The health status of the ‘old-old’: A reconsideration

Sot. Sci. .Med. Vol. 22. So. 9, pp. 893-899. 1986 Printed in Great Bntain

0277-9536 86 S3.00 + 0.00 Pergamon Journals Ltd

THE HEALTH STATUS OF THE ‘OLD-OLD’:

A RECONSIDERATION*

BURTON P. HALPERT’ and M.UY K. ZI~~MER.MAN’

‘Department of Sociology, Center on Aging Studies, University of Missouri, Kansas City. MO 64108 and ?Department of Health Services Administration, University of Kansas, Lawrence, KS 66045, U.S.A.

Abstract-This paper questions the universal applicability and utility of age groupings among the elderly and the predictions which result concerning health status and costs as more people like beyond age 75. Comprehensive health data from an elderly population in rural Minnesota show the ‘old-old’ to be comparable to and in some respects better off than the ‘young-old’. Drawing on the notions of ‘compression of morbidity’ and survivorship, this study su,, ooests looking beyond simple age ‘distinctions in order to identify groups with increased risk.

Key words-rural elderly, health policy and planning. health assessment, compression of morbidity, survivorship

INTRODUCTION

In recent years, policy-makers and program planners

have been placed in the position of making decisions about older people based upon what, under certain circumstances, may be an over-generalization. It has been stated and widely accepted that as more people live beyond 75 years, society will be faced with increased financial and social costs because of the greater number of physical, psychological and social problems the older group will experience [l-5]. Some writers, however, have called this view into question 16, 71.

Brody, in a recent article, termed the prediction of increasing numbers and percentages of sick, old people the ‘gloomy perspective’. He warned planners, arguing that the future is far from clear, especially since “the scientific community has produced conflicting data and opinions with which we may approach policy decisions. . .” [7, p. 4691. In stark contrast to the ‘gloomy’ view, Fries [8-lo] and Fries and Crapo [l l] have gone so far as to predict that older people soon will be free of chronic diseases until the very end of their lives. This phenomenon, called the ‘compression of morbidity’, is the hypothesized result of a fixed human life span (based on the idea that the biological limits of the life span soon will be reached) and, at the same time, the postponement of the onset of significant mortality. These circumstances would create a ‘rectangularization’ of the life table survival curve. The need for extended medical

*Portions of this research were carried out with funding provided under Title III of the Older Americans Act and by a grant from the St Louis County Health De- partment, State of Minnesota. The authors wish to thank John W. LaBree. M.D., Jennifer Dwyer. Paula Murphy, Colleen Renier, Carol Swanson, Rose Winters and June Ward, among others, for their assistance at various stages in this project. An earlier version of this paper was presented at the Gerontological Society of American annual meetings in Boston, November, 1982.

care services in later life would decrease. Meyers and Manton [I21 found that, as of 1980, there was little indication of rectangularization. On the other hand, it seems premature to render a conclusion about these predictions. As yet, little empirical evidence is available and more research needs to be done (131.

Central to this debate is the efficacy of the widely accepted practice of grouping the elderly into age categories, for example, the ‘young-old’ (60-74 years) and the ‘old-old’ (75 + years). When such age groupings are imposed on large-scale, aggregate data, such as data from the National Health Survey, it can be shown that, among the elderly, the older group is indeed at a disadvantage in terms of health and social status [14]. Given the methodological precision of these data sources, conclusions regarding the ‘old- old’ have been readily adopted and incorporated into policy and planning agendas.

Recently, however, it has been suggested that generalizations about the relative health status of age groups among the elderly should be considered more carefully and probably refined. One study concluded, “the elderly are not a homogeneous subpopulation with a uniform set of needs that can be determined simply on the basis of age groupings” [6, p. 61. While such findings do not dispute the overall contention that age groupings are associated with differential health status, they do qualify it by pointing out that the magnitude of disadvantage may be less than expected [15]. Furthermore, health status among the , aged may vary substantially by location and according to the nature of specific populations. Implied here is the importance of directly assessing local and regional health status rather than inferring it from national findings.

