Traversing the Aging Research and Health Equity Divide: Toward Intersectional Frameworks of Research Justice and Participation

Understanding Inclusion and Participation of People From Black African Diaspora Communities in Health and Care Research: A Realist Review

BACKGROUND

People from Black African Diaspora Communities (BAFDC) experience poorer health outcomes and are persistently under-represented in health and care research. There is limited understanding about how to support their greater inclusion and participation.

OBJECTIVES

Explore secondary data providing insights for the co-development of a realist theory of inclusion and participation for people from BAFDC in health and care research in the United Kingdom. Drawing on these theories, co-produce a realist review with a diverse range of people from BAFDC.

METHODS

A realist approach underpinned the study. Pawson's five steps to a realist approach were taken to shape the review, identify relevant sources, extract the data and then analyse and synthesise to inform an overarching programme theory. Initial programme theories (IPTs) were developed through context (C), mechanism (M), outcome (O) configurations (CMOCs).

MAIN RESULTS

The review identified 43 relevant documents. Synthesis of evidence from the documents resulted in 8 IPTs and 17 CMOCs helping to understand and explain the inclusion and participation of people from BAFDC. Four key thematic clusters emerged: (1) Health and care research as a White space, (2) Trust deficit: the expansiveness of broken trust, (3) Implicit and complicit bias and (4) Processes that affect inclusion and participation. Findings were underpinned by five existing mid-range theories (MRTs) around central concepts of candidacy, social dominance, networks, narratives and racism that guided analysis and synthesis, supporting conceptualisation of CMOCs. An overarching programme theory was developed.

CONCLUSION

The review identifies how the influence of perspectives, attitudes and beliefs held by individuals or groups about people from BAFDC operates in health and care research, resulting in exclusion, lack of trust and deficit thinking. The findings should be used to inform interventions aimed at increasing inclusion and participation of people from BAFDC.

PATIENT OR PUBLIC CONTRIBUTION

The co-production group comprised a diverse range of individuals from within the health and care research system with different lived experiences of being Black. They contributed to the entire review process, including the development of initial programme theories and retroductive thinking and interpretation of the evidence.

CLINICAL TRIAL REGISTRATION

Not applicable.

Introducing social determinants of health to the Alzheimer's Disease Research Center network: Development and implementation in the Uniform Data Set

The Alzheimer's Disease Research Centers (ADRCs) consortium represents a critical locus of research on Alzheimer's disease and related disorders (ADRD) prevention, diagnosis, and intervention. Through the National Alzheimer's Coordinating Center's (NACC) standardized protocol, the Uniform Data Set (UDS), ADRCs have collected rich, harmonizable clinical and cognitive data. However, the collection of social data has been sparse and Center specific, constraining ADRD science that addresses research priorities on social determinants of health (SDOH) and health equity. Capitalizing on the transition to a revised UDS version 4, an interdisciplinary committee representing 10 ADRCs reviewed the literature and instrumentation, ultimately creating a brief module covering multiple domains and levels of exposure required for mechanistic studies of SDOH and brain health. This article offers rationale, empirical support, and guidance for using the selected constructs: transportation security, financial security, social connectedness, health care experiences, and discrimination, as well as recommendations for next steps that each ADRC can take to maximize local and field-level progress. HIGHLIGHTS: Social determinants of health (SDOH) play a role in Alzheimer's disease and related dementias (ADRD) risk, diagnosis, care, and research participation. A new module adds SDOH to a revised Uniform Data Set (UDS) for the Alzheimer's Disease Research Center (ADRC) consortium. UDS SDOH include transportation, socioeconomic status, social relationships, health care, and discrimination. We provide evidence for causal SDOH associations with ADRD and guidelines for use. We include recommendations for next steps and expanding the impact of the SDOH module.

Emerging Trends in Research on Assisted Outpatient Treatment in the United States: A Narrative Review

OBJECTIVE

The use of court-ordered mental health treatment through programs such as assisted outpatient treatment (AOT) carries substantial ramifications for the welfare of individuals with serious mental health conditions.

METHODS

In this review, the authors used a narrative methodology and performed an interpretive synthesis of existing U.S.-based literature (2008-2023) on AOT implementation and outcomes.

RESULTS

The search yielded 21 peer-reviewed articles published between 2009 and 2022 that assessed various aspects and outcomes of AOT. Although many of these studies generally supported the use of AOT, most used a limited data set (i.e., AOT program data from New York or Ohio between 1999 and 2007). Much of the latest research on AOT did not include attention to possible mechanisms to explain observed outcomes. The emerging literature suggests that increased outreach and less coercive tactics may lead to better outpatient treatment outcomes. However, more research, especially from the point of view of individuals enrolled in AOT programs, is needed.

CONCLUSIONS

The authors strongly recommend that research into these interventions be broadened and include more geographic locations. A greater emphasis should be placed on identifying potential disparities, developing a better understanding of AOT-specific mechanisms of change, and continuing efforts to identify and use high-quality comparison groups.

Telomere Length and Cognitive Function Among Middle-Aged and Older Participants From Communities Underrepresented in Aging Research: A Preliminary Study

ObjectiveAccelerated biological aging is a plausible and modifiable determinant of dementia burden facing minoritized communities but is not well-studied in these historically underrepresented populations. Our objective was to preliminarily characterize relationships between telomere length and cognitive health among American Indian/Alaska Native (AI/AN) and Black/African American (B/AA) middle-aged and older adults.MethodsThis study included data on telomere length and neuropsychological test performance from 187 participants, enrolled in one of two community-based cognitive aging cohorts and who identified their primary race as AI/AN or B/AA.ResultsNested multivariable regression models revealed preliminary evidence for associations between telomere length and cognitive performance, and these associations were partially independent of chronological age.DiscussionSmall sample size limited estimate precision; however, findings suggest future work on telomere length and cognitive health in underrepresented populations at high risk for dementia is feasible and valuable as a foundation for social and behavioral intervention research.

Healthy Aging in Subsidized Housing in the United States: Exploring Older Adults' Views of Service Coordination

BACKGROUND AND OBJECTIVES

Low-income older adults face many barriers to healthy aging, including housing cost burden. Publicly subsidized rental units for older adults are one affordable housing option; these typically have a service coordinator who helps tenants access community resources. Previous research has indicated that service coordinators can support resident health. However, little is known about older adults' perspectives on service coordination. Our study aimed to explore how older adults living in subsidized housing perceive the relationship between service coordinators and healthy aging.

RESEARCH DESIGN AND METHODS

We conducted 5 focus group discussions with residents of 3 subsidized housing communities for older adults, all in medically underserved urban areas. Participants, 48 in total, were asked about barriers to healthy aging, resources for healthy aging, and what role, if any, service coordinators play in supporting healthy aging. Content analysis was used to identify themes emerging from the data.

RESULTS

Data analysis yielded 90 codes and subcodes falling under 4 themes: challenges in healthy aging, assets for healthy aging, perceptions of service coordinator role, and suggestions for improvement. Across focus groups, participants highlighted that service coordinators can connect residents to health-related assets. Participants also desired future opportunities to make their perspectives on healthy aging heard.

DISCUSSION AND IMPLICATIONS

Service coordinators are important, underrecognized collaborators for older adult health. Future healthcare interventions and policies should seek to support service coordinators and leverage their ability to connect older adults with healthcare professionals and community services.

Methods for community-engaged data collection and analysis in implementation research

BACKGROUND

Community engagement is widely recognized as critical to successful and equitable implementation of evidence-based practices, programs, and policies. However, there are no clear guidelines for community involvement in data collection and analysis in implementation research.

METHODS

We describe three specific methods for engaging community members in data collection and analysis: concept mapping, rapid ethnographic assessment, and Photovoice. Common elements are identified from a case study of each method: 1) selection and adaptation of evidence-based strategies for improving adolescent HPV vaccine initiation rates in disadvantaged communities, 2) strategies for implementing medication for opioid use disorders among low-income Medicaid enrollees during natural disasters, and 3) interventions to improve the physical health of adults with severe mental illness living in supportive housing.

RESULTS

In all three cases, community members assisted in participant recruitment, provided data, and validated preliminary findings created by researchers. In the Photovoice case study, community members participated in both data collection and analysis, while in the concept mapping, community members also participated in the initial phase of organizing and prioritizing evidence-based strategies during the data analysis.

