Changing Functional Status in a Biethnic Rural Population

The San Luis Valley Health and Aging Study

Lucinda L. Bryant, Susan M. Shetterly, Judith Baxter and Richard F. Hamman

From the Department of Preventive Medicine and Biometrics, University of Colorado School of Medicine, 4200 East Ninth Avenue, Box C245, Denver, CO 80262 (e-mail: richard.hamman{at}UCHSC.edu).


    ABSTRACT
 TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
The San Luis Valley Health and Aging Study, was designed to examine Hispanic versus non-Hispanic White differences in prevalence and incidence of aging-related outcomes in a rural population (1,358 community dwellers and 75 nursing home residents). Data presented here were gathered between 1993 and 1997Previously reported analyses identified greater prevalence of functional dependence in daily living activities among Hispanic elderly, especially females, than among non-Hispanic White elderly. This analysis explored the degree to which incident changes explain these patterns. Comparisons of incidence, recovery, and mortality rates after 22 months revealed no significant ethnic differences, although trends were as hypothesized: greater Hispanic incidence, lower Hispanic recovery rates, and less Hispanic mortality. Overall age-adjusted incidence (activities of daily living = 9.5; instrumental activities of daily living = 15.1 per 100 person-years) exceeded reports from most other studies, while rates of recovery (activities of daily living = 14.5; instrumental activities of daily living = 9.9) and mortality (4.8 among community dwellers; 6.7 including nursing home residents) were similar to those of other reports. Patterns of new dependence, recovery, and mortality did not increase the previously observed disparity. Greater prevalent disability in the Hispanic cohort, especially in women, may reflect a reservoir accumulated during younger years and related to culture and socioeconomic status as well as to older age.

activities of daily living; aging; ethnic groups; Hispanic Americans; population characteristics

Abbreviations: ADL, activities of daily living; IADL, instrumental activities of daily living; MMSE, Mini-Mental State Examination; SLVHAS, San Luis Valley Health and Aging Study


    INTRODUCTION
 TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Maintaining independence across multiple facets of daily life contributes to successful aging (1Go, 2Go). Functional disability diminishes independence and also predicts negative outcomes of aging such as mortality and institutionalization (3GoGo–5Go). To determine appropriate interventions to assist older people whose functional abilities decline, we first need to understand patterns of disability, with attention to differential impacts within communities.

Sociocultural factors and people's appraisals of symptoms and health can affect functional status (6Go). We previously found moderately greater prevalence of disability among Hispanic than among non-Hispanic White elderly in the San Luis Valley Health and Aging Study (SLVHAS) (7Go, 8Go). Hamman et al. (7Go) reported greater Hispanic dependence in activities of daily living (ADL) among people aged 65 years and older (age- and gender-adjusted Hispanic to non-Hispanic White odds ratio = 1.4, 95 percent confidence interval: 1.0, 1.9). Shetterly et al. (8Go) found the community-dwelling Hispanic cohort aged 60 years and older to be significantly more likely to report the need for assistance with instrumental activities of daily living (IADL) (age- and gender-adjusted Hispanic to non-Hispanic White odds ratio = 1.6, 95 percent confidence interval: 1.3, 2.1).

Prevalence has two components: incidence and duration. A higher incidence of disability and/or lower rates of recovery among Hispanic persons over time would result in greater prevalent disability. Differentially lower Hispanic mortality rates leading to more years of life in a disabled state would also increase prevalence among Hispanic persons. Exploring these possibilities requires estimates of incident disability, recovery, and mortality. Previous studies have provided some information about incidence and recovery rates in older populations, but few are ethnic specific, and we found no studies that compared Hispanic with non-Hispanic White rates (4Go, 9GoGoGo–12Go). Two national studies reported differences in mortality rates among the elderly of different racial/ethnic groups; both found lower rates among Hispanic elderly than in other populations (13Go, 14Go).

This report documents the incidence of ADL and IADL dependence, recovery from dependence, and mortality in the biethnic SLVHAS population during nearly 2 years between baseline and the first follow-up assessment (8Go). It examines the degree to which these patterns of incident dependence, recovery, and mortality explain the observed excess Hispanic prevalence of functional dependence previously reported (7Go, 8Go).


