Difficulty and help with activities of daily living among older adults living alone with cognitive impairment

Association of Social Disconnection With the Incidence and Prognosis of Atrial Fibrillation: A Multistate Analysis

BACKGROUND

Social disconnection, including loneliness and social isolation, is associated with increased morbidity and death. However, its impact on the incidence and prognosis of atrial fibrillation (AF) remains inconclusive.

METHODS AND RESULTS

The present prospective cohort study enrolled 418 656 participants without AF and cardiovascular disease from the UK Biobank. A loneliness scale was constructed with 2 domains (loneliness feeling, inability to confide) and social isolation scale was constructed with 3 domains (living alone, lack of social support, and lack of social activity). We used a multistate model to analyze the impacts of the 2 scales on the progression from baseline to incident AF and subsequent major adverse cardiovascular events and further to death. Over a median follow-up of 14.7 years, 25 539 participants developed incident AF, among whom 7283 developed incident major adverse cardiovascular events, and 5165 died. Social isolation and loneliness scales were associated with both a higher incidence and worse prognosis of AF, with hazard ratios per 1-point increase of 1.06 (95% CI, 1.04-1.09) for the loneliness scale and 1.03 (95% CI, 1.02-1.05) for the social isolation scale for incident AF, and 1.12 to 1.14 for the loneliness scale (all P<0.001) and 1.12 to 1.27 for the social isolation scale (all P<0.001) after AF development. Loneliness feeling and living alone may be important contributors.

CONCLUSIONS

Loneliness and social isolation were both associated with a higher incidence and a worse prognosis of AF but to different extents. These observations highlight the importance of integrating social connection into the prevention and management of AF.

Absence of care among community-dwelling older adults with dementia and functional limitations

Assistance with daily activities is crucial for persons living with dementia and functional limitations, yet many face substantial challenges in accessing adequate care and support. Using harmonized longitudinal survey data (2012-2018) from the United States, England, 18 European countries, Israel and China, we found that at least one-fifth of persons with dementia and functional limitations received no personal assistance for basic activities of daily living or instrumental activities of daily living, regardless of regional development level. Care gaps were widespread across both basic activities of daily living or instrumental activities of daily living limitations, as well as for informal and formal care. Disparities were evident, with less educated people more likely to lack formal care, whereas those living alone often lacked informal support, resulting in the absence of any care. Alarmingly, care availability showed no improvement over time. Our findings underscore the urgent need for policies to address inequities and ensure critical access to care services for this vulnerable population worldwide.

Network Analysis of Key Instrumental Activities of Daily Living and Cognitive Domains for Targeted Intervention in US Older Adults Without Dementia: Cross-Sectional Study

Background

Cognitive impairment in older adults reduces independence and raises health care costs but can be mitigated through stimulating activities. Based on network theory, intricate relationships within and between clusters of instrumental activities of daily living (IADLs) and cognitive domains suggest the existence of central IADLs and cognitive domains, as well as bridge IADLs. Modifying these can significantly enhance daily living activities and cognitive functions holistically.

Objective

This study aims to identify central IADLs (key activities within the IADL network), central cognitive domains (key domains within the cognitive network), and bridge IADLs (linking IADL and cognitive networks). These insights will inform targeted interventions to effectively improve IADL and cognitive well-being in older adults.

Methods

A cross-sectional analysis of adults aged 65 years and older in the United States focused on 5 IADLs and 6 cognitive domains from the National Health and Aging Trends Study (NHATS). Network analysis identified central and bridge variables. Nonparametric and case-dropping bootstrap methods checked network stability. Network comparison tests assessed sex differences with Benjamini-Hochberg adjustments.

Results

Of the 2239 participants, 56.4% were female (n=976). We computed and tested 3 networks: IADL, cognition, and bridge-with correlation stability coefficients of 0.67, 0.75, and 0.44, respectively (all>0.25). Meal preparation was identified as the central IADL, with a centrality index of 3.87, which was significantly higher than that of other IADLs (all P<.05). Visual attention emerged as the central cognition domain, with a centrality index of 0.86, which was significantly higher than that of other cognition domains (all P<.05). Shopping was determined to be the bridge IADL, with a centrality index of 0.41, which was significantly higher than that of other IADLs (all P<.05). Notably, gender differences emerged in the IADL network, with stronger associations between laundry and meal preparation in females (1.69 vs males: 0.74; P=.001) and higher centrality in meal preparation among females (difference=1.99; P=.007).

Conclusions

While broad enhancements in all IADL and cognitive domains are beneficial, targeting meal preparation, visual attention, and shopping may leverage their within-network influence to yield a more pronounced improvement in holistic IADL, holistic cognition, and holistic cognition function through IADL interventions among older adults. Notably, meal preparation interventions may be less effective in males, requiring tailored approaches.

Specific cultural traits of the precarity of older Latinos living alone with cognitive impairment in the San Francisco Bay Area

OBJECTIVES

Latinos are about twice as likely to develop cognitive impairment. Culturally, filial support and familismo are expected within Latino families. Yet approximately twenty percent of Latinos live alone in the United States. The purpose of this study is to explore the concerns and priorities of older Latinos living alone with cognitive impairment, using a precarity framework.

METHOD

We conducted 22 in-home interviews with older Latinos living alone with cognitive impairment, and we supplemented the interviews with interviews with members of the older adults' social circle and providers. Themes influencing the precarity of Latino older adults living alone were organized through the major areas of the precarity lens; 1) Limited awareness of cognitive impairment; 2) Self-management of cognitive impairment; and 3) Lacking tailored services for cognitive impairment.

