We examine how the passage of time since spousal loss varies by social and demographic characteristics, using data from the University of Alabama at Birmingham Study of Aging. In multivariate analyses, African American race, female sex, lower income, and higher risk of social isolation had significant and independent associations with variation in time since spousal loss. African American women were at highest risk for long-term widowhood. Accurate characterizations of widowhood among community-dwelling older adults must consider variation in the length of time individuals are living as widowed persons and socioeconomic concomitants of long-term widowhood.

Background

This study examined the effects of religiosity on the trajectories of depressive symptoms in a sample of community-dwelling older adults over a four-year period in a Southern state in the U.S.

Method

Data from the University of Alabama at Birmingham Study (UAB) of Aging were analyzed using a hierarchical linear modeling (HLM) method. This study involved 1,000 participants aged 65 and older (M age = 75 at baseline, SD = 5.97) and data were collected annually from 1999 through 2003. The Geriatric Depression Scale measured depressive symptoms; the Duke University Religion Index measured religious service attendance, prayer, and intrinsic religiosity; and control variables included sociodemographics, health, and social and economic factors.

Results

The HLM analysis indicated a curvilinear trajectory of depressive symptoms over time. At baseline, participants who attended religious services more frequently tended to report fewer depressive symptoms. Participants with the highest levels of intrinsic religiosity at baseline experienced a steady decline in the number of depressive symptoms over the four-year period, while those with lower levels of intrinsic religiosity experienced a short-term decline followed by an increase in the number of depressive symptoms.

Implications

In addition to facilitating access to health, social support and financial resources for older adults, service professionals might consider culturally-appropriate, patient-centered interventions that boost the salutary effects of intrinsic religiosity on depressive symptoms.

Little is known about the affect of reduced vision on physical activity in older adults. This study evaluates the association of visual acuity level, self-reported vision and ocular disease conditions with leisure-time physical activity and calculated caloric expenditure. A cross sectional study of 911 subjects 65 yr and older from the University of Alabama at Birmingham Study of Aging (SOA) cohort was conducted evaluating the association of vision-related variables to weekly kilocalorie expenditure calculated from the 17-item Leisure Time Physical Activity Questionnaire. Ordinal logistic regression was used to evaluate possible associations controlling for potential confounders. In multivariate analyses, each lower step in visual acuity category below 20/50 was significantly associated with reduced odds of having a higher level of physical activity OR 0.81, 95% CI 0.67, 0.97. Reduced visual acuity appears to be independently associated with lower levels of physical activity among community-dwelling adults.

Objectives.

Widowhood is associated with increased mortality. However, to what extent this association is independent of other risk factors remains unclear. In the current study, we used propensity score matching to design a study to examine the independent association of widowhood with outcomes in a balanced cohort of older adults in the United States.

Methods.

We used public-use copies of the Cardiovascular Health Study data obtained from the National Heart, Lung, and Blood Institute. Of the 5,795 community-dwelling older men and women aged 65 years and older in Cardiovascular Health Study, 3,820 were married and 1,436 were widows or widowers. Propensity scores for widowhood, estimated for each of the 5,256 participants, were used to assemble a cohort of 819 pairs of widowed and married participants who were balanced on 74 baseline characteristics. The 1,638 matched participants had a mean (± standard deviation) age of 75 (±6) years, 78% were women, and 16% African American.

Results.

All-cause mortality occurred in 46% (374/819) and 51% (415/819) of matched married and widowed participants, respectively, during more than 11 years of median follow-up (hazard ratio associated with widowhood, 1.18; 95% confidence interval, 1.03–1.36; p = .018). Hazard ratios (95% confidence intervals) for cardiovascular and noncardiovascular mortalities were 1.07 (0.87–1.32; p = .517) and 1.28 (1.06–1.55; p = .011), respectively. Widowhood had no independent association with all-cause or heart failure hospitalization or incident cardiovascular events.

Conclusions.

Among community-dwelling older adults, widowhood was associated with increased mortality, which was independent of confounding by baseline characteristics and largely driven by an increased noncardiovascular mortality. Widowhood had no independent association with hospitalizations or incident cardiovascular events.

Background

Heart failure (HF) patients often depend on driving for access to specialty care. We analyzed a public-use copy of the Cardiovascular Health Study (CHS) data to determine if HF is a risk factor for driving cessation and to identify other risk factors for driving cessation among those with HF.

