Moderating Effects of Informal Care on the Relationship Between ADL Limitations and Adverse Outcomes in Stroke Survivors.

BACKGROUND: Stroke survivors with limitations in activities of daily living (ADL) have a greater risk of experiencing falls, hospitalizations, or physical function decline. We examined how informal caregiving received in hours per week by stroke survivors moderated the relationship between ADL limitations and adverse outcomes. METHODS: In this retrospective cohort, community-dwelling participants were extracted from the National Health and Aging Trends Study (2011-2020; n=277) and included if they had at least 1 formal or informal caregiver and reported an incident stroke in the prior year. Participants reported the amount of informal caregiving received in the month prior (low [<5.8], moderate [5.8-27.1], and high [27.2-350.4] hours per week) and their number of ADL limitations (ranging from 0 to 7). Participants were surveyed 1 year later to determine the number of adverse outcomes (ie, falls, hospitalizations, and physical function decline) experienced over the year. Poisson regression coefficients were converted to average marginal effects and estimated the moderating effects of informal caregiving hours per week on the relationship between ADL limitations and adverse outcomes. RESULTS: Stroke survivors were 69.7% White, 54.5% female, with an average age of 80.5 (SD, 7.6) years and 1.2 adverse outcomes at 2 years after the incident stroke. The relationships between informal caregiving hours and adverse outcomes and between ADL limitations and adverse outcomes were positive. The interaction between informal caregiving hours per week and ADL limitations indicated that those who received the lowest amount of informal caregiving had a rate of 0.12 more adverse outcomes per ADL (average marginal effect, 0.12 [95% CI, 0.005-0.23]; P=0.041) than those who received the highest amounts. CONCLUSIONS: Informal caregiving hours moderated the relationship between ADL limitations and adverse outcomes in this sample of community-based stroke survivors. Higher amounts relative to lower amounts of informal caregiving hours per week may be protective by decreasing the rate of adverse outcomes per ADL limitation.

The Role of Rehabilitation for Early-Stage Alzheimer's Disease and Related Dementias: Practice and Priorities.

The World Health Organization describes rehabilitation as interventions that focus on addressing disability through optimizing functional ability for individuals living with various health challenges in their unique daily life contexts. Rehabilitation services are typically seeking to enhance functional capacity and health, either in concert with, or in place of pharmacologic interventions. These services typically fall into 2 categories, restorative, where the client endeavors to return to a prior level of independent function, and compensatory, where s/he may not. In the latter case, clients might receive, and be trained to use, technology aids or other external supports to enable them to engage in a safe, healthy, and meaningful day-to-day life. For some populations, however, even enhanced functional capacity can present in the form of an insidious, albeit slower decline. So, what is, or should, rehabilitation's role be in progressive neurologic conditions? Specifically, what are the policy and practice implications of rehabilitation for (not in the presence of, but for) the care of persons living with neurodegenerative conditions such as Alzheimer's disease and Alzheimer's disease related dementias (AD/ADRD)?

Development of a Dyad-Focused Intervention for Stroke Survivors and Their Family Caregivers: A Feasibility Study.

IMPORTANCE: Transitioning from the hospital to the community poses significant challenges for stroke survivors and their caregivers. OBJECTIVE: To examine the feasibility and preliminary effects of a dyad-focused strategy training intervention. DESIGN: Single-arm trial with data collection at baseline, postintervention, and 3-mo follow-up. SETTING: Rehabilitation settings in Taiwan. PARTICIPANTS: Sixteen stroke survivor-caregiver dyads. INTERVENTIONS: Dyad-focused strategy training was provided to stroke survivor-caregiver dyads twice a week over 6 wk. The training included shared decision-making, goal setting, performance evaluation, strategy development and implementation, and therapeutic guided discovery. OUTCOMES AND MEASURES: Feasibility indicators were Goal Attainment Scaling, Dyadic Relationship Scale, Participation Measure-3 Domains, 4 Dimensions, Activity Measure for Post-Acute Care, Montreal Cognitive Assessment, Trail Making Test, Stroop Color and Word Test, Preparedness for Caregiving Scale, and Zarit Burden Interview. RESULTS: In total, 15 dyads completed all intervention sessions with full attendance. Both stroke survivors and their caregivers demonstrated high engagement and comprehension and reported moderate to high satisfaction with the intervention. From baseline to postintervention, the effects on goal attainment, frequency and perceived difficulty of community participation, executive function, mobility function, and caregiver preparedness were significant and positive. CONCLUSIONS AND RELEVANCE: Our study supports the feasibility and preliminary efficacy of dyad-focused strategy training for stroke survivor-caregiver dyads transitioning from the hospital to the community in Taiwan. Our preliminary evidence indicates that dyads who receive strategy training exhibit advancement toward their goals and experience considerable enhancements in their individual outcomes. Plain-Language Summary: This study addresses the scarcity of interventions catering to both stroke survivors and their caregivers. By demonstrating the feasibility of our dyad-focused intervention, the research offers preliminary evidence that supports the potential advantages of involving both stroke survivors and their caregivers in the intervention process.

