Cognitive Impairment and Social Determinants of Health among Indigenous Women.

BACKGROUND AND OBJECTIVES: Cognitive impairment and Alzheimer's disease and related dementias (ADRD) pose significant challenges for Indigenous populations, necessitating urgent research. Limited evidence suggests that high rates of ADRD among Indigenous peoples are associated with social determinants of health (SDOH), such as education, income, health literacy, religion, and social engagement. RESEARCH DESIGN AND METHODS: Collaborating with a Northern Plains tribe, participants were recruited 123 self-identified Indigenous women aged 40 to 70 through a comprehensive recruitment strategy. Employing the SDOH framework, the research assessed cognitive impairment and Alzheimer's disease knowledge, utilizing the Ascertain Dementia 8 and AD knowledge scales (ADK-30). The investigation examined the relationships between selected SDOH variables and cognitive impairment status. RESULTS: More than half of the participants showed signs of cognitive impairment, which correlated with lower income and education levels. Increased knowledge about Alzheimer's disease, particularly in terms of treatment management and its life impact subscales, was associated with lower odds of cognitive impairment. Conversely, higher levels of depressive symptoms and participation in religious activities were linked to increased odds of cognitive impairment. DISCUSSION AND IMPLICATIONS: The findings underscore the importance of culturally grounded tools and SDOH frameworks tailored to Indigenous contexts in addressing ADRD disparities. Future research should integrate historical and cultural factors to advance health equity within Indigenous communities, ultimately mitigating the impact of ADRD and promoting overall well-being.

Prevalence of Dementia in American Indians and Alaska Natives Compared to White, Black, and Hispanic Medicare Beneficiaries: Findings from the National Health and Aging Trends Study.

OBJECTIVE: To estimate the prevalence of dementia among American Indian and Alaska Native (AIAN) Medicare beneficiaries and compare the prevalence of dementia in AIANs and other racial and ethnic minority groups-non-Hispanic Blacks (NHBs) and Hispanics-with non-Hispanic Whites (NHWs) Medicare beneficiaries. METHODS: We used survey data from Round 5 of the National Health and Aging Trends Study (NHATS, 2015) (N = 7,449), a nationally representative study of Medicare beneficiaries ages 65 years and older. We used logistic regression to estimate the age- and sex-adjusted prevalence of dementia with 95% confidence intervals by race/ethnicity as well as prevalence differences between groups. RESULTS: The majority of participants were between 65 and 74 years old. Approximately half of them were female. NHWs had a prevalence of 5% for dementia, and AIAIs had a prevalence of 9%, four percentage points higher than NHWs (95%CI 1%, 11%). We estimated a similar difference in the prevalence of dementia in AIAN Medicare beneficiaries compared to NHBs. CONCLUSION: While previous research has reported that AIANs share a similar or lower prevalence of dementia than NHWs, our findings suggest a potentially higher prevalence of dementia among AIAN Medicare beneficiaries. A relatively small number of AIAN resulted in wide confidence intervals for many of our associations. Future research should focus on recruiting a larger sample and on dementia prevalence and unique risk factors within and among AIAN tribes.

Paid Care Services and Transitioning out of the Community Among Black and White Older Adults With Dementia.

OBJECTIVES: Paid care provided in the home includes important support services for older adults with dementia such as cleaning and personal care assistance. By reducing unmet needs, these services could delay the transition to residential long-term care, but access may differ across racial groups. This study examined the relationship between paid care and transitioning out of the community among Black and White older adults with dementia. METHODS: Using data from 303 participants (29.4% Black) with probable dementia in the 2011 National Health and Aging Trends Study, competing risk hazards models estimated the association between receiving paid care at baseline and the probability of transitioning out of the community over 8 years (through 2019). Covariate selection was guided by the Andersen model of health care utilization. RESULTS: Paid care was associated with lower risk of transitioning out of the community (subhazard ratios [SHR] = 0.70, 95% CI [0.50, 0.98]). This effect was similar after controlling for predisposing factors and most prominent after controlling for enabling and need for services factors (SHR = 0.65, 95% CI [0.44, 0.95]). There was no racial difference in the use of paid care despite evidence of greater care needs in Blacks. Furthermore, Black participants were less likely to transition out of the community than Whites. DISCUSSION: Paid care services may help delay transitions out of the community. Future research should seek to explain racial differences in access to and/or preferences for home-based, community-based, and residential care.

