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Explaining the increasing disability prevalence among mid-life US adults, 2002 to 2016
Abstract
Several recent studies have documented an alarming upward trend in disability and functional limitations among US adults. In this study, we draw on the sociomedical Disablement Process framework to produce up-to-date estimates of the trends and identify key social and medical precursors of the trends. Using data on US adults aged 45-64 in the 2002-2016 National Health Interview Surveys, we estimate parametric and semiparametric models of disability and functional limitations as a function of interview time. We also determine the impact of socioeconomic resources, health behaviors, and health conditions on the trends. Our results show increasing prevalence of disability and functional limitations. These trends reflect the net result of complex countervailing forces, some associated with increases in functioning problems (unfavorable trends in economic well-being, especially income, and psychological distress) while other factors have suppressed the growth of functioning problems (favorable trends in educational attainment and some health behaviors, such as smoking and alcohol use). The results underscore that disability prevention must expand beyond medical interventions to include fundamental social factors and be focused on preventing or delaying the onset of chronic health problems and functional limitations.
... Several investigations have previously evaluated the prevalence and trends of ADL limitations at a population-level and have indicated that there is a considerable prevalence of ADL limitations [14][15][16][17][18]. For example, an investigation suggested a flattening of activity limitations for older adults [15], while other studies have revealed a differential ADL limitation prevalence [14][15][16][17][18]. Continual monitoring of ADL disability prevalence, including limitations in individual tasks and different sociodemographic groups, is important for providing precision to ADL care, informing screening, identifying populations at risk for functional disability, and guiding interventions. ...
... Several investigations have previously evaluated the prevalence and trends of ADL limitations at a population-level and have indicated that there is a considerable prevalence of ADL limitations [14][15][16][17][18]. For example, an investigation suggested a flattening of activity limitations for older adults [15], while other studies have revealed a differential ADL limitation prevalence [14][15][16][17][18]. Continual monitoring of ADL disability prevalence, including limitations in individual tasks and different sociodemographic groups, is important for providing precision to ADL care, informing screening, identifying populations at risk for functional disability, and guiding interventions. ...
... The decreasing estimated ADL prevalence among older Americans during the study period could be attributed to factors that foster the prevention of ADL loss and the recovery of ADLs [13]. The increasing prevalence of ADL disability among middle-aged Americans during the study period aligned with another study [18]. This could be related to morbidities that lead to disability such as diabetes [25]. ...
Background: Population-level surveillance of the prevalence and trends of basic self-care limitations will help to identify the magnitude of physical disablement in the rapidly growing older American demographic. We sought to evaluate the prevalence and trends of activities of daily living (ADL) limitations in the United States. Methods: The analytic sample included 30,418 Americans aged ≥50 years from the 2006–2018 waves of the Health and Retirement Study. ADLs were self-reported. Weighted prevalence estimates were presented, and trends analyses were performed. Results: Although overall ADL disability prevalence was 16.5% (95% confidence interval: 15.8–17.2) in 2018, there were no changes in limitations during the study period (p = 0.52). Older adults had a greater ADL disability prevalence than middle-aged adults (p < 0.001). While older persons experienced a declining trend of ADL limitations (p < 0.001), middle-aged persons had an increasing trend (p < 0.001). Males had a lower ADL limitation prevalence than females (p < 0.001). Hispanic and non-Hispanic Black had a higher ADL disability prevalence than non-Hispanic White (p < 0.001). Conclusions: This investigation revealed that while the estimated prevalence of ADL limitations in the United States was substantial, changes in such limitations were not observed. Our findings can help guide ADL screening, target sub-populations with an elevated ADL limitation prevalence, and inform interventions.
... [17][18][19] In contrast to many studies showing decreasing limitation trends in older adults, studies in middle-aged adults have often found evidence for increasing limitations across time. In the United States, for example, Zajacova and Montez 20 found that the prevalence of functional limitations has increased over time. Additionally, they found that this trend might partly result from countervailing forces: The increasing prevalence of psychological distress and income difficulties, as well as the rising incidence of obesity and alcohol use in the United States might have contributed to an increase in midlife disabilities. ...
... Several studies had suggested that limitations were increasing among the middle-aged population. 17,20 Supporting these studies, we found some increasing limitations over time. Limitation increases were strongest among those aged 50-54, the youngest age group considered, thus supporting previous research on birth cohort differences in limitations, in which an increasing trend in limitation across generations was found. ...
... 55 From a negative viewpoint, ours and several previous studies also observed increasing limitations among middleaged adults. 17,19,20 If these increases in limitations prove to be chronic throughout the life course, it is also likely that current middle-aged adults will experience further disabilities and health ailments as they age. Another factor to consider is that the aging of the population likely also affects the demographic composition of the working-age population, which in turn might lead to increased prevalence and severity of limitations in the future on its own. ...
Objectives
Previous studies have observed increasing limitations among the middle-aged, including those aged 40–64, raising the question how healthy work participation has changed. Helping answer this question, we ask: How have general and specific limitations changed in working and non-working adults in Germany?
Methods
We used population-based data of older working-age adults, aged 50–64 years old, from Germany provided by the Survey of Health Aging and Retirement (SHARE) study from 2004 to 2014 ( N = 3522). Multiple logistic regression analyses were used to study changes in limitations over time.
Results
We found that employment rates generally increased over time, whereas limitation rates mostly increased among participants aged 50–54 and mostly decreased among participants aged 60–64 in both the working and non-working population. Regarding type of disability, increases were more pronounced with movement-related and general activity-related limitations.
Conclusion
Therefore, if the comparatively younger more-limited cohorts age and replace the older less-limited cohorts, a larger part of the working and non-working life might be expected to be spent with limitations in the future, and it seems questionable whether further substantial increases in healthy work participation can be achieved. Further prevention efforts and assistance should be directed at current middle-aged cohorts to improve and maintain their health, including adapting current working conditions to a work force with more limitations.
... Yet a growing body of research shows that functional impairment is also common in middle-aged people (i.e., ages [45][46][47][48][49][50][51][52][53][54][55][56][57][58][59][60][61][62][63][64], and that the prevalence of functional impairment is increasing in this age group [7][8][9][10][11][12]. From 2000 to 2008, the prevalence of difficulty performing one or more ADLs increased from 15 to 16% among people aged 55-64 [9], an increase of approximately 420,000 people, and this upward trend continued through 2016 [12]. ...
... Yet a growing body of research shows that functional impairment is also common in middle-aged people (i.e., ages [45][46][47][48][49][50][51][52][53][54][55][56][57][58][59][60][61][62][63][64], and that the prevalence of functional impairment is increasing in this age group [7][8][9][10][11][12]. From 2000 to 2008, the prevalence of difficulty performing one or more ADLs increased from 15 to 16% among people aged 55-64 [9], an increase of approximately 420,000 people, and this upward trend continued through 2016 [12]. While needing help with ADLs remains relatively rare in middle age [7,9,11,12], developing difficulty with these activities represents a key step on the pathway towards needing help and strongly predicts adverse outcomes [13,14]. ...
... From 2000 to 2008, the prevalence of difficulty performing one or more ADLs increased from 15 to 16% among people aged 55-64 [9], an increase of approximately 420,000 people, and this upward trend continued through 2016 [12]. While needing help with ADLs remains relatively rare in middle age [7,9,11,12], developing difficulty with these activities represents a key step on the pathway towards needing help and strongly predicts adverse outcomes [13,14]. Recent research shows that developing ADL difficulty in middle age is associated with outcomes similar to those seen in late life, including hospitalization, nursing home admission, and death [13]. ...
Abstract To live independently, individuals must be able to perform basic activities of daily living (ADLs), including bathing, dressing, and transferring out of a bed or chair. When older adults develop difficulty or the need for help performing ADLs, they experience decreased quality of life and an increased risk of acute care utilization, nursing home admission, and death. For these reasons, slowing or preventing the progression to functional problems is a key focus of the care of older adults. While preventive efforts currently focus mainly on older people, difficulty performing basic ADLs (“functional impairment”) affects nearly 15% of middle-aged adults, and this prevalence is increasing. People who develop functional impairment in middle age are at increased risk for adverse outcomes similar to those experienced by older adults. Developing ADL impairment in middle age also impacts work force participation and health expenditures, not just in middle age but also older age. Middle-aged adults have a high capacity for recovery from functional impairment, and many risk factors for developing functional impairment in middle and older age have their roots in mid-life. Taken together, these findings suggest that middle age may be an ideal period to intervene to prevent or delay functional impairment. To address the rising prevalence of functional impairment in middle age, we will need to work on several fronts. These include developing improved prognostic tools to identify middle-aged people at highest risk for functional impairment and developing interventions to prevent or delay impairment among middle-aged people. More broadly, we need to recognize functional impairment in middle age as a problem that is as prevalent and central to health outcomes as many chronic medical conditions.
... We included covariates which prior studies of disability identified as particularly important (Martin and Schoeni 2014;Martin et al. 2010;Zajacova and Montez 2018). Most analyses are stratified by age and gender. ...
... Finally, health conditions, including asthma, arthritis, bowel disorder, cancer, diabetes, heart disease, and hypertension, are also dichotomized into two categories: (0) no and (1) yes. The covariates have all been identified as key additional factors in studies related to disability trends (Zajacova and Montez 2018). ...
... For example, work conditions, including stressful precarious employment and work-family conflicts, are linked to health deterioration over time (Lantz et al. 2005;Halpern 2005). Health behaviours are also linked to disability trends: lower smoking rates are beneficial but higher rates of obesity clearly increase disability rates (Freedman et al. 2007;Zajacova and Montez 2018). Interestingly, changes in the prevalence of relevant health conditions such as arthritis and heart disease did not play a major role in the disability trends of either age group we examined. ...
Objectives
Disability is a major concern for the health of midlife and older Canadians. Understanding disability trends is critical for detecting socio-economic and health precursors that could be amenable to policy interventions. The purpose of this study is to assess trends in rates of disability among Canadian adults age 40–64 and 65+. We also examine the impact of changing socio-demographic and health factors over time on the trends.
