uva-dare (digital academic repository) functional ... · chapterchapter 1 duringgth...
TRANSCRIPT
UvA-DARE is a service provided by the library of the University of Amsterdam (http://dare.uva.nl)
UvA-DARE (Digital Academic Repository)
Functional disability in elderly men
van den Brink, C.L.
Link to publication
Citation for published version (APA):van den Brink, C. L. (2005). Functional disability in elderly men.
General rightsIt is not permitted to download or to forward/distribute the text or part of it without the consent of the author(s) and/or copyright holder(s),other than for strictly personal, individual use, unless the work is under an open content license (like Creative Commons).
Disclaimer/Complaints regulationsIf you believe that digital publication of certain material infringes any of your rights or (privacy) interests, please let the Library know, statingyour reasons. In case of a legitimate complaint, the Library will make the material inaccessible and/or remove it from the website. Please Askthe Library: https://uba.uva.nl/en/contact, or a letter to: Library of the University of Amsterdam, Secretariat, Singel 425, 1012 WP Amsterdam,The Netherlands. You will be contacted as soon as possible.
Download date: 14 Aug 2019
Functiona ll disabilit y Étt in elderl y men H
Carolie nn van den Brin k
Functiona ll disabilit y
inn elderl y men
Carolie nn van den Brin k
©© 2005, CL. van den Brink
ISBN:: 90-71433-71-4
Departmentt of Social Medicine, Academie Medical Center, University of Amsterdam, Amsterdam
Nationall Institute for Public Health and the Environment, Center for Prevention and Health
Servicess Research, Bilthoven
Noo parts of this thesis may be reproduced in any form without permission from the copyright
holder. .
Printedd by: Ponsen & Looijen b.v., Wageningen
Functiona ll disabilit y
inn elderl y men
ACADEMISCHH PROEFSCHRIFT
terr verkrijging van de graad van doctor
aann de Universiteit van Amsterdam
opp gezag van de Rector Magnificus
prof.. mr. P.F. van der Heijden
tenn overstaan van een door
hett college voor promoties ingestelde commissie
inn het openbaar te verdedigen
inn de Aula der Universiteit
opp vrijdag 9 december 2005,
tete 10:00 uur
door r
Carolienn Lisette van den Brink
geborenn te Purmerend
Promotiecommissie : :
Promotores:: Prof. dr. G.A.M, van den Bos
Prof.. dr. D. Kromhout
Co-promotores:: Dr. M.A.R. Tijhuis
Prof.. dr. N.S. Klazinga
Overigee leden: Prof. dr. P.J.E. Bindels
Prof.. dr. D.J.H. Deeg
Prof.. dr. R.J. de Haan
Prof.. dr. G.I.J.M. Kempen
Prof.. dr. A.H. Schene
Faculteitt der Geneeskunde
Content s s
Page e
Chapte rr 1 Introduction 9
Chapte rr 2 Self-reported disability and performance-based limitation: a cross-national 19
comparison n
Chapte rr 3 Effect of widowhood on disability onset 31
Chapte rr 4 Physical activity and disability 43
Chapte rr 5 Disability and use of formal home care 55
Chapte rr 6 Disability and depressive symptoms 67
Chapte rr 7 Disability, self-rated health, depressive symptoms and mortality 81
Chapte rr 8 General discussion 93
Referencess 107
Summaryy 123
Samenvattingg 129
Dankwoordd 135
Curriculumm Vitae 141
Listt of publications 143
1 1 Introductio n n
ChapterChapter 1
Duringg the 20th century disability in elderly people has become a major public health problem in the
Westernn world due to demographic and epidemiologic transitions.
Thee demographic transition is characterised by a shift from patterns of high fertility and mortality
ratess to low fertility and delayed mortality.02* In the first half of the 20* century, there was
progressivee improvement of childhood survival caused by better living standards, advances in
nutrition,, and early sanitation measures, followed by declines in fertility. In the second half of that
century,, control of infectious diseases, preventive strategies in relation to chronic diseases, and
improvedd health care among adults contributed to the increase in life expectancy.
Ass a result of the demographic transition, the shape of the global age distribution is changing.'1 ;2)
Thee number of people aged 65 years and over has been increasing substantially in the
Netherlands;; from 1.3 millions in 1970 to 2.3 millions in 2005 (figure 1.1). In 2005, those older than
655 years comprise 14% of the total population. The post-war baby boom, people born between
19466 and 1955 who will reach the age of 65 after 2010, will lead to an even further increase in the
numberr and proportion of elderly people (figure 1.1 and 1.2). The peak will be reached in 2040,
whenn 4 millions people are expected to be aged 65 years and older, which is 24% of the total
Dutchh population. From 2040, the number of people aged 65 years and older will decrease,
becausee most baby boomers have reached the age for death.<3)
Thee epidemiologic transition results from a change in patterns of health, disease and mortality.
Betweenn 1875 and 1970 infectious diseases and acute illness as leading causes of death were
replacedd by "man-made" chronic degenerative diseases. The change in patterns of causes of
deathh was associated with an increase in life expectancy. For men in the Netherlands, life
expectancyy at birth increased from 44 years in 1875 to 71 in 1970. After 1970 the increase in life
expectancyy continued up to 76.4 in 2005 because of a decrease in for example mortality rates from
cardiovascularr diseases. This last phase of the epidemiologic transition is called the phase of
'delayedd degenerative diseases'. This means that chronic diseases and death are postponed to old
age,, resulting in higher prevalence rates of disability/4'
Thee ageing of the population is a success story but presents society with new challenges. During
thee past decades, trends in disability revealed a compression of severe disability and an expansion
off mild disability.*5* In 2005, the prevalence of severe disability among people aged 65 years and
olderr was 18%.(6) Together with the expanding number of elderly people, the absolute number of
peoplee with disability will increase considerably. Disabilities threaten older people's independence,
qualityy of life, and participation in the society, and will result in an upward pressure on health care
services. .
10 0
Introduction Introduction
4 4
3,5 5
3 3
2,5 5
EE 2
1,5 5
11 4
0,5 5
0 0
D D s 85 years
75-84 years
65-74 years
19700 1980 1990 2000 2010 2020 2030 2040
Figuree 1.1 Number of elderly people (> 65 years) in the Netherlands, 1970-2040 (absolute numbers).
Prognosiss by Statistics Netherlands.(6)
> 65 years
55-64 years
DD 15-54 years
DD 0-14 years
- r - — '' I ' ' I ' — ' T — — ' I ' ' I ' — T
19700 1980 1990 2000 2010 2020 2030 2040
Figuree 1.2 Age distribution of the Dutch population 1970-2040 (percentages)
Prognosiss by Statistics Netherlands.(6)
Inn this thesis we will address several aspects of functional disability. We aim to identify risk groups
andd risk factors for functional disability and to quantify health (care) impacts of functional disability.
Firstly,, the assessment of disability is validated by relating self-reported disability to performance
tests.. Thereafter, widowers are studied as a risk group for disability, and physical activity as a risk
factorr for disability. Furthermore, we investigate whether use of formal home care is according to
disability-relatedd needs. The health impact of disability is investigated by estimating its relationship
l l l
ChapterChapter 1
withh depressive symptoms and mortality. This knowledge can be helpful for developing preventive
strategiess and health care programs. The main research themes are shown in figure 1.3.
Wee used the data of the Finland, Italy and the Netherlands Elderly (FINE) Study, in which only men
weree included.
Thiss thesis focuses on functional disability, which is often defined as difficulty in doing activities of
dailyy living (ADL), ranging from household activities to personal care.(7> From the perspective of
healthh care we chose for a stricter criterion for functional disability, and defined functional disability
ass 'need for help to perform an activity'. This choice reflects the critical role the activities play in
maintainingg independent living. Although the activities of daily living usually concern any domain of
life,, we concentrate on three major domains for independent living: basic activities of daily living
(e.g.. dressing, washing and bathing), mobility (e.g. using stairs), and instrumental activities of daily
livingg (e.g. preparing meals and housework).
Wee assessed severity of disability by two methods: a sum score and a hierarchy score. The sum
scoree counts the number of disabilities. The hierarchy score is based on a hierarchical relationship
betweenn the three disability domains.(8) People who are disabled in mobility are also disabled in
instrumentall activities, and those who are disabled in basic activities are also disabled in mobility
andd instrumental activities. This hierarchy reflects levels of dependency, implying that dependency
inn the relatively simple basic activities is accompanied by dependency in the more complex
instrumentall activities.
Inn the next paragraphs the topics included in this thesis will be described.
Assessmen tt of disability : self-reporte d versu s performance-base d
Prevalencee figures of disability are often based on self-reports. The advantage of these
measurementss is that they are not costly and relatively easy to administer. Self-reported
measurementss are however influenced by cultural factors like norms and expectations/9' Although
measurementss of self-reported disability are often used to compare health status between
countries/10** differences in the prevalence of disability might reflect not only actual differences in
functioningg in daily life, but also differences in the meaning of disability. Performance tests, such as
walkingg speed or standing balance tests, are considered to be more objective measures.
Performancee tests are known to be associated with self-reported disability. Correlation coefficients
inn earlier studies varied between 0.22 and 0.72.(11) In this thesis, the validity of self-reported
measurementss is established in different countries, by comparing those measurements with
performancee tests.(8;12;13) In addition, we focus on differences between countries in self-reported
12 2
Introduction Introduction
disabilityy for levels of physical performance. We hypothesise that self-reported disability differs
betweenn countries, because of differences in social and cultural factors between these countries.
However,, we do not know in which direction self-reported disability will differ.
Widowhoo dd and disabilit y
Duringg the last decades the number of widowed men has been much lower than that of widowed
women,, because of the lower life expectancy among men. For example, in 2004 among people
agedd 65 and older in the Netherlands, the number of widowed women was 4.5 times higher than
thatt of widowed men (584,025 versus 127,890).<14) In the near future, the absolute number of
widowedd men is expected to increase because the life expectancy of men is rising faster than that
off women.(15) Loss of a partner has a greater impact on health status among men compared to
women,(16"18)) because of the stress of bereavement and the lack of support for maintaining a
healthyy lifestyle. The worsening health status among widowed men might result in health-related
disabilityy (= functional disability). In addition, since men might have been dependent on their
spousee for several daily tasks, especially household tasks, widowed men could be confronted with
disabilitiess because of loss of their primary caregiver. This is called situational disability, which is
nott health-related but occurs when persons have never learned to perform certain tasks
themselves.(19)) In this thesis we focus on the effect of widowhood among elderly men and we
hypothesisee that widowhood leads to both functional (reflected in all disability domains) and
situationall disability (reflected in the domain of instrumental activities).
Physica ll activit y and disabilit y
Functionall disability might be prevented or postponed by increasing physical activity. The Surgeon
General'ss recommendation for physical activity encompasses at least 30 minutes of endurance-
typee physical activity on all days of the week.(20) According to the report of the Surgeon General,'20'
furtherr research is needed to delineate the most important features of physical activity, e.g.
durationn or intensity, that might be associated with specific health benefits. Although a review study
onn physical activity and independent living reported that long-term physical activity is associated
withh postponed disability, no specific conclusions about duration or intensity of physical activity
weree drawn/21' Therefore in this thesis we focus on the relationship between physical activity and
disability,, separating duration and intensity of the activities. Because both aspects are known to be
associatedd with chronic diseases such as coronary heart disease/22' we hypothesise that both
durationn and intensity of physical activity are inversely associated with disability.
13 3
ChapterChapter 1
Disabilit yy and forma l hom e car e
Thee increase in the number of people with disability will lead to growing health care needs.
Becausee elderly people prefer care at home above institutionalisation, sustaining professional
homee care is essential. There is however a lot of pressure on professional home care, which might
conflictt with the principle of equity. This principle presupposes equal use for equal need. We
evaluatee whether the use of formal home care is according to disability-related needs, using the
Andersenn model.(23> According to that model, use of care is determined by predisposing
(demographicc characteristics), enabling (socioeconomic characteristics), and need factors (health
characteristics,, such as disability). According to the Andersen model care use is equitable if need
orr need-related factors are the primary determinants of care use. However, when factors that
enablee or impede use of health care are the primary determinants, home care services do not help
thee people who need help most. Given the principle of equity, we hypothesise that need factors are
thee dominant predictors of use of home care.
Disabilit yy and depressiv e symptom s
Thee onset of disability can be considered as a life event, i.e. a disruptive experience requiring
readjustmentt or behavioural change in daily life.(24) Because of this stressful condition among
peoplee with disability, their risk of depressive symptomatology is increased.(2425) The prevalence of
depressivee symptomatology among elderly people is about 15%.<26> Untreated depression can lead
too suicide, alcohol abuse, and overuse of health care services/27' It is important to identify people
whoo are at higher risk of depressive symptoms. According to a review,<24) greater specification of
riskk factors is needed by gradating disability into different levels of dependency, and by
investigatingg changes over time. Both topics are described in this thesis. We hypothesise that
disabilityy in the basic activities of daily living is associated with a higher risk of depressive
symptomss than disability in the instrumental activities, since disability in basic activities reflects
moree dependency. Because the domains of our hierarchical score reflect the level of dependency,
wee hypothesise that this hierarchical score of disability severity is a better predictor of depressive
symptomss than a sum score of disability. We also hypothesise that people who have developed
disabilityy recently are at higher risk of depressive symptoms than people who have had disability
forr a longer time, since the former ones have had less time to adapt to the new situation.
14 4
Introduction Introduction
Disabilit yy and mortalit y
Disabilityy is associated with an increased risk of mortality/28"31 * Elderly people often suffer from
mentall health problems. Therefore it is possible that aspects of health that are related to personal
feelingss on ones own situation (subjective health aspects) influence the risk of disability on
mortality.mortality. It is known that subjective health aspects like depressive symptoms and self-rated health
aree associated with mortality/32"35' It is however unclear how the combination of disability and more
subjectivee health aspects contributes to the mortality risk. It is possible that men with severe
disabilityy who have a good self-rated health have a lower risk of mortality than those with severe
disabilityy who feel unhealthy. We focus on combinations of disability and self-rated health or
depressivee symptoms, and we hypothesise that mental health aspects among elderly people play a
rolee in the relationship between functional disability and mortality. We however do not know
whetherr the effect of mental health aspects differs by severity levels of disability.
Studyy populatio n
Thee investigations described in this thesis are based on the study populations participating in the
Finland,, Italy and the Netherlands Elderly (FINE) Study, which is a continuation of the Seven
Countriess Study in three European countries. The Seven Countries Study was designed to
examinee systematically the relationships between diet, other lifestyle and risk factors, and the rates
off coronary heart disease and stroke in contrasting populations.(36) The baseline measurement was
carriedd out from 1958 to 1964 in 16 populations, mostly rural, from five European countries, the
Unitedd States, and Japan. At that time, middle-aged women were not considered for study
becausee of the apparent rarity of cardiac events among them. This selection of men has influenced
ourr choices for topics and hypotheses evaluated in this thesis.
Inn 1984 and 1985, 25-year follow-up surveys were carried out in the Finnish, Dutch, and Italian
cohorts.. Besides classical cardiovascular risk factors, also general gerontologie information was
collectedd because the men were at that time 65-84 years. These surveys became the baseline
surveyss of the FINE Study, a prospective study on risk factors and health in elderly men.
Inn Finland, men came from llomantsi in eastern Finland and Pöytya and Mellila in south-western
Finland.. In 1984, 716 men (response rate 93.5%) participated in the survey. The participants in
Italyy came from Crevalcore in the North and Montegiorgio in the Center of Italy. In 1985, 682 men
participatedd (response rate 76%). The Dutch contribution consisted of a cohort from Zutphen, a
townn in the eastern part of the country. Of the original cohort 380 men (response rate 68%)
participatedd in 1985. In addition, a new random sample of men living in Zutphen was selected with
aa response rate of 78%. In total, 887 Dutch men participated in the FINE Study.
15 5
ChapterChapter 1
Thee studies described in this thesis used data collected in four survey rounds: 1984-1985, 1989-
1991,, 1994-1995, and 1999-2000.
Outlin ee of thi s thesi s
Figuree 1.3 shows the main research themes of this thesis. In chapter 2 the validity of self-reported
disabilityy is investigated by assessing the association with performance tests in different countries.
Dataa from 1990 were analysed. Chapter 3 describes the longitudinal relationship between
widowhoodd and the onset of disability in different disability domains. Data of all four survey rounds
weree included. The longitudinal relationship between physical activity and disability onset is
describedd in chapter 4, distinguishing duration and intensity of physical activity. Analyses were
basedd on data from 1990 and 2000. In chapter 5 it is evaluated whether the use of formal home
caree is according to disability-related needs. Data from 2000 of the Dutch cohort of the FINE Study
weree analysed. Chapter 6 describes the longitudinal relationship between disability and depressive
symptoms,, focusing on severity of disability based on the different domains, sum score of
disability,, and changes over time. Analyses were based on data from 1990 and 1995. In chapter 7
wee describe the hierarchy score of disability in 1990 as predictor of 10-year mortality. Also the
contributionn of more subjective health aspects, i.e. self-rated health and depressive symptoms, in
combinationn with disability severity is investigated.
Inn the final chapter, the main results, methodological issues, and implications for prevention
strategiess and health care are discussed.
16 6
Introduction Introduction
>> > .a a CO O co o
TJ J
(N N
CJ J
to o -I-J J
c/> >
<x> <x> o o c c <c c £ £
0) ) -Q Q
(1) ) "O O CO O 0 0
E E
CD D
IT IT
3 3 D) )
17 7
2 2 Self-reporte dd disabilit y and performance -
basedd limitation : a cross-nationa l compariso n
PublishedPublished as: van den Brink C.L., Tijhuis M., Kalmijn S., Klazinga N.S., Nissinen A., Giampaoli S., Kivinen
P.,, Kromhout D., van den Bos G.A.M. Self-reported disability and its association with performance-based
limitationn in elderly men: a comparison of three European countries.
JournalJournal of the American Geriatrics Society, 2003; 51: 782-788
ChapterChapter 2
Abstrac t t
Objectiv ee To compare self-reported disability and performance-based limitations and their
associationn in elderly men from three European countries.
Method ss Cross-sectional data of three cohorts from Finland, the Netherlands and Italy was
collectedd around 1990. Complete information was available for 1161 men aged 70 years and older.
Disabilityy and functional limitation were measured in a standardised way in three countries. Self-
reportedd disability was estimated by questionnaire, assessing three domains of activities of daily
living:: instrumental activities of daily living, mobility, and basic activities of daily living (score 0-3).
Functionall limitation was measured by performance tests (score 0-16). In both scores, 0 indicated
thee healthiest score.
Result ss Both self-reported disability and performance-based limitation scores differed between
countries.. Mean self-reported disability score was worse in Italy (0.72) and the Netherlands (0.70)
thann in Finland (0.54). Italian men scored worst on the performance-based tests (mean 4.80 vs
4.044 for Finland and 3.74 for the Netherlands). Differences in self-reported disability remained after
adjustingg for performance scores: Dutch men reported more disabilities (odds ratio (OR): 1.66;
95%% confidence interval (CI): 1.23, 2.25) than men in Finland (reference group) and Italy (OR:
1.08;; 95% CI: 0.77, 1.53). Self-reported disability was positively associated with performance-
basedd score (OR: 1.28; 95% CI: 1.21, 1.35) and did not differ between countries.
Conclusio nn Cross-cultural variation was noted in self-reported disability adjusted for performance
score.. These differences may be due to sociocultural and physical environmental factors. Self-
reportedd disability was consistently associated with performance-based limitations in Finland, the
Netherlands,, and Italy.
20 0
Performance-basedPerformance-based limitation and self-reported disability
Introductio n n Disability-adjustedd life expectancy is increasingly used as a summary measure of a population's
healthh because of population ageing and the ensuing increase of chronic conditions.(37) According
too the Nagi Scheme on consequences of pathology, disability is defined as 'limitation in
performancee of socially defined roles and tasks within a sociocultural and physical environ ment'.(38)
Disabilityy is thus not only an indicator of a population's health. Another concept of the Nagi
Scheme,, which reflects more basic functioning, is functional limitation, defined as 'limitation in
performancee at the person level'. Functional limitation is usually measured using performance
tests,, which are considered to be objective, standardised measurements of functioning/39' Self-
reportedd measurements are more subjective, less time consuming, and cheaper than performance
tests.. Because self-reported disability is frequently used to compare health of populations between
differentt countries, it is of interest to investigate cross-cultural variation in self-reported disability
andd its association with functional limitation.
Thee association between self-reported disability and performance-based limitation has been
analysedd in several studies. Although all studies found a positive association between self-reported
disabilityy and performance-based limitation,(81113;4(M2> the strength of the association and the
percentagee of variance in self-reported disability explained by performance-based limitation
differedd considerably (from 4 to 50%) between the studies. These studies were performed in
differentt countries and used different methodology. It is not known whether self-reported disability
andd the strength of its association with performance-based limitation really differ between countries
andd cultures or whether the observed variations are due to methodological variations.
Inn the current study, self-reported disability and functional limitation were measured in a
standardisedd method in Finland, the Netherlands, and Italy. These data provide an opportunity to
makee cross-cultural comparisons of self-reported disability and to investigate its association with
performance-basedd limitation.
Method s s
Studyy population
Thee present study has a cross-sectional design and used data collected between 1989 and 1991
forr the Finland, Italy, and the Netherlands Elderly (FINE) Study. These countries participated in the
Sevenn Countries Study(36) that began in the 1960s in middle-aged men born between 1900 and
1920.. At that time, the main purpose of the study was the identification of risk factors for the
occurrencee of coronary heart disease. The FINE Study was begun in 1985 as a continuation of the
21 1
ChapterChapter 2
Sevenn Countries Study focusing on elderly men. Detailed information about the FINE Study and its
populationss has been reported elsewhere.<43)
Inn Finland, 469 of 524 men (response rate = 90%) were examined in 1989; in the Netherlands, 556
off 718 men (77%) were examined in 1990; and in Italy, 391 of 493 men (79%) were examined in
1991.. The analyses were restricted to men with complete information on self-reported disabilities
andd performance tests: 340 (72%) for Finland, 481 (87%) for the Netherlands, and 340 (87%) for
Italy.. The mean ages of the participants were 75.4, 75.4, and 77.0 respectively.
Self-reporte dd disability
Dataa collection followed the international protocol used in surveys of the Seven Countries Study.<36)
Self-reportedd disability was measured using a standardised questionnaire about daily routine
activities.(44>> To ensure maximum comparability of the results, the original English version of the
questionnairee was translated into the different languages, and then translated back into English to
checkk whether there had been any loss or change of meaning in the translation process. The
questionnairee consisted of 14 items, each mentioning one activity, which were classified into three
domains:: instrumental activities of daily living (lADLs: preparing meals, doing light and heavy
housework),, mobility (moving outdoors, using stairs, walking 400 meters, carrying a heavy object
1000 meters), and basic activities of daily living (BADLs: walking indoors, getting in and out of bed,
usingg toilet, washing and bathing, dressing and undressing, feeding oneself). The item 'cut
toenails'' was left out of the analyses, because of conceptual ambiguity.(45) Others have reported
moree details on the questionnaire.^
Thee participants were classified as being disabled in a certain activity if they reported a need for
helpp or were not able to perform that activity. Disability in a domain was classified on the basis of
disabilityy in at least one item of that domain. The domains were found to be hierarchically ordered;
menn who were disabled in BADLs were also disabled in mobility and lADLs. Men who were
disabledd in mobility were also disabled in lADLs. The following categories, based on the hierarchy
levels,, were assigned to the participants: not disabled = 0, disabled in lADLs only = 1, disabled in
mobilityy and lADLs = 2, disabled in BADLs, mobility and lADLs = 3. Twenty-nine men (2.6%) who
didd not follow the hierarchy were classified in line with the hierarchical order, according to the
methodd described by Hoeymans et al.(8)
Performance-base dd limitatio n
Fourr performance-based tests (standing balance test, walking speed test, chair stand test,
shoulderr rotation test) were adapted from the Established Populations for Epidemiologic Studies of
thee Elderly (EPESE),(46) and were designed to assess functions needed to perform daily routine
22 2
Performance-basedPerformance-based limitation and self-reported disability
activities.. The EPESE performance tests were administered in a standardised home setting or in
thee examination place.03' For the standing balance test, walking speed test, and chair stand test,
thee scoring methods previously described were followed.(13) The difference between the previous
scoringg and the scoring used in this study was that the best performance was scored as 0 and the
worstt as 4, in line with the hierarchical order concerning self-reported disability, whereas the other
studyy reversed the score. The cut-offs for the quartile score (0-3) in the walking speed and chair
standd test in the present study were based on the required times for the three countries combined
too be able to compare the performance scores between the countries. Those who could not
completee the task were assigned a score of 4. In the external shoulder rotation test, participants
weree scored on four criteria previously described/8' Participants were scored 0 if they met all
criteria,, 2 if they were unable to meet all four criteria, and 4 if they were unable to perform the test.
AA summary performance scale was created by summing the test scores, with a maximum score
(worstt performance) of 16.
Backgroun dd variables : sociodemographl c characteristic s and chroni c condition s
Sociodemographicc characteristics included were age, socioeconomic status (SES), and household
composition.. The profession that was held during the major part of the working life indicated SES.
Threee groups were defined: the high-SES group consisted of professionals and high-level
managerss and teachers. The mid-SES group consisted of middle-level managers and teachers and
(small)) business owners. The low-SES group consisted of nonmanual and manual workers.
Householdd composition was dichotomised as living with others or living alone.
Onee variable for history of chronic diseases was made as absence or presence of one of the
followingg chronic conditions: angina pectoris, myocardial infarction, heart failure, intermittent
claudication,, stroke, cancer, diabetes, and asthma and chronic obstructive pulmonary disease.
Diagnosess were obtained from a questionnaire'47' and verified using clinical examination and
writtenn information from the subjects' general practitioners and hospitals.
Statistica ll analyse s
Too investigate whether the three countries differed in self-reported disability and performance-
basedd limitation, the differences between countries in self-reported disability scores and
performancee scores were tested using analysis of variance, adjusted for age.
Too determine whether possible differences in self-reported disability between countries could be
attributedd to differences in performance score, the association between country and self-reported
disabilityy was adjusted for performance score. Therefore, polytomous logistic regression models
weree used with country as independent variable and the four-level self-reported disability score (0,
1,2,3)) as dependent variable. To gain insight into the effect of different covariates on self-reported
23 3
ChapterChapter 2
disability,, three models were used. In the first model, the association between country and self-
reportedd disability was calculated and adjusted for age only. In the second model, SES, household
composition,, and the prevalence of chronic diseases were added as covariates. The third model
wass also adjusted for performance score. The extent to which the variables of this final model
explainedd the variance in self-reported disability was determined by calculating the explained
variancee of the model.
Too compare the strength of the association between self-reported disability and performance-
basedd limitation between countries, stratified analyses were performed. For each country the
associationn between self-reported disability score and performance-based limitation score was
assessedd using a polytomous logistic regression model. Age, SES, household composition, and
thee prevalence of chronic diseases were adjusted for. In each country, the association between
self-reportedd disability and performance-based limitation was presented as odds ratio (OR).
Too check whether disability per domain of self-reported disability was associated with limitation in
specificc performance tests, the mean performance score between men with and without disability
inn that domain were compared per disability domain and per EPESE-test. Linear regression
modelss were used to calculate and compare these means, adjusted for age.
Statisticall analyses were performed using SAS, version 8.2 (SAS Inc., Cary, NC). All tests were
two-tailedd and a p-value < 0.05 was considered to be statistically significant.
Result s s
Sociodemographicc characteristics and prevalence figures of chronic conditions in the participants
aree shown in table 2.1. Men in Italy were older (77.0 vs 75.4 and 75.4 years), belonged more
frequentlyy to the low SES group (82.4% vs 40.8 and 44.6%) and had a higher prevalence of
chronicc diseases (73% vs 46 and 50%) compared with men in Finland and the Netherlands. The
percentagee of men living alone was highest in Finland (23% versus 17% in the Netherlands and
12%% in Italy).
Self-reportedd disability and performance-based limitation in different countries
Thee prevalence of self-reported disability on a certain item or domain differed between countries
(tablee 2.2). The overall disability in the IADL domain did not differ much between countries, but the
prevalencee of self-reported disability on 'do light housework' was about four times higher in Italy
thann in Finland and the Netherlands. Prevalence of self-reported disability on the mobility items
andd on most items in the BADL domain was highest in the Netherlands. Italian men had the
highestt overall prevalence of disability in the BADL domain (table 2.2).
24 4
Performance-basedPerformance-based limitation and self-reported disability
Regardingg the overall disability score of all countries, more than 80 percent of the men were not
disabledd or disabled in lADLs only (scores 0 and 1; table 2.2). The mean self-reported disability
score,, which was based on the hierarchy levels, was worse in Italy (0.72) and the Netherlands
(0.70)) than in Finland (0.54).
Thee performance-based limitation score was worse in Italy than in Finland and the Netherlands
(4.800 vs 4.04 and 3.74; table 2.3). Finnish men scored worst on standing balance (0.29 vs 0.22
andd 0.20) and scored best on chair stand (1.37 vs 1.56 and 2.00) and shoulder rotation (0.47
versuss 0.95 and 0.94). Dutch men scored best on walking speed (1.05 vs 1.92 and 1.67).
Tablee 2.1 Description of demographic characteristics and chronic conditions.
Finland d
(nn = 340)
Netherlands s (nn = 481)
Italy y
(nn = 340)
Meann age
Socioeconomicc status
%% low
%% middle
%% high
Householdd composition
%% living alone
Prevalencee of chronic diseases, %
75.4* * 75.4* * 77.0 0
40.8* *
58.9™ ™
0.3* *
2 3" "
46* *
44.6* *
40.2'* *
15.3** *
17* *
50* *
82.4*1 1
16.7'1 1
0.9* *
12" "
73* *
** Significantly different from Finland (p < 0.05); tested by analysis of variance (ANOVA) or chi-square test, tt Significantly different from the Netherlands (p < 0.05); tested by ANOVA or chi-square test, ii Significantly different from Italy (p < 0.05); tested by ANOVA or chi-square test.
Associatio nn betwee n self-reporte d disabilit y and countr y adjuste d for performance-base d
limitatio n n
Regressionn analyses on the association between country and self-reported disability (table 2.4)
showedd that, adjusted for age, Dutch and Italian men reported 50% more disabilities than Finnish
men.. This is in accordance with results from table 2.2. After adjustment for SES, household
composition,, and chronic diseases, Dutch men still reported 50% more disabilities than Finnish
men,, whereas the difference between Italian and Finnish men was reduced to 20%. Also after
furtherr adjustment for performance score, Dutch men reported most disabilities (OR: 1.66; 95%
confidencee interval (CI): 1.23, 2.25) and no difference was observed between Finland and Italy.
Thee variables of this final model explained 15% of the variance in self-reported disability.
25 5
ChapterChapter 2
Tabl ee 2.2 Self-reported disability per domain and per item and distribution of disability scores (%
participants)) by country, adjusted for age.
lADLs s
Preparee own meal
Doo light housework
Doo heavy housework
Mobility y
Movee outdoors
Usee stairs
Walkk at least 400 meters
Carryy a heavy object for 100 meters
BADLs s
Walkk between rooms
Usee the toilet
Washh and bath oneself
Dresss and undress
Gett in and out of bed
Feedd oneself
Meann disability score (0-3)*
Scoree 0
Scoree 1
Scoree 2
Scoree 3
Finland d
(nn = 340)
41.2(2.6)* *
17.11 (2.2)*
9.2{1.8)s s
36.88 (2.6)s
8.8(1.8)* *
1.11 (0.9)*
1.0(0.9)* *
2.0(1.2)* *
8.44 (1.7)*
3.2(1.2)§ §
0.44 (0.7)*
1.0(0.7) )
2.2(1.0) )
0.44 (0.8)*§
0.77 (0.8)*
0.44 (0.8)*
0.544 (0.04)s*
58.88 (2.6)*5
31.9(2.5) )
6.11 (1.5)*
3.22 (1.2)5
Netherlands s
(nn = 481)
prevalencee standard error
46.99 (2.2)
25.6(1.8)* *
7.9(1.5)s s
38.33 (2.2)s
15.4(1.5)* *
3.88 (0.7)*
4.66 (0.8)*
6.9(1.0)* *
12.9(1.4)* *
4.6(1.0) )
2.66 (0.6)*
2.66 (0.6)
4.00 (0.9)
3.11 (0.7)*
3.33 (0.6)*
2.99 (0.6)*
0.700 (0.04)*
50.66 (2.2)*
33.0(2.1) )
11.7(1.3)* *
4.6(1.0) )
Italy y
(nn = 340)
48.88 (2.6)T
21.3(2.2) )
33.3(1.8)** *
47.33 (2.6)**
12.3(1.8) )
2.77 (0.9)
2.55 (0.9)
4.5(1.2) )
10.6(1.7) )
7.0(1.2)* *
1.4(0.7) )
1.8(0.7) )
5.11 (1.0)
2.99 (0.8)*
1.4(0.8) )
2.33 (0.8)
0.722 (0.04)*
50.88 (2.6)*
34.00 (2.5)
8.2(1.6) )
7.0(1.2)* *
** 0 = not disabled; 1 = disabled in IADL only; 2 = disabled in IADL and mobility; 3 = disabled in IADL, mobility,, and BADL.
tt Significantly different from Finland (p < 0.05). tt Significantly different from the Netherlands (p < 0.05). §§ Significantly different from Italy (p < 0.05).