Racial Differences in the Dementia Caregiving Experience During the COVID-19 Pandemic: Findings From the National Health and Aging Trends Study (NHATS).

OBJECTIVES: Given racial disparities in both dementia and coronavirus disease 2019 (COVID-19), non-Hispanic Black (Black) dementia caregivers (CGs) may be at greater risk for care burden during the COVID-19 pandemic than non-Hispanic White (White) CGs. This study investigates the impact of dementia care provision on CGs' quality of life by race using the 2020 National Health and Aging Trends Study Family Members and Friends COVID-19 data (FF). METHODS: This study features a secondary analysis of FF data (2020-2021), including 216 Black and 1,204 White CGs. We used ANOVA to determine differences in caregiving stressors (i.e., changes in providing help with activities of daily living [ADL], instrumental ADL [IADL], and emotional support). Ordinary least square regression was used to investigate the moderating effects of dementia care on the associations of race with perceived well-being, care burden, and self-reported health and to conduct subgroups analyses of Black and White dementia CGs. RESULTS: Black dementia CGs provided significantly more help with ADL before and during the COVID-19 pandemic than Black nondementia, White dementia, and White nondementia CGs. Dementia care status did not moderate the associations between race and CG outcomes. For Black dementia CGs, changes in objective stressors (assistance with ADL and IADL) were associated with care burden and well-being. For White CGs, the provision of emotional support was associated with care burden and well-being. DISCUSSION: This study highlights that increased caregiving demands during the pandemic amplified racial differences in CG stress. Findings suggest that outreach to reduce CG stress and burden is critical for Black dementia CGs.

Exploring Coping Strategies and Barriers in Dementia Care: A Mixed-Methods Study of African American Family Caregivers in Kentucky.

This study explores coping strategies and barriers to dementia care experienced by African American dementia caregivers in Kentucky. Utilizing a convergent mixed-method design integrating focus group and survey data on African American dementia caregivers recruited through churches in Kentucky (N = 28), we elucidate three coping strategies: love-based coping, religion-based coping, and family support. Results from survey data supported these themes, with over 90% of participants reporting that they provide care to give back to family members and for religious reasons. However, over half of the caregivers' reported strain due to three barriers identified by focus group data: time constraints, low support, and the high cost of formal care. This exploratory study highlights the importance of intervention tactics for African American dementia caregivers that focus not only on individual and family support but also community-based outreach and support.

The Effects of Nativity Status on Well-Being Among Medicare Beneficiaries by Race/Ethnicity: A Multi-group Analysis.

Nativity status is related to stress, health and well-being, but the literature is scant concerning whether these effects differ by race/ethnicity for older adults. We examined direct and indirect effects of nativity status on stress, coping resources, health, and depression/anxiety for the three largest racial/ethnic groups [Non-Hispanic White (NHW), Non-Hispanic Black (NHB), and Hispanic] in the U.S. using the Transactional Model of Stress and Coping. We obtained the data from Round 1 of the National Health and Aging Trends Study (NHATS; U.S.-born Medicare beneficiaries = 4093, foreign-born Medicare beneficiaries = 382, N = 4475). We used the multi-group analysis function in structural equation modeling to examine similarities and differences in the stress coping processes for the three racial/ethnic groups. The results indicated there are multiple pathways from nativity status to depression or self-rated health. For all three groups, being foreign-born was directly associated with higher stress and indirectly associated with lower self-rated health via stress. Only for Hispanic older adults was being foreign-born directly associated with higher depression/anxiety. For NHWs, being foreign-born was indirectly associated with higher depression/anxiety via less coping resources. Nativity status may have similar effects on self-rated physical health but may exert very different effects on depression/anxiety, depending on race/ethnicity. Nativity status will require special attention for both assessment and management of depression/anxiety as well as self-rated health among older adults of all racial/ethnic backgrounds and especially for older Hispanics.

Caregiver Well-Being and Burden: Variations by Race/Ethnicity and Care Recipient Nativity Status.

