Association Between Caregiver Strain and Self-Care Among Caregivers With Hypertension: Findings From the REGARDS Study.

BACKGROUND: Self-care for adults with hypertension includes adherence to lifestyle behaviors and medication. For unpaid caregivers with hypertension, the burden of family caregiving may adversely impact self-care. We examined the association between caregiver strain and hypertension self-care among caregivers with hypertension. METHODS AND RESULTS: We included participants of the REGARDS (Reasons for Geographic and Racial Differences in Stroke) study who identified as caregivers and had hypertension. Caregiver strain, assessed by self-report, was categorized as "none/some" or "high." Hypertension self-care was assessed individually across 5 domains (Dietary Approaches to Stop Hypertension [DASH] diet, physical activity, alcohol use, cigarette smoking, and medication adherence) and a composite self-care score summing performance across them. The association between caregiver strain and hypertension self-care was examined with multivariable linear regression. Among the 2128 caregivers with hypertension, 18.1% reported high caregiver strain. Caregivers with high strain versus those with none/some were less adherent to the DASH diet (50.8% versus 38.9%, P<0.002), physically inactive (44.4% versus 36.2%, P<0.009), current smokers (19.7% versus 13.9%, P<0.004), and had lower overall self-care scores (6.6 [SD 1.7] versus 7.0 [SD 1.7], P<0.001). In an age-adjusted model, high caregiver strain was associated with worse hypertension self-care (ß=-0.37 [95% CI, -0.61 to -0.13]); this remained significant but was reduced in magnitude after adjustment for sociodemographics (ß=-0.35 [-0.59 to -0.11]), comorbidities (ß=-0.34 [-0.57 to -0.10]), caregiving intensity (ß=-0.34 [-0.59 to 0.10]), and psychological factors (ß=-0.26 [-0.51 to 0.00]). CONCLUSIONS: High caregiver strain was associated with worse hypertension self-care overall and across individual domains. Increased awareness of caregiver strain and its potential impact on hypertension self-care is warranted.

Stroke Severity, Caregiver Feedback, and Cognition in the REGARDS-CARES Study.

BACKGROUND: Cognitive impairment after stroke is common and is present in up to 60% of survivors. Stroke severity, indicated by both volume and location, is the most consequential predictor of cognitive impairment, with severe strokes predicting higher chances of cognitive impairment. The current investigation examines the associations of 2 stroke severity ratings and a caregiver-report of poststroke functioning with longitudinal cognitive outcomes. METHODS AND RESULTS: One hundred fifty-seven caregivers and stroke survivor dyads participated in the CARES (Caring for Adults Recovering From the Effects of Stroke) project, an ancillary study of the REGARDS (Reasons for Geographic and Racial Differences in Stroke) national cohort study. The Glasgow Outcome Scale and modified Rankin Scale scores collected at hospitalization discharge were included as 2 primary predictors of cognitive impairment. The number of caregiver-reported problems and impairments at 9 months following stroke were included as a third predictor. Cognition was measured using a biennial telephone battery and included the domains of learning, memory, and executive functioning. Multiple cognitive assessments were analyzed up to 5 years poststroke, controlling for prestroke cognition and demographic variables of the stroke survivor. Separate mixed models showed significant main effects of the Glasgow Outcome Scale (b=0.3380 [95% CI, 0.14-0.5]; P=0.0009), modified Rankin Scale (b=-0.2119 [95% CI, -0.32 to -0.10]; P=0.0002), and caregiver-reported problems (b=-0.0671 [95% CI, -0.09 to -0.04]; P<0.0001) on longitudinal cognitive scores. In a combined model including all 3 predictors, only caregiver-reported problems significantly predicted cognition (b=-0.0480 [95% CI, -0.08 to -0.03]; P<0.0001). CONCLUSIONS: These findings emphasize the importance of caregiver feedback in predicting cognitive consequences of stroke.

Assessing Advance Care Planning Fidelity within the Context of Cognitive Impairment: The SHARE Trial.