RESULTS

Latino culture permeated and intersected across the lived experiences of participants living alone with cognitive impairment. Precarity was prevalent in all participants' lives and was exacerbated by familismo combined with cognitive impairment.

CONCLUSION

Findings showed precarity in the experiences the participants shared. Participant narratives reveal how the Latino culture intersects with the experience of precarity while living alone with cognitive impairment, especially in reference to the role that family plays through the expectation of familismo. However, given the difficult demands of employment and raising their own families, familismo can become more like a goal than a practice. Further research is needed to better understand how to bridge the gap between the needs of these older Latino adults living alone with cognitive impairment, their families, and formal services.

The trajectories of depression and multimorbidity affect the patterns of cognitive decline: a prospective cohort study

BACKGROUND

The course of decline of global cognitive function is heterogeneous, with patterns varying among individuals. The influence of depression, functional limitations and multimorbidity on patterns of decline of global cognitive function among community-dwelling older adults remains unknown. This study examines the relationship between these health conditions and the course of decline of global cognitive function.

METHODS

A prospective cohort of 4032 participants aged ≥60 years at baseline was constructed using the Health and Retirement Study (2006-20), through surveys every 2 years. Information on depression, functional limitations and multimorbidity was collected from 2006 to 2012. Data on cognitive function were collected between 2012 and 2020. Latent class trajectory models were used to identify the latent trajectories. Multinomial logistic regression models were employed to analyse the association between the latent trajectories and cognitive function.

RESULTS

Different trajectories were identified for depression (low-stable, decline-rise and rise-decline), activities of daily living (ADLs; low-stable, decline-rise and rise-decline), instrumental activities of daily living (IADLs; low-stable and rise), and multimorbidity (stable and rise). Three trajectories of cognitive decline were identified: high stable, modest and later steep. The trajectories of depression (for decline-rise: OR: 1.47, 95% CI: 1.11-1.95; for rise-decline: OR: 1.72, 95% CI: 1.24-2.38) and multimorbidity (OR: 1.63, 95% CI: 1.08-2.46) increased the risk of cognitive decline.

CONCLUSION

The trajectories of depression and multimorbidity affect cognitive decline patterns. Longitudinal surveillance of health conditions can be used to identify different patterns of cognitive decline and predict faster cognitive decline.

Examining Help-Seeking Behavior in People Living Alone With Cognitive Impairment

More than 4 million people in the United States live alone with cognitive impairment or early dementia, yet research on their experiences is limited. Previous research has shown this population has higher levels of unmet care needs and lower financial resources than their married peers. By exploring the experiences of people living alone with cognitive impairment (PLACI), this research examines the successes and barriers within their journey to inform how interventions can improve their quality of life. We conducted qualitative interviews with 15 PLACI (median age 69, 87% white, and 80% female) to explore perceptions of future care needs and resources. Through a modified ideal-type analysis, participants' thought processes and actions regarding help-seeking were mapped to the five stages of the transtheoretical model. These perspectives suggest opportunities such as connecting them to community social work that could help facilitate their understanding of their needs, help them identify resources, and promote proactive aging.

"How do You Take that Much Time for One Person's Life?" Experiences of Dementia Caregivers Who are Not Immediate Family

One in three people with Alzheimer's or other dementias lives alone, without a spouse/partner or nearby children (i.e., is aging solo), yet most dementia caregiving research has focused solely on spouses or children. This study examined the experiences of friends, neighbors, siblings, and others providing unpaid care for someone with dementia. We conducted semi-structured interviews with 14 caregivers (100% female; age 54-85, mean 71; 93% white, 7% black; 29% friend, 29% sibling or in-law, 21% neighbor, 21% church congregant). Participants balanced three priorities: the person living with dementia's quality of life, the person's safety and well-being, and the caregiver's resources. Caregivers described tensions when these priorities conflicted, such as the person with dementia's goal to live alone versus risks to their physical safety. These findings and future research can inform policies and programs to support non-family dementia caregiving.

Home alone and high risk: Supporting medication management in older adults living alone with cognitive impairment

See related article by Growdon et al.

High-risk medication use among older adults with cognitive impairment living alone in the United States

BACKGROUND

More than one-fourth of older adults with cognitive impairment (CI) live alone; these individuals often lack support for medication management and face a high risk of adverse drug events. We characterized the frequency and types of high-risk medications used by older adults with CI living alone and, for context, compared patterns with those in older adults with CI living with others.

METHODS

This was a cross-sectional study of National Health and Aging Trends Study (NHATS) data and Medicare claims (2015-2017). We ascertained cognitive status from NHATS and medication use with Part D claims. We compared high-risk medication use (those with adverse cognitive effects or low tolerance for misuse) among older adults with CI living alone versus living with others using logistic regression models adjusted for demographic/clinical factors.

RESULTS

The unweighted sample included 1569 older adults with CI, of whom 491 (weighted national estimate, 31%) were living alone. In the living-alone group, the mean age was 79.9 years and 66% were female, 64% reported managing medications on their own without difficulty, 14% reported managing medications on their own with difficulty, and 18% received total support with medication management. Older adults with CI living alone used a median of 5 medications (IQR, 3-8), 16% took ≥10 medications, and 46% took ≥1 high-risk medication (anticholinergic/sedating: 24%; opioid: 13%; anticoagulant: 10%; sulfonylurea: 10%; insulin: 9%). Compared with those living with others, the use of high-risk medications was similar (p > 0.05 for unadjusted/adjusted comparisons). Those living alone were more likely both to take at least one high-risk medication and not receive help with medication management: 34% in those living alone versus 23% living with others (p < 0.05 for unadjusted/adjusted comparisons).

