Journals of Gerontology: MEDICAL SCIENCES Cite journal as: J Gerontol A Biol Sci Med Sci. 2014 November;69A(S2):S39–S45 doi:10.1093/gerona/glu173
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The Prevalence of Cardiopulmonary Symptoms Among Chinese Older Adults in the Greater Chicago Area XinQi Dong,1 Manrui Zhang,1 and Melissa Simon2 1 Rush Institute for Healthy Aging, Rush University Medical Center and Department of Obstetrics and Gynecology, Northwestern University Medical Center, Chicago, IL.
2
Address correspondence to XinQi Dong, MD, MPH, Professor of Medicine, Nursing and Behavioral Sciences. Director, Chinese Health, Aging and Policy Program, Associate Director, Rush Institute for Healthy Aging, Rush University Medical Center, 1645 West Jackson, Suite 675, Chicago, IL 60612. Email: [email protected]
Background. Cardiovascular and pulmonary symptoms influence health and well-being among older adults. However, minority aging populations are often underrepresented in most studies on cardiovascular and pulmonary symptoms. This study aims to examine the prevalence of cardiovascular and pulmonary symptoms among U.S. Chinese older adults. Methods. Data were drawn from the Population Study of Chinese Elderly study, a population-based survey of U.S. Chinese older adults in the Greater Chicago area. Guided by a community-based participatory research approach, a total of 3,159 Chinese older adults aged 60 and above were surveyed. Clinical Review of Systems was used to assess participants’ perceptions of their cardiovascular and pulmonary symptoms. Results. Cardiovascular symptoms (31.6%) and pulmonary symptoms (42.2%) were commonly experienced by U.S. Chinese older adults. Symptoms such as cough (27.4%), sputum production (22.7%), chest pain or discomfort (16.3%), shortness of breath at rest (15.1%), and shortness of breath with activity (12.9%) were commonly reported. Older age, lower income, fewer years residing in the community, poorer self-perceived health status and quality of life, and worsened health over the last year were associated with report of any cardiovascular or pulmonary symptom. Conclusions. Cardiovascular and pulmonary symptoms are common among Chinese older adults in the U.S. Future longitudinal research is needed to examine changes in Chinese older adults’ burden of cardiopulmonary symptoms and their health and well-being. Key Words: Population studies—Older adults—Cardiovascular—Pulmonary—Chinese aging. Received April 30, 2014; Accepted August 19, 2014 Decision Editor: Stephen Kritchevsky, PhD
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ymptoms may influence an individual’s perception of their overall health and quality of life (1). Cardiovascular and pulmonary symptoms in particular, may cause physical discomfort and negative psychological consequences among older adults (2). Functionally, the cardiovascular and pulmonary systems interact with each other. Thus, rather than attributing symptoms to a single disease, evaluating cross-disease symptoms with the cardiovascular and pulmonary systems can provide a better reflection of the clinical effects and health burden of multiple cardiovascular and pulmonary diseases and conditions. Older adults are often at higher risk for cardiovascular and pulmonary disorders. Notably, in the United States, cardiovascular disease is the leading cause of death among people aged 65 and older and chronic lower respiratory diseases are the third leading cause (3). Aging in conjunction with physical, psychological, and behavioral changes often contribute to multiple cardiovascular and pulmonary conditions and their resulting symptoms (4). As 50% of older adults aged 60 or older live with one or more chronic condition, identifying and alleviating cardiovascular and pulmonary
symptoms experienced by older adults is an important goal in multiple chronic diseases management (5). However, although several studies have evaluated the prevalence of diagnosed cardiovascular and pulmonary conditions, insufficient efforts have been made on assessing the prevalence and role of symptoms in older adults’ daily lives. Most prior studies were based on single symptom and single disease or single disease set, like cancer, heart failure, or chronic pulmonary diseases (2,6), and often did not assess the overall systematic symptom burden caused by multiple chronic conditions. Moreover, although a number of prior studies assessed the prevalence of symptoms among older patients with advanced chronic diseases, very few population-based studies have focused on the symptoms experienced by general community-dwelling older adults (7,8). In particular, underrepresented minority older adults in the United States may be disproportionately affected by cardiovascular and pulmonary disorders. National statistics indicate that a higher percentage of Asian Americans died because of cardiovascular diseases compared with S39
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whites and Hispanic (9). However, Asian Americans are consistently treated as a homogeneous group, which fails to acknowledge differences in cultural beliefs, health behaviors, and genetic inherence among diverse Asian subgroups (10). The demographic shifts and rapid growth of Chinese older adults in the United States warrant a better understanding of their cardiovascular and pulmonary symptoms. The Chinese community is the oldest and largest Asian American subgroup in the United States (11). However, the vast intragroup diversity in language, education level, socioeconomic status, and degree of acculturation among U.S. Chinese older adults have resulted in limited evidencebased research targeting this group (12). To build upon the social and health issues documented in previous research with U.S Chinese older adults (13–15) and paint their overall health burden, there is a need to assess the presence of clinical symptoms experienced by this population. In this study, we aim to (i) evaluate the prevalence of cardiovascular and pulmonary symptoms within the context of a large population-based cohort of U.S. Chinese older adults; (ii) examine the correlations between cardiovascular and pulmonary symptoms and sociodemographic characteristics; and (iii) examine the correlations between cardiovascular and pulmonary symptoms and self-reported health and quality of life measures.
Methods Population and Settings The Population Study of Chinese Elderly (PINE) is a population-based epidemiological study of U.S. Chinese older adults aged 60 and older in the Greater Chicago area. The purpose of the PINE study is to collect communitylevel data of U.S. Chinese older adults to examine the key cultural determinants of health and well-being. The project was initiated by a synergistic community–academic collaboration among the Rush University Institute for Healthy Aging, Northwestern University, and more than 20 Greater Chicago area community-based social service agencies and organizations (16). In brief, the PINE study implemented culturally and linguistically appropriate community recruitment strategies strictly guided by a community-based participatory research approach (17). All participants were consented and interviewed by trained bicultural research assistants in English or in a Chinese dialect according to respondent preference. Out of 3,542 eligible participants, 3,159 agreed to participate in the study, yielding a response rate of 91.9%. The largest proportion of missing data was presented with regard to income: we have completed data on 3,123 participants and thus the data of 36 participants (1.1%) are missing. Based on U.S. Census 2010 and a random block census data, the PINE study is representative of the Chinese aging
population in the Greater Chicago area (18). The study was approved by the Institutional Review Board at the Rush University Medical Center. Measurements Sociodemographics.—Basic demographic information was collected, including age, sex, education, annual income, marital status, number of children, living arrangement, and country of origin. Immigration data relating to participants’ years in the United States and years residing in the current community were also collected. Education was assessed by asking participant number of years of education completed. We created a dichotomous variable using “China” and “other” to distinguish respondents who were born in mainland China from those who were born in other countries. Living arrangement was assessed by asking participants how many people live in their household besides themselves and was categorized into groups. Self-reported annual income was categorized into four groups. Overall health status, quality of life, and health changes over the last year.—Overall health status was measured by the question, “In general, how would you rate your health?” on a 4-point scale. Quality of life was assessed by asking, “In general, how would you rate your quality of life?” on a four point scale. Health change in last year was measured by the question, “Compared to one year ago, how would you rate your health now?” on a 5-point scale. Health changes were then recategorized into three groups. Cardiovascular and pulmonary symptoms.—We used the Review of Systems to assess cardiovascular and pulmonary symptoms among our participants (19). Review of Systems is a list of questions organized by organ systems used by health care providers for eliciting a medical history from a patient. We assessed seven cardiovascular system symptoms and six pulmonary system symptoms (please see Table 1). Data Analysis Descriptive univariate statistics were used to summarize sociodemographic characteristics and the prevalence of cardiovascular and pulmonary symptoms. In bivariate analyses, chi-squared tests were used to compare sociodemographic characteristics between persons with and without cardiovascular symptoms, and between persons with and without pulmonary symptoms. The prevalence of each cardiovascular symptom and pulmonary symptom was calculated. Pearson correlation coefficients were used to examine the correlations between sociodemographic variables and cardiovascular and pulmonary symptoms. All statistical analyses were conducted using SAS, Version 9.2 (SAS Institute Inc., Cary, NC).
