Disability and care needs among older Americans

Who's On Your Team? Classifying Dementia Caregiving Networks and Associations With the Well-being of Caregivers and Care Recipients With Dementia

OBJECTIVES

While caregivers are typically enmeshed in broad networks of family and friends assisting with care, this network has been neglected in favor of examining a "primary" caregiver. This study examines types of family and unpaid friend networks for individuals with dementia and how one's network type relates to the well-being of care recipients with dementia and their caregivers.

METHODS

Data are drawn from the nationally representative 2017 National Health and Aging Trends Study and associated National Study of Caregiving. The sample includes 336 dementia care networks (network size mean = 2.9). We first identified network types using latent class analysis and then examined the extent to which network type is associated with the well-being of care recipients with dementia (sleep, depressive symptoms) and their caregivers (emotional difficulty, overload, social support from family and friends) using ANOVA and linear regressions adjusting for demographics.

RESULTS

3 network types were identified: "Siloed"-small networks, limited task sharing (29.8% of networks); "Small but Mighty"-small networks, high task sharing (23.0% of networks); and "Complex"-large networks, diverse membership, members who share and specialize in task assistance (47.2%). Individuals with dementia with a "Siloed" network had significantly poorer sleep quality and caregivers in "Siloed" networks reported receiving less social support from family and friends than those in "Small but Mighty" and "Complex" networks.

DISCUSSION

Caregiver networks that are less collaborative may need supports to reduce isolation among caregivers and improve health outcomes for individuals with dementia.

Occupational Therapists' Insights on Family Involvement in Videoconferencing-Based Home Assessments and Modifications in the Veterans Health Administration: A Descriptive Qualitative Study

IMPORTANCE

Collaboration between occupational therapists and family caregivers is essential during home assessments and modifications. The shift to videoconferencing-based assessments suggests increased family caregiver involvement, but the specifics of this change are unclear.

OBJECTIVE

To investigate family caregiver involvement during videoconferencing-based home assessments and subsequent modifications from the perspective of occupational therapists.

DESIGN

This descriptive qualitative study involved virtual, semistructured individual interviews with participants who were recruited through purposeful and snowball sampling. Data analysis followed a descriptive thematic analysis methodology with an inductive approach.

SETTING

All interviews were conducted virtually at each participant's preferred time and location.

PARTICIPANTS

Fifteen occupational therapists from the Veterans Health Administration (VHA) with experience in videoconferencing-based home assessments and subsequent modifications for rural veterans.

RESULTS

Four key themes were identified: (1) increased active involvement of family caregivers during the home assessment process, (2) circumstances that require family caregiver involvement for videoconferencing, (3) family caregiver-related factors affecting outcomes, and (4) strategies for effective family caregiver involvement.

CONCLUSIONS AND RELEVANCE

The findings suggest that veterans' family caregivers play a more active role during videoconferencing-based home assessments than they do during traditional in-person assessments. This increased involvement may lead to a higher workload for VHA occupational therapists, who should now train caregivers, and for family caregivers themselves, who need to perform tasks previously handled by occupational therapists during home visits. To address this challenge, occupational therapists can leverage the insights extracted from this study. Plain-Language Summary: Occupational therapists often collaborate with family caregivers to assess the safety and accessibility of clients in their homes, recommending changes to the home environment accordingly. However, occupational therapy practitioners do not fully understand how much family caregivers are involved in videoconferencing-based home assessments, which is a new remote method, and subsequent modifications to client interventions. In this study, we explored, through interviews with 15 occupational therapists from the Veterans Health Administration (VHA), how family caregivers are involved in videoconferencing-based home assessments and subsequent modifications that are made to client interventions. We found that family caregivers have a greater responsibility for additional tasks during videoconferencing compared with traditional in-person assessments, including conducting measurements typically handled by occupational therapists. This understanding will help VHA occupational therapists adjust their practices to improve service delivery and reduce the workload for both occupational therapists and family caregivers.

Breaking the silence: understanding the unique burden on informal Black male dementia caregivers

As the rates of Alzheimer's disease (AD) and AD and related dementias (ADRD) in the United States steadily rise, so too does the demand for informal caregiving. Research on AD/ADRD caregiving highlights the associated risk of adverse health outcomes and lower quality of life; however, there is a lack of discussion about Black male dementia caregivers, who already face unique health challenges. Through an intersectionality lens, this perspective will raise awareness of the multifaceted burden of Black male informal AD/ADRD caregiving, along with strategies to better support this underserved community. HIGHLIGHTS: The non-Hispanic Black population in the United States is disproportionately affected by Alzheimer's disease (AD) and AD and related dementias (ADRD), which will increase the demand for caregiving. Most dementia informal caregiving research focuses on non-Hispanic White females, with little emphasis on Black men, who represent an at-risk population. By adopting an intersectional approach, clinicians, researchers, and policymakers can better understand and improve the health of informal Black male AD/ADRD caregivers. The increasing prevalence of AD and ADRD in the US Black community can create an added strain on Black male informal caregivers. Examining the unique AD/ADRD caregiving needs of Black men can inform future research to improve the health of similar at-risk communities.

