Day-to-day living circumstances and the immediate physical and social environment can have a tremendous influence on the life quality, functional independence, and capacity of older women in the community. At the same time, functional limitation and disability can profoundly affect daily activities and social conditions. While physical functioning of the older population as a whole and some subgroups is well characterized (Cornoni-Huntley et al., 1986; Prohaska et al., 1993; Short and Leon, 1990), information on living circumstances and daily activities according to level of functional status is much more limited. This chapter describes many aspects of the daily lives of participants in the Women's Health and Aging Study (WHAS), including marital status and living arrangements, living environment, frequency of bedrest and reduced activity, health habits, physical activity, driving practices, eating patterns, social contact and activity, recent life events, and incontinence.
Table 5.1 describes the living arrangements, household composition, and housing type for this population of disabled older women. Most study participants-46 percent-lived alone, while 23 percent lived with their spouse and just over 30 percent lived with nonspouse others. While most of the married women lived with only their spouse, one quarter of these women (5.7 percent overall) resided with others as well. The households were typically small, with only 21 percent having more than two members. Adult children were the most common living companions, followed by spouse, grandchildren, and other relatives including siblings. The presence of non-relatives in the household was rare.
Household composition varied greatly by participant age and functional status. Just over one-third of those age 65 to 74 years, over half of those age 75 to 84 years, and 61 percent of the oldest group lived alone. Correspondingly, 32, 19, and 6 percent of women resided with their spouse, among those age 65 to 74, 75 to 84, and over 85 years, respectively. The proportion living with others only was similar across age groups, although the youngest tended to have more household members on average. The extended family household (i.e., living with grandchildren) was most common among those age 65 to 74 years (16.4 percent) and relatively rare for those age 85 years and older (5.3 percent). For women in the youngest age group, the presence of an adult child in the home may be more a function of the child's age and economic situation than of participant need (Speare and Avery, 1993).
The observed variation in living arrangement and household composition by age group reflects, in part, racial differences. Twenty-eight percent of study participants were African American, but this varied greatly by age group. Thirty-three, 26, and 20 percent of women age 65 to 74, 75 to 84, and 85 years and older, respectively, were African American (see Chapter 2, Table 2.1). Marital status and household composition varied greatly by race (data not shown). Twenty-seven percent of White participants were married and lived with their spouse as against 13 percent of the African American women. Comparing African American with White participants, 46 percent versus 25 percent lived with non-spouse others, 31 percent versus 16 percent had at least three members in their household, 33 percent versus 22 percent lived with an adult child, and 23 percent versus 8 percent lived with grandchildren. The proportion who lived alone, however, was more similar, 41 percent in comparison to 48 percent. For the African American participants the most frequent living arrangement was with nonspouse others, whereas White participants were most likely to live alone.
Participants who received help in activities of daily living (ADLs) were the least likely to live alone and most likely to live with nonspouse others. These "others" were most frequently adult children. More than 37 percent of women who received help in ADLs, in contrast to 22 percent who did not receive help, resided with adult children. This group was also more than twice as likely (7.3 percent versus 3.4 percent) to live with non-relatives as participants with a less severe level of disability.
More than 70 percent of the study population lived in single-family free-standing or semi-detached homes; 19 percent lived in apartments and 9 percent resided in some type of specialized retirement housing. The high percentage living in semi-detached, row, or town homes probably reflects the unique housing stock of Baltimore. The oldest age group had the highest proportion of apartment and retirement housing residents. Housing-type did not vary greatly by disability level.
