Research Article| Volume 26, ISSUE 3, P364-374, March 2018

Download started.


Purpose in Life and Hospitalization for Ambulatory Care-Sensitive Conditions in Old Age


      • In older adults, higher sense of purpose in life was associated with lower odds of subsequent hospitalization.
      • The association of purpose with hospitalization was stronger for ambulatory care-sensitive conditions and was weaker after controlling for common chronic conditions.
      • Results suggest that higher level of purpose in life is associated with lower odds of subsequent hospitalization for ambulatory care-sensitive conditions.


      To test the hypothesis that higher level of purpose in life is associated with lower subsequent odds of hospitalization.


      Longitudinal cohort study.


      Participants' residences in the Chicago metropolitan area.


      A total of 805 older persons who completed uniform annual clinical evaluations.


      Participants annually completed a standard self-report measure of purpose in life, a component of well-being. Hospitalization data were obtained from Part A Medicare claims records. Based on previous research, ICD-9 codes were used to identify ambulatory care-sensitive conditions (ACSCs) for which hospitalization is potentially preventable. The relation of purpose (baseline and follow-up) to hospitalization was assessed in proportional odds mixed models.


      During a mean of 4.5 years of observation, there was a total of 2,043 hospitalizations (442 with a primary ACSC diagnosis; 1,322 with a secondary ACSC diagnosis; 279 with no ACSCs). In initial analyses, higher purpose at baseline and follow-up were each associated with lower odds of more hospitalizations involving ACSCs but not hospitalizations for non-ACSCs. Results were comparable when those with low cognitive function at baseline were excluded. Adjustment for chronic medical conditions and socioeconomic status reduced but did not eliminate the association of purpose with hospitalizations involving ACSCs.


      In old age, higher level of purpose in life is associated with lower odds of subsequent hospitalizations for ambulatory care–sensitive conditions.

