Racial Differences in Nursing Home Quality of Life Among Residents Living With Alzheimer's Disease and Related Dementias.

ObjectivesAmong nursing home (NH) residents with Alzheimer's disease (AD) and AD-related dementias (AD/ADRD), racial/ethnic disparities in quality of care exist. However, little is known about quality of life (QoL). This study examines racial/ethnic differences in self-reported QoL among NH residents with AD/ADRD. Methods: Validated, in-person QoL surveys from 12,562 long-stay NH residents with AD/ADRD in Minnesota (2012-2015) were linked to Minimum Data Set assessments and facility characteristics. Hierarchical linear models assessed disparities in resident-reported mean QoL score (range, 0-100 points), adjusting for case-mix and facility factors. Results: Compared to White residents, racially/ethnically minoritized residents reported significantly lower total mean QoL scores (75.53 points vs. 80.34 points, p < .001). After adjustment for resident- and facility-level characteristics, significant racial/ethnic differences remained, with large disparities in food enjoyment, attention from staff, and engagement domains. Discussion: Policy changes and practice guidelines are needed to address racial/ethnic disparities in QoL of NH residents with AD/ADRD.

Evidence for Action: Addressing Systemic Racism Across Long-Term Services and Supports.

Long-term services and supports (LTSS), including care received at home and in residential settings such as nursing homes, are highly racially segregated; Black, Indigenous, and persons of color (BIPOC) users have less access to quality care and report poorer quality of life compared to their White counterparts. Systemic racism lies at the root of these disparities, manifesting via racially segregated care, low Medicaid reimbursement, and lack of livable wages for staff, along with other policies and processes that exacerbate disparities. We reviewed Medicaid reimbursement, pay-for-performance, public reporting of quality of care, and culture change in nursing homes and integrated home- and community-based service (HCBS) programs as possible mechanisms for addressing racial and ethnic disparities. We developed a set of recommendations for LTSS based on existing evidence, including (1) increase Medicaid and Medicare reimbursement rates, especially for providers serving high proportions of Medicaid-eligible and BIPOC older adults; (2) reconsider the design of pay-for-performance programs as they relate to providers who serve underserved groups; (3) include culturally sensitive measures, such as quality of life, in public reporting of quality of care, and develop and report health equity measures in outcomes of care for BIPOC individuals; (4) implement culture change so services are more person-centered and homelike, alongside improvements in staff wages and benefits in high-proportion BIPOC nursing homes; (5) expand access to Medicaid-waivered HCBS services; (6) adopt culturally appropriate HCBS practices, with special attention to family caregivers; (7) and increase promotion of integrated HCBS programs that can be targeted to BIPOC consumers, and implement models that value community health workers. Multipronged solutions may help diminish the role of systemic racism in existing racial disparities in LTSS, and these recommendations provide steps for action that are needed to reimagine how long-term care is delivered, especially for BIPOC populations.

Black and white chains of risk for hospitalization over 20 years.

Drawing from the life course perspective, racial disparities in hospitalization are considered in light of a chain of risk. We ask whether race influences admission to, length of stay in, and mortality following hospitalization. Analyses address these questions with data from a national longitudinal sample of adults to assess racial disparities in the hospitalization experience (n = 6,833). Survey data were merged with hospital records abstracted over 20 years of observation. Multivariate analyses revealed that there were no racial differences in admission, but that black adults generally had longer stays. When isolating each stay prospectively, black adults had longer stays during the first, third, and fourth hospitalizations. Post-hospital mortality after the first stay was also higher for black adults than for their white counterparts, even after controlling for morbidity and status resources. The findings suggest that the racial disparities in hospital length of stay and mortality are explained by the cumulative effects of social and health inequalities over the life course.

Beyond the barriers: racial discrimination and use of complementary and alternative medicine among Black Americans.

