Time Use and Well-Being in Family and Other Unpaid Caregivers of Older Adults.

OBJECTIVES: Caregivers report limited freedom to engage with others, participate in physical activities, pursue leisure activities, and sleep. Few studies have focused on caregivers' time use across different activities, particularly how different patterns of time use are associated with well-being. This study aimed to (a) identify time-use profiles of family caregivers of older adults and (b) examine associations between identified time-use profiles and caregiver well-being. METHODS: We analyzed data from 1,640 family caregivers of community-dwelling older adults from Round 7 (2017) of the National Study of Caregiving and the National Health and Aging Trends Study. Latent profile analysis was used to estimate time-use profiles based on 4 indicators (i.e., regenerative time, discretionary time, eldercare-related committed time, non-eldercare committed time). We conducted regressions to examine the relationship between the latent profiles and well-being outcomes. RESULTS: Three profiles of caregivers emerged based on time-use patterns. The Overloaded profile (20%) spent the greatest time in non-eldercare committed activities, such as household activities and paid work. The Flexible profile (49%) spent the most amount of time in social activities and physical activities, and the least amount of non-eldercare committed time compared to the other 2 caregiver types. Lastly, the Occupied profile (31%) allocated time relatively evenly in all activities. When comparing well-being outcomes, caregivers in the Flexible profile had lower levels of anxiety than the Occupied profile. DISCUSSION: The profiles acknowledge the diverse experiences of caregivers, underscoring the significance of granting them greater latitude in balancing eldercare responsibilities and personal life for enhanced well-being.

Frailty as a predictor of mortality: a comparative cohort study of older adults in Costa Rica and the United States.

BACKGROUND: Frailty is a common condition among older adults that results from aging-related declines in multiple systems. Frailty increases older adults' vulnerability to negative health outcomes, including loss of mobility, falls, hospitalizations, and mortality. The aim of this study is to examine the association between frailty and mortality in older adults from Costa Rica and the United States. METHODS: This prospective cohort study uses secondary nationally-representative data of community-dwelling older adults from the Costa Rican Longevity and Healthy Aging Study (CRELES, n = 1,790) and the National Health & Aging Trends Study (NHATS, n = 6,680). Frailty status was assessed using Physical Frailty Phenotype, which includes the following five criteria: shrinking, exhaustion, low physical activity, muscle weakness, and slow gait. We used Cox proportional hazard models to examine the association between frailty and all-cause mortality, including sociodemographic characteristics and health behaviors as covariates in the models. Mortality follow-up time was right censored at 8 years from the date at baseline interview. RESULTS: The death hazard for frail compared to non-frail older adults was three-fold in Costa Rica (HR = 3.14, 95% CI: 2.13-4.62) and four-fold in the White US (HR = 4.02, 95% CI: 3.04-5.32). Older age, being male, and smoking increased mortality risk in both countries. High education was a protective factor in the US, whereas being married/in union was a protective factor in Costa Rica. In the US, White older adults had a lower risk of death compared to all other races and ethnicities. CONCLUSIONS: Results indicate that frailty can have a differential impact on mortality depending on the country. Access to universal health care across the life course in Costa Rica and higher levels of stress and social isolation in the US may explain differences observed in end-of-life trajectories among frail older adults.

Residential Segregation, Social Cohesion, and Aging in Place: Health and Mental Health Inequities.

BACKGROUND AND OBJECTIVES: Research shows that living in segregated neighborhoods may have deleterious health outcomes via social, physical, and socioeconomic contexts that deepen existing inequities. However, there has been limited scholarship examining the effects of segregation on older adults, despite an increasing focus on aging in place. Guided by the Ecological Model of Aging, we examined the effects of segregation on older adults' self-rated health and mental health, accounting for both individual characteristics and neighborhood opportunities and risks (e.g., social cohesion) and the potential moderating role of race and economic vulnerability. RESEARCH DESIGN AND METHODS: We used data from the first 4 rounds of the National Health and Aging Trends Study (2011-2014) merged with tract-level census data for a final sample size of 3,084 community-dwelling older adults in urban areas. We conducted multivariate regression analyses after conditioning on residential location selection variables. RESULTS: There was no significant association between neighborhood segregation and self-rated health or between segregation and anxiety and depression symptoms. Consistent with the literature, perceived social cohesion was protective of health in each model. DISCUSSION AND IMPLICATIONS: Our findings highlight the need for more rigorous research on segregation and older residents that utilize longitudinal and spatial data. Our findings also have implications for policies and programs that aim to support the ability to age in place for older adults who have different racial identities and live in different neighborhood contexts. Because social cohesion can be a protective factor for older adults' health and mental health, policymakers and practitioners should support initiatives to increase social cohesion.

