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.

Cumulative effect of loneliness and social isolation on health outcomes among older adults.

OBJECTIVES: Loneliness and social isolation are described similarly yet are distinct constructs. Numerous studies have examined each construct separately; however, less effort has been dedicated to exploring the impacts in combination. This study sought to describe the cumulative effects on late-life health outcomes. METHOD: Survey data collected in 2018-2019 of a randomly sampled population of US older adults, age 65+, were utilized (N = 6,994). Survey measures included loneliness and social isolation using the UCLA-3 Loneliness Scale and Social Network Index. Participants were grouped into four categories based on overlap. Groups were lonely only, socially isolated only, both lonely and socially isolated, or neither. Bivariate and adjusted associations were examined. RESULTS: Among participants (mean age = 76.5 years), 9.8% (n = 684) were considered lonely only, 20.6% (n = 1,439) socially isolated only, 9.1% (n = 639) both lonely and socially isolated, and 60.5% (n = 4,232) neither. Those considered both lonely and socially isolated were more likely to be older, female, less healthy, depressed, with lower quality of life and greater medical costs in bivariate analyses. In adjusted results, participants who were both lonely and socially isolated had significantly higher rates of ER visits and marginally higher medical costs. CONCLUSION: Results demonstrate cumulative effects of these constructs among older adults. Findings not only fill a gap in research exploring the impacts of loneliness and social isolation later in life, but also confirm the need for approaches targeting older adults who are both lonely and socially isolated. As the COVID-19 pandemic continues, this priority will continue to be urgent for older adults.

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 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 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.

Reducing loneliness and improving well-being among older adults with animatronic pets.

BACKGROUND: Studies consistently demonstrate that older adults who are lonely have higher rates of depression and increased mortality risk. Pet ownership may be a solution for loneliness; however, challenges related to pet ownership exist for older adults. Therefore, researchers and practitioners are examining the use of animatronic pets to reduce loneliness. OBJECTIVE: To determine the feasibility of an animatronic pet program, and whether ownership of animatronic pets would decrease loneliness and improve well-being among lonely older adults. METHODS: Eligible individuals were identified as lonely through a prior survey. Participants were provided with the choice of an animatronic pet and completed T1/T2/T3 surveys. RESULTS: Attrition was high; 168 (63%) participants completed T1/T2 surveys, and 125 (48%) also completed a T3 survey. Post survey data indicated that loneliness decreased, while mental well-being, resilience, and purpose in life improved. Frequent interactions with the pets were associated with greater improvement in mental well-being and optimism. CONCLUSIONS: Animatronic pets appear to provide benefits for the well-being of lonely older adults. Future studies should employ randomized controlled designs examining the impact of animatronic pets.

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.

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.

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.

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.

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.

The impact of inadequate health literacy on patient satisfaction, healthcare utilization, and expenditures among older adults.

Inadequate health literacy (HL) is associated with impaired healthcare choices leading to poor quality-of-care. Our primary purpose was to estimate the prevalence of inadequate HL among two populations of AARP® Medicare Supplement insureds: sicker and healthier populations; to identify characteristics of inadequate HL; and to describe the impact on patient satisfaction, preventive services, healthcare utilization, and expenditures. Surveys were mailed to insureds in 10 states. Multivariate regression models were used to identify characteristics and adjust outcomes. Among respondents (N = 7334), 23% and 16% of sicker and healthier insureds, respectively, indicated inadequate HL. Characteristics of inadequate HL included male gender, older age, more comorbidities, and lower education. Inadequate HL was associated with lower patient satisfaction, lower preventive service compliance, higher healthcare utilization and expenditures. Inadequate HL is more common among older adults in poorer health, further compromising their health outcomes; thus they may benefit from expanded educational or additional care coordination interventions.

Pharmaceutical Cost-Saving Strategies and their Association with Medication Adherence in a Medicare Supplement Population.