Adaptation and Pilot Study of a Behavioral Intervention Targeting Morning Activation Deficits in Dementia Caregivers: Scheduling Activity and Monitoring Mornings (SAMM).

OBJECTIVES: Morning activation deficits (MADs) correlate with depression symptom persistence in older dementia caregivers. To clarify the potential of MADs as a target for depression interventions, we aimed to: 1) adapt an existing behavioral activation program, Engage therapy, to target mornings; and 2) evaluate effects on self-reported MADs and depression symptoms. METHODS: While trialing the 9-week Engage adaption (targeting mornings) in six older dementia caregivers, we incorporated feedback and finalized an adapted program called Scheduling Activity and Monitoring Mornings (SAMM). We delivered the SAMM protocol to 13 dementia caregivers (all female; mean age = 69, standard deviation = 7). We report modifications made/rationale, as well as changes in subjective MADs (relevant items from the Composite Scale of Morningness) and depression symptoms (Patient Health Questionnaire - 9). RESULTS: Using caregiver and expert input, we adapted the protocol to: include educational materials/content describing the potential relationship between morning inactivity and depression; target activity scheduling within 2 hours of awakening (preferably earlier); and focus only on the main components of morning activity scheduling, planning, and monitoring. This program was associated with decreases in subjective MADs averaging 29% at week 4, 52% at week 6, and 57% by week 9 (all p's <0.005). Initial depression symptoms were significantly reduced, by 62%, at week 9. CONCLUSIONS: These preliminary findings suggest that subjective MADs can be modified pragmatically, and that doing so may have antidepressant effects. A controlled trial with measures of the putative mechanism is needed to clarify whether, and if so how, targeting MAD with SAMM causally perturbs depression's mechanisms.

Project Unmute: A Digital Music Program Delivered by Adolescent Musicians to Older Adults with Cognitive Decline.

Effective intergenerational music programming has the power to positively influence the current lives of the millions of older adults who are experiencing Alzheimer's disease and dementia, as well as to support the confidence of the newest generation of young musicians. To explore this potential, we designed a digital, intergenerational music program delivered by adolescent musicians to older adults with cognitive decline. This program utilized songs preferred by the older adults and an interactive activity that engaged the two generations. We believe this type of easily scalable programming could support older adults and young musicians, as well as promote new intergenerational relationships.

Subjective Sleep Quality and Trajectories of Interleukin-6 in Older Adults.

BACKGROUND: We aimed to identify trajectories of inflammation in older adults at elevated risk for syndromal depression and anxiety and to determine whether baseline physical, cognitive, and psychosocial factors could distinguish 15-month longitudinal trajectories. METHODS: Older adults (N = 195, mean age (±SD) = 74.4 years (9.0) participating in three depression and anxiety prevention protocols completed a comprehensive battery of psychosocial assessments and provided blood samples for analysis of interleukin-6 (IL-6) every 3 months over a maximum of 15 months. Group-based trajectory modeling identified trajectories. Adjusted logistic regression examined associations between baseline factors and trajectory groups. RESULTS: Two 15-month trajectories were identified: stable lower IL-6 levels (84%; mean (±SD) = 3.2 (2.1) pg/mL); and consistently higher IL-6 levels (16%; mean = 9.5 (7.4) pg/mL). Poor sleep quality predicted consistently higher levels of IL-6 (OR = 1.9, 95% CI = 1.03-3.55). CONCLUSION: Poor sleep quality may represent a therapeutic target to reduce inflammation.

Evidence for the Effectiveness of Interventions for Caregivers of People With Chronic Conditions: A Systematic Review.