CONCLUSIONS

Older adults with CI living alone use many medications; nearly half use high-risk medications. Our findings can inform medication optimization interventions supporting this vulnerable population.

Changes in Family Structure and Increasing Care Gaps in the United States, 2015-2050

Research on caregiving in the United States has not clearly identified the scope of the gap between care needed and care received and the changes implied by ongoing and anticipated shifts in family structure. This article examines the magnitude of contemporary gaps in care among older adults in the United States and how they are likely to evolve through 2050. We use data from the Health and Retirement Study (1998-2014) to estimate care gaps, operationalized as having difficulties with activities of daily living (ADLs) or instrumental activities of daily living (IADLs) but not receiving care. We also estimate variation in care gaps by family structure. Then, we use data from demographic microsimulation to explore the implications of demographic and family changes for the evolution of care gaps. We establish that care gaps are common, with 13% and 5% of adults aged 50 or older reporting a care gap for ADLs and IADLs, respectively. Next, we find that adults with neither partners nor children have the highest care gap rates. Last, we project that the number of older adults with care gaps will increase by more than 30% between 2015 and 2050-twice the rate of population growth. These results provide a benchmark for understanding the scope of the potential problem and considering how care gaps can be filled.

Association of Family Support With Lower Modifiable Risk Factors for Dementia Among Cognitively Impaired Older Adults

OBJECTIVES

Cognitive impairment poses considerable challenges among older adults, with the role of family support becoming increasingly crucial. This study examines the association of children's residential proximity and spousal presence with key modifiable risk factors for dementia in cognitively impaired older adults.

METHODS

We analyzed 14,600 individuals (35,165 observations) aged 50 and older with cognitive impairment from the Health and Retirement Study (1995-2018). Family support was categorized by spousal presence and children's residential proximity. Modifiable risk factors, including smoking, depressive symptoms, and social isolation, were assessed. Associations between family support and the modifiable risk factors were determined using mixed-effects logistic regressions.

RESULTS

A significant proportion of older adults with cognitive impairment lacked access to family support, with either no spouse (46.9%) or all children living over 10 miles away (25.3%). Those with less available family support, characterized by distant-residing children and the absence of a spouse, had a significantly higher percentage of smoking, depressive symptoms, and social isolation. Moreover, we revealed a consistent gradient in the percentage of the risk factors by the degree of family support. Relative to older adults with a spouse and co-resident children, those without a spouse and with all children residing further than 10 miles displayed the highest percentage of the risk factors. These findings were robust to various sensitivity analyses.

CONCLUSIONS

Family support from spouses and nearby children serves as a protective factor against modifiable dementia risk factors in cognitively impaired older adults. Policies that strengthen family and social support may benefit this population.

Functional disability and receipt of informal care among Chinese adults living alone with cognitive impairment

BACKGROUND

Adults with cognitive impairment are prone to living alone in large numbers but receive relatively little attention. This study aimed to evaluate whether living alone with cognitive impairment was associated with a higher burden of functional disability but lack of informal care.

METHODS

982 observations of adults living alone with cognitive impairment and 50,695 observations of adults living with others and with normal cognition were identified from 4 waves (2011/2012, 2013, 2015, and 2018) of the China Health and Retirement Longitudinal Study (CHARLS). A matched comparator was selected using propensity score matching (1:2). Functional disability included disability in Activities of Daily Living (ADL), Instrumental Activities of Daily Living (IADL), and mobility. The time of receiving informal care was measured in monthly hours.

RESULTS

Adults living alone with cognitive impairment demonstrated significantly higher odds ratio of ADL disability (OR = 1.59, 95 % CI: 1.30, 1.95), IADL disability (OR = 1.19, 95 % CI: 1.00, 1.44), mobility disability (OR = 1.38, 95 % CI: 1.12, 1.70), but received fewer hours of informal care (β = -127.7 h per month, standard error = 25.83, P < 0.001), compared to the adults living with others and with normal cognition.

CONCLUSIONS

This study highlights the high burden of functional disability but low coverage of informal care among Chinese adults living alone with cognitive impairment and calls for more resources to be allocated to this vulnerable subpopulation to improve the functional health and to increase the provision of long-term care services.

Proactive Care-Seeking Strategies Among Adults Aging Solo With Early Dementia: A Qualitative Study

OBJECTIVES

People living with dementia need increasing care over time, but 1 in 3 adults with cognitive impairment lives alone. The goal of this study was to explore the self-identified strengths and resources for future care needs of adults aging solo with early dementia.

METHODS

Semistructured interviews with 15 adults not living with a partner and with no children in the same state, who self-identified as having early dementia or mild cognitive impairment; hybrid inductive/deductive reflexive thematic analysis using a successful aging framework.

RESULTS

Participants placed a high value on maintaining independence and expressed concerns about preserving selfhood and becoming a burden to others. These values influenced how participants appraised financial and social resources available to address future care needs and strategies to preempt or respond to needs such as transportation, help with finances, or activities of daily living.

DISCUSSION

Adults without close family are heterogeneous and have variable resources available to address care needs associated with dementia progression. Common values of retaining independence and minimizing burden to others may be helpful in motivating adults aging solo to undertake planning and help-seeking early.

