explained by social support but not by severity of medical illness. Interactions with race and sex were notable but reached statistical significance only among African Americans and women. In those groups, religious and/or spiritual characteristics also predicted future LTC use independent of physical health and baseline LTC status. CONCLUSIONS: Relationships with ACH were weak, were confined to ORA only, and disappeared in prospective analyses. However, robust and persistent effects were documented for religiousness and/or spirituality in the use of LTC among African Americans and women.

Functional disability, disability transitions, and depressive symptoms in late life.

OBJECTIVE: This article addresses how stable functional disability statuses and disability transitions are related to change in depressive symptoms in the elderly. METHOD: The authors estimate longitudinal residual change models using two waves of data, 1986 and 1992, from the National Institute of Aging Established Populations for Epidemiologic Studies of the Elderly, Duke University. RESULTS: Both stable disability statuses and transitions in disability statuses are significantly related to change in depressive symptoms (Center for Epidemiologic Studies depression scale [CES D]). Stable disability statuses in strength and mobility, instrumental activities of daily living (IADL) items and activities of daily living (ADL) items have increasing effects on increment in CES-D scores by the follow-up. The onset of disability has stronger effects on change in CES-D scores than recovery. These effects also differ by types of transitions in disability statuses. DISCUSSION: The authors discuss alternative interpretations of the findings and methodological concerns and also suggest avenues for future research.

Sex, Socioeconomic and Regional Disparities in Age Trajectories of Childhood BMI, Underweight and Overweight in China.

Using a longitudinal dataset from the China Health and Nutrition Survey (CHNS), growth curve models were employed to examine age trajectories of BMI for 1,694 subjects who were aged 2-11 in 1993 and followed in four waves (1997, 2000, 2004 and 2006). Based on age- and sex-specific BMI cut-points recommended for international use, the prevalence rates of overweight and underweight in the transition from childhood to adulthood (age 6-18) were also predicted. Sex, family income, rural-urban residency and geographical location were found to be significantly associated with the onsets, slopes, and acceleration of age trajectories in BMI, overweight, and underweight (P<0.01). Children who had lower prevalence of underweight in the transition from childhood to adulthood exhibited higher prevalence of overweight than their counterparts did. Moreover, the age interval during which children were more vulnerable to an increase in underweight was different from that for overweight. There were substantial regional disparities in the age trajectories of childhood overweight and underweight. Whereas the analyses suggest that the dual burden of nutritional problems (the coexistence of overweight and underweight) in China is more like two sides of a coin than two separate health issues, the critical age period for intervening in childhood overweight is different from that of childhood underweight. Geographical indicators of childhood obesity in China deserve further attention.

Association between divorce and risks for acute myocardial infarction.

BACKGROUND: Divorce is a major life stressor that can have economic, emotional, and physical health consequences. However, the cumulative association between divorce and risks for acute myocardial infarction (AMI) is unknown. This study investigated the association between lifetime exposure to divorce and the incidence of AMI in US adults. METHODS AND RESULTS: We used nationally representative data from a prospective cohort of ever-married adults aged 45 to 80 years (n=15,827) who were followed biennially from 1992 to 2010. Approximately 14% of men and 19% of women were divorced at baseline and more than one third of the cohort had ≥1 divorce in their lifetime. In 200,524 person-years of follow-up, 8% (n=1211) of the cohort had an AMI and age-specific rates of AMI were consistently higher in those who were divorced compared with those who were continuously married (P<0.05). Results from competing-risk hazard models showed that AMI risks were significantly higher in women who had 1 divorce (hazard ratio, 1.24; 95% confidence interval, 1.01-1.55), ≥2 divorces (hazard ratio, 1.77; 95% confidence interval, 1.30-2.41), and among the remarried (hazard ratio, 1.35; 95% confidence interval, 1.07-1.70) compared with continuously married women after adjusting for multiple risk factors. Multivariable-adjusted risks were elevated only in men with a history of ≥2 divorces (hazard ratio, 1.30; 95% confidence interval, 1.02-1.66) compared with continuously married men. Men who remarried had no significant risk for AMI. Interaction terms for sex were not statistically significant. CONCLUSIONS: Divorce is a significant risk factor for AMI. The risks associated with multiple divorces are especially high in women and are not reduced with remarriage.

Religion, spirituality, and health in medically ill hospitalized older patients.

OBJECTIVES: To examine the effect of religion and spirituality on social support, psychological functioning, and physical health in medically ill hospitalized older adults. DESIGN: Cross-sectional survey. SETTING: Duke University Medical Center. PARTICIPANTS: A research nurse interviewed 838 consecutively admitted patients aged 50 and older to a general medical service. MEASUREMENTS: Measures of religion included organizational religious activity (ORA), nonorganizational religious activity, intrinsic religiosity (IR), self-rated religiousness, and observer-rated religiousness (ORR). Measures of spirituality were self-rated spirituality, observer-rated spirituality (ORS), and daily spiritual experiences. Social support, depressive symptoms, cognitive status, cooperativeness, and physical health (self-rated and observer-rated) were the dependent variables. Regression models controlled for age, sex, race, and education. RESULTS: Religiousness and spirituality consistently predicted greater social support, fewer depressive symptoms, better cognitive function, and greater cooperativeness (P<.01 to P<.0001). Relationships with physical health were weaker, although similar in direction. ORA predicted better physical functioning and observer-rated health and less-severe illness. IR tended to be associated with better physical functioning, and ORR and ORS with less-severe illness and less medical comorbidity (all P<.05). Patients categorizing themselves as neither spiritual nor religious tended to have worse self-rated and observer-rated health and greater medical comorbidity. In contrast, religious television or radio was associated with worse physical functioning and greater medical comorbidity. CONCLUSION: Religious activities, attitudes, and spiritual experiences are prevalent in older hospitalized patients and are associated with greater social support, better psychological health, and to some extent, better physical health. Awareness of these relationships may improve health care.