Family Structure and Unmet Care Needs Among Older Adults With and Without Dementia in the United States

BACKGROUND AND OBJECTIVES

Family members provide the bulk of assistance to older adults with care needs, but implications of family structure for unmet care needs-and differences when dementia is present-are less clear.

RESEARCH DESIGN AND METHODS

We use samples of older adults with care needs from the 2015 National Health and Aging Trends Study (NHATS) and the 2017 Panel Study of Income Dynamics (PSID). We examine 2 measures that indicate whether needs are being met for self-care and mobility activities: having unassisted difficulty with at least one activity (NHATS, PSID) and experiencing any adverse consequences related to a lack of help (NHATS). In NHATS we also combine these to identify individuals with met (no unassisted difficulty; no consequences), self-met (unassisted difficulty only), under-met (any consequence only), and unmet needs (unassisted difficulty, any consequence).

RESULTS

Adverse consequences were reported more often among those with dementia (43%) relative to those without (24%); in contrast, unassisted difficulty was reported by fewer older adults with dementia (68%, 70%) than without dementia (85%, 87%). Having more family members was positively associated (OR = 1.039) and having a spouse or partner was inversely associated (OR = 0.700) with experiencing adverse consequences. Having stepchildren was associated with lower odds of having unassisted difficulty (OR = 0.228, 0.531), but greater odds of unmet (relative to met) needs (RRR = 1.610). Most family associations were not moderated by dementia.

DISCUSSION AND IMPLICATIONS

Adverse consequences, unassisted difficulty, and unmet need are distinct concepts, and produce different estimates and distinctive relationships with dementia and family structure.

Robotic support for older adults with cognitive and mobility impairments

Introduction

Robots have the potential to support older adults with cognitive impairments and mobility impairments in daily tasks that could promote their independence, enhance their abilities, ensure safety, and lower healthcare costs.

Method

Using a participatory design approach, we focused on identifying the functional capabilities of the Stretch robot to support older adults with various cognitive or mobility impairments. Twelve participants (aged 60-97) were recruited to interact with the robot and give feedback regarding support in a home environment. Stretch is a mobile robot manipulator designed to support everyday activities using a lightweight telescoping arm mounted on a mobile base. We conducted a semi-structured interview with participants as they observed and interacted with Stretch, performing tasks such as providing reminders, picking up and delivering items, and facilitating video calls.

Results and Discussion

The participants were asked to share potential areas of application related to their daily activities to illustrate how Stretch could support them in their homes. Our user-centered design approach provided a unique opportunity to understand the needs of older adults with mobility impairments and cognitive impairments, to identify the type of tasks the robot could support, and to gain insights into potential facilitators and barriers for robot adoption.

Association between hygiene environment, care needs, and depression among Chinese older adults: A cohort analysis from the CHARLS

Limited research has explored the link between functional dependency, care needs, and depression among older adults. This study aims to explore the association between dependency levels and depression among Chinese older adults, as well as examine the relationship between hygiene environment and these two factors. Data were obtained from the CHARLS 2011-2018. A total of 4871 individuals aged 60 years and older were included. Generalized estimating equations were employed for the analysis. A conceptual framework was established to longitudinally illustrate the pathway from hygiene environment to dependency levels to depression. Findings indicated higher dependency levels and poorer hygiene environments were associated with an increased risk of depression, with dependency serving as a mediator between hygiene environment and depression. Policymakers should prioritize improvements in rural sanitation and long-term care policies, healthcare providers should enhance depression screening and caregiver training, and clinicians should provide personalized interventions to better address mental health challenges.

Caregiving Trajectories and Unmet Care Needs in Later Life

BACKGROUND AND OBJECTIVES

The evolution of care networks accompanying older adults' changing care needs-and implications for unmet care needs-are not well described.

RESEARCH DESIGN AND METHODS

Using group-based trajectory models, we identify 4 incident care need patterns ("care need trajectory groups") for 1,038 older adults in the 2012-2018 National Health and Aging Trends Study and 5 caregiving patterns ("caregiving trajectory groups") and a transient group among their 4,106 caregivers. We model associations between care need/caregiving trajectory groups and the rate of (approximating the proportion of rounds with) unmet care needs. We illustrate how predicted rates vary by care need trajectory groups and by network composition for networks with 2 caregivers.

RESULTS

The percentage of rounds with unmet care needs varies from 13% among older adults with few, stable needs to 62% among those with many, stable needs (p < .01). In models, care need trajectory group is strongly associated with the rate of unmet care needs; among those with steep increasing care needs, network composition is also predictive. For older adults with steep increasing care needs, when 1 caregiver provides high, variable, and another medium, stable care hours, the predicted rate of unmet care needs is low (0.16) and similar to those with few, stable care needs (0.12).

