Reported Unmet Hearing Aid Need in Older People With Dementia: The US National Core Indicators Survey.

OBJECTIVES: Hearing aids have important health benefits for older adults with Alzheimer disease and related dementias (ADRD); however, hearing aid adoption in this group is low. This study aimed to determine where to target hearing aid interventions for American long-term care recipients with ADRD by examining the association of ADRD and residence type with respondent-reported unmet hearing aid need. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study used data from the United States National Core Indicators-Aging and Disabilities survey (2015-2019) for long-term care recipients aged ≥65 years. METHODS: We used multivariable logistic regression to model the likelihood of reporting unmet hearing aid need conditional on ADRD status and residence type (own/family house or apartment, residential care, or nursing facility/home), adjusting for sociodemographic factors and response type (self vs proxy). RESULTS: Of the 25,492 respondents [median (IQR) age, 77 (71, 84) years; 7074 (27.8%) male], 5442 (21.4%) had ADRD and 3659 (14.4%) owned hearing aids. Residence types were 17,004 (66.8%) own/family house or apartment, 4966 (19.5%) residential care, and 3522 (13.8%) nursing home. Among non-hearing aid owners, ADRD [adjusted odds ratio (AOR) 0.90, 95% CI 0.80-1.0] and residence type were associated with respondent-reported unmet hearing aid need. Compared to the nursing home reference group, respondents in their own/family home (AOR 1.85, 95% CI 1.61-2.13) and residential care (AOR 1.30, 95% CI 1.10-1.53) were more likely to report unmet hearing aid need. This pattern was significantly more pronounced in people with ADRD than in those without, stemming from an interaction between ADRD and residence type. CONCLUSIONS AND IMPLICATIONS: American long-term care recipients with ADRD living in their own/family home are more likely to report unmet hearing aid need than those with ADRD in institutional and congregate settings. This information can inform the design and delivery of hearing interventions for older adults with ADRD.

Nursing Home Resident Preferences for Daily Care and Activities: A Latent Class Analysis of National Data.

BACKGROUND AND OBJECTIVES: Uncovering subgroups of nursing home residents sharing similar preference patterns is useful for developing systematic approaches to person-centered care. This study aimed to (i) identify preference patterns among long-stay residents, and (ii) examine the associations of preference patterns with resident and facility characteristics. RESEARCH DESIGN AND METHODS: This study was a national cross-sectional analysis of Minimum Data Set assessments in 2016. Using resident-rated importance for 16 preference items in the Preference Assessment Tool as indicators, we conducted latent class analysis to identify preference patterns and examined their associations with resident and facility characteristics. RESULTS: We identified 4 preference patterns. The high salience group (43.5% of the sample) was the most likely to rate all preferences as important, whereas the low salience group (8.7%) was the least likely. The socially engaged (27.2%) and the socially independent groups (20.6%) featured high importance ratings on social/recreational activities and maintaining privacy/autonomy, respectively. The high salience group reported more favorable physical and sensory function than the other 3 groups and lived in facilities with higher staffing of activity staff. The low salience and socially independent groups reported a higher prevalence of depressive symptoms, whereas the low salience or socially engaged groups reported a higher prevalence of cognitive impairment. Preference patterns also varied by race/ethnicity and gender. DISCUSSION AND IMPLICATIONS: Our study advanced the understanding of within-individual variations in preferences, and the role of individual and environmental factors in shaping preferences. The findings provided implications for providing person-centered care in NHs.

Examining Satisfaction and Quality in Home- and Community-Based Service Programs in the United States: A Scoping Review.

