The health status of elderly men: A community study

PuhL Hlth, Lond. (|982)96. 3-15-354

The Health Status of Elderly M e n : A C o m m u n i t y Study Rosa Gofin M.D.M.P.H

Department of Social Medicine, Hebrew University, Hadassah School of Public Health and Community Medicine, P.O.B. 1172. Jerusalem, /srael

The health status o f 217 elderly men living in a neighbourhood of West Jerusalem was studied. Subjective good health was manifested by 47% of the population. However the coefficient of agreement with the doctor's appraisal of health was only 22~. Among lhe most prevalent disorders found, were cardiovascular diseases and symptoms of prostatic hj~pertrophy. A quarter o f the men were impaired in their functional capacity. The elderly aged 75 and more were found the most affected. Dissatisfaction with life situation was found in 13 % of the population. High use o f medical services was reported.

Introduction The continuous increase in the n u m b e r and p r o p o r t i o n o f elderly persons in m o s t industrialized and developed societies is well known. Israel is no exception to this p h e n o m e n o n and has seen its Jewish population changing from y o u n g to ageing, with 3-8% of people aged 65 or m o r e in the late 1940s to a projection o f nearly 10% for the next decade. ~- = This event is also seen at the local level and has resulted in an increasing focus in meeting the health and social needs o f the elderly in o r d e r to enable them to live for as long as possible in their natural setting. A d e q u a t e planning o f services or allocation o f h u m a n and material resources are essential for that purpose. This could only be d o n e by identifying the needs and the g r o u p at risk in the target population. Here w e present data o n the health status o f men aged 65 and m o r e living in a n e i g h b o u r h o o d o f West Jerusalem.

Methods The data presented here are an integral part o f a C o m m u n i t y Health Survey c o n d u c t e d in 1969-71 b y the D e p a r t m e n t o f Social Medicine, H e b r e w University H a d a s s a h School o f Public Health and C o m m u n i t y Medicine. The study p e p u l a t i o n , 10,000 in total, included all permanent residents o f a defined study area who lived in a 50% probability sample o f households. Interviews were c o n d u c t e d at home, a n d transportation to the health centre where examinations were p e r f o r m e d was provided when necessary. H o u s e b o u n d patients were examined at home. Examinations were performed by a physician and special tests were carried out; these included E.C.G., b l o o d and urine tests and a n t h r o p o m e t r i c measures. In order to clarify the diagnosis, use w a s m a d e of hospital or other medical records. 0033-3506/82/060345+ t0 $02.00/0

0

~982 The Society of Community Medicine

346

R. Gofin

Special attention was given to the r:andardization o f techniques and quatity control procedures were applied in the biochemical laboratory. E.C.G. tracings were sent to the laboratory of Physiological Hygiene of the University of Minnesota School o f Public Health for coding by the Minnesota Code. All data were stored in magnetic tapes. The S.P.S.S. program 3 was used for analysis. Age standardization was done by the direct method a n d chi square tests were performed to test significance in the relation o f variables. Kappa test was used to test for chance agreement• The proportion o f missing values for any variable was usually 2%, but was up to 1 1% for blood tests.

Population Of a total o f 250 elderly men living at home, 87% were interviewed, and 83% examined. The findings presented here refer to those persons who were interviewed and/or examined, a total of 217. A b o u t h a l f o f t h e m are in the age-group 65--69 and as expected the percentages are smaller in the other age groups; 7-4~ were aged 80 or more. Most of them were born in Europe and America (63.6~/~). Those born in Asia and Africa constitute a r o u n d 12% each, and the lsraelis 10%. Only 9-4% have less than 4 years of education, two-thirds belong to social class I, ii or II1. In,general, European and American born tend to be younger, more educated, and belong to higher social class than the other elderly men. Married men constitute 90~/~ of the population; 5 5/0 (12 men) are living alone. Most of them (84%) live in 2 or 3 r o o m flats and in 90% of the cases there are I to 2 persons per room. M o r e than one-third of the population is still working. Despite the fact that the majority of them (58/o) o/ have lived in the country for more than 20 years (only 6.7% came to Israel less than 10 years prior to the study), it was found that one in four did not speak Hebrew at all. Health care (mainly curative) is provided by Kupat Holim, the sick fund of the General Federation o f Labour. A sector of the neighbourhood receives preventive and curative services from the C o m m u n i t y Health Centre of the Department o f Social Medicine of the School of Public Health and C o m m u n i t y Medicine. The Centre also provides home care for the chronically sick in the entire neighbourhood. Only 3% o f the elderly men do not have a regular source ofeare. Social and welfare services are provided by a network of agencies from the local and national level. •

