Hindawi Journal of Aging Research Volume 2018, Article ID 2126368, 10 pages https://doi.org/10.1155/2018/2126368 Research Article PositiveMentalAttitudeAssociatedwithLower35-YearMortality: TheLeisure World Cohort Study 1 1,2,3 ´ 1,3,4 Annlia Paganini-Hill , Claudia H. Kawas, andMarıaM.Corrada 1Department of Neurology, School of Medicine, University of California, Irvine, California, USA 2Department of Neurobiology & Behavior, School of Biological Sciences, University of California, Irvine, California, USA 3Institute for Memory Impairments and Neurological Disorders, University of California, Irvine, California, USA 4Department of Epidemiology, School of Medicine, University of California, Irvine, California, USA Correspondence should be addressed to Annlia Paganini-Hill; annliahi@usc.edu Received 3 July 2018; Revised 22 October 2018; Accepted 25 October 2018; Published 25 November 2018 Academic Editor: Carmela R. Balistreri Copyright©2018AnnliaPaganini-Hilletal.)isisanopenaccessarticledistributedundertheCreativeCommonsAttribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Background. Although emerging research has suggested that “positive psychological well-being” is associated with better health outcomes, studies of long-term health and mortality in the elderly are limited. )is study assessed the relationship of mental attitude and mortality in older adults followed up for 35 years. Methods. In the 1980s, the Leisure World Cohort Study recruited residents of a California retirement community to a prospective cohort study of health promotion and disease prevention. Participants completed a postal survey including seven positively worded items from the Zung self-rating depression scale. Age- adjusted and multivariable-adjusted (for lifestyle behaviors and disease conditions) hazard ratios (HRs) for death were calculated using Cox regression for 8682 women and 4992 men (median age at entry, 74 years). During follow-up (1981–2016), 13,405 participants died (median age at death, 88 years). Results. In both women and men, HRs for death were significantly related to mental attitude with increasing risk with decreasing positive responses for total attitude and the seven individual items. )e multivariable-adjustedHR(95%CI)fordeathforindividualsinthelowestvs.highestquarteroftotalattitudewas1.24(1.16,1.32) for women and 1.30 (1.19, 1.41) for men. Some attenuation in the observed associations occurred after adjustment for potential confounders and after elimination of the first five years of follow-up. Conclusions. Our study suggests that persons with negative attitude have an increased risk of death even after many years of follow-up. Research into strategies to improve mental outlook may help improve the quantity as well as the quality of life. 1. Introduction and length of follow-up. Four prospective cohort studies of all-cause mortality in the elderly have included more than )enumberof elderly adults continues to increase as does 10,000 participants [10–13], and only one of these included the need for them to lead lives in good mental and physical both sexes [10]. Follow-up has been greater than 10 years in condition. Although “positive mental attitude,” “psycho- only three studies [10, 14, 15]. )us, little is known about logical well-being,” “life satisfaction,” and “happiness” are whether positive mental attitude has any predictive value in vague concepts, emerging research suggests that they are old age over a long-time span. associated with better health outcomes [1–5] while their In 1981, we undertook a prospective cohort study of opposites “negative mental attitude,” “life dissatisfaction,” nearly 14,000 elderly women and men in a California re- “pessimism,”and“depressionanddepressivesymptoms”are tirement community with the aim of studying factors as- associated with poorer outcomes [6–9]. sociated with longevity and successful aging. We report here Studies of mental attitude and long-term health (in- the results of positive mental attitude (seven items from the cluding mortality) in the elderly are limited by sample size Zungself-ratingdepressionscale[16])onall-causemortality 2 Journal of Aging Research with 35 years of follow-up. To determine whether mental time, someofthetime,agoodpartofthetime,mostorallof attitude is associated with mortality independently of the time” and were scored 1 through 4, respectively. A total known predictors of mortality, we