@article {1442, title = {Age-related trends in cardiovascular morbidity and physical functioning in the elderly: the Cardiovascular Health Study.}, journal = {J Am Geriatr Soc}, volume = {41}, year = {1993}, month = {1993 Oct}, pages = {1047-56}, abstract = {

OBJECTIVE: To describe relationships between age and sub-clinical cardiovascular disease, manifest chronic disease, and physical functioning and limitations among persons aged 65 years and older, with emphasis on the "oldest old," those 85 years and older.

DESIGN: Observational population-based study.

SETTING: Four U.S. communities: Forsyth County, North Carolina; Sacramento County, California; Washington County, Maryland; and Pittsburgh, Pennsylvania.

PARTICIPANTS: 5,201 men and women aged 65 years and older.

MEASUREMENTS: Demographic data; histories of cardiovascular disease (CVD), chronic lung disease, arthritis, diabetes, and hypertension; measures of subclinical disease including arm and ankle blood pressures, internal carotid wall thickness and stenosis, ejection fraction, left ventricular mass, fractional shortening, and diastolic function, electrocardiographic left ventricular hypertrophy and cardiac injury score, forced expiratory flow and volume; functional status including self-reported physical functioning, hearing and sight limitations and health status, and performance-based measures of function. These variables were examined among men and women in three age groups: 65-74 years, 75-84 years, and 85 + years. Subgroups of participants with and without manifest CVD were also examined.

MAIN RESULTS: In women, the prevalence of CVD and other chronic conditions increased with age, and the highest rates occurred among those 85 years and older. In men, prevalence rates increased between the two younger groups, but the oldest group had lower than expected rates for coronary heart disease, cerebrovascular disease, hypertension, and chronic lung disease. In contrast, there were strong age-related linear trends in most of the subclinical measures of blood pressure, atherosclerosis and pulmonary function and in virtually all measures of functional status in both gender groups across the age range. There was a particularly marked decline in functional status between the two older age groups. While subclinical disease was greater and functional status was poorer among those with manifest CVD, with few exceptions, age-related trends were not significantly different between the two groups.

CONCLUSIONS: Lower than expected prevalence rates of CVD among those aged 85 years and older, particularly among men, in this study of community-dwelling elderly may represent selection bias or a real plateauing in disease prevalence with age. However, subclinical disease appears to increase and functional status to decline across the age range in both men and women regardless of the presence of CVD. The apparent increase in subclinical disease with age indicates potential for CVD prevention after age 65.

}, keywords = {Activities of Daily Living, Age Distribution, Aged, Aged, 80 and over, Cardiovascular Diseases, Female, Humans, Male, Prevalence, Sex Distribution, Socioeconomic Factors}, issn = {0002-8614}, author = {Bild, D E and Fitzpatrick, A and Fried, L P and Wong, N D and Haan, M N and Lyles, M and Bovill, E and Polak, J F and Schulz, R} } @article {587, title = {Predictors of perceived health status in elderly men and women. The Cardiovascular Health Study.}, journal = {J Aging Health}, volume = {6}, year = {1994}, month = {1994 Nov}, pages = {419-47}, abstract = {

Baseline data on the perceived health status of participants (N = 5,201) in the Cardiovascular Health Study of the Elderly (CHS) are reported. The authors examined the predictive utility of health-related factors representing eight different domains, assessed gender differences in the prediction of perceived health, and tested a hypothesis regarding the role of known clinical conditions versus subclinical disease in predicting perceived health. Multivariate analyses showed that the majority of the explained variance in self-assessed health is accounted for by variables that fall into four general categories. Although gender differences were small, the analysis showed that the relative importance of several predictor variables did vary by gender.

}, keywords = {Aged, Cardiovascular Diseases, Data Collection, Female, Forecasting, Geriatric Assessment, Health Status, Humans, Male, Multivariate Analysis, Regression Analysis, Self-Assessment, Sex Factors, United States}, issn = {0898-2643}, doi = {10.1177/089826439400600401}, author = {Schulz, R and Mittelmark, M and Kronmal, R and Polak, J F and Hirsch, C H and German, P and Bookwala, J} } @article {1424, title = {Self-reported causes of physical disability in older people: the Cardiovascular Health Study. CHS Collaborative Research Group.}, journal = {J Am Geriatr Soc}, volume = {42}, year = {1994}, month = {1994 Oct}, pages = {1035-44}, abstract = {

OBJECTIVE: To determine the major conditions and symptoms reported to cause difficulty in 17 physical tasks of daily life and the criterion validity of self-report of diseases given as the causes of the difficulty in functioning, in community-dwelling older people.