CONCLUSIONS

Community involvement in implementation research data collection and analysis contributes to greater engagement and empowerment of community members and validation of study findings. Use of methods that exhibit both scientific rigor and community relevance of implementation research also contributes to greater community investment in successful implementation outcomes. Nevertheless, the case studies point to the importance and efficiency of the division of labor embedded in community-engaged implementation research. Building capacity for community members to assume greater roles in obtaining and organizing data for preliminary analysis prior to interpretation is recommended.

Increasing representation of Asian American, Native Hawaiian, and Pacific Islander communities in aging, dementia, and caregiving research: An update from the CARE registry

INTRODUCTION

Asian American, Native Hawaiian, and Pacific Islander (AANHPI) communities are among the fastest growing segments of older adults in the United States yet remain underrepresented in aging, dementia, and caregiving research.

METHODS

The Collaborative Approach for AANHPI Research & Education (CARE), a recruitment registry, aims to improve the representation of AANHPI older adults in research. We describe activity to date, as well as planned expansions in cultural groups, language capacity, and data collection in the registry.

RESULTS

Between October 15, 2020, and November 4, 2024, 10,367 total AANHPI adults enrolled in the CARE registry, including 50.0% with limited English proficiency, 35.1% age ≥ 65, and 80.2% with no prior participation in research. CARE has made more than 13,954 referrals of 6868 unique registrants to at least one study.

DISCUSSION

Through collaborative partnerships with AANHPI communities and researchers, the CARE Registry is achieving its goal of increasing AANHPI representation in research.

HIGHLIGHTS

The CARE registry has enrolled 10,367 AANHPI adults. More than 80% of those enrolled had no prior research experience. As of November 4, 2024, CARE had referred 6868 unique participants to at least one study. In total, CARE has made 13,954 referrals to requesting studies.

Community-engaged efforts to increase retention of Black American online registry participants

INTRODUCTION

Many longitudinal Alzheimer's disease studies fail to retain Black American adults once enrolled. This limits the generalizability of research findings.

METHODS

The Community-Engaged Digital Alzheimer's Research (CEDAR) study developed digital, culturally-informed, community-engaged efforts to increase longitudinal registry task completion of Black American Brain Health Registry (BHR) participants. Difference-in-differences analysis was conducted to compare longitudinal registry task completion rates within groups (before vs. after CEDAR referral) and between groups (enrolled in CEDAR vs. not enrolled).

RESULTS

Of 3888 invited Black American BHR participants, 420 (10.8%) enrolled in CEDAR. For CEDAR participants, we found significant increases in enrollment rate into referral studies and BHR timepoint completion rate after enrollment into CEDAR. Compared to those not enrolled, CEDAR participants had higher rates of: enrollment in referral studies, timepoint completion, initial questionnaire completion, and neuropsychological test completion.

DISCUSSION

The results provide preliminary evidence that CEDAR's culturally-informed, community-engaged research efforts were effective at improving engagement of Black American adults in an online longitudinal study. This is evidenced by increased registry engagement before and after enrollment and in comparison to Black American BHR participants not enrolled in CEDAR. These results need to be interpreted cautiously due to selection biases. This strategy can be adapted to other studies and settings.

Highlights

CEDAR is an online AD/ADRD registry engagement intervention for Black participants.The intervention is community-engaged, digital, culturally-informed, and multifaceted.Engagement rates increased before versus during the intervention for enrollees.Engagement rates decreased over the same time period for non-enrolled participants.Results need to be interpreted with caution due to selection biases.

Reviewing and Advocating for Data Disaggregation in Aging-Related Health Research: NIA Grants and Recommendations for Equity

Federal minimum standards for collecting and reporting race and ethnicity data implicitly categorize diverse individuals into broad, monolithic categories. Despite advancements in policy and practice and calls for inclusive research, data equity remains a significant issue in aging-related health research. Racially and ethnically diverse older adults are underrepresented in health research and rarely disaggregated by ethnicity in data collection, analysis, and reporting of aging-related health outcomes. Data disaggregation offers a promising approach to advancing data equity in aging research. We searched the National Institute on Health RePORT Expenditures and Results (NIH RePORTER) database to identify extramural National Institute on Aging (NIA) grants from 1985 to 2024 that proposed disaggregating race and ethnicity data for aging-related research. We found only 12 NIA-funded awards, visually demonstrating how understudied data disaggregation is within the field of aging. Most disaggregation-focused grants were awarded from 2015 onward (92%), with 42% being R01 grants. Enhancing methodological rigor in demographic data collection and reporting reflective of the diversifying aging population is crucial for data equity. We conclude with recommendations to advance aging health research and highlight considerations and ethical issues for data disaggregation for historically surveilled racial and ethnic minoritized communities.

A feasibility study of KINDER: an elder mistreatment intervention for family caregivers of persons living with dementia

Elder mistreatment occurs in as many as one-half of the 11 million family care partnerships with persons living with Alzheimer's disease or related dementias (AD/ADRD) in the United States. Knowledge and Interpersonal Skills to Develop Enhanced Relationships is an 8-week psychoeducational intervention to prevent psychological mistreatment among family caregivers to persons living with dementia by building healthy caregiving relationships. The investigators conducted a single-arm pre- and posttest study to assess KINDER's feasibility. A total of 45 caregivers enrolled, among whom 37 completed the follow-up survey (82.2% retention). Caregivers attended an average of 2.1 of 3 discussion sessions (SD = 0.76). Paired t-test analyses comparing outcomes at baseline and post-intervention demonstrated a statistically significant decrease in psychological mistreatment and relationship strain, and an increase in resourcefulness skills. These findings suggest KINDER is a feasible low- to moderate-intensity intervention to prevent psychological mistreatment with AD/ADRD caregiving. Future research will test KINDER's efficacy.

Inclusive Practices for Aging in Place: Environmental and Home Modifications for Older Adults

IMPORTANCE

As the aging population expands, the need to develop home modification programs that effectively support older adults living in low-income households is increasing.

OBJECTIVE

To examine how an interprofessional team implemented the Older Adult Home Modification Program (OAHMP) at a specific urban site and integrated functional interventions and home modifications to address the safety, accessibility, and functional needs of older adults in low-income households.

DESIGN

This program evaluation study used descriptive analysis to evaluate sociodemographic characteristics, pre- and postimplementation data, and home modifications.

SETTING

An urban city environment.

PARTICIPANTS

Sixty-five participants completed the program. The average age was 72 yr (SD = 7.3); participants were predominantly women (95.4%), Black or African American (87.7%), and living alone (81.5%).

INTERVENTION

Three in-home visits by an occupational therapist, a home modification team, and a social worker.

OUTCOMES AND MEASURES

A paired-samples t test was conducted to compare pre- and postimplementation functional scores on the assessments used, and Pearson's r correlation analysis was used to assess relationships between functional measures.

RESULTS

The OAHMP implementation led to significant improvements in self-care activities of daily living (ADLs) and home safety; significant positive relationships were found between health status and improved independence in ADLs and instrumental ADLs.

CONCLUSIONS AND RELEVANCE

The OAHMP enhances ADL independence and home safety for older adults in low-income, diverse communities. By addressing environmental barriers through client-centered modifications and interprofessional collaboration, the program supports aging in place. Its cost-effective approach fosters autonomy, occupational engagement, and health equity, highlighting occupational therapy's key role in safe, sustainable community living. Plain-Language Summary: This study evaluated the Older Adult Home Modification Program (OAHMP), which aims to help older adults in low-income communities age safely in place by addressing home safety, accessibility, and ADLs. Findings showed that participants experienced increased independence in ADLs and reduced home safety hazards, with 91% of personal goals met or partially met. The average cost of home modifications was significantly lower than national averages, making the program a cost-effective alternative to nursing home placement. The results highlight how tailored home modifications, combined with interprofessional collaboration, can promote ADL independence and safety in the home. This study emphasizes the essential role of occupational therapy in developing equitable, client-centered interventions that address environmental barriers, contributing valuable insights to occupational therapy research, practice, and education. Positionality Statement: The authors are one Black female therapist, one White female therapist, and two White female occupational therapy students. We acknowledge that our economic, educational, and cultural backgrounds may influence our perspectives and potential biases in this analysis.

