Measuring bereavement prevalence in a complex sampling survey: the 2019 Georgia Behavioral Risk Factor Surveillance System (BRFSS).

BACKGROUND: The Behavioral Risk Factor Surveillance System (BRFSS) is an annual survey designed to identify trends in the public's health. In its 2019 field survey, the U.S. state of GA tested a new 3 - item module to measure the numbers of bereaved, resident adults aged 18 years and older. Participants were eligible if they answered 'Yes' to the item 'Have you experienced the death of a family member or close friend in the years 2018 or 2019?'. This analysis explores two research questions. Can estimates for bereavement prevalence be derived without large sampling errors, low precision, and small subsamples? Can multiple imputation techniques be applied to overcome non-response and missing data to support multivariate modeling? METHODS: BRFSS is a non-institutionalized sample of adults aged 18 years and older living in the U.S. state of Georgia. Analyses in this study were conducted under two scenarios. Scenario 1 applies the complex sample weights created by the Centers for Disease Control and imputes values for missing responses. Scenario 2 treats the data as a panel - no weighting combined with removal of persons with missing data. Scenario 1 reflects the use of BRFSS data for public health and policy, while Scenario 2 reflects data as it is commonly used in social science research studies. RESULTS: The bereavement screening item has a response rate (RR) of 69.1% (5206 of 7534 persons). Demographic subgroups and categories of health have RR of 55% or more. Under Scenario 1, the estimated prevalence of bereavement is 45.38%, meaning that 3,739,120 adults reported bereaved in 2018 or 2019. The estimated prevalence is 46.02% with Scenario 2 which removes persons with any missing data (4,289 persons). Scenario 2 overestimates the bereavement prevalence by 1.39%. An illustrative logistic model is presented to show the performance of exposure to bereavement under the two data scenarios. CONCLUSIONS: Recent bereavement can be ascertained in a surveillance survey accounting for biases in response. Estimating bereavement prevalence is needed for measuring population health. This survey is limited to one US state in a single year and excludes persons aged 17 years and younger.

Indicators of resilience and healthcare outcomes: findings from the 2010 health and retirement survey.

OBJECTIVE: To test the hypothesis that higher levels of resilience indicators are associated with lower overall healthcare utilization (HCU) as well as improvements in self-rated health (SRH), we analyzed a representative sample of 4562 adults 50-70 years old enrolled in the US 2010 health and retirement survey. METHODS: Multivariable logistic regression models estimated odds ratios (ORs) and 95 % confidence intervals (CIs) for high versus low resilience in relation to HCU and SRH improvements over 2 years. Resilience indicators included: cumulative lifetime adversity, social support, global mastery and domain-specific mastery. Cumulative lifetime adversity was defined as 0, 1-2, 3-4 or 5+ events. HCU included hospitalization (any vs. none) and physician visits (< 20 vs. ≥ 20) over 2 years. FINDINGS: Hospitalization odds declined by 25 % (OR 0.75, 95 %CI 0.64-0.86), odds of ≥ 20 physician visits declined by 47 % (OR 0.53, 95 % CI 0.45-0.63) and the odds of SRH improvement increased by 49 % (OR 1.49, 95 % CI 1.17-1.88) for respondents with high versus low health mastery. Cumulative lifetime adversity manifested a dose-dependent positive relationship with HCU. Specifically, hospitalization odds was, respectively, 25, 80 and 142 % elevated for participants that reported 1-2, 3-4 and 5+ versus 0 lifetime adversities. High versus low global, financial and health mastery, respectively, predicted improved SRH, lower physician's visits and hospitalizations. CONCLUSION: In this sample of adults near or in retirement, resilience predicted lower HCU and improved SRH. Resilience is a dynamic state that can be enhanced in adults with positive impacts on subjective well-being and HCU.

The application of Belmont Report principles to policy development.

Attention to ethical issues is a routine part of medical research. In this article, we propose that health policy development, like research, include a formal review of these issues. Ethical knowledge is a critical component of epistemology and inherent in development of laws and principles of justice. However, we cannot assume that new policies are subject to a formal ethics review. The Belmont Report of 1978 provides a platform for this process. Prior to the Belmont Report, there was no foundation defining this process in medical research. Based on this history, we propose that health care payment policy development include a formal assessment of risks and benefits using an approach that is familiar to all researchers.

Factors affecting academic performance of college students in China during COVID-19 pandemic: a cross-sectional analysis.

