The number of elderly adults continues to increase as does the need for them to lead lives in good mental and physical condition. Although “positive mental attitude,” “psychological well-being,” “life satisfaction,” and “happiness” are vague concepts, emerging research suggests that they are associated with better health outcomes [
Studies of mental attitude and long-term health (including mortality) in the elderly are limited by sample size and length of follow-up. Four prospective cohort studies of all-cause mortality in the elderly have included more than 10,000 participants [
In 1981, we undertook a prospective cohort study of nearly 14,000 elderly women and men in a California retirement community with the aim of studying factors associated with longevity and successful aging. We report here the results of positive mental attitude (seven items from the Zung self-rating depression scale [
The Leisure World Cohort Study was established in the early 1980s when 13,978 residents (8,877 women and 5,101 men) of a California retirement community (Leisure World Laguna Hills) completed a postal health survey. Recruitment procedures have been previously described [
This study was approved by the Institutional Review Boards of the University of Southern California and the University of California, Irvine.
The survey included only the seven positively worded items from the 20-item Zung self-rating depression scale [
Attitude questions from the Zung self-rated depression scale in the Leisure World Cohort Study, 1980s,
Attitude statement | No response | None or a little of the time (1) | Some of the time (2) | A good part of the time (3) | Most or all of the time (4) |
---|---|---|---|---|---|
|
|
|
|
| |
My mind is as clear as it used to be | 104 (0.8%) | 233 (1.7%) | 823 (6.0%) | 3139 (23%) | 9375 (69%) |
I find it easy to do the things I used to do | 156 (1.1%) | 969 (7.1%) | 3080 (23%) | 5214 (38%) | 4255 (31%) |
I feel hopeful about the future | 263 (1.9%) | 530 (3.9%) | 1438 (11%) | 3170 (23%) | 8273 (61%) |
I find it easy to make decisions | 124 (0.9%) | 444 (3.2%) | 1596 (12%) | 4198 (31%) | 7312 (53%) |
I feel that I am useful and needed | 178 (1.3%) | 594 (4.3%) | 1573 (12%) | 2895 (21%) | 8434 (62%) |
My life is pretty full | 157 (1.1%) | 540 (3.9%) | 1321 (9.7%) | 3286 (24%) | 8370 (61%) |
I still enjoy the things I used to | 120 (0.9%) | 514 (3.8%) | 1662 (12%) | 3374 (25%) | 8004 (59%) |
Quarters of total attitude (sum of scores for the above seven items) | Q1 7–20 | Q2 21–24 | Q3 25–26 | Q4 27–28 | |
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All persons: those with no response on any of the seven items included in no response category | 657 (4.8%) | 2646 (19%) | 3421 (25%) | 2757 (20%) | 4193 (31%) |
All persons: if no response on any item that response recoded as 1 = “none or a little of the time” | 3057 (22%) | 3633 (27%) | 2791 (20%) | 4193 (31%) | |
All persons: if no response on any item that response recoded as 4 = “most or all of the time” | 2789 (20%) | 3617 (26%) | 2917 (21%) | 4357 (32%) |
Several factors asked on the same survey with the mental attitude variables were previously found to be related to mortality in this cohort. We included these in analyses as potential confounders.
Differences between women and men were tested using
After excluding 89 subjects with missing information on all seven attitude items and an additional 215 with missing information on potential confounding variables, data on 8682 women and 4992 men were analyzed. At study entry, the participants ranged in age from 44 to 101 years (median, 74 years). By December 31, 2016, 13,405 (98%) had died at ages 59 to 110 years (median, 88 years).
Table
Table
Baseline characteristics in the Leisure World Cohort Study, 1980s.
