Depressive Symptoms and Caregiving Intensity Before and After Onset of Dementia in Partners: A Retrospective, Observational Study.

BACKGROUND: Caring for a partner with dementia poses significant emotional burden and high care demands, but changes in impacts before and after dementia onset is unclear. OBJECTIVE: Examine changes in depressive symptoms and hours of care provided by caregivers through the course of their partners' cognitive decline. METHODS: Retrospective, observational study using household survey data from 2000-2016 Health and Retirement Study and count models to evaluate older individuals' (ages ≥51 y) depressive symptoms (measured using the shortened Center for Epidemiologic Studies Depression Scale) and weekly caregiving in the 10 years before and after their partners' dementia onset (identified using Telephone Interview Cognitive Status screening). Relationships were examined overall and by sex and race. RESULTS: We identified 8298 observations for 1836 older caregivers whose partners developed dementia. From before to after partners' dementia onset, caregivers' mean (SD) depressive symptoms increased from 1.4 (1.9) to 1.9 (2.1) ( P <0.001) and weekly caregiving increased from 4.4 (19.7) to 20.8 (44.1) ( P <0.001) hours. Depressive symptoms and caregiving hours were higher for women compared with men. Depressive symptoms were higher for Blacks compared with Whites, while caregiving hours were higher for Whites. The expected count of caregivers' depressive symptoms and caregiving hours increased by 3% ( P <0.001) and 9% ( P =0.001) before partners' dementia onset and decreased by 2% ( P <0.001) and 1% ( P =0.63) following partners' dementia onset. No differences observed by sex or race. DISCUSSION: Depressive symptoms and instrumental burdens for caregivers increase substantially before the onset of dementia in partners. Early referral to specialty services is critical.

Prescription characteristics associated with fall-related injury risk among older adults prescribed benzodiazepines: a cohort study.

BACKGROUND: Benzodiazepines (BZD) are widely prescribed to older adults despite their association with increased fall injury. Our aim is to better characterize risk-elevating factors among those prescribed BZD. METHODS: A retrospective cohort study using a 20% sample of Medicare beneficiaries with Part D prescription drug coverage. Patients with a BZD prescription ("index") between 1 April 2016 and 31 December 2017 contributed to incident (n=379,273) and continuing (n=509,634) cohorts based on prescriptions during a 6-month pre-index baseline. Exposures were index BZD average daily dose and days prescribed; baseline BZD medication possession ratio (MPR) (for the continuing cohort); and co-prescribed central nervous system-active medications. Outcome was a treated fall-related injury within 30 days post-index BZD, examined using Cox proportional hazards adjusting for demographic and clinical covariates and the dose prescribed. RESULTS: Among incident and continuing cohorts, 0.9% and 0.7% experienced fall injury within 30 days of index. In both cohorts, injury risk was elevated immediately post-index among those prescribed the lowest quantity: e.g., for <14-day fill (ref: 14-30 days) in the incident cohort, risk was 37% higher the 10 days post-fill (adjusted hazard ratio [HR] 1.37 [95% confidence interval [CI] 1.19-1.59]). Risk was elevated immediately post-index for continuing users with low baseline BZD exposure (e.g., for MPR <0.5 [ref: MPR 0.5-1], HR during days 1-10 was 1.23 [CI 1.08-1.39]). Concurrent antipsychotics and opioids were associated with elevated injury risk in both cohorts (e.g., incident HRs 1.21 [CI 1.03-1.40] and 1.22 [CI 1.07-1.40], respectively; continuing HRs 1.23 [1.10-1.37] and 1.21 [1.11-1.33]). CONCLUSIONS: Low baseline BZD exposure and a small index prescription were associated with higher fall injury risk immediately after a BZD fill. Concurrent exposure to antipsychotics and opioids were associated with elevated short-term risk for both incident and continuing cohorts.

Are Improvements Still Needed to the Modified Hospital Readmissions Reduction Program: a Health and Retirement Study (2000-2014)?