Introduction: Understanding the factors that affected academic performance of students during the COVID-19 pandemic will help design effective interventions for improving students' academic performance during emergency situations as well as during regular academic environment. This cross-sectional study aimed to identify the factors that explain academic performance of students in China during the pandemic. Methods: Data on college students from the 2020 China Family Panel Studies were used, and the final sample consisted of 728 students. Ordered probit regression models were estimated to explain students' relative performance in the semester when the in-person classes were suspended by using various student and household-related variables and characteristics. To compute missing values in selected variables, a multiple imputation technique was applied. Results: The odds of poor academic performance declined with higher Internet use for academic purposes, but Internet use for entertainment increased the probability of being in the poor academic performance. College students who spent more time studying on college work were less likely to have poor academic performance. Discussion: This study identified the factors (Internet use and study time) associated with academic performance among Chinese college students during the COVID-19 pandemic. These results can be used to design policies to improve educational outcomes and to address educational inequalities.

Estimating Prevalence of Bereavement, Its Contribution to Risk for Binge Drinking, and Other High-Risk Health States in a State Population Survey, 2019 Georgia Behavioral Risk Factor Surveillance Survey.

BACKGROUND: Binge drinking is a pattern of alcohol abuse. Its prevalence and associated risk factors are not well documented. Heavy drinking, on the other hand, has a well-documented association with bereavement. This report uses a cross-sectional, population-based survey to estimate prevalence of bingeing and its association with new bereavement. Bingeing is defined as 4 or more drinks (women) or 5 or more drinks (men) in a 2-4-h setting. For the first time in 2019, the Georgia Behavioral Risk Factor Surveillance Survey (BRFSS) included a bereavement item: 'Have you experienced the death of a family member or close friend in the years 2018 or 2019?' METHODS: Georgia BRFSS is a complex sampling survey administered annually. It is designed to represent the 8.1 million people aged 18 years and older in the U.S. state of Georgia. Alcohol consumption patterns are routinely measured in the common core. In 2019, the state added a new item probing for bereavement in the prior 24 months predating the COVID-19 pandemic. Imputation and weighting techniques were applied to yield the population prevalence rates of new bereavement, bingeing, and their co-occurrence with other high-risk health behaviors and outcomes. Multivariate models, adjusted for age, gender, and race, were used to estimate the risk for other unhealthy behaviors posed by the co-occurrence of bereavement and bingeing. RESULTS: In Georgia, bereavement (45.8%), and alcohol consumption (48.8%) are common. Bereavement and alcohol use co-occurred among 1,796,817 people (45% of all drinkers) with a subset of 608,282 persons reporting bereavement combined with bingeing. The most common types of bereavement were death of a friend/neighbor (30.7%) or three plus deaths (31.8%). CONCLUSIONS: While bingeing is a known risk to public health, its co-occurrence with recent bereavement is a new observation. Public health surveillance systems need to monitor this co-occurrence to protect both individual and societal health. In a time of global bereavement, documenting its influence on binge drinking can support the work towards Sustainable Development Goal #3-Good health and Well-Being.

Pregnancy as a risk factor for ambulatory limitation in later life.

OBJECTIVES: We investigated the relationship between the number of times a woman has been pregnant and walking difficulty in later life. METHODS: With data from the Hispanic Established Populations for Epidemiologic Studies of the Elderly, a representative population-based cohort of Mexican Americans aged 65 years and older residing in 5 Southwestern states, we measured walking difficulty using 2 items from the performance-oriented mobility assessments: the timed walk and seated chair rise. RESULTS: We observed significantly higher rates of ambulatory limitation among women with 6 or more pregnancies than among women with 4 or fewer pregnancies: 44.9% and 27.0%, respectively, were unable to perform or performed poorly in the seated chair rise and timed walk. Ordinal logistic regression models show that gravidity predicts level of performance in both mobility tasks and that higher gravidity is associated with worse performance, even after adjustment for both age and chronic disease. CONCLUSIONS: Gravidity is a risk factor for ambulatory limitation in old age. A life course approach to reproduction in public health research and practice is warranted.

The Impact of Stressful Life Events on the Incidence of Type 2 Diabetes in U.S. Adults From the Health and Retirement Study.

OBJECTIVES: We evaluated the association between cumulative stressful life events (SLE) and type of stress (lifetime vs recent) and incident diabetes (Type 2 diabetes mellitus [T2DM]) in middle-aged U.S. adults. METHODS: Data from the 2006-2014 waves of the Health and Retirement Study (HRS) were analyzed (n = 7,956). Stress-related differences in age at T2DM diagnosis were estimated using Cox proportional hazards models. RESULTS: The adjusted risk of T2DM significantly increased by 6% per unit increase in cumulative SLE (95% confidence interval [CI] = 1.03, 1.11), by 5% per unit increase in lifetime stress (95% CI = 1.00, 1.09), and by 23% per unit increase in recent stress (95% CI = 1.12, 1.36). Each level of cumulative SLE (1, 2, 3, and ≥4 events) and recent stress (1 and ≥2 events) compared to no stress was significantly associated with an increased risk of T2DM. Each level of lifetime stress compared to no stress was significantly associated with an elevated risk of T2DM except for 3 events. DISCUSSION: Cumulative SLE and type of stress were associated with incident T2DM in middle-aged adults. Reducing the direct effect of stress with management interventions may reduce the indirect effect of developing T2DM and warrants further investigation.