    MATERIALS AND METHODS
 TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Population and sampling
The population-based SLVHAS examined health and disability among older Hispanic and non-Hispanic White residents of Alamosa and Conejos counties in southern Colorado, including nursing home residents in surrounding counties who had previous home addresses in the two-county area. The study design has been described in detail elsewhere (7Go) and is summarized briefly here. Eligibility requirements included age 60 years or older, residence in either county, and Hispanic or non-Hispanic White origin. The 1980 US Census question, "Are you of Spanish or Hispanic origin or descent?" defined Hispanic ethnicity (15Go). Differential sampling within age and ethnic strata ensured appropriate numbers of subjects for the planned ethnic contrasts. The process yielded a sample of 1,757 eligible subjects.

Bilingual interviewers collected responses from 1,358 community-dwelling participants and 75 nursing home residents (81.5 percent response rate). The baseline response among nursing home residents was high and did not differ by ethnicity; among community dwellers, those who refused were more likely to be non-Hispanic White. Persons who refused at baseline were less likely to have any reported ADL difficulty and were slightly more likely to be at least age 80 years. They did not differ significantly from respondents by sex, education, self-rated health, or hospitalization in the previous year (8Go).

Interviewers revisited the respondents approximately 22 months later and administered a shortened version of the baseline assessment. By that time, 147 persons had died (105 community dwellers, 73 Hispanics, and 75 females), and 98 refused the follow-up visit (96 community dwellers, 59 Hispanics, and 54 females). Interviewers collected data from the remaining 1,188 study members (92.4 percent of the baseline cohort alive at follow-up), including 31 nursing home residents. We excluded from this analysis those who did not supply ADL or IADL information at baseline or follow-up. Subjects remaining for ADL analyses included 1,115 community dwellers and 30 nursing home residents. For IADL analyses, 1,099 community dwellers provided sufficient information.

Among community-dwelling and nursing home survivors at follow-up, those who refused (7.9 percent of Hispanics and 7.2 percent of non-Hispanic Whites) had significantly lower baseline cognition scores (p = 0.001) and somewhat lower levels of education (p = 0.13) than did respondents. They did not differ significantly by sex, age, or baseline reports of ADL difficulty or dependence, hospitalization in the past year, or number of chronic diseases.

Protocol
All interviewers were bilingual, and Spanish-translated forms were available. The Mini-Mental State Examination (MMSE) of Folstein et al. (16Go) measured cognitive status. Participants who scored 18 or higher on the MMSE completed the full protocol. A limited number of persons with literacy or vision difficulties who scored between 11 and 17 were judged cognitively capable of completing the entire protocol. All other participants who scored less than 18 completed the physical examination and selected performance tasks; a primary caregiver or close relative with knowledge of recent functioning and medical history, if available, supplied a subset of the remaining information. Hispanic respondents more often required proxy assistance than did non-Hispanic White respondents (12.1 vs. 6.1 percent of this study's sample at baseline, 20.9 vs. 12.0 percent at follow-up). This difference reflects a similar ethnic disparity in MMSE scores that correlated with lower levels of education among Hispanic elderly. An earlier report found that both education (p < 0.001) and ethnicity (p = 0.01) contributed significantly to the variation in MMSE scores in this population and that eliminating culturally sensitive items from the MMSE reduced, but did not eliminate, the ethnic disparity (17Go).

Reported disability
Disability questions came from the 1984 National Health Interview Supplement on Aging (18Go): "Because of a health or physical problem, do you have any difficulty" with ADL tasks (eating, bathing, dressing, toileting, transferring between bed and chair, walking across a room, and getting outside) and similarly with IADL tasks (shopping, transportation, preparing meals, using the telephone, taking medication, managing money, and doing light and heavy housework). Respondents who indicated any difficulty further rated their level of difficulty as some, a lot, able with help, or unable to do. We defined disability as dependence, that is, needing assistance with or being unable to do the task. The IADL difficulty question had an additional possible response, "does not do for other reasons" (e.g., for some men, preparing meals). We did not classify these responses as dependence because they typically indicate custom rather than ability (19Go, 20Go).