Prevalence of Cardiopulmonary Symptoms Among Chinese Older Adults
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Table 1. Characteristics of Study Participants by Cardiovascular and Pulmonary Symptoms Any Cardiovascular Symptom (N = 999) Age groups, n (%) 60–64 65–69 70–74 75–79 80–84 85 and older Sex, n (%) Male Female Education level, y (%) 0 1–6 7–12 13–16 17+ Income, n (%) $0–$4,999
No Cardiovascular Symptom (N = 2,160)
χ2, df (p value)
Any Pulmonary Symptom (N = 1,333)
No Pulmonary Symptom (N = 1,826)
χ2, df (p value)
184 (18.4) 183 (18.3) 199 (19.9) 192 (19.2) 141 (14.1) 100 (10.0)
497 (23.0) 458 (21.2) 407 (18.9) 363 (16.8) 259 (12.0) 175 (8.1)
17.4, 5 p < .01
251 (18.8) 251 (18.8) 258 (19.4) 252 (18.9) 182 (13.4) 139 (10.4)
430 (23.6) 392 (21.5) 348 (19.1) 305 (16.7) 214 (11.7) 137 (7.5)
22.6, 5 p < .001
375 (37.5) 624 (62.5)
953 (44.1) 1,207 (55.9)
45.7, 1 p < .001
555 (41.6) 778 (58.4)
742 (40.6) 1,084 (59.4)
0.3, 1 p = .57
−71 (7.2) 359 (36.3) 324 (32.8) 208 (21.0) 27 (2.7)
−124 (5.8) 820 (38.1) 779 (36.2) 368 (17.1) 59 (2.7)
10.8, 4 p < .05
87 (6.6) 520 (39.3) 454 (34.3) 234 (17.7) 27 (2.0)
108 (5.9) 659 (36.3) 649 (35.7) 342 (18.8) 60 (3.3)
7.7, 4 p = .10
370 (37.3)
671 (31.5)
22.9, 4 p < .001
449 (33.9)
592 (32.9)
21.1, 4 p < .001
509 (51.4) 83 (8.4) 14 (1.4) 15 (1.5)
1,108 (52.0) 227 (10.7) 54 (2.5) 72 (3.4)
717 (54.1) 115 (8.7) 24 (1.8) 20 (1.5)
900 (50.1) 195 (10.9) 44 (2.5) 67 (3.7)
673 (67.8) 21 (2.1) 31 (3.1) 267 (26.9)
1,563 (72.9) 36(1.68) 43 (2.0) 502 (23.4)
10.1, 3 p < .05
911 (68.7) 21 (1.6) 37 (2.8) 357 (26.9)
1,326 (73.2) 36 (2.0) 37 (2.0) 412 (22.8)
10.1, 3 p = .02
46 (4.6) 415 (41.6) 536 (53.8)
82 (3.8) 856 (39.7) 1,216 (56.5)
2.6, 2 p = .28
55 (4.1) 532 (40.0) 742 (55.8)
73 (4.0) 739 (40.6) 1,010 (55.4)
0.1, 2 p = .95
222 (22.2) 422 (42.2) 147 (14.7) 208 (20.8)
457 (21.2) 896 (41.5) 333 (15.4) 473 (21.9)
1.0, 3 p = .79
301 (22.6) 552 (41.4) 195 (14.6) 285 (21.4)
378 (20.7) 766 (42.0) 285 (15.6) 396 (21.7)
1.8, 3 p = .61
937 (93.7) 62 (6.2)
1,993 (92.3) 167 (7.7)
4.0, 1 p < .05
1,247 (93.6) 86 (6.5)
1,684 (92.2) 142 (7.8)
2.0, 1 p = .16
277 (27.9)
568 (26.4)
7.9, 3 p < .05
328 (24.8)
512 (28.1)
9, 3 p < .05
11–20 320 (32.2) 21–30 245 (24.7) 31+ 152 (15.3) Years in the community 0–10 625 (62.9) 11–20 233 (23.5) 21–30 93 (9.4) 31+ 42 (4.2) Overall health status, n (%) Very good 14 (1.4) Good 174 (17.4) Fair 476 (47.7) Poor 335 (33.5) Quality of life, n (%) Very good 59 (5.9) Good 400 (12.7) Fair 498 (49.9) Poor 41(4.1)
644 (30.0) 522 (24.3) 416 (19.4)
444 (33.5) 320 (24.2) 233 (17.6)
525 (28.9) 447 (24.6) 335 (18.4)
$5,000–$ 9,999 $10,000–$14,999 $15,000–$19,999 Over $20,000 Marital status, n (%) Married Separated Divorced Widowed Number of children (%) 0 1–2 3+ Living arrangement, n (%) Living alone With 1 person With 2–3 persons With 4 or more Country of origin China Other Years in United States 0–10
1,188 (55.1) 505 (23.4) 295 (13.7) 168 (7.8)
30.5, 3 p < .001
791 (59.7) 329 (24.8) 141 (10.6) 65 (4.9)
1,020 (56.0) 411 (22.6) 247 (13.6) 145 (8.0)
19.5, 3 p < .001
126 (5.8) 923 (42.7) 844 (39.1) 267(12.4)
329, 3 p < .001
30 (2.3) 324 (24.3) 619 (46.4) 360 (27.0)
110 (6.0) 773 (42.3) 701 (38.4) 242 (13.3)
185.3, 3 p < .001
157 (7.3) 983 (45.5) 959 (44.4) 60 (2.8)
14.7, 3 p < .01
81 (6.1) 543 (40.8) 661 (49.6) 47 (3.5)
135 (7.4) 840 (46.0) 796 (43.6) 54 (3.0)
13.6, 3 p < .01
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Table 1. Continued Any Cardiovascular Symptom (N = 999) Health status changes over the last year, n (%) Improved 80 (8.0) Same Worsened
312 (31.3) 606 (60.7)
No Cardiovascular Symptom (N = 2,160)
χ2, df (p value)
197 (9.1) 1,223 (56.7) 739 (34.2)
Results Sample Characteristics Of the 3,159 participants enrolled in the PINE study, 58.9% were women, 71.3% were married, and 85.1% had an annual income below $10,000. The mean age of participants was 72.8 (SD = 8.3) and the mean years of education completed was 8.7 (SD = 5.1). Approximately 31.6% of participants reported having at least one cardiovascular symptom and 42.2% reported having at least one pulmonary symptom (Table 1). Moreover, 22.1% of Chinese older adults reported both cardiovascular and pulmonary symptoms while 48.2% reported neither cardiovascular nor pulmonary symptoms. Prevalence of Cardiovascular and Pulmonary Symptoms With respect to cardiovascular symptoms, chest pain or discomfort (16.3%) was most commonly reported by participants, followed by shortness of breath with exertion (12.9%) and palpitations (10.5%). With respect to pulmonary system symptoms, cough (27.4%) was the most common symptom, followed by sputum (22.7%) and shortness of breath at rest (15.1%) (Table 2). Reports of cardiovascular and pulmonary symptoms increased with age. Whereas 27.0% of older adults aged 60–64 reported having cardiovascular symptoms in the last year, more than one in three older adults aged 85 and older (36.2%) reported having cardiovascular symptoms (Table 3). A similar pattern with respect to age was observed in pulmonary symptoms. Having any pulmonary symptom in the last year increased from 36.9% among older adults aged 60–64 to 50.4% among older adults aged 85 and older. Overall, women were more likely to report cardiovascular symptoms than men (33.5% vs 28.9%). In contrast, women were as likely as men to report pulmonary symptoms (41.8% vs 42.8%). The prevalence of pulmonary symptoms was lower among older adults with higher educational levels. Overall, cardiovascular symptoms and pulmonary symptoms were less likely to be reported by participants with very good self-reported health (10% and 21.4%) compared with older adults with poor self-reported health (55.4% and 59.8%), respectively. In addition, cardiovascular symptoms and pulmonary symptoms were less likely to be reported by older adults with self-reported very good quality of life (27.3% and 37.5%) compared with older adults with poor quality of life (40.6% and 46.5%).