CONTEXT: Advance care planning (ACP) is critical among primary care patients with cognitive impairment, but few interventions have tested ACP with this population. OBJECTIVE: Describe the development and evaluation of a tool for assessing ACP fidelity within the context of cognitive impairment, including inter-rater reliability, convergent validity, and overall fidelity using clinical trial data. DESIGN: SHARE is a multicomponent intervention inclusive of facilitated ACP conversations. From a two group, single blind, randomized controlled trial, recorded ACP conversations were rated for fidelity. 145 primary care patients and their care partners were randomized to receive the intervention. Participating patients were 80+ years, had a care partner, and indications of cognitive impairment. An ACP Fidelity Checklist was developed with three subscales: Meeting Set-Up; ACP Meeting Topics; and Communication Skills. Scores were converted to percentages (100% = perfect fidelity) with a target of ≥80% fidelity. A post-ACP meeting report completed by ACP facilitators was used to assess convergent validity of the checklist. Intra-class correlation (ICC) was to evaluate inter-rater reliability. RESULTS: ACP conversations averaged 33.6 minutes (SD = 14.1). The mean fidelity score across N = 91 rated meetings was 82.9%, with a range of 77.3%-90.6% for subscales. 63.7% of meetings achieved a rating of ≥80%. Cognitive function was positively associated with patient participation (rho = .59, P < 0.001). For checklist items, ICC scores ranged from 0.43-0.96. Post-ACP meeting form scores were correlated with the checklist Meeting Topics subscale (r = 0.36, P = 0.001). CONCLUSIONS: Assessing the fidelity of ACP conversations involving primary care patients living with cognitive impairment and their care partners is feasible.

Efficacy of the residential care transition module: A telehealth intervention for dementia family caregivers of relatives living in residential long-term care settings.

The purpose of this study was to evaluate the efficacy of the Residential Care Transition Module, a six-session, psychosocial, and psychoeducational telehealth intervention for family caregivers of cognitively impaired relatives living in a residential long-term care setting. Eligible participants (including care recipients, regardless of time since admission) were randomized to treatment or usual care control conditions. Survey data were collected at baseline, 4 months, 8 months, and 12 months (N = 240). Primary analytic outcomes included caregiver subjective stress (a stress process mechanism) and depressive symptoms (a measure of global well-being). Secondary analytic outcomes included secondary role strains, residential care stress, caregiver sense of competence, and self-efficacy (additional mechanisms of action). General linear models tested for the main effects of the intervention at 4 months, and longitudinal mixed models examined the 12-month effects of the intervention. Post hoc analyses also examined the influence of moderators. No significant differences between the treatment and control groups for any primary analytic outcome were apparent. Caregivers in the treatment group whose relatives were admitted to residential long-term care in the prior 3 months were more likely to indicate reductions in depressive symptoms over the first 4 months of participation. Over the 12-month study period, caregivers in the treatment group who were employed reported increased self-efficacy over time. The heterogeneity of dementia care requires a broader consideration of key contextual factors that may influence the efficacy of nonpharmacological interventions. Aligning measures with the preferences, goals, and values of dementia caregivers may further demonstrate the direct benefits of interventions such as the Residential Care Transition Module. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Embedding Caregiver Support Within Adult Day Services: Outcomes of a Multisite Trial.

