Social connections as determinants of cognitive health and as targets for social interventions in persons with or at risk of Alzheimer's disease and related disorders: a scoping review.

BACKGROUND: Social connections have a significant impact on health across age groups, including older adults. Loneliness and social isolation are known risk factors for Alzheimer's disease and related dementias (ADRD). Yet, we did not find a review focused on meta-analyses and systematic reviews of studies that had examined associations of social connections with cognitive decline and trials of technology-based and other social interventions to enhance social connections in people with ADRD. STUDY DESIGN: We conducted a scoping review of 11 meta-analyses and systematic reviews of social connections as possible determinants of cognitive decline in older adults with or at risk of developing ADRD. We also examined eight systematic reviews of technology-based and other social interventions in persons with ADRD. STUDY RESULTS: The strongest evidence for an association of social connections with lower risk of cognitive decline was related to social engagement and social activities. There was also evidence linking social network size to cognitive function or cognitive decline, but it was not consistently significant. A number of, though not all, studies reported a significant association of marital status with risk of ADRD. Surprisingly, evidence showing that social support reduces the risk of ADRD was weak. To varying degrees, technology-based and other social interventions designed to reduce loneliness in people with ADRD improved social connections and activities as well as quality of life but had no significant impact on cognition. We discuss strengths and limitations of the studies included. CONCLUSIONS: Social engagement and social activities seem to be the most consistent components of social connections for improving cognitive health among individuals with or at risk for ADRD. Socially focused technology-based and other social interventions aid in improving social activities and connections and deserve more research.

Remotely-administered resilience and self-compassion intervention targeting loneliness and stress in older adults: a single-case experimental design.

OBJECTIVES: Loneliness and chronic stress are prevalent issues for older adults that have been linked to adverse health outcomes. We conducted a remote resilience and self-compassion intervention targeting loneliness and chronic stress. METHODS: This study utilized a multiple-phase-change single-case experimental design with three consecutive 6-week phases: control, intervention, follow-up. Assessments and biomarker collection (blood pressure, inflammation, sleep actigraphy) were conducted at each phase. Participants completed a 6-week remotely-administered resilience and self-compassion intervention using techniques from cognitive behavioral therapy and resilience training. Repeated measures ANOVAs were conducted over the 12-week period from control (week 0) to intervention completion (week 12) and over the 18-week period from control (week 0) to follow-up (week 18) in supplemental analyses. RESULTS: Participants reported a reduction in stress (p < 0.001; ηp2 = 0.15), depression (p = 0.02; ηp2 = 0.08), and loneliness (p = 0.003; ηp2 = 0.18), and an increase in self-compassion (p = 0.01; ηp2 = 0.13) from control to intervention completion (weeks 0-12). Post-hoc tests revealed that stress reduced significantly during the intervention phase (weeks 6-12) and loneliness reduced significantly during the control phase (weeks 0-6). Some improvements in blood pressure, inflammation, and sleep quality were noted in a subsample of participants. CONCLUSION: Findings indicate that our remote resilience and self-compassion intervention for older adults targeting loneliness and chronic stress was efficacious.

Remotely Administered Resilience- and Wisdom-Focused Intervention to Reduce Perceived Stress and Loneliness: Pilot Controlled Clinical Trial in Older Adults.

OBJECTIVE: Older adults are vulnerable to perceived stress and loneliness, exacerbated by the COVID-19 pandemic. We previously reported inverse relationships between loneliness/perceived stress and wisdom/resilience. There are few evidence-based tele-health interventions for older adults. We tested a new remotely-administered manualized resilience- and wisdom-focused behavioral intervention to reduce perceived stress and loneliness in older adults. METHODS: This pilot controlled clinical trial used a multiple-phase-change single-case experimental design, with three successive 6-week phases: control, intervention, and follow-up periods. The intervention included six once-a-week one-hour sessions. Participants were 20 adults >65 years, without dementia. RESULTS: All 20 participants completed every session. The study indicated feasibility and acceptability of the intervention. While the sample was too small for demonstrating efficacy, there was a reduction (small-to-medium effect size) in perceived stress and loneliness, and increase in resilience, happiness, and components of wisdom and positive perceptions of aging. CONCLUSION: These preliminary data support feasibility, acceptability, and possible efficacy of a remotely-administered resilience- and wisdom-focused intervention in older adults to reduce stress and loneliness.

Perceived discrimination and nativity status: risk of cognitive impairment among Latin American older adults.

