Social connectedness, functional capacity, and longevity: A focus on positive relations with others.

RATIONALE: A large literature links social connectedness to health, but there is growing recognition of considerable nuance in the ways social connectedness is defined, assessed, and associated with health. OBJECTIVE: This study centers on positive relations with others - a measure derived from philosophical notions of the components of a "good life" - and the extent to which it predicts functional limitations and mortality using data from the national, longitudinal Mid-Life in the United States (MIDUS) study. We also assess whether these associations are independent of two common measures of social connectedness: social integration and social support. METHODS: Data on social connectedness came from the first wave of MIDUS (1994-1996), self-reported functional limitations were from the first (MIDUS 1) and third (MIDUS 3; 2013-2014) waves, and mortality data through 2022 were obtained from the National Death Index. RESULTS: Linear regression analyses showed that higher scores on positive relations with others predicted significantly less increase in functional limitations over time, and logistic regression models showed reduced probability of onset of functional limitations between MIDUS 1 and MIDUS 3 in those scoring higher on positive relations with others. Mortality was also significantly lower in those with higher scores on positive relations with others. All models adjusted for demographic and health characteristics, and all associations were robust to the inclusion of social integration and social support in the models. CONCLUSIONS: These results show that positive relations with others, a component of a well-lived life that describes sustained investment in social relationships that are mutual and trusting, is associated with two key health outcomes in aging adults: functional limitations and longevity. That these associations are independent of social integration and social support suggests a unique role for this formulation of social connectedness in the health of aging adults.

Educational Inequalities in Dual-Function Life Expectancy.

OBJECTIVES: This study investigates educational inequalities in dual functionality, a new concept that captures a combination of physical and cognitive functioning, both of which are important for independent living and quality of life. METHODS: Using data from the Health and Retirement Study and the National Health Interview Survey Linked Mortality Files, we define a measure of dual functionality based on the absence of limitations in activities of daily living and dementia. We estimate age-graded dual-function rates among adults 65+ and age-65 dual-function life expectancy across levels of education stratified by gender. RESULTS: In their mid-60s, 67% of women with less than a high school degree manifest dual functionality as compared with over 90% of women with at least a 4-year college degree. A similar pattern holds among men. These education-based gaps in dual functionality remain across later life, even as dual-function rates decline at older ages. Lower dual-function rates among older adults with less education translate into inequalities of 6.7 and 7.3 years in age-65 dual-function life expectancy between men and women, respectively, with at least a 4-year college degree compared to their counterparts with less than a high school degree. DISCUSSION: Older adults, particularly women, with less than a high school degree are estimated to live a smaller percentage of their remaining years with dual functionality compared with older adults with at least a college degree. These inequalities have implications for the distribution of caregiving resources of individuals, family members, and the broader healthcare community.

Religious Involvement and Cognitive Function Among White, Black, and Hispanic Older Adults.

We examined whether religious involvement was associated with cognitive function among older adults in the 2006-2020 waves of the Health and Retirement Study. Using growth curve analysis, we found the association between religious involvement and cognition varied by facet of religious involvement and race and Hispanic ethnicity. Attending religious services with friends was associated with higher initial levels of cognitive function (b = 0.22, p < .05). For Hispanic older adults, frequent attendance at religious services was associated with a slower rate of cognitive decline (b = 0.16, p < .01). Stratified models by race and Hispanic ethnicity demonstrated that religious salience was associated with lower initial levels of cognitive function among non-Hispanic White adults (b = -0.19, p < .01). We found no association between religious involvement and cognitive function among non-Hispanic Black respondents. In sum, elements of religious involvement are positively or negatively related to cognitive function in later life and vary by race and ethnicity.

A Time of Healing: Can Social Engagement After Bereavement Reduce Trajectories of Depression After the Death of a Child?

