La Redefinición Empírica de La Salud Integral y El Bienestar en Los Adultos Mayores de Los Estados Unidos

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Abstracto
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problema
www.pnas.org
(/) > Actualidad (/content/113/22.toc) > vol. 113 no. 22 Métodos SI
> Martha K. McClintock, E3071-E3080 , doi: 10.1073 / pnas.1514968113
Discusión
Métodos
Expresiones de gratitud
Notas a pie de página
Referencias
La rede nición empírica de la salud integral y el bienestar en (/content/113/22.toc)

31 de mayo de
los adultos mayores de los Estados Unidos 2016

vol. 113 no. 22
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a 1 Tabla de contenido
Martha K. McClintock (/search?author1=Martha+K.+McClintock&sortspec=date&submit=Submit) ,
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William Dale (/search?author1=William+Dale&sortspec=date&submit=Submit) , (/content/113/22/local/masthead.pdf)
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Edward O. Laumann (/search?author1=Edward+O.+Laumann&sortspec=date&submit=Submit) , and
, ARTÍCULO SIGUIENTE
ANTERIOR ARTÍCULO
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Linda Waite (/search?author1=Linda+Waite&sortspec=date&submit=Submit)
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aplicación de
La salud ha sido concebida desde hace mucho tiempo como no sólo la ausencia de enfermedad, sino forma gratuita
también la presencia de bienestar físico, psicológico y social. No obstante, el modelo médico desde Google Play
hoy!
tradicional se centra en enfermedades específicas del sistema de órganos. Este estudio
representativo de adultos mayores estadounidenses que viven en sus hogares amasó no sólo Article Tools
información médica integral, sino también datos psicológicos y sociales, y midió la función sensorial y
 Article Alerts
la movilidad, factores clave para una vida independiente y una vida gratificante. Este modelo completo
 Export Citation
reveló seis clases de salud únicas, que predecían la mortalidad / incapacidad. Las personas más
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sanas eran obesas y robustas; dos nuevas clases, con el doble de mortalidad / incapacidad, eran
© Request Permission
personas con huesos rotos cicatrizados o mala salud mental. Este enfoque proporciona un método
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empírico para reconceptualizar ampliamente la salud, lo que puede informar a la política de salud.
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 (/external-ref?
Abstracto Navegar este artículo
tag_url=http://www.pnas.org/cgi/content/short/113/22/E3071&title=Empirical%2
being%20in%20the%20older%20adults%20of%20the%20United%20States+--+M
La Organización Mundial de la Salud (OMS) define la salud como un "estado de completo bienestar físico, Parte superior
+PNAS&doi=10.1073/pnas.1514968113&link_type=FACEBOOK)
mental y social y no simplemente la ausencia de enfermedad o dolencia". A pesar de la aceptación general
de esta amplia definición, utilizarlo para medir y evaluar la salud de la población. En cambio, el modelo (/external-ref?
Abstracto
dominante de salud es un Modelo Médico (MM) centrado en la enfermedad, que ignora activamente muchos tag_url=http://www.pnas.org/cgi/content/long/113/22/E3071&title=Empirical%20
Resultados
dominios relevantes. En contraste con el MM, abordamos este tema a través de un Modelo Integral (CM) de
salud consistente con la definición de la OMS, dando la consideración estadísticamente igual a múltiples +PNAS&doi=10.1073/pnas.1514968113&link_type=TWITTER)
Métodos SI
dominios de salud, incluyendo los médicos, físicos, psicológicos, y las medidas sensoriales. Aplicamos un
Discusión
análisis de clase latente (LCA) basado en datos para modelar 54 variables de salud específicas del Proyecto
(/external-ref?
Nacional de Vida Social, Salud y Envejecimiento (NSHAP, por sus siglas en inglés), una muestra
Métodos
tag_url=http://www.pnas.org/cgi/content/long/113/22/E3071&title=Empirical%20
representativa a nivel nacional de adultos mayores de la comunidad estadounidense. Primero aplicamos el
LCA al MM, identificando cinco clases de salud diferenciadas principalmente por tener diabetes e Expresiones de gratitud
+PNAS&doi=10.1073/pnas.1514968113&link_type=CITEULIKE)
hipertensión. El CM identifica una gama más amplia de seis clases de salud, incluyendo dos clases
"emergentes" completamente oscurecidas por el MM. Encontramos que los diagnósticos médicos específicos (/external-ref?
(cáncer e hipertensión) y comportamientos de salud (fumar) son mucho menos importantes que la salud tag_url=http://www.pnas.org/cgi/content/long/113/22/E3071&title=Empirical%20
Referencias
mental (soledad) la función sensorial (audición), la movilidad y las fracturas óseas en la definición de clases being%20in%20the%20older%20adults%20of%20the%20United%20States+--+M
de salud vulnerables. Aunque el MM coloca a dos tercios de la población de los Estados Unidos en clases de +PNAS&doi=10.1073/pnas.1514968113&link_type=DEL_ICIO_US)
"salud robusta", el CM revela que la mitad pertenece a clases menos saludables, independientemente (/external-ref?
asociadas con una mayor mortalidad. Esta reconceptualización tiene importantes implicaciones para la tag_url=http://www.pnas.org/cgi/content/long/113/22/E3071&title=Empirical%20
prestación de atención médica, las prácticas preventivas de salud y la asignación de recursos. being%20in%20the%20older%20adults%20of%20the%20United%20States+--+M
independientemente asociada con mayor mortalidad. Esta reconceptualización tiene importantes +PNAS&doi=10.1073/pnas.1514968113&link_type=DIGG)
implicaciones para la prestación de atención médica, las prácticas preventivas de salud y la asignación de
(/external-ref?
recursos. independientemente asociada con mayor mortalidad. Esta reconceptualización tiene importantes
tag_url=http://www.pnas.org/cgi/content/short/113/22/E3071&title=Empirical%2
implicaciones para la prestación de atención médica, las prácticas preventivas de salud y la asignación de
recursos. +PNAS&doi=10.1073/pnas.1514968113&link_type=MENDELEY)
salud integral (/search?fulltext=comprehensive+health&sortspec=date&submit=Submit&andorexactfulltext=phrase) Published online before print

May 16, 2016, doi:
envejecimiento (/search?fulltext=aging&sortspec=date&submit=Submit&andorexactfulltext=phrase)
10.1073/pnas.1514968113
enfermedad (/search?fulltext=disease&sortspec=date&submit=Submit&andorexactfulltext=phrase) PNAS (procedimientos de la
bienestar (/search?fulltext=well-being&sortspec=date&submit=Submit&andorexactfulltext=phrase) Academia Nacional de Ciencias)
May 31, 2016 vol. 113 no. 22
política de salud (/search?fulltext=health+policy&sortspec=date&submit=Submit&andorexactfulltext=phrase) E3071-E3080
Classi cations
En 1946, la Organización Mundial de la Salud (OMS) definió la salud como "un estado de completo bienestar PNAS Plus (/search?
tocsectionid=PNAS+Plus&sortspec=date&submit=Submit)
físico, mental y social y no simplemente la ausencia de enfermedad o dolencia" ( 1 ). En 1977, George Engel Social Sciences
( 2 ) se basó en esta definición, llamando a un nuevo modelo biopsicosocial. Integró la medicina tradicional Social Sciences
con factores psicosociales, que estimularon el campo de la medicina psicosomática. Estas ideas se han (/search?
tocsectionid=Social+Sciences&sortspec=date&submit=Submit)
honrado más como un ideal que en la práctica.
