Growing Hispanic Population: Health Status and Policy Implications

1
Growing Hispanic Population Health Status and
Policy Implications

• Kyriakos S. Markides

2
Percent of Non-Hispanic Whites 65 and over in
United States Population, 1980 to 2050
Year
Percent Non-Hispanic Whites

• 1980
• 1995
• 2050

• 80
• 74
• 67

Source U.S. Bureau of the Census (1993)
3
Proportions of Hispanic Elderly (65) by Type of
Hispanic Origin (1993)
Type of Hispanic Origin
Percent

• Mexican
• Cuban
• Puerto Rican
• Other Hispanic

• 49
• 15
• 12
• 24

Source U.S. Bureau of the Census (1993)
4
Projections of U.S. resident population by Age,
Sex, Race and Hispanic Origin 1999, 2025, 2050
(in thousands)
Non- Hispanic White
Asian/ Pacific Islander
African American
Native American
Hispanic Origin
1999 All Ages 31,356 196,079
33,107 2,024 10,253 65 1,845
28,999 2,702 147 779 2025
All Ages 61,433 209,340 43,528 2,668
20,846 65 6,105 47,260
6,268 338 2,670 2050 All
Ages 98,229 212,991 53,466 3,241
35,760 65 13,442 52,684
9,997 530 5,366
5
Age-Adjusted Death Rates by Sex, Race, Ethnicity,
1995-97 (per 100,000)
Diseases of the Heart
Cerebro- vascular Diseases
All Causes
Malignant Neoplasms
Hispanic Male 477.6 117.4
22.4 94.2 Female 268.4
65.7 17.4 66.1 Non-Hispanic White Male
590.1 176.1 26.0
151.4 Female 363.8 93.4 22.9
109.5 African American Male 964.3
244.7 50.5 221.1 Female 559.0
152.4 38.9 159.2
6
Age-Adjusted Death Rates by Sex, Race, Ethnicity,
1995-97 (continued)
Diseases of the Heart
Cerebro- vascular Diseases
All Causes
Malignant Neoplasms
Native American Male 573.4
135.0 21.6 97.4 Female
365.1 75.3 20.1
74.0 Asian/Pacific Islander Male 361.7
99.4 28.6 94.3 Female 219.3
52.2 21.5 64.7
7
Health Status Indicators of Hispanic Elderly

• High Life Expectancy
• Diabetes (Mexican Americans, Puerto Ricans)
• Obesity
• Disability (Mexican Americans, Puerto Ricans)
• Low Rates of Institutionalization
• Low Medicare Coverage (especially among recent
  immigrants)

8
Hispanic Mortality Patterns

• Of the three major Hispanic Groups, Puerto Ricans
  appear to have the highest age-adjusted mortality
  rates and CUBAN AMERICANS the lowest
• Hispanic advantage holds for both genders and for
  all Hispanic subgroups
• Hispanic advantage also present at 65
• Hispanics have low mortality from major cancers,
  such as LUNG, COLON, BREAST and PROSTATE
• Hispanics have higher mortality from STOMACH,
  LIVER, GALLBLADDER, and CERVICAL cancers
  (continued on next slide)

9
Hispanic Mortality Patterns (continued)

• High death rates from DIABETES in Mexican
  Americans and Puerto Ricans
• High death rates from LIVER DISEASE/CIRRHOSIS
• Puerto Ricans have higher total mortality rates
  in New York City than in Puerto Rico or
  elsewhere, primarily because of higher HOMICIDE
  and CIRRHOSIS of the liver
• Mexican Americans have higher mortality from
  ACCIDENTS, but lower suicide rates than Puerto
  Ricans and Cuban Americans

10
An Epidemiologic Paradox

• Risk factor profiles
• High rates of DIABETES.
• High rates of obesity.
• Similar rates of hypertension, cholesterol.
• High SMOKING rates among men, lower among women
  (fewer cigarettes). Cuban American males smoke
  the most.
• High ALCOHOL (binge) drinking rates among men,
  low among women. Alcohol consumption in women
  increases with acculturation .
• Low rates of physical ACTIVITY.
• Strong families.
• Migration selection.

