580121 research-article2015
JAHXXX10.1177/0898264315580121Journal of Aging and HealthBowen and Ruch
Article
Depressive Symptoms and Disability Risk Among Older White and Latino Adults by Nativity Status
Journal of Aging and Health 2015, Vol. 27(7) 1286–1305 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0898264315580121 jah.sagepub.com
Mary Elizabeth Bowen, PhD1,2 and Alexandra Ruch, MPH2
Abstract Objective:To examine how the relationship between depressive symptoms and disability may vary by nativity status in later life. Method: This nationally representative prospective study of community-dwelling adults age 51 years and older in the Health and Retirement Study (1998-2010) used hierarchical linear modeling to examine how depressive symptoms (Center for Epidemiological Symptoms of Depression) and disability (instrumental activities of daily living [IADL]; activities of daily living [ADL]) vary by nativity status (U.S.- vs. foreign-born), accounting for changes in social support, health behaviors, and health conditions. Results: Depressive symptoms were associated with increased IADL and ADL disability among Latinos compared with Whites; foreign-born Latinos had lower than expected depressive symptom–related IADL and ADL (0.82; p ≤ .001) disability. Discussion: Given that U.S.-born Latinos had similar or poorer depressive symptom–related disability outcomes than Whites, interventions focused on early detection and treatment of depressive symptoms for this group are warranted and may improve disablement outcomes.
1Philadelphia 2West
VA Medical Center Philadelphia, PA, USA Chester University of Pennsylvania, USA
Corresponding Author: Mary Elizabeth Bowen, Research Health Science Specialist, Philadelphia VA Medical Center, 3900 Woodland Ave, Philadelphia, PA, 19104 USA. Email: [email protected]
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Keywords minority health, depression, activities of daily living (ADL), instrumental activities of daily living (IADL), health paradox
Introduction In the United States, about 20% of older adults have chronic disabilities (Manton & Gu, 2001) and 33% have mobility impairments (Freedman & Martin, 1998). Disability is a long-term process varying largely by disease type and severity but also by other physical and mental health conditions (Verbrugge & Jette, 1994). Disability is manifest by difficulties performing self-care and functional tasks (activities of daily living [ADL] and instrumental activities of daily living [IADL]). Difficulties such as bathing and dressing (ADL) and managing money and shopping for groceries (IADL) are associated with dependence, institutionalization, and increased medical care costs, which are about 3 times higher among disabled older adults (Trupin, Rice, & Max, 1995). Disabilities in IADL/ADL are higher among racial/ethnic minorities and persons of low socioeconomic status (SES; Ostchega, Harris, Hirsch, Parsons, & Kington, 2000). Though Latinos are more likely to be disabled than Whites, Latinos have lower mortality rates (Markides & Eschbach, 2011). This paradox may be because Latinos are less likely than Whites to suffer from disease-related disability (Zsembik & Fennell, 2005) and more likely to have injuries or musculoskeletal problems associated with work in physically laborious jobs (Smith et al., 2005; Toussaint-Comeau, 2006). Disability risk may vary by nativity status among older Latinos. For example, increased time in the United States is associated with the adoption of poor health behaviors such as drinking alcohol and smoking, which may disproportionately disadvantage U.S.-born, compared with foreign-born, Latinos (GordonLarsen, Harris, Ward, & Popkin, 2003). In addition, acculturation is associated with the erosion of family and other forms of social support, which increases the risk for poor mental (Hiott, Grzywacz, Arcury, & Quandt, 2006) and physical health outcomes (Penninx, Leveille, Ferrucci, van Eijk, & Guralnik, 1999; Waite & Hughes, 1999). However, increased time in the United States is also associated with access to valuable resources in later life, including health insurance (Gonzalez, Ceballos, et al., 2009). Depression is a major contributor to disability, accounting for 4.4% of total disability-adjusted life years (DALY) globally (Ustun, Ayuso-Mateos, Chatterji, Mathers, & Murray, 2004). Although prevalence rates vary (Dunlop, Song, Lyons, Manheim, & Chang, 2003; Gonzalez, Ceballos, et al.,
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2009; Gonzalez, Haan, & Hinton, 2001; Rogler, Cortes, & Malgady, 1991), an estimated 25.6% of older Latinos report depressive symptoms—compared with 9% to 16.9% for older White and Black adults (Black, Markides, & Miller, 1998; Blazer, Landerman, Hays, Simonsick, & Saunders, 1998). It is unclear whether depression contributes to disability (Penninx et al., 1999) or disability increases the risk for depression—though it is likely that this relationship is reciprocal in later life (Alexopoulos et al., 1996; Dunlop et al., 2003; Ormel, Rijsdijk, Sullivan, van Sonderen, & Kempen, 2002). Older Latinos may experience depression and disability differently than other racial/ethnic groups. For example, in one study examining disabled older adults, Latinos experienced higher levels of depressive symptoms in the context of disability than older Whites (Brown & Turner, 2010). This may be because disability is associated with chronic psychological stress and shame, limited social involvement, loneliness, and a perceived reduction in social support among older Latinos (Brown & Turner, 2010; Tomaka, Thompson, & Palacios, 2006). In sum, previous work has focused on depression (Dunlop et al., 2003) and disability (Hayward, Hummer, Chiu, González-González, & Wong, 2014) among older Latinos. The aim of this study is to examine the contribution of depressive symptoms to disability in a community-dwelling population of older adults and how this relationship may vary by nativity status (U.S. vs. foreign-born) among older Latinos. This is important as depressive symptoms may account for some of the observed racial/ethnic differences in disability between older Whites and Latinos and older Latinos are at greater risk for both depression and the onset and progression of disability in later life. As older Latinos experience the onset of disability at earlier ages than older Whites, it is expected that the effect of depressive symptoms on disability will be most pronounced for IADL disability (S. P. Wallace & Villa, 2003). It is unclear how nativity status may affect this relationship, though foreign-born Latinos may have access to social and other resources in later life that are beneficial to health outcomes. Given that depressive symptoms are amenable to intervention (Callahan et al., 2005), this study’s findings may be used to effectively delay the onset (IADL) and progression (ADL) of disability among at risk groups of older adults.
Method Data Source The Health and Retirement Study (HRS), a prospective multistage probability cohort sample of U.S. households, was conducted by the University of
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Michigan with support from the National Institute of Aging. The first wave of the HRS occurred in 1992 with a 51- to 61-year-old cohort and was merged with the older Asset and Health Dynamics Among the Oldest Old Study (AHEAD; born 1890-1923) in 1998. Two additional cohorts, Children of the Depression Age (CODA; 1924-1930) and War Babies (WB; born 1942-1947) were added in 1998 to fill in the gaps between these two groups, resulting in a sample design nationally representative of the U.S. population older than age 50 in 1998. Further details on the HRS design and methods have been previously published (Heeringa & Connor, 1995). Consistent with previous work, respondents scoring at or above 4 depressive symptoms at baseline (16.3%) were excluded to examine how depressive symptoms affect IADL/ADL disability (Mojtabai & Olfson, 2004). Older adults unable to answer survey questions themselves at baseline (and required a proxy) were also excluded. Data were weighted using respondentlevel sampling weights to account for the sample design in the HRS and to generalize findings to the community-dwelling older adult population (Heeringa & Connor, 1995). This study, using seven waves of data from the HRS (1998-2010), is a nationally representative sample of noninstitutionalized Americans age 51 and older (N = 15,444). All respondents in this study participated in the 1998 survey year. Approximately, 56.7% of respondents participated in all seven waves of the HRS (from 1998 to 2010). By year 2010, approximately 33.3% of respondents were deceased and 2.9% were lost to follow-up. Nonresponse rates increased with age and were higher for non-Whites, men, and respondents with low SES. Dependent variables. Disability was measured by IADL and ADL (each ranging from 0 to 5): mobility, IADL, and ADL (Lawton & Brody, 1969). For IADL, respondents were asked if they had difficulties (yes/no) using the phone, managing money, taking medications, shopping for groceries, and preparing hot meals. For ADL, respondents were asked if they had difficulties (yes/no) walking across a room, bathing, eating, dressing, and getting in and out of bed. The disability scales had high internal consistency (α = .80 IADL; α = .83 ADL). Independent variables. The brief Center for Epidemiologic Studies– Depression scale (CES-D) was the independent variable of interest in this study. The 8-item CES-D has similar symptom dimensions as the 20-item CES-D and has high internal consistency (α = .76; Steffick, 2000; R. Wallace et al., 2000). The CES-D consists of a summed scale detailing whether or not the respondent felt (a) depressed, (b) everything was an effort, (c) sleep was restless, (d) alone, (e) sad, (f) could not get going, (g) happy, and (h) enjoyed
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life in the past week. Items such as felt happy and enjoyed life were reverse coded. Race/ethnicity was measured by four mutually exclusive categories; if a respondent identified as Latino, he or she was considered to be Latino even if he or she was also a member of a racial group (Latino, non-Latino White, non-Latino Black, non-Latino other). Nativity status was either U.S.or foreign-born. Covariates. Additional variables included marital status (married/partnered vs. not), number of persons living in the household, health behaviors (current/former smoker, number of alcoholic drinks per week, and weight; body mass index [BMI]) and self-reported health conditions (summed scale ranging from 0 to 6 [yes/no]), including diabetes (high blood sugar), high blood pressure (or hypertension), lung disease, stroke (or transient ischemic attack), heart conditions (including coronary heart disease, heart attack, congestive heart failure, and the occurrence of heart surgery), and arthritis. SES was measured by education (years), income (the log transformed total household income including earnings, pensions, and social security), and wealth (the log transformed value of assets minus the sum of all debt, including mortgages). Demographic conditions included age (centered at age 65 for ease of interpretation) and gender (male, female).