      Key Words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to The American Journal of Geriatric Psychiatry
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Agency for Healthcare Research and Quality
        Facts and Figures 2008.
        (Healthcare cost and utilization project (Section 1); Rockville, MD. October; Available from)
        • Covinsky K.E.
        • Palmer R.M.
        • Fortinsky R.H.
        • et al.
        Loss of independence in activities of daily living in older adults hospitalized with medical illnesses: increased vulnerability with age.
        J Am Geriatr Soc. 2013; 51: 451-458
        • Gill T.M.
        • Allore H.G.
        • Holford T.R.
        • et al.
        Hospitalization, restricted activity, and the development of disability among older persons.
        JAMA. 2004; 292: 2115-2124
        • Gill T.M.
        • Allore H.G.
        • Gahbauer E.A.
        • et al.
        Change in disability after hospitalization or restricted activity in older persons.
        JAMA. 2010; 304: 1919-1928
        • Ehlenbach W.J.
        • Hough C.L.
        • Crane P.K.
        • et al.
        Association between acute care and critical illness hospitalization and cognitive function in older adults.
        JAMA. 2010; 303: 763-770
        • Wilson R.S.
        • Hebert L.E.
        • Dong X.
        • et al.
        Cognitive decline after hospitalization in a community population of older persons.
        Neurology. 2012; 78: 950-956
        • Gorina Y.
        • Pratt L.A.
        • Kramaro E.A.
        • et al.
        Hospitalization, readmission, and death experience of non-institutionalized Medicare fee-for-service beneficiaries aged 65 and older.
        (National health statistics reports; no. 84. Hyattsville, MD, National Center for Health Statistics; Available from)
        • Kubzansky L.D.
        • Kubzanisky P.E.
        • Maselko J.
        Optimism and pessimism in the context of health: bipolar opposites or separate construct?.
        Pers Soc Psychol Bull. 2004; 30: 943-956
        • Steptoe A.
        • Dockray S.
        • Wardle J.
        Positive affect and psychobiological processes relevant to health.
        J Pers. 2009; 77: 1474-1776
        • Ryff C.D.
        Happiness is everything, or is it? Explorations on the meaning of psychological well-being.
        J Pers Soc Psychol. 1989; 57: 1069-1081
        • Sone T.
        • Nakaya N.
        • Ohmori K.
        • et al.
        Sense of life worth living (Ikigai) and mortality in Japan: Ohsaki study.
        Psychosom Med. 2008; 70: 709-715
        • Boyle P.A.
        • Barnes L.L.
        • Buchman A.S.
        • et al.
        Purpose in life is associated with mortality among community-dwelling older persons.
        Psychosom Med. 2009; 71: 574-579
        • Ryff C.D.
        • Keyes C.L.
        The structure of psychological well-being revisted.
        J Pers Soc Psychol. 1995; 69: 719-727
        • Wood A.M.
        • Joseph S.
        The absence of positive psychological (eudemonic) well-being as a risk factor for depression: a ten year cohort study.
        J Affect Disord. 2010; 122: 213-217
        • Kim E.S.
        • Sun J.K.
        • Park N.
        • et al.
        Purpose in life and reduced incidence of self-reported stroke in older adults: the Health Retirement Study.
        J Psychosom Res. 2013; 74: 427-437
        • Yu L.
        • Boyle P.A.
        • Wilson R.S.
        • et al.
        Purpose in life and cerebral infarcts in community dwelling older persons.
        Stroke. 2015; 46: 1071-1076
        • Boyle P.A.
        • Buchman A.S.
        • Barnes L.L.
        • et al.
        Effect of a purpose in life on risk of incident Alzheimer disease and mild cognitive impairment in community-dwelling older persons.
        Arch Gen Psychiatry. 2010; 67: 304-310
        • Friedman E.M.
        • Ryff C.D.
        Living well with medical comorbidities: a biopsychosocial perspective.
        J Gerontol B Psychol Sci Soc Sci. 2012; 67: 535-544
        • Kim E.S.
        • Sun J.K.
        • Nansook P.
        • et al.
        Purpose in life and reduced risk of myocardial infarction among older U.S. adults with coronary heart disease: a two-year follow-up.
        J Behav Med. 2013; 36: 124-133
        • Wilson R.S.
        • Boyle P.A.
        • Segawa E.
        • et al.
        The influence of cognitive decline on well-being in old age.
        Psychol Aging. 2013; 28: 314-321
        • Kim E.S.
        • Strecher V.J.
        • Ryff C.D.
        Purpose in life and use preventive health care services.
        Proc Natl Acad Sci U S A. 2014; 111: 16331-16336
        • Wallihan D.B.
        • Stump T.E.
        • Callahan C.M.
        Accuracy of self-reported health services use and patterns of care among urban older adults.
        Med Care. 1999; 37: 662-670
        • O'Donnell C.J.
        • Glynn R.J.
        • Field T.S.
        • et al.
        Misclassification and under-reporting of acute myocardial infarction by elderly persons: implications for community-based observational studies and clinical trials.
        J Clin Epidemiol. 1999; 52: 745-751
        • Raina P.V.T.-R.
        • Wong M.
        • Woodward C.
        Agreement between self-reported and routinely collected health-care utilization data among seniors.
        Health Serv Res. 2002; 37: 751-774
        • Wolinsky F.D.
        • Jones M.P.
        • Ullrich F.
        • et al.
