One generation apart: Individual income and life expectancy in two Swedish cohorts born before and after the expansion of the welfare state.

AIMS: Social inequalities in mortality persist or even increase in high-income countries. Most evidence is based on a period approach to measuring mortality - that is, data from individuals born decades apart. A cohort approach, however, provides complementary insights using data from individuals who grow up and age under similar social and institutional arrangements. This study compares income inequalities in cohort life expectancy in two Swedish cohorts, one born before and one born after the expansion of the welfare state. METHODS: Data on individuals born in Sweden in 1922-1926 and 1951-1955 were obtained from total population registries. These data were linked to individual disposable income from 1970 and 1999 and mortality between 50 and 61 years of age in 1972-1987 and 2001-2016, respectively. We calculated cohort temporary life expectancies in the two cohorts by income and gender. RESULTS: Life expectancy, income, and income inequalities in life expectancy increased between the two cohorts, for both men and women. Women born in 1922-1926 had modest income differences in life expectancy, but pronounced differences emerged in the cohort born in 1951-1955. Men with low incomes born in 1951-1955 had roughly similar life expectancy as those with low incomes born in 1922-1926. CONCLUSIONS: Compared with a period approach to life expectancy trends, the cohort approach highlights the stagnation of mortality at the lowest income groups for men and the rapid emergence of a mortality gradient for women. Future research on health inequalities in welfare states should consider underlying factors both from a cohort and period perspective.

Longitudinal associations between sensory and cognitive functioning in adults 60 years or older in Sweden and Denmark.

BACKGROUND: The objective of this study is to explore the bidirectional, longitudinal associations between self-reported sensory functions (hearing/vision) and cognitive functioning among older adults in Sweden and Denmark during the period 2004-2017. METHODS: The study is based on data from The Survey of Health, Ageing and Retirement in Europe and consists of 3164 persons aged 60 to 93 years. Within-person associations between sensory and cognitive functions were estimated using random intercept cross-lagged panel models. RESULTS: The results indicated that cognitive and sensory functions were associated within their respective domains over time. The results on the bidirectional associations between sensory functions and cognition over time showed weak and statistically non-significant estimates. CONCLUSION: Our study showed no clear evidence for cross-lagged effects between sensory functions and cognitive functioning. Important to note, however, is that using longitudinal data to estimate change within persons is a demanding statistical test and various factors may have contributed to the absence of conclusive evidence in our study. We discuss several of these factors.

The Association between Education and Cognitive Performance Varies at Different Levels of Cognitive Performance: A Quantile Regression Approach.

INTRODUCTION: Educational differences in cognitive performance among older adults are well documented. Studies that explore this association typically estimate a single average effect of education on cognitive performance. We argue that the processes that contribute to the association between education and cognitive performance are unlikely to have equal effects at all levels of cognitive performance. In this study, we employ an analytical approach that enables us to go beyond averages to examine the association between education and five measures of global and domain-specific cognitive performance across the outcome distributions. METHODS: This cross-sectional study included 1,780 older adults aged 58-68 years from the Longitudinal Aging Study Amsterdam. Conditional quantile regression was used to examine variation across the outcome distribution. Cognitive outcomes included Mini-Mental State Examination (MMSE) score, crystallized intelligence, information processing speed, episodic memory, and a composite score of global cognitive performance. RESULTS: The results showed that the associations between education and different cognitive measures varied across the outcome distributions. Specifically, we found that education had a stronger association with crystallized intelligence, MMSE, and a composite cognitive performance measure in the lower tail of performance distributions. The associations between education and information processing speed and episodic memory were uniform across the outcome distributions. CONCLUSION: Larger associations between education and some domains of cognitive performance in the lower tail of the performance distributions imply that inequalities are primarily generated among individuals with lower performance rather than among average and high performers. Additionally, the varying associations across some of the outcome distributions indicate that estimating a single average effect through standard regression methods may overlook variations in cognitive performance between educational groups. Future studies should consider heterogeneity across the outcome distribution.

Disruption and selection: the income gradient in mortality among natives and migrants in Sweden.

