Aging, health risks, and cumulative disability

BACKGROUND: Persons with lower health risks tend to live longer than those with higher health risks, but there has been concern that greater longevity may bring with it greater disability. We performed a longitudinal study to determine whether persons with lower potentially modifiable health risks have more or less cumulative disability. METHODS: We studied 1741 university alumni who were surveyed first in 1962 (average age, 43 years) and then annually starting in 1986. Strata of high, moderate, and low risk were defined on the basis of smoking, body-mass index, and exercise patterns. Cumulative disability was determined with a health-assessment questionnaire and scored on a scale of 0 to 3. Cumulative disability from 1986 to 1994 (average age in 1994, 75 years) or death was the measure of lifetime disability. RESULTS: Persons with high health risks in 1962 or 1986 had twice the cumulative disability of those with low health risks (disability index, 1.02 vs. 0.49; P<0.001). The results were consistent among survivors, subjects who died, men, and women and for both the last year and the last two years of observation. The onset of disability was postponed by more than five years in the low-risk group as compared with the high-risk group. The disability index for the low-risk subjects who died was half that for the high-risk subjects in the last one or two years of observation. CONCLUSIONS: Smoking, body-mass index, and exercise patterns in midlife and late adulthood are predictors of subsequent disability. Not only do persons with better health habits survive longer, but in such persons, disability is postponed and compressed into fewer years at the end of life.     

Quantifying the burden of disease: the technical basis for disability-adjusted life years

Detailed assumptions used in constructing a new indicator of the burden of disease, the disability-adjusted life year (DALY), are presented. Four key social choices in any indicator of the burden of disease are carefully reviewed. First, the advantages and disadvantages of various methods of calculating the duration of life lost due to a death at each age are discussed. DALYs use a standard expected-life lost based on model life-table West Level 26. Second, the value of time lived at different ages is captured in DALYs using an exponential function which reflects the dependence of the young and the elderly on adults. Third, the time lived with a disability is made comparable with the time lost due to premature mortality by defining six classes of disability severity. Assigned to each class is a severity weight between 0 and 1. Finally, a three percent discount rate is used in the calculation of DALYs. The formula for calculating DALYs based on these assumptions is provided.     

Mortality in geriatric patients in the Hospital General of Mexico

In order to define the main diseases of the elderly and a possible changes of mortality causes at Hospital General of Mexico, SSA, the authors studied 586 autopsy reports of individuals over sixty years old, deceased between 1960 and 1965 and of 625 individuals of similar characteristics deceased between 1981 and 1985. The analysis of diseases showed qualitative and quantitative changes in the ten principal causes of death at each period: some of the most frequent diseases in the 60's, for instance, amebiasis, were not included among the then principal causes of death in the 80's. On the other hand, malignant neoplasms persisted as one of the principal death causes in both periods, but the most frequent carcinoma in the 60's, gastric carcinoma, was substituted in the 80's by bronchogenic carcinoma. This study suggests that great technical and sanitary interventions are necessary to promote health of third age persons, an increasing but poorly protected population in our country.     

The role of the pedunculopontine tegmental nucleus in relation to conditioned motor performance in the cat. II. Effects of reversible inactivation by intracerebral microinjections

OBJECTIVE: To describe lower-extremity functioning in community-dwelling older Mexican Americans and to examine its relationship with medical problems. DESIGN: Cross-sectional analyses of survey and performance-based data obtained in a population-based study employing area probability sampling. SETTING: Households within selected census tracts of five Southwestern states: Arizona, California, Colorado, New Mexico, and Texas. PARTICIPANTS: A total of 2873 Mexican Americans aged 65 years and older. MEASUREMENTS: A multidimensional questionnaire assessing demographic, sociocultural, and health variables. Standardized tests of lower-extremity physical functioning included measures of standing balance, repeated chair stands, walking, and an overall summary measure. RESULTS: Regression analyses revealed that being more than age 75 and female, having arthritis diabetes, visual impairments, or being obese or underweight were all significantly associated with performance on both individual and summary tests of lower-extremity functioning. In separate regression analyses, the total number of medical conditions was also associated with performance. CONCLUSIONS: The likelihood of predicting performance or inability to complete tests of lower-extremity functioning was greatest for those aged 80 and older, those with arthritis or diabetes, and those with three or more medical conditions. Because of the high prevalence of diabetes in Mexican Americans, documentation of the association of diabetes with performance-based tests of lower-extremity functioning may help guide early interventions targeted to prevent progression to more severe limitations or disability.     

