10
Health Status of Hispanic Elderly

Kyriakos S. Markides, Laura Rudkin, Ronald J. Angel,

David V. Espino

Introduction

Hispanics represent one of the fastest growing segments of America's elderly population. Although Hispanics accounted for only 3.7 percent of the 65 and older population in 1990, their share is projected to increase to 15.5 percent by the middle of the next century (Bureau of the Census, 1993). The future increases in the numbers and proportions of elderly Hispanics will be fueled by the recent rapid growth in the total number of U.S. Hispanics. Persons of Hispanic origin numbered 22.4 million in the 1990 census; this makes them the second largest minority population in the nation (Bureau of the Census, 1991). During the 1980s, this population increased by 53 percent, considerably faster than the general population.

By far the largest segment of the Hispanic population (61.2%) is of Mexican origin and resides primarily in the southwestern states of California, Texas, Arizona, Colorado, and New Mexico; they are followed by Puerto Ricans (12.1%), who live mainly in Puerto Rico and the New York City area, and by Cuban Americans (4.8%), who are concentrated in south Florida (Bureau of the Census, 1991). A variety of other Hispanic populations originating in various Central and South American countries live principally in the Northeast. The elderly Hispanic population in the United States reflects this diversity, although the distribution across subgroups differs in the older population. In 1990, roughly half (49%) of Hispanic elders were of Mexican origin, 15 percent were of Cuban origin, and 12 percent were of Puerto Rican origin. The relatively large proportion of Cuban-origin elders is due to the older age distribution of this subgroup. In general,



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--> 10 Health Status of Hispanic Elderly Kyriakos S. Markides, Laura Rudkin, Ronald J. Angel, David V. Espino Introduction Hispanics represent one of the fastest growing segments of America's elderly population. Although Hispanics accounted for only 3.7 percent of the 65 and older population in 1990, their share is projected to increase to 15.5 percent by the middle of the next century (Bureau of the Census, 1993). The future increases in the numbers and proportions of elderly Hispanics will be fueled by the recent rapid growth in the total number of U.S. Hispanics. Persons of Hispanic origin numbered 22.4 million in the 1990 census; this makes them the second largest minority population in the nation (Bureau of the Census, 1991). During the 1980s, this population increased by 53 percent, considerably faster than the general population. By far the largest segment of the Hispanic population (61.2%) is of Mexican origin and resides primarily in the southwestern states of California, Texas, Arizona, Colorado, and New Mexico; they are followed by Puerto Ricans (12.1%), who live mainly in Puerto Rico and the New York City area, and by Cuban Americans (4.8%), who are concentrated in south Florida (Bureau of the Census, 1991). A variety of other Hispanic populations originating in various Central and South American countries live principally in the Northeast. The elderly Hispanic population in the United States reflects this diversity, although the distribution across subgroups differs in the older population. In 1990, roughly half (49%) of Hispanic elders were of Mexican origin, 15 percent were of Cuban origin, and 12 percent were of Puerto Rican origin. The relatively large proportion of Cuban-origin elders is due to the older age distribution of this subgroup. In general,