BACKGROUND: To address concerns that the Hospital Readmissions Reduction Program (HRRP) unfairly penalized safety net hospitals treating patients with high social and functional risks, Medicare recently modified HRRP to compare hospitals with similar proportions of high-risk, dual-eligible patients ("peer group hospitals"). Whether the change fully accounts for patients' social and functional risks is unknown. OBJECTIVE: Examine risk-standardized readmission rates (RSRRs) and hospital penalties after adding patient-level social and functional and community-level risk factors. DESIGN: Using 2000-2014 Medicare hospital discharge, Health and Retirement Study, and community-level data, latent factors for patient social and functional factors and community factors were identified. We estimated RSRRs for peer groups and by safety net status using four hierarchical logistic regression models: "base" (HRRP model); "patient" (base plus patient factors); "community" (base plus community factors); and "full" (all factors). The proportion of hospitals penalized was calculated by safety net status. PATIENTS: 20,255 fee-for-service Medicare beneficiaries (65+) with eligible index hospitalizations MAIN MEASURES: RSRRs KEY RESULTS: Half of safety net hospitals are in peer group 5. Compared with other hospitals, peer group 5 hospitals (most dual-eligibles) treated sicker, more functionally limited patients from socially disadvantaged groups. RSRRs decreased by 0.7% for peer groups 2 and 4 and 1.3% for peer group 5 under the patient and full (versus base) models. Measured performance improved after adjusting for patient risk factors for hospitals in peer group 4 and 5 hospitals, but worsened for those in peer groups 1, 2, and 3. Under the patient (versus base) model, fewer safety net hospitals (48.7% versus 51.3%) but more non-safety net hospitals (50.0% versus 49.1%) were penalized. CONCLUSIONS: Patient-level risk adjustment decreased RSRRs for hospitals serving more at-risk patients and proportion of safety net hospitals penalized, while modestly increasing RSRRs and proportion of non-safety net hospitals penalized. Results suggest HRRP modifications may not fully account for hospital variation in patient-level risk.

Is social capital protective against hospital readmissions?

BACKGROUND: To evaluate the association between social capital and 30-day readmission to the hospital among Medicare beneficiaries overall, beneficiaries with dementia and related memory disorders, and beneficiaries with dual eligibility for Medicaid. METHODS: Using Health and Retirement Study (HRS) data linked with 2008-2015 Medicare claims from traditional Medicare beneficiaries hospitalized during the study period (1246 unique respondents, 2212 total responses), we examined whether dementia and related memory disorders and dual eligibility were associated with social capital. We then estimated a multiple regression model to test whether social capital was associated with a reduced likelihood of readmission. RESULTS: Dementia was associated with an - 0.241 standard deviation (sd) change in social capital (95% CI: - 0.378, - 0.103), dual eligibility with a - 0.461 sd change (95% CI: - 0.611, - 0.310), and the occurrence of both was associated with an additional - 0.236 sd change (95% CI: - 0.525, - 0.053). 30-day readmission rates were 14.47% over the study period. In both adjusted and unadjusted models, social capital was associated with small and nonsignificant differences in 30-day readmissions. These effects did not vary across dementia status and socioeconomic status. CONCLUSIONS: Dementia and dual eligibility were associated with lower social capital, but social capital was not associated with the risk of readmission for any population.

A Framework for Aging-Friendly Services and Supports in the Age of COVID-19.

COVID-19 has revealed gaps in services and supports for older adults, even as needs for health and social services have dramatically increased and may produce a cascade of disability after the pandemic subsides. In this essay, we discuss the perfect storm of individual and environmental risk factors, including deconditioning, reductions in formal and informal care support, and social isolation. We then evaluate opportunities that have arisen for strengthening person-centered services and supports for older adults, through in-home acute and primary medical care, aggressive use of video telehealth and social interaction, and implementation of volunteer or paid intergenerational service.

Partner Plan Choices and Medicare Advantage Enrollment Decisions Among Older Adults.

This study examines the association of partner Medicare Advantage plan status over 1 year with beneficiary and plan characteristics.

Older Adults' Perceptions of Their Fall Risk and Prevention Strategies After Transitioning from Hospital to Home.

Falls are common adverse events following hospital discharge. However, prevention programs are not tailored for older patients transitioning home. To inform development of transitional fall prevention programs, nine older adults designated as being at risk of falls during hospitalization who were recently discharged home were asked about their perceptions of fall risk and prevention, as well as their knowledge and opinion of materials from the Centers for Disease Control and Prevention Stopping Elderly Accidents, Deaths & Injuries Initiative. Using the constant comparative method, five themes were identified: Sedentary Behaviors and Limited Functioning; Prioritization of Social Involvement; Low Perceived Fall Risk and Attribution of Risk to External Factors; Avoidance and Caution as Fall Prevention; and Limited Falls Prevention Information During Transition from Hospital to Home. Limited awareness of and engagement in effective fall prevention may heighten recently discharged older adults' risks for falls. Prevention programs tailored to the post-discharge period may engage patients in fall prevention, promote well-being and independence, and link hospital and community efforts. [Journal of Gerontological Nursing, 45(1), 23-30.].