Table 5.2 describes self-rated health status and recent activity limitation. The majority (54 percent) of this population of moderate to severely disabled women perceived their health as only poor or fair. Nevertheless, 13 percent believed their health was very good and 4 percent reported excellent health. Self-rated health varied by age group, with the oldest reporting slightly better health: 26.5 percent of the oldest group reported very good to excellent health in contrast to 13.7 and 16.9 percent of women age 65 to 74 years and 75 to 84 years, respectively. The most disabled had the highest proportion who rated their health as fair or poor (62 percent), but this was not substantially higher than the other two groups (55 percent and 49 percent). Among women who received help in ADLs, the proportion who rated their health as fair or poor varied by age group: 65 percent of women age 65 to 74 years, 64 percent of women age 74 to 85 years, and 52 percent of the oldest women (data not shown). Although participants were not asked to rate their health in comparison to others of similar age, these data suggest that the perceived health of many older women is influenced by perceptions of their peers.
Eleven percent of the study population reported staying in bed for more than half a day in the 2 weeks preceding the interview because of illness or injury; 30 percent cut down on their activities for 1 or more days. The likelihood of bed-rest and reduced activity was greatest in the women younger than 85 years. While the percent reporting bedrest and reduced activity was lower among the oldest women, the average duration among those reporting bedrest and reduced activity was considerably longer in this age group. Women who received help in ADLs more often reported staying in bed and having reduced activity in the preceding 2 weeks than women with less severe disability. Those who received help in ADLs also had the longest average duration of bedrest and reduced activity.
Table 5.3 shows current and past smoking practices by age group and disability level. Current cigarette smoking was uncommon in this population of disabled older women; half the participants never smoked cigarettes and most who did quit 1 year or more before the study baseline. Smoking history varied greatly by age, a function of both birth cohort and survivorship (Harris, 1983). The oldest women had substantially lower rates of current and past smoking; two-thirds never smoked. In contrast, only 42 percent of women age 65 to 74 years never smoked. Smoking history and disability level were unrelated in this population. Among current smokers, the majority smoked less than one pack per day; only 6 percent of the total population smoked more than 20 cigarettes per day. Most of the current smokers had been smoking for more than 40 years. Among former smokers there was greater variation in the number of years smoked: 33 percent smoked fewer than 20 years, 30 percent smoked 20 to 39 years, and 38 percent smoked at least 40 years. Four percent had quit within the previous year.
Table 5.4 presents information on current alcohol consumption. Very few women in this population regularly consumed alcohol. Only 16 percent reported that they usually drink alcoholic beverages at least once every week, and 10 percent reported having at least four drinks per week. Most of the women who regularly consumed alcohol had one to two drinks per occasion. The frequency of drinking in this group ranged from 1 day a week to every day, with 39 percent reporting drinking 5 or more days a week. There was little notable variation in drinking habits by age or disability level in the study population, with the exception that among women who drank, the most disabled rarely had more than one drink per occasion.
Participants were asked the number of hours they usually slept at night and the number of hours they usually slept during the day. Table 5.5 presents data on nighttime, daytime, and total hours of sleep. For the general adult population, 7 to 9 hours of nighttime sleep is considered adequate and consistent with good health (Belloc and Breslow, 1972). In this population of older disabled women, fewer than half slept between 7 and 9 hours at night. The majority of the remainder slept 4 to 6 hours per night. Daytime sleep was common, with more than 40 percent sleeping some time during the day. Most napped 1 hour or less, although 13 percent got 2 hours and 5 percent got 3 or more hours of sleep during the daytime. For many participants, daytime sleep reduced the nighttime deficit. Combining nighttime and daytime sleep, about half got 7 to 9 hours and about one-third slept 6 or fewer hours in a 24-hour period.
Hours of nighttime sleep did not vary by age or functional status. The likelihood of daytime sleep, however, increased modestly with increasing age and contributed to the slightly higher percentage who slept 10 or more hours per day in the oldest age group (21 percent in contrast to 11 percent and 12 percent for women age 65 to 74 years and 75 to 84 years, respectively). Similar to those age 85 years and older, around 20 percent of the most severely disabled slept 10 or more hours in a 24-hour period.