From the hospital to the nursing home: the 75% rule and the transfer process.

This has been a commentary on the implications of policy changes for nursing homes and rehabilitation hospital admissions. Only time will show how greatly this will affect the nursing home. However, since the 2004 implementation of the 75% Rule, nursing homes have already seen a jump in patients who are more acutely ill and have multiple medical needs. To lessen the potential burden of these changes on patient safety and comfort and to increase family satisfaction with care, we propose the following steps be considered. 1. We need better integration between hospital and nursing homes. Indeed, a strategic alliance between hospitals and nursing homes would be something that we should consider sooner rather than later. 2. All providers should understand that this is a continued push by both private and government insurance to get the patient out of the hospital sooner. As a result, patients will be discharged either to the rehab hospital or to the nursing home "sicker and quicker." 3. The implementation of the 75% Rule will probably result in a decreased use of rehab hospitals and an increased use of the nursing home. 4. In looking even further into the future, the nursing homes themselves are likely to be under continued pressure to get patients out of the nursing home more quickly. This in turn will result in what we consider the next big thing-home care.

Suboptimal medication use and mortality in an older adult community-based cohort: results from the Hispanic EPESE Study.

BACKGROUND: Numerous methods have been used to evaluate medication management quality in older adults; however, their predictive validities are unknown. Major medication quality indicators include polypharmacy, drug-drug interactions, and inappropriate medication use. To date, no study has attempted to evaluate the three approaches systematically or the effect of each approach on mortality in a Hispanic population. Our objective was to evaluate the relationship between polypharmacy, drug-drug interactions, and inappropriate medication use on the mortality of a community-based population of Mexican American older adults. METHODS: We used a life table survival analysis of a longitudinal survey of a representative sample of 3,050 older Mexican Americans of whom 1,823 were taking prescription and over-the-counter medications. RESULTS: After adjustment for relevant covariates, use of more than four different medications (polypharmacy) was independently associated with mortality. The presence of major drug interactions and the use of inappropriate medications were not significantly associated with mortality in our study sample. CONCLUSION: Polypharmacy (>4 medications) is significantly associated with mortality in Mexican American older adults. This community-based study is the first to demonstrate a direct association between polypharmacy and mortality in this population.

Effect of a BMI chart on weight management discussions in a primary care setting.

OBJECTIVE: To measure whether the addition of a BMI chart to a patient's medical record at the time of the office visit would increase the likelihood of a physician discussing weight management with the patient. METHODS: Office staff were instructed to place a BMI chart on the front of medical charts of all patients aged 21 years to 65 years who were seen during a 2-month period in two urban university-affiliated clinics. The staff were to plot the BMI on the chart. The medical records were audited for the presence of the BMI chart and any documentation of a discussion of weight management. RESULTS: Of the 961 charts that were audited, 44% contained the BMI chart. A discussion of weight management issues was documented in 19% of those that contained a BMI chart and in 15% of those that did not contain a BMI chart. CONCLUSIONS: Data presented here suggest that adding a BMI chart to the patient medical record may increase the attention of a physician to weight management issues.

In a Longevity Society, Loss and Grief Are Emerging Risk Factors for Health Care Use: Findings From the Health and Retirement Survey Cohort Aged 50 to 70 Years.

In a society of long lives, parent and child life can overlap by as much as 50 years. Most children now experience the death of their parents as adults. Many of the 2.5 million deaths each year in the United States are parents. Parental loss is a risk factor for subsequent illness. The Health and Retirement Survey is a representative cohort of persons aged 50 to 70 years. Using the 2010 cohort data, we estimate risk for use of health care after the death of a parent. Loss is a near universal experience in the cohort (87%). A report of any loss increases risk of health care utilization by 20% to 30%. For a longevity society, preventing loss-related hospitalization is a measurable outcome for bereavement care.

Correctable sources of disparities in cancer among minority elders.

