Features of the Physical and Social Neighborhood Environment and Neighborhood-Level Alzheimer's Disease and Related Dementia in South Carolina.

BACKGROUND: Studies are increasingly examining the relationship between the neighborhood environment and cognitive decline; yet, few have investigated associations between multiple neighborhood features and Alzheimer's disease and related dementias (ADRD). OBJECTIVE: We investigated the relationship between neighborhood features and ADRD cumulative incidence from 2010 to 2014 in the South Carolina Alzheimer's Disease Registry (SCADR). METHODS: Diagnosed ADRD cases ≥50 years of age were ascertained from the SCADR by ZIP code and census tract. Neighborhood features from multiple secondary sources included poverty, air pollution [particulate matter with a diameter of 2.5 micrometers or less (PM2.5)], and rurality at the census-tract level and access to healthy food, recreation facilities, and diabetes screening at the county level. In addition to using Poisson generalized linear regression to estimate ADRD incident rate ratios (IRR) with 95% confidence intervals (CIs), we applied integrated nested Laplace approximations and stochastic partial differential equations (INLA-SPDE) to address disparate spatial scales. We estimated associations between neighborhood features and ADRD cumulative incidence. RESULTS: The average annual ADRD cumulative incidence was 690 per 100,000 people per census tract (95% CI: 660, 710). The analysis was limited to 98% of census tracts with a population ≥50 years old (i.e., 1,081 of 1,103). The average percent of families living below the federal poverty line per census tract was 18.8%, and ∼20% of census tracts were considered rural. The average percent of households with limited access to healthy food was 6.4%. In adjusted models, every 5µg/m3) increase of PM2.5 was associated with 65% higher ADRD cumulative incidence (IRR=1.65; 95% CI: 1.30, 2.09), where PM2.5 at or below 12 µg/m3 is considered healthy. Compared to large urban census tracts, rural and small urban tracts had 10% (IRR=1.10; 95% CI: 1.00, 1.23) and 5% (IRR=1.05; 95% CI: 0.96, 1.16) higher ADRD, respectively. For every percent increase of the county population with limited access to healthy food, ADRD was 2% higher (IRR=1.02; 95% CI: 1.01, 1.04). CONCLUSIONS: Neighborhood environment features, such as higher air pollution levels, were associated with higher neighborhood ADRD incidence. The INLA-SPDE method could have broad applicability to data collected across disparate spatial scales. https://doi.org/10.1289/EHP13183.

Longitudinal Associations of Diet, Food Insecurity, and Supplemental Nutrition Assistance Program Use with Global Cognitive Performance in Middle-Aged and Older Adults.

BACKGROUND: Diet quality, food access, and food assistance policies may be key modifiable factors related to cognitive decline. OBJECTIVE: We aimed to evaluate whether diet quality, food insecurity, and Supplemental Nutrition Assistance Program (SNAP) use are associated with longitudinal changes in cognition among older adults in the United States. METHODS: Food intake data from the Health Care and Nutrition Study were linked with longitudinal health information from 5 waves of the Health and Retirement Study (2012-2020). The analytic sample (n = 6968) included community-dwelling United States adults aged ≥51 y without cognitive impairment. Global cognition was measured using a telephone-based cognitive status interview (range: 0-27). Diet quality was measured with the Healthy Eating Index, using participants' average intake of 13 dietary components. Questions regarding food access and affordability were used to determine food insecurity and use of SNAP benefits. Linear mixed-effects regression models were used to estimate longitudinal associations between diet-related factors and cognitive score changes. RESULTS: Poorer diets [ß: -0.24; 95% confidence interval (CI): -0.33, -0.15], food insecurity (ß: -1.08; 95% CI: -1.31, -0.85), and SNAP use (ß: -0.57; 95% CI: -0.82, -0.32) were associated with lower baseline cognitive scores. Poorer diets (ß: -0.17; 95% CI: -0.29, -0.05) and food insecurity (ß: -0.23; 95% CI: -0.47, -0.01) were associated with significantly steeper declines in cognitive scores over time, after 8 and 2 y of follow-up, respectively; however, SNAP use was not significantly associated with the rate of cognitive decline over time. Estimates were qualitatively similar when restricting the sample to participants aged ≥65 y. CONCLUSIONS: Results suggest that food access and adherence to healthy diet recommendations may be important elements to maintain cognitive health in aging. SNAP benefits may be insufficient to prevent negative cognitive effects of poor diet and limited access to nutritious foods.

