SPECIAL ARTICLES
Morbidity, Disability, and Health Status of Black American Elderlv: A New Look at the Oldest-Old J
T. P. Miles, MD* and M. A. Bernard, M D t There are over 2.5 million black Americans aged 65 and over living in the United States today, including some 258,000 persons aged 85 years and over. The post-World War I1 baby boom within the US black population should ensure that the numbers of persons aged 65 and over will increase into the 21st Century. If present trends continue, it is projected that the current population of black elders will also age. This means that the numbers of black persons aged 85 and over will also increase. Data from both national surveys and population-based community studies concerning the health
and well-being of black elders are now becoming available. This report presents information concerning self-reported health status, chronic disease prevalence, disease-risk-factor prevalence, measures of physical functioning, and nursing home utilization rates for age groups within the black population aged 65 years and over. The availability of such data should lead to the development of targeted interventions designed to lessen impairment and prolong independent living. J Am Geriatr SOC40:1047-1054,1992
here are over 2.5 million black Americans aged 65 years and over living in the United States.’ This total includes some 6,000 persons aged 100 years and over. General awareness among health care providers of trends in the health status of this group of elders is often overshadowed either by the more dramatic mortality events observed among younger blacks or by the greater numbers of older whites. Researchers documenting the social, economic, and demographic factors underlying disease and disability observed among black elders have been hampered in the past by a paucity of both national- and communitylevel data sources.’ In recent years, however, new studies have been initiated which are now beginning to highlight this p o p ~ l a t i o n . ~Preliminary -~ data that have particular interest for health care providers are now becoming available. For the remainder of this report, information from these national surveys will be used to show trends. United States national trends may vary in their applicability to regional populations. When specific details are available, reference will be made to community-based studies. Additionally, where data are available, a specific emphasis will be placed on persons aged 85 years and over-the oldest old. To highlight factors contributing to the health and well being of this group, data illustrating mortality and morbidity trends will be presented. Social and economic issues relevant to health and well being will also be discussed.
national and regional surveys, was used to develop this report. Readers are encouraged to consult individual documents for greater details. In particular, as noted in the tables and figures, the following data sources were utilized: census counts from 1950-1988; US National Vital Statistics from the National Center for Health Statistics; cancer incidence data from the Surveillance Epidemiology and End Results program of the National Cancer Institute; and the 1984 National Health Interview Supplement on Aging. To highlight the physical functioning, chronic disease, and risk factor prevalence for blacks aged 85 years and over, data from the North Carolina Established Population for Epidemiologic Studies of the Elderly (EPESE)5were reviewed. The EPESE is a prospective epidemiologic study of health status, physical, social, and cognitive functioning of a biracial population of persons aged 65 years and older living in five North Carolina counties. The reader may consult Brock et a18 for an in-depth discussion of the sampling strategyRESULTS Age, sex and geographic distribution are factors relevant to the planning of health care resource utilization. The US black population over age 65 has an age distribution which is slightly younger than whites. For example, 61.8 percent of blacks over age 65 are between 65 and 74 years old, compared with 58.6 percent of older whites.’ The gender composition of black and white populations in the US is similar-59 percent female. In 1980, older black Americans (80.6%), like their white counterparts (73.8%), were more likely to live in urbanized areas than on farms.7 Within urban sites, the majority of blacks (69.1 percent) live within the central city area, while whites were equally distributed between central (39 percent) and suburban (40.2 percent) areas.
T
METHODS Information from a computerized search of the medical literature from 1987-1992, as well as data from *From the University of Illinois at Chicago, School of Public Health, Chicago, Illinois; and the tUniversity of Oklahoma, Department of Mediane, Oklahoma City, Oklahoma. An editorial concerning this issue by Dr. John Morley, Associate Editor, will appear in the November issue of JAGS. 1AGS 40:1047-1054, 1992 0 1992 by the American Geriatrics Society
0002-8614f 92/$3.50
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1AG.S-OCTOBER 1992-VOL. 40, NO. 10
MILES AND BERNARD
While black elders are a small proportion (8.2 percent) of the total population over age 65, their proportion within the US black population has been increasing over the past 40 years, leading to a “Graying of Black America” (Figure 1). During the period between 1950 and 1990, the percentage of blacks aged 65 years and over has increased by 50 percent.’-l5 In 1950 there were 621,000 blacks aged 65 years and older. By 1970 that number had more than doubled, increasing to 1.6 million. In 1988, there were an estimated 2.5 million black Americans aged 65 years and over living in the United States. The mortality experience of black elders is often obscured by the more dramatic events observed among younger members of the population. Over two-thirds of all deaths among US blacks in 1988 occurred in the group over age 65 years.16 Mortality rates in this age group are higher than any other age category (Figure 2). This trend of increasingly higher death rates with age is similar to that observed in the US white population, as are the causes of mortality among black
Percent age 65.
10
I I
1950
-
1960
1970
1980
TABLE 1. LEADING CAUSES OF DEATH, US BLACKS, 1988. AGED 25 YEARS AND OVER 65 Years and 25-44 Years 45-64 Years Over
1988
Year
~
% Over 65
Source: Bureau of the Census
elders. For comparison, Table 1shows the three leading causes of death for persons aged 25-44,45-64, and 65 years and over. While homicide and accidents predominate early in life, it is heart disease, cancer and stroke that are most prevalent at later ages. Age-specific life expectancy is a useful statistic because it more accurately reflects survival for the group of individuals currently at a given age. As shown in Figure 3, it is estimated that half of all blacks aged 65 years in 1988 will live an average of 15.5 additional years.I7 There are differences in survival between the sexes, with males aged 65 years having a lower average (13.5 years) and females aged 65 years a greater average (17.2 years). Similar trends are observed for persons aged 75 years. Age-specific life expectancy for persons aged 85 years is even more informative when one considers that this is the age group with the highest risk of institutionalization. Based on these data, onehalf of all black elders aged 85 years in 1988 will live an additional 6.8 years. For some black elders, these years of additional life are marked by high rates of poor health (Figures 4 and 5) and chronic disease (Tables 2a, 2b, and 3). Regardless of age, almost half of black respondents in national surveys of community-dwelling persons report poor health. Self-reported health status has been found to correlate with use of health care services. Black females aged 65 to 74 years have the highest rates of reported poor health (54.5 percent), while males aged 65 to 74 years have the lowest (47.4%).” Males and females aged 75 years and over have very similar rates of poor
FIGURE 1. Graying of Black America, 1950-1988; percent aged 65 years and over. Time trends presented were population figures of census counts as of April 1 for 1950, 1960,1970,1980 and estimates as of July 1, 1988.’-15
Heart Disease Cancer Stroke
1. Homicide 2. Accidents 3. Heart Disease
Heart Disease Cancer Stroke
Source: NCHS.’