BACKGROUND AND OBJECTIVES: Adult day services (ADS) provide quality-of-life benefits to people with dementia, but few provide systematic caregiver support. We report outcomes of a multisite, national trial testing a staff-delivered caregiver program, ADS Plus. RESEARCH DESIGN AND METHODS: Cluster-randomized trial involving 34 ADS: 18 sites provided ADS (controls) and 16 provided ADS and ADS Plus (intervention). Trained staff met with caregivers to provide dementia education, support/validation, referrals/linkages, and strategies for care challenges and self-care over 12 months. Main outcomes included depressive symptoms (Center for Epidemiological Studies Depression Scale [CES-D]) and well-being at 6 and 12 months, and client attendance over 12 months. RESULTS: Of 203 caregivers (Intervention = 102; Control = 101), 5.9% at 3 months, 12.8% at 6 months, and 22.7% at 12 months were lost to follow-up. Caregivers were predominantly female (80.3%), with 76.4% identifying as White/Caucasian, 14.8% Black/African American, and 12.3% Hispanic/Latino. Most (88.2%) had ≥college education and were 65.0 years old (SD = 13.46). For those with 6-month data, 40.4% control and 40.2% ADS Plus caregivers had depressed symptoms (≥16 CES-D) at baseline. By 6 months, 43.6% control versus 34.2% ADS Plus caregivers had ≥16 scores (odds ratio = 0.38, p = .072). By 12 months, after covariate adjustments, ADS Plus caregivers reported reduced total depression scores versus controls (p = .013) and lower depressed affect scores (p = .015). Of 18 sites providing 12-month client attendance data, 9 intervention sites reported 126.05 days attended versus 78.49 days for 9 control sites (p = .079). DISCUSSION AND IMPLICATIONS: Compared with ADS alone, by 12 months, ADS Plus improved caregiver mood and increased ADS utilization by 60.6%. Results support ADS staff delivering evidence-based caregiver support to enhance ADS benefits. CLINICAL TRIAL REGISTRATION: NCT02927821.

Stroke Severity, Caregiver Feedback, and Cognition in the REGARDS-CARES Study.

Objective: Cognitive impairment after stroke is common, present up to 60% of survivors. Stroke severity, indicated by both volume and location, is the most consequential predictor of cognitive impairment, with severe strokes predicting higher chances of cognitive impairment. The current investigation examines the associations of two stroke severity ratings and a caregiver-report of post-stroke functioning with longitudinal cognitive outcomes. Methods: The analysis was conducted on 157 caregivers and stroke survivor dyads who participated in the Caring for Adults Recovering from the Effects of Stroke (CARES) project, an ancillary study of the REasons for Geographic and Racial Differences in Stroke (REGARDS) national cohort study. Glasgow Outcome Scale (GOS) and modified Rankin Scale (mRS) collected at hospitalization discharge were included as two primary predictors of cognitive impairment. The number of caregiver-reported problems and impairments at nine months following stroke were included as a third predictor. Cognition was assessed using a biennial telephone battery, incorporating multiple cognitive assessments to assess learning, memory, and executive functioning. Longitudinal cognitive scores were analyzed up to five years post-stroke, controlling for baseline (pre-stroke) cognitive scores and demographic variables of each stroke survivor collected at CARES baseline. Results: Separate mixed models showed significant main effects of GOS (b=0.3280, p=0.0009), mRS (b=-0.2119, p=0.0002), and caregiver-reported impairments (b=-0.0671, p<0.0001) on longitudinal cognitive scores. In a combined model including all three predictors, only caregiver-reported problems significantly predicted cognitive outcomes (b=-0.0480, p<0.0001). Impact: These findings underscore the importance of incorporating caregivers feedback in understanding cognitive consequences of stroke.

Subtypes of Transitions into a Family Caregiving Role: A Latent Class Analysis.

This paper groups persons who have transitioned into family caregiving using a latent class analysis and examines class differences on measures of well-being. Latent classes were identified for a sample of 251 participants who became family caregivers while participating in a longitudinal national study, and linear regression analyses compared average well-being change scores across classes. Fit indices supported a four-class solution dispersed along two conceptual dimensions: caregiving intensity and caregiving stain. The largest class (35.5%) was characterized as low intensity, low strain. The smallest class (12.7%) was characterized as high intensity, high strain, and these caregivers had significantly worse well-being change scores compared to the other caregiving classes. Categorizing caregivers by differing levels of care intensity and caregiving strain helps identify caregivers who are at most risk for poor psychosocial outcomes, determines which caregivers might benefit from specific caregiver support programs, and informs investigators on possible refinements to interventions.

Examining the Malleability of Negative Views of Aging, Self-Efficacy Beliefs, and Behavioral Intentions in Middle-Aged and Older Adults.