BACKGROUND AND OBJECTIVES: Long-term services and supports in the United States are increasingly reliant on home- and community-based services (HCBS). Yet, little is known about the quality of HCBS. We conducted a scoping review of the peer-reviewed literature to summarize HCBS consumer, provider, and stakeholder satisfaction with services as a means of assessing quality. RESEARCH DESIGN AND METHODS: We searched PubMed, OVID-MEDLINE, and SCOPUS to identify articles published from 2000 to 2021 that reported on studies describing a U.S.-based study population. Articles were grouped into 3 categories: drivers of positive consumer satisfaction, drivers of negative consumer satisfaction, and provider and stakeholder perspectives on satisfaction. RESULTS: Our final sample included 27 articles. Positive perceptions of quality and reported satisfaction with services were driven by consistent, reliable, and respectful care providers, and adoption of person-centered models of service delivery. Mistreatment of consumers, staff turnover, training, service interruptions, and unmet functional needs were drivers of negative consumer perceptions of quality. Support for caregivers and emphasis on training were identified by providers and stakeholders as important for providing satisfactory services. DISCUSSION AND IMPLICATIONS: Multiple data challenges limit the ability to systematically evaluate HCBS program quality; however, studies examining single programs found that HCBS consumers are more satisfied and associate higher quality with easy-to-navigate programs and professional staff. Efforts to expand HCBS should also include requirements to systematically evaluate quality outcomes.

Identifying Nursing Homes With Diverse Racial and Ethnic Resident Compositions: The Importance of Group Heterogeneity and Geographic Context.

Racial/ethnic composition of nursing home (NH) plays a particularly important role in NH quality. A key methodological issue is defining when an NH serves a low versus high proportion of racially/ethnically diverse residents. Using the Minimum Data Set from 2015 merged with Certification and Survey Provider Enhanced Reports, we calculated the racial/ethnic composition of U.S.-based NHs for Black or Hispanic residents specifically, and a general Black, Indigenous, and People of Color (BIPOC) grouping for long-stay residents. We examined different definitions of having a high racial/ethnic composition by varying percentile thresholds of composition, state-specific and national thresholds, and restricting composition to BIPOC residents as well as only Black and Hispanic residents. NHs with a high racial/ethnic composition have different facility characteristics than the average NH. Based on this, we make suggestions for how to identify NHs with diverse racial/ethnic resident compositions.

Simultaneously Developing Interventions for Low-/Middle-Income and High-Income Settings: Considerations and Opportunities.

Most older adults reside in low- and middle-income countries (LMICs) but most research dollars spent on interventions to improve the lives of older adults are awarded to researchers in high-income countries (HICs). One approach to improve the implementation of evidence-based innovations for older adults in LMICs is designing interventions that are relevant to LMICs and HICs simultaneously. We propose that researchers in HICs could partner with stakeholders in an LMIC throughout the intervention design process to better position their intervention for the implementation in that LMIC. We provide an example study from an adaptation of the Resources for Enhancing Caregiver Health II in Vietnam, which did not use this strategy but may have benefited from this strategy. We then turn to several considerations that are important for researchers to contemplate when incorporating this strategy. Finally, we explore incentives for creating interventions that are relevant to both HICs and LMICs for funders, intervention designers, and intervention receivers. Although this is not the only strategy to bring interventions to LMICs, it may represent another tool in researchers' toolboxes to help expedite the implementation of efficacious interventions in LMICs.

Depressive Symptoms in Older African Immigrants with Mobility Limitations: A Descriptive Study.

OBJECTIVES: Before, during, and after their immigration to the United States, immigrants face stressful life circumstances that may render them at risk for depressive symptoms. However, there is a dearth of research on the mental health of African immigrants. We performed secondary data analyses of two studies in the Baltimore-Washington area to describe and identify correlates of depressive symptoms in older African immigrants. METHODS: Chi square tests, one-way ANOVAs, and linear regressions were used to describe and examine associations between depressive symptoms and immigrant-related risk factors. RESULTS: This sample included 148 participants who had a mean age of 62 (SD ± 8.2). Clinical depressive symptoms were present in 8.1% of participants, and trouble falling asleep for more than half of the days was the most prevalent symptom (20%). Levels of education, income, and migration reasons differed significantly from clinical depressive symptoms, but these were not significantly associated with more depressive symptoms after controlling for covariates. CONCLUSIONS: Longitudinal designs may further elucidate incidence, correlates, and long-term effects of depressive symptoms within this population. CLINICAL IMPLICATIONS: Knowledge of depressive symptom burden and risk factors can inform timely assessment, referral, and treatment of depressive symptoms and other mental health outcomes in older African immigrants.

