Social Isolation and Medicare Spending: Among Older Adults, Objective Social Isolation Increases Expenditures while Loneliness Does Not.

Objectives: Evaluate objective isolation and loneliness' impact on Medicare spending and outcomes. Methods: We linked Health and Retirement Study data to Medicare claims to analyze objective isolation (scaled composite of social contacts and network) and loneliness (positive response to 3-item loneliness scale) as predictors of subsequent Medicare spending. In multivariable regression adjusting for health and demographics, we determined marginal differences in Medicare expenditures. Secondary outcomes included spending by setting, and mortality. Results: Objective isolation predicts greater spending, $1,644(p<0.001) per beneficiary annually, whereas loneliness predicts reduced spending, -$768(p<0.001). Increased spending concentrated in inpatient and nursing-home (SNF) care; despite more healthcare, objectively isolated beneficiaries had 31%(p<0.001) greater risk of death. Loneliness did not predict SNF use nor mortality, but predicted slightly less inpatient and outpatient care. Conclusions: Objectively isolated seniors have higher Medicare spending, driven by increased hospitalization and institutionalization, and face greater mortality. Policies supporting social connectedness could reap significant savings.

Hearing loss is an early consequence of Npc1 gene deletion in the mouse model of Niemann-Pick disease, type C.

Niemann-Pick disease, type C1 (NPC1) is a rare lysosomal lipidosis that is most often the result of biallelic mutations in NPC1, and is characterized by a fatal neurological degeneration. The pathophysiology is complex, and the natural history of the disease is poorly understood. Recent findings from patients with NPC1 and hearing loss suggest that multiple steps along the auditory pathway are affected. The current study was undertaken to determine the auditory phenotype in the Npc1 (nih) mutant mouse model, to extend analyses to histologic evaluation of the inner ear, and to compare our findings to those reported from human patients. Auditory testing revealed a progressive high-frequency hearing loss in Npc1 (-/-) mice that is present as early as postnatal day 20 (P20), well before the onset of overt neurological symptoms, with evidence of abnormalities involving the cochlea, auditory nerve, and brainstem auditory centers. Distortion product otoacoustic emission amplitude and auditory brainstem response latency data provided evidence for a disruption in maturational development of the auditory system in Npc1 (-/-) mice. Anatomical study demonstrated accumulation of lysosomes in neurons, hair cells, and supporting cells of the inner ear in P30 Npc1 (-/-) mice, as well as increased numbers of inclusion bodies, myelin figures, and swollen nerve endings in older (P50-P70) mutant animals. These findings add unique perspective to the pathophysiology of NPC disease and suggest that hearing loss is an early and sensitive marker of disease progression.

Auditory phenotype of Niemann-Pick disease, type C1.

OBJECTIVES: The aim of this study was to comprehensively evaluate the auditory phenotype in Niemann-Pick disease, type C1 (NPC1), to understand better the natural history of this complex, heterogeneous disorder, and to define further the baseline auditory deficits associated with NPC1 so that use of potentially ototoxic interventions (e.g., 2-hydroxypropyl-ß-cyclodextrin) may be more appropriately monitored and understood. DESIGN: Fifty patients with NPC1 ranging in age from 4 months to 21 years (mean = 9.3 years) enrolled in a natural history/observational study at the National Institutes of Health. The auditory test battery included, when possible, immittance audiometry, pure-tone and speech audiometry, otoacoustic emission testing, and a neurotologic auditory brainstem response study. Longitudinal data were collected on a subset of patients. RESULTS: Over half of the cohort exhibited hearing loss involving the high frequencies ranging from a slight to moderate degree, and 74% of patients presented with clinically significant hearing loss involving the frequencies most important to speech understanding (0.5, 1, 2, 4 kHz). Despite the heterogeneity of the sample, results among patients were sufficiently consistent to implicate retrocochlear dysfunction in the majority (66%) of individuals, with (22%) or without (44%) accompanying cochlear involvement. Some patients (10%) presented with a profile for auditory neuropathy spectrum disorder. The combination of cross-sectional and longitudinal data indicates these patients are at risk for a progressive decline in auditory function. CONCLUSIONS: This is the largest cohort of patients with NPC1 evaluated comprehensively for auditory dysfunction, and results implicate the pathological processes of NPC1 in the manifestation of hearing loss. Patients with NPC1 should be monitored audiologically throughout their lives, beginning at the time of diagnosis. Clinicians and researchers should be aware of this historically overlooked aspect of the phenotype.

How the Affordable Care Act can help move States toward a high-performing system of long-term services and supports.

The United States may advance toward a high-performing health care system that offers long-term services and supports for people with disabilities and chronic conditions, or it may retreat from gains achieved in recent years. Since the 1980s, policy makers and advocates for the disabled have sought to move from a system that emphasizes nursing homes and institutional care to one that includes a broader range of care options. The Affordable Care Act of 2010 gives this movement a considerable boost by offering states timely new options and enhanced federal funding to create a care system that meets the diverse needs and preferences of people with disabilities and that also recognizes the role of family caregivers. In this paper we outline the five key characteristics of a high-performing system of long-term services and supports. We describe an emerging "scorecard" that could help measure states' progress toward this goal. And we itemize aspects of the Affordable Care Act intended to support the creation of such a high-performing system for the disabled and those with chronic conditions.

The international migration of nurses in long-term care.

This article describes five major factors that are affecting patterns of international migration among nurses who work in long-term care settings: DEMOGRAPHIC DRIVERS: The aging of the populations in developed countries and the low to negative growth in the working-age population will increase the demand for international workers to provide long-term care services. GENDER AND RACE: A dual labor market of long-term care workers, increasingly made up of women of color, is becoming internationalized by the employment of migrating nurses from developing countries. CREDENTIALING: The process of credentialing skilled workers creates barriers to entry for migrating nurses and leads to "decredentialing" where registered nurses work as licensed practical nurses or aides. COLONIAL HISTORY AND GEOGRAPHY: The colonial histories of many European countries and the United States have increased migration from former colonies in developing countries to former colonial powers. WORKER RECRUITMENT: Efforts to limit the recruitment of health care workers from some developing countries have had little effect on migration, in part because much of the recruitment comes through informal channels of family and friends.

Valuing the invaluable: a new look at the economic value of family caregiving.

The contributions of America's family caregivers, along with many friends and neighbors, often go unrecognized in public policy discussions about the financing and costs of health care and long-term services and supports (LTSS). Yet these unpaid caregivers provide by far the majority of long-term services and supports received by persons with disabilities of all ages. Many of these "informal" caregivers also provide health-related services. In fact, their contributions to loved ones and friends are not only the foundation of the nation's long-term care system but an important component of the U.S. economy, with an estimated economic value of about $350 billion in 2006. This issue brief discusses the financial impact of caregiving on the caregivers themselves as well as the economic value of their contributions to society. It compares the economic value of informal caregiving to other benchmarks in order to underscore the magnitude of these unpaid contributions, presents estimates of productivity losses to U.S. businesses from caregiving, and highlights the critical role that family caregivers play in the nation's long-term care system. Finally, it recommends ways to support informal caregivers through public policies and in the private sector.