Methods
Data from the 2001–2014 Canadian Community Health Survey (CCHS), a repeated cross-sectional nationally representative study, are used to estimate age- and gender-stratified logistic regression models of disability as a function of the year of interview to assess trends. Disability is defined as experiencing difficulties with a variety of individual functions, such as seeing, walking, climbing stairs, and bending.
Results
Among men and women 65 and older, disability has declined since 2001 in most subgroups and regardless of changing socio-economic and health characteristics. Adults 40–64 years of age, in contrast, have experienced stagnating disability over the observation period. If it were not for changes in the distribution of education and household income, the disability rate would be increasing significantly.
Conclusion
Older Canadian adults are experiencing mild but systemic improvements in disability. More worrisome is the stagnating trend among midlife cohorts, which could portend greater disability burden in the future as Canada’s population ages. Preventive efforts need to be targeted at vulnerable groups at earlier ages in order to prevent future increases in disability-related financial, caregiving, and medical burden.
... However, 15% of middle-aged adults (i.e., 45-64 years) have functional impairment, and this percentage is growing. [1][2][3][4][5][6][7][8][9] The reason for this increase is an area of active investigation, but risk factors include lower levels of education and lower economic wellbeing. [9][10][11] Developing functional impairment in middle age is associated with adverse outcomes similar to those among older adults, including hospitalization and nursing home admission. ...
... [1][2][3][4][5][6][7][8][9] The reason for this increase is an area of active investigation, but risk factors include lower levels of education and lower economic wellbeing. [9][10][11] Developing functional impairment in middle age is associated with adverse outcomes similar to those among older adults, including hospitalization and nursing home admission. [12][13][14] Yet little is known about the experiences and clinical needs of middle-aged people who develop functional impairment. ...
Background:
Difficulty performing basic daily activities such as bathing and dressing ("functional impairment") affects more than 15% of middle-aged people, and this proportion is increasing. Little is known about the experiences and needs of individuals who develop functional impairment in middle age.
Objective:
To examine the experiences and needs of adults who developed functional impairment in middle age.
Design:
Qualitative study using semi-structured interviews.
Participants:
Forty patients aged 50-64 years who developed functional impairment in middle age, recruited from four primary care clinics in San Francisco.
Approach:
Interviews included open-ended questions about participants' daily life, ability to perform activities of daily living (ADLs), and needs related to functional impairment. We analyzed interviews using qualitative thematic analysis.
Key results:
Interviews revealed several themes related to the psychosocial and physical impacts of developing functional impairment in middle age. Participants noted that losses associated with functional impairment, such as loss of independence, control, and social roles, caused conflict in their sense of identity. To cope with these losses, participants used strategies including acceptance, social comparison, adjusting standards, and engaging in valued life activities. Participants reflected on the intersection of their functional impairment with the aging process, noting that their impairments seemed premature compared to the more "natural" aging process in older adults. In terms of physical impacts, participants described how a lack of accommodations in the built environment exacerbated their impairments. While participants used behavioral strategies to overcome these challenges, unmet needs remained, resulting in downstream physical and psychological impacts including safety risks, falls, frustration, and fear.
Conclusions:
Unmet psychosocial and physical needs were common among middle-aged adults with functional impairment and led to negative downstream effects. Eliciting and addressing unmet needs may help mitigate downstream health consequences for this growing population, optimizing function and quality of life.
... This calls for more equitable distribution of health resources between rural and urban areas. Education reduced the increasing trends in disability, which was consistent with other study [21]. What's more, we also found the negative contributions were larger in more recent cohorts. ...
... As for social supports, family income showed the largest contribution to cohort trends in IADL and ADL disability, which had a negative contribution to cohort trends in IADL disabilities but a positive contribution to the increment of cohort trend in ADL disability. The results were inconsistent with Zajacova's studies, which only found declining trends in economic status, which were associated with increasing disability prevalence [21]. The reason may be because Zajacova's study did not distinguish between ADL and IADL disabilities. ...
Objective: This study aims to examine age and cohort trends in disability among Chinese older adults, and explore the disablement process factors that may explain the cohort trends in disability.
Methods: The study used data from five waves of the Chinese Longitudinal Healthy Longevity Study (CLHLS). A hierarchical logistic growth model was used to analyze the A-P-C effects and the contributors of cohort trends.
Results: Activity of Daily Living (ADL), Instrumental of Activity of Daily Living (IADL), and Functional Limitation (FL) among Chinese older adults showed increasing age and cohort trends. FL was more likely to result in IADL disability than ADL disability. Among the disablement process factors, gender, residence, education, health behavior, disease, and family income contributed to most of the cohort trends in disability.
Conclusions: As facing increasing disability trends among older adults, it is necessary to distinguish age and cohort trends, and develop more effective interventions according to relative contributors to prevent disability among older adults.
... 12 Overall, disability tended to increase with age, consistent with previous studies, 12 though there were substantial levels of variation within domains, which also has been observed and investigated before. 12,21,22 Within the Appalachian region, middle-aged adults (45e64 years old) had the highest prevalence of vision impairment and cognitive impairment. We did not perform statistical tests for effect modification by region, but we did not observe this pattern outside of Appalachia: in no disability domain was the prevalence point estimate highest for middle-aged adults in the non-Appalachian region of the state. ...
... Zajacova and Montez suggest that economic factors, particularly lower family income, may be a driving factor behind the increasing prevalence of disability in middle age. 22 Given that the Appalachian region tends to fare worse economically, this could explain the difference observed in North Carolina. Alternatively, the higher observed prevalence might be a result of selective mortality: people with disabilities living in Appalachia may have higher mortality earlier in life relative to people in the rest of the state. ...
Background
The health and social conditions of the Appalachian region generally are poorer than in the US overall, and this gap is widening, suggesting disability may be higher in Appalachia.
Objective
To describe the prevalence of disability overall and by domain in Appalachian and non-Appalachian regions in North Carolina (NC) and describe the characteristics of people with and without disability in each region.
Methods
We conducted a cross-sectional study using data from the NC Behavioral Risk Factor Surveillance System from 2013-2016 which assessed disability in five domains: vision, cognitive, mobility, self-care, and independent living. We calculated weighted proportions and age- and sex-adjusted prevalence using direct standardization to the 2010 Census.
Results
The prevalence of disability in Appalachian NC was significantly higher than in non-Appalachian NC after standardizing by age and sex (26.6% in Appalachia, 24.1% outside Appalachia, p<0.001). In both regions, mobility disability was most common and self-care disability was least common. People within Appalachia more frequently reported disability in all domains compared to people outside Appalachia.
Conclusions
More than one in four adults in Appalachian North Carolina experience disability in at least one domain and one in eight experiences disability in multiple domains. The high prevalence of disability should be considered when planning programs and services across the spectrum of public health. Understanding common disability domains present in populations can inform public health agencies and service providers and help them develop programs and messaging that meet the needs of residents in Appalachia and are accessible to people with disabilities.
... 9,23 This is considered to be a function of a variety of factors, including population aging, increasing chronic disease prevalence, increasing psychological stress, and economic distress. 5,49 Higher disability prevalence has resulted in an urgent need to identify disability's developmental process, its drivers, and groups most vulnerable. Despite a connection between the 2, pain has been greatly under-studied as a factor in disablement. ...
Previous literature has rarely examined the role of pain in the process of disablement. We investigate how pain associates with disability transitions among older adults, using educational attainment as a moderator. Data are from the National Health and Aging Trends Study, N=6,357; 33,201 one-year transitions between 2010-2020. We estimate multinomial logistic models predicting incidence or onset of and recovery from functional limitation and disability. Results show pain significantly predicts functional limitation and disability onset one year after a baseline observation, and decreases odds of recovery from functional limitation or disability. Contrary to expectations, higher education does not buffer the association of pain in onset of disability, but supporting expectations, it facilitates recovery from functional limitation or disability among those with pain. The analysis implicates pain as having a key role in the disablement process and suggests that education may moderate this with respect to coping with and subsequently recovering from disability.
... While declines in functioning can affect individuals of all ages, they are most common in older adulthood and are often precursors of disability and loss of independence (Verbrugge & Jette, 1994). Though findings are mixed, several measures suggest that physical functioning has worsened for middle aged and older adults in the US over the past two decades (Case et al., 2020;Crimmins et al., 2016;Zajacova & Montez, 2018;Zimmer & Zajacova, 2020), reversing the trend of improvements (Crimmins, 2004;Seeman et al., 2010). Black and Hispanic Americans have more functional limitations and higher rates of disability than do Whites (Haas & Rohlfsen, 2010;Hayward et al., 2014;Pebley et al., 2021;Zajacova et al., 2014), and lower levels of education are associated with a higher burden of these conditions (Townsend & Mehta, 2021;Zajacova et al., 2014). ...
Research in the US on the social determinants of reduced physical functioning at older ages has typically not considered physical work conditions as contributors to disparities. We briefly describe a model of occupational stratification and segregation, review and synthesize the occupational health literature, and outline the physiological pathways through which physical work exposures may be tied to long-term declines in physical functioning. The literature suggests that posture, force, vibration, and repetition are the primary occupational risk factors implicated in the development of musculoskeletal disorders, through either acute injuries or longer-term wear and tear. Personal risk factors and environmental and structural work characteristics can modify this association. In the long-term, these musculoskeletal disorders can become chronic and ultimately lead to functional limitations and disabilities that interfere with one’s quality of life and ability to remain independent. We then use data on occupational characteristics from the Occupational Information Network (O*NET) linked to the 2019 American Community Survey (ACS) to examine disparities among sociodemographic groups in exposure to these risk factors. Occupations with high levels of these physical demands are not limited to those traditionally thought of as manual or blue-collar jobs and include many positions in the service sector. We document a steep education gradient with less educated workers experiencing far greater physical demands at work than more educated workers. There are pronounced racial and ethnic differences in these exposures with Hispanic, Black, and Native American workers experiencing higher risks than White and Asian workers. Occupations with high exposures to these physical risk factors provide lower compensation and are less likely to provide employer-sponsored health insurance, making it more difficult for workers to address injuries or conditions that arise from their jobs. In sum, we argue that physical work exposures are likely an important pathway through which disparities in physical functioning arise.