Aquí, buscamos aplicar esta definición comprensiva para caracterizar la salud de los adultos mayores de los
EEUU que viven en sus hogares. Estudiando una muestra representativa de la población estadounidense de
57-85 años de edad [el Proyecto Nacional de Vida Social, Salud y Envejecimiento (NSHAP)], recopilamos Figures
amplia información sobre las enfermedades del tradicional "Modelo Médico" (MM) y también , el bienestar
psicológico y la función física en un "Modelo Integral" (CM) informado por el enfoque de Engel ( 2 , 3).
Determinamos empíricamente si estas medidas de salud formaron constelaciones distintas, caracterizando
grupos de personas con diferentes patrones de salud y bienestar. Nuestro amplio estudio de 3.005 adultos
mayores de edades comprendidas entre 57 y 85 años no fue una muestra clínica o una muestra de
conveniencia, sino una sistemáticamente seleccionada para representar a todos los adultos mayores de los
Estados Unidos, residentes en la comunidad, independientemente de su estado de salud.
El estándar MM de la salud, a veces llamado el modelo biomédico, tiene sus orígenes en el 1910 Flexner
Informe ( 4 ), que codificó la educación médica y se centra en las enfermedades, específicamente su (/content/113/22/E3071/F2.expansion.html)
patología, bioquímica y fisiología ( 5 ⇓ ⇓ - 8 ). Se ejemplifica en la atención hospitalaria que responde al
fracaso de sistemas de órganos específicos, codificados en categorías internacionales de reembolso de Fig. 1. Examinar todas las guras
(/content/113/22/E3071. gures-
servicios de salud [Códigos de Clasificación Internacional de Enfermedades (ICD) [ 9 ]] e históricamente
Navegar
only) este artículo
instanciados en la organización de los Institutos Nacionales de Salud , Instituto Nacional del Cáncer (1937) y
Instituto Nacional del Corazón, Pulmón y Sangre (1948) ( 10)]. Parte superior
Más típicamente, sin embargo, los adultos mayores a menudo tienen más de una enfermedad basada en el Otros Artículos
Abstracto
sistema de órganos (por ejemplo, diabetes e hipertensión), formando un grupo de problemas ( 11 ), aunque Citando este artículo
Resultados
sus otros sistemas de órganos continúan funcionando (por ejemplo, riñones y pulmones) . Por lo tanto, Google Académico
nuestro primer paso fue identificar empíricamente distintas constelaciones de estados de salud dentro del PubMed
Métodos SI
MM. Se utilizaron datos sobre las causas prevalentes de muerte para seleccionar enfermedades para su Similar a este artículo
inclusión ( 12). Estas enfermedades seleccionadas son enfermedad cardíaca, cáncer, enfermedad pulmonar, Discusión
apoplejía, diabetes, enfermedad renal y enfermedad hepática. También incluimos enfermedades comunes en ENVIAR UN ARTÍCULO
Métodos
(HTTP://WWW.PNASCENTRAL.ORG)
adultos mayores, aunque con baja mortalidad asociada: artritis, hipertensión, asma y enfermedad tiroidea (las
medidas 1-19 en la Fig. S1 documentan las enfermedades del sistema de órganos). Expresiones de gratitud
Referencias
(E3071/F1.expansion.html)
Parte superior
Abstracto
Resultados
Métodos SI
Discusión
Métodos
Referencias
Parte superior
Abstracto
Resultados
Métodos SI
Discusión
Métodos
Referencias
En una ventana nueva (E3071/F1.expansion.html) Descargar PPT (/powerpoint/113/22/E3071/F1)

Fig. S1.
Las definiciones de medidas de salud, sus puntos de corte y categorías utilizadas en ACV para el MM y
el MC y en los informes de su prevalencia dentro de cada clase de salud con relación a la población de
los Estados Unidos en las Figs. 1 y 2 y la figura S4 . La validación externa es proporcionada por
encuestas y citas nacionales que reportan una prevalencia de los EE. UU. Comparable a las del NSHAP,
junto con citas numeradas para las definiciones y categorías de las mediciones de salud ( 26 , 30 , 39 ,
65 ⇓ ⇓ ⇓ ⇓ ⇓ ⇓ ⇓ ⇓ ⇓ ⇓ ⇓ ⇓⇓ ⇓ ⇓ ⇓ ⇓ ⇓ ⇓ ⇓ ⇓ ⇓ ⇓ ⇓ ⇓ ⇓ ⇓ ⇓ ⇓ ⇓ ⇓ ⇓ ⇓ ⇓ ⇓ ⇓ ⇓ ⇓ ⇓ ⇓ ⇓ ⇓ ⇓ ⇓ ⇓ ⇓ ⇓ ⇓ ⇓ ⇓ ⇓ ⇓ ⇓
⇓ ⇓ ⇓ ⇓ ⇓ ⇓ ⇓ ⇓ ⇓ ⇓ ⇓ ⇓ ⇓ ⇓ ⇓ ⇓ ⇓ ⇓ ⇓ ⇓⇓ ⇓ ⇓ ⇓ ⇓ ⇓ ⇓ ⇓ ⇓ ⇓ ⇓ ⇓ ⇓ ⇓ ⇓ - 154). ADL, actividades de la vida
diaria; BP, presión arterial; CAPI, compuesto de una entrevista personal; CES-D, Centro de Estudios
Epidemiológicos Escala - Depresión; CRP, proteína C reactiva; CVD, enfermedad cardiovascular; PAD,
presión arterial diastólica; DCCT, Prueba de Control de la Diabetes y Complicaciones; HADS-A, Escala
Hospitalaria de Ansiedad y Depresión - Subescala de Ansiedad; HRS, Estudio de Salud y Retiro; HRS-
UCLA, HRS forma corta de la Universidad de California Los Angeles escala de la soledad; HTN,
hipertensión; ID, identificación; M, hombres; NASM, Medida de Síntomas de Ansiedad de NSHAP;
NFLM, la medida de la soledad del fieltro de NSHAP; NHUM, Felicidad NSHAP - medida de infelicidad;
NPSM, NSHAP ' s Medida de Estrés Percibida; NDSM, NSHAP Depressive Symptoms Measure; PAS,
presión arterial sistólica; SPMSQ, Cuestionario de Estado Mental Portátil Corto; ETS, enfermedad de
transmisión sexual; ITS, infección de transmisión sexual; TIA, ataque isquémico transitorio; W, mujeres.
A continuación, proponemos que el CM pretende corresponder teóricamente a las definiciones de salud de la

OMS ( 1 ) y Engel ( 2 ) incorporando cinco dimensiones funcionales adicionales relevantes para caracterizar
ampliamente la salud y el bienestar: comportamientos de salud, salud psicológica, habilidades sensoriales,
neuroimmune función y movilidad ( Fig. S1 ). Estas dimensiones y los dominios dentro de ellas no forman
parte del modelo biomédico ( 2 ). Reflejan el papel integrador del sistema nervioso central (SNC) y del
sistema nervioso periférico con el comportamiento ( 13 , 14 ) y sustentan la salud robusta crucial para la
calidad de vida y la independencia continua en los adultos mayores (15 , 16 ). Las 35 medidas adicionales de
salud ( figura S1 , medidas 20-54), aunque no exhaustivas, fueron seleccionadas para representar las cinco
dimensiones. Para la claridad conceptual y la trazabilidad analítica, enfocamos nuestro análisis en los
dominios físicos y psicológicos de estas dimensiones, manteniendo al individuo en el centro del análisis.