Average Remaining Years -
Deaths Per 100,OOO(Thousands)
1
* O r - -
16
r
14 12 10
8 6 4
-
2 vUnder 1 1-4
Y
75
65 5-u
15-24 25-34 35-44 45-54 56-64 85-74 75-84
=
Age Group
Males
85
Specific Age
85.
=Both
Sexes
Males
0Females
Females
Source: NCHS
FIGURE 2. Age-specific mortality, US blacks, 1988. Mortality rates presented were based on the US National Vital Statistics System compiled by the National Center for Health StatistiCs.l6
Source: NCHS
FIGURE 3. Average remaining years, by sex, 1984; US blacks aged 65, 75, and 85 years. Age-specific life expectancy estimates were developed by the National Center for Health Statistics based on current trends in age-specific mortality.”
JAGS-OCTOBER 1992-VOL.40,NO. 10
HEALTH STATUS OF BLACK AMERICAN ELDERLY
1049
colon/rectum (510 per 100,000), and lung (443 per 100,000) have the highest incidence rates among older black males, while breast (345 per 100,000), colon/ rectum (380 per 100,000), and lung (104 per 100,000) are highest among females 85 years and older. Among older whites similar patterns of mortality and incidence are observed. Other cancer sites are an important source of morbidity for older blacks (Table 2b)." Black females aged 85 years and over are at risk for morbidity due to 65-74 75-84 85. cervical (62 per 100,000) and uterine (73 per 100,000) Age Groups cancer. Multiple myeloma is another common source of morbidity for older blacks; incidence rates among Males Females males (67 per 100,000) and females (57 per 100,000) Source NCHS are higher than for ovary (37.6 per 100,000), skin FIGURE 4. Percent reporting poor health, by sex and age; US blacks, (males 5.2, females 8.9 per 100,000), and most leuke1984.Self-reported health status data were derived from the 1984 mias (both sexes combined: lymphocytic 29.4, granuNational Health Interview Survey Supplement on Aging Respond- locytic 23.2, and monocytic 3.1 per 100,000-data not ents were asked to rate their health in one of five categories: excellent, shown). very good, good, fair, or poor. To illustrate the burden of other chronic diseases among the oldest persons, Table 3 lists lifetime prevalence of selected medical conditions among black parPercent of Total Respondents 80 r ticipants in the EPESE.21-24Not surprisingly, hypertension was the most commonly reported medical history in this population. Over 51 percent of males, and 68.9 60 'O percent of females report a history of hypertension. The highest rates of occurrence were among females aged 70-74 years. Those 85 years and older had the lowest rates of hypertension. Prevalence rates for other diseases of the cardiovascular system-heart attack (13.4%-13.7%), stroke (9.O%-9.6%), and angina (2.3%-6.7%)-are also shown by age and sex. It is 65-74 75-84 85+ interesting to note that in this community there were Age Groups no sex differences nor age trends in heart attack, stroke, Males Females or angina. One major risk factor of heart disease is diabetes. Females between 65 and 84 years had higher Source: NCHS rates of disease (22.7%-30.5%) than did males (19.5%FIGURE 5. Disease-related activity limitation, by sex and age; US 24.9%).Among the oldest-old, no sex differences were blacks, 1984. Data derived from 1984 National Health Interview Survey Supplement on Aging.'" Activity limitation estimates were observed. This lower prevalence rate of diabetes among based on responses to the question, 'Are you limited in ANY WAY the oldest cohort may be due to increased mortality at in any activities because of an impairment or health problem?"" younger ages associated with this disease. Osteoporotic fractures and osteoarthritis are common skeletal diseases in late life. While osteoporosis is health; approximately 50 percent of this group report a poorly understood phenomenon among older blacks, poor health. The reported poor health of this popula- data are available describing the population prevalence tion correlates with reported disease-related activity of fractures, a marker of osteoporosis after age 50. In limitation (Figure 5)." the EPESE cohort, 3.0 percent of males and 2.4 percent Chronic diseases such as cancer, heart disease, and of females reported having had a hip fracture. The stroke are highly prevalent at older ages. Across most highest rates of hip fracture were reported among populations of elderly, cancer mortality and incidence males aged 75 to 79 (5.9%) and those 85 years and are higher in successively older age groups. A similar over (6.5%). While the prevalence of hip fracture inpattern of mortality (Table 2a) and incidence (Table creased with age among black females, no similar age 2b) also occurs for US black elder^.'^^^^ Older black trend was reported for fractures at other sites. There males have higher mortality and incidence rates overall was no sex difference in the occurrence of fractures at than black females. Among black males 85 years and other sites. History of arthritis, another common skelolder, the top three sites most frequently associated etal disease in late life, was not ascertained in the with annual cancer mortality are: prostate (937 per North Carolina sample. However, national surveys 100,000), lung (391 per 100,000), and colon/rectum indicate that among blacks aged 75 years and over, (307 per 100,000). Mortality rates for females aged 85 51.7 percent of males and 69.9 percent of females years and over are highest for colon/rectum (250 per report having been diagnosed by a physician as having 100,000), breast (156 per 100,000), and lung (100 per arthritis.24Among blacks aged 60 to 74 years in a 100,000). Annual incidence rates, though higher, fol- national survey, females were identified as the group low a similar pattern. Prostate (1448 per 100,000), with the most limited range of motion at both hip and Percent of Total Respondents
6o
r
-
I
=
1050
MILES AND BERNARD
JAGS-OCTOBER 1992-VOL.40, NO. 10
TABLE 2a. CANCER MORTALITY, SELECTED SITES, BY SEX, RACE, AND AGE, US 1983-1987. AVERAGE ANNUAL RATE PER 100,000i9 Black/Age Group WhiteIAge Group Site Males Skin Colon/rectum Lung* Multiple myeloma Prostate Breast Combined Females Skin Colon/Rectum Lung* Multiple myeloma Breast Cervix Corpus uterus Ovary Combined
65-69
70-74
75-79
80-84
85+
65-69
70-74
75-79
80-84
85+
2 111 494 30 174 2 1296
2 162 568 43 332 2 1727
4 206 560 54 516 3 2044
4 287 566 79 839 3 2693
3 307 391 60 937 4 2544
10 104 368 14 71 1 930
13 156 470 21 138 1 1286
15 216 544 28 245 2 1690
18 296 555 35 403 3 2127
20 379 441 39 606 3 2455
1 84 113 20 94 22 16 27 624
2 120 121 29 106 24 21 34 792
3 159 110 36 109 30 20 34 908
4 234 117 45 147 35 23 41 1204
3 250 100 40 156 39 19 35 1225
5 68 138 10 104 8 11 35 578
6 100 153 14 118 9 13 42 732
7 142 144 19 131 10 14 45 873
-10 200 129 24 151 12 15 50 1071
11 289 104 23 182 14 15 45 1289
* Includes lung and bronchus.