Neighborhood Socioeconomic Status, Green Space, and Walkability and Risk for Falls Among Postmenopausal Women: The Women's Health Initiative.

PURPOSE: This study estimated associations between neighborhood socioeconomic status (NSES), walkability, green space, and incident falls among postmenopausal women and evaluated modifiers of these associations, including study arm, race and ethnicity, baseline household income, baseline walking, age at enrollment, baseline low physical functioning, baseline fall history, climate region, and urban-rural residence. METHODS: The Women's Health Initiative recruited a national sample of postmenopausal women (50-79 years) across 40 U.S. clinical centers and conducted yearly assessments from 1993 to 2005 (n = 161,808). Women reporting a history of hip fracture or walking limitations were excluded, yielding a final sample of 157,583 participants. Falling was reported annually. NSES (income/wealth, education, occupation), walkability (population density, diversity of land cover, nearby high-traffic roadways), and green space (exposure to vegetation) were calculated annually and categorized into tertiles (low, intermediate, high). Generalized estimating equations assessed longitudinal relationships. RESULTS: NSES was associated with falling before adjustment (high vs. low, odds ratio, 1.01; 95% confidence interval, 1.00-1.01). Walkability was significantly associated with falls after adjustment (high vs. low, odds ratio, 0.99; 95% confidence interval, 0.98-0.99). Green space was not associated with falling before or after adjustment. Study arm, race and ethnicity, household income, age, low physical functioning, fall history, and climate region modified the relationship between NSES and falling. Race and ethnicity, age, fall history, and climate region modified relationships between walkability and green space and falling. CONCLUSIONS: Our results did not show strong associations of NSES, walkability, or green space with falling. Future research should incorporate granular environmental measures that may directly relate to physical activity and outdoor engagement.

Ten-Year Cardiovascular Disease Risk Score and Cognitive Function Among Older Adults: The National Health and Nutrition Examination Survey 2011 to 2014.

Background The Framingham 10-year cardiovascular disease risk score, which is based on age, sex, smoking, total cholesterol, high-density lipoprotein-cholesterol, blood pressure, and diabetes, has been found to be associated with cognitive health, but these findings have not been validated in a representative sample in the United States. We aimed to examine the associations of Framingham risk score with cognitive function among older adults in a nationally representative sample, as well as by race or ethnicity, education, and family income. Methods and Results A total of 2254 older adults ≥60 years (57% female, 79% non-Hispanic White) in the National Health and Nutrition Examination Survey 2011 to 2014 were included in the final sample for analysis. All components of the Framingham risk score were obtained with questionnaire or measured in the laboratory. Cognitive function was examined using the Consortium to Establish a Registry for Alzheimer's Disease Word List Memory Task (immediate and delayed memory), Digit Symbol Substitution Test, and Animal Fluency Test. Multivariable linear regression models were used to assess the associations between Framingham risk score and test-specific and global cognition Z scores. Each incremental 5% in Framingham 10-year cardiovascular disease risk was associated with lower Z scores for Digit Symbol Substitution Test (ß=-0.06 [95% CI, -0.09 to -0.03]), delayed memory (ß=-0.05 [95% CI, -0.08 to -0.01]), immediate memory (ß=-0.07 [95% CI, -0.10 to -0.03]), and global cognition (ß=-0.05 [95% CI, -0.09 to -0.02]). Socioeconomic status, particularly race or ethnicity and monthly income levels, were strong effect measure modifiers of the associations. Conclusions Lower cardiovascular risk factors are associated with better cognitive function.

Effect of anesthesia administration method on apgar scores of infants born to women undergoing elective cesarean section.