O/

Results Overall health status In answering the question: is your general state o f health nowadays very good, good, not so good, poor or very poor, 47~o said they were in good or very good health, 38-5% that they were in not so good health and 14-6% were in poor or very poor health. According to the doctor's appraisal after examination, only 24.6% o f the elderly men were found to be quite well and 28% had a moderate o r severe illness (Table 1). The coefficient o f agreement was 57-6~ but when controlling for chance agreement, this became only 22 ?/ -'oAn association was found between subjective poorer health and increasing age. When controlling for age, an association between subjective poorer health and decreasing income (P < 0-001)as well as with lower social class ( P < 0-05) was found. On the contrary doctor's appraisal of health was not associated with income or social class.

The Health Status of Elderly Men

347

TASTE 1. Self and doctor's appraisal of health by age ( ~ )

Age Appraisal oF health Self-appraisal* Good/very good Not so good Poor/very poor Doclor's appraisal Quite well Mildly ill Moderately or severely ill

65-69

70-74

75+

Tot~/i

27,3 47.7 25.0

45.7 41.4 12.9

56-0 32-0 12-0

47-0 38.5 |4-6

14.3 52-3 33-3

22.4 41,8 35.8

30-6 49-0 20-4

24,6 47,3 28.0

* P <0-025.

Selected diseases and disorders Table 2 shows that among cardiovascular diseases, coronary heart disease was present in t 8.9~ of the elderly men, congestive heart failure in 11-5~, hypertension in 39.8 ~ , varicose veins in 37.6~, self reported haemorrhoids in 31~o, intermittent ctaudication in I0-6~o. Cerebrovascu.lar accidents (3-2~) and hypertensive heart disease (3-4~) were tess prevalent. Diabetes was found in I 7 ~ of the population. Lung diseases were not so frequent, self reported asthma was present in 4-3~ of the elderly men, chronic bronchitis (based ~n the M.R.C. short questionnaire on respiratory symptoms 4) in 3.8~. Inguinal hernia was found in 33.2~ of the men, and peptic ulcer in 4.7~, gallbladder disease was reported by 8.9~ of the population. Symptoms of prostatic hypertrophy were reported by 40-1 ~, and of active potiarthritis by 2-9~, vision troubles by'9.0 ~ and hearing trouble by 6.1 ~. Only prostatic hypertrophy, congestive heart failure and the sensory disorders were positively associated to age. Controlling for age, no specific trends were found in respect to education or social class. While most of the conditions were more prevalent among the African born, none of the differences were statistically significant. Considering aggregates of diseases, at least one of the following conditions: Coronary heart disease, congestive heart failure, hypertensive heart disease or cerebrovascular accident, was present in 31-4~o of the elderly and in 45-6~ of the aged 75 or more. A much higher percent (71 "4~o) suffered from a t least one of the following: systolic hypertension, diastolic hypertension, intermittent claudication, diabetes, chronic bronchitis, asthma, prostatic hypertrophy. Functional capacity Around one in five of the elderly men was reported to be unable t o carry on his major usual activites: 6-2~ were homebound and 6-6~ bed ridden; 10-8~ had difficulties in performing A.D.L. (washing, dressing, going to the toilet). These impairments were positively associated

348

R . Gofin

o/ T^BLE 2. Prevalence of selected diseases and disorders by age (/o)