Impact of chronic diseases on functional limitations in elderly Chinese aged 70 years and over: a cross-sectional and longitudinal survey

OBJECTIVE: To examine the association of some common medical conditions with functional limitation in elderly Chinese aged 70 years and over, to estimate the percentage of disability attributable to individual diseases, and to attempt to identify predisposing factors by documenting the development of functional limitation over an 18-month period in those subjects with a particular disease who were independent initially. SUBJECTS AND METHODS: The cross-sectional data set consisted of 2,032 (999 M, 1,033 F) subjects aged 70 years and over recruited by random sampling (stratified by age and sex) of all recipients of old-age and disability allowance, which covers over 90% of the elderly population. Information regarding medical condition and functional assessment of ten basic activities of daily living using the Barthel Index were obtained by personal interviews and physical assessment of the respondents at their places of residence. The longitudinal data set consisted of 1,334 subjects with no functional limitation at baseline who were alive after 18 months. Functional status was reassessed. RESULTS: After adjusting for age and sex, diseases associated with severe functional limitation (Barthel Index < 15) were dementia, stroke, Parkinson's disease, and fractures. Those associated with mild to moderate functional limitation (Barthel Index 15-19) were the same, with the addition of asthma and diabetes mellitus. The attributable fraction for severe limitation was highest for stroke, dementia, and fractures. Stroke and arthritis were identified as diseases predisposing to mild to moderate functional limitation over an 18-month period among those subjects who were independent initially. CONCLUSION: Stroke, dementia, and fractures were the main chronic diseases associated with severe functional limitation in elderly Hong Kong Chinese. Attempts to reduce the disability burden in this population should target these diseases.     

Frontopolar ictal epileptiform discharges on scalp electroencephalogram in temporal lobe epilepsy

OBJECTIVE: To determine the prevalence of the smoking habit among Mexican physicians as well as some of their attitudes and information on specific issues concerning smoking. MATERIAL AND METHODS: In 1993, a survey was carried out among 3,568 physicians of the three major official health care institutions in Mexico City. A questionnaire designed for The Mexican National Survey of Addictions (ENA 1993) was used. Prevalence of cigarette smoking, age of onset, number of cigarettes per day; also information and attitudes concerning smoking were assessed. RESULTS: The mean age was 37, 66% were males. Of the 3,488 (98%) surveyed, 26.9% were smokers (62% daily), 20.6% were ex-smokers and 52.5% non-smokers. There were differences related to age and sex (p < 0.05). Of daily smokers, 36% smoked between 1 and 5 cigarettes. There was a significant trend among ex-smokers that linked the time they had ceased smoking with the fear to start smoking again. Physicians were well informed of the relationship between cigarette smoking and lung cancer. Over 80% considered tobacco an addictive drug but only 65% were in favor of banning smoking from their workplaces and over 10% were not aware that it is forbidden to smoke inside health care facilities. CONCLUSIONS: These results differ from other studies that find the prevalence of smoking among physicians lower than in the general population. Our study revealed a greater prevalence of the smoking habit among female physicians and the number of cigarettes smoked per day was greater than in the general population regardless of sex.     

Clinical features, molecular genetics, and pathophysiology of dominant optic atrophy