OBJECTIVES: We work from a stress and life-course perspective to examine the mental health of parents who experienced the death of their child. We examine whether mental health eventually returns to pre-bereavement levels and how social engagement after bereavement may shape the recovery process of depressive symptoms. METHODS: We analyze discontinuous growth curve models to assess the association between a child's death and trajectories of parents' depressive symptoms from the 1998-2016 Health and Retirement Study. The sample includes 16,182 parents aged 50 years and older. RESULTS: Those who transitioned to bereavement experienced an elevation in depressive symptoms and a relatively long recovery time (e.g., 7 years) to their pre-bereavement mental health in our findings. However, when engaging in volunteer work after their loss, depressive symptoms reduce more quickly to their pre-bereavement levels. Volunteering offsets up to 3 years of the negative consequences of child loss. DISCUSSION: The death of a child is a traumatic event with extensive health consequences, but research should more fully examine the dynamic nature and potential mitigation of these health consequences over time. Our findings expand the temporal lens to encompass healing processes after bereavement, incorporating the importance of social engagement.

Matters of the Heart: Childhood Maltreatment, Religious Transitions, and Cardiovascular-Related Problems over the Life Course.

OBJECTIVES: Childhood maltreatment is associated with a higher risk of cardiovascular-related problems, the leading cause of death in the United States. Drawing from cumulative inequality theory, this study considers whether transitions in religious attendance moderate the deleterious impact of childhood maltreatment on long-term cardiovascular risk. METHODS: We utilize over 35 years of prospective panel data from the National Longitudinal Study of Youth from the United States (1979-2015). RESULTS: Our findings suggest that decreases in religious attendance between adolescence and adulthood (from high to low, and high to moderate attendance) were associated with elevated cardiovascular-related risk for those abused as children. Neither stable high attendance nor increases in attendance buffered against the impact of childhood abuse on cardiovascular-related problems. DISCUSSION: We illustrate the importance of incorporating the role of stability and change in religious attendance across the life course and suggest directions for future research.

Racial-Ethnic Disparities in Dual-Function Life Expectancy.

BACKGROUND: This study develops a new concept, dual functionality, that integrates physical and cognitive function. We use the concept to define a measure of dual-function life expectancy (2FLE) and assess racial-ethnic inequalities in aging. METHODS: Drawing on data from the National Health Interview Survey Linked Mortality Files and the Health and Retirement Study, we define dual functionality as having no limitations in activities of daily living and being free of dementia. We use this measure and Sullivan life tables to estimate age-50 total life expectancy and age-50 2FLE for women and men across 4 racial-ethnic and nativity groups. RESULTS: At ages 50-54, between 79.0% (95% CI: 73.5, 84.5) and 87.6% (95% CI: 84.0, 91.2) of (non-Hispanic) Black, foreign-born Hispanic, and U.S.-born Hispanic women and men remain dual functional as compared with 90.4% (95% CI: 89.3, 91.4) and 91.4% (95% CI: 90.2, 92.5) of (non-Hispanic) White women and men, respectively. These and corresponding racial-ethnic disparities in dual functionality through ages 85 and older translate into substantial inequalities in 2FLE. For instance, the Black-White gap in age-50 2FLE is 6.9 years (95% CI: -7.5, -6.4) for women and 6.0 years (95% CI: -6.6, -5.4) for men. CONCLUSIONS: Black, foreign-born Hispanic, and U.S.-born Hispanic older adults are estimated to live a smaller percentage of their remaining years with dual functionality than White older adults. These results reveal stark racial-ethnic inequalities in aging that have significant implications for quality of life, caregiving, and health needs.

Dual Functionality in Later Life.

