Positive affect expression during a play interaction and psychological health among older adults living with cognitive impairment and their adult children.

OBJECTIVES: We examined the extent to which positive affect expression in play interactions between adult children and their parents living with cognitive impairment was associated with lower depressive symptoms and mental health difficulties for both dyad members. Gender differences in positive affect expression were also examined. METHOD: Dyads (N = 126) self-reported their depressive symptoms and mental health difficulties. Dyad members later engaged in a video-recorded play interaction together, and their positive affect expression was observationally coded by trained coders in terms of 'enjoyment', 'laughter', and 'positive affect towards partner'. RESULTS: Findings from mixed models using the Actor Partner Interdependence Model showed that one's partner's positive affect was associated with one's own lower depressive symptoms. There were no significant actor effects or effects of role (parent vs. child). Results also revealed that women expressed more positive affect and had greater mental health difficulties, but not depressive symptoms. We found that one's partner's positive affect expressions were more associated with women's mental health than men's mental health. CONCLUSION: Positive affect expression may be a useful indicator of psychological health in parent-child relationships in which the parent has cognitive impairment. Positive affect may be useful to target in supportive, dyadic, psychosocial interventions.

Developing an animated COVID-19 e-curriculum for adults with dementia and caregivers: Challenges and solutions.

OBJECTIVES: Effective education and support for adults with dementia and their caregivers around pandemic issues is critical for protecting them. Animation-based learning has shown promise in patient education. We collaborated with educators and support staff at Alzheimer's Association Connecticut (AACT) to conduct a mixed-methods study and develop an animated e-curriculum addressing pandemic related challenges. METHODS: We conducted focus groups and surveys with dementia and caregiver educators and support staff at AACT for the initial needs assessment and the later e-curriculum evaluation. An interdisciplinary team of educators followed a step-wise process to transform the needs assessment results into an animation based e-curriculum. RESULTS: Participants identified the following pandemic challenges: 1) social isolation, 2) caregiver fatigue, 3) safety, and 4) difficulty navigating the healthcare system. The overall quality and usefulness of the e-curriculum was "very good" or "excellent". CONCLUSIONS: An animated e-curriculum addressing pandemic related issues relevant to adults with dementia and caregivers had positive reviews and was associated with improvement in self-reported ability to perform curriculum objectives among community dementia educators. PRACTICE IMPLICATIONS: The pandemic challenges identified may facilitate the development of further resources. Additionally, this project may serve as a guide for clinicians interested in incorporating animation into education efforts.

Diversity of social networks versus quality of social support: Which is more protective for health-related quality of life among older adults?

Both social networks and social support are important in addressing bio-psycho-social events in older adults. Their associations with health-related quality of life (HRQOL), however, are not well understood. This study aims to examine the associations of diversity of social networks and perceived quality of social support with HRQOL in older adults. We used data from 2012 to 2013 National Epidemiological Survey on Alcohol and Related Conditions Wave III (NESARC-III), and included respondents aged 65 or older (n = 5799 unweighted). We used the Social Network Index (SNI) to measure diversity of social connections and the Interpersonal Support Evaluation List (ISEL-12) to measure perceived quality of social support. We also constructed HRQOL (mental component summary (MCS) and physical component summary (PCS)) and quality-adjusted life years (QALYs). We characterized socio-demographic, behavioral, and clinical factors, and HRQOL and QALYs by type of social support. We also used multivariable-adjusted regression analyses to assess the associations of diversity of social networks and perceived quality of social support with HRQOL and QALYs, respectively. Older adults with greater diversity of social networks, regardless of perceived quality of social support, had higher mean scores in HRQOL domains, although effect sizes were small. In multivariable-adjusted analyses, diversity of social networks was positively associated with HRQOL-MCS (coefficient = 0.59; 95% confidence intervals [CI], 0.08-1.09), HRQOL-PCS (coefficient = 1.00; 95% CI, 0.38-1.61), and QALYs (coefficient = 0.01; 95% CI, 0.00-0.02). Perceived quality of social support was not associated with HRQOL. The diversity of social networks, more than perceived quality of social support, may be protective for HRQOL in older adults.

Health-care use and cost for multimorbid persons with dementia in the National Health and Aging Trends Study.