Statistical Analysis Multilevel statistical modeling using hierarchical linear modeling software Version 7 (Scientific Software International, Lincolnwood, IL) was used to examine individual and aggregate levels of data over time and to account for the complex HRS sampling design and the subset analyzed (Raudenbush & Bryk, 2002). Multilevel modeling conceives of each individual as having his or her own regression equation but incorporates information from all seven (1998-2010) waves of data simultaneously in the same model. As many disability distributions are nonnormal, reflecting the higher frequency of intact functioning among the general older adult population, alternative disability distributions were considered. An examination of residual fit values suggested that nonlinear models were a better fit than linear models. The results of the Poisson nonlinear analyses (with overdispersion) are reported below. Models below are presented as a series of nested models, one for each level of the hierarchy. At the first level, each individual respondent’s trajectory of change in disability is represented as a function of person–time– specific parameters (e.g., depressive symptoms, income, wealth, health behaviors, health conditions) plus random error. These variables are time varying, measured at baseline (year 1998) and subsequently every 2 years
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over the 12-year course of the survey. The second level statistically models individual variations in growth parameters across a population of persons (e.g., gender, race/ethnicity, nativity status, education). Multilevel models account for between-subject heterogeneity and within-individual correlations and model cluster-induced errors in the intercepts and coefficients to increase the efficiency of the estimates. In the models below, effect estimates are presented in terms of event rate ratios (ERRs), which are the exponentiated beta coefficients from the Poisson model. An ERR is interpreted as the percentage change in a dependent variable associated with a 1-unit increase in an independent variable. To examine the association between depressive symptoms and the onset and progression of IADL/ADL disability among Latino adults, IADL and ADL models examine the effect of nativity (U.S.vs. foreign-born) on disability (Tables 3 and 4, Model 2) and interactions between nativity and depressive symptom–related disability (Tables 3 and 4, Model 3).
Results Bivariate As shown in Table 1, the average respondent was about 64 years old, female, and White. About 4.9% of the sample identified as Latino, about 2.5% of Latinos were U.S.- born, and 2.3% were foreign-born. On average, foreignborn Latinos reported living in the United States for about 38 years. Latinos (overall) reported 1.1 depressive symptoms at baseline, with foreign-born and U.S.- born Latinos reporting similar means. On average, respondents had at least a high school education and most respondents reported a history of smoking cigarettes (60%); only about 20% of respondents were currently smoking. As shown in Table 2, compared with Whites, Latinos reported significantly more difficulties performing IADL and ADL over the 12-year course of the study. For example, by 2010 Whites reported 0.37 IADL and ADL; Latinos reported 0.57 and 0.63, respectively. Among Latinos, foreign-born Latinos had more disabilities in IADL and ADL by survey year 2010 than their U.S.-born counterparts.
Multivariate As shown in Table 3, Model 1, each 2-year increase in age is associated with a 14% increase in IADL disability. Females are associated with 20% more IADL disability than males and Latinos are associated with 66% more IADL disability than Whites. Also shown in Model 1, a 1-unit increase in depressive symptoms is associated with a 52% increase in IADL disability.
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Table 1. Baseline Characteristics of Respondents in the Health and Retirement Study (HRS). Characteristic
Total sample n = 15,444
M age in years (SD) Female, n (%) Race/ethnicity, n (%) White Latino Black Other Nativity, n (%) U.S.-born Latino Foreign-born Latino Time in United States in years, M (SD) Depressive symptoms, M (SD) White Latino U.S.-born Latino Latino foreign-born Social support, M (SD) Married Number of persons living in home Socioeconomic status, M (SD) Years of education Income (log transformed) Wealth (log transformed) Health behaviors, M (SD) Number of drinks/week Current smoker Ever smoked Body mass index (BMI) Health conditions, M (SD)
64.1 (10.3) 8,801 (55.5) 12,359 (85.3) 905 (4.9) 1,914 (7.9) 262 (1.8) 451 (2.5) 454 (2.3) 38.4 (16.1) 0.8 (0.9) 1.1 (1.0) 1.1 (1.0) 1.1 (1.1) 0.7 (0.5) 2.2 (1.1) 12.6 (3.0) 4.5 (0.5) 4.8 (1.7) 2.5 (6.4) 0.2 (0.4) 0.6 (0.5) 26.9 (5.1) 0.4 (0.7)
In Model 2, nativity status, social support, SES, health behaviors, and health conditions are added to the model. With these additions, Latinos are associated with 20% more IADL disability than Whites but foreign-born Latinos are associated with 29% fewer IADL disabilities than their U.S.-born counterparts. A 1-unit increase in depressive symptoms is associated with a 46% increase in IADL disability.
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0.11 0.14* 0.14* 0.14*
White Latino U.S.-born Latino Foreign-born Latino
*p ≤ .001.
1998
Race/ethnicity
0.17 0.24* 0.28* 0.20*
2000 0.23 0.28* 0.32* 0.23
2002 0.26 0.29* 0.27* 0.30*
2004
IADL
0.31 0.35* 0.29* 0.41*
2006 0.32 0.43* 0.43* 0.43*
2008 0.37 0.57* 0.54* 0.62*
2010 0.17 0.20* 0.20* 0.21*
1998 0.20 0.25* 0.24* 0.25*
2000
0.25 0.30* 0.30* 0.31*
2002
0.28 0.36* 0.38* 0.34*
2004
ADL
0.32 0.45* 0.38* 0.52*
2006
0.33 0.47* 0.43* 0.52*
2008
0.37 0.63* 0.57* 0.71*
2010
Table 2. Racial/Ethnic Differences in Mean Instrumental Activities of Daily Living (IADL) and Activities of Daily Living (ADL) in the Health and Retirement Study (HRS), 1998 to 2010 (N = 15,444).
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1.14 [0.90, 1.46] 1.45*** [1.43, 1.47] 1.14*** [1.07, 1.22] 0.82*** [0.74, 0.94] 0.86*** [0.83, 0.89] 1.11*** [1.10, 1.12]
0.71*** [0.61, 0.84] 1.46*** [1.45, 1.48]
0.86*** [0.83, 0.89] 1.11*** [1.10, 1.12]
1.52*** [1.50, 1.53]
(continued)
1.12 [0.91, 1.37] 1.33*** [1.20, 1.46] 1.42** [1.11, 1.82]
1.20** [1.05, 1.37] 1.35*** [1.20, 1.46] 1.42** [1.11, 1.83]
1.66*** [1.44, 1.92] 1.98*** [1.79, 2.20] 1.64*** [1.26, 2.13]
1.10*** [1.09, 1.10] 1.09* [1.02, 1.17]
ERR (CI)
Model 3
1.10*** [1.09, 1.10] 1.09* [1.02, 1.17]
ERR (CI)
Model 2
1.14*** [1.14, 1.15] 1.20*** [1.12, 1.29]
ERR (CI)
Demographic characteristics Age Female Race/ethnicity Latino Black Other Nativity status Foreign-born Latino Depressive symptoms × Latino × Foreign-born Latino Social support Married/partnered Persons living in home
Model 1
IADL
Table 3. Hierarchical Poisson Models Examining the Relationship Between Depressive Symptoms and Instrumental Activities of Daily Living (IADL) in the Health and Retirement Study (HRS), 1998 to 2010 (N = 15,444).
