FUNCTIONAL STATUS OUTCOMES in a Quality of Life Study with Latinas
BACKGROUND: The majority of research related to the health of older Mexican Americans focuses on chronic illness and its contribution to disability without considering acculturation, social, financial, and cognitive factors as mediators or moderators in this relationship. OBJECTIVE: This study describes functional capacity as an outcome of the interface between components of quality of life in older Mexican-American women in South Texas and describes how function is related to symptoms of chronic illness, cognition, depression, social resources, financial strain, and acculturation. METHODS: Data collection interviews were completed with a convenience sample of 51 women of Mexican descent, aged 65 or older. Data were analyzed using descriptive and correlational statistics. RESULTS: Functional capacity and physical health was evaluated as very good in this sample. Findings point toward acculturation and cognitive status as mediators of functional capacity and depressive symptoms. In spite of the fact that most women had low incomes, few reported financial strain. The majority of women reported having strong and supportive relationships with family and friends. DISCUSSION: Although acculturation, social, financial, and cognitive factors are rarely considered in studies of functional status, they are important variables in research exploring health disparities among older Mexican-Americans.
In the US, the older adult population is growing as baby boomers reach retirement age. Many older adults have good health and a positive quality of life. Yet, 62% of all adults 65 years and older have more than one chronic disease (Eberhardt, Ingram, & Makuc, 2001). Co-morbidity is a prominent contributing factor in the health disparity between Hispanics and non-Hispanics. The prevalence of chronic conditions such as diabetes, hypertension, and obesity is two times greater among Hispanics (CDC, 1999). Those with more than one chronic illness may be at the beginning of the trajectory toward disability because chronic disease associated cognitive and functional decline and disease symptoms limit mobility and self-care (Nagi, 1976; Verbrugge & Jette, 1994). The costs associated with chronic illness management are illustrated by the fact that in 1996 1 in 5 Americans required assistance with basic hygiene, cooking or shopping at an annual average expense of $6,000 per person for home based services (AHRQ, 2002).
Older Mexican-Americans are expected to comprise approximately one-fifth of the US population by 2050 and are the fastest growing subpopulation of Hispanics in the US. Hispanic-Americans, including Mexican Americans, are disproportionately affected by health-related problems compared to other ethnic groups. Black and Rush (2002) reported that older Hispanics showed significantly greater decline in cognition and physical function than older European or African Americans with higher rates in women than men. Diabetes, hypertension and obesity, frequently occurring conditions in Hispanics, contribute to high rates of decline (Mokdad, Ford, & Bowman, 2003). The cognitive and functional disadvantage experienced by Mexican Americans may be related to their social position in the US. One third of US Hispanics do not have health insurance, their mean educational level is less than 10th grade, and language barriers limit communication with health care providers and comprehension of health information (Eberhardt, Ingram & Makuc, 2001). Health disparities are the focus of national efforts supporting research that will improve the health and quality of life of older Americans (NIA, 2001). The need for study of health disparities among Mexican American women (Latinas) is supported by reported higher rates of chronic illness, significantly greater physical and cognitive decline. This investigation used an integrated biopsychosocial approach to examine predictors of functional status in Latinas 65 years and older. This paper presents early findings of clinically relevant quality of life variables including symptoms of illness, cognition, depression, social support, financial strain, acculturation, and functional status in a sample of 51 older Mexican American women living in a large southwestern city.
Built on the concept of successful aging and known as the “new gerontology,” the contemporary trend is to view aging in a positive light. Rowe & Kahn (1998), proponents of the new gerontology, established criteria defining successful aging: absence of infirmity, disability, declining physical and mental function, and disengagement from life. This definition implies that healthy aging is prerequisite to good quality of life. Yet others (Strawbridge, Wallhagen, & Cohen, 2002) report that elders more often define themselves as aging successfully in spite of experiencing disease and decline. It will be important to integrate concepts of successful aging and subjective definitions of quality of life into studies of health disparities.
