Social Changes in Women's Roles, Families, and Generational Ties.

There has been much speculation around the aging of the Baby Boom Generation because they were at the forefront of turbulent social changes in women's roles, marriage, and childbearing. This article addresses the ways in which population aging is intertwined with family change, and how intergenerational relations in later life are being transformed by social and demographic changes. Increasing diversity of family types and potentially weaker family ties raise the possibility of challenges to come in the next century.

"It's got to be on this page": age and cognitive style in a study of online health information seeking.

BACKGROUND: The extensive availability of online health information offers the public opportunities to become independently informed about their care, but what affects the successful retrieval and understanding of accurate and detailed information? We have limited knowledge about the ways individuals use the Internet and the personal characteristics that affect online health literacy. OBJECTIVE: This study examined the extent to which age and cognitive style predicted success in searching for online health information, controlling for differences in education, daily Internet use, and general health literacy. METHODS: The Online Health Study (OHS) was conducted at Johns Hopkins School of Public Health and Stanford University School of Medicine from April 2009 to June 2010. The OHS was designed to explore the factors associated with success in obtaining health information across different age groups. A total of 346 men and women aged 35 years and older of diverse racial and ethnic backgrounds participated in the study. Participants were evaluated for success in searching online for answers to health-related tasks/questions on nutrition, cancer, alternative medicine, vaccinations, medical equipment, and genetic testing. RESULTS: Cognitive style, in terms of context sensitivity, was associated with less success in obtaining online health information, with tasks involving visual judgment most affected. In addition, better health literacy was positively associated with overall success in online health seeking, specifically for tasks requiring prior health knowledge. The oldest searchers were disadvantaged even after controlling for education, Internet use, general health literacy, and cognitive style, especially when spatial tasks such as mapping were involved. CONCLUSIONS: The increasing availability of online health information provides opportunities to improve patient education and knowledge, but effective use of these resources depends on online health literacy. Greater support for those who are in the oldest cohorts and for design of interfaces that support users with different cognitive styles may be required in an age of shared medical decision making.

Behavioral adaptation and late-life disability: a new spectrum for assessing public health impacts.

OBJECTIVES: To inform public health efforts to promote independent functioning among older adults, we have provided new national estimates of late-life disability that explicitly recognize behavioral adaptations. METHODS: We analyzed the 2011 National Health and Aging Trends Study, a study of Medicare enrollees aged 65 years and older (n = 8077). For 7 mobility and self-care activities we identified 5 hierarchical stages--fully able, successful accommodation with devices, activity reduction, difficulty despite accommodations, and receipt of help--and explored disparities and associations with quality of life measures. RESULTS: Among older adults, 31% were fully able to complete self-care and mobility activities. The remaining groups successfully accommodated with devices (25%), reduced their activities (6%), reported difficulty despite accommodations (18%), or received help (21%). With successive stages, physical and cognitive capacity decreased and symptoms and multimorbidity increased. Successful accommodation was associated with maintaining participation in valued activities and high well-being, but substantial disparities by race, ethnicity, and income existed. CONCLUSIONS: Increased public health attention to behavioral adaptations to functional change can promote independence for older adults and may enhance quality of life.

Why do lifespan variability trends for the young and old diverge? A perturbation analysis.

BACKGROUND: Variation in lifespan has followed strikingly different trends for the young and old: while total lifespan variability has decreased as life expectancy at birth has risen, the variability conditional on survival to older ages has increased. These diverging trends reflect changes in the underlying demographic parameters determining age-specific mortality. OBJECTIVE: We ask why the variation in the ages at death after survival to adult ages has followed a different trend than the variation at younger ages, and aim to explain the divergence in terms of the age pattern of historical mortality changes. METHODS: Using simulations, we show that the empirical trends in lifespan variation are well characterized using the Siler model, which describes the mortality trajectory using functions representing early-life, later-life, and background mortality. We then obtain maximum likelihood estimates of the Siler parameters for Swedish females from 1900 to 2010. We express mortality in terms of a Markov chain model, and apply matrix calculus to compute the sensitivity of age-specific variance trends to the changes in Siler model parameters. RESULTS: Our analysis quantifies the influence of changing demographic parameters on lifespan variability at all ages, highlighting the influence of declining childhood mortality on the reduction of lifespan variability, and the influence of subsequent improvements in adult survival on the rising variability of lifespans at older ages. CONCLUSIONS: These findings provide insight into the dynamic relationship between the age pattern of survival improvements and time trends in lifespan variability.