203.8, 2 p < .001
Any Pulmonary Symptom (N = 1,333)
No Pulmonary Symptom (N = 1,826)
108 (8.1)
169 (9.3)
486 (36.5) 738 (55.4)
1,049 (57.5) 607 (33.3)
χ2, df (p value) 159.6, 2 p < .001
Table 2. Presence of Cardiovascular and Pulmonary Symptoms Cardiovascular Symptoms Chest pain or discomfort Tightness Palpitations Shortness of breath with activity Difficulty breathing lying down (orthopnea) Swelling (edema) Sudden awakening from sleep w/ shortness of breath (paroxysmal nocturnal dyspnea) Pulmonary symptoms Cough (dry or wet, productive) Sputum (color or amount) Coughing up blood Shortness of breath at rest Wheezing Painful breathing
N
%
514 190 332 408 140 88 97
16.3 6.0 10.5 12.9 4.4 2.8 3.1
864 716 14 477 287 74
27.4 22.7 0.4 15.1 9.1 2.3
Correlations The prevalence of cardiovascular symptoms was significantly correlated with age (r = .07, p < .001), gender (r = .06, p < .001), overall health status (r = −.32, p < .001), quality of life (r = −.07, p < .001), health changes (r = −.23, p < .001), income (r = −.08, p < .001), marital status (r = −.05, p < .01), and years residing in the United Status (r = −.05, p < .01) and community (r = −.10, p < .001). Similarly, the prevalence of pulmonary symptoms was significantly correlated with age (r = .08, p < .001), overall health status (r = −.24, p < .001), quality of life (r = −.06, p < .001), health changes (r = −.19, p < .001), education (r = −.05, p < .01), income (r = −.07, p < .001), marital status (r = −.05, p < .01), and years in the community (r = −.07, p < .001) (Table 4). The prevalence of Chinese older adults with both cardiovascular and pulmonary symptoms is positively correlated with age (r = .10, p < .001), negatively correlated with overall health status(r = −.29, p < .001), life quality (r = −.05, p < .01), and health change over last year(r = −.21, p < .001). Discussion As the first population-based study of cardiovascular and pulmonary symptoms among U.S. Chinese older adults, we found that U.S. Chinese older adults commonly experienced cardiovascular symptoms and pulmonary symptoms. Chest pain and shortness of breath with activity were the most prevalent cardiovascular symptoms. Cough and sputum were the most commonly presented pulmonary
Very good (N = 216) 59 (27.3) 81 (37.5)
Improved (N = 277) 80 (28.9) 108 (39.0)
Quality of life Cardiovascular, N (%) Pulmonary, N (%)
Health changes Cardiovascular, N (%) Pulmonary, N (%)
Good (N = 1,383) 400 (28.9) 543 (39.3)
Good (N = 1,097) 174 (15.9) 324 (29.5)
$5,000–$9,999 (N = 1,617) 509 (31.5) 717 (44.3)
1–6 (N = 1,179) 359 (30.4) 520 (44.1)
Female (N = 1,862) 555 (42.8) 555 (42.8)
Same (N = 1,535) 312 (20.3) 486 (31.7)
Fair (N = 1,457) 498 (34.2) 661 (45.4)
Fair (N = 1,320) 476 (36.0) 619 (46.9)
$10,000–$14,999 (N = 310) 83 (26.8) 115 (37.1)
7–12 (N = 1,103) 324 (29.4) 454 (41.2)
70–74 (N = 606) 199 (32.8) 258 (42.6)
1.00 0.01 0.22 −0.38*** 0.02 −0.10*** −0.11*** −0.08*** −0.06*** −0.09*** −0.02 0.001 −0.05**
Edu
1.00 −0.03 0.00 0.16*** 0.35*** 0.24*** −0.20*** −0.12*** −0.08*** −0.05** −0.08*** −0.07***
Income
1.00 −0.13*** 0.24*** −0.20*** −0.13*** 0.05** −0.05** 0.03 −0.07*** −0.05** −0.05**
MS
1.00 −0.07*** 0.15*** 0.10*** 0.04* 0.00 −0.04* 0.02 −0.02 0.02
Children
1.00 −0.13*** 0.05*** −0.05** 0.00 0.01 −0.01 −0.01 −0.01
Living
1.00 0.66*** −0.20*** 0.01 0.00 0.04* −0.05** 0.00
Years in U.S.
1.00 −0.15*** −0.05*** 0.02 −0.03 −0.10*** −0.07***
Years in Com
1.00 0.03 0.04* 0.00 0.03 0.03
Origin
1.00 0.32*** 0.35*** −0.32*** −0.24***
OHS
Poor (N = 101) 41 (40.6) 47 (46.5)
Poor (N = 602) 335 (55.4) 360 (59.8)
1.00 0.15*** −0.07*** −0.06***
QOL
1.00 −0.23*** −0.19***
HC
$20,000 + (N = 87) 15 (17.2) 20 (23.0)
17 + (N = 87) 27 (31.0) 27 (31.0)
80–84 (N = 396) 141 (35.6) 182 (46.0)
Worsened (N = 1,345) 606 (45.1) 738 (54.9)
$15,000–$19,999 (N = 68) 14 (20.6) 24 (35.3)
13–16 (N = 576) 208 (36.1) 234 (40.6)
75–79 (N = 557) 192 (34.5) 252 (45.2)
1.00 0.38***
CDV
1.00
PUL
85 + (N = 276) 100 (36.2) 139 (50.4)
Prevalence of Cardiopulmonary Symptoms Among Chinese Older Adults
Notes: CDV = cardiovascular symptoms; Children = number of children; Edu = education; HC = health changes over the last year; Living = living arrangement; MS = marital status; OHS = overall health status; Origin = country of origin; PUL = pulmonary symptoms; QOL = quality of life; Years in Com = years in the community; Years in U.S. = Years in the United States. *p < .05; **p < .01; ***p < .001.
1.00 −0.21*** 0.00 −0.32*** 0.09*** −0.07*** 0.03 0.02 −0.01 0.06** −0.05** 0.03 0.06*** −0.01
Sex
Very good (N = 140) 14 (10) 30 (21.4)
Overall health status Cardiovascular, N (%) Pulmonary, N (%)
Age
$0–$4,999 (N = 1,041) 370 (35.5) 449 (43.1)
Income Cardiovascular, N (%) Pulmonary, N (%)
1.00 0.01 −0.12*** 0.05** −0.33*** 0.32*** −0.35*** 0.35*** 0.23*** 0.04* 0.08*** −0.06*** 0.11*** 0.07*** 0.08***
0 (N = 195) 71 (36.4) 87 (44.6)
Education Cardiovascular, N (%) Pulmonary, N (%)
Age Sex Edu Income MS Children Living Years in United States Years in Com Origin OHS QOL HC CDV PUL
Male (N = 1,297) 375 (28.9) 555 (42.8)
Sex Cardiovascular, N (%) Pulmonary, N (%)
65–69 (N = 643) 183 (28.5) 251 (39.0)
Table 4. Correlations Between Sociodemographic Characteristics, Cardiovascular, and Pulmonary Symptoms
60–64 (N = 681) 184 (27.0) 251 (36.9)
Age Cardiovascular, N (%) Pulmonary, N (%)
Table 3. Prevalence of Pulmonary and Cardiovascular Symptoms by Sociodemographic Characteristics
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symptoms. Participants were more likely to report cardiovascular or pulmonary symptoms if they were older, had lower income, resided fewer years in the community, had poorer self-perceived health status and quality of life, and perceived worsened health change over the last year. Our study indicates that cardiovascular and pulmonary symptoms were more prevalent among older participants. Prior studies have illustrated that aging of the human cardiovascular system plays a dominant role in the deterioration of cardiovascular system function (20), and that the changes in bones and muscles that accompany aging can result in lower levels of pulmonary capacity. In addition to the biological changes that accompany aging, age-related behavioral changes in lifestyles might also influence the function of cardiovascular and pulmonary system. Furthermore, our additional analysis showed a greater proportion of participants reported both cardiovascular and pulmonary symptoms in the older age group Prior studies often estimate a limited range of symptoms, such as coughing, pain, shortness of breath, and wheezing (7,21). However, even with these limited symptoms, variations in study design and sample composition make comparisons of these limited symptoms difficult. For instance, in our study, the prevalence of shortness of breath was 12.9% (with activity) and 15.1% (at rest). One study reported that the prevalence of shortness of breath was 35% among older adults who were diagnosed with chronic conditions) (7) while another study on a younger population aged 34–67 reported the prevalence to be 20.8% (22). In all, our study provided an overall estimate of clinical cardiopulmonary symptoms among U.S. Chinese older adults. Our study observed that compared with men, U.S. Chinese women were more likely to report cardiovascular symptoms but equally as likely to report pulmonary symptoms. Our findings offer some new insights on the traditional belief that men are of higher cardiovascular risk than women (23). Our findings are supported by recent U.S. national statistics demonstrating that older women have equaled and have even outnumbered men in the prevalence of cardiovascular diseases in the age group 60–79 (70.2% vs 70.9%) and the age group 80 and older (83.0% vs 87.1%) (9). With respect to pulmonary symptoms, although women are believed to have higher pulmonary risks (24), our findings suggest that women and men are similar in reporting pulmonary symptoms. The disparities between the prevalence of symptoms identified in our study and the prevalence of diagnosed cardiovascular and pulmonary conditions points to the need to pay special attention to potential gender differences in expressing and reporting symptoms. Our research suggests that U.S. Chinese older adults with higher educational level are less likely to experience pulmonary symptoms, which is in line with prior studies on education and risk of pulmonary diseases (25). Some potential contributing factors may be that better-educated older adults are more likely to engage in cognitively stimulating activities, have better economic circumstances, eat healthier, spend more time participating in physical activities, and