This article examines whether self-reported racial discrimination is associated with greater use of complementary and alternative medicine (CAM) and assesses whether the effects of reported racial discrimination are specific to the setting in which the unfair treatment occurred (i.e., medical or nonmedical settings). Data were drawn from the National Survey of Midlife Development in the United States (MIDUS) of Black adults aged 25 and older at baseline (N=201). Analyses account for multiple forms of discrimination: major lifetime discriminatory events and everyday discrimination (more commonplace negative occurrences). Using logistic and negative binomial regression, results reveal that racial discrimination was associated with a higher likelihood of using any type of CAM as well as using more modalities of CAM. Also, both discrimination in health care and discrimination in nonmedical contexts predicted greater use of CAM. The findings underscore the tenet that health care choices, while influenced by health status and availability of health care resources, are also shaped by perceived barriers. The experience of racial discrimination among Black people is associated with greater use of alternative means of health care, as a way to cope with the barriers they experience in institutional settings in the United States.

Accumulated financial strain and women's health over three decades.

OBJECTIVE: Drawing from cumulative inequality theory, this research examines how accumulated financial strain affects women's self-rated health in middle and later life. METHOD: Using data from the National Longitudinal Survey of Mature Women (1967-2003), we employ random-coefficient growth curve models to examine whether recurring financial strain influences women's health, above and beyond several measures of objective social status. Predicted probabilities of poor health were estimated by the frequency of financial strain. RESULTS: Financial strain is associated with rapid declines in women's health during middle and later life, especially for those women who reported recurrent strain. Changes in household income and household wealth were also associated with women's health but did not eliminate the effects due to accumulated financial strain. DISCUSSION: Accumulated financial strain has long-term effects on women's health during middle and later life. The findings demonstrate the importance of measuring life course exposure to stressors in studies of health trajectories.

"But I am not moving": residents' perspectives on transitions within a continuing care retirement community.

PURPOSE: This article investigates how continuing care retirement community (CCRC) residents define transitions between levels of care. Although older adults move to CCRCs to "age in place," moving between levels of care is often stressful. More than half a million older adults live in CCRCs, with numbers continually increasing; yet, no studies address transitions between levels of care in these communities. DESIGN AND METHODS: I completed 23 months of live-in observation and conducted 35 face-to-face in-depth interviews with CCRC residents across 3 levels of care. I performed a thematic analysis of observation notes and interview transcripts. RESULTS: Residents perceived transitions as both disempowering and final. They discussed decreases in social networks that occurred after such moves. Resident-maintained social boundaries exacerbated these challenges. IMPLICATIONS: Although the transition to institutional living is one of the most important events in older persons' lives, transitions within CCRCs also are consequential especially because they are coupled with declining functional ability. These findings may inform policy for retirement facilities on topics such as increasing privacy, challenging social boundaries, and educating residents to prepare them for transitions.

Aging and cumulative inequality: how does inequality get under the skin?

PURPOSE: This article draws from cumulative disadvantage and life course theories to develop a new theory for the social scientific study of aging. DESIGN AND METHODS: Five axioms of cumulative inequality (CI) theory are articulated to identify how life course trajectories are influenced by early and accumulated inequalities but can be modified by available resources, perceived trajectories, and human agency. RESULTS: Although the concept of CI has attracted considerable attention among social scientists, it holds promise for integrating additional disciplinary approaches to the study of aging including, but not limited to, biology, epidemiology, and immunology. The applicability of CI theory to gerontology is illustrated in research on the early origins of adult health. IMPLICATIONS: Primary contributions of the theory to gerontology include greater attention to family lineage as a source of inequality; genes, gestation, and childhood as critical to early and enduring inequalities; the onset, duration, and magnitude of exposures to risk and opportunity; and constraints on generalizations arising from cohort-centric studies.

Building the "bridge": linking gerontology education to a local retirement community.

There has been a substantial increase in the number of aging-related educational programs in the United States over the last two decades. Many of these programs utilize an experiential-learning approach, such as intergenerational service-learning, to train gerontology students to work effectively with older adults. This paper presents a model of training called the Bridge program, which is based in experiential learning and incorporates some of the broader goals of service-learning. Launched in 2003, the Bridge program involves graduate students residing in a retirement community for at least one academic year. The main goals of the program include: educating the students and the public about the aging process, recruiting future gerontologists, providing research opportunities for the Bridge students, and contributing to the retirement community. Evaluation of the program reveals several critical issues for successful implementation.