Disability-Free Life Expectancy Over 30 Years: A Growing Female Disadvantage in the US Population.

OBJECTIVES: To examine changes in active life expectancy in the United States over 30 years for older men and women (aged ≥ 65 years). METHODS: We used the 1982 and 2004 National Long Term Care Survey and the 2011 National Health and Aging Trends Study to estimate age-specific mortality and disability rates, the overall chances of survival and of surviving without disability, and years of active life for men and women. RESULTS: For older men, longevity has increased, disability has been postponed to older ages, disability prevalence has fallen, and the percentage of remaining life spent active has increased. However, for older women, small longevity increases have been accompanied by even smaller postponements in disability, a reversal of a downward trend in moderate disability, and stagnation of active life as a percentage of life expectancy. As a consequence, older women no longer live more active years than men, despite their longer lives. CONCLUSIONS: Neither a compression nor expansion of late-life disability is inevitable. Public health measures directed at older women to postpone disability may be needed to offset impending long-term care pressures related to population aging.

Disability and care needs among older Americans.

CONTEXT: The cost of late-life dependency is projected to grow rapidly as the number of older adults in the United States increases in the coming decades. To provide a context for framing relevant policy discussions, we investigated activity limitations and assistance, care resources, and unmet need for a national sample of older adults. METHODS: We analyzed the 2011 National Health and Aging Trends Study, a new national panel study of more than 8,000 Medicare enrollees. FINDINGS: Nearly one-half of older adults, or 18 million people, had difficulty or received help in the last month with daily activities. Altogether, 1 in 4 older adults receiving help lived in either a supportive care (15%) or a nursing home (10%) setting. Nearly 3 million received assistance with 3 or more self-care or mobility activities in settings other than nursing homes, and a disproportionate share of persons at this level had low incomes. Nearly all older adults in settings other than nursing homes had at least 1 potential informal care network member (family or household member or close friend), and the average number of network members was 4. Levels of informal assistance, primarily from family caregivers, were substantial for older adults receiving help in the community (164 hours/month) and living in supportive care settings (50 hours/month). Nearly all of those getting help received informal care, and about 3 in 10 received paid care. Of those who had difficulty or received help in settings other than nursing homes, 32% had an adverse consequence in the last month related to an unmet need; for community residents with a paid caregiver, the figure was nearly 60%. CONCLUSIONS: The older population-especially those with few economic resources-has substantial late-life care needs. Policies to improve long-term services and supports and reduce unmet need could benefit both older adults and those who care for them.

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.

Incident Care Trajectories for Older Adults With and Without Dementia.

OBJECTIVE: Despite cross-sectional evidence that persons living with dementia receive disproportionate hours of care, studies of how care intensity progresses over time and differs for those living with and without dementia have been lacking. METHOD: We used the 2011-2018 National Health and Aging Trends Study to estimate growth mixture models to identify incident care hour trajectories ("classes") among older adults (N = 1,780). RESULTS: We identified 4 incident care hour classes: "Low, stable," "High, increasing," "24/7 then high, stable," and "Low then resolved." The high-intensity classes had the highest proportions of care recipients with dementia and accounted for nearly half of that group. Older adults with dementia were 3-4 times as likely as other older adults to experience one of the 2 high-intensity trajectories. A substantial proportion of the 4 in 10 older adults with dementia who were predicted to be in the "Low, stable" class lived in residential care settings. DISCUSSION: Information on how family caregiving is likely to evolve over time in terms of care hours may help older adults with and without dementia, the family members, friends, and paid individuals who care for them, as well as their health care providers assess and plan for future care needs.

Potential national and state medical care savings from primary disease prevention.

OBJECTIVES: We estimated national and state-level potential medical care cost savings achievable through modest reductions in the prevalence of several diseases associated with the same lifestyle-related risk factors. METHODS: Using Medical Expenditure Panel Survey Household Component data (2003-2005), we estimated the effects on medical spending over time of reductions in the prevalence of diabetes, hypertension, and related conditions amenable to primary prevention by comparing simulated counterfactual morbidity and medical care expenditures to actual disease and expenditure patterns. We produced state-level estimates of spending by using multivariate reweighting techniques. RESULTS: Nationally, we estimated that reducing diabetes and hypertension prevalence by 5% would save approximately $9 billion annually in the near term. With resulting reductions in comorbidities and selected related conditions, savings could rise to approximately $24.7 billion annually in the medium term. Returns were greatest in absolute terms for private payers, but greatest in percentage terms for public payers. State savings varied with demographic makeup and prevailing morbidity. CONCLUSIONS: Well-designed interventions that achieve improvements in lifestyle-related risk factors could result in sufficient savings in the short and medium term to substantially offset intervention costs.