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285,138.03
0.98*** [0.98, 0.99] 0.95 [0.90, 1.01] 1.10** [1.02, 1.17] 0.99*** [0.98, 0.99] 1.41*** [1.39, 1.42]
0.98*** [0.98, 0.99] 0.95 [0.90, 1.01] 1.10** [1.02, 1.17] 0.99*** [0.98, 0.99] 1.41*** [1.39, 1.42] 285,138.04***
0.94*** [0.94, 0.95] 0.88*** [0.86, 0.89] 0.96*** [0.95, 0.96]
ERR (CI)
Model 3
0.94*** [0.93, 0.95] 0.88*** [0.86, 0.89] 0.96*** [0.95, 0.96]
ERR (CI)
Model 2
IADL
Note. Estimates are weighted to using respondent-level sampling weights to account for the sample design in the HRS and to generalize findings to the community-dwelling older adult population. ERR = event rate ratio; CI = confidence intervals; SES = socioeconomic status; BMI = body mass index. *p < .05. **p < .01. ***p ≤ .001.
372,804.69
ERR (CI)
SES Education (years) Income (logged value) Wealth (logged value) Health behaviors Drinks/week Current smoker Ever smoked BMI Health conditions Model fit statistics χ2
Model 1
Table 3. (continued)
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In Model 3, interactions between depressive symptoms, race/ethnicity, and nativity status are examined. In this model, a 1-unit increase in depressive symptoms is associated with increased IADL disability among Latinos, compared with Whites, but this relationship varies by nativity status. Foreignborn Latinos are associated with 18% fewer depressive symptom–related IADL disability than their U.S.-born counterparts, accounting for demographic characteristics, social support, SES, health behaviors, and health conditions. As shown at the bottom of Table 3, additions to the models improved model fit, accounting for additional variance explained. As shown in Table 4, Model 1, each 2-year increase in age is associated with a 10% increase in ADL disability. Females are associated with 14% more ADL disability than males and Latinos are associated with 51% more ADL disability than Whites. Also shown in Model 1, a 1-unit increase in depressive symptoms is associated with a 55% increase in ADL disability. As with the IADL model, nativity status, social support, SES, health behaviors, and health conditions are added to Model 2. These additions to the model statistically explain the relationship between Latino ethnicity and ADL disability. In this model, a 1-unit increase in depressive symptoms is associated with a 51% increase in ADL disability. In Model 3, interactions between depressive symptoms, race/ethnicity, and nativity are examined. In this model, foreign-born Latinos are associated with 53% more ADL disability than Whites. In addition, a 1-unit increase in depressive symptoms is associated with increased ADL disability but this relationship varies by nativity status. Foreign-born Latinos are associated with 18% fewer depressive symptom–related ADL disability than their U.S.born counterparts, accounting for the other factors considered in the model. As shown at the bottom of Table 4, additions to the models improved model fit, accounting for additional variance explained. Figure 1 graphically displays these depressive symptom–related IADL and ADL results, assuming three depressive symptoms (90% of the sample reported three or fewer depressive symptoms in survey year 2000). As shown here, accounting for all of the factors considered in this study, U.S.-born Latinos have the highest depressive symptom–related IADL and ADL disability over time, followed by Whites and foreign-born Latinos. Given that these results may suggest “protective” effects for depressive symptoms among foreign-born Latinos, we also examined the mean number of depressive symptoms across study years in post hoc analyses (not shown). Except for baseline year, 1998, when foreign-born Latinos and U.S.-born Latinos had similar means, foreign-born Latinos had consistently higher depressive symptom means (ranging from 1.11 to 1.60) than U.S.-born Latinos (ranging from 1.12 to 1.45) and Whites (ranging from 0.84 to 1.02).
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1.53** [1.13, 2.07] 1.51*** [1.49, 1.54] 1.00 [0.93, 1.08] 0.82*** [0.73, 0.93] 1.01 [0.97, 1.05] 1.03*** [1.02, 1.05]
1.20 [0.91, 1.60] 1.51*** [1.49, 1.53]
1.01 [0.97, 1.05] 1.03*** [1.02, 1.05]
1.55*** [1.53, 1.57]
(continued)
1.13 [0.94, 1.38] 1.35*** [1.24, 1.48] 1.24 [0.98, 1.56]
1.14 [0.96, 1.36] 1.35*** [1.24, 1.48] 1.24 [0.98, 1.56]
1.51*** [1.33, 1.73] 1.87*** [1.70, 2.06] 1.41** [1.11, 1.79]
1.06*** [1.06, 1.07] 1.10** [1.03, 1.17]
ERR (CI)
Model 3
1.06*** [1.06, 1.07] 1.10** [1.03, 1.17]
ERR (CI)
Model 2
1.10*** [1.09, 1.10] 1.14*** [1.07, 1.22]
ERR (CI)
Demographic characteristics Age Gender Race/ethnicity Latino Black Other Nativity status Foreign-born Latino Depressive symptoms × Latino × Foreign-born Latino Social support Married/partnered Persons living in home
Model 1
ADL
Table 4. Hierarchical Poisson Models Examining the Relationship Between Depressive Symptoms and Activities of Daily Living (ADL) in the Health and Retirement Study (HRS), 1998 to 2010 (N = 15,444).
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272,851.30***
0.98*** [0.98, 0.99] 0.95 [0.90, 1.00] 1.15*** [1.08, 1.22] 1.01*** [1.01, 1.02] 1.34*** [1.32, 1.35]
0.96*** [0.95, 0.96] 0.87*** [0.85, 0.89] 0.97*** [0.96, 0.97]
ERR (CI)
Model 2
ADL
272,979.83
0.96*** [0.95, 0.96] 0.87*** [0.85, 0.89] 0.97*** [0.96, 0.97] 0.98*** [0.98, 0.99] 0.95 [0.90, 1.00] 1.15*** [1.08, 1.22] 1.01*** [1.01, 1.02] 1.34*** [1.32, 1.35]
ERR (CI)
Model 3
Note. Estimates are weighted to using respondent-level sampling weights to account for the sample design in the HRS and to generalize findings to the community-dwelling older adult population. ERR = event rate ratio; CI = confidence intervals; SES = socioeconomic status; BMI = body mass index. *p < .05. **p < .01. ***p ≤ .001.
363,159.51
ERR (CI)
SES Education (years) Income (logged value) Wealth (logged value) Health behaviors Drinks/week Current smoker Ever smoked BMI Health conditions Model fit statistics χ2
Model 1
Table 4. (continued)
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2.3 2.1 1.9
ADL/IADL
1.7
IADL; White IADL; Foreign-born La no
1.5
IADL; U.S. born La no
1.3
ADL; White
1.1
ADL; Foreign-born La no ADL; U.S. born La no
0.9 0.7 0.5 1998
2000
2002
2004
2006
2008
2010
Figure 1. Rates of depressive symptom–related ADL and IADL disability in the HRS by race/ethnicity and nativity status, 1998 to 2010 (N = 15,444).
Note. Estimates are weighted; respondent-level sampling weights were used to account for the sample design in the HRS findings to the community-dwelling older adult population. ADL = activities of daily living; IADL = instrumental activities of daily living; HRS = Health and Retirement Study.
Discussion This prospective study of older adults in the United States found that foreignborn Latinos have lower than expected depressive symptom–related IADL and ADL disability than their older White and U.S.-born Latino counterparts. This study’s findings are important given that this study used a nationally representative sample of adults age 51 and older in the United States and accounted for social support, SES, health behaviors, and health conditions, which are associated with depression and disability. In addition, this study captured important health transitions, including intraindividual changes in disability among older Latinos and older Whites over the course of 12 years, with hierarchical linear modeling statistical techniques. There may be several explanations for this study’s findings. First, it may be that foreign-born Latinos have fewer depressive symptoms than Whites and thus lower than expected rates of depressive symptom–related disability. However, in post hoc analyses, this hypothesis was not supported; foreignborn Latinos had higher depressive symptom means. Second, there is research suggesting that Latinos and some other minority group members are more likely than Whites to report a physical concern or condition when experiencing psychological distress (Canino, Rubio-Stipec, Canino, & Escobar, 1992).