Neighborhood Age Composition and Self-Rated Health: Findings from a Nationally Representative Study.

Neighborhood age composition is an understudied area. Furthermore, existing empirical and conceptual work is conflicting, with some scholarship-indicating neighborhoods with older adults are beneficial and other scholarship suggesting it can be detrimental. Combining data from 7,197 older adults from the first wave (2011) of the National Health & Aging Trends Study and census tract data from the National Neighborhood Change Database, the purposes of our study were to: 1) identify the characteristics of neighborhoods experiencing different types of changes in age composition, and 2) examine the association between neighborhood age composition and self-rated health. Findings indicate that neighborhoods experiencing Concentration (where the number of older adults are declining but their percentage of the total population are increasing), the majority of which are in urban areas, have less aggregate economic resources, more indicators of neighborhood disorder, and less access to services and supports. Regression models also suggest older adults living in Concentration neighborhoods reported lower self-rated health compared to those living in the other three neighborhood types. Findings point to the importance of considering neighborhood age composition when targeting interventions and resources, and the potential consequences of being stuck in place in a neighborhood that does not meet elders' needs.

The Role of County Characteristics in Mental Health Service Use by Older African Americans.

OBJECTIVE: Older African Americans may underutilize mental health services, although they experience mental health problems at rates comparable with those of whites. Untreated mental disorders contribute to increased risk of morbidity and mortality and decreased quality of life, and therefore, understanding the factors that influence racial disparities in service use is critical. This study examined whether county characteristics were associated with mental health service use by older African Americans after the analyses adjusted for individual characteristics. METHODS: This study combined individual-level data from the 2008-2012 Medical Expenditure Panel Survey with county-level data for 2008-2012 from the 2013-2014 Area Health Resources Files and county-level data from the 2008-2012 Chronic Conditions Report of the Chronic Conditions Data Warehouse for 1,567 community-dwelling African Americans ages 60 and older. Multilevel logistic regressions were used to examine the role of county characteristics on mental health services use with adjustment for individual-level risk factors. RESULTS: At the county level, individuals living in a county with a higher proportion of African Americans were less likely to use mental health services. At the individual level, higher income and mental health status were associated with mental health service utilization. CONCLUSIONS: Among older African Americans, the racial composition of one's county of residence played a role in mental health service use, indicating the need for future research focusing on the relationship between an area's racial composition and mental health service use. Programs may be able to ameliorate racial disparities in mental health care by targeting areas with a higher percentage of African Americans.

Organizational Characteristics Associated With the Predicted Sustainability of Villages.

Guided by resource dependence theory, this mixed-methods study examined organizational characteristics contributing to the perceived sustainability of Villages, a rapidly proliferating grassroots approach for promoting social participation and service access for community-dwelling older adults. Surveys conducted with leaders of 86% of Villages in the United States in 2012 found that higher predicted confidence in their Village's 10-year survival was associated with greater financial reserves, human resources, number of Village members, formal policies and procedures, and formal collaboration agreements. Respondents' explanations of their confidence ratings revealed additional themes of organizational leadership and perceived community need. Member resource inputs were not found to be as salient for Village leaders' perceptions of sustainability as was anticipated given the Village model's emphasis on consumer involvement. Despite the lack of longitudinal prospective data, study findings suggest potential limitations of consumer-driven organizational models such as Villages, including the need for a more stable resource base.

Aging in Place in Gentrifying Neighborhoods: Implications for Physical and Mental Health.

