The association of psychological protective factors with caregiver mental health outcomes.

The primary objectives were to investigate the association of resilience, purpose-in-life, and social connections in additive combinations with mental health outcomes of caregivers: 1) reduced levels of loneliness and/or depression; and 2) higher levels of positive perception of aging and quality of life. The study sample was identified from adults age ≥65, who had completed a survey during May-June 2018 or May-June 2019, and self-identified as caregivers (N=1,015; 15.4%). Resilience, purpose-in-life, and social connections were dichotomized as high/low; then counted with equal weighting 0 to 3. Among caregiver respondents, 24%, 29%, 32%, and 15% had 0, 1, 2, or 3 of these protective factors, respectively. As the number of protective factors increased, loneliness and depression decreased and positive perception of aging and quality of life increased. Caregiver interventions that include a focus on psychological protective factors may help to buffer caregiving-related stress thereby improving mental health and quality of life.

The association of resilience, social connections, and internal locus of control with pain outcomes among older adults.

Our objective was to investigate the hypothesis that psychological resources, including resilience, social connections, and internal locus of control, separately and in additive combinations, would be associated with selected pain outcomes: 1) days of opioid use and 2) medical/drug expenditures over 2 years. A mailed survey was sent to a stratified sample of older adults age≥65 with diagnosed back pain, osteoarthritis, and/or rheumatoid arthritis. Each of the resources was dichotomized as high/low and/or counted with equal weighting. Among respondents (N=3,131), the prevalence of mild/no and moderate/severe pain severity was 59% and 41%, respectively. As hypothesized, each resource was associated with lower levels of pain; additively, reported pain severity decreased as the number of resources increased. For moderate/severe pain, there was reduced opioid use among those with more resources; and, for mild/no pain, decreased medical/drug expenditures among those with ≥2 resources. Interventions that integrate psychological resources may enhance their effectiveness.

The association of physical activity with loneliness, social isolation, and selected psychological protective factors among older adults.

The primary objectives were to investigate the association of physical activity levels with 1) loneliness and social isolation; 2) protective factors: resilience, purpose-in-life, and perception of aging; and 3) the impact of these factors on healthcare expenditure patterns across physical activity levels. The study sample was identified from adults age ≥65 who completed a health survey in 2018 or 2019 (N=6,652). Among survey respondents, the prevalence of low, moderate, and high physical activity levels was 29%, 31%, and 41%, respectively. Moderate and high physical activity were associated with 15%-30% lower likelihoods of loneliness and social isolation; and with 27% to 150% higher protective factors. In addition, physical activity was associated with the mitigation of increased healthcare expenditures associated with loneliness, social isolation, and low levels of protective factors. Thus, physical activity could serve as an intervention to reduce loneliness and social isolation, augment protective factors, and mitigate excess healthcare expenditures.

The association of increasing resilience with positive health outcomes among older adults.

Our objective was to investigate three levels of resilience (low, medium, and high), identify associated characteristics, and measure the impact of increasing resilience on quality of life (QOL), healthcare utilization and expenditures, and preventive services compliance. The study sample was identified from adults age ≥65 who completed surveys during May-June 2019 (N=3,573). Other protective factors, including purpose-in-life, optimism, locus of control, and social connections, were dichotomized as high/low and counted with equal weighting (0 to 4). Among survey respondents, the prevalence of low, medium, and high resilience levels was 27%, 29%, and 44%, respectively. The strongest predictors of medium and high resilience included increasing number of other protective factors, lower stress, and no depression. Individuals with medium and high resilience had significantly higher QOL and lower healthcare utilization and expenditures. Resilience strategies integrated into healthy aging programming could be associated with improvements in QOL and/or healthcare utilization and expenditure outcomes.

The additive impact of multiple psychosocial protective factors on selected health outcomes among older adults.