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For example, previous work showed that Mexican American women are more likely to report somatic symptoms of depression than White women (Escobar, Burnam, Karno, Forsythe, & Golding, 1987) and that Puerto Rican Americans are more likely than Whites to report somatic symptoms (Escobar & Canino, 1989). This idea of “somatization” was not supported here; the foreign-born Latinos in this study had more depressive symptoms and disability—so there was no evidence that this group had difficulty articulating psychological or physical conditions. Rather, it may be that the relationship between poor mental health and physical health outcomes is weaker among this group compared with older Whites, suggesting that depressive symptoms may be less consequential for older foreign-born Latinos in terms of disability outcomes. In this study, foreign-born Latinos continued to be at an increased risk for (ADL) disability—but this risk did not operate through depressive symptoms. Previous work in this area has reported similar results for older Blacks compared with older Whites (Rajan, Barnes, Wilson, Evans, & Mendes de Leon, 2014). Finally, acculturation may play a role in the relationship between depression and disability among older foreign-born Latinos. Some factors associated with low acculturation, such as limited English proficiency, retaining country of origin beliefs, traditions, communication patterns, and help-seeking behaviors, have been associated with increased depressive symptoms among older Latinos (Black et al., 1998; Gonzalez et al., 2001; GordonLarsen et al., 2003). However, some of these factors may also have health benefits. For example, due to immigration patterns, language barriers and other factors, foreign-born Latinos may be more likely than U.S.-born Latinos to live in Spanish-speaking neighborhoods that provide a variety of benefits including assistance with everyday activities, a shared system of reciprocity, and the exchange of goods and services—from employment opportunities and child care to recreational activities (Vega, Ang, Rodriguez, & Finch, 2011). Research suggests that foreign-born Latinos who reside in the United States for 15 years or more are “protected” from depressive symptoms and associated outcomes due to their integration into these Spanish-speaking communities (Vega et al., 2011). Other studies suggest that increased time in the United States is particularly important for older Latinos who have increased access to health care, insurance, and other socioeconomic resources (Gonzalez, Ceballos, et al., 2009). The foreign-born Latinos in this study resided in the United States for about 38 years, suggesting that they may benefit from these protective social networks, systems of reciprocity, and other neighborhood factors that are necessary for health benefits. There are several limitations to consider when interpreting results. First, attrition is a persistent problem in longitudinal studies. Although attrition has
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not significantly influenced the representativeness of the HRS sample in terms of demographic, economic, and health measures, it remains that the healthiest adults may be selected into and remain in the study over time. Thus, this study’s findings may err toward an underestimation of depressive symptoms and disability in the population. Similarly, the “salmon bias,” where ill or unemployed Latinos return to their country of origin and are not counted in health surveys such as this one may affect this study’s findings (Hayward et al. 2014; Abraido-Lanza, Dohrenwend, Ng-Mak, & Turner, 1999). However, there was no evidence of this bias in this study as foreignborn Latino respondents entered into and were retained in the study at similar rates to that of Whites and other racial/ethnic groups. In addition, disability increased steadily over time for the foreign-born Latinos in this study, which would not likely be the case had only the healthiest of this group remained in the study over time. Finally, the relationship between depressive symptoms and disability may vary by country of origin and other factors that were unable to be examined in this study. Future work accounting for these may further refine this study’s findings. In sum, this study found persistent differences in the relationship between depressive symptoms and IADL and ADL disability by race/ethnicity and nativity, with foreign-born Latinos reporting lower depressive symptom– related disability than their U.S.-born Latino and White counterparts. This relationship was not explained by somatization but may be related to protective aspects of the Latino foreign-born culture—strong social networks and ties among community members that help older foreign-born Latinos manage everyday self-care and functional tasks (Aranda, Ray, Snih, Ottenbacher, & Markides, 2011). Given that U.S.-born Latinos had similar or poorer depressive symptom–related disability outcomes than Whites, interventions focused on early detection and treatment of depressive symptoms for this group are warranted and may improve disablement outcomes (Bowen & Gonzalez, 2008; Gonzalez, Tarraf, et al., 2009). The collaborative primary care model, which includes structured interdisciplinary teams and focused interventions that vary in intensity, has been shown to have short- and long-term mental health benefits (Gilbody, Bower, Fletcher, Richards, & Sutton, 2006). This model may be an appropriate intervention for older Latinos who are likely to rely on primary care for the diagnosis and treatment of depression and other mental health disorders. Acknowledgment The authors would like to thank Dr. Hector González for his helpful comments on this article and the anonymous reviewers at the Journal of Aging and Health for their valuable editorial comments.
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Authors’ Note The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.
Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Dr. Bowen is supported by the Department of Veterans Affairs, Rehabilitation Research and Development (RR&D CDA E7503W).
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Canino, I. A., Rubio-Stipec, M., Canino, G., & Escobar, J. I. (1992). Functional somatic symptoms: A cross-ethnic comparison. American Journal of Orthopsychiatry, 62, 605-612. Dunlop, D. D., Song, J., Lyons, J. S., Manheim, L. M., & Chang, R. W. (2003). Racial/ ethnic differences in rates of depression among preretirement adults. American Journal of Public Health, 93, 1945-1952. Escobar, J. I., Burnam, M. A., Karno, M., Forsythe, A., & Golding, J. M. (1987). Somatization in the community. Archives of General Psychiatry, 44, 713-718. Escobar, J. I., & Canino, G. (1989). Unexplained physical complaints. Psychopathology and epidemiological correlates. British Journal of Psychiatry, 62(Suppl. 4), 24-27. Freedman, V. A., & Martin, L. G. (1998). Understanding trends in functional limitations among older Americans. American Journal of Public Health, 88, 1457-1462. Gilbody, S., Bower, P., Fletcher, J., Richards, D., & Sutton, A. J. (2006). Collaborative care for depression: A cumulative meta-analysis and review of longer-term outcomes. Archives of Internal Medicine, 166, 2314-2321. doi:10.1001/ archinte.166.21.2314 Gonzalez, H. M., Ceballos, M., Tarraf, W., West, B. T., Bowen, M. E., & Vega, W. A. (2009). The health of older Mexican Americans in the long run. American Journal of Public Health, 99, 1879-1885. doi:10.2105/AJPH.2008.133744 Gonzalez, H. M., Haan, M. N., & Hinton, L. (2001). Acculturation and the prevalence of depression in older Mexican Americans: Baseline results of the Sacramento Area Latino Study on Aging. Journal of the American Geriatrics Society, 49, 948-953. Gonzalez, H. M., Tarraf, W., West, B. T., Croghan, T. W., Bowen, M. E., Cao, Z., & Alegria, M. (2009). Antidepressant use in a nationally representative sample of community-dwelling US Latinos with and without depressive and anxiety disorders. Depression and Anxiety, 26, 674-681. doi:10.1002/da.20561 Gordon-Larsen, P., Harris, K. M., Ward, D. S., & Popkin, B. M. (2003). Acculturation and overweight-related behaviors among Hispanic immigrants to the US: The National Longitudinal Study of Adolescent Health. Social Science & Medicine, 57, 2023-2034. Hayward, M., Hummer, R., Chiu, C.-T., González-González, C., & Wong, R. (2014). Does the Hispanic paradox in U.S. adult mortality extend to disability? Population Research and Policy Review, 33, 81-96. doi:10.1007/s11113-013-9312-7 Heeringa, S. G., & Connor, J. (1995). Technical description of the Health and Retirement Study sample design (HRS/AHEAD documentation report DR-002). Retrieved from http://hrsonline.isr.umich.edu/docs/userg/HRSSAMP.pdf Hiott, A., Grzywacz, J. G., Arcury, T. A., & Quandt, S. A. (2006). Gender differences in anxiety and depression among immigrant Latinos. Families, Systems, & Health, 24, 137-146. doi:10.1037/1091-7527.24.2.137 Lawton, M. P., & Brody, E. M. (1969). Assessment of older people: Self-maintaining and instrumental activities of daily living. Gerontologist, 9, 179-186.
