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Objective: Although the adverse physical health consequences of negative emotions have been studied extensively, much less is known about the potential impact of positive emotions. This study examines whether emotional vitality protects against progression of disability and mortality in disabled older women., Design: A community-based study, The Women's Health and Aging Study., Participants: A total of 1002 moderately to severely disabled women aged 65 years and older living in the community., Measurements: Emotional vitality was defined as having a high sense of personal mastery, being happy, and having low depressive symptomatology and anxiety. The onset of new disability was determined by semiannual assessments of disability in performing activities of daily living (ADLs), walking across a room, walking 1/4 mile, and lifting/carrying 10 pounds. Mortality status was determined by proxy interviews and linkage with death certificates. Survival analyses with time to onset of specific disabilities (among those not disabled at baseline) and time to mortality were performed and adjusted for age, baseline level of difficulty, physical performance, and chronic conditions., Results: Three hundred fifty-one of the 1002 older disabled women studied were emotionally vital. Among women without the specific disability at baseline, emotional vitality was associated with a significantly decreased risk for incident disability performing ADLs (RR = 0.81, 95% CI = 0.66-0.99), for incident disability walking one-quarter mile (RR = 0.73, 95% CI = 0.59-0.92), and for incident disability lifting/carrying 10 pounds (RR = 0.77, 95% CI = 0.63-0.95). Emotional vitality was also associated with a lower risk of dying (RR = 0.56, 95% CI = 0.39-0.80). These results were not simply caused by the absence of depression since protective health effects remained when emotionally vital women were compared with 334 women who were not emotionally vital and not depressed., Conclusions: Emotional vitality in older disabled women reduces the risk for subsequent new disability and mortality. Our findings suggest that positive emotions can protect older persons against adverse health outcomes.

Background: The association between depression and increased mortality risk in older persons may depend on the severity of the depressive disorder and gender., Aims: To investigate the association between major and mild depressive syndromes and excess mortality in community-living elderly men and women., Method: Depression (Geriatric Mental State AGECAT) was assessed in 4051 older persons, with a 6-year follow-up of community death registers. The mortality risk of neurotic and psychotic depression was calculated after adjustment for demographic variables, physical illness, cognitive decline and functional disabilities., Results: A total of 75% of men and 41% of women with psychotic depression had diet at follow-up. Psychotic depression was associated with significant excess mortality in both men and women. Neurotic depression was associated with a 1.67-fold higher mortality risk in men only., Conclusions: In the elderly, major depressive syndromes increase the risk of death in both men and women, but mild depression increases the risk of death only in men.

This longitudinal study examines the physical health consequences of depression among 3107 older persons (55-85 years). Major depression was defined according to DSM-III criteria in a psychiatric interview. Minor depression was defined by a Center for Epidemiologic Studies Depression score > or = 16. Health consequences were assessed by 3-year change in self-reported functional status, 3-year change in performance on objective tests, and risk of death over 4.5 years. At baseline, 12.8% of the older persons had minor depression and 2.0% major depression. Minor depression was associated with a significantly greater decline in functional status and performance and, only in men but not in women, with an increased risk of death. Major depression also increases decline in functional status and the risk of death (irrespective of sex), but was not associated with decline in physical performance. These results show that late-life depression has strong unfavorable physical health consequences. The consequences of minor depression are comparable with those of major depression.