Cultural Safety in Clinical Research: A Conceptual Overview and Call to Action

Black Americans are two to three times more likely to develop ADRD than their white counterparts, yet Black Americans make up only 2.4% of ADRD clinical trial participants. Here we provide an overview of the current state of initiatives to maximize racial and ethnic inclusivity in clinical research, particularly among ethnoracialized groups, and introduce the Indigenous-rooted concept of cultural safety through an integrative review and outline of its applicability to the research context. Cultural safety ensures that cultural identities, values, and experiences of minoritized persons are respected, understood, and integrated in their health care journey, empowering them to define and evaluate their own experiences. Implementing cultural safety challenges individuals to confront and critically examine their own perspectives on the dominant culture's traditions and values, as well as their implicit racism, biases, privileges, and inherent power structures. We extend prior conceptual work on cultural safety by proposing two subdimensions: environmental and internal. These must be synergistically integrated to heal fractured relationships between communities of color and researchers. By championing cultural safety, we can create a workforce of self-aware researchers who embody cultural safety's true essence as defined by the communities they serve. Community-engaged research serves as an ideal platform for cultural safety to be meaningfully implemented and sustained. This approach can uplift previously silenced voices in research, build long-term relationships, and generate empirical data that substantiates its positive effects. Importantly, applying environmental and internal cultural safety can empower participants in ADRD research where it is critically needed.

Overview of Alzheimer's Disease Neuroimaging Initiative and future clinical trials

The overall goal of the Alzheimer's Disease Neuroimaging Initiative (ADNI) is to optimize and validate biomarkers for clinical trials while sharing all data and biofluid samples with the global scientific community. ADNI has been instrumental in standardizing and validating amyloid beta (Aβ) and tau positron emission tomography (PET) imaging. ADNI data were used for the US Food and Drug Administration (FDA) approval of the Fujirebio and Roche Elecsys cerebrospinal fluid diagnostic tests. Additionally, ADNI provided data for the trials of the FDA-approved treatments aducanumab, lecanemab, and donanemab. More than 6000 scientific papers have been published using ADNI data, reflecting ADNI's promotion of open science and data sharing. Despite its enormous success, ADNI has some limitations, particularly in generalizing its data and findings to the entire US/Canadian population. This introduction provides a historical overview of ADNI and highlights its significant accomplishments and future vision to pioneer "the clinical trial of the future" focusing on demographic inclusivity. HIGHLIGHTS: The Alzheimer's Disease Neuroimaging Initiative (ADNI) introduced a novel model for public-private partnerships and data sharing. It successfully validated amyloid and Tau PET imaging, as well as CSF and plasma biomarkers, for diagnosing Alzheimer's disease. ADNI generated and disseminated vital data for designing AD clinical trials.

Public and participant involvement as a pathway to inclusive dementia research

The field of Alzheimer's disease and related dementias (ADRD) urgently requires inclusive research to ensure the priorities and outcomes of research apply to those most impacted. We postulate public and participant involvement (PPI) as a pathway to achieving the best science, both in research that informs health and social policy as well as in therapeutic studies to treat and prevent ADRD. This position paper aims to provide dementia researchers with evidence to understand how to apply PPI. We begin by highlighting the disparities experienced by people with dementia, including ageism, stigma of cognitive impairment, and health disparities for minoritized communities. We then provide examples of PPI in ADRD across the research lifecycle, from defining research topics of priority to those impacted by ADRD, through the design, analysis, dissemination, and translation to policy and practice. We also provide recommendations to create and maintain collaboration between researchers and communities through PPI. HIGHLIGHTS: A central premise of public and participant involvement (PPI) is collaborative relationships between researchers and community members. To build equitable partnerships, researchers must acknowledge and understand the context of research. This includes ageism, the stigma of dementia, and ongoing discrimination for many minoritized communities. Meaningful partnerships include choice, respect, shared decision making, access, inclusion, and representation. Notably, we recommend that researchers begin partnerships early in the research process and share the impact of PPI on research.

Multimodal neuroimaging biomarkers and subtle cognitive decline in a population-based cohort without dementia

BACKGROUND

The relationship between subtle cognitive decline and Alzheimer's disease (AD) pathology as measured by biomarkers in settings outside of specialty memory clinics is not well characterized.

OBJECTIVE

To investigate how subtle longitudinal cognitive decline relates to neuroimaging biomarkers in individuals drawn from a population-based study in an economically depressed, small-town area in southwestern Pennsylvania, USA.

METHODS

A subset of participants without dementia (N = 115, age 76.53 years ± 6.25) from the Monongahela Youghiogheny Healthy Aging Team (MYHAT) study completed neuroimaging including magnetic resonance imaging (MRI) measures of AD-signature region cortical thickness and white matter hyperintensities (WMH), Pittsburgh compound B (PiB)-positron emission tomography (PET) for amyloid-β (Aβ) deposition, and [18F]AV-1451-PET for tau deposition. Neuropsychological evaluations were completed at multiple timepoints up to 11 years prior to neuroimaging. Aβ positivity was determined using a regional approach. We used linear mixed models to examine neuroimaging biomarker associations with retrospective cognitive slopes in five domains and a global cognitive composite.

RESULTS

Among Aβ(+) participants (38%), there were associations between (i) tau Braak III/IV and language decline (p < 0.05), (ii) cortical thickness and both memory decline (p < 0.001) and global cognitive decline (p < 0.01), and (iii) WMH and decline in executive function (p < 0.05) and global cognition (p < 0.05). Among Aβ(-) participants, there was an association between tau Braak III/IV and decline on tests of attention/psychomotor speed (p < 0.05).

CONCLUSIONS

These findings confirm an Aβ-dependent early AD biomarker pathway, and suggest a possible Aβ-independent, non-AD process underlying subtle cognitive decline in a population-based sample of older adults without dementia.

Social determinants of participation in genetic research among Puerto Ricans and in the Puerto Rican diaspora

Puerto Ricans are underrepresented in genetic research. This underrepresentation denies Puerto Ricans the benefit from therapeutic developments that could mitigate health disparities arising from conditions for which genetically-derived treatments exist. The Puerto Rican diaspora, especially post-2017 due to economic and environmental crises, has expanded within the USA. Prior research suggests that Latin American diaspora communities are less likely to participate in genetic research. We hypothesized, specifically, that the Puerto Rican diaspora in the USA would be less likely to participate in genetic research than would Puerto Ricans in their homeland's archipelago, and that accounting for social and cultural determinants related to the diaspora experience would mitigate this disparity. We implemented an analytical cross-sectional study of archipelago-residing Puerto Ricans and of the USA-residing diaspora to evaluate this hypothesis. With 1582 Puerto Ricans (723 in Puerto Rico, 859 in the USA), we found that while most participants would participate in genetic research, participation rates varied significantly by diaspora status. Puerto Ricans born and living in the USA were initially more likely to decline participation compared to those in Puerto Rico (OR = 1.54, p < 0.01). However, once adjusted for social and cultural variables, this difference was eliminated (aOR = 1.08, p = n.s.). The factors influencing non-participation include oppression, discrimination, distrust, and social determinants, aligning with the theory of minoritization. An important community in the USA and in the world, Puerto Ricans have the right to participate in well-conducted research and to benefit from its findings, particularly around topics that could help address existing disparities in health outcomes.

The Alzheimer's Disease Neuroimaging Initiative-4 (ADNI-4) Engagement Core: A culturally informed, community-engaged research (CI-CER) model to advance brain health equity

INTRODUCTION

The Alzheimer's Disease Neuroimaging Initiative-4 (ADNI-4) Engagement Core was launched to advance Alzheimer's disease (AD) and AD-related dementia (ADRD) health equity research in underrepresented populations (URPs). We describe our evidence-based, scalable culturally informed, community-engaged research (CI-CER) model and demonstrate its preliminary success in increasing URP enrollment.

METHODS

URPs include ethnoculturally minoritized, lower education (≤ 12 years), and rural populations. The CI-CER model includes: (1) culturally informed methodology (e.g., less restrictive inclusion/exclusion criteria, sociocultural measures, financial compensation, results disclosure, Spanish Language Capacity Workgroup) and (2) inclusive engagement methods (e.g., the Engagement Core team; Hub Sites; Community-Science Partnership Board).

RESULTS

As of April 2024, 60% of ADNI-4 new in-clinic enrollees were from ethnoculturally or educationally URPs. This exceeds ADNI-4's ≥ 50% URP representation goal for new enrollees but may not represent final enrollment.

DISCUSSION

Findings show a CI-CER model increases URP enrollment in AD/ADRD clinical research and has important implications for clinical trials to advance health equity.

HIGHLIGHTS

The Alzheimer's Disease Neuroimaging Initiative-4 (ADNI-4) uses a culturally informed, community-engaged research (CI-CER) approach. The CI-CER approach is scalable and sustainable for broad, multisite implementation. ADNI-4 is currently exceeding its inclusion goals for underrepresented populations.