Associatio nn betwee n self-reporte d disabilit y and performance-base d limitatio n
Figuree 2.1 shows the association between self-reported disability and performance-based
limitation.. In all countries, performance score was positively associated with self-reported disability
score.. Regression analyses showed that the strength of this association did not differ between the
countries,, because the ORs of performance score on self-reported disability were comparable. For
Finlandd the OR was 1.35 (95% CI: 1.21, 1.50), for the Netherlands 1.23 (95% CI: 1.13, 1.34), and
forr Italy 1.30 (95% CI: 1.18, 1.43). The summary OR for all three countries together was 1.28 (95%
CI:: 1.21, 1.35).
26 6
Performance-basedPerformance-based limitation and self-reported disability
Too explore the association further, the mean performance scores per disability domain and per
EPESEE test were compared between men with and without disability in that domain (results not
shown).. In all countries, men with iADL disabilities had worse performance of both the lower
(walkingg speed test, chair stand test) and the upper extremities (shoulder test) than men without
IADLL disabilities. Also men with mobility disabilities had worse performance in the walking speed
andd chair stand test. In all three countries, men with BADL disabilities had worse scores on the
chairr stand test. Balance test scores were related to disability for all domains in Finland and Italy
only. .
Tablee 2.3 Performance-based limitation scores by country, adjusted forr age.
Standingg balance8
Walkingg speed5
Chairr stand*
Shoulderr rotation5
Totall performance-based score"
Finland d
(nn = 340)
0.299 (0.03)*
1.92(0.05)* *
1.37(0.06)** *
0.477 (0.05)**
4.044 (0.12)*
Netherlands s
(nn = 481)
Meann Standard Error
0.222 (0.02)
1.05(0.05)** *
1.56(0.05)** *
0.955 (0.04)*
3.74(0.10)* *
Italy y
(nn = 340)
0.200 (0.03)
1.67(0.05)** *
2.000 (0.06)**
0.944 (0.05)*
4.80(0.12)** *
** Significantly different from Finland (p < 0.05). tt Significantly different from the Netherlands (p < 0.05). $$ Significantly different from Italy (p < 0.05). §§ Score varied from 0 (best) to 4 (worst). ||| Score varied from 0 (best) to 16 (worst).
Tablee 2.4 Effect of country on self-reported disability.
Modell 1 Modell 2* Model 3*
Oddss Ratio (95% Confidence Interval)
Finlandd (reference)
Netherlands s
Italy y
1.0 0
1.52(1.15,2.00) )
1.50(1.12,2.03) )
1.0 0
1.55(1.15,2.08) )
1.23(0.88,, 1.73)
1.0 0
1.66(1.23,2.25) )
1.08(0.77,, 1.53)
** Adjusted for age. tt Adjusted for age, socioeconomic status (SES), household composition, chronic diseases. tt Adjusted for age, SES, household composition, chronic diseases, performance-based limitation score.
27 7
ChapterChapter 2
OO Finland AA Netherlands DD Italy
0 11 2 3 4 5 6 7 8 9 10 11
performance-basedd score
Figur ee 2.1 Mean self-reported disability score (0-3) by performance-based limitation score per country,
adjustedd for age.
Discussio n n
Inn this study, self-reported disability, performance-based limitation, and the association between
themthem were compared in elderly men from Finland, the Netherlands and Italy. Overall, Dutch and
Italiann men reported more disabilities than Finnish men. Italian men scored worst on the
performance-basedd tests. After adjustment for performance-based score, Dutch men still reported
moree disabilities than Finnish men, whereas the difference between Italian and Finnish men
reduced.. Performance-based limitation score was positively associated with self-reported disability
score.. The strength of this association did not differ between countries.
Furtherr analyses of self-reported disability showed that, in Italy, these poor scores were partly
explainedd by a higher prevalence of lower SES, chronic diseases and performance scores. In the
Netherlands,, the prevalence of these factors was not high and did not explain the higher self-
reportedd scores. There are evidently other factors that influence the self-report of disability, which
iss confirmed by the finding that the model with all mentioned factors explained only 15% of the
variancee in self-reported disability.
Accordingg to the Nagi Scheme, sociocultural and physical environment also influence self-reported
disability.. All these factors influence self-reported disability in a complex way. Cross-cultural
28 8
Performance-basedPerformance-based limitation and self-reported disability
variationn in IADL disability could be caused by differences in role expectations.' ' It could be
explainedd by men of this generation not being accustomed to performing domestic activities at all
andd therefore reporting a need for help. According to one study,(48> IADL questions are based on
normativee roles and activities and might therefore not be applicable to determine health status or
physicall functioning. Another study(19> called these disabilities 'situational disabilities', which are
onlyy partly due to health problems. Mobility and BADL questions focus more on basic physical
ff unctions.(48) Also in these domains, Dutch men reported more disabilities than men from Finland
andd Italy, adjusted for performance score. Possibly men in the Netherlands have more assisting
devicess (social and physical)(39) in daily functioning at their disposal. Another possible difference
betweenn the cultures might be the interpretation of the meaning of the response scales due to
differencess in the cultural and linguistic meaning of 'good health or functioning'.(9;10;49"51) The
perceptionperception of 'objective' health problems differs between cultures.(49) Although all had mentioned
factorss that might have contributed to the differences found in self-reported disability between
countries,, an unequivocal explanation could not be given for these results. Although the authors
foundd no earlier studies comparing self-reported disability adjusted for performance between
differentt cultures, differences between cultures were also found for self-reports on health(49;5153)
andd vision-related functional capacity/54' after adjustment for objective measurements.
Despitee differences in the self-report of disability between countries, the strength of the association
betweenn self-reported disability and performance-based limitation did not differ between Finland,
thee Netherlands and Italy. Studies from the United States'111340' reported a stronger association
thann this study. This study investigated the association between overall limitation and disability in
differentt domains, whereas the U.S. studies used tests that were more specific to disability items
(e.g.,, restricted to lower extremity functioning). European studies are not comparable because of
differentt measurement and scoring methods.18124142' This is the first study that investigated this
associationn in different countries, using the same methodology. The authors in this study are aware
that,, despite the standardisation, some small methodological differences might still have been
present.. Overall, the self-reported disability and functional limitation appeared to be associated
consistentlyy in different countries, and this association can therefore be generalised.
Thee significant associations between performance of the lower (walking speed and chair stand
test)) and upper (shoulder test) extremities and disability in the IADL domain in the present study
weree in accordance with findings from other studies in elderly from Italy and the United States/40411
Otherr investigators also showed associations between lower and upper extremity functioning and
disabilitiess in the BADL domain.(13:40) This association with BADLs was not significant for all
performancee tests in the three countries, which the small number of men with BADL disabilities
mightt explain.
29 9
ChapterChapter 2
Somee methodological remarks must be made. Selection bias in the study populations might have
influencedd the results of the present study. In the Netherlands and Italy, non respondents had more
severee disabilities than respondents.(55:56) In the present study, there was also a selection bias
becausee of missing values. Men removed from this study because of missing values were older,
reportedd more disabilities and had more functional limitations. Both the bias due to non response
andd that to missing values have led to an underestimation of the disability and limitation levels in
thee populations. The number of men removed because of missing values was larger in Finland
thann in the Netherlands and Italy, which was primarily due to missing values on the performance
tests,, but the number of nonrespondents was lowest in Finland. The total percentage of the
numberr of nonrespondents and of men removed because of missing values did not differ between
thee countries. Because men excluded in this study had poor disability and performance scores, the
strengthh of the association between these scores might have been underestimated in this study.
AA few limitations of the present study must be mentioned. The results of the present study were
restrictedd to men aged 70 and older from three European countries around 1990. Whether the
observedd differences between men in different countries also hold for women is not known.
Unfortunately,, data on women was not available. Women o verre port disabilities and men
underreportt them, which complicates comparison of measurements of health based on self-report
betweenn men and women.(57) Also the role expectations, especially for the IADL domain, are
differentt between men and women, which will lead to different results. Furthermore, the differences
betweenn countries might change over time, because of changing roles, particularly on household
taskss for men. Only a restricted number of chronic conditions were considered in this study.
Informationn on musculoskeletal and neurological diseases was not available, which might also
havee influenced the results. Also poor cognitive functioning and clinical depression might play a
rolee in the self-report of disability. However, the prevalence of these conditions was low among the
participants. .
Ann important question is how to interpret the results. Performance tests assess basic objective
functionall limitation, whereas self-reported items reflect dependency and need for care.<7;42:58> If
comparingg the health of populations is based on an indicator for objective functioning, it can be
concludedd from the present study that men in Italy had the worst health. When health was
assessedd on the basis of a self-report of disability as an indicator for dependency and need for
care,, the Dutch men were the unhealthiest of all the populations studied.
Overall,, the results of the present study showed that the self-report of disability differed between
Finland,, the Netherlands, and Italy. These differences may be due to sociocultural and physical
environmentall factors. Self-reported disability was consistently associated with performance-based
limitationn in these countries.
30 0
3 3 Effec tt of widowhoo d on disabilit y onse t
PublishedPublished as: van den Brink C.L., Tijhuis M., van den Bos G.A.M., Giampaoli S., Nissinen A., Kromhout D.
Effectt of widowhood on disability onset among elderly men from three European countries.
JournalJournal of the American Geriatrics Society 2004; 52:353-358
ChapterChapter 3
Abstrac t t Objectiv ee To investigate in different countries the effects of becoming widowed, duration of
widowhood,, and household composition of widowed men on disability onset in different disability
domains. .
Method ss Longitudinal data of three cohorts from Finland, the Netherlands, and Italy was collected
aroundd 1990, 1995, and 2000. Complete information was available for 736 men, aged 70 and older
att baseline. Disability was measured using a standardised questionnaire on activities of daily living
(ADLs).. Three domains were assessed: instrumental ADLs (lADLs), mobility, and basic ADLs
(BADLs).. Duration of widowhood was divided into less than 5 years and more than 5 years and
householdd composition into living alone and living with family or in an institution.
Result ss Men who became widowed developed more IADL (odds ratio (OR): 2.15; 95% confidence
intervall (CI): 1.22, 3.81) and mobility (OR: 1.84; 95% CI: 1.15, 2.96) disabilities than men who were
stilll married. Men who had been widowed for less than 5 years developed more IADL disabilities
thann those who had been widowed for 5 years or more (OR: 2.27; 95% CI: 1.14, 4.54). Widowed
menn living alone showed fewer disabilities in mobility (OR: 0.25; 95% CI: 0.09, 0.73) and BADLs
(OR:: 0.02; 95% CI: 0.001-0.33) than those living with others. The effects on disability onset did not
differr between countries.
Conclusio nn Widowhood in elderly men is a risk factor for dependency in lADLs and mobility. The
growthh in the number of widowers may lead to higher demands on family care and professional
care. .
32 2
Widowhoodd and disability
Introductio n n Populationn ageing and the accompanying increase in the number of persons having problems
performingg activities of daily living (ADLs) independently will lead to a continuous rise in healthcare
needs/59:60)) An important growing group of elderly, expected to be vulnerable to these disabilities,
aree men who lose their partner. For example, in the Netherlands, the number of widowed men in
20011 increased more than 8 per cent over 1991,(61> which is related to the ageing of the population
andd the relatively greater increase in life expectancy in men than in women. To achieve better
insightt into future needs for care, it is of interest to study the effect of widowhood on disability
onset. .
Inn general, a distinction can be made between functional and situational disability/19* Functional
disabilityy is primarily caused by health problems and can affect all domains of disability in ADLs,
i.e.. instrumental ADLs (lADLs), mobility and basic ADLs (BADLs). Widowhood might lead to
functionall disability because of health problems after widowhood.*17162"64' Situational disability
concernss non-health factors and occurs when persons have never learned to perform certain
tasks,, such as household tasks for men. For these tasks, situational disability might appear in
widowers,, because these men were accustomed to receiving instrumental support from their
spouse.. For all disability domains, a higher risk of disability for widowed men was hypothesised
thann for men who did not become widowed.
Twoo factors might be associated with disability onset among widowed men: duration of widowhood
andd household composition. Over time a widower adapts his behaviour and changes his
standards/65'' so men who had been widowed longer were hypothesised to have a lower risk of
disabilityy than men who had become widowed recently. For household composition (living alone or
withh others), the hypothesis was that disability, especially in lADLs, would be more prevalent in
widowedd men living alone than in those living with others, because care tasks of the lost partner
cann be taken over by others for the widowed men not living alone.
Culturall factors might further influence the effect of widowhood on disability onset and the
associationn with household composition/161 Because the experience of widowhood and the way
livingg arrangements are valued may vary with culture/6667' the hypothesis was that the effects of
widowhood,, the duration of widowhood, and the association between household composition and
disabilityy domains would be greater in cultures promoting family interdependency than in those
promotingg autonomy.
Thee aim of the present study was to investigate in elderly men the influence of becoming widowed
andd the duration of widowhood on disability onset in different domains in Finland, the Netherlands,
andd Italy. Moreover, the association between household composition and disability onset was
33 3
ChapterChapter 3
studiedd in widowed men in the three countries. The study variables were measured in a
standardisedd way in all countries, providing the opportunity to evaluate cross-cultural differences.
Method s s
Stud yy populatio n
Thee present study had a longitudinal design and used data of the Finland, Italy, and Netherlands
Elderlyy (FINE) Study, collected around 1990, 1995 and 2000. The FINE Study began in 1985 as a
continuationn of the Seven Countries Study,(36) and is focused on elderly men born between 1900
andd 1920. Detailed information about the FINE Study and its populations has been reported
elsewhere.(43) )
Thee present study included 736 participants: 225 from Finland, 294 from the Netherlands, and 217
fromm Italy. Information was available on marital status and disability. Men who were divorced (2%),
hadd never been married (6%) or were already disabled in all domains in 1990 and 1995 (3%) were
excluded. .
Dataa was collected using a questionnaire and was checked for missing values and inconsistencies
byy staff, according to the international protocol used in surveys of the Seven Countries Study.(36)
Disabilit yy (1990, 1995 and 2000)
Disabilityy was defined as dependency in ADLs and was measured for 14 items, which were
groupedd into three domains: IADL (preparing meals, doing light and heavy housework), mobility
(movingg outdoors, using stairs, walkingg 400 meters, carrying a heavy object for 100 meters), BADL
(walkingg indoors, getting in and out of bed, using the toilet, washing and bathing, dressing and
undressing,, feeding oneself). The item 'cut toenails' was left out of the analysis, because it consists
off aspects of both the mobility and BADL domain (conceptual ambiguity).<8;45) Participants were
classifiedd as being disabled in a certain activity if they reported a need for help, or were not able to
performm that activity. For each domain, disability was dichotomised based on disability on at least
onee item of that domain.
Duratio nn of widowhoo d and househol d compositio n (1995 and 2000)
Durationn of widowhood at the end of a period was dichotomised as less than 5 years (men who
becamee widowed during a certain period) and 5 or more years (men who were widowed at both the
beginningg and the end of the period (in 1990 and 1995 or in 1995 and 2000)).
Householdd composition was dichotomised as living alone or living with other adults (living with
grownn children, family, others, and living in an institution).
34 4
WidowhoodWidowhood and disability
Countrie s s
Inn Finland, participants came from llomantsi, a hilly area in eastern Finland, and Pöytya and Mellila
inn southwestern Finland, which are flat, rural areas. In the Netherlands participants came from
Zutphen,, a commercial town in the eastern part of this flat, lowland country. In Italy, participants
camee from two rural villages: Montegiorgio, located in the hills, and Crevalcore, located in a flat
valley. .
Regardingg household composition and family structure, Italy differs from Finland and the
Netherlandss because the proportion of elderly living with their children is higher in Southern Europe
(Italy)) than in Northern Europe (Finland and the Netherlands)/6869*
Sociodemographi cc characteristic s
Sociodemographicc characteristics included were age and socioeconomic status (SES). The
professionn that was held during the major part of working life was selected as SES. Three groups
weree distinguished: high SES (professionals, high-level managers, and high-level teachers), middle
SESS (middle-level managers, middle-level teachers, and (small) business owners), and low SES
(nonmanuall and manual workers).
Statistica ll analyse s
Thee follow-up period was divided into two periods: from 1990 to 1995, and from 1995 to 2000. Of
thee 736 participants, 315 had complete information only for Period 1, 21 only for Period 2, and 400
forr both periods. Each period a subject participated in accounted for one observation. Combining
thee two periods resulted in 1,136 observations of 736 participants.
Forr all analyses, data from the two study periods were used. Although the outcome variable
disabilityy was measured at two points in time (repeated measurements), no repeated measurement
effectss were included in the logistic regression models because, for each person, the event
(disability)) can occur only once because, for each period, the analyses started with men without
disabilities. .
Too determine the effect of becoming widowed on disability onset, only men who were not widowed
andd had no disabilities at the beginning of the period were included in the analyses. At the end of
thee period, disability was compared between widowed and non-widowed men. Logistic regression
analysess were performed for each domain with 'disability at the end of the period' in that domain as
thee dependent variable and 'widowhood at the end of the period' as the independent variable.
Too determine the influence of duration of widowhood on disability onset, a logistic regression
modell was performed for each disability domain with disability as the dependent variable and
35 5
ChapterChapter 3
durationn of widowhood as the independent variable. These analyses were performed on men
withoutt disability at the beginning of the period who were widowed at the end of a period.
Too determine the association between household composition and disability in men who became
widowed,, only the incident cases of widowhood (men who became widowed between the
beginningg and the end of a period) were included in the analyses. The analyses were again
restrictedd to men without disability at the beginning of the period. At the end of the period, disability
wass compared between widowed men living alone and those living with others. A logistic
regressionn model was used with household composition as the independent variable and disability
ass the dependent variable. Exploratory analyses were done within the group of widowed men living
withh others by calculating mean disability scores for widowers living with family and for those living
inn an institution. Because of the relatively small number of men living in institutions (8%), this
differentiationn was not possible in the logistic regression analyses.
Too determine whether the effects of widowhood and duration of widowhood on disability onset, and
thee association with household composition differed between countries, interaction terms between
countryy and the different variables were added to the different models. Furthermore, the analyses
weree stratified by country.
Alll the logistic regression analyses were adjusted for age, SES, and country with exception of the
analysess stratified by country, which were only adjusted for age and SES.
Statisticall analyses were performed using SAS version 8.2 (SAS Institute, Inc., Cary, NC). All tests
weree two-tailed, and p < 0.05 was considered statistically significant.
Result s s
Tablee 3.1 shows the characteristics of the study population per period. Mean age around 1990 was
75.00 years for Finland, 74.8 for the Netherlands, and 76.3 for Italy. The prevalence of low SES was
considerablyy higher in Italy (83% in 1991) than in Finland (41% in 1989) and the Netherlands (42%
inn 1990). The prevalence of high SES was highest in the Netherlands (21% versus 1% in the other
countriess around 1990). The percentage of widowed men increased during the follow-up rounds,
fromm about 27% in 1990 to 34% in 2000. The percentage of widowed men living alone was
considerablyy higher in Finland (e.g. 65% in 1999) and the Netherlands (76% in 2000), than in Italy
(33%% in 2000). Furthermore, when living with others, Finnish and Dutch men were more likely to
livee in an institution, whereas Italian men were more likely to live with others (data not shown).
36 6
WidowhoodWidowhood and disability
• o o
3 3
O O
8 8 W W
CO O
o o CQ Q CO O c c O O O O £ £ Q. . CO O
en n o o r--© © T> T> o o o o o o
CO O
^ ^ CO O 0 0
13 3 (0 0 H H
T3 3 e> > ^ ^ 03 3
r r o o CO O d) )
CD D
C C i S S l _ _ CD D
'S S z z CD D
T3 T3 C C co o
o o o o o o CM M
i i If ) ) o> >
If ) ) O) ) O) )
O O O) )
o o o o o o CM M
i i I D D <D D O) )
If ) ) O) ) O) )
Ó Ó o> >
I I
o> >
"3--O O o> >
I I O) ) co o O) )
CM M CO O
o> >
If ) ) CO O
CO O
oo o co o -H H
r> --CO O r» --
-H H co o
CD D CO O •H H I» --co o
•H H o o if ) )
CO O CO O
CO O CO O
•«a --CO O
CO O CO O
CO O CO O o o f* . .
CM M CO O CO O
r-. . CO O
o o -* *
CO O CM M
CM M CM M
T T T
o> > • < * *
CO O CO O h --
CM M co o CO O co o
CM M CO O co o
o o Tl -- IT ) ) o o
CO O CO O
l O O CO O
co o If ) ) co o o o
CO O
O) )
c c . . CO O
c c o o ^ ^ CO O r* * CD D CO O
U U
D D
» » +1 1 C C CO O CD D
E E
< <
(0 0 3 3
CO O CO O o o F F o o o o ö ö CD D O O ü ü
CO O
•g g
' E E
O) )
c c c c c c O) ) 0> >
CO O TD D CU U
* * o o
T> >
CD D c c o o co o
c c
> > — — J2 2 CD D
5 5 o o
" O O
s? ?
o o C C CD D
CO O
TJ J CD D
5 5 o o T3 3
CD D C C O O
co o O) ) c c
> > --£ £
CD D
s s o o T> >
37 7
ChapterChapter 3
Effec tt of widowhoo d on disabilit y onse t
Tablee 3.2 shows, per domain the prevalence of disability at the end of the period, comparing men
whoo became widowed during the period with men who stayed married. In lADLs and mobility, men
whoo became widowed had 1.4 times more disabilities than men who did not become widowed
(59%% vs 42% in IADL and 28% vs 19% in mobility). In BADLs, the prevalence of disability (8-10%)
didd not differ between widowed and nonwidowed men.
Logisticc regression analyses adjusted for age, SES, and country resulted in an odds ratio (OR) for
thee effect of widowhood on disability onset in lADLs of 2.15 (95% confidence interval (CI): 1.22;
3.81),, in mobility of 1.84 (95% CI: 1.15, 2.96), and in BADLs of 0.76 (95% CI: 0.38, 1.52).
Tablee 3.2 Age-adjusted prevalence of disability per domain by widowhood at the end of the study period,
amongg men who were not widowed and had no disabilities for that domain at the beginning of the study
period. .
Widowed d
yes s
no o
Instrumentall activities of
dailyy living
nn disability
711 59%"
4711 42%
n n
112 2
717 7
Mobility y
disability y
28%* *
19% %
Basicc activities of daily
n n
120 0
761 1
living g
disability y
8% %
10% %
** significantly different from men not widowed, p < 0.05.
Tablee 3.3 Age-adjusted prevalence of disability per domain by duration of widowhood at the end of the
studyy period, in men who had no disabilities for that domain at the beginning of the study period.
Instrumentall activities of Mobility Basic activities of daily
dailyy living living
Durationn of n disability n disability n disability
widowhood,, years
<< 5 years 71 63%* 112 32% 120 10%
>> 5 years 112 47% 183 24% 206 14%
** significantly different from men widowed for 5 years or more, p < 0.05.
Effec tt of duratio n of widowhoo d on disability onset
Menn who had been widowed for less than 5 years showed significantly more disabilities in lADLs
thann men who had been widowed 5 years or more (63% vs 47%)(table 3.3). The differences in
mobilityy and BADLs were not significantly different between men widowed for less than 5 years
andd men widowed for 5 years or more (32% vs 24% in mobility and 10% vs 14% in BADLs).
38 8
WidowhoodWidowhood and disability
Logisticc regression analyses adjusted for age, SES, and country resulted in an OR for the effect of
durationn of widowhood on disability onset of 2.27 (95% CI: 1.14, 4.54) in lADLs, 1.68 (95% CI:
0.95,, 2.96) in mobility, and 0.76 (95% CI: 0.35, 1.66) in BADL.
Associatio nn betwee n househol d compositio n and disabilit y onse t
PrevalencePrevalence figures of disability in the different domains for widowed men living alone and those
livingg with others are shown in table 3.4. These men had become widowed during the study period
andd had no disability at the beginning. In lADLs, the difference in disability prevalence between
widowedd men living alone (68%) and those living with others (46%) was not statistically significant.
Inn mobility and BADLs, widowed men living alone showed significantly fewer disabilities than those
livingg with others (24% vs 43% in mobility and 2% vs 23% in BADLs). Further exploration of the
dataa showed that men who lived in an institution had more severe disabilities than those living with
familyy (data not shown).
Resultss of logistic regression analyses adjusted for age, SES, and country resulted in an OR for
thee association of living alone with disability in lADLs of 2.78 (95% CI: 0.60, 12.80), in mobility of
0.255 (95% CI: 0.09, 0.73), and in BADLs of 0.02 (95% CI: 0.001, 0.33)
Effect ss of widowhoo d and househol d compositio n in differen t countrie s
Interactionn effects between country and the variables widowhood, duration and household
compositionn were not statistically significant. Stratification by country also showed that the direction
off the effects of the variables on disability onset did not differ between countries.
Tablee 3.4 Age-adjusted prevalence of disability per domain by household composition at the end of the study
period,, in men who became widowed during that study period and had no disabilities for that domain at the
beginningg of the study period.
Instrumentall activities Mobility Basic activities of daily
off daily living living
Householdd n disability n disability n disability
composition n
livingg alone 51 68% 73 24%* 78 2%"
livingg with others 20 46% 39 43% 42 23%
** significantly different from men living with others, p < 0.05.
39 9
ChapterChapter 3
Discussio n n Inn this study the influence of becoming widowed and duration of widowhood on disability onset in
differentt domains and the association between household composition and disability in widowers
weree investigated in elderly men from Finland, the Netherlands and Italy. As hypothesised, men
whoo became widowed developed more IADL and mobility disabilities than men who did not
becomee widowed. Men who became widowed during the last 5 years developed more IADL
disabilitiess than men who had been widowed for a longer time, as hypothesised. Widowed men
livingg alone showed fewer disabilities in mobility and BADLs than those living with others. These
associationss did not differ between the three countries.
Somee methodological remarks must be made. Selection bias might have influenced the results of
thee study. An earlier report on the FINE data<70) showed that nonrespondents and men removed
becausee of missing values had more disabilities than men included in the study. If these men also
differedd in marital status or household composition, the results of the present study could be
biased.. Furthermore, men who died were not included in the analyses. Additional analyses
indicatedd that men who died had more disabilities and were more often widowed at the beginning
off a study period than men still alive, but because men who were widowed or had disabilities at the
beginningg of the period were not included in the analyses, this did not bias the results.
Anotherr remark concerns the low number of men in some analyses. Only a few men became
widowedd during the study period (table 3.4). Furthermore, the number of widowed men living alone
inn Italy was low, whereas the number of those living with others was low in Finland and the
Netherlands.. Consequently, the power might have been too low to detect differences in the effects
off widowhood and household composition between countries.
Healthh problems after widowhood (functional disability) might explain the effect of widowhood on
disabilityy onset in lADLs and mobility. Widowhood is a life event that can be accompanied by
emotionall stress, which can lead to depression.(16;67;71"73) Psychosocial factors seemed to be
intermediaryy variables in the process to physical health problems/7475' Furthermore, widowed men
mightt lose social relationships*65' or change their health behaviours/76' Another possible cause of
disabilityy is that men who depended on their spouses were not prepared to do tasks by themselves
(situationall disability). This could have especially been the case in lADLs involving household
tasks.. Functional and situational disability might influence each other, and situational disability
mightt in turn decrease psychological wellbeing, which can lead to more disabilities after health
problemss (functional disability). Widowhood was not associated with a higher risk of BADL
disability,, which the low prevalence of BADL disability might explain. BADL disability is expected to
occurr later in life, according to the earlier reported hierarchical order in the development of
disability:: IADL, mobility, BADL.<8;70)
40 0
WidowhoodWidowhood and disability
Thee effect of widowhood on IADL disability onset was shown to depend on duration of widowhood;
menn who had been widowed longer developed less disability than men who had become widowed
recently.. The direct effect of loss of the person who was used to perform lADLs could explain this.
Althoughh the results for mobility pointed into the same direction, the effect of duration was not
statisticallyy significant. However, one study found immediate effects of widowhood on physical
health.(62)) In that study, effects were measured within 1 year after spousal loss, whereas in the
presentt study the shortest period was between 0 and 5 years. Because the health effect of
widowhoodd appeared to lessen over time,(72) it is possible that men who had been widowed for
moree than 1 year had the same risk of disability as men who had been widowed for more than 5
years.. This may explain why, in the present study, no significant differences between the two
durationn groups were found in mobility and BADL disabilities.
Too examine further whether disability in widowers was associated with loss of support, household
compositionn was taken into account. It was hypothesised that the prevalence of IADL disability
wouldd be higher in widowed men living alone than in those living with others. Although the results
confirmedd this, the association was not statistically significant. For mobility and BADLs, widowed
menn living with others reported more disabilities than those living alone. A possible explanation for
thesee findings is that healthy widowed men live alone, but experience problems in lADLs, and
thosee having more severe problems (mobility or BADL disability) live with others, because they
needd help in performing ADLs. Also, from earlier studies, it is known that people with more
disabilitiess more often live with others,(77;78) but some other studies showed better health in those
livingg with others than those living alone.(79;80) Although those results and the results of the present
studyy seem contradictory, differences in the order of causality might explain the differences; those
whoo are already dependent in several activities might start living with others (present study),
whereass those who already live with others will develop fewer health problems than those living
alone. .
Becausee of the expected increase in the number of widowers in Europe, it is important to discuss
thee implications of this study for healthcare services and policy makers. In Finland and the
Netherlands,, widowed men living with others tended to live in an institution, and therefore the
burdenn on healthcare services will increase more in these countries. Because of the greater risk of
developingg situational disability in widowed men, preventive strategies should focus on training
menn who have become widowed recently to perform household tasks. Furthermore, healthcare
servicess need to be more responsive to meet the specific healthcare needs of men with functional
disabilities.. For general practitioners, it is important to be alert with men at risk, with the aim of
improvingg quality of life. It would be interesting to investigate whether there are risk groups within
thee group of men who have become widowed recently.
41 1
ChapterChapter 3
Thee present study was restricted to male subjects. It is known that women adjust more easily to
spousall loss,(81) and for them the protective effect of marriage on health is weaker than for men.($2)
Thiss suggests a lower risk on disability for widowed women than widowed men.(17) Especially for
lADLs,, weaker associations are expected, because, in general, women are used to performing
householdd tasks themselves and consequently have a lower risk of situational disability. Therefore,
thee effect of widowhood on the need for health care will be stronger in men than in women. In the
presentt study, the oldest-old group was small (only 3% was older than 85). Based on the findings
onn the effect of duration of widowhood on situational disability, it is expected that the risk of
disabilityy is relatively high in the oldest-old group, because they have fewer opportunities and a
shorterr time span to adapt to the new situation. It would be interesting to investigate whether the
presentt results also hold for the oldest-old group.
Summarising,, from the results of the present study it can be concluded that widowhood in men
increasess the risk of dependency in lADLs and mobility. For lADLs, this effect is higher in men who
havee become widowed recently than in those who had been widowed longer. Widowers living with
otherss have more mobility and BADL disabilities than those living alone. The growth in the number
off widowers may well lead to higher demands on family care and professional care.
42 2
4 4 Physica ll activit y and disabilit y
PublishedPublished as: van den Brink CL., Picavet H.S.J., van den Bos G A M . , Giampaoli S., Nissinen A., Kromhout
D.. Duration and intensity of physical activity and disability among European elderly men.
DisabilityDisability and Rehabilitation 2005; 27(6): 341-347 (http://www.tandf.co.uk)
ChapterChapter 4
Abstrac t t Objectiv ee To investigate the relationship between duration and intensity of physical activity and
disabilityy 10 years later, and to investigate the possible effect of selective mortality.
Method ss Longitudinal data of 560 men aged 70-89 years, without disability at baseline of the
Finland,, Italy and the Netherlands Elderly (FINE) Study was used. Physical activity in 1990 was
basedd on activities like walking, bicycling and gardening. Disability severity (3 categories) in 1990
andd 2000 was based on instrumental activities, mobility and basic activities of daily living.
Result ss Men in the highest tertile of total physical activity had a lower risk of disability than men in
thee lowest tertile {odds ratio (OR) 0.46; 95% confidence interval (CI): 0.26-0.84). This was due to
durationn of physical activity (OR highest tertile 0.42; 95% CI: 0.23-0.78 compared to the lowest
tertile).. Intensity of physical activity was not associated with disability. Addition of deceased men as
fourthh category led to weaker associations between physical activity and disability (OR highest
tertilee 0.67; 95% CI: 0.44-1.02).