BACKGROUND: On average, Medicare Supplement insureds take about seven unique prescription medications each year, resulting in substantial out-of-pocket drug copayments, in addition to Medicare Supplement and Part D premiums. To help alleviate this financial burden, many individuals resort to cost-saving strategies that are not trackable by Part D insurance plans, likely resulting in an underestimation of medication adherence rates. OBJECTIVE: We aimed to estimate utilization rates of cost-saving strategies, measure member characteristics associated with these strategies and estimate if these strategies are associated with medication adherence. DESIGN: This was a cross-sectional analysis of a 2012-2013 survey of AARP® Medicare Supplement plan insureds with Part D pharmaceutical coverage. PARTICIPANTS: The study included 5,784 community-dwelling survey respondents ≥ 65 years of age, living in ten states and with self-reported use of prescription medications. MAIN MEASURES: Self-reported use of cost-saving strategies included: obtaining free samples from physicians, splitting pills so medications lasted longer, purchasing medications from other countries and/or over the internet, or purchasing medications through the Veterans Administration. Propensity weighted multivariate regressions were utilized to determine characteristics associated with the use of such strategies and the association with medication adherence as measured from Medicare Part D claims. KEY RESULTS: Among those taking medications, 39.6% used cost-saving strategies. Those using these strategies were significantly (p < 0.05) more likely to be male, non-minority, have more comorbid conditions, have more disabilities and use more medications. Few variables were significantly related to pharmaceutical nonadherence, but those who were nonadherent were significantly more likely to use more medications, split pills, obtain free samples from their physicians and be male. CONCLUSION: Cost-saving strategies are used extensively as a means to augment Medicare Part D coverage. These strategies are associated with measured medication nonadherence and likely result in underreporting of medication adherence rates. Pharmacy management programs should consider these additional medication sources in assisting plan members to problem solve cost-related medication management issues.

Homebound older adults: Prevalence, characteristics, health care utilization and quality of care.

The purpose of this study was to estimate prevalence rates of homebound older adults, their characteristics and the impact of homebound status on health care utilization, expenditures and quality of medical care measures. Surveys were sent to new enrollees (n = 25,725) in AARP(®) Medicare Supplement plans (insured through UnitedHealthcare) to screen for serious chronic conditions, ambulatory disabilities and eligibility for care coordination programs. Health care utilization and expenditures were determined from paid claims. Member-level quality measures considered compliance with medication adherence and care patterns. Among survey respondents, 19.6% were classified as being homebound. The strongest predictors of being homebound included serious memory loss, being older, having more chronic conditions, taking more prescription medications and having multiple hospitalizations. Homebound had significantly higher health care utilization and expenditures. Homebound were more likely to be noncompliant with medication adherence and care pattern rules. Ongoing screening and subsequent interventions for new enrollees classified as homebound may be warranted.

Obese older adults report high satisfaction and positive experiences with care.

BACKGROUND: Obese, older adults often have multiple chronic conditions resulting in multiple health care encounters. However, their satisfaction and experiences with care are not well understood. The objective of this study was to examine the independent impact of obesity on patient satisfaction and experiences with care in adults 65 years of age and older with Medigap insurance. METHODS: Surveys were mailed to 53,286 randomly chosen adults with an AARP® Medicare Supplement Insurance Plan insured by UnitedHealthcare Insurance Company (for New York residents, UnitedHealthcare Insurance Company of New York) in 10 states. Following adjustment for non-response bias, multivariate regression modeling was used to adjust for demographic, socioeconomic and health status differences to estimate the independent impact of weight on satisfaction and experiences with care. Outcome variables included four global and four composite measures of satisfaction and experiences with care. RESULTS: 21.4% of the respondents were obese. Relative to normal weight, obesity was significantly associated with higher patient satisfaction and better experiences with care in seven of the eight ratings measured. CONCLUSIONS: Obese individuals were more satisfied and had better experiences with care. Obese individuals had more office visits and discussions about nutrition, exercise and medical checks. This may have led to increased attentiveness to care, explaining the increase in satisfaction and better experiences with care. Given the high level of satisfaction and experiences with care in older, obese adults, opportunities exist for clinicians to address weight concerns in this population.