Research design in end-of-life research: state of science.

PURPOSE: The volume of research on end-of-life care, death, and dying has exploded during the past decade. This article reviews the conceptual and methodological adequacy of end-of-life research to date, focusing on limitations of research to date and ways of improving future research. DESIGN AND METHODS: A systematic search was conducted to identify the base of end-of-life research. Approximately 400 empirical articles were identified and are the basis of this review. RESULTS: Although much has been learned from research to date, limitations in the knowledge base are substantial. The most fundamental problems identified are conceptual and include failure to define dying; neglect of the distinctions among quality of life, quality of death, and quality of end-of-life care. Methodologically, the single greatest problem is the lack of longitudinal studies that cover more than the time period immediately before death. IMPLICATIONS: Gaps in the research base include insufficient attention to psychological and spiritual issues, the prevalence of psychiatric disorder and the effectiveness of the treatment of such disorders among dying persons, provider and health system variables, social and cultural diversity, and the effects of comorbidity on trajectories of dying.

Interlocking trajectories of loss-related events and depressive symptoms among elders.

OBJECTIVES: As people age, their peers (who are also aging) become increasingly susceptible to health decline and death, implying potential growth in stressful loss-related events over time for the individual. Yet little research has examined trajectories of stress and their relationship to trajectories of depression among elders. The purpose of this research was to determine whether growth in loss-related events occurs for elders and whether stress growth is related to the well-known growth in depressive symptomatology in later life. METHODS: Three waves of National Institute on Aging Established Populations for Epidemiologic Studies of the Elderly (Duke University site) data were used in the analyses. Latent growth curve models were estimated for stress, for depressive symptoms, and for stress predicting depression net of several covariates. RESULTS: Findings include that (a) loss-events evidence clear growth across age at the aggregate level, but with much variation within the sample, and (b) variation in growth in stress is strongly related to variation in growth in depressive symptoms. DISCUSSION: The results suggest that stress in later life may be conceived of as a growth process, with strong consequences for trajectories of mental health.

Age-related declines in activity level: the relationship between chronic illness and religious activities.

OBJECTIVES: When they are faced with major life transitions such as worsening health, older adults may selectively withdraw from activities. Because of the importance of religion to a large proportion of the elderly population, research is needed to determine whether levels of religious involvement are affected by serious health problems such as the onset of a chronic disease. METHODS: Multiple waves of data from the Duke Established Populations for Epidemiologic Studies of the Elderly were used to analyze the effects of five different chronic conditions on two religious activities: service attendance and religious media use. RESULTS: Findings show that broken hip, cancer, and stroke were significantly related to levels of religious attendance. Furthermore, the combined conditions also significantly predicted religious attendance, with more conditions being associated with lower attendance. Neither the individual or summed conditions were significantly related to religious media use. DISCUSSION: The study finds some evidence to support the idea that older adults withdraw from social activities such as religious involvement when faced with declining health. In contrast, levels of religious media use remain stable following the onset of one or more new chronic conditions.

Race differences in depressive symptoms: a dynamic perspective on stress exposure and vulnerability.

The existence, nature, and strength of race differences in mental health remain unclear after several decades of research. In this research, we examine black-white differences in the relationship between acute stressors and depressive symptoms. We reframe the stress exposure and differential vulnerability hypotheses in the context of long-term trajectories of stress and depression, and we hypothesize that trajectories of stress growth will be associated with trajectories of depressive symptom growth. Using latent growth curve analysis of a sample of 1,972 older persons interviewed three times at three-year intervals, we test the hypotheses that (1) growth in exposure to loss-related events will predict growth in depressive symptoms, and (2) African Americans will experience greater stress growth than whites. Results support the hypotheses. Stress growth exhibited a linear increase for blacks but not for whites, and predicted depression growth for both races, but explained more variance for blacks than for whites.

Taking time seriously: a call to action in mental health research.

Sociological research on mental health focuses on a multitude of dynamic processes, including changes in psychological symptoms or the onset of a mental disorder, the course and outcome of mental health problems, and the associations of mental health with a wide variety of time-varying social risk and protective factors. I argue that scholars studying mental health have, thus far, only scratched the surface of the temporal dynamics upon which mental health and illness rest. Two broad research issues are reviewed to illustrate important temporal issues that have been neglected or understudied in mental health research: (1) specific dimensions of temporality, which focus on dynamic processes at the individual level, and (2) the age-period-cohort model, which focuses on mental health at the population level. Priority topics for future research that takes time seriously are recommended.