Characteristic | Total ( |
Men ( |
Women ( |
---|---|---|---|
Mean ± SD | |||
Age at baseline, years | 73.6 ± 7.3 | 74.3 ± 7.2 | 73.2 ± 7.4 |
Age at last follow-up, years | 87.6 ± 7.4 | 86.1 ± 7.1 | 88.5 ± 7.4 |
Follow-up years | 14.0 ± 8.3 | 11.7 ± 7.7 | 15.3 ± 8.3 |
Body mass index, kg/m2 | 23.5 ± 3.3 | 24.2 ± 2.9 | 23.1 ± 3.4 |
Exercise, hours/day | 1.0 ± 1.2 | 1.1 ± 1.3 | 0.9 ± 1.1 |
Alcohol, drinks/day | 1.4 ± 1.4 | 1.6 ± 1.5 | 1.2 ± 1.2 |
Caffeine, mg/day | 171 ± 168 | 176 ± 172 | 168 ± 166 |
| |||
History of disease | |||
High blood pressure | 5335 (39%) | 1803 (36%) | 3532 (41%) |
Angina | 1547 (11%) | 728 (15%) | 819 (9.4%) |
Heart attack | 1396 (10%) | 828 (17%) | 568 (6.5%) |
Stroke | 670 (4.9%) | 351 (7.0%) | 319 (3.7%) |
Cancer | 1593 (12%) | 467 (9.4%) | 1126 (13%) |
Diabetes | 841 (6.2%) | 414 (8.3%) | 427 (4.9%) |
Rheumatoid arthritis | 807 (5.9%) | 220 (4.4%) | 587 (6.8%) |
Cigarette use | |||
Never | 6436 (47%) | 1664 (33%) | 4772 (55%) |
Past | 5724 (42%) | 2900 (58%) | 2824 (33%) |
Current | 1514 (11%) | 428 (8.6%) | 1086 (12%) |
Total attitude | |||
Missing response | 657 (4.8%) | 207 (4.1%) | 450 (5.2%) |
7–20 | 2646 (19%) | 995 (20%) | 1651 (19%) |
21–24 | 3421 (25%) | 1286 (26%) | 2135 (25%) |
25–26 | 2757 (20%) | 1051 (21%) | 1706 (20%) |
27–28 | 4193 (31%) | 1453 (29%) | 2740 (32%) |
Alive at follow-up | 269 (2.0%) | 44 (0.9%) | 225 (2.6%) |
Abbreviation: SD, standard deviation.
HRs of mortality for the seven individual attitude items and for the total attitude score are shown in Table
Attitude and hazard ratio of death among women: the Leisure World Cohort Study, 1981–2016.
All subjects ( |
Excluding first five years of follow-up ( |
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---|---|---|---|---|---|---|---|---|---|---|---|---|
No. subjects† | No. deaths | Model 1a | Model 2b | No. subjects† | No. deaths | Model 1a | Model 2b | |||||
HR | 95% CI | HR | 95% CI | HR | 95% CI | HR | 95% CI | |||||
My mind is as clear as it used to be | ||||||||||||
None or little of the time | 124 | 121 | 1.43 | 1.20, 1.72 | 1.28 | 1.07, 1.54 | 78 | 75 | 1.14 | 0.91, 1.43 | 1.02 | 0.81, 1.29 |
Some of the time | 495 | 491 | 1.39 | 1.27 1.52 | 1.27 | 1.16, 1.40 | 406 | 402 | 1.43 | 1.30, 1.59 | 1.33 | 1.20, 1.47 |
A good part of the time | 1937 | 1901 | 1.09 | 1.03, 1.15 | 1.07 | 1.01, 1.12 | 1716 | 1680 | 1.09 | 1.03, 1.15 | 1.07 | 1.01, 1.13 |
Most or all of the time | 6048 | 5866 | 1.00 | 1.00 | 5558 | 5366 | 1.00 | 1.00 | ||||
|
||||||||||||
I find it easy to do the things I used to do | ||||||||||||
None or little of the time | 544 | 539 | 1.65 | 1.51, 1.82 | 1.39 | 1.26, 1.53 | 373 | 368 | 1.54 | 1.38, 1.72 | 1.30 | 1.16, 1.46 |