Metro-Nonmetro Differences in Adverse Events in Residential Care Communities: Results From the National Post-Acute and Long-Term Care Study.

More than 1 in 5 older Americans live in rural areas (10.6 million of the 46.2 million aged 65 and older). Long-term care for aging rural populations is a growing challenge in the United States. Research on long-term care services in nonmetro areas has focused almost exclusively on nursing home care, despite growth of residential care alternatives. This paper uses unique facility-level data from the 2020 National Post-acute and Long-term Care Study (NPALS) to examine the relationship of residential care community (RCC) features in metro and nonmetro settings with adverse outcomes (emergency department visits, overnight hospital stays, and falls). Nationally, in 2020, about 13.5% of RCC residents made visits to the emergency department, 8.6% had overnight hospital stays, and 21.3% had falls. Controlling for facility characteristics, RCCs in metro areas had higher risks of overnight hospital stays (p < .001) but lower risks of falls (p = .06).

The Changing Demography of Late-Life Family Caregiving: A Research Agenda to Understand Future Care Networks for an Aging U.S. Population.

Repeated claims that a dwindling supply of potential caregivers is creating a crisis in care for the U.S. aging population have not been well-grounded in empirical research. Concerns about the supply of family care do not adequately recognize factors that may modify the availability and willingness of family and friends to provide care to older persons in need of assistance or the increasing heterogeneity of the older population. In this paper, we set forth a framework that places family caregiving in the context of older adults' care needs, the alternatives available to them, and the outcomes of that care. We focus on care networks, rather than individuals, and discuss the demographic and social changes that may alter the formation of care networks in the future. Last, we identify research areas to prioritize in order to better support planning efforts to care for the aging U.S. population.

Effects of home, outside leisure, social, and peer activity on psychological health among Japanese family caregivers.

OBJECTIVE: Previous research has indicated that informal caregivers' personal activities are disrupted by their caregiving role, leading to psychological stress and lower life satisfaction. However, the extent to which engagement in personal activities affects caregivers' psychological health remains unclear. This study examines the relationship between different types and frequencies of activities and both positive and negative parameters of the psychological health of caregivers. METHODS: A mail survey was conducted with 727 family caregivers of older persons using adult day-care services in the Tokyo metropolitan area. Perceived caregiver burden, care satisfaction, life satisfaction, and depression were used as psychological health outcomes. Engagement in home, outside leisure, social, and peer activities, as well as caregiver and care-recipient characteristics and caregiving situations, were assessed using a multivariate regression analysis. RESULTS: Engagement in home activities was related to lower scores on burden and depression and greater care satisfaction after controlling for care needs and caregiver characteristics, and social and peer activities were associated with greater life satisfaction. More frequent engagement was also associated with better psychological health, but a moderate involvement in home activities was most strongly associated with better care satisfaction. The amount of outside leisure activity was not significantly related to any of the outcomes. CONCLUSION: This study shows that activity type and frequency are associated with caregivers' psychological health, extending previous findings and providing practical implications for the support of family caregivers through programs to improve their participation in specific types of activities.

Parity and parents' health in later life: the gendered case of Ismailia, Egypt.