Change Over Time in Caregiving Networks for Older Adults With and Without Dementia.

OBJECTIVES: We provide national estimates of caregiving networks for older adults with and without dementia and examine how these networks develop over time. Most prior research has focused on primary caregivers and rarely on change over time. METHOD: We identify a cohort of older adults continuously followed in the National Health and Aging Trends Study between 2011 and 2015 and receiving help from family members or unpaid caregivers in 2015 (n = 1,288). We examine differences by dementia status in network size, types of assistance and task sharing, and composition-differentiating between "specialist" and "generalist" caregivers helping in one versus multiple activity domains. Multinomial regression is used to estimate change over time in network task sharing and composition. RESULTS: In 2015, older adults with dementia had larger caregiving networks involving more task sharing than those without dementia and more often relied on generalist caregivers, especially the subset assisting with medical, household, and mobility or self-care activities. Uniformly greater reliance over time on these more intensely engaged generalist caregivers chiefly accounts for larger dementia networks. DISCUSSION: Findings lend support to the need for caregiver training on managing multiple task domains and-for dementia caregivers in particular-task-sharing skills. More generally, the design of new approaches to better support older adults and their caregivers should consider the complexity, heterogeneity, and change over time in caregiving networks.

Does high caregiver stress predict nursing home entry?

This study estimates how informal care, paid formal care, and caregiver stress or burden relate to nursing home placement. Data came from the 1999 National Long Term Care Survey and were merged with administrative data. Results show that stress is a strong predictor of entry over follow-up periods of up to two years, and physical strain and financial hardship are important predictors of high levels of caregiver stress. The estimates indicate that reducing these stress factors would significantly reduce caregiver stress and, as a result, nursing home entry. We conclude that initiatives to reduce caregiver stress hold promise as a strategy to avoid or defer nursing home entry.

Short-Term Changes in the Prevalence of Probable Dementia: An Analysis of the 2011-2015 National Health and Aging Trends Study.

Objectives: Studies have reported decreasing dementia prevalence in recent decades in the United States. We explore with a new national data source whether declines have occurred since 2011, whether trends are attributable to shifts in dementia incidence or mortality, and whether trends are related to shifts in population composition or subgroup prevalence. Methods: We use the 2011-2015 National Health and Aging Trends Study (N = 27,547) to examine prevalence of probable dementia among the 70 and older population. To minimize the influence of potential learning effects on prevalence rates, we require individuals to meet probable dementia criteria at two consecutive rounds. Results: Prevalence of probable dementia declines over this period by 1.4% to 2.6% per year. Declines are concentrated among women, non-Hispanic white and black groups, and those with no vascular conditions or risk factors. The latter group also has experienced declines in dementia incidence. Declines in prevalence are largely attributable to age- and education-related shifts in population composition. Discussion: Given the role of age and educational composition in short-term declines, the United States is likely to continue to experience short-term declines in dementia prevalence. However, persistently high rates among minority groups, especially of Hispanic origin, are concerning, and, barring new treatments, long-run trends may reverse course.

Successful Aging Through Successful Accommodation With Assistive Devices.

OBJECTIVES: To provide a profile of older adults who successfully accommodate declines in capacity by using assistive devices. METHOD: Using the National Health and Aging Trends Study, we provide national estimates of prevalent, incident, and persistent successful accommodation of mobility and self-care activity limitations. For incident and persistent accommodation groups, we describe their subjective wellbeing and participation restrictions, health and functioning, demographic and socioeconomic characteristics, and acquisition of assistive devices and environmental features. We estimate regression models predicting incident and persistent successful accommodation and the extent of wellbeing and participation restrictions for incident and persistent groups (vs. those who are fully able). RESULTS: Nearly one-quarter of older adults have put in place accommodations that allow them to carry out daily activities with no assistance or difficulty. In adjusted models, incident and persistent successful accommodation is more common for those ages 80-89, those with more children, and those living in homes with environmental features already installed; wellbeing levels for these groups are similar and participation restrictions only slightly below those who are fully able. DISCUSSION: A focus on facilitating successful accommodation among those who experience declines in capacity may be an effective means of promoting participation and wellbeing in later life.