adjusted for medical attitude score (7–28) was calculated by summing the seven history(hypertension,angina,heartattack,stroke,cancer, responses. A score of 7 indicates that the subject selected diabetes, and arthritis), body mass index, and lifestyle “none or a little of the time” as a response to all items and practices (smoking, alcohol consumption, caffeine intake, representsthepoorestpossiblementaloutlook.Ascoreof28 and exercise). In addition, the large size of our cohort indicatesthatallresponseswere“mostorallofthetime”and allowed us to analyze the two sexes separately. As those represents the most positive mental outlook. To account for withhealthproblemsmayhaveapoorermentalattitudein itemswithmissingresponses,wecalculatedthetotalattitude the time immediately preceding death, the elimination of score in three ways: (1) calculating the total score only for early deaths permitted us to determine the long-term participants without missing responses, (2) assigning effect of mental attitude. )us, our study adds to the a nonresponse item the lowest score of 1 and including it in existing knowledge on well-being and mortality in the thetotalattitudescore,and(3)assigninganonresponseitem aged. the highest score of 4 and including it in the total attitude score. For analyses of individual items, those with missing 2. Methods responses were excluded from the analyses. 2.1.ParticipantsandVitalStatus. )e Leisure WorldCohort 2.3. Potential Confounding Variables. Several factors asked Study was established in the early 1980s when 13,978 res- on the same survey with the mental attitude variables were idents (8,877 women and 5,101 men) of a California re- previously found to be related to mortality in this cohort. tirement community (Leisure World Laguna Hills) We included these in analyses as potential confounders. completed a postal health survey. Recruitment procedures Medical history was elicited in response to a question “Has have been previously described [17, 18]. Briefly, residents a doctor ever told you that you have any of these condi- were recruited in 4 waves: those who owned homes in tions?” Smoking refers to cigarette use [19]. We estimated Leisure World on June 1, 1981, and new residents who had daily caffeine intake by summing the frequency of con- movedintothecommunityandwerelivingthereonJune1, sumption of each beverage and chocolate multiplied by its 1982, June 1, 1983, and October 1, 1985. Recruitment average caffeine content (milligrams/standard unit) as 115, included mailing the survey with simultaneous advertise- 3, 50, 50, and 6 for regular coffee, decaffeinated coffee, tea, ments describing the study in the local community cola soft drinks, and chocolate, respectively [20]. Con- newspaper, second and third mailings to nonrespondents, sumption of alcoholic beverages was asked separately for and then telephoning nonrespondents (if a local phone wine, beer, and hard liquor and combined into number of number was listed). )e baseline survey asked for in- alcoholic drinks per day [21]. Body mass index (BMI) formation on demographic characteristics (sex, marital (weight (kilograms)/height2 (meters)) was calculated based status, height, and weight), basic medical history (high on self-reported height and weight at baseline and cate- blood pressure, heart attack, angina, stroke, diabetes, gorized according to federal guidelines: underweight rheumatoidarthritis, glaucoma,fractures,and cancer),and (<18.5), normal weight (18.5–24.9), overweight (25–29.9), several personal habits (smoking, alcohol consumption, and obese (30+) [22]. Exercise included active outdoor caffeine intake, vitamin supplement use, and physical ac- activities (e.g., swimming, biking, jogging, tennis, and tivity). )e Leisure World population and the cohort are vigorous walking) and active indoor activities predominantly Caucasian, well-educated, and upper- (e.g., exercising and dancing). )e time spent per day in middle class. Vital status of cohort members was de- active activities was calculated by summing the reported termined by periodic resurvey, annual mailings, search of times spent in active outdoor and active indoor activities death indexes, and ascertainment of death certificates. [23]. Previous reports present details of data collection Participants were followed to death or December, 31, 2016, [17–24]. whichever came first. To date, 25 cohort members have been lost to follow-up, including 5 who moved out of the country. 