... for cognitive functioning). Likewise, many aspects of physical and mental health have improved over the last decades, for example, in the area of functional health (Christensen et al., 2013;Zajacova & Montez, 2018). ...
A large body of empirical evidence has accumulated showing that the experience of old age is "younger," more "agentic," and "happier" than ever before. However, it is not yet known whether historical improvements in well-being, control beliefs, cognitive functioning, and other outcomes generalize to individuals' views on their own aging process. To examine historical changes in such views on aging, we compared matched cohorts of older adults within two independent studies that assessed differences across a two-decade interval, the Berlin Aging Studies (BASE; 1990/1993 vs. 2017/2018, each n = 256, Mage = 77) and the Midlife in the United States Study (MIDUS; 1995/1996 vs. 2013/14, each n = 848, Mage = 67). Consistent across four different dimensions of individuals' subjective views on aging (age felt, age appeared, desired age, and attitudes toward own aging) in the BASE and corroborated with subjective age felt and subjective age desired in the MIDUS, there was no evidence whatsoever that older adults of today have more favorable views on how they age than older adults did two decades ago. Further, heterogeneity in views on aging increased across two decades in the MIDUS but decreased in BASE. Also consistent across studies, associations of views on aging with sociodemographic, health, cognitive, and psychosocial correlates did not change across historical times. We discuss possible reasons for our findings, including the possibility that individual age views may have become increasingly decoupled from societal age views. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
... Addressing these questions is important in light of a steady rise in precarious work (Fullerton & Wallace, 2007;Kalleberg, 2018) alongside declining population health for non-elderly populations (Grol-Prokopczyk, 2017;Martin & Schoeni, 2014;Masters, Tilstra, & Simon, 2018;Zajacova & Montez, 2018). Moreover, involuntary part-time work is increasingly common in the United States and often spikes during recessions (Canon, Kudlyak, Luo, & Reed, 2014;Valletta & van der List, 2015). ...
Part-time work is a common work arrangement in the United States that can be precarious, insecure, and lacking opportunities for advancement. In turn, part-time work, especially involuntary part-time work, tends to be associated with worse health outcomes. Although prior research documents heterogeneity in the health consequences of precarious work across countries, we do not know whether state-level institutional contexts shape the association between part-time work and self-rated health in the United States. Using data from the Current Population Survey (2009–2019; n = 813,077), the present study examined whether linkages between part-time work and self-rated health are moderated by state-level social policies and contexts. At the population level, we document differences in the prevalence of fair/poor health among part-time workers across states. For instance, 21% of involuntary part-time workers reported fair/poor health in West Virginia compared to 7% of involuntary part-time workers in Massachusetts. Findings also provide evidence that voluntary (β =.51) and involuntary (β=.57) part-time work is associated with greater odds of fair/poor health among individuals. Moreover, the association between voluntary part-time work and self-rated health is weaker for individuals living in states with higher amounts for maximum unemployment insurance, higher minimum wage, and lower income inequality. State-level policies did not moderate the association between involuntary part-time work and health. The present study points to the need to mitigate the health consequences of part-time work with social policies that enhance the health of workers.
... Over the past decade, US midlife morbidity and mortality have increased, contributing to declines in life expectancy. 1 This worsening health status has been experienced disproportionately by low-socioeconomic status (SES) and racial/ethnic minority individuals 2, 3 and is associated with functional deterioration among low-SES middle-aged adults. 4 Yet it is unclear if disparities in functional status are rising. Functional impairment may not be recognized as a health problem for middle-aged adults, but it is common and, as for older adults, associated with disability and death. ...
... A recently published analysis of national trends in disability from 2002 to 2016 also found an increasing prevalence among the same age group, specifically a 23-25% increase during the time frame, explained theoretically by increases in various chronic diseases and declines in economic conditions. [23] While our claims were similar regarding the burden of chronic conditions among the 45-64 age group, the aforementioned project did not, however, consider other age groups. It is therefore possible that similar trends could be observed across other studies. ...
Background
The prevalence of disabilities is rising steadily, reflecting an aging population and an increasing burden of chronic conditions affecting quality of life. There are scant national data on the prevalence of disability among individuals with chronic obstructive pulmonary disease (COPD). The main objective was to estimate the prevalence of common disabilities among US-based individuals diagnosed with COPD.
Methods
Data from the BRFSS, a national telephone survey examining health-related behaviors in 2016–2017 were analyzed. The study population consisted of individuals with self-reported COPD (N = 38352 in 2016 and N = 35423 in 2017). The prevalence of disabilities in hearing, vision, cognition, mobility, and independent living were obtained and adjusted with sampling weights. Healthcare access measures were described by type of disability.
Results
Mobility disability had the highest prevalence of 45.9 (44.8–47.0) % in 2016 and 48.4 (47.3–49.5) % in 2017 among respondents with COPD. The prevalence of disabilities was highest among those 45–64 years old, except for hearing and cognition. Hearing disabilities were most prevalent among males with COPD while cognitive and mobility disabilities were most prevalent among females with COPD. While differences in the prevalence of disabilities were observed, access to health care was similar by disability type and age group among respondents.
Conclusion
Contrary to expectation, the highest prevalence of disabilities was found not to be among those 65 years old and above. Further research is needed to explain this age-specific shift in the burden of disability, as long-term care planning and prevention support systems should be informed by the demographical patterns of disabilities among individuals with COPD.
... For each measure and at each wave, respondents reported whether they had ever received a doctor's diagnosis. Disability is a binary indicator for which 1 = self-reported difficulty with any of 10 activities of daily living or instrumental activities of daily living, such as bathing and managing medications (Spector and Fleishman 1998;Zajacova and Montez 2018). Mobility limitations are also binary, where 1 = difficulty with any of five lower body tasks, such as walking a block or climbing a flight of stairs. ...
The positive association between educational attainment and adult health (“the gradient”) is stronger in some areas of the United States than in others. Explanations for the geographic pattern have not been rigorously investigated. Grounded in a contextual and life-course perspective, the aim of this study is to assess childhood circumstances (e.g., childhood health, compulsory schooling laws) and adult circumstances (e.g., wealth, lifestyles, economic policies) as potential explanations. Using data on U.S.-born adults aged 50 to 59 years at baseline ( n = 13,095) and followed for up to 16 years across the 1998 to 2014 waves of the Health and Retirement Study, the authors examined how and why educational gradients in morbidity, functioning, and mortality vary across nine U.S. regions. The findings indicate that the gradient is stronger in some areas than others partly because of geographic differences in childhood socioeconomic conditions and health, but mostly because of geographic differences in adult circumstances such as wealth, lifestyles, and economic and tobacco policies.
Objectives:
To quantify how poor health and inhospitable working conditions each contribute to educational disparities in work disability in mid-life and old age.
Methods:
We used the Health and Retirement Study (2006-2016) to examine educational disparities in reporting "any impairment or health problem that limits the kind or amount of paid work" in ages 51-80.
Results:
We found disparities to be profound and persistent over time. Blinder-Oaxaca three-fold decomposition revealed that distributions of income and employer insurance made the largest contribution to explaining different rates of work limitations among respondents with versus without high school degrees, followed by work characteristics (physical job demands, insufficient hours) and health conditions (diabetes, lung disease). Comparing respondents with high school versus college degrees, distributions of health conditions mattered most (high blood pressure, lung disease, heart disease, stroke), followed by health behaviors (smoking, drinking). Health-induced work limitations are often used as a measure of health, but we found that work characteristics explained 57% of the disadvantage of those without a high school degree and 44% of the disadvantage of high school compared to college graduates.
Discussion:
Therefore, work environments appear to play an important role in educational disparities in mid-to-late-life disability.
There have been few studies examining trajectories of functional decline among older adults in the United States using large representative databases. The purpose of this study was to describe the mean trajectory of functional decline for a representative sample of US older adults, to determine the optimal number of latent classes within that sample, and to identify key differences between the classes on select variables. Through the use of link functions, non-linear trajectories can be modeled. Three classes were identified and were named Rapid Decline, Late Decline, and High Baseline. The Late Decline Group was the most numerous and was characterized by low initial functional disability with a steep rise starting around age 85. The Rapid Decline Group also had low initial functional disability, but decline started around age 80. The High Baseline Group had high initial functional disability and less steep trajectory. Age and comorbidity were the most influential factors in functional decline. Race was statistically significant but the difference disappeared when controlling for other covariates. Sex did not significantly influence the trajectory. There were significant differences among the classes for mortality during study, initial age, initial functional status, and for several specific comorbidities: arthritis, diabetes, lung disease, and stroke.
This study assesses chronic pain prevalence among sexual minority U.S. adults who self-identify as gay/lesbian, bisexual, or "something else," and examines the role of select covariates in the observed patterns. Analyses are based on 2013 to 2018 waves of the National Health Interview Survey, a leading cross-sectional survey representative of the U.S. population. General chronic pain and chronic pain in 3+ sites among adults aged 18 to 64 years (N = 134,266 and 95,675, respectively) are analyzed using robust Poisson regression and nonlinear decomposition; covariates include demographic, socioeconomic, healthcare, and psychological distress measures. We find large disparities for both pain outcomes. Americans who self-identify as bisexual or "something else" have the highest general chronic pain prevalence (23.7% and 27.0%, respectively), compared with 21.7% among gay/lesbian and 17.2% straight adults. For pain in 3+ sites, disparities are even larger: Age-adjusted prevalence is over twice as high among adults who self-identify as bisexual or "something else" and 50% higher among gay/lesbian, compared with straight adults. Psychological distress is the most salient correlate of the disparities, whereas socioeconomic status and healthcare variables explain only a modest proportion. Findings thus indicate that even in an era of meaningful social and political advances, sexual minority American adults have significantly more chronic pain than their straight counterparts. We call for data collection efforts to include information on perceived discrimination, prejudice, and stigma as potential key upstream factors that drive pain disparities among members of these minoritized groups.