Background and Objectives: In the United States, the older adult population and the proportion of neighborhoods experiencing gentrification are both growing. However, there is limited scholarship on the effects of gentrification on older adults, with most work focusing on those who leave rather than stay. This study examines the effects of remaining in a gentrifying neighborhood on older adults' self-rated health and mental health, with particular attention to outcomes for those who are economically vulnerable. Research Design and Methods: Data are from 6,810 community-dwelling respondents in metropolitan areas from the first wave of the National Health & Aging Trends Study combined with the 1970-2010 National Neighborhood Change Database. We estimate the effects of gentrification on self-rated health and mental health separately using a quasi-experimental approach and comparing two methods: matching design and linear regression. Results: Economically vulnerable older adults in gentrifying neighborhoods reported higher self-rated health than economically vulnerable older adults in low-income neighborhoods. Both economically vulnerable and higher-income older adults in gentrifying neighborhoods had more depression and anxiety symptoms than those living in more affluent areas. Higher-income older adults in gentrifying neighborhoods had poorer mental health than their counterparts in low-income neighborhoods. Discussion and Implications: Findings call attention to the complexity of gentrification, and the need for more research examining how the intersection of neighborhood and individual characteristics influences older adults' health. Results reinforce the need for neighborhood-level interventions as well as relocation support to promote health in later life and caution against an overemphasis on aging in place.

Variations on the Village Model.

Villages, which are community-based initiatives designed to help older adults age in place through a combination of services, participant engagement, and peer support, have expanded rapidly since their initial development in the early 2000s. Using a sample of Villages in the United States, we examined variations from characteristics of the Village model as portrayed by media and organizational leaders. Results indicate there is no uniform Village model that can be implemented and evaluated by policy makers, funders, service providers, and researchers. Based on the extent of member involvement, methods of service provision, and funding sources, we developed a conceptually and empirically informed typology of Villages that reflects the model's focus on consumer involvement. Descriptive analyses indicate potential differences in member, community, and organizational characteristics. This emerging typology has implications for understanding the implementation and sustainability of Villages, including whether specific Village types are best suited to certain community contexts.

Caregiver stressors and depressive symptoms among older husbands and wives in the United States.

Framed by Pearlin's Stress Process Model, this study prospectively examines the effects of primary stress factors reflecting the duration, amount, and type of care on the depressive symptoms of spousal caregivers over a2-year period, and whether the effects of stressors differ between husbands and wives. Data are from the 2004 and 2006 waves of the Health and Retirement Study and we included community-dwelling respondents providing activities of daily life (ADL) and/or instrumental activities of daily life (IADL) help to their spouses/partners (N = 774). Results from multivariate regression models indicate that none of the primary stressors were associated with depressive symptoms. However, wives providing only personal care had significantly more depressive symptoms than wives providing only instrumental care, while husbands providing different types of care showed no such differences. To illuminate strategies for reducing the higher distress experienced by wife caregivers engaged in personal care assistance, further studies are needed incorporating couples' relational dynamics and gendered experiences in personal care.

Assessing the factor structure of well-being in older adults: findings from the National Health and Aging Trends Study.

OBJECTIVES: Well-being has been conceptualized as a two-dimensional construct that includes both hedonic and eudaimonic components. To date, existing measures of well-being may not adequately capture both of these components for older adults, and limited literature has explored whether the two constructs can be integrated into one factor to measure well-being in this population. METHOD: This study examined the factor structure of the 11 well-being items from the National Health and Aging Trends Study (NHATS), a nationally representative panel study of Medicare recipients in the US. Using data from the 2011 wave, we divided the community-dwelling sample into two random subsamples, testing our theory in sample 1 (n = 3305) and examining the replicability of the solution in sample 2 (n = 3297). RESULTS: We conducted confirmatory factor analyses using a correlated uniqueness approach to account for the frequency and negatively worded method effects. The findings from sample 1 indicated that the single factor structure was a superior fit to the data, and the solution was confirmed by sample 2 [χ(2)(33) = 85.002, p < .001, RMSEA = 0.022 (90% CI = 0.016-0.028), CFI = 0.993, TLI = 0.989, WRMR = 0.831]. CONCLUSION: Findings suggest that although the hedonic and eudaimonic components of well-being may be conceptually distinct, they are highly correlated in the NHATS well-being measures and should be measured as a single construct. Implications for future research using the NHATS and research using other data sources and focusing on other populations are discussed.