2.4. Statistical Analysis. Differences between women and )is study was approved by the Institutional Review men were tested using t-tests for continuous variables and Boards of the University of Southern California and the chi-squared tests for categorical variables. Hazard ratios University of California, Irvine. (HRs) for the association between mental attitude and mortality were calculated separately for women and men using Coxregression analysis [25] with age as the time scale. 2.2.MentalAttitudeVariables. )esurveyincludedonlythe Participants contributed person-years from age at baseline seven positively worded items from the 20-item Zung self- survey (delayed entry) to age at death or December 31, 2016, rating depression scale [16]; the other 13 items were not whichever occurred first. Total attitude (continuous and asked. Participants were asked to read the seven items quartile categories) as well as the seven individual itemswere (Table 1) and to indicate “how much of the time the analyzed as independent variables. )e reference category statement describes how you have been feeling during the for the HRs was “good mental attitude,” i.e., response of past week.” Possible responses were “none or a little of the “most or all of the time” for the seven individual items and Journal of Aging Research 3 Table 1: Attitude questions from the Zung self-rated depression scale in the Leisure World Cohort Study, 1980s, N � 13,674. Attitude statement No None or a little of Some of the Agood part Most or all of response the time (1) time (2) of the time (3) the time (4) N(%) N(%) N(%) N(%) N(%) Mymind 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%) Mylife 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%) Quartersoftotalattitude (sumofscoresfortheabove Q1 7–20 Q2 21–24 Q3 25–26 Q4 27–28 seven items) All persons: those with no response on any of the 657 (4.8%) 2646 (19%) 3421 (25%) 2757 (20%) 4193 (31%) seven items included in no response category All persons: if no response on any item that response 3057 (22%) 3633 (27%) 2791 (20%) 4193 (31%) recoded as 1 � “none or a little of the time” All persons: if no response on any item that response 2789 (20%) 3617 (26%) 2917 (21%) 4357 (32%) recoded as 4 � “most or all of the time” a total attitude score of 27-28. To control for potential Table 2 gives selected characteristics of the participants confounders, we performed analysis adjusting for factors by sex. Men were on average older than women at study previously found to be related to mortality in this cohort: entry(74vs.73years),andasmallerproportionwerealiveat smoking (never, past, and current), alcohol intake (0, ≤1, 2- the end of follow-up (0.9% vs. 2.7%). Men also had on 3, and 4+ drinks/day), caffeine (<50, 50–99, 100–199, average a greater BMI, exercised more, and consumed more 200–399,and400+mg/day),exercise(0,¼,½,¾-1¾,and2+ alcohol and caffeine than women, but a smaller proportion hour/day), BMI (underweight, normal, overweight, and never smoked. More men had a history of angina, heart obese), and histories (yes/no) of hypertension, angina, heart attack, stroke, and diabetes, while more women had high attack, stroke, diabetes, rheumatoid arthritis, and cancer blood pressure, cancer, and rheumatoid arthritis. Women [19–23]. To account for the possibility that recent disease were more likely to have a higher attitude score than men development may have altered attitude as well as be related (score ≥25: 52% vs. 50%). All differences were statistically to mortality, we repeated the analyses after excluding the significant (p<0.02). first five years of follow-up. We performed sensitivity an- HRsofmortalityfor the seven individual attitude items alyses to explore how results would change if the total at- and for the total attitude score are shown in Table 3 for titude score on the Zung scale was computed with missing women and in Table 4 for men. Analysis of total attitude itemsassignedtoeitherthelowestvalue(1�noneorlittleof score by quartiles showed higher mortality with lower thetime)oralternativelytothehighestvalue(4�allormost scores (more negative attitude) in both women and men of the time). Statistical analyses were performed using SAS (Figure 1). In the model fully adjusted for age and potential ® confounders, women with scores of <21 had 24% greater version9.4(SASInstituteInc.,Cary,NC).Alltestsweretwo- sided, and