Age differences in long-term mortality among male nonveterans, noncombat veterans, and combat veterans.

Research documenting differences in mortality risk across the life course between veterans and nonveterans has not accounted for combat status. To address this gap in the literature, the current study examined differences in long-term mortality among midlife and older-adult male nonveterans, noncombat veterans, and combat veterans. Data were drawn from Wave 2 (2004/2005) of the Midlife Development in the United States survey and linked to 2020 mortality data (N = 2,024). Based on interpretation of a veteran-combat status by age interaction term, compared to nonveterans, noncombat veterans experienced a mortality advantage at younger ages, ORmain effect = 0.12, 95% CI [0.03, 0.54], p = .006, and a mortality disadvantage at older ages, ORinteraction term = 1.06, 95% CI [1.01, 1.05], p = .004, with the crossover occurring at 73.4 years. A similar pattern was present among combat veterans, with the mortality advantage at younger ages not reaching significance, ORmain effect = 0.16; 95% CI [0.02, 1.18], p = .072; a mortality advantage at older ages, ORinteraction term = 1.03, 95% CI [1.00, 1.05], p = .040; and the crossover occurring 4.2 years earlier at 69.2 years. The findings suggest that combat status may accelerate the age-related mortality disadvantage among veterans. Studies of health and mortality outcomes among veterans should, therefore, account for combat status. When data allow, future studies should confirm whether this pattern is present in nationally representative samples.

Risk Factors Explaining Military Deaths From Suicide, 2008-2017:A Latent Class Analysis.

Military suicide prevention efforts would benefit from population-based research documenting patterns in risk factors among service members who die from suicide. We use latent class analysis to analyze patterns in identified risk factors among the population of 2660 active-duty military service members that the Department of Defense Suicide Event Report (DoDSER) system indicates died by suicide between 2008 and 2017. The largest of five empirically derived latent classes was primarily characterized by the dissolution of an intimate relationship in the past year. Relationship dissolution was common in the other four latent classes, but those classes were also characterized by job, administrative, or legal problems, or mental health factors. Distinct demographic and military-status differences were apparent across the latent classes. Results point to the need to increase awareness among mental health service providers and others that suicide among military service members often involves a constellation of potentially interrelated risk factors.

Racial-ethnic inequities in age at death among adults with/without intellectual and developmental disability in the United States.

To identify potential differences in racial-ethnic inequities in mortality between adults with/without intellectual and developmental disability, we compared patterns in age at death by race-ethnic status among adults who did/did not have intellectual and developmental disability reported on their death certificate in the United States. Data were from the 2005-2017 U.S. Multiple Cause-of-Death Mortality files. Average age at death by racial-ethnic status was compared between adults, age 18 and older, with/without different types of intellectual and developmental disability reported on their death certificate (N = 32,760,741). A multiple descent pattern was observed among adults without intellectual or developmental disability, with age at death highest among Whites, followed by Asians, Hispanics and Blacks, then American Indians. In contrast, a bifurcated pattern was observed among adults with intellectual disability, with age at death highest among Whites, but lower and similar among all racial-ethnic minority groups. The severity of racial-ethnic inequities in age at death was most pronounced among adults with cerebral palsy. Policy makers and public health experts should be aware that racial-ethnic inequities are different for adults with intellectual and developmental disability - all minorities with intellectual and developmental disability are at greater risk of premature death than their White counterparts.

Age differences in allostatic load among veterans: The importance of combat exposure.

The current study examinedage differences in allostatic load among nonveterans, noncombat veterans, and combat veterans. Participants included 280 individuals from the Midlife Development in the United States (MIDUS) survey, including 164 veterans (n = 48 combat veterans; n = 116 noncombat veterans) and 116 nonveterans. Age differences in allostatic load were similar among nonveterans and noncombat veterans, B = 0.002, SE = .011, p = .878, with older adults showing higher levels of allostatic load than their comparatively younger counterparts. Among combat veterans, however, a different pattern emerged. In this group, levels of allostatic load were similar across age, seemingly due to higher levels of allostatic load among younger combat veterans, B = -0.029, SE = .014, p = .031, ƞp 2  =  .022. Results reveal the importance of considering combat exposure when examining health outcomes of military veterans, particularly in the context of age.

