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1.  Cohort Profile: The English Longitudinal Study of Ageing 
The English Longitudinal Study of Ageing (ELSA) is a panel study of a representative cohort of men and women living in England aged ≥50 years. It was designed as a sister study to the Health and Retirement Study in the USA and is multidisciplinary in orientation, involving the collection of economic, social, psychological, cognitive, health, biological and genetic data. The study commenced in 2002, and the sample has been followed up every 2 years. Data are collected using computer-assisted personal interviews and self-completion questionnaires, with additional nurse visits for the assessment of biomarkers every 4 years. The original sample consisted of 11 391 members ranging in age from 50 to 100 years. ELSA is harmonized with ageing studies in other countries to facilitate international comparisons, and is linked to financial and health registry data. The data set is openly available to researchers and analysts soon after collection (
PMCID: PMC3900867  PMID: 23143611
Ageing; cohort; longitudinal; UK
2.  The Bidirectional Association between Depressive Symptoms and Gait Speed: Evidence from the English Longitudinal Study of Ageing (ELSA) 
PLoS ONE  2013;8(7):e68632.
Depressive symptoms and physical performance are inversely associated, but it is unclear whether their association is bidirectional. We examined whether the association between depressive symptoms and physical performance measured using gait speed is bidirectional.
We used a national sample of 4,581 community-dwelling people aged 60 years and older from the English Longitudinal Study of Ageing (from 2002–03 to 2008-09). We fitted Generalized Estimating Equation (GEE) regression models to analyse repeated measurements of gait speed (m/sec) and elevated depressive symptoms (defined as a score of ≥4 on the eight-item Center for Epidemiological Studies-Depression scale).
Slower gait speed was associated with elevated depressive symptoms both concurrently and two years later. After adjustment for previous depressive symptoms and sociodemographic, clinical, lifestyle, psychosocial, and cognitive factors the concurrent association was partially explained (Odds Ratio [OR] 0.42, 95% confidence interval [CI], 0.30 to 0.59, per 1m/sec increase in gait speed) and the two-year lagged association fully (OR 0.75, 95% CI, 0.56 to 1.00). Elevated depressive symptoms were associated with slower gait speed. Full adjustment for covariates (including previous gait speed) partially explained both the concurrent (β regression coefficient [β] -0.038, 95% CI, -0.050 to -0.026, for participants with elevated depressive symptoms compared with those with no or one symptom) and the two-year lagged associations (β -0.017, 95% CI, -0.030 to -0.005). Subthreshold depressive symptoms (defined as a score of two or three on the eight-item Center for Epidemiological Studies-Depression scale) were also associated with slower gait speed. Full adjustment for covariates partially explained both the concurrent (β -0.029, 95% CI, -0.039 to -0.019, for participants with subthreshold symptoms compared with those with no or one symptom) and the two-year lagged associations (β -0.011, 95% CI, -0.021 to -0.001).
The inverse association between gait speed and depressive symptoms appears to be bidirectional.
PMCID: PMC3706406  PMID: 23874698
3.  Higher Levels and Intensity of Physical Activity Are Associated with Reduced Mortality among Community Dwelling Older People 
Journal of Aging Research  2011;2011:651931.
Introduction. There is limited evidence on physical activity and mortality in older people. Methods. People aged 75–84 years (n = 1449) participating in a randomized trial of health screening in UK general practice were interviewed about their physical activity (PA) and were assessed for a wide range of health and social problems. Mortality data were collected over 7 years of followup. Results. Full information on PA and potential confounders was available in 946 people. Those in the highest third of duration of PA had a lower mortality, confounder-adjusted Hazard Ratio (HR) = 0.74, and 95% Confidence Interval (CI) 0.56–0.97, compared to the lowest third. Similar benefits were seen when categorized by intensity of PA, with those in the highest group having a lower mortality, confounder-adjusted HR = 0.61, and 95% CI 0.47–0.79, compared to the lowest category. Conclusions. Our results suggest the importance of providing older people with opportunities for physical activity.