BACKGROUND: Most persons with dementia have multiple chronic conditions; however, it is unclear whether co-existing chronic conditions contribute to health-care use and cost. METHODS: Persons with dementia and ≥2 chronic conditions using the National Health and Aging Trends Study and Medicare claims data, 2011 to 2014. RESULTS: Chronic kidney disease and ischemic heart disease were significantly associated with increased adjusted risk ratios of annual hospitalizations, hospitalization costs, and direct medical costs. Depression, hypertension, and stroke or transient ischemic attack were associated with direct medical and societal costs, while atrial fibrillation was associated with increased hospital and direct medical costs. No chronic condition was associated with informal care costs. CONCLUSIONS: Among older adults with dementia, proactive and ambulatory care that includes informal caregivers along with primary and specialty providers, may offer promise to decrease use and costs for chronic kidney disease, ischemic heart disease, atrial fibrillation, depression, and hypertension.

Associations of Social and Behavioral Determinants of Health Index with Self-Rated Health, Functional Limitations, and Health Services Use in Older Adults.

OBJECTIVES: To characterize the cumulative risk factors of social and behavioral determinants of health (SDoH) and examine their association with self-rated general health, functional limitations, and use of health services among US older adults. DESIGN: Cross-sectional analysis of the 2013-2014 National Health and Nutrition Examination Survey. SETTING: Nationally representative health interview survey in the United States. PARTICIPANTS: Survey respondents aged 65 or older (n = 1,306 unweighted). MEASUREMENTS: A cumulative risk score of SDoH, developed by the National Academy of Medicine expert panel, was assessed using validated measures. Outcome variables included self-rated general health, functional limitations (eg, activities of daily living), and use of health services (eg, usual source of care and overnight hospitalization). We quantified the cumulative risk score of SDoH in older adults and used multivariable-adjusted logistic and Poisson regression analyses to assess the association of SDoH with self-rated health, functional limitations, and use of health services, adjusting for other covariates. RESULTS: About 25.7% of older adults, representative of 11.0 million people nationwide, reported having three or more cumulative SDoH risk factors. These older adults were more likely to have functional limitations (eg, activities of daily living) and less likely to report their general health as "very good" or "excellent" than those with two or fewer cumulative SDoH risk factors (P < .001 for each). Each additional cumulative SDoH risk factor was associated with increased odds of not having a usual source of care (adjusted odds ratio = 1.57; 95% confidence interval = 1.09-2.27). CONCLUSION: The SDoH index score may be a useful tool to predict access to care and quality of care in older adults. J Am Geriatr Soc 68:1731-1738, 2020.

Cost-Related Medication Nonadherence Among Older Adults: Findings From a Nationally Representative Sample.

OBJECTIVES: To estimate the rate of and risk factors associated with cost-related medication nonadherence among older adults. DESIGN: Cross-sectional analysis of the 2017 National Health Interview Survey (NHIS). SETTING: Nationally representative health interview survey in the United States. PARTICIPANTS: Survey respondents, aged 65 years or older (n = 5701 unweighted) in the 2017 wave of the NHIS. MEASUREMENTS: Self-reported, cost-related medication nonadherence (due to cost: skip dose, reduce dose, or delay or not fill a prescription) and actions taken due to cost-related medication nonadherence (ask for lower-cost prescription, use alternative therapy, or buy medications from another country) were quantified. We used a series of multivariable logistic regression analyses to identify factors associated with cost-related medication nonadherence. We also reported analyses by chronic disease subgroups. RESULTS: In 2017, 408 (6.8%) of 5901 older adults, representative of 2.7 million older adults nationally, reported cost-related medication nonadherence. Among those with cost-related medication nonadherence, 44.2% asked a physician for lower-cost medications, 11.5% used alternative therapies, and 5.3% bought prescription drugs outside the United States to save money. Correlates independently associated with a higher likelihood of cost-related medication nonadherence included: younger age, female sex, lower socioeconomic levels (eg, low income and uninsured), mental distress, functional limitations, multimorbidities, and obesity (P < .05 for all). Similar patterns were found in subgroup analyses. CONCLUSION: Cost-related medication nonadherence among older adults is increasingly common, with several potentially modifiable risk factors identified. Interventions, such as medication therapy management, may be needed to reduce cost-related medication nonadherence in older adults. J Am Geriatr Soc 67:2463-2473, 2019.

Optimizing Clock Drawing Scoring Criteria: Development of the West Haven-Yale Clock Drawing Test.