Methods and results

Of the 5383 community-dwelling drivers ≥65 years (mean age, 73 years, 55% women, 13% African American), 839 had HF: 246 had baseline prevalent HF and 593 developed incident HF before driving cessation during 9 years of follow-up. Incident driving cessation occurred at rates of 3980 and 3709 per 10,000 person-years of follow-up for those with and without HF, respectively (unadjusted hazard ratio {HR} associated with HF as a time-varying variable, 2.13; 95% confidence interval {CI}, 1.83–2.47; p<0.001). This association remained unchanged after multivariable risk adjustment (HR, 1.43; 95% CI, 1.21–1.68; p<0.001). Among the 839 older drivers with HF, independent predictors for incident driving cessation were age ≥75 years (HR, 1.99; 95% CI, 1.44–2.73; p<0.001), female gender (HR, 1.93; 95% CI, 1.37–2.74; p<0.001), difficulty walking half a mile (HR, 1.47; 95% CI, 1.04–2.08; p=0.028), vision problems (HR, 1.47; 95% CI, 1.07–2.02; p=0.018), and stroke as a time-varying covariate (HR, 1.96; 95% CI, 1.38–2.79; p<0.001).

Conclusion

HF is an independent risk factor for incident driving cessation among community-dwelling older drivers. Several patient characteristics predicted driving cessation in older HF patients, which may be targets for interventions to prevent driving cessation among these patients.

Background.

Potential disparities in health care utilization were examined using overnight hospitalization data from the University of Alabama at Birmingham Study of Aging, a longitudinal investigation of a stratified sample of Medicare beneficiaries.

Methods.

Racial differences in self-reported surgical and nonsurgical overnight hospital admissions were examined using Cox proportional hazards models. Andersen’s Behavioral Model provided the conceptual framework to identify other potential predictors of admission.

Results.

Nine hundred and forty-two participants, 50.1% African American, provided data at baseline and at least one follow-up assessment (mean age = 75.3 years, range: 65–106). African Americans were less likely to utilize surgical admissions compared with Caucasians in a bivariate model (hazard ratio = 0.63, 95% confidence interval = 0.41–0.98). This effect was not significant after controlling for demographics and self-reported physical health. Additional bivariate predictors of surgical admission were intact mental status, having private insurance, and higher education. African Americans were less likely to utilize nonsurgical admissions in both bivariate (hazard ratio = 0.74, 95% confidence interval = 0.59–0.93) and covariate-adjusted models (hazard ratio = 0.64, 95% confidence interval = 0.50–0.84). This effect was significantly stronger for men than for women, with African American men only 0.50 times as likely as Caucasian men to report a nonsurgical admission. Other bivariate predictors of nonsurgical admission were increased age, poor physical health, negative psychological characteristics, higher levels of social support, and low perceived discrimination.

Conclusion.

Underutilization of services has been linked to increased mortality in African Americans. Modifications in mutable domains associated with service utilization such as perceived discrimination, social support, and having private insurance may be beneficial.

Purpose: To identify racial/ethnic differences in retention of older adults at 3 levels of participation in a prospective observational study: telephone, in-home assessments, and home visits followed by blood draws. Design and Methods: A prospective study of 1,000 community-dwelling Medicare beneficiaries aged 65 years and older included a baseline in-home assessment and telephone follow-up calls at 6-month intervals; at 4 years, participants were asked to complete an additional in-home assessment and have blood drawn. Results: After 4 years, 21.7% died and 0.7% withdrew, leaving 776 participants eligible for follow-up (49% African American; 46% male; 51% rural). Retention for telephone follow-up was 94.5% (N = 733/776); 624/733 (85.1%) had home interviews, and 408/624 (65.4%) had a nurse come to the home for the blood draw. African American race was an independent predictor of participation in in-home assessments, but African American race and rural residence were independent predictors of not participating in a blood draw. Implications: Recruitment efforts designed to demonstrate respect for all research participants, home visits, and telephone follow-up interviews facilitate high retention rates for both African American and White older adults; however, additional efforts are required to enhance participation of African American and rural participants in research requiring blood draws.

Background.