BACKGROUND AND OBJECTIVES: Despite growing diversity among the aging population and extensive previous research on racial/ethnic minority caregivers, little research has been conducted on the potentially unique experiences and outcomes of informal caregivers of foreign-born care recipients. Using nationally representative data and the Stress Process Model, the current study examined the differences in caregiver outcomes (care burden, psychological well-being, and self-rated health) by care recipient nativity status (U.S.-born vs. foreign-born) and the extent to which caregiver outcomes vary by care recipient nativity status and caregiver race/ethnicity (non-Hispanic white, non-Hispanic black, Hispanic, and Others). RESEARCH DESIGN AND METHODS: The current study used Round 5 of the National Health and Aging Trends Study and the National Study of Caregiving (N = 1,436). We conducted ordinary least squares regression to analyze the differences in caregiver's outcomes by care recipient nativity status and caregiver race/ethnicity and to investigate the impacts of the inclusion of caregiving factors (background factors, primary stressors, secondary stressors, and resources). RESULTS: Regression analyses showed that only care burden significantly varied by care recipient nativity status after controlling for covariates. Caregivers of foreign-born care recipients reported a higher burden. However, when interactions of care recipient nativity status × caregiver race/ethnicity were introduced, non-Hispanic black and Hispanic caregivers of foreign-born care recipients were more likely to report better psychological well-being and self-rated health compared to their counterparts. Across caregiver groups, better caregiver-care recipient relationship quality and less caregiver chronic conditions were associated with less burden and better caregiver psychological well-being and self-rated health. DISCUSSION AND IMPLICATIONS: Care recipient nativity status and caregiver race/ethnicity may have complex effects on caregiving experiences. Given the observed significant interaction effects for caregiver psychological well-being and self-rated health, cultural factors may affect the extent to which these caregivers appraise their caregiving. Future research should delve into the appropriate ways to assess care stress as well as resilience among each caregiver group. Our results indicate the need for research, education, and practice that assess cultural and within-group differences among caregivers and inform needed changes to structural barriers.

Institutional capacity to provide psychosocial care in cancer programs: Addressing barriers to delivering quality cancer care.

OBJECTIVE: This study investigates barriers and promoters to delivering quality psychosocial services in 58 cancer programs across North America. METHODS: Oncology care providers (n = 2008) participated in a survey in which they identified barriers and promoters for delivering psychosocial care at their respective institutions. Multilevel modeling was used to examine (a) the extent to which provider and institutional characteristics were associated with the most common barriers, and (b) associations between perceived barriers and institutional capacity to deliver psychosocial services as measured by the Cancer Psychosocial Care Matrix. RESULTS: Across 58 Commission on Cancer-accredited programs in North America, the most frequently reported barriers were inadequate number of psychosocial care personnel, lack of funding, inadequate amount of time, lack of systematic procedures, and inadequate training for oncology providers. Overall, there were few significant differences in reported barriers by type of institution or type of provider. In general, the most frequently reported barriers were significantly associated with the institution's capacity to deliver quality psychosocial care. In particular, the lack of a systematic process for psychosocial care delivery significantly predicted lower levels of institutional capacity to deliver quality psychosocial care. CONCLUSIONS: When identifying barriers, respondents reported a greater number of institutional barriers than barriers related to individual provider or patient characteristics. These results present a compelling case for cancer programs to implement and monitor systematic procedures for psychosocial care and to integrate these procedures in routine clinical practice.

Dementia Caregiving Research: Expanding and Reframing the Lens of Diversity, Inclusivity, and Intersectionality.

This forum expands and reframes the lens of dementia caregiving research among diverse racial and ethnic groups to better understand the unique needs, stressors, and strengths of multicultural and racial-ethnic family caregivers in the United States. By providing more diverse and inclusive knowledge on caregiving to older adults in the United States, we can create a new path forward with regards to caregiving research. Throughout the article, major questions and answers are supported by critiquing some of the caregiving literature. Discussions are provided to help create inclusive ways of conceptualizing caregiving research and using methodological approaches to reflect the diversity of caregivers and care recipients in the United States. Expanding and reframing the conceptual and methodological lens of diversity, inclusivity and intersectionality can provide evidence to support effective policy, practice, and care in addressing the needs of diverse groups of caregivers and older adults living with dementia.

Andersen's Behavioral Model to Identify Correlates of Breast Cancer Screening Behaviors among Indigenous Women.