This article explores the hypothesis that medical policies and procedures represent immediately correctible causes of disparity in minority elders. Evidence of policies and procedures that have the unintended consequence of creating disparity is presented. The text is focused on one site, prostate, as a sample tumor to present a strategy for correcting sources of disparities in cancer morbidity and mortality. Specific prostate cancer issues with unintended effects include the prostate cancer screening controversy, access to diagnostic facilities in minority communities, and special needs of older adult cancer survivors. A summary of all recommendations and their implications across cancer sites is provided.

Institutional Bereavement Care for Fictive Kin: Staff Grief in CCRCs.

PURPOSE: The purpose of this study was to explore approaches used by administrators to respond to grief and bereavement among staff after the death of a resident. METHODS: Continuing care retirement community (CCRC) facilities (n = 10) were randomly selected from a larger study of 31 facilities. Open-ended interviews were conducted using a structured interview protocol. Qualitative methods, specifically thematic analysis, were used to analyze the interview data. FINDINGS: Emergent themes suggest that LTC facilities have freedom in how to provide support for staff members, family members, and other residents after the death of a loved one. However, results show variations in methods for notifying staff of a resident's death, inclusion of direct care staff in caring for the deceased, providing memorial services, and offering grief/bereavement support. When speaking of the loss of a resident and ways to provide grief/bereavement support, only 3 of the 10 administrators discussed the importance of extending such services to the staff. IMPLICATIONS: Causes of staff burnout in the CCRC workplace is an unresolved issue. Research has shown that inadequate grief and bereavement support for staff contributes to factors associated with staff burnout and retention. Although administrators hold formal services after a resident has died, there are differences among facilities. It may be that organizations could improve bereavement services for staff.

Sexual Behaviors, Healthcare Interactions, and HIV-Related Perceptions Among Adults Age 60 Years and Older: An Investigation by Race/Ethnicity.

BACKGROUND: Older adults are remaining sexually active for longer periods of time, underscoring the need to assess sexual activity patterns in this group and identify differences by race/ethnicity, some of which may have implications for the development and implementation of sexual risk reduction interventions. METHODS: Using data from the 2010 National Social Life, Health, and Aging Project, this study examined responses from 1,429 adults aged 60 years and older. Multinomial logistic regression compared sexual behaviors, health-related indicators, interactions with healthcare professionals, and HIV-related perceptions across participants' race/ethnicity. RESULTS: Approximately 81% of participants self-reported as non-Hispanic white, 10.59% as African American, and 8.05% as Hispanic. On average, participants were 69.9 years of age. In the previous year, 49.3% of participants engaged in sexual intercourse; only 3% used condoms. The majority of participants (83.1%) visited a physician at least twice in the previous year, 30.9% had discussed sex with a physician since turning 50, and 14.2% had been tested for HIV. Relative to non-Hispanic whites, African Americans were more likely to be divorced (OR=3.23, P<0.001) or widowed (OR=2.90, P<0.001); have more lifetime sexually transmitted infection (STI) diagnoses (OR=1.67, P=0.030); and have paid for sex (OR=2.83, P=0.002). Although African Americans had greater perceived risk for HIV infection (OR=1.66, P=0.046), they were less likely to have discussed sex with a physician since turning 50 (OR=0.45, P=0.009). CONCLUSION: Contextualized interventions to improve patient-provider communication and proactive screening behaviors in sexually-active and aging African Americans are needed.

Prevalence and severity of urinary incontinence in elderly Mexican-American women.

OBJECTIVES: To measure prevalence and characteristics of urinary incontinence in older Mexican-American women. DESIGN: Cross-sectional analysis of a longitudinal survey of a representative sample of older Mexican Americans. SETTING: Five southwestern states in the United States. PARTICIPANTS: A total of 1589 Mexican-American women, aged 65 and older who were part of the Hispanic Established Population for the Epidemiologic Study of the Elderly. MEASUREMENTS: Self-reported psychosocial, demographic, and health variables; self-reported history of symptoms of urinary incontinence. RESULTS: Two hundred thirty-nine (15%) of the 1589 Mexican-American women reported having urinary incontinence. Almost 33% reported urge incontinence symptoms, 10% reported stress incontinence symptoms, and 42% had symptoms suggestive of mixed incontinence. Thirty-five percent of subjects reported incontinence episodes with moderate to large amounts of urine loss, and 15% reported that their urinary symptoms kept them from engaging in social activities. Age and body mass index were risk factors for incontinence (P=.02 and P=.03, respectively). CONCLUSION: This is the first community-based survey examining rates of urinary incontinence in Mexican-American women. The prevalence of urinary incontinence may be lower in older Mexican-American women than in the general population. They may also have a higher percentage of urge as opposed to stress incontinence symptoms and may suffer from moderate to large volumes of urine loss associated with their incontinence episodes.