• Hispanics (except Cuban Americans) are
  socioeconomically disadvantaged, but have
  favorable overall mortality

11
Other Health Status Indicators in old age in
Hispanics

• Functional limitations -- High in Mexican
  Americans and Puerto Ricans
• Self-assessed health -- Poorer in Mexican
  Americans and Puerto Ricans
• Mental Health -- High rates of DEPRESSION in
  Mexican Americans. Alzheimers disease?
• Institutionalization -- Low rates, more disabled
• Hispanic Elderly do not underutilize PHYSICIAN
  services, possibly because of Medicare

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A LONGITUDINAL STUDY OF THE HEALTH OF MEXICAN
AMERICAN ELDERLY 1992-2003 FUNDED BY NIA

• UNIVERSITY OF TEXAS MEDICAL BRANCH, GALVESTON, TX
• PI, Kyriakos S. Markides,Ph.D.
• CO-INVESTIGATORS
• David Chiriboga, Ph.D.
• James S. Goodwin, MD.
• Sandra A. Black, Ph.D.
• Christine Stroup-Benham, Ph.D.
• Laura Rudkin, Ph.D.
• Jean Freeman, Ph.D.
• Shiva Satish, M.D.
• Todd Q. Miller, Ph.D.
• Daniel H. Freeman, Jr., Ph.D -Biostatistician.
• Laura A. Ray, M.P.A. -Project Director

• NIA STAFF
• Sidney Stahl, Ph.D.
• Manuel Miranda, Ph.D.
• FIELD STAFF
• Louis Harris and Associates, Inc.

13
Investigators - continued

• UNIVERSITY OF TEXAS HEALTH SCIENCE CENTER,
• SAN ANTONIO, TX
• PI, David V. Espino, M.D.
• CO-INVESTIGATORS
• Michael J. Lichtenstein, M.D.
• Toni Miles, M.D., Ph.D.
• UNIVERSITY OF TEXAS,
• AUSTIN, TX
• PI, Ronald J. Angel, Ph.D.
• CO-INVESTIGATOR
• Jacqueline Angel, Ph.D.

14
A LONGITUDINAL STUDY of MEXICAN AMERICAN ELDERLY
HEALTH
SPECIFIC AIMS

• To estimate the prevalence of key physical and
  mental health conditions and functional
  impairments in older Mexican Americans and
  compare this prevalence with that in other
  populations for whom data exist

15
Specific Aims - continued

• To investigate predictors of physical and mental
  health conditions and functional status at
  baseline. Predictors will include
• Formal and informal supports
• Psychological resources
• Sociodemographic factors
• Health behaviors
• Migration history
• Acculturation
• Stressful life circumstances
• Access to and use of health services

16
Specific Aims - continued

• To investigate predictors of mortality over two
  years
• To study changes in health and functioning among
  survivors
• To examine changes in health behaviors and key
  social mediators of health status, including
  social networks and supports and various key
  transitions such as widowhood and changes in
  living arrangements, including institutionalizatio
  n