DISCUSSION AND IMPLICATIONS

The findings highlight the complexity and heterogeneity of older adults' care needs and caregiving patterns over time. For those with rapidly increasing needs, identifying and assessing the evolving care network may be a fruitful direction for forestalling unmet care needs.

Disparities by sex, race/ethnicity, and education in trends in the disability burden in the United States, 1996-2018

Research remains inconclusive on whether increased longevity is resulting in disability compression. Using the Health and Retirement Study and multistate models, this study is the first to examine trends (between 1996-2006 and 2008-18) across multiple key aspects of disability burden: namely, lifetime risk and age at onset of disability; recovery and mortality of the disabled; and disability-free life expectancy (DFLE) at age 50 in the United States' older population. Furthermore, we differentiate these trends by key socio-demographic factors: sex, race/ethnicity, and educational attainment. The analysis shows that over four-fifths of the total life expectancy increase at age 50 was in DFLE. This was accompanied by a one-year postponement in disability onset and insignificant recovery from disability. However, lifetime risk of disability remained unchanged between periods. Disability trends improved more for women than men. Latinx and the lowest-educated adults experienced no improvement in disability onset. The lowest-educated Whites exhibited substantial health deterioration.

Effects of an interdisciplinary programme on psychoemotional factors in informal caregivers of people with Alzheimer's disease

Alzheimer's disease (AD) causes a progressive deterioration in the person's memory and cognitive function, leading to a greater degree of dependency as the disease progresses. This causes a progressive increase in caregiver overload, leading to physical, psychological, and social impairments. This study aimed to evaluate the effects of a nine-month interdisciplinary intervention covering three areas (cognitive-behaviour, psycho-emotional, and physical activity) on various psycho-emotional variables in informal caregivers of people with AD. A trial was conducted in which 59 informal caregivers of people with AD were administered various instruments to assess psychoemotional aspects (EuroQol-5 Dimensions-3 Levels, Zarit Burden Inventory test, Satisfaction with Life Scale, General Happiness Questionnaire, Occupational Balance Questionnaire, Rosenberg Self-esteem Scale, Duke-UNC-11 Functional Social Support Questionnaire, and the Family Apgar Scale). Significant between-group improvements were obtained in occupational balance at 3 (p = 0.002), 6 (p = 0.013) and 9 months (p = 0.022) of intervention, in perceived social support at 3 months (p = 0.043) and satisfaction with life at 6 months (p = 0.020). No significant between-group differences were found in the remaining variables, although there were positive trends in intra-group scores for caregiver overload, quality of life, life satisfaction and family functioning. Thus, an interdisciplinary programme could have a positive influence on the variables assessed in informal caregivers of AD.

Hearing Loss, Difficulty With Activities of Daily Living, and Experience of Consequences of Related Unmet Needs in Older Adults: A Cross-Sectional Analysis

PURPOSE

Experiencing difficulty with activities of daily living (ADLs) and instrumental ADLs (IADLs) and/or the consequences of unmet ADL/IADL-related needs is associated with adverse health-related outcomes. The association of hearing loss (HL) with experiencing the consequences of unmet ADL/IADL-related needs is not well understood. We investigated the associations of HL with experiencing ADL/IADL difficulties and the consequences of unmet ADL/IADL-related needs in older adults.

METHOD

We investigated cross-sectional associations between audiometric HL, the number of ADL and IADL difficulties, and the number of consequences of unmet ADL/IADL-related needs among adults aged 65 years and older in the National Health and Aging Trends Study.

RESULTS

In 4,724 older adults, 30.5% (n = 1,736) and 30.9% (n = 1,727) had self-reported difficulty with ADLs and IADLs, respectively. Of the 2,289 participants who reported difficulty with at least one ADL/IADL, 14.0% (n = 741) reported experience of at least one consequence of an unmet ADL/IADL-related need. In multivariable ordinal regression analyses, mild (OR = 1.38, 95% CI [1.1, 1.73]) and moderate or greater (OR = 1.57, 95% CI [1.17, 2.1]) HL were associated with higher odds of difficulties with additional ADLs. Moderate or greater HL was associated with higher odds of reporting difficulties with additional IADLs (OR = 1.59, 95% CI [1.19, 2.12]). There was no significant association between HL and higher odds of having additional consequences of unmet needs.

CONCLUSIONS

Our results show an association between HL and a higher number of ADL and IADL difficulties. Adults with HL may require increased support to address difficulties with daily activities and prevent experiencing related consequences.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.28300049.