PMCID: PMC3062144  PMID: 21437004
4.  Coronary heart disease risk factors and regional deprivation in England: does age matter? 
Age and Ageing  2009;39(2):253-256.
PMCID: PMC2842111  PMID: 19923164
regional deprivation; older population; CHD risk factors; social position; elderly
5.  Inequalities in health at older ages: a longitudinal investigation of the onset of illness and survival effects in England 
Age and Ageing  2008;38(2):181-187.
Background: previous studies have suggested a decline in the relationship between socioeconomic circumstances and health or functioning in later life, but this may be due to survival effects.
Objective: to examine whether wealth gradients in the incidence of illness decline with age, and, if so, whether this decline is explained by differential mortality.
Methods: the study included participants in the first two waves of the English Longitudinal Study of Ageing (ELSA), a large national longitudinal study of the population aged 50+ in England, who reported good health, no functional impairment, or no heart disease at baseline. Wealth inequalities in onset of illness over 2 years were examined across age groups, with and without the inclusion of mortality. Outcome measures were functional impairment, heart disease, self-reported health, and all-cause mortality (in conjunction with self-reported health and disability) or circulatory-related mortality (in relation to heart disease).
Results: wealth predicted onset of functional impairment equally across age groups. For self-reported health and heart disease, wealth gradients in the onset of illness declined with age. Selective mortality contributed to this decline in the oldest age groups.
Conclusions: socioeconomic inequality in developing new health problems persist into old age for certain illnesses, particularly functional impairment, but not for heart disease. Selective mortality explains only some of the decline in health inequalities with age.
PMCID: PMC2724887  PMID: 19029098
health inequalities; ageing; selective mortality
6.  Do general practices provide equitable access to physical activity interventions? 
Exercise referral schemes are widespread across England. National guidance emphasises the need to engage groups that are disadvantaged.
To examine the influence of socioeconomic deprivation on referral to, and use of, exercise referral schemes.
Design of study
Cross-sectional analysis of patients referred by general practices to exercise referral schemes between 2004 and 2006.
Six primary care trusts (PCTs) in Greater London.
Routine data about patients who had been referred to exercise referral schemes were used to estimate risk ratios for referral by general practice deprivation quintile, odds ratios (ORs) for uptake, and ORs for completion of exercise referral schemes by patients' deprivation status quintile.
All 317 general practices in the six PCTs were included in the referral analysis. Referrals were less likely from general practices serving advantaged socioeconomic areas (adjusted risk ratio for trend across deprivation quintiles 0.84; 95% confidence interval [CI] = 0.76 to 0.93). This study found no association between patients' deprivation status and their likelihood of taking up (adjusted OR, least versus most deprived quintile 1.05; 95% CI = 0.83 to 1.33) or completing the scheme (adjusted OR 1.23; 95% CI = 0.84 to 1.79).
General practices within areas of deprivation were more likely to refer patients to exercise referral schemes than practices in more advantaged areas. Once referred, it was found that patients living in areas of deprivation were as likely to take up and to complete the scheme as those living in more advantaged locations. Research is needed to identify the organisational and contextual factors that allow this pattern of service delivery, which appears to facilitate access to care among patients who live in areas of deprivation.
PMCID: PMC2553553  PMID: 18826774
exercise; family practice; health promotion; healthcare disparities; referral and consultation; socioeconomic factors
7.  Cardiorespiratory risk factors as predictors of 40-year mortality in women and men 
Heart  2009;95(15):1250-1257.
Most historical studies of cardiorespiratory risk factors as predictors of mortality have been based on men. This study examines whether they predict mortality over long periods in women and men.
Prospective cohort study.
Participants were employees of the General Post Office.
Risk factor data were collected via clinical examination and questionnaire, 1966–67. Associations between cardiorespiratory risk factors and 40-year mortality were determined for 644 women and 1272 men aged 35–70 at examination.
Main outcome measures
All-cause, cardiovascular (CVD), cancer, and respiratory mortality.
