Association of cardiovascular fibrosis, remodeling, and dysfunction with frailty, pre-frailty, and functional performance: the Multi-Ethnic Study of Atherosclerosis (MESA).

BACKGROUND: Cardiovascular disease is associated with higher incidence of frailty. However, the nature of the mechanisms underlying this association remain unclear. The purpose of this study is to identify cardiovascular phenotypes most associated with physical frailty and functional performance in the Multi-Ethnic Study of Atherosclerosis (MESA). METHODS: As part of the MESA study, 3045 participants underwent cardiovascular magnetic resonance and computed tomography between 2010-2012. Of these, 1743 completed a Six-Minute Walk test (6MWT) and questionnaires (follow-up Exam: 2016-2018) which were used to generate a binary combined frail/prefrail vs. robust score according to a modified FRAIL Scale (self-report questionnaire). Multivariable logistic (binary frail outcome) or linear (6MWT) regression assessed the association between frailty and cardiovascular structure and function, aortic stiffness, coronary artery calcium, and myocardial fibrosis (ECV, extracellular volume fraction). RESULTS: Participants were 66±8yrs, 52% female at the time of imaging, and 29.4% were classified as frail or pre-frail. Older age and female gender were associated with greater odds of being in the frail/prefrail group. Concentric left ventricular remodeling (OR 1.89,p=0.008; Coef. -52.9,p<0.001), increased ECV (OR 1.10,p=0.002; Coef. -4.0,p=0.001), and worsening left atrial strain rate at early diastole (OR 1.56,p=<0.001; Coef. -22.75,p=0.027) were found to be associated with a greater likelihood of being in a frail state and lower 6MWT distance (m) . All associations with 6MWT performance were attenuated with adjustments for risk factors while ECV and LA strain rate remained independently associated with frailty. CONCLUSIONS: These findings suggest a significant overlap in pathways associated with subclinical cardiac dysfunction, cardiovascular fibrosis and physical frailty.

Nonlinear modeling of oral glucose tolerance test response to evaluate associations with aging outcomes.

As people age, their ability to maintain homeostasis in response to stressors diminishes. Physical frailty, a syndrome characterized by loss of resilience to stressors, is thought to emerge due to dysregulation of and breakdowns in communication among key physiological systems. Dynamical systems modeling of these physiological systems aims to model the underlying processes that govern response to stressors. We hypothesize that dynamical systems model summaries are predictive of age-related declines in health and function. In this study, we analyze data obtained during 75-gram oral-glucose tolerance tests (OGTT) on 1,120 adults older than 50 years of age from the Baltimore Longitudinal Study on Aging. We adopt a two-stage modeling approach. First, we fit OGTT curves with the Ackerman model-a nonlinear, parametric model of the glucose-insulin system-and with functional principal components analysis. We then fit linear and Cox proportional hazards models to evaluate whether usual gait speed and survival are associated with the stage-one model summaries. We also develop recommendations for identifying inadequately-fitting nonlinear model fits in a cohort setting with numerous heterogeneous response curves. These recommendations include: (1) defining a constrained parameter space that ensures biologically plausible model fits, (2) evaluating the relative discrepancy between predicted and observed responses of biological interest, and (3) identifying model fits that have notably poor model fit summary measures, such as [Formula: see text], relative to other fits in the cohort. The Ackerman model was unable to adequately fit 36% of the OGTT curves. The stage-two regression analyses found no associations between Ackerman model summaries and usual gait speed, nor with survival. The second functional principal component score was associated with faster gait speed (p<0.01) and improved survival (p<0.01).

Physical Function Trajectories and Mortality in Older Adults With Multisensory Impairment.