BACKGROUND: Neonatal health at delivery as measured by apgar scores is an important outcome. This study was done to assess the impact of anesthesia on Apgar 1-minute and 5-minute scores of infants delivered through elective cesarean section in Zimbabwe. METHODS: We carried out a secondary analysis of data from the Efficacy of Tranexamic Acid in Preventing Postpartum Hemorrhage (ETAPPH) clinical trial in Zimbabwe. Outcomes measured were infant Apgar scores at 1 and 5 min, exposure was the administration of either a general (intravenous propofol/ketamine/sodium thiopental) or spinal (hyperbaric bupivacaine 0.5%) anesthesia for anesthesia during the elective cesarean section procedure. Marginal Structural Logistic Modelling (MSM) using an unstabilized Inverse Probability Treatment Weight (IPTW) estimator was used to assess the relationship between anesthetic administration method and infant Apgar scores. RESULTS: Four hundred and twenty-one (421) women who had an elective caesarean section in the ETAPPH study had their infants assessed for Apgar scores. Comparing general anesthesia to spinal anesthesia, spinal anesthesia was related to good Apgar scores at 1-minute (adjusted odds ratio [aOR] = 4.0, 95% Confidence Interval = 1.5-10.7, sensitivity analysis E-value = 3.41). Spinal anesthetic administration was also related to good Apgar scores at 5 min (adjusted odds ratio [aOR] = 6.2, 95% Confidence Interval = 1.6-23.1, sensitivity analysis E-value = 4.42). CONCLUSIONS: When providing anesthesia for patients undergoing elective cesarean section, care should be taken on the method of administration of anesthetic agents. General anesthesia tends to depress Apgar scores at 1 min, although most neonates recover and have better scores at 5 min. Spinal anesthesia should be the first choice whenever possible. TRIAL REGISTRATION: The clinical trial from which data of this study was abstracted was registered under clinical trials registration number NCT04733157.

Association of Frailty With Risk of Suicide Attempt in a National Cohort of US Veterans Aged 65 Years or Older.

Importance: Frailty is associated with reduced physiological reserve, lack of independence, and depression and may be salient for identifying older adults at increased risk of suicide attempt. Objectives: To examine the association between frailty and risk of suicide attempt and how risk differs based on components of frailty. Design, Setting, and Participants: This nationwide cohort study integrated databases from the US Department of Veterans Affairs (VA) inpatient and outpatient health care services, Centers for Medicare & Medicaid Services data, and national suicide data. Participants included all US veterans aged 65 years or older who received care at VA medical centers from October 1, 2011, to September 30, 2013. Data were analyzed from April 20, 2021, to May 31, 2022. Exposures: Frailty, defined based on a validated cumulative-deficit frailty index measured using electronic health data and categorized into 5 levels: nonfrailty, prefrailty, mild frailty, moderate frailty, and severe frailty. Main Outcomes and Measures: The main outcome was suicide attempts through December 31, 2017, provided by the national Suicide Prevention Applications Network (nonfatal attempts) and Mortality Data Repository (fatal attempts). Frailty level and components of the frailty index (morbidity, function, sensory loss, cognition and mood, and other) were assessed as potential factors associated with suicide attempt. Results: The study population of 2 858 876 participants included 8955 (0.3%) who attempted suicide over 6 years. Among all participants, the mean (SD) age was 75.4 (8.1) years; 97.7% were men, 2.3% were women, 0.6% were Hispanic, 9.0% were non-Hispanic Black, 87.8% were non-Hispanic White, and 2.6% had other or unknown race and ethnicity. Compared with patients without frailty, risk of suicide attempt was uniformly higher among patients with prefrailty to severe frailty, with adjusted hazard ratios (aHRs) of 1.34 (95% CI, 1.27-1.42; P < .001) for prefrailty, 1.44 (95% CI, 1.35-1.54; P < .001) for mild frailty, 1.48 (95% CI, 1.36-1.60; P < .001) for moderate frailty, and 1.42 (95% CI, 1.29-1.56; P < .001) for severe frailty. Lower levels of frailty were associated with greater risk of lethal suicide attempt (aHR, 1.20 [95% CI, 1.12-1.28] for prefrail veterans). Bipolar disorder (aHR, 2.69; 95% CI, 2.54-2.86), depression (aHR, 1.78; 95% CI, 1.67-1.87), anxiety (aHR, 1.36; 95% CI, 1.28-1.45), chronic pain (aHR, 1.22; 95% CI, 1.15-1.29), use of durable medical equipment (aHR, 1.14; 95% CI, 1.03-1.25), and lung disease (aHR, 1.11; 95% CI, 1.06-1.17) were independently associated with increased risk of suicide attempt. Conclusions and Relevance: This cohort study found that among US veterans aged 65 years or older, frailty was associated with increased risk of suicide attempts and lower levels of frailty were associated with greater risk of suicide death. Screening and involvement of supportive services across the spectrum of frailty appear to be needed to help reduce risk of suicide attempts.