BACKGROUND/OBJECTIVES: The Clock Drawing Test (CDT) is a widely used measure, which has been included as a recommended cognitive screen for driving evaluations. This study aimed to develop an optimized scoring method-the West Haven-Yale CDT (WHY-CDT)-based on the scoring methods of Freund and Royall's CLOX, the latter of which is significantly associated with executive control functions. DESIGN: Retrospective cohort study. SETTING: Greater New Haven, Connecticut, area. PARTICIPANTS: A total of 237 adults, aged 70 years and older, who had a current driver's license and drove at least once a month. MEASUREMENTS: Clock drawings were independently scored using both scoring systems, as well as a qualitative-based 5-point gestalt score. Interrater reliability was calculated using Light's κ for dichotomous variables and intraclass correlations for continuous variables. A categorical principal component analysis was conducted to determine which items from the Freund and Royall scoring systems should be retained in the modified system, with the Kuder-Richardson test used to assess internal consistency (reliability). RESULTS: The majority of the quantitative scoring items had moderate to almost perfect interrater reliability, with excellent interrater reliability for the qualitative gestalt score. The final scoring method retained seven items from the Freund and Royall versions, of which over 85% were from the latter. Internal consistency was fair to acceptable for the WHY-CDT's two dichotomously scored subscales, but poor for both the Freund and Royall scoring methods. CONCLUSIONS: The WHY-CDT is a simple scoring method that combines elements of the Freund and Royall methods, as well as an overall gestalt score, and has strong interrater reliability. Future directions for use of this modified system are discussed. J Am Geriatr Soc 67:2129-2133, 2019.

Impact of Perceived Racism on Healthcare Access Among Older Minority Adults.

INTRODUCTION: Older minority individuals are less likely to receive adequate health care than their white counterparts. This study investigates whether perceived racism is associated with delayed/forgone care among minority older adults, and whether poor doctor communication mediates this relationship. METHODS: Study cohort consisted of minority participants, aged ≥65 years, in the 2015 California Health Interview Survey (N=1,756). Authors obtained data in November 2017, and statistical analyses were performed from February to April 2018. Multivariable logistic regression analyses were conducted with relevant covariates, including insurance coverage, years living in the U.S., and language. A mediation analysis was also performed. RESULTS: Among minority older individuals, perceived racism was significantly associated with delayed/forgone care (AOR=3.92, 95% CI=1.38, 11.15, p=0.010). Poor doctor communication significantly and partially mediated the relationship (AOR=3.64, 95% CI=1.30, 10.21, p=0.014), accounting for 9.9% of the total effect. CONCLUSIONS: Perceived racism may contribute to health disparities for older minority individuals in part through doctors communicating messages that discourage adequate utilization of health care. Future research should explore culturally sensitive communication skills that reduce this barrier to receiving adequate health care.

Longitudinal Associations Between Cognitive Functioning and Depressive Symptoms Among Older Adult Spouses in the Cardiovascular Health Study.

OBJECTIVE: To examine the bidirectional associations between older adult spouses' cognitive functioning and depressive symptoms over time. DESIGN: Longitudinal, dyadic path analysis with the actor-partner interdependence model. SETTING: Data were from visit 5 (1992/1993), visit 8 (1995/1996), and visit 11 (1998/1999) of the Cardiovascular Health Study, a multisite, longitudinal, observational study of risk factors for cardiovascular disease in adults 65 years or older. Demographic information was from the 1989/1990 original and 1992/1993 African American cohort baseline visits. PARTICIPANTS: Husbands and wives from 1,028 community-dwelling married couples (N = 2,065). MEASUREMENTS: Cognitive functioning was measured with the Modified Mini-Mental State Exam. Depressive symptoms were measured using the 10-item Center for Epidemiologic Studies Depression Scale. Age, education, and disability (activities of daily living and instrumental activities of daily living) were included as covariates. RESULTS: Cross-partner associations (partner effects) revealed that one spouse's greater depressive symptoms predicted the other spouse's lower cognitive functioning, but a spouse's lower cognitive functioning did not predict the other spouse's greater depressive symptoms over time. Within-individual associations (actor effects) revealed that an individual's lower cognitive functioning predicted the individual's greater depressive symptoms over time, but greater depressive symptoms did not predict lower cognitive functioning over time. Effects did not differ for husbands and wives. CONCLUSION: Having a spouse who is depressed may increase one's risk of cognitive decline as well as one's risk of depression. Interventions for preventing cognitive decline and depression among older adults may be enhanced by considering the marital context.

Patterns and Perceived Benefits of Utilizing Seven Major Complementary Health Approaches in U.S. Older Adults.