Snack Provision Practice in Long-Term Care Hospitals and Facilities in Korea

The study aimed to investigate the basic data to derive plans for snack provision to improve the nutritional status of older adults living in long-term care facilities (LFs) or long-term care hospitals (LHs). The 252 respondents (118 from LHs and 134 from LFs) were included in the study. The questionnaire of nationwide cross-sectional survey was developed by the authors and registered dietitians. The written questionnaire was sent to the food service managers across 800 LFs or LHs. The online survey was introduced using the online platform and network site for dietitians. More than 70% of live-in and non-live-in LFs provided snacks, which were mainly provided one to two times a day. Most institutions provided fruits one to three times a week. The main considerations when providing fruit were in the order of residents' preference, cost, and ease of consumption. The reasons for not serving fruit included cost and differences in the residents' eating and mastication abilities. Most institutions also provided dairy products at a frequency of one to three times a week. The reasons for not serving dairy products included cost and the lack of awareness of the need to provide them. To improve the quality of life and the offer benefits of fruits and dairy products to older people, efforts are needed to propose a plan to expand the provision of snacks in appropriate quantities and varieties.

State home and community-based services expenditures and unmet care needs in the United States: Has everyone benefitted equally?

OBJECTIVE

To test whether the impacts of Medicaid's Home and Community-Based Services (HCBS) expenditures have been equitable.

DATA SOURCES AND STUDY SETTING

This is a secondary data analysis. We linked annual data on state-level Medicaid HCBS expenditures with individual data from U.S. Health and Retirement Study (HRS; 2006-2016).

STUDY DESIGN

We evaluated the association between state-level HCBS expenditure quartiles and the risk of experiencing challenges in basic or instrumental activities of daily living (I/ADLs) without assistance (unmet needs for care). We fitted generalized estimating equations (GEE) with a Poisson distribution, log link function, and an unstructured covariance matrix. We controlled demographics, time, and place-based fixed effects and estimated models stratified by race and ethnicity, gender, and urbanicity. We tested the robustness of results with negative controls.

DATA COLLECTION/EXTRACTION METHODS

Our analytic sample included HRS Medicaid beneficiaries, aged 55+, who had difficulty with ≥1 I/ADL (n = 2607 unique respondents contributing 4719 person-wave observations).

PRINCIPAL FINDINGS

Among adults with IADL difficulty, higher quartiles of HCBS expenditure (vs. the lowest quartile) were associated with a lower overall prevalence of unmet needs for care (e.g., Prevalence Ratio [PR], Q4 vs. Q1: 0.91, 95% CI: 0.84-0.98). This protective association was concentrated among non-Hispanic white respondents (Q4 vs. Q1: 0.82, 95% CI: 0.73-0.93); estimates were imprecise for Hispanic individuals and largely null for non-Hispanic Black participants. We found no evidence of heterogeneity by gender or urbanicity. Negative control robustness checks indicated that higher quartiles of HCBS expenditure were not associated with (1) the risk of reporting I/ADL difficulty among 55+ Medicaid beneficiaries, and (2) the risk of unmet care needs among non-Medicaid beneficiaries.

CONCLUSION

The returns to higher state-level HCBS expenditures under Medicaid for older adults with I/ADL disability do not appear to have been equitable by race and ethnicity.

The impact of falls on activities of daily living in older adults: A retrospective cohort analysis

BACKGROUND

Falls contribute to impairments in activities of daily living (ADLs), resulting in significant declines in the quality of life, safety, and functioning of older adults. Understanding the magnitude and duration of the effect of falls on ADLs, as well as identifying the characteristics of older adults more likely to have post-fall ADL impairment is critical to inform fall prevention and post-fall intervention. The purpose of this study is to 1) Quantify the association between falls and post-fall ADL impairment and 2) Model trajectories of ADL impairment pre- and post-fall to estimate the long-term impact of falls and identify characteristics of older adults most likely to have impairment.

METHOD

Study participants were from the Ginkgo Evaluation of Memory Study, a randomized controlled trial in older adults (age 75+) in the United States. Self-reported incident falls and ADL scores were ascertained every 6 months over a 7-year study period. We used Cox proportional hazards analyses (n = 2091) to quantify the association between falls and ADL impairment and latent class trajectory modeling (n = 748) to visualize trajectories of ADL impairment pre-and post-fall.

RESULTS

Falls reported in the previous 6 months were associated with impairment in ADLs (HR: 1.42; 95% CI 1.32, 1.52) in fully adjusted models. Based on trajectory modeling (n = 748), 19% (n = 139) of participants had increased, persistent ADL impairment after falling. Participants who were female, lived in a neighborhood with higher deprivation, or experienced polypharmacy were more likely to have ADL impairment post-fall.

CONCLUSIONS

Falls are associated with increased ADL impairment, and this impairment can persist over time. It is crucial that all older adults, and particularly those at higher risk of post-fall ADL impairment have access to comprehensive fall risk assessment and evidence-based fall prevention interventions, to help mitigate the negative impacts on ADL function.

Children's Residential Proximity, Spousal Presence and Modifiable Risk Factors for Dementia among Older Adults with Cognitive Impairment

Background

Cognitive impairment in older adults poses considerable challenges, and the role of family support becomes increasingly crucial. This study aims to examine the impact of children's residential proximity and spousal presence on the key modifiable risk factors for dementia among older adults with cognitive impairment.

Methods

Utilizing the Health and Retirement Study (HRS) data from 1995 to 2018, we analyzed 14,731 participants (35,840 person-waves) aged 50 and older with cognitive impairment. Family support was characterized based on the presence of a spouse and residential proximity to children. Smoking, depressive symptoms and social isolation were included as the key modifiable risk factors for dementia identified in later life. Using mixed-effects logistic regressions, associations between access to family support and the modifiable risk factors were determined, adjusting for various socio-demographic and health-related factors.