Gerontologists have long shown interest in both longevity and quality of life during later life, but considerable debate has ensued as scholars sought to integrate the two. Drawing from research on the topics of exceptional longevity, successful aging, and active life expectancy, we propose the concept of dual functionality to examine how humans reach advanced ages while maintaining physical and cognitive function. Dual functionality refers to being free of both physical and cognitive impairment. The loss of dual functionality challenges social networks to respond to the functional loss and is a harbinger of additional losses. Evidence of change in the percent of the older population maintaining dual functionality would be helpful for evaluating public health policies to aid quality of life during later life. This article is based on the first author's Robert W. Kleemeier Award Lecture at The Gerontological Society of America 2022 Annual Scientific Meeting.

Subjective Memory Decline Predicts Incident Cognitive Impairment Among White-But Not Black or Hispanic-Older Adults.

BACKGROUND AND OBJECTIVES: This study investigates whether subjective memory decline (SMD) in a racially diverse sample of older adults without cognitive impairment at baseline is associated with incident cognitive impairment during a 12-year follow-up period. RESEARCH DESIGN AND METHODS: With panel data from a national sample (N = 9,244) of cognitively intact Black, White, and Hispanic Americans 65 years or older in 2004, we examine if SMD is associated with the loss of normal cognition by 2016. Cognitive status was assessed every 2 years with a modified version of the Telephone Interview for Cognitive Status to identify the transition from normal cognition to cognitive impairment. RESULTS: Estimates from Weibull accelerated failure-time models reveal that SMD is associated with earlier incident cognitive impairment (time ratio = 0.96, p < .05). In subsequent models stratified by race-ethnicity, this association was evident among White respondents (time ratio = 0.95, p < .01) but not among Black, U.S.-born Hispanic, or foreign-born Hispanic respondents. DISCUSSION AND IMPLICATIONS: Given that the prognostic validity of SMD differs by race and ethnicity, caution is warranted when using it as a screening or clinical tool in diverse populations.

Socioeconomic status and the Black-White mortality crossover.

OBJECTIVES: We investigated associations among age, race, socioeconomic status (SES), and mortality in older persons and whether low SES contributes to the Black-White mortality crossover (when elevated age-specific mortality rates invert). METHODS: We used panel data from the North Carolina Established Populations for Epidemiologic Studies of the Elderly to test the main and interactive effects of SES on mortality. RESULTS: Discrete-time hazard models showed that the association between low education and mortality did not vary by race or age and was only significant for men. For women, the effect of low income diminished with age and had little impact on the crossover. For men, low income varied by race and age, altering the Black-White crossover and producing low-high income crossovers at advanced ages. CONCLUSIONS: Low education and income were associated with increased mortality risk for older adults, but only low income had a differential impact on the Black-White mortality crossover. A primary route to reducing mortality differentials in later life is to prevent the disproportionate selective mortality of Blacks and the poor earlier in the life course.

Is Marital Quality Related to Physical Activity Across the Life Course for Men and Women?

OBJECTIVES: Although physical activity is linked to multiple health outcomes, a majority of Americans do not meet physical activity guidelines, often with precipitous declines among older adults. Marital quality is a less-explored, but important, factor that may influence physical activity, as spouses often influence each other's health behaviors. METHODS: We use nationally representative panel data to investigate whether positive and negative dimensions of marital quality influence physical activity, and whether age and gender moderate these relationships. RESULTS: We find that both marital support and strain are related to higher odds of more frequent active exercise and walking, pointing to the complex influence of marital quality. Marital support became increasingly important to higher levels of walking frequency as men aged. DISCUSSION: This study provides new information on the ways in which both positive and negative dimensions of marital quality may contribute to trajectories of physical activity across the life course.

Sibling Deaths, Racial/Ethnic Disadvantage, and Dementia in Later Life.