TABLE 2b. CANCER INCIDENCE, SELECTED SITES BY SEX, RACE, AND AGE, SEER. 1987-1987. AVERAGE ANNUAL RATE PER 100,000?" BlackIAge Group WhiteIAge Group Site Males Skin Colon/Rectum Lung* Multiple myeloma Prostate Breast Combined Females Skin Colon/rectum Lung* Multiple myeloma Breast Cervix Corpus Uterus Ovary Combined
65-69
70-74
75-79
80-84
85+
65-69
70-74
75-79
80-84
85+
2 266 663 47 702 4 2419
3 338 72 1 63 1022 5 3037
2 469 647 78 1260 8 3477
18 532 756 111 1581 4 4150
5 510 443 67 1448 3561
40 280 426 23 438 3 1899
40 390 529 28 682 5 2557
40 524 594 41 944 5 3241
51 628 564 45 1120 5 3692
52 664 429 52 1137 8 3708
3 228 166 32 280 43 72 39 1236
3 259 182 39 310 50 77 45 1396
6 323 153 52 360 57 73 54 1610
4 454 130 66 414 64 72 42 1987
9 381 104 58 345 62 73 38 1772
17 183 186 15 392 16 119 55 1324
21 264 202 18 418 18 118 59 1550
23 353 179 27 444 17 99 56 1723
22 447 143 30 442 16 82 58 1887
23 488 101 28 411 17 59 50 1894
* Includes lung and bronchus. SEER = Surveillance Epidemiology and End Resulfs Program.
knee joints.25Blacks aged 85 years and over, particularly females, report high prevalence rates of difficulty in tasks requiring back, hip, and knee mobility such as stooping, moving large objects, and walking. A person who reports limitation in activity or difficulty with the activities of daily living (ADL) is at risk for institutionalization. In the North Carolina EPESE, as with other populations of older persons, it is the oldest-old females, those 85 years and over, who have the highest rates of disability (Figures 6 and 7).22In each age cohort, females had the highest prevalence rates of activity limitation due to health, ranging from 50 percent of those 65-74 years to over 68.2 percent
of females aged 85 years and older. Among persons aged 85 years and over, both males (18.1%) and females (26.4%) reported that walking across a small room was the activity that most frequently required assistance. Females also reported higher rates of dependency in almost all ADLs. The group 85+ years also reported high rates of difficulty in instrumental activities of daily living (IADL) as measured by the Rosow-Breslau and Nagi scales.'" 27 Difficulty or inability to perform heavy housework (WORK) was highly prevalent among both males (78%) and females (81.7%).Among females, difficulty with pushing large objects (LARGE, 82.9%)and stooping (STOOP,78.5%)
IAGS-OCTOBER 1992-VOL. 40. N O . 10
1051
HEALTH STATUS OF BLACK AMERICAN ELDERLY
TABLE 3. PREVALENCE OF SELECTED MEDICAL HISTORIES, BY SEX AND AGE, BLACK RESPONDENTS, NORTH CAROLINA EPESE, 1984"
History Reported Sex & Age
HTN (1) MI (2)
Males 65-69 70-74 75-79 80-84 85+ Total Fema1es 65-69 70-74 75-79 80-84 85+ Total
CVA (3)
Angina (4)
Diabetes ( 5 )
Hip Fx (6)
Other Fx (7)
Cancer (8)
53.0 54.7 48.2 42.9 42.1 51.0
12.5 14.3 11.8 19.0 13.6 13.7
8.5 10.2 11.5 7.9 10.7 9.6
7.3 4.0 6.9 9.4 12.7 6.7
18.9 21.4 24.9 19.5 13.6 20.4
2.1 2.5 5.9 0.7 6.5 3.0
20.0 8.6 14.2 11.6 18.7 14.6
8.0 7.9 6.5 3.7 9.3 7.3
69.4 74.3 68.0 64.4 59.1 68.9
11.7 11.3 16.9 11.9 19.8 13.4
9.0 10.2 9.5 5.9 9.0 9.0
8.9 6.3 8.6 4.2 10.1 7.7
29.3 30.5 22.7 25.2 13.7 26.4
1.5 2.4 2.0 4.4 4.0 2.4
14.8 18.1 15.8 17.0 20.0 16.6
7.8 11.1 7.8 3.4 8.2 8.2
(1) H T N = Hypertension, "Doctor ever told you?" (2) MI = Heart Attack "Doctor ever told you?" (3) C V A = Stroke, "Doctor ever told you?" (4) Angina-based on responses to the Rose Questionnaire.
(5) Diabetes, "Doctor ever told diabetes, or high sugar in blood or urine?" (6) 6.(7) Fx = Fractures after age 50--hip or other sites. (8)Cancer, "Doctor ever told you?"