Conclusio nn Even in old age among relatively healthy men, a physically active lifestyle was
inverselyy related to disability. To prevent disability duration of physical activity seems to be more
importantt than intensity.
44 4
PhysicalPhysical activity and disability
Introductio n n Physicall activity in old age seems to be an important determinant of healthy ageing. In addition to
thee effect on postponement of mortality/82"84' physical activity preserves quality of life in the elderly
becausee of its positive longitudinal association with independent functioning ^functioning without
disability)/85"92'' Information on the importance of specific aspects of physical activity, i.e. duration
andd intensity, is however lacking.
Althoughh earlier studies found an association between physical activity and disability, global
assessmentss of physical activity only provide crude information about the role of physical
activity/85*7"90'' Studies that incorporated frequency or total energy expenditure of different activities
foundd a relationship between these aspects of physical activity and disability/869192' However,
durationn and intensity of the activities were not distinguished, so it is not known which role these
aspectss play in the relationship with disability. In the current longitudinal study both duration and
intensityy of physical activity are investigated.
Furthermore,, measures of association in longitudinal studies may be susceptible to bias. Especially
longitudinall studies among elderly people have large losses to follow-up because of death, which
mightt be non-random. Therefore, the effect of selective mortality should be considered when
studyingg associations with health outcome as dependent variable. In an earlier study with
functionall decline as health outcome, the associations with the determinants (social relations)
becamee stronger when death was included in the outcome measure/93'
Thee aim of the present study was to elaborate on earlier studies by investigating the relationship
betweenn physical activity and incident disability, taking into account duration and intensity of
physicall activity, and severity of disability. Furthermore, we investigated whether inclusion of
peoplee who died during the follow-up time resulted in a change in the risk of incident disability.
Dataa from a prospective study (10-years follow-up) in three European countries is presented.
Europeann longitudinal studies about physical activity and disability are lacking; the available
studiess were carried out in North America or Asia/85'
Method s s
Studyy population
Thee present study has a longitudinal design and used data collected around 1990 and 2000 for the
Finland,, Italy and the Netherlands Elderly (FINE) Study. The FINE Study started in 1985 as the
extensionn of the Seven Countries Study/36' consisting of men bom between 1900 and 1920. More
detailss about the FINE Study and its populations have been reported elsewhere/43'
45 5
ChapterChapter 4
Baselinee measurements for this study were earned out in 1990, and data collected in 2000 was
usedd for the 10-years follow-up. Around 1990, 1416 men were examined (response rate Finland
90%,, the Netherlands 78%, Italy 79%). The present study was focused on a subgroup of 560
subjects.. Men with any disability at baseline were excluded (n=780) in order to avoid the possibility
off lack of physical activity caused by disabilities. Of the survivors in 2000, 62 did not participate in
thatt examination year and were excluded. Furthermore, 10 men were removed because of
incompletee information on physical activity in 1990 and 4 because of missing values on disability in
2000.. Of the remaining 560 subjects, 183 came from Finland, 220 from the Netherlands, and 157
fromm Italy. The analyses among survivors in 2000 were restricted to 286 participants.
Dataa collection followed the international protocol used in surveys of the Seven Countries Study.(36)
Inn 1985 in Finland, the research was approved by the Ethical Committee of the Kuopio University
Hospitall and the Dutch part of the study by the Medical Ethical Committee of the University of
Leiden.. In Italy the research was approved by the Ethical Committees at local level. Subjects gave
theirr written informed consent to participate.
Disability y
Disabilityy was measured by a standardised questionnaire about daily routine activities, which was
describedd by Hoeymans et al.<8> Three domains, consisting of 13 items, were assessed:
•• instrumental activities of daily living: preparing one's own meal, doing light, and doing heavy
housework; ;
•• mobility: moving outdoors, using stairs, walking 400 meters, carrying a heavy object for 100
meters; ;
•• basic activities of daily living: walking indoors, getting in and out of bed, using toilet, washing
andd bathing, dressing and undressing, feeding oneself.
Disabilityy in a domain was defined as needing help on at least one item of that domain.
Disabilityy severity was based on the hierarchical order of the three disability domains, described by
Hoeymanss et al.(8) The two most severe groups (disability in instrumental activities and mobility,
andd disability in all domains) were taken together because of the small numbers. The following
classificationn was used:
0.. no disability;
1.. mild disability (instrumental activities);
2.. severe disability (instrumental activities and mobility, and no or any basic activities)
Too investigate the possible effect of selective mortality, further analyses were performed including
deceasedd men as fourth category.
46 6
PhysicalPhysical activity and disability
Physicall activity (In the year 1990)
Physicall activity in 1990 was measured by a standardised self-administered questionnaire,
speciallyy designed for retired men, which has been described in detail by Caspersen et al.(94) This
questionnairee is considered reliable and valid for measuring physical activity in elderly men, having
demonstratedd a 4 month test-retest correlation of 0.93 and having been validated by the doubly
labelledd water method (correlation with total energy expenditure was 0.61) in Dutch elderly.(95> The
coree questionnaire consisted of questions about six activities: the frequency and duration of
walkingg and bicycling during the previous week, the average amount of time spent weekly on
gardeningg and hobbies in both summer and winter, and the average amount of time spent monthly
onn sports and odd jobs. Because of the rural areas where the participants of Finland and Italy live,
questionss on the average amount of time spent weekly on farming in both summer and winter were
addedd to the questionnaire in these countries. Estimated times were converted to minutes per
weekk for each type of activity and summed to obtain total weekly duration of physical activity. For
hobbiess and sports, only activities that demanded a certain amount of physical effort (>2.0
kcal/kg-hour)) were included. For example, activities like playing chess or doing puzzles were not
consideredd as physical activities.
Alll activities were given an intensity code based on Caspersen et al.<94> The codes were expressed
ass kcal/kg-hour and reflected multiples of resting oxygen consumption. For walking and bicycling
thiss code was based on an additional question about the pace of the performed activity, divided
intoo three categories: calm, normal, fast. For gardening and farming the intensity code was based
onn an additional question about the strenuousness of the work, also divided into three categories.
Fromm all activities together, a mean intensity index was constructed by multiplying the intensity of
eachh activity by the time spent on that activity, summing this for all activities and dividing by total
timee spent on physical activity.
AA variable for total physical activity was constructed by multiplying duration with intensity of the
activities. .
Confoundingg factors (in the year 1990)
Possiblee confounding factors comprised of other lifestyle factors. Information on cigarette smoking
statuss (never, ever, current) was collected by questionnaire. Smoking was dichotomised as current
versuss non-smoking (never, ever).
Heightt and weight were measured while the participant stood in light clothing without shoes. Body
masss index was calculated by dividing weight (kg) by the square of height <m2). Men were
categorisedd as being obese (body mass index £ 30) or being non-obese. Although body mass
indexx < 18.5 is also a risk factor for disability, this group was not distinguished or excluded, since
onlyy four men belonged to this group and exclusion of these four men did not lead to other results.
47 7
ChapterChapter 4
Alcoholl consumption was obtained from questions about wine, spirits, and beer. These were
addedd to obtain total alcohol consumption. Alcohol consumption was dichotomised as non drinkers
versuss drinkers. Non drinkers did not drink alcohol at all. Information on beer was not available for
Italiann participants. Forty-two of the Finnish participants did not have any information on alcohol
consumptionn and were removed from the analyses in which alcohol was added as independent
variable. .
Statisticall analyses
Baselinee characteristics were compared between countries using analysis of variance for
continuouss variables and chi-square test for categorical variables.
Too investigate the relationship between total physical activity and incident disability 10 years later,
aa polytomous logistic regression model was constructed with the three levels of disability (no, mild,
severe)) as dependent variable and tertiles of total physical activity as independent dummy
variables.. The lowest fertile was the reference group. These analyses were repeated after addition
off deceased men as fourth category. The analyses were also performed adjusted for smoking,
obesity,, and alcohol consumption.
Too investigate whether duration and intensity of physical activity contributed separately to the
associationn between physical activity and incident disability, both variables were put into one model
ass separate independent variables. Because the association between duration and intensity was
nott strong (correlation coefficient = 0.20), collinearity between these factors is not likely to have
influencedd the results. To investigate whether smoking, obesity, and alcohol consumption
confoundedd the relationship between physical activity and disability, the models were also tested
adjustedd for these factors. Again, analyses were repeated with inclusion of men who died between
19900 and 2000.
Thee analyses were carried out for the men of all countries together. All analyses were adjusted for
agee and country, because these characteristics were associated with both physical activity and
disability.. Although chronic diseases were also associated with physical activity and disability, the
analysess were not adjusted for these diseases, because they are assumed to be reflected in the
disabilityy measurement.
Statisticall analyses were performed using SAS, version 8.2. All tests were two-tailed and a p-value
off < 0.05 was considered statistically significant.
48 8
PhysicalPhysical activity and disability
Result s s
Thee baseline characteristics of the participants are shown in table 4.1. Men in Italy were
statisticallyy significantly older (about 1.5 to 2 years) than men in Finland and the Netherlands. Men
inn Italy spent statistically significantly more time on physical activity (1120 minutes per week) than
menn in Finland (939) and the Netherlands (694). Mean intensity of the activities was also
statisticallyy significantly higher in Italy. In all three countries, walking contributed considerably (18-
34%)) to duration of physical activity. In the Netherlands, bicycling and gardening were also
importantt and in Italy gardening. Furthermore, in both Finland and Italy, farming contributed about
25%% to total physical activity.
Afterr 10 years of follow-up, Italian men had a statistically significantly lower mortality rate (35%
versuss 54%) and more often lived without disabilities (2000: 24% versus 14-19%) (table 4.1).
Menn who were excluded because of disabilities at baseline were 2.5 years older and their amount
off physical activity was 45% lower compared to men without disabilities at baseline. Furthermore,
100 years later, among the excluded men there were 25% more deceased men and the prevalence
off men without disabilities was 14% lower (data not shown).
Totall physica l activit y and inciden t disabilit y
Totall physical activity was related to disability, adjusted for age and country (table 4.2). Compared
too the lowest tertile of total physical activity, men from the middle (odds ratio (OR): 0.56; 95%
confidencee interval (CI): 0.32, 0.99) and highest tertile (OR: 0.50; 95% CI: 0.29, 0.88) had a lower
riskrisk of disability. Addition of deceased men resulted in slightly weaker associations between
physicall activity and disability.
Thee odds ratios of the middle and highest tertile of total physical activity did hardly differ, which
waswas the case for all models.
Adjustmentt for smoking, obesity, and alcohol consumption resulted in a slightly weaker association
betweenn physical activity and disability in the analyses in which deceased men were included. The
associationss however remained statistically significant.
Duratio nn and intensit y of physica l activit y and inciden t disabilit y
Thee cut-off points for the tertiles of duration of physical activity were 486 and 960 minutes per week
withh a median value of 270 minutes per week for the lowest tertile, 690 for the middle and 1432 for
thee highest tertile. Duration was statistically significantly associated with functional decline (table
4.3).. Men in the middle and highest tertile of duration of physical activity had about 50% lower risk
off disability (OR: 0.51; 95% CI: 0.29, 0.89 and OR: 0.45; 95% CI: 0.25, 0.81 respectively) than men
inn the lowest tertile. After adjustment for smoking, obesity, and alcohol consumption, the risk ratios
49 9
ChapterChapter 4
remainedd roughly the same. To explore the possible effect of selective mortality deceased men
weree added. The associations between physical activity and disability became weaker and became
borderlinee significant after adjustment for other lifestyle factors. The odds ratios for the middle and
highestt tertile became 0.68 (95% CI: 0.45,1.02) and 0.67 (95% CI: 0.44, 1.02) respectively.
Thee associations between intensity of physical activity and disability, independent of duration, were
nott statistically significant.
Tablee 4.1 Baseline characteristics (1990) and disability and mortality in 2000 in men free of disability at
baseline. .
Agee (years)
Physicall activity
Meann duration (min/week)
Meann intensity (kcal/kg/hour), adjusted for duration
Typee (% of total time)
walking g
bicycling g
gardening g
farming g
sports s
oddd jobs
hobbies s
Otherr lifestyle factors (%)
non-smokers s
non-obesee (body mass index < 30 kg/m2)
non-drinkers s
Disabilityy 2000 (%)
noo disability
mildd disability*
severee disability*
Deceasedd 1990-2000 (%)
Finland d
n=183 3
74.77 (4.0)
9399 (823)*
3.77 (0.7)*
34 4
11 1
12 2
25 5
1 1
9 9
8 8
87 7
86 6
13 3
14 4
16 6
16 6
54 4
Netherlands s
n=220 0
74.22 (4.1)
694(546) )
3.77 (0.7)
21 1
31 1
21 1
5 5
13 3
9 9
80 0
93 3
26 6
19 9
12 2
15 5
54 4
Italy y
n=157 7
76.11 (3.4)
1120(948) )
3.99 (0.7)
18 8
13 3
37 7
23 3
1 1
7 7
1 1
83 3
90 0
18 8
24 4
22 2
19 9
35 5
** Numbers in parentheses, standard deviation. tt Disability in instrumental activities of daily living. tt Disability in instrumental activities and mobility and no or any basic activities of daily living.
50 0
PhysicalPhysical activity and disability
Tablee 4.2 Relationship between total physical activity and disability.
Disability y Disabilityy including
deceasedd men
Totall physical activity 1990
lowestt tertile*
middlee tertile
highestt tertile
lowestt tertile*
middlee tertile
highestt tertile
oddss ratio
1.00 0
0.56 6
0.50 0
modelsmodels ac
1.00 0
0.55 5
0.46 6
95%% CI oddss ratio' 95%% CI
modelsmodels adjusted for age and country
1.00 0
0.32-0.999 0.58 0.38-0.88
0.29-0.888 0.52 0.34-0.80
modelsmodels adjusted for smoking, obesity, alcohol, age, and country
1.00 0
0.30-0.999 0.63 0.40-0.98
0.26-0.844 0.60 0.38-0.94
Abbreviations:: CI, confidence interval. ** polytomous logistic regression analysis: 3 categories of disability severity. tt polytomous logistic regression analysis: 3 categories of disability severity and 1 category of deceased men. %% reference category.
Tablee 4.3 Relationship between duration and intensity of physical activity and disability.
PhysicalPhysical activity 1990
Duration n
lowestt tertile*
middlee tertile
highestt tertile
Intensity y
Duration n
lowestt tertile*
middlee tertile
highestt tertile
Intensity y
Disability y
oddss ratio'
1.00 0
0.51 1
0.45 5
1.13 3
models models
1.00 0
0.50 0
0.42 2
1.22 2
95%% CI
Disabilityy including
deceasedd men
oddss ratioT
modelsmodels adjusted forage and country
0.29-0.89 9
0.25-0.81 1
0.81-1.58 8
1.00 0
0.59 9
0.59 9
0.89 9
adjustedadjusted for smoking, obesity, alcohol, age,
0.28-0.91 1
0.23-0.78 8
0.85-1.75 5
1.00 0
0.68 8
0.67 7
0.91 1
95%% CI
0.40-0.87 7
0.39-0.88 8
0.70-1.12 2
andand country
0.45-1.02 2
0.44-1.02 2
0.72-1.16 6
Abbreviations:: CI. confidence interval. ** polytomous logistic regression analyses: 3 categories of disability severity. tt polytomous logistic regression analyses: 3 categories of disability severity and 1 category of deceased men. %% reference category.
51 1
ChapterChapter 4
Discussio n n Thiss study shows that among relatively healthy men aged 70-89 years, total physical activity was
relatedd to decreased risk of disability 10 years later. Especially duration of physical activity was
associatedd with disability, whereas intensity was not. Addition of deceased men in our analyses
resultedd in weaker associations between physical activity and disability.
Forr the interpretation of our data, some methodological remarks on study design and selection bias
mustt be made. In order to create the most optimal design for the research question, men with
disabilityy at baseline were excluded. Although according to the definition of disability men who did
nott need help were included, these men might have had difficulties in performing activities of daily
livingg that contributed to lower physical activity. A large proportion of the population was excluded
inn the present study. However, the lower level of physical activity in this excluded group and the
higherr prevalence of disability and mortality 10 years later, point into the same direction as the
resultss of the men included in the analyses.
Selectionn bias caused by excluding men with missing values is also of concern. Men who were
removedd because of missing values on disability spent less time on physical activity and men
removedd because of missing values on physical activity had more disabilities than men included in
thee study. Also non respondents were known to have more disabilities/5556* It is however not known
whetherr the association between physical activity and disability is different in this group compared
too the men included in the present study.
Thee study population came from three countries, which differed in disability status and level of
physicall activity. Because the number of participants per country was too small to allow
comparisonss between countries, all participants were pooled. Since differences in circumstances
betweenn the countries, for example weather and physical environment (hills), could have affected
thee relationship between physical activity and disability, country was adjusted for, which resulted
onlyy in a small decrease of the associations between physical activity and disability.
Forr the present analyses elderly men with no disabilities at baseline were selected and were
thereforee relatively healthy. In addition, the amount of physical activity in these men was relatively
high,, even in men of the lowest activity group, who spent on average around 40 minutes per day
onn activities such as walking, bicycling, and gardening. Being active for 40 minutes per day is
consideredd good for health according to the Dutch physical activity guideline for elderly people that
recommendss 30 minutes per day of activities like walking and bicycling/96' However, the present
studyy suggests that spending around 100 minutes per day is even better.
Thee positive effect of physical activity on disability was found for both the middle and highest tertile
andd these odds ratios did not differ. This suggests a ceiling effect of physical activity. Earlier
52 2
PhysicalPhysical activity and disability
studiess on physical activity and disability from the United States and Hawaii did not find such a
ceilingg effect: the risk of disability decreased further between the middle and the most active
group.(86:88;91)) Studies on physical activity are however difficult to compare. One of the mentioned
studiess used tertiles of total energy expenditure, another used tertiles of frequency of certain
activities,, while the third used walking distances for determining the level of physical activity. In
general,, the dose-response curve of the relationship between physical activity and health benefit
showss that at higher levels of physical activity the effect levels off.<97) It is possible that in the
mentionedd studies from the United States and Hawaii the levels of physical activity were too low to
reachh the leveling off level, whereas in our study the physical activity level was much higher. In
general,, physical activity levels are known to be higher in European countries than in the United
Statess (United States: 38.3% inactive adults(98) versus 12% in the Netherlands<99)).
Inn addition to duration of physical activity, the effect of intensity was investigated. Earlier studies
investigatingg intensity of physical activity were not focused on disability but on diseases as health
outcomee and were described in a review that showed that the effect of intensity depended on the
individuall disease.(100) For example, for prevention of stroke moderate intensities were
recommended,, whereas for cardiovascular health a threshold of higher intensities seemed to be
better.. Our findings suggest that intensity of physical activity is not important for disability.
However,, our findings could be influenced by a limited measurement quantifying intensity.
Informationn about the intensity of walking, bicycling, gardening and farming was based on self-
report,, and for the other activities standard intensity values were used. Alternative methods would
bee to take into account individual physical fitness to determine relative intensity instead of absolute
intensityy or monitoring intensity directly. However, in another study using standard intensity values
perr activity, this kind of measurement was adequate to distinguish the effect of high and low
intensityy on coronary heart disease.(22) In our study only activities with an intensity above the
thresholdd of 2 kcal/kghour were included, and carrying out activities on a higher level seemed to
havee no additional effect on the prevention of disability. Further research on intensity of physical
activityy in relation to disability is recommended to confirm our results.
Inn the present study the role of selective mortality was also investigated. Although it is generally
assumedd that losses of follow-up due to death lead to underestimation of the association studied,
inclusionn of deceased men in our study led to weaker associations instead of stronger
associations.. Apparently, physical activity is a stronger determinant of disability than of mortality. It
iss possible that this is especially the case in our relatively healthy population with high levels of
physicall activity.
Physicall inactivity is known to occur together with other unfavourable lifestyle factors,'101} which
mightt confound the association between physical activity and disability. Because smoking,(86) body
masss index(102) and alcohol consumption003* appeared to be associated with disability in earlier
53 3
ChapterChapter 4
studiess and cluster with physical activity,'101 > these factors were adjusted for. The results of the
presentt study however showed that these lifestyle related factors hardly contributed to the
observedd association between physical activity and disability.
Althoughh we assumed that disability reflected the presence of chronic conditions at baseline, it is
possiblee that chronic conditions were present, while people were not yet disabled. Additional
analysess showed that chronic conditions such as myocardial infarction, stroke, and angina pectoris
weree associated with physical activity and with disability. However, exclusion of persons with these
chronicc conditions did not change the results, which confirms that the associations between lack of
physicall activity at baseline and higher levels of disability or mortality 10 years later were not
causedd by the presence of chronic conditions at baseline.
Inn order to translate the findings of this study to a public health message we have to consider that
physicall activity at older age might be a proxy for lifetime history of physical activity. If this is the
casee the observed effect of physical activity on disability late in life can be a result of life time
activityy pattern. However, the US Surgeon General's report on physical activity and health
suggestss that people of all ages can benefit from regular exercise.<20) Also an earlier program on
successfull ageing spread the message that it is never too late to begin healthy habits such as
moderatee physical activity.<104)
Inn conclusion, the results of the present study suggest that even in old age among relatively
healthyy men, a physically active lifestyle should be encouraged. Because the amount rather than
thee intensity of physical activity seemed to be important, there are more options for people to select
activitiess that can be incorporated into their daily lives. Spending 100 minutes per day on activities
likee walking, bicycling, and gardening decreases the risk of disability.
54 4
5 5 Disabilit yy and forma l hom e care
SubmittedSubmitted as: van den Brink CL., Tijhuis M., Klazinga N.S., Kromhout D., van den Bos GAM. Use of formal
homee care among elderly men according to need?
ChapterChapter 5
Abstrac t t
Objectiv ee - Due to pressure on professional home care, rationing and allocating care may conflict
withh the principle of equity, i.e. equal use for equal need. The aim of this study was to evaluate
whetherr use of formal home care (home nursing and home help) is according to need among
elderlyy men, using the Andersen model.
Method ss - Cross-sectional data was collected in 2000 by questionnaires, among 160 Dutch men
agedd 80 years and older in Zutphen, the Netherlands. Home nursing and home help were analysed
inn relation to need factors (e.g. chronic diseases, disability), predisposing (e.g. marital status), and
enablingg factors (e.g. occupation, informal care).
Result ss - Men with severe disability reported higher use of home nursing than men with no
disabilityy (odds ratio (OR): 20.6; 95% confidence interval (CI): 2.2, 188.8). Men who had more than
eightt years education used home nursing more often than men with less education (OR: 5.8; 95%
CI:: 1.0, 32.2). Home help was not associated with disability, but men who were married reported
lowerr use of home help (OR: 0.4; 95% CI: 0.2, 1.0).
Conclusio nn - The association of education with use of home nursing suggests inequity. Use of
homee help was not associated with health-related needs, but with marital status. Support by the
spousee decreases the demand for formal care, so there is no firm evidence for inequity in use of
homee help. Both phenomena require further attention in research and among care providers.
56 6
DisabilityDisability and formal care
Introductio n n Demographicc and epidemiologic transitions have resulted in increasing numbers of elderly people.
Ass a result, growing health care needs are expected in the decades to come, especially in long-
termm care. Because elderly people increasingly express the desire for care at home rather than
institutionalisation,, professional home care in elderly people should be sustained. However, there
iss a lot of pressure on professional home care nowadays, because of scarcity of financial
resources.. Rationing and allocating care can easily come into conflict with the principle of equity.
Thiss principle presupposes equal use for equal need. To evaluate whether use of care is according
too need for care, the model of Andersen can be used.{105) This model has often been applied to
evaluatee the use of a wide range of health care services, such as physical therapy, hospital
utilisation,, physician visits, home care, and institutional care.(106"114)
Accordingg to the model of Andersen, use of health care depends on three different groups of
determinants:: need factors, predisposing characteristics, and enabling resources. Equity in use of
caree is demonstrated when care use is explained by need or need-related factors. Inequity in use
off care is present if care use is explained by factors enabling or impeding use of health care. Need
factorss represent the most immediate cause for health service use, e.g. chronic diseases,
disability,, and perceived health. Earlier research showed that chronic diseases'1151 and
disability008112"114116117'' were associated with higher use of home care. For perceived health,
contradictoryy results were found. Some authors found a positive association with use of formal
homee care,<112:114;118> while others did not.<111;113;117)
Predisposingg characteristics refer to demographic and social structural characteristics, such as
age,, marital status, or living arrangement. From earlier research it is known that higher age<116) and
beingg widowed or living alone(108:111;112;114;117:118) are associated with higher use of home care.
Becausee help delivered by the spouse decreases the need for formal care, marital status and living
arrangementss can be considered as need-related predisposing factors.
Enablingg resources include the means and know-how people must have to obtain the services and
makee use of them, indicated by for example income or education. Studies on the association
betweenn income and formal home care use showed inconsistent results/111112114119'
Whetherr those in need of formal home care actually receive appropriate levels of care also
dependss on informal care. In the Andersen model informal care is an enabling or impeding factor.
Thee association between formal and informal care use is not unequivocal. There are two theories <120):: The first suggests an inverse association: informal caregivers are the preferred caregivers and
formall care is only delivered when informal care is not available ('hierarchical compensatory
model').(121>> The second suggests a positive association between formal and informal care, and
statess that the presence of informal care facilitates use of formal care ('bridging hypothesis').022'
57 7
ChapterChapter 5
Mostt studies in which use of home care was evaluated by the Andersen-model, were performed in
specificc patient groups, such as patients with stroke or rheumatoid arthritis.(108;111;117) Studies
directedd at the elderly did not investigate the effect of need factors, predisposing characteristics,
andd enabling resources simultaneously/116118;119:123) or were outdated/112"114'
Inn the present study we focused on elderly men, using more recent data and different groups of
determinantss simultaneously.
Thee aim of the present study is to evaluate whether use of formal home care is according to need
inn elderly men from the Netherlands.
Method s s
Studyy population
Thee present study has a cross-sectional design and used data collected on use of health care in
20000 in the Zutphen Elderly Study,(124) which belongs to the Seven Countries Study.(36) The
Zutphenn Elderly Study is a longitudinal population-based study in elderly men, born between 1900
andd 1920 and living in the town of Zutphen in the Netherlands. Of the 939 men enrolled in 1985,
2355 men were still alive in 2000. Of these survivors, 171 men participated, which corresponds with
aa response rate of 73%. Two participants were excluded because they lived in an institution. The
analysess were restricted to 160 men with complete information on chronic diseases, disability, and
formall care use.
Formall home care
Usee of formal home care was assessed as receiving home nursing or home help (yes/no) in the
previouss year. Home nursing particularly concerns personal care and nursing, while home help
concernss household activities. Both types of care were analysed separately and were
dichotomisedd as users versus non-users.
58 8
DisabilityDisability and formal care
Needd factor s
Needd factors comprised chronic diseases, disability severity and self-rated health. Information on
prevalencee of chronic diseases was collected for the following chronic conditions: myocardial
infarction,, stroke, diabetes, asthma, cancer, rheumatoid arthritis, chronic back complaints, and
arthrosis.. In the analyses one variable was used for the absence or presence of chronic diseases.
Disabilityy severity was based on 13 items of activities of daily living, which were grouped into three
domains: :
•• instrumental activities of daily living: preparing meals, doing light and heavy housework;
•• mobility: moving outdoors, using stairs, walking 400 meters, carrying a heavy object for 100
meters; ;
•• basic activities of daily living: walking indoors, getting in and out of bed, using the toilet,
washingg and bathing, dressing and undressing, feeding oneself.
Disabilityy in a domain was defined as needing help on at least one item of the domain. Disability
severityy was based on the hierarchical order of the three disability domains, which was described
inn earlier studies.(8;70)The following classification was used:
0.. no disability;
1.. mild disability (instrumental activities);
2.. moderate disability (instrumental activities and mobility);
3.. severe disability (all domains).
Twoo and a half percent of the men did not fit the hierarchy. One man who reported disability in
mobility,, but not in instrumental activities, was classified in category 2. Three men who reported to
needd help with instrumental and basic activities, but not with mobility were classified in category 3.
Categoryy 2 and 3 were combined, because of small numbers in those groups.
Globall self-rated health was assessed with a single-item question: 'How would you rate your
overalll health', with four answer categories: 1) healthy, 2) rather healthy, 3) moderately healthy, 4)
nott healthy. The categories 1 and 2, and the categories 3 and 4 were combined to 1) healthy; 2)
unhealthy. .
Predisposin gg factor s
Predisposingg factors included age and marital status. Age was dichotomised with 85 years as cut
offf point. Marital status was dichotomised as married versus not married. Of the 65 men who were
nott married, 4 were never married, 4 were divorced and 57 were widowed. Living arrangement was
nott included additionally, since most men who were married did not live alone (96%), and men who
weree not married most often lived alone (94%).
59 9
ChapterChapter 5
Enablin gg factor s
Enablingg factors encompassed occupation, education, and informal care. The information on
occupationn and education was based on the survey in 1990. Occupation was defined as the
professionn that was held during the major part of the working life. We dichotomised occupation as
highh versus low level. High occupation consisted of professionals and high-level managers and
high-levell teachers. Low occupation consisted of middle-level managers and middle-level teachers,
smalll business owners, nonmanual and manual workers.
Forr educational level the total number of years of education was asked and was categorised into
tertiles:: low: < 8 years; b) moderate: 9-12 years; c) high: > 13 years.
Informall care was defined as receiving assistance of the spouse, family members, neighbours, or
acquaintancess in the previous year. Receiving informal care was dichotomised (yes/no).
Statistica ll analyse s
Too investigate the crude associations between the determinants and use of formal home care,
generall linear models were used to assess the prevalence of formal home care for each factor.
P-valuess were calculated to determine whether differences in use of home care were statistically
significantt between categories.
Multivariatee logistic regression analyses were carried out to investigate the independent
associationss (odds ratios and 95% confidence intervals) of the need, predisposing, and enabling
factors,, in relation to use of home nursing and home help.
Inn addition, we calculated how much of the variation in home care use was explained by the
independentt variables in our models, also by using multivariate logistic regression analyses.
Statisticall analyses were performed using SAS, version 9.1 (SAS Inc., Cary, NC). All tests were
two-tailedd and a p-value < 0.05 was considered to be statistically significant.
Result s s
Menn included in this study were between 79.6 and 99.7 years old with a mean age of 84.5 years.
Tablee 5.1 shows the characteristics of the study population. About 70% of the men reported
chronicc diseases, 30% reported no disability, while 38% had severe disability. Only 17% of the
menn felt not healthy. More than 60% of the men were married. The mean educational level was
11.22 years and 40% had a high occupational level. Thirty percent of the men used formal care:
14%% received home nursing and 23% received home help. More than half of the men received
informall care (58%).
60 0
DisabilityDisability and formal care
Tablee 5.1 Prevalence of need, predisposing, and enabling factors and the association with use of home
nursingg and home help
NeedNeed factors
Chronicc diseases
no o
yes s
Disabilityy severity
noo disability
mildd disability
severee disability
Self-ratedd health
healthy y
unhealthy y
PredisposingPredisposing factors
Age e
80-855 years
85-1000 years
Maritall status
married d
nott married
EnablingEnabling factors
Occupation n
low w
high h
Education n
low w
moderate e
high h
Informall care
no o
yes s
inn elderly men (n=160).
** trend is statistically significant (p < 0.01). tt difference is statistically significant (p < 0.01).
n n
49 9
111 1
48 8
52 2
60 0
131 1
27 7
104 4
56 6
98 8
62 2
89 9
60 0
44 4
59 9
46 6
64 4
90 0
61 1
Homee nursing
8% %
17% %
2%" "
6% %
32% %
13% %
22% %
11% %
21% %
12% %
18% %
12% %
15% %
7% %
17% %
15% %
9% %
17% %
Homee help
12%+ +
27% %
13%' '
23% %
30% %
2 1 % %
30% %
21% %
25% %
16%* *
32% %
24% %
23% %
23% %
32% %
13% %
23% %
22% %
ChapterChapter 5
Determinant ss of use of forma l hom e care
HomeHome nursing
Disabilityy severity was significantly associated with the use of home nursing (table 5.1). While 2%
off men without disability received home nursing, about one third of the men with severe disability
receivedd home nursing. Neither the other need factors, nor predisposing and enabling factors were
significantlyy associated with use of home nursing.
HomeHome help
Thee need factors chronic diseases and disability severity were both associated with the use of
homee help (table 5.1). Use of home help among men with chronic diseases was more than twice
thatt of men without chronic diseases. Thirteen percent of men without disability used formal home
help,, 23% of the men having mild disability used home help, and 30% of men with severe disability
usedd home help. Also predisposing factors were of influence. Use of formal home help among men
whoo were not married was twice that of married men. None of the enabling factors were associated
withh use of formal home help.