OBJECTIVES: Sibling loss is understudied in the bereavement and health literature. The present study considers whether experiencing the death of siblings in mid-to-late life is associated with subsequent dementia risk and how differential exposure to sibling losses by race/ethnicity may contribute to racial/ethnic disparities in dementia risk. METHODS: We use discrete-time hazard regression models, a formal mediation test, and a counterfactual simulation to reveal how sibling loss in mid-to-late life affects dementia incidence and whether unequal exposures by race/ethnicity mediate the racial/ethnic disparities in dementia. We analyze data from the Health and Retirement Study (2000-2016). The sample includes 13,589 respondents (10,670 non-Hispanic White, 1,761 non-Hispanic Black, and 1,158 Hispanic adults) aged 65 years and older in 2000 who show no evidence of dementia at baseline. RESULTS: Discrete-time hazard regression results show that sibling loss in mid-to-late life is associated with up to 54% higher risk for dementia. Sibling loss contributes to Black-White disparities in dementia risk. In addition, a simulation analysis shows that dementia rates would be 14% lower for Black adults if they experienced the lower rates of sibling loss experienced by White adults. This pattern was not observed among Hispanic adults. DISCUSSION: The death of a sibling in mid-to-late life is a stressor that is associated with increased dementia risk. Black adults are disadvantaged in that they are more likely than Whites to experience the death of siblings, and such losses contribute to the already substantial racial/ethnic disadvantage in dementia.

Childhood Stressors, Relationship Quality, and Cognitive Health in Later Life.

OBJECTIVES: The rising prevalence of cognitive impairment, Alzheimer's disease, and related disorders signals the need for a better understanding of how social factors may affect cognitive health for millions of Americans. Drawing from cumulative inequality theory, we aim to understand the implications of a stressful childhood on social relationships and cognitive health in later life. METHODS: This study utilizes longitudinal data (2006-2016) from the Health and Retirement Study to examine pathways, both direct and indirect through social relationships in adulthood, from childhood stressors to cognitive health trajectories over time. RESULTS: Respondents reporting a greater number of stressors in childhood had worse cognitive health over time, but those negative effects were not as steep as time progressed. Early-life stressors are also associated with less social support and more social strain in adulthood which, in turn, are associated with initial cognitive health. Finally, pathway analyses confirm that childhood stressors are indirectly associated with initial cognitive health through social strain and social support. DISCUSSION: Findings reveal that a stressful childhood creates chains of risks that have lifelong implications for cognitive health, both directly and indirectly by creating obstacles for developing healthy and supportive social relationships.

Do Early-Life Social, Behavioral, and Health Exposures Increase Later-Life Arthritis Incidence?

OBJECTIVES: This study investigates direct and indirect influences of childhood social, behavioral, and health exposures on later-life osteoarthritis and rheumatoid arthritis development. METHODS: Drawing from cumulative inequality theory and six waves of the Health and Retirement Study (2004-2014), we estimate structural equation modeling-based discrete-time survival analysis of the association between six childhood exposure domains and both osteoarthritis and rheumatoid arthritis incidence for men (n = 2720) and women (n = 2974). Using the delta method to test for mediation, we examine indirect effects via selected health-related risks and resources. RESULTS: Risky adolescent behavior is associated with rheumatoid arthritis incidence for women (h.O.R. = 1.883, 95% C.I. [1.016, 3.490]), whereas several types of childhood exposures are associated with later-life osteoarthritis development for both men and women. Experiencing two or more childhood socioeconomic disadvantages is indirectly associated with osteoarthritis (men: coef. = 0.024, 95% C.I. [0.003, 0.045]; women: coef. = 0.111, 95% C.I. [0.071, 0.150]) and rheumatoid arthritis (men: coef. = 0.037, 95% C.I. [0.000, 0.074]; women: coef. = 0.097, 95% C.I. [0.035, 0.159]) development through adult body mass index. DISCUSSION: Findings highlight the importance of childhood contexts in understanding the development of later-life osteoarthritis and rheumatoid arthritis.

A controlled trial of team-based learning in an ambulatory medicine clerkship for medical students.