        The concordance of survey reports and Medicare claims in a nationally representative longitudinal cohort of older adults.
        Med Care. 2015; 52: 462-468
        • Wolinsky F.D.
        • Jones M.P.
        • Ullrich F.
        • et al.
        Cognitive function and the concordance between survey reports and Medicare claims in a nationally representative cohort of older adults.
        Med Care. 2015; 53: 455-462
        • Bennett D.A.
        • Schneider J.A.
        • Buchman A.S.
        • et al.
        The Rush Memory and Aging Project: study design and baseline characteristics of the study cohort.
        Neuroepidemiology. 2005; 25: 163-175
        • Bennett D.A.
        • Schneider J.A.
        • Buchman A.S.
        • et al.
        Overview and findings from the Rush Memory and Aging Project.
        Curr Alzheimer Res. 2012; 9: 646-663
        • Barnes L.L.
        • Wilson R.S.
        • Bienias J.L.
        • et al.
        Correlates of life space in a volunteer cohort of older adults.
        Exp Aging Res. 2007; 33: 77-93
        • Boyle P.A.
        • Buchman A.S.
        • Bennett D.A.
        Purpose in life is associated with a reduced risk of incident disability among community-dwelling older persons.
        Am J Geriatr Psychiatry. 2010; 18: 1093-1102
        • Bindman A.B.
        • Grumbach K.
        • Osmond D.
        • et al.
        Preventable hospitalizations and access to health care.
        JAMA. 1995; 274: 305-311
        • Oster A.
        • Bindman A.B.
        Emergency department visits for ambulatory care sensitive conditions: insights into preventable hospitalizations.
        Med Care. 2003; 41: 198-207
        • Phelan E.A.
        • Borson S.
        • Grothaus L.
        • et al.
        Association of incident dementia with hospitalizations.
        JAMA. 2012; 307: 165-172
        • McCall N.
        • Harlow J.
        • Dayhoff D.
        • et al.
        Rates of hospitalization for ambulatory care sensitive conditions in the Medicare+Choice population.
        Health Care Financ Rev. 2001; 22: 127-145
        • Wilson R.S.
        • Barnes L.L.
        • Bennett D.A.
        Assessment of lifetime participation in cognitively stimulating activities.
        J Clin Exp Neuropsychol. 2003; 25: 634-642
        • Wilson R.S.
        • Barnes L.L.
        • Krueger K.R.
        • et al.
        Early and late life cognitive activity and cognitive systems in old age.
        J Int Neuropsychol Soc. 2005; 11: 400-407
        • Wilson R.S.
        • Boyle P.A.
        • Yang J.
        • et al.
        Early life instruction in foreign language and music and incidence of mild cognitive impairment.
        Neuropsychology. 2015; 29: 292-302
        • Kohout F.J.
        • Berkman L.F.
        • Evans D.A.
        • et al.
        Two shorter forms of the CES-D depression symptoms index.
        J Aging Health. 1993; 5: 179-193
        • Radloff L.S.
        The CES-D scale: a self-report depression scale for research in the general population.
        Appl Psycholl Meas. 1977; 1: 385-401
        • Hadden W.C.
        • Rockswold P.D.
        Increasing differential mortality by educational attainment in adults in the United States.
        Int J Health Serv. 2008; 38: 47-61
        • Wilson R.S.
        • Scherr P.A.
        • Hoganson G.
        • et al.
        Early life socioeconomic status and late life risk of Alzheimer's disease.
        Neuroepidemiology. 2005; 25: 8-14
        • Capuano A.W.
        • Dawson J.D.
        The trend odds model for ordinal data.
        Stat Med. 2013; 32: 2250-2261
        • Kashdan T.B.
        • Nezlek J.B.
        Whether, when, and how is spirituality related to well-being? Moving beyond single occasion questionnaires to understanding daily process.
        Pers Soc Psychol Bull. 2012; 38: 1523-1535
        • Pinquart M.
        • Sorensen S.
        Influence of socioeconomic status, social network, and competence on subjective well-being in later life: a meta-analysis.
        Psychol Aging. 2000; 15: 187-224
        • Kim E.S.
        • Hershner S.D.
        • Strecher V.J.
        Purpose in life and incidence of sleep disturbances.
        J Behav Med. 2015; 38: 590-597
        • Ryff C.D.
        Self-realization and meaning making in the face of adversity: a eudaimonic approach to human resilience.
        J Psychol Afr. 2014; 24: 1-12
        • Moss A.S.
        • Reibel D.K.
        • Greeson J.M.
        • et al.
        An adaptive mindfulness-based stress reduction program for elders in a continuing care retirement community: quantitative and qualitative results from a pilot randomized controlled trial.
        J Appl Gerontol. 2015; 34: 518-538
        • Friedman E.M.
        • Ruini C.
        • Foy R.
        • et al.
        Lighten UP! A community-based group intervention to promote psychological well-being in older adults.
        Aging Ment Health. 2015; 13: 1-7
        • Cesetti G.
        • Vescovelli F.
        • Ruini C.
        The promotion of well-being in aging individuals living in nursing homes: a controlled pilot intervention with narrative strategies.
        Clin Gerontol. 2017; : 1-12
        • Heaven B.
        • Brown L.J.
        • White M.
        • et al.
        Supporting well-being in retirement through meaningful social roles: systematic review of intervention studies.
        Milbank Q. 2013; 9: 222-287
        • Frankl V.E.
        Man's Search for Meaning.
        Beacon Press, Boston, MA1959