DESIGN: Cross sectional analyses of data obtained in an observational cohort study.

SETTING: Research clinics in four US communities: Winston-Salem, NC, Hagerstown, MD, Pittsburgh, PA, and Sacramento, CA.

PARTICIPANTS: 5201 community-dwelling people > or = 65 years old.

RESULTS: Arthritis and other musculoskeletal diseases were given as the primary causes of difficulty in performing physical tasks by 49.0\% of the participants reporting difficulty in any task, followed by heart disease (13.7\%), injury (12.0\%), old age (11.7\%), lung disease (6.0\%), and stroke (2.9\%). The self-reports of diseases that caused disability varied by task. Whereas arthritis was given as a cause of difficulty in most of the 17 different tasks, heart and lung disease were more likely to be reported as causing difficulty with activities requiring high aerobic work capacity such as walking one-half mile or doing heavy housework. Stroke was more likely to be reported as causing difficulty with use of the upper extremities and in performing basic activities of daily living. There was a high degree of consistency (91\%) between the diseases and symptoms reported to cause disabilities. The percentage of people who reported a disease as the cause of their difficulty performing a task and had independent confirmation of the diagnosis was 85\% in men and 71\% in women, and varied according to type of disease and the individual{\textquoteright}s cognitive status and health status.

CONCLUSION: These data suggest that age-related chronic diseases are important causes of disability in older people but that the type of disability is dependent on the underlying disease that causes the disability. Also, self-report of the cause of disability appears to be generally accurate but is influenced by gender, health status, and type of disease.

}, keywords = {Activities of Daily Living, Aged, Aged, 80 and over, Arthritis, Cardiovascular Diseases, Chronic Disease, Cohort Studies, Cross-Sectional Studies, Disabled Persons, Female, Health Status, Health Surveys, Heart Diseases, Humans, Lung Diseases, Male, Observer Variation, Reproducibility of Results, Risk Factors, Sex Factors, United States}, issn = {0002-8614}, author = {Ettinger, W H and Fried, L P and Harris, T and Shemanski, L and Schulz, R and Robbins, J} } @article {1461, title = {Social support as a mediator in the relation between functional status and quality of life in older adults.}, journal = {Psychol Aging}, volume = {11}, year = {1996}, month = {1996 Mar}, pages = {34-44}, abstract = {

The relations among physical functioning, social support, depressive symptoms, and life satisfaction were examined in a national sample of 4,734 adults age 65 and older. Regression analyses were used to examine the relative importance of objective and subjective support measures in understanding the relation between physical impairment and quality of life. Impairment was associated with fewer friendship contacts, fewer family contacts, less perceived belonging support, and less perceived tangible aid, but only measures of perceived support predicted depressive symptomatology. A structural equation modeling approach was then used to explore the mediational role of perceived social support in the relation between impairment and quality of life variables. Results are consistent with the hypothesis that lower reported social support is an important reason for decreases in life satisfaction and increases in depressive symptoms found among older adult populations. Implications for understanding the role of social support in attenuating the effects of physical disability in older adults are discussed.

}, keywords = {Activities of Daily Living, Adaptation, Psychological, Aged, Aged, 80 and over, Aging, Depression, Disabled Persons, Geriatric Assessment, Health Status, Humans, Personal Satisfaction, Quality of Life, Sick Role, Social Support}, issn = {0882-7974}, author = {Newsom, J T and Schulz, R} } @article {1474, title = {Spousal similarity in subjective well-being: the Cardiovascular Health Study.}, journal = {Psychol Aging}, volume = {11}, year = {1996}, month = {1996 Dec}, pages = {582-90}, abstract = {

This study examines the extent to which one spouse{\textquoteright}s subjective well-being predicts that of the partner (N = 1,040 spousal pairs, 65 years or older). Prior research is extended in two ways: (a) The similarity of both affective domains (depressive symptoms, feelings about life as a whole, and satisfaction with the meaning and purpose of life) and nonaffective domains (perceived health) are examined, and (b) known predictors of well-being in older adults (sociodemographic variables, self and spouse health status variables, and exposure to common environmental events) are statistically controlled. Results indicate that one spouse{\textquoteright}s assessments of well-being and depression predict the other{\textquoteright}s well-being even after controlling for known predictors of these outcomes. Given the similarity of findings for affective and nonaffective domains, multiple mechanisms, including contagion, mate selection, and common environmental influences, are speculated as likely to contribute to this phenomenon.