CONTEXT: Russian life expectancy has fallen sharply in the 1990s, but the impact of the major causes of death on that decline has not been measured. OBJECTIVE: To assess the contribution of selected causes of death to the dramatic decline in life expectancy in Russia in the years following the breakup of the Soviet Union. DESIGN: Mortality and natality data from the vital statistics systems of Russia and the United States. SETTING: Russia, 1990-1994. POPULATION: Entire population of Russia. MAIN OUTCOME VARIABLES: Mortality rates, life expectancy, and contribution to change in life expectancy. METHODS: Application of standard life-table methods to calculate life expectancy by year, and a partitioning method to assess the contribution of specific causes of death and age groups to the overall decline in life expectancy. United States data presented for comparative purposes. RESULTS: Age-adjusted mortality in Russia rose by almost 33% between 1990 and 1994. During that period, life expectancy for Russian men and women declined dramatically from 63.8 and 74.4 years to 57.7 and 71.2 years, respectively, while in the United States, life expectancy increased for both men and women from 71.8 and 78.8 years to 72.4 and 79.0 years, respectively. More than 75% of the decline in life expectancy was due to increased mortality rates for ages 25 to 64 years. Overall, cardiovascular diseases (heart disease and stroke) and injuries accounted for 65% of the decline in life expectancy while infectious diseases, including pneumonia and influenza, accounted for 5.8%, chronic liver diseases and cirrhosis for 2.4%, other alcohol-related causes for 9.6%, and cancer for 0.7%. Increases in cardiovascular mortality accounted for 41.6% of the decline in life expectancy for women and 33.4% for men, while increases in mortality from injuries (eg, falls, occupational injuries, motor vehicle crashes, suicides, and homicides) accounted for 32.8% of the decline in life expectancy for men and 21.8% for women. CONCLUSION: The striking rise in Russian mortality is beyond the peacetime experience of industrialized countries, with a 5-year decline in life expectancy in 4 years' time. Many factors appear to be operating simultaneously, including economic and social instability, high rates of tobacco and alcohol consumption, poor nutrition, depression, and deterioration of the health care system. Problems in data quality and reporting appear unable to account for these findings. These results clearly demonstrate that major declines in health and life expectancy can take place rapidly.     

Epidemiological aspects of ageing

A major societal challenge is to improve quality of life and prevent or reduce disability and dependency in an ageing population. Increasing age is associated with increasing risk of disability and loss of independence, due to functional impairments such as loss of mobility, hearing and vision; a major issue must be how far disability can be prevented. Ageing is associated with loss of bone tissue, reduction in muscle mass, reduced respiratory function, decline in cognitive function, rise in blood pressure and macular degeneration which predispose to disabling conditions such as osteoporosis, heart disease, dementia and blindness. However, there are considerable variations in different communities in terms of the rate of age-related decline. Large geographic and secular variations in the age-adjusted incidence of major chronic diseases such as stroke, hip fracture, coronary heart disease, cancer, visual loss from cataract, glaucoma and macular degeneration suggest strong environmental determinants in diet, physical activity and smoking habit. The evidence suggests that a substantial proportion of chronic disabling conditions associated with ageing are preventable, or at least postponable and not an inevitable accompaniment of growing old. Postponement or prevention of these conditions may not only increase longevity, but, more importantly, reduce the period of illnesses such that the majority of older persons may live high-quality lives, free of disability, until very shortly before death. We need to understand better the factors influencing the onset of age-related disability in the population, so that we have appropriate strategies to maintain optimal health in an ageing population.     

The dynamics of dimensions of age-related disability 1982 to 1994 in the U.S. elderly population

Declines in chronic disability were observed in the National Long Term Care Survey (NLTCS) 1982 to 1994. We analyzed the 1982, 1984, 1989, and 1994 NLTCS to identify the dimensions of chronic disability from multivariate analyses of a rich battery of measures of the ability (or inability) to perform specific activities. Changes over time in the prevalence of individual disability dimensions can be tracked to evaluate the rate of age-related losses of specific functions, 1982-1994. Seven dimensions described changes in the age dependence of 27 activities of daily living, instrumental activities of daily living, and physical performance measures in community and institutional resident elderly individuals over the 12 year period. Adjusted for age, the healthiest dimension with the best physical function experienced the largest increase in prevalence (3.3%) implying a decline in age-related disability. Disability declines were correlated with reductions in select health conditions (e.g., dementia and circulatory disease) over the study period.     