Age Differences in Determinants of Self-Rated Health among Recipients of Publicly Funded Home-and-Community-Based Services.

This research examined determinants of self-rated health (SRH) of publicly funded home-and-community-based services (HCBS) recipients and tested if the effects of determinants differ between older recipients and younger recipients with disabilities. Using Minnesota's data of 2015-2016 National Core Indicators - Aging and Disabilities survey (n = 3,426), this study revealed that functional status and community inclusion had both direct and indirect effects on SRH, with negative mood as a mediator. Community inclusion had a more pronounced effect on SRH in younger recipients than in older recipients. HCBS should address psychosocial needs and be tailored for recipients of different age groups.

Evidence to Inform Policy and Practice: Mechanisms to Address Racial/Ethnic Disparities in Nursing Home Quality of Life.

Background and Objectives: Abundant evidence documents racial/ethnic disparities in access, quality of care, and quality of life (QoL) among nursing home (NH) residents who are Black, Indigenous, and people of color (BIPOC) compared with White residents. BIPOC residents are more likely to be admitted to lower quality NHs and to experience worse outcomes. Yet, little is known about processes for differences in QoL among residents receiving care in high-proportion BIPOC NHs. This study presents an examination of the processes for racial/ethnic disparities in QoL in high-proportion BIPOC facilities while highlighting variability in QoL between these facilities. Research Design and Methods: Guided by the Minority Health and Health Disparities Research Framework and the Zubritsky framework for QoL in NHs, we employ a concurrent mixed-methods approach involving in-depth case studies of 6 high-proportion BIPOC NHs in Minnesota (96 resident interviews; 61 staff interviews; 614 hours of observation), coupled with statewide survey data on residents' QoL linked to resident clinical Minimum Data Set assessments. Results: Quantitative findings show that BIPOC residents experience lower QoL than White residents across various domains. Qualitative findings reveal variability in BIPOC residents' QoL between high-proportion BIPOC facilities. In some facilities, BIPOC residents experienced worse QoL based on their race/ethnicity, whereas in others BIPOC residents QoL was not directly affected by their race/ethnicity or they had mixed experiences. Discussion and Implications: The findings highlight variability in racial/ethnic disparities in QoL across NHs with a high proportion of BIPOC residents. We identify health equity initiatives, including engaging with community BIPOC organizations and volunteers, and providing more resources to high-proportion BIPOC facilities to support staff training, additional staffing, and culturally specific programming. Given the increasing racial/ethnic diversity of NHs, ensuring equity in QoL for BIPOC residents is an urgent priority for NHs to remain relevant in the future.

Functional Limitations and Access to Long-Term Services and Supports Among Sexual Minority Older Adults.

Objective: Little is known about sexual minority (SM) older adults' activities of daily living (ADL) and instrumental activities of daily living (IADL) limitations and their subsequent access to long-term services and supports (LTSS). Methods: We analyzed cross-sectional data from the 2016 Health and Retirement Study limited to individuals ≥50 years old. Bivariate analyses were performed to examine 1) sexual identity differences in the prevalence of ADL/IADL limitations and 2) associations of sexual identity with having ADL/IADL limitations and having access to help with ADL/IADL limitations. Results: Our sample consisted of 3833 older adults, 6% (n = 213) were SM. Compared to heterosexual participants, bisexual older adults had greater reports of ADL/IADL limitations (20.9% vs. 35.9%, p = 0.013). Among those who reported having ADL/IADL limitations (n = 803), there were no sexual identity differences in accessing help for ADL/IADL limitations (p = .901). Discussion: Our findings contribute to the limited research on LTSS access among SM older adults.