Social Mediators of the Association Between Depression and Falls Among Older Adults.

OBJECTIVES: To investigate the role of social factors in the association between depression and falls among older adults. METHODS: The sample included data from 3443 older adults from three waves of the Health and Retirement Study (2010-2014). A Lifestyle Questionnaire was used to measure social engagement, social network contact, and neighborhood social context. Mediating effects of social factors were estimated through causal mediation analysis. Results: Poorer social engagement and network contact were associated with greater likelihood of falls, while poorer neighborhood context was associated with greater likelihood of fall injuries. Social engagement mediated a significant portion of the effect of depression on falls (OR: 1.03, 95% CI: 1.00, 1.06), and neighborhood context mediated a portion of the effect of depression on fall injuries (OR: 1.03, 95% CI: 1.00, 1.07). Discussion: The direct and indirect impacts of social factors suggest that considering them may help improve existing fall prevention approaches.

Depressive Symptoms Partially Mediate the Association of Frailty Phenotype Symptoms and Cognition for Females but Not Males.

OBJECTIVES: We aimed to evaluate whether depressive symptoms mediated the relationship between frailty phenotype and cognitive function by sex. METHODS: Data came from the Health and Retirement Study from 2012-2016. The outcome was measured by Fried's frailty criteria, our outcome was continuous global cognition, and mediator was depressive symptoms. We used mediation analysis, stratified by sex, to estimate the direct and indirect effects of frailty symptoms on cognition mediated by depressive symptoms. RESULTS: Males had a larger total effect (ß= -0.43; 95% CI: -0.66, -0.02) for lower cognitive score for each increase in frailty symptom compared to females (ß= -0.28; 95% CI: -0.47, -0.08). A significant indirect effect from frailty phenotype to cognition was found through depressive symptoms for females but not males. CONCLUSION: These results highlight the importance of identifying individuals with frailty and depressive symptoms to monitor and provide interventions to preserve cognitive function.

Patterns of depressive symptoms over 16 Years with incident dementia: The Health and Retirement Study.

The associations of patterns of depressive symptoms, including trajectories of depressive symptoms and significant depressive symptoms among older adults over a long period of time with incident dementia are not frequently studied. We aimed to examine the associations of patterns of depressive symptoms among older adults with incident dementia. Participants of the Health and Retirement Study from 1994 to 2018 with information of incident dementia and complete measurements of depressive symptoms were included. Depressive symptoms assessed on 8 waves between 1994 and 2010 using the 8-item Center for Epidemiologic Studies Depression (CES-D) Scale. Significant depressive symptoms were defined as ≥4 points in the CES-D. Trajectories of depressive symptoms and significant depressive symptoms were identified. Cox proportional hazards models were used to examine the associations of patterns of depressive symptoms with incident dementia. A total of 6317 participants were included in the analysis. Over the follow-up period of 8 years, trajectories of "increase from mild" (hazards ratio (HR): 1.84, 95% confidence interval (CI): 1.29, 2.63) and "persistently high" (HR: 1.76, 95% CI: 1.17, 2.65) depressive symptoms were associated with higher risk of incident dementia, after adjustment for covariates. Future studies are needed to examine the interaction of depression in different stages of life on incident dementia. Studies are also expected to estimate the effect of preventing dementia through reducing depressive symptoms.

Neighborhood characteristics and dementia symptomology among community-dwelling older adults with Alzheimer's disease.