Age Diseases and disorder Cardiovascular diseases Coronary heart dt,:,as~~ Congestive hearl failureb t~ypertension systolice diastolic'~ Hypertensive hearl diseaset" Cerebrovascular accidentsf lnte"mi'ltenl claudication~ Haemorrhoidsh Varicose veinst Endoclinal di~ase Diabet esJ Lun~ di~ases Chronic bronchitisk Asthma I Digestive diseases Peptic ulcerm Gallbladder disease" Jngtfinal hernia° Urinary disease Prostatic hypertrophy ~ Locomotor disease Active poliarthritis, Sensory disorders Cannot see letters in newspaper r Trouble with both or better ear s

65--69

70-74

75+

Total

21-8 5-0 34-4 26-9 2-2 4.0 11.0 35"0 33-0

15"3 8-6 31"1 9'8 5"2 0 15.7 28-6 42-4

18,9 30,4 47-6 19.0 3-6 5.5 2.4 25-6 41-0

18-9 11,5' 36-2 19"9 3,4 3.2 10,6 31 "0 37.6

11-9

25-0

15,6

17-0

2-0

1-4

11.9

3-8

3.0

7" I

2-2

4-3

4.0 10'0 25-8

5.7 4'3 37,9

4,8 13-9 42-9

4.7 8-9 33-2

28-0

45-7

59.5

40.1"~

1-0

3"0

7,1

2-9

3"0 2-0

12-8 7-1

16-7 ]4.3

9-0+* 6"1~

* P < 0 . 0 0 0 5 ; t Pi 160 mmHg. d Diastolic blood pressure >/95 mmHg. Probable hypertensive heart disease: hypertension (c or d) together with probable left ventricular hypertrophy diagnosed on basis of E,C,G, criteria. -.2 r Documented diagnosis on medical records. Based on responses to London School o f Hygiene cardiovascular questionnaire, according to Rose's criteria, 2~ n Self report of haemorrhoids diagnosed by a physician. i Clearly visible distended and tortuous leg veins, not including small subcutaneous venectasias, J Probable and definite diabetes. Diagnoses based on glucose tolerance tests and serum glucose levels, according to the criteria of the Israel lsehemic Heart Disease projecF s with additional subsidiary criteria based on serum levels after glucose challenge. k 'The persislent production ofphlegm (for at least three consecutive months in the year) and at least one chest illness with increased cough and sputum during the past three ),ears'. ~ based on the M,R.C, Short Questionnaire on Respiratory Symptoms. ~r I Self report of asthma (at least three episodes) diagnosed by a doctor. m Radiological evidence or documented diagnosis in previous hospital records; sought if report received of positive X-ray for ulcer, X-ray for stomach pain or operation for ulcer. n Self report of gallbladder disease diagnosed in hospital or by X-ray. o Obvious groin swellings (examination procedure as described by Bailey)zs and operated hernias; not including palpable impulse on coughing.

The Health Status o f Elderly Men

349

TAaLE 3. Functional capacity by age (~) Functional capacity Inability to carry on major activities a Mobility Home bound t' Bed .bound~ Performance of ADL~ At least 1 impairment 3 impairments * P <0.0005; t F<0.0l;

65--69 70--74

75+

Total

5-0

25-7

45-2

19-7"

1-0 2-0 4-0

5-7 7- I In-0

18.6 16"3 27-9

6-2t 6-61 t0-8'

7-9 2-0

30-0 7-1

50-0 21-7

24-9* 7-82[

P < 0.005.

a Amount or kind of activities such as social, hobbies, sports, and other activities. I, Confined It the house for most or all the time. ~' Confined to bed for most or all the time. Washing, dressing, or going to the toilet. with age (Table 3). A r o u n d o n e in four were impaired in at least o n e of the a b o v e , but one in t w o o f those aged 75 or more. African born were t h e most impaired b u t n o clear trends were present in respect of e d u c a t i o n or social class when controlling for age.

Somatic characteristics M e a n systolic blood pressure ,increased with age, a trend not shown f o r diastolic blood pressure (Table 4). A third o f the population had cholesterol levels over 2 4 0 m g ~ ; 30% were f o u n d to be heavier by 2 0 % or more than the standard weight? N o clear a g e trends were f o u n d for either cholesterol o r weight, or for uric acid. M e a n haemoglobin levels decreased slightly with age as did height.