Multivariat ee model s
HomeHome nursing
Too investigate the independent associations between the determinants and use of formal home
care,, multivariate logistic regression models were used (table 5.2). In accordance with the single
factorr analysis of table 5.1, the results showed that for use of home nursing, severe disability was
thee predominant explaining factor (p = 0.003), after adjustment for the other variables. The other
needd factors chronic diseases and self-rated health, and the predisposing factors did not contribute
too the use of home nursing. Of the enabling factors, higher educational level was associated with
higherr use of home nursing than low educational level. When the two highest tertiles of education
weree combined, the effect was statistically significant (p-value 0.045; odds ratio 5.8).
Additionall analyses showed that 19% of the variation in use of home nursing could be explained by
alll included independent variables together. About 14% of the variation was explained by the need
factorr disability. Educational level explained almost 2%.
HomeHome help
Thee multivariate analyses for use of home help showed different results compared to the univariate
analysess (table 5.2). None of the need or enabling factors were significantly associated with use of
homee help after adjustment for the other factors. The predisposing factor marital status was
62 2
DisabilityDisability and formal care
borderlinee statistically significantly associated with use of formal home help (p=0.058). Men who
weree not married received home help more often than those who were married.
Thee model of need, predisposing, and enabling factors explained 11 % of the variation in use of
homee help. Approximately 3% was explained by marital status.
Tablee 5.2 Multivariate logistic regression analyses (odds ratios and 95% confidence intervals) with use of
formall home care as dependent variable based on the Andersen model.
Homee nursing Homee help
NeedNeed factors
Chronicc diseases
noo (n=43)
yess <n=97)
Disabilityy severity
noo (n=45)
mildd <n=47)
severee (n=48)
Self-ratedd health
healthyy (n=115)
unhealthyy (n=25)
PredisposingPredisposing factors
Age e
80-855 years (n=94)
85-1000 years <n=46)
Maritall status
nott married (n=52)
marriedd (n=88)
EnablingEnabling factors
Occupation n
loww (n=82)
highh (rt=58)
Education n
loww (n=38)
moderatee (n=58)
highh (n=44)
Informall care
noo (n=58)
yess (n=82)
1.0 0
0.7(0.1,3.7) )
1.0 0
1.5(0.1,, 17.7)
20.66 (2.2, 188.8)
1.0 0
0.88 (0.2, 3.3)
1.0 0
1.4(0.4, ,
1.0 0
1.2(0.4, ,
4.7) )
4.3) )
1.0 0
0.5(0.1,2.0) )
1.0 0
5.9(1.0,34.8) )
5.55 (0.8, 40.4)
1.0 0
2.99 (0.7, 12.2)
1.0 0
1.6(0.5,4.9) )
1.0 0
2.55 (0.8, 7.9)
2.66 (0.8, 8.5)
1.0 0
1.3(0.5,3.9) )
1.1 1
0.4 4
1.0 0
(0.4,, 2.5)
1.0 0
(0.2,, ' 0) )
1.0 0
1.5(0.6,3.8) )
1.0 0
1.4(0.5,4.0) )
0.4(0.1,1.6) )
1.0 0
0.8(0.3,1.9) )
'' All independent variables were included in the same model.
63 3
ChapterChapter 5
Discussio n n
Thiss study among elderly men aged 80 years and older from the Netherlands aimed to evaluate
whetherr use of home care was according to need. We evaluated the principle of equal use for
equall need on the basis of the Andersen model, by distinguishing need, predisposing, and
enablingg factors. Disability severity was the predominant explaining factor of use of home nursing.
Inn addition, use of home nursing was associated with education. Men with higher educational level
usedd home nursing more often than men with low educational level. Predisposing and the other
enablingg factors were not statistically significantly associated with the use of home nursing.
Althoughh use of home nursing was associated with need factors, our findings showed that inequity
cannott be ruled out. For use of home help the multivariate analyses showed that none of the need
orr enabling factors were associated. Marital status was borderline statistically significantly
associatedd with use of home help: married men used home help less often than those not married.
Becausee support by the spouse decreases the demand for formal home help, there is no firm
evidencee for inequity in the use of formal home help.
Inn the present study there was selection bias in health status due to non-response. The non-
respondentss in 2000 reported more disabilities in 1995 and were older than the respondents. As a
consequencee the prevalence of disability in this population has been underestimated. Men who
weree excluded because of missing values on disability or formal care use, hardly differed from
thosee included in the analyses. The relatively small number of participants have caused the wide
confidencee intervals and the lack of statistical significance in some analyses.
Ourr data on use of home nursing and home help was restricted to the prevalence of care use. No
informationn was available on the frequency or intensity of care received.
Additionally,, we have to realise that our population came from one town in the eastern part of the
Netherlands.. Our results can probably not be generalised to other populations, because of e.g.
differentt population characteristics, cultural aspects and capacity of home care.
Ourr hierarchical disability scale was the predominant explaining factor of use of home nursing.
Accordingg to an earlier study among elderly people, in which also disability domains were
distinguished,, men with disability in instrumental activities received less home care than those with
disabilityy in basic activities of daily living.(116) Our results were also comparable with studies among
elderlyy people that evaluated use of home care using the Andersen model.<113;114) These studies
showedd that disability was more important than perceived health, and the amount of explained
variancee in these studies was comparable with ours. The amount of the total explained variance
wass not very high, but the relative contribution of disability was considerable.
64 4
DisabilityDisability and formal care
Accordingg to our results, use of home nursing was also associated with a higher educational level.
Thiss is in accordance with another Dutch study that demonstrated that people who are higher
educatedd are more inclined to search help when suffering from disabilities.025' Furthermore, people
withh lower education were admitted to a nursing home earlier than those with higher
education/107125'' These findings suggest inequity in use of home nursing.
Althoughh the distribution of home nursing was associated with need, it is possible that there is
underusee of home nursing at all levels of disability severity. For example, among men with severe
disabilityy in our study, only 32% received home nursing. Although among those with severe
disabilityy who did not receive home nursing, more than 60% received informal care, delivery of
caree by informal caregivers might be insufficient to meet the needs for personal care and nursing.
Inn contrast with home nursing, formal home help was not associated with health-related need
factors,, but was associated with marital status only. Men who were not married reported a higher
usee of formal home help than married men. Although disability severity was univariately associated
withh use of home help, this association disappeared after adjustment for marital status. This
suggestss that use of home help is not associated with health-related disability, but with situational
disability.. While disability among married men can be taken care of by the spouse, those who are
nott married are dependent on formal caregivers. Also earlier studies among elderly people and
peoplee with chronic diseases showed that widowers and people living alone received more home
caree than married people.(108;111;112;114:117;118>
Thee inverse association of being married with use of formal home help supports the 'hierarchical
compensatoryy model', which supposes that professional care is a substitute for informal care when
thiss informal care is not available. Support for this hypothesis was also found in an earlier Dutch
studyy that showed that after adjustment for disability severity, the presence of informal care and a
higherr number of network members were inversely associated with the use of formal home
help.'112'' No firm conclusions can be drawn on the bridging hypothesis, because of small numbers.
However,, the results suggest a positive association of informal care with use of home nursing.
Additionall analyses revealed that especially the presence of non-partners as informal caregivers
seemedd to facilitate the use of home nursing (not shown). These results were in accordance with
thee results of a recent Dutch study that showed a positive association between informal care and
formall care, and that the positive association was strongest when non-partners were involved.020'
Ourr analyses focused on characteristics of participants. However, access to formal care will also
dependd on characteristics of the health care system. In the Netherlands, financing of home care is
att present covered by the General Law on Special Medical Expenses (AWBZ). This law concerns
65 5
ChapterChapter 5
thee insurance of all Dutch citizens for care and support in cases of protracted illness, invalidity, or
geriatricc diseases. In the needs assessment under this Law the presence of a spouse or other
informall caregivers is taken into account.<126) In the present study, use of home help was borderline
significantlyy associated with marital status. However, use of home help was not associated with
health-relatedd need factors. This finding underpins the current reforms of the health care system in
thee Netherlands. In order to control the costs, in 2006 the AWBZ will be restricted to care, such as
homee nursing. Support, such as home help, will disappear from the AWBZ and becomes part of
thee new Law on Social Support (WMO). If family members are able to provide care, citizens will
receivee less or no support. The current government aims to promote individual responsibility, which
mightt be problematic for people without the availability of informal caregivers and those with lower
incomes.. In a few years it should be evaluated whether people who need home help actually
receivee this in the new system.
Inn supporting elderly people to stay home as long as possible, equal access to home care is
essential.. The results of the present study suggest that inequity in the use of home nursing cannot
bee ruled out, because the level of education influenced the use of home nursing. Especially those
whoo are lowly educated require attention. Use of home help was not health-related, but was
associatedd with marital status. Because support by the spouse decreases the demand for formal
homee help, there is no firm evidence for inequity in use of home help. However, the current reforms
off the Dutch health care system might cause changes in use of home help that merit careful
evaluation. .
66 6
6 6 Disabilit yy and depressiv e symptom s
WillWill be published as: van den Brink C.L., Tijhuis M.A.R., Aijönseppa S., Giampaoli S., Nissinen A., Kromhout
D.,, van den Bos G.A.M. Hierarchy levels, sum score and worsening of disability are related to depressive
symptomss in elderly men from three European countries.
JournalJournal of Aging and Health. In press.
ReprintedReprinted by Permission of Sage Publications, Inc.
ChapterChapter 6
Abstrac t t Objectiv ee To investigate the predictive value of hierarchy levels and sum score of disability, and
changee in disability on depressive symptoms.
Method ss Longitudinal data of 723 men aged 70 years and older of the Finland, Italy, and the
Netherlandss Elderly Study was collected in 1990 and 1995. Self-reported disability was based on
threee disability domains (instrumental activities, mobility, and basic activities) and depressive
symptomss on the Zung questionnaire.
Result ss Severity levels of disability were positively associated with depressive symptoms. Men
withh no disability scored 5 to 17 points lower (p<0.01) on depressive symptoms than those with
disabilityy in all domains. Among men with mild disability, those who had worsening of disability
statuss in the preceding 5 years scored 5 points higher (p=0.004) on depressive symptoms than
menn who improved.
Conclusio nn Hierarchic severity levels, sum score of disability, and preceding changes in disability
statuss are risk factors for depressive symptoms.
68 8
DisabilityDisability and depressive symptoms
Introductio n n Depressivee symptoms are considered to be the most common mental health problem in later life.
Depressivee symptoms are associated with lower quality of life and well-being,027128' a higher risk of
mortality'129130'' and a higher use of health care services.028' To prevent depressive symptoms,
moree knowledge is needed about risk factors for depressive symptoms.
Disabilityy among elderly people was associated with depressive symptoms in cross-sectional'131"136>
andd in longitudinal studies.*137"144' Disability in these studies was expressed as a sum score of
variouss disability items. It is however to be expected that besides the number of disabilities the
hierarchicc severity of the disability is also predictive of depressive symptoms. These severity levels
off disability can be expressed on the basis of different disability domains, that is instrumental
activities,, mobility, and basic activities of daily living, that are known to be hierarchically
associated.(8)) This means that people with disability in basic activities also have disability in the
otherr domains and that people with mobility disability are also disabled in instrumental activities.
Thee different hierarchy levels reflect the degree of dependence on other people. People with
disabilityy in basic activities need more help than people disabled in instrumental activities. We
thereforee hypothesised that the hierarchic severity of disability is a predictor of depressive
symptomss independent of the association of the sum score of disability with depressive symptoms.
Nott only current disability status, but also preceding change in disability status might influence
depressivee symptoms. Depressive symptoms are also influenced by changing circumstances, such
ass retirement, disability, or move to a nursing home.045146' Only a few of the mentioned longitudinal
studiess considered the effect of change in disability044' and reported that worsening of disability
statuss was related to depressive symptoms.038' The present study investigated whether current
disabilityy or change in disability is the predominant predictor of depressive symptoms.
Ann earlier study on the association between disability and depressive symptoms, carried out in
differentt countries worldwide, showed that the association was universal,047' but somewhat
strongerr in regions with a low prevalence of depressive symptoms. Studies comparing countries in
Europee showed that, in general, people in northern Europe reported fewer disabilities048' than
peoplee in southern Europe. Also depression score was known to be lower in northern Europe than
inn southern Europe.048149' In the current study we investigated whether the associations of
disabilityy with depressive symptoms differed among countries.
Thee aim of the present study was to investigate the association of the sum score and hierarchic
severityy levels of disability with depressive symptoms, and the association of the severity levels of
disabilityy with depressive symptoms, independent of the association of the sum score of disability.
Furthermoree the effect of preceding change in disability status on depressive symptoms was
69 9
ChapterChapter 6
investigated.. Finally, the various associations were compared between three European countries:
Finland,, the Netherlands, and Italy.
Method s s
Stud yy populatio n
Thee present study has a longitudinal design and used data of the Finland, Italy, and the
Netherlandss Elderly (FINE) Study, collected around 1990 and 1995. The FINE Study began in
19855 as a continuation of the Seven Countries Study,(36) and is focused on elderly men, born
betweenn 1900 and 1920. Detailed information about the FINE Study and its populations has been
reportedd elsewhere.(43)
Inn 1990, 1416 men were examined (response rates: Finland 90%, the Netherlands 78%, Italy
79%).. Between 1990 and 1995, 37% of the Finnish men died, 27% of the Dutch men died, and
20%% of the Italian men died. The response rates in 1995 were about the same as in 1990. The
presentt study included men who participated in both 1990 and 1995. A total of thirteen percent of
thee men were excluded from the analyses because of missing data on disability or depressive
symptoms.. The present study included 723 participants: Finland 221, the Netherlands 284, and
Italyy 218.
Disabilit yy (1990 and 1995)
Disabilityy was measured by a standardised questionnaire about daily routine activities.(8) Three
domainss were assessed:
•• instrumental activities of daily living (3 items): preparing meals, doing light and heavy
housework, ,
•• mobility (4 items): moving outdoors, using stairs, walking 400 meters, carrying a heavy object
forr 100 meters,
•• basic activities of daily living (6 items): walking indoors, getting in and out of bed, using toilet,
washingg and bathing, dressing and undressing, feeding oneself.
Thee participants were classified as being disabled on a certain item if they reported a need for help
orr were not able to perform that activity. A sum score was determined by counting the number of
disabilities.. The hierarchic severity level of disability was based on the ranking of the three
domains.. Disability in a domain was defined as disability in at least one item of that domain. The
domainss were hierarchically ordered as follows<8): Men who were disabled in basic activities were
alsoo disabled in mobility and instrumental activities of daily living. Men who were disabled in
mobilityy were also disabled in instrumental activities. The following hierarchic severity levels were
70 0
DisabilityDisability and depressive symptoms
distinguished:: 0) no disability, 1) mild disability: disability in instrumental activities only, 2) moderate
disability:: disability in instrumental activities and mobility, 3) severe disability: disability in
instrumentall activities, mobility and basic activities of daily living.
Changee in disability status was defined as change in hierarchic severity levels between 1990 and
19955 and was categorised as follows: 1) severe worsening: change of 2 or 3 levels to a worse
level;; for example, change from no disability to moderate or severe disability, 2) moderate
worsening:: change of 1 level to a worse level, 3) stable: stay in same level, 4) improving: change to
aa better level.
Depressiv ee symptom s (1990 and 1995)
Thee scale used to measure depressive symptoms in this study was the Self-rating Depression
Scalee (SDS) developed by Zung.<150) The questionnaire consisted of 20 items based on clinical
diagnosticc criteria most commonly used to characterise depressive disorders in terms of mood and
biologicall and psychological disturbances. In all, 10 items were worded symptomatically positive
andd 10 were worded symptomatically negative. Examples of items are: 'I feel down and sad', and 'I
cann think as clearly as before'. The items were coded as 1=never, 2=sometimes, 3=often, and
4=(almost)) always. For scoring the Self-rating Depression Scale, the positively worded items were
recoded,, so that a higher score indicated more depressive symptoms. An index for the SDS was
derivedd by dividing the sum of the item scores by 80 and multiplying it by 100, resulting in a range
fromm 25 to 100. Participants with more than 2 missing values on the 20 items were excluded. In
casee of 1 or 2 missing items, the mean score of the present items of the participant was given to
thee missing items.
Statistica ll analyse s
Forr each country the cross-sectional association between disability and depressive symptoms was
determinedd by calculating the mean level of depressive symptoms by sum score of disability and
byy hierarchic severity level of disability in 1990 and 1995. To determine the strength of these
associations,, the standardised beta and the explained variance were calculated by linear
regressionn analyses. The four categories of disability were put into the model as a continuous
variable.. To investigate whether the level of depressive symptoms differed between the countries,
regressionn analysis was performed with dummy variables for each country, with Finland as the
referencee group, adjusted for disability. To investigate whether the association between disability
andd depressive symptoms differed among countries, interaction terms of disability and country
weree added to the linear regression model.
Too investigate whether the hierarchic severity level of disability has additional value as predictor of
depressivee symptoms independent of the sum score of disabilities, cross-sectional analyses
71 1
ChapterChapter 6
(generall linear models) were carried out. The effect of hierarchic severity level of disability on
depressivee symptoms was investigated, stratified by the sum score of disability. For example,
amongg men with a sum score of two disabilities, the level of depressive symptoms of men with two
mildd disabilities (severity level 1) was compared with that of men with one mild and one moderate
disabilityy (severity level 2). Regression analysis was performed to determine the p for trend. For
menn with three disabilities and for men with four to six disabilities, the effect of hierarchic severity
levell was determined analogously. Men with seven or more disabilities were all in the level of
severee disability, so the analyses were not extended further.
Whetherr preceding change in disability was a predictor of depressive symptoms in addition to
currentt disability status was investigated by calculating the level of depressive symptoms for each
categoryy of change in the past 5 years, keeping current disability status (in 1995) constant. Firstly,
withinn the group of men with mild disability in 1995 (hierarchic severity level 1), men who had this
disabilityy already in 1990 were compared with men who developed this disability in the past 5 years
andd with men who improved in disability status during the past 5 years. The same analysis was
performedd among men with moderate disabilities in 1995 (hierarchic severity level 2) and among
menn with severe disabilities (hierarchic severity level 3). Regression analyses were performed to
determinee the p for trend. In these analyses, depressive symptoms in 1990 and country were
adjustedd for. To investigate whether the effects differed among countries, interaction terms
betweenn country and the independent variable were added.
Thee analyses were also adjusted for widowhood because widowhood appeared to be associated
withh both disability and depressive symptoms.
Statisticall analyses were performed using SAS version 8.2 (SAS Inc., Cary, NC). All tests were
two-tailedd and a p-value < 0.05 was considered to be statistically significant.
Result s s
Characteristicss of the study population are shown in table 6.1. Italian men were about 1.5 years
olderr and reported more disabilities in 1990 than Finnish and Dutch men (p = 0.0025). In both
years,, Italian men reported more depressive symptoms than Finnish and Dutch men (p < 0.0001).
Thesee differences were not explained by differences in age among the countries. Dutch men had
receivedd about six years more education and were less often widowed than Finnish and Italian
men. .
Aboutt 38% of men from Finland and the Netherlands reported worsening in disability between
19900 and 1995, compared to 28% of the Italian men. Although age and years of education varied
acrosss the populations, these variables did not confound the association between disability and
depressivee symptoms. The results are therefore shown unadjusted for these variables.
72 2
Tablee 6.1 Characteristics of the study populations.
Finland d
nn = 221
DisabilityDisability and depressive symptoms
Netherlands s
nn = 284
Italy y
nn = 218
1990 1990
Meann age (sd)
Meann number of years of education (sd)
Widowhoodd (% widowed)
Disabilityy sum score
meann sum score (sd)
Disabilityy hierarchic severity level
noo disability
mildd disability
moderatee disability
severee disability
Levell of depressive symptoms
Meann score (range 25-100)(sd)
Widowhoodd (% widowed)
Disabilityy sum score
meann sum score of disabilities
Disabilityy hierarchic severity level
noo disability
mildd disability
moderatee disability
severee disability
Levell of depressive symptoms
meann score (range 25-100)(sd)
Disabilityy change
improving g
stable e
moderatee worsening
severee worsening
** significantly different from Finland, tested by analysis tt significantly different from the Netherlands. tt significantly different from Italy.
75.0(4.1) )
4.4(3.1)T T
27% %
0.8(1.8)* *
65%* *
27% %
3%* *
5% %
45.44 (9.6)**
38% %
2.0(3.1) )
44% %
29% %
11%* *
16%* *
48.9(12.1)* *
8%* *
52% %
25%* *
14% %
off variance or chi
73 3
74.77 (4.3)
10.7(4.1)** *
19% %
0.8(1.6)* *
6 1 % %
30% %
8%* *
1% c c
41.8(8.7)** *
1995 1995
27% %
1.6(2.3) )
4 1 % * *
33%* *
19%** *
7%** *
45.77 (9.8)"*
1990-1995 1990-1995
7%* *
55% %
27%* *
11% %
-squaree test, p < 0.05.
76.44 (3.5)*T
5.00 (2.4)*
28% %
1.3(1.7)'* *
53%' '
32% %
6% %
9%b b
49.2(11.1)** *
33% %
1.7(2.7) )
51%* *
24%* *
10%* *
15%* *
50.77 (10.8)*
20%** *
52% %
17%** *
11% %
ChapterChapter 6
Cross-sectiona ll associatio n betwee n disabilit y and depressiv e symptom s
Inn all countries, in both 1990 and 1995, the sum score and the hierarchic severity levels of disability
weree positively associated with depressive symptoms (table 6.2). For example in Finland, men with
threee or more disabilities scored about 11 points higher on depressive symptoms than men without
disabilities.. Concerning the hierarchic severity level of disability, for example Italian men with
severee disability scored 5 points higher on depressive symptoms than those with moderate
disability,, who scored 5 points higher than men with mild disability, who scored 5 points higher than
thosee without disability. All p-values showed statistically significant trends indicating more
depressivee symptoms with higher levels of disability (table 6.2). In general, the strength of the
associationn between the hierarchy score of disability and depressive symptoms seemed to be
slightlyy higher than that between the sum score and depressive symptoms, which is indicated by
thee standardised betas and the explained variance (table 6.2).
Regressionn analyses showed that after adjustment for disability severity, Italian men had the
highestt score on depressive symptoms and Dutch men had the lowest score in both survey years
(pp < 0.0001). Addition of interaction terms of disability and country to the models showed that the
associationn of disability and depressive symptoms differed significantly among the countries (p =
0.01).. In the Netherlands, the strength of the association was smaller than in the other countries.
Thiss difference in the strength of association reached only statistical significance in 1990.
Hierarchi cc severit y leve l of disabilit y as predicto r of depressiv e symptoms , independen t of
th ee sum scor e of disabilitie s
Wee also investigated the additional value of hierarchic severity level of disability for a given sum
score,, as predictor of depressive symptoms (table 6.3). Among men with a sum score of two
disabilities,, men who had only mild disabilities scored 4 points lower on the scale of depressive
symptomss than men who had one mild and one moderate disability. This difference was only
borderlinee significant (p = 0.09). Among men with three disabilities a similar trend was seen: men
withh mild disability scored 7 points lower on depressive symptoms than men with severe disability
(pp = 0.07). Among men with four to six disabilities the trend was similar (p = 0.11). Furthermore,
tablee 6.3 shows that in each hierarchic level of disability, depressive symptoms do not vary with the
numberr of disabilities (= sum score).
Additionn of interaction terms between severity level of disability and country did not show
significantt differences in the effect of disability on depressive symptoms between the countries (2
disabilities:: p for interaction = 0.73; 3 disabilities: p for interaction = 0.33).
74 4
DisabilityDisability and depressive symptoms
Tablee 6.2 Cross-sectional association of sum score and hierarchic severity level of disability with
depressivee symptoms in 19900 and 1995, adjusted
Finland d (nn = 221)
forr widowhood.
Netherlands s (nn = 284)
Italy y (nn = 218)
depressivee symptoms
Summ score
noo disability
11 disability
22 disabilities
33 or more disabilities
standardisedd beta
explainedd variance
Hierarchyy severity level
noo disability
mildd disability
moderatee disability
severee disability
standardisedd beta
explainedd variance
Summ score
noo disability
11 disability
22 disabilities
33 or more disabilities
standardisedd beta
explainedd variance
Hierarchicc severity level
noo disability
mildd disability
moderatee disability
severee disability
standardisedd beta
explainedd variance
43.1 1
48.9 9
53.1 1
54.4 4
0.39 9
16% %
42.7 7
48.9 9
56.0 0
54.8 8
0.40 0
17% %
43.3 3
48.0 0
56.2 2
57.9 9
0.51 1
27% %
43.1 1
49.7 7
56.1 1
58.7 7
0.49 9
25% %
1990:1990: depressive symptoms
41.6 6
43.7 7
45.3 3
44.8 8
0.15 5
3% %
40.7 7
43.0 0
44.6 6
45.8 8
0.16 6
4% %
1995:1995: depressive symptoms
42.4 4
43.8 8
50.0 0
51.6 6
0.39 9
15% %
42.6 6
45.1 1
51.0 0
56.6 6
0.42 2
18% %
46.0 0
50.8 8
51.2 2
55.7 7
0.34 4
11% %
45.9 9
50.5 5
55.6 6
60.4 4
0.40 0
16% %
47.8 8
49.3 3
50.1 1
60.0 0
0.44 4
22% %
47.5 5
48.8 8
54.8 8
64.4 4
0.53 3
29% %
75 5
ChapterChapter 6
Tablee 6.3 The effect of hierarchic severity level of disability on depressive symptoms in 1995, given a total
numberr of disabilities {=sum score), adjusted for widowhood and country.
Disabilityy severity level
Mildd disability
Moderatee disability
Severee disability
pp for trend
22 disabilities
(nn = 94)
49.6 6
53.7 7
0.09 9
Depressivee symptoms
33 disabilities
(nn = 57)
49.1 1
53.5 5
56.1 1
0.07 7
4-66 disabilities
(nn = 52)
52.2 2
56.7 7
0.11 1
** mild disability - in instrumental activities of daily living (3 items); moderate disability - in instrumental activities, and mobilityy (4 items); severe disability - in mobility, instrumental, and basic activities of daily living (6 items).
Tablee 6.4 Mean level of depressive symptoms by preceding change in disability, stratified by current level of
disabilityy status (1995), adjusted for depression score in 1990, becoming widowed, and country.
Disabilityy change
1990-1995 5
Severee worsening
Moderatee worsening
Stable e
Improving g
pp for trend
noo disability
(n=325) )
44.7 7
41.5 5
0.006 6
Currentt disability
mildd disability
(n=204) )
48.5 5
45.6 6
43.7 7
0.004 4
statuss (1995)
moderatee disability
(n=102) )
54.5 5
52.2 2
52.4 4
49.2 2
0.20 0
severee disability
(n=87) )
59.9 9
60.7 7
60.6 6
0.77 7
Chang ee in disabilit y and depressiv e symptom s
Thee analyses on the effect of change in disability were stratified by current disability status and
showedd that change in disability was predictive of depressive symptoms (table 6.4). The level of
depressivee symptoms in 1995 was 3 points higher among men who developed mild disability
duringg the past 5 years than among those who already had this disability in 1990. Furthermore,
menn who improved toward the status of mild disability during the past five years scored 2 points
lowerr level on depressive symptoms compared to those who remained stable. The p-value for the
trendd was statistically significant (p=0.004). Among men with moderate disability in 1995, the same
trendd was observed, although statistically significance was not reached (p=0.20). For men who
reportedd severe disability in 1995, depressive symptoms did not depend on preceding change in
disabilityy (p=0.77).
Furthermore,, current disability status had the highest effect, because men with worse current
disabilityy status had higher levels of depressive symptoms, independent of preceding change.
76 6
DisabilityDisability and depressive symptoms
Additionn of the interaction between country and change in disabilities to the model did not show
differencess in effects of change on depressive symptoms among countries (p-values for
interaction:: 0.70-0.81).
Discussio n n
Thiss study among men aged 70 to 89 years at baseline from Finland, the Netherlands, and Italy
showedd that both the hierarchic severity levels and the sum score of disability were associated with
depressivee symptoms. The strength of the association with hierarchic severity levels seemed to be
slightlyy higher than that with the sum score. The results testing the hypothesis that the hierarchic
severityy level of disability was a predictor of depressive symptoms independent of the sum score of
disabilityy were borderline statistically significant. Men with a worsening of disability status in the
previouss 5 years had more depressive symptoms than those who remained stable or improved,
whichh is in accordance with our hypothesis.
Somee methodological remarks need to be made. Although standardised questionnaires were used
inn the different countries, some differences among countries caused by translation or interpretation
off the items might still exist. Furthermore, the assessment of disability might be influenced by the
presencee of depressive symptoms, because self-reports are subject to individual's emotional
states.(132)) In the interpretation of the results, possible overestimation of the association between
disabilityy and depression must therefore be taken into account. However, the longitudinal analyses
inn which changes in disability status were investigated, sustained the cross-sectional observations.
Earlierr reports showed that in the Netherlands and Italy, non-respondents had more severe
disabilitiess than respondents.(55;56) In the present study, selection bias might also have occurred
becausee of exclusion of men with missing values. Men excluded from this study were 1 year older,
reportedd more disabilities and scored 5 points higher on the scale of depressive symptoms.
Furthermore,, exploration of the data showed that the association of disability and depressive
symptomss was somewhat stronger among men who were excluded than among men who were
included,, which might have led to underestimation of the observed association.
Depressionn score was highest in Italy and lowest in the Netherlands, which was in accordance with
ann earlier study in the same countries.*149' Another study reported higher levels of depressive
symptomss in southern Europe (Spain) compared to northern Europe (Finland, Sweden).048'
Althoughh depressive symptoms were shown to be associated with disabilities in the three
countries,, these disabilities did not fully explain the observed differences in depressive symptoms:
Afterr adjustment for disability status, Italian men still reported most depressive symptoms and
Dutchh men the fewest.
77 77
ChapterChapter 6
Inn an earlier report on the FINE Study, it was shown that independent of an objective measurement
off physical functioning, Dutch men reported more disabilities than Finnish and Italian men.(70) The
presentt results showed that given a level of disability, Dutch men reported the fewest depressive
symptoms.. Speculating on these observations we suggest that Dutch men perceive more
disabilitiess in daily living, but do not express unpleasant personal feelings and emotions about their
functioning.. These results suggest that cultural differences in perception and report of physical and
mentall functioning hamper cross-national comparisons of prevalence rates.
Inn addition to the results of our and other studies showing that the sum score of disabilities was a
predictorr of depressive symptoms, the present study showed that given the number of disabilities,
thee hierarchic severity level of disability also tended to be predictive. The hierarchic severity level
itselff was a strong predictor of depressive symptoms and seemed to be an even stronger predictor
thann the sum score. Disability in the more severe disability domains might be associated with more
feelingss of worthlessness or hopelessness, because men become more dependent on others.
Earlierr studies investigating different levels of disability (instrumental and basic activities)
separatelyy observed a strong association between disabilities in the instrumental activities and
depressivee symptoms, but not with disabilities in the basic activities,031133' which is in contrast with
thee results of the present study. The lack of a significant association with basic activities in these
studies,, however, might be because of the younger age (mean 70) and lower prevalence of
disabilitiess in basic activities. Prince et al.(134) determined depression scores per disability item and
observedd a general correspondence between depressive symptoms and the disadvantages
associatedd with the disability. For example, people with disability in climbing stairs had fewer
depressivee symptoms than those with disabilities in feeding, which is in accordance with our
results.. Berkman et al.(151> constructed a disability scale with different levels (e.g. physical
performance,, mobility, basic activities). Men with severe disability (in basic activities) reported
moree depressive symptoms than men with moderate disability (in mobility). In contrast with their
expectation,, men with impairment in physical performance (for example stooping or reaching) did
nott report fewer depressive symptoms than men with mobility disability. The investigators
suggestedd that there is no association between disability and depression at levels of such minor
disability.. The results from the present study showed that our categorisation of disability severity
wass reflected in the depressive symptoms, and suggest that the type of disability has slightly more
influencee on depressive symptoms than the number of disabilities.
Inn addition to current disability status, depressive symptoms were dependent on preceding change
inn disability. Our results suggest that the development of disability is a disruptive experience that
requiress readjustment and is therefore associated with more depressive symptoms. The results
78 8
DisabilityDisability and depressive symptoms
furthermoree suggest that in the course of time, men get used to their disability status, and therefore
reportt fewer depressive symptoms when disability has already been present for 5 years - the so-
calledd response shift.(11) This refers to a change in the meaning of one's self-evaluation of health
aspectss as a result of a change in the respondent's values, dependent on social expectations. It
seemss that this shift was not present in men with disability in basic activities, which suggests that
whenn disability is severe, depressive symptoms are determined by the severity of the current
disabilityy status, and not by preceding change. Furthermore, for all levels of disability severity it
wass shown that current disability status was a stronger predictor of depressive symptoms than
precedingg change in disability status.
Inn the present study, the effect of disability on depression could also be dependent on factors that
weree not taken into account. An earlier study showed that more subjective measures, e.g.
subjectivee health, are more related to depressive symptoms than disabilities/152' Furthermore, the
presencee of and satisfaction with social support were known to influence the effect of disabilities on
depression.*1321153» »
Ourr population consisted of male participants aged 70 years and older who were relatively healthy.