OBJECTIVES: This study examined the malleability of a tripartite cluster of purported mechanistic variables targeted in a 4-week intervention program designed to improve adults' engagement in physical activity. The targeted cluster of purported mechanisms consisted of negative views of aging (NVOA), self-efficacy beliefs, and behavioral intentions. METHODS: A randomized single-blind control group design was used to implement the AgingPLUS program in a sample of middle-aged and older adults (N = 335; Mage = 60.1 years; SDage = 8.3 years; age range 45-75 years). RESULTS: Using an intention-to-treat approach and analyses of covariance adjusting for participants' baseline scores, findings showed significant improvements in the purported mechanistic variables both at the immediate (Week 4) and delayed posttest (Week 8) in the treatment group but not in the control group. These improvements were for the most part maintained until 8-month postrandomization, although to a smaller extent. Specifically, participants in the AgingPLUS group showed significant improvements in NVOA, self-efficacy beliefs, and behavioral intentions compared to the Health Education control group. Standardized effect sizes for statistically significant effects were variable and ranged from small (d = -0.23) to large (d = 0.80). Effect sizes showed some decay of the intervention at the 8-month posttest. DISCUSSION: Taken together, the findings supported the efficacy of the AgingPLUS program and showed that variables representing the purported mechanisms of the intervention were significantly moved in a positive direction. In doing so, the AgingPLUS program met a major requirement of the experimental medicine approach to behavior change interventions. CLINICAL TRIALS REGISTRATION NUMBER: NCT0329948.

Hierarchical Development of Physical Frailty and Cognitive Impairment and Their Association With Incident Cardiovascular Disease.

BACKGROUND: Frailty and cognitive impairment (CI) are geriatric conditions that lead to poor health outcomes among older adults with cardiovascular disease. The association between their temporal patterns of development and cardiovascular risk is unknown. OBJECTIVES: This study aims to examine the 5-year cardiovascular outcomes by the pattern of development of frailty and CI in older adults without a history of coronary artery disease. METHODS: We used the National Health and Aging Trends Study, linked to Medicare data. Frailty was measured using the physical frailty phenotype. CI was measured using the AD8 Dementia Screening Interview, measured cognitive performance, or self-report by patient or caregiver for a diagnosis given by a physician. The primary outcome was incident major adverse cardiovascular event at 5 years. RESULTS: Of a total 2,189 study participants aged 65 and older, 38.5% were male. In this study population, 154 (7%) participants developed frailty first, 829 (38%) developed CI first, and 195 (9%) participants developed both simultaneously (frail-CI group). Those who developed frailty and CI simultaneously were older, more likely to be female, and had multiple chronic conditions. The frail-CI group had the highest risk of major adverse cardiovascular event (hazard ratio [HR]: 1.81; 95% CI: 1.47-2.23) followed by frail first (HR: 1.46; 95% CI: 1.17-1.81) and CI first (HR: 1.31; 95% CI: 1.15-1.50). Frailty first was associated with the greater risk of stroke (HR: 1.49; 95% CI: 1.06-2.09) compared to the intact group. CONCLUSIONS: The simultaneous development of frailty and CI is associated with an increased risk of adverse cardiovascular outcomes including death compared with the development of each syndrome alone. Diagnostics to detect frailty and CI are critical in assessment of cardiovascular risk in the older population.

The role of caregiving in cognitive function and change: The REGARDS study.

Chronic stress is associated with negative health outcomes, including poorer cognition. Some studies found stress from caregiving associated with worse cognitive functioning; however, findings are mixed. The present study examined the relationship between caregiving, caregiving strain, and cognitive functioning. We identified participants in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study who were family caregivers at baseline assessment and used propensity matching on 14 sociodemographic and health variables to identify matched noncaregivers for comparison. Data included up to 14 years of repeated assessments of global cognitive functioning, learning and memory, and executive functioning. Our results showed that when compared to noncaregivers, caregivers had better baseline scores on global cognitive functioning and word list learning (WLL). Among caregivers, a lot of strain was associated with better WLL and delayed word recall in the unadjusted model only. Caregivers with a lot of strain had higher depressive symptoms but not significantly higher high-sensitivity c-reactive protein (hsCRP) at baseline compared to caregivers with no or some strain after covariate adjustment. Although caregiving can be highly stressful, we found caregiving status and caregiving strain were not associated with cognitive decline. More methodologically rigorous studies are needed, and conclusions that caregiving has negative effects on cognition should be viewed with caution. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Sharing Health Care Wishes in Primary Care (SHARE) among older adults with possible cognitive impairment in primary care: Study protocol for a randomized controlled trial.