Some of the time | 1920 | 1898 | 1.29 | 1.22, 1.37 | 1.18 | 1.11, 1.26 | 1635 | 1613 | 1.30 | 1.22, 1.38 | 1.18 | 1.11, 1.26 |
A good part of the time | 3283 | 3214 | 1.03 | 0.98, 1.09 | 0.99 | 0.94, 1.04 | 3072 | 3003 | 1.05 | 0.99, 1.11 | 1.01 | 0.95, 1.06 |
Most or all of the time | 2826 | 2697 | 1.00 | 1.00 | 2664 | 2535 | 1.00 | 1.00 | ||||
|
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I feel hopeful about the future | ||||||||||||
None or little of the time | 331 | 328 | 1.53 | 1.36, 1.71 | 1.34 | 1.20, 1.50 | 242 | 239 | 1.46 | 1.28, 1.66 | 1.29 | 1.13, 1.47 |
Some of the time | 924 | 911 | 1.25 | 1.16, 1.34 | 1.16 | 1.08, 1.24 | 785 | 772 | 1.22 | 1.13, 1.31 | 1.13 | 1.05, 1.22 |
A good part of the time | 1973 | 1941 | 1.09 | 1.04, 1.15 | 1.07 | 1.02, 1.13 | 1767 | 1735 | 1.08 | 1.02, 1.14 | 1.07 | 1.01, 1.13 |
Most or all of the time | 5275 | 5099 | 1.00 | 1.00 | 4885 | 4709 | 1.00 | 1.00 | ||||
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I find it easy to make decisions | ||||||||||||
None or little of the time | 289 | 282 | 1.18 | 1.05, 1.33 | 1.10 | 0.97, 1.24 | 213 | 206 | 1.09 | 0.95, 1.26 | 1.04 | 0.90, 1.19 |
Some of the time | 1101 | 1080 | 1.10 | 1.03, 1.17 | 1.05 | 0.99, 1.13 | 967 | 946 | 1.11 | 1.03, 1.18 | 1.07 | 0.99, 1.14 |
A good part of the time | 2698 | 2642 | 0.96 | 0.92, 1.01 | 0.96 | 0.91, 1.01 | 2451 | 2395 | 0.97 | 0.92, 1.02 | 0.96 | 0.91, 1.01 |
Most or all of the time | 4509 | 4370 | 1.00 | 1.00 | 4125 | 3986 | 1.00 | 1.00 | ||||
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I feel that I am useful and needed | ||||||||||||
None or little of the time | 412 | 406 | 1.28 | 1.16, 1.42 | 1.14 | 1.03, 1.26 | 305 | 299 | 1.21 | 1.08, 1.36 | 1.09 | 0.97, 1.22 |
Some of the time | 1038 | 1027 | 1.24 | 1.16, 1.33 | 1.16 | 1.09, 1.24 | 876 | 865 | 1.21 | 1.13, 1.31 | 1.14 | 1.06, 1.23 |
A good part of the time | 1750 | 1705 | 1.03 | 0.97, 1.08 | 1.02 | 0.96, 1.08 | 1581 | 1536 | 1.02 | 0.96, 1.08 | 1.01 | 0.95, 1.07 |
Most or all of the time | 5364 | 5203 | 1.00 | 1.00 | 4976 | 4815 | 1.00 | 1.00 | ||||
|
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My life is pretty full | ||||||||||||
None or little of the time | 316 | 310 | 1.58 | 1.41, 1.78 | 1.33 | 1.19, 1.50 | 228 | 222 | 1.45 | 1.26, 1.66 | 1.22 | 1.06, 1.40 |
Some of the time | 856 | 848 | 1.38 | 1.28, 1.48 | 1.25 | 1.16, 1.35 | 701 | 693 | 1.33 | 1.23, 1.44 | 1.21 | 1.12, 1.31 |
A good part of the time | 1996 | 1955 | 1.14 | 1.08, 1.20 | 1.09 | 1.03, 1.14 | 1788 | 1747 | 1.14 | 1.08, 1.20 | 1.09 | 1.03, 1.15 |
Most or all of the time | 5412 | 5242 | 1.00 | 1.00 | 5034 | 4864 | 1.00 | 1.00 | ||||