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--> Hispanics are a relatively youthful population, with only 5 percent being 65 and older (Bureau of the Census, 1993), but that proportion varies markedly across the ethnic subgroups. Less than 5 percent of Mexican Americans and Puerto Ricans are in the elderly age group, whereas 17 percent of Cuban Americans are elderly (Bureau of the Census, 1990). The limited gerontological research on older Hispanics has tended to focus on the importance of the strength of family ties and how these might be changing with greater industrialization, urbanization, and the acculturation of younger generations into the larger society (Angel and Hogan, 1991; Bastida, 1984; Lacayo, 1992; Markides and Martin, 1983; Paz, 1993; Sotomayor and Garcia, 1993). Despite increases in education and acculturation across generations, the elderly in various Hispanic groups appear to enjoy good relationships with their children (Markides et al., 1986), experiencing closer proximity, more frequent contact, and stronger familial attitudes than Anglo elderly (Keefe and Padilla, 1987; Sabogal et al., 1987). Other research has pointed out the needs of Hispanic elderly for health and social services, has emphasized the importance of linguistic and cultural barriers to adequate service provision, and has discussed the need for culturally sensitive health care and social services (e.g., Ginzberg, 1991; Ramirez de Arellano, 1994; Wolinsky et al., 1989). The literature on the non-Cuban Hispanic elderly has emphasized their low education, low incomes, and generally low political power and socioeconomic standing in society (e.g., Sotomayor and Garcia, 1993). Mortality And Life Expectancy Despite their disadvantaged socioeconomic status, Hispanics appear to have a generally favorable mortality profile (see reviews by Hayes-Bautista, 1992; Markides and Coreil, 1986; Rosenwaike, 1991; Vega and Amaro, 1994). As early as 1970, regional epidemiological evidence suggested that Spanish surnamed persons (largely Mexican Americans) had a life expectancy only slightly below that of Anglos and markedly higher than that of blacks (Bradshaw and Fonner, 1978; Schoen and Nelson, 1981; Siegel and Passel, 1979). Regional data for 1980 indicated that the already small Hispanic-Anglo gap in life expectancy had narrowed even further (California Center for Health Statistics, 1984; Gillespie and Sullivan, 1983). More recently, national data have provided more definitive evidence that older Hispanics appear to be advantaged relative to both Anglos and blacks in terms of mortality (Sorlie et al., 1993; National Center for Health Statistics, 1994). For the period 1989-1991, Hispanics in the age group 65 to 74 experienced 1,975 deaths per 100,000 population. In comparison, non-Hispanic whites had a death rate of 2,575 and blacks a death rate of 3,735. The Hispanic advantage held for deaths due to heart disease, cancer, stroke, and all other causes combined. Middle-aged (45 to 64 years) Hispanics experienced a similar advantage in rates

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--> of death due to heart disease and cancer. Only Asian Americans experienced more favorable mortality conditions at the older ages (see National Center for Health Statistics, 1994). A recent analysis of the National Longitudinal Mortality Study has added further evidence of a favorable mortality and health situation for Hispanics. This prospective study has found lower death rates for middle-aged (45 to 64) and older (65 and over) Hispanics than for non-Hispanic whites (Sorlie et al., 1993). The Hispanic advantage holds for both genders and for all Hispanic subgroups, although some of the differences were not statistically significant owing to the small number of deaths. Overall, for every 10 deaths among non-Hispanic white males and females aged 65 or older, Hispanic males experienced 7.2 deaths and Hispanic women 8.2 deaths. As might be expected, when adjustments for income were introduced, the relative Hispanic advantage was even greater for all causes of death (all causes, cardiovascular disease, cancer, and all other causes combined) for men of all ages and women younger than 65. Adjustments for income did not influence the relative mortality risks of older women. The analysis by Sorlie et al. (1993) of mortality by specific cause, which combined all ages (25 and over) because of small numbers, showed Hispanic adults to have lower rates of death for most cancers and cardiovascular diseases when compared with non-Hispanic whites. Both Hispanic men and women experienced this advantage, a contradiction of earlier regional research that had suggested the advantage in cardiovascular disease was confined to males, at least among the Mexican-origin population (Mitchell et al., 1990). In contrast, one recent analysis did not reveal an advantage for Mexican-American males in mortality from ischemic coronary disease and myocardial infarction (Espino et al., 1994). These data, however, were confined to 1 year in one city, San Antonio. The national data on mortality from specific cancers are consistent with previous data suggesting that Hispanics have a relatively lower incidence of major cancers, such as lung, colon, breast, and prostate cancers. At the same time, it has been found that Hispanics have a higher incidence of stomach, liver, gallbladder, and cervical cancer, all generally low-incidence cancers not considered separately in the analysis by Sorlie and colleagues. (For discussions of cancer incidence in Hispanic populations, see Gutierrez-Ramirez et al., 1994; Markides and Coreil, 1986; Montes, 1989; Polednak, 1989; and Trapido et al., 1990.) The analysis of the National Longitudinal Mortality Study did identify excess risk for Hispanics on two main causes of death. Consistent with past research, Sorlie et al. (1993) found that mortality rates from diabetes were roughly twice as high among Hispanic men and women than among non-Hispanics. Hispanics of both genders also experienced higher rates of death from liver disease/cirrhosis. Whereas this finding was expected for males, the female excess is a surprise because of the relatively low alcohol consumption rates among Hispanic women (Black and Markides, 1993). The Hispanic mortality advantage appears to be shared by all of the major