OBJECTIVES: We examined the association between perceived discrimination and the risk of cognitive impairment with no dementia (CIND) and Alzheimer's disease and related dementias (ADRD) while considering the potential effects of nativity status. DESIGN: A prospective analysis of discrimination and nativity status with dementia and cognitive impairment was conducted among Latinx adults aged 51 years and older who participated in the Health and Retirement Study. SETTING: A national representative sample. PARTICIPANTS: A sample of 1,175 Latinx adults aged 51 years and older. MEASUREMENTS: Demographics, cognitive functioning, perceived discrimination, and nativity status (US-born vs. non-US born) were assessed. Traditional survival analysis methods (Fine and gray models) were used to account for the semi-competing risk of death with up to 10 years of follow-up. RESULTS: According to our results, neither everyday discrimination nor nativity status on their own had a statistically significant association with CIND/ADRD; however, non-US-born Latinx adults who reported no discrimination had a 42% lower risk of CIND/ADRD (SHR = 0.58 [0.41, 0.83], p = .003) than US-born adults. CONCLUSIONS: These results highlight the need for healthcare providers to assess for discrimination and provide support and resources for those experiencing discrimination. It also highlights the need for better policies that address discrimination and reduce health disparities.

Sleep quality moderates the association between family bereavement and heart rate variability.

Two separate bodies of literature point to the link between family bereavement and cardiovascular health and between sleep quality and cardiovascular outcomes. However, less is known about the joint influence of family bereavement and sleep quality on cardiovascular functioning. The aims of this study were to examine the relationships between experiencing the death of a family member and heart rate variability (HRV) and to further explore whether these associations differ by sleep quality. Using data from the Midlife in the United States (MIDUS) Biomarker Project, the sample for this study included respondents who experienced the death of an immediate family member - father, mother, spouse, sibling, or child - within a year before the Biomarker project and those who did not experience any deaths (N = 962). We used two measures of HRV and sleep quality was measured using the Pittsburgh Sleep Quality Index. Results showed that experiencing the death of a family member was associated with worse HRV only among those with poor sleep quality and not for those with good sleep quality. These results suggest that poor sleep quality may indicate psychophysiological vulnerability for those who experienced the death of a family member. Interventions to improve sleep quality could be effective in enhancing cardiovascular health of bereaved individuals.

Trends, heterogeneity, and correlates of mental health and psychosocial well-being in later-life: study of 590 community-dwelling adults aged 40-104 years.

OBJECTIVE: The goal of this study was to examine if mental health and psychosocial well-being differed between middle-aged (MA; 40-59 years), younger-old (YO; 60-79 years), and older-old (OO; 80+ years) adults with respect to their trends, heterogeneity, and correlates. METHODS: Eighteen mental health and psychosocial well-being instruments were administered to 590 adults over age 40. Cross-sectional data also included self-report-based measures of sociodemographics, cognitive functioning, physical health and activity, and body mass index. RESULTS: Age trends across instruments varied in magnitude and shape, but generally supported an inverted U-shaped trend in mental health and psychosocial well-being, with small increases from MA to YO age (d = 0.29) and smaller declines from YO to OO age (d = -0.17). A U-shaped association between age and mental health heterogeneity was also observed. The strongest correlates of mental health and psychosocial well-being differed by age (MA: perceived stress; YO: successful aging; OO: compassion toward others), as did the associations of a flourishing versus languishing mental health and well-being profile. CONCLUSIONS: Our findings support the "paradox of aging," whereby declines in physical and cognitive health co-occur with relatively preserved mental health and well-being. Our findings indicate that variance in mental and psychosocial health does not increase linearly with age and support careful consideration of heterogeneity in mental health and aging research. Our findings also suggest that mental health and psychosocial well-being decouple from stress-related dimensions in MA and become increasingly associated with positive, other-oriented emotions in OO, broadly supporting socioemotional theories of aging.

Subjective social status moderates back pain and mental health in older men.

OBJECTIVES: Back pain and poor mental health are interrelated issues in older men. Evidence suggests that socioeconomic status moderates this relationship, but less is known about the role of subjective social status (SSS). This study examined if the association between back pain and mental health is moderated by SSS. METHOD: We used a sample of community-dwelling older men (≥65 years) from the Osteoporotic Fractures in Men Study (N = 5994). Participants self-reported their back pain severity and frequency over the past 12 months. SSS was assessed with the MacArthur Scale of SSS. Mental health was assessed with the SF-12 Mental Component Summary (MCS). RESULTS: Severe back pain was associated with lower SF-12 MCS scores (p = .03). Back pain frequency was not associated with SF-12 MCS scores. SSS moderated the back pain and mental health relationship. Among men with higher national or community SSS, the association between back pain severity and SF-12 MCS scores was not significant. However, among men with lower national or community SSS, more severe back pain was associated with lower SF-12 MCS scores (p's < .001). Among those with lower national or community SSS, greater back pain frequency was also associated with lower SF-12 MCS scores (p's < .05). CONCLUSION: Where one ranks oneself within their nation or community matters for the back pain and mental health relationship. Higher SSS may be a psychosocial resource that buffers the negative associations of severe and frequent back pain on mental health in older men.