Importance: Single sensory impairment is associated with reduced functional resilience and increased mortality, though the effects of multiple sensory deficits are not known. Objective: To investigate longitudinal associations of the type, severity, and number of sensory impairments with physical function trajectories and mortality in older adults. Design, Setting, and Participants: This retrospective analysis of a longitudinal cohort study, the Health, Aging, and Body Composition (Health ABC) study, incorporated data from April 1997 to July 2013, featuring a 16-year follow-up with annual examinations and questionnaires. The cohort comprised 3075 men and women, aged 70 to 79 years at baseline, residing in Memphis, Tennessee, and Pittsburgh, Pennsylvania. All participants with complete sensory testing and covariate data at analytical baseline (year 5, 2002) were included. The data were analyzed September 1, 2022. Exposures: Visual, olfactory, auditory, and touch sensory functions were assessed between 2000 and 2002. Main Outcomes: The main outcomes included physical functioning trajectories and mortality risk. Physical function was assessed longitudinally using the Health ABC physical performance battery (HABCPPB). Results: A total of 1825 individuals (mean [SD] age, 77.4 [3.2] years; 957 [52%] female) were included in this study. Multivariable analysis of HABCPPB decline indicated that having 1 sensory impairment (ß estimate, -0.01 [95% CI, -0.02 to -0.001]); 2 sensory impairments (ß estimate, -0.01 [95% CI, -0.02 to -0.01]); 3 sensory impairments (ß estimate, -0.03 [95% CI, -0.04 to -0.02]); or 4 sensory impairments (ß estimate, -0.04 [95% CI, -0.05,-0.03]) was significantly associated with a steeper HABCPPB score decline in a dose-dependent manner. Adjusted Cox proportional hazards models indicated that having 1 sensory impairment (hazard ratio [HR], 1.35 [95% CI, 1.01-1.81]), 2 sensory impairments (HR, 1.58 [95% CI, 1.19-2.11]), 3 sensory impairments (HR, 1.79 [95% CI, 1.33-2.42]), or 4 sensory impairments (HR, 1.97 [95% CI, 1.39-2.79]) was significantly associated with increased mortality risk in a similarly dose-dependent manner. Conclusion: In this retrospective cohort study, the degree and number of multiple sensory impairments were associated with worse physical functioning and increased mortality risk. These findings represent an opportunity for further investigation into the value of screening, prevention, and treatment of sensory impairments to reduce morbidity and mortality in older adults.

Prevalence and risk factors for dysphagia in older adults after thyroid and parathyroid surgery.

BACKGROUND: We aimed to determine the prevalence and risk factors for dysphagia in adults 65 years and older before and after thyroidectomy or parathyroidectomy. METHODS: We performed a longitudinal prospective cohort study of older adults undergoing initial thyroidectomy or parathyroidectomy. We administered the Dysphagia Handicap Index questionnaire preoperatively and 1, 3, and 6 months postoperatively. We compared preoperative and postoperative total and domain-specific scores using paired t tests and identified risk factors for worse postoperative scores using multivariable logistic regression. RESULTS: Of the 175 patients evaluated, the mean age was 71.1 years (range = 65-94), 73.7% were female, 40.6% underwent thyroidectomy, 57% underwent bilateral procedures, and 21.1% had malignant diagnoses. Preoperative swallowing dysfunction was reported by 77.7%, with the prevalence 22.4% greater in frail than robust patients (P = .013). Compared to preoperative scores, 43.4% and 49.1% had worse scores at 3 and 6 months postoperatively. Mean functional domain scores increased by 62.3% at 3 months postoperatively (P = .007). Preoperative swallowing dysfunction was associated with a 3.07-fold increased likelihood of worse functional scores at 3 months. Whereas frailty was associated with preoperative dysphagia, there was no association between worse postoperative score and age, sex, race, frailty, body mass index, smoking status, gastroesophageal reflux disease, comorbidity index, malignancy, surgical extent, or type of surgery. CONCLUSION: Adults 65 years and older commonly report swallowing impairment preoperatively, which is associated with a 3.07-fold increased likelihood of worsened dysphagia after thyroid and parathyroid surgery that may persist up to 6 months postoperatively.

Acceptability and Feasibility of a Pain and Depressive Symptoms Management Intervention in Middle-Aged and Older African American Women.