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--> subgroups, although some diversity among the groups is evident. The advantage appears to be more marked for men than for women among older Mexican Americans and Puerto Ricans, and the largest advantage is observed for older Cuban Americans of both genders (Sorlie et al., 1993). Of the three major Hispanic groups, Puerto Ricans appear to have the highest age-adjusted mortality rates and Cuban Americans the lowest (Rosenwaike, 1991; Sorlie et al., 1993). Among Puerto Ricans, mortality rates are higher for residents of New York City than for those living in Puerto Rico or elsewhere in the United States. The excess mortality among New York City Puerto Ricans is primarily due to higher death rates from homicide and from cirrhosis of the liver (Rosenwaike and Hempstead, 1990). Comparisons among Hispanic groups also reveal that the Mexican-origin population has higher mortality from accidents, but lower suicide rates than the populations of Cuban and Puerto Rican origin. Puerto Ricans have the highest death rate from cirrhosis of the liver, and the populations of both Puerto Rican and Mexican origin have higher death rates from diabetes than do Cuban Americans. The mortality profile of Cuban Americans by cause of death is generally similar to that of the non-Hispanic white population (Rosenwaike, 1991). The generally favorable mortality and health profile of Hispanics has been attributed both to possible protective cultural factors and to selective immigration. It is becoming increasingly evident that immigrants tend to be healthier than native-born persons at any age (Stephen et al., 1994), and large rates of Hispanic immigration in recent decades are no doubt a factor contributing to a favorable health profile. Foreign-born Hispanic males experience significantly lower death rates in middle and old age than do native-born Hispanic males, whereas among females, death rates are significantly lower for the foreign born only in middle age (Sorlie et al., 1993). These analyses suggest the operation of a ''healthy-migrant" effect to explain the low mortality of Hispanics. However, even when place of birth is adjusted for, Hispanic rates remained lower for men and women in middle age and for men in old age. Explaining The Hispanic Advantage In Heart Disease And Cancer Mortality Why Hispanics, especially men, appear to have an advantage in mortality from heart disease and cancer, remains a bit of a mystery. In addition to being socioeconomically disadvantaged, Hispanics tend to have risk profiles for chronic disease that are similar to or worse than the risk profiles of Anglos (e.g., Castro et al., 1985; Diehl and Stern, 1989; Mitchell et al., 1990; Samet et al., 1988). The development of chronic disease begins with health behaviors and conditions at younger ages. Therefore, most studies addressing risk factors, including those discussed in this section, focus on adults of all ages, not specifically elderly persons. Studies have shown that compared with Anglos, Mexican Americans are

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--> more likely to have been diagnosed with diabetes (Samet et al., 1988), are more likely to be obese (Balcazar and Cobas, 1993; Mitchell et al., 1990; Samet et al., 1988; Winkleby et al., 1993), and are more likely to experience upper-body obesity (Haffner et al., 1986). Mixed results have been obtained regarding ethnic differences in hypertension. Some studies report that Hispanics have higher prevalence than Anglos (Mitchell et al., 1990; Stern et al., 1987; Kraus et al., 1980); other studies find Hispanics to have lower prevalence rates (Franco et al., 1985; Sorel et al., 1991; Pappas et al., 1990; Samet et al., 1988), and at least one study finds no ethnic differential in hypertension rates (Winkleby et al., 1993). Cholesterol levels among Hispanics have been reported to be lower than Anglos (Mitchell et al., 1990), higher than Anglos (Kraus et al., 1980; Winkelby et al., 1993), and not significantly different (Derenowski, 1990). Likewise, results regarding ethnic differentials in physical activity have been mixed (Haffner et al., 1986; Markides and Coreil, 1986; Winkleby et al., 1993). Acculturation has been shown to be associated with risk factors for chronic disease. For example, recently analyzed data from the Hispanic Health and Nutrition Examination Survey (Hispanic HANES) found that acculturation was positively related to the presence of hypertension in Mexican Americans aged 55 to 74, suggesting that the prevalence of hypertension may very well increase as the population becomes more acculturated into the larger society (Espino and Maldonado, 1990). Acculturation has also been found to be negatively related to both diabetes and obesity (Hazuda et al., 1988), suggesting the possibility of some health benefits from becoming acculturated. Unpublished data from the recently conducted Hispanic Established Populations for the Epidemiologic Study of the Elderly (EPESE) that covered 3,050 Mexican Americans aged 65 and over from the five southwestern states (conducted by the authors) do not support the notion that rates of hypertension are lower among Mexican Americans, at least among the elderly. Data from this representative sample indicate that approximately 44 percent of Mexican-American elderly report being hypertensive (having been told by a doctor) compared with approximately 39 percent in a national sample interviewed in 1985-1987 (National Center for Health Statistics, 1993). As in the general population, hypertension rates were significantly higher among females than among males. Moreover, the Mexican-American excess in hypertension is confined to females. Among Mexican-American males, as among males in the general population, the prevalence of hypertension declines somewhat from ages 65 to 74 to ages 75 and over. Female rates, in contrast, show a slight increase, suggesting the operation of greater selective survival among males at advanced ages. Another factor that may be related to low rates of both heart disease and cancer mortality in Mexican Americans is the population's traditionally low cigarette smoking rates. Among males, however, these rates have gone up in recent years and are now equal to, if not higher than, other groups (Haynes et al., 1990). Hispanic females have relatively low smoking rates, but these