Consideramos los dominios sociales sólo en relación con estos otros dominios centrados en la persona y
caracterizamos a las personas en términos de estado civil, intimidad sexual, interacciones sociales, estatus
socioeconómico, edad, raza y sexo.
Parte superior
Para agrupar a todos los encuestados en distintas constelaciones o clases basadas en sus múltiples medidas
de salud, se utilizó el análisis de la clase latente (LCA, también llamado modelado de mezcla finita) ( 17). LCA Abstracto
postula una estructura subyacente a una población que no es directamente observable, pero que puede
Resultados
identificarse utilizando una colección suficientemente grande de variables observables. A continuación, la
LCA identifica subgrupos o clases diferentes dentro de la población más grande, basándose en las Métodos SI
características comunes subyacentes entre las variables, aspectos comunes que se supone que surgen de la
característica "latente" subyacente. Después de que las clases se han identificado matemáticamente Discusión
(especificando la constelación de valores de las medidas de salud que se agrupan), cada participante puede
Métodos
ser asignado a la clase más apropiada sobre la base de sus valores particulares para cada una de las
medidas de salud. Expresiones de gratitud
Hacemos varias preguntas. ¿Cuáles son las características de salud que aparecen juntas en cada una de las Notas a pie de página
clases identificadas? ¿Qué medidas de salud discriminan mejor entre las constelaciones? Presentamos la
Referencias
prevalencia de todas las medidas de salud en cada clase en relación con la población general de los Estados
Unidos. Utilizamos mapas de calor ( Figuras 1 y 2), en el que cada célula está codificada por color para
indicar la prevalencia de una medida significativamente menor que, típica o superior a la población general
(verde, amarillo y rojo, respectivamente). El mapa de calor resultante presenta una instantánea visual de las
características de las clases a través de todas las medidas de salud, permitiendo al lector analizar las
características de cada clase ya través de las clases para diferentes grupos de características, resumiendo
eficazmente y rápidamente las constelaciones de salud que aparecen en los EE.UU. población de adultos
mayores.

Figura 1.
El MM con cinco clases distintas de enfermedades del sistema de órganos y la salud. La columna
población de los EE.UU. (EE.UU. Pop.) Informa la prevalencia en 2005 de cada enfermedad en el más
antiguo EE.UU. Pop. edades 57-85 y viejo. Dentro de cada clase de salud (columnas), la prevalencia de
una enfermedad dada indiza la probabilidad de que cualquier miembro de la clase tenga esa enfermedad
en particular [filas; n = 19 medidas de salud ordenadas por prevalencia dentro de cada uno de los seis
dominios (columna 2) dentro de la dimensión del sistema de órganos (columna 1)] y comparte
constelaciones similares de enfermedad y salud. Los colores indican la prevalencia de la prevalencia de Parte superior
la enfermedad de cada clase en relación con los EE.UU. Pop .: verde, más bajo ( P≤ 0,01); amarillo,
típico [no significativo (NS)]; rojo, mayor ( P ≤ 0,01). La morbilidad fue indexada por la proporción de Abstracto

miembros de la clase que estaban incapacitados (es decir, demasiado enfermo para entrevistarse en el
Resultados
seguimiento de 5 años), y la mortalidad fue indexada por la proporción que había muerto. * Dado el 
contexto de la salud de la multimorbilidad extensa, la clasificación de estas medidas de la tensión arterial Métodos SI
fue anulada y designada vulnerable (rojo). BP, presión arterial; EPOC, enfermedad pulmonar obstructiva 
Discusión
crónica; CV, cardiovascular; CVD, enfermedad cardiovascular; HTN, hipertensión. 
Métodos



Referencias


Figura 2.
El CM de salud con seis clases de salud distintas basadas en 54 medidas de salud a través de seis
dimensiones (enumeradas en la columna 1). La columna población de los EE.UU. (EE.UU. Pop.) Informa
la prevalencia en 2005 de cada enfermedad o condición en el más antiguo de EE.UU. Pop. edades de
57-85 años (definiciones y validación en la Fig. S1 ). Dentro de cada clase de salud (columnas), la
prevalencia de una determinada enfermedad o condición indiza la probabilidad de que cualquier
miembro de la clase tenga esa enfermedad en particular [filas; norte= 54 medidas de salud ordenadas
por prevalencia dentro de cada dominio de salud (columna 2)] y comparte constelaciones similares de
enfermedad y salud. Los colores indican la prevalencia de la enfermedad y las afecciones de cada clase
en relación con la población de los Estados Unidos: verde, menor ( P ≤ 0,01); amarillo, típico [no
significativo (NS)]; rojo, más alto ( P≤ 0,01; lo que indica una mayor vulnerabilidad). La morbilidad fue
indexada por la proporción de miembros de la clase que estaban incapacitados y demasiado enfermos
para entrevistarse en el seguimiento de 5 años, y la mortalidad fue indexada por la proporción de los que
habían fallecido. * Dado el contexto de la salud de la multimorbilidad extensa, la clasificación de estas
medidas de la tensión arterial fue anulada y designada vulnerable (rojo). ADL, actividades de la vida
diaria; BP, presión arterial; EPOC, enfermedad pulmonar obstructiva crónica; HTN, hipertensión; ID,
identificación; STD, enfermedades de transmisión sexual.
Parte superior
La hipótesis de que la inclusión de las medidas que abarcan las cinco dimensiones adicionales de la CM de Abstracto
la salud cambiaría significativamente la constelación de características que definen grupos distintos de
adultos mayores en los Estados Unidos. Hacerlo, argumentamos, iluminaría las asociaciones significativas Resultados
entre el funcionamiento, el bienestar y la enfermedad en las personas mayores. Si es así, estas nuevas Métodos SI
constelaciones crearían un cuadro más rico de los diversos tipos de envejecimiento y podrían informar la
reestructuración en curso del sistema de cuidado médico de los EEUU. Discusión
Para validar con firmeza la salud de los individuos dentro de cada clase de salud, hemos utilizado tres Métodos
medidas estándar de salud que eran independientes de los ACV: ( i ) el número de medidas de salud
vulnerables por individuo, la vulnerabilidad definida por los puntos de corte clínicos o basados en la literatura
( Higos 1 y 2 y la figura S1 ); ( ii ) el número de las principales enfermedades crónicas que cada individuo Notas a pie de página
tenía [definido por el Índice de Charlson ( 18 , 19 ); etiquetados como enfermedades comórbidas de
Charlson], y ( iii) la proporción de individuos en cada clase que murieron o estaban demasiado incapacitados Referencias
para ser entrevistados en el momento de la segunda ola de recopilación de datos (etiquetados como
fallecidos o incapacitados 5 años después). Nos referimos a estas tres medidas como la mortalidad y la
morbilidad de los individuos dentro de una clase. Las evaluaciones subjetivas de la persona de la salud física
y mental global son validadores adicionales de las clases de salud ( 20 , 21 ).
El envejecimiento se ha conceptualizado como la pérdida creciente de la función fisiológica, una trayectoria

seguida por la mayoría de las personas a medida que envejecen ( 22 ). Si es así, las clases de salud en una
población envejecida deben ser ordenadas linealmente por edad cronológica a medida que las personas
progresan de una clase a otra en secuencia. Alternativamente, el envejecimiento puede ser conceptualizado
como un conjunto diverso de vías ( 23 , 24), siendo la edad cronológica un pobre predictor de si se seguirá
una vía de envejecimiento o una salud sostenida. Seguimos a las personas durante un período de 5 años,
evaluando la probabilidad de pertenencia a una clase estable y la transición hacia la mejora, la incapacidad o
la muerte.