no adjustment in the p-values was made for risk of death and men had a 30% greater risk of death multiple comparisons. compared with persons with scores of 27-28; these risks were 22% and 24% after exclusion of the first five years of 3. Results follow-up including 854 deaths in women and 1102 deaths in men.Asacontinuousvariable,riskofdeathsignificantly After excluding 89 subjects with missing information on all increased 2% (women) and 4% (men) for each unit de- seven attitude items and an additional 215 with missing crease in the total attitude score. In sensitivity analyses that information on potential confounding variables, data on calculated the total score by assigning either the lowest 8682 women and 4992 men were analyzed. At study entry, value(1�noneorlittleofthetime)orthehighestvalue(4� the participants ranged in age from 44 to 101 years (median, all or most of the time) to the missing items, the results 74 years). By December 31, 2016, 13,405 (98%) had died at were very similar to those where individuals with missing ages 59 to 110 years (median, 88 years). items were excluded when computing the total score Table 1 presents the responses to the seven individual (Tables 3 and 4). attitude questions. While 13,017 (95%) participants an- )esevenattitude items similarly showed a higher risk sweredall seven questions, 443 did not answer one, 123 two, of death with increasing level of negative attitude. Ad- 28 three, 20 four, 9 five, and 34 six. )e distributions of justment for potential confounders resulted in modest responses differed among the seven statements. )e state- attenuation of risks (less than 20%), and the HRs for poor ment“IfinditeasytodothethingsIusedtodo”hadtheleast mental attitude (responses of “none or little of the time” numberof“mostorallofthetime”responses(31%)andfar and “some of the time”) remained statistically significant fewer than the other statements (53–69%). for all items except “I find it easy to make decisions” in 4 Journal of Aging Research Table 2: Baseline characteristics in the Leisure World Cohort Study, 1980s. Characteristic Total (N � 13,674) Men (N�4992) Women (N�8682) 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 2 14.0 ± 8.3 11.7 ± 7.7 15.3 ± 8.3 Body mass index, kg/m 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 N(%) 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. p<0.0001 for all differences between men and women except caffeine (p<0.009) and total attitude (p<0.0006). women.Forallsevenitems,theHRsforthepoorestmental )eobservedrisks,especiallyforthemostnegativeattitudes, attitude (response of “none or little of the time”) were were attenuated after eliminating the first five years of larger in men than women (about 20% or more except for follow-up suggesting that diseases leading to early death “Mymindisclearasitusedtobe”).Witheliminationofthe mightbethecauseofsomeofthenegativity.)eassociations first five years of follow-up, the age-adjusted HRs for foundafter adjustment and elimination of the first five years womenchangedbyless than 10% for all items except “My of follow-up may thus be more accurate from a perspective mind is as clear as it used to be,” where the HR for the of a causal relationship. Although mental attitude is asso- poorest mental attitude (response of “none or little of the ciated with lifestyle practices and disease states which are time”) was reduced from 1.43 to 1.14. )e multivariable- also related with mortality, a poor attitude appears to confer adjusted HRs showed smaller reductions, and the HRs for additional risk of death. the poorest mental attitude (response of “none or a little of )ose with a positive mental attitude or psychological the time”) for three of the seven items (“mind is clear,” well-beingdifferfromthosewithamorenegativeoutlookon “easy to make decisions,” and “feel useful and needed”) a number of health processes—healthier lipid profile, lower were no longer statistically significant. For men with the levels of inflammatory markers, higher levels of serum elimination of the first five years of follow-up, the age- antioxidants, better immune responses, and healthier au- adjusted HRs for the poorest mental attitude (response of tonomic function [26]—and on a number of healthier “none or a little of the time”) for all seven items were behaviors—increased physical activity, nonsmoking, reduced 10–15% but remained statistically significant; the