A related issue concerns the need for more in-depth information. Stenback and associates have pointed out that “the mere numerical description of chronic ill health in the elderly can give a distorted and misleading view of the health conditions of this population” [ 161. According to these authors. chronic diseases differ in degree of severity, disability and

893

pain; there are chronic diseases which produce small amounts of disability and pain and have very little impact upon daily functioning. A recent analysis of data from the National Health Interview Survev focused on disability as measured by limitation of activity [17]. This study concluded that “disability reported among the U.S. population has increased substantially during the years 1966 to 1976”. Careful examination of the findings for those 65 and over. however. reveals that a statistically significant increase was found only in the category of males with severe limitation. No statistically significant increases were found among males with average and slight limitation or among any females. In fact, the percentage of males with average limitation significantly decreased. Wilson has cited this study in an editorial commenting on “the inability of health statistics to reflect what might really be happening to health status” [l8]. He pointed out a number of competing explanations for the increase in disability-factors which would have caused an artificial rather than a ‘real’ increase. Such problems call for clarification from more in-depth research and exemplify the difficulties which can accompany interpreting the results of large-scale health survey data.

To an extent, these debates and criticisms of past research also reflect the fact that studies typically have not taken as their central task comparative examination of age groupings in relation to health. Many of the previously reported findings with age comparisons have been drawn from studies where the major emphasis was on self-evaluations of health (such as ‘good’, ‘fair’, ‘poor’), or on basic assessments of chronic disease prevalence, etc. Thus, studies are needed which are comparative in terms of age and comprehensive in terms of health.

The data presented here provide an in-depth. focused comparison of ‘old-old’ and ‘young-old’ across a wide-range of specific health-related factors. Our central purpose in this paper is to introduce addi- tional evidence to stimulate thinking and clarification concerning the changing health status of the elderly- especially to question the wisdom of ‘blindly’ using simple age groupings as a fundamental way of drawing conclusions.

Our study is based on a relatively small (.V = 148) and geographically focused sample of rural and small town elderly. a group typically neglected in research on health and aging. Our study is distinctive in that it emiprically demonstrates the danger of generalizing from national data to localities and other sub-groups. Further, our rather detailed findings are distinctive in suggesting that the non-institutionalized ‘old-old’ may in some regions be as healthy-in some respects healthier-than their younger counterparts.

METHODS

A comprehensive health and social assessment of non-institutionalized elderly persons living in rural Northeastern Minnesota was carried out between 1978 and 1980. A sixteen township area covering some 900 square miles and containing seven small communities. the largest having a population of 1 100. was targeted for study. The area had a population of

nearly 1300 persons. 30% of whom we:? 40 years or older. Ethnically. the region was char-ct-rized by a large number of people with Northern European background. Those of Finnish descent w:rc the largest group. followed by those of Svvedish background. Other nationality groups represented were British. Irish, East and West European.

The gender breakdown in this area also is noteworthy. Based on available data from the 1980 Census, the 60 years and over population in this region was jj% male and 47% female. \Yhy this area had a sex ratio favoring males. opposed to national trends, is unclear. Several explanations can be suggested. One is a differential survivorship Fhenomenon which for some reason has favored maiss. Another possibility is that historically there has been a relatively high proportion of men in the region stemming from an influx of male immigrants in the early twentieth century, recruited to work in the logging and mining industries. A third explanation is that there has been disproportionate out-migration among women. especially widows. who have left the area in order to be close to family in nearby urban centers.

Approximately I IO/o of the area’s population 60 years of age or older was selected for the study. Because of the serious barriers to conducting random sampling in this rural area. a combination snowball’quota method was adopted. First participants (25%) v’ere direct respondents to community-wide requests for volunteers. These requests were made utilizing the unusually well- developed, de-centralized network of senior citizen organizations which exists in this region. It the time of data collection. there were seven such organizations dispersed geographically throughout the target area. Later participants (75%) were identified and contacted through a systematic snowball procedure, with attention placed on obtaining even geographic and demographic distribution. Given the fact that the majority of residents over age 60 had resided in the area for many years and either knew or knew of all their neighbors, however isolated. it seems likely that the snowball technique wou!d have re- sulted in a reasonable cross-section of the non- institutionalized elderly population. Of those contacted, less than 10% refused or were unable to participate.