This study examined predictive models of utilization of mammograms among Indigenous women adapting Andersen's behavioral model. Using a sample of 285 Indigenous women residing in South Dakota, nested logistic regression analyses were conducted to assess predisposing (age and marital status), need (personal and family cancer history), and enabling factors (education, monthly household income, mammogram screening awareness, breast cancer knowledge, self-rated health, and cultural practice to breast cancer screening). Results indicated that only 55.5% of participants reported having had a breast cancer screening within the past 2 years. After controlling for predisposing and need factors, higher education, greater awareness of mammogram, and higher utilization of traditional Native American approaches were significant predictors of mammogram uptake. The results provide important implications for intervention strategies aimed at improving breast cancer screening and service use among Indigenous women.

Caregiving Across Diverse Populations: New Evidence From the National Study of Caregiving and Hispanic EPESE.

BACKGROUND AND OBJECTIVES: The current study employs population-based data to determine the extent to which stress and coping factors are related to self-rated health and distress for informal caregivers (CGs) from the 3 largest racial/ethnic groups in the United States (non-Latino White, African American, and Mexican American). RESEARCH DESIGN AND METHODS: Data on primary, informal CGs are obtained from the 2015 National Study of Caregiving (NSOC) (n = 667) and the 2016 Hispanic Established Populations for the Epidemiologic Studies of the Elderly (H-EPESE) CG supplement (n = 287). Logistic regression models of health are presented for all CGs and specifically for dementia CGs. RESULTS: Caregiving intensity is related to health for non-Latino White CGs and African American dementia CGs. Support from family and friends is related to better self-rated health, but only for African American dementia CGs. While better relationship quality is related to better health for African American CGs and White dementia CGs, formal support utilization is related to worse CG health for Mexican American dementia CGs. DISCUSSION AND IMPLICATIONS: Findings emphasize the importance of earlier detection and intervention with CGs at the beginning in the caregiving career, the interplay of formal and informal support, and appropriate ways to intervene with dementia CGs. Culturally tailored home- and community-based care options are needed to supplement the low levels of CG support, especially for the Mexican American population.

Dementia Prevalence in Older Adults: Variation by Race/Ethnicity and Immigrant Status.

OBJECTIVE: To examine differences in prevalence and risk factors of dementia by race/ethnicity and immigrant status using a nationally representative sample of Medicare beneficiaries. METHODS: This was a cross-sectional study performed in the United States among non-Hispanic white (NHW), non-Hispanic black (NHB), Hispanic, and other Medicare beneficiaries from round 1 of the National Health and Aging Trends Study (N = 7,609). The authors used log-binomial regression analyses to investigate risk factors and interactions between race/ethnicity and immigrant status and dementia. Stratified log-binomial regression analyses by race/ethnicity were used to interpret the results of interaction effects of immigrant status found in these surveys. Analyses were conducted in three forms: probable dementia versus possible and no dementia, probable and possible dementia versus no dementia; and probable dementia versus no dementia. RESULTS: Consistent with previous studies, U.S.-born NHBs have a higher prevalence of dementia than U.S.-born whites, Hispanics, and others. Immigrant status moderated the relationship between race/ethnicity and dementia. NHWs, Hispanics, and other immigrants had a higher prevalence of dementia compared with their U.S.-born counterparts. However, U.S.-born NHBs had a higher prevalence of dementia compared with NHB immigrants. Results were consistent across the three forms of analysis. Greater age predicted higher dementia across the four racial/ethnic groups. CONCLUSION: Immigrant status may have complex effects on dementia risk. Selection factors affecting immigration-varied health and educational systems in diverse countries of origin, acculturative stress, and validity of dementia assessment across diverse groups-deserve further attention.

Factors that contribute to remaining in the community among older adults.

OBJECTIVES: Using national data on Medicare beneficiaries and their caregivers (CGs), we investigated CG and care recipient (CR) factors associated with the likelihood of remaining in the community. METHODS: We obtained data on 722 CG and CR dyads who lived in the community in 2011 from the National Study of Caregiving and the National Health Aging and Trend Study. We then used pooled data from 2011 to 2015 to track the CRs' likelihood of remaining in the community. Generalized Estimating Equation (GEE) analyses were used to assess the association between CG and CR factors and likelihood of community residence over five years. RESULTS: The GEE analyses showed that the strongest CR factors predicting continued community residence include lower CR age, higher CR ADL capabilities, not having dementia, and having a heightened sense of community. CG factors predicting continued community residence included reporting no physical difficulties from caregiving, and higher positive aspects of caregiving. CONCLUSION: In addition to widely found predictors of remaining in the community (e.g., CR age and dementia), psychosocial variables (CG positive aspects of caregiving, CR sense of community engagement) were also significant independent predictors. Interventions that emphasize not only traditional risk factors for placement, but also psychosocial factors such as promoting CG positive aspects of caregiving and strengthening CRs' linkages with their neighbors or community members deserves greater attention.