Objectives: It has been suggested that nondisabled older persons with poor performance of lower extremity function are ideal targets for interventions of disability prevention. However, health-related factors associated with poor performance are largely unknown. Using data from a representative sample of nondisabled older persons, this study identifies the diseases and biological markers that characterize this group of the population., Design and Participants: A total of 3,381 persons aged 71 or older, interviewed and administered a battery of physical performance tests at the sixth annual follow-up of the Established Populations for Epidemiologic Studies of the Elderly (EPESE), who reported no need for help in walking 1/4 mile or climbing stairs., Measurements: Lower extremity performance was measured using a short battery of tests including assessment of standing balance, a timed 2.4-m walk, and timed test of rising 5 times from a chair. Chronic conditions were ascertained as self-report of a physician diagnosis. Data on previous hospitalizations were obtained from the Medicare database. Nonfasting blood samples were obtained and processed with standard methods., Results: In a multivariate analysis, older age, female gender, higher BMI, history of hip fracture and diabetes, one or more hospital admissions for acute infection in the last 3 years, lower levels of hemoglobin and albumin, and higher leukocytes and gamma-glutamyl transferase were all associated independently with poor performance., Conclusions: Screening for older patients who are not disabled but have poor lower extremity performance selects a subgroup of the population with a high percentage of women, high prevalence of diabetes and hip fracture, and high levels of biological markers of inflammation. This group represents about 10% of the US population 70 to 90 years old. These findings should be considered in planning specifically tailored interventions for disability prevention in this subgroup.

Objective: To study depressed mood as a predictor of strength decline within body weight categories over a 3-year follow-up period., Design: A prospective cohort study over 3 years., Setting: Honolulu, Hawaii., Participants: The subjects were 2275 men participating in the Honolulu Heart Program with an average age of 77.1 years (range 71-92 years), who were not cognitively impaired at baseline (Exam 4), and who participated in maximal hand grip strength measurements at baseline and 3 years later (Exam 5)., Measurements: Hand grip strength was measured using a dynamometer. Depressive symptoms were studied using an 11-item version of Center for Epidemiologic Studies Depression Scale with 9 as a cutoff. Body weight categories were formed on the basis of body mass index (BMI) (BMI = weight/height2; underweight: BMI < 20; normal weight: BMI 20-24.99, overweight: BMI > or = 25)., Main Results: At baseline, 9.4% of the participants were rated as having depressed mood. The mean individual strength change over 3 years was - 6.9% (standard deviation 14.0). Steep strength decline was determined as losing > or = 14% (lowest quartile). The proportions of those with steep strength decline in the groups based on combined distributions of BMI and depressed mood were: underweight/ depressed (n = 22) 41%, underweight/not depressed (n = 200) 28%, normal weight/depressed (n = 127) 30%, normal weight/not depressed (n = 1181) 25%, overweight/depressed (n = 55) 31%, overweight/not depressed (n = 675, referent) 21%. After adjusting for baseline strength, age, height, sociodemographic variables and diseases, the odds ratio for steep strength decline was more than four times greater among those who were depressed and underweight, and twice as great among people who were depressed and normal weight compared with those who were nondepressed and overweight. The risks of nondepressed under- and normal weight people and depressed overweight people did not differ from the reference group., Conclusions: Depressed mood was associated with increased risk of steep strength decline, in particular in older men with low body weight. Low body weight in combination with depressed mood may be an indicator of frailty or severe disease status that leads to accelerated strength loss and disability.

The role of women in caregiving to elderly people has focused primarily on their involvement as givers of care. In contrast, this article focuses on older women as recipients of caregiving. Data from the WHAS and the WHAS Caregiving Study are used to describe: the relationship of caregiving arrangements among moderately to severely disabled older women to sociodemographic, health and functional status; the characteristics of primary family caregivers and the assistance they provide; preferences for caregiving arrangements among both care recipients and caregivers; and views on adequacy of caregiving among older women cared for by family. Overall, about one quarter of these women had no caregiver, reflecting the inclusion in the WHAS of women with only moderate functional difficulty, but close to two-thirds relied on family members, and 15% on paid help only. Greater reliance on family was associated with being age 80 or older, black, and living with others. Women with poorer functioning--more ADL and IADL difficulties, difficulty taking medications without help, low cognitive functioning, not emotionally vital--also were significantly more likely to be cared for by family. Caregiving preferences varied among older women and their husband and daughter caregivers. Husbands consistently viewed in-home family help as the best caregiving arrangement regardless of levels of need. Older women and daughter caregivers both saw nursing homes as the best option for people with dementia and substantial care needs. One-quarter of elderly women chose in-home paid help as the best arrangement for meeting ADL/IADL needs. Older women generally held positive views of the assistance they received from family members. Younger women and lower income women were more likely to indicate they received less help than needed.