For purposes of this analysis. the study population was divided into two age groups. 60-71 (Y = 107) and 751 years (N = 41). Table I shon-s selected socio-demographic characteristics of the study population. Looking at the group as a who!e. the demographic profile appears to accurately- reflect the’ ethmc and socio-economic composition of the region. From the time it was settled around the turn of the century. logging, mining and related indusrries as well as some light agriculture have formed the region’s economic base. Thus. the population is largely blue collar with relativelv low levels of forma! education among the older residents. As Table I shows. the two age groups in the sample were roughly equivalent in ethnic background and marital. occupxional and retirement status. On the other hand. qe group differences appeared in terms of amount of education completed. income and gender compos;tion. Ths

The health status of the ‘old-old‘ 895

Table I. Sow-demographic ch.smctwstics of the stud> populanon b) age group,“<

Age group (qears)

Statlstlccll

Charactenstic

6&71 7j, slgniticancr’

(%I (“01 P

Education completed

8th Grade or less

9th-I Ith Grade

13th Grade or more

Ethmcitv

Scan~inartsn

Finnish

British lnsh .Amsncan

European

Income+

< S5000

55000-59999

510.000-

Marital status

Married

Wldowed

Dworced. separated. neber marned

Occupation

Professional managerial

Clerical sales

Blue collar: Sex

Female 4Iale

16 il

17 I5

37 I-l 0.014

14

JO

21

15

19

JI

IO

57

31

IZ

IS

78

12

3

Sj

67 4-l

33 S6 0.016

24

29

I5

32

?I

I9

IO

jl

44

5

0.038

Retired 85 95

l z’ Test of Association. Probabtlity kalucs 20 05 are not reported.

+For 1978.

:Includrs full-time homemakers.

older group, as might be expected given their age and background, was less educated and had lower incomes. The gender composition difference, houever. was unexpected and was dealt with by a standard adjustment procedure which is discussed in the next section.

Data were collected through an extensive health interview survey. Five basic areas were dealt with: demographic/background information, housing and community, current and past health status, health care practices and attitudes and social activities. Interviews lasting one to two hours were conducted individually with the study participants in their homes. Two trained interviewers conducted the survey. Confidence in the validity of the data was enhanced by the fact that one of the interviewers. a physician’s assistant, lived. worked and was well- accepted in the community, Generally, such rapport can be expected to increase response accuracy.

Survey items were selected and organized into four groups, reflecting various facets of general heaith and well-being: physical health indicators. mental health indicators, social indicators and health behaviors. The health status items were taken from the medical history portion of the survey. Respondents were asked whether or not they currently were under care for each of a series of twenty-five common health problems. Results for all these problems are reported here. Three of the mental health items (‘depression’. nerves’ and ‘senility’) also were drawn from the medical history. The remaining mental health items were answered in terms of five Likert-type categories (ranging from ‘all the time’ to none of the time’). All

mental health items used in the survey are reported here. The measures of specific health attitudes and behaviors included here were chosen because they (I) represent standard measures of health care utilization or (2) address key gerontological concerns, i.e. medication behavior. knowledge of Medicare coverage, social participation. etc. Survey items not reported here consist of those dealing wtth housing. community satisfaction and evaluations of specific regional hospitals and ambulatory care arrangements.

Results for each item were examined according to age group. Statistical tests of significance using the z’ statistic were performed for each cross-tabulation. These tests were conducted primarily for their heuris- tic value and must be interpreted with caution since study participants were not selected using strict probability methods.

Health and related factors can vary significantly by sex as well as by age. Accordingly, gender distribution must be considered in comparisons of health status by age. In order to assess the possibility of bias due to disproportional gender composition. the sex breakdowns for each of the two age groups in the sample were compared to the sex breakdowns for the I corresponding age groups in the target population, based on data from the l9SO Census. Among the ‘old-old’. the gender composition of sample and population were equivalent. both reflecting the sur- prisingly high proportion of males discussed previously. Among the ‘young-old’, there were substantially more women in the sample than in the population (67 and 46% respectively).

To reduce the chance of bias resulting from this discrepancy. frequencies for all variables among the 60-74 year olds vvere adjusted for gender-i.e. they were recomputed to reflect the frequency which

996 BC.RTON P. H.~LPERT and MARY K. ZIMMERMAS

Table 2. Phksicni health mdlcators: self-reports of overall health status and prevalence of common hertlth problems by age grouping

Characteristic

Age group (years) Statistical

6&74* 7sc significance+ ( % 1 (%I P

Total number of health problems currently experienced l-3 79 78 4+

Self-report of health ‘Good’ to ‘excellent’ ‘Poor’ to ‘fair’

Alcohol problems Am~s,legs. difficulty using Arthritis. rheumatism Bowel problems Breathing difficulties Cancer Cataracts Dental problems Diabetes Digestive stomach problems CXlX0ma Hearing, ear problems Heart disease Hernia Hypertension Obesity Sexual problems Skm problems Speech problems Stroke Thyroid problems Urinary problems Varicose veins Veneral disease Vision problems (except glaucoma) Ability to get around