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Manton, K. G., & Gu, X. (2001). Changes in the prevalence of chronic disability in the United States black and nonblack population above age 65 from 1982 to 1999. Proceedings of the National Academy of Sciences of the United States of America, 98, 6354-6359. doi:10.1073/pnas.111152298 Markides, K. S., & Eschbach, K. (2011). Hispanic paradox in adult mortality in the United States. New York, NY: Springer. Mojtabai, R., & Olfson, M. (2004). Cognitive deficits and the course of major depression in a cohort of middle-aged and older community-dwelling adults. Journal of the American Geriatrics Society, 52, 1060-1069. doi:10.1111/j.15325415.2004.52302.x Ormel, J., Rijsdijk, F. V., Sullivan, M., van Sonderen, E., & Kempen, G. I. (2002). Temporal and reciprocal relationship between IADL/ADL disability and depressive symptoms in late life. The Journals of Gerontology, Series B: Psychological Sciences & Social Sciences, 57, P338-P347. Ostchega, Y., Harris, T. B., Hirsch, R., Parsons, V. L., & Kington, R. (2000). The prevalence of functional limitations and disability in older persons in the US: Data from the National Health and Nutrition Examination Survey III. Journal of the American Geriatrics Society, 48, 1132-1135. Penninx, B. W., Leveille, S., Ferrucci, L., van Eijk, J. T., & Guralnik, J. M. (1999). Exploring the effect of depression on physical disability: Longitudinal evidence from the established populations for epidemiologic studies of the elderly. American Journal of Public Health, 89, 1346-1352. Rajan, K. B., Barnes, L. L., Wilson, R. S., Evans, D. A., & Mendes de Leon, C. F. (2014). Racial differences on association of depressive symptoms with combined basic and instrumental activities of daily living. The Journals of Gerontology, Series A: Biological Sciences & Medical Sciences, 69, 215-222. doi:10.1093/ gerona/glt074 Raudenbush, S. W., & Bryk, A. S. (2002). Hierarchical linear models: Applications and data analysis methods. Thousand Oaks, CA: Sage. Rogler, L. H., Cortes, D. E., & Malgady, R. G. (1991). Acculturation and mental health status among Hispanics: Convergence and new directions for research. American Psychologist, 46, 585-597. Smith, G. S., Wellman, H. M., Sorock, G. S., Warner, M., Courtney, T. K., Pransky, G. S., & Fingerhut, L. A. (2005). Injuries at work in the US adult population: Contributions to the total injury burden. American Journal of Public Health, 95, 1213-1219. doi:10.2105/AJPH.2004.049338 Tomaka, J., Thompson, S., & Palacios, R. (2006). The relation of social isolation, loneliness, and social support to disease outcomes among the elderly. Journal of Aging and Health, 18, 359-384. doi:10.1177/0898264305280993 Toussaint-Comeau, M. (2006). The occupational assimilation of Hispanic immigrants in the U.S.: Evidence from panel data. International Migration Review, 40, 508-536. Ustun, T. B., Ayuso-Mateos, J. L., Chatterji, S., Mathers, C., & Murray, C. J. (2004). Global burden of depressive disorders in the year 2000. British Journal of Psychiatry, 184, 386-392.
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Vega, W. A., Ang, A., Rodriguez, M. A., & Finch, B. K. (2011). Neighborhood protective effects on depression in Latinos. American Journal of Community Psychology, 47, 114-126. doi:10.1007/s10464-010-9370-5 Verbrugge, L. M., & Jette, A. M. (1994). The disablement process. Social Science & Medicine, 38, 1-14. Waite, L. J., & Hughes, M. E. (1999). At risk on the cusp of old age: Living arrangements and functional status among black, white and Hispanic adults. The Journals of Gerontology, Series B: Psychological Sciences & Social Sciences, 54, S136-S144. Wallace, R., Herzog, A. R., Ofstedal, M. B., Steffick, D., Fonda, S., & Langa, K. (2000). Documentation of affective functioning measures in the Health and Retirement Study. Ann Arbor: Survey Research Center, University of Michigan. Wallace, S. P., & Villa, V. M. (2003). Equitable health systems: Cultural and structural issues for Latino elders. American Journal of Law & Medicine, 29, 247-267. Zsembik, B. A., & Fennell, D. (2005). Ethnic variation in health and the determinants of health among Latinos. Social Science & Medicine, 61, 53-63. doi:10.1016/j. socscimed.2004.11.040
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JAHXXX10.1177/0898264315580121Journal of Aging and HealthBowen and Ruch
Article
Depressive Symptoms and Disability Risk Among Older White and Latino Adults by Nativity Status
Journal of Aging and Health 2015, Vol. 27(7) 1286–1305 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0898264315580121 jah.sagepub.com
Mary Elizabeth Bowen, PhD1,2 and Alexandra Ruch, MPH2
Abstract Objective:To examine how the relationship between depressive symptoms and disability may vary by nativity status in later life. Method: This nationally representative prospective study of community-dwelling adults age 51 years and older in the Health and Retirement Study (1998-2010) used hierarchical linear modeling to examine how depressive symptoms (Center for Epidemiological Symptoms of Depression) and disability (instrumental activities of daily living [IADL]; activities of daily living [ADL]) vary by nativity status (U.S.- vs. foreign-born), accounting for changes in social support, health behaviors, and health conditions. Results: Depressive symptoms were associated with increased IADL and ADL disability among Latinos compared with Whites; foreign-born Latinos had lower than expected depressive symptom–related IADL and ADL (0.82; p ≤ .001) disability. Discussion: Given that U.S.-born Latinos had similar or poorer depressive symptom–related disability outcomes than Whites, interventions focused on early detection and treatment of depressive symptoms for this group are warranted and may improve disablement outcomes.
1Philadelphia 2West
VA Medical Center Philadelphia, PA, USA Chester University of Pennsylvania, USA
Corresponding Author: Mary Elizabeth Bowen, Research Health Science Specialist, Philadelphia VA Medical Center, 3900 Woodland Ave, Philadelphia, PA, 19104 USA. Email: [email protected]
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Keywords minority health, depression, activities of daily living (ADL), instrumental activities of daily living (IADL), health paradox
Introduction In the United States, about 20% of older adults have chronic disabilities (Manton & Gu, 2001) and 33% have mobility impairments (Freedman & Martin, 1998). Disability is a long-term process varying largely by disease type and severity but also by other physical and mental health conditions (Verbrugge & Jette, 1994). Disability is manifest by difficulties performing self-care and functional tasks (activities of daily living [ADL] and instrumental activities of daily living [IADL]). Difficulties such as bathing and dressing (ADL) and managing money and shopping for groceries (IADL) are associated with dependence, institutionalization, and increased medical care costs, which are about 3 times higher among disabled older adults (Trupin, Rice, & Max, 1995). Disabilities in IADL/ADL are higher among racial/ethnic minorities and persons of low socioeconomic status (SES; Ostchega, Harris, Hirsch, Parsons, & Kington, 2000). Though Latinos are more likely to be disabled than Whites, Latinos have lower mortality rates (Markides & Eschbach, 2011). This paradox may be because Latinos are less likely than Whites to suffer from disease-related disability (Zsembik & Fennell, 2005) and more likely to have injuries or musculoskeletal problems associated with work in physically laborious jobs (Smith et al., 2005; Toussaint-Comeau, 2006). Disability risk may vary by nativity status among older Latinos. For example, increased time in the United States is associated with the adoption of poor health behaviors such as drinking alcohol and smoking, which may disproportionately disadvantage U.S.-born, compared with foreign-born, Latinos (GordonLarsen, Harris, Ward, & Popkin, 2003). In addition, acculturation is associated with the erosion of family and other forms of social support, which increases the risk for poor mental (Hiott, Grzywacz, Arcury, & Quandt, 2006) and physical health outcomes (Penninx, Leveille, Ferrucci, van Eijk, & Guralnik, 1999; Waite & Hughes, 1999). However, increased time in the United States is also associated with access to valuable resources in later life, including health insurance (Gonzalez, Ceballos, et al., 2009). Depression is a major contributor to disability, accounting for 4.4% of total disability-adjusted life years (DALY) globally (Ustun, Ayuso-Mateos, Chatterji, Mathers, & Murray, 2004). Although prevalence rates vary (Dunlop, Song, Lyons, Manheim, & Chang, 2003; Gonzalez, Ceballos, et al.,
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2009; Gonzalez, Haan, & Hinton, 2001; Rogler, Cortes, & Malgady, 1991), an estimated 25.6% of older Latinos report depressive symptoms—compared with 9% to 16.9% for older White and Black adults (Black, Markides, & Miller, 1998; Blazer, Landerman, Hays, Simonsick, & Saunders, 1998). It is unclear whether depression contributes to disability (Penninx et al., 1999) or disability increases the risk for depression—though it is likely that this relationship is reciprocal in later life (Alexopoulos et al., 1996; Dunlop et al., 2003; Ormel, Rijsdijk, Sullivan, van Sonderen, & Kempen, 2002). Older Latinos may experience depression and disability differently than other racial/ethnic groups. For example, in one study examining disabled older adults, Latinos experienced higher levels of depressive symptoms in the context of disability than older Whites (Brown & Turner, 2010). This may be because disability is associated with chronic psychological stress and shame, limited social involvement, loneliness, and a perceived reduction in social support among older Latinos (Brown & Turner, 2010; Tomaka, Thompson, & Palacios, 2006). In sum, previous work has focused on depression (Dunlop et al., 2003) and disability (Hayward, Hummer, Chiu, González-González, & Wong, 2014) among older Latinos. The aim of this study is to examine the contribution of depressive symptoms to disability in a community-dwelling population of older adults and how this relationship may vary by nativity status (U.S. vs. foreign-born) among older Latinos. This is important as depressive symptoms may account for some of the observed racial/ethnic differences in disability between older Whites and Latinos and older Latinos are at greater risk for both depression and the onset and progression of disability in later life. As older Latinos experience the onset of disability at earlier ages than older Whites, it is expected that the effect of depressive symptoms on disability will be most pronounced for IADL disability (S. P. Wallace & Villa, 2003). It is unclear how nativity status may affect this relationship, though foreign-born Latinos may have access to social and other resources in later life that are beneficial to health outcomes. Given that depressive symptoms are amenable to intervention (Callahan et al., 2005), this study’s findings may be used to effectively delay the onset (IADL) and progression (ADL) of disability among at risk groups of older adults.
