Predictors of Successful Aging: A Twelve-Year Study of Manitoba Elderly

Noralou P. Roos, PhD, and Betty Havens, AM

Introdudion The elderly are not a homogeneous group. Some are beset by multiple chronic and/or acute conditions and spend considerable time in hospital. Still others, especially women, live a very long life but are afflicted by increasing frailty or declining mental status, passing their last years in nursing homes. Some elderly manage to avoid all of these scenarios, maintain themselves independently in the community and are described as "aging success-

fUlly."1',2 While other investigators have attempted to study successful aging, our analysis is unusual in its longitudinal design, its large representative sample, and in focusing on successful aging of an already elderly cohort. It addresses three questions: 1. What proportion of an elderly cohort will age successfully? 2. What are the health care expenditure patterns associated with successful aging? 3. Which characteristics of individuals predict successful aging? (From among all those interviewed in 1971, who will successfully age? And among those who survive to 1983, what are the factors which predict successful aging?)

Methods In 1971 a large (N = 3,573) representative sample of individuals ages 65-84 living in the community was interviewed as part of the Manitoba Longitudinal Study on Aging.3,4 In 1983 and 1984 survivors of this cohort were reinterviewed. In addition, the health care expenditures of this cohort over the period 1970 through

1983 were available from administrative records of the universally insured provincial health care program. The sample was selected as follows: 2.5 percent of the residents of urban areas and 5 percent of the residents of nonurban areas. Analyses were reweighted by the sampling proportions within strata to reflect population figures. A place of residence variable (urban/not) was included in each multivariate model to control for sampling fraction. Individuals were excluded from the analysis if they were not resident in the province (as judged by coverage in the health care system) for the period of the study, 1970 through 1983 or until death (310); if they were alive and resident in the province in 1983 but not reinterviewed (147); or if the 1971 or 1983 interview was conducted entirely through a proxy (101). (Proxy interviews were used primarily where individuals were too ill or confused to respond.) Native Manitobans (90) were also excluded from the analysis. The final sample for this analysis included 2,943 elderly. A comparison of baseline characteristics of those included and excluded in the study found no difference in age and sex or self-reported health status. However, the interviewer was significantly Address reprint requests to Noralou P. Roos, PhD, Professor, Department of Community Health Sciences, University of Manitoba, S101-750 Bannatyne Avenue, Winnipeg, Manitoba R3E OW3, Canada. Dr. Roos holds a Career Scientist Award (6607-1001-48) from NHRDP and is an Associate of the Canadian Institute for Advanced Research; Ms. Havens is Assistant Professor at the University of Manitoba, Provincial Gerontologist, and Acting Assistant Deputy Minister of Community Health Services, Manitoba Department of Health. This paper, submitted to the Journal November 27, 1989, was revised and accepted for publication May 29, 1990.

American Journal of Public Health 63

Roos and Havens more likely to rate the respondent's mind as steady or strong in general for those retained in the study. Successful aging was defined using the 1983 reinterview as follows: * Alive in 1983. * Not resident of a nursing home in 1983. * Did not receive more than 59 days of home care services in 1983. * In the 1983 interview: Rated health excellent to fair. Not dependent in any activities of daily living (getting in and out of bed, dressing, bathing, eating, using stairs). Did not use a wheelchair. Did not need help in going out doors. Able to walk outdoors. Scored seven or more correct answers on Mental Status Test. Interviewer judged respondent's state of mind to be steady and strong or a bit weak only after some interview time had elapsed. Cause of death was taken from death certificates. Less than 1 percent of the individuals (N = 26) died of accidents, poisonings, or violence and therefore lost the chance to age successfully. Claims data have been shown to provide a highly accurate, reliable, and valid representation of health care use.5,6 Claims were used to estimate health care expenditure patterns associated with healthy aging over the 14-year period 1970-83 (or until death). The following types of utilization were tracked: days spent in hospital (with days spent in intensive care treated separately); days spent in nursing home; days enrolled in the home care program; all physician visits and surgical fees (for both inpatient and