Results

Significant associations were found between access to family support and modifiable risk factors for dementia. Cognitively impaired older adults with less available family support, characterized by distant-residing children and the absence of a spouse, had significantly higher risks of smoking, depressive symptoms, and social isolation. Moreover, we revealed a consistent gradient in the prevalence of the risk factors based on the degree of family support. Relative to older adults with a spouse and co-resident children, those without a spouse and with all children residing further than 10 miles displayed the highest risks of smoking, depressive symptoms, and social isolation.

Conclusion

Access to family support, particularly from spouses and proximate children, plays a protective role against key modifiable risk factors for dementia in older adults with cognitive impairment. The findings highlight the need for bolstering family and social support systems to enhance the well-being of this vulnerable population.

Unaddressed functional difficulty and care support among White, Black, and Hispanic older adults in the last decade

Unaddressed functional difficulties contribute to disparities in healthy aging. While the Affordable Care Act (ACA) is believed to have reshaped long-term care, little is known how it has collectively altered the prevalence of older adults with functional difficulties and their use of family and formal care. This study uses nationally representative data from the Health and Retirement Study (2008 - 2018) to describe racial-ethnic differences in prevalence of community-dwelling older adults who had difficulty with, but lacked assistance for self-care, mobility, and household activities before and after the ACA. Individuals with functional difficulties accounted for about a third of Black and Hispanic, compared to one-fifth of White people. Prevalence of Black and Hispanic people with functional difficulties lacking corresponding care support was consistently 1.5 times higher than of White people. Racial-ethnic differences disappeared only for low-income households where unaddressed difficulties were uniformly high. While formal care quantity was similar, Black and Hispanic people with functional difficulties received nearly 50 percent more family care than White people. These gaps between White, Black, and Hispanic older adults were persistent over time. These findings suggest that racial-ethnic gaps in aging needs and supports remain despite major health care reforms in the past decade.

Expanding the ethnographic toolkit: Using medical documents to include kinless older adults living with dementia in qualitative research

Ethnographic research with cognitively impaired older adults can be challenging, in part because cognitive impairment raises questions about the ability to provide informed consent. Relying on proxy consent is a commonly used strategy, but often excludes people with dementia who lack close kin (de Medeiros, Girling, & Berlinger, 2022). In this paper, we describe how we have analyzed existing research data from a well-established and ongoing prospective cohort study, the Adult Changes in Thought Study, along with unstructured text from the medical records of participants who had no living spouse or adult children when they developed dementia, as a way of studying the circumstances, life trajectories, caregiving resources, and care needs of this vulnerable and difficult-to-research group. In this article, we detail this methodology, exploring what can and cannot be gleaned from it, what the ethical implications may be, and how and whether this type of research can be considered ethnographic. In conclusion, we argue that collaborative interdisciplinary research using existing, longitudinal research data and text from medical records deserves to be considered as a potentially useful addition to the ethnographic toolkit. We anticipate that this is a methodology that could be applied more broadly, and paired with more traditional ethnographic methods, might be one way to make research with this population more inclusive.

Self-Reported Visual Difficulty and Daily Activity Limitations: The Moderating Role of Neighborhood Characteristics

BACKGROUND AND OBJECTIVES

Understanding how neighborhood-level factors moderate the relationship between visual health and activity limitations could inform strategies for successful aging in place among older adults with sensory impairments. Guided by a vision loss impact framework, this study aims to examine whether neighborhood social cohesion and physical disorder moderate the association between visual difficulty and activity limitation.

RESEARCH DESIGN AND METHODS

Secondary analyses were conducted using data from Round 5 of the National Health and Aging Trend Study. A 4-level indicator was used to indicate the visual difficulty. Neighborhood social cohesion and physical disorder were each measured using a 3-item scale. Summary scores were created for daily activity limitations. Ordinary least squares regressions were performed to test the study hypotheses. The complex survey design factors were applied. Missing data were handled using multiple imputations.

RESULTS

Older adults reporting any type of visual difficulty experienced more limitations in self-care tasks, household activities, and mobility than those without visual difficulty. Neighborhood physical disorder moderated visual difficulty and activity limitations. Specifically, visual difficulty was associated with higher risk of activity limitations among participants perceiving physical disorder in the neighborhood compared to those perceiving no physical disorder.

DISCUSSION AND IMPLICATIONS

The study findings suggest that the vision loss impact framework provides an integrative approach to identify the health needs of older adults with visual difficulty. Future research is needed to further understand the role of neighborhood in independent living among older adults with visual difficulty and to inform community-level interventions.

Trends in Gender and Racial/Ethnic Disparities in Physical Disability and Social Support Among U.S. Older Adults With Cognitive Impairment Living Alone, 2000-2018

Background and Objectives

Informal care is the primary source of support for older adults with cognitive impairment, yet is less available to those who live alone. We examined trends in the prevalence of physical disability and social support among older adults with cognitive impairment living alone in the United States.

Research Design and Methods

We analyzed 10 waves of data from the U.S. Health and Retirement Survey spanning 2000-2018. Eligible people were those aged ≥65, having cognitive impairment, and living alone. Physical disability and social support were measured via basic and instrumental activities of daily living (BADLs, IADLs). We estimated linear temporal trends for binary/integer outcomes via logistic/Poisson regression, respectively.

Results

A total of 20 070 participants were included. Among those reporting BADL/IADL disability, the proportion unsupported for BADLs decreased significantly over time (odds ratio [OR] 0.98, 95% confidence interval [CI] 0.97-0.99), and the proportion unsupported for IADLs increased (OR = 1.02, CI 1.01-1.04). Among those receiving IADL support, the number of unmet IADL support needs increased significantly over time (relative risk [RR] 1.04, CI 1.03-1.05). No gender disparities were found for these trends. Over time, Black respondents had a relatively increasing trend of being BADL-unsupported (OR = 1.03, CI 1.0-1.05) and Hispanic and Black respondents had a relatively increasing trend in the number of unmet BADL needs (RR = 1.02, CI 1.00-1.03; RR = 1.01, CI 1.00-1.02, respectively), compared to the corresponding trends in White respondents.