% Need AssistlUnable to Do
% Difficulty/Unable to Do
r
30 r
251
loo
Q
20 15
to 5
n Bath
Dress
Walk
Groom
Transfer
Toilet
Eat
" Work
Stairs
Activities
=
Males
Distance
Reach
Small
Large
Stoop
Activities
Females
Males
aFemales
North Carolina EPESE. 1984
North Carolina EPESE. 1984
FIGURE 6. Dependency in personal care activities, by sex; blacks, age 85 years and over. Persons were counted as being dependent if they reported either needing assistance or being unable to do any of the following activities: bathing, dressing, walking across a small room, personal grooming, getting from a bed to a chair (TRANSFER), using the toilet, eating.*
FIGURE 7. Difficulty in physical activities, by sex; blacks, age 85 years and over. An individual was counted as having difficulty if they reported being unable to do: heavy housework (WORK), climb stairs (STAIRS), or walk half a mile without help (DISTANCE). Persons were counted as having difficulty if they reported ANY (a little, a lot, or unable) difficulty with any of these tasks: reaching above shoulder level (REACH), writing or handling small objects (SMALL), pulling or pushing large objects (LARGE), and stooping, crouching, or kneeling
were prevalent. Difficulty with more than one IADL task and/or dependency in multiple ADL tasks has been used to identify community-dwelling persons potentially in need of home-making services. US data for black elders from the National Medical Expenditure Surveyz8show trends in dependency for single ADL and IADL items comparable to those observed in the North Carolina EPESE. In addition, 9.6 percent of blacks aged 65 years and older reported difficulty with two or more ADL tasks, and 18.7 percent reported difficulty with two or more IADL tasks. Table 4 lists the prevalence of risk factors for disease in the North Carolina EPESE population.21These risk factors for disease-change in body weight, inconti-
nence, sleep problems, smoking, and alcohol use-can serve as focal points for intervention. Unexplained weight change (a gain or loss of more than 10 pounds in the past year) was reported by 32.6 percent of males and 42.3 percent of females. Among the oldest-old, 45.3 percent of males and 51.6 percent of females reported incontinence. The proportion of females reporting sleep problems was highest among those 80 to 84 years (58.2%)and among those 85 years and older (57.7%).The prevalence of current smoking and any alcohol use was lower in successively older cohorts.
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JAGS-OCTOBER 1992-VOL 40, NO. 10
MILES AND BERNARD
TABLE 4. PREVALENCE OF SELECTED HEALTH CHARACTERISTICS, BY SEX AND AGE, BLACK RESPONDENTS, NORTH CAROLINA EPESE, 1984'l Risk Factors
Sex & Age Males 65-69 70-74 75-79 80-84 85+ Total Females 65-69 70-74 75-79 80-84 85+ Total
Weight Change (1)
Urine Difficulty
Alcohol Use
(2)
Sleep Problems (3)
Smoke? (4)
29.9 33.1 33.9 34.9 39.8 32.6
32.1 33.8 40.3 42.6 45.3 35.9
47.7 50.0 52.3 46.9 40.0 50.5
40.9 32.0 21.6 13.5 9.3 30.1
36.8 33.2 29.3 15.1 32.5 31.9
42.0 40.8 39.7 43.3 53.6 42.3
27.7 36.1 35.4 41.5 51.6 35.7
51.7 50.4 43.3 58.2 57.7 49.7
14.3 6.8 4.1 3.0 1.4 7.8
13.8 9.4 12.1 7.9 7.9 11.2
(5)
(1) Weight Change = Percent with a gain or loss of more than 10 pounds in last year. (2) Urine Problem = Percent answering some, most, or all of the time to the question, "How often do you have difficulty holding your urine until you can get to a toilet?" (3) Sleep Problems = Percent reporting any problem. Problems include: Trouble falling asleep; Waking up at night; Waking too early and not being able to fall asleep again; Sleepy during the day; Awaken not rested. (4) Smoke? = Percent currently smoking. (5) Alcohol Use = Percent reporting any liquor in the past year.
Cognitive impairment, whether it is due to dementia or depression, is a common problem in the geriatric population as a whole. Studies designed to estimate the prevalence of dementia and depression among black elders are slowed by the need to develop reliable screening instruments valid for use in this population. Low educational attainment is a serious source of bias when either the Folstein Mini-mental Status Exam or the Short Portable Mental Status Questionnaire are used to diagnose mild to moderate It has been speculated that multi-infarct dementia might be common among black elders because of the high prevalence of stroke risk factors such as hypertension, diabetes, alcoholism, and head trauma.30 Populationbased estimates of definite and possible dementia among blacks aged 60 and over range from 8.9 percent of males and 19.9 percent of females3' to 20.7 percent of males and 25.5 percent of females.32The contribution of depression to cognitive impairment among black elders is less well studied than dementia. A study of patients seen in a large primary care setting in Durham, NC revealed that 22 percent of patients had symptoms of a clinical d e p r e ~ s i o nDefinitive .~~ information should become available as studies which are in progress ~ontinue.~'~~~~~~ How do these data translate into resource allocation for health care services? One measure of the need for health care service is the prevalence of persons receiving needed assistance with the performance of ADL. In 1984,10.3 percent of black elders aged 85 years and older who had difficulty with one ADL received help from another person.36Among those reporting difficulty with two or more ADLs, 29.9 percent received help from another person. A barrier to accessing
Percent Covered
80 1
60
40
20
0 Medicare 8 Private
Medicare 8 Medicaid
Medicare Only
Insurance Types
=
Blacks
aWhites
Source: NCHS
FIGURE 8. Health insurance coverage, by race. US persons aged 65 years and over. Health Insurance Coverage data were also derived from the National Health Interview Survey.37
needed health care and services is lack of adequate insurance coverage. Figure 8 shows US national trends in the attern of coverage for both black and white elders.' Over half (54.4%)of all black elders rely on either Medicare alone (37.9%) or a combination of Medicare/Medicaid (16.5%) to cover medical care expenses. By contrast, 77.3 percent of white elders reported having supplemental private insurance in addition to Medicare coverage. Low rates of supplemental insurance coverage by black elders may be related to census data which indicate that 66.4 percent of blacks aged 65 years and over had low incomes (C$11,894 for single individuals;
Morbidity, Disability, and Health Status of Black American Elderlv: A New Look at the Oldest-Old J
T. P. Miles, MD* and M. A. Bernard, M D t There are over 2.5 million black Americans aged 65 and over living in the United States today, including some 258,000 persons aged 85 years and over. The post-World War I1 baby boom within the US black population should ensure that the numbers of persons aged 65 and over will increase into the 21st Century. If present trends continue, it is projected that the current population of black elders will also age. This means that the numbers of black persons aged 85 and over will also increase. Data from both national surveys and population-based community studies concerning the health