}, keywords = {Activities of Daily Living, Adaptation, Psychological, Aged, Cardiovascular Diseases, Depression, Female, Geriatric Assessment, Humans, Male, Personal Satisfaction, Sick Role, Social Environment, Spouses}, issn = {0882-7974}, author = {Bookwala, J and Schulz, R} } @article {1485, title = {Correlates of performance-based measures of muscle function in the elderly: the Cardiovascular Health Study.}, journal = {J Gerontol A Biol Sci Med Sci}, volume = {52}, year = {1997}, month = {1997 Jul}, pages = {M192-200}, abstract = {

BACKGROUND: It is unknown how much age-related changes in muscle performance represent normal aging versus the effects of chronic disease and life style. We examined the correlates of four performance measures-gait speed, timed chair stands (TCS), grip strength, and maximal inspiratory pressure (MIP)-using baseline data from the Cardiovascular Health Study (CHS), a population-based study of risk factors for heart disease and stroke in persons > or = age 65.

METHODS: We analyzed data from the 5,201 CHS participants. Variables were arranged into nine categories: Personal Characteristics, Anthropometry, Physical Condition, Reported Functional Status, Subjective Health, Psychological Factors, Symptoms, Cognitive Status, Habits and Lifestyle, and Prevalent Disease. Independent correlates were identified using stepwise linear regression.

RESULTS: The regression models explained 17.7-25.4\% of the observed variability. Although age significantly correlated with each measure, it explained little of the variability (< or = 5.7\%). Anthropometric features plus physical condition explained 14.0-17.4\% of the variability for grip strength and MIP, but 2.8-12.9\% of the variability for gait speed and the log of TCS. Subjective health and psychological factors explained 1.8-9.4\% of the variability in gait speed and the log of TCS, but < or = 1.2\% of the variability in grip strength and MIP. Variables for prevalent disease explained < or = 1.3\% of the variability in each measure.

CONCLUSIONS: After age 64, age explained little of the variability in muscle performance in a large sample of mostly functionally intact, community-dwelling older persons. Complex measures such as gait speed were more associated with subjective factors than were direct measures of strength. Prevalent disease contributed surprisingly little to muscle performance.

}, keywords = {Aging, Anthropometry, Cardiovascular Physiological Phenomena, Female, Gait, Hand Strength, Health Status, Humans, Male, Middle Aged, Motor Activity, Muscles, Pressure, Regression Analysis, Respiration}, issn = {1079-5006}, author = {Hirsch, C H and Fried, L P and Harris, T and Fitzpatrick, A and Enright, P and Schulz, R} } @article {1506, title = {Health effects of caregiving: the caregiver health effects study: an ancillary study of the Cardiovascular Health Study.}, journal = {Ann Behav Med}, volume = {19}, year = {1997}, month = {1997 Spring}, pages = {110-6}, abstract = {

We propose that two related sources of variability in studies of caregiving health effects contribute to an inconsistent pattern of findings: the sampling strategy used and the definition of what constitutes caregiving. Samples are often recruited through self-referral and are typically comprised of caregivers experiencing considerable distress. In this study, we examine the health effects of caregiving in large population-based samples of spousal caregivers and controls using a wide array of objective and self-report physical and mental health outcome measures. By applying different definitions of caregiving, we show that the magnitude of health effects attributable to caregiving can vary substantially, with the largest negative health effects observed among caregivers who characterize themselves as being strained. From an epidemiological perspective, our data show that approximately 80\% of persons living with a spouse with a disability provide care to their spouse, but only half of care providers report mental or physical strain associated with caregiving.

}, keywords = {Activities of Daily Living, Aged, Arousal, Cardiovascular Diseases, Caregivers, Cerebrovascular Disorders, Coronary Disease, Cost of Illness, Female, Geriatric Assessment, Health Behavior, Health Status, Humans, Male, Psychophysiologic Disorders, Risk Factors, Spouses, Stress, Psychological}, issn = {0883-6612}, doi = {10.1007/BF02883327}, author = {Schulz, R and Newsom, J and Mittelmark, M and Burton, L and Hirsch, C and Jackson, S} } @article {1477, title = {Preventive health behaviors among spousal caregivers.}, journal = {Prev Med}, volume = {26}, year = {1997}, month = {1997 Mar-Apr}, pages = {162-9}, abstract = {

BACKGROUND: The physical and emotional burden of caring for a functionally impaired spouse may adversely affect the preventive health behavior of the caregiver. This study explores the relationship between caregiving and lifestyle health behaviors and use of preventive services.