Objectives: To examine patterns and perceived benefits of seven major complementary health approaches (CHA) among older adults in the United States. Methods: Data from the 2012 National Health Interview Survey (NHIS), which represents non-institutionalized adults aged 65 or older (n = 7,116 unweighted), were used. We elicited seven most common CHA used in older adults, which are acupuncture, herbal therapies, chiropractic, massage, meditation, Tai Chi, and yoga. Survey participants were asked to self-report perceived benefits (eg, maintaining health and stress reduction) in their CHA used. We estimated prevalence and perceived benefits of CHA use. We also investigated socio-demographic and clinical factors associated with the use of any of these seven CHA. Results: Overall, 29.2% of older adults used any of seven CHA in the past year. Most commonly used CHA included herbal therapies (18.1%), chiropractic (8.4%), and massage (5.7%). More than 60% of older CHA users reported that CHA were important for maintaining health and well-being. Other perceived benefits included improving overall health and feeling better (52.3%), giving a better sense of control over health (27.4%), and making it easier to cope with health problems (24.7%). Older adults with higher education and income levels, ≥2 chronic conditions, and functional limitations had greater odds of using CHA (p < .01, respectively). Conclusion: A substantial number of older CHA users reported CHA-related benefits. CHA may play a crucial role in improving health status among older adults. At the population level, further research on the effects of CHA use on bio-psycho-social outcomes is needed to promote healthy aging in older adults.

Driving with Mild Cognitive Impairment or Dementia: Cognitive Test Performance and Proxy Report of Daily Life Function in Older Women.

OBJECTIVES: To investigate associations between proxy report of cognitive and functional limitations and cognitive performance and current or former driving status in older women with mild cognitive impairment (MCI) and all-cause dementia. DESIGN: Cross-sectional data analysis of retrospectively identified older women with adjudicated MCI and all-cause dementia in the Women's Health Initiative Memory Study-Epidemiology of Cognitive Health Outcomes (WHIMS-ECHO). SETTING: Academic medical center. PARTICIPANTS: Women (mean age ± standard deviation 83.7 ± 3.5) adjudicated with MCI or dementia during Year 1, 2, 3, or 4 of the WHIMS-ECHO follow-up period (N = 385). MEASUREMENTS: The telephone-administered cognitive battery included tests of attention, verbal learning and memory, verbal fluency, executive function, working memory, and global cognitive function plus self-report measures of depressive symptomatology. The Dementia Questionnaire (DQ) was administered to a knowledgeable proxy (family member, friend). RESULTS: Sixty percent of women with MCI and 40% of those with dementia are current drivers. Proxy reports of functional limitations in instrumental activities of daily living (IADLs) are associated with current driving status in women with MCI, whereas performance-based cognitive tests are not. In women with dementia, proxy reports of functional limitations in IADLs and performance-based cognitive tests are associated with current driving status, as expected. CONCLUSION: These findings have clinical implications for the importance of evaluating driving concurrently with other instrumental functional abilities in MCI and dementia. Additional work is needed to determine whether proxy report of cognitive and functional impairments should help guide referrals for driving assessment and rehabilitation or counseling for driving transition.

Restructuring care for older adults undergoing surgery: preliminary data from the Co-Management of Older Operative Patients En Route Across Treatment Environments (CO-OPERATE) model of care.

Surgery is common in older adults, so geriatric and surgical providers need to develop expertise in the care of older adults undergoing surgery. The Co-management of Older Operative Patients En Route Across Treatment Environments (CO-OPERATE) program is a clinical and educational collaboration between geriatrics and several surgical specialties at Veterans Affairs Health Care Connecticut. Individuals in CO-OPERATE are co-managed during the pre-, peri-, and postoperative periods. General surgery, urology, vascular surgery, orthopedics, cardiothoracic surgery and neurosurgery all participate in the program, with geriatrics expertise provided by a geriatrician, geriatric nurse practitioner and a geriatric clinical pharmacist. In the initial 3 years, there were 211 CO-OPERATE participants; 31% were evaluated preoperatively, and 62% of the individuals seen preoperatively were seen in clinic. There was a median of three recommendations per consultation. At discharge, 56% returned to the community. Individuals seen preoperatively were more likely to return to the community (63%) than those seen after surgery (50%, P = .10). Geriatrics co-management with a variety of surgical specialties is feasible and may be associated with higher rates of discharge back to the community.

Consensus statements on driving for persons with dementia.

The presence of dementia can have a profound effect on a person's capacity for driving, and will lead to eventual cessation of driving and reliance on alternative transportation options. This paper offers evidence and discussion that affirm eight consensus statements related to drivers with dementia and the impact of dementia on the driving task. These statements offer guidance for occupational therapy practitioners when addressing driving and community mobility, a valued instrumental task of daily living.

Sleep disturbances and driving practices of older drivers.

