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147
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 rights It 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 regulations If you believe that digital publication of certain material infringes any of your rights or (privacy) interests, please let the Library know, stating your reasons. In case of a legitimate complaint, the Library will make the material inaccessible and/or remove it from the website. Please Ask the 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

Transcript of UvA-DARE (Digital Academic Repository) Functional ... · ChapterChapter 1 Duringgth...

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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

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Functiona ll disabilit y Étt in elderl y men H

Carolie nn van den Brin k

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Functiona ll disabilit y

inn elderl y men

Carolie nn van den Brin k

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©© 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

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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

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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

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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

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1 1 Introductio n n

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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

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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

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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

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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.

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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

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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

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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

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Introduction Introduction

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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

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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

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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

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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

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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

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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).

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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.

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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).

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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.

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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

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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.

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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.

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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

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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. .

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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

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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).

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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

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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).

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WidowhoodWidowhood and disability

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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).

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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.

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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)

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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.

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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.

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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)

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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.

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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'

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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.

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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.

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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.

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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

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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.

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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.

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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

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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

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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.

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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?

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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.

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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'

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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.

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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%).

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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%).

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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% %

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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

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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.

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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.

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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

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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. .

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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.

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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.

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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

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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

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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

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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.

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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% %

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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).

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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% %

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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.

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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.

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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

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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. .

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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

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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.

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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.

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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,

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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.

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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

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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

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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,

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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.

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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.

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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-

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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. .

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8 8 Genera ll discussio n

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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

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GeneralGeneral d/scuss/on

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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

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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

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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.

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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. .

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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.

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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.

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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.

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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

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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

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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

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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.

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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.

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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.

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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.

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208.. Langhorne P, Dennis MS. Stroke units: the next 10 years. Lancet 2004;363(9412):834-5.

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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. .

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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.

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Summar y y

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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

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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

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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.

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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.

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Samenvattin g g

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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

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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.

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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.

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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.

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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. .

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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: © .

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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.

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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'.

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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.

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