The vestibular nerve: its course to the anterior and lateral ampullae

In order to assess the health status and risk of various diseases in the population of Guangzhou, the surveillance data of death in 1983-1994 in Guangzhou was analyzed by indicesas: year of potential life lost (YPLL), work year of lost (WYPLL) and valued year of potential life lost (VYPLL). It was indicated that both Chinese standardized mortality rates (CSMR) and Chinese standardized rates (CSYPLLR) had been declined from 448.2 x 10(-5) and 53.16/1000 to 398.6 x 10(-5) and 42.29/1000 during 1983-1994, respectively. It was suggested that the health status of inhabitants in Guangzhou had been gradually improved. Cancer lesion and poisoning, cardiovascular diseases rank top in CSYPLLR, were the most important diseases affecting life span of the inhabitants. Lesion and poisoning, infectious disease, psychotic disease, ranked the first in Chinese tandardized WYPLL rates (CSWYPLLR) and Chinese standardized VYPLL rates (CSVYPLLR), were important factors that periled the society labor force and economic development. By comparison of sex, both CSMR and CSYPLLR were higher in male than in female (u = 14.76, P < 0.01; u = 27.05, P < 0.01, respectively). Although both values of CSWYPLLR and CSVYPLLR were negative, they were still higher in male than in female. The zero-age-group was far more higher than all the other age groups in CSPLLR, CSWYPLLR and CSVYPLLR.     

Prevalence of human papillomavirus in squamous cell carcinoma of the head and neck determined by polymerase chain reaction and Southern blot hybridization: proposal for optimized diagnostic requirements

OBJECTIVE: To develop Canadian projections for the prevalence and numbers of people with arthritis and arthritis disability, overall and in major age groups. METHODS: Age and sex specific data from the 1991 General Social Survey and the 1994 National Population Health Survey on the prevalence of arthritis and arthritis disability were applied to population projections for Canada for every 5 years between 1991 and 2031. RESULTS: Between 1991 and 2031 we project that the prevalence of arthritis diagnosed by a health professional as a longterm condition in Canada will increase from 10.7 to 15.7%, an increase of 46.7%, and the number of people with arthritis will increase from 2.9 to 6.5 million, an increase of 124%. Comparable changes in prevalence and numbers of people with self-reported arthritis are 17.1% (4.7 million) to 23.6% (9.7 million). Most of the increase will be in the population aged 45+, and not until after 2020 will the comparative increase in the 65+ age group be greater than that for the 45-64 age group. Disability attributed to arthritis in the population aged 15+ is projected to increase from a prevalence of 2.3% (595,000) in 1991 to 3.3% (1.13 million) in 2031. CONCLUSION: There are large projected increases in both the prevalence and numbers of people with arthritis and arthritis related disability that, at least in the next 20 years, will be split between the older half of the working population and those aged 65 and older.     

Older workers in the construction industry: results of a routine health examination and a five year follow up

OBJECTIVE: To describe the health status of older construction workers and the occurrence of early retirement due to disability or of mortality within a five year follow up. METHODS: Firstly, a cross sectional study was performed among 4958 employees in the German construction industry, aged 40-64 years, who underwent standardised routine occupational health examinations in 1986-8. The study population included plumbers, carpenters, painters/varnishers, plasterers, unskilled workers, and white collar workers (control group). Job specific prevalence and age adjusted relative prevalence were calculated for hearing loss, abnormal findings at lung auscultation, reduced forced expiratory volume, increased diastolic blood pressure, abnormalities in the electrocardiogram, increased body mass index, hypercholesterolaemia, increased liver enzymes, abnormal findings in an examination of the musculoskeletal system, and abnormalities of the skin. Secondly, follow up for disability and all cause mortality was ascertained between 1992 and 1994 (mean follow up period = 4.5 y). Job specific crude rates were calculated for the occurrence of early retirement due to disability and for all cause mortality. With Cox's proportional hazards model, job specific relative risks, adjusted for age, nationality, and smoking were obtained. RESULTS: Compared with the white collar workers, a higher prevalence of hearing deficiencies, signs of obstructive lung diseases, increased body mass index, and musculoskeletal abnormalities were found among the construction workers at the baseline exam. During the follow up period, 141 men died and 341 men left the labour market due to disability. Compared with white collar workers, the construction workers showed a 3.5 to 8.4-fold increased rate of disability (P < 0.05 for all occupational groups) and a 1.2 to 2.1-fold increased all cause mortality (NS). CONCLUSIONS: This study shows the need and possibilities for further health promotion in workers employed in the construction industry, targeting both work related conditions and personal lifestyle factors. Rehabilitation measures should be enforced to limit the rate of disability among construction workers.     

