Widowhood and Mortality Among Chinese Older Adults in Singapore: The Roles of Gender and Perceived Social Support.

OBJECTIVES: Although the association between widowhood and mortality is well established, the impact of widowhood on mortality could differ by social support, gender, and widowhood duration. We studied the association between widowhood and mortality among older Chinese adults in Singapore and analyzed how social support, gender, and widowhood duration may modify this association. METHODS: We used data from 15,858 participants aged 61-96 years from the third follow-up of the population-based Singapore Chinese Health Study in 2014-2016. Mortality data were obtained through linkage with the national death registry through 31st December 2018, and social support was measured with the Duke Social Support Scale. We used Cox proportional hazard models to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for the association between widowhood and mortality risk. RESULTS: Compared with those married, widowed adults had a higher mortality risk (HR = 1.18, 95% CI = 1.01-1.38), and this risk was higher for those who were either recently widowed (<5 years; HR = 1.28, 95% CI = 1.00-1.63) or long-term widowed (>10 years; HR = 1.27, 95% CI = 1.07-1.54). Among men, those recently widowed had the highest mortality risk (HR = 1.50, 95% CI = 1.06-2.13), whereas, among women, those long-term widowed had the highest mortality risk (HR = 1.26, 95% CI = 0.99-1.60). In the analysis stratified by social support, widowhood was associated with mortality among those with low social support (HR = 1.27, 95% CI = 1.05-1.54), but not among those with high social support (HR = 1.01, 95% CI = 0.76-1.33). DISCUSSION: Widowhood was associated with increased mortality risk, particularly among recently widowed men and long-term widowed women. Having adequate social support could attenuate the adverse effects of widowhood among older adults.

Social Disconnection and Living Arrangements among Older Adults: The Singapore Chinese Health Study.

INTRODUCTION: Although living alone is associated with social disconnection, older adults could be socially disconnected despite living with others. Understanding the factors associated with social disconnection by living arrangement could help identify vulnerable older adults in the community. We examined the sociodemographic and health factors associated with social disconnection among two groups of older adults: those living alone and those living with others. METHODS: We used data from 16,943 community-dwelling older adults from the third follow-up of the Singapore Chinese Health Study (mean age: 73 years, range: 61-96 years). We defined social disconnection as having no social participation and scoring in the lowest decile on the Duke Social Support Scale of perceived social support. We ran logistic regression models to study the sociodemographic (age, gender, and education) and health (self-rated health, instrumental limitations, cognitive function, and depression) factors associated with social disconnection, stratified by living arrangement. RESULTS: About 6% of our participants were socially disconnected. Although living alone was significantly associated with social disconnection (OR 1.93, 95% CI: 1.58-2.35), 85.6% of socially disconnected older adults lived with others, most of them (92%) with family. Lower education level, cognitive impairment, fair/poor self-rated health, instrumental limitations, and depression were independently associated with social disconnection. Among those living alone, men were more likely to experience social disconnection than women (OR 2.18, 95% CI: 1.43-3.32). DISCUSSION/CONCLUSION: Though living alone is associated with social disconnection, most socially disconnected individuals lived with family. Community interventions could focus on those in poor health despite living with family and older men living alone.

Factors associated with depression across age groups of older adults: The Singapore Chinese health study.

OBJECTIVES: We studied sociodemographic and health factors associated with depression across three age groups of community-dwelling older adults. METHODS/DESIGN: We used data from 16,785 participants from the third follow-up of the Singapore Chinese Health Study (mean age: 73, range: 61-96 years). We defined depression as having a score of ≥5 using the 15-item Geriatric Depression Scale. We used regression splines to examine the pattern of depression risk with age and applied multivariable logistic regression to study factors associated with depression. RESULTS: Increasing age was associated with depression in an inverted J-shape relationship with the highest odds ratio (OR) at age 75. Compared to the youngest-old (<70 years), the middle-old (70-80 years) had higher odds of depression [OR = 1.20, 95% confidence interval (CI) = 1.09-1.31], while the oldest-old (>80 years) had no increased risk (OR = 1.01, 95% CI = 0.89-1.15). We also found demographic (men, lower education, unemployment), social (living alone, poor social support, no social activity) and health factors (instrumental limitations, poor physical function, function-limiting pain, chronic diseases, cognitive impairment, poor sleep quality, poor self-rated health) associated with depression. In stratified analysis by age groups, the OR estimates for lower education level, instrumental limitations and cognitive impairment decreased with age, whereas the risk of depression for men increased with age (all p-values for interaction<0.03). CONCLUSIONS: Compared to the youngest-old, the likelihood of depression was highest among middle-old adults and decreased to null in the oldest-old. The associations between some factors and depression were attenuated with age, suggesting a coping mechanism among oldest-old survivors.