Resultados
MM: Clases Distintas Distinguidas por la Diabetes y la Hipertensión. El análisis de las
enfermedades del sistema de órganos de la MM identificó cinco clases distintas de enfermedad y salud entre
los estadounidenses mayores, residentes en la comunidad, cada uno estadísticamente independiente de los
otros ( Fig. 1 ). La diabetes, que representó sólo el 3% de las muertes de más de 55 años en 2010 ( 25 ), sin
embargo, tuvo el mayor poder para distinguir entre estas cinco clases de salud, dividiendo las cinco en dos
series más amplias. Un conjunto fue muy robusto, con una ausencia total de diabetes diagnosticada (0%) y
sólo 7% (MM1) y 2% (MM2) con diabetes medida [HbA1C> 6,5 ( 26 )] ( Figura 1, medidas 1 y 2). El otro
conjunto era bastante vulnerable a la diabetes y otras enfermedades (MM3-5: 39-100% habían diagnosticado
diabetes y 30-69% habían medido la diabetes).
Cardiovascular diseases (Fig. 1, measures 4–10), which account for 35% of deaths over the age of 55 y old
(25), did not distinguish robust from vulnerable classes. Rather, blood pressure measured in the home
distinguished the two robust nondiabetic classes. No one in MM1 [Unrecognized Hypertension class] had
normal systolic blood pressure; 100% were elevated (61% into hypertension stage I or II). In sharp contrast,
0% of the second robust class (MM2 One Noncardiovascular Disease) had hypertensive blood pressure, and
even the 34% diagnosed with hypertension were well-controlled. Instead, most in MM2 had only one, if any, of
a variety of noncardiovascular diseases or conditions (e.g., asthma, chronic obstructive pulmonary disease,
thyroid disease, ulcers, or cancer) (27).
All three indicators of mortality and morbidity (bottom three rows of Fig. 1) were significantly lower in the two
robust classes (MM1 and -2) than in the overall population. These classes had the fewest number of health
measures signifying disease as well as the lowest prevalence of physician-identified organ system diseases
(Charlson comorbid diseases) (Fig. 1) (18, 19). Fully two-thirds of older adults in America were members of Parte superior
these robust classes.
Abstracto
Surprisingly, although cancer caused 24% of deaths among those over the age 55 y old in 2005 (25), no
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cancer type distinguished the five MM classes (Fig. 1, measures 17⇓–19). Rather, cancers seemed to develop
randomly with respect to other organ system diseases. Métodos SI
The three vulnerable classes (MM3–5) shared a high prevalence of diabetes and hypertensive blood pressure Discusión
but were distinguished by their constellations of other diseases. The Uncontrolled Diabetes class (MM3) was
comprised entirely of diagnosed diabetics (100%), primarily uncontrolled (69% HbA1C > 6.5). Most (70%) Métodos
were also diagnosed with hypertension, but it was well-controlled in the home interview (only 32% with systolic
blood pressure in hypertension stage I or II), reflecting the recommended clinical practice of controlling
hypertension before diabetes. In addition, one-half had arthritis (49%), which is typical of older adults, and 3% Notas a pie de página
had severe liver disease, three times more than the overall population. In sum, they had more diseases than
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the general population (4.0, vulnerable health measures; 2.2, Charlson comorbid diseases).
Members of the remaining two diabetic classes (MM4 and -5) were the most vulnerable. In MM4, the
prevalence of diabetes was twice that of the older population nationally, and most had been diagnosed with
hypertension that was not controlled when measured at home (76–89%), with 0% in the normal range.
Strikingly, cardiovascular diseases were two to three times more prevalent in MM4 than in the older US
population, defining it as the Cardiovascular Disease and Diabetes class. Only arthritis and peptic ulcers had
a higher prevalence, whereas lung, kidney, and liver diseases were typical of the general population, and
cancer prevalence was low. The fifth most vulnerable class had a very high prevalence of all diseases, making
it the Extensive Multimorbidity class. Of note, the measured blood pressure of those in this class was usually
lower than that in the other classes, consistent with advanced heart failure (28).
The characterization of the MM classes as either robust or vulnerable was independently supported by the
2.5-fold difference across the classes in the prevalence of being incapacitated or deceased (bottom row of Fig.
1). Of the two robust classes, 14% and 15% were incapacitated or deceased 5 y later, respectively,
significantly lower than the three vulnerable classes at 20%, 24%, and 35%.
The constellations of diseases in the five MM classes are consistent with the traditional MM of organ system
diseases with two added contributions. Diabetes and elevated blood pressure were identified as the “first tier”
traits distinguishing among health classes of older community-dwelling adults. In addition, cancers did not
form a distinct health class. Moreover, this analysis reveals that there are no significant differences in
chronological age among the five classes, supporting the hypothesis that health and well-being of older adults
do not follow a single linear progression and are associated less with age than with such sociodemographic
traits as race, education, and gender (23, 29).
CM of Health: New Constellations of Disease and Health. Organ function is coordinated in part by
the CNS and the peripheral nervous system, which also integrate the body with the social and physical worlds
essential for health and well-being. To create a CM of health, we augmented the MM with 35 measures drawn
from five additional health dimensions involving the nervous systems: health behaviors, such as smoking,
exercise, and sleep; psychological health (i.e., mental health and cognition); sensory function, such as vision
and olfaction; neuroimmunity; and frailty. Within each dimension, specific domains included measures of
conditions common at older ages, such as depressive symptoms, memory loss, poor vision, chronic
inflammation, and impaired mobility. They also included trauma, such as bone fractures, as well as health
behaviors, such as body composition, sleep quality, drinking, smoking, and sexually transmitted diseases.
Although some of these comprehensive measures are physical, none are part of the standard MM (2).
Six distinct, statistically independent health classes emerged (Fig. 2). Many individuals categorized as in
robust health by the MM were revealed to have important health vulnerabilities when the broader definition of
health was used. Conversely, some with organ system disease showed many counterbalancing strengths,
leading to a reassignment to a robust health class in the CM. Many individuals were reclassified from their MM
classes to different CM classes (Fig. 3), yielding a rich reconceptualization of what constitutes health and well-
being in the older population at home in the United States, characterized by specific constellations of disease
and function. Parte superior
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Métodos SI
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Fig. 3.
Reclassification of each individual from a given MM class (columns) into one of the CM class (rows). The
percentage of individuals in each MM class that was reclassified across the six CM classes is provided in
Upper table, and the ORs of doing so are in Lower table. CV, cardiovascular; CVD, cardiovascular
disease; HTN, hypertension. *P < 0.05; **P < 0.01; ***P < 0.001 (Bonferroni adjusted for multiple
comparisons).
The CM identified two types of robust health at older ages (CM1 and -2), strikingly different from those
identified by the MM and also, strikingly different from each other. Obesity characterized the first robust class,
which comprised 22% of the older US population [54% of the Robust Obese class had an obese body mass
index (BMI; 41% moderately obese and 13% morbidly obese; 0% had a normal BMI), and 60% had central
obesity] (Fig. 2, measures 20 and 21). This class was also characterized by elevated blood pressure
measured at home (45% systolic blood pressure hypertension stage I or II and 31% diastolic hypertension
stage I or II) (Fig. 2 measures 5 and 6) (30). Although obesity is typically viewed as a severe health risk (31),
this obese class had few organ system diseases or conditions per individual (Fig. 2) (individual average: 7.2,
vulnerable health measures; 1.2, Charlson comorbid diseases). This class (CM1) had the lowest prevalence
of dying or becoming incapacitated 5 y later (6%; one-third the prevalence in the general population),
supporting the emerging concept that being overweight without complications and impaired mobility is not
always deleterious to health, particularly in older adults (31⇓⇓–34). This class had notably better psychological
health than the overall older population as well as better mobility and sensory function (other than taste) [Fig.