Nursing home residents were assumed to be IADL dependent in at least one task and so were not asked about IADL disability. Almost all (92 percent) reported ADL dependence at baseline as well, and none recovered from dependence. We therefore included nursing home residents only in analyses of mortality.

Statistical methods
Computation of density rates (21Go) for incident disability and recovery from disability assumed that relevant events occurred at the midpoint between the baseline and follow-up interviews. Person-years at risk prior to death were based on actual dates of death. The SAS analysis package version 6.12 (SAS Institute, Inc., Cary, North Carolina) and PEPI version 3.0 (22Go) were used for analysis.

Density rates were adjusted to the age distribution of the subset of the population eligible for the particular outcome. Age-standardization weights therefore differed by outcome, precluding comparison of rates across outcomes but allowing comparisons within outcomes. This constraint seemed preferable to the distortion (e.g., overestimating incidence) that would be introduced by, for example, applying age-specific incidence rates to the age structure of the entire older and already partially disabled population rather than to the generally younger, incidence-eligible subgroup free of dependence at baseline.


    RESULTS
 TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Description of the population
Table 1 presents relevant population characteristics at baseline and follow-up. There were no ethnic differences by age or gender. By follow-up, a greater percentage of non-Hispanic White elderly had died (12.0 percent compared with 8.9 percent for Hispanics); most of the difference occurred in the nursing home sample. Crude, gender-specific baseline ADL and IADL prevalences by ethnicity show a pattern of significant excess prevalent disability in Hispanic females.


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TABLE 1. Characteristics of population, San Luis Valley Health and Aging Study, 1993–1997

 
Nursing home residents differed from community dwellers. They were older on average by more than 10 years, and 75 percent were female compared with 57 percent of the community dwellers. A much smaller proportion of Hispanic than of non-Hispanic White elderly resided in nursing homes: 2.9 compared with 8.3 percent at baseline.

Change in functional status
During the approximately 22 months between visits, persons who survived could develop functional dependence, recover from existing dependence, or continue as at baseline. Table 2 provides numbers of events and person-years of eligibility for these events and mortality. Table 3 presents age-adjusted rates of incident ADL and IADL dependence, recovery, and mortality, by sex and ethnicity.


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TABLE 2. Disability outcomes in the community-dwelling cohort, by baseline status and ethnicity, San Luis Valley Health and Aging Study, 1993–1997*

 

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TABLE 3. Incident functional dependence, recovery, and mortality rates per 100 person-years (age adjusted), by ethnicity and gender, San Luis Valley Health and Aging Study, 1993–1997

 
Incident functional dependence. We defined incident dependence as a newly acquired need for assistance from other people or equipment in order to perform one or more of the daily living tasks at follow-up among those persons who reported no such need at baseline. Among the study participants who survived and provided follow-up information, 964 were free of ADL dependence at baseline; 147 (15 percent) of these reported incident dependence at follow-up. No significant difference in age-adjusted ADL incidence rates existed between Hispanic and non-Hispanic White respondents overall (9.5 and 9.8 per 100 person-years, respectively; p = 0.81, from Mantel-Haenszel estimation of differences in rates). Women tended to report greater incidence than did men, non-Hispanic White males reported the lowest rate, and non-Hispanic White females reported the highest, but no differences were statistically significant.

A total of 186 (23 percent) of the 806 persons with no IADL dependence at baseline reported dependence at follow-up. Hispanic respondents had higher, but not significantly different, IADL incidence rates than did non-Hispanic White respondents (16.2 compared with 13.4 per 100 person-years; p = 0.17). As with ADL dependence, women had a slightly greater risk than did men.

Recovery from dependence. Thirty-four (23 percent) of the 151 community-dwelling persons with ADL dependence at baseline reported no dependence at follow-up. Similarly, 47 (16 percent) of the 293 community-dwelling persons with baseline IADL dependence did not report dependence at follow-up. Hispanic females had substantially lower rates of recovery than did other sex-ethnicity groups, but the small number of persons eligible for recovery limited the power to identify statistically significant differences.