Evidence of continued reduction in the age-at-death disparity between adults with and without intellectual and/or developmental disabilities.

BACKGROUND: This study examines recent trends in the age-at-death disparity between adults with and without intellectual and/or developmental disabilities in the United States. METHOD: Data were from the 2005-2017 U.S. death certificates. Average age at death was compared between adults whose death certificate did or did not report an intellectual and/or developmental disability. RESULTS: Age at death increased minimally for adults without, but markedly for adults with intellectual and/or developmental disabilities. As a result, the age-at-death disparity decreased: 2.2 years between adults with/without intellectual disability; 1.9 years between adults with/without Down syndrome; 2.7 years between adults with/without cerebral palsy; and 5.1 years between adults with/without rare developmental disabilities. CONCLUSION: Evidence from this study demonstrates that the age-at-death disparity between adults who did or did not have an intellectual and/or developmental disability reported on their death certificate continues to decrease, but the magnitude of the remaining disparity varied considerably by type of disability.

Attention Deficit Hyperactivity Disorder and adult mortality.

This study examines the relationship between self-reported ADHD and adult mortality over a four-year period, and whether ADHD is associated with underlying cause of death (accidents versus all others). If ADHD increases mortality risk through accidents, then interventions may be designed and implemented to reduce risk and prevent premature death. We estimate descriptive statistics and multivariate logistic regression models using data from the 2007 U.S. National Health Interview Survey (NHIS) Sample Adult File linked to National Death Index (NDI) data through 2011 (N=23,352). Analyses are weighted and standard errors are adjusted for the complex sampling design. We find that the odds of dying are significantly higher among those with ADHD than among those without ADHD net of exogenous sociodemographic controls (adjusted odds ratio=1.78, 95% confidence interval=1.01, 3.12). Although marginally non-significant, accidental death is more common among those with ADHD than among those without ADHD (13.2% versus 4.3%, p=0.052). Few population-representative studies examine the relationship between ADHD and adult mortality due to data limitations. Using NHIS data linked to the NDI, we are only able to observe a few deaths among adults with ADHD. However, ADHD is associated with significantly higher odds of dying for adults and results suggest that accidents may be an underlying cause of death more often for decedents with ADHD. Future research should further examine the mechanisms linking ADHD to adult mortality and the extent to which mortality among persons with ADHD is preventable. Regular measurement of ADHD among adults in the NHIS is warranted.

Disability Mortality Disparity: Risk Of Mortality For Disabled Adults Nearly Twice That For Nondisabled Adults, 2008-19.

After years of advocacy by the disability community and allied organizations, on September 26, 2023, the National Institute on Minority Health and Health Disparities (NIMHD) designated disabled people as a health disparities population in the US. During its deliberations, the NIMHD emphasized that there was not sufficient empirical evidence on health disparities between disabled and nondisabled adults. My study addressed this gap by examining 2008-19 data from the National Health Interview Survey Linked Mortality Files on people ages eighteen and older to identify, categorize, and quantify disparities in mortality risk among disabled and nondisabled adults. The risk of mortality during the study period was 1.9 times higher overall for disabled compared with nondisabled adults. The risk increased with the number of reported disabilities and varied by disability category. These findings underscore the need to improve access to high-quality, evidence-based health care among disabled people. To gain a full understanding of the scope of disparity and the interventions needed to mitigate it, it is critical to develop more equitable and inclusive measures of disability and ableism for use in population health surveys.

Health equity for people with intellectual and developmental disability requires vast improvements to data collection: Lessons from the COVID-19 pandemic.

The COVID-19 pandemic drastically underscored the lack of proper health surveillance for people with intellectual and developmental disability (IDD) in the USA. This data equity failure resulted in researchers having to rely on nontraditional data sources to develop an understanding of how this population was faring during the pandemic. To begin addressing this data equity concern, in this commentary, we (1) discuss the difficulties in accessing data during the pandemic specifically related to people with IDD; (2) provide guidance regarding how existing data can be used to examine COVID-19 outcomes for people with IDD; and (3) provide recommendations for improving data collection for people with IDD in light of lessons learned during the pandemic. In sum, the data currently available to examine COVID-19 as well as other health outcomes among people with IDD are severely limited, compromising the ability to both understand and address health disparities among this population.