Health disparities, where there is a higher incidence of disease (health inequality) and undeserved marginalization (health inequity) create the need for another perspective on aging and quality of life. This perspective would understand limitations posed by difficult life circumstances on lifestyle choices and access to health care. In addition it would lead researchers to examine the human response to differential access to resources. This approach was used by Seeman, Crimmins, Huang, Singer, Bucur, Gruenewald et al. (2004) who suggested that the collective effect of Stressors combined with lower social standing increased mortality risks. Their conception, a biological analogy to the acculturative stress concept, is that adjusting to Stressors from multiple environmental sources may exact a physiological toll on the body known as allostatic load. Allostatic load exerts an influence on health in addition to the effects of inequalities due to social status. Allostatic load, as a potential mediator of health outcomes of acculturative stress, partially explains the poorer health status of more acculturated Mexican Americans who have been in the US long term. Another view is that acculturative stress can be mediated by intrinsic and extrinsic factors, such as resilience and social support that reduce the likelihood of negative responses regardless of social status (Heilemann, Lee & Kury, 2002). These approaches to studies of health disparities in aging have the potential to uncover points of intervention that would improve quality of life in later life.
Functional capacity is one of the domains of quality of life. Higher levels of physical function contribute to successful aging by preserving mobility, balance, flexibility, and therefore, safety from injury. Physical activity and exercise contribute to better physical function as people age. In fact, there is some evidence that activity limits cognitive decline among elderly adults (Verghese, Lipton, Katz, Hall, Derby, Kuslansky, Ambrose, et al., 2003). Successful aging requires that resources be available to address the impact of chronic illness. Opportunities for successful aging will be limited in people with chronically stressful lives and fewer social and economic resources (Kawachi. Subramanian. & Almeida-Filho. 2002).
When compared to European American women (Smith & Kington, 1997), Latinas of lower socioeconomic status have more functional limitations, contributing significantly to dependency (USDHHS, 2000). Furthermore, when compared to older European American and African American women, older Spanish-speaking Hispanic women practice fewer preventative health behaviors, have less access to health care, and are more likely to be uninsured (Sundquist, Winkelby, & Pudaric, 2001; Hollen, Balcazar, Medina, & Ahmed, 2002). It will be important for researchers to examine the nature of the relationships between socioeconomic status, Latina culture, and health outcomes.
One goal of Healthy People 2010 is to eliminate health disparities (USDHHS, 2000) prevalent in Mexican-American women who “face tremendous social, economic, cultural, and other barriers to achieving optimal health” (Office of Research on Women’s Health, 2000). The growing population of older Latinas, their potential for marginalization in mainstream society and their limited entrée to health care emphasizes trends that underline the importance of studying factors contributing to aging related quality of life. Studies of the relationship between complex variables are necessary for health disparities mechanisms to be fully understood.
Links between Quality of Life and Health Status
Older adults who are able to be physically and socially active are less depressed (Verghese, Lipton, Katz, et al., 2003; Vogt, Lauerman, Chirumbole, & Kuller, 2002), have better health and quality of life (Lindberg & Iwarsson, 2002), fewer falls (Day, Fildes, Gordon, et al., 2002), less frailty (Binder et al., 2002), and improved performance on tests of physical functioning (Escalante, Lichtenstein, & Hazuda, 2001; Studenski, Perera, Wallace, et al., 2003; Tennstedt, Lawrence, & Kasten, 2001). A significant relationship between physical activity and emotional well-being, moderated by level of chronic social and financial stress, was identified by Chirioga et al., (2002). Low levels of emotional well-being contribute to mortality in some populations. For example, Stern, Dhanda, and Hazuda (2001) found that higher levels of hopelessness were associated with higher mortality rates among Mexican-American men and women. Conversely, higher levels of emotional well-being have been linked with the maintenance of functional ability and longer life in older Mexican-Americans (Ostir, Markides, Black, & Goodwin, 2000). Heilemann, Lee, and Kury studied how depression was influenced by acculturative stress in low income women and found higher rates of alcohol use in depressed women who lived in the US since childhood, proposing that cumulative acculturative stress had an influence on depression and alcohol use.