IMPORTANCE: Caregivers are pivotal in supporting the growing population of people with chronic conditions. Yet, engaging in the caregiver role involves the risk of poor outcomes. Caregiver interventions are needed that address poor outcomes while fostering engagement in role-related activities. OBJECTIVE: To evaluate the evidence for interventions to support caregivers of adults with chronic conditions. DATA SOURCES: Five databases were searched for studies of interventions for caregivers and patient-caregiver dyads published between 1995 and 2019. Study Selection and Data Collection: We reviewed the titles, abstracts, and full-text articles of the initial search results (N = 12,216 studies) according to a predetermined protocol. FINDINGS: Forty-eight studies met the inclusion criteria. Psychoeducation and education with skills training were the two caregiver intervention themes. Studies evaluating psychoeducation (n = 28) provided low strength of evidence for improved psychosocial outcomes. Within this theme, problem-solving and coping skills training were common intervention components associated with significant improvements in depression and quality of life. Studies evaluating education with skills training (n = 20) provided moderate strength of evidence for improved knowledge and low strength of evidence for improved psychosocial outcomes. Dyadic self-management education and hands-on training were common components associated with significant improvements in knowledge, quality of life, and burden or strain. CONCLUSIONS AND RELEVANCE: We found low strength of evidence to support the use of psychoeducation and education with skills training. Within these approaches, problem-solving and coping skills training, dyadic self-management education, and hands-on training show promise for improving caregiver outcomes. What This Article Adds: Findings of this systematic review are inconclusive with respect to psychoeducation and education with skills training leading to improved caregiver well-being. Within these broad approaches, the findings support the use of problem-solving and coping skills training, dyadic self-management education, and hands-on training to improve knowledge and well-being among caregivers of people with chronic conditions.

Unpaid Caregiving and Aging in Place in the United States: Advancing the Value of Occupational Therapy.

Unpaid caregivers are often expected to help family members or friends overcome activity limitations and participation restrictions to successfully age in place. Caregivers assume multiple responsibilities, such as managing their own physical and psychosocial needs and navigating a complex health care system, and many feel ill equipped to fulfill the necessary health care responsibilities for their care recipients. Underprepared caregivers may cause poor outcomes for care recipients. Federal and state policy proposals call attention to the need to better support caregivers, especially as their numbers increase. Occupational therapy practitioners are well positioned to effectively engage caregivers as they navigate the health care system. The occupational therapy process looks broadly at the functional abilities, environmental contexts, and occupational demands that play a pivotal role in successful aging in place for clients and better outcomes for their caregivers. Now is the time to define occupational therapy's distinct value to this area.

Including and Training Family Caregivers of Older Adults in Hospital Care: Facilitators and Barriers.

BACKGROUND: Despite the role caregivers play in the delivery of care, the interactions and training methods used with caregivers during an inpatient stay are not clear. PURPOSE: The purpose was to examine interactions and training methods used with caregivers during hospital care. METHODS: A mixed-methods case study was conducted. Observations were summarized and interviews were analyzed using thematic analysis. RESULTS: The frequency of caregiver engagement varied at different points in the care process but was highest among observations during the stay care point. Providers were most commonly using written and verbal instructions to train caregivers. Three themes emerged from the interviews and were described to be both facilitators and barriers to caregiver involvement: experience, time, and relationship. CONCLUSIONS: High-quality person and family-centered care depends upon coordinated efforts among health care systems, providers, patients, and caregivers. Future caregiver initiatives should aim to decrease disengagement, increase assessment, and broaden the use of training methods.

A Need to Activate Lasting Engagement.

Occupational therapy practitioners provide interventions to promote activity engagement to multiple clinical populations. They help clients develop restorative, adaptive, and compensatory skills to improve their performance in daily activities. The issue addressed in this article is that current clinical frameworks lack translation of learned skills to consistent everyday performance. There is a gap between what clients can do and what clients actually do in everyday life. Behavioral activation provides an explicit, structured, and practical approach that can translate capacity into long-term engagement. This article presents behavioral activation as a transdiagnostic approach that targets populations experiencing chronic illness to bridge the gap between what the client can do in therapy and what the client could do in everyday life. WHAT THIS ARTICLE ADDS: People with chronic illness have difficulty translating the skills learned in traditional practice settings to everyday life. Behavioral activation offers occupational therapy practitioners a practical structure to promote the translation of learned skills.