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--> increase with acculturation (Coreil et al., 1991). Data from the Hispanic HANES (Rogers, 1991) show that smoking rates among Puerto Ricans in the Northeast have increased substantially in recent years and may very well translate into higher rates of heart disease and smoking-related cancers. These data show high smoking rates among males in all three major Hispanic populations (Mexican Americans, mainland Puerto Ricans, and Cuban Americans). However, Mexican-American males smoke significantly fewer cigarettes compared with males in the general population and other Hispanic males. Cuban-American males smoke the most, which is consistent with their high lung cancer mortality rates. Alcohol consumption is another important health behavior to consider. As mentioned earlier, Mexican-American and Puerto Rican men have high mortality from cirrhosis of the liver, which is probably related to heavy use of alcohol. Data for Mexican-American men indicate continued heavy use into late middle age, but rather low rates of consumption in old age (Markides et al, 1990; Rogers, 1991). Mexican-American women have low alcohol use, with alcohol consumption being positively associated with acculturation, at least among younger women (Black and Markides, 1993). Heavy drinking rates are also high among Puerto Rican males (Rogers, 1991), while Cuban American males exhibit more moderate consumption patterns similar to those in the general population (Black and Markides, 1994). Of the three Hispanic groups, Puerto Rican Americans exhibit the highest consumption of hard liquor at any age and in both genders (Rogers, 1991). When all the above evidence is considered, any advantage in heart disease and cancer in Mexican Americans and Puerto Ricans is difficult to explain. However, this advantage appears to be narrowing and may very well disappear in the near future as more Hispanics adopt the lifestyle of the larger society. Why the advantage appears to be greater among men is not clear, except that older Hispanic males, especially Mexican Americans, may be survivors from cohorts experiencing high mortality in earlier years. Other Diseases Whereas Hispanics may be advantaged in some major diseases, they are disadvantaged in others. For example, both Mexican Americans and Puerto Ricans have high rates of diabetes. Various research projects have shown that the prevalence rate of non-insulin-dependent diabetes mellitus is two to five times greater among Mexican Americans than among the general population. Higher prevalence is present in all age groups, with the risk being highest in older Mexican-American women (Stern and Haffner, 1990). Factors related to the high prevalence of diabetes in Hispanics include high rates of obesity and high levels of poverty. However, even after these factors are controlled for, Mexican Americans have substantially higher rates of diabetes