OBJECTIVE: Little is known about effective strategies to improve advance care planning (ACP) for persons with cognitive impairment in primary care, the most common setting of care. We describe a randomized controlled trial to test the efficacy of a multicomponent communication intervention, "Sharing Healthcare Wishes in Primary Care" (SHARE). PARTICIPANTS: Planned enrollment of 248 dyads of adults 80 years and older with possible cognitive impairment and their care partner, from primary care clinics at 2 Mid-Atlantic health systems. METHODS: The treatment protocol encompasses an introductory letter from the clinic; access to a designated facilitator trained in ACP; person-family agenda-setting to align perspectives about the family's role; and print education. The control protocol encompasses minimally enhanced usual care, which includes print education and a blank advance directive. Randomization occurs at the individual dyad-level. Patient and care partner surveys are fielded at baseline, 6-, 12-, and 24- months. Fidelity of interventionist delivery of the protocol is measured through audio-recordings of ACP conversations and post-meeting reports, and by ongoing monitoring and support of interventionists. OUTCOMES: The primary outcome is quality of end-of-life care communication at 6 months; secondary outcomes include ACP process measures. An exploratory aim examines end-of-life care quality and bereaved care partner experiences for patients who die by 24 months. CONCLUSIONS: Caregiver burden, clinician barriers, and impaired decisional capacity amplify the difficulty and importance of ACP discussions in the context of cognitive impairment: this intervention will comprehensively examine communication processes for this special subpopulation in a key setting of primary care. REGISTRATION: ClinicalTrials.gov: NCT04593472.

SHARING Choices: Lessons Learned from a Primary-Care Focused Advance Care Planning Intervention.

BACKGROUND: Few advance care planning (ACP) interventions have been scaled in primary care. PROBLEM: Best practices for delivering ACP at scale in primary care do not exist and prior efforts have excluded older adults with Alzheimer's Disease and Related Dementias (ADRD). INTERVENTION: SHARING Choices (NCT#04819191) is a multicomponent cluster-randomized pragmatic trial conducted at 55 primary care practices from two care delivery systems in the Mid-Atlantic region of the U.S. We describe the process of implementing SHARING Choices within 19 practices randomized to the intervention, summarize fidelity to planned implementation, and discuss lessons learned. OUTCOMES: Embedding SHARING Choices involved engagement with organizational and clinic-level partners. Of 23,220 candidate patients, 17,931 outreach attempts by phone (77.9%) and the patient portal (22.1%) were made by ACP facilitators and 1215 conversations occurred. Most conversations (94.8%) were less than 45 minutes duration. Just 13.1% of ACP conversations included family. Patients with ADRD comprised a small proportion of patients who engaged in ACP. Implementation adaptations included transitioning to remote modalities, aligning ACP outreach with the Medicare Annual Wellness Visit, accommodating primary care practice flexibility. LESSONS LEARNED: Study findings reinforce the value of adaptable study design; co-designing workflow adaptations with practice staff; adapting implementation processes to fit the unique needs of two health systems; and modifying efforts to meet health system goals and priorities.

The association of vitamin D supplementation and serum vitamin D levels with physical activity in older adults: Results from a randomized trial.