Psychological characteristics Dissatisfaction with life situation was f o u n d in 12-49/o o f the elderly men, with a higher percentage among those aged 65-69 (Table 5). There was more life satisfaction associated with increasing income ( P < 0-005), with reported g o o d health ( P < 0-01), with doctor's appraisal o f good health (P < 0.005) a n d with g o o d family situation ( P < 0*005). S y m p t o m s o f emotional ill health like irritability were reported b y 29-6~/o, tenseness by 25-4%. Less frequent were depression (14-7%), nervous exhaustion (10.89/o), jitteriness (10-0%), anxiety (t0-5%), hopelessness (9-0%) and sudden fears (6-7 %). O nly tenseness was significantly associated t o age (P < 0.025). A r o u n d one in four people reported having t r o u b l e with m e m o r y . P Probable prostatic"hypertrophy inferred from the presence ~f at least three of the following: frequency of micturition, nocturia, hesitancy, weak stream, terminal dribbling, selfreported prostalcctomy.

Cbaractetisticman~festations:at least three of the fiveeriteria proposed by the third International Symposium on Population Studies in the Rheumatic Diseases.~9 r Reported inability to see letters ,;n ordinary ~ewspaper, even with spectacles. Self report: much trouble with hearing or deaf.

350

R. aofin TAaLIZ 4. Mean values of ~leeted somatic characteristics by age

(%)

Age Somatic characteristics Blood pressure ~ Systolic (mmHg) Diastolic (mmHg) Cholesterol (gr/dl) D Serum uric acid (mg/dl) e Hb (gr/lt) a H t (~)e Height (era) ~

Mean s.D. Mean s.D, Mean S.D. Mean s.D. Mean s,D. Mean s.D. Mean s.o.

65--69

70-74

75 +

Total

146-5 25.7 85- I 14.3 221.9 45-3 5-6 1'1 15.5 I. I 45,5 3.6 164,1 6.2

149.9 26.2 79-9 11-2 228,9 52'3 5.9 i'5 t5.2 1.3 45.2 3"4 164,0 7.7

158-9 26.6 80-6 13.5 210.7 43-3 5-4 0.8 14.7 ! -6 43-7 4-3 162,9 6-1

150"2 26-3 82-5 14-6 222-I 47"6 5-7 1"2 15"3 1"3 45" 1 3"7 I63-9 6.7

Measured with a variable - zero sphygmomanometer a° in the right arm with the subject supine; after resl o f at least 5 min; diastolic blood pressure is taken as the disappearance of K o r o l k o f f sounds (phase 5). r. AutoAnalysis~l Technicon U.S.A. c Modification of the manual method described by Hawk e t al. ~ d Cyanmethaemoglobin method using Klett spectrophotometer. Venous blood. e Mierohaematrocrit m ~ h o d . Venous blood. r Without shoes.

Health relevant beha~iour Around a third of the elderly men (34-8~) smoke at present, of whom 2 8 ~ smoke 20 or more cigarettes a day. In respect of use of health services, it was found that one in three people had had at least one contact with a doctor in the previous 2 weeks. With perceived poorer health these rates increase (P < 0.005); no differences were found according to age, ethnic origin, education or social class. Reports of hospital admission were given by ! 6 ~ ; of these one-third stayed in the hospital for more than two weeks. Discussion

The elderly population in this community is not very different from that of Israel as a whole, ~,7 except that this one is slightly " y o u n g e r " and European and Americans are over-represented. Thus, results of this study could be taken into a broader perspective. We will discuss now the different topics studied.

Appraisal of health Around half the elderly (47~) in our community reported enjoying good health, as compared to 2 3 ~ in a sample of Jewish urban residents of all Israel. ~ This difference should be taken into account allowing for the possibility that it is due to the type of questions asked.