Losses in functional capacity have been associated with increases in depression (Chirioga, Black, Aranda, & Markides, 2002; Pennix, Guralnik, Ferrucci, et al, 1998), medication side effects (Struck, Walthert, Nikolaus, et al., et al., 1999), pain and fatigue (Bennett, Stewart, Kayser-Jones, & Glaser, 2002; Vogt, Lauerman, Chirumbole, & Kuller, 2002), and chronic conditions (Perkowski, Stroup-Benham, Markides, et al., 1998). Chronic conditions such as diabetes, hypertension and obesity can cause limitations in mobility and physical inactivity. Physical inactivity is a major risk factor for obesity (BMI > 30), hypertension (Crespo, Smit, Anderson, Carter-Pokras, & Ainsworth, 2000), and non-insulin dependent diabetes (NIDDM) (Brownson, Eyler, King, Brown, Shyu, & Sallis, 2000). Related to these are the findings demonstrating that obesity and NIDDM are contributing factors to CVD mortality (CDC, 2002), the leading cause of death among Hispanic women in the US (USDHHS, 2000). Nearly half of Mexican-American women aged 65 years and older in Texas have a BMI of 27.3 or higher, 31% have diabetes, and they are less physically active than Hispanic men and Anglo men and women (Smith & Kington, 1997). For older Hispanic women, the lack of physical activity is particularly harmful because of their strong vulnerability to obesity and diabetes (COSSMHO, 1990).
Links between Quality of Life and Functional Capacity
The conceptual components of quality of life are social, spiritual, physical, and mental health. The outcomes of the interface between these components are subjective well being and functional status. Functional status includes the ability to manage daily life activities including personal care (Activities of Daily Life – ADL) and household management (Independent Activities of Daily Life – IADL). Balance, muscular strength, endurance, and flexibility are specific physical performance measures of functional status. Individual characteristics relevant to health disparity research of quality of life include family support and demands, socioeconomic status, and acculturation. There are varied measures of the components and outcomes of quality of life. The literature was reviewed to identify research studies conducted in the last five years that incorporated any component of quality of life and functional status. From the literature reviewed, the author selected quality of life measures for this study because, at face value, they were judged to be culturally relevant and feasible to use with older women in community settings.
Figure 1 depicts aging related quality of life as it was conceived for this study. The concepts of interest are bolded. Concept related phenomena specific to this study are listed beneath each concept.
Design and Methods
This was an exploratory descriptive-correlational pilot study using measures of functional status and physical and mental health. Following approval from the university’s institutional review board, a convenience sample of 51 Mexican-American women > or = 65 years old was recruited from community centers, senior nutrition sites, and elder housing in a large Southwestern city with a majority population of Mexican Americans. Women were invited to participate if they spoke either English or Spanish, lived without assistance for routine self-care, and did not have limitations in physical function requiring the use of mobility assistive devices. We interviewed in the preferred language (Spanish or English) of participants to collect data. We chose not to assess reading level as requisite to study enrollment and wanted a range of educational and cognitive status levels. Undergraduate and graduate nursing students and a bilingual research associate visited the homes of women who qualified for the study to obtain informed consent and then collected data using interviews. The time necessary for one data collection episode averaged one and one half hours. At the completion of each data collection session, a grocery gift card worth $15 was given as payment.
Instruments used in the study were available in English and Spanish. Latinas specified their preference for English or Spanish prior to data collection. We were able to honor their choice since the research associate was bilingual and was well known in the Mexican American community as a promotora. The instruments used in the study are described below.
Acculturation was assessed using country of birth, language spoken at home, with friends, family, for reading and interview, generation in the US and self identity as Mexican or American. Lower scores (range = 8-16) indicated less acculturation.