outpatient procedures). Since nursing home services in Manitoba have been universally insured only since 1973, costs incurred by nursing home residents prior to July 1973 were estimated as described elsewhere.7 Since September 1974, home care services in the province have also been universally provided at no charge to consumer. Manitoba hospitals and nursing homes are funded on the basis of global budgets.8 An estimate of mean costs per day in hospital ($322) and nursing home ($49) was calculated by dividing total Manitoba Health Services Commission payments (including capital repayment) to hospitals and to nursing homes in fiscal 1984 by the number of days of care produced that year by these institutions. The cost of a day in intensive care was estimated to be $1,610, five times the cost of 64 American Journal of Public Health

a hospital day. Although per diem costs escalated markedly in both the hospital and nursing home sectors over the time period studied, constant dollar costs were used. The estimate of home care costs per day ($4) were derived by dividing service costs per user over a six-month period by the 182 days in that period.9 Total payments for physician visits and consultations were divided by the total numbers of visits to obtain an average cost per visit ($17). All costs are in constant 1984 Canadian dollars. Variables available from the 1971 interview represent potential predictors of successful aging, while diagnoses made during physician visits over the period 1970 through 1982 and variables constructed from administrative records recording events occurring to spouse (death or admission to nursing home) during this same period are potential factors associated with successful aging. Thus predictors of successful aging may include characteristics of the individual's demographic, ethnic and cultural background, socioeconomic characteristics, and characteristics of the support network. The individual's mental status was also assessed in 1971, as well as satisfaction with life, and several characteristics of health status. Factors studied for association with successful aging include changes in the individual's support network over time (whether the individual's spouse predeceased him or her and whether the spouse entered a nursing home prior to the interviewee's death or 1983). The extent to which specific diseases pose threats to successful aging was examined using both self-reports in 1971 and claims-derived measures of physician contact for five conditions judged to place an elderly individual at "risk for recovery."10 The Manitoba Cancer Registry was used to determine whether the individual had been diagnosed as having cancer (other than skin). Whether individuals had regular contacts with physicians (and therefore would be available for the early detection and treatment of disease) was measured by the percent of years the individual was alive between 1970 and 1982 during which one or more (or two or more) visits were made to physicians. (See Appendix for a complete listing of predictor variables.) Two dependent variables were examined: successful aging (yes-no); and successful aging versus survival to 1983 in a dependent state.

In the analyses, using the first dependent variable, all individuals sampled were used to determine which variables were predictive of successful aging. The second analysis examined the association between all dependent variables and successful aging among those who survived to 1983. Because of the large number of independent variables, a two-step process was followed for each group of variables (see Appendix for grouping). First, the relation of each variable to each dependent variable was tested by univariate analyses. A forward step-wise fitting algorithm for the multiple logistic regression model was used to determine which variables among each group of predictor variables made a contribution to each model at a p value level of 0.05. Age and sexwere included in every model. From among those variables within a set which were substantially correlated with one another (i.e. absolute value of Pearson correlation coefficient .5 or greater) only one was selected for modeling. The variables which made the most contribution to model fit, or, where there was little difference, the variables most commonly used in previous studies were selected. A final multiple logistic regression model was fit including the variables from each set selected as described above. Contributions to the model of the combined effect of 1) sex and income, 2) sex and spousal death/nursing home entry, 3) income and spousal death/nursing home, were assessed by including interaction terms in the model. The data were randomly split with one-half of the records used to develop the models and to estimate the coefficients of the logistic regression models." The final model was tested on the other half of the records to see if the same variables entered the model and whether the coefficients were estimated in similar magnitude. All data have been pooled for presentation since the larger sample provides more stable estimates of the coefficients.