Cardiovascular risk factors and educational attainment in Southern Spain: a study of a random sample of 3091 adults

Muscle mass decreases with age, leading to "sarcopenia," or low relative muscle mass, in elderly people. Sarcopenia is believed to be associated with metabolic, physiologic, and functional impairments and disability. Methods of estimating the prevalence of sarcopenia and its associated risks in elderly populations are lacking. Data from a population-based survey of 883 elderly Hispanic and non-Hispanic white men and women living in New Mexico (the New Mexico Elder Health Survey, 1993-1995) were analyzed to develop a method for estimating the prevalence of sarcopenia. An anthropometric equation for predicting appendicular skeletal muscle mass was developed from a random subsample (n = 199) of participants and was extended to the total sample. Sarcopenia was defined as appendicular skeletal muscle mass (kg)/height2 (m2) being less than two standard deviations below the mean of a young reference group. Prevalences increased from 13-24% in persons under 70 years of age to >50% in persons over 80 years of age, and were slightly greater in Hispanics than in non-Hispanic whites. Sarcopenia was significantly associated with self-reported physical disability in both men and women, independent of ethnicity, age, morbidity, obesity, income, and health behaviors. This study provides some of the first estimates of the extent of the public health problem posed by sarcopenia.     

Widening social inequalities in mortality: the case of Barcelona, a southern European city

OBJECTIVE: To analyse trends in mortality inequalities in Barcelona between 1983 and 1994 by comparing rates in those electoral wards with a low socioeconomic level and rates in the remaining wards. DESIGN: Mortality trends study. SETTING: The city of Barcelona (Spain). SUBJECTS: The study included all deaths among residents of the two groups of city wards. Details were obtained from death certificates. MAIN OUTCOME MEASURES: Age standardised mortality rates, age standardised rates of years of potential life lost, and age specific mortality rates in relation to cause of death, sex, and year were computed as well as the comparative mortality figure and the ratio of standardised rates of years of potential life lost. RESULTS: Rates of premature mortality increased from 5691.2 years of potential life lost per 100,000 inhabitants aged 1 to 70 years in 1983 to 7606.2 in 1994 in the low socioeconomic level wards, and from 3731.2 to 4236.9 in the other wards, showing an increase in inequalities over the 12 years, mostly due to AIDS and drug overdose as causes of death. Conversely, cerebrovascular disease showed a reduction in inequality over the same period. Overall mortality in the 15-44 age group widened the gap between both groups of wards. CONCLUSION: AIDS and drug overdose are emerging as the causes of death that are contributing to a substantial increase in social inequality in terms of premature mortality, an unreported observation in European urban areas.     

Laparoscopic gastric devascularization and splenectomy for sclerotherapy-resistant esophagogastric varices with hypersplenism

BACKGROUND: Cervical cancer is the most important cancer in Mexican women. Early detection is possible by means of the Papanicolaou (Pap) test; however, the coverage in Mexico is low. METHODS: A cross-sectional survey was carried out in a representative sample of women from the Tlalpan area of Mexico City. Social, reproductive and health care factors associated with the lack of use of the Pap test with respect to adequate use and misuse were identified. Both bivariate and logistic regression analyses were used for the adjustment of variables. RESULTS: Of 1,215 women studied, 22.5% had never had a Pap smear, 42% had misused the test (< 90% of triennial performance), and 35.5% had adequately used the test (> or = 90% of triennial performance). The main factors related to the lack of use were the following: not knowing about the Pap test (ORa = 35.16, 95% C.I. = 17.4-70.9); having fewer than 6 years of education (ORa = 4.5, 95% C.I. = 2.5-8.4); women younger than 30 years of age (ORa = 3.4 95% C.I. = 2.3-5.1); use of contraceptives (ORa = 0.4, 95% C.I. = 0.2-0.8); history of sexually transmitted diseases (ORa = 0.3, 95% C.I. = 0.1-0.8), and the principal informant about the Pap test, i.e., the health services personnel (ORa = 0.02, 95% C.I. = 0.0008-0.05). CONCLUSIONS: The lack of use and the misuse of Pap smears vary importantly among the different social and reproductive factors. But the principal reasons for lack of use were not knowing about the Pap test and a low educational level. We propose a greater diffusion on the benefits of the test in the Mexican population, through massive means of communication and health services.     