Factors Associated with American Indian Mental Health Service Use in Comparison with White Older Adults.

OBJECTIVE: Our objective was to identify the factors that impact mental health service use among American Indian (AI) older adults living in South Dakota compared to their White counterparts. DESIGN AND METHODS: Using a cross-sectional design with 735 participants (n = 502 Whites, n = 233 AIs), we used ordinal regressions to analyze the extent to which predisposing, need, and enabling/hindering factors predicted the level of mental health service utilization. RESULTS: White older adults used more mental health services as compared with AI older adults. For both groups, more adverse childhood experiences along with prior negative experience with mental health service use were significantly related to an increased level of mental health service use. Compared to their White counterparts, AI older adults who reported a higher level of depressive symptoms, better self-perceived physical health, and a more positive attitude toward mental health services tended to use more mental health services. CONCLUSIONS: To reduce mental health disparities among AI older adults, community, local government, and academic partners should pay attention to how to encourage the use of mental health services to meet the unique needs of AI older adults.

Racial/Ethnic Differences in Caregiving Frequency: Does Immigrant Status Matter?

Objectives: With growing diversity in the older adult and caregiver populations, the purpose of the current study is to describe the extent to which elder care frequency varies by race/ethnicity and immigrant/native status using national data from the United States. Method: Using pooled data from the 2011-2014 American Time Use Surveys (ATUS; N = 7,855), we present multinomial logistic regressions of caregiving frequency by race/ethnicity and immigrant/native status and explore whether factors within the caregiving domain (duration of care, number of care recipients, and coresidence) attenuate any observed differences. Results: Compared to non-Latino Whites, non-Latino Black, Mexican-origin, and other Latino caregivers engage in more frequent elder care activities, which is partially attributable to high levels of coresidence among these subpopulations. Although immigrant caregivers, in general, tend to engage in more time-intensive caregiving, for Mexican-origin and other Latino caregivers, U.S.-born caregivers report more frequent elder care provision. Discussion: More time-intensive and demanding caregiving careers reported by racial/ethnic minority and immigrant caregivers further emphasize the need for culturally competent home- and community-based care options.

Quality of Life for Dementia Caregiving Dyads: Effects of Incongruent Perceptions of Everyday Care and Values.

Purpose of the Study: This dyadic study investigated incongruence in care recipients' (CRs') and caregivers' (CGs') perceptions of (a) CRs' involvement in decision making and (b) how much CRs value social relations as predictors of subjective quality of life (QOL) of CRs with mild-to-moderate dementia and their primary family CGs. Design and Methods: A secondary analysis of cross-sectional, dyadic data from in-person interviews with 205 CRs with mild-to-moderate dementia and their primary family CGs Incongruence was operationalized in two ways: absolute difference and direction of difference. Paired t tests and multilevel modeling were used to analyze differences. Results: CGs reported CRs were significantly less involved in decision making and valued social relations significantly less than CRs. Greater incongruence on CRs' values significantly predicted lower QOL of CG and CR. When CGs reported that CRs valued social relationships less than the CR himself/herself reported, CGs' and CRs' QOL was significantly lower compared with QOL for dyads where there was no incongruence on CRs' values. Incongruent perceptions of CRs' involvement in decisions were not a significant predictor of QOL. Implications: This study provides evidence for the importance of assessing both CRs' and CGs' QOL, as well as incongruence in their perceptions in domains that may affect both of their QOL.

Caregiving setting and Baby Boomer caregiver stress processes: Findings from the National Study of Caregiving (NSOC).

