Judith D. Kasper

The Protective Effect of Emotional Vitality on Adverse Health Outcomes in Disabled Older Women

OBJECTIVE: Although the adverse physical health consequences of negative emotions have been studied extensively, much less is known about the potential impact of positive emotions. This study examines whether emotional vitality protects against progression of disability and mortality in disabled older women.

Gaining and losing health insurance: strengthening the evidence for effects on access to care and health outcomes.

This study uses longitudinal data to examine the consequences of losing and gaining health insurance coverage for access to care and health. For both Medicaid and privately insured persons, compared with those who remained insured, persons losing coverage over a 2-year period were more likely to lack a usual source of care, encounter difficulty in obtaining medical care, be very dissatisfied with ability to obtain needed care, and report no physician visits in the previous 12 months. Uninsured people who gained coverage showed improvement across all indicators of access, in contrast to those who remained without insurance. The effects of changes in coverage on health were in the same direction as those for access, but did not reach statistical significance. This study strengthens the evidence that health insurance coverage has a substantial impact on ability to gain access to medical care and may affect health status.

Frailty in Older Adults: A Nationally Representative Profile in the United States

BACKGROUND Frailty assessment provides a means of identifying older adults most vulnerable to adverse outcomes. Attention to frailty in clinical practice is more likely with better understanding of its prevalence and associations with patient characteristics. We sought to provide national estimates of frailty in older people. METHODS A popular, validated frailty phenotype proposed by Fried and colleagues was applied to 7,439 participants in the 2011 baseline of the National Health and Aging Trends Study, a national longitudinal study of persons aged 65 and older. All measures drew on a 2-hour in-person interview. Weighted estimates of frailty prevalence were obtained. RESULTS Fifteen percent (95% CI: 14%, 16%) of the older non-nursing home population is frail, and 45% is prefrail (95% CI: 44%, 47%). Frailty is more prevalent at older ages, among women, racial and ethnic minorities, those in supportive residential settings, and persons of lower income. Independently of these characteristics, frailty prevalence varies substantially across geographic regions. Chronic disease and disability prevalence increase steeply with frailty. Among the frail, 42% were hospitalized in the previous year, compared to 22% of the prefrail and 11% of persons considered robust. Hip, back, and heart surgery in the last year were associated with frailty. Over half of frail persons had a fall in the previous year. CONCLUSIONS Our findings support the importance of frailty in late-life health etiology and potential value of frailty as a marker of risk for adverse health outcomes and as a means of identifying opportunities for intervention in clinical practice and public health policy.

Designing a community study of moderately to severely disabled older women: the Women's Health and Aging Study.

PURPOSE This paper reports on the design of a community-based study focusing on the effects of prevalent and incident disease and other modifying influences, on changes in functioning among moderately and severely disabled elderly women over a 3-year period [the Womens Health and Aging Study (WHAS)]. METHODS An approach to conceptualizing and assessing disability which captured functional difficulty across a broad range of activities and tasks was developed, tested on existing national data, and used, in the form of a brief screening instrument, to identify moderately to severely disabled elderly women in a large community sample representative of women 65 and older. Women meeting study criteria were recruited for a baseline interview, a 3-hour in-home clinical exam, as well as follow-up interviews and physical performance tests at 6-month intervals for three years. RESULTS Prevalence of moderate to severe disability among the screened population proved similar to that expected from analysis of national data (about one-third). The screening interview response rate was 78%, and 71% of women eligible by disability criteria participated. Only women completing both the baseline interview and clinical exam were counted as respondents. Analysis of characteristics of participants and nonparticipants indicated no selection bias related to levels of disability. However, education, race, and age were associated with participation. Women with some college education, black women, and younger women were more likely to participate. CONCLUSIONS The approach used to identify and recruit moderately to severely disabled elderly women in the WHAS is both feasible and applicable to other community-based research where inclusion of elderly people with moderate to severe disability across several areas of functioning is an objective. Other aspects of study design, such as use of proxy respondents, will also affect recruitment of individuals with impaired functioning into epidemiologic studies.

Family roles, structure, and stressors in relation to sex differences in obtaining psychotropic drugs.

Although it is well-documented that women are more likely than men to use prescribed psychotropic drugs, there are conflicting explanations of this pattern. The purpose of this paper is to examine this sex difference in relation to three theoretical perspectives: (1) the sex-role theory, (2) social support theory, and (3) stress theory. Data from the National Medical Care Expenditure Survey confirm that women were more likely than men to obtain a psychotropic drug. The data also showed that for both men and women, the likelihood of obtaining a psychotropic drug is influenced by family role responsibilities, family structure, and stressful events. However, women had a significantly higher likelihood of use than men under similar family circumstances. When sociodemographic and health-statuslaccess-to-care variables were controlled, the association for men between family circumstances and obtaining a psychotropic drug disappeared. For women, however, certain family role responsibilities, structures, and stressful events significantly affected the likelihood of obtaining a psychotropic drug even when sociodemographic and health-statuslaccess-to-care variables were controlled.