S2A presents odds ratios (ORs) for the constellation of health characteristics, whose presence and absence
distinguished the Robust Obese class from the rest of the population].
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(E3071/F5.expansion.html) Métodos
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Fig. S2.
(A) Robust classes (CM1 and -2). Health measures that significantly distinguished a given CM health
class from the remaining population [six logistic regression analyses, one for each CM class, each with all
54 health measures, and ORs (rounded to similar precision for ratios ranging from 0.0000 to 61)]. Cells
above the dashed line (green) are health measures whose presence significantly distinguished the health
class (OR > 1.0) independent of the other health measures. Cells below the dashed line (rose) are health
measures whose absence significantly distinguished the health class (OR < 1.0). (B) Intermediate
classes (CM3 and -4). Health measures that significantly distinguished a given CM health class from the
remaining population [six logistic regression analyses, one for each CM class, each with all 54 health
measures, and ORs (rounded to similar precision for ratios ranging from 0.0000 to 61)]. Cells above the
dashed line (green) are health measures whose presence significantly distinguished the health class (OR
> 1.0) independent of the other health measures. Cells below the dashed line (rose) are health measures
whose absence significantly distinguished the health class. (OR < 1.0). (C) Vulnerable classes (CM5 and
-6). Health measures that significantly distinguished a given CM health class from the remaining
population [six logistic regression analyses, one for each CM class, each with all 54 health measures,
and ORs (rounded to similar precision for ratios ranging from 0.0000 to 61)]. Cells above the dashed line
(green) are the health measures whose presence significantly distinguished the health class (OR > 1.0)
independent of the other health measures. Cells below the dashed line (rose) are health measures
whose absence significantly distinguished the health class (OR < 1.0). ADL, activities of daily living; BP,
blood pressure; COPD, chronic obstructive pulmonary disease; Dx, diagnosis. *P ≤ 0.05; **P ≤ 0.01; ***P
†
≤ 0.001; biomedical health measures included in both the CM and the MM.
In marked contrast, people in the second robust class (One Minor Condition, CM2) were normal weight (0%
central obesity and ≤1% obese; central obesity OR = 0.048; P = 0.001) (Fig. 2, measures 20 and 21 and Fig.
S2A), with a low prevalence of cardiovascular diseases and diabetes. Instead, people in this class had one
minor condition or disease [(e.g., peptic ulcers, problems with voiding, skin cancer, thyroid disease, or anemia
(Fig. 2, measures 3, 14, 17, 49, and 53 and Fig. S2A)]. Although none of these are recognized high-risk
factors for death, let alone its causes, the prevalence of dying or being incapacitated 5 y later (16%) was
significantly higher than in the Robust Obese class, suggesting that these “minor” conditions could be early
harbingers of vulnerability and might mandate aggressive preventive care, although cardiovascular, metabolic,
lung, and kidney functions are robust. This class also had worse sensory function than the Robust Obese
class (Fig. 2, measures 35–40), particularly hearing (Fig. S2A).
Parte superior
With two different models for defining health classes, we can ask which best discriminates robust health at
older ages. The MM classified fully two-thirds of the older US population as robust in two classes with a low Abstracto
prevalence of disease (Fig. 1). The definition of robust health was fine-tuned by the CM; only one-half (54%)
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of people identified as robust in the MM were also assigned to the robust classes in the CM (Fig. 3, columns 2
and 3). But what of the other one-half deemed in robust health by the traditional MM? Métodos SI
Most were reassigned to two emergent classes (CM3 and -4) defined by traits actively ignored by the MM, Discusión
which together comprised fully 28% of the US population (Figs. 2 and 3). The first new class (CM3) was
characterized by people who had broken a bone after age 45 y old (100% of Broken Bones class; OR = 61) Métodos
(Fig. S2B) and had the highest prevalence of osteoporotic fractures (28%; OR = 27.7) (Fig. 2, measures 47
and 48). These healed bone fractures were not the well-recognized end-of-life hip fractures that can lead to
immobilization and eventually death from complications. Its members were less likely to be immobile, be Notas a pie de página
inactive, or have trouble walking than the general population (0.152 ≤ OR ≤ 0.43) (Fig. S2B). In sharp
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contrast, mental health problems, poor sleep, and heavy drinking characterized the second new class (CM4;
Poor Mental Health, particularly depression; OR = 12.4 (Fig. 2, measures 22–25 and 29–32 and Fig. S2B)
along with poor olfactory function and slow gait, known correlates of depression (35, 36), as well as voiding
dysfunction (Fig. 2, measures 39, 43, and 53).
None of the traditional medical health classes predicted membership in the new Broken Bones or Poor Mental
Health classes, although participants from all MM classes were reassigned to these two new classes,
underscoring the unique contribution of the CM and its additional health dimensions (0.7 ≤ all ORs ≤ 1.3; all
NS) (Fig. 3). The Broken Bones class had a lower prevalence of diabetes but other than that, intermediate
prevalence of organ system diseases typical of the older US population (Fig. 2, measures 1–19). Their
mobility was relatively robust as was their mental and cognitive health. The Poor Mental Health class also had
typical prevalence of traditional organ system diseases accompanied by normal weight and a low prevalence
of immune surveillance dysfunction (Fig. 2, measures 1–20 and 41).
Finally, the two most vulnerable classes (CM5 and -6) were characterized by multiple comorbid diseases,
which are common causes of death among older adults. In CM5 (Diabetes, Hypertension, and Immobility),
uncontrolled diabetes and hypertension were more common than in the general population as were immobility
and urinary incontinence, obesity (particularly morbid obesity at 36% and moderate at 35%), arthritis, peptic
ulcers, and impaired immune function along with impaired vision, hearing, and touch (Fig. 2, measures 1, 2,
4–7, 13, 14, 20, 21, 27, 29, 37, 38, 40–46, 50, and 52). Nonetheless, they had lower odds of all mental health
problems than the rest of the population (0.295 ≤ OR ≤ 0.74) (Fig. S2C). In contrast, the most vulnerable class
(Extensive Multimorbidity and Frailty) was distinguished by poor mental health (anxiety OR = 5.2) (Fig. S2C)
and a high prevalence of 47 of 54 measures indicating disease and health conditions, including cardiac, lung,
liver, and kidney diseases and nonreproductive cancers as well as poor mental health, memory, and sensory
function. As expected, these two most vulnerable classes had more diseases than older adults in the United
States (individual averages of 12.1 and 17.0, vulnerable health conditions and 2.2 and 3.3, Charlson comorbid
diseases in CM5 and -6, respectively) (Fig. 2). Although the Extensive Multimorbidity and Frailty class (CM6)
had the highest concordance with the most vulnerable MM class [38% of those with extensive multisystem
disease (MM5) were reclassified to Extensive Multimorbidity and Frailty (CM6) with an OR = 6.1] (Fig. 3), a
majority came from other classes. The marked increase in the proportion of women in the most vulnerable
classes between the MM and CM (39% vs. 65% women) (Fig. 4) indicates the two most vulnerable classes in
these two models are quite distinct.
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Fig. 4.
Demographic description of each class in (A) the MM and (B) the CM; ↑ indicates a significantly higher
prevalence relative to the US population (US Pop.), and ↓ indicates a significantly lower prevalence. The
US Pop. prevalence is based on 2005 Wave 1 weighted data. CV, cardiovascular; CVD, cardiovascular
disease; HS, high school; HTN, hypertension.