The Health Status of Elderly Men

351

TABLE 5. Selected psychological characleristics by age ('~o) Age Psycholo#cal characteristics Overall salisfaction with life situation: ~ Unsatisfied Mildly satisfied Satisfied Selected psychological symptoms ~' Depression Hopelessness Anxiety Tenseness Considered a nervous person Irritability Jitteriness Sudden fears Nervous e~haustion Memory for words and names" Memory for events: Recent only Recent and remote

65--69

70.-74

75+

Total

13,5 45.8 43.7

11.1 46-0 42-9

ll.1 36" 1 52-7

12.4 42.6 45-1

12-0 5.0 8.0 25-0 33-3 32-0 9-0 5.0 10.0 16.2

! 7-1 i ! .4 10"I 27"4 30-4 24"6 11"6 5"8 t2"9 27'5

14-7 14-6 17"5 40-0 35"9 32"5 10-0 12'5 9.5 35"0

14.7 9.0 10.5 25-4* 32,9 29.6 10-0 6.7 10.8 23"6t

3.0 24.0

7.2 33"2

17.1 24.4

7.2* 27-2

* P < 0.025;'t P < 0.05, Self-rating from ! - t 0 : < 4 was taken as dissatisfaction, 5-6, mild satisfaction, 7-10 satisfaction. *' Positive responses to specific questions about these symptoms. " Self appraisal.

The fact that agreement between self-report and the doctor's appraisal on the basis o f medical examination was very low has been reported by others?. ~o

Prevalence of selected diseases Comparisons with the prevalence of diseases in other studies are very important but at the same time difficult to interpret because of differences in methods of collecting data, luck o f uniform criteria in diagnosis or in the way data are presented: i.e. different age groups, both sexes together. We are therefore not systematically comparing our findings with those o f other studies and will mention a few examples only. Prevalence o f C.H.D. (18-9 ~ ) is similar to that found in the study o f a total c o m m u n i t y in Tecumseh, Michigan, ~1who found it in 1 8 ~ o f t h o s e aged 60-69 and 1 7 . 8 ~ in those aged 70-79. Criteria of diagnosis were similar in both studies except that in the presec~t one, E.C.G. from clinical records were also used for diagnosis. Rates for diabetes are much higher in our population (17~) than in Tecumseh: 5.6~,, for the age group 60-69 and 6 - 9 ~ for those aged 70-79) a This disparity cannot be explained by the difference in the criteria alone. Chronic bronchitis in our study (3-7~) has a lower prevalence than in that community, where they found 12-4~ in the age group 60-69 and 10.9~ tbr those aged 70-79. ~ Both used similar criteria. Differences in smoking habits and environment could account for the differences.

352

R. Gofin

Although no clear age trends were shown for most of the diseases of the old, those aged 75 or more are the ones with higher prevalence of diseases. As this is a survival population we can say that as the sicker people died, they left behind the elderly who were "healthier". Their prolonged exposure to conditions and behaviour that affect health, causes them to show higher prevalence rates of disease than do younger groups in the same community, a"-A cohort effect could also be present in this population: these elderly men came from a generation or countries in which coronary heart disease was less prevalent. Now with the passing of time this disease has become more prevalent and the number one killer in this population.

Functional capacity The percez~tage of home and bedbound men in our population (12-8°(,) is slightly higher than that in the study of Jewish urban residents in Israel (I 10/(,)YIn that study, unlike ours, length of time of being bed or homebound is considered an integral part of the definition. People aged 75 or more are the most impaired. Again survival with long exposure to diseases that lead to impairment of functioning could explain these findings. The finding that African born present the highest rates of dysfunction, while European and Americans tend to function better than people from other backgrounds is consistent with other studies in Israel?. ~'~ This could be the expression of actual differences as well as cultural values.

Somatic characteristics tdaemoglobin levels are above the 13 gm/dl stipulated by the W.H.O. as anaemia. ~ This value as well as the haematocrit are similar to the one found in an International haematological survey of 12 countries. ~5 Mean cholesterol values are slightly lower than those of the National Health Survey in the U,S.A. t~ The mean systolic blood pressure and diastolic blood pressure are similar to those found by that surveyJ 7 Mean height decreased with increasing age, a trend which was apparent already at younger ages. a~ That could be an expression of secular trend or birth cohort membership.