Associations between systolic blood pressure and all-cause and stroke mortality were equally strong for women and men, hazard ratio (95% confidence interval): 1.25 (1.1–1.4) and 1.18 (1.1–1.3); and 2.17 (1.7–2.8) and 1.69 (1.4–2.1) respectively. Cholesterol was higher in women and was associated with all-cause 1.22 (1.1–1.4) and CVD 1.39 (1.2–1.7) mortality, while associations between 2-hour glucose and all-cause 1.15 (1.1–1.2), coronary heart disease (CHD) 1.25 (1.1–1.4) and respiratory mortality 1.21 (1.0–1.5) were observed in men. Obesity was associated with stroke in women 2.42 (1.12–5.24) and CHD in men 1.59 (1.02–2.49), while ECG ischaemia was associated with CVD in both sexes. The strongest, most consistent predictor of mortality was smoking in women and poor lung function in men. However, evidence of sex differences in associations between the cardiorespiratory risk factors measured and mortality was sparse.
Data from a 40-year follow-up period show remarkably persistent associations between risk factors and cardiorespiratory and all-cause mortality in women and men.
PMCID: PMC2746941  PMID: 19389720
Adult; Aged; Blood Pressure; physiology; Body Mass Index; Cause of Death; Cohort Studies; Female; Heart Diseases; mortality; physiopathology; Humans; Male; Middle Aged; Respiratory Function Tests; Respiratory Tract Diseases; mortality; physiopathology; Risk Factors; Smoking; mortality; physiopathology; cardiorespiratory mortality; risk factors; 40-year mortality; 1960s
8.  Life expectancy in relation to cardiovascular risk factors: 38 year follow-up of 19 000 men in the Whitehall study 
Objective To assess life expectancy in relation to cardiovascular risk factors recorded in middle age.
Design Prospective cohort study.
Setting Men employed in the civil service in London, England.
Participants 18 863 men examined at entry in 1967-70 and followed for 38 years, of whom 13 501 died and 4811 were re-examined in 1997.
Main outcome measures Life expectancy estimated in relation to fifths and dichotomous categories of risk factors (smoking, “low” or “high” blood pressure (≥140 mm Hg), and “low” or “high” cholesterol (≥5 mmol/l)), and a risk score from these risk factors.
Results At entry, 42% of the men were current smokers, 39% had high blood pressure, and 51% had high cholesterol. At the re-examination, about two thirds of the previously “current” smokers had quit smoking shortly after entry and the mean differences in levels of those with high and low levels of blood pressure and cholesterol were attenuated by two thirds. Compared with men without any baseline risk factors, the presence of all three risk factors at entry was associated with a 10 year shorter life expectancy from age 50 (23.7 v 33.3 years). Compared with men in the lowest 5% of a risk score based on smoking, diabetes, employment grade, and continuous levels of blood pressure, cholesterol concentration, and body mass index (BMI), men in the highest 5% had a 15 year shorter life expectancy from age 50 (20.2 v 35.4 years).
Conclusion Despite substantial changes in these risk factors over time, baseline differences in risk factors were associated with 10 to 15 year shorter life expectancy from age 50.
PMCID: PMC2746269  PMID: 19762417
9.  Socioeconomic status and health: the role of subjective social status 
Social science & medicine (1982)  2008;67(2):330-340.
Studies have suggested that subjective social status (SSS) is an important predictor of health. This study examined the link between SSS and health in old age and investigated whether SSS mediated the associations between objective indicators of socioeconomic status and health. It used cross-sectional data from the second wave (2004–05) of the English Longitudinal Study of Ageing, which were collected through personal interviews and nurse visits. The study population consisted of 3368 men and 4065 women aged 52 years or older. The outcome measures included: self-rated health, long-standing illness, depression, hypertension, diabetes, central obesity, high-density lipoprotein cholesterol, triglycerides, fibrinogen, and C-reactive protein. The main independent variable was SSS measured using a scale representing a 10-rung ladder. Wealth, education, and occupational class were employed as covariates along with age and marital status and also, in additional analyses, as the main independent variables. Gender-specific logistic and linear regression analyses were performed. In age-adjusted analyses SSS was related positively to almost all health outcomes. Many of these relationships remained significant after adjustment for covariates. In men, SSS was significantly (p≤0.05) related to self-rated health, depression, and long-standing illness after adjustment for all covariates, while its association with fibrinogen became non-significant. In women, after adjusting for all covariates, SSS was significantly associated with self-rated health, depression, long-standing illness, diabetes, and high-density lipoprotein cholesterol, but its associations with central obesity and C-reactive protein became non-significant. Further analysis suggested that SSS mediated fully or partially the associations between education, occupational class and self-reported and clinical health measures. On the contrary, SSS did not mediate wealth’s associations with the outcome measures, except those with self-reported health measures. Our results suggest that SSS is an important correlate of health in old age, possibly because of its ability to epitomize life-time achievement and socioeconomic status.