Fully 44% of this most vulnerable class [Extensive Multimorbidity and Frailty (CM6)] died within 5 y of the
original interview or became incapacitated (Fig. 2), making its constellation of diseases a much better
predictor of poor health outcomes than the MM based only on organ system diseases. In sum, the CM
differentiated classes with more precision than the MM, because it expanded the range of class differences in
prevalence of dying or becoming incapacitated from a 2.5-fold to a 7.3-fold range (14–35% to 6–44%).
Causes of Mortality and Morbidity. In both models, the causes of death and becoming incapacitated
were reassuringly consistent with the most prevalent diseases in a particular class. For example, in the three
“diabetes” classes (MM3–5), deaths caused by diabetes, cardiovascular disease, and genitourinary
complications were higher than the population average (Fig. S3A). In CM4, a class defined by mental health
problems, deaths from substance abuse and suicide/homicide were higher than in either most robust or more
vulnerable classes (Fig. S3B).
Parte superior
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Fig. S3.
(A) Mortality. Causes of 5-y mortality among community-dwelling US adults (ages 57–85 y old in 2005)
for health classes of the MM and the CM. The US population (US Pop.) prevalence is based on 2005
Wave 1 weighted data. (B) Morbidity. Causes of being too sick to interview in 2010 (incapacitated) among
community-dwelling US adults (ages 57–85 y old in 2005) for health classes of the MM and the CM. The
US Pop. prevalence is based on 2005 Wave 1 weighted data. CV, cardiovascular; CVD, cardiovascular
disease; HTN, hypertension.
More interestingly, deaths from cancer confirmed its random occurrence with respect to the health classes
identified in both the MM and the CM of health. Deaths from cancer were higher than average in the healthier
MM2 class, but in MM5, the most vulnerable class, cancer deaths were lower than the population average
(Fig. S3A). Likewise, cancer more often afflicted the healthiest classes of the CM (CM1 and -2) (Fig. S3A), Parte superior
whereas in CM5, deaths were more often caused by cardiovascular, diabetic, and elimination system diseases
rather than cancer. This pattern is consistent with a “competing causes of death” model, in which prevalence Abstracto
of a more randomly distributed cause of death (in this case cancer) is highest when other causes of death are
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low.
Métodos SI
The most common disease causing incapacity 5 y later and preventing a second interview was dementia or
other mental deterioration (63% across all classes) (Fig. S3B). Strikingly, frailty or accidents in the intervening Discusión
5 y were three to five times more likely to incapacitate the Broken Bones class (CM3). Additionally, no one
Métodos
was incapacitated by alcohol, drug abuse, or suicide attempts, except those in the Poor Mental Health class
(9% of CM4), showing that identifying this novel health class has prognostic power over 5 y. Expresiones de gratitud
Sexual Motivation and Social Ties. After assigning participants to a latent class based on their health Notas a pie de página
measures [average assignment certainty = 0.83 (MM) and 0.89 (CM)], we sought to characterize the classes
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in terms of the participants’ social and demographic traits. At older ages, sexual motivation can be a key
component of social connection, vitality, and well-being (37⇓–39). A fourfold difference in sexual motivation,
indexed by sexual ideation (40), significantly distinguished the health classes in the CM [only 12% of the
Robust Obese (CM1) class rarely thought about sex (less than once a month) in contrast with 52% of
Extensive Multimorbidity and Frailty (CM6)] (Fig. 5B). In the MM, however, sexual motivation did not differ
among its health classes (range = 26–33%) (Fig. 5A).

Fig. 5.
Psychosocial descriptors (20, 21, 40⇓⇓⇓⇓–45) of the health classes from (A) the MM and (B) the CM.
Self-rated health (physical and mental), sexual ideation, and social ties are shown; ↑ indicates a
significantly higher prevalence relative to the US population (US Pop.), and ↓ indicates a lower
prevalence. The US Pop. prevalence is based on 2005 Wave 1 weighted data. CV, cardiovascular; CVD,
cardiovascular disease; HTN, hypertension.
Likewise, social lives differed more among the CM than among the MM classes; only MM1 and -2, the robust
classes, were more engaged socially than the US population and even so, on only a few measures (Fig. 5A)
(41⇓⇓⇓–45). The two robust classes of the CM (CM1 and -2) had stronger and more varied social lives than Parte superior
the US population [e.g., more members of Robust Obese (CM1) were married, and few felt socially isolated,
lived alone, or had low social participation] (Fig. 5B). Abstracto
There was a socially embedded class and an isolated class within both the intermediate (CM3 and -4) and the Resultados
vulnerable classes (CM5 and -6) (Fig. 5B). Members of the intermediate classes [Broken Bones (CM3)] rarely Métodos SI
felt isolated (13%), had low social participation (14%), or a small social network (11%). In stark contrast,
members of Poor Mental Health (CM4) were the most likely to feel isolated (64%), live alone (38%), rarely Discusión
participate socially (37%), and have small social networks (23%). A similar dichotomy was observed within the
Métodos
vulnerable classes. Members of Diabetes, Hypertension, and Immobility (CM5) were less likely to feel isolated
(17%) and as socially engaged as the general population, whereas 45% of the most vulnerable Extensive Expresiones de gratitud
Multimorbidity and Frailty (CM6) felt isolated, were not socially engaged (35%), and lived alone (32%). The
marked differences in social characteristics captured by the CM are clinically relevant, because social Notas a pie de página
connections affect not only well-being but also, access to health care and compliance (46⇓–48).
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Demographics of the Classes. CM classes did not differ in age from the population average, with the
exception of the sickest class (Extensive Multimorbidity and Frailty), which is 3 y older, and the Robust Obese
class, which is 2.5 y younger (Fig. 4B), indicating that the health classes are not simply a strong age gradient.
However, they did differ significantly in terms of gender, race, education, and household financial assets (Fig.
4B), again with greater differences within the CM than within the MM (Fig. 4A).
The two healthiest classes (CM1 and -2) were, on average, disproportionately men of all races, with more
education and assets than the population as a whole. The Broken Bones class (CM3) was predominantly
white women. Members of the Poor Mental Health class (CM4) were more likely to live alone with moderate
income. Members of the Diabetes, Hypertension, and Immobility class (CM5) were more likely to be black, not
have a high school degree, and have assets under $50,000. The most vulnerable class, Extensive
Multimorbidity and Frailty (CM6), was disproportionately older women of all races, also with low education and
few household assets.
Class Stability over 5 y. We sought to confirm the CM by determining whether the same health classes
emerged in 2010 when we followed the same LCA procedures (SI Methods and Fig. S4). We asked whether
the health class structure of the population persisted as states of being over 5 y or whether it changed as the
population aged and new participants were recruited. We found that the six class structure did persist virtually
unchanged in 2010 with constellations of disease and characteristics similar to those in 2005, replicating the
health classes derived from the CM (compare Fig. 2 with Fig. S4).
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Fig. S4.
Replication of CM health classes. Based on LCA of 2010 Wave 2 [ages 62−90 y old; returning
respondents n = 2,422 (76%) and their partners n = 774 (24%)]. Footnotes indicate how health measures
in 2010 Wave 2 differed from those in 2005 Wave 1 (as described in SI Methods and Fig. S1). The US
population (US Pop.) prevalence is based on 2005 Wave 1 weighted data. ADL, activities of daily living;
BP, blood pressure; HTN, hypertension; ID, identification; MOCA-SA, Montreal Cognitive Assessment -
Survey Adaptation; SPMSQ, Short Portable Mental Status Questionnaire; STD, sexually transmitted
disease.