and well-being of black elders are now becoming available. This report presents information concerning self-reported health status, chronic disease prevalence, disease-risk-factor prevalence, measures of physical functioning, and nursing home utilization rates for age groups within the black population aged 65 years and over. The availability of such data should lead to the development of targeted interventions designed to lessen impairment and prolong independent living. J Am Geriatr SOC40:1047-1054,1992
here are over 2.5 million black Americans aged 65 years and over living in the United States.’ This total includes some 6,000 persons aged 100 years and over. General awareness among health care providers of trends in the health status of this group of elders is often overshadowed either by the more dramatic mortality events observed among younger blacks or by the greater numbers of older whites. Researchers documenting the social, economic, and demographic factors underlying disease and disability observed among black elders have been hampered in the past by a paucity of both national- and communitylevel data sources.’ In recent years, however, new studies have been initiated which are now beginning to highlight this p o p ~ l a t i o n . ~Preliminary -~ data that have particular interest for health care providers are now becoming available. For the remainder of this report, information from these national surveys will be used to show trends. United States national trends may vary in their applicability to regional populations. When specific details are available, reference will be made to community-based studies. Additionally, where data are available, a specific emphasis will be placed on persons aged 85 years and over-the oldest old. To highlight factors contributing to the health and well being of this group, data illustrating mortality and morbidity trends will be presented. Social and economic issues relevant to health and well being will also be discussed.
national and regional surveys, was used to develop this report. Readers are encouraged to consult individual documents for greater details. In particular, as noted in the tables and figures, the following data sources were utilized: census counts from 1950-1988; US National Vital Statistics from the National Center for Health Statistics; cancer incidence data from the Surveillance Epidemiology and End Results program of the National Cancer Institute; and the 1984 National Health Interview Supplement on Aging. To highlight the physical functioning, chronic disease, and risk factor prevalence for blacks aged 85 years and over, data from the North Carolina Established Population for Epidemiologic Studies of the Elderly (EPESE)5were reviewed. The EPESE is a prospective epidemiologic study of health status, physical, social, and cognitive functioning of a biracial population of persons aged 65 years and older living in five North Carolina counties. The reader may consult Brock et a18 for an in-depth discussion of the sampling strategyRESULTS Age, sex and geographic distribution are factors relevant to the planning of health care resource utilization. The US black population over age 65 has an age distribution which is slightly younger than whites. For example, 61.8 percent of blacks over age 65 are between 65 and 74 years old, compared with 58.6 percent of older whites.’ The gender composition of black and white populations in the US is similar-59 percent female. In 1980, older black Americans (80.6%), like their white counterparts (73.8%), were more likely to live in urbanized areas than on farms.7 Within urban sites, the majority of blacks (69.1 percent) live within the central city area, while whites were equally distributed between central (39 percent) and suburban (40.2 percent) areas.
T
METHODS Information from a computerized search of the medical literature from 1987-1992, as well as data from *From the University of Illinois at Chicago, School of Public Health, Chicago, Illinois; and the tUniversity of Oklahoma, Department of Mediane, Oklahoma City, Oklahoma. An editorial concerning this issue by Dr. John Morley, Associate Editor, will appear in the November issue of JAGS. 1AGS 40:1047-1054, 1992 0 1992 by the American Geriatrics Society
0002-8614f 92/$3.50
1048
1AG.S-OCTOBER 1992-VOL. 40, NO. 10
MILES AND BERNARD
While black elders are a small proportion (8.2 percent) of the total population over age 65, their proportion within the US black population has been increasing over the past 40 years, leading to a “Graying of Black America” (Figure 1). During the period between 1950 and 1990, the percentage of blacks aged 65 years and over has increased by 50 percent.’-l5 In 1950 there were 621,000 blacks aged 65 years and older. By 1970 that number had more than doubled, increasing to 1.6 million. In 1988, there were an estimated 2.5 million black Americans aged 65 years and over living in the United States. The mortality experience of black elders is often obscured by the more dramatic events observed among younger members of the population. Over two-thirds of all deaths among US blacks in 1988 occurred in the group over age 65 years.16 Mortality rates in this age group are higher than any other age category (Figure 2). This trend of increasingly higher death rates with age is similar to that observed in the US white population, as are the causes of mortality among black
Percent age 65.
10
I I
1950
-
1960
1970
1980
TABLE 1. LEADING CAUSES OF DEATH, US BLACKS, 1988. AGED 25 YEARS AND OVER 65 Years and 25-44 Years 45-64 Years Over
1988
Year
~
% Over 65
Source: Bureau of the Census
elders. For comparison, Table 1shows the three leading causes of death for persons aged 25-44,45-64, and 65 years and over. While homicide and accidents predominate early in life, it is heart disease, cancer and stroke that are most prevalent at later ages. Age-specific life expectancy is a useful statistic because it more accurately reflects survival for the group of individuals currently at a given age. As shown in Figure 3, it is estimated that half of all blacks aged 65 years in 1988 will live an average of 15.5 additional years.I7 There are differences in survival between the sexes, with males aged 65 years having a lower average (13.5 years) and females aged 65 years a greater average (17.2 years). Similar trends are observed for persons aged 75 years. Age-specific life expectancy for persons aged 85 years is even more informative when one considers that this is the age group with the highest risk of institutionalization. Based on these data, onehalf of all black elders aged 85 years in 1988 will live an additional 6.8 years. For some black elders, these years of additional life are marked by high rates of poor health (Figures 4 and 5) and chronic disease (Tables 2a, 2b, and 3). Regardless of age, almost half of black respondents in national surveys of community-dwelling persons report poor health. Self-reported health status has been found to correlate with use of health care services. Black females aged 65 to 74 years have the highest rates of reported poor health (54.5 percent), while males aged 65 to 74 years have the lowest (47.4%).” Males and females aged 75 years and over have very similar rates of poor
FIGURE 1. Graying of Black America, 1950-1988; percent aged 65 years and over. Time trends presented were population figures of census counts as of April 1 for 1950, 1960,1970,1980 and estimates as of July 1, 1988.’-15
Heart Disease Cancer Stroke
1. Homicide 2. Accidents 3. Heart Disease
Heart Disease Cancer Stroke
Source: NCHS.’