Telomere length and cognitive function among middle-aged and older participants from communities underrepresented in aging research: A preliminary study

Objective

Accelerated biological aging is a plausible and modifiable determinant of dementia burden facing minoritized communities, but is not well-studied in these historically underrepresented populations. Our objective was to preliminarily characterize relationships between telomere length and cognitive health among American Indian/Alaska Native (AI/AN) and Black/African American (B/AA) middle-aged and older adults.

Methods

This study included data on telomere length and cognitive test performance from 187 participants, enrolled in one of two community-based cognitive aging cohorts and who identified their primary race as AI/AN or B/AA.

Results

Nested multivariable regression models revealed preliminary evidence for associations between telomere length and cognitive performance, and these associations were partially independent of chronological age.

Discussion

Small sample size limited estimate precision, however, findings suggest future work on telomere length and cognitive health in underrepresented populations at high risk for dementia is feasible and valuable as a foundation for social and behavioral intervention research.

Everyday functioning as a predictor of cognitive status in a group of community-dwelling, predominantly Black adults

INTRODUCTION

We examined whether the Performance Assessment of Self-Care Skills (PASS) and Everyday Cognition Scale-12 (ECog-12) dichotomized cognitive groups in a sample of predominantly Black adults.

METHODS

Two hundred forty-six community-dwelling adults (95% Black, age 50+) completed cognitive testing, the PASS, and the ECog. Cognitive groups (probable vs unlikely cognitive impairment) were determined by performance on the Modified Mini-Mental State Examination. We examined the predictive validity of the PASS shopping, medication management, and information retrieval subtests and the ECog-12 to dichotomize cognitive groups.

RESULTS

Performance on all PASS subtests (all p's < .05) differed between cognitive groups, but not ECog-12 (p = 0.17). Only the PASS shopping and medication management had good reliability for determining cognitive group (areas under the curve (AUCs) of .74 each).

DISCUSSION

PASS shopping and medication management exhibited adequate predictive validity when distinguished between cognitive status groups, whereas the PASS information retrieval and ECog-12 did not.

Highlights

Mild functional decline is a core diagnostic criterion for cognitive impairment.Performance-based assessments are a valuable tool for assessing functional decline.Most performance-based measures were developed using homogenous samples.Few studies have validated these measures in other racial and ethnic populations.

Age-Specific Barriers and Facilitators to Research Participation Amongst African Americans in Observational Studies of Memory and Aging

BACKGROUND

Black/African Americans experience a high burden of Alzheimer disease and related dementias yet are critically underrepresented in corresponding research. Understanding barriers and facilitators to research participation among younger and older African Americans is necessary to inform age-specific strategies to promote equity in studies of early- and late-onset neurodegenerative diseases.

STUDY DESIGN

Survey respondents (n = 240) rated barriers and facilitators of research participation. Age-specific differences were evaluated using nonparametric Kruskal-Wallis tests across respondents aged 18-44 years (n = 76), 45-64 years (n = 83), and ≥ 65 years (n = 81). Strategies to mitigate barriers and promote facilitators were further explored via community-based focus groups. Pooled frequency of common themes discussed in focus groups were evaluated and compared across different ages including ≥ 45 years, ≥ 65 years, and mixed ages ≥ 45 years.

RESULTS

Younger respondents (aged 18-44 and 45-64 years) expressed a greater need for flexibility in when, where, and how research testing takes place versus adults ≥ 65 years. Focus groups emphasized long-lasting consequences of systemic racism and the need to build and foster trust to resolve barriers and promote research engagement amongst African Americans.

DISCUSSION

Age-specific strategies are needed to increase engagement, address recruitment disparities, and promote retention of African American participants in memory and aging studies across the lifespan.

Sex and gender differences in cognitive resilience to aging and Alzheimer's disease

Sex and gender-biological and social constructs-significantly impact the prevalence of protective and risk factors, influencing the burden of Alzheimer's disease (AD; amyloid beta and tau) and other pathologies (e.g., cerebrovascular disease) which ultimately shape cognitive trajectories. Understanding the interplay of these factors is central to understanding resilience and resistance mechanisms explaining maintained cognitive function and reduced pathology accumulation in aging and AD. In this narrative review, the ADDRESS! Special Interest Group (Alzheimer's Association) adopted a multidisciplinary approach to provide the foundations and recommendations for future research into sex- and gender-specific drivers of resilience, including a sex/gender-oriented review of risk factors, genetics, AD and non-AD pathologies, brain structure and function, and animal research. We urge the field to adopt a sex/gender-aware approach to resilience to advance our understanding of the intricate interplay of biological and social determinants and consider sex/gender-specific resilience throughout disease stages. HIGHLIGHTS: Sex differences in resilience to cognitive decline vary by age and cognitive status. Initial evidence supports sex-specific distinctions in brain pathology. Findings suggest sex differences in the impact of pathology on cognition. There is a sex-specific change in resilience in the transition to clinical stages. Gender and sex factors warrant study: modifiable, immune, inflammatory, and vascular.

Project ECHO Brain Health: Assessing the Impact of a Pilot Program to Promote Self-Efficacy Among Community Health Workers

This mixed-methods study sought to examine the impact of the Project ECHO Brain Health program on participating community health workers' (CHWs') self-efficacy to address dementia, promote brain health, and advocate for research among Latinx South Texas communities. Using an explanatory sequential design, quantitative data collected from pre- and post-program surveys were analyzed to inform the collection of qualitative data, followed by an interpretation of all findings to better understand the impact of the program on self-efficacy. Pre- and post-surveys were collected from 25 CHWs, 13 of whom later participated in individual interviews. There was a statistically significant increase in mean self-efficacy scores between the pre- and post-surveys among participants. Three categories reflecting the experiences of participants were identified from the qualitative data: addressing training needs; impact on CHWs and their practice; and community of learning. The findings suggest that Project ECHO Brain Health program is a timely intervention that may facilitate increased self-efficacy among CHWs as they navigate the impacts of dementia in their communities.

A randomised controlled trial of the Learning Skills Together (LST) intervention to improve dementia family caregivers' self-efficacy with complex care

BACKGROUND

Nearly two-thirds of family caregivers of persons living with Alzheimer's disease or related dementias (AD/ADRD) provide complex care, including medical care. Family caregivers typically receive little to no training on how to provide this care. Furthermore, family caregivers simultaneously grapple with the presence of behavioral and psychological symptoms of dementia (BPSD), diminished communication abilities, and comorbidities such as diabetes. We developed Learning Skills Together (LST), a 6-week digitally delivered psychoeducational program, to facilitate family caregiver abilities to administer complex care tasks. The goal of the present study is to test the efficacy of LST and to reduce adverse outcomes associated with caregiving, such as depressive symptomology and negative appraisal of BPSD.

METHODS

To test the efficacy of LST, we will conduct a two-arm single-site randomized controlled trial (RCT) with N = 200 family caregivers of persons living with AD/ADRD. Eligible family caregivers will be randomly assigned to participate in either the LST intervention or a structurally equivalent control condition focused on healthy living. All family caregivers will complete four surveys, including a baseline survey administered prior to randomization, a post-intervention survey, and a 3- and 6-month follow-up survey to assess change in study outcomes. Between-group comparisons of each outcome will be evaluated using generalized estimating equation models. Mediation analyses will assess family caregiver self-efficacy as the intervention's mechanism of change in depressive symptomology and BPSD. We will also examine caregiver race, ethnicity, and gender as effect modifiers of the intervention.

DISCUSSION

LST findings will inform the field of AD/ADRD and caregiving regarding optimally supporting family caregivers in managing complex care tasks. If efficacious, the LST intervention will support family caregivers in preserving their own mental health while providing complex care.

TRIAL REGISTRATION

Clinical Trials.gov NCT05846984 . This study was registered on May 6, 2023.

A randomised controlled trial of the Learning Skills Together (LST) intervention to improve dementia family caregivers' self-efficacy with complex care

Background

Nearly two-thirds of family caregivers of persons living with Alzheimer's disease or related dementias (AD/ADRD) provide complex care, including medical care. Family caregivers typically receive little to no training on how to provide this care. Furthermore, family caregivers simultaneously grapple with the presence of behavioral and psychological symptoms of dementia (BPSD), diminished communication abilities, and comorbidities such as diabetes. We developed Learning Skills Together (LST), a six-week digitally delivered psychoeducational program, to facilitate family caregiver abilities to administer complex care tasks. The goal of the present study is to test the efficacy of LST and to reduce adverse outcomes associated with caregiving, such as depressive symptomology and negative appraisal of BPSD.