Background and Objectives: The intersection of race, gender, and age puts older African American women at high risk of experiencing comorbid pain and depressive symptoms. The purpose of this study was to assess the feasibility and acceptability of a 12-week behavioral activation intervention to target self-selected goals related to pain and depressive symptoms in middle-aged and older African American women. Research Design and Methods: This randomized waitlist control study included 34 self-identified African American women, 50 years of age or older, with moderate-to-severe chronic pain and depressive symptoms. The intervention consisted of 8 in-person or virtual 1-hour visits with a nurse. Follow-up acceptability assessments were conducted with 10 participants. Results: The average age of the participants was 64.8 (standard deviation [SD] 10.5). They reported an average pain intensity score of 7.0 (SD 1.9) out of 10 and an average Patient Health Questionnaire-9 depressive symptoms score of 11.9 (SD 4.0) at baseline. Of the 34 participants who consented, 28 (82.4%) women started the intervention and 23 (82.1%) completed the intervention. Participants described the study as useful and beneficial. Participants recommended including a group component in future iterations. Effect sizes at 12 weeks were -0.95 for depressive symptoms indicating a substantial decrease in experienced depressive symptoms, but pain intensity was virtually unchanged (+0.09). Discussion and Implications: The findings of this study demonstrate that the intervention is acceptable among middle-aged and older African American women and their personal goals were met. Including a group component and identifying effective ways to decrease attrition rates will be key in the next steps of development for this intervention. It is crucial to provide tailored, nonpharmacological approaches to pain, and depression symptom management in older adult populations who experience inequities in pain and mental health outcomes. This study emphasizes the importance of participant-driven goal-setting interventions.

Resilient Adaptation Strategies: Unveiling Older Adults' Coping Dynamics Amidst the COVID-19 Pandemic.

Older adults, who are particularly vulnerable to coronavirus disease 2019 (COVID-19), exhibit less stress and greater well-being than their younger peers. However, there have been no in-depth explorations of adaptive coping strategies among this population, nor has the role of frailty status been addressed. The current study examined stress and coping in 30 U.S. older adults (mean age = 81 years, range = 68 to 95 years) amidst the COVID-19 pandemic, uncovering themes of: (1) Pandemic Stresses: stresses experienced during the pandemic centered around social isolation and concern for others' well-being; (2) Resilience: older adults proved highly adaptable, with lifetime experience as a stress buffer; and (3) Silver Linings: older adults reported positive by-products, such as reconnecting with and a renewed appreciation for life and nature. Motivation for change and change itself centered around creating value and meaning in the present, especially around social isolation. Findings challenge existing ageist stereotypes, give insight into interventional design, and highlight the importance of ensuring infrastructural and societal support. [Journal of Gerontological Nursing, 49(12), 32-39.].

Life Space and Activity Space Measurement: Making 'Room' for Structural Racism.

As we age, the ability to move is foundational to health. Life space is one measure of a person's ability to move and engage in activity beyond the home. A separate but related concept is activity space, a measurement of a person's spatial behaviors and visited locations that include social networks, neighborhoods, and institutions. In this article, we integrate the literature on life space and activity space discussing how physical function is not only determined by individual capabilities, but also by the surrounding social and environmental factors which may limit their agency. We show how structural racism contributes to inequities within this paradigm linking related concepts of movement, agency, belonging, and timing. We also explore implications for research and theory for mobility, social connection, and activity.

Hearing Loss and Frailty among Older Adults: The Atherosclerosis Risk in Communities Study.