METHODS: The Caregiver Health Effects Study identified spousal caregivers among a sample of more than 3,000 married, community-dwelling older persons, from four counties in the United States, who were enrollees in the Cardiovascular Health Study. High-level caregivers were defined as having a spouse with an ADL impairment (n = 212) and moderate-level caregivers, a spouse with one or more IADL impairments (n = 222). For each caregiver, a control, matched for age and gender, was selected (n = 385). Structured interviews were conducted in the home, following enrollment.

RESULTS: Being a high-level caregiver significantly increased the odds of not getting enough rest, not having enough time to exercise, not having time to rest to recuperate from illness, and forgetting to take prescription medications, compared with noncaregivers. These findings did not hold for moderate-level caregivers. The odds were not significantly different for either level of caregiver compared with noncaregivers for missing meals, missing doctor appointments, missing flu shots, and not refilling medications. Larger proportions of caregivers with a strong sense of control had good preventive health behaviors, compared with caregivers with a weak sense of control.

}, keywords = {Activities of Daily Living, Aged, Aged, 80 and over, Analysis of Variance, Caregivers, Case-Control Studies, Chi-Square Distribution, Confidence Intervals, Exercise, Female, Health Behavior, Health Status, Health Surveys, Humans, Internal-External Control, Life Style, Logistic Models, Male, Odds Ratio, Preventive Health Services, Self Care, Social Support, Spouses, United States}, issn = {0091-7435}, doi = {10.1006/pmed.1996.0129}, author = {Burton, L C and Newsom, J T and Schulz, R and Hirsch, C H and German, P S} } @article {1501, title = {Caregiving from the recipient{\textquoteright}s perspective: negative reactions to being helped.}, journal = {Health Psychol}, volume = {17}, year = {1998}, month = {1998 Mar}, pages = {172-81}, abstract = {

This study investigated predictors of negative reactions to assistance provided to a physically disabled spouse (n = 276, M age: 76.6 years) and the consequences that negative reactions may have for the mental health of the care recipient. Nearly 40\% of recipients reported some emotional distress in response to help they received. Fatalistic attitudes, perceived control, and lower self-esteem predicted greater helping distress, whereas lower self-esteem, fatalistic beliefs, and marital conflict were especially likely to lead to helping distress for those who received higher levels of assistance. Helping distress was also found to predict depression as much as 1 year later, suggesting that there may be long-term consequences of negative reactions to assistance. These findings have important implications for the study of caregiving and the relationship between physical impairment and depression.

}, keywords = {Activities of Daily Living, Aged, Caregivers, Chronic Disease, Depression, Disabled Persons, Factor Analysis, Statistical, Female, Helping Behavior, Humans, Internal-External Control, Longitudinal Studies, Male, Regression Analysis, Self Concept, Spouses, United States}, issn = {0278-6133}, author = {Newsom, J T and Schulz, R} } @article {1503, title = {Correlates and prevalence of benzodiazepine use in community-dwelling elderly.}, journal = {J Gen Intern Med}, volume = {13}, year = {1998}, month = {1998 Apr}, pages = {243-50}, abstract = {

OBJECTIVE: To describe the prevalence of benzodiazepine use, sociodemographic and physical health factors associated with use, dosages taken, and directions for use among individuals aged 65 years and older.

DESIGN: Cross-sectional analysis of baseline data from the community-based, prospective observational Cardiovascular Health Study.

PATIENTS/PARTICIPANTS: Medicare eligibility lists from four U.S. communities were used to recruit a representative sample of 5,201 community-dwelling elderly, of which 5,181 participants met all study criteria.

MEASUREMENTS AND MAIN RESULTS: Among participants, 511 (9.9\%) were taking at least one benzodiazepine, primarily anxiolytics (73\%). Benzodiazepines were often prescribed to be taken pro re nata (PRN "as needed"), and 36.5\% of prescriptions with instructions to be taken regularly were taken at a dose lower than prescribed. Reported over-the-counter (OTC) sleep aid medication use was 39.2\% in benzodiazepine users and 3.3\% in nonusers. In a multivariate logistic model, the significant independent correlates of benzodiazepine use were being white (odds ratio [OR] 1.9; 95\% confidence interval [CI] 1.0, 3.4), female (OR 1.7; CI 1.4, 2.2), and living in Forsyth County, North Carolina, or Washington County, Maryland, compared with living in Sacramento County, California, or Allegheny County, Pennsylvania (OR 2.3; CI 1.4, 2.2); having coronary heart disease (OR 1.6; CI 1.2, 2.1), health status reported as poor or fair (OR 1.8; CI 1.4, 2.3), self-reported diagnosis of nervous or emotional disorder (OR 6.7; CI 5.1, 8.7), and reporting use of an OTC sleep aid medication (OR 18.7; CI 14.1, 24.7).