We investigate the relationship between reproduction and functional health in later life among women and men in the resource-poor and gender-stratified setting of Ismailia governorate, Egypt. Analyses of survey data collected in 2003 show a statistically significant positive association between parity and difficulty with activities of daily living (ADLs), controlling for demographic and socio-economic factors and other co-morbid conditions. We also find that the number of daughters (but not sons) is associated with worse physical functioning, and this association is more pronounced for older fathers than for older mothers. Our results indicate that both biological and social pathways link fertility and later-life health in this context, and that prescribed familial roles may underlie the differential impact of sons and daughters on the health of mothers and fathers in later life.

Self-selected walking speed was consistent when recorded while using a cane.

OBJECTIVE: To assess whether loss of consistency or systematic measurement error is introduced by allowing older individuals to use a cane during measurement of self-selected walking speed (SSWS). STUDY DESIGN AND SETTING: Observational study of women aged 65+ (Women's Health and Aging Study I, n=1,002). RESULTS: Of individuals who use a cane in daily life, 201 (50.76%) did not use an aid during testing. The Coefficient of Variation was low in individuals who reported cane use in daily life but did not use one in testing (10.72%), and did not vary substantially if a cane was used (12.04%). The Intra-Class Correlation Coefficient was high: 0.958 for those who reported cane use in daily life but did not use one during testing and 0.962 for those who used a cane. In both groups, Bland-Altman plots revealed a small systematic difference between the first and second trials. There was no evidence of effect modification of the association between SSWS and mobility disability by cane use during testing. CONCLUSION: This observational study found neither evidence of poorer consistency nor increased measurement bias in SSWS recorded while using a cane compared to using no assistive device.

Disability Measurement in the Health and Retirement Study.

The Health and Retirement Study (HRS) has provided extensive and detailed national data on disability since it began in 1992, and has been used extensively in studies of disability trends and trajectories. We summarize conceptual frameworks used to characterize disability and review the HRS measures of functioning, work disability, and employer accommodations. HRS survey questions have experienced changes in wording, skip logic, or other design features over the life of the study, and we comment on the analytic challenges posed by those changes. Among our conclusions are (1) work disability and benefit eligibility are important concepts that should be considered for redesign to better reflect current concepts and policy issues; (2) methodological studies of changes in wording or skip logic should be undertaken; and (3) minor additions to survey content in areas such as temporal reference periods or changes in social-participation activities would improve measurement.

Disaster Preparedness Among Older Japanese Adults With Long-Term Care Needs and Their Family Caregivers.

OBJECTIVE: In the 2011 Great East Japan Earthquake, as in Hurricanes Katrina and Rita in the United States, older individuals were at the greatest risk of mortality. Much concern has been raised about developing plans to reduce these risks, but little information has been provided about preparedness, and the key role played by caregivers has been largely unexplored. The aims of this study were thus to examine the preparedness of family caregivers of older adults with long-term care needs and to identify the characteristics of older adults and their caregivers that are associated with poor preparedness and greater concern about disasters. METHODS: Shortly after the Great East Japan Earthquake, the second wave of the Fukui Longitudinal Caregiver Study was administered to the family caregivers of older Japanese individuals with long-term care needs. The sample included 952 caregivers from 17 municipalities in Fukui prefecture. Logistic regression analyses were used to identify the factors associated with self-assessed preparedness, evacuation planning, and caregivers' concerns about preparedness. RESULTS: The majority (75%) of the caregivers had no concrete plans for evacuation in an emergency, and those caring for persons with dementia were 36% less likely to have any plan. In multivariate models, caregivers who were more experienced and wealthier and who reported more family and community support were more likely to feel well prepared. Caregivers with poor health or limited financial resources or who were responsible for older persons with mobility difficulties reported higher levels of anxiety about their disaster preparedness. CONCLUSIONS: This study indicates that most caregivers are ill prepared to respond in emergencies and that caregiver resources, community support, and the needs of older care recipients influence both preparedness and concern about disasters. Education for caregivers and the development of community support programs could provide important sources of assistance to this vulnerable group. (Disaster Med Public Health Preparedness. 2017;11:31-38).