The prevalence of diabetes and associated coronary risk factors in urban and rural older Mexican populations

OBJECTIVE: To determine the prevalence of diabetes and examine its association with food intake, anthropometric and metabolic variables, and other coronary risk factors in urban and rural older Mexican populations. DESIGN: A cross-sectional study. SETTING: Three Mexican communities (urban areas of medium and low income and a rural area). PARTICIPANTS: A total of 121 men and 223 women aged 60 years and older and 93 men and 180 women aged 35 to 59 years were selected randomly for inclusion in the survey, which was derived from the CRONOS study (Cross-Cultural Research on Nutrition in the Older Adult Study Group) promoted by the European Economic Community. MEASUREMENTS: A personal interview assessed demographic information, personal medical history, and functional status, and a 24-hour diet recall was obtained. A physical examination included anthropometric and blood pressure measurements. A fasting blood sample was obtained for measurements of lipids, insulin, and glucose. RESULTS: Diabetes prevalence was higher in men than in women for all age groups: 16.7% versus 9.5% in younger adults and 30.8% versus 22.8% in older adults. For all age groups, diabetes was more highly prevalent in urban communities. Using a multivariate stepwise logistic regression, variables associated independently with diabetes in older individuals were: gender (male sex: OR = 2.1; P < .009); diminished carbohydrate intake in the diet (OR = 0.77; P < .03); central distribution of adiposity (OR = 1.9; P < .03); and functional disability (OR = 2.3; P < .01). This relationship was not observed with living area, income, education, fiber and alcohol intake, body mass index, or age. Individuals 80 years and older had a diminished atherogenic risk profile. Diabetes in older people was associated significantly with hypertriglyceridemia, impaired functional status, and an increased prevalence of ischemic heart disease; in younger adults diabetes was associated with low density lipoprotein (LDL) hypercholesterolemia, hypertriglyceridemia, and a proportionally higher fat intake. CONCLUSION: This survey confirms the high prevalence of diabetes in the older Mexican population - particularly in men and in individuals living in urban areas - associated with an increased prevalence of other coronary risk factors. Diabetes was associated with higher fat, low carbohydrate, low fiber diets and increased prevalence of central distribution of adiposity. In the older subjects, diabetes was associated significantly with hypertriglyceridemia, impaired functional status, and increased prevalence of ischemic heart disease. A bias produced by early mortality and a survivorship effect must be considered in studies of older individuals. The health situation in the older Mexican population presents a complex problem that needs correct diagnosis and better strategies to benefit those segments of the population at increased risk.     

The prevalence of non-insulin-dependent diabetes mellitus and the associated risk factors in a population of Mexico, D. F

Non-insulin-dependent diabetes mellitus (NIDDM) is a chronic disabling disease, that shortens length of life and implies a high burden for a community. Its prevalence goes from 0 per cent in Papua, New Guinea to 34 per cent in Pima Indians. There are very few prevalence studies in Mexico, and the strength of association of the known risk factors with the occurrence of the disease is not established. A prevalence cross sectional study was carried out with users of a first level medical care unit, with a meter measure of capillary glucose levels. Those with a previous diagnosis of diabetes or whose capillary glucose level were 200 mg or over were considered diabetics. Hyperglycemia was when the levels were recorded between 121 and 199 mg. The crude prevalence of NIDDM was 5.6 per cent (CI 95% 4.5-6.8), With almost no sex difference. Hyperglycemia prevalence was 2.9 per cent (CI 95% 2.0-3.7). Age was the main risk factor for the development of NIDDM. Those between 40 and 59 years showed a high risk (OR 10.8; CI 95% 5.4-22.0; p < 0.0001), and it was greater for the 60 years or elder (OR 20.6; CI 95% 9.8-44.1; p < 0.0001). Weight was also an important risk factor, with a 2.7 fold greater risk for obese persons (CI 95% 1.6-4.6; p < 0.0001). Other, risk factors were familiar history of diabetes (OR 1.5; CI 95% 0.9-2.3; p = 0.096), and overcrowding (OR 1.9; CI 95% 1.0-3.4; p = 0.03). In order to analyze independently each variable, a logistic regression model was applied, and a similar strength of association was observed for the crude model, but for obesity whose effect was modified by age. When only new cases were analyzed in the former model, the association with obesity was maintained. There is a need to develop prevalence studies of NIDDM in Mexico and to measure the strength of association with the known and the not jet well known risk factors of this disease in order to establish health policies according to the Mexican reality.     