are less stressed. However, inconsistent with previous study (26), similar trend was not found between prevalence of cardiovascular symptoms and education. Participants with 13–16 years of education fall out the trend and displayed a relatively higher prevalence of cardiovascular symptoms. In addition, our study found that cardiovascular and pulmonary symptoms were less prevalent among higher income participants, which was supported by prior research (24,25). Specifically, while prevalence of cardiovascular symptoms displayed a gradual decreasing trend with the increase of income, an annual income level of $10,000 may be the threshold before a decrease in prevalence of reported pulmonary symptoms. Our study reveals that a larger proportion of Chinese older adults report cardiovascular and pulmonary symptoms if they perceive themselves with poorer health status and poorer quality of life, which is consistent with prior studies (1,7). Moreover, participants with both cardiovascular and pulmonary symptoms tend to perceive themselves with poorer health status and poorer quality of life. Specifically, one prior study found that shortness of breath was associated with lower selfrated health and quality of life, an association that was maintained while multiple symptoms were concurrently examined (1). Our findings may indicate a series of psychophysical changes along with the presence of symptoms: experiencing cardiovascular and pulmonary symptoms may negatively influence the psychological well-being of older adults, while the psychological burden can reversely add to the frequency and severity of cardiovascular and pulmonary symptoms. The findings of this study should be interpreted with limitations. First, this study was representative of Chinese older adults in the Greater Chicago area, so generalizing our findings to other Chinese populations in the United States or in Asia should be done with caution. Additional studies are needed to explore the risk factors and impact of cardiovascular and pulmonary symptoms in diverse Chinese populations. In addition, recall bias is likely, therefore symptoms may be likely underreported. Moreover, the cross-sectional design limits our assessment of the development of symptoms and we are not able to delineate the mechanisms of these symptoms. Furthermore, we were unable to assess the severity or frequency of symptoms from the data collected, as well as those who experience multiple symptoms. Future studies applying mixed research strategies and longitudinal designs are needed to better understand the cardiovascular and pulmonary risks. Nonetheless, this study has wide implications for researchers and practitioners. First, this study points to the need for improving investigations on cardiovascular and pulmonary symptoms among Chinese older adults. Interdisciplinary teams composed of research experts in physiology, biomedicine, pathology, and epidemiology, and clinical practitioners are needed to understand how those symptoms may influence the health and well-being trajectories of Chinese older adults. Health care professionals should pay special attention in screening subgroups of Chinese older adults who may have higher prevalence of cardiovascular and
Prevalence of Cardiopulmonary Symptoms Among Chinese Older Adults
pulmonary symptoms. These include the oldest old, women, low income, and the new immigrants to the community. It is important to raise community awareness to cardiovascular and pulmonary symptoms as early signs for detecting cardiopulmonary disorders as well as symptoms that are the results of existing cardiopulmonary disorders. Social services providers should design culturally and linguistically appropriate prevention strategies tailored to the needs of older adults. In light of the traditional tabooed cultural belief of talking about the potential risks of developing diseases, culturally sensitive interventions and education are needed to alleviate stress and anxiety associated with self-reporting early symptoms. Our findings advocate for changes in the practice of preventative care and for better access to health care resources for low-resource communities. Conclusion Our report indicates that cardiovascular and pulmonary symptoms are common among U.S Chinese older adults in the Greater Chicago area. Our findings call for further investigations on several subgroups of Chinese older adults who reported higher prevalence of symptoms, including the oldest old, those with low income, and with lower educational attainment. Future longitudinal studies are needed to improve our understanding of the outcomes and functional mechanisms underlying cardiovascular and pulmonary symptoms among Chinese aging populations. Funding Dr. X.D. and M.S. were supported by National Institute on Aging grant (R01 AG042318, R01 MD006173, R01 CA163830, R34MH100443, R34MH100393, P20CA165588, R24MD001650, and RC4 AG039085); Paul B. Beeson Award in Aging; The Starr Foundation; American Federation for Aging Research; John A. Hartford Foundation; and The Atlantic Philanthropies. Acknowledgments We are grateful to Community Advisory Board members for their continued effort in this project. Particular thanks are extended to Bernie Wong, Vivian Xu, Yicklun Mo with Chinese American Service League (CASL), Dr. David Lee with Illinois College of Optometry, David Wu with Pui Tak Center, Dr. Hong Liu with Midwest Asian Health Association, Dr. Margaret Dolan with John H. Stroger Jr. Hospital, Mary Jane Welch with Rush University Medical Center, Florence Lei with CASL Pine Tree Council, Julia Wong with CASL Senior Housing, Dr. Jing Zhang with Asian Human Services, Marta Pereya with Coalition of Limited English Speaking Elderly, Mona El-Shamaa with Asian Health Coalition. References 1. Walke LM, Byers AL, Gallo WT, Endrass J, Fried TR. The association of symptoms with health outcomes in chronically ill adults. J Pain Symptom Manage. 2007;33:58–66. 2. Walke LM, Byers AL, Tinetti ME, Dubin JA, McCorkle R, Fried TR. Range and severity of symptoms over time among older adults with chronic obstructive pulmonary disease and heart failure. Arch Intern Med. 2007;167:2503–2508. 3. Heron M. National Vital Statistics Reports: 2010 Leading Causes for Death. U.S. Department of Health and human services, Centers for Disease Control and Prevention; 2013. Report No.: 6. 4. Janssens JP, Pache JC, Nicod LP. Physiological changes in respiratory function associated with ageing. Eur Respir J. 1999;13:197–205.
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5. Fried TR, Tinetti ME, Iannone L, O’Leary JR, Towle V, Van Ness PH. Health outcome prioritization as a tool for decision making among older persons with multiple chronic conditions. Arch Intern Med. 2011;171:1854–1856. 6. Solano JP, Gomes B, Higginson IJ. A comparison of symptom prevalence in far advanced cancer, AIDS, heart disease, chronic obstructive pulmonary disease and renal disease. J Pain Symptom Manage. 2006;31:58–69. 7. Walke LM, Gallo WT, Tinetti ME, Fried TR. The burden of symptoms among community-dwelling older persons with advanced chronic disease. Arch Intern Med. 2004;164:2321–2324. 8. Morita T, Tsunoda J, Inoue S, Chihara S. Survival prediction of terminally ill cancer patients by clinical symptoms: development of a simple indicator. Jpn J Clin Oncol. 1999;29:156–159. 9. Go AS, Mozaffarian D, Roger VL, et al.; American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics–2013 update: a report from the American Heart Association. Circulation. 2013;127:e6–e245. 10. Holland AT, Palaniappan LP. Problems with the collection and interpretation of Asian-American health data: omission, aggregation, and extrapolation. Ann Epidemiol. 2012;22:397–405. 11. US Census Bureau U. American Community Survey; 2010. 12. Dong X, Chang E, Wong E, Wong B, Skarupski KA, Simon MA. Assessing the health needs of Chinese older adults: findings from a community-based participatory research study in Chicago’s Chinatown. J Aging Res. 2010;2010:12. doi:10.4061/2010/124246. 13. Dong X, Simon MA, Odwazny R, Gorbien M. Depression and elder abuse and neglect among a community-dwelling Chinese elderly population. J Elder Abuse Negl. 2008;20:25–41. 14. Dong X, Simon MA, Gorbien M, Percak J, Golden R. Loneliness in older Chinese adults: a risk factor for elder mistreatment. J Am Geriatr Soc. 2007;55:1831–1835. 15. Dong X, Chang E-S, Wong E, Simon M. A qualitative study of filial piety among community dwelling, Chinese, older adults. J Intergener Relationships. 2012;10(2):131–146. 16. Dong X, Wong E, Simon MA. Study design and implementation of the PINE Study. J Aging Health. 2014;0898264314526620. 17. Dong X, Chang E-S, Wong E, Simon M. Working with culture: lessons learned from a community-engaged project in a Chinese aging population. Aging Health. 2011;7(4):529–537. 18. Simon M, Chang E, Rajan K, Welch M, Dong X. Demographic characteristics of U.S Chinese older adults in the greater Chicago area. J Aging Health. 2014;26(7):1100–1115. doi:10.1177/0898264314543472. 19. Fortinm AH, Dwamena FC, Smith RC. Chapter 4. Clinician-Centered Interviewing; 2012. 20. Kitzman DW, Taffet G. Chapter 74. Effects of aging on cardiovascular structure and function. In: Halter JB, Ouslander JG, Tinetti ME, Studenski S, High KP, Asthana S, eds. Hazzard’s Geriatric Medicine and Gerontology. 6th ed. 2009. 21. Tinetti ME, McAvay G, Chang SS, et al. Effect of chronic diseaserelated symptoms and impairments on universal health outcomes in older adults. J Am Geriatr Soc. 2011;59:1618–1627. 22. Dean G, Lee PN, Todd GF, Wicken AJ, Sparks DN. Factors related to respiratory and cardiovascular symptoms in the United Kingdom. J Epidemiol Community Health. 1978;32:86–96. 23. Barrett-Connor E. Sex differences in coronary heart disease. Why are women so superior? The 1995 Ancel Keys Lecture. Circulation. 1997;95:252–264. 24. Harms CA. Does gender affect pulmonary function and exercise capacity? Respir Physiol Neurobiol. 2006;151:124–131. 25. Prescott E, Vestbo J. Socioeconomic status and chronic obstructive pulmonary disease. Thorax. 1999;54:737–741. 26. Winkleby MA, Jatulis DE, Frank E, Fortmann SP. Socioeconomic status and health: how education, income, and occupation contribute to risk factors for cardiovascular disease. Am J Public Health. 1992;82:816–820.