Att baseline, less than 10% reported severe disabilities and only 9% could be classified as at least
moderatee depressive (cut off point of 60 on the SDS).<150) This might because of non-response,
exclusionn of men with missing values, and men who died between 1990 and 1995. It is not
possiblee to generalise the results of the present study to the general population, i.e. women and
youngerr men. Women are known to have more depressive symptoms compared to men,(154) but
theyy are less susceptible to depressive symptoms when suffering physical health problems.(152)
Thee association between disability and depressive symptoms might therefore be somewhat weaker
inn women. Furthermore, the results probably do not hold for men younger than 70. An earlier study
showedd that the effect of disability on depressive symptoms was stronger among old-old men (75+)
thann among young-old men (55-64).<152>
Fromm the results of the present study we conclude that hierarchic disability severity and the
disabilityy sum score are major predictors for depressive symptoms. In identifying men who are at
higherr risk of depressive symptoms, preceding changes in disability should also be taken into
account. .
79 9
7 7 Disability ,, self-rate d health , depressiv e
symptom ss and mortalit y
PublishedPublished as: van den Brink CL., Tijhuis MAR. , van den Bos G.A.M., Giampaoli S., Nissinen A., Kromhout
D.. The contribution of self-rated health and depressive symptoms to disability severity as predictor of 10-year
mortalityy in European elderly men.
AmericanAmerican Journal of Public Health 2005; 95(11):2029-2034
ReprintedReprinted with permission from the American Public Health Association
ChapterChapter 7
Abstrac t t Objectiv ee To investigate the effect of disability severity and the contribution of self-rated health
andd depressive symptoms to 10-year mortality.
Method ss Longitudinal data was collected of 1,141 men aged 70-89 years of the Finland, Italy, and
thee Netherlands Elderly Study from 1990 to 2000. Disability severity was classified into four
categories:: no disability, instrumental activities, mobility, and basic activities of daily living. Self-
ratedd health and depressive symptoms were classified into two and three categories respectively.
Multivariatee Cox proportional hazard models were used to calculate mortality risks.
Result ss Men with severe disability had a more than twofold (2.41; 95% confidence interval 1.84-
3.16)) higher risk of mortality than men without disability. Men who had severe disability and did not
feell healthy had the highest mortality risk (HR: 3.30; 95% CI: 2.52, 4.33). This risk was lower at
lowerr levels of disability and higher levels of self-rated health. The same trend was observed for
depressivee symptoms.
Conclusio nn For adequate prognoses on mortality or for developing intervention strategies, not
onlyy physical aspects of health, but also other health outcomes should be taken into account.
82 2
DisabilityDisability and mortality
Introductio n n Thee prediction of mortality in elderly people is a subject with a huge body of knowledge. There is
littlee debate about the importance of functional disability as a predictor of mortality. However, there
aree still unresolved issues in the pathway from disability to mortality, that are important for
enhancingg insight into long-term prognosis, planning health care facilities or for developing
interventionn strategies.
First,, disabilities in different domains, i.e. in instrumental activities/155"158' in mobility,059' and in
basicc activities*95160"163' are known to be associated with mortality risk. These earlier studies are
restrictedd to only one of the disability domains. These domains reflect differences in severity levels
off disability, but the relative impact of these domains on mortality is unknown. An earlier study that
incorporatedd disability in both mobility and basic activities reported that men with disability in basic
activitiess and mobility had a higher risk of mortality than those with disability in mobility only.(84) In
anotherr study about the association between disability and mortality, it was recommended to use
differentt severity levels of disability, e.g. instrumental activities, mobility, and basic activities, as
predictorss of mortality.*161' Although it seems plausible that mortality risk increases with the severity
levell of the disability, no earlier study incorporated the three severity levels in one classification,
andd it is not known whether there is a gradual or exponential increase in risk. In earlier studies in
whichh disability severity was classified in instrumental activities, mobility, and basic activities,
disabilityy severity was strongly associated with other health outcomes, such as performance-based
functionall limitations and chronic diseases.064165'
Inn addition to physical aspects of health, subjective aspects also may play a role in the association
withh mortality. From earlier research it is known that factors such as self-rated health and
depressivee symptoms are associated with disability<24;25;166;167> as well as with mortality/34155168"170'
However,, it is unclear how the combination of disability and more subjective health aspects
contributess to the mortality risk. A person's actual health and mood probably contribute to the
mortalityy risk besides disability.
Thee aim of the present study was to investigate severity levels of disability as predictor of mortality.
Furthermore,, we assessed how different combinations of levels of disability and self-rated health,
andd levels of disability and depressive symptoms contributed to mortality during a 10-year follow-
upp period. We had the opportunity to investigate the different associations in three European
countries,, i.e. Finland, the Netherlands, and Italy.
83 3
ChapterChapter 7
Method s s Stud yy populatio n
Thee present study has a longitudinal design and used data of the Finland, Italy, and the
Netherlandss Elderly (FINE) Study, collected in 1989, 1991, and 1990, respectively, with a mortality
follow-upp up to 2000. The FINE Study started in 1985 as a continuation of the Seven Countries
Study,<171)) focusing on elderly men, bom between 1900 and 1920. In 1985, there were 716
participantss from Finland, 887 from the Netherlands, and 682 from Italy.
Aroundd 1990, 1,416 men were examined {response rates: Finland, 90% of 523 survivors; the
Netherlands,, 78% of 718; Italy, 79% of 493). Six percent of the men were removed because of
missingg values on disability, 6% because of missing values on self-rated health, 6% because of
missingg values on depressive symptoms, and 2% because of missing values on both. In total,
1,1411 men were left for the analyses.
Inn 1985 in Finland, the research was approved by the Ethics Committee of the Kuopio University
Hospitall and in the Netherlands by the Medical Ethics Committee of the University of Leiden. In
Italyy an ethical committee at the local level approved the research. More information about the
FINEE Study and its populations has been reported elsewhere.(149)
Disabilit y y
Disabilityy was measured by a standardised questionnaire about daily routine activities.072' Three
domainss were assessed:
•• instrumental activities of daily living (3 items): preparing meals, doing light housework, and
doingg heavy housework;
•• mobility (4 items): moving outdoors, using stairs, walking 400 meters, carrying a heavy object
1000 meters;
•• basic activities of daily living (6 items): walking indoors, getting in and out of bed, using toilet,
washingg and bathing, dressing and undressing, and feeding oneself.
Thee participants were classified as being disabled on a certain item if they reported a need for help
orr were not able to perform that activity. Disability in a domain was defined as disability in at least
onee item of the domain. The domains were found to be hierarchically ordered.<172) Men who were
disabledd in basic activities were also disabled in mobility and instrumental activities of daily living.
Menn who were disabled in mobility were also disabled in instrumental activities. The following
severityy levels of disability status were distinguished: 0) no disability, 1) mild disability: disability in
instrumentall activities only, 2) moderate disability: disability in instrumental activities and mobility,
3)) severe disability: disability in instrumental activities, mobility, and basic activities of daily living.
Almostt 3% of the men did not fit the hierarchy. Fourteen men who reported disabilities in mobility,
84 4
DisabilityDisability and mortality
butt not in IADL, were classified in category 2. Nineteen men who reported to need help with IADL
andd BADL, but not with mobility were classified in category 3.
Self-rate dd healt h
GlobalGlobal self-rated health was assessed with a single-item question: 'We would like to know what
youu think about your health', with four answer categories: 1) healthy, 2) rather healthy, 3)
moderatelyy healthy, 4) not healthy. For the analyses self-rated health was dichotomised as healthy
andd not healthy, by combining category 1 with 2 and category 3 with 4.
Depressiv ee symptom s
Depressivee symptoms were measured by the Self-rating Depression Scale (SDS) developed by
Zung.(173)) The questionnaire consisted of 20 items developed from clinical diagnostic criteria most
commonlyy used to characterise depressive disorders in terms of mood and biological and
psychologicall disturbances. The items were scored from 1 to 4 on frequency of occurrence of the
symptoms.. An index for the Self-rating Depression Scale was derived by dividing the sum of the
itemss score by 80 and multiplying it by 100, resulting in a range from 25 to 100.
Chroni cc disease s
Informationn on prevalence of chronic diseases was collected for the following chronic conditions:
myocardiall infarction, stroke, angina pectoris, heart failure, intermittent claudication, cancer,
diabetess mellitus, and asthma and chronic obstructive pulmonary disease. Diagnoses were
obtainedd from a questionnaire and verified by written information from general practitioners or
hospitall registries. In the analyses one variable was used for the absence or presence of chronic
diseases. .
Mortalit yy (1990-2000)
Inn 2000 the vital status of the participants was checked through municipality registries. For Finland
thee censor date was January 2000, for the Netherlands and the Italian cohort Montegiorgio the
censorr date was June 2000, and for the Italian cohort Crevalcore, the censor date was March
2000.. Three men were lost to follow-up. These men were censored on the date of the last
examination.. For the 10-year follow-up, survival time was calculated based on the examination
datee around 1990.
Causess of death were obtained from general practitioners or hospital registries and were checked
forr consistency by one clinical epidemiologist of our research group.
85 5
ChapterChapter 7
Statisticall analyses
SASS PROC PHREG was used to generate proportional hazards model estimates of mortality in
relationn to severity levels of disability, with survival time as dependent variable. The severity levels
off disability were entered into the model as dummy variables. The same analyses were performed
withh the two categories of self-rated health and tertiles of depressive symptoms as independent
variables.. The cut off points for the tertiles of depressive symptoms were 40 and 50.
Thee independent associations between mortality and different health aspects, i.e. disability, self-
ratedd health, and depressive symptoms, were studied by including these three variables in one
model.. We tested the interaction between disability and the more subjective health aspects by
includingg interaction terms in the model.
Inn addition, we constructed six strata by cross-tabulating disability and self-rated health and nine
strataa for disability and depressive symptoms. For these analyses the two most severe levels of
disabilityy were put together. A Cox proportional hazards model was used to determine the
relationshipp between the strata and survival time. The combinations of no disability with good self-
ratedd health and of no disability with the lowest fertile of depressive symptoms were defined as
referencee category in the analyses.
Althoughh disability is assumed to reflect the impact of medical chronic conditions, these conditions
mightt also act as a confounding factor in the association between disability and mortality. We
thereforee adjusted for the presence of chronic diseases in some analyses. Furthermore, all
analysess were adjusted for age and country.
Thee analyses were performed using SAS, version 8.2 (SAS Inc., Cary, NC), the tests were two-
tailed,, and a p-value < 0.05 was considered to be statistically significant.
Result s s
Thee prevalence of severe disability was about three times higher in Finland and Italy (11-12%) than
inn the Netherlands (4%)(table 7.1). In addition, a large variation was observed in self-rated health.
Inn Finland, only 17% of the men felt healthy, and in the Netherlands and Italy more than 80%. Men
inn Italy scored three to seven points higher on depressive symptoms compared to men in Finland
andd the Netherlands respectively.
Inn 2000, among the Italian men there were 10% less deceased men than in Finland and the
Netherlands.. After adjustment for the shorter follow-up time in this country, this difference became
evenn larger. The leading cause of death was cardiovascular disease (51%), followed by cancer
(26%)) and stroke (14%). In Italy, the prevalence of chronic diseases was almost 30% higher than
86 6
DisabilityDisability and mortality
inn the other countries, caused primarily by a higher prevalence of asthma and chronic obstructive
pulmonaryy disease.
Althoughh health outcomes differed largely between the three countries, the associations with
mortalityy did not differ statistically significantly and are therefore presented for the three countries
together. .
Tablee 7.1 Characteristics of European elderly men at the baseline survey and 10-year mortality.
Meann age in years (sd)
Disabilityy severity (%)
noo disability
mildd disability
moderatee disability
severee disability
Self-ratedd health {%)
healthy y
nott healthy
Depressivee symptoms (range 25-100)
meann score (sd)
Prevalencee of chronic diseases (%)
Deceasedd between 1990 and 2000 (%)
Finland d
n=324 4
76.44 (4.8)
53 3
29 9
7 7
11 1
17 7
83 3
47.6(10.5) )
60 0
60 0
Netherlands s
n=469 9
75.77 (4.5)
52 2
32 2
12 2
4 4
89 9
11 1
43.77 (10.0)
58 8
59 9
Italy y
n=348 8
77.88 (4.0)
45 5
34 4
9 9
12 2
82 2
18 8
50.9(11.9) )
87 7
49 9
Abbreviation:: sd, standard deviation.
Disabilit yy severity , self-rate d health , and depressiv e symptom s as predictor s of mortalit y
Disability,, self-rated health and depressive symptoms were associated with each other. The
prevalencee of men who felt not healthy increased significantly from 27% among men without
disabilityy to 62% among men with severe disability. The mean score of depressive symptoms
increasedd from 43.2 to 60.2 between these disability levels. The mean score of depressive
symptomss was 44.7 for those who felt healthy and 51.7 for those who felt unhealthy.
Severityy level of disability appeared to be a strong predictor of mortality (table 7.2). The basic
modell showed that although mild disability was already associated with a 34% increased risk of
mortality,, disability at moderate or severe level was associated with a 2.5 and a threefold higher
riskk respectively (table 7.2). Addition of self-rated health and depressive symptoms to the model
87 7
ChapterChapter 7
resultedd in lower risk ratios of disability severity, but the associations were still statistically
significant.. Addition of the prevalence of chronic diseases into the model also slightly decreased
thee hazard ratios. The independent contribution of the prevalence of chronic diseases to mortality
wass statistically significant (HR: 1.59; 95 % CI: 132, 1.92).
Inn addition, self-rated health was predictive of mortality (table 7.2). After addition of disability
severityy and depressive symptoms to the model, the mortality risk in the not healthy category was
23%% higher than in the healthy category. Addition of the prevalence of chronic diseases into the
modell slightly decreased the risk of self-rated health on mortality to 19%.
Forr depressive symptoms a similar trend was observed (table 7.2). Men in the highest fertile of
depressivee symptoms had a 4 2 % higher mortality risk than men in the lowest tertile, after
adjustmentt for disability, self-rated health, and prevalence of chronic diseases.
Tablee 7.2 Disability severity, self-rated health and depressive symptoms as predictors of 10-year mortality,
adjustedd for age and country.
Unadjustedd for thee other health
outcomes' '
Adjustedd for thee other health
outcomes* * HRR (95% CI) HRR (95% CI)
Adjustedd for other health outcomess and chronic
diseases* * HRR (95% CI)
Disabilityy severity
noo disability
mildd disability
moderatee disability
severee disability
Self-ratedd health
healthy y
nott healthy
Depressivee symptoms
lowestt tertile
middlee tertile
highestt tertile
1.00 0
1.34(1.11,, 1.61)
2.45(1.90,3.15) )
3.022 (2.34, 3.89)
1.00 0
1.63(1.35,1.98) )
1.00 0
1.29(1.05,, 1.59)
1.90(1.56,2.32) )
1.00 0
1.24(1.03,1.50) )
2.22(1.72,2.87) )
2.411 (1.84,3.16)
1.00 0
1.23(1.01,, 1.51)
1.00 0
1.19(0.97,, 1.46)
1.44(1.15,, 1.79)
1.00 0
1.18(0.98,1.43) )
2.06(1.59,2.67) )
2.28(1.74,3.00) )
1.00 0
1.19(0.97,, 1.46)
1.00 0
1.17(0.95,1.44) )
1.42(1.14,, 1.77)
Abbreviation:: CI, confidence interval. ** disability severity, self-rated health and depressive symptoms in three different models, tt independent association: disability severity, self-rated health and depressive symptoms tt independent association: disability severity, self-rated health and depressive symptoms adjustedd for chronic diseases.
togetherr in one model, togetherr in one model,
88 8
DisabilityDisability and mortality
severe e m i |dd disability
noo severity
self-ratedd health
Figur ee 7.1 Mortality risk3 for six different combinations of disability severity and self-rated health aa hazard ratio on z-axis, with men with no disability who felt healthy as reference group, adjusted for age, country, and chronicc diseases
re re
e e o o E E Lm Lm
re re
severe e mildd disabilit y
noo severit y
tertile ss depressiv e symptom s s
Figur ee 7.2 Mortality risk3 for nine different combinations of disability severity and depressive symptoms. 33 hazard ratio on z-axis, with men with no disability who felt healthy as reference group, adjusted for age, country, and chronicc diseases.
89 9
ChapterChapter 7
Combinatio nn of disabilit y and self-rate d healt h
Whenn participants were classified into six groups on the basis of categories of disability severity
andd self-rated health, mortality risks varied markedly (figure 7.1). The highest risk was observed
amongg those who had severe disability and did not feel healthy (HR: 3.30; 95% CI: 2.52, 4.33).
Thiss risk decreased with lower disability levels and with higher level of self-rated health. Among
thosee with mild or severe disability, (borderline) significant associations between self-rated health
andd mortality were noted (figure 7.1). Men withh mild disability who did not feel healthy had a hazard
ratioo of 1.36 (95% CI: 0.95, 1.93) compared with those who felt healthy. Among men with severe
disability,, those who did not feel healthy had a 45% higher risk (95% CI: 1.02, 2.04) than those
whoo felt healthy.
Thee p-value for interaction between disability and self-rated health was 0.11.
Combinationn of disability and depressive symptoms
Menn with severe disability in the two highest tertiles of depressive symptoms had a threefold higher
riskk of mortality compared with men without disability in the lowest tertile of depressive symptoms
(figuree 7.2). This risk decreased with lower levels of disability severity and was also lower among
menn with severe disability in the lowest tertile of depressive symptoms (HR: 2.16; 95% CI: 1.33,
3.51). .
Inn the lowest levels of disability severity, dose-response relationships between depressive
symptomss and mortality were found. Among men with no disability, those in the highest tertile of
depressivee symptoms had a hazard ratio of 1.62 (95% CI: 1.19, 2.20) with the lowest tertile as
referencee group. Men with mild disability in the highest tertile of depressive symptoms had a 59%
higherr mortality risk (95% CI: 1.11, 2.30) than those in the lowest tertile.
Thee p-value for interaction between disability and depressive symptoms was 0.34.
Discussio n n
Thee present study was designed to investigate disability severity and its combination with self-rated
healthh and depressive symptoms as risk factors for mortality among men aged 70 to 89 years at
baseline,, from Finland, the Netherlands, and Italy. The results showed that severity levels of
disability,, self-rated health, and depressive symptoms were independent predictors of 10-year
mortality.. The combinations of disability with self-rated health or with depressive symptoms were
stronglyy associated with mortality. For several levels of disability, dose-response relationships
betweenn self-rated health or depressive symptoms and mortality were observed.
90 0
DisabilityDisability and modality
Theree was a selection on health caused by non-response and by removing men with missing
values.. Men removed because of missing values on self-rated health or depressive symptoms had
moree disabilities than men included in the study. Furthermore, men removed because of missing
valuess for disability, self-rated health, depressive symptoms, or who were nonrespondents, had a
higherr mortality rate than men who were included. The exclusions might have led to
underestimationn of the strength of the associations.
Ass far as we know, there are few investigations of the association between different disability
domainss and mortality. Bernard et al. investigated the three domains separate from each other and
foundd an association between disability and mortality only for the instrumental and basic
activities.074)) Khokhar et al. showed that men with disabilities in basic activities and mobility
{severee disability) had a higher risk of mortality than men with disabilities in mobility only (moderate
disability)/84** These results were in accordance with our findings. Our study, using one additional
disabilityy domain (instrumental activities), showed that the classification of disability severity on the
basiss of three domains, i.e. instrumental activities, mobility, and basic activities of daily living, was
aa strong predictor of mortality risk. According to an earlier study, concerning mobility disability, self-
reportedd disability even predicted mortality as well as more objective measurements of disability,
suchh as gait speed.(92)
Afterr adjustment for self-rated health and depressive symptoms, disability was still a significant
predictorr of mortality. In accordance with earlier studies, also self-rated health(34174~176) and
depressivee symptoms(155) were, independently of disability, associated with mortality. Disability,
however,, had a stronger association with mortality than self-rated health and depressive symptoms
inn the present study. In contrast, earlier studies showed the strongest association for self-rated
healthh and mortality.<174;175> These divergent findings might have been caused by differences in the
measurementt or distribution of self-rated health. Furthermore, these studies had a shorter follow-
upp period (3-5 years), and self-rated health(96) and depressive symptoms(155) are known to be better
predictorss of mortality in short-term studies (3-5 years). However, it is also possible that our
classificationn of disability, encompassing several domains, was a better predictor of mortality than
thatt in the other studies, in which the disability domains were investigated separately. In addition,
thee present study was restricted to male subjects from three European countries, while the other
studiess included both sexes and also other countries.
First,, although there were differences in disability, self-rated health, and depressive symptoms
betweenn the three countries, the associations between these health aspects and mortality were not
differentt and can therefore be generalised to European men. Second, women have a higher risk of
disabilityy than men<161) and a lower risk of mortality.055' Furthermore, depression seemed to be
associatedd with a higher mortality risk in men than in women.(100) Some studies found that self-
91 1
ChapterChapter 7
ratedd health is a better predictor of mortality in men(175;177178) and other studies have found the
reverse.(162)) Considering these results, it is not justified to generalise our results to women.
Wee assumed that disability reflects the consequences of several underlying diseases and might
thereforee be associated with mortality. The prevalence of chronic diseases was associated with
bothh disability and mortality, and may therefore confound the association between disability and
mortality.. It is also possible that adjustment for these disease removes the association between
disabilityy and mortality. We therefore reported the associations of disability, self-rated health and
depressivee symptoms with mortality, both adjusted and unadjusted for the prevalence of chronic
diseases.. The strength of the association between disability and mortality only slightly decreased
afterr adjustment, which shows that disability is associated with mortality also independent of these
chronicc diseases. Disability reflects more aspects of overall health and functioning than the
disabilityy impact of chronic diseases alone.
Thee interaction terms between disability and self-rated health or depressive symptoms were not
statisticallyy significant, which means that the associations of self-rated health and depressive
symptomss with mortality did not differ among the levels of disability severity. At the lower levels of
disabilityy however, clear dose-response relationships were observed between depressive
symptomss and mortality, that were not present at the most severe disability level. Nevertheless,
menn with severe disability had a high mortality risk, and the small numbers of men in these
differentt categories made it difficult to interpret the findings. In contrast, self-rated health was
associatedd with mortality only in the higher levels of disability. These results suggest that positive
healthh perceptions (self-rated health) and less depressive symptoms may postpone mortality.
Knowledgee about risk factors for mortality in old age is important for enhancing insight into
prognosis,, planning long-term facilities and developing intervention strategies. Firstly, disability is
ann important risk factor. Men with only mild disability have an increased mortality risk, and further
deteriorationn of disability should be encountered effectively to prevent a much higher risk.
Secondly,, although depressive symptoms are often unrecognised/179' depression as well as self-
ratedd health are both important. Intervention strategies should therefore not only focus on
preventionn of deterioration of physical disability, but also on reinforcing mental functioning.
Interventionss on disability, self-rated health, and depressive symptoms will not only postpone
mortality,, but will also improve quality of life.
Fromm the results of the present study we conclude that in elderly men the risk of mortality increases
withh severity level of disability. Furthermore, self-rated health and depressive symptoms increase
thee mortality risk at different levels of disability. This knowledge may be helpful for enhancing
insightt into long-term prognosis, planning health care facilities, and developing intervention
strategies. .
92 2
8 8 Genera ll discussio n
ChapterChapter 8
Thiss thesis addresses functional disability among European elderly men. We aimed to identify risk
groupss and risk factors for functional disability and to quantify health (care) impacts of functional
disability.. Firstly, the assessment of disability was validated by relating self-reported disability to
performance-basedd functioning, and by comparisons between three different countries. Thereafter,
wee focused on the main research questions of this thesis. Widowhood was studied as a risk group
forr disability, and physical activity as risk factor. We investigated whether use of formal home care
wass according to disability-related needs. The health impact of disability was investigated by
determiningg its effect on depressive symptoms and on mortality.
Thee data for our study came from the Finland, Italy and the Netherlands Elderly (FINE) Study, that
consistss of 2285 men born between 1900 and 1920. Four surveys were carried out in 1984-1985,
1989-1991,, 1994-1995, and 1999-2000.
Wee focused on functional disability: dependency in instrumental activities of daily living, mobility, or
basicc activities of daily living. Functional disability is a growing public health problem, related to the
increasee in the number of elderly people and the ensuing rise in prevalence of chronic diseases.
Disabilityy seems to be an irreversible process for the individual. Although previous research has
shownn that disability is a dynamic process in which people can recover,(180) this recovery is often
short-lasting,, because people who recover are at high risk for recurrent disability/181* Particularly at
oldd age, people hardly recover from disability/182183' In order to anticipate the growing burden for
thee individual as well as society as a whole, more insight is needed into different aspects of
disabilityy among elderly people.
Inn this chapter the main findings of the thesis are summarised. Methodological considerations are
discussedd and the implications for public health and health care, such as preventive strategies and
consequencess for care delivery, are addressed.
Mainn finding s
Inn table 8.1 the main findings for each chapter described in this thesis are summarised.
Assessmen tt of disabilit y (chapter 2)
Self-reportedd disability is often used to compare health status between countries. We examined
whetherr there is cross-cultural variation in the self-report of disability, independent of differences in
physicall functioning. The association of self-reported disability with performance tests was
94 4
GeneralGeneral d/scuss/on
c c o o
0)) Q-
EE Ö «
S i s s WW O 4> 33 £ DO
cc 3 -22 © cy rogrog J|
* »» i - *i •SS © . •oo H.9-
?? 3>2 co o © ©
(O O ™™ 3 oo ~ — O O
o>> co
CC (D
55 g»
É ~ ~
5 * f f © 3 c c SS MO rara © •*-ÖÖ ©
- oo «-_ CO
©© ei COO "m . £
9-- ro 5 «« E o-h-- c co £ .2 .£
O) ) c c '"55 -£ TJ J
££ o
ro ro
©© i= coo «o .99 =5
f' S S li i II I QQQ co
<D D (0 0 co o 3 3 j 5 5 co o
>% % (0 0 co o
T» »
c c co o 0) ) O) ) c c ffl ffl
F F ,g g Q. .
F F co o CD D
> > co o CO O
2 2 Q. . <D D TJ J
£ £ co o
o o t3 3
g - D D ££ © oo n too v S"s= = 33 CD COO (0 ,_-- co -C?? CO == r
•99 ü
(00 3 coo co
T JJ CO
2 ^ ^ * -- <p t== a oo «o ' ^^ co TJJ £ X II ü CDD CO r-- ©
CD D
CD D
CO O
EE . oo -* O * *
«oo t
Q-£ £
oo ^ ;
«oo ro . cc - e ^^ o coo o .
I I I
3 3 CO O CD D
< o> JS g Ü Ï
ga: : 1CDD o
£!E E * S S
ss S QQ E
roro <B
55 o. >> <D >% %
. t ii C == CD roro c
.«22 J= "OO .0 "oo = jgg Q oo có CLCL CD 22 "£
j -- c
"®® o ,» COO o O
CDD £
Ë& & O )) V4-
mm O
CDD J
£ • = = £ra a •oo 2 ro£ ro£ i l S S
CDD k
E d d
«22 O
a: : n o . .
rö.2 rö.2
( M I OO *=
< S i o o C Z ®® 3
** - o
.oo . . coo Q;
^ O O
S3 3 CDD *
III I lil l rara co c
CDD CM - o EE w .2 "OO ^ £ <a<a — m Ï Ü E E QQ . 0 ^
Ö.E E ü ü
2 o > >
CDD . . Ö ^ ^ E O O
££ c
'55 B T33 E ®® => roro -o
' öö CD
SS 03
roro CN
roro o ^^ • .
"GG 5 & &
>»» CV I j ; ;
22 c -^^ ®
OO C
.22 5
too 5 CDD CD CC . « 13)) TJ
t o o ï == co -s ;
o o ^ « « 'cö ö
—— o --^^ ro ooo .£» h-- -o dd x:
cc o 55 o
CO O (N N O O
u u 0 s s
i n n CD D
% % u u CD D ro ro ' o o o o CO O co o ro ro
§ 1 ? ? 3 3
__ C SS 'O CD . ^ E E
E E
oo ^ - c
£ l o o >> CD CD ** CO CO
SS 3 JBB * •-roro 2 »
"" £ ro 8 ** f 55 c § a>> © CD ££ 2 = COO _ ; CD
|s. i i Eröö s oo c -o -CC .Q CD
©© 3 £ , COO - o .O) 33 0! £
c c --
CJJ ^ o
«"55 0 ill S^
é|S S SS -go: •*== ? o
55 g.S • 5 CDD TJ C0
ra.®ra.® E OO CD O
COO " ^ CD
™™ £ O C SS o COO «0 _ r -roro — > 55 ro >
lil l -9 -££ £
5 1 1 1
cc _ ro CDD .£»£
üü = * ^ —— = co
CC • g EE co O 33 TJ Q. ^ ' ss E EE >H > ,, CD co M q 5 5 CDD O . > >> CO CO
22 P Q. Q.. (O CD
TJJ . 2 r-MM - C S
99 2 S CD D —— cT JJ " ^ CD
i S ^ r o o o o g g g-dd 8 22 II co i== >. CD ü ££ CD
Sii i ro ^
, , 55 CD CO cc co co CDD O CD
2 ££ 5
2 2 o o
JZJZ E
( D t 9 9 coo o o
££ 2 -~~ Cö O) 'X'X CD 2 - SK O
8 »» & ^^ O) .E 2 || o
CDD = CDD c
££ c= EE .£ £ 5?? > • « o == E
<< co 9-
2 2 ? * * oo o w
OO _ CD WW ? > c== ~ co cc c co 33 CD CD COO C0 C ©© O g" ££ 5 -o
caa a II I ro'S ro'S
TJJ C CDD ©
55 E
II I ££ 2 £= *= ;=-=SS a. o? o 2
© ©
o o J :: - :
.&»t N N == l O ^99 <vi coo .. C00 TT
> .. Q)
coo -c COO m
TJJ CD ©
EE co o ££ E CD
%&ë %&ë cc E • -SS >.© ££ co co i ?>£ £ OO co <-
l i l l ££ TJ 2 ^^ ^_ co coo o csi © ©
fiü£| fiü£| ©© 3*;
>> S coo o
* -- CO
SS 's
;; -e -^ && B *-99 w ü ff iaP ^^ ^ o> !oo © ó) roro £ m coo ** • T 5 . EE C-
ü ü
© ©
ro ro
co o
(0 0
E E < <
üü LL
__ £? © ££ =5 © . S SS >
«iï ï oo ^ WW TJ J3 coo a) co roro t ; ©
© © © ©
a jj ra c
• M M
c c ro ro
» ii 8
oo © c ?È I—— ^ 3 CO TJ
>«-- CD OO co co
ftft TJ . E © e g g t o E E ®® TJ -9 ©© « ^ mm ° © ®® TJ C
I'll l COO c ,_ $ Ë ~ ~ c o © © —— o co
.OO © C h-- ^ i o
LU U
O O
o o £ £ © © © © -C C © © ro ro .g) ) ts s © ©
> > c c o o 1--
sz sz u. . o o ^ ^ (0 0 c c © © _c c TJ J c c co o r r o o m m T T
TJ J
>. . J2 J2 co o ro o TJ J c c o o & & > > o o co o
N N
EE co .!2 SS ra "o
co o o o © © 3 3 co o
© ©
> > ü ü
2 2 a . . © ©
© © ro ro
'̂ ^ co o © © > > c c o o r--
I— — _ l l
fc fc 3 3
TJ J C C ro ro © ©
8 8 co o
*>, , sz sz Ü Ü m m © ©
-C C
ro ro o o
er r © © Ut Ut c c co o
o o TJ J c c ro ro
>. . —— — .o o ro ro co o
u u o o © ©
8 8 co o
LU U
a. . © ©
TJ J
c c OO CO
== o J 33 Q. roro c .SS >. TJJ CO
TJ J
"ro o TJ J
== ©
"ii w
"" a
It t ' mm CO
i i C00 x -©© O CC t3
—— £0 OO t t
r -- ©
ca a co o
2 2 aa .
o4S S ££ O SS E
95 5
ChapterChapter 8
determinedd in three countries separately. Disability was defined as dependency in activities of daily
living.. These activities were divided into three domains: instrumental activities (e.g. doing
housework),, mobility (e.g. walking 400 meters), and basic activities of daily living (e.g. washing and
bathing).. Disability severity was based on the hierarchical order between these disability domains.
Inn all three countries disability was significantly associated with performance tests. In addition to
physicall functioning, other factors (e.g. cultural factors) seemed to play a role in the self-report of
disability,, since Dutch men reported more disabilities than men in the other countries, at each level
off performance test. Although our disability measurement reflected physical functioning, the results
suggestt that absolute figures based on self-report of disability can not be used for comparing
healthh status between countries.