Educational Attainment and Perceived Need for Future ADL Assistance.

The current study examined whether educational attainment was associated with perceived need of assistance with future activities of daily living (ADL) among middle-aged and early older-aged adults in the United States. Data for 54,946 adults aged 40-65 years from the 2011-2014 National Health Interview Survey (NHIS) were analyzed using ordered logistic regression. Adults with more education will on average need less ADL assistance than adults with less education. Paradoxically, this study found that higher levels of formal education were associated with perceiving more need for future ADL assistance. This association was also found to vary between males and females. Building knowledge of long-term care planning into existing public educational structures and providing this knowledge to adults no longer involved in the formal educational system through medical providers may lead to better anticipation of future care needs.

Counting disability in the National Health Interview Survey and its consequence: Comparing the American Community Survey to the Washington Group disability measures.

BACKGROUND: The objective of the National Health Interview Survey (NHIS) is to provide data that can be used to monitor the health of the US population. OBJECTIVE: In this study, we evaluate whether the disability questions currently used in the NHIS - the Washington Group questions - threaten the ability of this survey to fulfil its stated objective for disabled people. METHODS: Data were from the 2011-2012 NHIS with linkage to mortality status through 2019. We examined whether people who reported a disability in the American Community Survey disability questions had their disability counted in the Washington Group questions. We then examined the consequence of use of the Washington Group as opposed to the American Community Survey questions, on estimates of disability prevalence and comparative mortality risk. RESULTS: We find that when compared to their predecessor, the American Community Survey disability questions, the Washington Group questions accounted for less than half of disabled people, primarily counting disabled people with more than one disability status, but not counting many disabled people with only one disability status. As a result of this undercount, disability prevalence rates based on the Washington Group questions underestimate the size of the disabled population in the US, and overestimate the comparatively higher mortality risk associated with disability status. CONCLUSIONS: These results underscore the need to re-evaluate the disability questions used in the NHIS, and invest in the development of improved and expanded disability questionnaires for use in national surveys.

Covid-19 patterns among adults with intellectual and developmental disability and the general population in New York state during the first year of the pandemic.

BACKGROUND: People with intellectual and developmental disabilities (IDD) in the US, especially those living in group homes, experienced comparatively higher Covid-19 case/case fatality rates than the general population during the first year of the pandemic. There is no information about the patterns of case/case fatality rates during this time. OBJECTIVE: This study compared Covid-19 case/case fatality rates among people with IDD living in residential group homes to the general population across the first year of the pandemic in New York State (NYS). METHODS: Covid-19 positive cases and deaths collected from New York Disability Advocates (NYDA), a coalition of organizations serving individuals with IDD, was compared to data for the NYS general population from the first pandemic year. Case rates/100,000 and case fatality rates were calculated for the study period. Joinpoint Trend Analysis Software was used to analyze patterns in weekly case/case fatality rates. RESULTS: Case fatality rates for people with IDD were higher than for the overall state population throughout the pandemic's first year. Case rates were higher among people with IDD across most of this year. Although the patterns in rates were similar, there was a sharp increase in cases for those with IDD during Fall 2020 beginning eight weeks before the general NYS population and a significant decrease in fatalities in late December 2020 into January 2021. CONCLUSIONS: Consistently higher case fatality rates and significant differences in case/case fatality rates for people with IDD living in group homes require further consideration. Planning for future emergencies will require an enhanced federal/state understanding of the needs of people with IDD and a responsive surveillance system.

Reporting Down syndrome on the death certificate for Alzheimer disease/unspecified dementia deaths.