Housing characteristics of low and moderate income older adults with and without disabilities

Housing is relevant to quality-of-life for older adults with and without disabilities, particularly those with limited financial resources. Among 4,898 low- and moderate-income community-living National Health and Aging Trends Study respondents, we describe and examine differences in housing characteristics of older adults with (n = 2774) and without disability (n = 2124). Next, among those with disability (self-care, household-activity, or mobility limitations), we examine associations of housing characteristics with adverse consequences due to unmet care needs, including soiling oneself or having to stay inside. In descriptive analyses, those with disability (vs without) more commonly rented, lived in subsidized housing, lived in apartments or mobile homes, and with home disorder, home disrepair, and street disorder. In adjusted logistic regressions among the subgroup with disability, several housing characteristics were statistically significantly associated with adverse consequences. Policy, programmatic, and clinical interventions that account for housing as an important social determinant of older adult quality-of-life should be advanced.

Impact of Older Adults' Internet Use on Economic Burden of Informal Caregiving

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Housing stability for households with LTSS needs in America: Contrasting pre-pandemic housing data from 2017 with data from 2021

BACKGROUND

Economically insecure people with disabilities are often forced to choose between health and housing. Housing instability in the form of mortgage, rent delinquency, or missing utility payments can adversely affect the health and well-being of people with disabilities and, specifically, people with LTSS needs.

OBJECTIVE

Our study investigates the disparity in housing stability for LTSS households and non-LTSS disability households in comparison to non-disability households. We also investigate the differences in housing stability indicators between 2017 and 2021 (during COVID-19) to assess the potential impact of the COVID-19 crisis on housing instability. Finally, we conducted a stratified analysis to investigate the intricate relationship between LTSS needs and aging.

METHODS

We used data from the American Housing Survey (AHS) from 2017 to 2021 to conduct a logistic regression analysis to examine housing instability for households with members with LTSS needs. We also conducted a stratified logistic regression analysis, with data stratified by age groups, to investigate whether this relationship varied across different age groups.

RESULTS

LTSS households faced housing instability in 2017 and 2021, with higher odds of missing mortgage, rent, and utility payments. Compared to 2017, LTSS households in 2021 face marginally lower odds of missing mortgage and utility payments but higher odds of missing rent.

CONCLUSION

We need sustained policy intervention to reduce housing instability for LTSS and non-LTSS households. Some policies employed during the COVID-19 crisis at both federal and state levels may have reduced housing instability for the LTSS and non-LTSS disability households.

Identifying Needs and Support Services for Family Caregivers of Older Community-Based Family Members: Mixed-Method Research Findings

A recent Canadian study conducted in one province identified family caregiver support needs and essential support services when caring for older community-based family members requiring assistance with activities of daily living. Weekly interviews of 150 volunteer caregivers over 6 months identified 11 support needs and 5 essential support services. Scoping literature reviews of the 11 needs found they had all been identified before. Program logic investigations of the 5 support services identified a patch-work of temporarily available support services in existence across the province. Two governmental policies are recommended: (a) provincial policy assuring access to the five support services, and (b) federal policy for federal-provincial funding transfers to address the provincial cost of assured community-based support services. Family caregivers require this support to maintain their own and their family member's well-being, particularly as this caregiving prevents or delays older family member hospitalizations and nursing home entry.

Family Care Partners and Paid Caregivers: National Estimates of Role-Sharing in Home Care

BACKGROUND AND OBJECTIVES

We describe "role-sharing" in home care, defined as family care partners and paid caregivers assisting with the same task(s).

RESEARCH DESIGN AND METHODS

We studied 440 participants in the 2015 National Health and Aging Trends Study receiving paid help with self-care, mobility, or medical care. We describe patterns in receiving paid help only, help from care partners only, and role-sharing. We examine whether sole reliance on paid help or role-sharing differs by Medicaid-enrollment and dementia status.

RESULTS

Half (52.9%) of care networks involved role-sharing. Care networks involving role-sharing more often occurred among older adults with dementia (48.7% vs 25.6%, p < .001) and less often for those who were Medicaid-enrolled (32.1% vs 49.4%, p < .01). Those living with dementia more often experienced role-sharing in eating (odds ratio [OR] 3.9 [95% confidence interval {CI} 1.20, 8.50]), bathing (OR 2.7, [95% CI 1.50, 4.96]), dressing (OR 2.1 [95% CI 1.14, 3.86]), toileting (OR 2.9 [95% CI 1.23, 6.74]), and indoor mobility (OR 2.8 [95% CI 1.42, 5.56]), and less often received help solely from paid helpers with medication administration (OR 0.24, [95% CI .12, .46]). Medicaid-enrollees more often received paid help only in dressing (OR 2.0 [95% CI 1.12, 3.74]), outdoor (OR 2.4 [95% CI 1.28, 4.36]), and indoor mobility (OR 4.3 [95% CI 2.41, 7.62]), and with doctor visits (OR 2.8 [95% CI 1.29, 5.94]).

DISCUSSION AND IMPLICATIONS

Role-sharing is common, especially among older adults living with dementia who are not Medicaid-enrolled. Strategies supporting information sharing and collaboration in home-based care merit investigation.