Emergency hospital admissions among older adults living alone in the community.

BACKGROUND: Among older adults, living alone is often associated with higher risk of Emergency Department (ED) admissions. However, older adults living alone are very heterogeneous in terms of health. As more older adults choose to live independently, it remains unclear if the association between living alone and ED admissions is moderated by health status. We studied the association between living alone and ED admission outcomes (number of admissions, inpatient days and inpatient costs) among older adults with and without multimorbidity. METHODS: We used data from 16,785 individuals of the third follow-up of the Singapore Chinese Health Study, a population-based cohort of older Singapore Chinese (mean age: 73(61-96) years). Participants were interviewed face-to-face from 2014 to 2016 for sociodemographic/health factors and followed-up for one year on ED admission outcomes using Singapore Ministry of Health's Mediclaim Database. We first applied multivariable logistic regression and two-part models to test if living alone is a risk factor for ED admission outcomes. We then ran stratified and joint effect analysis to examine if the associations between living alone and ED admission outcomes were moderated by multimorbidity. RESULTS: Compared to living with others, living alone was associated with higher odds of ED admission [Odds Ratio (OR) 1.28, 95 % Confidence Interval(CI) 1.08-1.51)], longer inpatient days (+0.61, 95 %CI 0.25-0.97) and higher inpatient costs (+322 USD, 95 %CI 54-591). The interaction effects of living arrangement and multimorbidity on ED admissions and inpatient costs were not statistically different, whereas the interaction between living arrangements and multimorbidity on inpatient days was borderline significant (p-value for interaction=0.050). Compared to those living with others and without multimorbidity, the relative mean increase was 1.13 inpatient days (95 %CI 0.39-1.86) for those living alone without multimorbidity, and 0.73 inpatient days ( 95 %CI 0.29-1.17) for those living alone with multimorbidity. CONCLUSIONS: Older adults living alone were at higher risk of ED admission and higher inpatient costs regardless of multimorbidity, while those living alone without multimorbidity had the longest average inpatient days. To enable aging in place while avoiding ED admissions, interventions could provide instrumental support and regular health monitoring to older adults living alone, regardless of their health status.

Functional Divergence of Mammalian TFAP2a and TFAP2b Transcription Factors for Bidirectional Sleep Control.

Sleep is a conserved behavioral state. Invertebrates typically show quiet sleep, whereas in mammals, sleep consists of periods of nonrapid-eye-movement sleep (NREMS) and REM sleep (REMS). We previously found that the transcription factor AP-2 promotes sleep in Caenorhabditiselegans and Drosophila In mammals, several paralogous AP-2 transcription factors exist. Sleep-controlling genes are often conserved. However, little is known about how sleep genes evolved from controlling simpler types of sleep to govern complex mammalian sleep. Here, we studied the roles of Tfap2a and Tfap2b in sleep control in mice. Consistent with our results from C. elegans and Drosophila, the AP-2 transcription factors Tfap2a and Tfap2b also control sleep in mice. Surprisingly, however, the two AP-2 paralogs play contrary roles in sleep control. Tfap2a reduction of function causes stronger delta and theta power in both baseline and homeostasis analysis, thus indicating increased sleep quality, but did not affect sleep quantity. By contrast, Tfap2b reduction of function decreased NREM sleep time specifically during the dark phase, reduced NREMS and REMS power, and caused a weaker response to sleep deprivation. Consistent with the observed signatures of decreased sleep quality, stress resistance and memory were impaired in Tfap2b mutant animals. Also, the circadian period was slightly shortened. Taken together, AP-2 transcription factors control sleep behavior also in mice, but the role of the AP-2 genes functionally diversified to allow for a bidirectional control of sleep quality. Divergence of AP-2 transcription factors might perhaps have supported the evolution of more complex types of sleep.