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||||||||||||
I still enjoy the things I used to | ||||||||||||
None or little of the time | 289 | 285 | 1.62 | 1.44, 1.82 | 1.39 | 1.23, 1.57 | 200 | 196 | 1.44 | 1.25, 1.67 | 1.27 | 1.10, 1.46 |
Some of the time | 990 | 973 | 1.29 | 1.20, 1.38 | 1.18 | 1.10, 1.26 | 820 | 803 | 1.27 | 1.18, 1.37 | 1.17 | 1.08, 1.26 |
A good part of the time | 2011 | 1978 | 1.07 | 1.02, 1.13 | 1.02 | 0.97, 1.08 | 1812 | 1779 | 1.07 | 1.01, 1.13 | 1.02 | 0.97, 1.08 |
Most or all of the time | 5304 | 5133 | 1.00 | 1.00 | 4925 | 4754 | 1.00 | 1.00 | ||||
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Attitude score (persons with missing items excluded) | ||||||||||||
<21 | 1651 | 1632 | 1.38 | 1.29, 1.46 | 1.24 | 1.16, 1.32 | 1354 | 1335 | 1.35 | 1.26, 1.44 | 1.22 | 1.14, 1.31 |
21–24 | 2135 | 2092 | 1.12 | 1.05, 1.18 | 1.07 | 1.01, 1.13 | 1927 | 1883 | 1.11 | 1.05, 1.18 | 1.06 | 1.00, 1.13 |
25-26 | 1706 | 1662 | 1.02 | 0.96, 1.09 | 0.99 | 0.94, 1.06 | 1589 | 1543 | 1.03 | 0.96, 1.10 | 1.00 | 0.94, 1.07 |
27-28 | 2740 | 2625 | 1.00 | 1.00 | 2592 | 2472 | 1.00 | 1.00 | ||||
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Attitude score (missing items given score of 1) | ||||||||||||
<21 | 1925 | 1904 | 1.37 | 1.29, 1.45 | 1.23 | 1.16, 1.31 | 1561 | 1540 | 1.34 | 1.26, 1.43 | 1.22 | 1.14, 1.30 |
21–24 | 2289 | 2244 | 1.12 | 1.06, 1.19 | 1.06 | 1.00, 1.13 | 2067 | 2021 | 1.12 | 1.06, 1.19 | 1.07 | 1.01, 1.13 |
25-26 | 1728 | 1684 | 1.02 | 0.96, 1.09 | 1.00 | 0.94, 1.06 | 1608 | 1562 | 1.03 | 0.97, 1.10 | 1.00 | 0.94, 1.07 |
27-28 | 2740 | 2625 | 1.00 | 1.00 | 2592 | 2472 | 1.00 | 1.00 | ||||
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Attitude score (missing items given score of 4) | ||||||||||||
<21 | 1741 | 1721 | 1.38 | 1.30, 1.47 | 1.24 | 1.17, 1.32 | 1418 | 1397 | 1.34 | 1.26, 1.44 | 1.22 | 1.14, 1.30 |
21–24 | 2272 | 2227 | 1.12 | 1.06, 1.18 | 1.07 | 1.01, 1.13 | 2039 | 1994 | 1.11 | 1.05, 1.18 | 1.07 | 1.01, 1.13 |
25-26 | 1823 | 1779 | 1.04 | 0.98, 1.10 | 1.01 | 0.95, 1.07 | 1686 | 1642 | 1.04 | 0.97, 1.10 | 1.01 | 0.95, 1.08 |
27-28 | 2846 | 2730 | 1.00 | 1.00 | 2686 | 2570 | 1.00 | 1.00 |
Abbreviations: CI, confidence interval; HR, hazard ratio. †Subjects do not always total 8682 or 7828 due to those with missing values. aModel 1: adjusted for age (i.e., age as time scale). bModel 2: adjusted for age, smoking, body mass index, exercise, alcohol intake, caffeine consumption, and histories of hypertension, angina, heart attack, stroke, diabetes, rheumatoid arthritis, and cancer.
Attitude and hazard ratio of death among men: the Leisure World Cohort Study, 1981–2016.