BACKGROUND: Death certificates are crucial for understanding population health trends including the burden of disease mortality. Accurate reporting of causes of death on these records is necessary in order to implement adequate public health policies and fund disease research. While there is evidence that Alzheimer disease and unspecified dementia are prevalent among people with Down syndrome, a 2014 Centers for Disease Control and Prevention (CDC) rule change instructing that Down syndrome should be reported as the underlying cause of death in instances when death occurred from Alzheimer disease or unspecified dementia threatens the accuracy and the utility of death certificates for this population. METHODS: This study used 15 years (2005-2019) of US death certificate data for adults with and without Down syndrome. We compare the mortality burden due to Alzheimer disease and unspecified dementia prior to and after amending death certificates that report Down syndrome as the underlying cause of death. RESULTS: When analyzing death certificates without addressing the reporting of Down syndrome as the underlying cause of death, rates of death due to Alzheimer disease and dementia ranked as the third leading cause of death for both adults with and without Down syndrome. After amending death certificates that reported Down syndrome as the underlying cause of death, Alzheimer disease and dementia were the leading cause of death among those with Down syndrome, occurring 2.7 times more in adults with compared to without Down syndrome. CONCLUSION: The findings of this study highlight the importance of accurate mortality data for studying and addressing population health trends. The current practice of reporting Down syndrome as the underlying cause of death rather than the disease responsible for death needs to be reconsidered and modified. If not, people with Down syndrome may be further marginalized within dementia related support and research.

Attention deficit hyperactivity disorder and the age pattern of adult mortality.

We draw upon the life-course perspective and examine whether Attention Deficit Hyperactivity Disorder (ADHD) moderates the age pattern of adult mortality using data from the 2007 and 2012 National Health Interview Survey Sample Adult File linked to National Death Index data through 2015. Overall, 7.0% of respondents died by 2015. Discrete-time hazard analysis indicates that the log odds of mortality were significantly lower among 18 and 19 year old adults ever diagnosed with ADHD and significantly higher among 46 to 64 year old adults ever diagnosed with ADHD, with a crossover occurring at age 33. Results were similar among men and women. It is not known specifically which risks drive changes in the risk of mortality documented among persons with ADHD during the transition to adulthood, the increased risk of mortality in midlife, or whether some risks operate more or less at particular ages. Additional research can lead to targeted, age- and life-course stage-focused interventions for specific risks and contribute to the reduction of ADHD-related mortality.

Postmortem Diagnostic Overshadowing: Reporting Cerebral Palsy on Death Certificates.

Postmortem diagnostic overshadowing-defined as inaccurately reporting a disability as the underlying cause of death-occurs for over half of adults with cerebral palsy. This practice obscures cause of death trends, reducing the effectiveness of efforts to reduce premature mortality among this marginalized health population. Using data from the National Vital Statistics System 2005 to 2017 U.S. Multiple Cause of Death files (N = 29,996), we identify factors (sociodemographic characteristics, aspects of the context and processing of death, and comorbidities) associated with the inaccurate reporting of cerebral palsy as the underlying cause of death. Results suggest that inaccurate reporting is associated with heightened contexts of clinical uncertainty, the false equivalence of disability and health, and potential racial-ethnic bias. Ending postmortem diagnostic overshadowing will require training on disability and health for those certifying death certificates and efforts to redress ableist death certification policies.

COVID-19 mortality burden and comorbidity patterns among decedents with and without intellectual and developmental disability in the US.

BACKGROUND: While there is ample evidence of increased COVID-19 mortality risk among people with intellectual and developmental disability (IDD), research has not documented whether this higher risk resulted in increased COVID-19 mortality burden in the US or whether comorbidity patterns among COVID-19 deaths are similar or distinct for people with IDD. OBJECTIVE: To determine the differences in COVID-19 mortality burden between decedents with and without IDD during the first year of the pandemic. METHODS: This study uses 2020 US death certificate data to compare COVID-19 mortality burden and comorbidity patterns among decedents with and without IDD. RESULTS: COVID-19 was the leading cause of death among decedents with IDD in 2020, compared with the 3rd leading cause among decedents without IDD. The proportion of deaths from COVID-19 was also higher for decedents with compared to without IDD. Comorbidities resulting from COVID-19 were similar among decedents with and without IDD, but there were some differences among reported pre-existing conditions, notably higher rates of hypothyroidism and seizures among decedents with IDD. CONCLUSION: The COVID-19 mortality burden was greater for people with than without IDD during the first year of the pandemic. The continued practice of postmortem diagnostic overshadowing prevents analyzing whether this difference continues through today. Action is needed by the Centers for Disease Control and Prevention to mitigate this data inequity. Out of an abundance of caution, medical providers should carefully monitor symptoms among COVID-19 patients with IDD diagnosed with hypothyroidism and/or seizures.