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--> than non-Hispanic whites. There has been speculation that genetic factors are involved, related to the high degree of American Indian admixture found in Mexican Americans (Diehl and Stern, 1989; Stern and Haffner, 1990). Puerto Ricans also have significant rates of Indian admixture as well as a significant degree of African-American ancestry. Cuban Americans, on the other hand, do not appear to have substantially higher rates of diabetes than non-Hispanic whites (Rogers, 1991). The high prevalence of diabetes among Mexican Americans is also present in persons 65 and over. Data from the Hispanic EPESE indicate that approximately 23 percent of elderly Mexican Americans report having been told by a doctor that they have diabetes compared with approximately 10 percent in the general population (National Center for Health Statistics, 1993). Moreover, both male and female rates among Mexican Americans decline significantly from ages 65 to 74 to ages 75 and older, a situation that does not occur in the general population. This finding underscores the much higher negative consequences of diabetes among Mexican Americans, including higher mortality rates. Previous literature has suggested that not only do Mexican Americans have higher diabetes prevalence and mortality, but they are also more likely to suffer severe complications of the disease than are diabetics in the general population (Stern and Haffner, 1990). Other diseases of high prevalence in Hispanics, including the elderly, include infectious and parasitic diseases, influenza and pneumonia, tuberculosis, and gallstone disease, at least in Mexican Americans (Carter-Pokra, 1994; Vega and Amaro, 1994). Gallstone disease appears to be associated with the population's high degree of American-Indian admixture, much like the case with diabetes (Diehl and Stern, 1989; Mauer et al., 1990). Research by Mauer et al. (1990) shows that among Hispanics, Mexican Americans of both genders have a higher prevalence of gallstone disease than do Puerto Ricans or Cuban Americans. Recent research in San Antonio has found that for Mexican Americans of both sexes the risk for hip fracture is lower than for other whites, but higher than for African Americans. Other research showed that Mexican-American women are at substantially lower risk for vertebral fracture. Both these findings have led to speculation about the need for different recommendations regarding prophylactic treatment for osteoporosis in Mexican-American women compared with other white women (Bauer and Deyo, 1987). Data from Los Angeles, from San Antonio, and from the Hispanic HANES southwestern sample have also suggested that the prevalence of arthritis might be lower among middle-aged and older Mexican Americans (Espino et al., 1991). However, these data are based on small numbers of older people. Data from the Hispanic EPESE show that approximately 41 percent of Mexican-American elderly report having arthritis compared with over 50 percent in the general elderly population (Guralnik et al., 1989).

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--> Functional Limitations While data on mortality and disease prevalence are important in describing the health status of populations, functional health indicators also provide information that is particularly important among the elderly. Data on the functional limitations of Hispanic elderly have been lacking until recently. Limited information, mostly on Mexican Americans, has traditionally suggested that the functional health of Hispanic elderly is slightly worse than the functional health of other whites and better than that of African Americans (Markides et al., 1989). More recent data show the same: in 1986, for example, 19.2 percent of Hispanics 65 and older reported needing assistance with everyday activities, compared with 22.7 percent of African Americans and 15.4 of whites (Bureau of the Census, 1992). The recently conducted Hispanic EPESE makes it possible to compare data on specific functional limitations among Mexican-American elderly in the Southwest with national estimates for whites and African Americans. Table 10-1 presents such comparisons for five activities of daily living. The table shows that more Mexican Americans than whites and nonwhites report difficulty with eating, toileting, and dressing. On bathing and transferring (out of a bed), Mexican Americans report greater difficulty than whites but less than nonwhites. As Table 10-2 shows, with respect to four instrumental activities of daily living (meal preparation, shopping, using the telephone, and performing light housework), Mexican-American elderly are more dependent than both white and nonwhite elderly. Data from a 1988 survey of elderly Hispanics permits comparisons across the ethnic subgroups on rates of difficulty with activities of daily living and instrumental activities of daily living. Regarding the activities of daily living (bathing, dressing, eating, etc.), Mexican-origin and Cuban-origin elders exhibit comparable rates of functional limitations, whereas Puerto Ricans report consistently higher rates of limitation. Older Puerto Ricans and Mexican Americans tend to report greater difficulty in performing instrumental activities of daily TABLE 10-1 Percentage of Persons 65 and Older Reporting Difficulty Performing Selected Activities of Daily Living by Ethnicity Activities of Daily Living Whites (N = 24,753) Nonwhites (N = 2,784) Mexican Americans (N = 3,050) Eating 1.9 1.3 5.4 Toileting 4.4 7.0 7.5 Dressing 5.7 8.6 9.6 Bathing 9.5 14.0 11.8 Transferring out of a bed 8.2 11.6 8.9   SOURCE: Data on whites and nonwhites are from the 1986 National Health Interview Survey (National Center for Health Statistics, 1993). Data on Mexican Americans are from the 1993-1994 Hispanic EPESE.