Bereavement is a risk factor for poor health, yet prior research has not considered how exposure to parental death across the life course may contribute to lasting social isolation and, in turn, poor health among older adults. Moreover, prior research often fails to consider the racial context of bereavement in the United States wherein Black and Hispanic Americans are much more likely than White Americans to experience parental death earlier in life. The present study uses longitudinal data from the Health and Retirement Study (HRS; 1998–2016) to consider linkages of parental death, social isolation, and health (self-rated health, functional limitations) for Black, Hispanic, and White older adults. Findings suggest that exposure to parental death is associated with higher levels of isolation, greater odds of fair/poor self-rated health, and greater odds of functional limitations in later life. Moreover, social isolation partially explains associations between parental bereavement and later-life health. These patterns persist net of psychological distress—an additional psychosocial response to bereavement. Racial inequities in bereavement are central to disadvantage: Black and Hispanic adults are more likely to experience a parent’s death earlier in the life course, and this differential exposure to parental death in childhood or young adulthood has implications for racial and ethnic inequities in social isolation and health throughout life.
Objective
This study aimed to examine age and cohort trends in disability among Chinese older adults and explore the disablement process factors that may explain the cohort trends in disability.Methods
This study used data from five waves of the Chinese Longitudinal Healthy Longevity Survey (CLHLS). A hierarchical logistic growth model was used to analyze the A–P–C effects and the contributors of cohort trends.ResultsADL, IADL, and FL among Chinese older adults showed increasing age and cohort trends. FL was more likely to result in IADL disability than ADL disability. Among the disablement process factors, gender, residence, education, health behavior, disease, and family income contributed to most of the cohort trends in disability.Conclusions
As older adults face increasing disability trends, it is necessary to distinguish age and cohort trends and develop more effective interventions according to relative contributors to prevent disability among them.
Objectives: Examine trends in limitations among young (15–39), middle-aged (40–64) and older age-groups (>=65) and their socioeconomic differences. Methods: Population-based European Social Survey data ( N = 396,853) were used, covering 30 mostly European countries and spanning the time-period 2002–2018. Limitations were measured using a global activity limitations indicator. Results: Age-differential trends in limitations were found. Activity limitations generally decreased in older adults, whereas trends varied among younger and middle-aged participants, with decreasing limitations in some countries but increasing limitations in others. These age-differential trends were replicated across limitation severity and socioeconomic groups; however, stronger limitation increases occurred regarding less-severe limitations. Discussion: Functional health has improved in older adults. Contrarily, the increasing limitations in younger and middle-aged individuals seem concerning, which were mostly observed in Western and Northern European countries. Given its public health importance, future studies should investigate the reasons for this declining functional health in the young and middle-aged.
The authors examine how state policy contexts may have contributed to unfavorable adult health in recent decades, using merged individual-level data from the 1993–2016 Behavioral Risk Factor Surveillance System ( n = 2,166,835) and 15 state-level policy domains measured annually on a conservative-to-liberal continuum. The authors examine associations between policy domains and health among adults 45 to 64 years old and assess how much of the associations are accounted for by adults’ socioeconomic, behavioral and lifestyle, and family factors. A more liberal version of the civil rights domain was associated with better health. It was disproportionately important for less educated adults and women, and its association with adult health was partly accounted for by educational attainment, employment, and income. Environment, gun safety, and marijuana policy domains were, to a lesser degree, predictors of health in some model specifications. In sum, health improvements require a greater focus on macro-level factors that shape the conditions in which people live.
Objective
Disability in the US has not improved in recent decades. Comparing temporal trends in disability prevalence across different income groups, both within and between the US and England, would inform public policy aimed at reducing disparities in disability.
Methods
Using the Health and Retirement Study (HRS) and the English Longitudinal Study of Ageing (ELSA), we estimated annual percent change from 2002 to 2016 in disability among community dwelling adults (197,021 person-years of observations). Disability was defined based on self-report of limitations with five instrumental activities of daily living (IADLs) and six activities of daily living (ADLs). We examined the trends by age and income quintile and adjusted for individual-level sociodemographic status and survey design.
Results
The adjusted annual percent change (AAPC) in disability prevalence declined significantly in both countries for ages 75 and older during 2002--2016. For ages 55-64 and 65-74, disability prevalence was unchanged in the US but declined in England. Both countries experienced a widening gap in disability between low- and high-income adults among the younger age groups. For example, for those ages 55-64 in each country, there was no significant improvement in disability for the low-income group but a significant improvement for the high-income group (AAPC=-3.60 95% CI [-6.57,-0.63] for the US; AAPC=-6.06 95% CI [-8.77,-3.35] for England).
Discussion
Improvements in disability were more widespread in England than in the US between 2002 and 2016. In both countries, the disparity in disability between low- and high-income adults widened for middle-aged adults. Policies targeted at preventing disability among low-income adults should be a priority in both countries.
Although prior research documents adverse health consequences of precarious work, we know less about how chronic exposure to precarious work in midlife shapes health trajectories among aging adults. The present study uses longitudinal data from the Health and Retirement Study to consider how histories of precarious work in later midlife (ages 50–65) shape trajectories of health and mortality risk after age 65. Results show that greater exposure to unemployment, job insecurity, and insufficient work hours in midlife predicts more chronic conditions and functional limitations after age 65. Characteristics of precarious work also predict increased mortality risk in later life. Findings indicate few gender differences in linkages between precarious work and health; however, women are more likely than men to experience job insecurity throughout midlife. Because precarious work is unlikely to abate, results suggest the need to reduce the health consequences of working in precarious jobs.
Precarious work has the potential to undermine workers’ health and well-being, and linkages between precarious work and health may depend on contextual measures of unemployment. The present study uses data from the Current Population Survey (CPS; 2001–2019) to examine whether several characteristics of precarious work are associated with self-rated health, with attention to differences in these associations by occupation- and state-specific unemployment rates. Findings indicate that experiences of unemployment, part-time work, and poor work quality (limited social benefits and low wages) are associated with worse self-rated health for working women and men. Moreover, associations between some measures of precarious work and health are weaker at higher levels of occupation- and state-specific unemployment for men, but not for women. The present study points to precarious work as a chronic stressor for many workers that must be considered within broader economic contexts.
Objective
To provide nationally representative prevalence estimates of disability associated with prior head injury with loss of consciousness in the U.S. and to examine associations between prior head injury and disability.
Methods
Cross-sectional analysis of 7,390 participants aged ≥40 years in the 2011-2014 National Health and Nutrition Examination Surveys (NHANES). Head injury with loss of consciousness was assessed by self-report. Domains of disability were assessed using a standardized structured questionnaire and measured grip strength. Logistic regression models adjusted for demographic, socioeconomic/behavioral, and medical comorbidity variables were used. Multiple imputation was used to account for missing covariate data.
Results
Mean age of participants was 58 years, 53% were female, 71% were non-Hispanic white, and 16% had a history of head injury with loss of consciousness. Overall, participants with a history of head injury had higher prevalence of disability in at least one domain of functioning compared to individuals without head injury (47.4% versus 38.6%, p<0.001), with the highest prevalence of disability in the domains of mobility and work productivity. In fully adjusted models, head injury was significantly positively associated with disability in all domains assessed on the standardized questionnaire (all p<0.05), but not with upper extremity grip strength (all p>0.05).
Conclusions
47.4% of individuals aged ≥40 years in the U.S with a history of head injury are living with disability in at least one domain of functioning, corresponding to 11.4 million affected individuals. This significant burden of disability suggests that efforts are needed to improve functioning among individuals with head injury.
Background
Between 2008 and 2014, annual estimates of disability prevalence among U.S. adults varied somewhat across federal surveys that use a standardized measure of disability, but trends over-time were relatively stable and consistent. In 2014, however, estimates of disability from the Survey of Income and Program Participation (SIPP) increased markedly relative to previous years and were much higher than disability estimates from other federal surveys.
Objective
To examine why disability prevalence among adults aged 40 and older substantially increased in the first wave of the 2014 SIPP Panel.
Methods
We consider three factors that may have contributed to the rise in disability: data processing, context effects linked to question order, and sampling. To do so, we compare estimates with and without survey weights and imputed data, analyze supplemental disability-related data collected among SIPP participants, and employ decomposition analysis to assess what proportion of the increase in disability can be attributed to changes in sample composition.
Results
We find evidence that differences in sample composition contributed to the observed rise in disability prevalence in SIPP between 2011 and 2014. There is less evidence that weighting and imputation or context effects played a role.
Conclusions
Previous studies emphasize differences in operationalization and conceptualization of disability as the major factor driving discrepancies in disability estimates. This study suggests that other factors related to survey design and administration may influence disability measurement. Such aspects of surveys, like question order and sampling, may be difficult to standardize, leading to meaningful cross-survey differences in disability estimates.
Determining long-term trends in chronic pain prevalence is critical for evaluating and shaping U.S. health policies, but little research has examined such trends. This study (1) provides estimates of pain trends among U.S. adults across major population groups; (2) tests whether sociodemographic disparities in pain have widened or narrowed over time; and (3) examines socioeconomic, behavioral, psychological, and medical correlates of pain trends. Regression and decomposition analyses of joint, low back, neck, facial/jaw pain, and headache/migraine using the 2002–2018 National Health Interview Survey for adults aged 25–84 (N = 441,707) assess the trends and their correlates. We find extensive escalation of pain prevalence in all population subgroups: overall, reports of pain in at least one site increased by 10%, representing an additional 10.5 million adults experiencing pain. Socioeconomic disparities in pain are widening over time, and psychological distress and health behaviors are among the salient correlates of the trends. This study thus comprehensively documents rising pain prevalence among Americans across the adult life span and highlights socioeconomic, behavioral, and psychological factors as important correlates of the trends. Chronic pain is an important dimension of population health, and demographic research should include it when studying health and health disparities.
Objectives:
Assess trends in pain prevalence from 1992 to 2014 among older U.S. adults and by major population subgroups, and test whether the trends can be explained by changes in population composition.