Results By our definition, 20 percent of those individuals ages 65 to 84 interviewed in 1971 were judged to have successfully aged in 1983, 22.6 percent were alive but dependent, and 57.5 percent were deceased (Table 1). Males were more likely to be deceased by 1983 than females. Although females ages 65 to 74 were somewhat more likely to have aged success-

January 1991, Vol. 81, No. 1

Predictors of Succssful Aging a higher level of satisfaction with life in older age (see Table 2). Separate comparisons by age confirmed this relationship (data available on request to author). However, maintaining functional independence is not a guarantee for being satisfied with one's life in advanced old age. Moreover, losing one's independence is not necessarily judged a disaster. Among those reporting their satisfaction with life to be excellent, 30.4 percent were classifed as "alive but dependent" in 1983. Individuals who remained independent made markedly fewer demands on the health care system (Table 3). About two-thirds (67.7 percent) of those aging successfully used less than $10,000 worth of health care resources over the 14-year period 1970 through 1983, averaging $736 per year. In contrast, those who lived to 1983 in a more dependent state averaged $3,850 per year over the 14-year period. Those who died before 1983 had the highest resource use averaging $5,955 peryear lived. Further analyses (not presented in Table 3) demonstrated that the low resource utilization patterns of those aging successfullywere observedboth formales ($768 per year lived) and females ($710) and were independent of age ($744 per year for those aged 65-74 in 1971 and $671 for those aged 75-84). Table 4, using multivariate analysis, suggests that the most important factors distinguishing those who successfully aged from all others interviewed in 1971, apart from age, were: bad outcomes occurring to a spouse, self-reported health in 1971, retirement because of poor health, not developing cancer or diabetes, and not having good mental status. Females were no more likely to age successfully than were males. Factors which distinguish those who successfully aged from those who survived to 1983 but were functionally dependent are shown in Table 5. After controlling for age, self-rated health was again a strong predictor of successful aging. Individuals who did not have diabetes were also more likely to age successfully, although cancer had no similar impact. The odds of successful aging were decreased if one's spouse died or was assessed for or placed in a nursing home.

fully than males, there was little difference in successful aging by sex in the older age group (p = .466). Recalculating the percentages in Table 1 (not shown) and focusing upon those who survived to 1983 shows no difference in the percentage of females versus males in the youngest

January 1991, Vol. 81, No. 1

group who successfully aged (p = 0.172). However, among survivors in the oldest age group, males were more likely to successfully age than were females (32.7 percent versus 18.0 percent, p = 0.006). Remaining independent (the definition of successful aging) is associated with

Discussion Successful aging has been defined in terms of an individual retaining the ability to function independently.12 Those who age successfully remain out of institutions and do not have continuing input from a

American Journal of Public Health 65

Roos and Havens

home health agency. They remain mobile and competent in all the activities of daily living. While these individuals defined their health status in 1983 as fair or better, we deliberately did not label these individuals the "healthy aged." Healthy implies the absence of disease and further, individuals with the "same disease" may have a different sense of well-being and ability to function.'2 Our results are interesting not only because of the variables they include, but also for the variables which they do not include. None of the measures of socioeconomic status were significant in the final models, even though the measures available in 1971 were extensive. Also, an index combining high scores on the education, occupation and income variables was constructed but did not prove significant. Two recent studies'314 have reported that low incomes are associated with poor health outcomes for Canadians despite universally insured medical and hospital care. Guralnik and Kaplan'2 also found

66 American Journal of Public Health

income predictive of a high level of functioning in the 19-year follow-up of Alameda County residents. Two factors may help to account for our contradictory findings compared to these earlier studies. The income effect may decrease with age because: not as many poor people as others survive long enough to be classified as "old"; the income gradient among the elderly may narrow with government transfer payments improving the lot of the poor, while advancing age is depleting the resources of the wealthy. Haan, et al,'5 compared age-specific mortality rates among White Alameda County residents of poverty and non-poverty areas. While in the younger age groups the mortality rates in poverty areas were much higher, among those ages 65 and older, there was essentially no difference. Finally, the one group in Canadian society which is most economically disadvantaged, Native Canadians, were excluded from the analysis. This study presents strong evidence that regular contact with physicians, even among elderly individuals (one ofthe high-