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--> TABLE 10-2 Percentage of Persons 65 and Older Reporting Difficulty Performing Instrumental Activities of Daily Living by Ethnicity Instrumental Activities of Daily Living Whites (N = 24,753) Nonwhites (N = 2,784) Mexican Americans (N = 3,050) Meal preparation 6.6 12.8 14.0 Shopping 12.1 18.8 22.3 Using telephone 4.8 6.7 11.2 Light housework 11.2 12.8 15.6   SOURCE: Data on whites and nonwhites are from the 1986 National Health Interview Survey (National Center for Health Statistics, 1993). Data on Mexican Americans are from the 1993-1994 Hispanic EPESE. living (preparing meals, managing money, shopping, housework, etc.) than do older Cuban Americans. The data also confirm that Hispanic elderly face higher rates of limitation on both categories of activities than does the general population of elderly persons (see Ramirez de Arellano, 1994). Self-Assessed Health Self-assessed health is frequently used as an indicator of global health status because it correlates with the entire range of health outcomes, including mortality and use of health care. Self-assessments are the result of complex subjective processes that are influenced by culture and temperament, as well as by actual health status (Angel and Guarnaccia, 1989; Angel and Thoits, 1987). Data from the Hispanic HANES corroborate other data showing that among Hispanics, Puerto Ricans rate their health as poorest and Cuban Americans rate their health as best, with Mexican Americans somewhere in between (Angel and Angel, 1992; Angel and Guarnaccia, 1989). Of course, factors besides group membership influence self-assessments of health. For example, findings from the Hispanic HANES show that although Puerto Ricans consistently rate their health as poorer than do Mexican Americans, for individuals in either group, depression lowers self-assessments of health independently of physician's evaluations. Among the elderly, social interaction, such as attending church, seeing friends, and engaging in group activities, is associated with better self-assessed health. In one study, social involvement of this sort largely accounts for the difference in self-assessed health between elderly Mexican Americans and Puerto Ricans (Angel and Angel, 1992). Recent findings based on the Health and Retirement Survey show that Hispanics, especially Mexican Americans, are much more likely than non-Hispanic whites to rate their health as fair or poor, rather than as excellent, very good, or good (Angel and Angel, 1996). Speculation that this indicates that Hispanics are health pessimists may be premature since these same data show that a large

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--> fraction of African Americans also rate their health as fair or poor. In light of the occupational and health insurance disadvantages faced by poor and minority Americans, poorer self-assessments of health at all ages may be more a reflection of the real health risks they face than of a culturally based pessimistic outlook. Mental Health More recently, however, there is increasing evidence of high rates of psychological distress among the elderly, particularly among women. One study of Mexican Americans yielded rates of depression that were very high among older women and very low among older men (Mendes de Leon and Markides, 1988); this parallels the findings on physical health discussed earlier and also suggests the potential presence of selective factors in the survival of males. Data from the Hispanic HANES yielded low rates of depressive symptoms among Mexican Americans aged 20 to 74 (Moscicki et al., 1989). Although no age differences were noted, rates were lower among the foreign born and the less acculturated, which is consistent with a healthy-migrant effect also suggested with respect to physical health. A similar finding was observed with the Los Angeles Epidemiologic Catchment Area Study (Burnam et al., 1987). These low rates compare with inconsistent findings of other literature comparing Mexican Americans and non-Hispanic whites (Vega and Rumbaut, 1991). A different pattern has been observed among Puerto Ricans, who have been found to have higher rates of depression in New York than in Puerto Rico, and who also have higher rates than Mexican Americans, African Americans, and non-Hispanic whites. These patterns, along with relatively low rates among Cuban Americans in Miami, remain unexplained. However, they do provide useful insights for further research (Vega and Rumbaut, 1991). The numbers of older people in these studies were too small for meaningful analysis of age difference in depression (Moscicki et al., 1987). At this point, we simply do not know what the prevalence of Alzheimer's disease and other dementias is among Hispanic elderly. Limited evidence, however, suggests that the typical Hispanic elderly person diagnosed with possible Alzheimer's disease is younger than is the case among the general population. Clearly, research utilizing appropriate instruments with large and representative samples is needed to give us a better picture of the mental health functioning of older Hispanics. Issues In Medical Care There has been a long tradition of research with Hispanic populations that has suggested that the population underutilizes formal medical care, including psychiatric care. Suggested reasons for underutilization have included culturally inappropriate services and lack of adequate access to care because of low rates of