© The Author 2014. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: [email protected].
The Prevalence of Cardiopulmonary Symptoms Among Chinese Older Adults in the Greater Chicago Area XinQi Dong,1 Manrui Zhang,1 and Melissa Simon2 1 Rush Institute for Healthy Aging, Rush University Medical Center and Department of Obstetrics and Gynecology, Northwestern University Medical Center, Chicago, IL.
2
Address correspondence to XinQi Dong, MD, MPH, Professor of Medicine, Nursing and Behavioral Sciences. Director, Chinese Health, Aging and Policy Program, Associate Director, Rush Institute for Healthy Aging, Rush University Medical Center, 1645 West Jackson, Suite 675, Chicago, IL 60612. Email: [email protected]
Background. Cardiovascular and pulmonary symptoms influence health and well-being among older adults. However, minority aging populations are often underrepresented in most studies on cardiovascular and pulmonary symptoms. This study aims to examine the prevalence of cardiovascular and pulmonary symptoms among U.S. Chinese older adults. Methods. Data were drawn from the Population Study of Chinese Elderly study, a population-based survey of U.S. Chinese older adults in the Greater Chicago area. Guided by a community-based participatory research approach, a total of 3,159 Chinese older adults aged 60 and above were surveyed. Clinical Review of Systems was used to assess participants’ perceptions of their cardiovascular and pulmonary symptoms. Results. Cardiovascular symptoms (31.6%) and pulmonary symptoms (42.2%) were commonly experienced by U.S. Chinese older adults. Symptoms such as cough (27.4%), sputum production (22.7%), chest pain or discomfort (16.3%), shortness of breath at rest (15.1%), and shortness of breath with activity (12.9%) were commonly reported. Older age, lower income, fewer years residing in the community, poorer self-perceived health status and quality of life, and worsened health over the last year were associated with report of any cardiovascular or pulmonary symptom. Conclusions. Cardiovascular and pulmonary symptoms are common among Chinese older adults in the U.S. Future longitudinal research is needed to examine changes in Chinese older adults’ burden of cardiopulmonary symptoms and their health and well-being. Key Words: Population studies—Older adults—Cardiovascular—Pulmonary—Chinese aging. Received April 30, 2014; Accepted August 19, 2014 Decision Editor: Stephen Kritchevsky, PhD
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ymptoms may influence an individual’s perception of their overall health and quality of life (1). Cardiovascular and pulmonary symptoms in particular, may cause physical discomfort and negative psychological consequences among older adults (2). Functionally, the cardiovascular and pulmonary systems interact with each other. Thus, rather than attributing symptoms to a single disease, evaluating cross-disease symptoms with the cardiovascular and pulmonary systems can provide a better reflection of the clinical effects and health burden of multiple cardiovascular and pulmonary diseases and conditions. Older adults are often at higher risk for cardiovascular and pulmonary disorders. Notably, in the United States, cardiovascular disease is the leading cause of death among people aged 65 and older and chronic lower respiratory diseases are the third leading cause (3). Aging in conjunction with physical, psychological, and behavioral changes often contribute to multiple cardiovascular and pulmonary conditions and their resulting symptoms (4). As 50% of older adults aged 60 or older live with one or more chronic condition, identifying and alleviating cardiovascular and pulmonary
symptoms experienced by older adults is an important goal in multiple chronic diseases management (5). However, although several studies have evaluated the prevalence of diagnosed cardiovascular and pulmonary conditions, insufficient efforts have been made on assessing the prevalence and role of symptoms in older adults’ daily lives. Most prior studies were based on single symptom and single disease or single disease set, like cancer, heart failure, or chronic pulmonary diseases (2,6), and often did not assess the overall systematic symptom burden caused by multiple chronic conditions. Moreover, although a number of prior studies assessed the prevalence of symptoms among older patients with advanced chronic diseases, very few population-based studies have focused on the symptoms experienced by general community-dwelling older adults (7,8). In particular, underrepresented minority older adults in the United States may be disproportionately affected by cardiovascular and pulmonary disorders. National statistics indicate that a higher percentage of Asian Americans died because of cardiovascular diseases compared with S39
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whites and Hispanic (9). However, Asian Americans are consistently treated as a homogeneous group, which fails to acknowledge differences in cultural beliefs, health behaviors, and genetic inherence among diverse Asian subgroups (10). The demographic shifts and rapid growth of Chinese older adults in the United States warrant a better understanding of their cardiovascular and pulmonary symptoms. The Chinese community is the oldest and largest Asian American subgroup in the United States (11). However, the vast intragroup diversity in language, education level, socioeconomic status, and degree of acculturation among U.S. Chinese older adults have resulted in limited evidencebased research targeting this group (12). To build upon the social and health issues documented in previous research with U.S Chinese older adults (13–15) and paint their overall health burden, there is a need to assess the presence of clinical symptoms experienced by this population. In this study, we aim to (i) evaluate the prevalence of cardiovascular and pulmonary symptoms within the context of a large population-based cohort of U.S. Chinese older adults; (ii) examine the correlations between cardiovascular and pulmonary symptoms and sociodemographic characteristics; and (iii) examine the correlations between cardiovascular and pulmonary symptoms and self-reported health and quality of life measures.
Methods Population and Settings The Population Study of Chinese Elderly (PINE) is a population-based epidemiological study of U.S. Chinese older adults aged 60 and older in the Greater Chicago area. The purpose of the PINE study is to collect communitylevel data of U.S. Chinese older adults to examine the key cultural determinants of health and well-being. The project was initiated by a synergistic community–academic collaboration among the Rush University Institute for Healthy Aging, Northwestern University, and more than 20 Greater Chicago area community-based social service agencies and organizations (16). In brief, the PINE study implemented culturally and linguistically appropriate community recruitment strategies strictly guided by a community-based participatory research approach (17). All participants were consented and interviewed by trained bicultural research assistants in English or in a Chinese dialect according to respondent preference. Out of 3,542 eligible participants, 3,159 agreed to participate in the study, yielding a response rate of 91.9%. The largest proportion of missing data was presented with regard to income: we have completed data on 3,123 participants and thus the data of 36 participants (1.1%) are missing. Based on U.S. Census 2010 and a random block census data, the PINE study is representative of the Chinese aging
population in the Greater Chicago area (18). The study was approved by the Institutional Review Board at the Rush University Medical Center. Measurements Sociodemographics.—Basic demographic information was collected, including age, sex, education, annual income, marital status, number of children, living arrangement, and country of origin. Immigration data relating to participants’ years in the United States and years residing in the current community were also collected. Education was assessed by asking participant number of years of education completed. We created a dichotomous variable using “China” and “other” to distinguish respondents who were born in mainland China from those who were born in other countries. Living arrangement was assessed by asking participants how many people live in their household besides themselves and was categorized into groups. Self-reported annual income was categorized into four groups. Overall health status, quality of life, and health changes over the last year.—Overall health status was measured by the question, “In general, how would you rate your health?” on a 4-point scale. Quality of life was assessed by asking, “In general, how would you rate your quality of life?” on a four point scale. Health change in last year was measured by the question, “Compared to one year ago, how would you rate your health now?” on a 5-point scale. Health changes were then recategorized into three groups. Cardiovascular and pulmonary symptoms.—We used the Review of Systems to assess cardiovascular and pulmonary symptoms among our participants (19). Review of Systems is a list of questions organized by organ systems used by health care providers for eliciting a medical history from a patient. We assessed seven cardiovascular system symptoms and six pulmonary system symptoms (please see Table 1). Data Analysis Descriptive univariate statistics were used to summarize sociodemographic characteristics and the prevalence of cardiovascular and pulmonary symptoms. In bivariate analyses, chi-squared tests were used to compare sociodemographic characteristics between persons with and without cardiovascular symptoms, and between persons with and without pulmonary symptoms. The prevalence of each cardiovascular symptom and pulmonary symptom was calculated. Pearson correlation coefficients were used to examine the correlations between sociodemographic variables and cardiovascular and pulmonary symptoms. All statistical analyses were conducted using SAS, Version 9.2 (SAS Institute Inc., Cary, NC).