All subjects ( |
Excluding first five years of follow-up ( |
|||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|
No. subjects† | No. deaths | Model 1a | Model 2b | No. subjects† | No. deaths | Model 1a | Model 2b | |||||
HR | 95% CI | HR | 95% CI | HR | 95% CI | HR | 95% CI | |||||
My mind is as clear as it used to be | ||||||||||||
None or little of the time | 109 | 109 | 1.55 | 1.27, 1.88 | 1.41 | 1.16, 1.71 | 55 | 55 | 1.38 | 1.06, 1.80 | 1.34 | 1.02, 1.75 |
Some of the time | 328 | 327 | 1.47 | 1.31, 1.65 | 1.31 | 1.17, 1.47 | 203 | 202 | 1.44 | 1.25, 1.66 | 1.30 | 1.13, 1.50 |
A good part of the time | 1202 | 1194 | 1.10 | 1.03, 1.17 | 1.06 | 0.99, 1.13 | 957 | 949 | 1.16 | 1.08, 1.25 | 1.13 | 1.05, 1.21 |
Most or all of the time | 3327 | 3292 | 1.00 | 1.00 | 2749 | 2713 | 1.00 | 1.00 | ||||
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I find it easy to do the things I used to do | ||||||||||||
None or little of the time | 425 | 425 | 2.02 | 1.81, 2.25 | 1.64 | 1.46, 1.83 | 205 | 205 | 1.76 | 1.52, 2.05 | 1.49 | 1.28, 1.73 |
Some of the time | 1160 | 1157 | 1.32 | 1.22, 1.42 | 1.19 | 1.10, 1.28 | 848 | 845 | 1.32 | 1.21, 1.44 | 1.20 | 1.10, 1.32 |
A good part of the time | 1931 | 1914 | 1.10 | 1.03, 1.18 | 1.05 | 0.98, 1.13 | 1645 | 1628 | 1.13 | 1.05, 1.22 | 1.09 | 1.01, 1.17 |
Most or all of the time | 1429 | 1405 | 1.00 | 1.00 | 1250 | 1225 | 1.00 | 1.00 | ||||
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I feel hopeful about the future | ||||||||||||
None or little of the time | 199 | 199 | 1.79 | 1.55, 2.07 | 1.51 | 1.31, 1.75 | 104 | 104 | 1.62 | 1.33, 1.98 | 1.46 | 1.20, 1.79 |
Some of the time | 514 | 512 | 1.31 | 1.19, 1.44 | 1.17 | 1.06, 1.29 | 353 | 351 | 1.23 | 1.10, 1.38 | 1.11 | 0.99, 1.24 |
A good part of the time | 1197 | 1188 | 1.04 | 0.98, 1.12 | 0.99 | 0.92, 1.06 | 953 | 944 | 1.04 | 0.96, 1.12 | 0.99 | 0.92, 1.07 |
Most or all of the time | 2998 | 2966 | 1.00 | 1.00 | 2520 | 2487 | 1.00 | 1.00 | ||||
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I find it easy to make decisions | ||||||||||||
None or little of the time | 155 | 155 | 1.90 | 1.62, 2.24 | 1.53 | 1.30, 1.80 | 71 | 71 | 1.83 | 1.44, 2.31 | 1.48 | 1.17, 1.89 |
Some of the time | 495 | 494 | 1.17 | 1.07, 1.29 | 1.10 | 1.00, 1.21 | 354 | 353 | 1.14 | 1.02, 1.27 | 1.07 | 0.96, 1.20 |
A good part of the time | 1500 | 1489 | 1.07 | 1.01, 1.14 | 1.03 | 0.96, 1.09 | 1207 | 1196 | 1.09 | 1.01, 1.17 | 1.04 | 0.97, 1.12 |
Most or all of the time | 2803 | 2771 | 1.00 | 1.00 | 2317 | 2284 | 1.00 | 1.00 | ||||
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I feel that I am useful and needed | ||||||||||||
None or little of the time | 182 | 181 | 1.83 | 1.57, 2.12 | 1.64 | 1.40, 1.90 | 88 | 87 | 1.53 | 1.23, 1.89 | 1.44 | 1.16, 1.78 |
Some of the time | 535 | 531 | 1.29 | 1.17, 1.41 | 1.14 | 1.04, 1.25 | 374 | 370 | 1.20 | 1.07, 1.33 | 1.06 | 0.95, 1.18 |
A good part of the time | 1145 | 1136 | 1.10 | 1.02, 1.17 | 1.08 | 1.01, 1.16 | 907 | 898 | 1.06 | 0.98, 1.14 | 1.05 | 0.97, 1.13 |
Most or all of the time | 3070 | 3041 | 1.00 | 1.00 | 2575 | 2546 | 1.00 | 1.00 | ||||