Methods

To test the efficacy of LST, we will conduct a two-arm single-site randomised controlled trial (RCT) with N = 200 family caregivers of persons living with AD/ADRD. Eligible family caregivers will be randomly assigned to participate in either the LST intervention or a structurally equivalent control condition focused on healthy living. All family caregivers will complete four surveys, including a baseline survey administered prior to randomisation, a post-intervention survey, and a three- and six-month follow-up survey to assess change in study outcomes. Between-group comparisons of each outcome will be evaluated using generalized estimating equation models. Mediation analyses will assess family caregiver self-efficacy as the intervention's mechanism of change in depressive symptomology and BPSD. We will also examine caregiver race, ethnicity, and gender as effect modifiers of the intervention.

Discussion

LST findings will inform the field of AD/ADRD and caregiving regarding optimally supporting family caregivers in managing complex care tasks. If efficacious, the LST intervention will support family caregivers in preserving their own mental health while providing complex care.

Building Back Better: Going Big with Emancipatory Sciences

This commentary argues that precarity and inequity across the life course and aging has accelerated via the COVID-19 pandemic. President Biden's vaccination efforts, $1.9 trillion American Rescue Plan Act, and Build Back Better framework reflect a paradigm shift to restore faith and trust in government that boldly confronts entrenched austerity ideologues. We offer emancipatory sciences as a conceptual framework to analyze and promote social structural change and epic theory development. Emancipatory sciences aim to advance knowledge and the realization of dignity, access, equity, respect, healing, social justice, and social change through individual and collective agency and social institutions. Epic theory development moves beyond isolated incidents as single events and, instead, grasps and advances theory through attempts to change the world itself by demanding attention to inequality, power, and action. Gerontology with an emancipatory science lens offers a framework and vocabulary to understand the individual and collective consequences of the institutional and policy forces that shape aging and generations within and across the life course. It locates an ethical and moral philosophy engaged in the Biden Administration's approach, which proposes redistributing - from bottom-up - material and symbolic resources via family, public, community, and environmental benefits.

2024 Alzheimer's disease facts and figures

This article describes the public health impact of Alzheimer's disease (AD), including prevalence and incidence, mortality and morbidity, use and costs of care and the ramifications of AD for family caregivers, the dementia workforce and society. The Special Report discusses the larger health care system for older adults with cognitive issues, focusing on the role of caregivers and non-physician health care professionals. An estimated 6.9 million Americans age 65 and older are living with Alzheimer's dementia today. This number could grow to 13.8 million by 2060, barring the development of medical breakthroughs to prevent or cure AD. Official AD death certificates recorded 119,399 deaths from AD in 2021. In 2020 and 2021, when COVID-19 entered the ranks of the top ten causes of death, Alzheimer's was the seventh-leading cause of death in the United States. Official counts for more recent years are still being compiled. Alzheimer's remains the fifth-leading cause of death among Americans age 65 and older. Between 2000 and 2021, deaths from stroke, heart disease and HIV decreased, whereas reported deaths from AD increased more than 140%. More than 11 million family members and other unpaid caregivers provided an estimated 18.4 billion hours of care to people with Alzheimer's or other dementias in 2023. These figures reflect a decline in the number of caregivers compared with a decade earlier, as well as an increase in the amount of care provided by each remaining caregiver. Unpaid dementia caregiving was valued at $346.6 billion in 2023. Its costs, however, extend to unpaid caregivers' increased risk for emotional distress and negative mental and physical health outcomes. Members of the paid health care and broader community-based workforce are involved in diagnosing, treating and caring for people with dementia. However, the United States faces growing shortages across different segments of the dementia care workforce due to a combination of factors, including the absolute increase in the number of people living with dementia. Therefore, targeted programs and care delivery models will be needed to attract, better train and effectively deploy health care and community-based workers to provide dementia care. Average per-person Medicare payments for services to beneficiaries age 65 and older with AD or other dementias are almost three times as great as payments for beneficiaries without these conditions, and Medicaid payments are more than 22 times as great. Total payments in 2024 for health care, long-term care and hospice services for people age 65 and older with dementia are estimated to be $360 billion. The Special Report investigates how caregivers of older adults with cognitive issues interact with the health care system and examines the role non-physician health care professionals play in facilitating clinical care and access to community-based services and supports. It includes surveys of caregivers and health care workers, focusing on their experiences, challenges, awareness and perceptions of dementia care navigation.

COVID-19 pandemic's relationship with enrollment at US Alzheimer's Disease Research Centers

INTRODUCTION

We aimed to characterize the COVID-19 pandemic's relationship with enrollment in US Alzheimer's Disease Research Centers (ADRCs).

METHODS

Using data on 10,105 participants from 30 ADRCs, we conducted interrupted time series analyses to assess the relationship of the pandemic with enrollment and calculate projected dates of enrollment recovery.

RESULTS

Participants enrolled during the pandemic (vs pre-pandemic) were more likely to have dementia and be referred by health professionals. The pandemic was associated with a 77% drop in enrollment, with projected trend recovery in March 2024 and 100% recovery in September 2024. COVID was associated with a 91% drop in Black/African American participants, compared to 71% in White participants. Enrollment of both Hispanic and female participants was declining 1.4% and 0.3%/month pre-pandemic.

DISCUSSION

Funders and researchers should account for ongoing COVID-19 impact on ADRD research enrollment. Strategies to speed enrollment recovery are needed, especially for Black/African American and Hispanic groups.

HIGHLIGHTS

Tested COVID pandemic association with enrollment at Alzheimer's Disease Research Centers. During versus pre-pandemic enrollees differed on demographic and clinical variables. Interrupted time series analyses: immediate 77% drop in enrollment related to COVID. Recovery projections: trend recovery in March 2024, 100% recovery in September 2024. Enrollment of African American and Hispanic participants should be prioritized.

A service-oriented approach to clinical trial recruitment for dementia and brain health: Methods and case examples of MyAlliance for Brain Health

INTRODUCTION

Recruitment of sufficient and diverse participants into clinical research for Alzheimer's disease and related dementias remains a formidable challenge. The primary goal of this manuscript is to provide an overview of an approach to diversifying research recruitment and to provide case examples of several methods for achieving greater diversity in clinical research enrollment.

METHODS

The University of Kansas Alzheimer's Disease Research Center (KU ADRC) developed MyAlliance for Brain Health (MyAlliance), a service-oriented recruitment model. MyAlliance comprises a Primary Care Provider Network, a Patient and Family Network, and a Community Organization Network, each delivering tailored value to relevant parties while facilitating research referrals.

RESULTS

We review three methods for encouraging increased diversity in clinical research participation. Initial outcomes reveal an increase in underrepresented participants from 17% to 27% in a research registry. Enrollments into studies supported by the research registry experienced a 51% increase in proportion of participants from underrepresented communities.

DISCUSSION

MyAlliance shifts power, resources, and knowledge to community advocates, promoting brain health awareness and research participation, and demands substantial financial investment and administrative commitment. MyAlliance offers valuable lessons for building sustainable, community-centered research recruitment infrastructure, emphasizing the importance of localized engagement and cultural understanding.

Highlights

MyAlliance led to a significant increase in the representation of underrepresented racial and ethnic groups and individuals from rural areas.The service-oriented approach facilitated long-term community engagement and trust-building, extending partnerships between an academic medical center and community organizations.While effective, MyAlliance required substantial financial investment, with costs including infrastructure development, staff support, partner organization compensation, and promotional activities, underscoring the resource-intensive nature of inclusive research recruitment efforts.

Promoting diverse perspectives: Addressing health disparities related to Alzheimer's and all dementias

Dementia research lacks appropriate representation of diverse groups who often face substantial adversity and greater risk of dementia. Current research participants are primarily well-resourced, non-Hispanic White, cisgender adults who live close to academic medical centers where much of the research is based. Consequently, the field faces a knowledge gap about Alzheimer's-related risk factors in those other groups. The Alzheimer's Association hosted a virtual conference on June 14-16, 2021, supported in part by the National Institute on Aging (R13 AG072859-01), focused on health disparities. The conference was held entirely online and consisted of 2 days of core programming and a day of focused meetings centered on American Indian and Alaska Natives and on LGBTQIA+ populations. Over 1300 registrants attended discussions focused on the structural and systemic inequities experienced across diverse groups, as well as ways to investigate and address these inequities.