BACKGROUND: To assess whether vitamin D3 supplementation attenuates the decline in daily physical activity in low-functioning adults at risk for falls. METHODS: Secondary data analyses of STURDY (Study to Understand Fall Reduction and Vitamin D in You), a response-adaptive randomized clinical trial. Participants included 571 adults aged 70 years and older with baseline serum 25(OH)D levels of 10-29 ng/mL and elevated fall risk, who wore a wrist accelerometer at baseline and at least one follow-up visit and were randomized to receive: 200 IU/day (control), 1000, 2000, or 4000 IU/day of vitamin D3 . Objective physical activity quantities and patterns (total daily activity counts, active minutes/day, and activity fragmentation) were measured for 7-days, 24-h/day, in the free-living environment using the Actigraph GT9x over up to 24-months of follow-up. RESULTS: In adjusted models, physical activity quantities declined (p < 0.001) and became more fragmented, or "broken up", (p = 0.017) over time. Supplementation with vitamin D3 did not attenuate this decline. Changes in physical activity were more rapid among those with baseline serum 25(OH)D <20 ng/mL compared to those with baseline 25(OH)D levels of 20-29 ng/mL (time*baseline 25(OH)D, p < 0.05). CONCLUSION: In low-functioning older adults with serum 25(OH)D levels 10-29 ng/mL, vitamin D3 supplementation of 1000 IU/day or higher did not attenuate declines in physical activity compared with 200 IU/day. Those with baseline 25(OH)D <20 ng/mL showed accelerated declines in physical activity. Alternative interventions to supplementation are needed to curb declines in physical activity in older adults with low serum 25(OH)D.

Social isolation and 9-year dementia risk in community-dwelling Medicare beneficiaries in the United States.

BACKGROUND: Social isolation can influence whether older adults develop dementia. We examine the association between social isolation and incident dementia among older adults in a nationally representative sample of community dwelling older adults in the United States (U.S.). We also investigate whether this association varies by race and ethnicity. METHODS: Data (N = 5022) come from the National Health and Aging Trends Study, a longitudinal and nationally representative cohort of older adults in the U.S. A composite measure of social isolation was used to classify older adults as socially isolated or not socially isolated at baseline. Demographic and health factors were measured at baseline via self-report. Dementia was measured at each round of data collection. Discrete-time proportional hazard time-to-event models were used to assess the association between social isolation and incident dementia over 9 years (2011-2020). RESULTS: Of 5022 older adults, 1172 (23.3%) were socially isolated, and 3850 (76.7%) were not socially isolated. Adjusting for demographic and health factors, being socially isolated (vs. not socially isolated) was associated with a 1.28 (95% CI: 1.10-1.49) higher hazard of incident dementia over 9 years. There was no statistically significant difference by race and ethnicity. CONCLUSION: Social isolation among older adults is associated with greater dementia risk. Elucidating the pathway by which social isolation impacts dementia may offer meaningful insights for the development of novel solutions to prevent or ameliorate dementia across diverse racial and ethnic groups.

Positive aspects of caregiving in incident and long-term caregivers: Role of social engagement and distress.

OBJECTIVES: Positive caregiver adaptation over time may be associated with reports of positive aspects of caregiving (PAC). We examined differences in PAC by caregiving duration and social engagement, controlling for measures of distress. METHODS: Participants included 283 African American or White caregivers from the Caregiving Transitions Study with a wide range of caregiving durations. PAC are defined as positive appraisals that caregivers report about their role, such as feeling appreciated or confident. We fit multivariable linear models with the total PAC score as the outcome to assess its association with years of caregiving and social engagement (social network, monthly social contact). Models were adjusted for age, sex, race, marital status, relationship to care recipient, care recipient's dementia status, perceived stress and caregiving strain. RESULTS: Caregivers with higher social engagement reported significantly higher PAC. A non-significant trend was found in most analytic models for caregivers with longer duration of care to report higher PAC. African American caregivers reported higher PAC compared to White caregivers. Dementia caregivers reported lower PAC than non-dementia caregivers in models adjusting for demographics and social network size, but the association was attenuated with the addition of caregiving strain. DISCUSSION: Higher social engagement and longer duration of care tend to be associated with higher PAC after adjusting for demographics and measures of distress. Future studies should aim to leverage longitudinal data to understand whether caregivers shift appraisal to positive aspects of their role and explore implementation of caregiving interventions targeting PAC in order to improve the caregiving experience.