est risk groups in the population), is not related to successful aging. Regular contact with the health care system was measured with a high degree of accuracy. Neither the percentage of years in which individuals made one or more visits, nor the percentage of years in which two or more visits were made, was associated with successful aging. Many measures of disease and functional status were not useful predictors of successful aging. None of the measures of poor functional status in 1971, including indicators that an individual needed help in the activities of daily living or in instrumental activities, none of the self-reported health conditions (including stroke, arthritis, etc.) and only one of the conditions for which physician visit data were available (diabetes) was negatively associated with successful aging. These findings are contrary to most preconceptions and to some literature. The National Institute of Mental Health's Human Aging II Study,'6 a longitudinal follow-up of a small number of very healthy males, found even asymptomatic disease was negatively predictive of longevity. However, that study focused on longevity alone and longevity is only one (albeit an important) aspect of successful aging. Having cancer was negatively associated with successful aging but primarily influenced longevity; people with cancer were less likely to live long enough to age successfully by our criteria. However, if such individuals did survive to 1983 (6.7 percent ofthose surviving to 1983 had cancer), they were just as likely to have aged successfully as those without cancer. Since age is strongly related to mortality, odds ratios for categories associated with successful aging are greater for the model whose comparison group included decedents (Table 4). The magnitude of the odds ratio for the female sex decreased somewhat from model one to model two (Table 5) reflecting the fact that, although more females may survive, their chance of aging successfully appears to be lower than that for males who survive.'7 A comparison of self-rated health in the two models suggests the distribution of self-rated health in 1971 among those who subsequently died was similar to that among those who remained alive but dependent. Previous work in Manitoba demonstrated that self-rated health was a predictor of mortality over a six-year period independent of objective health statusl8 and this relationship has been confirmed by

January 1991, Vol. 81, No. I

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others.19 The present study extends these findings by demonstrating that self-rated health is not only an important predictor of mortality over the longer 12-year period, but is also one of the few factors associated with successful aging among those who survive. Muller20 suggested that the predictive contribution of self-rated health could be partly due to Mossey and Shapiro's including indicators developed from utilization data in their measure of objective health status. She suggested pessimism and depression might be the actual causal factors. Although measures of life satisfaction in 1971 were predictive of successful aging in early models, they made no contribution here to the final models which included the self-rated health measure. There were measures unavailable to this project which might have made useful contributions. The most obvious limitation of the data was the lack of biological measures of function (blood pressure, etc.) and the lack of measures of health practices (smoking history, alcohol con-

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This research was supported by grant (66071440-57) from the National Health Research and Development Program (NHRDP). The 1971 interview was funded by the Government of Manitoba, Department of Health, with the 1983 interview funded by NHRDP grant (66071302-06) and the Government of Manitoba, Department of Health. The assistance of Robert Tate, Carmen Steinbach, Bogdan Bogdanovic, Betje Jacobs, and Debbie Molina is acknowledged with thanks. The authors are indebted to the Manitoba Health Services Commission, the Manitoba Cancer Treatment and Research Foundation, and the Manitoba Department of Vital Statistics which helped make this research possible. Interpretations of the data are the authors' own.

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sumption, regular physical activity, etc. although the latter could be approximated by the questions pertaining to leisure time activities). The Alameda County study found individuals with more low risk practices to have lower mortality rates.21 The Framingham Study, after 21 years of biennial observations, also reported that alcohol intake, smoking, ventricular rate, and education were related to good functioning status for men although, for women, the only significant predictor other than age was education.22 In conclusion, a significant group of elderly do age successfully. These individuals express more satisfaction with their lives and incur substantially fewer health expenditures than other elderly. Individuals at particular risk of not aging successfully include those with poor self-assessed health, whose spouse has died, whose mental status is somewhat compromised, who developed cancer, and those who are forced to retire or retire because of poor health. O