Listening to the nurse pays off: an integrated Nurse HealthLine programme was associated with significant cost savings.

AIM: To estimate the relationship between adherence to nurse recommendations about where to seek care and expenditures for health-care services received by callers to a Nurse HealthLine telephone-based triage programme. METHODS: Health-care utilization and claims data from callers to the Nurse HealthLine were included. Adherent callers were those who followed the nurse recommendations, while those who did not were classified as non-adherent. Programme-related savings were estimated using differences in downstream health-care expenditures between adherent and non-adherent callers after using multivariate modelling to adjust for between-group differences. RESULTS: Fifty-five per cent of callers were adherent. Nurses were over three times as likely (41% vs. 13%) to recommend seeking a higher level of care (e.g. emergency room vs. urgent care). Regression analyses showed that the impact of getting members to the appropriate place of care was associated with significant annual savings of $13.8 million (P < 0.05), attributable mostly to Medicare, generating a positive return on investment of $1.59. CONCLUSIONS: This is the first known Nurse HealthLine triage programme exclusively for Medicare beneficiaries with supplemental coverage. IMPLICATIONS FOR NURSING MANAGEMENT: Nurse managers should consider promoting telephone-based triage programmes as complementary to clinical nursing, which has a direct impact on health-care utilization and costs.

Barriers to managing coronary artery disease among older women.

Numerous barriers to managing coronary artery disease (CAD) among older women are reported in the literature; however, few studies adjust for demographic and health status differences. A survey assessing barriers and other factors was distributed to a stratified random sampling of older women with CAD. Factor analysis and multiple logistic regression procedures were used to estimate the impact of these issues on receiving a CAD-related office visit. The most problematic barriers included denial and low health literacy. Efforts to promote patient awareness of heart health and better communication between patients and clinicians may alleviate these barriers.

The impact of pain on physical and mental quality of life in adults 65 and older.

Pain is a frequent and debilitating problem among older adults, decreasing quality of life (QOL) both physically and mentally. The burden of arthritis, sciatica, and back pain on QOL was estimated using ordinary least squares regression techniques to estimate the impact of each of these types of pain on QOL, controlling for patient demographic, socioeconomic, and health status characteristics. For individuals with arthritis, sciatica, and back pain, the adjusted average physical component scores were 4.19, 1.39, and 6.75 points lower, respectively (all p < 0.0001), than those without pain. Adjusted average mental component scores were 1.33, 0.47, and 2.93 points lower (all p < 0.01) for individuals with arthritis, sciatica, and back pain, respectively. The impact of pain on QOL was greater than that for many other commonly treated medical conditions. Clinicians should discuss pain with their patients to maximize their QOL.

Interventions to Modify Psychological Well-Being: Progress, Promises, and an Agenda for Future Research.

Psychological well-being, characterized by feelings, cognitions, and strategies that are associated with positive functioning (including hedonic and eudaimonic well-being), has been linked with better physical health and greater longevity. Importantly, psychological well-being can be strengthened with interventions, providing a strategy for improving population health. But are the effects of well-being interventions meaningful, durable, and scalable enough to improve health at a population-level? To assess this possibility, a cross-disciplinary group of scholars convened to review current knowledge and develop a research agenda. Here we summarize and build on the key insights from this convening, which were: (1) existing interventions should continue to be adapted to achieve a large-enough effect to result in downstream improvements in psychological functioning and health, (2) research should determine the durability of interventions needed to drive population-level and lasting changes, (3) a shift from individual-level care and treatment to a public-health model of population-level prevention is needed and will require new infrastructure that can deliver interventions at scale, (4) interventions should be accessible and effective in racially, ethnically, and geographically diverse samples. A discussion examining the key future research questions follows.