The Immigrant Memory Collaborative: A Community-University Partnership to Assess African Immigrant Families' Experiences with Dementia.

Research suggests a disparity in the prevalence of dementia, with Black older adults having double the risk compared to their White counterparts. African immigrants are a fast-growing segment of the U.S. Black population, but the dementia care needs and resources of this population are not fully understood. In this paper, we describe the process of working collaboratively with a community partner and project advisory board to conduct a culturally informed project. Specifically, we describe the process of developing culturally informed instruments to collect data on dementia care needs and resources among African immigrants. Working together with a diverse project advisory board, a guide was developed and used to conduct community conversations about experiences with dementia/memory loss. Transcripts from six conversations with 24 total participants were transcribed and analyzed thematically by two independent coders in Nvivo. These qualitative findings were used to inform the development of a survey for quantitative data collection that is currently ongoing. Themes (e.g., cultural attitudes, challenges, and current resources) from the community conversations that informed the survey are described briefly. Despite the challenges of conducting research during a global pandemic, having trusting relationships with a partnering community organization and project advisory board facilitated the successful development of instruments to conduct preliminary dementia care research in an underserved population. We anticipate that survey results will inform interventions that increase education, outreach, and access to dementia care and caregiving resources for this population. It may serve as a model for community-university partnerships for similar public health efforts in dementia as well as other chronic disease contexts.

Where to Retire? Experiences of Older African Immigrants in the United States.

Doubling in size since the 1970s, the aging needs of the African immigrant population are not fully understood. This qualitative study examined experiences of aging and retirement planning for African immigrant older adults in the United States (U.S.). Specifically, it explored the factors, processes, and ultimate decision of where these older adults planned to retire. Secondary analysis of semi-structured interviews with 15 older African immigrants in the Baltimore-Washington Metropolitan area was conducted. Data was analyzed using thematic analyses in NVivo. The majority of participants were women, with a mean age of 64. Three overarching themes with ten sub-themes were identified. The themes included: (1) cultural identity, which indicated the participant's comfort with the U.S. society and culture; (2) decision making, meaning factors that impact participants' choice of retirement location; and (3) decision made, meaning the final choice of where participants would like to retire. Age-friendliness for immigrant older adults in the U.S. is complex and it includes traditional domains such as physical and sociocultural environment (e.g., housing, transportation, and income). However, immigrant age-friendliness also needs to include wider contextual aspects such as political climate of their country of origin, immigrant status, family responsibilities, and acculturation in the U.S. More research is needed to better understand and facilitate age-friendly environments and transnational aging of immigrant older adults.

Social Isolation and Incident Heart Failure Hospitalization in Older Women: Women's Health Initiative Study Findings.

Background The association of social isolation or lack of social network ties in older adults is unknown. This knowledge gap is important since the risk of heart failure (HF) and social isolation increase with age. The study examines whether social isolation is associated with incident HF in older women, and examines depressive symptoms as a potential mediator and age and race and ethnicity as effect modifiers. Methods and Results This study included 44 174 postmenopausal women of diverse race and ethnicity from the WHI (Women's Health Initiative) study who underwent annual assessment for HF adjudication from baseline enrollment (1993-1998) through 2018. We conducted a mediation analysis to examine depressive symptoms as a potential mediator and further examined effect modification by age and race and ethnicity. Incident HF requiring hospitalization was the main outcome. Social isolation was a composite variable based on marital/partner status, religious ties, and community ties. Depressive symptoms were assessed using CES-D (Center for Epidemiology Studies-Depression). Over a median follow-up of 15.0 years, we analyzed data from 36 457 women, and 2364 (6.5%) incident HF cases occurred; 2510 (6.9%) participants were socially isolated. In multivariable analyses adjusted for sociodemographic, behavioral, clinical, and general health/functioning; socially isolated women had a higher risk of incident HF than nonisolated women (HR, 1.23; 95% CI, 1.08-1.41). Adding depressive symptoms in the model did not change this association (HR, 1.22; 95% CI, 1.07-1.40). Neither race and ethnicity nor age moderated the association between social isolation and incident HF. Conclusions Socially isolated older women are at increased risk for developing HF, independent of traditional HF risk factors. Registration URL: http://www.clinicaltrials.gov; Unique identifier: NCT00000611.