Background: Neuropsychiatric symptoms (NPSs) lead to myriad poor health outcomes among individuals with Alzheimer's disease (AD). Prior studies have observed associations between the various aspects of the home environment and NPSs, but macro-level environmental stressors (e.g., neighborhood income) may also disrupt the neuronal microenvironment and exacerbate NPSs. Yet, to our knowledge, no studies have investigated the relationship between the neighborhood environment and NPSs. Methods: Using 2010 data among older adults with AD collected from a sample of the South Carolina Alzheimer's Disease Registry, we estimated cross-sectional associations between neighborhood characteristics and NPSs in the overall population and by race/ethnicity. Neighborhood measures (within a 1/2-mile radius of residence) came from the American Community Survey and Rural Urban Commuting Area Code. We categorized median household income into tertiles: < $30,500, $30,500-40,000, and > $40,000, and rurality as: rural, small urban, and large urban. Residential instability was defined as the percent of residents who moved within the past year. NPSs were defined using the Neuropsychiatric Inventory Questionnaire that included the composite measure of all 12 domains. Adjusting for age, sex/gender, race/ethnicity, and caregiver educational attainment, we used negative binomial regression to estimate prevalence ratios (PR) and 95% confidence intervals (CI) for NPSs by neighborhood characteristics. Results: Among 212 eligible participants, mean age was 82 ± 8.7 years, 72% were women, and 55% non-Hispanic (NH)-Black. Individuals with AD living in < $30,500 vs. > $40,000 income neighborhoods had a 53% (PR = 1.53; 95% CI = 1.06-2.23) higher prevalence of NPSs while individuals living in rural vs. large urban neighborhoods had a 36% lower prevalence of NPSs (PR = 0.64; 95% CI = 0.45-0.90), after adjustment. We did not observe an association between residential instability and NPSs (PR = 0.92; 95% CI = 0.86-1.00); however, our estimates suggested differences by race/ethnicity where NH-White older adults living in residential instable areas had lower NPSs (PR = 0.89; 95% CI = 0.82-0.96) compared to NH-Black older adults (PR = 0.96; 95% CI = 0.86-1.07). Discussion: Across racial/ethnic groups, individuals with AD had more symptomology when living in lower income areas. Pending replication, intervention efforts should consider resource allocation to high-need neighborhoods (e.g., lower income), and studies should investigate underlying mechanisms for this relationship.

The role of frailty in the association between depression and fall risk among older adults.

OBJECTIVES: Although there is a recognized association between depression and greater fall risk among older adults, the mechanisms explaining this association are unclear. This study evaluated the role of frailty, a common geriatric syndrome, in determining greater risk of falls among older adults with depression. METHOD: We used longitudinal data from three biennial waves of the Health and Retirement Study (HRS; 2010-2014). The sample included community-dwelling survey respondents age ≥ 65 who participated in objective physiological measures. Major Depression (MD) was measured using Composite International Diagnostic Interview for depression short form. Frailty was measured using criteria outlined in the frailty phenotype model. Causal mediation analysis was used to differentiate the direct effect of depression and indirect effect mediated by frailty on falls, fall injuries, and multiple falls. RESULTS: Major depression was associated with significantly greater odds of experiencing a fall (OR: 1.91; 95% CI: 1.31, 2.77), fall injury (OR: 1.86; 95% CI: 1.17, 2.95), and multiple falls (OR: 2.26; 95% CI: 1.52, 3.37) over a two-year period. Frailty was a significant mediator of the effects of depression on falls and multiple falls, accounting for approximately 18.9% and 21.3% of the total effects, respectively. We found no evidence of depression-frailty interaction. Sensitivity analyses showed that results were robust to unmeasured confounding and alternative operationalizations of depression. CONCLUSION: Frailty explains a significant proportion of increased likelihood of falls among older adults with depression. Treatment and management of frailty symptoms may be an important components of fall prevention among older adults with depression.

Social Determinants of Health and Depression among African American Adults: A Scoping Review of Current Research.

Depression in the United States (US) is increasing across all races and ethnicities and is attributed to multiple social determinants of health (SDOH). For members of historically marginalized races and ethnicities, depression is often underreported and undertreated, and can present as more severe. Limited research explores multiple SDOH and depression among African American adults in the US. Guided by Healthy People (HP) 2030, and using cross-disciplinary mental health terminology, we conducted a comprehensive search to capture studies specific to African American adults in the US published after 2016. We applied known scoping review methodology and followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines. From 12,315 initial results, 60 studies were included in our final sample. Most studies explored the HP 2030 Social and Community Context domain, with a heavy focus on discrimination and social support; no studies examined Health Care Access and Quality. Researchers typically utilized cross-sectional, secondary datasets; no qualitative studies were included. We recommend research that comprehensively examines mental health risk and protective factors over the life course within, not just between, populations to inform tailored health promotion and public policy interventions for improving SDOH and reducing racial and ethnic health disparities.