Able to go most places Get around wth difficultv

?I

55 45

0

16 56 I7 ?I

0 IO 83 13 16

2 35 23

8 56 46

6 20

6

: 22 ?I

0 99

51 49

0 22 78 IO 27

0 25 85

7 12 0

54 29

3 34 23

22 2

I5 8

22 20

2 93

88 76 I2 24

22

0.013

0.023

0.035

0.016 0.010

0.037

*Adjusted to approximate the sex distribution of the population. tl’ Test of Association. Probability values ~0.05 are not reported.

would be expected using the gender composition of ‘young-old’ in the target population. First, sex- specific frequency rates were found for each item. These rates then were applied to the male-female proportions in the population, producing the sex adjusted frequencies. In the analysis reported here, the adjusted data were used.

RESULTS

Health status (Table 2)

The total numbers of health problems currently being experienced in the two age groups were nearly equal. Twenty-two percent of the ‘old-old’ and 21% of the ‘young-old’ reported four or more health problems. Self-evaluation of health was roughly equivalent with 51% of the 55 + group and 55% of the 60-74 year olds perceiving themselves to be in ‘good to excellent’ health.

For the physical health measures reported in Table 2, the status of the ‘old-old’ approximated that of the ‘young-old’. Proportional frequences varied slightly between age groups. Overall, the direction of these differences was balanced. The major distinguishing health characteristics between the two age groups (as indicated by percentage differences as well as by statistical significance) were found to be:

_ arthritis/rheumatism, cataracts, hearing/ear problems

and, to a lesser extent, stroke. All these were more prevalent among the ‘old-old’. In contrast, hypertension and obesity were problems more prevalent among the ‘young-old’.

Mental health status (Table 3)

Findings showed that the mental health status of the older group was considerably better than that of the younger group. The ‘old-old’ reported that they were happier, less anxious, and were not experiencing depression as were the ‘young-old’. These results, taken together with the finding that 54% of the 75 + group reported never being sad compared to 40% in the younger group, would suggest that the ‘old-old’ had a substantially more positive outlook than the ‘young-old’. Reinforcing this interpretation were data which showed that 46% of the ‘old-old’ perceived their financial situation to be comfortable. compared to 42% among the ‘young-old’. This was true even though the ‘old-old’ as a group reported substantially lower incomes (see Table 5).

Health behaviors (Table 4)

Health care utilization rates in this population were mixed. The younger group was more likely to have a regular source of care and reported more physican visits during the past year. In the older group, there were proportionally more persons hospitalized. None of these differences was statistically significant, how-

The health status of the ‘old-old’ 997

Table 3. 4Lsntal health Indicators: self-reports of selected problems experienced by age grouping

Characteristic


60-7-1’ 75+ si_tificancet i 4’0 ) c % ) P

Depression Nerves Senility “Are you happy?’

ALI1 of the time “Do you find yourself anxious’?”

.Vonr of the time “Are you under stress?”

.Voone of the time “Are you sad?”

,Lone of the time “Do you feel like staying in bed or staying away from people?”

,Vune of the time

13 00 0.014 20 13

6 0

7 29 0.001

8 32 0.001

10 39

40 54

58 61

‘Adjusted to approximate the sex distribution of the population. tx’ Test of .Associauon. Probability values >0.05 are not reported

ever. The younger group consistently reported more health maintenance problems. Specifically, proportionally more of the ‘young-old’ found it difficult to see a doctor when needed (29% compared to 12%), were taking two or more prescribed medications (44% compared to 39%), forgot to take their medications (39% compared to 23%), had difficulty in paying for medications and medical needs (21% compared to 2%), and reported problems in person- ally maintaining their health care (14% compared to

none). At the same time, both groups were equivalent in exercising regularly.

Social status (Table 5)

As indicated earlier, a larger proportion of 75f persons had 1978 income below $5000 (17% compared to 49% among the ‘young-old’) even though proportionally more of the ‘old-old’ perceived their financial situation to be comfortable.