Receipt of Caregiving and Fall Risk in US Community-dwelling Older Adults.

BACKGROUND: Falls and fall-related injuries (FRI) are common and costly occurrences among older adults living in the community, with increased risk for those with physical and cognitive limitations. Caregivers provide support for older adults with physical functioning limitations, which are associated with fall risk. DESIGN: Using the 2004-2012 waves of the Health and Retirement Study, we examined whether receipt of low (0-13 weekly hours) and high levels (≥14 weekly hours) of informal care or any formal care is associated with lower risk of falls and FRIs among community-dwelling older adults. We additionally tested whether serious physical functioning (≥3 activities of daily living) or cognitive limitations moderated this relationship. RESULTS: Caregiving receipt categories were jointly significant in predicting noninjurious falls (P=0.03) but not FRIs (P=0.30). High levels of informal care category (P=0.001) and formal care (P<0.001) had stronger associations with reduced fall risk relative to low levels of informal care. Among individuals with ≥3 activities of daily living, fall risks were reduced by 21% for those receiving high levels of informal care; additionally, FRIs were reduced by 42% and 58% for those receiving high levels of informal care and any formal care. High levels of informal care receipt were also associated with a 54% FRI risk reduction among the cognitively impaired. CONCLUSIONS: Fall risk reductions among older adults occurred predominantly among those with significant physical and cognitive limitations. Accordingly, policy efforts involving fall prevention should target populations with increased physical functioning and cognitive limitations. They should also reduce financial barriers to informal and formal caregiving.

Claims-based Identification Methods and the Cost of Fall-related Injuries Among US Older Adults.

OBJECTIVES: Compare expenditures of fall-related injuries (FRIs) using several methods to identify FRIs in administrative claims data. RESEARCH DESIGN: Using 2007-2009 Medicare claims and 2008 Health and Retirement Survey data, FRIs were identified using external-cause-of-injury (e-codes 880/881/882/884/885/888) only, e-codes plus a broad set of primary diagnosis codes, and a newer approach using e-codes and diagnostic and procedural codes. Linear regression models adjusted for sociodemographic, health, and geographic characteristics were used to estimate per-FRI, service component, patient cost share, expenditures by type of initial FRI treatment (inpatient, emergency department only, outpatient), and total annual FRI-related Medicare expenditures. SUBJECTS: The analysis included 5497 community-dwelling adults ≥65 (228 FRI, 5269 non-FRI individuals) with continuous Medicare coverage and alive during the 24-month study. RESULTS: The 3 FRI identification methods produced differing distributions of index FRI type and varying estimated expenditures: $12,171 [95% confidence interval (CI), $4662-$19,680], $5648 (95% CI, $3819-$7476), and $9388 (95% CI, $5969-$12,808). In all models, most spending occurred in hospital, outpatient, and skilled nursing facility (SNF) settings, but greater proportions of SNF and outpatient spending were observed with commonly used FRI identification methods. Patient cost-sharing was estimated at $691-$1900 across the 3 methods. Inpatient-treated index FRIs were more expensive than emergency department and outpatient-treated FRIs across all methods, but were substantially higher when identifying FRI using only e-codes. Estimated total FRI-related Medicare expenditures were highly variable across methods. CONCLUSIONS: FRIs are costly, with implications for Medicare and its beneficiaries. However, expenditure estimates vary considerably based on the method used to identify FRIs.

Association of Medicare Home Health Ratings With Older Adult Fall Injuries: An Instrumental Variables Analysis.

OBJECTIVES: To understand the role of high-quality home health care for fall prevention. DESIGN: A 100% sample of national Medicare claims and home health survey data (2015-2017) were used to assess fall injuries and receipt of a fall risk assessment among recently hospitalized Medicare fee-for-service home health users aged ≥66 years. Subanalyses examined patients by prior fall history status and hospital admission diagnosis type (eg, neurologic, respiratory, cardiovascular, infection, and orthopedic diagnoses). An instrumental variables design addressed potential endogeneity in home health care use by patient fall risk. SETTING AND PARTICIPANTS: Home health agencies and Medicare fee-for-service beneficiaries. METHODS: Multivariate regression and instrumental variables. RESULTS: Among 962,610 patients with hospital discharges to home health, being treated by home health agencies with the highest star ratings in a person's zip code was associated with a 1.8-percentage point (ppt) (95% CI: 0.1, 3.5; P = .03) higher likelihood of receipt of fall risk assessment. There was no overall change in 30-day (-0.6 ppt, 95% CI: -1.3, 0.1; P = .09), 15-day (-0.3 ppt, 95% CI: -0.0.8, 0.2; P = .35), or 7-day fall injury risk (-0.2 ppt, 95% CI: -0.5, 0.1; P = .22), but a 1.9-ppt (95% CI: -3.9, -0.02; P = .048) lower 30-day fall injury risk for individuals with a history of falls. Effects were directionally similar by diagnosis type. CONCLUSIONS AND IMPLICATIONS: Fall injury risk is reduced at higher-rated home health agencies. Star ratings may be adequate indicators of quality for key outcomes not explicitly measured in the ratings.