Widowhoo dd (chapter 3)
Thee number of widowed men is expected to increase because the life expectancy of men is rising
fasterr than that of women, and because of ageing of the population. Widowed men might be at
higherr risk of disability, because of health problems occurring after widowhood (functional
disability)) due to stress of bereavement and the lack of support for maintaining a healthy lifestyle.
Furthermore,, disability might occur because men are accustomed to receiving instrumental support
fromm their spouse and have never learned to perform certain tasks (situational disability). We
investigatedd in a longitudinal study whether widowhood, duration of widowhood, and household
composition,, are associated with disability onset. The results showed that widowers had a higher
riskk for dependency in instrumental activities of daily living and mobility than men who were
married.. For instrumental activities the risk was highest among men who had become widowed
recently.. Widowers who lived with others were more often disabled in mobility than those living
alone.. We concluded that in terms of disability, widowers are a risk group, and their risk is related
too aspects of both functional and situational disability.
Physica ll activit y (chapter 4)
Itt is known that physical activity is inversely associated with disability. However, it was not known
whichh aspects of physical activity explained the association with disability. We examined in a
longitudinall study whether duration and intensity of physical activity were associated with disability
onsett among men without disability at baseline. Men in the middle and highest fertile of duration,
whoo spent on average respectively 100 and 250 minutes per day on activities like walking,
bicycling,, playing billiards and gardening, had a lower risk of disability 10 years later compared to
menn from the lowest fertile (mean: 38 minutes per day). Intensity of the activities was not
associatedd with disability onset. The results indicated that even in old age a physically active
lifestylee should be encouraged. Because duration rather than the intensity of physical activity
96 6
GeneralGeneral discussion
seemedd to be important, there are several options for people to select activities that can be
incorporatedd in their daily life.
Forma ll hom e car e (chapter 5)
Becausee elderly people desire care at home rather than institutionalisation, sustaining home care
iss essential. The growing pressure on health care services might however lead to problems with
thee principle of equity. This principle presupposes equal use for equal need. We evaluated use of
formall home care among men in the Netherlands on the basis of the Andersen model.(105) Need
factorss (disability, chronic diseases, self-rated health), predisposing factors (age, marital status),
andd enabling factors (occupation, education, informal care) were incorporated as explaining factors
forr use of home nursing and home help. The results showed that use of home nursing was
associatedd with disability severity and educational level. The association with education suggests
inequityy in use of home nursing. Formal home help was only associated with marital status. Men
whoo were married used less formal home help than men who were not married. Because support
byy the spouse decreases the demand for formal home help, these findings do not suggest inequity
inn the use of home help.
Depressiv ee symptom s (chapter 6)
Thee onset of disability can be considered as a life event. Therefore, disability is one of the risk
factorss for depressive symptoms. In order to prevent depressive symptoms, more specification is
neededd about the association between disability and depressive symptoms. The associations of
thee hierarchy score of disability, the sum score of disability, and changes in disability with
depressivee symptoms were investigated. In a cross-sectional analysis we showed that both
hierarchicc severity levels and sum score of disability were predictors of depressive symptoms. The
associationn between the hierarchy score of disability and depressive symptoms was somewhat
strongerr than that between the sum score and depressive symptoms. Preceding changes in
disabilityy were also predictive of depressive symptoms; men who developed disability in the past
fivee years had more depressive symptoms than those who had been disabled for a longer time. In
conclusion,, men who have disability are at risk of depressive symptoms, particularly those with
disabilityy in all domains. Special attention should be given to those who have developed disability
recently. .
Mortalit yy (chapter 7)
Disabilityy is an important predictor of mortality. It is however not known whether this mortality risk
increasess with severity level of the disability domains. In addition, subjective aspects, such as self-
ratedd health and depressive symptoms may play a role in the association of disability with
97 7
ChapterChapter 8
mortality.. The relationship between disability and mortality was explored, incorporating self-rated
healthh and depressive symptoms. Disability severity, self-rated health, and depressive symptoms
weree each strong predictors of 10-year mortality. Among those with lower severity levels of
disability,, depressive symptoms were positively associated with the mortality risk. Self-rated health
wass associated with mortality risk in the higher disability levels. These results suggest that
disabilityy is important for the prevention of mortality. In addition, among people with disability, self-
ratedd health and depressive symptoms are also important for their mortality risk.
Methodologica ll consideration s Inn this paragraph we comment on our operationalisation of disability, and we discuss the reliability
andd validity of the measurement of disability. In addition, the internal (selection bias, confounding,
informationn bias) and external validity (generalisability) of the results of this thesis are discussed.
Assessmen tt of disabilit y
Thee assessment of disability used in this thesis is based on several choices.
Firstly,, from the perspective of health care we chose a strict criterion for disability. Disability was
definedd as 'needing help to perform an activity'. Furthermore, it is known that the measurement
errorr over time is smaller when the dependency approach is used instead of 'difficulty' as criterion
forr disability.084*
Secondly,, severity of disability was determined in two ways: a sum score that counted the number
off disabilities, and a score based on the hierarchical association between the disability domains,
i.e.. instrumental activities, mobility, and basic activities. We particularly focused on the hierarchy
score,, because we expected that this score better reflects the severity level of disability. The
disabilityy domains, that are hierarchically related, have been determined on the basis of factor
analysiss on the 1990 data, which suggests that there are underlying dimensions/8'
Thirdly,, our purpose was to measure functional disability caused by health problems. However, we
realisee that including items on instrumental activities in our disability measurement among elderly
menn is questionable, because problems in household activities might be associated with the
situationall context or role patterns (situational disability).'19' Nevertheless, the domain of
instrumentall activities seemed to fit well in our hierarchy score. In chapter 2 it was shown that the
hierarchyy score of disability severity was associated with performance tests.
98 8
GeneralGeneral discussion
Reliabilityy of disability
Thee reliability of our hierarchy score of disability has been investigated in a 2-week test-retest
studyy among the Dutch population of the FINE Study in 1995.(185) The self-reported disability score,
basedd on the hierarchy of the disability domains, was reproducible (kappa=0.63). The correlation
coefficientt between the first and second measurement amounted to 0.87, which shows that also
thee test-retest reliability is good.
Validity y
Inn chapter 2 the validity of our hierarchy score of disability was determined by associations of
disabilityy severity with performance-based scores, which are assumed to be more objective and
standardisedd measurements of physical functioning. In all three countries, disability severity was
clearlyy associated with performance-based scores, which suggests that the measurement was
valid. .
However,, we also showed that given a certain level of performance test, Dutch men reported more
disabilityy than Finnish and Italian men (chapter 2). This finding suggests that factors other than
physicall functioning, such as cultural factors, also play a role when reporting disability. It is
thereforee not possible to compare prevalences of disability between countries that are based on
self-report.. However, the focus in this thesis is on associations between self-reported disability and
otherr factors, instead of prevalence data of disability.
Selectionn bias
Thee response rates ranged from 72% to 94% over the years and between the countries. In
general,, our non-respondents were less healthy and older than the respondents. This resulted in
underestimationss of the prevalence of disability. It is not known whether selection bias also
influencedd the observed associations. On the one hand, there are indications that associations can
bee biased by non-response. An earlier non-response study in the Dutch cohort of the FINE Study
showedd that the associations between disability and disease differed between respondents and
non-respondents,, and that the direction of those associations depended on the type of disease/55'
Onn the other hand, it was concluded that attrition is not a serious problem when associations
betweenn variables (in that study: between psychological characteristics and disability) are the focus
off study, but only affects descriptive outcomes.(186> Because of the contrasting results in earlier
studies,, we cannot conclude on the presence and the direction of selection bias in the present
study. .
99 9
ChapterChapter 8
Confoundin g g
Confoundingg factors must also be taken into account when investigating associations between
variables.. In the studies described in this thesis we used a limited number of confounders. In most
off our studies, age, country, socio-economic status, and chronic diseases were incorporated as
potentiall confounders. We chose these confounders from an epidemiologic point of view. We
realisee that adjustment for a small number of confounders has its limitations. For example factors
suchh as perceiving social support or personal coping strategies were not taken into account. Such
factorss should be included in future research before definite statements can be made about the
importancee of the associations with disability found in our studies.
Informatio nn bias
Errorss in the measurements of variables cause information bias. When the self-report of one
variablee is influenced by the value of another, the misclassification is differential. For example,
whenn the self-report of disability is influenced by the presence of depressive symptoms,
independentt of the actual disability level, there is differential misclassification of disability. The
(longitudinal)) designs of the studies described in this thesis have reduced the possibility of
differentiall misclassification. We expect that self-report of depressive symptoms in 1995 was not
influencedd by the self-report of functional disability in 1990. However, the influence of personality of
peoplee either to complain or to be optimistic, on the strength of the observed associations can not
bee ruled out.
Generalisabilit y y
TotalTotal population of the elderly
Ass a consequence of the selection bias in our study, the respondents were healthier than the
generall population of the same age. It is therefore not possible to generalise our results to the total
populationn of elderly men.
Youngerr age groups
Ourr analyses were restricted to men aged 70 to 100 years. Other studies showed that for example
thee effect of disability on depressive symptoms was stronger among old-old men (75+) than among
young-oldd men (55-64),<152) and that the association between disability status and mortality
decreasedd with age.(104) Furthermore, men of older age might have fewer opportunities to adapt to
neww situations, e.g. after becoming widowed. We therefore suppose that the results can not be
generalisedd to younger ages.
100 0
GeneralGeneral discussion
ElderlyElderly women
Ourr study population consisted solely of men, because the aim of the Seven Countries Study was
too investigate coronary heart disease. At the initiation of the study coronary heart disease was
viewedd as a major health problem of middle-aged men, but not of middle-aged women. It is known
thatt the prevalence of disability differs between sexes.<187) Especially differences in the domain of
instrumentall activities are expected, since among women a smaller portion of dependency is
basedd on situational factors than among men.(19) Furthermore, differences between sexes have
beenn found in the association between performance tests and self-reported disability/57* the loss of
aa spouse and disability/17* between self-rated health and mortality/177* between depressive
symptomss and mortality/154* between disability and depressive symptoms/188' and between
disabilityy and mortality/104' Our results can therefore not be generalised to women.
Ofherr countries
Thee data came from men living in specific parts of three countries. In Finland, the men came from
rurall areas, in the Netherlands from a commercial town, and in Italy from two rural villages. Those
areass are not representative for the population of the whole country. However, because the
associationss found in the different studies described in this thesis were observed in all cohorts (see
e.g.. chapter 2 and 6), we expect that our results on associations are generalisable to populations
off other European countries.
Inn contrast, we showed that given a certain level of performance test, Dutch men reported more
disabilitiess than Finnish and Italian men (chapter 2), which suggests that also factors other than
physicall functioning, such as cultural factors, play a role when reporting disability. An earlier study
showedd that also dynamics of disability (10-year changes) differed between countries/189'
Prevalencee figures can therefore not be generalised to other countries.
Implication ss for preventio n and healt h care deliver y
Thee results of our study confirm the importance of some determinants and consequences of
disabilityy found in earlier research, and also shed light on new aspects. While earlier studies
showedd that widowhood has consequences for physical health aspects, our study showed that
widowedd men are also at higher risk of disability. In addition, physical activity had been known to
bee an important determinant of disability, and our study showed that especially duration of physical
activityy is important. As in earlier studies, men with disabilities were at higher risk of depressive
symptoms,, and both disability and subjective health aspects contribute to mortality risk. Finally,
theree was an indication for inequity in the use of home nursing.
101 1
ChapterChapter 8
Viewingg these results, some interesting issues have been obtained that can serve as starting point
forr prevention or care programs. In this section, the results of the present study and those of other
studies,, and their implications for prevention strategies and health care services are discussed.
Physica ll activit y program s
Ass a potentially modifiable risk factor, physical activity represents an attractive target for
interventionss designed to prevent or postpone functional disability. Several prospective studies
showedd beneficial effects of physical activity on minimising disability/21162* Two reviews in which
thee effectiveness of physical interventions were evaluated, reported that significant numbers of
olderr adults increased their physical activity levels in response to experimental interventions,0761901
althoughh changes in physical activity were small and short-lived.(176) In addition, there is no strong
evidencee that disability can be prevented in the long-term by physical activity interventions/21162'
Effectss of exercise or strength training were only found for correlates of disability, such as muscle
strength,, gait speed, or performance-based tests, but not for disability itself/191"193*
Conclusionss of prospective studies are usually based on activities like walking, bicycling, jogging,
orr gardening and usually do not incorporate exercise training. That is probably the most important
differencee between prospective observational and experimental studies. The results of chapter 4,
showingg that duration and not intensity of physical activities was associated with the onset of
disability,, also suggest that elderly people should be counselled to incorporate moderate-intensity
activityy into daily life instead of structured exercise programmes. Earlier intervention studies, which
didd not focus on elderly people, confirmed that most of the health benefits can be gained from
regularr physical activity of moderate intensity rather than from specific tailored exercise
programs.<194;195)) Our results (100 minutes of physical activity per day) are in accordance with the
Dutchh physical activity guideline that recommends at least 30 minutes of moderate intense physical
activityy (e.g. walking or bicycling) most days of the week, and suggest that the best way for
adherencee is to incorporate physical activity in daily life.(96) In addition, we found that spending
moree than 30 minutes on physical activity is even better.
Publicc health advice should inform people that regular physical activity is desirable in old age, and
cann simply be achieved by adopting enjoyable activities. Furthermore, it is important to provide an
attractivee physical environment/196* e.g. safe areas or parks for walking, and to support community
activitiess that stimulate physical activity. Physical activity can also be stimulated by general
practitionerss and as a part of care programs in home care services or elderly homes. Future
researchh should focus on the development of effective physical activity intervention strategies
amongg elderly people.
102 2
GeneralGeneral discussion
Inn addition to physical activity, other behavioural risk factors play a role in the disablement process.
Smoking,, alcohol consumption, low or high body mass index, and diet have been associated with
functionall disability.<92:197201) Although these lifestyle factors could also be incorporated into
preventionn or intervention strategies related to disability, it is not known whether these strategies
aree effective. There is a need for intervention studies among elderly people including different
lifestyle-relatedd risk factors for disability.
Preventiv ee car e program s
Theree are several approaches for care programs aimed at prevention of disability among elderly
people.. Many randomised trials have been carried out in which the effect of preventive home visits
iss investigated.*202' Preventive home visits are aimed at medical, functional, psychosocial, and
environmentall evaluation of problems and resources. Participants are selected from general
practicess lists or population registers. Evaluation of the situation of elderly persons during a visit
resultss in specific recommendations, referrals and other actions in order to delay or prevent
functionall decline. The effectiveness of preventive home visits is however not unequivocally
established/202"204'' According to a review, preventive home visits could be effective provided the
interventionss are based on multidimensional geriatric assessment (medical, functional,
psychosocial,, and environmental domains), include multiple follow-up home visits, and are offered
too relatively young elders with good physical functioning.<202) This stresses the importance of
tailoredd programs, i.e. choosing the right program for the right target populations, to improve the
effectivenesss of home visits. Although some countries have national programs of preventive home
visits,, more insight should be gained into the predictors of success and failure for these programs.
Widowerss are an important target group for care programs, since men who have recently become
widowedd are at higher risk of disability (chapter 3), caused by the loss of social support, the stress
off bereavement, or adjustments to managing a household alone.(205> In the literature, some starting
pointss have been given for the content of programs for widowers. A program was developed in
whichh widowers were provided with important health information and were taught new self-care
skills.(206>> This program resulted in better ability to maintain a clean and safe home and to obtain
betterr diet and exercise, so for widowers this program was a useful resource to improve self-care
skillss and to learn creating healthier lives. This will prevent both situational disability (never learned
skills)) and functional disability (health problems) respectively.
Inn the Netherlands, there are different programs for widowers (and widows) (see e.g.
http://www.trimbos.nl).. Widowers are visited by professionals or join peer groups. Those care
programss are particularly focused on psychological aspects, such as coping and prevention of
depression,, and not on physical health or disability in activities of daily living. Caregivers should be
103 3
ChapterChapter 8
awaree that widowers are more susceptible to decline in physical and mental health. Disability
preventionn programs must be available and widowers should be made aware of the existence of
suchh programs.
Alsoo management of chronic diseases might be a starting point for postponement of disability. For
example,, stroke services are increasingly initiated to improve quality of life or survival.(207) In stroke
services,, the patient flow from the hospital to (nursing) home is regulated through capacity
planningg and efficient hospital discharge procedures. A stroke service can be defined as a regional
chainn of caregivers from many disciplines, i.e. medical, nursing and therapy staff, aimed at
dedicatedd care and good cooperation. Organising stroke care in a stroke service appeared to be
associatedd with reduced disability/208"210* Studies on this topic thus far are limited to stroke patients.
Nevertheless,, those findings emphasise that health gains can be achieved by strengthening
coordinationn of multidisciplinary care among patients with chronic diseases and disabilities.
Psychosocia ll suppor t program s
Inn care programs more attention should be paid to psychosocial aspects. Sixteen percent of elderly
peoplee suffer from clinically relevant depressive symptoms/211' The results of chapter 5 and 6
showedd that elderly people who have disability are a risk group for depressive symptoms. In
accordancee with the World Health Organisation, Dutch policy recognises the impact of depression
andd aims at identifying depressive symptoms among elderly people and at preventive strategies
amongg high risk groups.<211) Although from the literature there is knowledge on treatment and
interventionn programs available/212"214' the main problem is that depressive symptoms are often
unrecognised.. Depressive symptoms are recommended to be approached from different areas
(e.g.. care, wellbeing, sport activities, security, living, dwelling), the so-called 'integral approach'/211'
Cooperationn between the different areas should be strengthened and case-finding and screening
protocolss should become available to identify people with (high risk of) depressive symptoms.
Forma ll hom e car e
Accordingg to the results described in this thesis, there was equity in the use of formal home help in
thee Dutch cohort of the FINE study, which implies that those who receive help are those who need
help.. Financing of home care in the Netherlands is covered by the Law on Special Medical
Expensess (AWBZ). This law concerns the insurance of all Dutch citizens for care and support in
casess of protracted illness, invalidity, or geriatric diseases. Between 2000 and 2020, the potential
demandd for home care is expected to increase from 735.000 people to over one million people, as
aa consequence of the demographic ageing of the population/125' This increase in demand and the
risingg costs necessitated a reform of the AWBZ. In the past years, a number of measures have
104 4
Genera// discussion
alreadyy been implemented. Entry requirements have been made more restrictive and the
managementt of entry into the AWBZ has been centralised. In 2006, a new Law on Social Support
(WMO)) will be introduced. Starting points for this act are individual responsibility, solidarity in
society,, proper care for people who really need it, and less bureaucracy.
Ann important consequence is that home help will be removed from the AWBZ. People who have
informall care or who can afford private help, are assumed to need no formal home help.
Responsibilitiess for home help delivery are planned to shift to the municipality. Although currently
theree is equity in the use of formal home help, within a few years it should be evaluated whether
usee of home help is according to need in the new health care system.
Withh respect to home nursing, inequity in use could not be ruled out. Special attention is required
forr men who are low educated. As proposed in an earlier study, communication of information on
caree arrangements should be improved, and also effective individual coaching could compensate
forr low education.*120' Also for home nursing the effects of the new health care system should be
determined. .
Informall care
Thee demand for informal care will increase as a consequence of the growing number of elderly
peoplee and the changing health care system. From 2006 people have to search for care in their
ownn environment, while personal budgets will become more restrictive. Being the primary informal
caregiverr of an elderly person can be quite burdensome.(215"217) Studies in this field revealed that
thee strains from informal care giving contribute to lower quality of life, depression and even to early
mortalityy of the caregiver.(215"220) To maintain a sustainable input of caregivers in the future and to
counterr overburdening, the burden of informal care giving should be alleviated, for example by
offeringg respite care(221) or (psycho-)social support. In the Netherlands the support group for
informall caregivers (LOT) was founded to assist them. It is important that informal caregivers are
awaree of the support available for them. Health care services and municipalities should be aware
off the burden for spouses or other informal caregivers. It should also be evaluated what the long-
termm impact is of the reforms of the Dutch health care system on the supply of informal care.
Epilogue e
Thee increasing number of elderly people is a growing public health problem. Many people wish to
groww old, but ageing is often accompanied by health problems, such as functional disability. In this
thesis,thesis, several starting points for interventions on risk factors and risk groups have been identified,
inn order to prevent or postpone functional disability among elderly people. Also adequate care and
psychosociall support programs deserve attention in anticipating the growing burden of elderly
105 5
ChapterChapter 8
peoplee with disability. These issues should get high priority in research and policy in the years to
come,, in order to sustain the autonomy and independent living of the elderly.
106 6
Reference s s
References s
1.. Maas PJvd, Mackenbach JP. Volksgezondheid en Gezondheidszorg. Maarssen: Elsevier/ Bunge; 1999. .
2.. Omran AR. The epidemiologic transition. A theory of the epidemiology of population change. Milbank Memm Fund Q 1971;49(4):509-38.
3.. Imhoff EvN. Wat zijn de belangrijkste verwachtingen voor de toekomst? In: Volksgezondheid Toekomstt Verkenning, Nationaal Kompas Volksgezondheid. Bilthoven: RIVM, <http://www.nationaalkompas.nl>> Bevolking, 14 februari 2003.
4.. Caldwell JC. Population health in transition. Bull World Health Organ 2001 ;79{2):159-60.
5.. Perenboom RJM, Mulder YM, Herten LMv, Oudshoorn K, Hoeymans N. Trends in gezonde levensverwachting:: Nederland 1983-2000. Leiden: TNO Preventie En Gezondheid; 2002.
6.. Centraal Bureau voor de Statistiek. Prognose-intervallen van de bevolking naar leeftijdsgroep. http://statline.cbs.nll (bezocht 6 mei 2005).
7.. Verbrugge LM, Jette AM. The disablement process. Soc Sci Med 1994;38(1):1-14.
8.. Hoeymans N, Feskens EJ, van den Bos GAM, Kromhout D. Measuring functional status: cross-sectionall and longitudinal associations between performance and self-report (Zutphen Elderly Study 1990-1993).. J Clin Epidemiol 1996;49(10):1103-10.
9.. Angel R, Thoits P. The impact of culture on the cognitive structure of illness. Cult Med Psychiatry 1987;11(4):465-94. .
10.. Jee M, Or Z. Health outcomes in OECD countries: a framework of health indicators for outcome-orientedd policymaking. Paris: Organisation for Economic Co-Operation and Development; 1999.
11.. Daltroy LH, Larson MG, Eaton HM, Phillips CB, Liang MH. Discrepancies between self-reported and observedd physical function in the elderly: the influence of response shift and other factors. Soc Sci Medd 1999;48( 11): 1549-61.
12.. Kivinen P, Sulkava R, Halonen P, Nissinen A. Self-reported and performance-based functional status andd associated factors among elderly men: the Finnish cohorts of the Seven Countries Study. J Clin Epidemioll 1998;51 (12): 1243-52.
13.. Guralnik JM, Simonsick EM, Ferrucci L, Glynn RJ, Berkman LF, Blazer DG, Scherr PA, Wallace RB. A shortt physical performance battery assessing lower extremity function: association with self-reported disabilityy and prediction of mortality and nursing home admission. Journal of Gerontol A Med Sci 1994;49(2):M85-M94. .
14.. Centraal Bureau voor de Statistiek. Bevolking per regio naar leeftijd, geslacht en burgerlijke staat. http://statline.cbs.nll (bezocht 6 mei 2005).
15.. Maas IAM, Gijsen R, Lobbezoo IE, Poos MJJC. Volksgezondheid Toekomst Verkenning 1997. 1. De gezondheidstoestand:: een actualisering. Maarssen: RIVM / Elsevier/ De Tijdstroom; 1997.
16.. Wisocki PA, Skowron J. The effects of gender and culture on adjustment to widowhood. Handbook of
108 8
References References
Genderr Culture and Health 2000:429-47.
17.. Goldman N, Korenman S, Weinstein R. Marital status and health among the elderly. Soc Sci Med 1995;40(12):: 1717-30.
18.. Mendes de Leon CF, Kasl SV, Jacobs S. Widowhood and mortality risk in a community sample of the elderly:: a prospective study. J Clin Epidemiol 1993;46(6):519-27.
19.. Deeg DJH. Sex differences in IADL in the Netherlands: functional and situational disability. In Robine JM,, Mathers CD, Bone MR Eds. Calculation of Health Expectancies: Harmonization, Consensus Achievedd and Future Perspectives. Montrouge, France: Colleque INSERM/John Libbey Eurotext Ltd; 1993:p.. 203-13.
20.. U.S. Department of Health and Human Services. Physical Activity and Health: A Report of the Surgeon General.. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control andd Prevention, National Center for Chronic Disease Prevention and Health Promotion; 1996.
21.. Spirduso WW, Cronin DL. Exercise dose-response effects on quality of life and independent living in olderr adults. Med Sci Sports Exerc 2001 ;33(6 Suppl):S598-S608.
22.. Tanasescu M, Leitzmann MF, Rimm EB, Willett WC, Stampfer MJ , Hu FB. Exercise type and intensity inn relation to coronary heart disease in men. JAMA 2002;288{16): 1994-2000.
23.. Andersen R, Aday LA. Access to medical care in the U.S.: realized and potential. Med Care 1978;16(7):533-46. .
24.. Bruce ML. Depression and disability in late life: directions for future research. Am J Geriatr Psychiatry 20011 ;9{2):102-12.
25.. Cole MG, Dendukuri N. Risk factors for depression among elderly community subjects: a systematic revieww and meta-analysis. Am J Psychiatry 2003; 160(6): 1147-56.
26.. Stek ML, Gussekloo J, Beekman AT, van Tilburg W, Westendorp RG. Prevalence, correlates and recognitionn of depression in the oldest old: the Leiden 85-plus study. J Affect Disord 2004;78(3):193-200. .
27.. Hartman-Stein PE, Potkanowicz ES. Behavioral determinants of healthy aging: good news for the baby boomerr generation. Online J Issues Nurs 2003;8(2):6.
28.. Hirvensalo M, Rantanen T, Heikkinen E. Mobility difficulties and physical activity as predictors of mortalityy and loss of independence in the community-living older population. J Am Geriatr Soc 2000;48(5):493-8. .
29.. Ginsberg GM, Hammerman-Rozenberg R, Cohen A, Stessman J. Independence in instrumental activitiess of daily living and its effect on mortality. Aging (Milano) 1999; 11(3): 161-8.
30.. Wolinsky FD, Callahan CM, Fitzgerald JF, Johnson RJ. Changes in functional status and the risks of subsequentt nursing home placement and death. J Gerontol 1993;48(3):S94-101.
31.. Reuben DB, Rubenstein LV, Hirsch SH, Hays RD. Value of functional status as a predictor of mortality:
109 9
resultss of a prospective study. Am J Med 1992;93(6):663-9.
32.. Ramasubbu R, Patten SB. Effect of depression on stroke morbidity and mortality. Can J Psychiatry 2003;48(4):250-7. .
33.. Schulz R, Drayer RA, Rollman BL. Depression as a risk factor for non-suicide mortality in the elderly. Bioll Psychiatry 2002;52(3):205-25.
34.. Benyamini Y, Idler EL. Community studies reporting association between self-rated health and mortalityy - Additional studies, 1995-1998. Res Aging 1999;21 (3):392-401.
35.. Idler EL, Benyamini Y. Self-rated health and mortality: a review of twenty-seven community studies. J Healthh Soc Behav 1997;38:21-37.
36.. Keys A, Aravanis C, Blackburn H, van Buchem FSP, Buzina R, Djordjevic BS, Dontas AS, Fidanza F, Karvonenn MJ, Kimura N, et al. Epidemiological studies related to coronary heart disease; characteristicss of men aged 40-59 in seven countries. Acta Med Scan 1967;460(suppl): 1-392.
37.. World Health Organization. World Health Report 2000. Geneva: World Health Organization; 2000.
38.. Nagi S. Disability concepts revisited: implications for prevention. In Pope AM, Tarlov AR Eds. Disability inn America. Toward a National Agenda for Prevention. Washington, DC: National Academy Press; 1991. .
39.. Sager MA, Dunham NC, Schwantes A, Mecum L, Halverson K, Harlowe D. Measurement of activities off daily living in hospitalized elderly: a comparison of self-report and performance-based methods. J Amm Geriatr Soc 1992;40(5):457-62.
40.. Simonsick EM, Kasper JD, Guralnik JM, Bandeen-Roche K, Ferrucci L, Hirsch R, Leveille S, Rantanen T,, Fried LP. Severity of upper and lower extremity functional limitation: scale development and validationn with self-report and performance-based measures of physical function. J Gerontol B Psycholl Sci Soc Sci 2001;56B(1):S10-S19.
41.. Langlois JA, Maggi S, Harris T, Simonsick EM, Ferrucci L, Pavan M, Sartori L, Enzi G. Self-report of difficultyy in performing functional activities identifies a broad range of disability in old age. J Am Geriatr Soc1996;44(12):1421-8. .
42.. Kempen Gl, Steverink N, Ormel J, Deeg DJ. The assessment of ADL among frail elderly in an intervieww survey: self- report versus performance-based tests and determinants of discrepancies. J Gerontoll B Psychol Sci Soc Sci 1996;51B(5):P254-P260.
43.. Bijnen FC, Feskens EJ, Caspersen CJ, Giampaoli S, Nissinen AM, Menotti A, Mosterd WL, Kromhout D.. Physical activity and cardiovascular risk factors among elderly men in Finland, Italy, and the Netherlands.. Am J Epidemiol 1996;143(6):553-61.
44.. World Health Organization. The elderly in eleven countries. Copenhagen: World Health Organization; 1983. .
45.. König-Zahn C, Furer JW, Tax B. Het meten van de gezondheidstoestand. 2 Lichamelijke gezondheid, socialee gezondheid. Assen: Van Gorcum; 1994.
110 0
References References
46.. Cornoni-Huntley J, Brock DB, Ostfeld AM, Taylor JO, Wallace RB . Established populations for epidemiologicc studied of the elderly. Resource data book. New Haven: National Institute on Aging.
47.. Rose GA, Blackburn H. Cardiovascular survey methods. Monogr Ser World Health Organ 1968;56:1-188. .
48.. Sadana R, Mathers CD, Lopez AD, Murray CJL, Iburg K. Comparative analyses of more than 50 householdd surveys on health status. Geneva: World Health Organization; 2000.
49.. Cavelaars AE, Kunst AE, Geurts JJ, Crialesi R, Grotvedt L, Helmert U, Lahelma E, Lundberg O, Mathesonn J, Mielck A, et al. Differences in self reported morbidity by educational level: a comparison off 11 western European countries. J Epidemiol Community Health 1998;52(4):219-27.
50.. Russell K, Jewell N. Cultural impact of health-care access: challenges for improving the health of Africann Americans. J Community Health Nurs 1992;9{3):161-9.
51.. Jylha M, Guralnik JM, Ferrucci L, Jokela J, Heikkinen E. Is self-rated health comparable across culturess and genders? J Gerontol B Psychol Sci Soc Sci 1998;53B(3):S144-S152.
52.. Huijbregts PPCW, Feskens EJM, RSsSnen L Diet, energy intake, and self-rated health in elderly men. InIn Dietary Patterns and Health in the Elderly: a North-South Comparison in Europe [Dissertation]. Den Haag:: CIP-Data, Koninklijke Bibiotheek; 1997: p. 93-107.
53.. Meredith LS, Siu AL. Variation and quality of self-report health data. Asians and Pacific Islanders comparedd with other ethnic groups. Med Care 1995 Nov;33{11):1120-31.
54.. Alonso J, Black C, Norregaard JC, Dunn E, Andersen TF, Espallargues M, Bemth-Petersen P, Andersonn GF. Cross-cultural differences in the reporting of global functional capacity: an example in cataractt patients. Med Care 1998;36(6):868-78.
55.. Hoeymans N, Feskens EJ, Van Den Bos GA, Kromhout D. Non-response bias in a study of cardiovascularr diseases, functional status and self-rated health among elderly men. Age Ageing 1998;27(1):: 35-40.
56.. Giampaoli S, Menotti A. Performance ed autosufficienza nella popolazione italiana. In La Salute DegN Italian!.. Roma: La Nuova Italia Scientifica. 1993: p. 287-96.
57.. Merrill SS, Seeman TE, Kast SV, Berkman LF. Gender differences in the comparison of self-reported disabilityy and performance measures. J Gerontol A Biol Sci Med Sci 1997;52A(1):M19-M26.
58.. Spector WD, Katz S, Murphy JB, Fulton JP. The hierarchical relationship between activities of daily livingg and instrumental activities of daily living. J Chronic Dis 1987;40(6):481-9.
59.. World Health Organization. The World Health Organization Collection on Long-Term Care. Current andd Future Long-Term Care Needs. 2002.
60.. Guralnik JM, Alecxih L, Branch LG, Wiener JM. Medical and long-term care costs when older persons becomee more dependent. Am J Public Health 2002;92(8): 1244-5.
61.. Central Bureau of Statistics. [Increasing incidence of widowhood among men]. Voorburg/Heerlen, the
111 1
Netherlands:: CBS; 2002.