BACKGROUND: Team-based learning (TBL) has been studied in several preclinical settings, but there is less evidence for its effectiveness in clinical curricula. PURPOSE: We compared the impact of TBL versus usual small group lecture (SGL) on knowledge objectives in a clinical clerkship. METHODS: We used an unblinded crossover design with 112 students rotating through the Ambulatory Medicine clerkship. In each rotation of the clerkship, 3 clinical topics were taught as SGL and 3 as TBL. We compared performance on the knowledge examination for those items taught with TBL and those with SGL. RESULTS: Performance by students taught by TBL was higher than those taught by SGL in each topic, except Hypertension. The average effect size of the six measures was 0.51. CONCLUSIONS: TBL appears to be a more effective method than the usual small group lecture in achievement of knowledge objectives for clinical clerkship students.

Gaining Faith, Losing Faith: How Education Shapes the Relationship between Religious Transitions and Later Depression.

Using the life course perspective, we assess the "resources" and "risks" to mental health associated with transitions in religious attendance between early life and midlife and how this process may be influenced by education. Drawing on over 35 years of prospective panel data from the National Longitudinal Study of Youth, baseline models suggest that stable, frequent attendance accumulated between adolescence to midlife and increases to frequent attendance by adulthood are associated with the lowest depression relative to consistent nonattenders. Individuals who declined in their religious participation report higher depression. Education conditioned this association, whereby declines in religious participation negatively impacted the health of those without a college degree more strongly and increases benefitted the well-educated to a greater extent. We combine insights from the life course perspective and work on social stratification and religiosity to interpret our results and offer directives for future research.

Lost Touch? Implications of Physical Touch for Physical Health.

OBJECTIVES: Growing research on the impact of physical touch on health has revealed links to lower blood pressure, higher oxytocin levels, and better sleep, but links to inflammation have not been fully explored. Physical touch may also buffer stress, underscoring its importance during the stressful time of living in the COVID-19 global pandemic-a time that has substantially limited social interactions and during which physical touch has been specifically advised against. METHOD: We analyze nationally representative longitudinal data on older adults (N = 1,124) from the National Social Life, Health, and Aging Project using cross-lagged path models. RESULTS: More frequent physical touch is significantly related to a lower likelihood of subsequent elevated inflammation. DISCUSSION: These findings highlight the importance of finding safe ways to incorporate physical touch, even in the aftermath of the COVID-19 pandemic.

Using Kern's 6-Step Approach to Integrate Health Systems Science Curricula Into Medical Education.

The term "health systems science" (HSS) has recently emerged as a unifying label for competencies in health care delivery and in population and community health. Despite strong evidence that HSS competencies are needed in the current and future health care workforce, heretofore the integration of HSS into medical education has been slow or fragmented-due, in part, to a lack of evidence that these curricula improve education or population outcomes. The recent COVID-19 pandemic and the national reckoning with racial inequities in the United States further highlight the time-sensitive imperative to integrate HSS content across the medical education continuum. While acknowledging challenges, the authors highlight the unique opportunities inherent in an HSS curriculum and present an elaborated curricular framework for incorporating health care delivery and population health into undergraduate medical education. This framework includes competencies previously left out of medical education, increases the scope of faculty development, and allows for evidence of effectiveness beyond traditional learner-centric metrics. The authors apply a widely adopted 6-step approach to curriculum development to address the unique challenges of incorporating HSS. Two examples-of a module on quality improvement (health care delivery) and of an introductory course on health equity (population and community health)-illustrate how the 6-step approach can be used to build HSS curricula. The Supplemental Digital Appendix (at http://links.lww.com/ACADMED/B106) outlines this approach and provides specific examples and resources. Adapting these resources within local environments to build HSS curricula will allow medical educators to ensure future graduates have the expertise and commitment necessary to effect health systems change and to advocate for their communities, while also building the much-needed evidence for such curricula.

Exacerbating Inequalities: Social Networks, Racial/Ethnic Disparities, and the COVID-19 Pandemic in the United States.