Prevalence of Cardiopulmonary Symptoms Among Chinese Older Adults
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Table 1. Characteristics of Study Participants by Cardiovascular and Pulmonary Symptoms Any Cardiovascular Symptom (N = 999) Age groups, n (%) 60–64 65–69 70–74 75–79 80–84 85 and older Sex, n (%) Male Female Education level, y (%) 0 1–6 7–12 13–16 17+ Income, n (%) $0–$4,999
No Cardiovascular Symptom (N = 2,160)
χ2, df (p value)
Any Pulmonary Symptom (N = 1,333)
No Pulmonary Symptom (N = 1,826)
χ2, df (p value)
184 (18.4) 183 (18.3) 199 (19.9) 192 (19.2) 141 (14.1) 100 (10.0)
497 (23.0) 458 (21.2) 407 (18.9) 363 (16.8) 259 (12.0) 175 (8.1)
17.4, 5 p < .01
251 (18.8) 251 (18.8) 258 (19.4) 252 (18.9) 182 (13.4) 139 (10.4)
430 (23.6) 392 (21.5) 348 (19.1) 305 (16.7) 214 (11.7) 137 (7.5)
22.6, 5 p < .001
375 (37.5) 624 (62.5)
953 (44.1) 1,207 (55.9)
45.7, 1 p < .001
555 (41.6) 778 (58.4)
742 (40.6) 1,084 (59.4)
0.3, 1 p = .57
−71 (7.2) 359 (36.3) 324 (32.8) 208 (21.0) 27 (2.7)
−124 (5.8) 820 (38.1) 779 (36.2) 368 (17.1) 59 (2.7)
10.8, 4 p < .05
87 (6.6) 520 (39.3) 454 (34.3) 234 (17.7) 27 (2.0)
108 (5.9) 659 (36.3) 649 (35.7) 342 (18.8) 60 (3.3)
7.7, 4 p = .10
370 (37.3)
671 (31.5)
22.9, 4 p < .001
449 (33.9)
592 (32.9)
21.1, 4 p < .001
509 (51.4) 83 (8.4) 14 (1.4) 15 (1.5)
1,108 (52.0) 227 (10.7) 54 (2.5) 72 (3.4)
717 (54.1) 115 (8.7) 24 (1.8) 20 (1.5)
900 (50.1) 195 (10.9) 44 (2.5) 67 (3.7)
673 (67.8) 21 (2.1) 31 (3.1) 267 (26.9)
1,563 (72.9) 36(1.68) 43 (2.0) 502 (23.4)
10.1, 3 p < .05
911 (68.7) 21 (1.6) 37 (2.8) 357 (26.9)
1,326 (73.2) 36 (2.0) 37 (2.0) 412 (22.8)
10.1, 3 p = .02
46 (4.6) 415 (41.6) 536 (53.8)
82 (3.8) 856 (39.7) 1,216 (56.5)
2.6, 2 p = .28
55 (4.1) 532 (40.0) 742 (55.8)
73 (4.0) 739 (40.6) 1,010 (55.4)
0.1, 2 p = .95
222 (22.2) 422 (42.2) 147 (14.7) 208 (20.8)
457 (21.2) 896 (41.5) 333 (15.4) 473 (21.9)
1.0, 3 p = .79
301 (22.6) 552 (41.4) 195 (14.6) 285 (21.4)
378 (20.7) 766 (42.0) 285 (15.6) 396 (21.7)
1.8, 3 p = .61
937 (93.7) 62 (6.2)
1,993 (92.3) 167 (7.7)
4.0, 1 p < .05
1,247 (93.6) 86 (6.5)
1,684 (92.2) 142 (7.8)
2.0, 1 p = .16
277 (27.9)
568 (26.4)
7.9, 3 p < .05
328 (24.8)
512 (28.1)
9, 3 p < .05
11–20 320 (32.2) 21–30 245 (24.7) 31+ 152 (15.3) Years in the community 0–10 625 (62.9) 11–20 233 (23.5) 21–30 93 (9.4) 31+ 42 (4.2) Overall health status, n (%) Very good 14 (1.4) Good 174 (17.4) Fair 476 (47.7) Poor 335 (33.5) Quality of life, n (%) Very good 59 (5.9) Good 400 (12.7) Fair 498 (49.9) Poor 41(4.1)
644 (30.0) 522 (24.3) 416 (19.4)
444 (33.5) 320 (24.2) 233 (17.6)
525 (28.9) 447 (24.6) 335 (18.4)
$5,000–$ 9,999 $10,000–$14,999 $15,000–$19,999 Over $20,000 Marital status, n (%) Married Separated Divorced Widowed Number of children (%) 0 1–2 3+ Living arrangement, n (%) Living alone With 1 person With 2–3 persons With 4 or more Country of origin China Other Years in United States 0–10
1,188 (55.1) 505 (23.4) 295 (13.7) 168 (7.8)
30.5, 3 p < .001
791 (59.7) 329 (24.8) 141 (10.6) 65 (4.9)
1,020 (56.0) 411 (22.6) 247 (13.6) 145 (8.0)
19.5, 3 p < .001
126 (5.8) 923 (42.7) 844 (39.1) 267(12.4)
329, 3 p < .001
30 (2.3) 324 (24.3) 619 (46.4) 360 (27.0)
110 (6.0) 773 (42.3) 701 (38.4) 242 (13.3)
185.3, 3 p < .001
157 (7.3) 983 (45.5) 959 (44.4) 60 (2.8)
14.7, 3 p < .01
81 (6.1) 543 (40.8) 661 (49.6) 47 (3.5)
135 (7.4) 840 (46.0) 796 (43.6) 54 (3.0)
13.6, 3 p < .01
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Dong et al.
Table 1. Continued Any Cardiovascular Symptom (N = 999) Health status changes over the last year, n (%) Improved 80 (8.0) Same Worsened
312 (31.3) 606 (60.7)
No Cardiovascular Symptom (N = 2,160)
χ2, df (p value)
197 (9.1) 1,223 (56.7) 739 (34.2)
Results Sample Characteristics Of the 3,159 participants enrolled in the PINE study, 58.9% were women, 71.3% were married, and 85.1% had an annual income below $10,000. The mean age of participants was 72.8 (SD = 8.3) and the mean years of education completed was 8.7 (SD = 5.1). Approximately 31.6% of participants reported having at least one cardiovascular symptom and 42.2% reported having at least one pulmonary symptom (Table 1). Moreover, 22.1% of Chinese older adults reported both cardiovascular and pulmonary symptoms while 48.2% reported neither cardiovascular nor pulmonary symptoms. Prevalence of Cardiovascular and Pulmonary Symptoms With respect to cardiovascular symptoms, chest pain or discomfort (16.3%) was most commonly reported by participants, followed by shortness of breath with exertion (12.9%) and palpitations (10.5%). With respect to pulmonary system symptoms, cough (27.4%) was the most common symptom, followed by sputum (22.7%) and shortness of breath at rest (15.1%) (Table 2). Reports of cardiovascular and pulmonary symptoms increased with age. Whereas 27.0% of older adults aged 60–64 reported having cardiovascular symptoms in the last year, more than one in three older adults aged 85 and older (36.2%) reported having cardiovascular symptoms (Table 3). A similar pattern with respect to age was observed in pulmonary symptoms. Having any pulmonary symptom in the last year increased from 36.9% among older adults aged 60–64 to 50.4% among older adults aged 85 and older. Overall, women were more likely to report cardiovascular symptoms than men (33.5% vs 28.9%). In contrast, women were as likely as men to report pulmonary symptoms (41.8% vs 42.8%). The prevalence of pulmonary symptoms was lower among older adults with higher educational levels. Overall, cardiovascular symptoms and pulmonary symptoms were less likely to be reported by participants with very good self-reported health (10% and 21.4%) compared with older adults with poor self-reported health (55.4% and 59.8%), respectively. In addition, cardiovascular symptoms and pulmonary symptoms were less likely to be reported by older adults with self-reported very good quality of life (27.3% and 37.5%) compared with older adults with poor quality of life (40.6% and 46.5%).