Barriers to and benefits of leisure time physical activity in the elderly: differences across cultures.

The purpose of this study was to compare ethnic differences in attitudes toward barriers and benefits of leisure-time physical activity (LTPA) in sedentary elderly Mexican (MAs) and European Americans (EAs). An in-home, cross-sectional survey was performed on 210 community-dwelling elders from 10 primary care practices in south Texas that are part of the South Texas Ambulatory Research Network, a practice-based research network. Analytical variables included ethnicity, age, sex, income, education, marital status, and LTPA. Fisher exact test was used to analyze the 100 sedentary elders (LTPA <500 kcal/wk; 63 MAs and 37 EAs). Self-consciousness and lack of self-discipline, interest, company, enjoyment, and knowledge were found to be the predominant barriers to LTPA in both groups. Both groups held similar beliefs about benefits gained from exercise, such as improved self-esteem, mood, shape, and health, but the beliefs about the positive benefits of exercise were more prevalent in MAs. These findings remained after adjusting for age, income, education, marital status, and sex. Some might think that a major barrier lies in misconception about benefits of LTPA, but in this study, both ethnic groups were accurate in their perceived benefits of LTPA. When attempting to engage elderly in LTPA, it is important not only to consider what barriers exist but also what beliefs about the benefits exist.

Strength and muscle quality in a well-functioning cohort of older adults: the Health, Aging and Body Composition Study.

OBJECTIVES: To determine whether lower lean mass and higher fat mass have independent effects on the loss of strength and muscle quality in older adults and might explain part of the effect of age. DESIGN: Single-episode, cross-sectional analyses of a cohort of subjects in the Health, Aging and Body Composition (Health ABC) Study. SETTING: Ambulatory clinic and research laboratory. PARTICIPANTS: Two thousand six hundred twenty-three men and women aged 70 to 79 from the Health ABC Study. MEASUREMENTS: Upper and lower extremity strength was measured using isokinetic (knee extension) and isometric (grip strength) dynamometers. Body composition (lean mass and fat mass) was determined by measuring lean mass of upper and lower extremities and the total body by dual-energy x-ray absorptiometry. Muscle quality was ascertained by taking the ratio of strength to muscle mass for both upper and lower extremities. RESULTS: Upper and lower extremity strength and muscle quality decreased as age increased. Most of the explained variance in strength was due to differences in muscle mass, but, in those at the extremes of body fat and lower leg muscle quality, the association with body fat was independent of the effect of age. Although blacks had greater muscle strength and mass than whites, leg muscle quality tended to be lower in blacks than in whites. Upper extremity strength adjusted for lean mass and muscle quality were also associated inversely and independently with age, body fat, and black race. CONCLUSION: In this older cohort, lower strength with older age was predominantly due to a lower muscle mass. Age and body fat also had significant inverse associations with strength and muscle quality. Both preservation of lean mass and prevention of gain in fat may be important in maintaining strength and muscle quality in old age.

Multiple primary malignant neoplasms: case report and a comprehensive review of the literature.

A case is presented of an elderly patient with synchronous ureteral/bladder/urethral transitional cell carcinoma and prostatic adenocarcinoma. In a subsequent review of 1,104,269 cancer patients in the literature, the reported prevalence of multiple primary malignant neoplasms (MPMN) varies between 0.734% and 11.7%. It appears that MPMN might occur more frequently than can be explained on the basis of random chance. As expected, the incidence of developing MPMN is noted to rise with increasing age. In addition, the preponderance of men with MPMN is caused primarily by the high frequency of prostatic cancer. Current studies and research need to address the potential of older cancer patients being at higher risk of second primaries.

Characteristics of Mexican-American elders with dementia presenting to a community-based memory evaluation program.

OBJECTIVE: To determine sociodemographic characteristics associated with the initial presentation of Mexican-American elders to a community-based memory evaluation clinic. METHODS: Retrospective review of the charts of 89 Mexican Americans presenting consecutively to an outpatient memory evaluation clinic in San Antonio, Texas. PRINCIPAL FINDINGS: Mexican Americans presented for evaluation with more moderate-to-severe cognitive impairment than previously reported. They also tended to have high levels of IADL (83.1%) and gait/balance (52.3%) impairment, as well as high levels of depressive symptoms (63.1%). CONCLUSIONS: Mexican Americans present for initial evaluation for memory decline with moderate-to-severe cognitive decline and significant dementia-associated co-morbidities. In Mexican Americans, caregiver burden, fall risks, depressive symptoms, and need for IADL support should be addressed on the initial visit for memory decline.