Caregiving During the COVID-19 Pandemic: A Cross-Sectional Study with Older Cisgender Sexual Minority Women in the United States

Purpose: This study describes prevalence of caregiving before and after the onset of the COVID-19 pandemic among racially diverse older cisgender sexual minority women, examines factors associated with caregiving, and assesses relationships between caregiving and health. Methods: A convenience sample of participants aged ≥50 years completed self-administered online surveys assessing sociodemographic characteristics, caregiver status, self-rated health, and depressive symptoms. Bivariate statistics compared response variables by race, caregiver status, and timing of caregiving relative to the pandemic. Results: Of 365 participants, 82.7% identified as lesbian or gay and 41.1% as Black/African American; 40% were caregivers before (n = 32), during (n = 34), or both before and during (n = 80) the pandemic. A greater proportion of caregivers lived with a partner (45.9% vs. 35.6%, p = 0.06), were unemployed (37.7% vs. 29.7%, p = 0.07), and had high school or lower education (11.6% vs. 5%, p = 0.09). No differences were found in self-rated health by caregiver status; however, a higher proportion of Black (vs. White) caregivers reported good to excellent physical health (77.9% vs. 62.9%, p = 0.05). Caregivers more frequently reported depressive symptoms (28.1% vs. 17.8%, p = 0.03). Caregivers both before and during the pandemic had lower educational attainment than those who provided care only before or only during the pandemic (p = 0.04). Conclusion: Caregiving was common among older sexual minority women during the pandemic and experiences varied by race and other social factors. Consideration of these intersecting experiences is important for fully understanding caregiver experiences during COVID-19. Overall, caregiving was associated with depressive symptoms, underscoring the importance of psychosocial support for all caregivers.

Understanding the inclusion and participation of adults from Black African Diaspora Communities (BAFDC) in health and care research in the UK: a realist review protocol

INTRODUCTION

People from Black African Diaspora Communities (BAFDC) experience poorer health outcomes, have many long-term conditions and are persistently under-represented in health and care research. There is limited focus on programmes, or interventions that support inclusion and participation of people from BAFDC in research. Through coproduction, this realist review seeks to provide a programme theory explaining what context and mechanisms may be required, to produce outcomes that facilitate inclusion and participation for people from BAFDC in health and care research, in the UK.

METHODS AND ANALYSIS

A group of people from BAFDC with lived and professional experience, representing all levels of the health and care research system, will coproduce a realist review with a team of African-Caribbean, white British and white British of Polish origin health and care researchers. They will follow Pawson's five steps: (1) shaping the scope of the review; (2) searching for evidence; (3) document selection and appraisal; (4) data extraction and (5) data synthesis. The coproduction group will help to map the current landscape, identifying key issues that may inhibit or facilitate inclusion. Data will be extracted, analysed and synthesised following realist logic analysis, identifying and explaining how context and mechanisms are conceptualised in the literature and the types of contextual factors that exist and impact on inclusion and participation. Findings will be reported in accordance with Realist and Meta-narrative Evidence Synthesis Evolving Standards .

ETHICS AND DISSEMINATION

The coproduction group will agree an ethical approach considering accountability, responsibility and power dynamics, by establishing a terms of reference, taking a reflexive approach and coproducing an ethical framework. Findings will be disseminated to BAFDC and the research community through arts-based methods, peer-reviewed publications and conference presentations, agreeing a coproduced strategy for dissemination. Ethical review is not required.

PROSPERO REGISTRATION NUMBER

CRD42024517124.

A Scoping Review of Neighborhoods and Cognitive Health Disparities Among US Midlife and Older Adults

Objectives: The neighborhood environment may be an important determinant of racial/ethnic disparities in cognitive function. To understand how neighborhoods are linked to cognition across racial/ethnic groups, this scoping review organizes research investigating relationships between multiple neighborhood domains and cognitive function in diverse samples of US midlife and older adults. Methods: PubMed/MEDLINE, Web of Science, and CAHL were used to extract quantitative disparities-focused studies (n = 17) that included US adults ages 50+, racial/ethnic minoritized populations, cognitive dependent variable(s), and neighborhood-level independent variable(s) published from January 2010 to October 2021. Results: Studies demonstrate variation within and between racial/ethnic groups in how neighborhood factors are associated with cognition. Economically and socially advantaged neighborhoods were associated with better cognition. Findings were mixed for built and neighborhood composition measures. Discussion: More research with greater racial/ethnic representation is needed to disentangle which aspects of the neighborhood are most salient for specific cognitive function domains across diverse populations.

A Framework for Assessing the Effects of Climate Change on Dementia Risk and Burden

Alzheimer's disease and related dementias (ADRD) represent a public health crisis poised to worsen in a changing climate. Substantial dementia burden is modifiable, attributable to risk rooted in social and environmental conditions. Climate change threatens older populations in numerous ways, but implications for cognitive aging are poorly understood. We illuminate key mechanisms by which climate change will shape incidence and lived experiences of ADRD, and propose a framework for strengthening research, clinical, and policy actions around cognitive health in the context of climate change. Direct impacts and indirect risk pathways operating through built, social, interpersonal, and biomedical systems are highlighted. Air pollution compromises brain health directly and via systemic cardiovascular and respiratory ailments. Flooding and extreme temperatures constrain health behaviors like physical activity and sleep. Medical care resulting from climate-related health shocks imposes economic and emotional tolls on people living with dementia and caregivers. Throughout, inequitable distributions of climate-exacerbated risks and adaptive resources compound existing disparities in ADRD incidence, comorbidities, and care burden. Translational research, including work prioritizing underserved communities, is crucial. A mechanistic framework can guide research questions and methods and identify clinical- and policy-level intervention loci for prevention and mitigation of climate-related impacts on ADRD risk and burden.

Conversation for change: engaging older adults as partners in research on gerotechnology

There is increasing research and public policy investment in the development of technologies to support healthy aging and age-friendly services in Canada. Yet adoption and use of technologies by older adults is limited and rates of abandonment remain high. In response to this, there is growing interest within the field of gerotechnology in fostering greater participation of older adults in research and design. The nature of participation ranges from passive information gathering to more active involvement in research activities, such as those informed by participatory design or participatory action research (PAR). However, participatory approaches are rare with identified barriers including ageism and ableism. This stigma contributes to the limited involvement of older adults in gerotechnology research and design, which in turn reinforces negative stereotypes, such as lack of ability and interest in technology. While the full involvement of older adults in gerotechnology remains rare, the Older Adults' Active Involvement in Ageing & Technology Research and Development (OA-INVOLVE) project aims to develop models of best practice for engaging older adults in these research projects. In this comment paper, we employ an unconventional, conversational-style format between academic researchers and older adult research contributors to provide new perspectives, understandings, and insights into: (i) motivations to engage in participatory research; (ii) understandings of roles and expectations as research contributors; (iii) challenges encountered in contributing to gerotechnology research; (iv) perceived benefits of participation; and (v) advice for academic researchers.

Brain Health Registry Study Partner Portal: Novel infrastructure for digital, dyadic data collection

BACKGROUND

In Alzheimer's disease (AD) research, subjective reports of cognitive and functional decline from participant-study partner dyads is an efficient method of assessing cognitive impairment and clinical progression.

METHODS

Demographics and subjective cognitive/functional decline (Everyday Cognition Scale [ECog]) scores from dyads enrolled in the Brain Health Registry (BHR) Study Partner Portal were analyzed. Associations between dyad characteristics and both ECog scores and study engagement were investigated.

RESULTS

A total of 10,494 BHR participants (mean age = 66.9 ± 12.16 standard deviations, 67.4% female) have enrolled study partners (mean age = 64.3 ± 14.3 standard deviations, 49.3% female), including 8987 dyads with a participant 55 years of age or older. Older and more educated study partners were more likely to complete tasks and return for follow-up. Twenty-five percent to 27% of older adult participants had self and study partner-report ECog scores indicating a possible cognitive impairment.

DISCUSSION

The BHR Study Partner Portal is a unique digital tool for capturing dyadic data, with high impact applications in the clinical neuroscience and AD fields. Highlights The Brain Health Registry (BHR) Study Partner Portal is a novel, digital platform of >10,000 dyads. Collection of dyadic online subjective cognitive and functional data is feasible. The portal has good usability as evidenced by positive study partner feedback. The portal is a potential scalable strategy for cognitive impairment screening in older adults.

From Sheltered in Place to Thriving in Place: Pandemic Places of Aging

BACKGROUND AND OBJECTIVES

Response to the coronavirus disease 2019 pandemic required rapid changes to physical, social, and technological environments. There is a need to understand how independent-living older adults are adapting to pandemic-borne transformations of place and how environmental factors may shape experiences of aging well in the context of a public health emergency response.