BACKGROUND: The income gradient in mortality is generated through an interplay between socio-economic processes and health over the life course. International migration entails the displacement of an individual from one context to another and may disrupt these processes. Furthermore, migrants are a selected group that may adopt distinct strategies and face discrimination in the labour market. These factors may have implications for the income gradient in mortality. We investigate whether the income gradient in mortality differs by migrant status and by individual-level factors surrounding the migration event. METHODS: We use administrative register data comprising the total resident population in Sweden aged between 30 and 79 in 2015 (n = 5.7 million) and follow them for mortality during 2015-17. We estimate the income gradient in mortality by migrant status, region of origin, age at migration and country of education using locally estimated scatterplot smoothing and Poisson regression. RESULTS: The income gradient in mortality is less steep among migrants compared with natives. This pattern is driven by lower mortality among migrants at lower levels of income. The gradient is less steep among distant migrants than among close migrants, migrants that arrived as adults compared with children and migrants that received their education in Sweden as opposed to abroad. CONCLUSIONS: Our results are consistent with the notion that income inequalities in mortality are generated through life-course processes that may be disrupted by migration. Data restrictions prevent us from disentangling life-course disruption from selection into migration, discrimination and labour market strategies.

Cohort Trajectories by Age and Gender for Informal Caregiving in Europe Adjusted for Sociodemographic Changes, 2004 and 2015.

OBJECTIVES: We present a dynamic view of gender patterns in informal caregiving across Europe in a context of sociodemographic transformations. We aim to answer the following research questions: (a) has the gender gap in informal caregiving changed; (b) if so, is this due to changes among women and/or men; and (c) has the gender care gap changed differently across care regimes? METHODS: Multilevel growth curve models are applied to gendered trajectories of informal caregiving of a panel sample of 50+ Europeans, grouped into 5-year cohorts and followed across 5 waves of the Survey of Health, Ageing and Retirement in Europe survey, stratified by sex and adjusted for several covariates. RESULTS: For men in cohorts born more recently, there is a decrease in the prevalence of informal care outside the household, whereas cohort trajectories for women are mostly stable. Prevalence of care inside the household has increased for later-born cohorts for all without discernible changes to the gender care gap. Gender care gaps overall widened among later-born cohorts in the Continental cluster, whereas they remained constant in Southern Europe, and narrowed in the Nordic cluster. DISCUSSION: We discuss the cohort effects found in the context of gender differences in employment and care around retirement age, as well as possible demographic explanations for these. The shift from care outside to inside the household, where it mostly consists of spousal care, may require different policies to support carers, whose age profile and possible care burden seem to be increasing.

Cohort-specific disability trajectories among older women and men in Europe 2004-2017.

As the population of Europe grows older, one crucial issue is how the incidence and prevalence of disabilities are developing over time in the older population. In this study, we compare cohort-specific disability trajectories in old age across subsequent birth cohorts in Europe, during the period 2004-2017.We used data from seven waves of data from the Survey of Health, Ageing and Retirement in Europe (SHARE). Mixed effects logistic regression models were used to model trajectories of accumulation of ADL limitations for subsequent birth cohorts of older women and men in different European regions. The results showed that there were sex differences in ADL and IADL limitations in all regions for most cohorts. Women reported more limitations than men, particularly in Eastern and Southern rather than Northern and Western Europe. Among men in Eastern, Northern and Western Europe, later born cohorts reported more disabilities than did earlier born birth cohorts at the same ages. Similar patterns were observed for women in Northern and Western Europe. In contrast, the risk of disabilities was lower in later born cohorts than in earlier born birth cohorts among women in Eastern Europe. Overall, results from this study suggest that disability trajectories in different cohorts of men and women were by and large similar across Europe. The trajectories varied more depending on sex, age and region than depending on cohort. Supplementary Information: The online version contains supplementary material available at 10.1007/s10433-022-00684-4.

Gender differences in access to community-based care: a longitudinal analysis of widowhood and living arrangements.

