The importance of education for understanding variability of dementia onset in the United States.

BACKGROUND: Greater levels of education are associated with lower risk of dementia, but less is known about how education is also associated with the compression of dementia incidence. OBJECTIVE: We extend the literature on morbidity compression by evaluating whether increased levels of education are associated with greater dementia compression. We evaluate these patterns across race and gender groups. METHODS: We use the Health and Retirement Study (2000-2016), a nationally representative longitudinal study of older adults in the United States. To evaluate the onset and compression of dementia across education groups, we examine the age-specific distribution of dementia events, identifying the modal age of onset and the standard deviation above the mode (a measure of compression). RESULTS: While the modal age of onset is around 85 years among adults with a college degree, the modal age for adults with less than a high school education occurs before age 65 - at least a 20-year difference. The standard deviation of dementia onset is about three times greater for adults with less than a high school education compared to adults with a college degree. Patterns were consistent across race and gender groups. CONCLUSION: This research highlights the variability of dementia experiences in the older population by documenting differences in longevity without dementia and compression of dementia onset among more educated adults and less educated adults. CONTRIBUTION: We incorporate conceptual insights from the life span variability and compression literature to better understand education-dementia disparities in both the postponement and uncertainty of dementia onset in the US population.

Racial/Ethnic differences in inflammation levels among older adults 56+: an examination of sociodemographic differences across inflammation measure.

OBJECTIVE: Chronic inflammation is a key biological risk factor for many widespread adult health conditions. This study examines racial/ethnic differences in inflammation across several inflammatory markers, including selected cytokines that are identified as important for aging and age-related health outcomes. METHODS: Data came from the 2016 Venous Blood Collection Subsample of the Health and Retirement Study. Using logistic regression models, we compared high-risk categories of C-reactive protein and cytokine markers (IL-6, IL-10, IL-1RA, TNFR1, and TGF-Beta), across race/ethnicity and whether these differences persisted among men and women. RESULTS: The findings provided evidence of significant race/ethnic differences in inflammatory measures, but the patterns differed across marker types. CONCLUSIONS: These findings emphasize that race/ethnic differences are not consistently captured across markers of inflammation and that researchers should proceed with caution when using individual markers of inflammation in an effort to not overlook potential racial/ethnic differences in biological risk.

The embodiment of parental death in early life through accelerated epigenetic aging: Implications for understanding how parental death before 18 shapes age-related health risk among older adults.

Parental death in early life has been linked to various adverse health outcomes in older adulthood. This study extends prior research to evaluate how parental death in early life is tied to accelerated epigenetic aging, a potentially important biological mechanism from which social and environmental exposures impact age-related health. We used data from the 2016 Venous Blood Study (VBS), a component of the Health and Retirement Study (HRS), to examine the association between parental death in early life and accelerated epigenetic aging as measured by three widely used epigenetic clocks (PCPhenoAge, PCGrimAge, and DunedinPACE). We also assessed whether some of the association is explained by differences in educational attainment, depressive symptoms, and smoking behavior. Methods included a series of linear regression models and formal mediation analysis. Findings indicated that parental death in early life is associated with accelerated epigenetic aging for PCPhenoAge and DunedinPACE. The inclusion of educational attainment, depressive symptoms, and smoking behavior attenuated this association, with formal mediation analysis providing additional support for these observations. Parental death in early life may be one of the most difficult experiences an individual may face. The elevated biological risk associated with parental death in early life may operate through immediate changes but also through more downstream risk factors. This study highlights how early life adversity can set in motion biological changes that have lifelong consequences.

State-level desegregation in the U.S. South and mid-life cognitive function among Black and White adults.

RATIONALE: Black adults experience worse cognitive function than their White peers. Although educational attainment is an important predictor of cognitive function, other aspects of education, including school desegregation, may also shape this relationship. For Black adults who grew up in the U.S. South in the 1950s-1970s, exposure to school desegregation may have altered life course pathways critical for later cognitive function. OBJECTIVE: We determined if state variation in exposure to school desegregation in the U.S. South was associated with cognitive function at mid-life, if the association varied by race, and if the association remained after adjustment for state-level education quality and respondents' educational attainment. METHODS: We linked historical data on state-level school desegregation to the Health and Retirement Study, a nationally representative sample of U.S. adults aged 50 and older. We restricted our sample to Black (n = 1443) and White (n = 1507) adults born between 1948 and 1963 who resided in the U.S. South during primary school. We assessed three cognition outcomes: total cognitive function, episodic memory, and mental status. We estimated race-stratified linear regression models with cluster adjustment and a final model using state fixed effects. RESULTS: Greater exposure to desegregated primary schooling was associated with higher cognitive function and episodic memory among Black but not White adults. Among Black adults, the association between school desegregation and cognitive function and episodic memory remained after adjustment for state-level education quality and educational attainment. CONCLUSIONS: Our findings suggest that state-level school desegregation efforts played a consequential role in shaping the cognitive function of Black adults who grew up in the U.S. South.