Psychological characteristics Life satisfaction has long been considered a measure of mental health ~"-'~ and successful adjustment to ageing) s-2° In this study, low income, perceived health status~ the doctor's appraisal of health and satisfaction with family life were found to be associated with satisfaction with life situatio~. However, we do not know if these variables aare independent or interact with each other. These are questions that were out of the scope of this study. The symptoms showing emotional ill health were found to be less frequent than m the years before those "defined'" as old, as is sho~vn in other ~..alyses of data from the same community)" This could be an expression of the problems of transition in life that becomes less evident once the "'landmark" is passed, and there is a better adjustment to ageing.

The Health Status o f ElderO" Men

353

Health relevant behaviour Elderly men smoke less than the men aged 20-64 in the same p o p u l a t i o n ? 2 It a p p e a r s that elderly men give up smoking or they d o n ' t start smoking in later life. It could also be an expression o f a cohort effect, these people coming from a generation that smoked less, o r be due to premature death o f those w h o smoked. Even though perceived p o o r health was associated with increased contacts with a doctor, a r o u n d half o f those in p o o r health did not have contact with a d o c t o r in the previous 2 weeks, but a quarter o f those in good health did have contact with the doctor. It would be important to k n o w if all persons in need o f medical services got them, and on the other hand if medical services are used for reasons other than health. High rates o f utilization were also found in the Baka n e i g h b o u r h o o d o f Jerusalem. zl Rates o f hospitalization in o u r s t u d y (16%) are not very different to others found in Baka n e i g h b o u r h o o d (19%), e~ urban elderly population (13%), b u t are higher than in other countries which participated in a crossnational study o f the elderly: Britain 8 ~ , D e n m a r k I 1%.~ This m a y be an expression o f differences in prevalence of disease and disability, o f the practices o f the medical profession, o f different criteria for hospital admission, or o f the inability to care for the elderly at home.

Acknowledgements I wish to express my. thanks to Prof. J. H. Abramson for his help. This was a study supported by the United States Pu]~lie Health Service (P.L. 480 counter part funds, Research Agreement no. CD. 15-20) and the Chief Scientist's Office, Israel Ministry of Health.

References 1. Statistical Abstract of Israel No. 3 (1951/52). Jerusalem: Central Bureau o f Statistics and Economic Research. 2. Statistical Abstract of lsrael No. 27 (1975), Jerusalem: Central Bureau of Statistics and Economic Research. 3. Nie, N. H., Hull, C. H., Jenkins, J. G., Steinbrenner, K. & Bent, D. H. (1975). in Statistical Package.for the Social Sciences, 2nd Edition, K. J. Bowman & M. Cahilt (Ed.), New York: McGraw-Hill. 4. Higgias, i. T, T. (1957). Respiratory symptoms, bronchitis and ventilatory capacity in a random sample of an agricultural population. British Medical Journal 2, 1198--03. 5. Interdepartmental Committee for National Defense. (1963). Manual for Nutrition Surveys. Bethesda M.D.N.I.H. 6. Statistical Abstract oflsrael No. 22 (1971). Jerusalem: Central Bureau of Statistics and Economic Research. 7. Statistical Abstract of Israel No. 23 (1972). Jerusalem: Central Bureau of Statistics and Economic Research. 8. Weihl, H., Nathan, T., Avner, N., Finkelstein. N. & Getter, N. (1970). h:vestigution of the Family Life, Living Conditions and Needs of the Non-institutionalized Urban Jewish aged 65-plus it: Israel. State of Israel: Ministry of Social Welfare. 9. Friedsam, H. J. & Martin, H. W. (I963). A comparison of self and physician health ratings in an older population. Journal of Health and Social Behavior 18, 160-4. 10. Maddox, G. L. (1962). Some correlates of differences in self-assessments of health status among the elderly. Journal of Gerontology 17, 180--5. 11. Epstein. F . H . , Francis, T.. Hafner, N. S., Jok,~.,5on, B. C., Kjelsberg, M. D., Napier, J. A., Ostrander, L.O., Payne, M.W. & Dodge, H.S. (1965). Prevalence of chronic diseases and distribution of selected physiological variables in a total community. Tecumseh, Michigan, American Journal of Epidemiology 81,307-22.