Discussion and Implications

Among lone-dwelling U.S. older adults with cognitive impairment, fewer people received IADL support over time, and the extent of unmet IADL support needs increased. Racial/ethnic disparities were seen both in the prevalence of reported BADL/IADL disability and unmet BADL/IADL support needs; some but not all were compatible with a reduction in disparity over time. This evidence could prompt interventions to reduce disparities and unmet support needs.

The identification of clusters of risk factors and their association with hospitalizations or emergency department visits in home health care

AIMS

To identify clusters of risk factors in home health care and determine if the clusters are associated with hospitalizations or emergency department visits.

DESIGN

A retrospective cohort study.

METHODS

This study included 61,454 patients pertaining to 79,079 episodes receiving home health care between 2015 and 2017 from one of the largest home health care organizations in the United States. Potential risk factors were extracted from structured data and unstructured clinical notes analysed by natural language processing. A K-means cluster analysis was conducted. Kaplan-Meier analysis was conducted to identify the association between clusters and hospitalizations or emergency department visits during home health care.

RESULTS

A total of 11.6% of home health episodes resulted in hospitalizations or emergency department visits. Risk factors formed three clusters. Cluster 1 is characterized by a combination of risk factors related to "impaired physical comfort with pain," defined as situations where patients may experience increased pain. Cluster 2 is characterized by "high comorbidity burden" defined as multiple comorbidities or other risks for hospitalization (e.g., prior falls). Cluster 3 is characterized by "impaired cognitive/psychological and skin integrity" including dementia or skin ulcer. Compared to Cluster 1, the risk of hospitalizations or emergency department visits increased by 1.95 times for Cluster 2 and by 2.12 times for Cluster 3 (all p < .001).

CONCLUSION

Risk factors were clustered into three types describing distinct characteristics for hospitalizations or emergency department visits. Different combinations of risk factors affected the likelihood of these negative outcomes.

IMPACT

Cluster-based risk prediction models could be integrated into early warning systems to identify patients at risk for hospitalizations or emergency department visits leading to more timely, patient-centred care, ultimately preventing these events.

PATIENT OR PUBLIC CONTRIBUTION

There was no involvement of patients in developing the research question, determining the outcome measures, or implementing the study.

"What If I Die and No One Notices?" A Qualitative Study Exploring How Living Alone and in Poverty Impacts the Health and Well-Being of Older People in Hong Kong

Despite the growing number of older people who live alone and in poverty, the intersection of these two social risk factors and the impacts on older adults' health and well-being have not been widely examined. This qualitative study explores the challenges and strengths of 47 older people who live alone and in poverty in Hong Kong. Thematic analysis was used to identify eight themes related to challenges: (i) social isolation and loneliness, (ii) self-esteem and self-efficacy, (iii) declining mobility, health and activity levels, (iv) high medical expenses, (v) age discrimination and long wait times for medical health services, (vi) age discrimination, retirement, and wanting part-time employment, (vii) not enough gender-specific social participation activities, and (viii) housing insecurity. Four themes related to strengths were identified: (i) An "I have enough" mindset, (ii) strong formal social support, (iii) contributing to the community and others, and (v) "Most of us like to be alone." Successfully addressing poverty in old age and tackling the challenges associated with living alone will require focusing on and activating not only external and systemic resources but also the intrinsic capacities and strengths of older adults themselves. Five discussion points are raised addressing the implications for future gerontological research and practice.

Catastrophic health expenditure among Chinese adults living alone with cognitive impairment: findings from the CHARLS

BACKGROUND

The catastrophic health expenditure of older adults results in serious consequences; however, the issue of whether cognitive status and living situations contribute to such financial burdens is uncertain. Our aim was to compare the differences in catastrophic health expenditure between adults living alone with cognitive impairment and those adults living with others and with normal cognition.

METHODS

We identified 909 observations of participants living alone with cognitive impairment (cases) and 37,432 observations of participants living with others and with normal cognition (comparators) from the 2011/2012, 2013, 2015 and 2018 waves of the China Health and Retirement Longitudinal Study (CHARLS). We used propensity score matching (1:2) to create matched cases and comparators in a covariate-adjusted logistic regression analysis. Catastrophic health expenditure was defined as an out-of-pocket cost for health care ≥40% of a household's capacity to pay.

RESULTS

In comparison with participants living with others and with normal cognition, those adults living alone with cognitive impairment reported a higher percentage of catastrophic health expenditure (19.5% vs. 11.8%, respectively, P < 0.001). When controlling for age, sex, education, marital status, residence areas, alcohol consumption, smoking status and disease counts, we found that this subpopulation had significantly higher odds of having catastrophic health expenditure (odds ratio [OR] = 1.89, 95% confidence interval [CI]: 1.40, 2.56). Additional analyses confirmed the robustness of the results.

CONCLUSIONS

This study demonstrated that adults living alone with cognitive impairment in the CHARLS experienced a high burden of catastrophic health expenditure. Health care policies on social health insurance and medical assistance should consider these vulnerable adults.