Method Data Source The Health and Retirement Study (HRS), a prospective multistage probability cohort sample of U.S. households, was conducted by the University of
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Michigan with support from the National Institute of Aging. The first wave of the HRS occurred in 1992 with a 51- to 61-year-old cohort and was merged with the older Asset and Health Dynamics Among the Oldest Old Study (AHEAD; born 1890-1923) in 1998. Two additional cohorts, Children of the Depression Age (CODA; 1924-1930) and War Babies (WB; born 1942-1947) were added in 1998 to fill in the gaps between these two groups, resulting in a sample design nationally representative of the U.S. population older than age 50 in 1998. Further details on the HRS design and methods have been previously published (Heeringa & Connor, 1995). Consistent with previous work, respondents scoring at or above 4 depressive symptoms at baseline (16.3%) were excluded to examine how depressive symptoms affect IADL/ADL disability (Mojtabai & Olfson, 2004). Older adults unable to answer survey questions themselves at baseline (and required a proxy) were also excluded. Data were weighted using respondentlevel sampling weights to account for the sample design in the HRS and to generalize findings to the community-dwelling older adult population (Heeringa & Connor, 1995). This study, using seven waves of data from the HRS (1998-2010), is a nationally representative sample of noninstitutionalized Americans age 51 and older (N = 15,444). All respondents in this study participated in the 1998 survey year. Approximately, 56.7% of respondents participated in all seven waves of the HRS (from 1998 to 2010). By year 2010, approximately 33.3% of respondents were deceased and 2.9% were lost to follow-up. Nonresponse rates increased with age and were higher for non-Whites, men, and respondents with low SES. Dependent variables. Disability was measured by IADL and ADL (each ranging from 0 to 5): mobility, IADL, and ADL (Lawton & Brody, 1969). For IADL, respondents were asked if they had difficulties (yes/no) using the phone, managing money, taking medications, shopping for groceries, and preparing hot meals. For ADL, respondents were asked if they had difficulties (yes/no) walking across a room, bathing, eating, dressing, and getting in and out of bed. The disability scales had high internal consistency (α = .80 IADL; α = .83 ADL). Independent variables. The brief Center for Epidemiologic Studies– Depression scale (CES-D) was the independent variable of interest in this study. The 8-item CES-D has similar symptom dimensions as the 20-item CES-D and has high internal consistency (α = .76; Steffick, 2000; R. Wallace et al., 2000). The CES-D consists of a summed scale detailing whether or not the respondent felt (a) depressed, (b) everything was an effort, (c) sleep was restless, (d) alone, (e) sad, (f) could not get going, (g) happy, and (h) enjoyed
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life in the past week. Items such as felt happy and enjoyed life were reverse coded. Race/ethnicity was measured by four mutually exclusive categories; if a respondent identified as Latino, he or she was considered to be Latino even if he or she was also a member of a racial group (Latino, non-Latino White, non-Latino Black, non-Latino other). Nativity status was either U.S.or foreign-born. Covariates. Additional variables included marital status (married/partnered vs. not), number of persons living in the household, health behaviors (current/former smoker, number of alcoholic drinks per week, and weight; body mass index [BMI]) and self-reported health conditions (summed scale ranging from 0 to 6 [yes/no]), including diabetes (high blood sugar), high blood pressure (or hypertension), lung disease, stroke (or transient ischemic attack), heart conditions (including coronary heart disease, heart attack, congestive heart failure, and the occurrence of heart surgery), and arthritis. SES was measured by education (years), income (the log transformed total household income including earnings, pensions, and social security), and wealth (the log transformed value of assets minus the sum of all debt, including mortgages). Demographic conditions included age (centered at age 65 for ease of interpretation) and gender (male, female).
Statistical Analysis Multilevel statistical modeling using hierarchical linear modeling software Version 7 (Scientific Software International, Lincolnwood, IL) was used to examine individual and aggregate levels of data over time and to account for the complex HRS sampling design and the subset analyzed (Raudenbush & Bryk, 2002). Multilevel modeling conceives of each individual as having his or her own regression equation but incorporates information from all seven (1998-2010) waves of data simultaneously in the same model. As many disability distributions are nonnormal, reflecting the higher frequency of intact functioning among the general older adult population, alternative disability distributions were considered. An examination of residual fit values suggested that nonlinear models were a better fit than linear models. The results of the Poisson nonlinear analyses (with overdispersion) are reported below. Models below are presented as a series of nested models, one for each level of the hierarchy. At the first level, each individual respondent’s trajectory of change in disability is represented as a function of person–time– specific parameters (e.g., depressive symptoms, income, wealth, health behaviors, health conditions) plus random error. These variables are time varying, measured at baseline (year 1998) and subsequently every 2 years
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over the 12-year course of the survey. The second level statistically models individual variations in growth parameters across a population of persons (e.g., gender, race/ethnicity, nativity status, education). Multilevel models account for between-subject heterogeneity and within-individual correlations and model cluster-induced errors in the intercepts and coefficients to increase the efficiency of the estimates. In the models below, effect estimates are presented in terms of event rate ratios (ERRs), which are the exponentiated beta coefficients from the Poisson model. An ERR is interpreted as the percentage change in a dependent variable associated with a 1-unit increase in an independent variable. To examine the association between depressive symptoms and the onset and progression of IADL/ADL disability among Latino adults, IADL and ADL models examine the effect of nativity (U.S.vs. foreign-born) on disability (Tables 3 and 4, Model 2) and interactions between nativity and depressive symptom–related disability (Tables 3 and 4, Model 3).
Results Bivariate As shown in Table 1, the average respondent was about 64 years old, female, and White. About 4.9% of the sample identified as Latino, about 2.5% of Latinos were U.S.- born, and 2.3% were foreign-born. On average, foreignborn Latinos reported living in the United States for about 38 years. Latinos (overall) reported 1.1 depressive symptoms at baseline, with foreign-born and U.S.- born Latinos reporting similar means. On average, respondents had at least a high school education and most respondents reported a history of smoking cigarettes (60%); only about 20% of respondents were currently smoking. As shown in Table 2, compared with Whites, Latinos reported significantly more difficulties performing IADL and ADL over the 12-year course of the study. For example, by 2010 Whites reported 0.37 IADL and ADL; Latinos reported 0.57 and 0.63, respectively. Among Latinos, foreign-born Latinos had more disabilities in IADL and ADL by survey year 2010 than their U.S.-born counterparts.
Multivariate As shown in Table 3, Model 1, each 2-year increase in age is associated with a 14% increase in IADL disability. Females are associated with 20% more IADL disability than males and Latinos are associated with 66% more IADL disability than Whites. Also shown in Model 1, a 1-unit increase in depressive symptoms is associated with a 52% increase in IADL disability.