healthier diets, and higher quality of sleep [27]. )ese may HRs for other response categories changed by less than partly serve as mechanisms for the association of mental 10%. )e multivariable-adjusted HRs showed smaller re- attitude with mortality. ductions, and HRs for the poorest mental attitude Previous prospective population-based studies have remained statistically significant for all seven items. evaluated mental attitude and all-cause mortality in older population groups [10–15, 28–35]. However, follow-up has 4. Discussion generally been less than 10 years, the cohort size less than 10,000, or the study has included only one sex. Table 5 Wefoundmodestincreasedrisksofdeathwithpoormental summarizes these studies. Similar to our study, all previous attitude that persisted after adjustment for potential con- studies except two [12, 28] found that persons with the most founders including disease history and lifestyle practices. positive attitude (measured in different ways) had the lowest Journal of Aging Research 5 Table 3: Attitude and hazard ratio of death among women: the Leisure World Cohort Study, 1981–2016. All subjects (N � 8682) Excluding first five years of follow-up (N � 7828) a Model 2b a Model 2b No. No. Model 1 No. No. Model 1 † † subjects deaths HR 95%CI HR 95%CI subjects deaths HR 95% CI HR 95%CI Mymind 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 Agood 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 Agood 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 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 Agood 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 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 Agood 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 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 Agood 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 Mylife 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 Agood 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 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 Agood 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 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 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 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 † a Abbreviations:CI,confidenceinterval;HR,hazardratio. Subjectsdonotalwaystotal8682or7828duetothosewithmissingvalues. Model1:adjustedforage (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. 6 Journal of Aging Research Table 4: Attitude and hazard ratio of death among men: the Leisure World Cohort Study, 1981–2016. All subjects (N � 4992) Excluding first five years of follow-up (N � 3980) No. No. Model 1a Model 2b No. No. Model 1a Model 2b † † subjects deaths HR 95%CI HR 95%CI subjects deaths HR 95% CI HR 95%CI Mymind 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 Agood 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 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 Agood 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 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 Agood 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 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 Agood 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 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 Agood 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 Mylife 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 Agood 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 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 Agood 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 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 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 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 hy- pertension, angina, heart attack, stroke, diabetes, rheumatoid arthritis, and cancer. Journal of Aging Research 7 Women Men All subjects Excluding 5 years All subjects Excluding 5 years 1.4 ale) c1.3 1.2 io (95% CI) (log s t1.1 d ra r aza H1.0 0.9 <21 <21 <21 <21 21–24 25–26 27–28 21–24 25–26 27–28 21–24 25–26 27–28 21–24 25–26 27–28 Attitude score Figure1:Attitudescoreandhazardratiosofdeath:theLeisureWorldCohortStudy,1981–2016.Note:datashownarefromanalysesoftotal 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. risk of death, and that the risk was attenuated after ad- easy to make decisions” (RR � 2.27), “My mind is as clear as justment of health conditions and lifestyle