Objectives: This study examined sex differences in the prevalence of mobility disability in older adults according to the influences of three components of prevalence: disability incidence, recovery from disability, and mortality., Methods: Participants in a population-based study of older adults from three communities in the United States (N = 10,263) were studied for up to 7 years. Life table methods were used to estimate the influence of each of the three components of disability prevalence in women and men. Sex differences in probabilities for transition states were measured by relative risks derived from a single model using a Markov chain approach., Results: The proportion of disabled women increased from 22% of women aged 70 years to 81% of those aged 90 years. In men, comparable figures were 15% and 57%. Incidence had the greatest impact on the sex differences in disability prevalence until age 90 and older when recovery rates had a greater impact on differences in prevalence. Mortality differences in men and women had only a modest impact on sex differences in disability prevalence. These findings initially seemed to contradict striking sex differences observed in the relative risks for mortality in men compared with women. Subsequent graphical analyses showed that incidence rather than recovery or mortality largely accounted for sex differences in disability prevalence in old age., Conclusion: Disability incidence, recovery from disability, and mortality dynamically influence the sex differences in the prevalence of mobility disability. However, incidence has the greatest impact overall on the higher prevalence of disability in women compared with men.

Background: Many previous investigations of cobalamin and folate status were performed in white populations., Objective: Our objective was to determine whether there are racial differences in the prevalence of cobalamin and folate deficiency., Design: The study was a cross-sectional comparison of baseline serum cobalamin, folate, methylmalonic acid (MMA), total homocysteine (tHcy), and creatinine concentrations, complete blood count, and vitamin supplementation in 550 white and 212 African American subjects from a cohort of physically disabled older women., Results: The mean (+/-SD) serum MMA concentration was significantly higher in whites than in African Americans: 284 +/- 229 compared with 218 +/- 158 nmol/L (P = 0.0001). tHcy concentration was higher in African Americans than in whites: 12.4 +/- 7.0 compared with 10.9 +/- 4.6 micromol/L (P = 0.001). Serum cobalamin was lower in whites (P = 0.0002). Cobalamin deficiency (serum cobalamin <258 pmol/L and MMA >271 nmol/L) was more frequent in the white women (19% compared with 8%; P < 0.0003). Folate deficiency (serum folate <11.4 nmol/L, tHcy >13.9 micromol/L, and MMA <271 nmol/L) was more prevalent in African Americans than in whites (5% compared with 2%; P = 0.01). Multivitamin use was associated with lower tHcy but not with MMA concentrations. Regression models showed that age >85 y, African American race, serum creatinine >90 micromol/L, and high MMA concentration were all significantly correlated with higher tHcy. Creatinine > 90 micromol/L, white race, and folate concentration were positively associated with MMA concentration., Conclusions: Cobalamin deficiency with elevated serum MMA concentration is more prevalent in elderly white than in African American women and elevated serum tHcy and folate deficiency are more prevalent in elderly African American than in white women.

Background: The association between depression and mortality in older community-dwelling populations is still unresolved. This study determined the effect of both minor and major depression on mortality and examined the role of confounding and explanatory variables on this relationship., Methods: A cohort of 3056 men and women from the Netherlands aged 55 to 85 years were followed up for 4 years. Major depression was defined according to DSM-III criteria by means of the Diagnostic Interview Schedule. Minor depression was defined as clinically relevant depression (defined by a Center for Epidemiologic Studies Depression score > or = 16) not fulfilling diagnostic criteria for major depression., Results: After adjustment for confounding variables (sociodemographics, health status), men with minor depression had a 1.80-fold higher risk of death (95% confidence interval, 1.35-2.39) during follow-up than nondepressed men. In women, minor depression did not significantly increase the mortality risk. Irrespective of sex, major depression was associated with a 1.83-fold higher mortality risk (95% confidence interval, 1.09-3.10) after adjustment for sociodemographics and health status. Health behaviors such as smoking and physical inactivity explained only a small part of the excess mortality risk associated with depression., Conclusion: Even after adjustment for sociodemographics, health status, and health behaviors, minor depression in older men and major depression in both older men and women increase the risk of dying.