The aim of this study was to provide a comprehensive understanding of how the caregiving setting relates to caregiving experience among Baby Boomer caregivers (CGs). Based on a secondary data analysis (the National Study of Caregiving, N = 782), compared with CGs providing care to an older adult living in the community, CGs to older adults in non-NH residential care settings reported better emotional well-being, self-rated health, and relationship quality and less provision of assistance older adults with daily activities. While chronic conditions, relationship quality, and financial strain were associated with the health and well-being for both CG groups, degree of informal support was more consequential for the health of CGs providing care to older adults in the community. Our results provide critical information on the risk factors and areas of intervention for both CG groups.

Predictors of Discrepancy Between Care Recipients With Mild-to-Moderate Dementia and Their Caregivers on Perceptions of the Care Recipients' Quality of Life.

PURPOSE: The goal of this study was to explore predictors of discrepancy between reports of caregivers (CGs) and care recipients (CRs) with mild-to-moderate dementia about CRs' quality of life (QOL). DESIGN AND METHODS: This study was a secondary analysis of cross-sectional data drawn from a study of 200 care dyads of CRs with mild-to-moderate dementia and their primary family CGs. Paired t test, ordinary least squares multiple regression, and binary logistic regression were used for the analyses. RESULTS: Caregivers rated CRs' QOL significantly lower (worse) than CRs did. Ordinary least square regression results showed that greater incongruence in perceptions of CRs' decision-making involvement (DMI) and higher level of CR impairment in activities of daily living were significantly related to higher absolute discrepancy between CG and CR about CRs' QOL. In the logistic models, when the dyad had more DMI incongruence, or CG reported higher relationship strain, the CG was more likely to report a lower CR QOL than CR reported. IMPLICATIONS: Practitioners should consider incorporating CRs' perspective when planning care instead of solely depending on CGs' perspective. Also, practitioners should pay attention to any gap between perceptions of CGs and CRs, particularly with regard to CRs' QOL.

Disparities in Health, Health Care Access, and Life Experience Between American Indian and White Adults in South Dakota.

OBJECTIVES: The objective of this study is to investigate the factors associated with depressive symptoms and chronic illnesses in American Indians compared with White adults born in the post-World War II period, 1946 to 1964, and living in South Dakota. DESIGN: A cross-sectional design of American Indian and White adults aged 50 and older in South Dakota (Brookings, Vermillion, Sioux Falls, and all others areas of South Dakota) between January 2013 and May 2013 was used. American Indian and White adults (born between 1946 and 1964; N = 349). Data included sociodemographic factors and measures of chronic physical health condition, health care access, adverse childhood experiences, body mass index (BMI), Alcohol Use Disorders Identification Test, Technology Acceptance Model, and Multidimensional Scale of Perceived Social Support and Depressive Symptoms. RESULTS: American Indian adults reported more chronic diseases and conditions, a lower self-perceived physical health, were more likely to be overweight or obese, had more adverse childhood experience (ACE), and reported a lower level of alcohol intake compared to White adults. BMI was significantly associated with an increased number of chronic conditions for both groups, and American Indians' better perception of their physical health was significantly associated with lower total number of chronic conditions. Self-perceived mental health, a better level of access to health care, and a higher degree of social support were significantly inversely associated with the number of depressive symptoms for American Indian adults, while a greater level of ACE was significantly associated with an increased number of depressive symptoms for this group. CONCLUSION: The current study not only support previous studies but also contributes to understanding the disparities in and risk factors potentially impacting American Indians' physical and mental health. Our findings highlight the need to investigate the American Indians' perceptions and knowledge about health care accessibility including availability as well as perceived barriers including social sensitivity and trust. Health professionals might need to pay attention to BMI, ACE, and social relationship among American Indian adults to improve physical and mental health.

Predictors of perceived benefits and drawbacks of using paid service among daughter and daughter-in-law caregivers of people with dementia.

This study examines the types of benefits and drawbacks of a sample of daughter and daughter-in-law caregivers (CG) of people with dementia and explores the predictors associated with the identified benefits and drawbacks. The current study used a secondary analysis of a purposive sample of 102 daughters or daughters-in-law living in Northeast Ohio who were required to be using at least 8 hours of paid services per week to help in caring for their care recipient (CR) with Alzheimer's disease or other memory problems. Logistic regression was used. All respondents answered that there were benefits of having the paid help, but 51% of them reported drawbacks as well. The analyses revealed that predictors of each identified benefit and drawback were different. Information about benefits and drawbacks of paid help is useful for service providers to design better services for CGs of people with dementia.