RESEARCH DESIGN AND METHODS

We conducted a photovoice study to examine the characteristics associated with aging in place. Our study investigated how independent-living older adults characterized aging in a "right" place approximately 1 year after the onset of the pandemic.

RESULTS

Six themes categorized into 2 groups capture how older adults describe a "right" place to age. The first category, "places as enactors of identity and belonging," describes the significance of places contributing to intimate relationships, social connections, and a sense of personal continuity. The second category, "places as facilitators of activities and values," recognizes environments that promote health, hobbies, goals, and belief systems. Participants reported modifying their daily living environments with increased use of technology and more time outdoors.

DISCUSSION AND IMPLICATIONS

Our findings emphasize older adults' active engagement with place and strategies used to maintain healthy aging despite public health restrictions. The results also identify place-based characteristics that may help overcome stressful circumstances from older adults' perspectives. These findings inform pathways to pursue to facilitate resiliency for aging in place.

The use of race terms in epigenetics research: considerations moving forward

The field of environmental epigenetics is uniquely suited to investigate biologic mechanisms that have the potential to link stressors to health disparities. However, it is common practice in basic epigenetic research to treat race as a covariable in large data analyses in a way that can perpetuate harmful biases without providing any biologic insight. In this article, we i) propose that epigenetic researchers open a dialogue about how and why race is employed in study designs and think critically about how this might perpetuate harmful biases; ii) call for interdisciplinary conversation and collaboration between epigeneticists and social scientists to promote the collection of more detailed social metrics, particularly institutional and structural metrics such as levels of discrimination that could improve our understanding of individual health outcomes; iii) encourage the development of standards and practices that promote full transparency about data collection methods, particularly with regard to race; and iv) encourage the field of epigenetics to continue to investigate how social structures contribute to biological health disparities, with a particular focus on the influence that structural racism may have in driving these health disparities.

Baseline levels and longitudinal rates of change in plasma Aβ42/40 among self-identified Black/African American and White individuals

Objective

The use of blood-based biomarkers of Alzheimer disease (AD) may facilitate access to biomarker testing of groups that have been historically under-represented in research. We evaluated whether plasma Aβ42/40 has similar or different baseline levels and longitudinal rates of change in participants racialized as Black or White.

Methods

The Study of Race to Understand Alzheimer Biomarkers (SORTOUT-AB) is a multi-center longitudinal study to evaluate for potential differences in AD biomarkers between individuals racialized as Black or White. Plasma samples collected at three AD Research Centers (Washington University, University of Pennsylvania, and University of Alabama-Birmingham) underwent analysis with C2N Diagnostics' PrecivityAD™ blood test for Aβ42 and Aβ40. General linear mixed effects models were used to estimate the baseline levels and rates of longitudinal change for plasma Aβ measures in both racial groups. Analyses also examined whether dementia status, age, sex, education, APOE ε4 carrier status, medical comorbidities, or fasting status modified potential racial differences.

Results

Of the 324 Black and 1,547 White participants, there were 158 Black and 759 White participants with plasma Aβ measures from at least two longitudinal samples over a mean interval of 6.62 years. At baseline, the group of Black participants had lower levels of plasma Aβ40 but similar levels of plasma Aβ42 as compared to the group of White participants. As a result, baseline plasma Aβ42/40 levels were higher in the Black group than the White group, consistent with the Black group having lower levels of amyloid pathology. Racial differences in plasma Aβ42/40 were not modified by age, sex, education, APOE ε4 carrier status, medical conditions (hypertension and diabetes), or fasting status. Despite differences in baseline levels, the Black and White groups had a similar longitudinal rate of change in plasma Aβ42/40.

Interpretation

Black individuals participating in AD research studies had a higher mean level of plasma Aβ42/40, consistent with a lower level of amyloid pathology, which, if confirmed, may imply a lower proportion of Black individuals being eligible for AD clinical trials in which the presence of amyloid is a prerequisite. However, there was no significant racial difference in the rate of change in plasma Aβ42/40, suggesting that amyloid pathology accumulates similarly across racialized groups.

Racial, Ethnic, and Geographic Diversity in Population Neuroscience

In this chapter, we consider lack of racial, ethnic, and geographic diversity in research studies from a public health perspective in which representation of a target population is critical. We review the state of the research field with respect to racial, ethnic, and geographic diversity in study participants. We next focus on key factors which can arise from the lack of diversity and can negatively impact external validity. Finally, we argue that the public's health, and future research, will ultimately be served by approaches from both recruitment and representation science and population neuroscience, and we close with recommendations from these two fields to improve diversity in studies.

Synthesizing Best Practices to Promote Health Equity for Older Adults Through Community-Engaged Research

Achieving health equity requires creating evidence that reflects the nuance and diversity of experiences among populations disproportionately impacted by age- and race-related disparities. Community-engaged research (CEnR) is one way to pursue equity in research on health and aging to ensure the relevance and translational potential of findings. The current review synthesizes best practices regarding CEnR that promote health equity among older adults, including an overview of CEnR, benefits, and fundamental principles, and three research exemplars from the authors' CEnR. Finally, we discuss these best practices and considerations for advancing CEnR to reduce health disparities experienced by historically underserved older adults and their families. [Research in Gerontological Nursing, 17(1), 9-16.].

Tele-Savvy Outcomes of Non-Hispanic Black American and White Caregivers

BACKGROUND AND OBJECTIVES

Tele-Savvy is a synchronous/asynchronous psychoeducation program for caregivers of community-dwelling persons living with Alzheimer's disease and related dementias (ADRD) designed to increase caregivers' competence and confidence (mastery) in caregiving. Its overall efficacy was tested in a randomized controlled trial.

RESEARCH DESIGN AND METHODS

This secondary data analysis examined the caregiver mastery and psychological health (i.e., perceived stress, depressive symptoms, and burden) outcome of 153 non-Hispanic Black American and White caregivers (31 non-Hispanic Black American and 122 White caregivers) from baseline to 6 months postintervention. Given the difference in the sample sizes of Black and White caregivers, a descriptive post hoc subgroup analysis was conducted of 21 non-Hispanic Black American and 20 White adult children and grandchildren caregivers.

RESULTS

In the overall sample, Black American caregivers demonstrated higher levels of mastery and lower levels of distress than White caregivers at baseline and across all time points. Over time, White caregivers, but not Black American caregivers, experienced significantly improved levels of mastery and significantly lowered levels of depression. Within the subgroup analysis, except for a moderate effect size in the management of situation scores over time among Black American adult children caregivers, similar results were obtained.

DISCUSSION AND IMPLICATIONS

The findings highlight the strengths and shortcomings of the Tele-Savvy program in improving caregiver mastery and reducing negative psychological health outcomes. Intentionally tailoring the Tele-Savvy program to certain racial and caregiving groups may hold promise in meeting the needs of more ADRD caregivers.

CLINICAL TRIAL REGISTRATION

NCT03033875.

Including Socially Isolated Black, Older Old Adults (Aged 80 and Above) with and without Mild Cognitive Impairment in a Clinical Trial: Recruitment Strategies and Perspectives

Objective

This study describes strategies for the recruitment of socially isolated older old Black individuals to participate in the "Internet-based conversational engagement clinical trial (I-CONECT)" (Clinical Trial.gov: NCT02871921) and lessons learned in this critical population segment.

Methods

Best practice strategies to recruit the target population included mass mailings, advertisements, and direct community outreach, including the collaboration with a community group created to reach Black individuals interested in research participation. We also made protocol changes to measure recruitment criteria for older old Black adults more accurately and to increase their participation.

Results

Descriptive data related to the challenges and successes in recruiting Black participants compared to the White participants is presented. The primary site contacted 17,523 primarily White potential participants and enrolled/randomized 145 White and 2 Asian/mixed race participants (0.8%). The Midwest site contacted 12,141 Black potential participants and enrolled/randomized 39 (0.3%) participants.

Discussion

While best practices were employed, several factors complicated recruitment, including the need to adjust recruitment criteria, navigate regional regulations, and respect diverse community preferences.

Conclusion

Older old African Americans are reachable and willing to participate in research when considering their beliefs and practices, influenced by their community and experience.