CONCLUSIONS: One in 10 participants reported taking a benzodiazepine, most frequently an anxiolytic, often at a lower dose than prescribed and usually PRN. The high prevalence of OTC sleep aid medication and benzodiazepine use may place the patient at increased risk of psychomotor impairment. Physicians should assess OTC sleep aid medication use when prescribing benzodiazepines.

}, keywords = {Aged, Aged, 80 and over, Benzodiazepines, Cross-Sectional Studies, Drug Utilization, Female, Humans, Male, Practice Patterns, Physicians{\textquoteright}, Socioeconomic Factors}, issn = {0884-8734}, author = {Gleason, P P and Schulz, R and Smith, N L and Newsom, J T and Kroboth, P D and Kroboth, F J and Psaty, B M} } @article {1505, title = {The role of neuroticism and mastery in spouse caregivers{\textquoteright} assessment of and response to a contextual stressor.}, journal = {J Gerontol B Psychol Sci Soc Sci}, volume = {53}, year = {1998}, month = {1998 May}, pages = {P155-64}, abstract = {

Data from more than 300 spousal caregivers and their care recipients were analyzed to demonstrate the effects of caregivers{\textquoteright} personality attributes--neuroticism and mastery--on their assessment of a contextual stressor (the care recipient{\textquoteright}s behavioral and functional impairment) and on their experience of distress associated with that stressor. Caregivers who were high in neuroticism and/or low in mastery reported higher levels of behavioral and functional impairment in their disabled spouse and experienced more strain and depressive symptoms associated with caregiving relative to caregivers with lower neuroticism or higher mastery scores. We further showed that the widely reported association between caregiver-assessed impairment of the care recipient and caregiver outcomes can in part be explained by caregivers{\textquoteright} personality attributes, such as neuroticism and mastery. Our findings that caregivers{\textquoteright} personality variables are related to their assessment of a given objective stressor and their response to a given level of stress have implications for interventions targeting caregivers and for the use of caregivers as proxy informants.

}, keywords = {Aged, Caregivers, Depression, Female, Humans, Male, Neurotic Disorders, Personality, Personality Assessment, Stress, Psychological}, issn = {1079-5014}, author = {Bookwala, J and Schulz, R} } @article {605, title = {Caregiving as a risk factor for mortality: the Caregiver Health Effects Study.}, journal = {JAMA}, volume = {282}, year = {1999}, month = {1999 Dec 15}, pages = {2215-9}, abstract = {

CONTEXT: There is strong consensus that caring for an elderly individual with disability is burdensome and stressful to many family members and contributes to psychiatric morbidity. Researchers have also suggested that the combination of loss, prolonged distress, the physical demands of caregiving, and biological vulnerabilities of older caregivers may compromise their physiological functioning and increase their risk for physical health problems, leading to increased mortality.

OBJECTIVE: To examine the relationship between caregiving demands among older spousal caregivers and 4-year all-cause mortality, controlling for sociodemographic factors, prevalent clinical disease, and subclinical disease at baseline.

DESIGN: Prospective population-based cohort study, from 1993 through 1998 with an average of 4.5 years of follow-up.

SETTING: Four US communities.

PARTICIPANTS: A total of 392 caregivers and 427 noncaregivers aged 66 to 96 years who were living with their spouses.

MAIN OUTCOME MEASURE: Four-year mortality, based on level of caregiving: (1) spouse not disabled; (2) spouse disabled and not helping; (3) spouse disabled and helping with no strain reported; or(4) spouse disabled and helping with mental or emotional strain reported.

RESULTS: After 4 years of follow-up, 103 participants (12.6\%) died. After adjusting for sociodemographic factors, prevalent disease, and subclinical cardiovascular disease, participants who were providing care and experiencing caregiver strain had mortality risks that were 63\% higher than noncaregiving controls (relative risk [RR], 1.63; 95\% confidence interval [CI], 1.00-2.65). Participants who were providing care but not experiencing strain (RR, 1.08; 95 \% CI, 0.61-1.90) and those with a disabled spouse who were not providing care (RR, 1.37; 95\% CI, 0.73-2.58) did not have elevated adjusted mortality rates relative to the noncaregiving controls.