Mortality. Hispanic and non-Hispanic White mortality rates in community-dwelling residents were similar. Men had significantly higher rates than did women, due to higher rates among non-Hispanic White men aged 80 years or older (17.2 per 100 person-years) and lower rates among non-Hispanic White women in that age group (5.5 per 100 person-years).

Mortality rates in the total population that included nursing home residents were higher than those in the community-dwelling cohort, especially among non-Hispanic Whites, because a greater percentage of non-Hispanic White than of Hispanic elderly resided in nursing homes (data not shown). As in the community-dwelling cohort, rates for males were higher than those for females. Sex-ethnicity subgroups showed the same sex-related differences as in the community-dwelling sample.


    DISCUSSION
 TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
The goals of this analysis were to determine patterns of incident functional dependence, recovery, and mortality among rural Hispanic and non-Hispanic White elderly and to evaluate the extent to which these incident patterns explain the previously observed greater Hispanic prevalence of functional dependence in this population (7Go, 8Go).

Patterns of incidence, recovery, and mortality
This study found overall age-adjusted incidence rates of 9.5 for ADLs and 15.1 for IADLs, both per 100 person-years. The only other study of ADL incidence in Hispanic elderly that we found reported a rate only about one fourth as large, but that study examined a less rural and physically more capable population (9Go). Two-year studies of Longitudinal Study on Aging data also reported ADL rates about one fourth as large and IADL rates about half as large as we found (4Go, 10Go).

Our higher incidence rates may reflect an actual greater functional burden due to environmental as well as social and cultural factors specific to the rural SLVHAS study population. The differences in reported rates may, however, also reflect differences between studies or measurement reliability. Earlier studies differed from this one and each other in purposes of the analyses, characteristics of populations, definitions of disability (23Go), the number of activities assessed (the greater the number, the more likely the identification of any disability), and the extent of dependence on proxy response (24Go). Unreliability of response, if present, could distort rates. Retesting a sample of this study's population (n = 60) indicated only moderate reliability for the ADL questions (kappa = 0.56). Attribution of ADL incidence for 43 percent of respondents was based on reports of newly identified dependence in only a single activity, which might have resulted from test-retest unreliability over the span of the study. Conversely, however, the majority of respondents reported new dependence in more than one activity, a finding that suggests real new disability.

ADL recovery rates reported here correspond with those found in studies lasting 2 years (12Go, 25Go). Longer studies (4Go, 10Go) reported lower rates, but decline during the later years may well have masked or erased earlier periods of recovery.

Other studies have reported mortality rates similar to the 4.8 per 100 person-years found here (4Go, 10Go, 12GoGo–14Go). Two national studies that compared Hispanic and non-Hispanic White mortality rates (13Go, 14Go) reported significantly higher rates for non-Hispanic Whites than for Hispanics, a pattern that our study does not confirm, although we found a trend in that direction.

Determinants of prevalence
We examined the possibility that greater incident dependence among Hispanic elderly, combined with lower mortality rates and decreased recovery from dependence, would explain the previously observed greater Hispanic prevalence of functional dependence in this community-dwelling population. We found a slight, nonsignificantly greater Hispanic experience of incident IADL dependence and no ethnic difference in ADL incidence among community-dwelling study members. Hispanic women reported lower rates of recovery than did other sex-ethnicity groups, although the differences were not statistically significant and the numbers were small. There were no significant ethnic differences in mortality. Men experienced significantly higher mortality rates than did women, while women tended to report a greater risk of dependence in ADL. Sensitivity analyses estimating the prevalence of disability over time, using this study's ethnic-specific incidence, mortality, and recovery confidence interval rate boundaries as input (analyses not shown, but available from the authors), suggest that prevalence comparisons of Hispanics with non-Hispanic Whites are sensitive to incidence rates (only in males) but not to mortality or recovery rates. These results do not offer clear explanations for the observed excess Hispanic prevalence previously reported.