Table 4. Selected health behaviors and atutudes bv age uouuina

Variable


60-74’ 75+ significancet ( % ) (%) P

See physician on a regular basis 36 27 Saw physIcIan within last 12 months 91 83 It is difficult to see the doctor when I need treatment

Yes 29 I2 0.03 I

NO 71 88 Hospitalized one day or more within past year I8 27 Number of prescription medications taken regularly

0 31 37 I 25 24 2-6 44 39

“Do you ever forget to take medication?” NO 61 77

Have problems paying for medicine/medical needs 21 2 Difficult to maintain health care on my own I4 0 “How much do you understand about Medicare?”

Some to a lot 24 17 Very little 50 56 Nothing 26 27

Get regular exercise 40 39

*Adjusted to approximate the sex distribution of the population. tx’ Test of Association. Probability values >0.05 are not reported.

0.007 0.01 I

Table 5. Social indicators: socio-economic and social support/social participation variables by age grouping

Characteristic


u&74* 75i significance+

(%) (%) P

Income below 55000 (I 978) 45 71 0.005 Financial situation perceived as comfortable 41 46 Attend club meetings at least once/month 47 63 Have visitors in home at least once.‘week 78 73 Visit other people’s homes at least once week 69 49 Children provided help in the last year 71 85 Moderatelv to verv religious 69 70

*Adjusted to approximate the sex distribution of the population. fzL Test of Association. Probability values >0.05 are not reported

898 BLRTOS P. HALPERT and MARY K. ZIMMEKWAS

Mot-2 surprising in ths s2ns2 of contradicting ste- reotypes u-as thr finding that comparatively more of the ‘old-old’ attrndsd club me2tings at least monthly (639/o compared to -!7%). At th2 same time. however. the older group visited othsr people‘s homes 12s

(-19-694’0) and were slightly less likely to have weekly visitors in their homes (73-75%). Religiosity a-as found to bs equivalsnt bstueen the two groups. And finally. more of th2 older group received help from thsir children (85-7 1 O/b among the ‘young-old’).

DISCLSSIOU

In reviewing thess data, on2 finds those 75 years and older generally to be comparable to and, in some important ways, better off than the 6&74 year olds. These findings, bassd upon sslf-reports of health. are particularly noteworthy in light of the fact that previous studies have shown szlf-report data from the young-old and the old-old to be significantly cor- relatzd with both physician ratings and objective measures of health [ 19-231. These authors have gone so far as to recommend sslf-reports as a valid, cost<ffective means of health assessment.

The health problems (arthritis, rheumatism, cataracts. etc.) which w2r2 found to be more characteristic of our older group also have been found to characterize the ‘old-old’ in other studies [2]_ These problzms can restrict one’s daily activities; yet, as the social variables shovvsd, a large proportion of those 75+ years attendsd club mertings at least once a month (two-thirds) and visited other people’s homes at lsast once a week (nearly half). These findings corroborate the argument that policy-makers and program planners should not automatically assume that chronic disease debilitates and immobilizes the older adult in all populations [2]. Chronic diseases vary in severity of pain and disability.

The relative well-being of the 75 + group was also evidenced in their more favorable mental attitude about themselves and about life in general. The ‘old-old’ reported less depression, anxiety and ner- vousness. They wer2 happier and it would appear were in better control of their lives, despite the fact that they had less income.

One explanation for these positive feelings and attitudes can be found in the work of several in- vestigators, all of whom concluded that older elderly were more pleased and positive about their health and social status because. from their perspective, they were better off in the later years than they had expected to be [X,24-251. Also. it was suggested that the 75+ group, in contrast to the 60-74 year olds. had come to terms with the role changes and chronic ailments which commonly occur in later life.

As our data show. those 75t had good reason to feel this way. In comparison to the younger group. they were better abl2 to maintain their own health, control their weight. avoid hypertension, afford and take medications as prescribed and take’ fewer of these medications. Also, they were equally able to exercise regularly and w2r2 nearly as likely to evalu- at2 their overall health as good to excellent. Another explanation for these findings vvhich we cannot elim- inate is the possibility of a cohort effect. Our data do not allow us to examine such a phenomenon: how-

2v2r. it is somsthing for subsrquent ressarchers to taken into account.

Thess tindings seem to point to a survivorship phenomenon in the 75 f group. Since 1967, Linn and Linn hav2 contended that people who have liv2d beyond 75+ years have been able to do so because they are physically resistant to disease [31. 233. They are th2 biologically elite. sxempt from the killer diseases of younger cohorts. and are. therefore. survivors. Furthsrmore, the Linns have shown that diseases among the ‘old-old’ seem to cluster around the last few years of their livss. This clustering also may support what has been hypothesized in terms of the ‘compression of morbidity’ [8-l I].