COVID-19 Incidence and Mortality Among Long-Term Care Facility Residents and Staff in South Carolina.

OBJECTIVES: This study explored differences in COVID-19 incidence, mortality, and timing among long-term care facility (LTCF) residents and staff with those living in the community in South Carolina (SC). DESIGN: Longitudinal secondary data analysis. SETTING AND PARTICIPANTS: Adults age ≥18 in SC with confirmed COVID-19 diagnosis from 3/15/2020 and 1/2/2021 (n = 307,891). METHODS: COVID-19 data came from the SC Department of Health and Environmental Control (SCDHEC). We included all COVID-19 cases, hospitalizations, and deaths among adult residents. Residence and employment in LTCF were confirmed by SCDHEC. Descriptive statistics and trends for cases, hospitalizations, and deaths were calculated. We used Cox proportional hazards to compare COVID-19 mortality in LTCF residents and staff to community dwelling older adults and adults not employed in LTCF, respectively, controlling for age, gender, race, and pre-existing chronic health conditions. RESULTS: LTC residents experienced greater incidence of cases throughout the study period until the week ending on 1/2/21. LTCF residents with COVID-19 were more likely to be hospitalized compared to older adults in the community and 74% more likely to die (HR: 1.74, 95% CI: 1.59-1.90), after adjusting. LTC staff experienced greater incidence of cases compared to adults not employed in LTCF until the week ending on 12/26/2020, while experiencing similar incidence of death compared to the similar community members. After adjusting, LTC staff had 0.58 (HR = 0.58; CI: 0.39-0.88) times lower hazard of death compared to community members that did not work in a LTCF. CONCLUSIONS AND IMPLICATIONS: Narrowing of the gap between LTCF and community-wide infection and mortality rates over the study period suggests that early detection of COVID-19 in LTCFs could serve as a first indicator of disease spread in the greater community. Results also indicate that policies and regulations addressing staff testing and protection may help to slow or prevent spread within facilities.

Incident Impaired Cognitive Function in Sarcopenic Obesity: Data From the National Health and Aging Trends Survey.

Objectives: The prevalence of obesity with sarcopenia is increasing in adults aged ≥65 years. This geriatric syndrome places individuals at risk for synergistic complications that leads to long-term functional decline. We ascertained the relationship between sarcopenic obesity and incident long-term impaired global cognitive function in a representative US population. Design: A longitudinal, secondary data set analysis using the National Health and Aging Trends Survey. Setting: Community-based older adults in the United States. Participants: Participants without baseline impaired cognitive function aged ≥65 years with grip strength and body mass index measures. Methods: Sarcopenia was defined using the Foundation for the National Institutes of Health Sarcopenia Project grip strength cut points (men <35.5 kg; women <20 kg), and obesity was defined using standard body mass index (BMI) categories. Impaired global cognition was identified as impairment in the Alzheimer's Disease-8 score or immediate/delayed recall, orientation, clock-draw test, date/person recall. Proportional hazard models ascertained the risk of impaired cognitive function over 8 years (referent = neither obesity or sarcopenia). Results: Of the 5822 participants (55.7% women), median age category was 75 to 80, and mean grip strength and BMI were 26.4 kg and 27.5 kg/m2, respectively. Baseline prevalence of sarcopenic obesity was 12.9%, with an observed subset of 21.2% participants having impaired cognitive function at follow-up. Compared with those without sarcopenia or obesity, the risk of impaired cognitive function was no different in obesity alone [hazard ratio (HR) 0.98; 95% confidence interval (CI) 0.82-1.16]), but was significantly higher in sarcopenia (HR 1.60; 95% CI 1.42-1.80) and sarcopenic obesity (HR 1.20; 95% CI 1.03-1.40). There was no significant interaction term between sarcopenia and obesity. Conclusions: Both sarcopenia and sarcopenic obesity are associated with an increased long-term risk of impaired cognitive function in older adults.

State Variation in Long-Term Care Availability, Regulation, and Cost and Suicide Mortality Among Older Adults in the United States: 2010-2015.