Persistent inequalities in access to community-based support limit opportunities for independent living for older people with care needs in Europe. Our study focuses on investigating how gender, widowhood and living arrangement associate with the probability of receiving home and community-based care, while accounting for the shorter-term associations of transitions into widowhood (bereavement) and living alone, as well as the longer-term associations of being widowed and living alone. We use comparative, longitudinal data from the Survey of Health, Ageing and Retirement in Europe (collected between 2004 and 2015 in 15 countries) specifying sex-disaggregated random-effects within-between models, which allow us to examine both cross-sectional and longitudinal associations among widowhood, living arrangements and community-based care use. We find widowhood and living alone are independently associated with care use for both older women and men, while bereavement is associated with higher probability of care use only for women. Socio-economic status was associated with care use for older women, but not for men in our sample. The gender-specific associations we identify have important implications for fairness in European long-term care systems. They can inform improved care targeting towards individuals with limited informal care resources (e.g. bereaved older men) and lower socio-economic status, who are particularly vulnerable to experiencing unmet care needs. Gender differences are attenuated in countries that support formal care provision, suggesting gender equity can be promoted by decoupling access to care from household and family circumstances. Supplementary Information: The online version contains supplementary material available at 10.1007/s10433-022-00717-y.

A social exclusion perspective on loneliness in older adults in the Nordic countries.

Several factors associated with loneliness are also considered indicators of social exclusion. While loneliness has been proposed as an outcome of social exclusion, there is limited empirical evidence of a link. This study examines the associations between social exclusion indicators and loneliness in older adults (60+ years) in four Nordic countries. Data from four waves of the European Social Survey were pooled, providing a total of 7755 respondents (Denmark n = 1647; Finland n = 2501, Norway n = 1540; Sweden n = 2067). Measures of loneliness, demographic characteristics, health, and eight indicators of social exclusion were selected from the survey for analysis. Country-specific and total sample hierarchical logistic regression models of loneliness were developed. Significant model improvement occurred for all models after social exclusion indicators were added to models containing only demographic and health variables. Country models explained between 15.1 (Finland) and 21.5% (Sweden) of the variance in loneliness. Lower frequency of social contacts and living alone compared to in a two-person household was associated with a higher probability of loneliness in all countries, while other indicators were associated with loneliness in specific countries: lower neighbourhood safety (Sweden and Denmark); income concern (Sweden and Finland); and no emotional support (Denmark, Finland, and Sweden). A robust relationship was apparent between indicators of social exclusion and loneliness with the direction of associations being highly consistent across countries, even if their strength and statistical significance varied. Social exclusion has considerable potential for understanding and addressing risk factors for loneliness. Supplementary Information: The online version contains supplementary material available at 10.1007/s10433-022-00692-4.

Trends in the shape of the income-mortality association in Sweden between 1995 and 2017: a repeated cross-sectional population register study.

OBJECTIVE: We investigate recent trends in income inequalities in mortality and the shape of the association in Sweden. We consider all-cause, preventable and non-preventable mortality for three age groups (30-64, 65-79 and 80+ years). DESIGN AND SETTING: Repeated cross-sectional design using Swedish total population register data. PARTICIPANTS: All persons aged 30 years and older living in Sweden 1995-1996, 2005-2006 and 2016-2017 (n=8 084 620). METHODS: Rate differences and rate ratios for all-cause, preventable and non-preventable mortality were calculated per income decile and age group. RESULTS: From 1995 to 2017, relative inequalities in mortality by income increased in Sweden in the age groups 30-64 years and 65-79 years. Absolute inequalities increased in the age group 65-79 years. Among persons aged 80+ years, inequalities were small. The shape of the income-mortality association was curvilinear in the age group 30-64 years; the gradient was stronger below the fourth percentile. In the age group 65-79 years, the shape shifted from linear in 1995-1996 to a more curvilinear shape in 2016-2017. In the oldest age group (80+ years), varied shapes were observed. Inequalities were more pronounced in preventable mortality compared with non-preventable mortality. Income inequalities in preventable and non-preventable mortality increased at similar rates between 1995 and 2017. CONCLUSIONS: The continued increase of relative (ages 30-79 years) and absolute (ages 65-79 years) mortality inequalities in Sweden should be a primary concern for public health policy. The uniform increase of inequalities in preventable and non-preventable mortality suggests that a more complex explanatory model than only social causation is responsible for increased health inequalities.