203.8, 2 p < .001
Any Pulmonary Symptom (N = 1,333)
No Pulmonary Symptom (N = 1,826)
108 (8.1)
169 (9.3)
486 (36.5) 738 (55.4)
1,049 (57.5) 607 (33.3)
χ2, df (p value) 159.6, 2 p < .001
Table 2. Presence of Cardiovascular and Pulmonary Symptoms Cardiovascular Symptoms Chest pain or discomfort Tightness Palpitations Shortness of breath with activity Difficulty breathing lying down (orthopnea) Swelling (edema) Sudden awakening from sleep w/ shortness of breath (paroxysmal nocturnal dyspnea) Pulmonary symptoms Cough (dry or wet, productive) Sputum (color or amount) Coughing up blood Shortness of breath at rest Wheezing Painful breathing
N
%
514 190 332 408 140 88 97
16.3 6.0 10.5 12.9 4.4 2.8 3.1
864 716 14 477 287 74
27.4 22.7 0.4 15.1 9.1 2.3
Correlations The prevalence of cardiovascular symptoms was significantly correlated with age (r = .07, p < .001), gender (r = .06, p < .001), overall health status (r = −.32, p < .001), quality of life (r = −.07, p < .001), health changes (r = −.23, p < .001), income (r = −.08, p < .001), marital status (r = −.05, p < .01), and years residing in the United Status (r = −.05, p < .01) and community (r = −.10, p < .001). Similarly, the prevalence of pulmonary symptoms was significantly correlated with age (r = .08, p < .001), overall health status (r = −.24, p < .001), quality of life (r = −.06, p < .001), health changes (r = −.19, p < .001), education (r = −.05, p < .01), income (r = −.07, p < .001), marital status (r = −.05, p < .01), and years in the community (r = −.07, p < .001) (Table 4). The prevalence of Chinese older adults with both cardiovascular and pulmonary symptoms is positively correlated with age (r = .10, p < .001), negatively correlated with overall health status(r = −.29, p < .001), life quality (r = −.05, p < .01), and health change over last year(r = −.21, p < .001). Discussion As the first population-based study of cardiovascular and pulmonary symptoms among U.S. Chinese older adults, we found that U.S. Chinese older adults commonly experienced cardiovascular symptoms and pulmonary symptoms. Chest pain and shortness of breath with activity were the most prevalent cardiovascular symptoms. Cough and sputum were the most commonly presented pulmonary
Very good (N = 216) 59 (27.3) 81 (37.5)
Improved (N = 277) 80 (28.9) 108 (39.0)
Quality of life Cardiovascular, N (%) Pulmonary, N (%)
Health changes Cardiovascular, N (%) Pulmonary, N (%)
Good (N = 1,383) 400 (28.9) 543 (39.3)
Good (N = 1,097) 174 (15.9) 324 (29.5)
$5,000–$9,999 (N = 1,617) 509 (31.5) 717 (44.3)
1–6 (N = 1,179) 359 (30.4) 520 (44.1)
Female (N = 1,862) 555 (42.8) 555 (42.8)
Same (N = 1,535) 312 (20.3) 486 (31.7)
Fair (N = 1,457) 498 (34.2) 661 (45.4)
Fair (N = 1,320) 476 (36.0) 619 (46.9)
$10,000–$14,999 (N = 310) 83 (26.8) 115 (37.1)
7–12 (N = 1,103) 324 (29.4) 454 (41.2)
70–74 (N = 606) 199 (32.8) 258 (42.6)
1.00 0.01 0.22 −0.38*** 0.02 −0.10*** −0.11*** −0.08*** −0.06*** −0.09*** −0.02 0.001 −0.05**
Edu
1.00 −0.03 0.00 0.16*** 0.35*** 0.24*** −0.20*** −0.12*** −0.08*** −0.05** −0.08*** −0.07***
Income
1.00 −0.13*** 0.24*** −0.20*** −0.13*** 0.05** −0.05** 0.03 −0.07*** −0.05** −0.05**
MS
1.00 −0.07*** 0.15*** 0.10*** 0.04* 0.00 −0.04* 0.02 −0.02 0.02
Children
1.00 −0.13*** 0.05*** −0.05** 0.00 0.01 −0.01 −0.01 −0.01
Living
1.00 0.66*** −0.20*** 0.01 0.00 0.04* −0.05** 0.00
Years in U.S.
1.00 −0.15*** −0.05*** 0.02 −0.03 −0.10*** −0.07***
Years in Com
1.00 0.03 0.04* 0.00 0.03 0.03
Origin
1.00 0.32*** 0.35*** −0.32*** −0.24***
OHS
Poor (N = 101) 41 (40.6) 47 (46.5)
Poor (N = 602) 335 (55.4) 360 (59.8)
1.00 0.15*** −0.07*** −0.06***
QOL
1.00 −0.23*** −0.19***
HC
$20,000 + (N = 87) 15 (17.2) 20 (23.0)
17 + (N = 87) 27 (31.0) 27 (31.0)
80–84 (N = 396) 141 (35.6) 182 (46.0)
Worsened (N = 1,345) 606 (45.1) 738 (54.9)
$15,000–$19,999 (N = 68) 14 (20.6) 24 (35.3)
13–16 (N = 576) 208 (36.1) 234 (40.6)
75–79 (N = 557) 192 (34.5) 252 (45.2)
1.00 0.38***
CDV
1.00
PUL
85 + (N = 276) 100 (36.2) 139 (50.4)
Prevalence of Cardiopulmonary Symptoms Among Chinese Older Adults
Notes: CDV = cardiovascular symptoms; Children = number of children; Edu = education; HC = health changes over the last year; Living = living arrangement; MS = marital status; OHS = overall health status; Origin = country of origin; PUL = pulmonary symptoms; QOL = quality of life; Years in Com = years in the community; Years in U.S. = Years in the United States. *p < .05; **p < .01; ***p < .001.
1.00 −0.21*** 0.00 −0.32*** 0.09*** −0.07*** 0.03 0.02 −0.01 0.06** −0.05** 0.03 0.06*** −0.01
Sex
Very good (N = 140) 14 (10) 30 (21.4)
Overall health status Cardiovascular, N (%) Pulmonary, N (%)
Age
$0–$4,999 (N = 1,041) 370 (35.5) 449 (43.1)
Income Cardiovascular, N (%) Pulmonary, N (%)
1.00 0.01 −0.12*** 0.05** −0.33*** 0.32*** −0.35*** 0.35*** 0.23*** 0.04* 0.08*** −0.06*** 0.11*** 0.07*** 0.08***
0 (N = 195) 71 (36.4) 87 (44.6)
Education Cardiovascular, N (%) Pulmonary, N (%)
Age Sex Edu Income MS Children Living Years in United States Years in Com Origin OHS QOL HC CDV PUL
Male (N = 1,297) 375 (28.9) 555 (42.8)
Sex Cardiovascular, N (%) Pulmonary, N (%)
65–69 (N = 643) 183 (28.5) 251 (39.0)
Table 4. Correlations Between Sociodemographic Characteristics, Cardiovascular, and Pulmonary Symptoms
60–64 (N = 681) 184 (27.0) 251 (36.9)
Age Cardiovascular, N (%) Pulmonary, N (%)
Table 3. Prevalence of Pulmonary and Cardiovascular Symptoms by Sociodemographic Characteristics
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Dong et al.
symptoms. Participants were more likely to report cardiovascular or pulmonary symptoms if they were older, had lower income, resided fewer years in the community, had poorer self-perceived health status and quality of life, and perceived worsened health change over the last year. Our study indicates that cardiovascular and pulmonary symptoms were more prevalent among older participants. Prior studies have illustrated that aging of the human cardiovascular system plays a dominant role in the deterioration of cardiovascular system function (20), and that the changes in bones and muscles that accompany aging can result in lower levels of pulmonary capacity. In addition to the biological changes that accompany aging, age-related behavioral changes in lifestyles might also influence the function of cardiovascular and pulmonary system. Furthermore, our additional analysis showed a greater proportion of participants reported both cardiovascular and pulmonary symptoms in the older age group Prior studies often estimate a limited range of symptoms, such as coughing, pain, shortness of breath, and wheezing (7,21). However, even with these limited symptoms, variations in study design and sample composition make comparisons of these limited symptoms difficult. For instance, in our study, the prevalence of shortness of breath was 12.9% (with activity) and 15.1% (at rest). One study reported that the prevalence of shortness of breath was 35% among older adults who were diagnosed with chronic conditions) (7) while another study on a younger population aged 34–67 reported the prevalence to be 20.8% (22). In all, our study provided an overall estimate of clinical cardiopulmonary symptoms among U.S. Chinese older adults. Our study observed that compared with men, U.S. Chinese women were more likely to report cardiovascular symptoms but equally as likely to report pulmonary symptoms. Our findings offer some new insights on the traditional belief that men are of higher cardiovascular risk than women (23). Our findings are supported by recent U.S. national statistics demonstrating that older women have equaled and have even outnumbered men in the prevalence of cardiovascular diseases in the age group 60–79 (70.2% vs 70.9%) and the age group 80 and older (83.0% vs 87.1%) (9). With respect to pulmonary symptoms, although women are believed to have higher pulmonary risks (24), our findings suggest that women and men are similar in reporting pulmonary symptoms. The disparities between the prevalence of symptoms identified in our study and the prevalence of diagnosed cardiovascular and pulmonary conditions points to the need to pay special attention to potential gender differences in expressing and reporting symptoms. Our research suggests that U.S. Chinese older adults with higher educational level are less likely to experience pulmonary symptoms, which is in line with prior studies on education and risk of pulmonary diseases (25). Some potential contributing factors may be that better-educated older adults are more likely to engage in cognitively stimulating activities, have better economic circumstances, eat healthier, spend more time participating in physical activities, and