Anticipatory stress, state policy contexts, and mental health during the COVID-19 pandemic.

Substantial economic disruptions during the COVID-19 pandemic upended daily life and contributed to a widespread symptom of psychological distress during this period. Disruptions also led to more concerns about future stressful events related to financial hardship, or economic-related anticipatory stress, with the potential to undermine mental health. Although prior research provides ample evidence that state policies can impact mental and physical health, it has not considered how state policy contexts reduce adverse psychological outcomes stemming from economic-related anticipatory stress. The present study uses national survey data from the Census Bureau's Household Pulse Survey (April 2020-October 2020) to examine the extent to which state policy contexts moderate the association between economic-related anticipatory stress and depression/anxiety. We find that states with stronger social safety nets weakened the impact of anticipatory stress on depression/anxiety. This finding held for different types of anticipated economic hardships (i.e., reduced income, difficulty paying rent, difficulty affording food), as well as for policies that existed prior to COVID-19 and policies enacted in response to COVID-19. Findings provide strong evidence that state policies may buffer against poor mental outcomes for people who even anticipate facing economic uncertainty during the COVID-19 pandemic. We provide insight into how state policy contexts can shape individual experiences in ways that impact the mental health outcomes of the United States population.

Does adding MRI and CSF-based biomarkers improve cognitive status classification based on cognitive performance questionnaires?

BACKGROUND: Cognitive status classification (e.g. dementia, cognitive impairment without dementia, and normal) based on cognitive performance questionnaires has been widely used in population-based studies, providing insight into the population dynamics of dementia. However, researchers have raised concerns about the accuracy of cognitive assessments. MRI and CSF biomarkers may provide improved classification, but the potential improvement in classification in population-based studies is relatively unknown. METHODS: Data come from the Alzheimer's Disease Neuroimaging Initiative (ADNI). We examined whether the addition of MRI and CSF biomarkers improved cognitive status classification based on cognitive status questionnaires (MMSE). We estimated several multinomial logistic regression models with different combinations of MMSE and CSF/MRI biomarkers. Based on these models, we also predicted prevalence of each cognitive status category using a model with MMSE only and a model with MMSE + MRI + CSF measures and compared them to diagnosed prevalence. RESULTS: Our analysis showed a slight improvement in variance explained (pseudo-R2) between the model with MMSE only and the model including MMSE and MRI/CSF biomarkers; the pseudo-R2 increased from .401 to .445. Additionally, in evaluating differences in predicted prevalence for each cognitive status, we found a small improvement in the predicted prevalence of cognitively normal individuals between the MMSE only model and the model with MMSE and CSF/MRI biomarkers (3.1% improvement). We found no improvement in the correct prediction of dementia prevalence. CONCLUSION: MRI and CSF biomarkers, while important for understanding dementia pathology in clinical research, were not found to substantially improve cognitive status classification based on cognitive status performance, which may limit adoption in population-based surveys due to costs, training, and invasiveness associated with their collection.

Dynamic Changes in the Association Between Education and Health in the United States.

Policy Points We reviewed some of the recent advances in education and health, arguing that attention to social contextual factors and the dynamics of social and institutional change provide critical insights into the ways in which the association is embedded in institutional contexts. Based on our findings, we believe incorporating this perspective is fundamentally important to ameliorate current negative trends and inequality in Americans' health and longevity.

Changes in social lives and loneliness during COVID-19 among older adults: a closer look at the sociodemographic differences.