Experiences of three states implementing the Medicaid health home model to address opioid use disorder-Case studies in Maryland, Rhode Island, and Vermont.

PURPOSE: The United States is facing an unprecedented opioid epidemic. The Affordable Care Act (ACA) included several provisions designed to increase care coordination in state Medicaid programs and improve outcomes for those with chronic conditions, including substance use disorders. Three states-Maryland, Rhode Island, and Vermont - adopted the ACA's optional Medicaid health home model for individuals with opioid use disorder. The model coordinates opioid use disorder treatment that features opioid agonist therapy provided at opioid treatment programs (OTPs) and Office-based Opioid Treatment (OBOT) with medical and behavioral health care and other services, including those addressing social determinants of health. This study examines state approaches to opioid health homes (OHH) and uses a retrospective analysis to identify facilitators and barriers to the program's implementation from the perspectives of multiple stakeholders. METHODS: We conducted 28 semi-structured discussions with 70 discussants across the three states, including representatives from state agencies, OHH providers (OTPs and OBOTs), Medicaid health plans, and provider associations. Discussions were recorded, transcribed, and analyzed using NVivo. In addition, we reviewed state health home applications, policies, regulatory guidance, reporting, and other available OHH materials. We adapted the Exploration, Preparation, Implementation, and Sustainment (EPIS) model as a guiding framework to examine the collected data, helping us to identify key factors affecting each stage of the OHH implementation. RESULTS: Overall, discussants reported that the OHH model was implemented successfully and was responsible for substantial improvements in patient care. Contextual factors at both the state level (e.g., legislation, funding, state leadership, program design) and provider level (OHH provider characteristics, leadership, adaptability) affected each stage of implementation of the OHH model. States took a variety of approaches in designing and implementing the model, with facilitators related to gathering stakeholder input, receiving guidance and technical assistance, and tailoring program design to build on the state's existing care coordination initiatives and provider infrastructure. The OHH model constituted a substantial change for almost all OHH providers in the study, who reported that facilitators to implementation included having goals and workplace culture that were compatible with the OHH model, and having technical support from the state or non-governmental organizations. Some of the main barriers to implementation reported by OHH providers include shortages of primary care providers, dentists, and other providers willing to accept referrals of patients with opioid use disorder; limited community resources to address social determinants of health; challenges related to state-specific program design, such as staffing requirements and reimbursement methodology; care coordination limitations due to confidentiality restrictions and technological barriers; and internal capacity of providers to adopt the new model of care. CONCLUSIONS: The OHH model appears to have the potential to effectively address the complex needs of individuals with opioid use disorder by providing whole-person care that integrates medical care, behavioral health, and social services and supports. The experiences of Maryland, Rhode Island, and Vermont can guide development and implementation of similar OHH initiatives in other states.

Active Life Expectancy In The Older US Population, 1982-2011: Differences Between Blacks And Whites Persisted.

Understanding long-range trends in longevity and disability is useful for projecting the likely impact of the baby-boom generation on long-term care utilization and spending. We examine changes in active life expectancy in the United States from 1982 to 2011 for white and black adults ages sixty-five and older. For whites, longevity increased, disability was postponed to older ages, the locus of care shifted from nursing facilities to community settings, and the proportion of life at older ages spent without disability increased. In contrast, for blacks, longevity increases were accompanied by smaller postponements in disability, and the percentage of remaining life spent active remained stable and well below that of whites. Older black women were especially disadvantaged in 2011 in terms of the proportion of years expected to be lived without disability. Public health measures directed at older black adults-particularly women-are needed to offset impending pressures on the long-term care delivery system as the result of population aging.

A National Profile of Family and Unpaid Caregivers Who Assist Older Adults With Health Care Activities.