OBJECTIVES: Residential long-term care (LTC) facilities may be key settings for the prevention of suicide among older adults; however, little is known about the relationship between statewide policies determining characteristics of LTC facilities and suicide mortality. The primary goal of this study was to evaluate the association between state policies regarding availability, regulation, and cost of LTC and suicide mortality among adults aged 55 and older in the United States over a 5-year period. DESIGN: Longitudinal ecological study. SETTING AND PARTICIPANTS: LTC residents from 16 states reporting mortality data to the National Violent Death Reporting System (NVDRS) from 2010 to 2015. METHODS: We linked suicide data from the NVDRS and data sources on LTC services and regulations for 16 states. We applied a natural language-processing algorithm to identify suicide deaths related to LTC. We used fixed effect regression models to assess whether state variation in LTC characteristics is related to variation in the rate of suicide (both overall and related to LTC) among older adults. RESULTS: There were 25,040 suicides among those aged 55 and older reported to the NVDRS during the study period; 382 suicides were determined to be associated with LTC in some manner. After adjusting for state-level characteristics, greater average nursing home capacity was significantly associated with increase in the cumulative incidence of suicide related to LTC (ß = 0.087, SE = 0.026, P < .01), but not overall suicide incidence. Neither cost nor regulation measures were significantly associated with state-level LTC-related suicide incidence. CONCLUSIONS AND IMPLICATIONS: State-level variations in LTC facility capacity are related to variation in LTC-related suicide incidence among older adults. Given the challenges of preventing suicide among older adults through facility- or individual-level interventions, policies governing the features and provision of LTC services may therefore serve as a means for public health suicide prevention.

Modified STEADI Fall Risk Categories Predict Incident Cognitive Impairment.

BACKGROUND/OBJECTIVES: It is unknown whether older adults at high risk of falls but without cognitive impairment have higher rates of subsequent cognitive impairment. DESIGN: This was an analysis of cross-sectional and longitudinal data from National Health and Aging Trends Study (NHATS). SETTING: NHATS, secondary analysis of data from 2011 to 2019. PARTICIPANTS: Community dwelling adults aged 65 and older without cognitive impairment. MEASUREMENTS: Participants were classified at baseline in three categories of fall risk (low, moderate, severe) using a modified algorithm from the Center for Disease Control's STEADI (Stop Elderly Accidents, Deaths, and Injuries) and fall risk from data from the longitudinal NHATS. Impaired global cognition was defined as NHATS-derived impairment in either the Alzheimer's Disease-8 score, immediate/delayed recall, orientation, clock-drawing test, or date/person recall. The primary outcome was the first incident of cognitive impairment in an 8 year follow-up period. Cox-proportional hazard models ascertained time to onset of cognitive impairment (referent = low modified STEADI incidence). RESULTS: Of the 7,146 participants (57.8% female), the median age category was 75 to 80 years. Prevalence of baseline fall modified STEADI risk categories in participants was low (51.6%), medium (38.5%), and high (9.9%). In our fully adjusted model, the risk of developing cognitive impairment was hazard ratio (HR) 1.18 [95% CI = 1.08, 1.29] in the moderate risk category, and HR 1.74 [95% CI = 1.53, 1.98] in the high-risk category. CONCLUSION: Older, cognitively intact adults at high fall risk at baseline had nearly twice the risk of cognitive decline at 8 year follow-up.

Neighborhood Characteristics and the Mental Health of Caregivers Cohabiting with Care Recipients Diagnosed with Alzheimer's Disease.

While studies have documented the influence of caregiver and care recipient factors on caregiver health, it is important to address the potential impact of neighborhood contexts. This study estimated the cross-sectional associations between neighborhood characteristics and mental health among caregivers cohabiting with Alzheimer's disease care recipients that were experiencing severe or non-severe neuropsychiatric symptoms (NPSs) (e.g., aggression/anxiety). We obtained data collected in 2010 on caregivers and care recipients (n = 212) from a subset of South Carolina's Alzheimer's Disease Registry. Neighborhood measures (within 1 mile of the residence) came from the American Community Survey and the Rural-Urban Commuting Area Code. We categorized the neighborhood median household income into tertiles, namely, "low" (<$31,000), "medium" ($31,000-40,758), and "high" (>$40,758), and rurality as "large urban," "small urban," and "rural." We used negative binomial regression to estimate the prevalence ratios (PRs) and 95% confidence intervals (CIs) for caregiver mental health using neighborhood characteristics. The mean age was 58 ± 10.3 years, 85% were women, and 55% were non-Hispanic Black. Among the caregivers cohabiting with a recipient experiencing severe NPS, higher distress was experienced by caregivers living in low- (PR = 1.61 (95% CI = 1.26-2.04)) and medium- (PR = 1.45 (95% CI = 1.17-1.78)) vs. high-income neighborhoods after an adjustment. These results suggest that neighborhood characteristics may amplify other social stressors experienced by caregivers.