Medicare's Hospital Readmission Reduction Program reduced fall-related health care use: An unexpected benefit?

OBJECTIVE: To assess whether Medicare's Hospital Readmissions Reduction Program (HRRP) was associated with a reduction in severe fall-related injuries (FRIs). DATA SOURCES AND STUDY SETTING: Secondary data from Medicare were used. STUDY DESIGN: Using an event study design, among older (≥65) Medicare fee-for-service beneficiaries, we assessed changes in 30- and 90-day FRI readmissions before and after HRRP's announcement (April 2010) and implementation (October 2012) for conditions targeted by the HRRP (acute myocardial infarction [AMI], congestive heart failure [CHF], and pneumonia) versus "non-targeted" (gastrointestinal) conditions. We tested for modification by hospitals with "high-risk" before HRRP and accounted for potential upcoding. We also explored changes in 30-day FRI readmissions involving emergency department (ED) or outpatient care, care processes (length of stay, discharge destination, and primary care visit), and patient selection (age and comorbidities). DATA COLLECTION: Not applicable. PRINCIPAL FINDINGS: We identified 1.5 million (522,596 pre-HRRP, 514,844 announcement, and 474,029 implementation period) index discharges. After its announcement, HRRP was associated with 12%-20% reductions in 30- and 90-day FRI readmissions for patients with CHF (-0.42 percentage points [ppt], p = 0.02; -1.53 ppt, p < 0.001) and AMI (-0.35, p = 0.047; -0.97, p = 0.001). Two years after implementation, HRRP was associated with reductions in 90-day FRI readmission for AMI (-1.27 ppt, p = 0.01) and CHF (-0.98 ppt, p = 0.02) patients. Results were similar for hospitals at higher versus lower baseline risk of FRI readmission. After HRRP's announcement, decreases were observed in home health (AMI: -2.43 ppt, p < 0.001; CHF: -8.83 ppt, p < 0.001; pneumonia: -1.97 ppt, p < 0.001) and skilled nursing facility referrals (AMI: -5.95 ppt, p < 0.001; CHF: -3.19 ppt, p < 0.001; pneumonia: -10.27 ppt, p < 0.001). CONCLUSIONS: HRRP was associated with reductions in FRIs, primarily for HF and pneumonia patients. These decreases may reflect improvements in transitional care including changes in post-acute referral patterns that benefit patients at risk for falls.

Achieving goal-concordant care: Formal and informal advance care planning for White, Black, and Hispanic older adults.

INTRODUCTION: Advance care planning (ACP) aims to ensure that patients receive goal-concordant care (GCC), which is especially important for racially or ethnically minoritized populations at greater risk of poor end-of-life outcomes. However, few studies have evaluated the impact of advance directives (i.e., formal ACP) or goals-of-care conversations (i.e., informal ACP) on such care. This study aimed to examine the relationship between each of formal and informal ACP and goal-concordant end-of-life care among older Americans and to determine whether their impact differed between individuals identified as White, Black, or Hispanic. METHODS: We conducted a retrospective cohort study using 2012-2018 data from the biennial Health and Retirement Study. We examined the relationships of interest using two, separate multivariable logistic regression models. Model 1 regressed a proxy report of GCC on formal and informal ACP and sociodemographic and health-related covariates. Model 2 added interaction terms between race/ethnicity and the two types of ACP. RESULTS: Our sample included 2048 older adults. There were differences in the proportions of White, Black, and Hispanic decedents who received GCC (83.1%, 75.3%, and 71.3%, respectively, p < 0.001) and in the use of each type of ACP by racial/ethnic group. In model 1, informal compared with no informal ACP was associated with higher odds of GCC (adjusted odds ratio = 1.38 [95% confidence interval, 1.05-1.82]). In model 2, Black decedents who had formal ACP were more likely to receive GCC than those who did not, but there were no statistically significant differences between decedents of different racial/ethnic groups who had no ACP, informal ACP only, or both types of ACP. CONCLUSIONS: Our results build on previous work by indicating the importance of incorporating goals-of-care conversations into routine healthcare for older adults and encouraging ACP usage among racially and ethnically minoritized populations who use ACP tools at lower rates.