OBJECTIVES: The COVID-19 pandemic greatly impacted the social lives of older adults across several areas, leading to concern about an increase in loneliness. This study examines the associations of structural, functional, and quality aspects of social connection with increased loneliness during COVID-19 and how these associations vary by sociodemographic factors. DESIGN: Secondary data analyses on a nationally representative survey of older US adults. SETTING: The 2020 Health and Retirement Study (HRS) COVID-19 module. PARTICIPANTS: The study sample includes 3,804 adults aged 54 or older. MEASUREMENTS: Increased loneliness was based on respondents' self-report on whether they felt lonelier than before the COVID-19 outbreak. RESULTS: While 29% felt lonelier after COVID-19, middle-aged adults, women, non-Hispanic Whites, and the most educated were more likely to report increased loneliness. Not having enough in-person contact with people outside the household was associated with increased loneliness (OR = 10.07, p < .001). Receiving emotional support less frequently (OR = 2.28, p < .05) or more frequently (OR = 2.00, p < .001) than before was associated with increased loneliness. Worse quality of family relationships (OR = 1.85, p < .05) and worse friend/neighbor relationships (OR = 1.77, p < .01) were related to feeling lonelier. Significant interactions indicated stronger effects on loneliness of poor-quality family relationships for women and insufficient in-person contact with non-household people for the middle-aged group and non-Hispanic Whites. CONCLUSIONS: Our findings show an increase in loneliness during COVID-19 that was partly due to social mitigation efforts, and also uncover how sociodemographic groups were impacted differently, providing implications for recovery and support.

Racial/Ethnic Differences in Biological Aging and Their Life Course Socioeconomic Determinants: The 2016 Health and Retirement Study.

Objectives: This study examined differences in accelerated biological aging among non-Hispanic Blacks, Hispanics, and non-Hispanic Whites in the United States and assessed whether including life course socioeconomic conditions attenuated observed racial/ethnic differences. Methods: Data came from the Venous Blood Collection Subsample of the Health and Retirement Study. We used a comprehensive summary measure of biological age (BA-22). We determined whether key lifetime socioeconomic conditions contributed to racial/ethnic differences in biological aging. Results: Findings indicated that non-Hispanic Blacks and Hispanics have accelerated aging, and non-Hispanic Whites have decelerated aging. Racial/ethnic differences were strongly tied to educational attainment. We also observed a significant difference by birthplace for Hispanics. US-born Hispanics had accelerated biological aging, whereas foreign-born Hispanics did not. In age-stratified analyses, these racial/ethnic differences were found for adults aged 56-74, but not for adults aged 75+. Conclusions: These findings provide insight into biological differences underlying racial/ethnic disparities in health.

Depressive Symptoms Partially Mediate the Association of Frailty Phenotype Symptoms and Cognition for Females but Not Males.

OBJECTIVES: We aimed to evaluate whether depressive symptoms mediated the relationship between frailty phenotype and cognitive function by sex. METHODS: Data came from the Health and Retirement Study from 2012-2016. The outcome was measured by Fried's frailty criteria, our outcome was continuous global cognition, and mediator was depressive symptoms. We used mediation analysis, stratified by sex, to estimate the direct and indirect effects of frailty symptoms on cognition mediated by depressive symptoms. RESULTS: Males had a larger total effect (ß= -0.43; 95% CI: -0.66, -0.02) for lower cognitive score for each increase in frailty symptom compared to females (ß= -0.28; 95% CI: -0.47, -0.08). A significant indirect effect from frailty phenotype to cognition was found through depressive symptoms for females but not males. CONCLUSION: These results highlight the importance of identifying individuals with frailty and depressive symptoms to monitor and provide interventions to preserve cognitive function.

Race, gender, and cohort differences in the educational experiences of Black and White Americans.

Federal legislation and judicial intervention led to significant transformation in the U.S. education system during the early to mid-20th century. These changes may differentiate older adults in their experiences of aging, particularly at the intersection of race, gender, and cohort, but are not well documented among current cohorts of older adults. Our study addresses this gap by providing rich, descriptive information on the educational experiences of U.S. adults who attended primary or secondary school between 1915 and 1977. We used data from the Health and Retirement Study (HRS), a nationally representative, prospective study of U.S. adults over age 50 years. The HRS collected information on respondents' schooling history and experiences through a Life History Mail Survey (LHMS). We restricted our sample to age-eligible HRS-LHMS respondents who self-identified as non-Hispanic White or non-Hispanic Black and completed at least 75% of their primary or secondary schooling in the U.S. (n=10,632). Educational experiences, defined as pre-k to post-secondary education, varied across cohort, regardless of race or gender. Greater course offerings, improvements in learning support, and increasing exposure to integrated schools occurred across successive cohorts. We found the highest rates of enrollment in college preparatory curriculum and foreign-language courses as well as diagnosed learning differences in cohorts born after 1948. Among White adults, many of the gender differences in educational experiences documented in the oldest cohort were still found among the most recent cohort. Few gender differences, however, were found for Black adults regardless of cohort. Conversely, most race inequities in educational experiences persisted. Such inequities may be an important source of continued differences in experiences of aging observed across demographic groups.