OBJECTIVES: Hearing loss may contribute to frailty through cognitive and physical decline, but population-based evidence using validated measures remains scarce. We investigated the association of hearing loss with phenotypic frailty and its individual components and explored the potential protective role of hearing aid use. DESIGN: Cross-sectional study of community-dwelling older adults at visit 6 (2016-2017) of the Atherosclerosis Risk in Communities (ARIC) study, a cohort study of older adults from 4 U.S. communities (Washington County, MD; Forsyth County, NC; Jackson, MS; and Minneapolis, MN). SETTING AND PARTICIPANTS: Population-based study of 3179 participants (mean age = 79.2 years, 58.9% female). METHODS: Pure-tone audiometry at 0.5-4 kHz was used to assess unaided hearing, and the better-hearing ear's pure-tone average was categorized as follows: no [≤25 dB hearing level (HL)], mild (26-40 dB HL), and moderate or greater (>40 dB HL) hearing loss. Hearing aid use was self-reported. The Fried/physical frailty phenotype was used to categorize frailty status (robust, pre-frail, or frail). Multivariable multinomial and logistic regression models were used to study the association of hearing loss/hearing aid use with frailty status and individual frailty components, respectively. RESULTS: In our sample, 40% had mild and 27% had moderate or greater hearing loss (12% and 55% reported hearing aid use, respectively). Moderate or greater hearing loss was associated with greater odds of being pre-frail [odds ratio (OR), 1.25; 95% CI, 1.01-1.57] and frail (OR, 1.62; 95% CI, 1.06-2.47) vs robust, and greater odds of having slow gait, low physical activity, and exhaustion, compared with no hearing loss. Among those with hearing loss (>25 dB HL), compared with hearing aid users, nonusers had greater odds of being frail vs robust, and having unintentional weight loss, slow gait, and low physical activity. CONCLUSIONS AND IMPLICATIONS: Hearing loss is associated with pre-frailty and frailty. Longitudinal studies are warranted to establish if hearing aid use may prevent or delay frailty onset.

Identifying predictors of resilience to stressors in single-arm studies of pre-post change.

Many older adults experience a major stressor at some point in their lives. The ability to recover well after a major stressor is known as resilience. An important goal of geriatric research is to identify factors that influence resilience to stressors. Studies of resilience in older adults are typically conducted with a single-arm where everyone experiences the stressor. The simplistic approach of regressing change versus baseline yields biased estimates due to mathematical coupling and regression to the mean (RTM). We develop a method to correct the bias. We extend the method to include covariates. Our approach considers a counterfactual control group and involves sensitivity analyses to evaluate different settings of control group parameters. Only minimal distributional assumptions are required. Simulation studies demonstrate the validity of the method. We illustrate the method using a large, registry of older adults (N  =7239) who underwent total knee replacement (TKR). We demonstrate how external data can be utilized to constrain the sensitivity analysis. Naive analyses implicated several treatment effect modifiers including baseline function, age, body-mass index (BMI), gender, number of comorbidities, income, and race. Corrected analysis revealed that baseline (pre-stressor) function was not strongly linked to recovery after TKR and among the covariates, only age and number of comorbidities were consistently and negatively associated with post-stressor recovery in all functional domains. Correction of mathematical coupling and RTM is necessary for drawing valid inferences regarding the effect of covariates and baseline status on pre-post change. Our method provides a simple estimator to this end.

Substitution of self-reported measures for objectively assessed grip strength and slow walk in the Physical Frailty Phenotype: ramifications for validity.

BACKGROUND: Frailty assessment promises to identify older adults at risk for adverse consequences following stressors and target interventions to improve health outcomes. The Physical Frailty Phenotype (PFP) is a widely-studied, well validated assessment but incorporates performance-based slow walk and grip strength criteria that challenge its use in some clinical settings. Variants replacing performance-based elements with self-reported proxies have been proposed. Our study evaluated whether commonly available disability self-reports could be substituted for the performance-based criteria in the PFP while still identifying as "frail" the same subpopulations of individuals. METHODS: Parallel analyses were conducted in 3393 female and 2495 male Cardiovascular Health Study, Round 2 participants assessed in 1989-90. Candidate self-reported proxies for the phenotype's "slowness" and "weakness" criteria were evaluated for comparable prevalence and agreement by mode of measurement. For best-performing candidates: Frailty status (3 + positive criteria out of 5) was compared for prevalence and agreement between the PFP and mostly self-reported versions. Personal characteristics were compared between those adjudicated as frail by (a) only a self-reported version; (b) only the PFP; (c) both, using bivariable analyses and multinomial logistic regression. RESULTS: Self-reported difficulty walking ½ mile was selected as a proxy for the phenotype's slowness criterion. Two self-reported weakness proxies were examined: difficulty transferring from a bed or chair or gripping with hands, and difficulty as just defined or in lifting a 10-pound bag. Prevalences matched to within 4% between self-reported and performance-based criteria in the whole sample, but in all cases the self-reported prevalence for women exceeded that for men by 11% or more. Cross-modal agreement was moderate, with by-criterion and frailty-wide Kappa statistics of 0.55-0.60 in all cases. Frail subgroups (a), (b), (c) were independently discriminated (p < 0.05) by race, BMI, and depression in women; by age in men; and by self-reported health for both. CONCLUSIONS: Commonly used self-reported disability items cannot be assumed to stand in for performance-based criteria in the PFP. We found subpopulations identified as frail by resultant phenotypes versus the original phenotype to systematically differ. Work to develop self-reported proxies that more closely replicate their objective phenotypic counterparts than standard disability self-reports is needed.