Table 5.6 describes the frequency of participation in five physically strenuous activities performed most commonly by older women-walking, household chores, outdoor chores, dancing, and regular exercise programs. More than 60 percent of participants reported performing some type of physical activity in the past 2 weeks. The most common activity overall was doing household chores, followed by walking for exercise, although in the oldest age group walking was the more frequent activity. Fourteen percent participated in regular exercise programs, which could include stretching or strengthening activities. Outdoor chores such as gardening were done by 12 percent of the population. Dancing and bowling were uncommon, with less than 6 percent and 2 percent, respectively, reporting participation (data not shown). With the exception of walking, the proportion who participated in each activity decreased with increasing age, particularly for household and outdoor chores. The percent who did any physical activity also decreased with increasing age. As expected, participation in physical activity also declined with increasing severity of disability. Women with moderate disability and those with difficulty in ADLs who did not receive help reported similar types and amounts of physical activity. Among women who received ADL help, fewer than one-third did any physical activity, in contrast to over two-thirds of the less severely disabled. Walking was the predominant activity reported by the most severely disabled women.
The amount of time spent in physical activity varied widely. Thirty-eight percent were completely inactive, 16 percent spent less than 1 hour per week in any activity, 20 percent spent 1 to 3 hours and 25 percent were physically active more than 3 hours per week. Hours per week spent being physically active declined with increasing age in the total population and in the subgroup of women who reported any physical activity. For instance, among women age 65 to 74 years who did any physical activity, 48 percent were active 3 hours per week; among those age 85 years and older who did any physical activity, 27 percent were active at least 3 hours per week. Among women who reported walking for exercise, hours spent per week did not decline with increasing age.
Table 5.7 provides data on the number of blocks walked and flights of stairs climbed per week and self-reported walking pace. Distance walked gives a different picture of activity level than time spent walking for exercise per week (Table 5.6). The majority of participants walked less than 7 blocks (about 1/2 mile) over a 1-week period. Distance covered declined with increasing age even after excluding the non-ambulatory. This contrasts with the relationship between age and walking time presented in Table 5.6. Casual strolling was by far the most frequently reported walking pace, over 2.5 times more common than average- to normal-paced walking. Among the women who could walk across a small room, 22 percent did not climb stairs in a typical week, 40 percent climbed between 1 and 20 flights, and 39 percent climbed more than 20 flights per week. The number of flights climbed per week decreased substantially with increasing age. Walking pace, blocks walked, and stairs climbed per week also diminished with increasing severity of disability. This decline was largely a function of higher rates of inability to walk in the most disabled group, although even among the ambulatory, a reduction in blocks walked and flights climbed was observed. Overall, 28 percent walked at least 1 block per day, on average; only 16 percent of the oldest old and 8 percent of the most severely disabled walked this much.
This cohort of older disabled women reported higher levels of participation in physical activity and exercise than might be expected given the high prevalence of difficulty in mobility-related tasks (Table 2.2). The levels of participation in walking and in any physical activity were surprisingly similar to those observed in a general population of older persons (Seigel et al., 1995). While the majority of these women engaged in some form of physical activity, much of it was related to household chores, particularly for the youngest age group. Although walking was also common, the amount of time spent walking and the distances covered were generally short and declined with age.
The ability to drive a car and having access to a car and driver are important aspects of social functioning. Table 5.8 describes driving status, who usually drives, and the reasons for any change in driving practices. Twenty-five percent of participants were current drivers, 24 percent had quit driving, and 51 percent had never held a driver's license. Although 25 percent could drive, 19 percent were the usual driver (76 percent of the women who could drive) when they traveled by car. Most typically, the usual driver resided outside the participant's home. Six percent of participants reported they never traveled by car. Among the current drivers, the majority drove less than they used to because of health or vision problems, and among those who had stopped driving, the majority stopped for the same reasons. Another 45 percent quit driving for other reasons, usually related to the costs of buying and maintaining a car.