MDASI (MD Anderson Symptom Inventory) assessed symptoms that were experienced in the past 24 hours. The MDASI originally was developed for use with cancer patients; however, it is used for symptom reporting by patients with other health problems including chronic illnesses (C. Cleeland, personal communication, June 12, 2003). The instrument has two constructs: symptom severity (pain, fatigue, disturbed sleep, distress (emotional), shortness of breath, drowsy, dry mouth, sad, remembering, nausea, emesis, lack of appetite, and numbness or tingling) and the interference of symptoms with activity, mood, work, relationships with others, walking and enjoyment of life. Ten-point Likert type scales rated each item with higher scores indicative of greater problems with symptoms. Reported internal reliability (Cronbach alpha) for the symptom and interference scales ranged from .84 to .91 in a study of cancer patients (Cleeland, Mendoza, Wang, et al., 2000). In this study the internal reliability using Cronbach alpha were .824 for the symptom subscale and .643 for the interference subscale. Scores for the MDASI subscales, (items =13 symptoms; 6 interference) are obtained by summing across subscale items. MDASI symptom subscale scores can range from 0-130, and interference scores from 0-60.
BPI (Brief Pain Inventory) in English and Spanish (Cleeland, Gonin, Baez, Loehrer, & Pandya, 1997) assessed two factors: the intensity of pain and its impact on sleep, mood, relationships with others, and work. Respondents reported if they have had pain in the past 24 hours indicating the location of their pain on anterior and posterior human body diagrams. The occurrence of pain and its severity are graded on a 10-point scale from “no pain” (0) to the “pain as bad as you can imagine” (10). A total score is calculated with higher scores indicative of worse pain and interference. Test-retest reliability in one week ranged from .93 to .59 and at three months from .34 to .22 with ratings corresponding to pain medication use (Cleeland, Gonin, Baez, Loehrer, & Pandya, 1997). In this study the Cronbach alpha coefficients were .937 for the pain subscale and .734 for the interference subscale. This instrument offered us the chance to evaluate pain as a symptom of chronic illness more specifically. BPI pain subscale scores can range from 0-80 and interference scores from 0-70.
GDS (Geriatric Depression Scale) is a 15 item instrument using a dichotomous yes/no response format. It was chosen over the Center for Epidemiological Studies – Depression (CES-D) because it does not assess somatic symptoms that could be associated with illness and age rather than depression. Some items are reversed to avoid consistent response patterns. Higher scores indicate greater likelihood of depression. This instrument was translated to Spanish by Baker & Espino (1997) using input from community resident elders and Mexican American physicians. It is reported to have acceptable reliability and in this study the Cronbach alpha coefficient was .635.
EXIT 25 (Cronbach alpha=.545) assessed the executive control function (ECF) dimension of cognition (Royall, Chiodo, & Polk, 2000) which is necessary for complex activities involving step by step actions toward goals, self-control and self-regulation of activities. Unlike the Mini Mental State Exam that assesses dementia arising in the cortical areas of the brain, the EXIT 25 is sensitive to non-cortical frontal dementia. Its reported interrater reliability is .90 (Royal, Polk and Chiodo, in press) and it is well correlated with other measures of executive control function (Royall, Palmer, Chiodo, & Polk, 2004). A total score is obtained ranging from zero to 50 with higher scores (>15) signifying impairment. Using latent growth curve models, the rate of change in executive control function explained 25-40% of the variance in rates of change in instrumental activities of daily living among elderly retirees (Royall, Palmer, Chiodo, & Polk, 2004). We selected this instrument to evaluate cognition and compare its dementia rating with the ratings obtained with the Mini Mental State Exam and the CLOX 1 and 2.
MMSE assessed cortical dementia using a series of items requiring memory, orientation, calculation, repetition, and responses to instructions. Scores range from 0-30 with high scores indicating intact cognition. Scores are reported by others (Black, Espino, Mahurin, Lichtenstein, Hazuda, Fabrizio, et al., 1999) to be influenced by non-cognitive factors among Mexican Americans with education explaining the most variability in scores. The usual cutoff score of 23/30 demarcates probable cognitive impairment with scores less than 18 indicating severe impairment.