Should I stay or should I go again: Multiple switching between fee-for-service Medicare and Medicare advantage among older beneficiaries.

OBJECTIVE: To evaluate whether having previously disenrolled from Medicare Advantage (MA) is associated with lower hazards of future MA enrollment. DATA SOURCES AND STUDY SETTING: Secondary data from Medicare. STUDY DESIGN: We examined beneficiaries with baseline FFS enrollment from 2017-2019 using a 20% sample of Medicare claims. Cox proportional hazard models were used to examine the association of prior MA enrollment (in the three years prior to baseline FFS enrollment) with MA re-enrollment, and whether this association is modified by Alzheimer's Disease and Related Dementias (ADRD), prior nursing home use, chronic illness, dual eligible status, and availability of MA plans and quality. DATA COLLECTION: Not applicable. PRINCIPAL FINDINGS: Overall, 3.3% of beneficiaries switched to MA annually. Of those with prior MA enrollment, MA switching percentages were 9.0%, 4.6%, and 6.8% for those whose most recent MA enrollments were 1, 2, and 3 years prior to their baseline FFS year. Comparatively, the switching percentages was 3.2% for those with no prior MA enrollment. The hazards of switching to MA were 2.73 (p < 0.001), 1.29 (p < 0.001), and 1.97 (p < 0.001) times greater than remaining in FFS for beneficiaries whose most recent MA enrollments were one, two, and three years prior to their baseline FFS year. Hazards of switching were generally similar between those with and without ADRD, stratified by recency in prior MA experience, except those with dual eligibility. Among those with ADRD, switching hazards were greatest for 3 years prior MA enrollees in counties with the fewest available (HR: 3.84, p < 0.001) and lowest-rated plans (HR: 4.02, p < 0.001). CONCLUSIONS: Recency of switching from MA to FFS was the strongest predictor of a FFS-to-MA switch, identifying a population of beneficiaries who multiply switch regardless of health status or MA access. Future health policy considerations should more closely examine the vulnerabilities and long-term outcomes of this population.

Impact of Medicare eligibility on informal caregiving for surgery and stroke.

OBJECTIVE: To assess whether the intensity of family and friend care changes after older individuals enroll in Medicare at age 65. DATA SOURCES: Health and Retirement Study survey data (1998-2018). STUDY DESIGN: We compared informal care received by patients hospitalized for stroke, heart surgery, or joint surgery and who were stratified into propensity-weighted pre- and post-Medicare eligibility cohorts. A regression discontinuity design compared the self-reported likelihood of any care receipt, weekly hours of overall informal care, and intensity of informal care (hours among those receiving any care) at Medicare eligibility. DATA COLLECTION: Not applicable. PRINCIPAL FINDINGS: A total of 2270 individuals were included; 1674 (73.7%) stroke, 240 (10.6%) heart surgery, and 356 (15.7%) joint surgery patients. Mean (SD) care received was 20.0 (42.1) weekly hours. Of the 1214 (53.5%) patients who received informal care, the mean (SD) care receipt was 37.4 (51.7) weekly hours. Mean (SD) overall weekly care received was 23.4 (45.5), 13.9 (35.8), and 7.8 (21.6) for stroke, heart surgery, and joint surgery patients, respectively. The onset of Medicare eligibility was associated with a 13.6 percentage-point decrease in the probability of informal care received for stroke patients (p = 0.003) but not in the other acute care cohorts. Men had a 16.8 percentage-point decrease (p = 0.002) in the probability of any care receipt. CONCLUSIONS: Medicare coverage was associated with a substantial decrease in family and friend caregiving use for stroke patients. Informal care may substitute for rather than complement restorative care, given that Medicare is known to expand the use of postacute care. The observed spillover effect of Medicare coverage on informal caregiving has implications for patient function and caregiver burden and should be considered in episode-based reimbursement models that alter professional rehabilitative care intensity.

Medicare spending associated with a dementia diagnosis among older adults.