Geriatric Mental Healthcare Training: A Mini-Fellowship Approach to Interprofessional Assessment and Management of Geriatric Mental Health Issues.

INTRODUCTION: The population in United States aged 65 and older has rapidly grown and is projected to grow faster than any other segment of the population. Despite this demographic shift, the nation's geriatric workforce is shrinking. AIM: The primary goal of the fellowship was to form a learning collaborative that would help trainees in medicine, nursing, social work, pharmacy and occupational/physical therapy understand the roles of each discipline involved in the provision of geriatric mental healthcare and to enhance basic knowledge of common geriatric syndromes. METHODS: Faculty from the University of Pittsburgh developed a format for the mini-fellowship. Trainees from five disciplines were recruited for participation in the mini-fellowship. This was offered annually over four-year period, hosted by the John A. Hartford Foundation Centers of Excellence in Geriatric Psychiatry at the University of Pittsburgh and University of California at San Diego. RESULTS: Eighty-one participants across five schools of the health sciences completed the mini-fellowship. Feedback was positive: most participants appreciated learning from other team members, endorsed appreciation of the contributions of other disciplines to patient care, and reported improved understanding of three major geriatric syndromes. CONCLUSION: Conducting an interdisciplinary mini-fellowship in geriatric mental health was feasible and well received by trainees. The fellowship enabled better appreciation for the provision of geriatric mental health care within the context of an interprofessional team. However, decanal and faculty leadership across the schools needs to place greater emphasis on the importance of interprofessional team-based learning and to free up time for such activity.

Treatment Considerations for Depression Research in Older Married Couples: A Dyadic Case Study.

OBJECTIVE: Critical gaps remain in understanding optimal approaches to intervening with older couples. The focus of this report is to describe the pros and cons of incorporating spousal dyads into depression-prevention research. METHODS: In an intervention development study, the authors administered problem-solving therapy (PST) dyadically to participants with mild cognitive impairment (MCI) and their caregivers. Dyads worked with the same interventionist in the same therapy session. The dyadic PST (highlighted in a case example of a husband with MCI and his wife/support person) and the potential feasibility of the program are described. RESULTS: The authors found that the wife of the individual with MCI could be trained as a PST coach to help her husband learn and use problem-solving skills. A decrease in depressive symptom severity was observed for the individual with MCI, which was sustained over 12 months of follow-up. Neither the husband nor wife experienced an incident episode of major depression over the course of the study. CONCLUSION: Dyadic interventions need to be further developed in geriatric psychiatry; proven methods such as PST can be modified to include patients' support persons. Recommendations are offered for developing randomized controlled trials that aim to recruit dyads and prevent depression in at-risk older married couples.

Systematic review of dyadic and family-oriented interventions for late-life depression.

OBJECTIVE: Supportive behaviors (both instrumental and emotional) from spouses and close family members can impact the trajectory of older adults' depressive symptoms. Interventions that target both the patient and support person may be more effective than interventions that target the patient only, in terms of alleviating mood symptoms in the identified patient. The purpose of this paper was to review the characteristics and findings of dyadic and family-oriented interventions for late-life mood disorders to determine if they are effective and beneficial. METHODS: Following PRISMA guidelines, we conducted a systematic review of reports in the literature on dyadic or family-oriented interventions for late-life mood disorders. We searched PubMed, OVID PsycINFO, and EMBASE for peer-reviewed journal articles in English through October 2014. RESULTS: We identified 13 articles, representing a total of 10 independent investigations. Identified studies focused on spouses and close family members as support persons. Effect sizes for dyadic interventions that treated major depressive disorder were, on average, moderately strong, while effect sizes for dyadic interventions that reduced depressive symptoms were generally small. We did not identify any dyadic studies that treated bipolar disorder. CONCLUSIONS: This review showed that dyadic interventions are feasible and that these interventions can decrease symptomatology in individuals who have major depressive disorder. Research is needed to understand the relative efficacy of a dyadic approach over a single-target approach in treating depression. Copyright © 2016 John Wiley & Sons, Ltd.

Deconstructing Chronic Low Back Pain in the Older Adult--Step by Step Evidence and Expert-Based Recommendations for Evaluation and Treatment. Part V: Maladaptive Coping.

