Loneliness and Social Isolation as Risk Factors for Mortality Article Summary

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Summarize and critique each of those articles to support your study which is arrange transportation can prevent social isolation on the elderly. Apply critical thinking to engage in a thorough analysis of each quantitative or qualitative research article. What interventions were evaluated? How was it studied/what methodology was used? what were the results? limitations?





 

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182 European Journal of Public Health ......................................................................................................... European Journal of Public Health, Vol. 26, No. 1, 182–187 ß The Author 2015. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved. doi:10.1093/eurpub/ckv052 Advance Access published on 28 March 2015 ......................................................................................................... Clément Pimouguet1,2,3, Debora Rizzuto1, Pär Schön1,4, Behnaz Shakersain1, Sara Angleman1, Marten Lagergren1,4, Laura Fratiglioni1,4, Weili Xu1 1 Aging Research Center, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet and Stockholm University, Stockholm, Sweden 2 INSERM, ISPED, Centre INSERM U897-Epidemiologie-Biostatistique, Bordeaux, France 3 University of Bordeaux, Centre INSERM U897-Epidemiologie-Biostatistique, Bordeaux, France 4 Stockholm Gerontology Research Center, Stockholm, Sweden Correspondence: Clément Pimouguet, Institut de Santé Publique, d’Epidémiologie et de Développement, Université Victor Segalen Bordeaux 2, 146 rue Leo Saignat, 33076 Bordeaux Cedex, France. Tel: +33 05 57 57 56 44, Fax: +33 05 56 24 00 81, e-mail: clement.pimouguet@isped.u-bordeaux2.fr Background: Living alone is common among elderly people in Western countries, and studies on its relationship with institutionalization and all-cause mortality have shown inconsistent results. We investigated that the impact of living alone on institutionalization and mortality in a population-based cohort of elderly people. Methods: Data originate from the Swedish National study on Aging and Care-Kungsholmen. Participants aged 66 years and living at home (n = 2404) at baseline underwent interviews and clinical examination. Data on living arrangements were collected in interviews. All participants were followed for 6 years; survival status and admission into institutions were tracked continuously through administrative registers from 2001 to 2007. Data were analysed using Cox proportional hazard models, competing risk regressions and Laplace regressions with adjustment for potential confounders. Results: Of the 2404 participants, 1464 (60.9%) lived alone at baseline. During the follow-up, 711 (29.6%) participants died, and 185 (15.0%) were institutionalized. In the multi-adjusted Cox model, the hazard ratio (HR) of mortality in those living alone was 1.35 (95% confidence interval [CI] 1.18 to 1.54), especially among men (HR = 1.44, 95% CI 1.18 to 1.76). Living alone shortened survival by 0.6 years and was associated with the risk of institutionalization (HR = 1.74, 95% CI 1.10 to 2.77) after taking death into account as a competing risk. Conclusions: Living alone is associated with elevated mortality, especially among men and an increased risk of institutionalization. Over a 6-year period, living alone was related to a half year reduction in survival among elderly people in Sweden. ......................................................................................................... Introduction emographic projections predict a sharp increase in the of elderly people in the near future in most developed countries.1 The living arrangements of older people have been substantially affected by reduced intergenerational living, greater social and geographical mobility and widowhood.2 As a consequence, an increased proportion of elderly people now live alone in Western countries.2–3 Among elderly people, the prevalence of living alone varies widely by country and by sex. In Sweden, half of women aged 65 and over live alone; this proportion is about twice high as among men.1 Elderly people who live alone may be particularly vulnerable to poorer medical follow-up, social isolation and loneliness, all of which have been described as predictors of mortality4–7 and institutionalization.8 However, several recent studies addressing these issues have shown inconsistent results. Some studies reported that living alone was associated with increased mortality, particularly among the young-old.9–10 In contrast, other studies reported no association between living alone and increased mortality11–12 or even increased survival among frail elderly people who live alone.13 Most elderly people prefer to remain in their homes because this enables them to maintain the integrity of their social network.2 Furthermore, admission to nursing homes is expensive both in terms of public and private finances. Institutionalization is, therefore, a relevant prognostic outcome for individuals, families and policy makers. The association between living arrangements and institutionalization has been addressed in several studies with Dpopulation inconsistent findings mostly due of methodological limitations.14 Importantly, previous studies have not addressed death as a competing risk which could have led underestimation of the role of living arrangements.15 To date, no population-based longitudinal study has examined the association between living alone and both mortality and institutionalization taking into account death as a competing risk. In this study, we aimed to use 6-year follow-up data from a populationbased cohort study to investigate the impact of living alone on morality and on institutionalization. Methods Study population Data were derived from the Swedish National study on Aging and Care in Kungsholmen (SNAC-K).16 This study includes two parts: the SNAC-K care system study and the SNAC-K population study. Study participants were randomly selected from adults aged 60 years living at home or in institutions in Kungsholmen, a central district of Stockholm, Sweden. Eleven age cohorts were chosen with different follow-up examination intervals, 6 years between groups in the younger cohorts (aged 60 to 78), and 3 years in the older cohorts (aged 81 or over). The baseline examination was carried out between March 2001 and June 2004. A total of 5111 persons were initially selected for participation. Of the latter, 