Expanding Understanding of Racial-Ethnic Differences in ADHD Prevalence Rates among Children to Include Asians and Alaskan Natives/American Indians.

BACKGROUND: Prior studies show that ADHD prevalence rates vary by race-ethnicity, but these studies do not include a full range of racial-ethnic minority groups. OBJECTIVE: This study aimed to understand differences in ADHD prevalence among children across a wider range of racial-ethnic groups, overall and stratified by biological sex. METHOD: Data on children aged 5 to 17 from the 2004 to 2018 National Health Interview Survey Sample Child Files were used in analyses (N = 120,129). RESULTS: Compared to Non-Hispanic White children, ADHD prevalence was lower among Hispanic and Non-Hispanic Asian children. This difference was present for both males and females. Across all racial-ethnic groups, males had higher ADHD prevalence than females. CONCLUSION: Results from this study provide further evidence that racial-ethnic disparities in ADHD prevalence rates persist across sex and provide initial evidence of substantially lower ADHD prevalence among Non-Hispanic Asians. Implications, limitations, and future research directions derived from the results are discussed.

Cause of death trends among adults with and without cerebral palsy in the United States, 2013-2017.

BACKGROUND: Adults with cerebral palsy (CP) in the United States die much earlier than those without CP, a health inequality likely shaped by causes of death. Existing research has not considered demographic differences in mortality patterns. OBJECTIVES: To analyze differences in cause of death for adults who did/did not have CP reported on their death certificates and to assess sex and racial-ethnic difference in causes of death among adult decedents with CP. METHODS: Data are from the 2013-2017 US Multiple Cause of Death Mortality files (N = 13,332,871; n = 13,897 with CP). Multiple logistic regression models were used to compare differences in causes of death between adults with and without CP and to determine sex and racial-ethnic differences in causes of death among adults with CP. Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) were estimated. RESULTS: As compared with decedents without CP, those with CP were more likely to die from pneumonitis (aOR 31.14, 95% CI 29.42-32.96), influenza/pneumonia (8.78, 8.30-9.29), respiratory failure (17.24, 15.19-18.69), and choking (20.66, 18.86-22.62) and less likely to die from heart disease (0.61, 0.58-0.65), cancer (0.12, 0.11-0.13), chronic lower respiratory diseases (0.50, 0.44-0.56), and cerebrovascular diseases (0.66, 0.59-0.75). Among adults with CP, female decedents were more likely than males to die from respiratory failure (1.21, 1.03-1.42), and non-Hispanic Black decedents were more likely than non-Hispanic White decedents to die from heart disease (1.24, 1.07-1.45) and cerebrovascular disease (1.77, 1.29-2.49). CONCLUSIONS: In 2013-2017, heart disease was the leading cause of death for adults with and without CP. However, for people with compared to those without CP, likelihood of death from likely preventable respiratory causes of death was higher. Non-Hispanic Black adults were more likely than non-Hispanic White adults to die from heart and cerebrovascular diseases. Public health, clinical, and rehabilitation efforts must use a multifaceted approach to address respiratory and circulatory health among people with CP. DATABASE: United States National Vital Statistics System of the Centers for Disease Control and Prevention Multiple Cause of Death Mortality files (National Bureau of Economic Research: https://www.nber.org/research/data/vital-statistics-mortality-data-nber).

Self-Reported ADHD and Adult Health in the United States.

Objective: Informed by a social determinants of health framework, we investigate the relationship between self-reported ADHD diagnosis status and adult health, and whether observed associations are attenuated by biomedical and socioeconomic factors. Method: Using 2007 National Health Interview Survey data (N = 19,104), we present multivariate logistic regression analyses of associations between self-reported ADHD diagnosis status and five adult health outcomes. Results: ADHD diagnosis was significantly associated with higher odds of injury, physical health conditions, functional limitations, fair/poor health, and psychological distress in fully specified models (adjusted odds ratios [AORs] = 1.62-2.36). Inclusion of controls for exogenous demographic characteristics, psychiatric comorbidities and health behaviors, and adult social and economic statuses attenuated but did not eliminate observed associations between ADHD and poorer adult health. Conclusion: Research on adult health outcomes for those with ADHD should include consideration of the mechanisms by which a diagnosis of ADHD leads to cumulative social disadvantages that independently contribute to poorer health outcomes.