We then asked whether individuals also persisted in their classes in the intervening 5 y, which would be
expected if membership was the cumulative result of having lived their particular lives. Indeed, those in good
health in 2005 often remained in good health (CM1 OR = 6.65; CM2 OR = 6.79; both P values ≤ 0.001). Parte superior
Likewise, people in the most vulnerable health class with multiple comorbid diseases in 2005 remained so
(CM6 OR = 5.87; P ≤ 0.001) and faced a high risk of death or becoming incapacitated (OR = 4.44; P ≤ 0.001). Abstracto
Those in intermediate health classes were also significantly likely to remain in their 2005 classes but with
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lower odds, particularly Poor Mental Health (CM4) (CM3 OR = 3.41; CM4 OR = 1.57; CM5 OR = 3.33; all P
values ≤ 0.001). Métodos SI
Discusión
SI Methods Métodos
LCAs for 2005 Wave 1 and 2010 Wave 2. The LCAs for both the MM and the CM of 2005 (Wave 1)
were estimated by maximum likelihoods with robust SEs (MLR), which were optimized by an expectation, Expresiones de gratitud
maximization, and acceleration algorithm and set to converge when the magnitude of the log-likelihood
estimates change between iterations reached 0.011D-06 (Table S1). Ultimately, the models ended up
converging after 112 and 569 iterations, respectively (typical numbers for models of these sizes and Referencias
levels of complexity), yielding entropy values of 0.751 for the MM and 0.838 for the CM (entropy values
>0.80 are thought to signify good classification quality) and Bayesian Information Criterion values (BIC, a
conservative optimal penalized likelihood criterion) of 57,017 and 195,679, respectively (55, 59, 60).
Our sample of 3,005 respondents in 2005 was categorized using Bayesian Information Criterion values
as criteria into five distinct classes based on 19 organ system health measures and six distinct classes
based on these same organ system measures plus the additional more varied 35 health measures of the
CM. For the CM, the respondents in class CM1 had an average certainty of belonging in class CM1 of
85%. Similarly, average certainties for classes CM2–CM6 were also high (87%, 96%, 86%, 85%, and
93%, respectively), indicating high certainty of individuals being assigned to their classes. In contrast,
average certainties for the MM classes were a bit lower, reflecting the model’s lower classification quality:
83%, 82%, 87%, 81%, and 84% for the five classes, respectively. In addition, better model fit was
indicated by higher entropy values for the CM than for the MM.
The 2010 Wave 2 LCA was conducted in exactly the same manner as Wave 1. The sole difference is in
measurement of 19 of 54 health measures. Five disease measures were coded from an open-ended
question listing “other diseases” rather than a direct question [thyroid disease, peptic ulcers, kidney
disease, or cirrhosis/sexually transmitted disease(s) (STDs)] and one combined two 2005 questions
(asthma plus emphysema/chronic obstructive pulmonary disease/chronic bronchitis). Seven were
measured with different methods in 2010 (eyesight, smoking, drinking problem, hours of sleep, cognition,
gait speed, and pain while walking) (61⇓–63) (detailed in Fig. S4). Two (broken bones and osteoporotic
fractures) measured broken bones just within the intervening 5 y (not since age 45 y old). Four of 2005
measures were unavailable in 2010 (taste identification, sense of touch threshold, self-esteem, and
exercise restrictions).
Mortality and Incapacity. Proxy reports of date and cause of death have been found to match or
exceed the accuracy of information from death certificates (57). Moreover, reports of death or incapacity
were available immediately after the proxy interview, enabling the NSHAP researchers to code the date
and cause of death or incapacity with the participation of a geriatrician in the study who routinely assigns
cause of death for death certificates.
In contrast, the National Death Index (NDI) is produced by individual states, which varies considerably in
the timeliness and completeness of the death certificates that are submitted to the Centers for Disease
Control and Prevention. The NDI with cause of death codes can lag the date of death more than 2 y, and
codes for cause of death are available only for “well-matched” cases (64). Therefore, proxy interviews
ensured that cause and dates of death were available for virtually all deceased and incapacitated
respondents and are at least as good as data from the NDI (if not better).
Discussion Navegar este artículo
In defining health in older adults, medicine traditionally focuses on absence of chronic diseases of major organ Parte superior
systems; those without diabetes, cancer, or cardiovascular, kidney, liver, or pulmonary disease are generally
Abstracto
considered healthy. Medications treat hypertension and elevated cholesterol, risk factors for developing a
chronic disease. When applied to the population of older adults in the United States, this standard MM (4⇓⇓⇓– Resultados
8), identifies about two-thirds of the older US population as generally healthy, with no diseases of major organ
systems. However, a closer look that includes health behaviors, psychological health, sensory function, Métodos SI
neuroimmunity, and frailty paints a very different picture. It does so by both revealing constellations of health Discusión
completely hidden by the MM and reclassifying about one-half of the people seen as healthy as having
significant vulnerabilities that affect the chances that they die or become incapacitated within 5 y. At the same Métodos
time, some people with chronic disease are revealed as having many strengths that lead to their
reclassification as quite healthy, with low risks of death and incapacity.
A number of surprises appear in the CM. First, cancer, the second leading cause of death in the United
States, is unrelated to the presence of organ systems disease (a pattern also seen in the MM; there is no Referencias
cancer class). In fact, cancer is unrelated to health behaviors, psychological health, sensory function, and
frailty. Cancer seems to appear essentially at random in the general population of older adults; those who get
it either succumb to the disease or are treated and recover, in which case, they are randomly distributed
across classes like anyone else.
Second, obesity, often pointed to as “epidemic” and life-threatening (49), characterizes those older adults in
the most robust health as well as in more vulnerable health. Obesity in a person with excellent mental health,
no chronic disease, intact sensory function, good health habits, and excellent physical functioning seems to
pose very little risk. Obesity in a person with diabetes, poor mental health, poor sensory function, and poor
mobility is a very bad sign in a tidal wave of bad signs for those in the vulnerable health classes.
Third, having broken a bone during or after middle age uniquely identifies a class consisting of one in seven
older US adults. This is a class that is “hidden” in the MM of health. This class is about “average” in other
respects, but having broken a bone removes them from being in one of the robust groups. In a medical history,
a past broken bone might signal osteoporosis risk but little else. However, according to the CM, a broken bone
is a “marker” for future health; accidents are the primary cause of incapacity 5 y later, and member’s mortality
is as high as the general population. This group is an excellent “target” for interventions—to prevent these
individuals from declining over time and move them into more robust health.
Fourth, another one in eight older adults is revealed as having pervasive poor mental health, including high
levels of stress, symptoms of anxiety and depression, loneliness, unhappiness, and poor self-esteem. More of
the people in this group sleep poorly, wake up tired, or drink excessively compared with those in other groups.
This constellation of mental health problems and the consequences of attempts to deal with them stand out
from the population of older adults more generally for the shape and scope of the health problems those in
this group face, including high incapacity and mortality. They too are completely hidden in the MM of health.
Fifth, the most vulnerable group of older adults has serious problems in all health dimensions from chronic
diseases and neuroimmunity to mental health, health behaviors, cognition, sensory function, and frailty. Note
that 44% of this group, which comprises one older adult in eight living at home, will die or become
incapacitated in the next 5 y. Only 35% of those in the sickest health class as identified in the MM died or
became incapacitated. Clearly, the CM contains a great deal of prognostic information left out of the MM.