Burden of disability
Several issues relevant to the community emerge from these analyses. It appears that the burden related to functional disability is greater in this rural community than in others. That burden is larger among Hispanic elderly because of higher baseline prevalence, although it is not increasing more rapidly. The impact on the Hispanic community caregivers is even greater because fewer Hispanic elderly use nursing homes, as also noted in earlier SLVHAS studies (7Go, 8Go). Of particular concern are the observed excess prevalence of disability and lower rates of recovery among Hispanic females.

Conclusions
We have described patterns of functional dependence and mortality over a 22-month period as a step toward understanding ethnic differences and their effects on the community. Hispanic elderly experienced greater baseline levels of prevalent functional dependence than did their non-Hispanic White counterparts, but patterns of new dependence, recovery, and mortality did not increase the disparity. In particular, Hispanic elderly did not appear to be at increased risk of new dependence.

There are several plausible explanations for the results. The trends of the observed differences are in the expected directions, and the hypothesis may, in fact, be correct, but the study population may be too small or the duration of the study too short to identify significant ethnic differences. It is also possible that the single "independence" category may mask some relevant information about timing. Among those who reported "no disability" at baseline, a greater proportion of Hispanic than of non-Hispanic White respondents indicated "difficulty" with at least one activity at follow-up (crude ADL rates, 9.4 percent compared with 7.8 percent; crude IADL rates, 18.6 percent compared with 11.6 percent). Observation over a longer period might reveal that Hispanic elderly would acquire incident dependence at a greater rate than non-Hispanic White elderly if this reported increased incidence of difficulty were to evolve into dependence.

Culturally different interpretation of interview questions and resulting misclassification may have distorted the reported ethnic results. Zimmer et al. (26Go) suggested that daily living activity indicators may not adequately measure functional limitations cross-culturally because they reflect role expectations, norms, and living circumstances specific to particular (Western) societies and cultures. Johnson and Wolinsky (27Go) proposed that racial differences in study outcomes may derive from the variable validity of scaled items between racial/ethnic groups. It is possible that culturally different interpretations of questions at baseline led to an overstatement of disparities, a difference in interpretation that decreased with repeated exposure to the interview-data collection experience. Transitions from dependence and independence to mortality were similar in both ethnic groups (table 2), which suggests that misclassification due to respondent interpretation or cultural norming is unlikely to be responsible for the patterns seen here.

The results more likely reflect a real decrease in or a stabilization of the disparity between prevalences of functional disability for Hispanics and non-Hispanic Whites over time. Greater prevalent disability in the Hispanic cohort, especially in women, may reflect a reservoir accumulated during younger years, possibly related to culture and socioeconomic status as well as to increasing age.

We have suggested several possible explanations for our results. Actual answers will require longer follow-up beginning at earlier ages, more sensitive indicators of disability, and exploration of cultural interpretations of relevant concepts.


    ACKNOWLEDGMENTS
 
Supported by National Institute on Aging grant RO1 AG10940 to Dr. Richard F. Hamman, Principal Investigator.


    NOTES
 
(Reprint requests to Dr. Richard F. Hamman at this address).