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Table 1. Baseline Characteristics of Respondents in the Health and Retirement Study (HRS). Characteristic
Total sample n = 15,444
M age in years (SD) Female, n (%) Race/ethnicity, n (%) White Latino Black Other Nativity, n (%) U.S.-born Latino Foreign-born Latino Time in United States in years, M (SD) Depressive symptoms, M (SD) White Latino U.S.-born Latino Latino foreign-born Social support, M (SD) Married Number of persons living in home Socioeconomic status, M (SD) Years of education Income (log transformed) Wealth (log transformed) Health behaviors, M (SD) Number of drinks/week Current smoker Ever smoked Body mass index (BMI) Health conditions, M (SD)
64.1 (10.3) 8,801 (55.5) 12,359 (85.3) 905 (4.9) 1,914 (7.9) 262 (1.8) 451 (2.5) 454 (2.3) 38.4 (16.1) 0.8 (0.9) 1.1 (1.0) 1.1 (1.0) 1.1 (1.1) 0.7 (0.5) 2.2 (1.1) 12.6 (3.0) 4.5 (0.5) 4.8 (1.7) 2.5 (6.4) 0.2 (0.4) 0.6 (0.5) 26.9 (5.1) 0.4 (0.7)
In Model 2, nativity status, social support, SES, health behaviors, and health conditions are added to the model. With these additions, Latinos are associated with 20% more IADL disability than Whites but foreign-born Latinos are associated with 29% fewer IADL disabilities than their U.S.-born counterparts. A 1-unit increase in depressive symptoms is associated with a 46% increase in IADL disability.
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0.11 0.14* 0.14* 0.14*
White Latino U.S.-born Latino Foreign-born Latino
*p ≤ .001.
1998
Race/ethnicity
0.17 0.24* 0.28* 0.20*
2000 0.23 0.28* 0.32* 0.23
2002 0.26 0.29* 0.27* 0.30*
2004
IADL
0.31 0.35* 0.29* 0.41*
2006 0.32 0.43* 0.43* 0.43*
2008 0.37 0.57* 0.54* 0.62*
2010 0.17 0.20* 0.20* 0.21*
1998 0.20 0.25* 0.24* 0.25*
2000
0.25 0.30* 0.30* 0.31*
2002
0.28 0.36* 0.38* 0.34*
2004
ADL
0.32 0.45* 0.38* 0.52*
2006
0.33 0.47* 0.43* 0.52*
2008
0.37 0.63* 0.57* 0.71*
2010
Table 2. Racial/Ethnic Differences in Mean Instrumental Activities of Daily Living (IADL) and Activities of Daily Living (ADL) in the Health and Retirement Study (HRS), 1998 to 2010 (N = 15,444).
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1.14 [0.90, 1.46] 1.45*** [1.43, 1.47] 1.14*** [1.07, 1.22] 0.82*** [0.74, 0.94] 0.86*** [0.83, 0.89] 1.11*** [1.10, 1.12]
0.71*** [0.61, 0.84] 1.46*** [1.45, 1.48]
0.86*** [0.83, 0.89] 1.11*** [1.10, 1.12]
1.52*** [1.50, 1.53]
(continued)
1.12 [0.91, 1.37] 1.33*** [1.20, 1.46] 1.42** [1.11, 1.82]
1.20** [1.05, 1.37] 1.35*** [1.20, 1.46] 1.42** [1.11, 1.83]
1.66*** [1.44, 1.92] 1.98*** [1.79, 2.20] 1.64*** [1.26, 2.13]
1.10*** [1.09, 1.10] 1.09* [1.02, 1.17]
ERR (CI)
Model 3
1.10*** [1.09, 1.10] 1.09* [1.02, 1.17]
ERR (CI)
Model 2
1.14*** [1.14, 1.15] 1.20*** [1.12, 1.29]
ERR (CI)
Demographic characteristics Age Female Race/ethnicity Latino Black Other Nativity status Foreign-born Latino Depressive symptoms × Latino × Foreign-born Latino Social support Married/partnered Persons living in home
Model 1
IADL
Table 3. Hierarchical Poisson Models Examining the Relationship Between Depressive Symptoms and Instrumental Activities of Daily Living (IADL) in the Health and Retirement Study (HRS), 1998 to 2010 (N = 15,444).
1295
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285,138.03
0.98*** [0.98, 0.99] 0.95 [0.90, 1.01] 1.10** [1.02, 1.17] 0.99*** [0.98, 0.99] 1.41*** [1.39, 1.42]
0.98*** [0.98, 0.99] 0.95 [0.90, 1.01] 1.10** [1.02, 1.17] 0.99*** [0.98, 0.99] 1.41*** [1.39, 1.42] 285,138.04***
0.94*** [0.94, 0.95] 0.88*** [0.86, 0.89] 0.96*** [0.95, 0.96]
ERR (CI)
Model 3
0.94*** [0.93, 0.95] 0.88*** [0.86, 0.89] 0.96*** [0.95, 0.96]
ERR (CI)
Model 2
IADL
Note. Estimates are weighted to using respondent-level sampling weights to account for the sample design in the HRS and to generalize findings to the community-dwelling older adult population. ERR = event rate ratio; CI = confidence intervals; SES = socioeconomic status; BMI = body mass index. *p < .05. **p < .01. ***p ≤ .001.
372,804.69
ERR (CI)
SES Education (years) Income (logged value) Wealth (logged value) Health behaviors Drinks/week Current smoker Ever smoked BMI Health conditions Model fit statistics χ2
Model 1
Table 3. (continued)
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In Model 3, interactions between depressive symptoms, race/ethnicity, and nativity status are examined. In this model, a 1-unit increase in depressive symptoms is associated with increased IADL disability among Latinos, compared with Whites, but this relationship varies by nativity status. Foreignborn Latinos are associated with 18% fewer depressive symptom–related IADL disability than their U.S.-born counterparts, accounting for demographic characteristics, social support, SES, health behaviors, and health conditions. As shown at the bottom of Table 3, additions to the models improved model fit, accounting for additional variance explained. As shown in Table 4, Model 1, each 2-year increase in age is associated with a 10% increase in ADL disability. Females are associated with 14% more ADL disability than males and Latinos are associated with 51% more ADL disability than Whites. Also shown in Model 1, a 1-unit increase in depressive symptoms is associated with a 55% increase in ADL disability. As with the IADL model, nativity status, social support, SES, health behaviors, and health conditions are added to Model 2. These additions to the model statistically explain the relationship between Latino ethnicity and ADL disability. In this model, a 1-unit increase in depressive symptoms is associated with a 51% increase in ADL disability. In Model 3, interactions between depressive symptoms, race/ethnicity, and nativity are examined. In this model, foreign-born Latinos are associated with 53% more ADL disability than Whites. In addition, a 1-unit increase in depressive symptoms is associated with increased ADL disability but this relationship varies by nativity status. Foreign-born Latinos are associated with 18% fewer depressive symptom–related ADL disability than their U.S.born counterparts, accounting for the other factors considered in the model. As shown at the bottom of Table 4, additions to the models improved model fit, accounting for additional variance explained. Figure 1 graphically displays these depressive symptom–related IADL and ADL results, assuming three depressive symptoms (90% of the sample reported three or fewer depressive symptoms in survey year 2000). As shown here, accounting for all of the factors considered in this study, U.S.-born Latinos have the highest depressive symptom–related IADL and ADL disability over time, followed by Whites and foreign-born Latinos. Given that these results may suggest “protective” effects for depressive symptoms among foreign-born Latinos, we also examined the mean number of depressive symptoms across study years in post hoc analyses (not shown). Except for baseline year, 1998, when foreign-born Latinos and U.S.-born Latinos had similar means, foreign-born Latinos had consistently higher depressive symptom means (ranging from 1.11 to 1.60) than U.S.-born Latinos (ranging from 1.12 to 1.45) and Whites (ranging from 0.84 to 1.02).