Risks and Outcomes of New Onset of Unmet Need for Mobility and Self-Care Daily Activities

BACKGROUND AND OBJECTIVES

Among community-living older adults who have limitations in completing activities of daily living (ADLs), unmet need occurs when they cannot complete an ADL task because no one was available to help. Prior research described correlates of existing unmet needs but did not consider which older adults are at risk for new onset of unmet needs. This study assessed health characteristics that increased risk for new onset of unmet needs within a year and subsequent health outcomes.

RESEARCH DESIGN AND METHODS

Data are from 2011 to 2019 annual interviews of the National Health and Aging Trends Study. For each pair of 2 consecutive annual interviews, we determined whether new onset of unmet needs occurred between the first and second consecutive interviews. Mixed effects logistic regression models were computed to assess risks for new onset of unmet need across 14,890 paired observations from persons who needed help with mobility tasks and 12,514 paired observations from persons who needed help with self-care tasks.

RESULTS

Although demographic characteristics and chronic conditions had modest associations with new onset of unmet need, hospitalization between the 2 consecutive interviews was associated with a twofold increase in risk for new onset of unmet need. New onset of unmet need was associated with hospitalization, nursing home placement, and death in the year following the 2 consecutive annual interviews.

DISCUSSION AND IMPLICATIONS

The findings inform the need for frequent assessments of ADL care needs with the goal of preventing new onset of unmet needs, especially after hospitalization.

Family caregiving experiences of medical school faculty: high prevalence, high strain, and low resource awareness

BACKGROUND

Adult caregiving can be demanding and stressful, especially when the caregiver is employed. As the age of the U.S. population and workforce increases, more adults are providing care to aging family members.

OBJECTIVE

To understand the prevalence and aspects of the caregiving experience and caregiving strain among department of medicine faculty members, and to gauge their awareness and utilization of caregiving resources.

DESIGN

We used a cross-sectional survey design. A questionnaire survey was developed and launched in Redcap in October, 2022, and an invitation was emailed followed by two reminders to all full-time and part-time faculty members (N = 1053) in our department of medicine.

MAIN MEASURES

Faculty demographics, caregiver status, caregiving details, degree of mental or emotional strain, and knowledge of and use of employer and external caregiver resources.

KEY RESULTS

Of the 1053 faculty members who received up to three email survey invitations, 209 (20%) responded of which 76 (36%) were current caregivers and 117 (56%) were non-caregivers. Among the 76 current caregivers, 53 (70%) reported providing care for parents or parent-in-laws and 9 (12%) reported caring for a spouse. One-third of current caregivers reported caring for individuals with Alzheimer's disease or dementia/memory problems. Ninety-five% of current caregivers reported some or a lot of caregiving strain. A wide variation in knowledge of and use of employer and external caregiver resources was reported.

CONCLUSIONS

Department of medicine faculty who provide adult caregiving report a high prevalence of strain and wide variation in knowledge of and use of employer and external caregiver support services, suggesting opportunity to better understand where gaps exist in providing support for caregivers.

Trend in Respite Use by Race Among Caregivers for People Living With Dementia

BACKGROUND

Respite care provides short-term relief for caregivers. Despite efforts to promote respite use among Black caregivers, little is known if disparities in respite use between Black and White dementia caregivers have decreased over time. We examined a trend nationally to see if more recent efforts may have helped reduce disparities in respite use.

METHODS

We used a repeated cross-sectional design, with the data from 2015, 2017, and 2021 of the National Health and Aging Trends Study and National Study of Caregiving. Our study sample included 764 (in 2015), 839 (in 2017), and 521 (in 2021) non-Hispanic White and Black caregivers who provided care to older adults living with dementia, representing weighted 5 157 569 (2015), 5 877 997 (2017), and 4 712 144 (2021) dementia caregivers nationally. We conducted logistic regression models to assess the differences in respite use between White and Black caregivers over time.

RESULTS

In 2015, Black dementia caregivers had a respite care use rate 11.6 percentage points (95% CI: -16.9 to -6.4) lower than that of White dementia caregivers. However, both in 2017 and 2021, the difference in the use of respite was not statistically significant, leading to a reduced or no gap in respite use between White and Black dementia caregivers. However, respite use remained low in both groups.

CONCLUSIONS

Although the gap in respite use between Black and White dementia caregivers had been gradually narrowed over time, more efforts are needed to encourage more respite use among both groups through targeted efforts to address factors that hinder respite use.