A Study of Physical Resilience and Aging (SPRING): Conceptual framework, rationale, and study design.

Understanding the physiological basis of physical resilience to clinical stressors is crucial for the well-being of older adults. This article presents a novel framework to discover the biological underpinnings of physical resilience in older adults as part of the "Characterizing Resiliencies to Physical Stressors in Older Adults: A Dynamical Physiological Systems Approach" study, also known as The Study of Physical Resilience and Aging (SPRING). Physical resilience, defined as the capacity of a person to withstand clinical stressors and quickly recover or improve upon a baseline functional level, is examined in adults aged 55 years and older by studying the dynamics of stress response systems. The hypothesis is that well-regulated stress response systems promote physical resilience. The study employs dynamic stimulation tests to assess energy metabolism, the hypothalamic-pituitary-adrenal axis, the autonomic nervous system, and the innate immune system. Baseline characteristics influencing resilience outcomes are identified through deep phenotyping of physical and cognitive function, as well as of biological, environmental, and psychosocial characteristics. SPRING aims to study participants undergoing knee replacement surgery (n = 100), bone and marrow transplantation (n = 100), or anticipating dialysis initiation (n = 60). Phenotypic and functional measures are collected pre-stressor and at multiple times after stressor for up to 12 months to examine resilience trajectories. By improving our understanding of physical resilience in older adults, SPRING has the potential to enhance resilient outcomes to major clinical stressors. The article provides an overview of the study's background, rationale, design, pilot phase, implementation, and implications for improving the health and well-being of older adults.

Sinus inflammation and chronic rhinosinusitis are associated with a diagnosis of new onset asthma in the following year.

BACKGROUND: Chronic rhinosinusitis (CRS) and asthma commonly co-occur. No studies have leveraged large samples needed to formally address whether preexisting CRS is associated with new onset asthma over time. METHODS: We evaluated whether prevalent CRS [identified in two ways: validated text algorithm applied to sinus computerized tomography (CT) scan or two diagnoses] was associated with new onset adult asthma in the following year. We used electronic health record data from Geisinger from 2008 to 2019. For each year we removed persons with any evidence of asthma through the end of the year, then identified those with new diagnosis of asthma in the following year. Complementary log-log regression was used to adjust for confounding variables (e.g., sociodemographic, contact with the health system, comorbidities), and hazard ratios (HRs) and 95% confidence intervals (CI) were calculated. RESULTS: A total of 35,441 persons were diagnosed with new onset asthma and were compared to 890,956 persons who did not develop asthma. Persons with new onset asthma tended to be female (69.6%) and younger (mean [SD] age 45.9 [17.0] years). Both CRS definitions were associated (HR, 95% CI) with new onset asthma, with 2.21 (1.93, 2.54) and 1.48 (1.38, 1.59) for CRS based on sinus CT scan and two diagnoses, respectively. New onset asthma was uncommonly observed in persons with a history of sinus surgery. CONCLUSION: Prevalent CRS identified with two complementary approaches was associated with a diagnosis of new onset asthma in the following year. The findings may have clinical implications for the prevention of asthma.