Impact of establishing a Geriatrics Workforce Enhancement Program clinic on preventive health and Medicare Annual Wellness Visits.

We established a Geriatrics Workforce Enhancement Program (GWEP) clinic to enhance resident training on comprehensive preventive care and chronic disease management, and to increase the number of older patients who received Medicare Annual Wellness Visit (AWV) preventive services. A total of 1,104 patients were tracked at baseline and during the intervention period. Patients were grouped into two categories: Adult (aged 55-64) and Senior (aged 65+). Clinical quality measures were monitored by electronic health record and tracked through monthly reports at baseline (May 2018) and during the intervention period (July 2018-June 2019). In the Senior group, the proportion of patients receiving the Medicare AWV increased after GWEP began (p <.001). Additionally, the Senior group showed significant improvements in the frequency of body mass index assessments (p = .04), colorectal cancer screenings (p < .001), advance directive documentation (p < .001), cognitive screenings (p < .001), and pneumococcal vaccinations (p < .001). In the Adult group, a trending increase was seen in influenza vaccinations (p = .06). Curricular innovations including the establishment of a GWEP clinic in our residency outpatient center, development of new educational materials, and use of a nurse coordinator resulted in significant improvements in the percentage of older adults who received the Medicare AWV benefit and preventive health performance metrics.

The Relationship Between Staffing Levels and Consumer Complaints in Nursing Homes.

While research tends to find an association of nurse staffing with quality in nursing homes, few studies examine complaints as a quality measure or account for ancillary staff. This study used federal nursing home complaint data to examine how key explanatory variables including nursing and ancillary staffing were associated with numbers of complaints and the likelihood of receiving a complaint. Results support that nursing home staffing is associated with quality. While direct care staffing was associated with fewer complaints, larger effects were found for social service and activities staffing. Increasing ancillary staffing may be a cost-effective way to reduce complaints.

Cognitive Reserve, Alzheimer's Neuropathology, and Risk of Dementia: A Systematic Review and Meta-Analysis.

Cognitive reserve (CR) may reduce the risk of dementia. We summarized the effect of CR on progression to mild cognitive impairment (MCI) or dementia in studies accounting for Alzheimer's disease (AD)-related structural pathology and biomarkers. Literature search was conducted in Web of Science, PubMed, Embase, and PsycINFO. Relevant articles were longitudinal, in English, and investigating MCI or dementia incidence. Meta-analysis was conducted on nine articles, four measuring CR as cognitive residual of neuropathology and five as composite psychosocial proxies (e.g., education). High CR was related to a 47% reduced relative risk of MCI or dementia (pooled-hazard ratio: 0.53 [0.35, 0.81]), with residual-based CR reducing risk by 62% and proxy-based CR by 48%. CR protects against MCI and dementia progression above and beyond the effect of AD-related structural pathology and biomarkers. The finding that proxy-based measures of CR rivaled residual-based measures in terms of effect on dementia incidence underscores the importance of early- and mid-life factors in preventing dementia later.

Cognitive Phenotypes of Older Adults with Subjective Cognitive Decline and Amnestic Mild Cognitive Impairment: The Czech Brain Aging Study.

OBJECTIVE: To compare cognitive phenotypes of participants with subjective cognitive decline (SCD) and amnestic mild cognitive impairment (aMCI), estimate progression to MCI/dementia by phenotype and assess classification error with machine learning. METHOD: Dataset consisted of 163 participants with SCD and 282 participants with aMCI from the Czech Brain Aging Study. Cognitive assessment included the Uniform Data Set battery and additional tests to ascertain executive function, language, immediate and delayed memory, visuospatial skills, and processing speed. Latent profile analyses were used to develop cognitive profiles, and Cox proportional hazards models were used to estimate risk of progression. Random forest machine learning algorithms reported cognitive phenotype classification error. RESULTS: Latent profile analysis identified three phenotypes for SCD, with one phenotype performing worse across all domains but not progressing more quickly to MCI/dementia after controlling for age, sex, and education. Three aMCI phenotypes were characterized by mild deficits, memory and language impairment (dysnomic aMCI), and severe multi-domain aMCI (i.e., deficits across all domains). A dose-response relationship between baseline level of impairment and subsequent risk of progression to dementia was evident for aMCI profiles after controlling for age, sex, and education. Machine learning more easily classified participants with aMCI in comparison to SCD (8% vs. 21% misclassified). CONCLUSIONS: Cognitive performance follows distinct patterns, especially within aMCI. The patterns map onto risk of progression to dementia.