Average Remaining Years -
Deaths Per 100,OOO(Thousands)
1
* O r - -
16
r
14 12 10
8 6 4
-
2 vUnder 1 1-4
Y
75
65 5-u
15-24 25-34 35-44 45-54 56-64 85-74 75-84
=
Age Group
Males
85
Specific Age
85.
=Both
Sexes
Males
0Females
Females
Source: NCHS
FIGURE 2. Age-specific mortality, US blacks, 1988. Mortality rates presented were based on the US National Vital Statistics System compiled by the National Center for Health StatistiCs.l6
Source: NCHS
FIGURE 3. Average remaining years, by sex, 1984; US blacks aged 65, 75, and 85 years. Age-specific life expectancy estimates were developed by the National Center for Health Statistics based on current trends in age-specific mortality.”
JAGS-OCTOBER 1992-VOL.40,NO. 10
HEALTH STATUS OF BLACK AMERICAN ELDERLY
1049
colon/rectum (510 per 100,000), and lung (443 per 100,000) have the highest incidence rates among older black males, while breast (345 per 100,000), colon/ rectum (380 per 100,000), and lung (104 per 100,000) are highest among females 85 years and older. Among older whites similar patterns of mortality and incidence are observed. Other cancer sites are an important source of morbidity for older blacks (Table 2b)." Black females aged 85 years and over are at risk for morbidity due to 65-74 75-84 85. cervical (62 per 100,000) and uterine (73 per 100,000) Age Groups cancer. Multiple myeloma is another common source of morbidity for older blacks; incidence rates among Males Females males (67 per 100,000) and females (57 per 100,000) Source NCHS are higher than for ovary (37.6 per 100,000), skin FIGURE 4. Percent reporting poor health, by sex and age; US blacks, (males 5.2, females 8.9 per 100,000), and most leuke1984.Self-reported health status data were derived from the 1984 mias (both sexes combined: lymphocytic 29.4, granuNational Health Interview Survey Supplement on Aging Respond- locytic 23.2, and monocytic 3.1 per 100,000-data not ents were asked to rate their health in one of five categories: excellent, shown). very good, good, fair, or poor. To illustrate the burden of other chronic diseases among the oldest persons, Table 3 lists lifetime prevalence of selected medical conditions among black parPercent of Total Respondents 80 r ticipants in the EPESE.21-24Not surprisingly, hypertension was the most commonly reported medical history in this population. Over 51 percent of males, and 68.9 60 'O percent of females report a history of hypertension. The highest rates of occurrence were among females aged 70-74 years. Those 85 years and older had the lowest rates of hypertension. Prevalence rates for other diseases of the cardiovascular system-heart attack (13.4%-13.7%), stroke (9.O%-9.6%), and angina (2.3%-6.7%)-are also shown by age and sex. It is 65-74 75-84 85+ interesting to note that in this community there were Age Groups no sex differences nor age trends in heart attack, stroke, Males Females or angina. One major risk factor of heart disease is diabetes. Females between 65 and 84 years had higher Source: NCHS rates of disease (22.7%-30.5%) than did males (19.5%FIGURE 5. Disease-related activity limitation, by sex and age; US 24.9%).Among the oldest-old, no sex differences were blacks, 1984. Data derived from 1984 National Health Interview Survey Supplement on Aging.'" Activity limitation estimates were observed. This lower prevalence rate of diabetes among based on responses to the question, 'Are you limited in ANY WAY the oldest cohort may be due to increased mortality at in any activities because of an impairment or health problem?"" younger ages associated with this disease. Osteoporotic fractures and osteoarthritis are common skeletal diseases in late life. While osteoporosis is health; approximately 50 percent of this group report a poorly understood phenomenon among older blacks, poor health. The reported poor health of this popula- data are available describing the population prevalence tion correlates with reported disease-related activity of fractures, a marker of osteoporosis after age 50. In limitation (Figure 5)." the EPESE cohort, 3.0 percent of males and 2.4 percent Chronic diseases such as cancer, heart disease, and of females reported having had a hip fracture. The stroke are highly prevalent at older ages. Across most highest rates of hip fracture were reported among populations of elderly, cancer mortality and incidence males aged 75 to 79 (5.9%) and those 85 years and are higher in successively older age groups. A similar over (6.5%). While the prevalence of hip fracture inpattern of mortality (Table 2a) and incidence (Table creased with age among black females, no similar age 2b) also occurs for US black elder^.'^^^^ Older black trend was reported for fractures at other sites. There males have higher mortality and incidence rates overall was no sex difference in the occurrence of fractures at than black females. Among black males 85 years and other sites. History of arthritis, another common skelolder, the top three sites most frequently associated etal disease in late life, was not ascertained in the with annual cancer mortality are: prostate (937 per North Carolina sample. However, national surveys 100,000), lung (391 per 100,000), and colon/rectum indicate that among blacks aged 75 years and over, (307 per 100,000). Mortality rates for females aged 85 51.7 percent of males and 69.9 percent of females years and over are highest for colon/rectum (250 per report having been diagnosed by a physician as having 100,000), breast (156 per 100,000), and lung (100 per arthritis.24Among blacks aged 60 to 74 years in a 100,000). Annual incidence rates, though higher, fol- national survey, females were identified as the group low a similar pattern. Prostate (1448 per 100,000), with the most limited range of motion at both hip and Percent of Total Respondents
6o
r
-
I
=
1050
MILES AND BERNARD
JAGS-OCTOBER 1992-VOL.40, NO. 10
TABLE 2a. CANCER MORTALITY, SELECTED SITES, BY SEX, RACE, AND AGE, US 1983-1987. AVERAGE ANNUAL RATE PER 100,000i9 Black/Age Group WhiteIAge Group Site Males Skin Colon/rectum Lung* Multiple myeloma Prostate Breast Combined Females Skin Colon/Rectum Lung* Multiple myeloma Breast Cervix Corpus uterus Ovary Combined
65-69
70-74
75-79
80-84
85+
65-69
70-74
75-79
80-84
85+
2 111 494 30 174 2 1296
2 162 568 43 332 2 1727
4 206 560 54 516 3 2044
4 287 566 79 839 3 2693
3 307 391 60 937 4 2544
10 104 368 14 71 1 930
13 156 470 21 138 1 1286
15 216 544 28 245 2 1690
18 296 555 35 403 3 2127
20 379 441 39 606 3 2455
1 84 113 20 94 22 16 27 624
2 120 121 29 106 24 21 34 792
3 159 110 36 109 30 20 34 908
4 234 117 45 147 35 23 41 1204
3 250 100 40 156 39 19 35 1225
5 68 138 10 104 8 11 35 578
6 100 153 14 118 9 13 42 732
7 142 144 19 131 10 14 45 873
-10 200 129 24 151 12 15 50 1071
11 289 104 23 182 14 15 45 1289
* Includes lung and bronchus.