Trends in the use of assistive technology and personal care for late-life disability, 1992-2001.

We describe national trends during the 1990s in late-life difficulty and assistance with self-care activities. Among older Americans living in the community and experiencing difficulty with self-care activities, assistive-technology use increased substantially whereas use of personal care declined. Using a decomposition technique, we demonstrate that these shifts in assistance toward technology account for half the decline in the number of people dependent on personal care.

Fertility decline, family structure, and support for older persons in Latin America and Asia.

OBJECTIVE: To compare family structures and support for older persons in two Asian countries (Taiwan and the Philippines) and six urban areas in Latin America (Buenos Aires, São Paulo, Havana, Santiago, Mexico City, and Montevideo). METHODS: Using the 1999 Survey of Health and Living Status of the Elderly in Taiwan, the 2000 Philippine Survey of the Near Elderly and Elderly, and the 2001 Pan American Health Organisation surveys on Salud, Bienestar y Envejecimiento en América Latina y el Caribe, descriptive tables show variations across countries in family structure, proximity, and transfers of support by the timing of the fertility transition in each location. RESULTS: Older people in settings with earlier transitions had fewer children and more childlessness, higher levels of solitary living, and lower levels of co-residence with children. In earlier transition settings, receipt of family support was lower and provision higher. DISCUSSION: The timing of the demographic transition has significant implications for kin availability and support.

Wheelchairs, walkers, and canes: what does Medicare pay for, and who benefits?

Medicare's role in the distribution of mobility-related assistive technology has not been well documented, yet rapid growth and regional variation in spending, and concerns over "in-the-home" coverage criteria, highlight the need for facts. Using the 2001 Medicare Current Beneficiary Survey, we find that 6.2 percent percent of beneficiaries obtained mobility assistive technology under the Medicare durable medical equipment (DME) benefit. These beneficiaries were disproportionately poor, disabled, and users of both acute and postacute services. Average per item spending ranged from $52 for canes to $6,208 for power wheelchairs. Among beneficiaries who acquired such technology through the DME benefit, these devices comprised just 2 percent of overall Medicare spending.

Measurement of assistive device use: implications for estimates of device use and disability in late life.

PURPOSE: This study systematically reviews approaches that national surveys have used to measure the use of assistive devices and examines the implications of these different approaches for prevalence estimates of device use and disability in late life. DESIGN AND METHODS: Cross-sectional data from six national surveys are used to compare rates of assistive device use and disability among community-dwelling adults aged 65 and older. RESULTS: Estimates of the use of any device are similar across surveys, ranging from 14% to 18% for the population of adults aged 65 and older. However, one survey design element-the restriction of device-use questions to those reporting difficulty with daily activities-omits a potentially sizeable group: those who use devices but report no difficulty. Including this group of device users significantly increases the prevalence estimates of both device use and disability. IMPLICATIONS: The use of assistance and perceptions of difficulty are inextricably interwoven, and attention to the measurement of these concepts is needed. Survey designers may want to consider asking questions about assistive device use independent of questions about difficulty. In addition, researchers who study disability may want to consider including those who report using devices but no difficulty, a group that may become more prevalent as new cohorts age.

Racial differences in formal long-term care: does the timing of parenthood play a role?

OBJECTIVE: This article examines the association between race and the timing of formal long-term care (LTC) service use, both institutional and community based. It seeks to understand whether early parenthood predicts the timing of LTC use later in life and whether it in turn mediates the association between race and LTC use. In particular, it explores whether the lower rate of formal LTC use among African Americans is due in some part to the earlier inception of parenthood. METHODS: Linking measures from the 1989 National Long-Term Care Survey with Medicare claims (1989-1993), we model age at first use of institutional (skilled nursing facility) care and home health as competing risks using a Cox proportional hazards model. RESULT: Early parenthood accelerates first use of home health for Whites but delays first use for Blacks. The likelihood of any LTC use by race group converges as timing of parenthood increases. DISCUSSION: Differential effects of teen childbearing across race groups indicate differential vulnerability to LTC needs among early parents.