Aging in Place vs. Relocation for Older Adults with Neurocognitive Disorder: Applications of Wiseman's Behavioral Model.

Some older adults are more vulnerable to housing concerns due to physical and cognitive challenges, including those with a neurocognitive disorder who need extensive support. Environmental gerontology frameworks, including Wiseman's 1980 Behavioral Model of Elderly Migration, have informed scholarship on aging in place and relocation. Understanding Wiseman's model, including considerations for working with families confronting a neurocognitive disorder, can help practitioners ensure that older clients live in settings that best meet their wants and needs.

Do age-friendly characteristics influence the expectation to age in place? A comparison of low-income and higher income Detroit elders.

Currently there is limited evidence linking age-friendly characteristics to outcomes in elders. Using a representative sample of 1,376 adults aged 60 and older living in Detroit, this study examined the association between age-friendly social and physical environmental characteristics and the expectation to age in place, and the potential differences between low- and higher-income elders. Based on U.S. Environmental Protection Agency's (EPA) age-friendly guide, we identified six factors reflecting age-friendly characteristics. Logistic regression models indicated that regardless of income level only neighborhood problems were significantly associated with expecting to age in place. Low-income elders were more likely to expect to age in place than their higher-income counterparts, and it is unclear whether this resulted from a desire to remain in the home or that there is no place else to go. Future research should address the ways in which financial resources affect the choices, expectations, and outcomes of aging in place.

Does the Village model help to foster age-friendly communities?

This article explores the potential role of the Village model, a social initiative that emphasizes member involvement and service access, in helping communities to become more age-friendly. A survey of 86.3% of operational Villages examined activities designed to help members access a variety of supports and services consistent with the World Health Organization's (WHO) Global Network of Age-Friendly Cities and Communities program model, as well as other potential contributions to community age friendliness. Analysis revealed that 85.5% of Villages provided assistance with at least six of the eight WHO domains, but only 10.1% implemented features of all eight; more than one-third were engaged in direct or indirect efforts to improve community physical or social infrastructures or improve community attitudes toward older persons. These findings suggest that Villages and other social organizations may have untapped potential for enhancing their members' ability to age in place consistent with the goals of age-friendly initiatives while also promoting constructive changes in the overall community.

Local and regional governments and age-friendly communities: a case study of the San Francisco Bay Area.

The purpose of this study was to assess the extent to which cities, county departments of adult and aging services, county transportation authorities, and public transit agencies in the San Francisco Bay Area have in place age-friendly policies, programs, and infrastructure in the areas of community design, housing, transportation, health care and supportive services, and opportunities for community engagement. The most common age-friendly features include those that target alternative forms of mobility (for example, incentives for mixed-use neighborhoods and changes to improve the accessibility of public transit), while the least common policies and programs are those that aim to help older adults continue driving, such as driver education programs, driver assessment programs, and slow-moving vehicle ordinances. The article concludes with policy and research implications of these findings.

Does becoming an ADL spousal caregiver increase the caregiver's depressive symptoms?

This study investigated whether transitioning into the role of activities of daily living (ADL) spousal caregiver is associated with increased depressive symptoms for older husbands and wives among a sample of coresiding community-dwelling older couples. Using data from the Health and Retirement Study, we estimated a two-level linear model to examine the association between change in caregiver status and respondents' depressive symptoms at follow-up, controlling for other factors identified in Pearlin's stress process model (PSPM). Results indicate that both husbands and wives who become ADL caregivers have more follow-up depressive symptoms than noncaregivers. Furthermore, wives continuing as caregivers have more follow-up depressive symptoms than wives who do not provide care. Finally, the physical health of the spousal caregiver is related to depressive symptoms at follow-up. We conclude with policy and practice implications of these three main findings.

Age-friendly environments and self-rated health: an exploration of Detroit elders.