OBJECTIVE: As part of a series of articles designed to deconstruct chronic low back pain (CLBP) in older adults, this article focuses on maladaptive coping--a significant contributor of psychological distress, increased pain, and heightened disability in older adults with CLBP. METHODS: A modified Delphi technique was used to develop a maladaptive coping algorithm and table providing the rationale for the various components of the algorithm. A seven-member content expert panel and a nine-member primary care panel were involved in the iterative development of the materials. While the algorithm was developed keeping in mind resources available within the Veterans Health Administration (VHA) facilities, panelists were not exclusive to the VHA, and therefore, materials can be applied in both VHA and civilian settings. The illustrative clinical case was taken from one of the contributors' clinical practice. RESULTS: We present a treatment algorithm and supporting table to be used by providers treating older adults who have CLBP and engage in maladaptive coping strategies. A case of an older adult with CLBP and maladaptive coping is provided to illustrate the approach to management. CONCLUSIONS: To promote early engagement in skill-focused treatments, providers can routinely evaluate pain coping strategies in older adults with CLBP using a treatment algorithm.

Deconstructing Chronic Low Back Pain in the Older Adult-Step by Step Evidence and Expert-Based Recommendations for Evaluation and Treatment: Part XI: Dementia.

OBJECTIVE : To present the 11th in a series of articles designed to deconstruct chronic low back pain (CLBP) in older adults. The series presents CLBP as a syndrome, a final common pathway for the expression of multiple contributors rather than a disease localized exclusively to the lumbosacral spine. Each article addresses one of 12 important contributions to pain and disability in older adults with CLBP. This article focuses on dementia. METHODS: A modified Delphi technique was used to develop an algorithm for an approach to treatment for older adults living with CLBP and dementia. A panel of content experts on pain and cognition in older adults developed the algorithm through an iterative process. Though developed using resources available within Veterans Health Administration (VHA) facilities, the algorithm is applicable across all health care settings. A case taken from the clinical practice of one of the contributors demonstrates application of the algorithm. RESULTS: We present an evidence-based algorithm and biopsychosocial rationale to guide providers evaluating CLBP in older adults who may have dementia. The algorithm considers both subtle and overt signs of dementia, dementia screening tools to use in practice, referrals to appropriate providers for a complete a workup for dementia, and clinical considerations for persons with dementia who report pain and/or exhibit pain behaviors. A case of an older adult with CLBP and dementia is presented that highlights how an approach that considers the impact of dementia on verbal and nonverbal pain behaviors may lead to more appropriate and successful pain management. CONCLUSIONS: Comprehensive pain evaluation for older adults in general and for those with CLBP in particular requires both a medical and a biopsychosocial approach that includes assessment of cognitive function. A positive screen for dementia may help explain why reported pain severity does not improve with usual or standard-of-care pain management interventions. Pain reporting in a person with dementia does not always necessitate pain treatment. Pain reporting in a person with dementia who also displays signs of pain-associated suffering requires concerted pain management efforts targeted to improving function while avoiding harm in these vulnerable patients.Key Words. Dementia; Chronic Pain; Low Back Pain; Lumbar; Primary Care.

Attribution of mild cognitive impairment etiology in patients and their care partners.

OBJECTIVE: This study examined the attribution of mild cognitive impairment (MCI) etiology assigned by individuals with MCI and their care partners, and the extent to which the dyads agreed on the attribution of MCI etiology. METHODS: We conducted secondary analyses of cross-sectional data from a cohort of individuals with MCI (n = 60) and their care partners (n = 60). The mean age of the individuals with MCI was 71.0 ± 9.4 years and of care partners 64.2 ± 11.0 years. The primary outcome was attribution assigned to memory deficits on the Illness Perception Questionnaire. We categorized the attribution of MCI etiology as either potentially controllable or uncontrollable factors. We described the distribution of MCI etiology with descriptive and contingency tables. We determined the odds of a patient or care partner choosing one type of MCI etiology over another. RESULTS: Although individuals with MCI and their care partners most frequently attributed MCI to uncontrollable factors (81.7% and 61.0%, respectively), care partners were 28.41 (95% CI, 1.26 to 645.48) times more likely to attribute MCI etiology to potentially controllable factors than individuals with MCI. No significant associations between demographic factors and attribution of MCI etiology were found for the individuals with MCI or the care partners. CONCLUSION: Findings demonstrated that members of the dyad attributed MCI etiology to different causes. Attributions of MCI etiology should be explored by professionals to clarify misconceptions and potentially improve subsequent voluntary actions intended to assist oneself or others.