The association between loneliness, social isolation and all-cause mortality in a nationally representative sample of older women and men.

OBJECTIVES: Individuals who feel lonely and those who are socially isolated have higher mortality risks than those who are not lonely or socially isolated. However, the importance of loneliness and social isolation for survival is rarely analysed in the same study or with consideration of gender differences. The aim was to examine the separate, mutually adjusted, and combined effects of loneliness and social isolation with mortality in older women and men. METHODS: Data from the SWEOLD study, a nationally representative sample of people aged 69+ years living in Sweden, was combined with register data on mortality and analysed using Cox regressions. RESULTS: Mortality was higher among older women and men with higher levels of loneliness or social isolation. Social isolation was more strongly associated with mortality than loneliness and the association remained when controlling for health. The combined effects of loneliness and social isolation did not surpass their independent effects. CONCLUSION: Loneliness and social isolation is associated with an increased mortality risk, and social integration should be a prioritised target for activities and services involving older adults.

Excess Mortality by Individual and Spousal Education for Recent and Long-Term Widowed.

OBJECTIVES: The loss of a spouse is followed by a dramatic but short-lived increase in the mortality risk of the survivor. Contrary to expectations, several studies have found this increase to be larger among those with high education. Having a spouse with high education is associated with lower mortality, which suggests that losing a spouse with high education means the loss of a stronger protective factor than losing a spouse with low education. This may disproportionately affect the high educated because of educational homogamy. METHODS: We use Swedish total population registers to construct an open cohort of 1,842,487 married individuals aged 60-89 during 2007-2016, observing 239,276 transitions into widowhood and 277,946 deaths. We use Poisson regression to estimate relative and absolute mortality risks by own and spousal education among the married and recent and long-term widows. RESULTS: We find an absolute increase in mortality risk, concentrated to the first 6 months of widowhood across all educational strata. The relative increase in mortality risk is larger in higher educational strata. Losing a spouse with high education is associated with higher excess mortality, which attenuates this difference. DISCUSSION: When considering the timing and the absolute level of excess mortality, we find that the overall patterns of excess mortality are similar across educational strata. We argue that widowhood has a dramatic impact on health, regardless of education.

Interdependent pathways between socioeconomic position and health: A Swedish longitudinal register-based study.

Health inequalities are generated by the conditions in which people are born, grow, live, work and age. From a life-course perspective, these conditions are formed by complex causal relationships with mutual and intertwined paths between socioeconomic position and health. This study attempts to disentangle some of these processes by examining pathways between socioeconomic position and health across the life-course. We used yearly Swedish national register data with information from over 31 years for two cohorts born 1941-1945 and 1961-1965. We analyzed associations between several indicators of childhood and adult socioeconomic position and health, measured by number of in-patient hospitalizations. We estimated within- and between-person associations using random intercept cross-lagged panel models. The results showed bi-directional associations between socioeconomic position and health that varied in strength across the life-course. Age variations in the associations were primarily observed when individuals aged into or out of age-stratified institutions. In ages where transitions from education to the labor market are common, the associations from health to income and education were strong. Around and after retirement age, the between-person association from health to income was weak, while the association from income to health strengthened. Within-person estimates showed no association between income and subsequent hospitalization among older persons, indicating no direct causal effect of income change on health in this age group. For persons of middle age, the associations were of similar strength in both directions and present at both the between- and within-person level. Our findings highlight the importance of theoretical frameworks and methods that can incorporate the interplay between social, economic, and biological processes over the life-course in order to understand how health inequalities are generated.

What Levels the Association Between Income and Mortality in Later Life: Age or Health Decline?