OBJECTIVES: To evaluate the associations between sleep disturbances and driving practices, including driving cessation and trajectories of daily driving mileage (change over time), in older drivers. DESIGN: Longitudinal. SETTING: New Haven, Connecticut. PARTICIPANTS: Four hundred thirty older drivers, mean age 78.5, recruited from clinic and community sites. MEASUREMENTS: Baseline measures included medical history, daily driving mileage, Insomnia Severity Index (ISI), Epworth Sleepiness Scale (ESS), and Sleep Apnea Clinical Score (SACS). Longitudinal outcomes included at least one episode of driving cessation and trajectories of miles driven per day, as recorded every 6 months over 2 years. RESULTS: At baseline, participants drove an average of 22.2 miles per day; 26.0% (112/430) had insomnia (ISI ≥ 8), 19.3% (83/430) had daytime drowsiness (ESS ≥ 10), and 19.9% (84/422) had high sleep apnea risk (SACS > 15). The sleep-based predictors of insomnia (risk ratio (RR) = 1.20, 95% confidence interval (CI) = 0.65-2.20), daytime drowsiness (RR = 0.94, 95% CI = 0.46-1.95), and high sleep apnea risk (RR = 0.62, 95% CI = 0.27-1.42) did not confer a significantly greater risk of driving cessation. Insomnia was the only sleep-based predictor that conferred a significant change in driving mileage, yielding an average decrease of 4.5 miles per day over 2 years (P = .01). In the insomnia model, covariates that were associated with less driving mileage were polypharmacy (≥ 4 medications) and each year of additional age, yielding an average decrease of 8.3 (P = .01) and 0.4 miles per day (P = .02), respectively, over 2 years. CONCLUSION: In a cohort of older drivers, insomnia and the covariates of polypharmacy and advancing age were longitudinally associated with less daily driving mileage. Because reductions in driving mileage in older persons often occur in response to reductions in driving capacity, these results support a clinical approach that considers insomnia-based cognitive-behavioral therapy and reduced polypharmacy as strategies for improving driving capacity in older persons.

Performance of a computer-based assessment of cognitive function measures in two cohorts of seniors.

BACKGROUND: Computer-administered assessment of cognitive function is being increasingly incorporated in clinical trials; however, its performance in these settings has not been systematically evaluated. DESIGN: The Seniors Health and Activity Research Program pilot trial (N = 73) developed a computer-based tool for assessing memory performance and executive functioning. The Lifestyle Interventions and Independence for Elders investigators incorporated this battery in a full-scale multicenter clinical trial (N = 1635). We describe relationships that test scores have with those from interviewer-administered cognitive function tests and risk factors for cognitive deficits and describe performance measures (completeness, intraclass correlations [ICC]). RESULTS: Computer-based assessments of cognitive function had consistent relationships across the pilot and full-scale trial cohorts with interviewer-administered assessments of cognitive function, age, and a measure of physical function. In the Lifestyle Interventions and Independence for Elders cohort, their external validity was further demonstrated by associations with other risk factors for cognitive dysfunction: education, hypertension, diabetes, and physical function. Acceptable levels of data completeness (>83%) were achieved on all computer-based measures; however, rates of missing data were higher among older participants (odds ratio = 1.06 for each additional year; p < 0.001) and those who reported no current computer use (odds ratio = 2.71; p < 0.001). ICCs among clinics were at least as low (ICC < 0.013) as for interviewer measures (ICC < 0.023), reflecting good standardization. All cognitive measures loaded onto the first principal component (global cognitive function), which accounted for 40% of the overall variance. CONCLUSION: Our results support the use of computer-based tools for assessing cognitive function in multicenter clinical trials of older individuals.

A psychological predictor of elders' driving performance: social-comparisons on the road.

Older individuals often believe they can drive better than their contemporaries. This belief is an example of downward social-comparisons; they can be self-enhancing tools that lead to beneficial outcomes. As predicted, we found that drivers who engaged in downward social-comparisons were significantly less likely to have adverse driving events over time, after controlling for relevant factors (p = .02). This effect was particularly strong among women, who tend to experience more negative driving stereotypes (p = .01). The study was based on 897 interviews of 117 elder drivers, aged 70-89 years, over 2 years. Our findings suggest that interventions to reduce adverse driving events among elders could benefit from including a psychological component.

Mobility and aging: new directions for public health action.

Optimal mobility, defined as relative ease and freedom of movement in all of its forms, is central to healthy aging. Mobility is a significant consideration for research, practice, and policy in aging and public health. We examined the public health burdens of mobility disability, with a particular focus on leading public health interventions to enhance walking and driving, and the challenges and opportunities for public health action. We propose an integrated mobility agenda, which draws on the lived experience of older adults. New strategies for research, practice, and policy are needed to move beyond categorical promotion programs in walking and driving to establish a comprehensive program to enhance safe mobility in all its forms.