Additive effect of age on disability for individuals with spinal cord injuries.

OBJECTIVE: To examine the additive effect of age on disability for adults with spinal cord injury (SCI). DESIGN: Prospective cohort study. SETTING: SCI Model Systems. PARTICIPANTS: Individuals with SCI (median age at injury, 32 y; range, 6-88 y) with a discharge motor FIM score and at least 1 follow-up motor FIM score who also provided measures of other covariates (N=1660). Of the total sample, 79% were men, 72% were white, 16% had incomplete paraplegia, 33% had complete paraplegia, 30% had incomplete tetraplegia, and 21% had complete tetraplegia. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The primary study outcome was the motor subscale of the FIM. A mixed-models approach was used to examine the additive effect of age on disability for individuals with SCI. RESULTS: When controlling for motor FIM at discharge from rehabilitation, level and severity of injury, age at injury, sex, race, and the age × time interaction were not significant (P=.07). Age at the time of SCI was significantly associated with motor FIM (F1,238=22.49, P<.001). Two sensitivity analyses found significant interactions for both age × time (P=.03, P=.02) and age × time-square (P=.01, P=.006) models. Trajectory of motor FIM scores is moderated slightly by age at the time of injury. The older participants were at the time of injury, the greater the curvature and the more rapid decline were found in later years. CONCLUSIONS: These findings indicate that age moderately influences disability for some individuals with SCI: the older the age at the time of injury, the greater the influence age has on disability. The findings serve as an important empirical foundation for the evaluation and development of interventions designed to augment accelerated aging experienced by individuals with SCI.

Depressive Symptoms Associated With Social Participation in Older Adults Living With Mild Cognitive Impairment.

Mild Cognitive Impairment (MCI) affects 15% of adults 50 years old and over. Individuals living with MCI have shown decreased social participation, a critical activity as it may delay cognitive decline. Depression may be a key factor in limiting participation. This study is a secondary data analysis of 30 older adults living with MCI, looking for associations with participation. Participation was examined using the Patient Reported Outcomes Measurement Information System (PROMIS®) Satisfaction with Participation in Social Roles Computer Adaptive Test (CAT) form. Depressive symptoms were reported using the PROMIS Quality of Life in Neurological Disorders Depression CAT form and the Patient Health Questionnaire (PhQ-9) form. Results showed that demographics (age, sex) were not significantly associated with participation, but depressive symptoms were significantly associated. This suggests that adults living with MCI who have higher levels of depressive symptoms may be a uniquely vulnerable population who benefit from interventions that support participation.

Sleep-wake behaviors associated with cognitive performance in middle-aged participants of the Hispanic Community Health Study/Study of Latinos.

OBJECTIVES: Many sleep-wake behaviors have been associated with cognition. We examined a panel of sleep-wake/activity characteristics to determine which are most robustly related to having low cognitive performance in midlife. Secondarily, we evaluate the predictive utility of sleep-wake measures to screen for low cognitive performance. METHODS: The outcome was low cognitive performance defined as being >1 standard deviation below average age/sex/education internally normalized composite cognitive performance levels assessed in the Hispanic Community Health Study/Study of Latinos. Analyses included 1006 individuals who had sufficient sleep-wake measurements about 2years later (mean age=54.9, standard deviation= 5.1; 68.82% female). We evaluated associations of 31 sleep-wake variables with low cognitive performance using separate logistic regressions. RESULTS: In individual models, the strongest sleep-wake correlates of low cognitive performance were measures of weaker and unstable 24-hour rhythms; greater 24-hour fragmentation; longer time-in-bed; and lower rhythm amplitude. One standard deviation worse on these sleep-wake factors was associated with ∼20%-30% greater odds of having low cognitive performance. In an internally cross-validated prediction model, the independent correlates of low cognitive performance were: lower Sleep Regularity Index scores; lower pseudo-F statistics (modellability of 24-hour rhythms); lower activity rhythm amplitude; and greater time in bed. Area under the curve was low/moderate (64%) indicating poor predictive utility. CONCLUSION: The strongest sleep-wake behavioral correlates of low cognitive performance were measures of longer time-in-bed and irregular/weak rhythms. These sleep-wake assessments were not useful to identify previous low cognitive performance. Given their potential modifiability, experimental trials could test if targeting midlife time-in-bed and/or irregular rhythms influences cognition.