Although chronic kidney disease (CKD) is associated with poor physical function, less is known about the longitudinal association between CKD and the decline of instrumental activities of daily living (IADL) and basic activities of daily living (BADL) among community-dwelling older adults.

Methods.

Participants were part of the prospective observational University of Alabama at Birmingham Study of Aging (n = 357). CKD was defined as an estimated glomerular filtration rate less than 60 mL/min/1.73 m2 using the Modification of Diet in Renal Disease equation. Primary outcomes were IADL and BADL decline defined as an increase in the number of activities for which participants reported difficulty after 2 years. Forward stepwise logistic regression was used to determine associations of baseline CKD and functional decline.

Results.

Participants had a mean age of 77.4 (SD = 5.8) years, 41% were African American, and 52% women. IADL decline occurred in 35% of those with CKD and 17% of those without (unadjusted odds ratio, 2.62, 95% confidence intervals [95% CI], 1.59–4.30, p < .001). BADL decline occurred in 20% and 7% of those with and without CKD, respectively (unadjusted odds ratio, 3.37; 95% CI, 1.73–6.57; p < .001). Multivariable-adjusted odds ratio's (95% CI’s) for CKD-associated IADL and BADL decline were 1.83 (1.06–3.17, p =.030) and 2.46 (1.19–5.12, p = .016), respectively. CKD Stage ≥3B (estimated glomerular filtration rate <45 mL/min/1.73 m2) was associated with higher multivariable-adjusted odds of both IADL (3.12, 95% CI, 1.38–7.06, p = .006) and BADL (3.78, 95% CI, 1.36–9.77, p = .006) decline.

Conclusion.

In community-dwelling older adults, CKD is associated with IADL and BADL decline.

Objectives

To quantify the associations between measures of oral health-related quality of life (OHRQoL) and life-space mobility (LSM) in community-dwelling older adults.

Design

Cross-sectional study using a 54-item OHRQoL questionnaire.

Setting

Five counties in central Alabama: Jefferson and Tuscaloosa (urban), and Bibb, Hale, and Pickens (rural).

Participants

The 288 Dental Study volunteers were recruited from participants in the University of Alabama at Birmingham Study of Aging, a longitudinal study of mobility in community-dwelling adults age 65 and older.

Measurements

Participants completed an in-home interview about their OHRQoL and LSM. Life-space was assessed by asking questions about where, how often, and the degree of independence in getting to areas ranging from the home to beyond town. Unadjusted and adjusted regression models were used to quantify associations between OHRQoL and LSM. Other factors examined included: age, race, gender, income, education, residence, transportation difficulty, marital status, depressive symptoms, and comorbidity.

Results

Unadjusted and adjusted analyses suggested significant associations between OHRQoL and LSM in these components of oral health: oral functional limitation, oral pain and discomfort, oral disadvantage, and self-rated oral health.

Conclusion

OHRQoL decrements reported by participants were associated with decreased LSM, suggesting that perceptions of oral well-being have a significant impact on mobility and the social participation of older adults.

OBJECTIVES

To understand the potential roles of various patient and provider factors in the underutilization of pneumococcal vaccination among Medicare-eligible older African Americans.

DESIGN

The Cardiovascular Health Study.

SETTING

Four US states.

PARTICIPANTS

795 pairs of community-dwelling Medicare-eligible African American and white adults, ≥65 years, balanced by age and gender.

MEASUREMENTS

Data on self-reported race, receipt of pneumococcal vaccination and other key socio-demographic and clinical variables were collected at baseline.

RESULTS

Participants had a mean (±SD) age of 73 (±6) years and 63% were women. Pneumococcal vaccination was received by 22% African Americans and 28% whites (unadjusted odds ratios {OR} for African Americans, 0.75; 95% confidence interval {CI}, 0.60–0.94; P=0.013). This association remained significant despite adjustment for socio-demographic and clinical confounders including education, income, chronic obstructive pulmonary disease and prior pneumonia (OR, 0.74; 95% CI, 0.56– 0.97; P=0.030). However, the association was no longer significant after additional adjustment for the receipt of influenza vaccination (OR, 0.79; 95% CI, 0.59–1.06; P=0.117). A receipt of an influenza vaccination was associated with higher odds of receiving a pneumococcal vaccination (unadjusted OR, 6.43; 95% CI, 5.00–8.28; P<0.001) and the association between race and pneumococcal vaccination lost significance when adjusted for influenza vaccination alone (OR, 0.81; 95% CI, 0.63–1.03; P=0.089).