Methods:
Health and Retirement Study data include information on any pain, pain intensity, and limitations in usual activities due to pain. Average annual percent change in prevalence is calculated for any and for 2 levels of pain-mild/moderate and nonlimiting and severe and/or limiting-across demographic and socioeconomic characteristics, and for those with and without specific chronic conditions. Generalized linear latent and mixed models examine trends adjusting for covariates.
Results:
Linear and extensive increases in pain prevalence occurred across the total population and subgroups. The average annual percent increase was in the 2%-3% range depending upon age and sex. Increases were consistent across subgroups, persistent over time, and not due to changes in population composition. Without increases in educational attainment over time, pain prevalence increases would be even higher.
Discussion:
The increases in pain prevalence among older Americans are alarming and potentially of epidemic proportions. Population-health research must monitor and understand these worrisome trends.
Background
Life expectancy at birth in the United States will likely surpass 80 years in the coming decade. Yet recent studies suggest that longevity gains are unevenly shared across age and socioeconomic groups. First, mortality in midlife has risen among non-Hispanic whites. Second, low-educated whites have suffered stalls (men) or declines (women) in adult life expectancy, which is significantly lower than among their college-educated counterparts. Estimating the number of life years lost or gained by age and cause of death, broken down by educational attainment, is crucial in identifying vulnerable populations.
Methods and Findings
Using U.S. vital statistics data from 1990 to 2010, this study decomposes the change in life expectancy at age 25 by age and cause of death across educational attainment groups, broken down by race and gender. The findings reveal that mortality in midlife increased for white women (and to a lesser extent men) with 12 or fewer years of schooling, accounting for most of the stalls or declines in adult life expectancy observed in those groups. Among blacks, mortality declined in nearly all age and educational attainment groups. Although an educational gradient was found across multiple causes of death, between 60 and 80 percent of the gap in adult life expectancy was explained by cardiovascular diseases, smoking-related diseases, and external causes of death. Furthermore, the number of life years lost to smoking-related, external, and other causes of death increased among low- and high school-educated whites, explaining recent stalls or declines in longevity.
Conclusions
Large segments of the American population—particularly low- and high school-educated whites under age 55—are diverging from their college-educated counterparts and losing additional years of life to smoking-related diseases and external causes of death. If this trend continues, old-age mortality may also increase for these birth cohorts in the coming decades.
Background: Trends in disability among older Americans has declined since the 1980s. The study examines whether the trend continues to decline and whether educational disparities exist in the prevalence of functional limitations.
Methods: I used the 2000-2014 National Health Interview Survey and included adults aged ≥65 years. Functional limitations was measured by three outcomes: the need for help with activities of daily living (ADLs) or instrumental activities of daily living (IADLs) and physical function limitations. I used a set of logistic models to estimate the average annual change rate of functional limitations. I examined whether the annual rate of change differed by education, age group, and sex.
Results: During 2000-2014, the annual increase rate of ADL limitations was 1.7% (p<0.001) and was 2.0% (p<0.001) for physical function limitations; IADL limitation did not change significantly. All subgroups experienced an increase in ADL and physical function limitations except for adults with a more than high school education. The lower-educated group had a higher proportion and a higher annual rate of increase in all outcomes. Increasing trends in chronic conditions may contribute to the increasing
trend in functional limitations.
Conclusions: The study highlighted a large educational disparity in late-life disability among older Americans.
Smoking is considered the single most important preventable cause of morbidity and mortality worldwide, contributing to increased incidence and severity of disabling conditions. The aim of this study was to assess the contribution of chronic conditions to the disability burden across smoking categories in middle-aged adults in Belgium.Data from 10,224 individuals aged 40 to 60 years who participated in the 1997, 2001, 2004, or 2008 Health Interview Surveys in Belgium were used. Smoking status was defined as never, former (cessation ≥2 years), former (cessation
Data from the 1997 to 2004 National Health Interview Survey Sample Adult questionnaires were linked to the National Death Index (N = 242,397) to examine mortality risks associated with average and episodic heavy drinking. Cox proportional hazard models (Stata 12.0) revealed that (average) heavier drinkers and episodic heavy drinkers (5+ in a day) had increased mortality risks but when examined together, episodic heavy drinking added only modestly to the mortality risks of light and moderate drinkers. Limitations and implications of results for survey measurement of potentially harmful levels of alcohol use are noted. This was a Federal study that received no outside funding.
This is the first analysis that demonstrates empirically the likely tie between activities (time spent) and disability (health-related difficulty in activities). We compare trends in activities and disability for Americans ages 55 to 69 in recent years, and assess cross-sectional linkages of activities and disability.
Data are from the Health and Retirement Study, a longitudinal survey of community-dwelling U.S. adults. Trends are estimated by mixed-effects regression models (MRMs) with time, age, and time-age interaction predictors. Links of activities and disability also use MRM.
For midlife adults, hobbies/leisure and sports/exercise increased, repairs/yard decreased, and several activities had convex patterns; by contrast, disability prevalence was stable. Personal care hours rise with disability, but most activities decline.
Activities are more dynamic than disability, and time use is associated with disability. Taken together, the results encourage broader activities in disability measures to capture better disability's scope and dynamics.
Missing data are a common occurrence in real datasets. For epidemiological and prognostic factors studies in medicine, multiple imputation is becoming the standard route to estimating models with missing covariate data under a missing-at-random assumption. We describe ice, an implementation in Stata of the MICE approach to multiple imputation. Real data from an observational study in ovarian cancer are used to illustrate the most important of the many options available with ice. We remark briefly on the new database architecture and procedures for multiple imputation introduced in releases 11 and 12 of Stata.
Objectives:
To elucidate why the inverse association between education level and mortality risk (the gradient) has increased markedly among White women since the mid-1980s, we identified causes of death for which the gradient increased.
Methods:
We used data from the 1986 to 2006 National Health Interview Survey Linked Mortality File on non-Hispanic White women aged 45 to 84 years (n = 230 692). We examined trends in the gradient by cause of death across 4 time periods and 4 education levels using age-standardized death rates.
Results:
During 1986 to 2002, the growing gradient for all-cause mortality reflected increasing mortality among low-educated women and declining mortality among college-educated women; during 2003 to 2006 it mainly reflected declining mortality among college-educated women. The gradient increased for heart disease, lung cancer, chronic lower respiratory disease, cerebrovascular disease, diabetes, and Alzheimer's disease. Lung cancer and chronic lower respiratory disease explained 47% of the overall increase.
Conclusions:
Mortality disparities among White women widened across 1986 to 2006 partially because of causes of death for which smoking is a major risk factor. A comprehensive policy framework should address the social conditions that influence smoking among disadvantaged women.
This article updates trends from five national U.S. surveys to determine whether the prevalence of activity limitations among the older population continued to decline in the first decade of the twenty-first century. Findings across studies suggest that personal care and domestic activity limitations may have continued to decline for those ages 85 and older from 2000 to 2008, but generally were flat since 2000 for those ages 65-84. Modest increases were observed for the 55- to 64-year-old group approaching late life, although prevalence remained low for this age group. Inclusion of the institutional population is important for assessing trends among those ages 85 and older in particular.
We compared health outcomes for adults with the General Equivalency Diploma (GED) and regular high school diploma to determine whether GED recipients are equivalent to regular graduates despite research that documents their disadvantages in other outcomes.
We used 1997 to 2009 National Health Interview Survey cross-sectional data on high school dropouts, graduates, and GED recipients aged 30 to 65 years (n = 76,705). Five general health indicators and 20 health conditions were analyzed using logistic models.
GED recipients had a significantly higher prevalence of every health outcome compared with high school graduates (odds ratios = 1.3-2.7). The GED-high school differences attenuated but remained evident after controlling for health insurance, economic status, and health behaviors. For most conditions, the 95% confidence interval for GED earners overlapped with that for high school dropouts.
The high school equivalency diploma was associated with nonequivalent health: adults with a GED had health comparable to that of high school dropouts, not graduates. GED recipients were at increased risk for many health conditions, and their health should be viewed as distinct from regular graduates. The findings have implications for health and educational policies.
This paper reviews trends in mortality and morbidity to evaluate whether there has been a compression of morbidity.
Review of recent research and analysis of recent data for the United States relating mortality change to the length of life without 1 of 4 major diseases or loss of mobility functioning.
Mortality declines have slowed down in the United States in recent years, especially for women. The prevalence of disease has increased. Age-specific prevalence of a number of risk factors representing physiological status has stayed relatively constant; where risks decline, increased usage of effective drugs is responsible. Mobility functioning has deteriorated. Length of life with disease and mobility functioning loss has increased between 1998 and 2008.
Empirical findings do not support recent compression of morbidity when morbidity is defined as major disease and mobility functioning loss.
We investigated trends in disability among older Americans from 1988 through 2004 to test the hypothesis that more recent cohorts show increased burdens of disability.
We used data from 2 National Health and Nutrition Examination Surveys (1988-1994 and 1999-2004) to assess time trends in basic activities of daily living, instrumental activities, mobility, and functional limitations for adults aged 60 years and older. We assessed whether changes could be explained by sociodemographic, body weight, or behavioral factors.
With the exception of functional limitations, significant increases in each type of disability were seen over time among respondents aged 60 to 69 years, independent of sociodemographic characteristics, health status, relative weight, and health behaviors. Significantly greater increases occurred among non-Whites and persons who were obese or overweight (2 of the fastest-growing subgroups within this population). We detected no significant trends among respondents aged 70 to 79 years; in the oldest group (aged>or=80 years), time trends suggested lower prevalence of functional limitations among more recent cohorts.
Our results have significant and sobering implications: older Americans face increased disability, and society faces increased costs to meet the health care needs of these disabled Americans.