62.. Joung IMA, Stronks K, van de Mheen H, van Poppel FWA, van der Meer JBW, Mackenbach JP. The contributionn of intermediary factors to marital status differences in self-reported health. Journal of Marriagee and the Family 1997;59:476-90.
63.. van Poppel F, Joung I. Long-term trends in marital status mortality differences in The Netherlands 1850-1970.. J Biosoc Sci 2001;33(2):279-303.
64.. Ben-Shlomo Y, Smith GD, Shipley M, Marmot MG. Magnitude and causes of mortality differences betweenn married and unmarried men. J Epidemiol Community Health 1993;47{3):200-5.
65.. De Jong Gierveld J, Dykstra PA. Life transitions and the network of personal relationships. Theoretical andd methodological issues. In Duck, S. Ed. Advances in Personal Relationships. Jessica Kingsley Publisherss Ltd; 1993. p. 195-227.
66.. Antonucci TC, Lansford JE, Schaberg L , Baltes M, Takahashi K, Dartigues JF, Smith J, Akiyama H, Fuhrerr R. Widowhood and illness: a comparison of social network characteristics in France, Germany, Japan,, and the United States. Psychol Aging 2001;16(4):655-65.
67.. O'Bryant SL, Hansson RO. Widowhood. In R. Blieszner & V.H. Bedford Eds. Handbook of Aging and thee Family. Westport: CT: Greenwood Press; 1995: p. 440-59.
68.. Jacobzone, S. Ageing and care for frail elderly persons: an overview of international perspectives. Paris:: Organisation for economic co-operation and development; 1999.
69.. Sociaal en Cultureel Planbureau. Sociaal en Cultureel Rapport 2000. Nederland in Europa. The Hague,, the Netherlands: Sociaal en Cultureel Planbureau; 2000.
70.. van den Brink CL, Tijhuis M, Kalmijn S, Klazinga NS, Nissinen A, Giampaoli S , Kivinen P, Kromhout D,, van den Bos GA. Self-reported disability and its association with performance-based limitation in elderlyy men: a comparison of three European countries. J Am Geriatr Soc 2003;51(6):782-8.
71.. Glass TA, Kasl SV, Berkman LF. Stressful life events and depressive symptoms among the elderly. J Agingg Health 1997;9(1):70-89.
72.. Umberson D, Wortman CB, Kessler RC. Widowhood and depression: explaining long-term gender differencess in vulnerability. J Health Soc Behav 1992;33(1):10-24.
73.. Billings AG, Moos RH. Stressful life events and symptoms: a longitudinal model. Health Psychol 1982;1:99-117. .
74.. Bieliauskas LA, Counte MA, Glandon GL. Inventorying stressing life events as related to health change inn the elderly. Stress Medicine 1995;11(2):93-103.
75.. Grand A, Grosclaude P, Bocquet H, Pous J, Albarede JL. Predictive value of life events, psychosocial factorss and self-rated health on disability in an elderly rural French population. Soc Sci Med 1988;27(12):1337-42. .
76.. Umberson D. Gender, marital status and the social control of health behavior. Soc Sci Med 1992;34-
112 2
References References
8:907-17. .
77.. Lichtenberg PA, MacNeill SE, Mast BT. Environmental press and adaptation to disability in hospitalizedd iive-alone older adults. Gerontologist 2000 Oct;40{5):549-56.
78.. Speare AJ, Avery R, Lawton L. Disability, residential mobility, and changes in living arrangements. J Gerontoll 1991 ;46(3):S133-42.
79.. Zunzunegui MV, Beland F, Otero A. Support from children, living arrangements, self-rated health and depressivee symptoms of older people in Spain. Int J Epidemiol 2001 ;30(5): 1090-9.
80.. Joung IMA, Mheen Hvd, Stronks K, Poppel FWAv, Mackenbach JP. Differences in self-reported morbidityy by marital status and by living arrangement. Intern J Epidemiol 1994;23(1):91-7.
81.. Fry PS. Predictors of health-related quality of life perspectives, self-esteem, and life satisfactions of olderr adults following spousal loss: an 18- month follow-up study of widows and widowers. Gerontologistt 2001 ;41(6):787-98.
82.. Erlichman J, Kerbey A, James W. Physical activity and its impact on health outcomes. Paper 1: The impactt of physical activity on cardiovascular disease and all-cause mortality: an historical perspective. Obesityy Reviews 2002;3:257-71.
83.. Lee I, Skerrett P. Physical activity and all-cause mortality: what is the dose-response relation? Med Sci Sportss Exerc 2001 ;33(6 Suppl):S459-71.
84.. Bijnen FC, Caspersen CJ, Feskens EJ, Saris WH, Mosterd WL, Kromhout D. Physical activity and 10-yearr mortality from cardiovascular diseases and all causes: The Zutphen Elderly Study. Arch Intern Medd 1998;158(14):1499-505.
85.. Miller ME, Rejeski WJ, Reboussin BA, Ten Have TR, Ettinger WH. Physical activity, functional limitations,, and disability in older adults. J Am Geriatr Soc 2000;48{10):1264-72.
86.. Ferrucci L, Izmirlian G, Leveille S, Phillips CL, Corti MC, Brock DB, Guralnik JM. Smoking, physical activity,, and active life expectancy. Am J Epidemiol 1999;149(7):645-53.
87.. Wu SC, Leu SY, Li CY. Incidence of and predictors for chronic disability in activities of daily living amongg older people in Taiwan. J Am Geriatr Soc 1999;47(9): 1082-6.
88.. Huang Y, Macera CA, Blair SN, Brill PA, Kohl HW 3rd, Kronenfeld JJ. Physical fitness, physical activity,, and functional limitation in adults aged 40 and older. Med Sci Sports Exerc 1998;30(9): 1430-5.
89.. Unger JB, Johnson CA, Marks G. Functional decline in the elderly: evidence for direct and stress-bufferingg protective effects of social interactions and physical activity. Ann Behav Med 1997; 19(2): 152-60. .
90.. Strawbridge WJ, Cohen RD, Shema SJ, Kaplan GA. Successful aging: predictors and associated activities.. Am J Epidemiol 1996; 144(2): 135-41.
91.. Young DR, Masaki KH, Curb JD. Associations of physical activity with performance-based and self-reportedd physical functioning in older men: the Honolulu Heart Program. J Am Geriatr Soc
113 3
1995;43(8):845-54. .
92.. LaCroix AZ, Guralnik JM, Berkman LF, Wallace RB, Satterfield S. Maintaining mobility in late life. II. Smoking,, alcohol consumption, physical activity, and body mass index. Am J Epidemiol 1993;137(8):858-69. .
93.. Avlund K, Lund R, Holstein BE, Due P, Sakari-Rantala R , Heikkinen RL. The impact of structural and functionall characteristics of social relations as determinants of functional decline. J Gerontol B Psychol Scii Soc Sci 2004;59(1 ):S44-S51.
94.. Caspersen CJ, Bloemberg BP, Saris WHM , Merritt RK, Kromhout D. The prevalence of selected physicall activities and their relation with coronary heart disease risk factors in elderly men: the Zutphen Study,, 1985. Am J Epidemiol 1991; 133(11): 1078-92.
95.. Westerterp KR, Saris WHM, Bloemberg BPM, Kempen K, Caspersen CJ, Kromhout D. Validation of thee Zutphen Physical Activity Questionnaire for the Elderly with doubly labeled water. Med. Sci. Sports Exerc.. 1992;24:S68.
96.. Kemper HCG, Ooijendijk WTM, Stiggelbout M. [Consensus about the Dutch physical activity guideline].. Tijdschr Soc Geneeskd 2000;78:180-3.
97.. Pate RR, Pratt M, Blair SN, Haskell WL, Macera CA, Bouchard C, Buchner D, Ettinger W, Heath GW , Kingg AC, et al. Physical activity and public health. A recommendation from the Centers for Disease Controll and Prevention and the American College of Sports Medicine. JAMA 1995;273(5):402-7.
98.. Schoenborn CA, Barnes P.M. Leisure-time physical activity among adults: United States, 1997-98. Advancee data from vital and health statistics; no. 325. Hyattsville, Maryland: National Center for Health Statisticss 2002.
99.. Hildebrandt VH, Ooijendijk WTM, Stiggelbout M. [Trend report on physical activity and health 1998/1999].. Lelystad, NL: Koninklijke Vermande; 1999.
100.. Shephard R. Absolute versus relative intensity of physical activity in a dose-response context. Med Sci Sportss Exerc 2001 ;33(6 Suppl):S400-18.
101.. Schuit AJ, van Loon AJ, Tijhuis M, Ocké M. Clustering of lifestyle risk factors in a general adult population.. Prev Med 2002;35(3):219-24.
102.. Ferraro KF, Su YP, Gretebeck RJ, Black DR, Badylak SF. Body mass index and disability in adulthood:: a 20-year panel study. Am J Public Health 2002;92(5):834-40.
103.. Oslin DW. Alcohol use in late life: disability and comorbidity. J Geriatr Psychiatry Neurol 2000;; 13(3): 134-40.
104.. Lamarca R, Ferrer M, Andersen PK, Liestol K, Keiding N, Alonso J. A changing relationship between disabilityy and survival in the elderly population: differences by age. J Clin Epidemiol 2003;56(12):1192-201. .
105.. Andersen RM. Revisiting the behavioral model and access to medical care: does it matter? J Health Socc Behav 1995;36(1):1-10.
114 4
References References
106.. Algera M, Francke AL, Kerkstra A, van der Zee J. Home care needs of patients with long-term conditions:: literature review. J Adv Nurs 2004;46(4):417-29.
107.. van den Bos GA, Smits JP, Westert GP, van Straten A. Socioeconomic variations in the course of stroke:: unequal health outcomes, equal care? J Epidemiol Community Health 2002;56(12):943-8.
108.. Jacobi CE, Triemstra M, Rupp I, Dinant HJ, Van Den Bos GA. Health care utilization among rheumatoidd arthritis patients referred to a rheumatology center: unequal needs, unequal care? Arthritis Rheumm 2001 ;45(4):324-30.
109.. Scholte op Reimer WJM, de Haan RJ, Rijnders PT, Limburg M, van den Bos GAM. Unmet care demandss as perceived by stroke patients: deficits in health care? Qual Health Care 1999;8:30-5.
110.. de Boer AG, Wijker W, de Haes HC. Predictors of health care utilization in the chronically ill: a review off the literature. Health Policy 1997;42{2):101-15.
111.. de Haan R, Limburg M, van der Meulen J, van den Bos GA. Use of health care services after stroke. Quall Health Care 1993;2(4): 222-7.
112.. Kempen Gl, Suurmeijer TP. Professional home care for the elderly: an application of the Andersen-Newmann model in The Netherlands. Soc Sci Med 1991;33(9):1081-9.
113.. Wolinsky FD, Johnson RJ. The use of health services by older adults. J Gerontol 1991 ;46{6):S345-S357. .
114.. Evashwick C, Rowe G, Diehr P, Branch L. Factors explaining the use of health care services by the elderly.. Health Serv Res 1984;19(3):357-82.
115.. Westert GP, Satariano WA, Schellevis FG, van den Bos GA. Patterns of comorbidity and the use of healthh services in the Dutch population. Eur J Public Health 2001;11(4):365-72.
116.. Liu K, Manton KG, Aragon C. Changes in home care use by disabled elderly persons: 1982-1994. J Gerontoll B Psychol Sci Soc Sci 2000;55(4):S245-S253.
117.. Scholte op Reimer WJM, de Haan RJ, Limburg M, van den Bos GAM. Use of long-term health care afterr stroke. In Long-term use after stroke [dissertation]. Amsterdam; 1999.
118.. Stoddart H, Whitley E, Harvey I, Sharp D. What determines the use of home care services by elderly people?? Health Soc Care Community 2002;10{5):348-60.
119.. Portrait F, Lindeboom M, Deeg D. The use of long-term care services by the Dutch elderly. Health Econ2000;9(6):513-31. .
120.. Geerlings SW, Pot AM, Twisk JWR, Deeg DJH. Predicting transitions in the use of informal and professionall care by older adults. Aging and Society 2005;25:111-30.
121.. Cantor MH. Neighbours and friends: an overlooked resource in the informal support system. Res Agingg 1979;1:434-63.
122.. Sussman M. The family life of old people, in Binstock, R. & Shanas, EH Eds. Handbook of Aging and
115 5
thee Social Sciences. New York: Van Nostrand Reinhold, 1976.
123.. Kempen Gl, Suurmeijer TP. Factors influencing professional home care utilization among the elderly. Socc Sci Med 1991 ;32(1):77-81.
124.. Feskens E, Bloemberg B, Pijls L, Kromhout D. A longitudinal study on elderly men: the Zutphen Study. InIn Schroots JJF Ed. Aging, Health and Competence. Amsterdam: Elsevier Science Publishers; 1993.
125.. Berg Jeths A vd, Timmermans JM, Hoeymans N, Woittiez IB. Ouderen nu en in de toekomst. Gezondheid,, verpleging en verzorging 2000-2020. Bilthoven: RIVM/ Bohn Stafleu Van Loghum; 2004.
126.. Algera M, Francke AL, Schreeuwenberg P, Zee Jvd. The match between Dutch chronic patients' felt needd and home care delivered and its determinants. In All You Need Is... Home Care [Dissertation]. Utrecht;; 2005.
127.. Ruo B, Rumsfeld JS, Hlatky MA, Liu H, Browner WS, Whooley MA. Depressive symptoms and health-relatedd quality of life. JAMA 2003;290(2):215-21.
128.. Beekman AT, Penninx BW, Deeg DJ, de Beurs E, Geerling SW , van Tilburg W. The impact of depressionn on the well-being, disability and use of services in older adults: a longitudinal perspective. Actaa Psychiatr Scand 2002; 105(1 ):20-7.
129.. Ganguli M, Dodge HH, Mulsant BH. Rates and predictors of mortality in an aging, rural, community-basedd cohort: the role of depression. Arch Gen Psychiatry 2002;59(11): 1046-52.
130.. Blazer DG, Hybels CF, Pieper CF. The association of depression and mortality in elderly persons: a casee for multiple, independent pathways. J Gerontol A Biol Sci Med Sci 2001;56<8):M505-M509.
131.. Cummings SM, Neff JA, Husaini BA. Functional impairment as a predictor of depressive symptomatology:: the role of race, religiosity, and social support. Health Soc Work 2003;28(1):23-32.
132.. Jang Y, Haley WE, Small BJ, Mortimer J A. The role of mastery and social resources in the associationss between disability and depression in later life. Gerontologist 2002;42(6):807-13.
133.. Steffens DC, Hays JC, Krishman K.R.R. Disability in geriatric depression. Am J Geriatr Psychiatry 1999;7:34-40. .
134.. Prince MJ, Harwood RH, Blizard RA, Thomas A, Mann AH. Impairment, disability and handicap as risk factorss for depression in old age. The Gospel Oak Project V. Psychol Med 1997;27(2):311-21.
135.. Alexopoulos GS, Vrontou C, Kakuma T, Meyers BS, Young RC, Klausner E, Clarkin J . Disability in geriatricc depression. Am J Psychiatry 1996;153(7):877-85.
136.. Forsell Y, Jorm AF, Winblad B. Association of age, sex, cognitive dysfunction, and disability with major depressivee symptoms in an elderly sample. Am J Psychiatry 1994; 151 (11): 1600-4.
137.. Kessler RC, Berglund P, Dernier O, Jin R, Koretz D, Merikangas KR, Rush AJ, Walters EE, Wang PS . Thee epidemiology of major depressive disorder. Results from the National Comorbidity Survey Replicationn (NCS-R). JAMA 2003;289(23):3095-105.
116 6
References References
138.. Ormel J, Rijsdijk FV, Sullivan M, van Sonderen E, Kempen Gl. Temporal and reciprocal relationship betweenn IADL/ADL disability and depressive symptoms in late life. J Gerontol B Psychol Sci Soc Sci 2002;57(4):P338-P347. .
139.. Geerlings SW, Beekman ATF, Deeg DJH, Van Tilburg W. Physical health and the onset and persistencee of depression in older adults: an eight-wave prospective community-based study. Psychol Medd 2000;30:369-80.
140.. Prince MJ, Harwood RH, Thomas A, Mann AH. A prospective population-based cohort study of the effectss of disablement and social milieu on the onset and maintenance of late-life depression. The Gospell Oak Project VII. Psychol Med 1998;28:337-50.
141.. Henderson AS, Korten AE, Jacomb PA, Mackinnon AJ, Jorm AF , Christensen H, Rodgers B. The coursee of depression in the elderly: a longitudinal community-based study in Australia. Psychol Med 1997;27(1):119-29. .
142.142. Zeiss AM, Lewinsohn PM, Rohde P, Seeley JR. Relationship of physical disease and functional impairmentt to depression in older people. Psychol Aging 1996;11(4):572-81.
143.. Beekman ATJ, Deeg DJH, Smit JH, Van Tilburg W. Predicting the course of depression in the older population:: results from a community-based study in The Netherlands. J Affect Disord 1995;34:41-9.
144.. Kennedy GJ, Kelman HR, Thomas C. The emergence of depressive symptoms in late life: the importancee of declining health and increasing disability. J Community Health 1990;15(2):93-104.
145.. Kraaij V, Arensman E, Spinhoven P. Negative life events and depression in elderly persons: a meta-analysis.. J Gerontol B Psychol Sci Soc Sci 2002;57(1):P87-P94.
146.. Lindeboom M, Portrait F, van den Berg GJ. An econometric analysis of the mental-health effects of majorr events in the life of older individuals. Health Econ 2002; 11 (6):505-20.
147.. Simon GE, Goldberg DP, Von Korff M, Ustun TB. Understanding cross-national differences in depressionn prevalence. Psychol Med 2002;32(4):585-94.
148.. Heslin JM, Soveri PJ, Winoy JB, Lyons RA, Buttanshaw AC, Kovacic L, Daley JA, Gonzalo E. Health statuss and service utilisation of older people in different European countries. Scand J Prim Health Care 20011 ;19(4):218-22.
149.. De Leo D, Diekstra RF, Lonnqvist J, Trabucchi M, Cleiren MH, Frisoni GB, Dello Buono M, Haltunen A, Zucchettoo M, Rozzini R, et al. LEIPAD, an internationally applicable instrument to assess quality of life inn the elderly. Behav Med 1998;24(1): 17-27.
150.. Zung WWK. A self-rating depression scale. Arch Gen Psychiatry 1965;12:63-70.
151.. Berkman LF, Berkman CS, Kasl S, Freeman DH Jr, Leo L, Ostfeld AM, Cornoni-Huntley J, Brody JA. Depressivee symptoms in relation to physical health and functioning in the elderly. Am J Epidemiol 1986;124(3):372-88. .
152.152. Beekman AT, Kriegsman DM, Deeg DJ, van Tilburg W. The association of physical health and depressivee symptoms in the older population: age and sex differences. Soc Psychiatry Psychiatr Epidemioll 1995;30{1):32-8.
117 7
References References
153.. Allen SM, Mor V. The prevalence and consequences of unmet need. Contrasts between older and youngerr adults with disability. Med Care 1997;35( 11):1132-48.
154.. Hybels CF, Pieper CF, Blazer DG. Sex differences in the relationship between subthreshold depressionn and mortality in a community sample of older adults. Am J Geriatr Psychiatry 2002; 10 (3):283-91. .
155.. Idler EL, Russell LB, Davis D. Survival, functional limitations, and self-rated health in the NHANES I Epidemiologicc Follow-up Study, 1992. First National Health and Nutrition Examination Survey. Am J Epidemioll 2000;152(9):874-83.
156.. Dorn J, Cemy F, Epstein L, Naughton J, Vena J, Winkelstein V, Schisterman E, Trevisan M. Work and leisuree time physical activity and mortality in men and women from a general population sample. Ann Epidemioll 1999;9(6):366-73.
157.. Ostbye T, Taylor DH, Jung SH. A longitudinal study of the effects of tobacco smoking and other modifiablee risk factors on ill health in middle-aged and old Americans: results from the Health and Retirementt Study and Asset and Health Dynamics among the Oldest Old survey. Prev Med 2002; 34(3):334-45. .
158.. Williamson GM, Schulz R. Symptoms of depression in elderly persons: beyond the effects of physical illnesss and disability. In Facts and Research in Gerontology; 1995.
159.. Hybels CF, Blazer DG, Pieper CF. Toward a threshold for subthreshold depression: an analysis of correlatess of depression by severity of symptoms using data from an elderly community sample. Gerontologistt 2001 ;41 (3):357-65.
160.. AijSnseppa S, Kivinen P, Helkala EL, Kivela SL, Tuomilehto J, Nissinen A. Serum cholesterol and depressivee symptoms in elderly Finnish men. Int J Geriatr Psychiatry 2002;17(7):629-34.
161.. Andersen LB, Schnohr P, Schroll M, Hein HO. All-cause mortality associated with physical activity duringg leisure time, work, sports, and cycling to work. Arch Intern Med 2000;160:1621-8.
162.. Keysor J J. Does late-life physical activity or exercise prevent or minimize disablement? A critical revieww of the scientific evidence. Am J Prev Med 2003;25:129-36.
163.. Blair SN, Wei M. Sedentary habits, health, and function in older women and men. Am J Health Promot 2000;; 15(1): 1-8.
164.. Ormel J, Lindenberg S, Steverink N, Vonkorff M. Quality of life and social production functions: a frameworkk for understanding health effects. Soc Sci Med 1997;45(7):1051-63.
165.. Hoeymans N, Feskens EJ, Kromhout D, van den Bos GA. The contribution of chronic conditions and disabilitiess to poor self-rated health in elderly men. J Gerontol A Biol Sci Med Sci 1999;54(10):M501-M506. .
166.. Gama EV, Damian JE, Perez de Molino J, Lopez MR, Lopez Perez M, Gavira Iglesias FJ. Association off individual activities of daily living with self-rated health in older people. Age Ageing 2000;29(3):267-70. .
167.. Alexander NB, Guire KE, Thelen DG, Ashton-Miller JA, Schultz AB, Grunawalt JC, Giordani B. Self-
118 8
References References
reportedd walking ability predicts functional mobility performance in frail older adults. J Am Geriatr Soc 2000;48(11):: 1408-13.
168.. Kushiro W, Yokoyama T, Date C, Yoshiike N, Tanaka H. Association of activities of daily living and indicess of mental status with subsequent 20-year all-cause mortality in an elderly Japanese population. Nursingg and Health Sciences 2002;4 (suppl):A5.
169.. Kelly-Hayes M, Jette AM, Wolf PA, D'Agostino RB, Odell PM. Functional limitations and disability amongg elders in the Framingham Study. Am J Public Health 1992;82(6):841-5.
170.. Schoevers RA, Geerlings Ml, Beekman AT, Penninx BW, Deeg DJ, Jonker C, Van Tilburg W. Associationn of depression and gender with mortality in old age. Results from the Amsterdam Study of thee Elderly (AMSTEL). Br J Psychiatry 2000; 177:336-42.
171.. Ferrer M, Lamarca R, Orfila F, Alonso J. Comparison of performance-based and self-rated functional capacityy in Spanish elderly. Am J Epidemiol 1999; 149 (3):228-35.
172.172. Addington-Hall J, Kalra L. Who should measure quality of life? BMJ 2001 ;322:1417-20.
173.. Rowe JW. Health care of the elderly. N Engl J Med 1985;312(13):827-35.
174.. Cross-national comparisons of the prevalences and correlates of mental disorders. WHO International Consortiumm in Psychiatric Epidemiology. Bull World Health Organ 2000; 78(4):413-26.
175.. Clark J. Preventive home visits to elderly people. Their effectiveness cannot be judged by randomised controlledd trials. BMJ 2001;323{7315):708.
176.. Van der Bij AK, Laurant MG, Wensing M. Effectiveness of physical activity interventions for older adults:: a review. Am J Prev Med 2002;22(2): 120-33.
177.. Deeg DJ, Kriegsman DM. Concepts of self-rated health: specifying the gender difference in mortality risk.. Gerontologist 2003;43{3):376-86; discussion 372-5.
178.. Bickenbach JE, Chatterji S, Badley EM, Ustun TB. Models of disablement, universalism and the internationall classification of impairments, disabilities and handicaps. Soc Sci Med 1999;48(9):1173-87. .
179.. Colsher PL, Wallace RB. Data quality and age: health and psychobehavioral correlates of item nonresponsee and inconsistent responses. J Gerontol 1989;44(2):P45-P52.
180.. Hardy SE, Gill TM. Factors associated with recovery of independence among newly disabled older persons.. Arch Intern Med 2005;165:106-12.
181.. Hardy SE, Gill TM. Recovery from disability among community-dwelling older persons. JAMA 2004;2911 (13): 1596-602.
182.182. Al Snih S, Markides KS, Ostir GV, Ray L, Goodwin JS. Predictors of recovery in activities of daily living amongg disabled older Mexican Americans. Aging Clin Exp Res 2003; 15(4):315-20.
183.. Gill TM, Robison JT, Tinetti ME. Predictors of recovery in activities of daily living among disabled older
119 9
References References
personss living in the community. J Gen Intern Med 1997;12(12):757-62.
184.. Crawford SL, Jette AM, Tennstedt SL. Test-retest reliability of self-reported disability measures in older adults.. J Am Geriatr Soc 1997;45(3):338-41.
185.. Hoeymans N, Wouters ER, Feskens EJM, van den Bos GAM, Kromhout D. Reproducibility of performance-basedd and self-reported measures of functional status. J Gerontol A Biol Sci Med Sci 1997;52(6):M363-8. .
186.. Kempen Gl, van Sonderen E. Psychological attributes and changes in disability among low-functioning olderr persons: does attrition affect the outcomes? J Clin Epidemiol 2002;55(3):224-9.
187.. McCurry SM, Gibbons LE, Bond GE, Rice MM, Graves AB, Kukull WA, Teri L, Higdon R, Bowen JD, McCormickk WC, et al. Older adults and functional decline: a cross-cultural comparison. Int Psychogeriatrr 2002; 14(2): 161 -79.
188.. Schoevers RA, Beekman AT, Deeg DJ, Hooijer C, Jonker C, van Tilburg W. The natural history of late-lifee depression: results from the Amsterdam Study of the Elderly (AMSTEL). J Affect Disord 2003;76(1-3):5-14. .
189.. Aijanseppa S, Notkola IL, Tijhuis M, van Staveren W, Kromhout D, Nissinen A. Physical functioning in elderlyy Europeans: 10 year changes in the north and south: the HALE project. J Epidemiol Community Healthh 2005;59(5):413-9.
190.. Conn VS, Minor MA, Burks KJ, Rantz MJ, Pomeroy SH. Integrative review of physical activity interventionn research with aging adults. J Am Geriatr Soc 2003;51:1159-68.
191.. Cyarto EV, Moorhead GE, Brown WJ. Updating the evidence relating to physical activity intervention studiess in older people. J Sci Med Sport 2004;7(1 Suppl ):30-8.
192.. Latham NK, Bennett DA, Stretton CM, Anderson CS. Systematic review of progressive resistance strengthh training in older adults. J Gerontol A Biol Sci Med Sci 2004;59(1):48-61.
193.. Singh MA. Exercise to prevent and treat functional disability. Clin Geriatr Med 2002;18(3):431-62, vi-vii. .
194.. Andersen RE, Wadden TA, Bartlett SJ, Zemel B, Verde TJ, Franckowiak SC. Effects of lifestyle activity vss structured aerobic exercise in obese women: a randomized trial. JAMA 1999;281(4):335-40.
195.. Dunn AL, Marcus BH, Kampert JB, Garcia ME, Kohl HW 3rd, Blair SN. Comparison of lifestyle and structuredd interventions to increase physical activity and cardiorespiratory fitness: a randomized trial. JAMAA 1999;281(4):327-34.
196.. Shumway-Cook A, Patla A, Stewart A, Ferrucci L, Ciol MA, Guralnik JM. Environmental components of mobilityy disability in community-living older persons. J Am Geriatr Soc 2003;51(3):393-8.
197.. Brach JS, VanSwearingen JM, FitzGerald SJ, Storti KL, Kriska AM. The relationship among physical activity,, obesity, and physical function in community-dwelling older women. Prev Med 2004;39(1):74-80. .
120 0
References References
198.. Bratzler DW, Oehlert WH, Austelle A. Smoking in the elderly-it's never too late to quit. J Okla State Medd Assoc 2002;95(3): 185-91; quiz 192-3.
199.. Fries JF. Reducing disability in older age. JAMA 2002;288(24):3164-6.
200.. Andrews GR. Promoting health and function in an ageing population. BMJ 2001 ;322(7288):728-9.
201.. Stuck AE, Walthert JM, Nikolaus T, Bula CJ, Hohmann C, Beck JC. Risk factors for functional status declinee in community-living elderly people: a systematic literature review. Soc Sci Med 1999; 48(4):445-69. .
202.. Stuck AE, Egger M, Hammer A, Minder CE, Beck JC. Home visits to prevent nursing home admission andd functional decline in elderly people: systematic review and meta-regression analysis. JAMA 2002;287(8):: 1022-8.
203.. Elkan R, Kendrick D, Dewey M, Hewitt M, Robinson J, Blair M, Williams D, Brummell K. Effectiveness off home based support for older people: systematic review and meta-analysis. BMJ 2001;323(7315):719-25. .
204.. van Haastregt JC, Diederiks JP, van Rossum E, de Witte LP, Crebolder HF. Effects of preventive homee visits to elderly people living in the community: systematic review. BMJ 2000;320(7237):754-8.
205.. Williams K. The transition to widowhood and the social regulation of health: consequences for health andd health risk behavior. J Gerontol B Psychol Sci Soc Sci 2004;59(6):S343-S349.
206.. Caserta MS, Lund DA, Rice SJ. Pathfinders: a self-care and health education program for older widowss and widowers. Gerontologist 1999;39(5):615-20.
207.. Van Exel J, Koopmanschap MA, Van Wijngaarden JD, Scholte Op Reimer WJ. Costs of stroke and strokee services: Determinants of patient costs and a comparison of costs of regular care and care organisedd in stroke services. Cost Eff Resour Alloc 2003;1(1):2.
208.. Langhorne P, Dennis MS. Stroke units: the next 10 years. Lancet 2004;363(9412):834-5.
209.. Langhorne P, Duncan P. Does the organization of postacute stroke care really matter? Stroke 2001;32(1):268-74. .
210.. Anderson C, Ni Mhurchu C, Brown PM, Carter K. Stroke rehabilitation services to accelerate hospital dischargee and provide home-based care: an overview and cost analysis. Pharmacoeconomics 2002;20(8):537-52. .
211.. Bohlmeijer E, Smit F, Smits C, Cuijpers P. Integrale aanpak depressiepreventie bij ouderen. Utrecht: Trimbos-Instituut;; 2005.
212.. Alexopoulos GS, Buckwalter K, Olin J, Martinez R, Wainscott C, Krishnan KR. Comorbidity of late life depression:: an opportunity for research on mechanisms and treatment. Biol Psychiatry 2002;52(6):543-58. .
213.. Cameron ID, Kurrle SE. 1: Rehabilitation and older people. Med J Aust 2002;177(7):387-91.
121 1
References s
214.. Klausner EJ, Clarkin JF, Spielman L, Pupo C, Abrams R, Alexopoulos GS. Late-life depression and functionall disability: the role of goal- focused group psychotherapy. Int J Geriatr Psychiatry 1998;13<10):707-16. .
215.. van Exel NJ, Koopmanschap MA, van den Berg B, Brouwer WB, van den Bos GA. Burden of informal caregivingg for stroke patients. Identification of caregivers at risk of adverse health effects. Cerebrovasc Diss 2005; 19(1 ):11-7.
216.. Brouwer WB, van Exel NJ, van de Berg B, Dinant HJ, Koopmanschap MA, van den Bos GA. Burden of caregiving:: evidence of objective burden, subjective burden, and quality of life impacts on informal caregiverss of patients with rheumatoid arthritis. Arthritis Rheum 2004;51(4):570-7.
217.. Jacobi CE, van den Berg B, Boshuizen HC, Rupp I, Dinant HJ, van den Bos GA. Dimension-specific burdenn of caregiving among partners of rheumatoid arthritis patients. Rheumatology (Oxford) 2003; 42(10):1226-33. .
218.. Nijboer C, Triemstra M, Tempelaar R, Mulder M, Sanderman R, van den Bos GA. Patterns of caregiver experiencess among partners of cancer patients. Gerontologist 2000;40(6):738-46.
219.. Schulz R, Beach SR. Caregiving as a risk factor for mortality: the Caregiver Health Effects Study. JAMAA 1999;282(23):2215-9.
220.. Scholte op Reimer WJ, de Haan RJ, Rijnders PT, Limburg M, van den Bos GA. The burden of caregivingg in partners of long-term stroke survivors. Stroke 1998;29(8):1605-11.
221.. Koopmanschap MA, van Exel NJ, van den Bos GA, van den Berg B, Brouwer WB. The desire for supportt and respite care: preferences of Dutch informal caregivers. Health Policy 2004;68(3):309-20.