Difficulties with Activities of Daily Living and Receipt of Care Among Older Adults with Cognitive Impairment: Differences Between Those Living Alone and Those Living with Others

We compared the prevalence of reporting difficulty with basic and instrumental activities of daily living without help received for persons with cognitive impairment living alone versus those living with others. We used data on 13,782 community-dwelling participants aged 55+ with cognitive impairment in the Health and Retirement Study (2000–2016). Models were stratified by gender and race/ethnicity. Among cognitively impaired older adults, those living alone were more likely to report difficulty without help received than those living with others. Results were similar by gender and race/ethnicity. Providers and policymakers might focus their efforts on ensuring the adequate provision of home and community-based services for older adults living alone with cognitive impairment.

The Living Alone with Cognitive Impairment Project's Policy Advisory Group on Long-Term Services and Supports: Setting a Research Equity Agenda

(1) Background: A United States national policy advisory group (PAG) was convened to identify barriers and facilitators to expand formal long-term services and support (LTSS) for people living alone with cognitive impairment (PLACI), with a focus on equitable access among diverse older adults. The PAG's insights will inform the research activities of the Living Alone with Cognitive Impairment Project, which is aimed at ensuring the equitable treatment of PLACI. (2) Methods: The PAG identified barriers and facilitators of providing effective and culturally relevant LTSS to PLACI via one-on-one meetings with researchers, followed by professionally facilitated discussions among themselves. (3) Results: The PAG identified three factors that were relevant to providing effective and culturally relevant LTSS to PLACI: (i) better characterization of PLACI, (ii) leveraging the diagnosis of cognitive impairment, and (iii) expanding and enhancing services. For each factor, the PAG identified barriers and facilitators, as well as directions for future research. (4) Conclusions: The barriers and facilitators the PAG identified inform an equity research agenda that will help inform policy change.

Living Arrangements and Dementia Among the Oldest Old: A Comparison of Mexicans and Mexican Americans

Background and Objectives

The growing population of adults surviving past age 85 in the United States and Mexico raises questions about the living arrangements of the oldest old and those living with dementia. This study compares Mexican and Mexican American individuals aged 85 and older to identify associations with cognitive status and living arrangements in Mexico and the United States.

Research Design and Methods

This study includes 419 Mexican Americans in 5 southwestern states (Hispanic Established Population for the Epidemiologic Studies of the Elderly) and 687 Mexicans from a nationally representative sample (Mexican Health and Aging Study). It examines characteristics associated with living alone using logistic regression and describes the living arrangements of older adults with probable dementia in each country.

Results

Older adults with dementia were significantly less likely to live alone than with others in the United States while there were no relationships between dementia and living arrangements in Mexico. However, a substantial proportion of older adults with dementia lived alone in both nations: 22% in the United States and 21% in Mexico. Among Mexican Americans with dementia, those living alone were more likely to be women, childless, reside in assisted living facilities, and less likely to own their homes. Similarly, Mexican individuals with dementia who lived alone were also less likely to be homeowners than those living with others.

Discussion and Implications

Contextual differences in living arrangements and housing between the United States and Mexico pose different challenges for aging populations with a high prevalence of dementia.

Difficulty and help with activities of daily living among older adults living alone during the COVID-19 pandemic: a multi-country population-based study

Background

Older adults who live alone and have difficulties in activities of daily living (ADLs) may have been more vulnerable during the COVID-19 pandemic. However, little is known about pandemic-related changes in ADL assistance (such as home care, domiciliary care) and its international variation. We examined international patterns and changes in provision of ADL assistance, and related these to country-level measures including national income and health service expenditure.

Methods

We analysed data covering 29 countries from three longitudinal cohort studies (Health and Retirement Study, English Longitudinal Study of Aging, and Survey of Health, Ageing and Retirement in Europe). Eligible people were aged ≥50 years and living alone. Outcomes included ADL difficulty status (assessed via six basic ADLs and five instrumental ADLs) and receipt of ADL assistance. Wealth-related inequality and need-related inequity in ADL assistance were measured using Erreygers’ corrected concentration index (ECI). Correlations were estimated between prevalence/inequality/inequity in ADL assistance and national health-related indicators. We hypothesized these measures would be associated with health system factors such as affordability and availability of ADL assistance, as well as active ageing awareness.

Results

During COVID-19, 18.4% of older adults living alone reported ADL difficulties (ranging from 8.8% in Switzerland to 29.2% in the USA) and 56.8% of those reporting difficulties received ADL assistance (ranging from 38.7% in the UK to 79.8% in Lithuania). Females were more likely to receive ADL assistance than males in 16/29 countries; the sex gap increased further during the pandemic. Wealth-related ECIs indicated socioeconomic equality in ADL assistance within 24/39 countries before the pandemic, and significant favouring of the less wealthy in 18/29 countries during the pandemic. Needs-related ECIs indicated less equity in assistance with ADLs during the pandemic than before. Our hypotheses on the association between ADL provision measures and health system factors were confirmed before COVID-19, but unexpectedly disconfirmed during COVID-19.

Conclusion

This study revealed an unequal (and in some countries, partly needs-mismatched) response from countries to older adults living alone during the COVID-19 pandemic. The findings might inform future research about, and policies for, older adults living alone, particularly regarding social protection responses during crises.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-02799-w.

Inconvenience and adaptation in Japanese adult achondroplasia and hypochondroplasia: A cross-sectional study

The health-related quality of life is reduced in patients with achondroplasia (ACH) and hypochondroplasia (HCH); however, the detailed inconveniences in the daily living and individual adaptations have not been elucidated. This study aimed to evaluate the inconvenience and adaptation in patients with ACH/HCH. A cross-sectional study was conducted in patients with ACH/HCH aged 20 yr or older. Questionnaires were sent to 567 patients (described 86) with a medical history at the co-authors’ institutions or who were registered at the patients’ association with ACH in Japan. The questionnaire included a free description format for the inconveniences and adaptations in daily living; a content analysis was performed. The recorded inconveniences included 148 physical, 84 mental, and 52 social problems. Patients who underwent spine surgery had significantly more recorded physical problems than those who did not (p < 0.05). Pain and numbness were significantly higher in patients aged ≥ 50 yr (p < 0.05). The 160 and 1 adaptations were for physical and social problems, respectively. No patient adaptation was found for mental health problems. Individual adaptations by ACH/HCH patients can improve only some aspects of physical and social problems. Multilateral social support is needed to resolve patients’ issues.