Objective: This study examined whether dementia patients with greater cognitive reserve had increased mortality rates, and whether this association was different across strata of cognition, functional ability and depression., Methods: In the community-based Amsterdam Study of the Elderly, 261 non-institutionalized dementia patients, identified using the Geriatric Mental State Schedule (GMS), were followed for an average of 55.5 months after which mortality data were obtained. Cognitive reserve was indicated by years of education and pre-morbid intelligence (measured using the Dutch Adult Reading Test). Cognition, functional ability and depression were indicated by Mini-Mental State scores, ADL and IADL measurements and GMS depressive syndrome, respectively., Results: During the follow-up 146 persons (55.9%) died. Cox regression analyses showed that more highly educated dementia patients had higher mortality rates, only if they had low MMSE scores or if they had a concurrent depression. Pre-morbid intelligence was associated with a higher mortality rate, independent of cognition, but this association was much stronger among patients with depression. The positive association between education or intelligence and mortality was not modified by functional disabilities., Conclusions: The results suggest that dementia patients with greater cognitive reserve have increased mortality rates, only if the disease has progressed to such an extent that clinical symptoms are more severe. In this respect, the reserve hypothesis needs a modification. Depression in dementia patients with greater cognitive reserve may reflect a subgroup of patients with poor prognosis.

Background: The serum concentration of interleukin 6 (IL-6), a cytokine that plays a central role in inflammation, increases with age. Because inflammation is a component of many age-associated chronic diseases, which often cause disability, high circulating levels of IL-6 may contribute to functional decline in old age. We tested the hypothesis that high levels of IL-6 predict future disability in older persons who are not disabled., Methods: Participants at the sixth annual follow-up of the Iowa site of the Established Populations for Epidemiologic Studies of the Elderly aged 71 years or older were considered eligible for this study if they had no disability in regard to mobility or in selected activities of daily living (ADL), and they were re-interviewed 4 years later. Incident cases of mobility-disability and of ADL-disability were identified based on responses at the follow-up interview. Measures of IL-6 were obtained from specimens collected at baseline from the 283 participants who developed any disability and from 350 participants selected randomly (46.9%) from those who continued to be non-disabled., Findings: Participants in the highest IL-6 tertile were 1.76 (95% CI, 1.17-2.64) times more likely to develop at least mobility-disability and 1.62 (95% CI, 1.02-2.60) times more likely to develop mobility plus ADL-disability compared with to the lowest IL-6 tertile. The strength of this association was almost unchanged after adjusting for multiple confounders. The increased risk of mobility-disability over the full spectrum of IL-6 concentration was nonlinear, with the risk rising rapidly beyond plasma levels of 2.5 pg/mL., Interpretation: Higher circulating levels of IL-6 predict disability onset in older persons. This may be attributable to a direct effect of IL-6 on muscle atrophy and/or to the pathophysiologic role played by IL-6 in specific diseases.

Objectives: This study examines whether patterns of social network size, functional social support, and loneliness are different for older persons with different types of chronic diseases., Methods: In a community-based sample of 2,788 men and women age 55 to 85 years participating in the Longitudinal Aging Study Amsterdam, chronic diseases status, social network size, support exchanges, and loneliness were assessed., Results: Social network size and emotional support exchanges were not associated with disease status. The only differences between healthy and chronically ill people were found for receipt of instrumental support and loneliness. Disease characteristics played a differential role: greater feelings of loneliness were mainly found for persons with lung disease or arthritis, and receiving more instrumental support was mainly found for persons with arthritis or stroke., Discussion: The specifics of a disease appear to play a (small) role in the receipt of instrumental support and feelings of loneliness of chronically ill older persons.