CONCLUSIONS: Our study suggests that being a caregiver who is experiencing mental or emotional strain is an independent risk factor for mortality among elderly spousal caregivers. Caregivers who report strain associated with caregiving are more likely to die than noncaregiving controls.

}, keywords = {Activities of Daily Living, Aged, Aged, 80 and over, Caregivers, Disabled Persons, Female, Health Status, Home Nursing, Humans, Male, Mortality, Proportional Hazards Models, Prospective Studies, Risk Factors, Socioeconomic Factors, Spouses, Stress, Psychological, United States}, issn = {0098-7484}, doi = {10.1001/jama.282.23.2215}, author = {Schulz, R and Beach, S R} } @article {603, title = {Stability and change in older adults{\textquoteright} social contact and social support: the Cardiovascular Health Study.}, journal = {J Gerontol B Psychol Sci Soc Sci}, volume = {54}, year = {1999}, month = {1999 Sep}, pages = {S302-11}, abstract = {

OBJECTIVES: The aim of this study was to examine the degree of individual change in structural indicators of social support (family network contact and close friend network contact) and functional indicators of social support (belonging, appraisal, and tangible support) during late life.

METHODS: Using a large population-based sample of older adults, hierarchical linear modeling was applied to examine the extent of change in social contact and support as well as sociodemographic characteristics (age, race, gender, and education) that might explain individual variability in contact and support at baseline and over time.

RESULTS: Consistent with predictions, small yet significant increases were observed in belonging support and tangible support. Contrary to predictions, no evidence was found for significant individual change in family network contact, close friend network contact, or appraisal support. Sociodemographic characteristics were more consistent predictors of variability in contact and support at baseline than variability over time.

DISCUSSION: The findings of this study add to a growing literature suggesting that late life is not typically characterized by a decline in important social resources.

}, keywords = {Age Factors, Aged, Aged, 80 and over, Cross-Sectional Studies, Educational Status, Family, Female, Health Status, Humans, Interpersonal Relations, Linear Models, Longitudinal Studies, Male, Predictive Value of Tests, Sex Factors, Social Support, Socioeconomic Factors, Surveys and Questionnaires, Time Factors, United States}, issn = {1079-5014}, doi = {10.1093/geronb/54b.5.s302}, author = {Martire, L M and Schulz, R and Mittelmark, M B and Newsom, J T} } @article {618, title = {Association between depression and mortality in older adults: the Cardiovascular Health Study.}, journal = {Arch Intern Med}, volume = {160}, year = {2000}, month = {2000 Jun 26}, pages = {1761-8}, abstract = {

BACKGROUND: Studies of the association between depressive symptoms and mortality in elderly populations have yielded contradictory findings. To address these discrepancies, we test this association using the most extensive array of sociodemographic and physical health control variables ever studied, to our knowledge, in a large population-based sample of elderly individuals.

OBJECTIVE: To examine the relation between baseline depressive symptoms and 6-year all-cause mortality in older persons, systematically controlling for sociodemographic factors, clinical disease, subclinical disease, and health risk factors.

METHODS: A total of 5201 men and women aged 65 years and older from 4 US communities participated in the study. Depressive symptoms and 4 categories of covariates were assessed at baseline. The primary outcome measure was 6-year mortality.

RESULTS: Of the 5201 participants, 984 (18.9\%) died within 6 years. High baseline depressive symptoms were associated with a higher mortality rate (23.9\%) than low baseline depression scores (17.7\%) (unadjusted relative risk [RR], 1.41; 95\% confidence interval [CI], 1.22-1.63). Depression was also an independent predictor of mortality when controlling for sociodemographic factors (RR, 1.43; 95\% CI, 1.23-1.66), prevalent clinical disease (RR, 1.25; 95\% CI, 1.07-1.45), subclinical disease indicators (RR, 1.35; 95\% CI, 1.15-1.58), or biological or behavioral risk factors (RR, 1.42; 95\% CI, 1.22-1.65). When the best predictors from all 4 classes of variables were included as covariates, high depressive symptoms remained an independent predictor of mortality (RR, 1.24; 95\% CI, 1.06-1.46).

CONCLUSIONS: High levels of depressive symptoms are an independent risk factor for mortality in community-residing older adults. Motivational depletion may be a key underlying mechanism for the depression-mortality effect.