Why Men Fare Worse: A Mixed-Methods Study Examining Gender Differences in Nursing Home Resident Quality of Life.

BACKGROUND AND OBJECTIVES: Despite research documenting gender differences in numerous outcomes in later life, we know little about gender differences in quality of life (QoL) for nursing home (NH) residents. This study examines the relationship between gender and residents' QoL, including possible reasons for differences observed. RESEARCH DESIGN AND METHODS: We used a mixed-methods design including surveys with a random sample of Minnesota NH residents using a multidimensional measure of QoL (n = 9,852), resident clinical data, facility-level characteristics (n = 364), interviews with residents (n = 64), and participant observations. We used linear mixed models and thematic analysis of resident interviews and observations to examine possible gender-related differences in residents' QoL. RESULTS: After controlling for individual and facility characteristics, men reported lower overall QoL than women, including significantly lower ratings in several QoL domains. In interviews, men noted being less satisfied with activities than women, having fewer friends, and being less able to rely on family for support. Some women described the NH as a place of respite, but men more often described being dissatisfied with life in the NH and undesirable for long-term living. Our observations were consistent with interview findings but provide additional nuances, such as that some men organized their own social groups. DISCUSSION AND IMPLICATIONS: Our findings suggest that men and women experience QoL differently in NHs, with men reporting lower QoL in several domains. Tailoring more activities for men and finding ways to strengthen relationships for men in NHs could help reduce the gender differences in QoL we observed.

Quality of Life Scores for Nursing Home Residents are Stable Over Time: Evidence from Minnesota.

Quality of life (QoL) is important to nursing home (NH) residents, yet QoL is only publicly reported in a few states, in part because of concerns regarding measure stability. This study used QoL data from Minnesota, one of the few states that collects the measures, to test the stability of QoL over time. To do so, we assessed responses from two resident cohorts who were surveyed in subsequent years (2012-2013 and 2014-2015). Stability was measured using intra-class correlation (ICC) obtained from hierarchical linear models. Overall QoL had ICCs of 0.604 and 0.614, respectively. Our findings show that person-reported QoL has adequate stability over a period of one year. Findings have implications for higher adoption of person-reported QoL measure in long-term care.

The Relationships of Nursing Home Culture Change Practices With Resident Quality of Life and Family Satisfaction: Toward a More Nuanced Understanding.

Transforming nursing homes (NHs) from restrictive institutions to person-centered homes, referred to as NH culture change, is complex and multifaceted. This study, based on a survey of administrators in Minnesota NHs (n = 102), tested the domain-specific relationships of culture change practices with resident quality of life (QOL) and family satisfaction, and examined the moderating effect of small-home or household models on these relationships. The findings revealed that culture change operationalized through physical environment transformation, staff empowerment, staff leadership, and end-of-life care was positively associated with at least one domain of resident QOL and family satisfaction, while staff empowerment had the most extensive effects. Implementing small-home and household models had a buffering effect on the positive relationships between staff empowerment and the outcomes. The findings provide meaningful implications for designing and implementing NH culture change practices that best benefit residents' QOL and improve family satisfaction.

The Quality Measures Domain in Nursing Home Compare: Is High Performance Meaningful or Misleading?