TABLE 2b. CANCER INCIDENCE, SELECTED SITES BY SEX, RACE, AND AGE, SEER. 1987-1987. AVERAGE ANNUAL RATE PER 100,000?" BlackIAge Group WhiteIAge Group Site Males Skin Colon/Rectum Lung* Multiple myeloma Prostate Breast Combined Females Skin Colon/rectum Lung* Multiple myeloma Breast Cervix Corpus Uterus Ovary Combined
65-69
70-74
75-79
80-84
85+
65-69
70-74
75-79
80-84
85+
2 266 663 47 702 4 2419
3 338 72 1 63 1022 5 3037
2 469 647 78 1260 8 3477
18 532 756 111 1581 4 4150
5 510 443 67 1448 3561
40 280 426 23 438 3 1899
40 390 529 28 682 5 2557
40 524 594 41 944 5 3241
51 628 564 45 1120 5 3692
52 664 429 52 1137 8 3708
3 228 166 32 280 43 72 39 1236
3 259 182 39 310 50 77 45 1396
6 323 153 52 360 57 73 54 1610
4 454 130 66 414 64 72 42 1987
9 381 104 58 345 62 73 38 1772
17 183 186 15 392 16 119 55 1324
21 264 202 18 418 18 118 59 1550
23 353 179 27 444 17 99 56 1723
22 447 143 30 442 16 82 58 1887
23 488 101 28 411 17 59 50 1894
* Includes lung and bronchus. SEER = Surveillance Epidemiology and End Resulfs Program.
knee joints.25Blacks aged 85 years and over, particularly females, report high prevalence rates of difficulty in tasks requiring back, hip, and knee mobility such as stooping, moving large objects, and walking. A person who reports limitation in activity or difficulty with the activities of daily living (ADL) is at risk for institutionalization. In the North Carolina EPESE, as with other populations of older persons, it is the oldest-old females, those 85 years and over, who have the highest rates of disability (Figures 6 and 7).22In each age cohort, females had the highest prevalence rates of activity limitation due to health, ranging from 50 percent of those 65-74 years to over 68.2 percent
of females aged 85 years and older. Among persons aged 85 years and over, both males (18.1%) and females (26.4%) reported that walking across a small room was the activity that most frequently required assistance. Females also reported higher rates of dependency in almost all ADLs. The group 85+ years also reported high rates of difficulty in instrumental activities of daily living (IADL) as measured by the Rosow-Breslau and Nagi scales.'" 27 Difficulty or inability to perform heavy housework (WORK) was highly prevalent among both males (78%) and females (81.7%).Among females, difficulty with pushing large objects (LARGE, 82.9%)and stooping (STOOP,78.5%)
IAGS-OCTOBER 1992-VOL. 40. N O . 10
1051
HEALTH STATUS OF BLACK AMERICAN ELDERLY
TABLE 3. PREVALENCE OF SELECTED MEDICAL HISTORIES, BY SEX AND AGE, BLACK RESPONDENTS, NORTH CAROLINA EPESE, 1984"
History Reported Sex & Age
HTN (1) MI (2)
Males 65-69 70-74 75-79 80-84 85+ Total Fema1es 65-69 70-74 75-79 80-84 85+ Total
CVA (3)
Angina (4)
Diabetes ( 5 )
Hip Fx (6)
Other Fx (7)
Cancer (8)
53.0 54.7 48.2 42.9 42.1 51.0
12.5 14.3 11.8 19.0 13.6 13.7
8.5 10.2 11.5 7.9 10.7 9.6
7.3 4.0 6.9 9.4 12.7 6.7
18.9 21.4 24.9 19.5 13.6 20.4
2.1 2.5 5.9 0.7 6.5 3.0
20.0 8.6 14.2 11.6 18.7 14.6
8.0 7.9 6.5 3.7 9.3 7.3
69.4 74.3 68.0 64.4 59.1 68.9
11.7 11.3 16.9 11.9 19.8 13.4
9.0 10.2 9.5 5.9 9.0 9.0
8.9 6.3 8.6 4.2 10.1 7.7
29.3 30.5 22.7 25.2 13.7 26.4
1.5 2.4 2.0 4.4 4.0 2.4
14.8 18.1 15.8 17.0 20.0 16.6
7.8 11.1 7.8 3.4 8.2 8.2
(1) H T N = Hypertension, "Doctor ever told you?" (2) MI = Heart Attack "Doctor ever told you?" (3) C V A = Stroke, "Doctor ever told you?" (4) Angina-based on responses to the Rose Questionnaire.
(5) Diabetes, "Doctor ever told diabetes, or high sugar in blood or urine?" (6) 6.(7) Fx = Fractures after age 50--hip or other sites. (8)Cancer, "Doctor ever told you?"