Prevalence of psychotropic polypharmacy in nursing home residents with dementia: a meta-analysis.

OBJECTIVES: Nursing home (NH) residents with dementia is exposed to high rates of psychotropic prescriptions. Our objectives were to: (1) pool the prevalence estimates of psychotropic polypharmacy from the existing literature and (2) examine potentially influential factors that are related to a higher or lower prevalence. DESIGN: Meta-analysis of data collected from randomized trials, quasi-experimental, prospective or retrospective cohort, and cross-sectional studies. English-language searches of PubMed and PsycINFO were completed by November 2020. Included studies reported prevalence estimates of psychotropic polypharmacy (i.e. defined as either two-or-more or three-or-more medications concurrently) in NH residents with dementia. SETTING AND PARTICIPANTS: NH residents with dementia. MEASUREMENTS: Random-effects models were used to pool the prevalence of psychotropic polypharmacy in NH residents with dementia across studies. Estimates were provided for both two-or-more and three-or-more concurrent medications. Heterogeneity and publication bias were measured. Meta-regression examined the influence of the percentage of the sample who were male, mean age of the sample, geographic region (continent), sample size, and study year on the prevalence of psychotropic polypharmacy. RESULTS: Twenty-five unique articles were included comprising medications data from 92,370 NH residents with dementia in 12 countries. One-in-three (33%, [95% CI: 28%, 39%]) NH residents with dementia received two-or-more psychotropic medications concurrently. One-in-eight (13%, [95% CI: 10%, 17%]) received three-or-more psychotropic medications concurrently. Estimates were highly variable across both definitions of psychotropic polypharmacy (p < 0.001). Among study-level demographics, geographic region, sample size, or study year, only male sex was associated with greater use of two-or-more psychotropic medications (Unadjusted OR = 1.02, p = 0.006; Adjusted OR = 1.04, p = 0.07). CONCLUSIONS: Psychotropic polypharmacy is common among NH residents with dementia. Identifying the causes of utilization and the effects on resident health and well-being should be prioritized by federal entities seeking to improve NH quality.

Assessment of Anxiety in Long-Term Care Residents: Issues and Strategies.

The experience of clinically significant anxiety and anxiety disorders represent significant and often debilitating problems for many residents in long-term care (LTC) settings. However, anxiety problems often go undetected and untreated in this growing population. The purposes of this paper are to examine the prevalence and impact of anxiety problems among residents in LTC facilities, describe the efficacy of the current instruments that are used to detect anxiety in these settings, and provide clinical guidance for the thorough assessment of anxiety. Regarding measurement tools, the GAI, GAI-SF, GAS-LTC, and the BADS are the only self-report measures designed for older adults that have been successfully validated for use with older adults living in LTC settings. Clinicians should focus on ways to educate LTC directors and staff to emphasize the importance of screening and assessing for anxiety, using validated measures, to improve the assessment and treatment of anxiety in their residents.

Attitudes toward aging of health professions students: Implications for geriatrics education.

We compared attitudes toward aging of students from several health professions (N = 1,156: 286 medical, 275 pharmacy, 213 undergraduate nursing, 160 graduate nursing, 139 Internal Medicine residents, 49 physical therapy, and 34 physician assistant), and assessed the construct validity of the Image of Aging Scale. Physical therapy and graduate nursing students reported more positive attitudes toward aging in comparison to all other health professions (all p <.001). Differences in attitudes were not strongly affected by demographic variables, clinical exposure, desire to pursue primary care, or interest in providing care to older adults. The Image of Aging Scale yielded good internal reliability and adequate construct validity for health professions students. Health professions students' attitudes toward aging largely reflect the students' professional training, rather than student characteristics or career goals. The Image of Aging Scale is a robust measure of attitudes toward aging in health professions students and in older adults.

Beliefs regarding geriatrics primary care topics among medical students and internal medicine residents.