    REFERENCES
 TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 

  1. Rowe JW, Kahn RL. Successful aging. New York, NY: Pantheon Books, 1998.
  2. Berkman LF, Seeman TE, Albert M, et al. High, usual and impaired functioning in community-dwelling older men and women: findings from the MacArthur Foundation Research Network on Successful Aging. J Clin Epidemiol 1993;46:1129–40.[ISI][Medline]
  3. Manton KG. A longitudinal study of functional change and mortality in the United States. J Gerontol 1988;43:S153–61.[ISI][Medline]
  4. Mor V, Wilcox V, Rakowski W, et al. Functional transitions among the elderly: patterns, predictors, and related hospital use. Am J Public Health 1994;84:1274–80.[Abstract]
  5. Reuben DB, Siu AL, Kimpau S. The predictive validity of self-report and performance-based measures of function and health. J Gerontol 1992;47:M106–10.[ISI][Medline]
  6. Marshall P. Cultural influences on perceived quality of life. Semin Oncol Nurs 1990;6:278–82.[Medline]
  7. Hamman RF, Mulgrew CL, Baxter J, et al. Methods and prevalence of ADL limitations in Hispanic and non-Hispanic white subjects in rural Colorado: The San Luis Valley Health and Aging Study. Ann Epidemiol 1999;9:225–35.[ISI][Medline]
  8. Shetterly SM, Baxter J, Morgenstern NE, et al. Higher instrumental activities of daily living disability in Hispanics compared with non-Hispanic Whites in rural Colorado. The San Luis Valley Health and Aging Study. Am J Epidemiol 1998;147:1019–27.[Abstract]
  9. Ostir GV, Markides KS, Black SA, et al. Lower body functioning as a predictor of subsequent disability among older Mexican Americans. J Gerontol A Biol Sci Med Sci 1998;53A:M491–5.[Abstract]
  10. Trends in the health of older Americans: United States, 1994. Analytical and epidemiological studies no. 3. Vital Health Stat 3 1995;30:1–328.[Medline]
  11. Boult C, Kane RL, Louis TA, et al. Chronic conditions that lead to functional limitation in the elderly. J Gerontol 1994;49:M28–36.[ISI][Medline]
  12. Manton KG, Corder LS, Stallard E. Estimates of change in chronic disability and institutional incidence and prevalence rates in the U.S. elderly population from the 1982, 1984, and 1989 National Long Term Care Survey. J Gerontol 1993;48:S153–66.[ISI][Medline]
  13. Liao Y, Cooper RS, Cao G, et al. Mortality patterns among adult Hispanics: findings from the NHIS, 1986 to 1990. Am J Public Health 1998;88:227–32.[Abstract]
  14. Sorlie PD, Backlund E, Johnson NJ, et al. Mortality by Hispanic status in the United States. JAMA 1993;270:2464–8.[Abstract]
  15. US Department of Commerce. Bureau of the Census. 1980 Census of population and housing, summary characteristics for governmental units and standard metropolitan statistical areas, Colorado. PHC80–3–7. Washington, DC: US GPO, 1982.
  16. Folstein MF, Folstein SE, McHugh PR. "Mini-mental state": a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;12:189–98.[ISI][Medline]
  17. Mulgrew CL, Morgenstern NE, Shetterly SM, et al. Cognitive functioning and impairment among rural elderly Hispanics and non-Hispanic whites as assessed by the Mini-Mental State Examination. J Gerontol B Psychol Sci Soc Sci 1999;54B:P223–30.[Abstract]
  18. Fitti JE, Kovar MG. The supplement on aging to the 1984 National Health Interview Survey. Hyattsville MD: National Center for Health Statistics, 1987:1–115.
  19. Mermelstein R, Miller B, Prohaska T, et al. Health data on older Americans: United States, 1992. Measures of health. Hyattsville MD: National Center for Health Statistics, 1993:9–21.
  20. Dawson D, Hendershot G, Fulton J. Aging in the eighties. Functional limitations of individuals age 65 years and over. Rockville MD: National Center for Health Statistics, 1987:1–11.
  21. Rothman KJ, Greenland S. Modern epidemiology. 2nd ed. Philadelphia PA: Lippincott-Raven, Publishers, 1998.
  22. Abramson JH, Gahlinger PM. Computer programs for epidemiologists: PEPI Version 3. Stone Mountain GA: USD, Inc, 1999.
  23. Jette AM. How measurement techniques influence estimates of disability in older populations. Soc Sci Med 1994;38:937–42.[ISI][Medline]
  24. Wiener JM, Hanley RJ, Clark R, et al. Measuring the activities of daily living: comparisons across national surveys. J Gerontol 1990;45:S229–37.[ISI][Medline]
  25. Gill TM, Robison JT, Tinetti ME. Predictors of recovery in activities of daily living among disabled older persons living in the community. J Gen Intern Med 1997;12:757–62.[ISI][Medline]
  26. Zimmer Z, Liu X, Hermalin A, et al. Educational attainment and transitions in functional status among older Taiwanese. Demography 1998;35:361–75.[ISI][Medline]
  27. Johnson RJ, Wolinsky FD. Gender, race, and health: the structure of health status among older adults. Gerontologist 1994;34:24–35.[Abstract]
Received for publication July 20, 2000. Accepted for publication August 15, 2001.