Our objective was to investigate the additive properties of five psychosocial protective factors: purpose-in-life, resilience, optimism, internal locus of control and social connections. Self-reported psychological (depression, stress) and physical (health status, functionality) health outcomes and measured healthcare utilization and expenditures were included. The study sample was identified from adults age ≥65 who completed a health survey during May-June 2019 (N = 3,577). Each of the five protective factors was dichotomized as high/low (1/0) and counted with equal weighting. The protective factors were additive such that significant improvements in psychological and physical health outcomes were evident across factor subgroups: as the number of factors increased, health outcomes improved. The magnitude of the improvements was greatest between 0 and 1 factor. In addition, a significant linear trend for reduced healthcare expenditures ($1,356 reduction per factor added) was evident. Interventions promoting at least one protective factor would be beneficial for older adult populations.

Safety Events Associated with Tramadol Use Among Older Adults with Osteoarthritis.

Tramadol is a low-level opioid increasingly recommended to treat moderate-to-severe acute and chronic pain. Although characterized as having fewer opioid-related adverse events, the longer term safety of tramadol use among older adults has not been thoroughly documented. Thus, the primary objective was to examine the risk of safety events associated with chronic tramadol use compared to other chronic opioid use or no opioids among older adults with osteoarthritis. Safety events considered included: ≥3 emergency room (ER) visits, falls/hip fractures, cardiovascular (CVD) hospitalization, composite safety event hospitalization, and all-cause mortality. The study population included older adults ages ≥65 years diagnosed with osteoarthritis and classified into new or continuing tramadol use, new or continuing other opioid use, or nonuse. Inclusion criteria included: 6-month pre period and up to 33 months post period. Tramadol, other opioid, and no opioid users were 1:1 propensity-matched providing study populations of 25,899 within each category; 72% were new chronic opioid users. Multiple logistic regression or Cox proportional hazard ratios were used to document risk. Generally, tramadol users had fewer adverse event risks compared to other opioid users but higher risks than nonusers. New users of tramadol or other opioids had higher risks than continuing users. Tramadol use was associated with increased risk of multiple ER utilizations, falls/fractures, CVD hospitalizations, safety event hospitalizations, and mortality (new users only) compared to nonuse. Thus, although tramadol use may be appropriately recommended within a pain management strategy for older adults with osteoarthritis, careful monitoring for adverse safety events is warranted.

The association of pain locus of control with pain outcomes among older adults.

Our primary objective was to 1) determine the prevalence of pain locus of control (LOC) subscales in a population of older adults with pain conditions, and 2) estimate their associated protective effects on pain outcomes. A mailed survey was sent to a stratified sample of older adults age≥65 with diagnosed back pain, osteoarthritis and/or rheumatoid arthritis. Multivariate logistic regression modeling was used to determine the relative protective associations of positive resources, including LOC, resilience and social networks, on pain outcomes. Among respondents (N = 3,824), 31% were identified as internal; 34% as powerful others; and 35% as chance. In adjusted models, internal was associated with outcomes of lower pain severity, reduced chronic opioid use and increased physical functionality. Powerful others was partially protective; chance was associated with the poorest outcomes. Multidimensional pain programs should incorporate the enhancement of positive resources, including LOC, to maximize the effectiveness of pain management strategies.

Concurrent Use of Opioids with Other Central Nervous System-Active Medications Among Older Adults.

The primary objective was to determine the prevalence and characteristics of older adults concurrently using opioids and other central nervous system (CNS)-active medications, and the specialties of providers who ordered the medications. A secondary objective was to document medication-related adverse effects associated with such concurrent drug use. Study populations were identified as older adults aged ≥65 years with 1 year continuous medical and drug plan enrollment during 2017 and opioid use of ≥2 prescriptions for ≥15 days' supply. CNS-active medications included benzodiazepines, non-benzodiazepine hypnotics, muscle relaxants, antipsychotics, and gabapentinoids. Provider specialties were identified from the National Provider Identification database. Characteristics associated with opioids only, opioids plus 1, and opioids plus ≥2 additional CNS-active medications were determined using multinomial logistic regression. Outcome measures during 2017 included injurious falls/fractures and ≥3 emergency room (ER) visits. Among eligible insureds (N = 209,947), 57% used opioids only, 28% used opioids plus 1 additional CNS medication, and 15% used ≥2 additional medications. About 60% of opioids and other concurrent CNS medications were prescribed by the same provider, generally a primary care provider. Benzodiazepines and gabapentinoids were most often used concurrently with opioids. Health status, insomnia, anxiety, depression, and low back pain had the strongest associations with concurrent medication use. Overall, concurrent use with ≥2 CNS medications increased the likelihood of injurious falls/fractures or ≥3 ER visits in this population by about 18% and 21%, respectively. Both patients and providers may benefit from an awareness of adverse outcomes associated with concurrent opioid and other CNS-active medication use.