This study evaluated beliefs regarding 25 content areas essential to the primary care of older adults and attitudes toward aging held by first-yearmedical students and Internal Medicine residents. A survey of 136 medical students and 61 Internal Medicine residents was conducted at an academic health-center. Beliefs were assessed by the 25-item Geriatrics Clinician-Educator Survey. Gap scores reflecting the difference in ratings between self-rated importance and knowledge were calculated. Attitudes toward aging was assessed by the Images of Aging Scale. Students and residents expressed similar beliefs about the importance of content areas, but students provided lower ratings in knowledge. Students reported larger gap scores in areas that reflected general primary care (e.g., chronic conditions, medications), whereas residents reported larger gap scores in areas that reflected specialists' expertise (e.g., driving risk, cognition, psychiatric symptoms). Attitudes toward aging did not differ appreciably between students and residents. Our findings suggest that primary care topics applicable for any age demographic were rated as most important by first-year medical students and Internal Medicine residents. Topics relevant to older populations--particularly those requiring specialists' knowledge of or requiring sensitive discussion with older adults-were rated as less important and were less well-mastered.

Cognitive deficits in Parkinson's disease with excessive daytime sleepiness: a systematic review.

Objectives: This systematic review synthesizes the most recent literature on neuropsychological deficits in adults with Parkinson's disease who experience excessive daytime sleepiness (EDS). Confounds and methodological limitations are explored. A framework entitled the Cascade Model of Excessive Daytime Sleepiness (CMEDS) is proposed to explain the role of EDS in contributing to cognitive impairment for patients with Parkinson's disease.Method: Systematic search through PubMed, PsychInfo and citation records. In total, 175 articles were screened for possible inclusion. Eight studies were included, encompassing 1373 patients with Parkinson's disease - 442 of whom had Parkinson's disease with EDS.Results: For Parkinson's disease patients with EDS, global deficits, executive dysfunction and deficits in processing speed were found beyond the typical cognitive phenotype of patients without EDS. Language skills, memory and visuospatial skills appeared to be similar between those with and without EDS. In untreated, de novo, patients, there were no cognitive differences between the EDS groups.Conclusion: This review suggests that Parkinson's disease patients suffering from EDS may have additional cognitive deficits globally, in executive control, and in processing speed. As suggested by the CMEDS framework, the impact of EDS on cognition may be related to Parkinson's disease pathology, comorbidities and medication use.

Heart rate variability biofeedback: implications for cognitive and psychiatric effects in older adults.

OBJECTIVES: Two decades of heart rate variability (HRV) biofeedback research have focused on adolescent and adult populations with a variety of symptoms and conditions at the exclusion of older adults. This study explores HRV biofeedback as a novel treatment to decrease psychiatric symptoms and improve cognitive functioning in older adults. METHODS: Participants enrolled in a three-week intervention that included six 30-min biofeedback sessions. Neuropsychological and psychiatric measures were administered before and after the intervention. RESULTS: Decreases in depression (Cohen's d = 1.02, p < .001), state anxiety (Cohen's d = 0.82, p = .003), and trait anxiety (Cohen's d = 0.84, p = .002) were observed. An increase in attentional skills as measured by the Trail Making Test - Part A was seen (Cohen's d = 1.00, p = .001). Differences in executive skills as measured by the Trial Making Test - Part B and the Stroop Task did not reach statistical significance. CONCLUSION: This study suggests that older adults may benefit from HRV biofeedback interventions much like the younger populations that have been studied for decades. Depression, anxiety, and attentional skills were positively affected. Several participants reported improved sleep quality and stress management. Future studies should corroborate these findings.

Age-dependent determinants of antipsychotic use among newly admitted residents of skilled nursing facilities: A population-based study.

OBJECTIVES: To assess factors related to antipsychotic (AP) use in skilled nursing facilities for newly admitted residents aged 18 to 49, 50 to 64, 65 to 84, and 85 years or older. METHODS: Retrospective, population-level, Minimum Data Set (MDS) 2.0 data from the United States during the year of 2009 were used. Over 1 million residents were included. Fourteen clinically relevant variables were identified through a literature search. Antipsychotic use was defined as APs dispensed daily for the prior 7 days. Logistic regression was used to identify clinically relevant variables, which were then ranked based on magnitude of their association with APs. RESULTS: Bipolar disorder and schizophrenia were consistently related to AP use across age groups. For older age groups, off-label indications such as cognitive impairment, dementia, behavioral symptoms, and physical restraint use were more closely related to AP use, while delusions and hallucinations decreased in strength. Higher proportions of APs were found in all diseases and symptoms in nonelderly adults, with the exception of physical restraint use. Concurrent physical restraint and AP use was highest for older adults aged 65 to 84 at 36%. CONCLUSIONS: Correlates of AP use varied by age, with stronger associations between on-label conditions and AP use among younger adults and off-label conditions among older adults. Several less conventional determinants, namely, Parkinson disease, traumatic brain injury, and the use of physical restraints were identified to increase the likelihood of AP use. This study highlights the importance of monitoring for adverse effects for residents of all ages.