Reconsidering substitution in long-term care: when does assistive technology take the place of personal care?

OBJECTIVE: Assistive technology (AT) may improve quality of life and reduce dependence for older persons with disabilities. In this article, we examine tradeoffs between the use of AT and reliance on personal care, with attention to factors that may influence those relationships. METHODS: We jointly modeled hours of formal and informal care with use of AT in order to address the interdependence of these outcomes in ways not taken into account in previous studies. We analyzed a national sample of older persons with difficulty in activities of daily living drawn from Phase 2 of the 1994-1995 National Health Interview Survey (NHIS) Disability Supplement. RESULTS: Our findings show that the use of AT was associated with reductions in informal care hours, especially for those who were unmarried, better educated, or had better cognitive abilities, but appeared to supplement formal care services for these groups. Individuals with cognitive impairment were less likely than others to substitute AT with either type of personal care. DISCUSSION: These models raise the possibility that reductions of informal care hours may be accomplished with a combination of formal care and assistive devices, rather than from either alternative alone.

Gender and use of health care among older adults in Egypt and Tunisia.

In Western industrialized countries, women report using health services more often than do men. We explore the applicability of existing theory to explain gender differences in use of health care among older adults in Egypt and Tunisia, where females have received less health care than males in early life. Findings show that women report visiting providers and using medications more often than do men; however, adjusted odds of visiting doctors are comparable for women and men in Tunisia and lower for women than men in Egypt. Odds of using health care are higher for women than men among those reporting no morbidity or functional impairment, but these relative odds diminish or reverse among those reporting multiple morbidities or severe impairments. The contributions of subjective and objective illness, quality of social support, and availability of services on gender differences in care in later life should be assessed in these and other settings where girls' excess mortality persists.

A comparison of assistive technology and personal care in alleviating disability and unmet need.

PURPOSE: The authors examine differences in reports of residual disability and unmet need by type of long-term care arrangement (assistive technology or personal care). DESIGN AND METHODS: This study compares three specific dimensions of residual difficulty (pain, fatigue, and time intensity) and reports of unmet need across care arrangements. Samples from the U. S. 1994-1995 National Health Interview Survey Phase 2 Disability Supplements include adults with limitations in bathing, transferring, walking, and getting outside. RESULTS: Even when differences in underlying disability are accounted for, assistive technology (AT) confers no additional benefit in the three dimensions of residual difficulty analyzed here. AT users equally or more often report that tasks are tiring, time consuming, or painful, even when they use assistance. Though this would appear to indicate unmet needs for care, fewer AT users report a desire for hands-on personal care. IMPLICATIONS: Though disability alleviation by technology is no better on specific dimensions of difficulty, technology users report less unmet need for personal care. Designing appropriate and cost-effective home care for adults with disabilities requires a better understanding of the ways in which technology users may differ from others and the circumstances under which technology can be most effective.

Depression among recipients of informal care: the effects of reciprocity, respect, and adequacy of support.

OBJECTIVES: The objective of this work was to examine the relationship of perceived quality of care to depression among recipients of informal long-term care. METHODS: Generalized estimating equations were used to generate population-average logistic regression models of prevalent depression, using a sample of 420 disabled community-dwelling women aged 65 or older receiving informal care obtained from the Women's Health and Aging Study Caregiving Survey. RESULTS: Findings confirm a substantial prevalence of depression among older women with disabilities and support the hypothesis that perceived reciprocity and respect afforded by one's primary caregiver as well as adequacy of instrumental support all were associated with a lower likelihood of being categorized as depressed, even after controlling for sociodemographic, health, and psychosocial characteristics that are known to be related to depression. DISCUSSION: Perceived quality of informal care arrangements has a bearing on the psychological health of care recipients. Individuals in more reciprocal relationships and in relationships where they felt respected and valued were less likely to be depressed than their counterparts.