The impact of internal locus of control on healthcare utilization, expenditures, and health status across older adult income levels.

Our objectives were to 1) determine the prevalence of locus of control (LOC) dimensions stratified by older adult income levels; 2) characterize internal LOC attributes within income subgroups; and 3) investigate LOC associations with healthcare utilization and expenditures; self-rated health and functionality. The survey sample was identified from adults age ≥65 years with diagnosed pain conditions. Internal LOC characteristics were determined from logistic regressions; outcomes regression-adjusted. Among respondents, internal prevalence for low (N = 554), medium (N = 1,394) and high income (N = 2040) was 27%, 30% and 30%, respectively. Internal was associated with high resilience, less stress, exercise and less opioid use across income levels. Lower-income internal was additionally associated with diverse social networks, physical therapy and less drug use. Those with high internal generally had lower healthcare utilization and expenditures; better self-rated health and functionality. Internal LOC is a powerful positive resource associated with better health outcomes, especially influential for lower income.

Association of Resilience and Social Networks with Pain Outcomes Among Older Adults.

Depression, stress, and poor sleep have been associated with increased pain among older adults; positive resources, such as resilience and social networks, may help to buffer the impacts of these negative attributes on pain outcomes. The primary objective was to determine the relative effects of positive resources and negative attributes on pain outcomes among older adults with diagnosed back pain, osteoarthritis, and rheumatoid arthritis. The stratified study sample was identified from older adults ages ≥65 years. Members received a survey assessing positive resources (resilience, social networks), negative attributes (depression, stress, poor sleep), and pain outcomes (severity, interference). Opioid and other medication use was determined from pharmaceutical claims. After weighting to representative distributions of pain conditions and adjusting for survey response bias, multinomial logistic regressions were used to determine the relative associations of positive and negative attributes on pain outcomes. Among survey respondents (N = 4161), prevalence of self-reported pain severity and interference for no/mild, moderate, and severe categories was 61%, 21%, and 18%, and 67%, 16%, and 17%, respectively. In bivariate models, negative attributes of depression, stress, and poor sleep had stronger associations with pain severity and interference than the moderating effects of positive resources of high resilience and diverse social networks. In fully adjusted multivariate models, the strongest associations with moderate and severe pain severity and interference remained depression, stress, and poor sleep. Based on these results, multidimensional pain management strategies should include management of negative attributes along with enhancement of positive resources for effective management of chronic pain.

Using Pain Medication Intensity to Stratify Back Pain Among Older Adults.

OBJECTIVE: To examine the prevalence of musculoskeletal back pain among older adults stratified by pain medication intensity to 1) review treatment patterns and 2) consider targeted back pain prevention interventions. METHODS: A random sample of older adults age 64 years and older was utilized to identify new and recurring back pain. Prescription pain medications from drug claims were used to stratify to five unique intensity levels. The characteristics of each level were determined using regression models. RESULTS: About 10% had musculoskeletal back pain. Of these, 54% (N = 20,645) had new back pain and 46% (N = 17,252) had recurring back pain. Overall, about 35% received physical therapy. Pain medication intensity levels included no prescription pain medications, nonsteroidal anti-inflammatory drugs (NSAIDs), muscle relaxants, low-dose opioids, and high-dose opioids (new back pain: 39%, 10%, 6%, 23%, and 23%, respectively; recurring back pain 32%, 9%, 4%, 17%, and 38%, respectively). NSAID and muscle relaxant users were younger, healthier, and received physical therapy. Opioid users were younger, in poorer health, used sleep medications, received physical therapy, and had more falls and higher health care utilization and expenditures. CONCLUSIONS: New and recurring back pain patients can be stratified by pain medication intensity to review treatment patterns and target back pain prevention programs. Those with back pain but taking no prescription pain medications may benefit from back pain prevention programs. More research on guidelines for treatment options for those on high levels of pain medications is warranted.