Connecting memory and functional brain networks in older adults: a resting-state fMRI study

Limited research exists on the association between resting-state functional network connectivity in the brain and learning and memory processes in advanced age. This study examined within-network connectivity of cingulo-opercular (CON), frontoparietal control (FPCN), and default mode (DMN) networks, and verbal and visuospatial learning and memory in older adults. Across domains, we hypothesized that greater CON and FPCN connectivity would associate with better learning, and greater DMN connectivity would associate with better memory. A total of 330 healthy older adults (age range = 65-89) underwent resting-state fMRI and completed the Hopkins Verbal Learning Test-Revised (HVLT-R) and Brief Visuospatial Memory Test-Revised (BVMT-R) in a randomized clinical trial. Total and delayed recall scores were assessed from baseline data, and a learning ratio calculation was applied to participants' scores. Average CON, FPCN, and DMN connectivity values were obtained with CONN Toolbox. Hierarchical regressions controlled for sex, race, ethnicity, years of education, and scanner site, as this was a multi-site study. Greater within-network CON connectivity was associated with better verbal learning (HVLT-R Total Recall, Learning Ratio), visuospatial learning (BVMT-R Total Recall), and visuospatial memory (BVMT-R Delayed Recall). Greater FPCN connectivity was associated with better visuospatial learning (BVMT-R Learning Ratio) but did not survive multiple comparison correction. DMN connectivity was not associated with these measures of learning and memory. CON may make small but unique contributions to learning and memory across domains, making it a valuable target in future longitudinal studies and interventions to attenuate memory decline. Further research is necessary to understand the role of FPCN in learning and memory.

Assessing Equitable Inclusion of Underrepresented Older Adults in Alzheimer's Disease, Related Cognitive Disorders, and Aging-Related Research: A Scoping Review

BACKGROUND AND OBJECTIVES

The rapidly aging and diversifying U.S. population is challenged by increases in prevalence of Alzheimer's disease (AD) and aging-related disorders. We conducted a scoping review to assess equitable inclusion of diverse older adult populations in aging research focused on National Institutes of Health (NIH)-sponsored research.

RESEARCH DESIGN AND METHODS

The scoping review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocol. The search was limited to NIH-funded studies focusing on aging, AD, and Alzheimer's disease-related dementias (ADRD) and included adults aged 55 and older. The priority populations and health disparities put forth by the National Institute on Aging Health Disparities Framework serve as a model for guiding inclusion criteria and for interpreting the representation of these underrepresented groups, including racial-ethnic minorities, socioeconomically disadvantaged, rural populations, groups with disabilities, and lesbian, gay, bisexual, transgender, and queer or questioning (LGBTQ) communities.

RESULTS

Our search identified 1,177 records, of which 436 articles were included in the analysis. Inclusion of individuals with ADRD and mild cognitive impairment, racial-ethnic minorities, rural populations, socioeconomically disadvantaged, groups with disabilities, and LGBTQ communities were poorly specified in most studies. Studies used multiple recruitment methods, conducting studies in community settings (59%) and hospitals/clinics (38%) most frequently. Incentives, convenience factors, and sustained engagement via community-based and care partners were identified as key strategies for improved retention.

DISCUSSION AND IMPLICATIONS

This scoping review identified gaps in existing literature and aims for future work, including stronger research focus on, better inclusion of, and improved data collection and reporting of older adults from underrepresented groups.

Practical Approaches to Advancing Health Equity in Radiology, From the AJR Special Series on DEI

Despite significant advances in health care, many patients from medically under-served populations are impacted by existing health care disparities. Radiologists are uniquely positioned to decrease health disparities and advance health equity efforts in their practices. However, literature on practical tools for advancing radiology health equity efforts applicable to a wide variety of patient populations and care settings is lacking. Therefore, this article seeks to equip radiologists with an evidence-based and practical knowledge tool kit of health equity strategies, presented in terms of four pillars of research, clinical care, education, and innovation. For each pillar, equity efforts across diverse patient populations and radiology practice settings are examined through the lens of existing barriers, current best practices, and future directions, incorporating practical examples relevant to a spectrum of patient populations. Health equity efforts provide an opportune window to transform radiology through personalized care delivery that is responsive to diverse patient needs. Guided by compassion and empathy as core principles of health equity, the four pillars provide a helpful framework to advance health equity efforts as a step toward social justice in health.

Plasma Aβ42/40 and cognitive variability are associated with cognitive function in Black Americans: Findings from the AA-FAIM cohort

Introduction

It is critical to develop more inclusive Alzheimer's disease (AD) research protocols to ensure that historically excluded groups are included in preclinical research and have access to timely diagnosis and treatment. If validated in racialized groups, plasma AD biomarkers and measures of subtle cognitive dysfunction could provide avenues to expand diversity in preclinical AD research. We sought to evaluate the utility of two easily obtained, low-burden disease markers, plasma amyloid beta (Aβ)42/40, and intra-individual cognitive variability (IICV), to predict concurrent and longitudinal cognitive performance in a sample of Black adults.

Methods

Two hundred fifty-seven Black participants enrolled in the African Americans Fighting Alzheimer's in Midlife (AA-FAIM) study underwent at least one cognitive assessment visit; a subset of n = 235 had plasma samples. Baseline IICV was calculated as the standard deviation across participants' z scores on five cognitive measures: Rey Auditory Verbal Learning Test Delayed Recall, Trail Making Test Parts A and B (Trails A and B), and Boston Naming Test. Using mixed effects regression models, we compared concurrent and longitudinal models to baseline plasma Aβ42/40 or IICV by age interactions. PrecivityAD assays quantified baseline plasma Aβ42/40.

Results

IICV was associated with concurrent/baseline performance on several outcomes but did not modify associations between age and cognitive decline. In contrast, plasma Aβ42/40 was unrelated to baseline cognitive performance, but a pattern emerged in interactions with age in longitudinal models of Trails A and B and Rey Auditory Verbal Learning Test total learning trials. Although not significant after correcting for multiple comparisons, low Aβ42/40 was associated with faster cognitive declines over time.

Discussion

Our results are promising as they extend existing findings to an Black American sample using low-cost, low-burden methods that can be implemented outside of a research center, thus supporting efforts for inclusive AD biomarker research.

Racial and Ethnic Disparities in Chronic Stress among Male Caregivers

Whereas research on caregiving is well documented, less is known about gender inequalities in caregiver stress, coping mechanisms, and health outcomes, all of which may vary by race, ethnicity, and socioeconomic status. This scoping review investigated racial and ethnic disparities using the Stress Process Model among male caregivers. Several databases were searched including Academic Search Premier, Medline Complete, APA PsycInfo, CINHAL, Google, ProQuest, and Web of Science. Included were peer-reviewed articles in English, published from 1990 to 2022. A total of nine articles fulfilled inclusion criteria. Most of the articles indicated that compared to White male caregivers, African American male caregivers provided more hours of care, assisted with more activities of daily living (ADLs) and instrumental activities of daily living (IADLs), and experienced more financial stress. In terms of coping style, one study found African American male caregivers, compared to White male caregivers, held negative religious beliefs. Another study showed that they were at a higher risk for stroke than their White counterparts. The search revealed a dearth of studies on racial disparities in stress, coping, and health outcomes among male caregivers. Further research is needed on the experiences and perspectives of male minority caregivers.

Factors affecting the recruitment of Hispanic/Latinx American older adults in clinical trials in the United States: A scoping review

OBJECTIVE

Participation of Hispanic/Latinx American older adults (HLAOA) in clinical trials is fundamental to health equity in aging research. However, information on strategies for the successful recruitment of this population in clinical trials is limited.

DESIGN

This scoping review aims to identify hindering and facilitating factors that impact the recruitment of HLAOA in clinical trials in the United States.

METHODS

Two databases (PubMed, EMBASE) were searched for original research articles from inception until March 2022 reporting on factors that engaged HLAoa (≥65) in clinical trials. One thousand and thirteen studies were scrutinized to identify 31 eligible articles.

RESULTS

Most articles were from cancer clinical trials (14 studies). Hindering factors that impacted the recruitment of HLAoa in clinical trials were related to (i) study design and logistics challenges, (ii) challenges imposed by social determinants of health, (iii) communication barriers, and (iv) patients' mistrust, and (v) family issues. Facilitating factors include (i) effective modes of outreach, (ii) strategic clinical trial design, (iii) incorporating culturally-respectful approaches that are tailored to the participants' sociocultural background, and (iv) bridging language barriers.

CONCLUSIONS

Successful recruitment of HLAOA into clinical trials requires identifying the study question, co-designing the trial design, implementation, and evaluation in respectful collaboration with the Hispanic/Latinx community with careful attention to their needs and minimizing the study burden on this vulnerable population. Factors identified here may guide researchers to better understand the needs of HLAOA and successfully recruit them into clinical trials, leading to more equitable research that increases their representation in clinical research.