Family Involvement in the Care of Nursing Home Residents With Dementia: A Scoping Review

Family members are involved in the lives of older adults with dementia in complex ways. This scoping review synthesizes existing research on family involvement in the care of nursing home residents with advanced dementia. Using the Arksey and O'Malley scoping review framework, electronic searches of PubMed, EBSCO's CINAHL Complete, and APA PsychInfo on the Ovid platform were conducted. Twenty-eight studies met inclusion criteria. Emergent themes and definitions of involvement were obtained through thematic analysis, including: (1) contact (through visitation, calling, or writing letters); (2) engagement in care activities (instrumental/activities of daily living); (3) planning and monitoring care (being aware of health and treatment changes, partnership with care staff, ensuring adequate care, and decision-making); and (4) supporting the resident (advocacy, socioemotional support, and financial support). Moreover, limited psychometrically sound instruments exist to measure family involvement. These limitations stall the progression of research targeting family involvement.

Confidants and Caregivers: Network Multiplexity and Subjective Well-Being of Older Adults

OBJECTIVES

Older adults rely on personal networks for different types of support. Given shifts in family composition in later adulthood, more work is needed to map network members who can provide multiple aspects of support and the implications for older adults. We explore the phenomenon of having the same network members as both a confidant and a caregiver (multiplexity) and its implications for the well-being of older adults.

METHODS

Using the 2011 National Health and Aging Trends Study, we describe the prevalence of having someone as both a confidant and a caregiver (henceforth "multiplex helper") for older adults and examine its association with subjective well-being. We also investigate the differences by having whom as multiplex helpers.

RESULTS

About three-quarters (76%) of older adults with at least 1 confidant and 1 caregiver have at least 1 multiplex helper. Partnered older adults are more likely to have any multiplex helpers than unpartnered counterparts and usually nominate their partner as a multiplex helper, whereas the unpartnered are more likely to rely on their children to serve multiple roles, especially for widowed older adults. Having a multiplex helper is associated with better subjective well-being.

DISCUSSION

Network multiplexity is prevalent and positively associated with the subjective well-being of older adults who have at least 1 confidant and 1 caregiver, above and beyond having any confidants or caregivers separately. The baseline patterns established in this study lay the groundwork for future research to further explore support dynamics in older adults' networks.

Physical, emotional, and financial burdens of toileting assistance for family caregivers in home care settings and factors associated with each burden: A cross-sectional study

AIM

Caregivers in home care settings may experience significant physical, emotional, and financial burdens in providing toileting assistance. However, few studies have evaluated these three aspects of caregiver burden. Therefore, this study aimed to clarify the physical, emotional, and financial burdens of toileting assistance and examine the factors associated with each burden.

METHODS

A self-administered postal questionnaire was distributed to 405 family caregivers of older adults receiving home care and subsidies for incontinence products in Japan in 2019. Family caregivers answered questions about toileting assistance, the perceived physical, emotional, and financial burdens of providing toileting assistance at home, and the urinary/fecal symptoms of older adults.

RESULTS

Of the 242 family caregivers who reported each burden, 213 (88%) had experienced at least one physical, emotional, or financial burden. The prevalence of physical, emotional, and financial burdens was 77.3%, 78.1%, and 70.7%, respectively. Approximately 60% of respondents reported experiencing all three burdens. Physical burden was associated with spouses acting as primary caregivers, nocturia, fecal incontinence, and the odor of urine/feces from toileting assistance. Emotional burden was associated with nighttime assistance, urinary/fecal leakage from absorbent incontinence products, and the odor of urine/feces. Financial burden was associated with frequent assistance, disposal costs of absorbent incontinence products, and the degree of toileting assistance.

CONCLUSIONS

The results revealed a high prevalence of the three burdens of toileting assistance among family caregivers, suggesting the need to assess these burdens. Furthermore, they suggested the importance of providing guidance to family members, which may help reduce these burdens.

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.

Examining Care Network Characteristics in Older Adults' Relocation to Residential Care Settings

Background and Objectives

When older adults face increasing care needs or limited support, remaining safely and comfortably at home becomes challenging. Extant research has primarily concentrated on characteristics of the older adult or their primary caregiver on nursing home admission. This study examines the risk of older adults transitioning to residential care (e.g., assisted living, nursing home), focusing on the influence of their care network or involvement of multiple helpers.

Research Design and Methods

Using the National Health and Aging Trends Study, we conducted competing risk regression models that account for mortality, following 7,085 initially community-dwelling older adults across Rounds 1-9 (2011-2019). We assessed network composition, size, shared tasks, and the number of in-network specialists or generalists while controlling for individual sociodemographic and health factors.

Results

Individuals with care networks that shared medical tasks had the highest risk of moving to a residential care setting, followed by those sharing household tasks. Conversely, shared mobility or self-care and transportation responsibilities were associated with lower risks. Having more generalists, but not specialists, increased the risk. Larger networks were associated with heightened risk, although having close family members like a spouse was protective.

Discussion and Implications

The findings underscore that care network characteristics are critical to older adults' ability to age in place. Specifically, older adults with larger networks, lacking a spouse or child, and providing complex care are at greater risk for relocating. Understanding care networks can guide interventions related to care network coordination and resource allocation to help avoid or postpone a residential care move.