CONCLUSION

The strong association between the receipt of influenza and pneumococcal vaccinations suggests that patients’ and providers’ attitudes toward vaccination, rather than traditional confounders such as education and income, may help explain the underutilization of pneumococcal vaccination among older African Americans.

The CLOX is a clock drawing test used to screen for cognitive impairment in older adults, but there is limited normative data for this measure. This study presents normative data for the CLOX derived from a diverse sample of 585 community-dwelling older adults with complete cognitive data at baseline and 4-year follow-up. Participants with evidence of baseline impairment or substantial 4-year decline on the Mini-Mental State Examination were excluded from the normative sample. Spontaneous clock drawing (CLOX1) and copy (CLOX2) performances were stratified by age group and reading ability from the Wide Range Achievement Test, 3rd edition (WRAT-3). Lowest mean CLOX scores were observed for the oldest age group (75+ years old) with the lowest WRAT-3 reading scores. For all groups, average scores were higher for CLOX2 than CLOX1. These normative data may be helpful to clinicians and researchers for interpreting CLOX performance in older adults with diverse levels of reading ability.

OBJECTIVES

To determine the incidence of fecal incontinence (FI) in community-dwelling older adults and identify risk factors associated with incident FI.

DESIGN

Planned secondary analysis of a longitudinal, population-based cohort study.

SETTING

Three rural and two urban Alabama counties (in-home assessments 2000–2005).

PARTICIPANTS

Stratified random sample of 1,000 Medicare beneficiaries: 25% African-American men, 25% white men, 25% African-American women, 25% white women, aged 65 and older. Eligible participants for this analysis were continent at baseline and community-dwelling 4 years later (n =557).

MEASUREMENTS

FI was defined as any loss of control of bowels occurring during the previous year. Independent variables were sociodemographics, Charlson comorbidity counts, self-reported bowel symptoms (chronic diarrhea and constipation), depression, and body mass index (BMI). Multivariable logistic regression models were constructed using incident FI as the dependent variable.

RESULTS

The incidence rate of FI at 4 years was 17% (95% confidence interval (CI) =13.7–20.1), with 6% developing FI at least monthly (95% CI =4.0–8.3). White women were more likely to have incident FI (22%) than African-American women (13%, P =.04); no racial differences were observed in men. Controlling for age, comorbidity count, and BMI, significant independent risk factors for incident FI in women were white race, depression, chronic diarrhea, and urinary incontinence (UI). UI was the only significant risk factor for incident FI in men.

CONCLUSION

The occurrence of new FI is common in men and women aged 65 and older, with a 17% incidence rate over 4 years. FI and UI may share common pathophysiologic mechanisms and need regular assessment in older adults.

Objectives

To determine the prevalence and correlates of nocturia in community-dwelling older adults.

Design

Planned secondary analysis of cross-sectional data from the University of Alabama at Birmingham Study of Aging population-based survey.

Setting

Participants’ homes.

Participants

One thousand older adults (aged 65 to 106 years) recruited from Medicare beneficiary lists between 1999 and 2001. The sample was selected to include 25% African American women, 25% African American men, 25% white women, and 25% white men.

Measurements

In-person interviews included socio-demographic information, medical history, Mini-Mental State Examination, and measurement of body mass index (BMI). Nocturia was defined in the main analyses as getting up 2 or more times per night to void.

Results

Nocturia was more common among men than women (63.2% vs. 53.8%, OR=1.48, 95% CI=1.15–1.91, P=.003) and more common among African Americans than whites (66.3% vs. 50.9%, OR=1.89, CI=1.46–2.45, P< .0001). In multiple backward elimination regression analysis in men, nocturia was significantly associated with African American race (OR=1.54) and BMI (OR=1.22 per 5 kg/m2). Higher MMSE was protective (OR=0.96). In women, nocturia was associated with older age (OR=1.21 per 5 years), African American race (OR=1.64), history of any urine leakage (OR=2.17), swelling in feet and legs (OR=1.67), and hypertension (OR=1.62). Higher education was protective (OR=0.92).