Background: Depression has been proposed as a predisposing factor for cancer, but prospective studies have been inconclusive. We examined whether a high level of depressive symptoms, present for a long time, is associated with increased risk of cancer in the elderly., Methods: Data were obtained and analyzed from persons who lived in three communities (Massachusetts, Iowa, and Connecticut) of the Established Populations for Epidemiologic Studies of the Elderly, a prospective cohort study with a mean follow-up of 3.8 years that included 4825 persons (1708 men and 3117 women) aged 71 years and older. Chronically depressed mood was defined as present when the number of depressive symptoms exceeded specific cut points on the Center for Epidemiologic Studies-Depression scale at baseline (1988) and 3 and 6 years before baseline. New cases of cancer were identified from Medicare hospitalization records and death certificates., Results: Of the 4825 persons studied, 146 (3.0%) were chronically depressed. The incidence rate of cancer was 30.5 per 1000 person-years for the 146 persons with chronic depression and 21.9 per 1000 person-years for the 4679 nonchronically depressed persons. After adjustment for age, sex, race, disability, hospital admissions, alcohol intake, and smoking, the hazard ratio for cancer associated with chronically depressed mood was 1.88 (95% confidence interval = 1.13-3.14). The excess risk of cancer associated with chronic depression was consistent for most types of cancer and was not specific to cigarette smokers., Conclusion: When present for at least 6 years, depression was associated with a generally increased risk of cancer.

Effects of psychosocial coping resources on depressive symptoms were examined and compared in older persons with no chronic disease or with recently symptomatic diabetes mellitus, lung disease, cardiac disease, arthritis, or cancer. The 719 persons without diseases reported less depressive symptoms than the chronically ill. Direct favorable effects on depressive symptoms were found for having a partner, having many close relationships, greater feelings of mastery, greater self-efficacy expectations, and high self-esteem. Buffer effects were observed for feelings of mastery, having many diffuse relationships, and receiving emotional support. Buffer effects were differential across diseases for emotional support (in cardiac disease and arthritis only) and for diffuse relationships (in lung disease). Receiving instrumental support was associated with more depressive symptoms, especially in diabetes patients.

Depression in survivors of stroke is both common and clinically relevant. It is associated with excess suffering, handicap, suicidal ideation and mortality and it hampers rehabilitation. Most of the data currently available are derived from clinical studies. The objective of the present study was to study the prevalence, risk factors and consequences of depression in survivors of stroke, in a large (n = 3050) community-based study of older (55-85 years) people in three regions of the Netherlands. Depression was measured using the CES-D scale; histories of stroke were obtained using self-reports and data from general practitioners. The study was designed as a case-control study, using both bivariate and multivariate analyses. The prevalence of depression in stroke survivors was 27%, which was significantly higher than the base rate (OR 2.28, 95% CI 1.61-3.24). Both stroke-related disease characteristics and psychosocial characteristics of the respondents were predictors of depression. The consequences of depression were most evident in the realm of disability and impairment of well-being. The patterns of service utilization showed that depressed survivors of stroke are relatively high users of a wide range of health services.

Objective: To examine correlates of high overall level of emotional functioning (emotional vitality) in disabled older women., Design: A community-based study: The Women's Health and Aging Study., Population: A total of 1002 moderately to severely disabled women aged 65 and older living in the community., Measurements: Emotional vitality was defined as having a high sense of personal mastery, being happy, and having low depressive symptomatology and anxiety. Correlations with demographics, health status, and social context were examined., Results: Despite their physical disabilities, 35% of the 1002 disabled older women were emotionally vital. The percent of emotionally vital women declined with increasing severity of disability. After adjustment for disability status, a significantly increased likelihood for being emotionally vital was found for black race (OR=1.69) and for having higher income (OR=1.77), better cognition (OR=2.36), no vision problems (OR=1.61), adequate emotional support (OR=2.54), and many face-to-face contacts (OR=1.64). Having more than one negative life event reduced the likelihood of emotional vitality (OR=0.57)., Conclusion: A substantial proportion of even the most disabled older women can be described as emotionally vital. Findings also suggest that emotional vitality is not solely a function of stable, enduring individual characteristics but that health status, disability, and sociodemographic context also have an influence on emotional vitality.