Association between chronic conditions, multimorbidity, and dependence levels in Chinese community-dwelling older adults with functional dependence: a cross-sectional study in south-central China

Background

The rising prevalence of multimorbidity and functional dependence in community-dwelling older adults contribute to the demand for home care services. Evidence on how chronic conditions, especially multimorbidity, affect dependence levels among older adults with functional dependence in a socio-cultural context is much needed to inform policy, workforce, aged care service development to meet the care needs of this population.

Objectives

This study aimed to determine the association between chronic conditions, multimorbidity and dependence levels among Chinese community-dwelling older adults with functional dependence.

Methods

A cross-sectional study was conducted with 1,235 community-dwelling older adults with functional dependence in Hunan province, China, from June to October 2018. Data on socio-demographic factors, cognitive function, vision and hearing conditions, activities of daily living (ADLs), and health conditions were collected, and binary logistic regression analyses were used to determine the association between chronic conditions, multimorbidity and dependence levels, with adjustments for relevant covariates.

Results

Among the participants, 62.9% had multimorbidity. Parkinson's disease, stroke, COPD, hypertension, mood and psychotic disorders (Anx/Sch/Dep) were significantly associated with high levels of functional dependence. After adjusting for demographic variables, cognitive function, vision, and hearing conditions, we observed a significant relationship between multimorbidity and higher functional dependence, but this association became insignificant when including certain chronic diseases closely associated with high-level dependence. Study revealed that Parkinson's disease and stroke notably increase dependency risk across seven ADL domains, demonstrating their extensive impact on daily functioning.

Conclusion

The prevalence of multimorbidity among Chinese community-dwelling older adults with functional dependence is very high. The association of multimorbidity with functional dependence is mediated by specific chronic conditions. These findings highlight the necessity of adopting an integrated care model that combines medical and social care, with a particular emphasis on managing multimorbidity and critical chronic conditions that lead to severe functional dependence to preventing and diminish the onset of disabilities.

A Care Paradox: The Relationship Between Older Adults' Caregiving Arrangements and Institutionalization and Mortality

We investigate how the type of caregiving arrangement is associated with older Americans' outcomes. We use the Health and Retirement Study (2004-2018) and discrete-time event history analysis to assess the odds of institutionalization or death over a 14-year period among older adults with limitations in Activities of Daily Living (ADLs; e.g., bathing). We consider caregiving arrangements as conventional (i.e., spouse or adult child), unconventional (e.g., extended family, employee, friend), or self-directed (i.e., no caregiver). We find a "care paradox" in that self-directing one's own care was associated with a lower risk of institutionalization or death compared with having conventional care (spouse/adult caregiver) and unconventional care (employee). Relative to conventional care, having an employee caregiver was associated with increased risk of institutionalization. Findings are still observed when controlling for level of impairment and various health-related factors. More research is needed to understand older adults who self-direct their own care.

The Consequences of Unmet Needs for Assistance With Daily Life Activities Among Older Adults: A Systematic Review

Many older adults are experiencing unmet needs for assistance with the activities of daily living (ADLs) and instrumental activities of daily living (IADLs). Such unmet needs might threaten their physical and psychosocial well-being. We conducted a systematic review to provide a comprehensive picture of the health consequences of unmet ADL/IADL needs among older adults. Twenty-eight published articles were included for qualitative synthesis. We found that unmet ADL/IADL needs were consistently associated with higher health care utilization (e.g., hospitalization, medical spending) and adverse psychosocial consequences (e.g., anxiety, depression), while the findings of falls and mortality remain inconsistent. More studies are needed to draw firm conclusions and to allow for quantitative synthesis. This review advocates for more coordinated and comprehensive long-term care services for older adults. Future studies should explore how the adverse health outcomes identified in this review can be prevented or improved by adequately meeting older adults' needs for assistance.

Racial/Ethnic Differences in Self-Reported Upper Limb Limitations Among U.S. Older Adults

BACKGROUND

The development of disability related to activities of daily living (ADL) is of great concern in the aging population, particularly for Hispanic and Non-Hispanic (NH) Black older adults, where disability prevalence is greater compared to NH Whites. ADL-disability is typically measured across many functional tasks without differentiating upper- versus lower-limb limitations, hindering our understanding of disability burden. Despite the importance of the upper limbs for completing ADL and known age-related declines in function, racial/ethnic differences in upper limb function remain largely unknown.

METHODS

We identified 4 292 NH White, NH Black, and Mexican American older adults (≥65) from the 2011-2018 waves of the National Health and Nutrition Examination Survey (NHANES). We classified participants as having a limitation based on their ability to complete 5 upper-limb tasks (preparing meals, eating, dressing, reaching overhead, and grasping small objects) and compared limitation rates across racial/ethnic groups.