CLOX 1 is a test of executive control function. The tester asks “draw me a clock with the time at 1:45.” Higher scores (> or = 11/15) indicate better symmetry, sequencing, spacing, detail and accuracy and therefore better cognition.
Social and Financial Resources were assessed with 2 questions about friends and family who could be counted on to be confidants in times of problems. Chronic financial strain was measured with 5 questions ascertaining adequate income for bills, food, health care expenses, and how often medications were missed because of financial problems. Both used a Likert scale (0- very often to 4-rarely) with higher scores indicating fewer resources and greater financial strain.
ADL and IADL (Cronbach alpha = .816) assesses independence in performing basic (ADL) and complex (IADL) self-care behaviors using a dichotomous response format (1=able; 2=needs help). Scores were compiled by summing “needs help” items and dividing by the number of women who reported needing help. Higher scores indicate functional limitations. Since these are subjective measures they may lose validity if cognition is impaired or if there is self consciousness about admitting losses in function.
Characteristics of the sample are depicted in Table 1. The sample profile was older, more acculturated Latinas, widowed, in their seventh decade of life, with middle school education, annual income less than $16,000.
Acculturation mean score of 11.67 (range = 8-15; SD=-2.62) indicated the sample was more acculturated.
Physical Health: The mean scores for the MDASI symptom and interference subscales were 13.39 (SD = 15.15) and 3.06 (SD=6.44) indicating that the symptom experience was quite variable but generally mild. The BPI pain subscale mean score was 3.19 (SD=7.02) and the interference subscale mean score was 1.44 (SD=4.14). The majority reported no experience of symptoms and pain. There were significant but only weak to moderate correlations between these and ADL/IADL. The strongest of these were between the MDASI symptoms and the MDASI interference subscales and IADL (r=.426, p=.003 and r=.553, p=.000). There was not a significant correlation between pain and ADL/IADL.
Mental Health: Scores on the GDS identified that 36% of the women met scoring criteria (5-9) for probable (5 women) or actual (> or = 10) depression (11 women). Women meeting scoring criteria for cognitive impairment varied by measure with 17.3% impaired using the MMSE, 19.6% using the EXIT 25, and 37.8% using the CLOX 1. Social Resource scores indicated the majority of women (54.9%) reporting strong ties with family and friends. Most women (91.3%) reported rarely having financial problems.
Functional Status using ADL and IADL measures indicated few women reporting functional impairments. Mean ADL and IADL scores were .25 (SD=.487, range 0-12) and .83 (SD=1.62, range=9-39) respectively. The most commonly reported ADL impairment was incontinence with 10 (25%) of women responding yes to the question, “Do you have any trouble controlling your bladder or your bowels?” Five women reported needing help with one to four IADL activities; the remainder of the women reported being able to fully perform activities. Cognitive impairment (CLOX 1 and EXIT 25) and functional status (ADL/IADL) were correlated. Pearson’s correlation coefficients ranged from r=-.452 (p=. 002) to r=-.523 (p=000). The MMSE was significantly correlated with IADL (r=-. 488, p= 001), but not with ADL. Older women reported significantly more problems with functional status.
Functional Status: Women in this study reported good functional ability. This finding is interesting in that we expected more women to report needing help in managing household tasks and personal care. It may be that our sample is more functional due to our recruitment methods. The community settings providing congregate meals and activities for seniors used for recruitment are location specific and not readily available to the women with less function. Thus, our sample may not be representative of all older Latinas in this city.
Physical Health: There were few reported problems with symptoms and pain in this sample. Although we might assume that women’s good functional status was an outcome of fewer symptoms, it could be possible for those with chronic illness to find methods for managing symptoms and to reduce symptom interference. Furthermore, we would suggest that chronic illness alone does not predict functional status, but that there is a set of factors, such as cognitive status and depressive symptoms, acting as mediators between chronic illness and function. There was a relationship between more symptoms and needing help with daily life activities as expected. In a larger sample with more variability, it is possible the strength of relationships between these measures of physical health and function will be stronger.