IMPORTANCE: Family and unpaid caregivers commonly help older adults who are at high risk for poorly coordinated care. OBJECTIVE: To examine how caregivers' involvement in older adults' health care activities relates to caregiving responsibilities, supportive services use, and caregiving-related effects. DESIGN, SETTING, AND PARTICIPANTS: A total of 1739 family and unpaid caregivers of 1171 community-dwelling older adults with disabilities who participated in the 2011 National Health and Aging Trends Study (NHATS) and National Study of Caregiving (NSOC). MAIN OUTCOMES AND MEASURES: Caregiving-related effects, including emotional, physical, and financial difficulty; participation restrictions in valued activities; and work productivity loss. EXPOSURES: Caregivers assisting older adults who provide substantial, some, or no help with health care, defined by coordinating care and managing medications (help with both, either, or neither activity, respectively). RESULTS: Based on NHATS and NSOC responses from 1739 family and unpaid caregivers of 1171 older adults with disabilities, weighted estimates were produced that accounted for the sampling designs of each survey. From these weighted estimates, 14.7 million caregivers assisting 7.7 million older adults, 6.5 million (44.1%) provided substantial help, 4.4 million (29.8%) provided some help, and 3.8 million (26.1%) provided no help with health care. Almost half (45.5%) of the caregivers providing substantial help with health care assisted an older adult with dementia. Caregivers providing substantial help with health care provided more hours of assistance per week than caregivers providing some or no help (28.1 vs 15.1 and 8.3 hours, P < .001 for both). The use of supportive services was low but was greater among caregivers providing substantial vs some or no help (26.7% vs 15.5% and 7.6%, P < .001 for both). In multivariable regression models adjusting for older adults' function and caregivers' sociodemographic and health characteristics, caregivers providing substantial help with health care were significantly more likely to experience emotional difficulty (adjusted odds ratio [aOR], 1.79; 95% CI, 1.20-2.66), physical difficulty (aOR, 2.03; 95% CI, 1.39-2.97), and financial difficulty (aOR, 2.21; 95% CI, 1.52-3.22) than caregivers providing no help. Compared with caregivers providing no help with health care activities, caregivers providing substantial help with health care activities were more than 5 times as likely to experience participation restrictions in valued activities (aOR, 5.32; 95% CI, 3.31-8.59) and more than 3 times as likely to experience work productivity loss (aOR, 3.14; 95% CI, 1.40-7.02). CONCLUSIONS AND RELEVANCE: Family caregivers providing substantial assistance with health care experience significant emotional difficulty and role-related effects, yet only one-quarter use supportive services.

Disability Trajectories at the End of Life: A "Countdown" Model.

OBJECTIVES: Studies of late-life disablement typically address the role of advancing age as a factor in developing disability, and in some cases have pointed out the importance of time to death (TTD) in understanding changes in functioning. However, few studies have addressed both factors simultaneously, and none have dealt satisfactorily with the problem of missing data on TTD in panel studies. METHODS: We fit latent-class trajectory models of disablement using data from the Health and Retirement Study. Among survivors (~20% of the sample), TTD is unknown, producing a missing-data problem. We use an auxiliary regression equation to impute TTD and employ multiple imputation techniques to obtain final parameter estimates and standard errors. RESULTS: Our best-fitting model has 3 latent classes. In all 3 classes, the probability of having a disability increases with nearness to death; however, in only 2 of the 3 classes is age associated with disability. We find gender, race, and educational differences in class-membership probabilities. DISCUSSION: The model reveals a complex pattern of age- and time-dependent heterogeneity in late-life disablement. The techniques developed here could be applied to other phenomena known to depend on TTD, such as cognitive change, weight loss, and health care spending.

The Disproportionate Impact Of Dementia On Family And Unpaid Caregiving To Older Adults.

The number of US adults ages sixty-five and older who are living with dementia is substantial and expected to grow, raising concerns about the demands that will be placed on family members and other unpaid caregivers. We used data from the 2011 National Health and Aging Trends Study and its companion study, the National Study of Caregiving, to investigate the role of dementia in caregiving. We found that among family and unpaid caregivers to older noninstitutionalized adults, one-third of caregivers, and 41 percent of the hours of help they provide, help people with dementia, who account for about 10 percent of older noninstitutionalized adults. Among older adults who receive help, the vast majority in both community and residential care settings other than nursing homes rely on family or unpaid caregivers (more than 90 percent and more than 80 percent, respectively), regardless of their dementia status. Caregiving is most intense, however, to older adults with dementia in community settings and from caregivers who are spouses or daughters or who live with the care recipient.

Policy implications of an annuity approach to integrating long-term care financing and retirement income.

The authors consider an integrated income and disability annuity as an alternative framework for long-term care financing, show that pooling disability and mortality risks can reduce the need for medical underwriting, and discuss private and public implications. Data from the National Mortality Followback Survey of 1986 were used to simulate current underwriting and minimal underwriting, excluding only those already eligible for benefits. Remaining disability, life expectancy, and premiums are compared under both underwriting assumptions. Under minimal underwriting, 98% of persons age 65 would be eligible to purchase disability protection through an integrated annuity, versus 77% under current underwriting. Premiums for both the income and disability components were lower with minimal underwriting. Combining income and disability protection may be able to expand private markets for long-term care financing beyond what appears possible in the long-term care insurance market. Public policy should avoid the distortion of choices created by focusing exclusively on an insurance model.