Conclusion

Nocturia in community-dwelling older adults is a common symptom associated with male gender, African-American race, and some medical conditions. Given the significant morbidity associated with nocturia, any evaluation of lower urinary tract symptoms should include assessment for the presence of nocturia.

Objectives

We investigated whether factors related to health disparities – race, rural residence, education, perceived racial discrimination, vascular disease, and health care access and utilization – may moderate the association between diabetes and cognitive decline.

Methods

Participants were 624 community-dwelling older adults (49% African American, 49% rural) who completed in-home Mini-Mental State Examination at baseline and four-year follow-up.

Results

Diabetes at baseline predicted cognitive decline over four years in regression models adjusted for a number of possible confounds. Only perceived discrimination and health utilization showed significant interaction effects with diabetes. Among African Americans who reported experiencing racial discrimination, there was a stronger relationship between diabetes and cognitive decline. Among participants who reported absence of visiting a physician within the past six months, the association between diabetes and cognitive decline was substantially larger.

Discussion

Findings suggest that factors related to health disparities may influence cognitive outcomes among older adults with diabetes.

PURPOSE

To determine incidence and predictors of incident urinary incontinence over 3 years in community-dwelling older adults.

MATERIALS & METHODS

A population-based, prospective cohort study was conducted with a random sample of Medicare beneficiaries, stratified to be 50% African American, 50% men, and 50% rural. In-home baseline assessment included standardized questionnaires and short physical performance battery. Three annual follow-up interviews were conducted by telephone. Incontinence was defined as any degree of incontinence occurring at least once a month in the past 6 months.

RESULTS

Participants were 490 women and 496 men, age 65 to 106 years (mean=75 years). Prevalence of incontinence at baseline was 41% in women and 27% in men. Three-year incidence of incontinence was 29% (84/290) in women and 24% (86/363) in men. There were no differences by race in prevalent or incident incontinence. In multivariable logistic regression models for women, significant independent baseline predictors of new incontinence included: stroke (OR 3.4, p=.011), incontinence < monthly (OR 3.3, p=.001), past or current post-menopausal estrogen (OR 2.3, p<.006), slower time to stand from a chair 5 times (OR 1.3, p<.045), and higher Geriatric Depression Scale Score (OR 1.2, p=.016). For men, significant independent baseline predictors of new incontinence included: incontinence < monthly (OR 4.2, p<.001) and lower score on the composite Physical Performance Score (OR 1.2, p<.001).

CONCLUSIONS

Prevalence of incontinence among community-dwelling older adults was high with an additional 29% of women and 24% of men reporting incident incontinence over 3 years of follow-up. Infrequent incontinence is a strong risk factor for developing at least monthly incontinence in both men and women.

The purpose of this study was to examine the effects of religiousness on the trajectories of difficulties with activities of daily living (ADLs) and instrumental ADLs (IADLs) in community-dwelling older adults over a three-year period. Seven waves of data from the University of Alabama at Birmingham Study of Aging were analyzed using a hierarchical linear modeling method. The study was based on the 784 participants who completed interviews every six months between December 1999 and February 2004. Frequent religious service attendance was associated with fewer ADL difficulties and IADL difficulties at baseline. Furthermore, religious service attendance predicted slower increases for frequent churchgoers and steeper increases for less frequent churchgoers in IADL difficulties, controlling for variables related to demographics and resources. Religious service attendance was independently associated with ADL and IADL difficulties cross-sectionally. However, significant protective effects of religious service attendance were identified longitudinally only for the IADL trajectory.

Background

Life-space, a measure of movement through one’s environment, may be viewed as one aspect of environmental complexity for older adults. We examined the relationship between life-space and subsequent change in cognitive function.

Methods

Participants were 624 community-dwelling Medicare beneficiaries (49% African American) who completed in-home assessments at baseline and follow-up 4 years later. The Life-Space Assessment was used at baseline to measure extent, frequency, and independence of participants’ movement within and outside the home. Cognitive decline was measured with the Mini-Mental State Examination (MMSE).