Disability status for the non-institutional population in the United States has been substantially documented from national surveys such as the American Community Survey (ACS), the Current Population Survey (CPS), the National Health Interview Survey (NHIS), and the Survey of Income and Program Participation (SIPP). No comparable surveys have been fielded to collect information for the institutional population as a whole, however, including the large share of the institutional population having disabilities. In general, much less is known about the disability status of the institutional population than about the disability status of the non-institutional population, particularly for those of working age. In light of this gap in knowledge, we compiled and examined existing disability information for the institutional population to evaluate the implications of the exclusion of the institutional population from national surveys for disability statistics and research, with an emphasis on working-age people (She and Stapleton 2006). This research brief summarizes our key findings.
This paper analyzes evidence on changes in disability among the elderly and considers its implications. Disability among the elderly has declined by 1 percent or more per year for the past several decades. Strong evidence relates these changes to improved medical technology and to behavioral changes. Changes in socioeconomic status, disease exposure, and use of supportive aids are likely important as well, although their magnitude is difficult to gauge. Should disability improvements continue, the projected increase in medical spending resulting from technological changes in health care would be moderated, but not eliminated. Disability change also may facilitate an increase in age of retirement.
A 10-question screening scale of psychological distress and a six-question short-form scale embedded within the 10-question scale were developed for the redesigned US National Health Interview Survey (NHIS).
Initial pilot questions were administered in a US national mail survey (N = 1401). A reduced set of questions was subsequently administered in a US national telephone survey (N = 1574). The 10-question and six-question scales, which we refer to as the K10 and K6, were constructed from the reduced set of questions based on Item Response Theory models. The scales were subsequently validated in a two-stage clinical reappraisal survey (N = 1000 telephone screening interviews in the first stage followed by N = 153 face-to-face clinical interviews in the second stage that oversampled first-stage respondents who screened positive for emotional problems) in a local convenience sample. The second-stage sample was administered the screening scales along with the Structured Clinical Interview for DSM-IV (SCID). The K6 was subsequently included in the 1997 (N = 36116) and 1998 (N = 32440) US National Health Interview Survey, while the K10 was included in the 1997 (N = 10641) Australian National Survey of Mental Health and Well-Being.
Both the K10 and K6 have good precision in the 90th-99th percentile range of the population distribution (standard errors of standardized scores in the range 0.20-0.25) as well as consistent psychometric properties across major sociodemographic subsamples. The scales strongly discriminate between community cases and non-cases of DSM-IV/SCID disorders, with areas under the Receiver Operating Characteristic (ROC) curve of 0.87-0.88 for disorders having Global Assessment of Functioning (GAF) scores of 0-70 and 0.95-0.96 for disorders having GAF scores of 0-50.
The brevity, strong psychometric properties, and ability to discriminate DSM-IV cases from non-cases make the K10 and K6 attractive for use in general-purpose health surveys. The scales are already being used in annual government health surveys in the US and Canada as well as in the WHO World Mental Health Surveys. Routine inclusion of either the K10 or K6 in clinical studies would create an important, and heretofore missing, crosswalk between community and clinical epidemiology.
Changes in the health and functioning of the Medicare-enrolled population aged 65+ are tracked by using the 1982–2004/2005 National Long-Term Care Surveys. We found a significant rate of decline in the prevalence of chronic disability that accelerated from 1982 to 2004. These declines are significant for both persons with less severe chronic disability, which might be compensated by modifying the built environment and providing assistive devices, and for persons with more serious disability, which may be affected by reductions in the incidence and severity of disease through biomedical interventions. Declines in chronic disability continued over the 22-year period at a rate fast enough (i.e., 1.52% per annum) to contribute significantly to the long-term fiscal stability of the Medicare (and Medicaid) programs. Changes in the rate and substance of disability declines seem consistent with the intentions of policy interventions in Medicare and Medicaid.
• Medicare
• National Long-Term Care Surveys (NLTCS)
• long-term care
• activities of daily living
• Medicaid
Health among the older population as measured by most dimensions has improved during the last two decades. Mortality has continued to decline, and disability and functioning loss are less common now than in the past. However, the prevalence of most diseases has increased in the older population as people survive longer with disease, and the reduction in incidence does not counter the effect of increased survival. On the other hand, having a disease appears to be less disabling than in the past.
For decades, it was taken as a given that an increased homeownership rate was a desirable goal. But after the financial crises and Great Recession, in which roughly eight million homes were foreclosed on and about $7 trillion in home equity was erased, economists and policymakers are re-evaluating the role of homeownership in the American Dream. Many question whether the American Dream should really include homeownership or instead focus more on other aspects of upward mobility, and most acknowledge that homeownership is not for everyone. We take a detailed look at US homeownership from three different perspectives: 1) an international perspective, comparing US homeownership rates with those of other nations; 2) a demographic perspective, examining the correlation between changes in the US homeownership rate between 1985 and 2015 and factors like age, race/ethnicity, education, family status, and income; 3) and, a financial benefits perspective, using national data since 2002 to calculate the internal rate of return to homeownership compared to alternative investments. Our overall conclusion: homeownership is a valuable institution. While two decades of policies in the 1990s and early 2000s may have put too much faith in the benefits of homeownership, the pendulum seems to have swung too far the other way, and many now may have too little faith in homeownership as part of the American Dream.
Background
Major depression is associated with significant disability, morbidity, and mortality. The current study estimated trends in the prevalence of major depression in the US population from 2005 to 2015 overall and by demographic subgroups.
Methods
Data were drawn from the National Survey on Drug Use and Health (NSDUH), an annual cross-sectional study of US persons ages 12 and over (total analytic sample N = 607 520). Past-year depression prevalence was examined annually among respondents from 2005 to 2015. Time trends in depression prevalence stratified by survey year were tested using logistic regression. Data were re-analyzed stratified by age, gender, race/ethnicity, income, and education.
Results
Depression prevalence increased significantly in the USA from 2005 to 2015, before and after controlling for demographics. Increases in depression were significant for the youngest and oldest age groups, men, and women, Non-Hispanic White persons, the lowest income group, and the highest education and income groups. A significant year × demographic interaction was found for age. The rate of increase in depression was significantly more rapid among youth relative to all older age groups.
Conclusions
The prevalence of depression increased significantly in the USA from 2005 to 2015. The rate of increase in depression among youth was significantly more rapid relative to older groups. Further research into understanding the macro level, micro level, and individual factors that are contributing to the increase in depression, including factors specific to demographic subgroups, would help to direct public health prevention and intervention efforts.
Objectives
We estimated state-level disability-associated health-care expenditures (DAHE) for the U.S. adult population.
Methods
We used a two-part model to estimate DAHE for the noninstitutionalized U.S. civilian adult population using data from the 2002–2003 Medical Expenditure Panel Survey and state-level data from the Behavioral Risk Factor Surveillance System. Administrative data for people in institutions were added to generate estimates for the total adult noninstitutionalized population. Individual-level data on total health-care expenditures along with demographic, socioeconomic, geographic, and payer characteristics were used in the models.
Results
The DAHE for all U.S. adults totaled $397.8 billion in 2006, with state expenditures ranging from $598 million in Wyoming to $40.1 billion in New York. Of the national total, the DAHE were $118.9 billion for the Medicare population, $161.1 billion for Medicaid recipients, and $117.8 billion for the privately insured and uninsured populations. For the total U.S. adult population, 26.7% of health-care expenditures were associated with disability, with proportions by state ranging from 16.9% in Hawaii to 32.8% in New York. This proportion varied greatly by payer, with 38.1% for Medicare expenditures, 68.7% for Medicaid expenditures, and 12.5% for nonpublic health-care expenditures associated with disability.
Conclusions
DAHE vary greatly by state and are borne largely by the public sector, and particularly by Medicaid. Policy makers need to consider initiatives that will help reduce the prevalence of disabilities and disability-related health disparities, as well as improve the lives of people with disabilities.
Functional limitations and disability declined in the US during the 1980s and 1990s, but reports of early 21st century trends are mixed. Whether educational inequalities in functioning increased or decreased is also poorly understood. Given the importance of disability for productivity, independent living, and health care costs, these trends are critical to US social and health policies. We examine recent trends in functional limitations and disability among women and men aged 45–64. Using 2000–2015 National Health Interview Surveys data on over 155,000 respondents, semiparametric and logistic regression models visualize and test functioning trends by education. Among women and men with at least a college degree, there was no change in disability and mild increase in limitations over time. All other education levels experienced significant increases in functioning problems ranging from 18% higher odds of functional limitations in 2015 compared to 2000 among men with some college to about 80% increase in the odds of disability among women and men with less than high school education. The similar trends for both genders suggest common underlying causes, possibly including the worsening economic well-being of middle- and working-class families. The pervasive growth of functioning problems is a cause for concern that necessitates further scholarly investigation.
Existing estimates of sociodemographic disparities in chronic pain in the United States are based on cross-sectional data, often treat pain as a binary construct, and rarely test for nonresponse or other types of bias. This study uses 7 biennial waves of national data from the Health and Retirement Study (1998-2010; n = 19,776) to describe long-term pain disparities among older (age 51+) American adults. It also investigates whether pain severity, reporting heterogeneity, survey nonresponse, and/or mortality selection might bias estimates of social disparities in pain. In the process, the article clarifies whether 2 unexpected patterns observed cross-sectionally-plateauing of pain above age 60, and lower pain among racial/ethnic minorities- A re genuine or artefactual. Findings show high prevalence of chronic pain: 27.3% at baseline, increasing to 36.6% thereafter. Multivariate latent growth curve models reveal extremely large disparities in pain by sex, education, and wealth, which manifest primarily as differences in intercept. Net of these variables, there is no racial/ethnic minority disadvantage in pain scores, and indeed a black advantage vis-à-vis whites. Pain levels are predictive of subsequent death, even a decade in the future. No evidence of pain-related survey attrition is found, but surveys not accounting for pain severity and reporting heterogeneity are likely to underestimate socioeconomic disparities in pain. The lack of minority disadvantage (net of socioeconomic status) appears genuine. However, the age-related plateauing of pain observed cross-sectionally is not replicated longitudinally, and seems partially attributable to mortality selection, as well as to rising pain levels by birth cohort.
To examine disability trends among U.S. near-elderly and elderly persons and explain observed trends.