Adiposity, Weight Change, and Risk of Cognitive Impairment: The Singapore Chinese Health Study.

BACKGROUND: Few prospective studies with long duration of follow-up have assessed the relations of body mass index (BMI) and weight change with cognitive function, especially in Asian populations. OBJECTIVE: To investigate whether BMI and weight change in midlife are associated with cognitive impairment in old age. METHODS: We used data from 14,691 participants in the Singapore Chinese Health Study and computed weight change as the difference between weight reported at baseline (1993-1998) at mean age of 53.0 years and follow-up 1 (1999-2004) at mean age of 58.6 years. Cognitive impairment was determined using education-specific cut-offs of the Singapore Modified Mini-Mental State Examination at follow-up 3 (2014-2016) at mean age of 72.9 years. We used multivariable logistic regression models to estimate the odds ratios (ORs) and 95% confidence intervals (CIs) for the associations. RESULTS: Obesity (as defined BMI ≥27.5 kg/m2) was associated with a higher risk of cognitive impairment at baseline (OR 1.33, 95% CI 1.12-1.58) and follow-up 1 (OR 1.30, 95% CI 1.10-1.54) compared to BMI of 18.5-22.9 kg/m2. Underweight (BMI <18.5 kg/m2) was not associated with a significant risk either at baseline (OR 0.91, 95% CI 0.73-1.13) or follow-up 1 (OR 1.05, 95% CI 0.85-1.28). Compared to participants with <5% weight change, the ORs (95% CIs) of cognitive impairment were 1.20 (1.03-1.41) for those with 5-9.9% weight loss, 1.53 (1.29-1.81) for ≥10% weight loss, 1.00 (0.85-1.17) for 5-9.9% weight gain, and 1.50 (1.28-1.75) for ≥10% weight gain. CONCLUSION: Obesity, weight loss, and excessive weight gain at midlife were associated with an increased risk of cognitive impairment at old age.

Government pharmaceutical pricing strategies in the Asia-Pacific region: an overview.

Background and objectives: Governments in Asia Pacific (APAC) are increasingly using pharmaceutical pricing strategies to contain rising healthcare costs. The objective of this narrative review is to discuss formal pricing strategies for reimbursed prescription medication in APAC, supported by relevant examples of implementation differences across countries. In the discussion section, we examine key advantages and disadvantages of each strategy. Methods: A narrative review of the peer-reviewed and grey literature was undertaken to retrieve information, including strategy definitions, practising countries, country-specific implementation considerations, and merits and demerits of each strategy. Results: Seven strategies (Internal Reference Pricing, External Reference Pricing, Special Pricing Agreements, Pharmacoeconomic Evaluation, Cost plus pricing, Price Maintenance Premium, and Tendering and negotiations) were identified as most commonly practised in APAC through the review process. Most countries use multiple strategies that differ in how they are implemented. Conclusion: APAC countries use multiple strategies simultaneously with varying implementation methods, including different formulae and sub-types of medication that a strategy applies to, whether the strategy is a mandate or guideline, and the extent of negotiations and transparency. Strategies are instituted partly with the aim of cost containment, and may also promote price stability, innovation, and increased access in the short and longer term. Abbreviations: APAC - Asia Pacific; WHO - World Health Organisation; IRP - Internal Reference Pricing; ERP - External Reference Pricing; SPA - Special Pricing Agreement; MES - Managed Entry Scheme; PVA - Price-Volume Agreement; RSA - Risk Sharing Agreement; NHIS - National Health Insurance System; PE - Pharmacoeconomic Evaluation; CEA - Cost-Effectiveness Analysis; QALY - Quality-adjusted Life Year; BIA - Budget Impact Analysis; PMP - Price Maintenance Premium; R&D - Research & Development.