factors. An in- it used to be” (RR � 2.05), “I feel hopeful about the future” versedose-responserelationship(decreasedriskofmortality (RR � 1.67), and “I feel that I am useful and needed” (RR � withincreasinglevelsofpositivementalattitude)wasseenin 1.44). )e item “I still enjoy the things I used to do” (RR � both women and men and in studies conducted in diverse 1.35) was not related to mortality. In our older cohort, all countries (USA, Canada, England, the Netherlands, Spain, seven items were related to mortality. )at the individual Sweden, Finland, and China). items we used had a high predictive value of risk of death Asinpreviousstudies, risk of death was attenuated after indicates that refusing to answer any single question does adjustment of health conditions and lifestyle factors asso- not invalidate the use of the questionnaire nor does the use ciated with both mental attitude and survival. To reduce of the seven rather than the 20 items of the Zung scale. concerns that recent changes in mental attitude may be due Several strengths and limitations of this study must be to underlying illness, we analyzed the data excluding par- considered. Our data on mental attitude were self-reported ticipants who died within five years of study baseline. using a mailed questionnaire. )e seven items included in Likewise, early deaths were eliminated in the Nurses’ Health our survey were extracted from the Zung self-rating de- Study(withintwoyears)[11]andtheMillionWomenStudy pression scale, but we did not ask the other 13 items. )us, (within five years) [12] to reduce these concerns about re- wearenotabletocompareourresultswithstudiesreporting verse causality. However, mental attitude may alter the time the full Zung scale. Similar to other studies, we previously course of disease processes and influence health behaviors foundourmentalattitudescoretoberelatedtosuicideinthe directly, so the possibility of overadjustment exists and we first five years of follow-up [40]. However, conclusions maybeadjusting for the effect of intermediate factors in the regarding attitude are limited by the crudeness of mea- causal pathway. surement. Although assessing the true level of attitude is Although some studies have evaluated the association of difficult, self-reported rating is suitable for ranking of theZungself-ratingdepressionscalewithmortality[36–38], individuals. only those reporting results on the individual items can be Our large cohort size allowed us to analyze men and directly compared to our study. Takeida and colleagues women separately. We did this for comparison with other analyzed the Zung scale as a predictor of death in a Japanese studies reporting sex-specific results [11, 13, 30], because of cohort of 2,166 aged 60–74 years and followed five years differences between men and women on baseline charac- [39]. Ofthesevenitemsincludedinourstudy,theyfoundsix teristics and mortality rates, and due to the possibility of significantly related to mortality. )ose items and their differential response on attitude between men and women. relative risks (RR) were “I find it easy to do the things I used Chang and coworkers showed significant sex differences in to” (RR � 3.84), “My life is pretty full” (RR � 2.39), “I find it reporting of psychological outcomes with more women 8 Journal of Aging Research † model ‡ 14‡1 1 1 1∗ 1 factors CI 1. 1.8 1.08 1.80 1.04 1.021.03 1.331.0 95%sex-adjusted0.42–0.770.52–0.970.53–0.870.83–0.93—0.79–0.930.64–0.950.75–1.29–2.21.00–0.53–0.80.67–1.33–2.261.03–0.66–0.860.78–0.36–0.490.58–0.830.94–0.94–—0.79–0.881.25–0.94–0.66–0.760.85–0.970.38–0.430.53–0.6 HR,andadjusted1, 0.92,1.35, 0.98,1,1,1, demographic Most0.55,0.70.67,0.89,0.86,0.78,1.60,0.65,0.85,1.73,1.36,0.75,0.90,0.42,0.70,0.98,0.99,0.84,1.29,0.70.90.40.57, Age- additional for for life Center orientationCenterScale well-beinghappy?” est-Revised life est-Revisedfeelest-Revised∗Adjusted instrumentWell-BeingPersonspositiveTquestionsScaleScalewell-beingTyouT HR. on GeriatricpositiveGeriatric do CASP-12 attitudeSubjectiveOlderorientationMoraleonMorale psychological elderly. of questionsOrientation“happiness”errible-DelightfulEudemonicOrientationonoftenOrientation‡Unadjusted the Mental 6 Life 2 PhiladelphiaPhiladelphiaT Life Life Scale questions items“How in 6 7 category. F F F high mortalitySex M,F M,F M,F M,F M,F M,F M,F M,F M,F M,F M,F vs. low and (years)9 8 8 � 8 7 5 5 5 � 12 � 6 12 compared 