While a number of organizations and government entities have encouraged the development of more "age-friendly" environments, to date there has been limited research linking these environment features to elder outcomes. Using a representative sample of older adults living in Detroit, this study examined the association between age-friendly environment factors and self-rated health. Results indicated that access to health care, social support, and community engagement were each associated with better self-rated health, while neighborhood problems were associated with poorer self-rated health. Moreover, individual-level income and education no longer predicted self-rated health once age-friendly environment factors were taken into account. These findings highlight the need for more research documenting the effects of age-friendly environments, particularly across diverse contexts and populations.

A tale of two community initiatives for promoting aging in place: similarities and differences in the national implementation of NORC programs and villages.

PURPOSE: Villages and Naturally Occurring Retirement Community (NORC) Supportive Service Programs (NORC programs) are among the most prominent community-based models for promoting aging in place. To advance systematic understanding of their development, this study examined how these models have been implemented nationally and the models' similarities and differences. DESIGN AND METHODS: A survey of program leaders representing 69 Villages and 62 NORC programs was conducted from January to June of 2012. Bivariate analyses compared measures of the initiatives' services/activities, beneficiaries, service delivery processes, and funding sources. RESULTS: Village members were reportedly more likely than NORC program participants to be younger, to be less functionally impaired, to be more economically secure, and to reside in higher socioeconomic communities. Reflecting these differences in populations served, NORC programs reported offering more traditional health and social services, had more paid staff, and relied more on government funding than Villages. IMPLICATIONS: Findings indicate that Villages and NORC programs both aim to promote aging in place by offering a diverse range of supports and services to older adults within a locally defined geographic area. Nevertheless, key differences were found in the means through which they seek to achieve these aims, as well as the populations likely to benefit from their efforts. These differences raise questions regarding the models' inclusivity, sustainability, expansion, and effectiveness and have implications for community aging in place initiatives more broadly.

Facilitators of home and community-based service use by urban African American elders.

OBJECTIVE: To examine the factors associated with urban African American elders' utilization of home and community-based services and explore whether these factors differ by category of service. METHODS: Data came from a representative sample of 1,099 African American older adults living in Detroit. Logistic regression models were used to explore the predisposing, enabling, and need factors associated with any service use and five categories of service use: in-home care, household services, functional care, out-of-home services, and financial/legal services. RESULTS: Findings suggest that previous studies using the Andersen model may not be generalizable to an urban African American population. Service use was related primarily to enabling resources, particularly in terms of financial resources, not driving a car, and social resources and support. Future research should further examine the facilitators and barriers to service use by urban African Americans to improve their access to care.

Conceptualizing age-friendly community characteristics in a sample of urban elders: an exploratory factor analysis.

Accurate conceptualization and measurement of age-friendly community characteristics would help to reduce barriers to documenting the effects on elders of interventions to create such communities. This article contributes to the measurement of age-friendly communities through an exploratory factor analysis of items reflecting an existing US Environmental Protection Agency policy framework. From a sample of urban elders (n = 1,376), we identified 6 factors associated with demographic and health characteristics: access to business and leisure, social interaction, access to health care, neighborhood problems, social support, and community engagement. Future research should explore the effects of these factors across contexts and populations.

City governments and aging in place: community design, transportation and housing innovation adoption.

PURPOSE OF THE STUDY: To examine the characteristics associated with city government adoption of community design, housing, and transportation innovations that could benefit older adults. DESIGN AND METHODS: A mixed-methods study with quantitative data collected via online surveys from 62 city planners combined with qualitative data collected via telephone interviews with a subsample of 18 survey respondents. RESULTS: Results indicate that advocacy is an effective strategy to encourage city government adoption of these innovations. Percent of the population with a disability was positively associated, whereas percent of the population aged 65 and older was not associated or negatively associated, with innovation adoption in the regression models. Qualitative interviews suggest that younger individuals with disabilities are more active in local advocacy efforts. IMPLICATIONS: Results suggest that successful advocacy strategies for local government adoption include facilitating the involvement of older residents, targeting key decision makers within government, emphasizing the financial benefits to the city, and focusing on cities whose aging residents are vulnerable to disease and disability.