354

R. Gofin

12. Kark, S, L,, Gofin, J., Abramson, J. H., Makler, A., Mainemer, N., K a r l E,, Epstein, L. M. & Hopp. C. (1979), Prevalence of selected health characteristics of men. A community health sur~'ey in Jerusalem, israe[ Journal o[ Medical Sciences 15. 732--41. 13. Si)berstein. J,. Kossovsky, R. & Lilus. P. (1977). Emotional dependency in the aged. Jaurp;a,j o/ Geromolog)" 32, 222-4). 14. Nutritional ar~aemias. Report ofa W.H.O. group of experts (]972). World Health Organization, Technical Reports Series No. 503, t5. E]wood. P, C., Hughes. J., Abernathy. M., Davies, R,, Cough, R., Johnson, A. P. & Dubourg. A, V. (t976}. An International haematological survey, B~dletinof the World Health Organization ~ , 87-95, 16. National Center for Health Statistics, (t967). Serum cholesterol teveis of adults, U.S. 1960-62. Vital and Hea13h Statistics P.H.S, Series 11 No. 22. 17. National Center for Heallh Statistics. (1973). Blood pressure of persons 18-74 years. Vital and Health Statistics P.H.S. series 11 No. 150. 18. Palmore. E. & Luikart, C. (1972]. Health and Social factors related to life satisfaction. Journa! of Heallh a~td Social Behaviour 13, 68-80. 19. Medley, M. (1976), Satisfaction with life among persons sixty five years old. A causal mode]. Jt~urt~a) of Gerontology 31.4.4g~55. 20. Wolk. S,, & Tellen, S. L. (1976). Psychological and Social correlates of life satisfaction as a functiort ot residential cor)straint. Jo)~rnal of Gerontology 41, g9-98, 21. Davies, A, M, & Fleishman, R, (1981). Health status and use of health services as reported by the older residents of the Baka neighborhood, Jerusalem, lsrael Journal ~( Medico[ 2cie~ces ~7, 138-44. 22. Epstein, F. H., Oslrander, L. P., Johnson, B, (7., Payne. M. W,, Hayner, N, S,, Keller. J. B. & Francis, T. Jr. (1965), Epidemiological studies of cardiovascular disease in a total community, Tecumseh, Michigan. Anna& qf Internal Medicine 62. I170--85, 23, Bedford, S, D. & Caird, F. I, (]960). Vah,utar Disease of the Heart in Old Age. Boslon: Little Brown. 24, Rose, G, A, ~1962). The diagnosis of ischaemic heart pains and intermittent claudication in field surveys. 6u&tfn of the Worm Health Organization 27, 645-8. 25. Herman, J. B., Mount. F. W., Med~lie, J, H., Green, J. J., Dublin, T. D., Neufeld, N. I4. & Riss, E, (1967). Diabetes prevalence and serum uric acid: observations among 10,000 men in a survey of ischaemic hear', disease in Israel. Diabetes 16. 858-68. 26. Higgins, 1. T. T. (t957). Respiralory symptoms, bronchiIis and ,~entilalory capacity in random sample of an agricultural population. British Medical Journal 2, 1t98-03. 27. Rose. G, A. & Blackburn, H.(l%8),CardiovascularSurveyMethods. World Health Organi:ation. Monograph Series 56, 177-8. 28. Bailey, H. (1942), Demonstration of Physical Signs in Clinical Surgery. Bristol: Wright. 29. Bennett, P. 14. & Butch, F, D. (I967). New York Symposium on population sludies in Ihe rheumatic diseases: new diagnostic criteria. Bulletin of Rheumatic Dise(z¢es 17, 453-8. 30. Garrow, ], S. (1963)~ Zero-mudd]er for unprejudiced sphygmomanometry. The Lancet ii, ! 205, 31 Block, W. D , Jarrctt, K. J. & Levine, J. B. (1966). An improved automated determination of serum cho}esterol with a simple color reagent, Clinical Chemic'try 12, 681-9, 32. Ha'~k. F. B., Oser, B. k & Summerson, W. H. (1954). In PracticalPhysiologicalChernisrry. 13th Edition, New York: McGraw Hill.