are less stressed. However, inconsistent with previous study (26), similar trend was not found between prevalence of cardiovascular symptoms and education. Participants with 13–16 years of education fall out the trend and displayed a relatively higher prevalence of cardiovascular symptoms. In addition, our study found that cardiovascular and pulmonary symptoms were less prevalent among higher income participants, which was supported by prior research (24,25). Specifically, while prevalence of cardiovascular symptoms displayed a gradual decreasing trend with the increase of income, an annual income level of $10,000 may be the threshold before a decrease in prevalence of reported pulmonary symptoms. Our study reveals that a larger proportion of Chinese older adults report cardiovascular and pulmonary symptoms if they perceive themselves with poorer health status and poorer quality of life, which is consistent with prior studies (1,7). Moreover, participants with both cardiovascular and pulmonary symptoms tend to perceive themselves with poorer health status and poorer quality of life. Specifically, one prior study found that shortness of breath was associated with lower selfrated health and quality of life, an association that was maintained while multiple symptoms were concurrently examined (1). Our findings may indicate a series of psychophysical changes along with the presence of symptoms: experiencing cardiovascular and pulmonary symptoms may negatively influence the psychological well-being of older adults, while the psychological burden can reversely add to the frequency and severity of cardiovascular and pulmonary symptoms. The findings of this study should be interpreted with limitations. First, this study was representative of Chinese older adults in the Greater Chicago area, so generalizing our findings to other Chinese populations in the United States or in Asia should be done with caution. Additional studies are needed to explore the risk factors and impact of cardiovascular and pulmonary symptoms in diverse Chinese populations. In addition, recall bias is likely, therefore symptoms may be likely underreported. Moreover, the cross-sectional design limits our assessment of the development of symptoms and we are not able to delineate the mechanisms of these symptoms. Furthermore, we were unable to assess the severity or frequency of symptoms from the data collected, as well as those who experience multiple symptoms. Future studies applying mixed research strategies and longitudinal designs are needed to better understand the cardiovascular and pulmonary risks. Nonetheless, this study has wide implications for researchers and practitioners. First, this study points to the need for improving investigations on cardiovascular and pulmonary symptoms among Chinese older adults. Interdisciplinary teams composed of research experts in physiology, biomedicine, pathology, and epidemiology, and clinical practitioners are needed to understand how those symptoms may influence the health and well-being trajectories of Chinese older adults. Health care professionals should pay special attention in screening subgroups of Chinese older adults who may have higher prevalence of cardiovascular and
Prevalence of Cardiopulmonary Symptoms Among Chinese Older Adults
pulmonary symptoms. These include the oldest old, women, low income, and the new immigrants to the community. It is important to raise community awareness to cardiovascular and pulmonary symptoms as early signs for detecting cardiopulmonary disorders as well as symptoms that are the results of existing cardiopulmonary disorders. Social services providers should design culturally and linguistically appropriate prevention strategies tailored to the needs of older adults. In light of the traditional tabooed cultural belief of talking about the potential risks of developing diseases, culturally sensitive interventions and education are needed to alleviate stress and anxiety associated with self-reporting early symptoms. Our findings advocate for changes in the practice of preventative care and for better access to health care resources for low-resource communities. Conclusion Our report indicates that cardiovascular and pulmonary symptoms are common among U.S Chinese older adults in the Greater Chicago area. Our findings call for further investigations on several subgroups of Chinese older adults who reported higher prevalence of symptoms, including the oldest old, those with low income, and with lower educational attainment. Future longitudinal studies are needed to improve our understanding of the outcomes and functional mechanisms underlying cardiovascular and pulmonary symptoms among Chinese aging populations. Funding Dr. X.D. and M.S. were supported by National Institute on Aging grant (R01 AG042318, R01 MD006173, R01 CA163830, R34MH100443, R34MH100393, P20CA165588, R24MD001650, and RC4 AG039085); Paul B. Beeson Award in Aging; The Starr Foundation; American Federation for Aging Research; John A. Hartford Foundation; and The Atlantic Philanthropies. Acknowledgments We are grateful to Community Advisory Board members for their continued effort in this project. Particular thanks are extended to Bernie Wong, Vivian Xu, Yicklun Mo with Chinese American Service League (CASL), Dr. David Lee with Illinois College of Optometry, David Wu with Pui Tak Center, Dr. Hong Liu with Midwest Asian Health Association, Dr. Margaret Dolan with John H. Stroger Jr. Hospital, Mary Jane Welch with Rush University Medical Center, Florence Lei with CASL Pine Tree Council, Julia Wong with CASL Senior Housing, Dr. Jing Zhang with Asian Human Services, Marta Pereya with Coalition of Limited English Speaking Elderly, Mona El-Shamaa with Asian Health Coalition. References 1. Walke LM, Byers AL, Gallo WT, Endrass J, Fried TR. The association of symptoms with health outcomes in chronically ill adults. J Pain Symptom Manage. 2007;33:58–66. 2. Walke LM, Byers AL, Tinetti ME, Dubin JA, McCorkle R, Fried TR. Range and severity of symptoms over time among older adults with chronic obstructive pulmonary disease and heart failure. Arch Intern Med. 2007;167:2503–2508. 3. Heron M. National Vital Statistics Reports: 2010 Leading Causes for Death. U.S. Department of Health and human services, Centers for Disease Control and Prevention; 2013. Report No.: 6. 4. Janssens JP, Pache JC, Nicod LP. Physiological changes in respiratory function associated with ageing. Eur Respir J. 1999;13:197–205.
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5. Fried TR, Tinetti ME, Iannone L, O’Leary JR, Towle V, Van Ness PH. Health outcome prioritization as a tool for decision making among older persons with multiple chronic conditions. Arch Intern Med. 2011;171:1854–1856. 6. Solano JP, Gomes B, Higginson IJ. A comparison of symptom prevalence in far advanced cancer, AIDS, heart disease, chronic obstructive pulmonary disease and renal disease. J Pain Symptom Manage. 2006;31:58–69. 7. Walke LM, Gallo WT, Tinetti ME, Fried TR. The burden of symptoms among community-dwelling older persons with advanced chronic disease. Arch Intern Med. 2004;164:2321–2324. 8. Morita T, Tsunoda J, Inoue S, Chihara S. Survival prediction of terminally ill cancer patients by clinical symptoms: development of a simple indicator. Jpn J Clin Oncol. 1999;29:156–159. 9. Go AS, Mozaffarian D, Roger VL, et al.; American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics–2013 update: a report from the American Heart Association. Circulation. 2013;127:e6–e245. 10. Holland AT, Palaniappan LP. Problems with the collection and interpretation of Asian-American health data: omission, aggregation, and extrapolation. Ann Epidemiol. 2012;22:397–405. 11. US Census Bureau U. American Community Survey; 2010. 12. Dong X, Chang E, Wong E, Wong B, Skarupski KA, Simon MA. Assessing the health needs of Chinese older adults: findings from a community-based participatory research study in Chicago’s Chinatown. J Aging Res. 2010;2010:12. doi:10.4061/2010/124246. 13. Dong X, Simon MA, Odwazny R, Gorbien M. Depression and elder abuse and neglect among a community-dwelling Chinese elderly population. J Elder Abuse Negl. 2008;20:25–41. 14. Dong X, Simon MA, Gorbien M, Percak J, Golden R. Loneliness in older Chinese adults: a risk factor for elder mistreatment. J Am Geriatr Soc. 2007;55:1831–1835. 15. Dong X, Chang E-S, Wong E, Simon M. A qualitative study of filial piety among community dwelling, Chinese, older adults. J Intergener Relationships. 2012;10(2):131–146. 16. Dong X, Wong E, Simon MA. Study design and implementation of the PINE Study. J Aging Health. 2014;0898264314526620. 17. Dong X, Chang E-S, Wong E, Simon M. Working with culture: lessons learned from a community-engaged project in a Chinese aging population. Aging Health. 2011;7(4):529–537. 18. Simon M, Chang E, Rajan K, Welch M, Dong X. Demographic characteristics of U.S Chinese older adults in the greater Chicago area. J Aging Health. 2014;26(7):1100–1115. doi:10.1177/0898264314543472. 19. Fortinm AH, Dwamena FC, Smith RC. Chapter 4. Clinician-Centered Interviewing; 2012. 20. Kitzman DW, Taffet G. Chapter 74. Effects of aging on cardiovascular structure and function. In: Halter JB, Ouslander JG, Tinetti ME, Studenski S, High KP, Asthana S, eds. Hazzard’s Geriatric Medicine and Gerontology. 6th ed. 2009. 21. Tinetti ME, McAvay G, Chang SS, et al. Effect of chronic diseaserelated symptoms and impairments on universal health outcomes in older adults. J Am Geriatr Soc. 2011;59:1618–1627. 22. Dean G, Lee PN, Todd GF, Wicken AJ, Sparks DN. Factors related to respiratory and cardiovascular symptoms in the United Kingdom. J Epidemiol Community Health. 1978;32:86–96. 23. Barrett-Connor E. Sex differences in coronary heart disease. Why are women so superior? The 1995 Ancel Keys Lecture. Circulation. 1997;95:252–264. 24. Harms CA. Does gender affect pulmonary function and exercise capacity? Respir Physiol Neurobiol. 2006;151:124–131. 25. Prescott E, Vestbo J. Socioeconomic status and chronic obstructive pulmonary disease. Thorax. 1999;54:737–741. 26. Winkleby MA, Jatulis DE, Frank E, Fortmann SP. Socioeconomic status and health: how education, income, and occupation contribute to risk factors for cardiovascular disease. Am J Public Health. 1992;82:816–820.
