- Email: [email protected]
The oldest-old in China – Authors' reply
Correspondence
We declare no competing interests.
*Tomohiro Morita, Kana Yamamoto, Akihiko Ozaki, Kenji Tsuda, Tetsuya Tanimoto [email protected] Soma Central Hospital, Fukushima,976 0016, Japan (TM); Minamisoma Municipal General Hospital, Fukushima, Japan (KY, AO); Teikyo University Chiba Medical Center, Chiba, Japan (KT); and Navitas Clinic, Tokyo, Japan (TT) 1
2
3
4 5
Zeng Y, Feng Q, Hesketh T, Christensen K, Vaupel JW. Survival, disabilities in activities of daily living, and physical and cognitive functioning among the oldest-old in China: a cohort study. Lancet 2017; 389: 1619–29. Zhou M, Wang H, Zhu J, et al. Cause-specific mortality for 240 causes in China during 1990–2013: a systematic subnational analysis for the Global Burden of Disease Study 2013. Lancet 2016; 387: 251–72. Yi Z, Wang Z. Dynamics of family and elderly living arrangements in China: new lessons learned from the 2000 census. China Review 2003; 3: 95–119. Li LW, Zhang J, Liang J. Health among the oldestold in China: which living arrangements make a difference? Soc Sci Med 2009; 68: 220–27. Schulz R, Sherwood PR. Physical and mental health effects of family caregiving. Am J Nurs 2008; 108: 23–27.
Authors’ reply
We agree with Fuzhong Li and Peter Harmer that our data1 have limitations, including the unmeasured burden of non-communicable disease. In fact, we acknowledge this in our paper, and conclude that “further studies need to include chronic diseases”. Li and Harmer also point out that we did not assess the magnitude of rural–urban differences, and Tomohiro Morita and colleagues describe our rural–urban www.thelancet.com Vol 390 August 26, 2017
dichotomy as “too simplistic”. We agree that an investigation of rural– urban differences is important, which is why we adjusted for rural–urban residence as a covariate in our study. We would like to point out that it might not be appropriate to divide the data into rural and urban subsamples, because it would cut the sample size by about half, and make the subsample data not fully compatible between 1998 and 2008 because of rural–urban migration. Morita and colleagues correctly point out that the Global Burden of Disease Study showed China can be divided into five areas, and suggest we consider this. However, besides the fact that the division of data would largely reduce the statistical power because of a much smaller sample size, there are wide disparities within each of the five areas, so we believe such analysis would be unhelpful. Adjustment for rural and urban residence plus education, although imperfect, cap tures most socioeconomic disparities. We disagree with Li and Harmer’s comment that our ascribing of greater longevity or lower mortality among the oldest-old to benefits of success is “problematic because no valid measure of health status exists for this population”. The standard activities of daily living and objective tests of physical performance and cognitive function are valid measures of health status strongly associated with survival. We believe Li and Harmer’s com ment that “the costs of success hypothesis might not be tenable because of the lack of key measures, such as non-communicable disease” is invalid, because: the costs of success is an interpretation of the decline in average scores of physical performance and cognitive function as the survival of more frail, elderly individuals with health problems, rather than a hypothesis to be tested; and, a lack of non-communicable disease data does not prevent analysis of changes in the health status of physical and cognitive abilities.
We agree with Morita and colleagues that “the information about family members who support an oldest-old individual is of concern”; however, we did adjust for marital status (ie, living with or without spouse), and thus the effects of family member support are controlled for, to some extent. Additionally, some studies indicate elderly-only households can increase risk of dementia and disability,2,3 whereas others show that elderly people who live alone might be selectively in better health because of different context and motivations.4
DN6/Fotolia
individual is of concern. In China, the One-Child Policy (launched in 1979) has resulted in an increase in the number of elderly-only households. Among those aged 65 years or older, 29% of men and 24% of women lived either alone or only with their spouse in 1990, as compared with 37% of men and 30% of women in 2000.3 The increase in solitary or elderly-only households can result in an increase in the prevalence of dementia and disability in activities of daily living.4,5 The change in household structure might have affected the health out comes among the elderly.
We declare no competing interests.
*Yi Zeng, Qiushi Feng, Therese Hesketh, Kaare Christensen, James W Vaupel [email protected] Center for the Study of Aging and Human Development, Medical School of Duke University, Durham, NC, 27710, USA (YZ); Center for Healthy Aging and Development Studies, National School of Development, Raissun Institute for Advanced Studies, Peking University, Beijing, China (YZ); Department of Sociology, Centre for Family and Population Research, National University of Singapore, Singapore (QF); Institute for Global Health, University College London, London, UK (TH); Institute for Global Health, School of Public Health, Zhejiang University, Zhejiang Sheng, China (TH); Danish Aging Research Centre, Unit of Epidemiology, Biostatistics and Biodemography, Institute of Public Health, University of Southern Denmark, Odense, Denmark (KC); and Max Planck Institute for Demographic Research, Rostock, Germany (JWV) 1
2 3 4
Zeng Y, Feng Q, Hesketh T, Christensen K, Vaupel JW. Survival, disabilities in activities of daily living, and physical and cognitive functioning among the oldest-old in China: a cohort study. Lancet 2017; 389: 1619–29. Li LW, Zhang J, Liang J. Health among the oldestold in China: which living arrangements make a difference? Soc Sci Med 2009; 68: 220–27. Schulz R, Sherwood PR. Physical and mental health effects of family caregiving. Am J Nurs 2008; 108: 23–27. Yeung, WJ, Cheung AK. Living alone: One-person households in Asia. Demographic Res 2015; 32: 1099–112.
Improving post-surgical management of resected pancreatic cancer We read with interest the results of the ESPAC-4 trial and congratulate John Neoptolemos and colleagues 847
We declare no competing interests.