PMCID: PMC2547480  PMID: 18440111
subjective social status; health inequalities; education; wealth; UK; occupational class; old age
10.  Self reported receipt of care consistent with 32 quality indicators: national population survey of adults aged 50 or more in England 
Objective To assess the receipt of effective healthcare interventions in England by adults aged 50 or more with serious health conditions.
Design National structured survey questionnaire with face to face interviews covering medical panel endorsed quality of care indicators for both publicly and privately provided care.
Setting Private households across England.
Participants 8688 participants in the English longitudinal study of ageing, of whom 4417 reported diagnoses of one or more of 13 conditions.
Main outcome measures Percentage of indicated interventions received by eligible participants for 32 clinical indicators and seven questions on patient centred care, and aggregate scores.
Results Participants were eligible for 19 082 items of indicated care. Receipt of indicated care varied substantially by condition. The percentage of indicated care received by eligible participants was highest for ischaemic heart disease (83%, 95% confidence interval 80% to 86%), followed by hearing problems (79%, 77% to 81%), pain management (78%, 73% to 83%), diabetes (74%, 72% to 76%), smoking cessation (74%, 71% to 76%), hypertension (72%, 69% to 76%), stroke (65%, 54% to 76%), depression (64%, 57% to 70%), patient centred care (58%, 57% to 60%), poor vision (58%, 54% to 63%), osteoporosis (53%, 49% to 57%), urinary incontinence (51%, 47% to 54%), falls management (44%, 37% to 51%), osteoarthritis (29%, 26% to 32%), and overall (62%, 62% to 63%). Substantially more indicated care was received for general medical (74%, 73% to 76%) than for geriatric conditions (57%, 55% to 58%), and for conditions included in the general practice pay for performance contract (75%, 73% to 76%) than excluded from it (58%, 56% to 59%).
Conclusions Shortfalls in receipt of basic recommended care by adults aged 50 or more with common health conditions in England were most noticeable in areas associated with disability and frailty, but few areas were exempt. Efforts to improve care have substantial scope to achieve better health outcomes and particularly need to include chronic conditions that affect quality of life of older people.
PMCID: PMC2515887  PMID: 18703659
11.  Cross-sectional survey of older peoples' views related to influenza vaccine uptake 
BMC Public Health  2006;6:249.
The population's views concerning influenza vaccine are important in maintaining high uptake of a vaccine that is required yearly to be effective. Little is also known about the views of the more vulnerable older population over the age of 74 years.
A cross-sectional survey of community dwelling people aged 75 years and over wh, previous participant was conducted using a postal questionnaire. Responses were analysed by vaccine uptake records and by socio-demographic and medical factors.
85% of men and 75% of women were vaccinated against influenza in the previous year. Over 80% reported being influenced by a recommendation by a health care worker. The most common reason reported for non uptake was good health (44%), or illness considered to be due to the vaccine (25%). An exploration of the crude associations with socio-economic status suggested there may be some differences in the population with these two main reasons. 81% of people reporting good health lived in owner occupied housing with central heating vs. 63% who did not state this as a reason (p = 0.04), whereas people reporting ill health due to the vaccine was associated with poorer social circumstances. 11% lived in the least deprived neighbourhood compared to 36% who did not state this as a reason (p = 0.05) and were less likely to be currently married than those who did not state this as a reason (25% vs 48% p = 0.05).