}, keywords = {Aged, Alcohol Drinking, Depression, Depressive Disorder, Female, Health Status Indicators, Humans, Male, Motivation, Prevalence, Risk Factors, Smoking, Socioeconomic Factors, United States}, issn = {0003-9926}, doi = {10.1001/archinte.160.12.1761}, author = {Schulz, R and Beach, S R and Ives, D G and Martire, L M and Ariyo, A A and Kop, W J} } @article {627, title = {A comparison of primary stressors, secondary stressors, and depressive symptoms between elderly caregiving husbands and wives: the Caregiver Health Effects Study.}, journal = {Psychol Aging}, volume = {15}, year = {2000}, month = {2000 Dec}, pages = {607-16}, abstract = {

The present study examined gender differences in the experience of primary and secondary caregiving stressors, depressive symptoms, and their interrelationships using a sample of 283 elderly spouse caregivers (145 women, 138 men). Two primary stressors, two secondary stressors, and depressive symptoms were assessed. In general, t-tests indicated that caregiving husbands experience fewer stressors and depressive symptoms than their female counterparts. Multiple group analysis revealed that the primary stressors were more useful in explaining variance associated with the secondary stressors for women than men and that the path coefficients linking amount of caregiving assistance to caregivers{\textquoteright} activity restriction was significantly different across men and women. Other paths linking primary stressors, secondary stressors, and depressive symptoms, however, were statistically equivalent across men and women. Hence, although caregiving women and men may vary in their reports of caregiving stressors, the complexity of the caregiving experience appears to be quite uniform for both groups.

}, keywords = {Aged, Aging, Caregivers, Depressive Disorder, Female, Health Status, Humans, Male, Spouses, Stress, Psychological}, issn = {0882-7974}, doi = {10.1037//0882-7974.15.4.607}, author = {Bookwala, J and Schulz, R} } @article {619, title = {Negative and positive health effects of caring for a disabled spouse: longitudinal findings from the caregiver health effects study.}, journal = {Psychol Aging}, volume = {15}, year = {2000}, month = {2000 Jun}, pages = {259-71}, abstract = {

Data from the first 2 waves of the Caregiver Health Effects Study (n = 680) were analyzed to examine the effects of changes in caregiving involvement on changes in caregiver health-related outcomes in a population-based sample of elders caring for a disabled spouse. Caregiving involvement was indexed by levels of (a) spouse physical impairment, (b) help provided to the spouse, and (c) strain associated with providing help. Health-related outcomes included perceived health, health-risk behaviors, anxiety symptoms, and depression symptoms. Increases in spouse impairment and caregiver strain were generally related to poorer outcomes over time (poorer perceived health, increased health-risk behaviors, and increased anxiety and depression), whereas increased helping was related to better outcomes (decreased anxiety and depression). Results suggest that caring for a disabled spouse is a complex phenomenon that can have both deleterious and beneficial consequences.

}, keywords = {Aged, Anxiety, Caregivers, Depression, Disabled Persons, Female, Health Behavior, Health Status, Humans, Longitudinal Studies, Male, Mental Health, Risk-Taking, Spouses}, issn = {0882-7974}, doi = {10.1037//0882-7974.15.2.259}, author = {Beach, S R and Schulz, R and Yee, J L and Jackson, S} } @article {657, title = {Area characteristics and individual-level socioeconomic position indicators in three population-based epidemiologic studies.}, journal = {Ann Epidemiol}, volume = {11}, year = {2001}, month = {2001 Aug}, pages = {395-405}, abstract = {

PURPOSE: There is growing interest in incorporating area indicators into epidemiologic analyses. Using data from the 1990 U.S. Census linked to individual-level data from three epidemiologic studies, we investigated how different area indicators are interrelated, how measures for different sized areas compare, and the relation between area and individual-level social position indicators.

METHODS: The interrelations between 13 area indicators of wealth/income, education, occupation, and other socioenvironmental characteristics were investigated using correlation coefficients and factor analyses. The extent to which block-group measures provide information distinct from census tract measures was investigated using intraclass correlation coefficients. Loglinear models were used to investigate associations between area and individual-level indicators.

RESULTS: Correlations between area measures were generally in the 0.5--0.8 range. In factor analyses, six indicators of income/wealth, education, and occupation loaded on one factor in most geographic sites. Correlations between block-group and census tract measures were high (correlation coefficients 0.85--0.96). Most of the variability in block-group indicators was between census tracts (intraclass correlation coefficients 0.72--0.92). Although individual-level and area indicators were associated, there was evidence of important heterogeneity in area of residence within individual-level income or education categories. The strength of the association between individual and area measures was similar in the three studies and in whites and blacks, but blacks were much more likely to live in more disadvantaged areas than whites.