An overview of the resilience world: Proceedings of the American Geriatrics Society and National Institute on Aging State of Resilience Science Conference.

Resilience, which relates to one's ability to respond to stressors, typically declines with age and the development of comorbid conditions in older organisms. Although progress has been made to improve our understanding of resilience in older adults, disciplines have employed different frameworks and definitions to study various aspects of older adults' response to acute or chronic stressors. "Overview of the Resilience World: State of the Science," a bench-to-bedside conference on October 12-13, 2022, was sponsored by the American Geriatrics Society and National Institute on Aging. This conference, summarized in this report, explored commonalities and differences among the frameworks of resilience most commonly used in aging research in the three domains of resilience: physical, cognitive, and psychosocial. These three main domains are intertwined, and stressors in one domain can lead to effects in other domains. The themes of the conference sessions included underlying contributors to resilience, the dynamic nature of resilience throughout the life span, and the role of resilience in health equity. Although participants did not agree on a single definition of "resilience(s)," they identified common core elements of a definition that can be applied to all domains and noted unique features that are domain specific. The presentations and discussions led to recommendations for new longitudinal studies of the impact of exposures to stressors on resilience in older adults, the use of new and existing cohort study data, natural experiments (including the COVID-19 pandemic), and preclinical models for resilience research, as well as translational research to bring findings on resilience to patient care.

Clinical trial participation predicts improved survival in older adults receiving allogeneic blood and marrow transplant.

BACKGROUND: Older adults represent a large oncologic demographic and are under-represented within oncology research despite constituting nearly two-thirds of the oncologic population in the United States. Because many social factors influence research participation, those who enroll in research do not reflect the oncology population at large, introducing bias and creating issue with external validity of studies. The same factors that influence study enrollment may also impact cancer outcomes, meaning that those who enroll in studies may already have an improved chance of cancer survival, further skewing results of these studies. This study evaluates characteristics that influence study enrollment in older adults and explore to what degree these factors may influence survival after allogeneic blood or marrow transplantation. METHODS: This retrospective comparison study evaluates 63 adults aged 60 and above undergoing allogenic transplantation at one institution. Patients who elected and declined enrollment in a non-therapeutic observational study were evaluated. Demographic and clinical characteristics between groups were compared and assessed as predictors of transplant survival, including decision to enroll in the study. RESULTS: Participants who chose to enroll in the parent study were not different with regard to gender, race/ethnicity, age, insurance type, donor age, and neighborhood income/poverty level compared to patients who were invited to participate but declined enrollment. The research participant group had higher proportion assessed as being fully active (23.8% vs. 12.7%, p = 0.034) and lower mean comorbidity scores (1.0 vs 2.47, p = 0.008). Enrollment in an observational study independently predicted transplant survival (HR = 0.316, 95% CI 0.12-0.82, p = 0.017). When controlling for relevant confounders of disease severity, comorbidities, and transplant age, enrolling in the parent study was associated with a lower hazards of death following transplant (HR = 0.302, 95% CI 0.10-0.87, p = 0.027). CONCLUSIONS: Despite being demographically comparable, persons who enrolled in one non-therapeutic transplant study had significantly improved survivorship than those who did not participate in observational research. These findings suggest that there are unidentified factors that influence study involvement that may also impact disease survivorship, over-estimating outcomes from these studies. Results from prospective observational studies should be interpreted with the consideration that study participants have an improved chance of survival at baseline.

Risk of new-onset and prevalent disease in chronic rhinosinusitis: A prospective cohort study.