Free-Living Gait Cadence Measured by Wearable Accelerometer: A Promising Alternative to Traditional Measures of Mobility for Assessing Fall Risk.

BACKGROUND: Wearable devices have become widespread in research applications, yet evidence on whether they are superior to structured clinic-based assessments is sparse. In this manuscript, we compare traditional, laboratory-based metrics of mobility with a novel accelerometry-based measure of free-living gait cadence for predicting fall rates. METHODS: Using negative binomial regression, we compared traditional in-clinic measures of mobility (6-minute gait cadence, speed, and distance, and 4-m gait speed) with free-living gait cadence from wearable accelerometers in predicting fall rates. Accelerometry data were collected with wrist-worn Actigraphs (GT9X) over 7 days in 432 community-dwelling older adults (aged 77.29 ± 5.46 years, 59.1% men, 80.2% White) participating in the Study to Understand Fall Reduction and Vitamin D in You. Falls were ascertained using monthly calendars, quarterly contacts, and ad hoc telephone reports. Accelerometry-based free-living gait cadence was estimated with the Adaptive Empirical Pattern Transformation algorithm. RESULTS: Across all participants, free-living cadence was significantly related to fall rates; every 10 steps per minute higher cadence was associated with a 13.2% lower fall rate (p = .036). Clinic-based measures of mobility were not related to falls (p > .05). Among higher-functioning participants (cadence ≥100 steps/minute), every 10 steps per minute higher free-living cadence was associated with a 27.7% lower fall rate (p = .01). In participants with slow baseline gait (gait speed <0.8 m/s), all metrics were significantly associated with fall rates. CONCLUSION: Data collected from biosensors in the free-living environment may provide a more sensitive indicator of fall risk than in-clinic tests, especially among higher-functioning older adults who may be more responsive to intervention. CLINICAL TRIAL REGISTRATION: NCT02166333.

Transitions to Family Caregiving and Latent Variables of Systemic Inflammation Over Time.

Circulating levels of inflammatory biomarkers may be influenced by chronic psychological stressors such as those experienced by family caregivers. However, previous studies have found mostly small and inconsistent differences between caregivers and control samples on individual measures of systemic inflammation. Latent variables of inflammation were extracted from six biomarkers collected from two blood samples over 9 years apart for 502 participants in a national cohort study. One-half of these participants transitioned into a sustained family caregiving role between the blood samples. Two latent factors, termed "up-regulation" and "inhibitory feedback," were identified, and the transition to family caregiving was associated with a lower increase over time on the inhibitory feedback factor indexed by interleukin (IL)-2 and IL-10. No caregiving effect was found on the up-regulation factor indexed primarily by IL-6 and C-reactive protein. These findings illustrate the advantages of using latent variable models to study inflammation in response to caregiving stress.

Associations of perceived stress, depressive symptoms, and caregiving with inflammation: a longitudinal study.

OBJECTIVES: Higher inflammation has been linked to poor physical and mental health outcomes, and mortality, but few studies have rigorously examined whether changes in perceived stress and depressive symptoms are associated with increased inflammation within family caregivers and non-caregivers in a longitudinal design. DESIGN: Longitudinal Study. SETTING: REasons for Geographic And Racial Differences in Stroke cohort study. PARTICIPANTS: Participants included 239 individuals who were not caregivers at baseline but transitioned to providing substantial and sustained caregiving over time. They were initially matched to 241 non-caregiver comparisons on age, sex, race, education, marital status, self-rated health, and history of cardiovascular disease. Blood was drawn at baseline and approximately 9.3 years at follow-up for both groups. MEASUREMENTS: Perceived Stress Scale, Center for Epidemiological Studies-Depression, inflammatory biomarkers, including high-sensitivity C-reactive protein, D dimer, tumor necrosis factor alpha receptor 1, interleukin (IL)-2, IL-6, and IL-10 taken at baseline and follow-up. RESULTS: Although at follow-up, caregivers showed significantly greater worsening in perceived stress and depressive symptoms compared to non-caregivers, there were few significant associations between depressive symptoms or perceived stress on inflammation for either group. Inflammation, however, was associated with multiple demographic and health variables, including age, race, obesity, and use of medications for hypertension and diabetes for caregivers and non-caregivers. CONCLUSIONS: These findings illustrate the complexity of studying the associations between stress, depressive symptoms, and inflammation in older adults, where these associations may depend on demographic, disease, and medication effects. Future studies should examine whether resilience factors may prevent increased inflammation in older caregivers.