17
SAMPLING PROCEDURES
Area probability multi-stage sample of Mexican
Americans aged 65 and over residing in the five
Southwestern states (Texas, New Mexico, Colorado,
Arizona, and California) (Non-institutionalized
population). Data collected during 1993-1994. N
3,050
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SELECTED SAMPLE CHARACTERISTICSN3,050
AGE RANGE 65-99 MEAN 73.0 yrs.
MARITAL STATUS MARRIED 55.3
DIV/SEP 7.9 WIDOWED
31.6 NEVER MARRIED 5.3
GENDER MALE 43.3 FEMALE 56.7
LIVING ARRANGEMENTS ALONE 20.9
2 PERSONS 41.0 3 PERSONS 15.3
4 PERSONS 22.8
YEARS of SCHOOL MEAN 5.1 yrs.
PLACE OF BIRTH MEXICO 46.8 U.S.A.
53.2
Continued on next slide
19
SELECTED SAMPLE CHARACTERISTICS
CONTINUED
HOUSEHOLD INCOME 0- 4,999 13.2
5,000- 9,999 37.7 10,000-14,999
25.8 15,000-19,999 11.7 20,000-29,999
6.2 30,000 5.4
SPEAKS ENGLISH NOT AT ALL 30.1
NOT TOO WELL 27.0 PRETTY WELL
17.0 VERY WELL 24.6
SOURCES OF INCOME SOCIAL SECURITY 96.1
PRIVATE PENSION 17.1 SSI
25.4 CHILDREN
7.0 RENT/STOCKS/ BONDS, ETC.
4.4
HEALTH INSURANCE MEDICARE 87.4
MEDICAID 34.1 PRIVATE 23.5
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PERCENT REPORTING SELECTED CHRONIC CONDITIONS
MEXICAN AMERICANS
GURALNIK (1989)
65 41.2 39.9 22.7 19.8 6.2 5.3 3.4
60
41.8 49.0 9.5 14.0 5.4 6.6 NOT AVAILABLE
HYPERTENSION ARTHRITIS DIABETES HEART
DISEASE STROKE CANCER HIP FRACTURE
NHIS Supplement on Aging, 1984 (60 yrs. )
21
PERCENT REPORTING SELECTED CHRONIC CONDITIONS by
AGE and GENDER
65-74 75 (n 863) (n 431) 34.5
31.4 28.4 28.2 25.0 17.6 19.2
22.9 5.9 6.7 4.4 6.7 1.6
3.5
MALES
HYPERTENSION ARTHRITIS DIABETES HEART
DISEASE STROKE CANCER HIP FRACTURE
22
PERCENT REPORTING SELECTED CHRONIC CONDITIONS by
AGE and GENDER
continued
65-74 75 (n1139) (n 615) 45.6
49.3 47.3 50.5 24.6 19.5 21.9 23.2 3.5
9.8 4.7 6.7 2.4 7.5
FEMALES
HYPERTENSION ARTHRITIS DIABETES HEART
DISEASE STROKE CANCER HIP FRACTURE
23
Percent of Persons 65 and Over Who Report
Difficulty Performing Selected Activities of
Daily Living by Ethnicity
Whites (n24,753)
Non-Whites (n2,784)
Mexican Americans (n3,050)
Note Data on Whites and Non-Whites are from the
1986 National Health Survey (NCHS, 1993). Data
on Mexican Americans are from the 1993-94
Hispanic EPESE.
24
Percent of Persons 65 and Over Who Report
Difficulty Performing Selected Activities of
Daily Living by Ethnicity
Whites (n24,753)
Non-Whites (n2,784)
Mexican Americans (n3,050)
Note Data on Whites and Non-Whites are from the
1986 National Health Survey (NCHS, 1993). Data
on Mexican Americans are from the 1993-94
Hispanic EPESE.
25
Mean CES-D Scores and Prevalence of High
Depressive Symptoms, for Sociodemographic
Characteristics (weighted)
N Mean Score (SE) Prevalence() All CES-D
Respondents 2823 10.54 (.191)
25.6 Gender Females 1647 12.21 (.263)
31.9 Males 1176 8.30 (.258)
17.3 Age Groups 65-74 1895 10.12
(.233) 24.4 75-84 764 11.24 (.353)
28.1 85 164 12.16 (.896) 28.6
plt.10 plt.01 plt.001 Based on a total
CES-D score of 16 or greater
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Changes in Blood Pressure and Risk Factors for
Cardiovascular Disease among Older Mexican
Americans from 1982-1984 to 1993-1994
C. A. Stroup-Benham, K. S. Markides, D. V. Espino
J. S. Goodwin
Results Among 65-74 year old Mexican Americans,
there were decreases over time (1982-84), HHANES
to (1993-94), HEPESE in the percent who smoked
cigarettes from 27.6 to 13.98 and in mean
systolic blood pressure level. The percent of
subjects categorized as obese or severely obese
increased, as did the prevalence of diagnosed
diabetes, increasing from 20.06 in 1982-84 to
29.81 in 1993-94. Mean diastolic blood pressure
increased from 77.15 mmHg in 1982-84 to 81.21
mmHg in 1993-94.
27
Factors Influencing Unawareness of Hypertension
Among Older Mexican AmericansS.Satish, K.S.
Markides, D. Zhang J.S. Goodwin
Results Thirty-seven percent of hypertensives
were unaware of their diagnosis. Unaware
hypertensives had significantly higher blood
pressures than did aware hypertensives. In
multivariate analyses, factors associated with
unawareness included male gender (O.R.gt1.8),
being married (O.R.1.6), poor memory (O.R.1.6),
having Medicaid (O.R.1.6), having less than 2
visits to a doctor in the past year (O.R..2.8),
having a history of heart disease (O.R.0.57), or
stroke (O.R.0.37), and poor self-reported health
(O.R..43).
28
Depressive symptoms and Mortality in Older
Mexican AmericansBlack, S.A. and Markides, K.S.
Results Multivariate analyses indicated a
synergistic effect for comorbid diabetes and
depressive symptoms such that the odds of having
died among diabetics with high levels of
depressive symtpoms (OR4.03, 95CI2.67-6.11)
were three times that of diabetics without high
levels of depressive symptoms. Conclusions High
Levels of depressive symptoms concomitant with
major chronic medical conditions elevate the risk
for death among older Mexican Americans. Given
the fact that depression is often unrecognized
and undertreated in the elderly, awareness of the
potential for loss of life as well as the
potential for treatment may help to improve this
situation not only for older Mexican Americans,
but for older adults in general.
29
Lower Body Functioning as a Predictor of
Subsequent Disability among Older Mexican
AmericansOstir, G.V., Markides, K.S., Black,
S.A. and Goodwin, J.S.