The residential continuum from home to nursing home: size, characteristics and unmet needs of older adults.

OBJECTIVES: Older adults with care needs live in a variety of settings-from traditional community housing to nursing homes. This analysis provides new estimates of the size and characteristics of the older population across settings and examines unmet needs for assistance. METHOD: Data are from the 2011 National Health and Aging Trends Study (N = 8,077). Multinomial logistic regressions focus on people in settings other than nursing homes who are at risk for unmet needs, defined as receiving help or having difficulty with household, self-care, or mobility activities (N = 4,023). RESULTS: Of 38.1 million Medicare beneficiaries ages 65 and older, 5.5 million (15%) live in settings other than traditional housing: 2.5 million in retirement or senior housing communities, nearly 1 million in independent- and 1 million in assisted-living settings, and 1.1 million in nursing homes. The prevalence of assistance is higher and physical and cognitive capacity lower in each successive setting. Unmet needs are common in traditional community housing (31%), but most prevalent in retirement or senior housing (37%) and assisted living settings (42%). After controlling for differences in resident characteristics across settings, those in retirement or senior housing communities have a higher likelihood of unmet needs than those in traditional community housing, while those in independent or assisted living settings have a lower relative likelihood. DISCUSSION: Substantial numbers of older adults, many with care needs, live in a continuum of settings other than traditional community housing. Unmet needs are prevalent among older adults with limitations across all settings and warrant further investigation and monitoring.

Reliability and validity of self-care and mobility accommodations measures in the National Health and Aging Trends Study.

PURPOSE OF THE STUDY: Comprehensive measures of disability accommodations have been lacking in national health and aging studies. This article introduces measures of accommodations developed for the National Health and Aging Trends Study, evaluates their reliability, and explores the validity and reliability of hierarchical classification schemes derived from these measures. DESIGN AND METHODS: We examined test-retest reliability for questions about assistive device use, doing activities less often, and getting help from another person with both percentage agreement and kappa (N = 111). Summary measures across activities and several hierarchical classification schemes (e.g., no accommodation, devices/activity reductions only, help) were developed. For the latter, we also evaluated validity by examining correlations with measures of capacity and demographic characteristics (N = 326). RESULTS: Items about assistive device use and help in the last month were robust (most kappas 0.7-0.9). Activity reduction measures were moderately reliable (around 0.5) but still showed reasonable agreement. Reliabilities for summary measures were good for device use (0.78-0.89) and help (0.62-0.67) but lower, albeit acceptable, for activity reduction (0.53). Hierarchical classifications had acceptable reliability and levels demonstrated hierarchical properties. IMPLICATIONS: National Health and Aging Trends Study's self-care and mobility accommodation measures offer ample reliability to study adaptation to limitations and can be used to construct a reliable and valid hierarchy.

Trends in late-life activity limitations in the United States: an update from five national surveys.

This article updates trends from five national U.S. surveys to determine whether the prevalence of activity limitations among the older population continued to decline in the first decade of the twenty-first century. Findings across studies suggest that personal care and domestic activity limitations may have continued to decline for those ages 85 and older from 2000 to 2008, but generally were flat since 2000 for those ages 65-84. Modest increases were observed for the 55- to 64-year-old group approaching late life, although prevalence remained low for this age group. Inclusion of the institutional population is important for assessing trends among those ages 85 and older in particular.

Lifetime risk and duration of chronic disease and disability.

OBJECTIVE: To estimate risk and duration of chronic conditions and disability for all older Americans and demographic subgroups. METHOD: Analysis of National Mortality Followback Survey data for survivors to age 65 to project lifetime risk and duration of selected conditions and examine their relationship with life expectancy and disability. RESULTS: For women, Blacks, and non-Blacks, arthritis is most common and has the longest average duration, followed by diabetes and COPD. Among men, diabetes duration is longest, followed by COPD. Disability risk is elevated for all conditions studied, except heart attack. Those very overweight most of life and persons with dementia have the greatest disability risk and relatively long disability durations. Among women, those very overweight most of life can expect to die 3.1 years sooner and have above average disability duration. DISCUSSION: Findings provide new information about the relative burden of common chronic diseases among all older Americans and major subgroups.