Context: Significant symptoms of depression are common in the older community-dwelling population. Although depressive symptoms and disability may commonly occur in the same person, whether depressive symptoms contribute to subsequent functional decline has not been elucidated., Objective: To determine whether depressive symptoms in older persons increase the risk of subsequent decline in physical function as measured by objective performance-based tests., Design: A 4-year prospective cohort study., Setting: The communities of Iowa and Washington counties, Iowa., Participants: A total of 1286 persons aged 71 years and older who completed a short battery of physical performance tests in 1988 and again 4 years later., Main Outcome Measures: Baseline depressive symptoms were assessed by the Center for Epidemiological Studies Depression Scale. Physical performance tests included an assessment of standing balance, a timed 2.4-m (8-ft) walk, and a timed test of 5 repetitions of rising from a chair and sitting down., Results: After adjustment for baseline performance score, health status, and sociodemographic factors, increasing levels of depressive symptoms were predictive of greater decline in physical performance over 4 years (odds ratio for decline in those with depressed mood vs those without, 1.55; 95% confidence interval [CI], 1.02-2.34). Even among those at the high end of the functional spectrum, who reported no disability, the severity of depressive symptoms predicted subsequent decline in physical performance (odds ratio for decline, 1.03; 95% CI, 1.00-1.08)., Conclusions: This study provides evidence that older persons who report depressive symptoms are at higher risk of subsequent physical decline. These results suggest that prevention or reduction of depressed mood could play a role in reducing functional decline in older persons.

Background: This study describes the differences in psychological distress, disability and psychosocial resources between types of major medical conditions and sensory impairments (collectively denoted as CMCs); and tests whether disability and psychosocial resources mediate CMC-specific mental health effects., Methods: Data were obtained from a population-based, cross-sectional survey of 5078 non-institutionalized, late middle-aged and older Dutch persons. The predictors were 16 types of CMCs, including all major chronic medical diseases as well as impairment of hearing, vision, and cognition. The outcomes were assessed in terms of psychological distress as measured by the Hospital Anxiety and Depression Scale. Two aspects of disability were measured (namely, physical and role functioning) and also three psychosocial resources (namely, mastery, self-efficacy and social support)., Results: Level of psychological distress varied across type of CMC. Hearing impairment, neurological disease, vision impairment, and lung and heart disease had particularly strong associations with distress. The level of distress in patients with hearing impairment was 0.45 standard deviation higher than in those without hearing impairment (adjusted for demographics and all other CMCs). Roughly similar patterns of association were found between type of CMC and disability, and also, but to a lesser extent, mastery and self-efficacy. Stepwise multiple regression revealed that type of CMC accounted for 9% of the variance in distress initially, but this fell to 1% after the variance due to disability, mastery and self-efficacy was taken out. Social support was not a mediator. Disability and psychosocial resources accounted for 13% and 14% of the variance in distress, respectively., Conclusion: These results support the conventional wisdom that it is not the nature of the condition that determines psychological distress, but instead the severity of the disability and loss of psychological resources associated with the condition on the one hand and the psychological characteristics of the patient on the other.

The direct and buffer effects of various aspects of social support and personal coping resources on depressive symptoms were examined. The study concerned a community-based sample of 1690 older persons aged 55-85 yrs, of whom 719 had no chronic disease, 612 had mild arthritis and 359 had severe arthritis. Persons with arthritis reported more depressive symptoms than persons with no chronic diseases. Irrespective of arthritis, the presence of a partner, having many close social relationships, feelings of mastery and a high self-esteem were found to have direct, favourable effects on psychological functioning. Mastery, having many diffuse social relationships, and receiving emotional support seem to mitigate the influence of arthritis on depressive symptoms, which is in conformity with the buffer hypothesis. Favourable effects of these variables on depressive symptomatology were only, or more strongly, found in persons suffering from severe arthritis.