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--> insurance coverage and other factors. More recent data, however, suggest that elderly Hispanics utilize physicians at rates equal to or greater than those of Anglo elderly, leading to speculation that many Hispanics underutilize services until they turn 65, when most qualify for Medicare (Vega and Amaro, 1994). Data from the Hispanic EPESE suggest that the proportion of Mexican-American elderly in the Southwest who have Medicare is approximately 87 percent. There is strong evidence that Hispanic elderly underutilize nursing homes, much as black elderly do. Possible factors behind these low rates include discrimination against members of minority groups and stronger family supports. Hispanic families may view the nursing home as a last resort; this is borne out by recent data from San Antonio suggesting that Hispanic nursing home residents are significantly more functionally impaired and have higher rates of mental impairment than Anglo residents (Chiodo et al., 1994; Espino and Burge, 1989). Although elderly Hispanics may not underutilize physician services, there is evidence that they may delay seeking treatment for certain symptoms or conditions. This has been particularly noted in studies of cancer treatment in Texas and, more recently, New Mexico (Samet et al., 1988). Conclusion What does the available evidence tell us? With respect to mortality, there is accumulating evidence of a Hispanic advantage at least at ages 45 and above. This advantage is greater among men than women and results from lower cardiovascular and cancer mortality. However, the evidence on risk factors explaining such an advantage is mixed, and researchers have speculated about the protective effects of cultural factors such as strong family ties as well as selective immigration (Mitchell et al., 1990; Markides and Coreil, 1986). Recent data show that immigrant Hispanics have better health than native-born Hispanics (Stephen et al., 1994). Age-adjusted proportions of persons 18 years and older show that immigrant Hispanics were slightly less likely than native-born Hispanics to assess their health as fair or poor or to report activity limitation due to chronic conditions or impairments, and less likely to report 4 or more bed days in the previous year. These rates increased steadily with years since immigration (less than 5, 5 to 9, and 10 or more years), suggesting better health among recent immigrants. Although these data were adjusted for age, they were not broken up by age group, so it is not clear that a healthy-migrant effect is present among the elderly. When we analyzed data on a variety of health indicators from the Hispanic EPESE, we found no consistent differences between foreign-born and native-born Mexican-American elderly. Since most foreign-born Mexican-American elderly have lived in the United States for many years, the absence of a healthy-migrant effect in old age is not surprising. When all available evidence is considered, the mortality advantages of His-

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--> panics do not translate into health advantages in the older years. The data suggest, if anything, more functional limitations among Hispanic than among other white elderly. Until recently, research on elderly Hispanics has concentrated on the population's general needs relating to its poverty, linguistic and cultural barriers, and family relationships. An important matter to underscore is the great heterogeneity of the Hispanic population. Mexican-American and Puerto Rican elderly have a great deal in common by virtue of their lower socioeconomic status, whereas Cuban Americans are closer to the general population in socioeconomic status and prevalence of most conditions. All three groups share a common language. Furthermore, little is known about the increasing numbers of elderly in a variety of groups that have their origins in Central and South American countries. One thing is clear: Hispanic populations, including the elderly, are increasing at much more rapid rates than the general population. We need large and more systematic studies that identify the population's special problems and needs as well as the various socioeconomic, cultural, and genetic factors relevant to understanding the health and health care behavior of its members. References Angel, J.L., and R.J. Angel 1992 Age at migration, social connections, and well-being among elderly Hispanics. Journal of Aging and Health 4:480-499. Angel, J.L., and D.P. Hogan 1991 The demography of minority aging populations. Pp. 1-13 in Minority Elders: Longevity, Economics, and Health. Washington, DC: The Gerontological Society of America. Angel, R.J., and J.L. Angel 1996 The extent of private and public health insurance coverage among adult Hispanics. The Gerontologist 36:332-340. Angel, R.J., and P.J. Guarnaccia 1989 Mind, body, and culture: Somatization among Hispanics. Social Science and Medicine 28:1229-1238. Angel, R.J., and P. Thoits 1987 The impact of culture on the cognitive structure of illness. Culture, Medicine, and Psychiatry 11:23-52. Balcazar, H., and J.A. Cobas 1993 Overweight among Mexican Americans and its relationship to life style behavioral risk factors. Journal of Community Health 18:55-67. Bastida, E. 1984 Reconstructing the world at sixty: Older Cubans in the U.S.A. The Gerontologist 24:465-470. Bauer, R.L., and R.A. Deyo 1987 Low risk of vertebral fracture in Mexican American women. Archives of Internal Medicine 147:1437-1439. Black, S.A., and K.S. Markides 1993 Acculturation and alcohol consumption in Puerto Rican, Cuban American and Mexican American females in the United States. American Journal of Public Health 83:890-893.

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