OBJECTIVES: The disruption and contraction of older adults' social networks are among the less discussed consequences of the COVID-19 pandemic. Our objective was to provide an evidence-based commentary on racial/ethnic disparities in social network resources and draw attention to the ways in which disasters differentially affect social networks, with meaningful insight for the ongoing pandemic. METHODS: We draw upon prior research on social networks and past natural disasters to identify major areas of network inequality. Attention is given to how pre-pandemic racial/ethnic network disparities are exacerbated during the current crisis, with implications for physical and mental health outcomes. RESULTS: Evidence from the literature shows a robust association between strong social networks and physical and mental health outcomes. During times of crisis, access to social networks for older adults is disrupted, particularly for marginalized groups. We document pre-pandemic disparities in social networks resources and offer insight for examining the impact of COVID-19 on disrupting social networks among older adults. DISCUSSION: Importantly, racial/ethnic disparities in social networks both prior to and as a result of the pandemic intensify existing inequalities and demonstrate the necessity of better understanding social network inequalities for marginalized older adults, particularly in the context of the COVID-19 health crisis.

Lobular carcinoma in situ/atypical lobular hyperplasia on breast needle biopsies: does it warrant surgical excisional biopsy? A study of 27 cases.

Lobular neoplasia including lobular carcinoma in situ (LCIS) and atypical lobular hyperplasia (ALH) may be identified in breast core needle biopsies as incidental findings or associated with microcalcifications. There are no general consensus guidelines for follow-up management in patients when lobular neoplasia is the only abnormal finding on core needle biopsy. The aim of this study was to evaluate our experience in the follow-up of these patients. A total of 3163 breast core needle biopsies were retrieved from the surgical pathology files between 2003 and 2009; among them, 56 (1.8%) cases were identified with a diagnosis of ALH or LCIS. Eleven cases were excluded because of the presence of a concurrent more severe lesion in the biopsies that mandated excision. The remaining 45 cases contained only ALH or LCIS and otherwise benign breast tissue; 27 had surgical excision follow-up. In the surgical excision specimens, 5 (19%) of 27 cases showed more severe lesions or were "upgraded" (3 invasive ductal carcinomas, 1 invasive lobular carcinoma, and 1 ductal carcinoma in situ). Histologic features of the lobular neoplasia on the cores, including association with microcalcifications, pagetoid involvement of ducts, and extensive lobular involvement, were retrospectively evaluated. These histologic features were found to have no predictive value for a more severe lesion in the subsequent excision. We suggest that patients with LCIS/ALH on core needle biopsy should be considered for surgical excision to rule out a more significant lesion regardless of the histologic features.

Angiosarcoma of the breast: a clinicopathologic analysis of cases from the last 10 years.

Breast angiosarcoma may occur de novo, or as a complication of radiation therapy, or chronic lymphedema secondary to axillary lymph node dissection for mammary carcinoma. In our effort to characterize the clinicopathologic features of breast angiosarcoma, we reviewed all breast angiosarcoma cases in the University of Kansas Medical Center and Ohio State University Medical Center archives from 1997 to 2007. Clinical histories and follow-up data for identified patients were reviewed. The tumors were graded histologically according to Rosen's method. Only 11 angiosarcomas were identified among more than 5000 malignant breast neoplasms (0.1%-0.2% incidence) for the last 10 years. Eight cases (6 high grade, 1 intermediate grade, 1 low grade) were identified as postradiation angiosarcoma (postradiation time interval, 4-12 years), and 3 cases were identified as primary angiosarcomas (1 high grade, 2 low grade). Follow-up (median, 36 months) revealed that 3 cases of postradiation angiosarcoma recurred as skin and/or chest wall lesions and 1 case of primary angiosarcoma developed liver metastases (all high-grade). In conclusion, breast angiosarcoma remains a rare disease. Rosen's method for grading breast angiosarcoma is easy to implement and correlates well with clinical outcome. There are no distinct clinical or histologic differences between primary and postradiation breast angiosarcomas.