*Tomohiro Morita, Kana Yamamoto, Akihiko Ozaki, Kenji Tsuda, Tetsuya Tanimoto [email protected] Soma Central Hospital, Fukushima,976 0016, Japan (TM); Minamisoma Municipal General Hospital, Fukushima, Japan (KY, AO); Teikyo University Chiba Medical Center, Chiba, Japan (KT); and Navitas Clinic, Tokyo, Japan (TT) 1
2
3
4 5
Zeng Y, Feng Q, Hesketh T, Christensen K, Vaupel JW. Survival, disabilities in activities of daily living, and physical and cognitive functioning among the oldest-old in China: a cohort study. Lancet 2017; 389: 1619–29. Zhou M, Wang H, Zhu J, et al. Cause-specific mortality for 240 causes in China during 1990–2013: a systematic subnational analysis for the Global Burden of Disease Study 2013. Lancet 2016; 387: 251–72. Yi Z, Wang Z. Dynamics of family and elderly living arrangements in China: new lessons learned from the 2000 census. China Review 2003; 3: 95–119. Li LW, Zhang J, Liang J. Health among the oldestold in China: which living arrangements make a difference? Soc Sci Med 2009; 68: 220–27. Schulz R, Sherwood PR. Physical and mental health effects of family caregiving. Am J Nurs 2008; 108: 23–27.
Authors’ reply
We agree with Fuzhong Li and Peter Harmer that our data1 have limitations, including the unmeasured burden of non-communicable disease. In fact, we acknowledge this in our paper, and conclude that “further studies need to include chronic diseases”. Li and Harmer also point out that we did not assess the magnitude of rural–urban differences, and Tomohiro Morita and colleagues describe our rural–urban www.thelancet.com Vol 390 August 26, 2017
dichotomy as “too simplistic”. We agree that an investigation of rural– urban differences is important, which is why we adjusted for rural–urban residence as a covariate in our study. We would like to point out that it might not be appropriate to divide the data into rural and urban subsamples, because it would cut the sample size by about half, and make the subsample data not fully compatible between 1998 and 2008 because of rural–urban migration. Morita and colleagues correctly point out that the Global Burden of Disease Study showed China can be divided into five areas, and suggest we consider this. However, besides the fact that the division of data would largely reduce the statistical power because of a much smaller sample size, there are wide disparities within each of the five areas, so we believe such analysis would be unhelpful. Adjustment for rural and urban residence plus education, although imperfect, cap tures most socioeconomic disparities. We disagree with Li and Harmer’s comment that our ascribing of greater longevity or lower mortality among the oldest-old to benefits of success is “problematic because no valid measure of health status exists for this population”. The standard activities of daily living and objective tests of physical performance and cognitive function are valid measures of health status strongly associated with survival. We believe Li and Harmer’s com ment that “the costs of success hypothesis might not be tenable because of the lack of key measures, such as non-communicable disease” is invalid, because: the costs of success is an interpretation of the decline in average scores of physical performance and cognitive function as the survival of more frail, elderly individuals with health problems, rather than a hypothesis to be tested; and, a lack of non-communicable disease data does not prevent analysis of changes in the health status of physical and cognitive abilities.
We agree with Morita and colleagues that “the information about family members who support an oldest-old individual is of concern”; however, we did adjust for marital status (ie, living with or without spouse), and thus the effects of family member support are controlled for, to some extent. Additionally, some studies indicate elderly-only households can increase risk of dementia and disability,2,3 whereas others show that elderly people who live alone might be selectively in better health because of different context and motivations.4
DN6/Fotolia
individual is of concern. In China, the One-Child Policy (launched in 1979) has resulted in an increase in the number of elderly-only households. Among those aged 65 years or older, 29% of men and 24% of women lived either alone or only with their spouse in 1990, as compared with 37% of men and 30% of women in 2000.3 The increase in solitary or elderly-only households can result in an increase in the prevalence of dementia and disability in activities of daily living.4,5 The change in household structure might have affected the health out comes among the elderly.
We declare no competing interests.
*Yi Zeng, Qiushi Feng, Therese Hesketh, Kaare Christensen, James W Vaupel [email protected] Center for the Study of Aging and Human Development, Medical School of Duke University, Durham, NC, 27710, USA (YZ); Center for Healthy Aging and Development Studies, National School of Development, Raissun Institute for Advanced Studies, Peking University, Beijing, China (YZ); Department of Sociology, Centre for Family and Population Research, National University of Singapore, Singapore (QF); Institute for Global Health, University College London, London, UK (TH); Institute for Global Health, School of Public Health, Zhejiang University, Zhejiang Sheng, China (TH); Danish Aging Research Centre, Unit of Epidemiology, Biostatistics and Biodemography, Institute of Public Health, University of Southern Denmark, Odense, Denmark (KC); and Max Planck Institute for Demographic Research, Rostock, Germany (JWV) 1
2 3 4
Zeng Y, Feng Q, Hesketh T, Christensen K, Vaupel JW. Survival, disabilities in activities of daily living, and physical and cognitive functioning among the oldest-old in China: a cohort study. Lancet 2017; 389: 1619–29. Li LW, Zhang J, Liang J. Health among the oldestold in China: which living arrangements make a difference? Soc Sci Med 2009; 68: 220–27. Schulz R, Sherwood PR. Physical and mental health effects of family caregiving. Am J Nurs 2008; 108: 23–27. Yeung, WJ, Cheung AK. Living alone: One-person households in Asia. Demographic Res 2015; 32: 1099–112.
Improving post-surgical management of resected pancreatic cancer We read with interest the results of the ESPAC-4 trial and congratulate John Neoptolemos and colleagues 847