% Need AssistlUnable to Do
% Difficulty/Unable to Do
r
30 r
251
loo
Q
20 15
to 5
n Bath
Dress
Walk
Groom
Transfer
Toilet
Eat
" Work
Stairs
Activities
=
Males
Distance
Reach
Small
Large
Stoop
Activities
Females
Males
aFemales
North Carolina EPESE. 1984
North Carolina EPESE. 1984
FIGURE 6. Dependency in personal care activities, by sex; blacks, age 85 years and over. Persons were counted as being dependent if they reported either needing assistance or being unable to do any of the following activities: bathing, dressing, walking across a small room, personal grooming, getting from a bed to a chair (TRANSFER), using the toilet, eating.*
FIGURE 7. Difficulty in physical activities, by sex; blacks, age 85 years and over. An individual was counted as having difficulty if they reported being unable to do: heavy housework (WORK), climb stairs (STAIRS), or walk half a mile without help (DISTANCE). Persons were counted as having difficulty if they reported ANY (a little, a lot, or unable) difficulty with any of these tasks: reaching above shoulder level (REACH), writing or handling small objects (SMALL), pulling or pushing large objects (LARGE), and stooping, crouching, or kneeling
were prevalent. Difficulty with more than one IADL task and/or dependency in multiple ADL tasks has been used to identify community-dwelling persons potentially in need of home-making services. US data for black elders from the National Medical Expenditure Surveyz8show trends in dependency for single ADL and IADL items comparable to those observed in the North Carolina EPESE. In addition, 9.6 percent of blacks aged 65 years and older reported difficulty with two or more ADL tasks, and 18.7 percent reported difficulty with two or more IADL tasks. Table 4 lists the prevalence of risk factors for disease in the North Carolina EPESE population.21These risk factors for disease-change in body weight, inconti-
nence, sleep problems, smoking, and alcohol use-can serve as focal points for intervention. Unexplained weight change (a gain or loss of more than 10 pounds in the past year) was reported by 32.6 percent of males and 42.3 percent of females. Among the oldest-old, 45.3 percent of males and 51.6 percent of females reported incontinence. The proportion of females reporting sleep problems was highest among those 80 to 84 years (58.2%)and among those 85 years and older (57.7%).The prevalence of current smoking and any alcohol use was lower in successively older cohorts.
1052
JAGS-OCTOBER 1992-VOL 40, NO. 10
MILES AND BERNARD
TABLE 4. PREVALENCE OF SELECTED HEALTH CHARACTERISTICS, BY SEX AND AGE, BLACK RESPONDENTS, NORTH CAROLINA EPESE, 1984'l Risk Factors
Sex & Age Males 65-69 70-74 75-79 80-84 85+ Total Females 65-69 70-74 75-79 80-84 85+ Total
Weight Change (1)
Urine Difficulty
Alcohol Use
(2)
Sleep Problems (3)
Smoke? (4)
29.9 33.1 33.9 34.9 39.8 32.6
32.1 33.8 40.3 42.6 45.3 35.9
47.7 50.0 52.3 46.9 40.0 50.5
40.9 32.0 21.6 13.5 9.3 30.1
36.8 33.2 29.3 15.1 32.5 31.9
42.0 40.8 39.7 43.3 53.6 42.3
27.7 36.1 35.4 41.5 51.6 35.7
51.7 50.4 43.3 58.2 57.7 49.7
14.3 6.8 4.1 3.0 1.4 7.8
13.8 9.4 12.1 7.9 7.9 11.2
(5)
(1) Weight Change = Percent with a gain or loss of more than 10 pounds in last year. (2) Urine Problem = Percent answering some, most, or all of the time to the question, "How often do you have difficulty holding your urine until you can get to a toilet?" (3) Sleep Problems = Percent reporting any problem. Problems include: Trouble falling asleep; Waking up at night; Waking too early and not being able to fall asleep again; Sleepy during the day; Awaken not rested. (4) Smoke? = Percent currently smoking. (5) Alcohol Use = Percent reporting any liquor in the past year.
Cognitive impairment, whether it is due to dementia or depression, is a common problem in the geriatric population as a whole. Studies designed to estimate the prevalence of dementia and depression among black elders are slowed by the need to develop reliable screening instruments valid for use in this population. Low educational attainment is a serious source of bias when either the Folstein Mini-mental Status Exam or the Short Portable Mental Status Questionnaire are used to diagnose mild to moderate It has been speculated that multi-infarct dementia might be common among black elders because of the high prevalence of stroke risk factors such as hypertension, diabetes, alcoholism, and head trauma.30 Populationbased estimates of definite and possible dementia among blacks aged 60 and over range from 8.9 percent of males and 19.9 percent of females3' to 20.7 percent of males and 25.5 percent of females.32The contribution of depression to cognitive impairment among black elders is less well studied than dementia. A study of patients seen in a large primary care setting in Durham, NC revealed that 22 percent of patients had symptoms of a clinical d e p r e ~ s i o nDefinitive .~~ information should become available as studies which are in progress ~ontinue.~'~~~~~~ How do these data translate into resource allocation for health care services? One measure of the need for health care service is the prevalence of persons receiving needed assistance with the performance of ADL. In 1984,10.3 percent of black elders aged 85 years and older who had difficulty with one ADL received help from another person.36Among those reporting difficulty with two or more ADLs, 29.9 percent received help from another person. A barrier to accessing
Percent Covered
80 1
60
40
20
0 Medicare 8 Private
Medicare 8 Medicaid
Medicare Only
Insurance Types
=
Blacks
aWhites
Source: NCHS
FIGURE 8. Health insurance coverage, by race. US persons aged 65 years and over. Health Insurance Coverage data were also derived from the National Health Interview Survey.37
needed health care and services is lack of adequate insurance coverage. Figure 8 shows US national trends in the attern of coverage for both black and white elders.' Over half (54.4%)of all black elders rely on either Medicare alone (37.9%) or a combination of Medicare/Medicaid (16.5%) to cover medical care expenses. By contrast, 77.3 percent of white elders reported having supplemental private insurance in addition to Medicare coverage. Low rates of supplemental insurance coverage by black elders may be related to census data which indicate that 66.4 percent of blacks aged 65 years and over had low incomes (C$11,894 for single individuals;