Links between inflammation and immune functioning with cognitive status among older Americans in the Health and Retirement Study.

Elevated inflammation and poor immune functioning are tied to worse cognitive health. Both processes are fundamental to aging and are strongly implicated in the development of age-related health outcomes, including cognitive status. However, results from prior studies evaluating links between indicators of inflammation and immune function and cognitive impairment have been inconsistent due to biomarker selection, sample selection, and cognitive outcome. Using the Health and Retirement Study (HRS), a nationally representative study of older adults in the United States, we assessed how indicators of inflammation (neutrophil-lymphocyte ratio (NLR), albumin, CRP, IL6, IL10, IL-1Ra, sTNFR1, and TGFß1) and immune functioning (CMV, CD4+ TN/TM, and CD8+ TN/TM) are associated with cognitive status. First, to examine the association between each biomarker and cognitive status, we tested whether markers of inflammation and immune functioning varied across cognitive status categories. We found that dementia and cognitive impairment without dementia (CIND) were associated with elevated inflammation and poorer immune functioning across biomarkers except for CD4+ TN/TM. Next, we estimated multinomial logistic regression models to assess which biomarkers would continue to be associated with dementia and CIND, net of each other. In these models, albumin, cytokines, CMV, CD4+ TN/TM, and CD8+ TN/TM are associated with cognitive status. Because poor immune functioning and increased inflammation are associated with cognitive impairment, improving immune functioning and reducing inflammation may provide a mechanism for reducing ADRD risk in the population.

Sociodemographic and health status differences in delaying medical care during the COVID-19 pandemic among older adults: findings from the Health and Retirement Study.

BACKGROUND: During the COVID-19 Pandemic, adults in the United States reported delaying medical care, which may be tied risk of infection and local policies limiting appointment. Some populations may have been more likely to delay care than others, leading to other forms of health inequality during this period. To-date there is little research on delayed care among U.S. older adult. We determine the prevalence of delayed medical care among older adults and investigate sociodemographic and health status inequalities in delaying health care. METHOD: We used data from the first public release of the nationally representative Health and Retirement Study COVID-19 Subsample (N = 3006). Using logistic regression, we assessed whether differences in delaying health care varied by age, sex, race/ethnicity, education, self-rated health (SRH), and having any Activity of Daily Living (ADL) limitation. We also conducted additional analysis that evaluated differences in delaying care by two care subtypes: doctor and dental care visits. RESULTS: About 30% of U.S. older adults reported delaying care with the most common types of delayed care being dental or doctor visits. Adults ages 75 and older were less likely to delay care, while women, college educated, and those with poor SRH, and any ADL limitations were more likely to delay care. CONCLUSIONS: Nearly one-third of older adults delayed care during the COVID-19 pandemic. The increased likelihood of delayed care among people with worse health suggests that there may be longer-term impacts on the health care system and population health from the COVID-19 pandemic, and may contribute to health inequalities in the near future.

Race Inequity in School Attendance Across the Jim Crow South and Its Implications for Black-White Disparities in Trajectories of Cognitive Function Among Older Adults.

OBJECTIVES: Although education is a key determinant of cognitive function, its role in determining Black-White disparities in cognitive function is unclear. This may be due, in part, to data limitations that have made it difficult to account for systemic educational inequities in the Jim Crow South experienced by older cohorts, including differences in the number of days Black students attended school compared to their White counterparts or Black peers in better-funded southern states. We determine if accounting for differential rates of school attendance across race, years, and states in the Jim Crow South better illuminates Black-White disparities in trajectories of cognitive function. METHODS: We linked historical state-level data on school attendance from the 1919/1920 to 1953/1954 Biennial Surveys of Education to the Health and Retirement Study, a nationally representative, longitudinal study of U.S. adults older than age 50. We restricted our sample to Black and White older adults who attended school in the Jim Crow South and began primary school in/after 1919/1920 and completed primary/secondary school by 1953/1954 (n = 4,343). We used linear mixed models to estimate trajectories of total cognitive function, episodic memory, and working memory. RESULTS: Self-reported years of schooling explained 28%-33% of the Black-White disparity in level of cognitive function, episodic memory, and working memory. Duration of school, a measure that accounted for differential rates of school attendance, explained 41%-55% of the Black-White disparity in these outcomes. DISCUSSION: Our study highlights the importance of using a more refined measure of schooling for understanding the education-cognitive health relationship.