Results

In a regression model adjusted for baseline MMSE, age, gender, race, residence (rural/urban), and education, greater life-space at baseline predicted reduced cognitive decline (β = −.177, p < .001). This association remained statistically significant in subsequent models that examined what proportion of the observed association was explained by baseline physical activity, physical function, vascular risk factors, comorbidity, and psychosocial factors. Physical function accounted for the largest proportion (37.3%) of the association between life-space and cognitive decline. There was no significant interaction between life-space and race, gender, or age in predicting cognitive decline. In a logistic regression analysis, participants in the highest quartile of life-space had 53% reduced odds of substantial cognitive decline (≥4 points on MMSE) compared to those in the lowest quartile.

Conclusions

These preliminary findings suggest that life-space may be a useful identifier of older adults at risk for cognitive decline. Future research should investigate the potential reciprocal relationship between life-space and cognitive function as well as the interrelationship between these factors and physical function.

The purpose of this study was to understand self-reported transportation difficulty among rural older adults. We used data from the UAB Study of Aging (255 Black and 259 White), community-dwelling participants residing in rural areas. We examined the relationship of predisposing characteristics, enabling resources, and measures of need for care with self-reports of transportation difficulty. Blacks reported having more transportation difficulty than Whites (24.7% vs. 11.6%; p ≤ .05). When we introduced other variables, race differences disappeared, but there was a race by income interaction with transportation difficulty. Whites with lower incomes were more likely to have transportation difficulty than Whites with higher incomes. When data from Blacks and Whites were analyzed separately, income was the only variable associated with transportation difficulty among Whites. Among Blacks, income was not related to transportation difficulty but several variables other than income (age, gender, marital status, MMSE scores and depression) were.

Background

Life-space mobility, reflecting participation patterns as well as physical ability, may be useful in assessing important functional changes after hospitalization.

Objective

(1) To assess effects of hospitalization on life-space; and (2) To identify differences in life-space trajectories associated with surgical and non-surgical hospitalizations.

Design

Longitudinal growth models were used to compare life-space mobility trajectories among participants in a prospective observational study.

Setting

Central Alabama

Patients

687 community-dwelling Medicare beneficiaries (age ≥ 65 years) with and without hospitalizations.

Measurements

The Life-Space Assessment (LSA) measures mobility and function by incorporating where a person goes, the frequency of going there, and the degree of dependence required to get there in the four weeks before the assessment. Scores range from 0–120 with higher scores reflecting greater mobility.

Results

Participants (N=687) had a mean (SD) age of 74.6 (6.3) years, 50% were African-American and 46% were male. After adjustment for covariates, LSA scores prior to hospitalization were not significantly different for surgical and non-surgical admissions. Immediately after hospitalization, adjusted LSA scores decreased in non-surgical patients by 10.31 points (95% CI −14.30 to −6.32) and in surgical patients by 22.45 points (95% CI −29.91 to −14.99). While surgical hospitalizations resulted in a greater immediate LSA point decline, the recovery of LSA scores in these patients was also greater compared to non-surgical hospitalizations by 4.72 points (95% CI 2.03 to 7.42) per log week post-discharge. Indeed, LSA score recovery after non-surgical hospitalizations was non-significantly different from the null (average recovery of 0.66 points [95% CI −0.6 to 1.91] per log week).

Limitations

Assessments of life-space mobility could not be captured immediately before and after hospitalization in each patient, but we provided estimates using growth curve models.

Conclusions

Non-surgical hospitalizations were associated with moderate life-space mobility declines with little evidence of recovery even after up to two years of follow-up. Surgical hospitalizations were associated with mobility recovery despite marked early declines.

Background

The relationship between body mass index (BMI), weight loss, and mortality in older adults is not entirely clear. The purpose of this article is to evaluate the associations between BMI, weight loss (either intentional or unintentional), and 3-year mortality in a cohort of older adults participating in the University of Alabama at Birmingham (UAB) Study of Aging.

Methods

This article reports on 983 community-dwelling older adults who were enrolled in the UAB Study of Aging, a longitudinal observational study of mobility among older African American and white adults.

Results

In both raw and adjusted Cox proportional hazards models, unintentional weight loss and underweight BMI were associated with elevated 3-year mortality rates. There was no association with being overweight or obese on mortality, nor was there an association with intentional weight loss and mortality.

Conclusions

Our study suggests that undernutrition, as measured by low BMI and unintentional weight loss, is a greater mortality threat to older adults than is obesity or intentional weight loss.