OBJECTIVE: To systematically review U.S. studies examining the relationship between literacy and health in the elderly, and to determine what interventions may mitigate the effects of low literacy on health in an older population. METHODS: I searched the MEDLINE database from its beginning through September, 2009 and identified 676 health-related articles that referred to the term literacy and studied adults age 65 and older. After reviewing titles and abstracts, I further excluded 433 articles. Of the remaining 243 articles that were reviewed in their entirety, only 29 articles met my pre-specified inclusion/exclusion criteria and were included in this review. I included cross-sectional and cohort observational studies that measured participant literacy on an individual level, and measured one or more health outcomes in older adults. Each included study had to address at least one of my key questions: Key Question 1) In elderly individuals, are literacy skills related to a) use of health care services, b) health outcomes, c) health-related knowledge, d) costs of health care, or e) disparities by race, ethnicity, culture, education, or age? Key Question 2) For elderly individuals with low literacy skills, what interventions may mitigate the effects of low literacy on: a) use of health care services, b) health outcomes, c) health-related knowledge, d) costs of care, ore) disparities by race, ethnicity, culture, education, or age? RESULTS: The 29 articles in this review include data on 14,891 distinct individuals. All of the studies addressed Key Question 1. I was unable to identify any studies that addressed Key Question 2. Substantial evidence demonstrated that elderly individuals with lower literacy often have worse health outcomes than their counterparts with higher literacy, including lower rates of influenza vaccination, higher rates of ER use and hospitalization, worse self-rated health, higher rates of cognitive impairment and decline, and higher mortality. Despite clear associations between literacy and health in older adults, no researchers have tested interventions designed to mitigate the health effects of low literacy in an elderly population. The instruments most commonly used to measure literacy in this body of literature were the S-TOFHLA and the REALM. The average methodological quality of included studies was fair to good. DISCUSSION: This systematic review demonstrates that elderly individuals with lower literacy often have worse health outcomes than those with higher health literacy. It also identifies a critical gap in the health literacy literature: no interventions designed to mitigate the effects of literacy on health have been tested in an elderly population. It is crucial for clinicians and researchers to recognize the burden of limited health literacy in the elderly population and begin to test interventions that can improve the health of older adults with limited literacy.Master of Public Healt