References 1. Rowe JW: Seeking the keys to successful aging. Geriatrics 1987; 42:99-100. 2. Stallones RA: Epidemiological studies of health: A commentary on the Framingham studies. J Chronic Dis 1987; 40(Suppl 1):177S-180S. 3. Manitoba Department of Health and Social Development: Aging in Manitoba. Winnipeg: Queen's Printer, 1973. 4. Mossey JM, Havens B, Roos NP, Shapiro E: The Manitoba longitudinal study on aging: Description and methods. Gerontologist 1981; 21:551-558. 5. Roos LL, Roos NP, Cageorge SM, Nicol JP: How good are the data? Reliability of one health care data bank. Med Care 1982; 20:266-276. 6. Roos LL, Sharp SM, Wajda A: Assessing data quality: A computerized approach. Soc Sci Med 1989; 28:175-182. 7. Roos NP, Shapiro E, Tate R: Does a small minority of elderly account for a majority of health care expenditures: a sixteen year perspective. Milbank Mem Fund Q 1989;

67(3-4):347-369. 8. DetskyAS, Stacey SR, Bombardier C: The effectiveness of a regulatory strategy in containing hospital costs: The Ontario experience, 1967-1981. N Engl J Med 1983; 309:151-159. 9. Chappell N, Horne J: Housing and support of services for elderly persons in Manitoba: Ottawa: Canada Mortgage and Housing Corporation, 1987. 10. Jones EW: Patient classification for longterm care: User's manual. DHEW Pub. No. HRA 75-3107. Washington, DC: Govt Print Office, 1974. 11. Mosteller F, Tukey JW: Data Analysis and Regression. Reading, MA: Addison-Wesley, 1977. 12. Guralnik JM, Kaplan GA: Predictors of healthy aging: Prospective evidence from the Alameda County study. Am J Public Health 1989; 79:703-708. 13. Wigle DG, Mao Y: Mortality by income level in urban Canada. Ottawa: Health and Welfare Canada, Health Protection Branch, 1980. 14. Wilkins R, Adams OB: Health expectancy in Canada, late 1970s: Demographic, regional, and social dimensions. Am J Public Health 1983; 73:1073. 15. Haan M, Kaplan GA, Camacho T: Poverty

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and health. Prospective evidence from the Alameda County Study. Am J Epidemiol 1987; 125:989-998. Granick S, Patterson RD (eds): Human Aging II. An Eleven-Year Follow-up Biomedical and Behavioral Study. DHEW Pub. No. (ADM) 77-123. Washington, DC: Govt Printing Office, 1976. Jette AM, Branch LG: The Framingham Disability Study: II. Physical disability among the aging. Am J Public Health 1981; 71:1211-1216. Mossey JM, Shapiro E: Self-rated health: A predictor of mortality among the elderly. Am J Public Health 1982; 72:800-8. Idler EL, Kasl SV, Lemke JH: Self-evaluated health and mortality among the elderly in New Haven, Connecticut, and Iowa and Washington Counties, Iowa, 1982-1986. Am J Epidemiol 1990; 131:91103. Muller C: Health status and survival needs of the elderly. (Editorial) Am J Public Health 1982; 72:789-790. Wingard DL, Berkman LF, Brand RJ: A multivariate analysis ofhealth-related practices. A nine-year mortality follow-up of the Alameda County study. Am J Epidemiol 1982; 116:765-774. Pinsky JL, Leaverton PE, Stokes J: Predictors of good function: the Farmingham Study. J Chronic Dis 1987; 40(Suppl 1):159S-167S. Kahn RL, Goldfarb AI, Pollack ME, Peck A: Brief objective measures for the determination of mental status in the aged. Am J Psychiatry 1960; 117:326-328. Neugarten BL, Havighurst RJ, Toblin SS: The measurement oflife satisfaction. J Gerontol 1961; 16:134-143.

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68 American Journal of Public Health

January 1991, Vol. 81, No. 1