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My life is pretty full | ||||||||||||
None or little of the time | 224 | 223 | 1.89 | 1.64, 2.16 | 1.56 | 1.36, 1.80 | 111 | 110 | 1.59 | 1.31, 1.92 | 1.38 | 1.14, 1.68 |
Some of the time | 465 | 462 | 1.37 | 1.24, 1.51 | 1.20 | 1.09, 1.33 | 306 | 303 | 1.25 | 1.11, 1.41 | 1.10 | 0.97, 1.24 |
A good part of the time | 1290 | 1279 | 1.14 | 1.07, 1.22 | 1.06 | 0.99, 1.14 | 1022 | 1011 | 1.14 | 1.06, 1.23 | 1.07 | 1.00, 1.15 |
Most or all of the time | 2958 | 2929 | 1.00 | 1.00 | 2509 | 2480 | 1.00 | 1.00 | ||||
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I still enjoy the things I used to | ||||||||||||
None or little of the time | 225 | 225 | 2.23 | 1.95, 2.56 | 1.76 | 1.53, 2.03 | 86 | 86 | 1.86 | 1.50, 2.31 | 1.45 | 1.16, 1.81 |
Some of the time | 672 | 668 | 1.36 | 1.25, 1.48 | 1.20 | 1.10, 1.31 | 455 | 451 | 1.31 | 1.18, 1.45 | 1.18 | 1.06, 1.31 |
A good part of the time | 1363 | 1354 | 1.11 | 1.04, 1.19 | 1.05 | 0.99, 1.13 | 1116 | 1107 | 1.14 | 1.06, 1.22 | 1.08 | 1.00, 1.16 |
Most or all of the time | 2700 | 2669 | 1.00 | 1.00 | 2305 | 2274 | 1.00 | 1.00 | ||||
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Attitude score (persons with missing items excluded) | ||||||||||||
<21 | 995 | 993 | 1.54 | 1.42, 1.67 | 1.30 | 1.19, 1.41 | 631 | 629 | 1.43 | 1.30, 1.58 | 1.24 | 1.12, 1.37 |
21–24 | 1286 | 1273 | 1.16 | 1.08, 1.25 | 1.09 | 1.01, 1.18 | 1056 | 1043 | 1.19 | 1.10, 1.29 | 1.13 | 1.04, 1.23 |
25-26 | 1051 | 1041 | 1.13 | 1.04, 1.22 | 1.06 | 0.98 1.15 | 893 | 883 | 1.17 | 1.08, 1.28 | 1.12 | 1.02, 1.22 |
27-28 | 1453 | 1435 | 1.00 | 1.00 | 1270 | 1252 | 1.00 | 1.00 | ||||
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Attitude score (missing items given score of 1) | ||||||||||||
<21 | 1132 | 1130 | 1.55 | 1.43, 1.67 | 1.32 | 1.21, 1.43 | 706 | 704 | 1.43 | 1.31, 1.57 | 1.25 | 1.14, 1.38 |
21–24 | 1344 | 1330 | 1.15 | 1.07, 1.24 | 1.08 | 1.00, 1.16 | 1103 | 1089 | 1.18 | 1.09, 1.28 | 1.12 | 1.03, 1.22 |
25-26 | 1063 | 1053 | 1.13 | 1.04, 1.23 | 1.06 | 0.98, 1.15 | 901 | 891 | 1.18 | 1.08, 1.28 | 1.12 | 1.03, 1.22 |
27-28 | 1453 | 1435 | 1.00 | 1.00 | 1270 | 1252 | 1.00 | 1.00 | ||||
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Attitude score (missing items given score of 4) | ||||||||||||
<21 | 1048 | 1046 | 1.55 | 1.43, 1.67 | 1.31 | 1.21, 1.42 | 655 | 653 | 1.43 | 1.30, 1.57 | 1.24 | 1.13, 1.37 |
21–24 | 1345 | 1332 | 1.17 | 1.09, 1.26 | 1.10 | 1.02, 1.18 | 1092 | 1079 | 1.20 | 1.10, 1.30 | 1.13 | 1.04, 1.23 |
25-26 | 1094 | 1084 | 1.13 | 1.04, 1.22 | 1.06 | 0.98 1.14 | 924 | 914 | 1.17 | 1.08, 1.28 | 1.11 | 1.02, 1.21 |
27-28 | 1505 | 1486 | 1.00 | 1.00 | 1309 | 1290 | 1.00 | 1.00 |
Abbreviations: CI, confidence interval; HR, hazard ratio. †Subjects do not always total 4992 or 3980 due to those with missing values. aModel 1: adjusted for age (i.e., age as time scale). bModel 2: adjusted for age, smoking, body mass index, exercise, alcohol intake, caffeine consumption, and histories of hypertension, angina, heart attack, stroke, diabetes, rheumatoid arthritis, and cancer.