• Results Performance on 8-foot walk, repeated
  chair stands, and standing balance among
  non-disabled subjects at baseline were
  significantly associated with the onset of ADL
  and lower body disability two years later,
  controlling for age, gender, and the presence of
  medical conditions. The results were significant
  for each performance measure and for a measure
  combining all three.
• Conclusions This study offers further
  evidence that performance-based measures of lower
  body function are able to predict future
  disability in Mexican American elderly as has
  been found with other elderly populations. These
  measures were able to detect changes over a
  relatively short period of time (2 years). In
  addition, the study found that the short walk
  (8-foot walk) was the most sensitive measure in
  predicting future disability.

30
Depressive Symptomatology and Low Positive
Well-Being Predict the Onset of Functional
Disability in Older Mexican Americans Results
from the Hispanic EPESEGlenn Ostir, Kyriakos S.
Markides, Sandra A. Black, and James S. Goodwin
Scores on the Center for Epidemiologic
Studies Depression (CES-D) Scale were linearly
associated with the probability of becoming
disabled in Activities of Daily Living (ADLs)
two years later among initially nondisabled
persons controlling for age, gender, presence of
medical conditions and socioeconomic factors.
Furthermore, scores on a four-item positive
well-being scale were associated with a lower
probability of becoming ADL-disabled. The same
two variables were similarly associated with the
development of lower body difficulties two years
later.
31
Stage I
Stage II
Stage III
Stage IV
Stressors/Transitions
Cognitive
Major Life Events
Status
(e.g. widowhood)
Financial Strain
etc.
Functional
Sociodemographic
Status
Variables
Social Support
Mortality
Age, Gender,
Social Class,
Acculturation,
Migration History
Depression
Medical Conditions
Institutionalization
Changes in
Living Arrangements
Figure 1. Conceptual Model