OBJECTIVES: Researchers frequently use the "age-as-leveler" hypothesis to explain decreasing inequality and a weakened relationship between socioeconomic position and health in old age. This study examined whether health status can explain the age pattern in the association between income and mortality as predicted by the age-as-leveler hypothesis. METHOD: This study used longitudinal (1991-2002) data from the SWEOLD and LNU surveys. The analytical sample consisted of 2,619 people aged 54-92 in 2003. Mortality (2003-2014) and income (1991-2000) was collected from Swedish national registers. Poisson regression was used to estimate associations between mortality, income, age, and health status. Average marginal effects were used to visualize interaction effects between income and age. RESULTS: The association between income and mortality weakened in those aged 84 and older. However, health status explained a large part of the effect that age had on the association between income and mortality. Analyses done after stratifying the sample by health status showed that the association between income and mortality was strong in people who reported good health and weak or nonexistent in those who reported poor health. DISCUSSION: Age leveled the income-mortality association; however, health status, not age, explained most of the leveling.

Divergence and Convergence: How Do Income Inequalities in Mortality Change over the Life Course?

BACKGROUND: Do inequalities in health by income increase or decrease with age? The empirical evidence is not conclusive and competing theories arrive at different conclusions. OBJECTIVE: This study examined inequality in mortality by income over the adult life course with longitudinal data on people aged 30-99 between the years 1990 and 2009. Each person was followed for 19 years. METHODS: We used Swedish total population data with 5,011,414 individual observations. We calculated the probability of having died for ages between 31 and 99. This approach to calculating death risk incorporates selective mortality during the follow-up period into the measure. Age and year standardized income positions were calculated for all individuals. Inequality was assessed by comparing the top 10% income group and the bottom 10% income group. Relative inequality was measured by risk ratios (RR) and absolute inequality by percentage point differences. RESULTS: The results showed that the highest relative income inequality in mortality was at age 56 for men (RR: 4.7) and at age 40 for women (RR: 4.1) with differing patterns across the younger age categories between the sexes. The highest absolute income inequality in mortality was found at age 78 for men (19% difference) and at age 89 for women (14% difference) with similar patterns for both sexes. Both measures of inequality decreased after the peak, with small or no inequalities above age 95. Income inequality in mortality remained in advanced age, with larger absolute inequalities in older ages and larger relative inequalities in younger ages. CONCLUSION: The results for absolute and relative measures of inequality differed substantially; this highlights the importance of discussing and making an active choice of inequality measure. To explain and understand the patterns of inequality in mortality over the adult life course, we conclude that the "age-as-leveler" and "cumulative disadvantage" theories are best applied to an absolute measure of inequality.

Income trajectories prior to alcohol-attributable death in Finland and Sweden.

BACKGROUND AND AIMS: Mortality from alcohol-attributable causes is patterned by income. We study the income trajectories 17-19 years prior to death in order to determine: (1) whether income levels and trajectories differ between those who die of alcohol-attributable causes, survivors with similar socio-demographic characteristics, all survivors and those dying of other causes; (2) whether the income trajectories of these groups differ by education; and (3) whether there are differences in income trajectories between Finland and Sweden-two countries with differing levels of alcohol-attributable mortality but similar welfare-provision systems. DESIGN: Retrospective cohort study using individual-level longitudinal register data including information on income, cause of death and socio-economic status. SETTING: Finland and Sweden. PARTICIPANTS: The subjects comprised an 11% sample of the Finnish population in 2006-07 and the total population of Sweden aged 45-64 years in 2007-08. MEASUREMENTS: Median household income trajectories by educational group were calculated by cause of death and population alive during the respective years. Additionally, propensity score matching was used to match the surviving population to those dying from alcohol-attributable causes with regard to socio-demographic characteristics. FINDINGS: The median income 17-19 years prior to death from alcohol-attributable causes was 92% (Finland) and 91% (Sweden) of survivor income: 1 year prior to death, the respective figures were 47% and 57%. The trajectories differed substantially. Those dying of alcohol-attributable causes had lower and decreasing incomes for substantially longer periods than survivors and people dying from other causes. These differences were more modest among the highly educated individuals. The baseline socio-demographic characteristics of those dying of alcohol causes did not explain the different trajectories. CONCLUSIONS: In Finland and Sweden, income appears to decline substantially before alcohol-attributable death. Highly educated individuals may be able to buffer the negative effects of extensive alcohol use on their income level. Income trajectories are similar in Finland and Sweden, despite marked differences in the level of alcohol-attributable mortality.