Trends in Dementia Prevalence, Incidence, and Mortality in the United States (2000-2016).

Objectives: The prevalence of dementia has declined in the United States; how this parallels to changes in incidence and mortality, and how improvements in educational attainment may have influences these trends, is not known. Methods: Using the Health and Retirement Study (2000-2016), we estimated logistic regression models to examine trends in dementia prevalence and incidence, and mortality for those with and without dementia. Results: The relative decline was about 2.4% per year for dementia prevalence and 1.9% for dementia incidence. Mortality declined similarly for those with and without dementia. Improved educational attainment accounted for decline in incidence, some of the decline in prevalence, and had a negligible role in mortality. Discussion: The declines in dementia incidence provide evidence that dementia prevalence should continue to decline in the near future. These declines are most likely largely driven by continued improvements in older adult education.

Inequality in Household Job Insecurity and Mental Health: Changes During the COVID-19 Pandemic.

Using nationally representative data from the Household Pulse Survey (April 2020-March 2021), we examined how associations between household job insecurity and mental health changed throughout the first year of the COVID-19 pandemic in the United States (n = 1,248,043). We also documented changes in the unequal distribution of job insecurity by race/ethnicity and educational attainment over time. We find that job insecurity was strongly associated with depression and anxiety throughout the study period, and the associations strengthened as the pandemic continued, especially in fall 2020. Moreover, racial/ethnic minorities with lower levels of educational attainment had the greatest risk of job insecurity, and educational disparities in job insecurity changed over time. Psychological distress during the pandemic, including disparities therein, must be considered a public health priority.

COVID-19 Social Distancing Measures and Loneliness Among Older Adults.

OBJECTIVES: In response to the coronavirus disease 2019 (COVID-19) pandemic, older adults are advised to follow social distancing measures to prevent infection. However, such measures may increase the risk of loneliness. The current study aimed to investigate (a) whether social distancing measures, particularly limiting close social interactions, are associated with loneliness among older adults, and (b) whether the association between social distancing measures and loneliness is moderated by sociodemographic characteristics. METHOD: Data were from the fourth wave (April 29 to May 26, 2020) of the nationally representative Understanding America Study COVID-19 Survey. We used data on adults 50 years or older (N = 3,253). Logistic regression models of loneliness were performed. Five indicators of social distancing measures were considered: (a) avoiding public spaces, gatherings, or crowds; (b) canceling or postponing social activities; (c) social visits; (d) no close contact (within 6 feet) with people living together; and (e) with people not living together. RESULTS: Cancelling or postponing social activities and avoiding close contact with people living together were associated with 33% (odds ratio [OR] = 1.33, confidence interval [CI] = 1.06-1.68, p < .05) and 47% (OR = 1.47, CI = 1.09-1.99, p < .05) greater odds of loneliness, respectively. Furthermore, limiting close contact with coresidents increased the probability of loneliness more for males, non-Hispanic Whites, and those with higher levels of education and income. DISCUSSION: Efforts should be made to help older adults maintain social connectedness with close others by virtual communication methods. Our findings also call special attention to vulnerable groups at elevated risks of loneliness, emphasizing the need for tailored interventions.

Socioeconomic status across the life course and dementia-status life expectancy among older Americans.

This study examines how socioeconomic status (SES) across the life course is associated with individuals' lifetime dementia experience - the years of life persons can expect to live and without with dementia. Conceptually, dementia-free life expectancy reflects the ability to postpone dementia onset while dementia life expectancy reflects the average lifetime period with the condition. How SES across the life course contributes to dementia-status life expectancy is the focus of this study. We assess whether persons who are advantaged in their lifetime SES live the most years without dementia and the fewest years with dementia compared to less advantaged persons. Using the Health and Retirement Study (2000-2016), we examine these questions for U.S. adults aged 65 and older using multistate life tables and a microsimulation approach. The results show that higher SES persons can expect to live significantly more years of life without dementia and that the period of life with dementia is compressed compared to less advantaged persons. The results also underscore that importance of cumulative exposure, showing that adults from disadvantaged childhoods who achieve high education levels often have dementia experiences that are similar to or better than those of adults from advantaged childhoods who achieved low education levels.