The importance of type of usual source of care for children's physician access and expenditures.

Despite the overall improvement in access to medical care for low-income people, differences in access to care by income levels remain for children. One reason may be the types of places low-income children often go for care. This paper examines the importance of type of usual source of care—physicians office versus hospital outpatient/emergency room sites and the potential mitigating influence of a specific physician as caregiver at these sites—on physician access and expenditures. Likelihood of a visit, number of visits, distribution of visits for preventive and illness-related care, and likelihood of a preventive visit are examined for all children and for those under 6 years. Implications of different types of usual source of care for costs of physician care are discussed as well.

Emotional vitality among disabled older women: the Women's Health and Aging Study.

OBJECTIVE: To examine correlates of high overall level of emotional functioning (emotional vitality) in disabled older women.

Validation of New Measures of Disability and Functioning in the National Health and Aging Trends Study

BACKGROUND Measurement gaps continue to hamper fuller understanding of late-life disability trends and dynamics. This article reports findings that validate the self-reported components of the disability protocol to be used in the new National Health and Aging Trends Study. The protocol was designed to redress existing measures by attending to environmental aspects of disability, capturing a broader range of capacity to perform tasks and including participation restriction items. METHODS We undertook an in-person validation study to determine the reliability, validity, and initial measurement properties of the National Health and Aging Trends Study self-reported disability protocol (n = 326). A random subset (n = 111) was readministered the protocol within 2-4 weeks. The interview and reinterview included new self-reported measures of physical capacity, activity limitations, and participation restrictions, as well as established performance and cognitive tests. We calculated percent agreement and kappa between interviews for all self-reported items and summary measures. We also assessed the construct validity of summary measures through correlations with demographic characteristics, frailty, memory, and performance-based mobility and confirmed whether activity limitations and participation restrictions were distinct domains. RESULTS New items and derived summary measures demonstrate robustness over a short time period, with kappas for retained/recommended items in the .60-.80 range. The summary measures correlate as expected with age, sex, residential status, and established performance-based constructs. Two factors, representing activity limitations and participation restrictions, were confirmed. CONCLUSIONS The National Health and Aging Trends Study protocol preserves the ability to examine more traditional measures of functioning while offering new insights into how activities are performed and preserving key conceptual distinctions.

Family structure and children's use of ambulatory physician services.

The purpose of this article is to examine childrens use of ambulatory physician services in relation to three dimensions of family life: maternal employment, single-parent versus two-parent households, and the presence of a nuclear or extended family. Data from the National Medical Care Expenditure Survey show that maternal employment has no relationship to childrens experience of disability days, and although children of mothers employed full-time are less likely to have a physician contact than are other children, this is attributable to a lower probability of seeing a doctor for children in good health (i.e., no disability days). Multivariate analysis confirms that although maternal employment decreases the likelihood of an ambulatory physician visit (among children with no disability days), it does not affect the total number of ambulatory physician visits or the likelihood of a telephone consultation with the childs physician. Children in single-parent families are more likely to see a physician when they have no disability days, than are children in families with two parents present. Children in nuclear rather than extended families do not differ in patterns of use, even when the mother works. Aside from other characteristics that might be expected to affect use (e.g., age, health status, insurance coverage, a usual source of care), there is a clear relationship between likelihood and volume of use by mothers and children.

Measurement Equivalence in ADL and IADL Difficulty Across International Surveys of Aging: Findings From the HRS, SHARE, and ELSA

OBJECTIVE To examine the measurement equivalence of items on disability across three international surveys of aging. METHOD Data for persons aged 65 and older were drawn from the Health and Retirement Survey (HRS, n = 10,905), English Longitudinal Study of Aging (ELSA, n = 5,437), and Survey of Health, Ageing and Retirement in Europe (SHARE, n = 13,408). Differential item functioning (DIF) was assessed using item response theory (IRT) methods for activities of daily living (ADL) and instrumental activities of daily living (IADL) items. RESULTS HRS and SHARE exhibited measurement equivalence, but 6 of 11 items in ELSA demonstrated meaningful DIF. At the scale level, this item-level DIF affected scores reflecting greater disability. IRT methods also spread out score distributions and shifted scores higher (toward greater disability). Results for mean disability differences by demographic characteristics, using original and DIF-adjusted scores, were the same overall but differed for some subgroup comparisons involving ELSA. DISCUSSION Testing and adjusting for DIF is one means of minimizing measurement error in cross-national survey comparisons. IRT methods were used to evaluate potential measurement bias in disability comparisons across three international surveys of aging. The analysis also suggested DIF was mitigated for scales including both ADL and IADL and that summary indexes (counts of limitations) likely underestimate mean disability in these international populations.