1996-2010 waves of the Health and Retirement Study.
We first examined trends in Activities of Daily Living and Instrumental Activities of Daily Living limitations, and large muscle, mobility, gross motor, and fine motor indexes. Then we used decomposition analysis to estimate contributions of changes in sociodemographic composition, self-reported chronic disease prevalence and health behaviors, and changes in disabling effects of these factors to disability changes between 1996 and 2010.
Disability generally increased or was unchanged. Increased trends were more apparent for near-elderly than elderly persons. Sociodemographic shifts tended to reduce disability, but their favorable effects were largely offset by increased self-reported chronic disease prevalence. Changes in smoking and heavy drinking prevalence had relatively minor effects on disability trends. Increased obesity rates generated sizable effects on lower-body functioning changes. Disabling effects of self-reported chronic diseases often declined, and educational attainment became a stronger influence in preventing disability.
Such unfavorable trends as increased chronic disease prevalence and higher obesity rates offset or outweighed the favorable effects with the result that disability remained unchanged or increased.
© Health Research and Educational Trust.
This article provides estimates of active life expectancy, defined as disability-free life expectancy, for males and females for three dates: 1970, 1980, and 1990. Increases in life expectancy during the 1980s were concentrated in years without disability. This contrasts with the preceding decade during which almost all of the increase in life expectancy was in disabled years. Recent increases in both total life expectancy and disability-free life expectancy have been greater for males than for females. The primary reason for the increase in disability-free life during the 1980s is a decrease in the proportion of the population who are disabled among those in their late 50s and their 60s.
Downward trends in activity limitations among the older U.S. population have recently plateaued, while activity limitation among the pre-retirement population has increased.
Update temporal trends in limitations in sensory and physical functions, instrumental activities of daily living (IADLs), and activities of daily living (ADLs) for the 40-64 and 65-and-over U.S. populations; assess the extent to which trends in education, smoking, and obesity could account for the trends in limitations; and examine trends in conditions cited as causes of limitations, their durations, and proportion of life spent with them.
Multivariate analysis of the 1997-2010 National Health Interview Survey.
For the younger group, there have been increases in all limitations, except trouble hearing, which has declined. Increased obesity could account for the increases in vision, physical function, and IADL limitations. Musculoskeletal conditions, such as arthritis and back/neck problems, are frequently cited as causes of limitation, and there are growing roles for depression and nervous system conditions. For the 65-and-over group, there have been decreases in all limitations, except difficulty with physical functions, which is up. Increased education could account for the decline in ADL limitation, and increased obesity could account for increased difficulty with physical functions. Musculoskeletal conditions are also frequently cited as causes of limitation, but declines in heart- and vision-related limitations have been important.
Trends should continue to be monitored closely for both groups, since younger people have not experienced the improvements of the older group, but are its future members.
This article presents a method for estimating and interpreting total, direct, and indirect effects in logit or probit models. The method extends the decomposition properties of linear models to these models; it closes the much-discussed gap between results based on the “difference in coefficients” method and the “product of coefficients” method in mediation analysis involving nonlinear probability models models; it reports effects measured on both the logit or probit scale and the probability scale; and it identifies causal mediation effects under the sequential ignorability assumption. We also show that while our method is computationally simpler than other methods, it always performs as well as, or better than, these methods. Further derivations suggest a hitherto unrecognized issue in identifying heterogeneous mediation effects in nonlinear probability models. We conclude the article with an application of our method to data from the National Educational Longitudinal Study of 1988.
In a series of recent articles, Karlson, Holm, and Breen (Breen, Karlson, and Holm, 2011, http://papers.ssrn.com/sol3/papers.cfm?abstractid=1730065; Karlson and Holm, 2011, Research in Stratification and Social Mobility 29: 221– 237; Karlson, Holm, and Breen, 2010, http://www.yale.edu/ciqle/Breen Scaling effects.pdf) have developed a method for comparing the estimated coefficients of two nested nonlinear probability models. In this article, we describe this method and the user-written program khb, which implements the method. The KHB method is a general decomposition method that is unaffected by the rescaling or attenuation bias that arises in cross-model comparisons in nonlinear models. It recovers the degree to which a control variable, Z, mediates or explains the relationship between X and a latent outcome variable, Y ∗, underlying the nonlin- ear probability model. It also decomposes effects of both discrete and continuous variables, applies to average partial effects, and provides analytically derived statistical tests. The method can be extended to other models in the generalized linear model family.
This article describes the plreg Stata command, which implements the difference-based algorithm for estimating the partial linear regression models.
The visual information on a scatterplot can be greatly enhanced, with little additional cost, by computing and plotting smoothed points. Robust locally weighted regression is a method for smoothing a scatterplot, (x i , y i ), i = 1, …, n, in which the fitted value at z k is the value of a polynomial fit to the data using weighted least squares, where the weight for (x i , y i ) is large if x i is close to x k and small if it is not. A robust fitting procedure is used that guards against deviant points distorting the smoothed points. Visual, computational, and statistical issues of robust locally weighted regression are discussed. Several examples, including data on lead intoxication, are used to illustrate the methodology.
Information about residents of institutional and noninstitutional group quarters (GQ), particularly those with disabilities, has been limited by gaps in survey data, and statistics based on data that exclude some or all GQ residents are biased as estimates of total population statistics. We used the 2006 and 2007 American Community Survey (ACS) to identify the distribution of working-age populations with and without disabilities by major residence type and to assess the sensitivity of disability statistics to GQ residence. Our findings show that (1) of those with disabilities, about 1 in 13 males and 1 in 33 females live in GQ; (2) GQ rates are higher for individuals reporting mental, self-care, or go-outside-the-home disabilities than for those reporting sensory, physical, or employment disabilities; (3) younger males with disabilities are more likely to reside there, particularly at institutional GQ, reflecting their relatively high incarceration rate; (4) individuals with and without disabilities who are black, American Indian, were never married, or have less than a high school education have higher GQ residence rates; (5) 40% of male and 62% of female GQ residents have a disability; (6) adding GQ residents to household residents increases estimated disability prevalence for males by 6%, and the estimated difference between disability prevalence rates by gender nearly disappears; and (7) inclusion of the GQ population substantially lowers employment rate estimates for young males, blacks, and American Indians.
The decline in late-life disability prevalence in the United States was one of the most important developments in the well-being of older Americans in the 1980s and 1990s, but there is no guarantee that it will continue into the future. We review the past literature on trends in disability and other health indicators and then estimate the most recent trends in biomarkers and limitations for both the population aged 65 and older and those aged 40 to 64, the future elderly. We then investigate the extent to which trends in education, smoking, and obesity can account for recent trends in limitations and discuss how these three factors might influence future prospects for late-life health. We find that improvements in the health of the older population generally have continued into the first decade of the twenty-first century. The recent increase in the proportion of the younger population needing help with activities of daily living is concerning, as is the doubling of obesity in the last few decades. However the increase in obesity has recently paused, and favorable trends in education and smoking are encouraging.
When missing data occur in one or more covariates in a regression model, multiple imputation (MI) is widely advocated as an improvement over complete-case analysis (CC). We use theoretical arguments and simulation studies to compare these methods with MI implemented under a missing at random assumption.
When data are missing completely at random, both methods have negligible bias, and MI is more efficient than CC across a wide range of scenarios. For other missing data mechanisms, bias arises in one or both methods. In our simulation setting, CC is biased towards the null when data are missing at random. However, when missingness is independent of the outcome given the covariates, CC has negligible bias and MI is biased away from the null. With more general missing data mechanisms, bias tends to be smaller for MI than for CC.
Since MI is not always better than CC for missing covariate problems, the choice of method should take into account what is known about the missing data mechanism in a particular substantive application. Importantly, the choice of method should not be based on comparison of standard errors. We propose new ways to understand empirical differences between MI and CC, which may provide insights into the appropriateness of the assumptions underlying each method, and we propose a new index for assessing the likely gain in precision from MI: the fraction of incomplete cases among the observed values of a covariate (FICO). Copyright
Introduction General Conditions for the Randomization-Validity of Infinite-m Repeated-Imputation Inferences Examples of Proper and Improper Imputation Methods in a Simple Case with Ignorable Nonresponse Further Discussion of Proper Imputation Methods The Asymptotic Distribution of (Q̄m, Ūm, Bm) for Proper Imputation Methods Evaluations of Finite-m Inferences with Scalar Estimands Evaluation of Significance Levels from the Moment-Based Statistics Dm and Δm with Multicomponent Estimands Evaluation of Significance Levels Based on Repeated Significance Levels
Although still below 2 percent, the proportion of people ages 50-64 who reported needing help with personal care activities increased significantly from 1997 to 2007. The proportions needing help with routine household chores and indicating difficulty with physical functions were stable. These patterns contrast with reported declines in disability among the population age sixty-five and older. Particularly concerning among those ages 50-64 are significant increases in limitations in specific mobility-related activities, such as getting into and out of bed. Musculoskeletal conditions remained the most commonly cited causes of disability at these ages. There were also substantial increases in the attribution of disability to depression, diabetes, and nervous system conditions for this age group.
Missing indicator method (MIM) and complete case analysis (CC) are frequently used to handle missing confounder data. Using empirical data, we demonstrated the degree and direction of bias in the effect estimate when using these methods compared with multiple imputation (MI).
From a cohort study, we selected an exposure (marital status), outcome (depression), and confounders (age, sex, and income). Missing values in "income" were created according to different patterns of missingness: missing values were created completely at random and depending on exposure and outcome values. Percentages of missing values ranged from 2.5% to 30%.
When missing values were completely random, MIM gave an overestimation of the odds ratio, whereas CC and MI gave unbiased results. MIM and CC gave under- or overestimations when missing values depended on observed values. Magnitude and direction of bias depended on how the missing values were related to exposure and outcome. Bias increased with increasing percentage of missing values.
MIM should not be used in handling missing confounder data because it gives unpredictable bias of the odds ratio even with small percentages of missing values. CC can be used when missing values are completely random, but it gives loss of statistical power.