Attitude score and hazard ratios of death: the Leisure World Cohort Study, 1981–2016. Note: data shown are from analyses of total attitude score as quartile categories excluding persons with missing items. HRs and 95% confidence intervals derived from Cox regression analysis model 2, which adjusts for age (as the time scale), smoking, body mass index, exercise, alcohol intake, caffeine consumption, and histories of hypertension, angina, heart attack, stroke, diabetes, rheumatoid arthritis, and cancer.
The seven attitude items similarly showed a higher risk of death with increasing level of negative attitude. Adjustment for potential confounders resulted in modest attenuation of risks (less than 20%), and the HRs for poor mental attitude (responses of “none or little of the time” and “some of the time”) remained statistically significant for all items except “I find it easy to make decisions” in women. For all seven items, the HRs for the poorest mental attitude (response of “none or little of the time”) were larger in men than women (about 20% or more except for “My mind is clear as it used to be”). With elimination of the first five years of follow-up, the age-adjusted HRs for women changed by less than 10% for all items except “My mind is as clear as it used to be,” where the HR for the poorest mental attitude (response of “none or little of the time”) was reduced from 1.43 to 1.14. The multivariable-adjusted HRs showed smaller reductions, and the HRs for the poorest mental attitude (response of “none or a little of the time”) for three of the seven items (“mind is clear,” “easy to make decisions,” and “feel useful and needed”) were no longer statistically significant. For men with the elimination of the first five years of follow-up, the age-adjusted HRs for the poorest mental attitude (response of “none or a little of the time”) for all seven items were reduced 10–15% but remained statistically significant; the HRs for other response categories changed by less than 10%. The multivariable-adjusted HRs showed smaller reductions, and HRs for the poorest mental attitude remained statistically significant for all seven items.
We found modest increased risks of death with poor mental attitude that persisted after adjustment for potential confounders including disease history and lifestyle practices. The observed risks, especially for the most negative attitudes, were attenuated after eliminating the first five years of follow-up suggesting that diseases leading to early death might be the cause of some of the negativity. The associations found after adjustment and elimination of the first five years of follow-up may thus be more accurate from a perspective of a causal relationship. Although mental attitude is associated with lifestyle practices and disease states which are also related with mortality, a poor attitude appears to confer additional risk of death.
Those with a positive mental attitude or psychological well-being differ from those with a more negative outlook on a number of health processes—healthier lipid profile, lower levels of inflammatory markers, higher levels of serum antioxidants, better immune responses, and healthier autonomic function [
Previous prospective population-based studies have evaluated mental attitude and all-cause mortality in older population groups [
Prospective cohort studies of mental attitude and mortality in the elderly.