Prevalence and characteristics associated with high dose opioid users among older adults.

Our primary objective was to determine the prevalence and characteristics of high dose opioid users among older adults. Study populations included adults ≥65 years with: 1) 12-month continuous medical plan enrollment; and 2) at least 2 opioid prescriptions with a cumulative day supply ≥15 days. Opioid users were categorized as high dose >120 milligram morphine equivalents (MME) per day or lower dose ≤120 MMEs per day. Among eligible insureds, 3% (N = 7616) were identified as high dose opioid users. Compared to lower dose users, high dose opioid users were male, younger, depressed, in poorer health, had back pain, used benzodiazepines and/or sleep medications, and used 4 or more pharmacies. The prevalence of high dose opioid users was relatively small but users were characterized by a complex mix of physical and mental health issues. Interventions to reduce reliance on opioids may need mental health management to promote more effective pain management.

Underutilization of Statin Therapy for Secondary Prevention of Cardiovascular Disease Among Older Adults.

Secondary cardiovascular disease (CVD) clinical trials have demonstrated that higher intensity levels of statin therapy are more effective than lower levels in reducing mortality rates. Despite updated treatment guidelines, statin therapy may be underutilized, with evidence that females are treated less aggressively than males. The primary objective of this study was to determine the prevalence of statin utilization by varying therapy intensity by sex. The secondary objective was to document the benefits of statin therapy intensity levels on all-cause mortality for males and females. A 25% random sample of adults ≥65 years was utilized to identify those with established CVD. Inclusion criteria included: (1) 12-month pre period and (2) up to 30 months post period. Five categories of statin utilization were established: adherent to high-, moderate-, or low-intensity statin therapy, nonadherent, and no statins. Among eligible insureds (N = 49,530 males; N = 44,710 females), 20% of males and 12% of females were identified as high-intensity statin users. Mortality rates significantly increased similarly for males and females as statin therapy intensity decreased. Likewise, mortality hazard ratios indicated the most benefit from high-intensity statin therapy compared to all other categories. Statin therapy for secondary prevention of CVD is beneficial in reducing mortality for males and females but is underutilized, especially among females. Education programs among patients to increase heart health awareness and among physicians to promote the benefits of updated statin guidelines should be encouraged.

Characteristics associated with transition from opioid initiation to chronic opioid use among opioid-naïve older adults.

Our primary objective was to determine the prevalence and characteristics of opioid-naïve older adults who initiated opioids and transitioned to chronic use. Study populations included older adults ≥ 65years with continuous medical and drug plan enrollment one-year prior to opioid initiation (pre-period) through one-year after initiation (post-period). Characteristics were determined using multivariate logistic regression. Among eligible insureds (N = 180,498), 70% used only the initial opioid prescription; 30% continued to use opioids requiring ≥ 2 prescriptions with ≥ 15 days' supply. Overall, 6% transitioned to chronic use > 90days. Characteristics associated with chronic use included: (1) Low income, older, females, in poor health, with new/chronic back pain; (2) opioid initiation with long-acting opioids or tramadol; (3) prescriptions for other pain, sleep or antipsychotic medications; and (4) indications of pre and/or post mental health issues. Careful screening, monitoring and/or alternative non-opioid pain management strategies may be warranted for those at risk for chronic opioid use.

Characteristics of New-Onset and Chronic Sleep Medication Users Among Older Adults: A Retrospective Study of a US Medigap Plan Population using Propensity Score Matching.