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1.53** [1.13, 2.07] 1.51*** [1.49, 1.54] 1.00 [0.93, 1.08] 0.82*** [0.73, 0.93] 1.01 [0.97, 1.05] 1.03*** [1.02, 1.05]
1.20 [0.91, 1.60] 1.51*** [1.49, 1.53]
1.01 [0.97, 1.05] 1.03*** [1.02, 1.05]
1.55*** [1.53, 1.57]
(continued)
1.13 [0.94, 1.38] 1.35*** [1.24, 1.48] 1.24 [0.98, 1.56]
1.14 [0.96, 1.36] 1.35*** [1.24, 1.48] 1.24 [0.98, 1.56]
1.51*** [1.33, 1.73] 1.87*** [1.70, 2.06] 1.41** [1.11, 1.79]
1.06*** [1.06, 1.07] 1.10** [1.03, 1.17]
ERR (CI)
Model 3
1.06*** [1.06, 1.07] 1.10** [1.03, 1.17]
ERR (CI)
Model 2
1.10*** [1.09, 1.10] 1.14*** [1.07, 1.22]
ERR (CI)
Demographic characteristics Age Gender Race/ethnicity Latino Black Other Nativity status Foreign-born Latino Depressive symptoms × Latino × Foreign-born Latino Social support Married/partnered Persons living in home
Model 1
ADL
Table 4. Hierarchical Poisson Models Examining the Relationship Between Depressive Symptoms and Activities of Daily Living (ADL) in the Health and Retirement Study (HRS), 1998 to 2010 (N = 15,444).
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272,851.30***
0.98*** [0.98, 0.99] 0.95 [0.90, 1.00] 1.15*** [1.08, 1.22] 1.01*** [1.01, 1.02] 1.34*** [1.32, 1.35]
0.96*** [0.95, 0.96] 0.87*** [0.85, 0.89] 0.97*** [0.96, 0.97]
ERR (CI)
Model 2
ADL
272,979.83
0.96*** [0.95, 0.96] 0.87*** [0.85, 0.89] 0.97*** [0.96, 0.97] 0.98*** [0.98, 0.99] 0.95 [0.90, 1.00] 1.15*** [1.08, 1.22] 1.01*** [1.01, 1.02] 1.34*** [1.32, 1.35]
ERR (CI)
Model 3
Note. Estimates are weighted to using respondent-level sampling weights to account for the sample design in the HRS and to generalize findings to the community-dwelling older adult population. ERR = event rate ratio; CI = confidence intervals; SES = socioeconomic status; BMI = body mass index. *p < .05. **p < .01. ***p ≤ .001.
363,159.51
ERR (CI)
SES Education (years) Income (logged value) Wealth (logged value) Health behaviors Drinks/week Current smoker Ever smoked BMI Health conditions Model fit statistics χ2
Model 1
Table 4. (continued)
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2.3 2.1 1.9
ADL/IADL
1.7
IADL; White IADL; Foreign-born La no
1.5
IADL; U.S. born La no
1.3
ADL; White
1.1
ADL; Foreign-born La no ADL; U.S. born La no
0.9 0.7 0.5 1998
2000
2002
2004
2006
2008
2010
Figure 1. Rates of depressive symptom–related ADL and IADL disability in the HRS by race/ethnicity and nativity status, 1998 to 2010 (N = 15,444).
Note. Estimates are weighted; respondent-level sampling weights were used to account for the sample design in the HRS findings to the community-dwelling older adult population. ADL = activities of daily living; IADL = instrumental activities of daily living; HRS = Health and Retirement Study.
Discussion This prospective study of older adults in the United States found that foreignborn Latinos have lower than expected depressive symptom–related IADL and ADL disability than their older White and U.S.-born Latino counterparts. This study’s findings are important given that this study used a nationally representative sample of adults age 51 and older in the United States and accounted for social support, SES, health behaviors, and health conditions, which are associated with depression and disability. In addition, this study captured important health transitions, including intraindividual changes in disability among older Latinos and older Whites over the course of 12 years, with hierarchical linear modeling statistical techniques. There may be several explanations for this study’s findings. First, it may be that foreign-born Latinos have fewer depressive symptoms than Whites and thus lower than expected rates of depressive symptom–related disability. However, in post hoc analyses, this hypothesis was not supported; foreignborn Latinos had higher depressive symptom means. Second, there is research suggesting that Latinos and some other minority group members are more likely than Whites to report a physical concern or condition when experiencing psychological distress (Canino, Rubio-Stipec, Canino, & Escobar, 1992).
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For example, previous work showed that Mexican American women are more likely to report somatic symptoms of depression than White women (Escobar, Burnam, Karno, Forsythe, & Golding, 1987) and that Puerto Rican Americans are more likely than Whites to report somatic symptoms (Escobar & Canino, 1989). This idea of “somatization” was not supported here; the foreign-born Latinos in this study had more depressive symptoms and disability—so there was no evidence that this group had difficulty articulating psychological or physical conditions. Rather, it may be that the relationship between poor mental health and physical health outcomes is weaker among this group compared with older Whites, suggesting that depressive symptoms may be less consequential for older foreign-born Latinos in terms of disability outcomes. In this study, foreign-born Latinos continued to be at an increased risk for (ADL) disability—but this risk did not operate through depressive symptoms. Previous work in this area has reported similar results for older Blacks compared with older Whites (Rajan, Barnes, Wilson, Evans, & Mendes de Leon, 2014). Finally, acculturation may play a role in the relationship between depression and disability among older foreign-born Latinos. Some factors associated with low acculturation, such as limited English proficiency, retaining country of origin beliefs, traditions, communication patterns, and help-seeking behaviors, have been associated with increased depressive symptoms among older Latinos (Black et al., 1998; Gonzalez et al., 2001; GordonLarsen et al., 2003). However, some of these factors may also have health benefits. For example, due to immigration patterns, language barriers and other factors, foreign-born Latinos may be more likely than U.S.-born Latinos to live in Spanish-speaking neighborhoods that provide a variety of benefits including assistance with everyday activities, a shared system of reciprocity, and the exchange of goods and services—from employment opportunities and child care to recreational activities (Vega, Ang, Rodriguez, & Finch, 2011). Research suggests that foreign-born Latinos who reside in the United States for 15 years or more are “protected” from depressive symptoms and associated outcomes due to their integration into these Spanish-speaking communities (Vega et al., 2011). Other studies suggest that increased time in the United States is particularly important for older Latinos who have increased access to health care, insurance, and other socioeconomic resources (Gonzalez, Ceballos, et al., 2009). The foreign-born Latinos in this study resided in the United States for about 38 years, suggesting that they may benefit from these protective social networks, systems of reciprocity, and other neighborhood factors that are necessary for health benefits. There are several limitations to consider when interpreting results. First, attrition is a persistent problem in longitudinal studies. Although attrition has
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not significantly influenced the representativeness of the HRS sample in terms of demographic, economic, and health measures, it remains that the healthiest adults may be selected into and remain in the study over time. Thus, this study’s findings may err toward an underestimation of depressive symptoms and disability in the population. Similarly, the “salmon bias,” where ill or unemployed Latinos return to their country of origin and are not counted in health surveys such as this one may affect this study’s findings (Hayward et al. 2014; Abraido-Lanza, Dohrenwend, Ng-Mak, & Turner, 1999). However, there was no evidence of this bias in this study as foreignborn Latino respondents entered into and were retained in the study at similar rates to that of Whites and other racial/ethnic groups. In addition, disability increased steadily over time for the foreign-born Latinos in this study, which would not likely be the case had only the healthiest of this group remained in the study over time. Finally, the relationship between depressive symptoms and disability may vary by country of origin and other factors that were unable to be examined in this study. Future work accounting for these may further refine this study’s findings. In sum, this study found persistent differences in the relationship between depressive symptoms and IADL and ADL disability by race/ethnicity and nativity, with foreign-born Latinos reporting lower depressive symptom– related disability than their U.S.-born Latino and White counterparts. This relationship was not explained by somatization but may be related to protective aspects of the Latino foreign-born culture—strong social networks and ties among community members that help older foreign-born Latinos manage everyday self-care and functional tasks (Aranda, Ray, Snih, Ottenbacher, & Markides, 2011). Given that U.S.-born Latinos had similar or poorer depressive symptom–related disability outcomes than Whites, interventions focused on early detection and treatment of depressive symptoms for this group are warranted and may improve disablement outcomes (Bowen & Gonzalez, 2008; Gonzalez, Tarraf, et al., 2009). The collaborative primary care model, which includes structured interdisciplinary teams and focused interventions that vary in intensity, has been shown to have short- and long-term mental health benefits (Gilbody, Bower, Fletcher, Richards, & Sutton, 2006). This model may be an appropriate intervention for older Latinos who are likely to rely on primary care for the diagnosis and treatment of depression and other mental health disorders. Acknowledgment The authors would like to thank Dr. Hector González for his helpful comments on this article and the anonymous reviewers at the Journal of Aging and Health for their valuable editorial comments.
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Authors’ Note The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.
Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Dr. Bowen is supported by the Department of Veterans Affairs, Rehabilitation Research and Development (RR&D CDA E7503W).
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