We are enthusiastic about the potential for multiple imputation and other methods 14 to improve the validity of medical research results and to reduce the waste of resources caused by missing data. The cost of multiple imputation analyses is small compared with the cost of collecting the data. It would be a pity if the avoidable pitfalls of multiple imputation slowed progress towards the wider use of these methods. It is no longer excusable for missing values and the reason they arose to be swept under the carpet, nor for potentially misleading and inefficient analyses of complete cases to be considered adequate. We hope that the pitfalls and guidelines discussed here will contribute to the appropriate use and reporting of methods to deal with missing data.
Building on prior conceptual schemes, this article presents a sociomedical model of disability, called The Disablement Process, that is especially useful for epidemiological and clinical research. The Disablement Process: (1) describes how chronic and acute conditions affect functioning in specific body systems, generic physical and mental actions, and activities of daily life, and (2) describes the personal and environmental factors that speed or slow disablement, namely, risk factors, interventions, and exacerbators. A main pathway that links Pathology, Impairments, Functional Limitations, and Disability is explicated. Disability is defined as difficulty doing activities in any domain of life (from hygiene to hobbies, errands to sleep) due to a health or physical problem. Feedback effects are included in the model to cover dysfunction spirals (pernicious loops of dysfunction) and secondary conditions (new pathology launched by a given disablement process). We distinguish intrinsic disability (without personal or equipment assistance) and actual disability (with such assistance), noting the scientific and political importance of measuring both. Disability is not a personal characteristic, but is instead a gap between personal capability and environmental demand. Survey researchers and clinicians tend to focus on personal capability, overlooking the efforts people commonly make to reduce demand by activity accommodations, environmental modifications, psychological coping, and external supports. We compare the disablement experiences of people who acquire chronic conditions early in life (lifelong disability) and those who acquire them in mid or late life (late-life disability). The Disablement Process can help inform research (the epidemiology of disability) and public health (prevention of disability) activities.
Measures of functional disability typically contain items that reflect limitations in performing activities of daily living (ADLs) or instrumental activities of daily living (IADLs). Combining IADL and ADL items together in the same scale would provide enhanced range and sensitivity of measurement. This article presents psychometric justification for a combined ADL/IADL scale. Data come from 2,977 disabled respondents in the 1989 National Long-Term Care Survey. Respondents indicated whether they received human help on 7 ADL items; they also indicated whether they were unable to perform each of 9 IADL items due to health reasons. Factor analyses using tetrachoric correlations demonstrated that 15 of the 16 items reflected one major dimension. Item response theory (IRT) methods were used to calibrate the items; a one-parameter IRT model fit the data. Item calibrations showed that ADL and IADL items were not hierarchically related. Analyses showed that a simple sum of item responses could be used to derive a measure of functional disability. Implications of using a 15-item ADL/IADL scale for eligibility determination and for comparing groups are discussed.
Using the Survey of Income and Program Participation, we document the importance of education in accounting for declines in functional limitations among older Americans from 1984 to 1993. Of the eight demographic and socioeconomic variables considered, education is most important in accounting for recent trends. The relationship between educational attainment and functioning has not changed measurably, but educational attainment has increased greatly during this period. Our analysis suggests, all else being equal, that future changes in education will continue to contribute to improvements in functioning, although at a reduced rate.
This paper examines healthy life expectancy by gender and education for whites and African Americans in the United States at three dates: 1970, 1980 and 1990. There are large racial and educational differences in healthy life expectancy at each date and differences by education in healthy life expectancy are even larger than differences in total life expectancy. Large racial differences exist in healthy life expectancy at lower levels of education. Educational differences in healthy life expectancy have been increasing over time because of widening differentials in both mortality and morbidity. In the last decade, a compression of morbidity has begun among those of higher educational status; those of lower status are still experiencing expansion of morbidity.
The rapidly expanding proportion of the US population 65 years and older is anticipated to have a profound effect on health care expenditures. Whether the changing health status of older Americans will modulate this effect is not well understood. This study sought to determine the relationship between functional status and government-reimbursed health care services in older persons.
Longitudinal cohort study of a representative sample of community-dwelling persons 72 years or older. Clinical data were linked with data on 2-year expenditures for Medicare-reimbursed hospital, outpatient, and home care services and Medicare- and Medicaid-reimbursed nursing home services. Per capita expenditures associated with different functional status transitions were calculated, as were excess expenditures associated with functional disability adjusted for demographic, health, and psychosocial variables.
The 19.6% of older persons who had stable functional dependence or who declined to dependence accounted for almost half (46.3%) of total expenditures. Persons in these groups had an excess of approximately $10 000 in expenditures in 2 years compared with those who remained independent. The 9.6% of patients who were dependent at baseline accounted for more than 40.0% of home health and nursing home expenditures; the 10.0% who declined accounted for more than 20.0% of hospital, outpatient, and nursing home expenditures.
Functional dependence places a large burden on government-funded health care services. Whereas functional decline places this burden on short- and long-term care services, stable functional dependence places the burden predominantly on long-term care services. Declining rates of functional disability and interventions to prevent disability hold promise for ameliorating this burden.
Several well-publicized recent studies have suggested that disability among older Americans has declined in the last decade.
To assess the quality, quantity, and consistency of recent evidence on US trends in the prevalence of self-rated old age disability and physical, cognitive, and sensory limitations during the late 1980s and 1990s and to evaluate the evidence on trends in disparities by major demographic groups.
We searched MEDLINE and AGELINE for relevant articles published from January 1990 through May 2002 and reviewed reference lists in published articles.
From more than 800 titles reviewed, we selected 16 articles based on 8 unique repeat cross-sectional and cohort surveys of US prevalence trends in disability or functioning among persons generally aged 65 or 70 years or older.
We evaluated survey quality according to 10 criteria, ranked the surveys as good, fair, or poor, and calculated for each outcome the average annual percent change.
Among the 8 surveys, 2 were rated as good, 4 as fair, 1 as poor, and 1 as mixed (fair or poor, depending on the outcome) for assessing trends. Analyses of surveys rated fair or good showed consistency of declines in any disability (-1.55% to -0.92% per year), instrumental activities of daily living disability (-2.74% to -0.40% per year), and functional limitations. Surveys provided limited evidence on cognition and conflicting evidence on self-reported ADL (changes ranged from -1.38% to 1.53% per year) and vision trends. Evidence on trends in disparities by age, sex, race, and education was limited and mixed, with no consensus yet emerging.
Several measures of old age disability and limitations have shown improvements in the last decade. Research into the causes of these improvements is needed to understand the implications for the future demand for medical care.
We addressed three questions: Have recent improvements in old-age disability been mirrored in changes in self-reported general health status? Are general health status trends similar for younger and older Americans? Have changes in general health status been uniform across demographic and socioeconomic groups?
Using logistic regression, we analyzed data from the 1982-2003 National Health Interview Surveys (n = 1,445,872 aged 18-69; n = 178,384 aged 70 and older).
The proportion of people aged 70 and older reporting disability declined at 1.38% per year and the proportion 70 and older reporting poor/fair health declined at 1.85% per year. There was less of a decline in reports of poor/fair health at younger ages. Trends for the 18-69 population showed widening health disparities by income but narrowing of the race/ethnicity and education gaps. In the older population, there was no change for those aged 80-84 and 85 and older, the race/ethnicity gap persisted, and both education and income differentials widened over time.
Declines in proportions reporting poor/fair health among the older population in recent decades mirror declines in disability. Although the younger population has not experienced such progress, its prevalence of poor/fair health is low throughout the 21-year analysis period. Of concern are the growing socioeconomic disparities in health for both younger and older populations.
Late-life disability has been declining in the United States since the 1980s. This study provides the first comprehensive investigation into the reasons for this trend.
The study draws on evidence from two sources: original data analyses and reviews of existing studies. The original analyses include trend models of data on the need for help with daily activities and self-reported causes of such limitations for the population aged seventy and older, based on the National Health Interview Surveys from 1982 to 2005.
Increases in the use of assistive and mainstream technologies likely have been important, as have declines in heart and circulatory conditions, vision, and musculoskeletal conditions as reported causes of disability. The timing of the improvements in these conditions corresponds to the expansion in medical procedures and pharmacologic treatment for cardiovascular disease, increases in cataract surgery, increases in knee and joint replacements, and expansion of medications for arthritic and rheumatic conditions. Greater educational attainment, declines in poverty, and declines in widowhood also appear to have contributed. Changes in smoking behavior, the population's racial/ethnic composition, the proportion of foreign born, and several specific conditions were eliminated as probable causes.
The substantial reductions in old-age disability between the early 1980s and early 2000s are likely due to advances in medical care as well as changes in socioeconomic factors. More research is needed on the influence of health behaviors, the environment, and early- and midlife factors on trends in late-life disability.
Ipums Health Surveys: National Health Interview Survey
- Lynn A Blewett
- Rivera Drew
- Julia A Griffin
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- King
- L Miram
- Kari C W Williams
- M N Minneapolis
Blewett, Lynn A., Rivera Drew, Julia A., Griffin, Risa, King, Miram L., Williams, Kari C.W.,
2016. Ipums Health Surveys: National Health Interview Survey. Version 6.2
[Dataset]. edited by U. o. Minnesota. Minneapolis, MN..
Disability and Care Needs of Older Americans: an Analysis of the 2011 National Health and Aging Trends Study. Office of Disability, Aging and Long-Term Care Policy
- Vicki Freedman
- Brenda Spillman
Freedman, Vicki, Spillman, Brenda, 2014. Disability and Care Needs of Older Americans:
an Analysis of the 2011 National Health and Aging Trends Study. Office of Disability,
Aging and Long-Term Care Policy, Washington, DC.
Disability and the disablement process
- Alan M Jette
Jette, Alan M., 2007. Disability and the disablement process. In: Markides, K.S. (Ed.),
Encyclopedia of Health and Aging. Sage Publications Inc, Thousand Oaks, CA, pp.
157-159.
- A Zajacova
A. Zajacova, J.K. Montez
Social Science & Medicine 211 (2018) 1-8