10 15 � 16 10 ∼ attitude Mean Mean< mean which mental Follow-up of 85 65 70 studies (years) 80, 65+ 75 85+ 65+ � 50+ 122 � 50+ Liu studiesAge 65–8575, 50–7965–85 > Mean 80– 50–69Mean and cohort 1 1 16 1 1 1 Niklasson, 999 49 97,25386 25 2490 646 175 9050 876 18,67619,6770,0213,596 Number 7 Prospective in and Benito-Leon, 5: Study Study Health StudyHealthyStudy for able StudyInitiative FinlandofCanada StudyAgingEuropeexcept T name DisordersSpainSample Aging SurveyKingdom in ElderlyNetherlandsAgingFinlandHealthUSAElderlyNetherlandsFinlandGERDAandStudyLongitudinalofBernardoUSAWomenHealthUSAHealth StudyPopulation)e )e CentralNationalAging,Study LongitudinalLongevityUnitedofattitude, ArnhemHelsinki ArnhemNeurologicalSwedenManitobaandEnglishRanchoMillionNurses’Retirementmental Women’s Chinese Survey positive of [reference] 14] [29] 1] category [ 10 [3 [28] date [32] 13] 10 20 15 [33] [34] 15] low [30] [ 16 10] [ 20 [35] 20 [ 11] vs. 15 15 20 12] [ 2004 2004 2009 12 20 20 16 [ 17 18 author, 20 20 16 20 20 high indle, ilvis, John, 20 forwell. First Gitlay,Pitkala,TKoopmans,Benito-Leon,TNiklasson,StSteptoe,Anthony,Gong,Liu,Kim,Okely,†HRas Journal of Aging Research 9 reporting negative outcomes [41]. )is was also seen in [3] R. A. Burns, J. Byles, P. Mitchell, and K. J. Anstey, “Positive several of the prospective studies of attitude and mortality components of mental health provide significant protection [29, 31], but they did not report sex-specific HRs for death. against likelihood of falling in older women over a 13-year Differential reporting may help explain the lower HRs for period,” International Psychogeriatrics, vol. 24, no. 9, negative attitudes we observed in women compared with pp. 1419–1428, 2012. men. )e cohort reported here is elderly, white, and in the [4] C. R. Gale, C. Cooper, I. J. Deary, and A. Aihie Sayer, uppermiddlesocioeconomicstratum.)erefore,ourresults “Psychological well-being and incident frailty in men and may not be generalizable to other populations. women: the english longitudinal study of ageing,” Psycho- Our study has the advantages of a prospective design, logical Medicine, vol. 44, no. 4, pp. 697–706, 2014. large size, long and essentially complete follow-up, and the [5] J. C. Huffman, S. R. Legler, and J. K. Boehm, “Positive psy- capability to control for numerous potential confounding chologicalwell-beingandhealthinpatientswithheartdisease: a brief review,” Future Cardiology, vol.13, no. 5, pp. 443–450, factors. Still our investigation is an observational study, not 2017. a randomized trial. It does, however, suggest that con- [6] D. G. Blazer and C. F. Hybels, “What symptoms of depression founders account for only a portion of the associations predict mortality in community-dwelling elders?,” Journal of betweenmentalattitudeandriskofdeath.However,residual theAmericanGeriatricsSociety,vol.52,no.12,pp.2052–2056, confounding due to suboptimal variables or to unmeasured 2004. variables remain possibilities. [7] M. T. Pankalainen, T. V. Kerola, and J. J. Hintikka, “Pessi- mismandtherisk for coronary heart disease among middle- 5. Conclusions aged and older finnish men and women: a ten-year follow-up study,” BMC Cardiovascular Disorders, vol. 15, no. 1, p. 113, Results in this large elderly cohort with long follow-up are 2015. consistent with a modest relationship between mental at- [8] P. Saz and M. E. Dewey, “Depression, depressive symptoms titude and long-term mortality. )e development of in- and mortality in persons aged 65 and over living in the community: a systematic review of the literature,” In- terventions to foster a positive outlook may improve the ternational Journal of Geriatric Psychiatry, vol. 16, no. 6, personal and public health of the elderly and prolong life. pp. 622–630, 2001. [9] M. A. Whooley, W. S. Browner, and S. O. F. R. Grp, “As- Abbreviations sociation between depressive symptoms and mortality in older women,” Archives of Internal Medicine, vol.158, no.19, BMI: Body mass index pp. 2129–2135, 1998. CI: Confidence interval [10] E. Y. Gong, Y. C. Hua, and L. J. L. Yan, “Psychological HR: Hazard ratio wellbeing and all-cause mortality in the oldest old in China: PGCMS: Philadelphia Geriatric Center Morale Scale a longitudinal survey-based study,” 1e Lancet, vol. 388, LOT-R: Life Orientation Test-Revised p. S22, 2016. RR: Relative risk. [11] E. S. Kim, K. A. 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