BACKGROUND AND OBJECTIVES: The reported percent of nursing home residents suffering adverse outcomes decreased dramatically since Nursing Home Compare began reporting them, but the validity of scores is questionable for nursing homes that score well on measures using facility-reported data but poorly on inspections. Our objective was to assess whether nursing homes with these "discordant" scores are meaningfully better than nursing homes that score poorly across domains. RESEARCH DESIGN AND METHODS: We used a convergent mixed-methods design, starting with quantitative analyses of 2012-2016 national data. We conducted in-depth interviews and observations in 12 nursing homes in 2017-2018, focusing on how facilities achieved their Nursing Home Compare ratings. Additional quantitative analyses were conducted in parallel to study performance trajectories over time. Quantitative and qualitative results were interpreted together. RESULTS: Discordant facilities engage in more quality improvement strategies than poor performers, but do not seem to invest in quality improvement in resource-intensive, broad-based ways that would spill over into other domains of quality and change their trajectory of improvement. Instead, they focus on lower-resource improvements related to data quality, staff training, leadership, and communication. In contrast, poor-performing facilities seemed to lack the leadership and continuity of staff required for even these low-resource interventions. DISCUSSION AND IMPLICATIONS: High performance on the quality measures using facility-reported data is mostly meaningful rather than misleading to consumers who care about those outcomes, although discordant facilities still have quality deficits. The quality measures domain should continue to have a role in Nursing Home Compare.

Longitudinal Comparison of Stability and Sensitivity in Quality of Life Scores Among Nursing Home Residents With and Without Diagnoses of Alzheimer's Disease and Related Dementias.

BACKGROUND AND OBJECTIVES: Prevalence of nursing home residents with Alzheimer's disease and related dementias (ADRD) has increased along with a growing consensus that person-centered ADRD care in nursing homes should maximize quality of life (QoL). However, concerns about whether residents with ADRD can make appropriate QoL judgments persist. This study assesses the stability and sensitivity of a self-reported, multidomain well-being QoL measure for nursing home residents with and without ADRD. RESEARCH DESIGN AND METHODS: This study linked the 2012-2015 Minnesota Nursing Home Resident QoL and Satisfaction with Care Survey, Minimum Data Set 3.0 (nursing home assessments), and Minnesota Department of Human Services Cost Reports. The QoL survey included cohort-resident pairs who participated for 2 consecutive years (N = 12 949; 8 803 unique residents from 2012-2013, 2013-2014, and 2014-2015 cohorts). Change in QoL between 2 years was conceptualized as stable when within 1.5 SD of the sample average. We used linear probability models to estimate associations of ADRD/Cognitive Function Scale status with the stability of QoL summary and domain scores (eg, social engagement) and the absolute change in QoL summary score, controlling for resident and facility characteristics. RESULTS: Most (86.82%) residents had stable QoL summary scores. Residents with moderate to severe cognitive impairment, irrespective of ADRD, were less likely to have stable summary scores than cognitively capable residents without ADRD (p < .001), but associations varied by QoL domains. Among those with stable summary QoL scores, changes in health/functional status were associated with absolute changes in summary QoL score (p < .001), suggesting sensitivity of the QoL measure. DISCUSSION AND IMPLICATIONS: QoL scores were similarly stable over time for most residents with and without ADRD diagnoses and were sensitive to changes in health/functional status. This self-reported QoL measure may be appropriate for nursing home residents, regardless of ADRD diagnosis, and can efficaciously be recommended to other states.

The Porchlight Project: A Pilot Study to Adapt the Senior Companion Program to Enhance Memory Care Services and Supports.

Older adult volunteer programs present an important opportunity to provide low cost, community-based support to families living with Alzheimer's disease and Alzheimer's disease related dementias (AD/ADRD). In this mixed methods pilot study, volunteers (n = 15) from the Minnesota Senior Companion Program received training in AD/ADRD and palliative care, with the objective of providing more "dementia capable" support to people living with memory loss and their family caregivers. Volunteers applied their skills by engaging clients in a series of guided conversations over 3 months of dementia capable visits. Despite enrollment challenges, volunteers, clients, and caregivers reported that the intervention was appropriate and useful to improve understanding of memory loss and enhance volunteer-client communication. Results of the pilot study were used to refine the Porchlight Project for a future statewide evaluation.