BACKGROUND: Prescription sleep medications are often utilized to manage sleep problems among older adults even though these drugs are associated with multiple risks. OBJECTIVE: The aim was to determine the prevalence and characteristics of new-onset compared to chronic sleep medication users and to examine factors associated with the conversion from new to chronic use. A secondary objective was to investigate the impact of sleep medications on health outcomes of injurious falls and patterns of healthcare utilization and expenditures. METHODS: A 25% random sample of adults ≥ 65 years with 3-year continuous AARP® Medicare Supplement medical and AARP® MedicareRx drug plan enrollment was utilized to identify new-onset and chronic sleep medication users. Prescription sleep medication drugs were defined using National Drug Codes (NDCs); falls or hip fractures were identified from diagnosis codes. New users had no sleep medication use in 2014, but initiated medication use in 2015; chronic users had at least one sleep medication prescription in 2014 and in 2015; both groups had follow-up through 2016. Characteristics associated with new users, new users who converted to chronic use, and chronic users were determined using multivariate logistic regression. Prevalence of falls, healthcare utilization and expenditures were regression adjusted. RESULTS: Among eligible insureds, 3 and 9% were identified as new-onset and chronic sleep medication users, respectively. New-onset sleep medication prescriptions were often associated with an inpatient hospitalization. The strongest characteristics associated with new users, those who converted to chronic use, and chronic users were sleep disorders, depression and opioid use. About 50% of new users had > 30 days' supply; 25% converted to chronic use with ≥ 90 days' supply. The prevalence of falls for new-onset users increased by 70% compared to a 22% increase among chronic users. CONCLUSION: New-onset and chronic sleep medication users were characterized by sleep disorders, depression and pain. Addressing the underlying problems associated with sleep problems among older adults may decrease the need for sleep medications and thus reduce the risk of sleep medication-related adverse events.

The impact of mobility limitations on health outcomes among older adults.

The purpose of this study was to stratify an older adult population for subsequent interventions based on functional ability, and to estimate prevalence, characteristics and impact of mobility limitations on health outcomes. In 2016, surveys were sent to a stratified random sample of AARP® Medicare Supplement insureds; mobility limitations were defined using two screening questions. Responses were stratified to three mobility limitation levels. Multivariate regression models determined characteristics and impact on health outcomes. Among weighted survey respondents (N = 15,989), severe, moderate and no limitation levels were 21.4%, 18.4% and 60.3%, respectively. The strongest predictors of increased limitations included pain and poor health. Individuals with more severe limitations had increased falls, decreased preventive services compliance and increased healthcare utilization and expenditures. Utilizing two screening questions stratified this population to three meaningful mobility limitation levels. Higher levels of mobility limitations were strongly associated with negative health outcomes. Mobility-enhancing interventions could promote successful aging.

Purpose in Life and Positive Health Outcomes Among Older Adults.

Purpose in life (PIL) is conceptualized as having goals, a sense of direction, and a feeling that there is meaning to present and past life. PIL has been associated with positive health outcomes among older adults, including fewer chronic conditions, less disability, and reduced mortality. The purpose of this study was to estimate the prevalence of PIL among AARP Medicare Supplement insureds, identify associated characteristics, and measure impact on selected health outcomes. In 2016, surveys were sent to a random stratified sample; PIL was measured using a 7-item scale with 5 responses. Scores were averaged across responses and categorized to PIL levels of low, medium, and high. Survey responses were weighted to adjust for nonresponse bias and to weight to a nationally representative population. Multivariate regression models, adjusting for confounding covariates, were utilized to determine characteristics associated with PIL levels and the impact on health care utilization and expenditures, preventive services compliance and quality of life (QOL). Among weighted survey respondents (N = 15,680), low, medium, and high PIL levels were 24.2%, 21.1%, and 54.7%, respectively. The strongest characteristics of medium and high PIL included social support, resilience, reliance on faith, high health literacy, and good health status. Individuals with medium and high PIL had significantly lower health care utilization and expenditures, increased preventive services compliance, and higher QOL. PIL is strongly associated with improved mental and physical health outcomes among older adults. Thus, interventions to improve and/or maintain higher levels of PIL over time may promote successful aging.