Time-Varying Insomnia Symptoms and Incidence of Cognitive Impairment and Dementia among Older US Adults.

There is conflicting evidence regarding the association between insomnia and the onset of mild cognitive impairment (MCI) or dementia. This study aimed to evaluate if time-varying insomnia is associated with the development of MCI and dementia. Data from the Health and Retirement Study (n = 13,833) from 2002 to 2014 were used (59.4% female). The Brief Insomnia Questionnaire was used to identify insomnia symptoms which were compiled in an insomnia severity index, ranging from 0 to 4. In analysis, participants' symptoms could vary from wave-to-wave. Dementia was defined using results from the Health and Retirement Study (HRS) global cognitive assessment tool. Respondents were classified as either having dementia, MCI, or being cognitively healthy. Cox proportional hazards models with time-dependent exposure using the counting process (start-stop time) were used for analysis. For each one-unit increase in the insomnia symptom index, there was a 5-percent greater hazard of MCI (HR = 1.05; 95% CI: 1.04-1.06) and dementia (HR = 1.05; 95% CI: 1.03-1.05), after fully adjusting. Using a nationally representative sample of adults age 51 and older, this study found that time-varying insomnia symptoms are associated with risk of MCI and dementia. This highlights the importance of identifying sleep disturbances and their change over time as potentially important risk factors for MCI and dementia.

Antidepressant Use Partially Mediates the Association Between Depression and Risk of Falls and Fall Injuries Among Older Adults.

BACKGROUND: The association between depression and fall risk in older adults is recognized, yet the mechanisms underlying this association are unclear. This study estimated the mediating role of antidepressant use in the association between depression and falls and fall injuries. METHODS: Longitudinal data from the Health and Retirement Study (2004-2006) were linked with medication data from the Prescription Drug Study (2005). The sample included community-dwelling adults aged ≥65 with data on depression and medication use (n = 3565). Depression was measured using 2 independent survey tools: Composite International Diagnostic Interview for depression short form and an 8-item version of the Center for Epidemiological Studies-Depression scale. We used causal mediation analysis to estimate and compare the direct and indirect (mediated by antidepressant use) effects of depression on falls and fall injuries. RESULTS: Individuals with major depressive disorder were significantly more likely to experience a fall (OR: 1.92; 95% CI: 1.41, 2.62) and a fall injury (OR: 1.67; 95% CI: 1.09, 2.55) over 2 years. Indirect effect estimates showed that antidepressant medication use accounted for approximately 19% and 18% of the association between major depressive disorder and falls and fall injuries, respectively. Results were similar when using an alternative depression measure and when considering only selective serotonin reuptake inhibitor antidepressants. CONCLUSIONS: Antidepressant use explains a significant proportion, but not a majority, of the association between depression and greater fall risk. Treatment benefits of antidepressants should be considered with, and may outweigh, concerns about increased risk of falls associated with antidepressant use.

Mentorship and Training to Increase Diversity of Researchers and Practitioners in the Field of Aging and Alzheimer's Disease: A Scoping Review of Program Characteristics.

Objectives: Diversity is needed within the aging and Alzheimer's disease and related dementias (ADRD) research and practice workforce to comprehensively address health inequities faced by underrepresented minority (URM) older adults. We conducted a scoping review of training programs designed to diversify the pool of researchers and practitioners in the field of aging and ADRD. Methods: Online database searches yielded 3976 articles published from 1999 to 2019. Fourteen studies met the inclusion criteria. Results: All programs were from the United States and included URM populations. Nine programs included students, one targeted university faculty, and four targeted clinical staff. Only five programs were guided by theory. Discussion: Our review identified URMs' desire for culturally diverse and representative mentorship, the need for career development support at various training stages, and the importance of incorporating theory to program design. It also identified key characteristics for future program development, creation of systematic evaluation standards, and opportunities for promotion.