BACKGROUND: Over 6 million Americans have Alzheimer's Disease or Related Dementia (ADRD) but whether spikes in spending surrounding a new diagnosis reflect pre-diagnosis morbidity, diagnostic testing, or treatments for comorbidities is unknown. METHODS: We used the 1998-2018 Health and Retirement Study and linked Medicare claims from older (≥65) adults to assess incremental quarterly spending changes just before versus just after a clinical diagnosis (diagnosis cohort, n = 2779) and, for comparative purposes, for a cohort screened as impaired based on the validated Telephone Interview for Cognitive Status (TICS) (impairment cohort, n = 2318). Models were adjusted for sociodemographic and health characteristics. Spending patterns were examined separately by sex, race, education, dual eligibility, and geography. RESULTS: Among the diagnosis cohort, mean (SD) overall spending was $4773 ($9774) per quarter - 43% of which was spending on hospital care ($2048). In adjusted analyses, spending increased by $8400 (p < 0.001), or 156%, from $5394 in the quarter prior to $13,794 in the quarter including the diagnosis. Among the cohort in which impairment was incidentally detected using the TICS, adjusted spending did not change from just before to after detection of impairment, from $2986 before and $2962 after detection (p = 0.90). Incremental spending changes did not differ by sex, race, education, dual eligibility, or geography. CONCLUSION: Large, transient spending increases accompany an ADRD diagnosis that may not be attributed to impairment or changes in functional status due to dementia. Further study may help reveal how treatment for comorbidities is associated with the clinical diagnosis of dementia, with potential implications for Medicare spending.

Changes in activity levels, physical functioning, and fall risk during the COVID-19 pandemic.

BACKGROUND: Physical function worsens with older age, particularly for sedentary and socially isolated individuals, and this often leads to injuries. Through reductions in physical activity, the COVID-19 pandemic may have worsened physical function and led to higher fall-related risks. METHODS: A nationally representative online survey of 2006 U.S. adults aged 50-80 was conducted in January 2021 to assess changes in health behaviors (worsened physical activity and less daily time spent on feet), social isolation (lack of companionship and perceived isolation), physical function (mobility and physical conditioning), and falls (falls and fear of falling) since March 2020. Multivariable logistic regression was used to assess relationships among physical activity, social isolation, physical function, falls, and fear of falling. RESULTS: Among respondents, 740 (36.9%) reported reduced physical activity levels, 704 (35.1%) reported reduced daily time spent on their feet since March 2020, 712 (37.1%) reported lack of companionship, and 914 (45.9%) social isolation. In multivariable models, decreased physical activity (adjusted risk ratio, ARR: 2.92, 95% CI: 2.38, 3.61), less time spent on one's feet (ARR: 1.95, 95% CI: 1.62, 2.34), and social isolation (ARR: 1.51, 95% CI: 1.30, 1.74) were associated with greater risks of worsened physical conditioning. Decreased physical activity, time spent daily on one's feet, and social isolation were similarly associated with worsened mobility. Worsened mobility was associated with both greater risk of falling (ARR: 1.70, 95% CI: 1.35, 2.15) and worsened fear of falling (ARR: 2.02, 95% CI: 1.30, 3.13). Worsened physical conditioning and social isolation were also associated with greater risk of worsened fear of falling. CONCLUSION: The COVID-19 pandemic was associated with worsened physical functioning and fall outcomes, with the greatest effect on individuals with reduced physical activity and social isolation. Public health actions to address reduced physical activity and social isolation among older adults are needed.

Racial and Ethnic Differences in Informal and Formal Advance Care Planning Among U.S. Older Adults.

OBJECTIVE: To examine advance care planning (ACP) trends among an increasingly diverse aging population, we compared informal and formal ACP use by race/ethnicity among U.S. older adults (≤65 years). METHODS: We used Health and Retirement Study data (2012-2018) to assess relationships between race/ethnicity and ACP type (i.e., no ACP, informal ACP only, formal ACP only, or both ACP types). We reported adjusted risk ratios with 95% confidence intervals. RESULTS: Non-Hispanic Black and Hispanic respondents were 1.77 (1.60, 1.96) and 1.76 (1.55, 1.99) times as likely, respectively, to report no ACP compared to non-Hispanic White respondents. Non-Hispanic Black and Hispanic respondents were 0.74 (0.71, 0.78) and 0.74 (0.69, 0.80) times as likely, respectively, to report using both ACP types as non-Hispanic White respondents. DISCUSSION: Racial/ethnic differences in ACP persist after controlling for a variety of barriers to and facilitators of ACP which may contribute to disparities in end-of-life care.