Falls-Related Drug Use and Risk of Falls Among Older Adults: A Study in a US Medicare Population.

BACKGROUND: Approximately one-third of community-dwelling older adults fall each year, and approximately 10% have falls requiring medical services. Among other factors, research studies have linked certain medications with an increased risk of falls. OBJECTIVE: The aim of this study was to examine the risk of falls relative to use patterns among new and continuing falls-related drug (FRD) users. METHODS: A 10% random sample, insured in AARP® Medicare Supplement and AARP Medicare Part D Rx plans, was utilized to define new and continuing FRD users. New users had a 12-month pre-period without FRD use, whereas continuing users had at least one FRD in the pre-period. Both groups had 12-month follow-up after initiating or continuing FRD use. Characteristics associated with the risk of falls for new and continuing users were determined using multivariate logistic regression models. RESULTS: Among insureds, 44% used at least one of the FRD classes. Of these, 29% were new users (N = 35,340) and 71% were continuing users (N = 121,488). Fall rates for the two subgroups were similar at 7 and 8%, respectively. Characteristics associated with the risk of falls were previous injurious fall, use of two or more classes of FRDs, older age, poorer health, and being female. New users were at higher risk than continuing users. CONCLUSION: New users of FRDs were at highest risk of falls, and continuing users were at increased risk, especially with higher numbers of FRD classes. Both groups could benefit from falls awareness and prevention programs.

The Frequency and Health Benefits of Physical Activity for Older Adults.

The benefits of physical activity (PA) for older adults have been demonstrated in reduced prevalence of common chronic conditions, improved mental health, decreased cognitive decline, and reduced mortality rates. Less is understood concerning the health impacts of light-to-moderate intensity PA. The purpose of this study was to estimate light-to-moderate PA frequency levels-low (0-2 days/week), intermediate (3-4 days/week) and high (≥5 days/week)-among AARP Medicare Supplement insureds, identify characteristics, and estimate the association of PA levels with the prevalence of selected chronic conditions, health care utilization, and expenditures. In 2015, surveys were sent to a random sample of insureds. PA was determined from survey responses querying self-reported days per week of at least 30 minutes of light-to-moderate PA. Multivariate regression models, adjusting for confounding covariates and survey nonresponse bias, were utilized to determine the characteristics and association of intermediate and high PA levels with health outcomes. In a second analysis, results were stratified by age groups: 65-69, 70-79, and ≥80 years. Among survey respondents (n = 17,676), 23.3%, 33.9%, and 42.9% engaged in low, intermediate, and high PA, respectively. The strongest predictors of intermediate and high PA included being male, younger, self-reporting better health, using fewer prescription drugs, and being less likely to be diagnosed with common chronic conditions or depression. Those engaged in intermediate and high PA, overall and across age groups, had significantly lower health care utilization and expenditures and lower prevalence of most chronic conditions. Efforts to increase intermediate and high levels of PA among older adults should be encouraged.

Caregivers for older adults: Prevalence, characteristics, and health care utilization and expenditures.

The purpose of this study was to provide an overview of caregiver prevalence and characteristics and to estimate the impact of caregiving on health care utilization and expenditures among AARP® Medicare Supplement insureds to inform caregiver intervention strategies. A subgroup with live-in partners was used to investigate the additional effect of live-in health status on caregiver health. Multivariate regression models were utilized to determine caregivers' characteristics and associated impacts on their health care utilization and expenditures. Among respondents (n = 18,928), 14.9% self-identified as caregivers. The strongest characteristics included being younger, healthier, but reporting depression or loneliness. Caregivers of sicker live-ins were female, older and indicated moderate loneliness; caregivers of healthier live-ins were younger, healthier, but reported severe loneliness. Caregivers had significantly lower inpatient admissions and medical and prescription drug expenditures. These results indicated an adverse impact on psychological health associated with caregiving but no evidence of a negative impact on physical health.