Vaccine uptake was high, but non uptake was still noted in 1 in 4 women and 1 in 7 men aged over 74 years. Around 70% reported they would not have the vaccine in the following year. The divergent reasons for non-uptake, and the positive influence from a health care worker, suggests further uptake will require education and encouragement from a health care worker tailored towards the different views for not having influenza vaccination. Non-uptake of influenza vaccine because people viewed themselves as in good health may explain the modest socio-economic differentials in influenza vaccine uptake in elderly people noted elsewhere. Reporting of ill-health due to the vaccine may be associated with a different, poorer background.
PMCID: PMC1621069  PMID: 17034625
12.  Trends in influenza vaccination uptake among people aged over 74 years, 1997–2000: Survey of 73 general practices in Britain 
Influenza vaccination policy for elderly people in Britain has changed twice since 1997 to increase protection against influenza but there is no information available on how this has affected vaccine uptake, and socioeconomic variation therein, among people aged over 74 years.
Vaccination information for 1997–2000 was collected directly from general practices taking part in a MRC-funded Trial of the Assessment and Management of Older People in the Community. This was linked to information collected during assessments carried out as part of the Trial. Regression modelling was used to assess relative probabilities (as relative risks, RR) of having vaccination according to year, gender, age, area and individual socioeconomic characteristics.
Out of 106 potential practices, 73 provided sufficient information to be included in the analysis. Uptake was 48% (95% CI 45%, 55%) in 1997 and did not increase substantially until 2000 when the uptake was a third higher at 63% (50%, 66%). Vaccination uptake was lower among women than men (RR 0.9), people aged 85 or more compared to people aged under 80 (RR 0.9), those in the most deprived areas (RR 0.8) compared to the least deprived, and was relatively high for those in owner-occupied homes with central heating compared to other non-supported housing (RR for remainder = 0.9). This pattern did not change over the years studied.
Increased uptake in 2000 may have resulted from the additional financial resources given to practices; it was not at the expense of more disadvantaged socioeconomic groups but nor did they benefit disproportionately.
PMCID: PMC421730  PMID: 15099402
13.  Randomised comparison of three methods of administering a screening questionnaire to elderly people: findings from the MRC trial of the assessment and management of older people in the community 
BMJ : British Medical Journal  2001;323(7326):1403.
To compare three different methods of administering a brief screening questionnaire to elderly people: post, interview by lay interviewer, and interview by nurse.
Randomised comparison of methods within a cluster randomised trial.
106 general practices in the United Kingdom.
32 990 people aged 75 years or over registered with participating practices.
Main outcome measures
Response rates, proportion of missing values, prevalence of self reported morbidity, and sensitivity and specificity of self reported measures by method of administration of questionnaire for four domains.
The response rate was higher for the postal questionnaire than for the two interview methods combined (83.5% v 74.9%; difference 8.5%, 95% confidence interval 4.4% to 12.7%, P<0.001). The proportion of missing or invalid responses was low overall (mean 2.1%) but was greater for the postal method than for the interview methods combined (4.1% v 0.9%; difference 3.2%, 2.7% to 3.6%, P<0.001). With a few exceptions, levels of self reported morbidity were lower in the interview groups, particularly for interviews by nurses. The sensitivity of the self reported measures was lower in the nurse interview group for three out of four domains, but 95% confidence intervals for the estimates overlapped. Specificity of the self reported measures varied little by method of administration.
Postal questionnaires were associated with higher response rates but also higher proportions of missing values than were interview methods. Lower estimates of self reported morbidity were obtained with the nurse interview method and to a lesser extent with the lay interview method than with postal questionnaires.
What is already known on this topicThe optimum method of administering a brief multidimensional screening assessment to elderly people is not knownWhat this study addsPostal questionnaires produce a higher response rate than interviews by nurses or lay interviewers but also higher proportions of missing dataInterview by nurses and to a lesser degree by lay interviewers is associated with lower levels of self reported morbidity than are postal questionnaires
PMCID: PMC60986  PMID: 11744565

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