First author, date [reference] | Study name |
Number | Age (years) | Follow-up (years) | Sex | Mental attitude instrument | HR, 95% CI†Age- and sex-adjusted Most adjusted model |
---|---|---|---|---|---|---|---|
Gitlay, 2004 [ |
Arnhem Elderly Study |
999 | 65–85 | Mean = 9 | M,F | Scale of Subjective Well-Being for Older Persons | 0.55, 0.42–0.77 |
Pitkala, 2004 [ |
Helsinki Aging Study |
491 | 75, 80, 85 | 10 | M,F | 6 questions on positive life orientation | 0.67, 0.53–0.87‡ |
Tindle, 2009 [ |
Women’s Health Initiative |
97,253 | 50–79 | 8 | F | Life Orientation Test-Revised | — |
Koopmans, 2010 [ |
Arnhem Elderly Study |
861 | 65–85 | 15 | M,F | 2 “happiness” questions | 0.78, 0.64–0.95 |
Benito-Leon, 2010 [ |
Neurological Disorders in Central Spain | 2516 | 65+ | 7 | M,F | Philadelphia Geriatric Center Morale Scale | 1.60, 1.29–2.21‡ |
Tilvis, 2012 [ |
National Sample |
2490 | >75 | 5 | M,F | 6 questions on positive life orientation | 0.65, 0.53–0.81 |
Niklasson, 2015 [ |
GERDA |
646 | 85+ | 5 | M,F | Philadelphia Geriatric Center Morale Scale | 1.73, 1.33–2.26 |
St John, 2015 [ |
Manitoba Study of Health and Aging, Canada | 1751 | 65+ | 5 | M,F | Terrible-Delightful Scale | 0.75, 0.66–0.86 |
Steptoe, 2015 [ |
English Longitudinal Study of Aging | 9050 | Mean = 65 | Mean = 8 | M,F | Eudemonic well-being | 0.42, 0.36–0.49 |
Anthony, 2016 [ |
Rancho Bernardo Study |
876 | 50+ | < = 12 mean = 8 | M,F | Life Orientation Test-Revised | 0.98, 0.94–1.02 |
Gong, 2016 [ |
Chinese Longitudinal Healthy Longevity Survey | 18,676 | 80–122 | 16 | M,F | 7 items on psychological well-being | — |
Liu, 2016 [ |
Million Women Study |
719,671 | 50–69 | 10 | F | “How often do you feel happy?” | 1.29, 1.25–1.33 |
Kim, 2017 [ |
Nurses’ Health Study |
70,021 | Mean = 70 | 6 | F | Life Orientation Test-Revised | 0.71, 0.66–0.76∗ |
Okely, 2018 [ |
Survey of Health Aging and Retirement in Europe | 13,596 | 50+ | ∼12 | M,F | CASP-12 | 0.41, 0.38–0.43 |
†HR for high vs. low category of positive mental attitude, except for Benito-Leon, Niklasson, and Liu studies which compared low vs. high category. ‡Unadjusted HR. ∗Adjusted for additional demographic factors as well.
As in previous studies, risk of death was attenuated after adjustment of health conditions and lifestyle factors associated with both mental attitude and survival. To reduce concerns that recent changes in mental attitude may be due to underlying illness, we analyzed the data excluding participants who died within five years of study baseline. Likewise, early deaths were eliminated in the Nurses’ Health Study (within two years) [
Although some studies have evaluated the association of the Zung self-rating depression scale with mortality [
Several strengths and limitations of this study must be considered. Our data on mental attitude were self-reported using a mailed questionnaire. The seven items included in our survey were extracted from the Zung self-rating depression scale, but we did not ask the other 13 items. Thus, we are not able to compare our results with studies reporting the full Zung scale. Similar to other studies, we previously found our mental attitude score to be related to suicide in the first five years of follow-up [
Our large cohort size allowed us to analyze men and women separately. We did this for comparison with other studies reporting sex-specific results [
Our study has the advantages of a prospective design, large size, long and essentially complete follow-up, and the capability to control for numerous potential confounding factors. Still our investigation is an observational study, not a randomized trial. It does, however, suggest that confounders account for only a portion of the associations between mental attitude and risk of death. However, residual confounding due to suboptimal variables or to unmeasured variables remain possibilities.
Results in this large elderly cohort with long follow-up are consistent with a modest relationship between mental attitude and long-term mortality. The development of interventions to foster a positive outlook may improve the personal and public health of the elderly and prolong life.
Body mass index
Confidence interval
Hazard ratio
Philadelphia Geriatric Center Morale Scale
Life Orientation Test-Revised
Relative risk.
The data used to support the findings of this study are available from the corresponding author upon request.
The authors declare that they have no conflicts of interest.
This work was supported by the National Institutes of Health under Grant nos. R01CA32197 and R01AG21055, Wyeth-Ayerst Laboratories, and the Earl Carrol Trust Fund.