Driving practices varied by age group, with only 7 percent of women age 85 years and older still driving compared with 32 percent of women age 65 to 74 years. A much higher percentage of the oldest women had quit driving, however. The proportion who never held a license was unrelated to age group. The oldest women were also the least likely to travel by car and, when they did, were most likely to be driven by someone residing outside their home. Women who received ADL help had a very low rate of current driving; most of them had quit due to health problems.
Problems chewing and swallowing, difficulty preparing food, and social isolation are major factors that contribute to poor or inadequate nutrition in older adults (Fischer and Johnson, 1990). Table 5.9 reports the prevalence of difficulties related to eating and meal preparation and describes who prepares meals in the participant's household and the participant's eating environment. Nearly one-fifth of study women reported problems chewing or swallowing that limited their ability to eat. The prevalence of this problem was highest in the youngest age group and in women who received help in ADLs.
Almost four-fifths of study participants had the primary responsibility for preparing meals in their households. This rate decreased from 82 percent of women age 65 to 74 years to 65 percent of women age 85 years and older, largely because of health problems. Among women who received help with ADLs, only 37 percent prepared the meals in their household in contrast to 86 percent of less disabled women. It is notable that among women age 65 to 74 years, only 58 percent of whom lived alone or with only their husband (Table 5.1), 82 percent had the main responsibility for meal preparation. Thus, despite their physical limitations, many of these women made substantial contributions to the household.
The majority of participants ate meals alone. This was not merely a function of living arrangement, because a higher proportion of women age 65 to 84 years ate alone than lived alone (Table 5.1). Meal services such as "Meals on Wheels," "Eating Together" programs, and residential group meals were not widely used by this population of disabled women. The majority of women either had no difficulty preparing meals or they received assistance from someone who resided either with them or outside their home. Of those who had access to group meals at their place of residence-about 8 percent- only about half used this service. Use of meal services was highest in the most severely disabled, but only a small proportion of women who had difficulty preparing meals due to health problems used these services.
The size of one's social world and the amount of social contact and activity have important implications for life quality. Table 5.10 presents size of life space, the distance participants venture from their home in a typical week; frequency of leaving the home; number of telephone contacts and face-to-face contacts per week; and frequency of attendance at church and other functions reported by this population of disabled women. Social contact and life space varied substantially within and across subgroups of this population. A small but meaningful proportion of women appeared to be fairly isolated and homebound: 23 percent had no face-to-face contact with persons residing outside the home in a typical week, 15 percent never left their home, and 34 percent left their home three or fewer times per week. On the other hand, a sizable percentage were out and about every day. Forty-one percent left their home more than once a day, 49 percent were on the phone with relatives or friends more than once a day, and the majority had a life space extending beyond the neighborhood.
Social contact tended to diminish with age. The oldest women had the lowest frequency of telephone and face-to-face contact with persons residing outside their home. The majority of the oldest women did not leave their neighborhood in a typical week and had the highest proportion who did not leave their home (29 percent). Similar trends were observed for disability, with the most severely disabled having the highest rates of low contact and not leaving the home.
Over half of these disabled older women participated in church and church-related events in the past year; the majority attended regularly, at least twice a month. About one-third of participants usually attended other social functions, such as concerts, movies and plays, about once a month. Participation in this type of social activity diminished with increasing age and severity of disability.
In addition to the day-to-day aspects of one's social and physical environment, major life events, such as the death of a loved one, can have a tremendous impact on affect and feelings of life quality (Holmes and Rahe, 1967). Table 5.11 shows the frequency of six major life events occurring in the past year for this population of disabled older women. Nearly half of the study participants reported the loss of a spouse, close relative, and/or close friend through death in the past year; 7 percent had become separated from a child, friend, or relative on whom they depended for help; and 7 percent lost a pet. Nineteen per-
cent reported giving up a hobby or activity important to them in the past year. Seven percent of all participants (29 percent of the married women) reported that their husband suffered a serious illness or accident. Nearly 70 percent of participants experienced at least one of these events in the past year. The likelihood of death of or separation from relatives or close friends in the past year decreased with age in this population, a function, in part, of less opportunity for such losses to occur. Only 5 percent of the oldest women were still married, and many had outlived most of their friends. With the possible exception of giving up a hobby or favored activity, the rate of major life events did not vary by disability level.