Mental Health: The percent (30%) of women in this sample who reported depressive symptoms corresponded to the prevalence rate of 25.6% reported from The Hispanic Established Populations for Epidemiologic Studies of the Elderly (H-EPESE) that used the Center for Epidemiologie Studies-Depression (CES-D) scale. This compares to rates in European Americans and African Americans ranging from 9-16.9% (González, Haan, & Hinton, 2001). We found women qualified their responses to GDS questions indicating that there may be a cultural proscription related to sadness. It is possible that older Latinas find the idea of “hopelessness,” “emptiness,” and “worthlessness” unacceptable. We found support for this in that the Pearson’s correlation coefficient between the GDS and acculturation (r=-.428, p=.008) representing that less acculturation was related to an increase in depressive symptoms. This association may reflect language barriers as reported by others (González, Haan, & Hinton, 2001). However, this is less likely given the community prevalence of bilingualism and the many concentrated and stable Mexican American neighborhoods in the city. It may be that being born in the US to immigrant parents contributes to the tension of living between two cultures, creating the need for daily adaptation to both Mexican and American traditions and conduct. This would be in concurrence with the Heilemann, Lee and Kury (2002) report that depressive symptoms were higher in women who had been exposed to the US in childhood. Our findings indicated that depressive symptoms were not related significantly to income and education. Given that the income (X=$15,600) and education (X=7th grade) levels of this sample were comparatively low, this was surprising. A larger sample may yield different results.
Instruments assessing cognition gave disparate results with greater similarity between the MMSE and the EXIT 25. The CLOX 1 identified considerably more impairment than the MMSE and the EXIT 25. There were significant relationships between better education and better cognition. This is probably related to the educational bias of cognitive tests (Crum, Anthony, Bassett, & Folstein, 1993). The different results obtained using the CLOX 1 may be due to the nature of the test. The construction of a clock face set at 1:45 is a substantial task that is qualitatively different from tasks on the other tests. We examined the histories of two women with poor CLOX 1 results to uncover a possible cause for their low scores. One woman had never attended school and the other completed 4th grade. Neither was identified as impaired using the MMSE, however, both were designated impaired using the EXIT 25 and both had multiple chronic illnesses, took several medications, were care givers for handicapped family members, reported that they had few social resources and experienced chronic financial strain. Since the EXIT 25 and the CLOX 1 both assess executive control function they are more sensitive to impairments in functions requiring complex skill sets. Given the findings in these cases, it is possible that the relationship between cognition and education is mediated by age related chronic illness, medications, or stress, in line with the findings by Crum, Anthony, Bassett, & Folstein (1993) that MMSE scores decline with age.
The limitations of this pilot study were that it was cross- sectional and the sample size was small. These pilot data are part of a larger study of Mexican American and European American women that will examine the fit of predictive models of functional status with each group to allow us to identify more specifically differences in health outcomes and the nature of health disparities.
The results of this study validated the proposition that cognition was a critical variable in explaining variations in function of Latinas with chronic illnesses. With complete findings we may be able to extrapolate interventions which could improve Latinas’ quality of life. In future studies, repeated measures of both predictor variables and functional capacity would provide a more comprehensive picture of the course of aging that could demonstrate how changes in symptoms and cognition influence functional capacity. While we acknowledge the sample size and cross-sectional data limitations, we were pleased to find that Latinas are aging well in many ways. Given that the functional capacity of this sample was good, our planned comparison study with European American women may better delineate areas of health disparities that could not be established in this study.
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Kelly Dunn, PhD, APRN, BC
Angelica Torres, BSN, BS
Joseph Tiscani, LVN
ACKNOWLEDGMENT: Funded by MESA: Center for Health Disparities – NIH/NINR P20 NR08378.
Kelly Dunn, PhD, APRN, BC, Angelica Torres, BSN, BS, Joseph Tiscani, LVN; University of Texas, San Antonio.
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