Fielding the quality of communication questionnaire to persons with cognitive impairment and their family in primary care: A pilot study.

BACKGROUND: The quality of communication (QOC) questionnaire has been widely used to assess foundational aspects of patient-clinician communication about end-of-life (EOL) care. However, this instrument has never before been fielded with primary care patients who have cognitive impairment and their caregivers, a population with unique communication needs. DESIGN: We report on baseline data from a completed pilot study and ongoing efficacy trial of advance care planning involving dyads of primary care patients ages 80 and older with cognitive impairment and their family care partners. Two QOC subscales assessed ratings of general communication and EOL care communication from 0 ("worst") to 10 ("best"). Due to challenges piloting the EOL subscale, we integrated skip logic to improve cognitive accessibility and measurement precision. Participants were first asked whether EOL communication occurred (yes/no); those responding affirmatively were subsequently asked to rate communication. We report experiences with EOL subscale adaptations from our ongoing trial (NCT04593472). RESULTS: Using the original instrument in our pilot (13 dyads), mean patient and family general communication ratings were similar (9.65 and 9.60, respectively), but EOL ratings diverged (4.23 and 5.88, respectively), and "Don't Know" comprised 5% of patient and 32% of family responses. Interviewers reported patient and family participants expressed confusion when asked to rate EOL communication behaviors that had not occurred. Using the adapted instrument in our efficacy trial (43 dyads), EOL communication behaviors were most often reported as not having occurred (76% of patient and 73% of family responses across all items). Mean patient and family EOL subscale ratings were similar (2.23 and 2.26) and responses of "Don't Know" were minimal (<1%). CONCLUSION: The original QOC EOL subscale involves rating conversations that rarely occur in primary care but are important for older adults with cognitive impairment. Subscale adaptations may reduce confusion and response uncertainty and improve measurement accuracy.

Enhanced Street Crossing Features are Associated with Higher Post-Stroke Physical Quality of Life.

BACKGROUND: Features of the physical environment may affect post-stroke recovery, but empirical evidence is limited. This study examines associations between features of the physical environment and post-stroke physical quality of life (PH-QOL). METHODS: The study sample included stroke survivors enrolled in the Caring for Adults Recovering from the Effects of Stroke project, a prospective cohort. Features of the physical environment surrounding participants' home addresses were audited using Google Earth. Audits captured information about crossings (e.g. curb-cuts; range 0-4), street segments (e.g. sidewalks; range 0-17.5), and a route (e.g. parks; range 0-27) near participants' home. Summary scores were categorized into tertials representing "few," "some," and "many" pedestrian-friendly features. Post-stroke PH-QOL was measured by the SF-12 (range 0-100) around 6 to 12-, 18-, 27-, and 36-months post-stroke. Linear mixed models were used to estimate PH-QOL over time. Chained multiple imputation was used to account for missing data. RESULTS: Two hundred and seventy-five participants were eligible, among whom 210 had complete data. Most participants lived in areas with "few" features to promote outdoor mobility. Participants living in environments with "some" crossing features had a 4.90 (95% CI: 2.32, 7.48) higher PH-QOL score across the observation period in comparison to participants living in environments with "few" crossing features. Features of the physical environment along street segments and routes were not associated with post-stroke PH-QOL. CONCLUSION: Crossing features are associated with post-stroke PH-QOL. Modifying features of the physical environment at nearby crossings, such as curb-cuts, may be a promising strategy for increasing PH-QOL.