Associations Between Midlife Functional Limitations and Self-Reported Health and Cognitive Status: Results from the 1998-2016 Health and Retirement Study

BACKGROUND

Life-course approaches to identify and help improve modifiable risk factors, particularly in midlife, may mitigate cognitive aging.

OBJECTIVE

We examined how midlife self-rated physical functioning and health may predict cognitive health in older age.

METHODS

We used data from the Health and Retirement Study (1998-2016; unweighted-N = 4,685). We used survey multinomial logistic regression and latent growth curve models to examine how midlife (age 50-64 years) activities of daily living (ADL), physical function, and self-reported health affect cognitive trajectories and cognitive impairment not dementia (CIND) and dementia status 18 years later. Then, we tested for sex and racial/ethnic modifications.

RESULTS

After covariates-adjustment, worse instrumental ADL (IADL) functioning, mobility, and self-reported health were associated with both CIND and dementia. Hispanics were more likely to meet criteria for dementia than non-Hispanic Whites given increasing IADL impairment.

CONCLUSION

Midlife health, activities limitations, and difficulties with mobility are predictive of dementia in later life. Hispanics may be more susceptible to dementia in the presence of midlife IADLs. Assessing midlife physical function and general health with brief questionnaires may be useful for predicting cognitive impairment and dementia in later life.

Aging in Place with Age-Related Cognitive Changes: The Impact of Caregiving Support and Finances

In the United States, aging in place is a common concept that refers to older adults’ desire to remain in their homes as they age. However, this ability to age in place is a complex process that is not only impacted by the home’s accessibility or individual functional abilities. This paper aims to examine different factors, such as home environment and home modification, caregivers, finances, and other supports present in the participants’ lives, that impact older adults with age-related cognitive changes (ARCC) (in)ability to age in place. Qualitative interviews with older adults with ARCC (n = 5) and their caregivers (n = 5) were conducted. The participants’ experiences while aging in place indicate that finances and caregiving support greatly impacted their lives at home and ability to age in place. Personal finances dictated where some of the participants could age and the support, they could afford from home health aides. Additionally, informal and formal caregivers were an important source of support that aided in the older adults’ ability to remain home. As researchers, we need to continue to address personal finances and the support that the individual has in their lives to most effectively promote aging in place and their life at home.

The Effects of the COVID-19 Pandemic on the Lived Experience of Diverse Older Adults Living Alone With Cognitive Impairment

BACKGROUND AND OBJECTIVES

Even before the COVID-19 pandemic, older adults with cognitive impairment living alone (an estimated 4.3 million individuals in the United States) were at high risk for negative health outcomes. There is an urgent need to learn how this population is managing during the pandemic.

RESEARCH DESIGN AND METHODS

This is a qualitative study of 24 adults aged 55 and older living alone with cognitive impairment from diverse racial/ethnic backgrounds. Participants' lived experiences during the pandemic were elicited via 59 ethnographic interviews conducted over the phone either in English, Spanish, or Cantonese. Using a qualitative content analysis approach, interview transcripts were analyzed to identify codes and themes.

RESULTS

Qualitative analysis of transcripts revealed 5 themes: (a) fear generated by the pandemic, (b) distress stemming from feeling extremely isolated, (c) belief in misinformation, (d) strategies for coping during the pandemic, and (e) the importance of access to essential services.

DISCUSSION AND IMPLICATIONS

This pandemic put a spotlight on the precarity and unmet needs of older adults living alone with cognitive impairment. Findings underscore the need to expand access to home care aides and mental health services for this population.

Use of Services by People Living Alone With Cognitive Impairment: A Systematic Review

BACKGROUND AND OBJECTIVES

Formal supports and social services are essential to people living alone with cognitive impairment (PLACI) because they are at risk of negative health outcomes and lack cohabitants who may support them with cognitively demanding tasks. To further our understanding of this critical and worldwide issue, we conducted a systematic review to understand whether, and how, PLACI access and use essential formal supports and services.

RESEARCH DESIGN AND METHODS

We searched 6 databases (PubMed, Embase, PsycINFO, CINAHL, Web of Science, and Sociological Abstracts) to identify quantitative and mixed-method literature on formal service use among PLACI. The initial search was conducted in 2018 and updated in 2020.

RESULTS

We identified 32 studies published between 1992 and 2019, representing 13 countries, that met our criteria: 16 reported on health services and 26 on social services. Most studies compared PLACI with people with cognitive impairment living with others. Health service use was lower or similar among PLACI, as opposed to counterparts living with others. Most studies reported a higher use of social services (e.g., home services) among PLACI than those living with others. Overall use of essential home service among PLACI was higher in Europe than in the United States, a country where large portions of PLACI were reported receiving no formal services.

DISCUSSION AND IMPLICATIONS

We identified wide variability among countries and major gaps in service use. Results for use of health services were mixed, although our findings suggest that PLACI may have fewer physician visits than counterparts living with others. Our findings suggest that varying policies and budgets for these services among countries may have affected our findings. We encourage researchers to evaluate and compare the influence of social policies in the well-being of PLACI. We also encourage policy makers to prioritize the needs of PLACI in national dementia strategies.