As spousal health has been found to be a major predictor of depressive symptomatology (Simon-sick, 1993), married women were asked some additional questions about the health status of their spouse. Fifty-six percent of the married women rated their husband's health as fair or poor, and 30 percent reported that their husband's health had become worse in the past 6 months. Poor or declining health may seriously reduce the capacity of the husband to provide companionship and caregiving assistance.
Bowel and bladder incontinence are socially embarrassing and potentially disruptive conditions that can have multiple effects on the daily activities and social relationships of older women (Wyman et al., 1990). Severe incontinence is a major contributing factor in the decision to institutionalize an older person (Ouslander et al., 1982). Table 5.12 shows the prevalence and severity of bowel and bladder incontinence. Eighteen percent of participants reported occasional bowel incontinence; only 1 percent soiled themselves "all the time." There was a small but consistent age-associated increasing trend in prevalence of bowel incontinence from 17.5 percent in women age 65 to 74 years to 21.9 percent in women age 85 years and older. Prevalence also increased with increasing severity of disability, from 12 percent in the moderately disabled to nearly 30 percent in women receiving help in ADLs.
Bladder incontinence was common in this population, with nearly 65 percent reporting having lost control of their urine at some time during the past year. The majority (51 percent) had problems because they could not get to the toilet quickly enough; 40 percent had stress-related incontinence, losing bladder control when coughing, sneezing, laughing, or lifting; and 27 percent reported having both problems. Although the annual prevalence was exceptionally high, less than half reporting incontinence lost bladder control on a weekly basis (30.6 percent overall). Nevertheless, 13.6 percent lost control at least once a day. The amount of urine leakage was generally small, with only 7.9 percent overall losing more than one-quarter cup per episode.
The prevalence of bladder incontinence varied somewhat by age, with the oldest age group having the lowest prevalence of any type of incontinence in the past year. Among women who reported problems with bladder control, frequency of episodes and amount of urine lost did not vary consistently by age group. The prevalence of bladder incontinence increased moderately with increasing severity of disability, from 60 percent in the moderately disabled women to 70 percent among women receiving ADL help. Among those with urinary incontinence, the frequency of episodes did not vary much by disability level; the likelihood of substantial loss of urine (more than one-quarter cup), however, was twice as great in the most severely disabled compared with the moderately disabled (21.0 percent versus 8.5 percent).
This population of older disabled women exhibits great diversity in social environments, activities, health habits, and other life circumstances. Age and level of disability were associated with many of the factors examined, but it is also clear that age and disability do not dictate social environment. The data presented only begin to describe the tremendous range of living environments and social conditions these women face on a daily basis. Briefings by the interviewers and nurse examiners in the WHAS have conveyed the wide spectrum of living environments among these older disabled women. At one extreme are women who live in the most severely impoverished circumstances: unsanitary, dilapidated homes; homes with inadequate light, heating, and plumbing; neighborhoods that suffer from pervasive illicit drug activity and violent behavior; and extreme poverty. At the other extreme are the affluent women who reside in comfortable, well-appointed homes in secure neighborhoods and have paid help, which may include a housekeeper, a cook, and 24-hour nursing care. The rest of the study population is more or less equally distributed between these extremes of poverty and wealth. Despite extreme differences in social and economic resources, these women share many features-functional limitation and disability, chronic disease, and old age. Disentangling the roles of disease and social circumstances in the disabling process could provide important insights for maintaining physical function, preserving community existence, and improving life quality.
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