Shape of the association between income and mortality: a cohort study of Denmark, Finland, Norway and Sweden in 1995 and 2003.

OBJECTIVES: Prior work has examined the shape of the income-mortality association, but work has not compared gradients between countries. In this study, we focus on changes over time in the shape of income-mortality gradients for 4 Nordic countries during a period of rising income inequality. Context and time differentials in shape imply that the relationship between income and mortality is not fixed. SETTING: Population-based cohort study of Denmark, Finland, Norway and Sweden. PARTICIPANTS: We collected data on individuals aged 25 or more in 1995 (n=12.98 million individuals, 0.84 million deaths) and 2003 (n=13.08 million individuals, 0.90 million deaths). We then examined the household size equivalised disposable income at the baseline year in relation to the rate of mortality in the following 5 years. RESULTS: A steep income gradient in mortality in men and women across all age groups except the oldest old in Denmark, Finland, Norway and Sweden. From the 1990s to 2000s mortality dropped, but generally more so in the upper part of the income distribution than in the lower part. As a consequence, the shape of the income gradient in mortality changed. The shift in the shape of the association was similar in all 4 countries. CONCLUSIONS: A non-linear gradient exists between income and mortality in most cases and because of a more rapid mortality decline among those with high income the income gradient has become steeper over time.

The shape of the association between income and mortality in old age: A longitudinal Swedish national register study.

This study used data on the total population to examine the longitudinal association between midlife income and mortality and late-life income and mortality in an aging Swedish cohort. We specifically examined the shape of the associations between income and mortality with focus on where in the income distribution that higher incomes began to provide diminishing returns. The study is based on a total Swedish population cohort between the ages of 50 and 60 years in 1990 (n=801,017) followed in registers for up to 19 years. We measured equivalent disposable household income in 1990 and 2005 and mortality between 2006 and 2009. Cox proportional hazard models with penalized splines (P-spline) enabled us to examine for non-linearity in the relationship between income and mortality. The results showed a clear non-linear association. The shape of the association between midlife (ages 50-60) income and mortality was curvilinear; returns diminished as income increased. The shape of the association between late-life (ages 65-75) income and mortality was also curvilinear; returns diminished as income increased. The association between late-life income and mortality remained after controlling for midlife income. In summary, the results indicated that a non-linear association between income and mortality is maintained into old age, in which higher incomes give diminishing returns.

Absolute or relative? A comparative analysis of the relationship between poverty and mortality.

OBJECTIVES: We aimed to examine the cross-national and cross-temporal association between poverty and mortality, in particular differentiating the impact of absolute and relative poverty. METHODS: We employed pooled cross-sectional time series analysis. Our measure of relative poverty was based upon the standard 60% of median income. The measure of absolute, or fixed, poverty was based upon the US poverty threshold. Our analyses were conducted on data for 30 countries between 1978 and 2010, a total of 149 data points. We separately studied infant, child, and adult mortality. RESULTS: Our findings highlight the importance of relative poverty for mortality. Especially for infant and child mortality, we found that our estimates of fixed poverty is close to zero either in the crude models, or when adjusting for gross domestic product. Conversely, the relative poverty estimates increased when adjusting for confounders. Our results seemed robust to a number of sensitivity tests. CONCLUSIONS: If we agree that risk of death is important, the public policy implication of our findings is that relative poverty, which has close associations to overall inequality, should be a major concern also among rich countries.

Towards evidence-based emergency medicine: Best BETs from the Manchester Royal Infirmary. BET 3: Pulmonary embolism rule-out criteria (PERC) for excluding pulmonary embolism.

A short-cut review was carried out to establish whether the pulmonary embolism rule-out criteria (PERC) can safely exclude the diagnosis of pulmonary embolism (PE) in the emergency department (ED). One recent systematic review was directly relevant to the question and incorporated all the other relevant evidence identified. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these papers are shown in table 3. The clinical bottom line is that PERC may be safely applied to patients aged 18-49 years presenting to the ED with chest pain and/or dyspnoea providing that the pre-test probability of PE is 7% or less (equivalent to a Wells score of <2).