Body mass index, weight change, and risk of mobility disability in middle-aged and older women. The epidemiologic follow-up study of NHANES I

OBJECTIVE: As disability is highly prevalent among older women, is costly, and affects the quality of life, preventable causes of disability must be identified. In this study, we investigated the relationship between the body mass index (BMI), weight change, and the onset of disability in older women. DESIGN: Prospective cohort study. SETTING: The nationally representative US epidemiologic follow-up study of the National Health and Nutrition Examination Survey (NHANES) I (1971 through 1987). PATIENTS: White women classified as young-old (mean age 60 years at baseline, mean age 65 years at follow-up) and old-old (mean age 76 years at baseline, mean age 80 years at follow-up). MAIN OUTCOME MEASURES: The relative odds for the onset of mobility disability associated with tertiles of past BMI (measured 8 to 16 years prior to disability ascertainment) and current BMI (measured 2 to 5 years prior to disability ascertainment) and with weight change between the two weight measurements. RESULTS: In both cohorts, women in the high past BMI group (> 27 in the young-old and > 28.1 in the old-old cohort) had a twofold increase in the risk for disability compared with women in the low past BMI group. High current BMI was as strongly related as past BMI to risk of disability in the young-old women; it was not as strong a predictor in old-old women. In the old-old group only, women who experienced a weight loss of more than 5% had a twofold increase in risk of disability compared with weight-stable women. These results were adjusted for age, smoking, education, and study time and were not importantly modified with the addition into the models of single or multiple health conditions. CONCLUSIONS: These prospective data suggest that high BMI is a strong predictor of long-term risk for mobility disability in older women and that this risk persists even to very old age. However, the paradoxical increase in risk associated with weight loss in the old-old women requires further study. Programs to prevent overweight may have potential for decreasing disability in women.     

Demographic and epidemiological determinants of healthcare costs in Netherlands: cost of illness study

OBJECTIVES: To determine the demands on healthcare resources caused by different types of illnesses and variation with age and sex. DESIGN: Information on healthcare use was obtained from all 22 healthcare sectors in the Netherlands. Most important sectors (hospitals, nursing homes, inpatient psychiatric care, institutions for mentally disabled people) have national registries. Total expenditures for each sector were subdivided into 21 age groups, sex, and 34 diagnostic groups. SETTING: Netherlands, 1994. MAIN OUTCOME MEASURES: Proportion of healthcare budget spent on each category of disease and cost of health care per person at various ages. RESULTS: After the first year of life, costs per person for children were lowest. Costs rose slowly throughout adult life and increased exponentially from age 50 onwards till the oldest age group (> or = 95). The top five areas of healthcare costs were mental retardation, musculoskeletal disease (predominantly joint disease and dorsopathy), dementia, a heterogeneous group of other mental disorders, and ill defined conditions. Stroke, all cancers combined, and coronary heart disease ranked 7, 8, and 10, respectively. CONCLUSIONS: The main determinants of healthcare use in the Netherlands are old age and disabling conditions, particularly mental disability. A large share of the healthcare budget is spent on long term nursing care, and this cost will inevitably increase further in an ageing population. Non-specific cost containment measures may endanger the quality of care for old and mentally disabled people.     

Social welfare and health services in the Fraylesca Region in Chiapas: the use of prenatal care services

OBJECTIVE: To analyze the use of antenatal care services (ACS) in the Fraylesca Region of Chiapas, Mexico, and to identify groups with lower probability of receiving ACS. MATERIAL AND METHODS: In 1994, a health survey was performed on a random sample of 1,100 households, which compiled sociodemographic information and on the use of ACS during the last pregnancy within the two years previous to the study (n = 297 women from 15 to 49 years of age). The groups with lower probability of receiving adequate ACS (5 or more visits) were identified with a log-linear model. RESULTS: Forty-two percent of women received inadequate ACS (0 to 4 visits). Women with better socioeconomic status had higher probability of using ACS adequately than women with lower socioeconomic status: OR 2.47 (Cl 95% 1.12-5.44). CONCLUSIONS: Results provide evidence of the need to improve the quality of ACS, to support the traditional midwives and to improve living conditions of the population.