BACKGROUND: Chronic rhinosinusitis (CRS) is accompanied by burdensome comorbid conditions. Understanding the relative timing of the onset of these conditions could inform disease prevention, detection, and management. OBJECTIVE: To evaluate the association between CRS and new-onset and prevalent asthma, noncystic fibrosis bronchiectasis (NCFBE), chronic obstructive pulmonary disease (COPD), gastroesophageal reflux disease (GERD), and obstructive sleep apnea (OSA). METHODS: We conducted a prospective cohort study among primary care patients using a detailed medical and symptom questionnaire in 2014 and again in 2020. We used questionnaire and electronic health record (EHR) data to determine CRS status: CRSSE (moderate to severe symptoms with EHR evidence), CRSE (limited symptoms with EHR evidence), CRSS (moderate to severe symptoms without EHR evidence), CRSneg (limited symptoms and no EHR evidence; reference). We evaluated the association between CRS status and new-onset and prevalent disease using logistic regression to estimate odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS: There were 7847 and 4445 respondents to the 2014 and 2020 questionnaires, respectively. CRSSE (vs CRSneg ) was associated with increased odds of new-onset asthma (OR, 1.74 [CI, 1.09-2.77), NCFBE (OR, 1.87 [CI, 1.12-3.13]), COPD (OR, 1.73 [CI, 1.14-2.68]), GERD (OR, 1.95 [CI, 1.61-2.35]), and OSA (OR, 1.91 [CI, 1.39-2.62]). Similarly, increased odds were observed for associations with the prevalence of these conditions. CONCLUSION: The findings from the study support further exploration of CRS as a target for the prevention and detection of asthma, NCFBE, COPD, GERD, and OSA.

Barriers to and solutions for representative inclusion across the lifespan and in life course research: The need for structural competency highlighted by the COVID-19 pandemic.

Exclusion of special populations (older adults; pregnant women, children, and adolescents; individuals of lower socioeconomic status and/or who live in rural communities; people from racial and ethnic minority groups; individuals from sexual or gender minority groups; and individuals with disabilities) in research is a pervasive problem, despite efforts and policy changes by the National Institutes of Health and other organizations. These populations are adversely impacted by social determinants of health (SDOH) that reduce access and ability to participate in biomedical research. In March 2020, the Northwestern University Clinical and Translational Sciences Institute hosted the "Lifespan and Life Course Research: integrating strategies" "Un-Meeting" to discuss barriers and solutions to underrepresentation of special populations in biomedical research. The COVID-19 pandemic highlighted how exclusion of representative populations in research can increase health inequities. We applied findings of this meeting to perform a literature review of barriers and solutions to recruitment and retention of representative populations in research and to discuss how findings are important to research conducted during the ongoing COVID-19 pandemic. We highlight the role of SDOH, review barriers and solutions to underrepresentation, and discuss the importance of a structural competency framework to improve research participation and retention among special populations.

Caregiving-Related Work Productivity Loss Among Employed Family and Other Unpaid Caregivers of Older Adults.

OBJECTIVES: Although nearly half of all family and unpaid caregivers to older adults work, little is known about short-term work impacts of caregiving using measures encompassing both missed work time and reduced productivity while physically at work. We quantify the prevalence, costs, and correlates of caregiving-related work productivity loss. METHODS: We used the 2015 National Study of Caregiving and National Health and Aging Trends Study to estimate caregiving-related work absences (absenteeism) and reduced productivity while at work (presenteeism). We calculated costs of lost productivity using hours lost, compensation, and a wage multiplier, accounting for the additional cost of replacing employee time. We examined correlates of caregiving-related absenteeism and presenteeism separately, using multivariable logistic regression models, adjusting for caregiver sociodemographic characteristics, occupation and hours worked, role overload, older adult health, use of respite care, support groups, flexible workplace schedules, help from family or friends, and caregiver training. RESULTS: Nearly 1 in 4 (23.3%) of the estimated 8.8 million employed family caregivers reported either absenteeism or presenteeism over a 1-month period owing to caregiving. Among those affected, caregiving reduced work productivity by one-third on average-or an estimated $5600 per employee when annualized across all employed caregivers-primarily because of reduced performance while present at work. Productivity loss was higher among caregivers of older adults with significant care needs and varied according to sociodemographic characteristics and caregiver supports. CONCLUSIONS: Findings emphasize the potential economic value of targeted policy intervention to support working caregivers.