4590 were eligible persons (those who were alive, contactable, speaking Swedish and living in Kungsholmen) and 3363 (73.3%) participated at the baseline exam. Downloaded from https://academic.oup.com/eurpub/article-abstract/26/1/182/2467054 by University of Maryland College Park user on 08 March 2019 Impact of living alone on institutionalization and mortality: a population-based longitudinal study A population-based longitudinal study Data collection The baseline survey collected information about present status and past events through interviews, clinical examinations and psychological testing by trained staff, including nurses, psychologists and physicians, following structured protocols (available at http://www. snac.org). Assessments comprised a social interview to collect sociodemographic data, evaluation of physical function performed by a nurse, clinical examination performed by a physician and a psychological test battery administered by a psychologist. Information on living arrangements, age, sex and education were recorded during the nurse interview. Participants were asked at baseline if they lived alone in their household or not. Education was measured as the highest level of formal schooling and was categorized as elementary school (grades 1–9), high school (grades 10–12), or university or above. Financial status was ascertained with a question about the presence of any trouble keeping up with regular expenses in the last 12 months. Smoking status was assessed, and participants were classified as current smokers, former smokers and persons who had never smoked. Alcohol consumption was assessed on the basis of self-reported frequency of alcohol intake on a typical day and was classified as no or occasional drinking, light to moderate drinking (1–14 drinks per week for men or 1–7 drinks per week for women) and heavy drinking (>14 drinks per week for men or >7 drinks per week for women).17 Loneliness was assessed by asking the participants if they ever felt lonely, and, if so, how strong (mild, moderate or strong) the feeling was. Medical conditions (diabetes, hypertension, stroke, heart failure, coronary heart disease, depression, dementia, cancer) were diagnosed by the examining physicians based on the clinical examination, selfreported medical history and laboratory data (see Supplementary file for more information). Information on medical history was also taken from the computerized inpatient register system that encompassed all hospitals in Stockholm since 1967 in which the criteria of International Classification of Diseases, ninth and 10th revision (ICD-9 and ICD-10) were followed (full description in Supplementary file). Nurses measured weight and height using a standard scale with the participant in light clothing and no shoes. Body mass index (BMI) was calculated as weight in kilograms divided by squared height in metres. BMI was divided into four categories: underweight (BMI < 20), normal weight (BMI between 20 and 24.9), overweight (BMI between 25 and 29.9) and obese (BMI  30).18 As BMI was missing for 7.6 % of the sample, a specific missing category was created and used for survival analyses. The Mini-Mental State Examination score (MMSE) was used to control for global cognitive abilities.19 Basic activities of daily living (ADL) and instrumental activities of daily living (IADL) were assessed. Disability in ADL was defined as any restriction in bathing, dressing, toileting, mobility, continence or feeding. Disability in IADL was defined as the inability to carry out at least one of the following four activities: using the telephone, using public transportation, handling finances and shopping. Ascertainment of death and institutionalization Death certificates from the Swedish Cause of Death Register at the National Board of Health and Welfare were used to ascertain deaths and dates of deaths from baseline to 15 October 2012. Data on institutionalization and the dates of institutionalization were ascertained through linkage to the care system part of SNAC-K (from baseline to 25 February 2013) that recorded the amount of public eldercare services granted in accordance with the Social Services Act. Statistical analyses Baseline characteristics were compared by living arrangement status (living alone or not living alone) with 2 test for categorical variables and t-test for continuous variables. Outcomes studied included time to death and time to institutionalization. We investigated survival and institutionalization over 6 years because this timeframe was close to the median delay for the two outcomes. Incidence rates of death and institutionalization by living arrangements and 95% CIs were estimated using a Poisson regression model. Cox proportional hazards regression models were used to estimate the hazard ratio (HR) of all-cause mortality and 95% CIs associated with living alone. Survival time was calculated as the number of years from the baseline interview to the date of death or the censored date for those who were still alive at the end of the follow-up time. Laplace regression was used to model percentiles of survival.20 In our study population, 29.6% of the participants died during the follow-up period. We therefore used the first quartile (the 25th percentile) of the survival time, expressed in years; that is the time by which 25% of the participants in the current study had died. As risk for death competes with risk for institutionalization, competing risk models were used to estimate the association between living alone and institutionalization, treating death as an explicit competing risk.21 Time to institutionalization was measured in years from the baseline survey to either the date of admission to an institution, date of death (without prior institution admission), or 6 years after baseline for those still living at home. In all Cox and competing risk regression analyses, age, sex, educational level, presence of a recent financial difficulty, vascular risk factors (BMI, smoking habits and alcohol consumption), chronic diseases, cognitive function, functional disability and feelings of loneliness were considered as confounders. We also adjusted the survival analyses by using institutionalization as a time dependant variable because moving into an institution can be considered a proxy of functional and/or cognitive decline and could modify the relationship between living arrangements and survival. We tested for possible interactions between living arrangements, age (
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