If the Fries argument is correct, thsn the 75+ group in this study as well as in futurs generations can sxpect to spend a much shorter infirm period occurring near the end of their lives. Fries [lo] cites evidence from the past 20 years suggesting that those 75 years of age and older are healthier now than in previous generations due to more health promoting behavior and fewer chronic disorders in the major areas of stroke and cardiovascular diseass [IO]. Given these trends, it is argued. prophecies of impending social catastrophies for the 9th and 10th decades of the 20th century need to be questioned. Furthermore, according to Fries, if age specific morbidity rates are adjusted. removing medical and social costs occurring in the last year of life when infirmity is greatsst. then higher costs to society from an incrsasingly agsd population cannot be confirmed. Medical and social costs will not in fact spiral upward as psople lib2 beyond 75 years.

An alternative explanation for our findings is that the sampling procedure we employed may hav2 32- lected the more active and healthy among the older age group. Certainly this type of bias is one to be considered in any study using non-probability methods. especially volunteers. The likelihood of this having occurred in the present study. however, is diminished by the fact that (1) volunteers constitutsd only 25% of the sample; (2) the snowball procedure drew upon multiple networks spread throughout th2 target area; (3) participation was not contingent on an individual’s health or mobility since the survsy interviews were conducted at the participants’ con- venience and in their homes; and (4) th2 refusal rate for the survey was low (10%).

In sum. policy-makers and others should exercise caution in their use of age categories such as ths ‘young-old’ and the ‘old-old’. Of critical importance is analysis of diffsrences r~ithin these groups on the basis of health and social status, as wsll as the identification of variables which may contribute to ’ such differences. As discussed here and in other studies cited. th2 ‘old-old’ as a group may not always be worse off than the ‘young-old’. They may be a select group of survivors, comparable to and in som2 ways 2ven better off than those aged 60-7-l years.

The argument has been made that th2 practice of making assumptions about older people on the basis of chronological age groups should be more carefully considered. especially when focusing on specific local-

The health status of the ‘old-old’ ,899

ities and populations. The research reported here suggests that. among rural elderly in Northeastern Minnesota, people 75+ years are not substantially worse off than those 60-7-l years. As a matter of fact, they may in some respects be better off. More attention should be given to the view of older persons as survivors. In future work. researchers also should look rtithin the age groups to help answer the question of who is at Increased risk. The ‘compression of morbidity’ perspective suggests that life-style and preventive measures such as self-care, not smoking, diet, exercise. etc., may be important in

differentiating those at risk from those who are not.

It also suggests that postponement of infirmity can result from changing social expectations among the elderly in terms of such things as ‘social withdrawal’. Certainly, in our findings the relatively healthy ‘old-old’ had not withdrawn and were quite active participants in community and social life. In sum, analyses which go beyond simple age groupings will

provide policy-makers and program planners with a more accurate assessment of w:hat to expect in terms of health care and social costs to society as the population expands beyond 75 years.

REFERESCES

I. Neugarten B. L. Age groups in American society and the use of the young-old. dnn. Am. Acad. Polio. Sot. Sri. 415, 187-198, 1974.

2. Shanas E. and Maddox G. L. Aging, health and the organization of health resources. In Handbook ofAging and the Social Sciences (Edited by Binstock R. and Shanas E.). Van Nostrand Reinhold, New York. 1976.

3. Kovar M. G. Health of the elderly and use of health services. Publ. Hirh Rep. 92, 9-19, 1977.

4. Neugarten B. L. and Havighurst R. J. Aging and the future. In Dimensions of Aging (Edited by Hendricks J. and Hendricks C. D.). Winthrop, Cambridge. 1979.

5. Verbrugge L. M. Longer life but worsening health? Trends in health and mortality of middle-aged and older persons. Milbank mem. Fund Q./Hlrh Sot. 62,475-j 19, 1984.

6. Buesching A. and Glasser M. Aee-health group differences in elderly populations: rela&e influences of health status, finances, and social support variables. Paper presented at American Public Healrh Asocialion .Meeting. Montreal, 1982.

7. Brody J. A. Facts, projections, and gaps concerning data in aging. Publ. Hlrh Rep. 99, 468-475, 1984

s

9

IO.

II

12.

I3

I1

I5

I6

I7

18

I9

20.

21.

22.

23.

24

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The health status of the ‘old-old’: A reconsideration