CONCLUSIONS: Area measures of wealth/income, education, and occupation are moderately to highly correlated. Differences between using census tract or block-group measures in contextual investigations are likely to be relatively small. Area and individual-level indicators are far from perfectly correlated and provide complementary information on living circumstances. Differences in the residential environments of blacks and whites may need to be taken into account in interpreting race differences in epidemiologic studies.

}, keywords = {Adult, Black or African American, Cardiovascular Diseases, Demography, Educational Status, Factor Analysis, Statistical, Humans, Income, Linear Models, Occupations, Risk Factors, Social Class, Social Environment, Socioeconomic Factors, Statistics, Nonparametric, United States, White People}, issn = {1047-2797}, doi = {10.1016/s1047-2797(01)00221-6}, author = {Diez-Roux, A V and Kiefe, C I and Jacobs, D R and Haan, M and Jackson, S A and Nieto, F J and Paton, C C and Schulz, R} } @article {653, title = {Involvement in caregiving and adjustment to death of a spouse: findings from the caregiver health effects study.}, journal = {JAMA}, volume = {285}, year = {2001}, month = {2001 Jun 27}, pages = {3123-9}, abstract = {

CONTEXT: Most deaths in the United States occur among older persons who have 1 or more disabling conditions. As a result, many deaths are preceded by an extended period during which family members provide care to their disabled relative.

OBJECTIVE: To better understand the effect of bereavement on family caregivers by examining predeath vs postdeath changes in self-reported and objective health outcomes among elderly persons providing varying levels of care prior to their spouse{\textquoteright}s death.

DESIGN AND SETTING: Prospective, population-based cohort study conducted in 4 US communities between 1993 and 1998.

PARTICIPANTS: One hundred twenty-nine individuals aged 66 to 96 years whose spouse died during an average 4-year follow-up. Individuals were classified as noncaregivers (n = 40), caregivers who reported no strain (n = 37), or strained caregivers (n = 52).

MAIN OUTCOME MEASURES: Changes in depression symptoms (assessed by the 10-item Center for Epidemiological Studies-Depression [CES-D] scale), antidepressant medication use, 6 health risk behaviors, and weight among the 3 groups of participants.

RESULTS: Controlling for age, sex, race, education, prevalent cardiovascular disease at baseline, and interval between predeath and postdeath assessments, CES-D scores remained high but did not change among strained caregivers (9.44 vs 9.19; P =.76), while these scores increased for both noncaregivers (4.74 vs 8.25; F(1,116) = 14.33; P<.001) and nonstrained caregivers (4.94 vs 7.13; F(1,116) = 4.35; P =.04). Noncaregivers were significantly more likely to be using nontricyclic antidepressant medications following the death than the nonstrained caregiver group (odds ratio [OR], 12.85; 95\% confidence interval [CI], 1.02-162.13; P =.05). The strained caregiver group experienced significant improvement in health risk behaviors following the death of their spouse (1.47 vs 0.66 behaviors; F(1,118) = 20.23; P<.001), while the noncaregiver and nonstrained caregiver groups showed little change (0.27 vs 0.27 [P =.99] and 0.46 vs 0.27 [P =.39] behaviors, respectively). Noncaregivers experienced significant weight loss following the death (149.1 vs 145.3 lb [67.1 vs 65.4 kg]; F(1,101) = 8.12; P =.005), while the strained and nonstrained caregiving groups did not show significant weight change (156.2 vs 155.2 lb [70.3 vs 69.8 kg] [P =.41] and 156.2 vs 154.0 lb [70.3 vs 69.3 kg] [P =.12], respectively).

CONCLUSIONS: These data indicate that the impact of losing one{\textquoteright}s spouse among older persons varies as a function of the caregiving experiences that precede the death. Among individuals who are already strained prior to the death of their spouse, the death itself does not increase their level of distress. Instead, they show reductions in health risk behaviors. Among noncaregivers, losing one{\textquoteright}s spouse results in increased depression and weight loss.

}, keywords = {Aged, Aged, 80 and over, Antidepressive Agents, Bereavement, Caregivers, Death, Depression, Female, Follow-Up Studies, Health Behavior, Humans, Male, Socioeconomic Factors, Spouses, Weight Loss}, issn = {0098-7484}, doi = {10.1001/jama.285.24.3123}, author = {Schulz, R and Beach, S R and Lind, B and Martire, L M and Zdaniuk, B and Hirsch, C and Jackson, S and Burton, L} }