122 2
Summar y y
Summary Summary
Duringg the 20th century, functional disability in elderly people has become a major public health
problemm in the Western world due to demographic and epidemiologic transitions. The demographic
transition,, i.e. a shift from patterns of high fertility and mortality rates to low fertility and delayed
mortality,, has led to a growing number of elderly people. The post-war baby boom (people born
betweenn 1946 and 1955) will further increase the number of elderly people in the next decades.
Thee epidemiologic transition, i.e. a change in patterns of health, disease, and mortality, has led to
ann increase in the prevalence of chronic diseases and disability. Disability has a major impact on
qualityy of life and the demand on health care. It is therefore time now to focus on disability in
researchh and health care. The ageing of the population is a success story, but presents society
withh new challenges related to the independency of elderly people.
Thiss thesis aimed to identify risk groups and risk factors for functional disability and to quantify
healthh (care) impacts of functional disability. Firstly, the assessment of disability was validated by
relatingg self-reported disability to performance tests. Thereafter, widowers were studied as a risk
groupp for disability, and physical activity as a risk factor for disability. Furthermore, we investigated
whetherr use of formal home care was according to disability-related needs. The health impact of
disabilityy was investigated by estimating its relationship with depressive symptoms and mortality. In
thee discussion section, the main findings were presented, and some methodological issues and
implicationss for preventive strategies and health care programs were addressed.
Wee defined functional disability as needing help in daily activities. These activities could be
categorisedd into three domains: 1). instrumental activities of daily living (e.g. preparing meals,
doingg housework); 2). mobility (e.g. moving outdoors, using stairs); 3). basic activities of daily living
(e.g.. dressing, using toilet). Disability severity was based on the hierarchical order of these three
disabilityy domains.
Thee data for our study came from the Finland, Italy and the Netherlands Elderly (FINE) Study, that
consistss of 2285 men born between 1900 and 1920. The FINE Study is a prospective study on risk
factorss and health in elderly men. Four surveys were carried out in 1984-1985, 1989-1991, 1994-
1995,, and 1999-2000.
Self-reportedd disability is often used to compare health status between countries. We therefore
investigatedd cross-sectionally whether self-reported disability and its association with performance-
basedd tests is comparable between countries, using data of the second survey (chapter 2). The
scoree on the performance tests was based on a standing balance test, walking speed test, chair
standd test, and shoulder rotation test. In all three countries, statistically significant associations
betweenn self-reported disability and performance-based tests were found, in the sense that more
124 4
Summary Summary
disabilitiess were related to less performance according to the tests. Dutch men reported more
disabilitiess than men from Finland and Italy, after adjustment for performance-based scores. From
thiss study we concluded that the association between self-reported disability and performance tests
iss comparable between countries, but that cross-cultural variation is present in self-reported
disability,, adjusted for performance-based scores. This suggests that the comparison of health
statuss between countries can not be based on prevalence figures of self-reported disability.
Thee number of widowed men is increasing because the life expectancy of men is rising faster than
thatt of women. We studied longitudinally the relationship between becoming widowed and the
onsett of disability (chapter 3). We started with men who were married at baseline and compared
thee disability status five years later between those who were still married and those who had
becomee widowed. Men who had become widowed had a higher risk of disability in instrumental
activities,, and in mobility, but not in basic activities of daily living. Moreover, men who became
widowedd during the past five years had a higher risk of disability in instrumental activities than
thosee who had been widowed for a longer time. We also studied whether household composition
amongg widowers was associated with disability by comparing widowers living alone with those who
livedd with others. Widowers living alone tended to have more disability in instrumental activities and
lesss disability in mobility compared to widowers living with others. We concluded that widowhood in
elderlyy men is a risk factor for dependency in instrumental activities and mobility and that therefore
thee increase in the number of widowers will lead to higher demands on health care.
Althoughh it was known that physical activity is inversely associated with disability, it was not known
whichh aspects of physical activity explain that association. We therefore studied longitudinally the
relationshipp between two aspects of physical activity, i.e. duration and intensity, and disability onset
(chapterr 4). Only men without disability at baseline were incorporated. Data on physical activity,
collectedd by questionnaire, were based on activities like walking, bicycling, playing billiards, and
gardening.. Men in the highest fertile of duration of physical activity (median of 205 minutes per
day)) had a lower risk of disability than those in the lowest fertile (median of 39 minutes per day),
afterr adjustment for other lifestyle factors. Intensity of physical activity was not associated with
disabilityy onset. We concluded from this study that a physically active lifestyle is important even in
oldd age. This can be achieved by adopting enjoyable activities into daily life. Although the Dutch
physicall activity guideline recommends 30 minutes of physical activity a day, our results suggest
thatt spending more is even better.
Elderlyy people desire care at home rather than institutionalisation. The demand of home care will
increasee because of the rising numbers of elderly people. We evaluated among the Dutch
125 5
Summary Summary
participantss in 2000 whether use of formal home care was according to need, using the Andersen
modell {chapter 5). Need factors (chronic diseases, self-rated health, disability), predisposing (age,
maritall status), and enabling factors (occupation, education, informal care) were incorporated as
predictorss of use of home nursing and home help. Disability was strongly associated with use of
homee nursing. Also educational level was associated with use of home nursing, which suggests
inequity.. Home help use was associated with marital status. Married men had lower use of home
helpp than men not married. Because support by the spouse decreases the demand for formal
homee help, there is no firm evidence for inequity in the use of home help.
Becausee the onset of disability can be considered as a life event, it is a risk factor for depressive
symptoms.. We studied cross-sectionally the association between disability and depressive
symptomss and longitudinally the effect of change in disability (chapter 6). Severity of disability was
determinedd in two ways: by a hierarchy score of the disability domains and by a sum score of
disability.. Depressive symptoms were determined by the Zung questionnaire. Both disability scores
weree significantly associated with depressive symptoms in all three countries. The association
betweenn the hierarchy score of disability and depressive symptoms seemed to be somewhat
strongerr than that between the sum score and depressive symptoms. We also investigated
whetherr depressive symptoms depended on the domains of the disabilities, or whether the
disabilitiess could simply be summed. Although not statistically significant, the results showed that
thee domains of disability were indeed important. Longitudinally, changes in disability were
associatedd with depressive symptoms. Men who had worsening of disability status in the preceding
fivee years reported more depressive symptoms than men who improved in disability status. Health
professionalss should be aware of the risk of depressive symptoms among elderly men with
disability,, especially those with a severe worsening in the past years.
Disabilityy is an important predictor of mortality. We explored this association, focusing on the role
off subjective health aspects. We studied the effect of disability and the additional contribution of
self-ratedd health and depressive symptoms to 10-year mortality (chapter 7). All health aspects
weree significantly associated with mortality. In addition, men with severe disability who felt not
healthy,, had a higher mortality risk than men with severe disability who felt healthy. Among men
withoutt disability, those with more depressive symptoms had a higher mortality risk than those with
lessless depressive symptoms. The association between self-rated health and mortality was
particularlyy present among men with severe disability, while the association between depressive
symptomss and mortality was clearest among men with less severe disability. We concluded that for
adequatee prognoses of mortality, or for developing intervention strategies among elderly people,
nott only physical health aspects, but also subjective health outcomes should be taken into account.
126 6
Summary Summary
Afterr summarising the most important findings of our research, some methodological issues were
addressed,, i.e. the validity of our assessment of disability and internal and external validity (chapter
8).. Furthermore, implications for public health (care) were discussed. Public health programs must
respondd to the challenges created by the growing burden of disability. We addressed strategies to
preventt or postpone disability, related to the topics of our thesis. An attractive target for
interventionss designed to prevent or postpone disability, is the increase of duration of physical
activityy among elderly people. Public health advice should inform people that regular physical
activityy is desirable and can be achieved by adopting enjoyable activities. Furthermore, widowers
shouldd be offered programs that provide health and wellness information, teach new self-care skills
andd focus on psychological aspects, such as coping and prevention of depression. Because elderly
peoplee with disability are a risk group for depression, care programs should also take into account
psychosociall aspects. Finally, the impact of the changing health care system (introduction of the
Sociall Support Act) was discussed. In a few years it should be evaluated whether people who
needd care actually receive care in the new system. In addition, informal caregivers should be
supported,, in order to alleviate the growing burden and to provide a sustainable system of long-
termm care and social support.
Althoughh many people wish to grow old, ageing is often accompanied by health problems, for
examplee functional disability. In this thesis, several starting points for preventing or postponing
disabilityy and other health problems in old age have been identified. Also adequate care and
psychosociall support programs deserve attention in anticipating the growing burden of elderly
peoplee with disability. These issues should get high priority in research and policy in the years to
come,, in order to sustain the autonomy and independent living of the elderly.
127 7
Samenvattin g g
Samenvatting Samenvatting
Ditt proefschrift gaat over functionele beperkingen bij oudere mannen. Functionele beperkingen zijn
gedefinieerdd als het niet zelfstandig kunnen uitvoeren van algemene dagelijkse activiteiten.
Functionelee beperkingen bij ouderen zijn in de loop van de twintigste eeuw uitgegroeid tot een
omvangrijkk volksgezondheidprobleem, als gevolg van demografische en epidemiologische
transities.. Zo heeft de demografische transitie, de verschuiving van hoge naar lage geboorte- en
sterftecijfers,, geleid tot een toenemende vergrijzing van onze samenleving. Onder invloed van de
naoorlogsee geboortegolf zal het aantal ouderen in de komende decennia verder stijgen. Daarnaast
heeftt de epidemiologische transitie, de verschuiving in mortaliteit- en morbiditeitpatronen van
infectieziektenn naar chronische ziekten, geleid tot een hogere levensverwachting en een toename
vann het aantal personen met functionele beperkingen. Functionele beperkingen hebben een grote
weerslagg op de kwaliteit van leven en het zorggebruik van ouderen.
Hett doel van dit proefschrift is het identificeren van risicogroepen en risicofactoren voor functionele
beperkingenn bij oudere mannen. Daarnaast beoogt dit proefschrift de invloed van functionele
beperkingenn op andere aspecten van de gezondheid, en de gezondheidszorg te bepalen.
Allereerstt is de validiteit van zelf-gerapporteerde beperkingen bestudeerd. Vervolgens is
onderzochtt of weduwnaars een risicogroep vormen en of lichamelijke inactiviteit een risicofactor is
voorr functionele beperkingen. Voorts is geanalyseerd of het gebruik van thuiszorg gerelateerd is
aann de met functionele beperkingen samenhangende behoefte aan zorg. Ten slotte is de invloed
vann functionele beperkingen op depressieve symptomen en sterfte bestudeerd.
Dee gegevens voor dit proefschrift zijn afkomstig uit de FINE Studie, een internationaal prospectief
onderzoek,, uitgevoerd onder 2285 mannen die geboren zijn tussen 1900 en 1920 uit Finland, Italië
enn Nederland. De FINE Studie is gericht op determinanten van gezondheid bij oudere mannen. De
resultatenn die in dit proefschrift zijn beschreven, zijn gebaseerd op gegevens die in vier
onderzoeksrondess zijn verzameld: 1984-1985,1989-1991, 1994-1995, en 1999-2000.
Functionelee beperkingen zijn bepaald op basis van verschillende activiteiten in drie domeinen:
1.. instrumentele activiteiten van het dagelijks leven (IADL; bijvoorbeeld koken en huishoudelijke
activiteiten);; 2. mobiliteit (bijvoorbeeld buitenshuis verplaatsen en traplopen); 3. basale activiteiten
vann het dagelijks leven (BADL; bijvoorbeeld aankleden en naar het toilet gaan). In dit proefschrift is
dee ernst van de functionele beperkingen gebaseerd op de hiërarchie van deze domeinen,
oplopendd van IADL via mobiliteit naar BADL.
Inn hoofdstuk 2 werd de validiteit van zelf-gerapporteerde beperkingen bestudeerd. Zelf-
gerapporteerdee beperkingen worden vaak als indicator gebruikt om verschillen in volksgezondheid
130 0
Samenvatting Samenvatting
tussenn landen vast te stellen. Aan de hand van gegevens verzameld in de tweede
onderzoeksrondee werd bepaald of de prevalentie van zelf-gerapporteerde beperkingen en de
associatiee met performance-testen vergelijkbaar zijn tussen de drie landen. Performance werd
geëvalueerdd op basis van vier testen: een balans-, loop-, stoel- en armtest. Voor de drie landen
goldd dat mannen die minder functionele beperkingen rapporteerden, beter scoorden op de
performance-testen.. Mannen in Nederland rapporteerden echter meer functionele beperkingen dan
mannenn in Finland en Italië, ook bij dezelfde scores op de performance-testen. De conclusie luidde
datt associaties tussen performance-testen en zelf-gerapporteerde beperkingen vergelijkbaar zijn
tussenn landen, maar dat er wel variatie tussen landen is in het rapporteren van beperkingen. Zelf-
gerapporteerdee beperkingen zijn daarom geen valide indicator voor het vaststellen van verschillen
inn volksgezondheid tussen landen.
Hoofdstukk 3 richt zich op de relatie tussen weduwnaarschap en de incidentie van functionele
beperkingen.. De resultaten lieten zien dat weduwnaars meer dan getrouwde mannen beperkingen
rapporteerdenn in instrumentele activiteiten en mobiliteit, maar niet in basale activiteiten. Tevens
rapporteerdenn mannen die in de afgelopen vijf jaar weduwnaar waren geworden, meer
beperkingenn in instrumentele activiteiten dan zij die al langer weduwnaar waren. Geconcludeerd
werdd dat weduwnaarschap de kans op beperkingen in instrumentele activiteiten en mobiliteit
verhoogt.. Doordat de levensverwachting van mannen sneller stijgt dan die van vrouwen, zal het
aantall weduwnaars de komende jaren stijgen. Deze groei zal leiden tot een hogere vraag naar
thuiszorgg of mantelzorg.
Inn hoofdstuk 4 werd onderzocht in hoeverre duur en intensiteit van lichamelijke activiteit
gerelateerdd zijn aan functionele beperkingen. Het was reeds bekend dat lichamelijke activiteit
samenhangtt met functionele beperkingen, maar niet of hiervoor de duur of de intensiteit bepalend
is.. De relatie tussen lichamelijke activiteit en de incidentie van functionele beperkingen werd
longitudinaall bestudeerd bij mannen die bij de baseline-meting (1989-1991) geen functionele
beperkingenn hadden. De gegevens over lichamelijke activiteit waren gebaseerd op zelf-rapportage
vann activiteiten zoals lopen, fietsen en tuinieren. Mannen die meer tijd aan lichamelijke activiteit
besteeddenn (mediaan van 100 minuten per dag) rapporteerden vijfjaar later minder functionele
beperkingenn dan mannen die minder tijd hieraan besteedden (mediaan 39 minuten per dag). De
intensiteitt van de lichamelijke activiteiten hing echter niet samen met het ontstaan van functionele
beperkingen.. De resultaten wijzen erop dat een actief leven zelfs op hoge leeftijd de kans op
functionelee beperkingen verlaagt. Hoewel volgens de Nederlandse norm voor gezond bewegen 30
minutenn per dag wordt aanbevolen, liet dit onderzoek zien dat meer bewegen (tenminste 100
minutenn per dag) de kans op functionele beperkingen verder vermindert.
131 1
Samenvatting Samenvatting
Hoofdstukk 5 richt zich op de associatie tussen functionele beperkingen en het gebruik van
thuiszorg.. Met behulp van het model van Andersen werd geëvalueerd of er gelijkheid is in het
gebruikk van wijkverpleging en huishoudelijke verzorging. Er is sprake van gelijkheid in zorggebruik
wanneerr het zorggebruik primair wordt bepaald door de consumptie-noodzaak. Er werd
onderscheidd gemaakt naar een drietal groepen determinanten: 1. consumptie-geneigdheid
(demografischee kenmerken zoals leeftijd en burgerlijke staat); 2. consumptie-mogelijkheid (sociaal-
economischee kenmerken zoals opleiding en beroep, en mantelzorg); 3. consumptie-noodzaak
(gezondheidstoestandd zoals chronische ziekten, beperkingen en ervaren gezondheid). Voor de
analysess werd gebruik gemaakt van de laatste onderzoeksronde in Nederland (2000). Mannen met
ernstigee functionele beperkingen maakten meer gebruik van wijkverpleging dan mannen zonder of
mett minder ernstige beperkingen. Verder maakten mannen met een hogere opleiding naar
verhoudingg meer gebruik van wijkverpleging. Huishoudelijke verzorging hing niet samen met
functionelee beperkingen, maar wel met burgerlijke staat, ook wanneer er rekening gehouden werd
mett de ernst van de beperkingen. Getrouwde mannen deden minder vaak een beroep op
huishoudelijkee verzorging dan niet-getrouwde mannen. Geconcludeerd werd dat ongelijkheid in het
gebruikk van wijkverpleging niet kan worden uitgesloten, omdat mannen met een lagere opleiding
minderr zorg gebruikten bij dezelfde beperkingen. Hoewel huishoudelijke verzorging niet primair
bepaaldd werd door de consumptie-noodzaak, wijst de associatie met burgerlijke staat mogelijk niet
opp ongelijkheid in zorggebruik. Huishoudelijke verzorging wordt immers minder vaak geïndiceerd
alss er sprake is van informele zorg door de partner.
Hett krijgen van functionele beperkingen is voor veel mensen een ingrijpende gebeurtenis. Mensen
diee functionele beperkingen ontwikkelen, hebben daarom een hogere kans op depressie.
Hoofdstukk 6 gaat hier nader op in. Daarbij werden associaties tussen de prevalenties van
functionelee beperkingen en depressieve symptomen zowel cross-sectioneel als longitudinaal
bestudeerd.. Mannen met meer of meer ernstige beperkingen rapporteerden meer depressieve
symptomenn dan mannen met minder of minder ernstige beperkingen in alle drie landen. De
associatiee tussen de ernst van de functionele beperkingen en depressieve symptomen was echter
ietss sterker dan de associatie tussen het aantal functionele beperkingen en depressieve
symptomen.. Ook veranderingen in functionele beperkingen waren voorspellend voor depressieve
symptomen.. Mannen die in de afgelopen vijf jaar functioneel achteruitgingen, hadden meer
depressievee symptomen dan mannen die vooruitgingen. De bevindingen impliceren dat
hulpverlenerss in de gezondheidszorg alert moeten zijn op depressieve symptomen bij ouderen met
functionelee beperkingen, in het bijzonder bij degenen die recent een (behoorlijke) achteruitgang in
beperkingenn lieten zien.
132 2
Samenvatting Samenvatting
Inn hoofdstuk 7 werd de impact van functionele beperkingen op sterfte bestudeerd. Daarbij is in het
bijzonderr gekeken naar het additionele effect van ervaren gezondheid en depressieve symptomen.
Meerr depressieve symptomen, een slechtere ervaren gezondheid en ernstigere functionele
beperkingenn waren geassocieerd met een hogere kans op sterfte. Mannen met zowel ernstige
functionelee beperkingen als een slechte ervaren gezondheid hadden een hogere kans op sterfte
dann mannen met ernstige functionele beperkingen en een goede ervaren gezondheid. De relatie
tussenn ervaren gezondheid en sterfte was sterker bij mannen die relatief ernstige beperkingen
haddenn ten opzichte van degenen zonder of met minder ernstige beperkingen. De relatie tussen
depressievee symptomen en sterfte was juist het sterkst in de minder ernstige niveaus van
beperkingen.. Geconcludeerd werd dat niet alleen lichamelijke aspecten van gezondheid, maar ook
psychischee aspecten gerelateerd zijn aan sterfte.
Inn hoofdstuk 8 zijn de belangrijkste bevindingen samengevat en zijn enkele methodologische
overwegingenn besproken. Daarbij werd ingegaan op de operationalisatie en de interne en externe
validiteitt van functionele beperkingen. Vervolgens werden de implicaties van de resultaten van dit
onderzoekk voor de gezondheidszorg besproken. Hierbij werd gewezen op het belang van
preventiee op het gebied van lichamelijke activiteit, en zelfredzaamheid in huishoudelijke activiteiten
bijj weduwnaars. Ook ging aandacht uit naar de psychische gezondheid bij ouderen en de
introductiee van de Wet Maatschappelijke Ondersteuning.
Tott slot zijn enkele prioriteiten voor beleid en onderzoek in de komende jaren aangegeven.
133 3
Dankwoor d d
Dankwoord d
Nuu ik toe ben aan het laatste deel van mijn proefschrift, besef ik dat de drukke periode bijna achter
dee rug is. Toch wil ik voor dit hoofdstuk graag nog even gaan zitten, om van de gelegenheid
gebruikk te maken een aantal mensen bij naam te noemen die (direct of indirect) hebben
bijgedragenn aan het tot stand komen van mijn proefschrift.
Allereerstt wil ik mijn promotores prof. dr. Trudi van den Bos en prof. dr. Daan Kromhout en co-
promotoress dr. Marja Tijhuis en prof. dr. Niek Klazinga bedanken, omdat zij het meest hebben
bijgedragenn aan de inhoud van dit proefschrift.
Trudi,, jouw betrokkenheid bij mijn onderzoek was groot. Jij hebt me op weg geholpen in de
onderzoekswereldd en je kritische blik op mijn stukken heeft er toe geleid dat er nu een mooi stuk
werkk ligt waar ik trots op ben.
Daan,, ik heb waardering voor de grondigheid waarmee je mijn artikelen hebt doorgenomen en van
commentaarr voorzien. Je waardevolle epidemiologische adviezen en je enthousiasme voor de
FINEE Studie brachten me vaak tot nieuwe inzichten en motiveerden me om verder te gaan.
Marja,, je was altijd bereid mee te denken over de opzet van artikelen, de interpretatie van de
analysess en het opschrijven daarvan. Ik heb veel van je geleerd en het was prettig om iemand in
dee buurt te hebben bij wie ik voor (soms kleine) vragen zo even binnen kon lopen.
Niek,, je toonde veel belangstelling voor de gang van zaken. Jouw frisse kijk op stukken waar ik al
eenn tijd mee bezig was, hielpen me weer een stap verder.
Julliee uiteenlopende expertises waren waardevol voor de totstandkoming van dit proefschrift. Dank
voorr jullie inzet om het promotie-traject zo snel mogelijk af te ronden na de start van mijn nieuwe
baan. .
Daarnaastt wil ik dr. Susan Picavet en dr. Sandra Kalmijn bedanken voor hun hulp bij het schrijven
vann artikelen tijdens de zwangerschapsverloven van Marja. Bedankt voor jullie positieve input. Het
wass erg plezierig om met zulke enthousiaste personen als jullie samen te werken.
Dr.. Hendriek Boshuizen wil ik bedanken voorde hulp bij de statistische analyses. Hendriek, fijn dat
ikk altijd zo bij je binnen kon lopen om geholpen te worden met lastige kwesties.
II am grateful to dr. Simona Giampaoli, prof. dr. Aulikki Nissinen, and dr. Sinikka Aijënseppa" for
theirr cooperation in the FINE Study.
Dee deelnemers aan de FINE Studie wil ik bedanken voor hun bijdragen. Zonder hun respons op de
vragenlijstenn en de medewerking aan het lichamelijk onderzoek was dit proefschrift niet tot stand
gekomen. .
136 6
Dankwoord Dankwoord
Naastt de mensen die me met de inhoud hebben geholpen, ben ik erg blij met degenen die voor de
ondersteuningg gezorgd hebben. Anke, Noor, Els vd W, Marina en Els S, bedankt voor de
secretariëlee ondersteuning. Hans en Jan, computers en printers vind ik leuk zo lang ze het doen en
daarr zetten jullie je altijd weer voor in.
Ookk alle andere collega's wil ik bedanken. Boukje en Jessica, het was prettig om al die jaren
ongeveerr gelijk op te gaan als aio's. Naast onze aio-frustraties waren er gelukkig genoeg leuke
momenten.. Lilian, Astrid, Bas, Tommy, Brian en Saskia, ik denk graag terug aan de gezellige tijd
'achterr de klapdeuren'. Carolien en Wil, mijn ex-kamergenoten, ik wil jullie bedanken voor jullie
betrokkenheid.. Carolien, naast onze namen hebben we ook onze volleybalwedstrijden gemeen.
Eenn goede afleiding om naast het werk daarover te kunnen praten. Wil, het is al weer even
geledenn dat wij kamergenoten waren, maar nog steeds kom je naar beneden om te vragen hoe het
mett mij en mijn proefschrift gaat. Nu kan ik zeggen dat het allemaal bijna achter de rug is. Wanda,
gelukkigg zijn wij na vijf jaar nog steeds kamergenoten. Bedankt voor al je hulp bij de
totstandkomingg van dit proefschrift en ook voor de persoonlijke gesprekken die we de afgelopen
jarenn hebben gehad. Ik ben blij datje na de roze pakken van vorig jaar nu mijn paranimf wilt zijn.
Ines,, wij waren ook een beetje kamergenoten. Dank je wel voor je gastvrijheid als ik weer eens op
hett AMC kwam en voor je bereidheid me te helpen bij vragen die ik vanuit het RIVM niet zo snel
konn oplossen.
Mariël,, ik wil jou bedanken voor de ruimte die je mij gegeven hebt om mijn proefschrift zo snel
mogelijkk af te ronden naast de gewone werkzaamheden. Jouw positieve feedback en stimulans
hebbenn me erg geholpen me door de laatste zware periode heen te worstelen.
Ookk wil ik Lucie, Anneke, Mieneke, Jeanne, Jantine en alle andere collega's bedanken voor het
meedenken,, het meeleven en voor de gezelligheid. De afdeling PZO is de afgelopen jaren
behoorlijkk gegroeid, waardoor het te veel wordt iedereen bij naam te noemen. Ik vind het nog
steedss erg plezierig met jullie als collega's in G9 te vertoeven en wat mij betreft moeten we de
koffiepauzess maar weer gaan invoeren.
Hett grootste deel van de week breng ik op mijn werk door en daar is mijn proefschrift tot stand
gekomen.. Maar omdat het leven naast mijn werk echt onmisbaar is, wil ik ook graag enkele
mensenn noemen die daarin een grote rol spelen.
Dee vrienden uit de Oosterkerk, die een beetje mijn tweede 'werkplek' is geworden, wil ik bedanken
voorr alle steun en de welkome afleiding. Dat geldt ook voor de meiden van Cito. Meiden, speciaal
voorr jullie: © .
137 7
Dankwoord Dankwoord
Froukje,, John en Andreas, ik kijk altijd uit naar onze spelletjesweekenden. Andreas, jouw
relativerendee blik maakte het aio-schap soms wat eenvoudiger. John, dank voor de
computerondersteuningg aan huis die onmisbaar was in het afgelopen jaar. Froukje, onze fiets-,
volleybal-- en tafeltennisacties had ik echt nodig om mijn energie een beetje kwijt te kunnen. Dank
jee dat je mijn paranimf wilt zijn en dat je dat met veel enthousiasme doet.
Jan-Willem,, Rineke, Judith, Jolien en Joris, fijn dat ik altijd bij jullie terecht kan voor wat afleiding,
leukee dingen doen, of een goed gesprek. Het was misschien wat vaag wat ik op mijn werk aan het
doenn was, maar dit boekje is het resultaat.
Jaap-Jann en Erna, het was heerlijk jullie als vrienden in de buurt te hebben. Jullie verhuisden
steedss iets verder weg en als dit proefschrift verschijnt wonen jullie inmiddels in Kenia. Toch zal ik
nogg af en toe langskomen, zodat jullie mij een beetje in de gaten kunnen blijven houden.
Papaa en mama, jullie vertrouwen in mij is altijd groot geweest. Bedankt dat jullie voor me
klaarstaann en als trotse ouders de Nederlandse teksten in mijn proefschrift wilden bekijken.
Danielle,, Erik, Marleen, Maurits en Peter, het is altijd gezellig om als zussen en (schoon)broers bij
elkaarr te zijn. Een reisje naar het 'verre oosten' heb ik er graag voor over om mijn humoristische
familiee te ontmoeten. Joel, jij krijgt een eigen zin in het proefschrift van tante Caatje, omdat jij voor
dee meest positieve afleiding hebt gezorgd in het afgelopen jaar. Ik ben trots op je, neef!
Tott slot wil ik de meeste dank geven aan God, mijn hemelse Vader, die mij helpt bij alles wat ik
doee en zonder wie ik mijn leven niet kan voorstellen.
138 8
. .
CurriculumCurriculum VHae
Curriculu mm Vitae Carolienn van den Brink is op 28 april 1976 geboren in Purmerend. In 1994 behaalde zij haar
eindexamenn VWO aan Het Noord ik te Almelo. Van 1994 tot 1999 studeerde zij
Bewegingswetenschappenn aan de Vrije Universiteit te Amsterdam. Als onderdeel van deze studie
liepp zij stage in het VU-ziekenhuis op de afdeling fysiotherapie en deed daar onderzoek naar
ademhalingsbewegingenn bij COPD-patiënten. Voor diezelfde afdeling schreef zij een scriptie over
hett trainen van het inspanningsvermogen bij mensen met cystic fibrosis. In het laatste studiejaar
volgdee zij tevens de docentenopleiding van de faculteit Bewegingswetenschappen. In het kader
daarvann liep zij stage aan de Hogeschool Leiden, afdeling fysiotherapie.
Vann september 1999 tot september 2000 heeft zij deelgenomen aan een diaconaal jaar bij de
stichtingg Youth for Christ Nederland in Driebergen.
Inn september 2000 begon zij aan haar promotieonderzoek bij het centrum voor Preventie- en
Zorgonderzoekk van het Rijksinstituut voor Volksgezondheid en Milieu in Bilthoven, in
samenwerkingg met de afdeling Sociale Geneeskunde van het Academisch Medisch Centrum te
Amsterdam.. Tijdens het promotieonderzoek volgde zij de opleiding Epidemiologie van het National
Institutee of Health Sciences (NIHES) in Rotterdam. In 2003 behaalde zij het Master-diploma
Epidemiologie. .
Sindss september 2004 is zij werkzaam als epidemiologisch onderzoeker bij het centrum voor
Preventie-- en Zorgonderzoek van het Rijksinstituut voor Volksgezondheid en Milieu. Momenteel
werktwerkt zij aan de projecten 'Lokale en Nationale Monitor Volksgezondheid' en
'Gezondheidsbenchmarkk Grote Steden Beleid'.
141 1
ListList of publications
Listt of publication s vann den Brink C.L., Tijhuis M., Kalmijn S., Ktazinga N.S., Nissinen A., Giampaoli S., Kivinen P.,
Kromhoutt D., van den Bos G.A.M. Self-reported disability and its association with performance-
basedd limitation in elderly men: a comparison of three European countries. Journal of the American
GeriatricsGeriatrics Society, 2003; 51: 782-788.
vann den Brink CL., Tijhuis M., van den Bos G.A.M., Giampaoli S., Kivinen P., Nissinen A.,
Kromhoutt D. Effect of widowhood on disability onset in elderly men from three European countries.
JournalJournal of the American Geriatrics Society, 2004; 52:353-358.
vann den Brink C.L., Picavet H.S.J., van den Bos GAM, , Giampaoli S., Nissinen A., Kromhout D.
Durationn and intensity of physical activity and disability among European elderly men. Disability
andand Rehabilitation, 2005; 27(6):341-347.
vann den Brink C.L., Tijhuis M., van den Bos G.A.M., Giampaoli S., Nissinen A., Kromhout D. The
contributionn of self-rated health and depressive symptoms to disability severity as predictor of 10-
yearr mortality in European elderly men. American Journal of Public Health, 2005; 95(11):2029-
2034. 2034.
vann den Brink CL., Tijhuis M., Aijanseppa S., Giampaoli S., Nissinen A., Kromhout D., van den
Boss G.A.M. Hierarchy levels, sum score and worsening of disability are related to depressive
symptomss in elderly men from three European countries. Journal of Aging and Health. In press.
vann den Brink CL., Tijhuis M., Klazinga N.S., Kromhout D., van den Bos G.A.M. Use of formal
homee care among elderly men according to need? Submitted.
vann den Brink CL., Ocké M.C., Houben T., van Nierop P., Droomers M. Validering van
standaardvraagstellingg voeding voor Lokale en Nationale Monitor Volksgezondheid (RIVM
rapportnrr 260854008). Bilthoven: Rijksinstituut voor Volksgezondheid en Milieu, 2005.
vann den Brink CL., Viet L., Boshuizen H., van Ameijden E., Droomers M. Methodologie Lokale en
Nationalee Monitor Volksgezondheid. Gevolgen voor vergelijkbaarheid van gegevens (RIVM
rapportnrr 260854009). Bilthoven: Rijksinstituut voor Volksgezondheid en Milieu, 2005.
Wouters-vann Bruggenum S.H.W., van den Brink CL., Houben A.W. Het gebruik van internet bij
gezondheidsenquêtes.. Verschillen resultaten van schriftelijke vragenlijsten van
internetvragenlijsten?? Submitted.
143 3