Health status in older adults does not correspond with chronological age; age differentiates only two of the
classes at most by 3 y. The gender story is bigger, with disproportionately more men in the two robust classes
and more women in broken bones and multimorbidity and frailty classes. The apparent paradox in having
more men in the youngest and healthiest class and more women in the oldest and sickest class results
directly from men having higher mortality rates. They die younger, and women survive longer, often with
chronic disease and other aging conditions. This well-known pattern was not captured by the MM.
The current MM of health emphasizes organ system disease categories as the fundamental conception of
health. A list of “diagnostic codes,” embodied in the ICD-10 system used to bill for health services, is
emblematic of this approach. One consequence is that health policy neglects important aspects of health,
such as mental health (50) and medical training for managing comorbidities in geriatric populations (51). By Parte superior
using the WHO definition of health, we have shown how expanding health dimensions and domains and
incorporating positive aspects of health reveal six unique, replicable constellations of disease and health, Abstracto
including two previously unrecognized classes not apparent in the organ disease-focused MM. From a health
Resultados
system perspective, a shift of attention is needed from disease-focused management, such as medications for
hypertension or high cholesterol, to overall health, especially for mental health concerns, sensory function, Métodos SI
and mobility.
Discusión
Although public health campaigns, such as “Choosing Wisely,” rightly emphasize the need to decrease
Métodos
unnecessary health interventions (52), they still accept the basic health conception of the MM as resting on
organ system disease. Instead, the CM instantiates comorbidities and the equal importance of mental health, Expresiones de gratitud
mobility, and sensory function in health and should inform policy redesign. For example, including
assessments of sensory function, mental health, broken bones in middle age, and frailty in annual physician Notas a pie de página
visits would enhance risk management. In addition to policies focused on reducing BMI, greater support for
Referencias
preventing loneliness among isolated older adults would be effective. In place of additional (expensive) new
medicines for hypertension, helping older adults find social support through home care services or alternative
living arrangements could be developed. In summary, taking a broad definition of health seriously and
empirically identifying specific constellations of health and comorbidities in the US population provide a new
way of assessing health and risk in older adults living in their homes and thereby, may ultimately inform health
policy.
Methods
NSHAP Sampling and Field Methods. The NSHAP designed and collected a probability sample of
individuals ages 57–85 y old selected to represent US households in 2005 and 2006 [response rate of 74%; n
= 3,005 (53)], and these individuals were reinterviewed (reinterview rate of 89%) together with their
spouses/partners [response rate of 84%; total n = 3,377 (54)]. The data are sample-weighted values, so that
they reflect estimates of the characteristics of the US community-dwelling population at the time of interview
(SI Methods).
The interviews were comprised of a personal interview; anthropometric, clinical, and physiological measures;
and a self-administered questionnaire (27, 40, 45). The study was approved by the Institutional Review
Boards of The University of Chicago and NORC of The University of Chicago; all respondents provided written
informed consent.
Classifying Health Measures. Each variable was coded either dichotomously or into ordinal categories, in
which higher values indicate worse health. We used the 2005 clinical and literature-based cut points when
available (Fig. S1 provides cut points). Respondents reported whether health professionals had told them that
they had a specific disease. For other measures, such as happiness and how many hours the person usually
sleeps, we identified those at the low ends of the measures as poor health scores.
Latent Classes and Heat Maps of Their Composition. The latent class models described earlier were
estimated using Mplus, version 6 (55). SI Methods and Table S1 provide model parameters and Bayesian
Information Criterion values for determining class number. LCA searches for an underlying statistical structure
to a population that is not directly observable but can be identified using a sufficiently large collection of
observable variables. The LCA then identifies distinct subgroups, or classes, within the overall population
based on underlying commonalities among variables, commonalities that are assumed to be caused by the
underlying latent characteristic. Classes are estimated through structural equation modeling. There are no a
priori assumptions about class identity that constrain the model, and it is possible to test the hypothesis that
there are significant co-occurrences of diseases and other health states across the identified latent classes
rather than random noise (under the assumption that health measures are independent given class
membership). Each person can then be assigned to a single class based on his or her value on each of the
health measures (average class assignment certainty = 0.83 for the MM and 0.89 for the CM).
Table S1. Parte superior
In this window (E3071/T1.expansion.html) Characteristics of the LCA for the MM in 2005 and the CM Abstracto
In a new window (E3071/T1.expansion.html) for 2005 Wave 1 and 2010 Wave 2
Resultados
Métodos SI
We then characterized the constellation of presence of disease and health states for each class by calculating
the percentage of each class with a particular disease (e.g., diabetes) or a poor score for a measure (e.g., Discusión
waking up tired) (MM and CM of health in Figs. 1 and 2, respectively). We illustrate the constellation of
Métodos
disease and healthy states that characterizes each class reading down the columns of Figs. 1, MM and 2, CM
of health. Class percentages were statistically compared with the overall population percentages using logistic Expresiones de gratitud
regression (56) and then categorized as being higher, the same, or lower (P < 0.05). Color codes indicate the
prevalence of each variable relative to the US population prevalence based on 2005 Wave 1 weighted data.
Referencias
Our goal for the CM was consideration of all variables that could be useful beyond the MM by adding 35
health measures chosen for their connections to the broad functions of the nervous systems: mental health,
cognition, sensory function, health behaviors, neuroimmunity, and frailty. After we established the six latent
health classes, we then asked which of the 54 health measures distinguished each health class from the
remaining population by either the presence or absence of disease or health states (i.e., their power to
significantly predict class membership; six logistic regression analyses) (Fig. S2). Each logistic regression
analysis determined the independent contribution (OR) of each of the 54 variables, controlling for the
presence of the other health measures. Future work will determine the most parsimonious set of measures for
predicting class membership.
Mortality and Incapacity. Our measures were death and being “too sick to interview” (incapacity). If a
respondent was unable to participate in 2010, a proxy was asked why and the date and cause of death or
incapacity were coded overseen by a geriatrician who routinely assigns cause of death (Fig. S3). Such proxy
reports are as accurate, if not more so, than the National Death Index (57) and were available immediately (SI
Methods) (58).
Acknowledgments
We thank Michael Kozlowski for running the time-consuming analyses, Hannah You, Joscelyn Hoffmann, and
Jaclyn Smith for manuscript preparation, and the entire NSHAP team for fielding this survey and creating the
extensive dataset. Support was provided by National Institute of Aging Grants R01AG021487, R37AG030481,
and R01AG033903 and NORC of The University of Chicago.
Footnotes
1
To whom correspondence should be addressed. Email: mkm1@uchicago.edu (mailto:mkm1@uchicago.edu).
Author contributions: M.K.M., W.D., E.O.L., and L.W. designed research, performed research, contributed new
reagents/analytic tools, analyzed data, and wrote the paper.
The authors declare no conflict of interest.
This article is a PNAS Direct Submission.
Data deposition: The data reported in this paper are publically available at
www.icpsr.umich.edu/icpsrweb/NACDA/studies/20541/version/6
(http://www.icpsr.umich.edu/icpsrweb/NACDA/studies/20541/version/6) and
www.icpsr.umich.edu/icpsrweb/NACDA/studies/34921/version/1
(http://www.icpsr.umich.edu/icpsrweb/NACDA/studies/34921/version/1).
This article contains supporting information online at
www.pnas.org/lookup/suppl/doi:10.1073/pnas.1514968113/-/DCSupplemental
(/lookup/suppl/doi:10.1073/pnas.1514968113/-/DCSupplemental).
Parte superior
Freely available online through the PNAS open access option.
Abstracto
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