RESULTS

Compared to NH Whites, NH Black older adults had significantly greater odds of reporting difficulties preparing meals (odds ratio [OR]: 1.36, 95% confidence interval [95% CI]: 1.01, 1.86) and dressing (OR: 1.55, 95% CI: 1.19, 2.02), while Mexican Americans had greater difficulty preparing meals (OR: 1.70, 95% CI: 1.12, 2.58), dressing (OR: 1.63, 95% CI: 1.12, 2.36), and grasping small objects (OR: 1.48, 95% CI: 1.06, 2.07).

CONCLUSIONS

Our results demonstrate differences in self-reported upper limb ADL-disability across racial/ethnic groups, particularly for Mexican American older adults. Such findings underscore the need for routine monitoring of upper limb function throughout adulthood to identify limitations and target therapeutic interventions before independence is compromised.

Who do patients depend on as they age and for what medical needs? An exploratory study of Chinese and Latino primary care patients

BACKGROUND

As the U.S. population ages, family members increasingly act as informal caregivers, particularly for minority patients and those with limited English proficiency (LEP). However, physicians often do not identify or engage caregivers until there is a health crisis. This study aims to further our understanding of characteristics associated with having a caregiver present at a primary care visit, and better understand the specific roles family caregivers engage in to support older Chinese and Latino primary care patients.

METHODS

Primary care patients were surveyed by telephone in a study of language access and communication. Participants included Chinese and Latino primary care patients (≥ 65 years old) from an academic general medicine practice. We asked patients if anyone was in the room with them during their most recent primary care visit (yes = caregiver accompanied). We asked about caregiving support for various needs, and examined associations of patient and visit characteristics with being accompanied, and frequency of caregiver support roles overall and by caregiver accompaniment.

RESULTS

Among 906 participants, 80% preferred a non-English language, 64% were women, 88% had Medicare, and mean age was 76 years (range 65-97). 43% were accompanied to their most recent visit. Speaking English 'not at all' vs. 'very well' was associated with being caregiver accompanied (OR 3.5; 95% CI 1.3-9.7), as was older age ≥ 75 vs. 65-74 (OR 2.7; 95% CI 2.0-3.7). The most common roles being supported by caregivers included: transportation to medical appointments (63%), helping with medical decisions (60%), and talking with the doctor about the patient's medical care (54%). Even among unaccompanied patients, substantial proportions reported caregiver support with medical decisions (45%), talking with the doctor (33%), and medical needs at home (26%).

CONCLUSIONS

Opportunities for physicians to engage caregivers who have active support roles may be missed, especially if those caregivers are not present at the visit. Future interventions should aim to help physicians identify which patients have caregivers and for what needs, so they may effectively engage caregivers before a health crisis occurs.

Moderating Effects of Informal Care on the Relationship Between ADL Limitations and Adverse Outcomes in Stroke Survivors

BACKGROUND

Stroke survivors with limitations in activities of daily living (ADL) have a greater risk of experiencing falls, hospitalizations, or physical function decline. We examined how informal caregiving received in hours per week by stroke survivors moderated the relationship between ADL limitations and adverse outcomes.

METHODS

In this retrospective cohort, community-dwelling participants were extracted from the National Health and Aging Trends Study (2011-2020; n=277) and included if they had at least 1 formal or informal caregiver and reported an incident stroke in the prior year. Participants reported the amount of informal caregiving received in the month prior (low [<5.8], moderate [5.8-27.1], and high [27.2-350.4] hours per week) and their number of ADL limitations (ranging from 0 to 7). Participants were surveyed 1 year later to determine the number of adverse outcomes (ie, falls, hospitalizations, and physical function decline) experienced over the year. Poisson regression coefficients were converted to average marginal effects and estimated the moderating effects of informal caregiving hours per week on the relationship between ADL limitations and adverse outcomes.

RESULTS

Stroke survivors were 69.7% White, 54.5% female, with an average age of 80.5 (SD, 7.6) years and 1.2 adverse outcomes at 2 years after the incident stroke. The relationships between informal caregiving hours and adverse outcomes and between ADL limitations and adverse outcomes were positive. The interaction between informal caregiving hours per week and ADL limitations indicated that those who received the lowest amount of informal caregiving had a rate of 0.12 more adverse outcomes per ADL (average marginal effect, 0.12 [95% CI, 0.005-0.23]; P=0.041) than those who received the highest amounts.

CONCLUSIONS

Informal caregiving hours moderated the relationship between ADL limitations and adverse outcomes in this sample of community-based stroke survivors. Higher amounts relative to lower amounts of informal caregiving hours per week may be protective by decreasing the rate of adverse outcomes per ADL limitation.

Older adults preferences for long-term caregivers in China: a discrete choice experiment

OBJECTIVE

Understanding the preferences of old-age adults for their long-term caregivers can improve person-centred health care and the quality of long-term care (LTC). This study examines Chinese older adults' preferences for long-term caregivers.

STUDY DESIGN

This is a cross-sectional study.

METHODS

A national representative discrete choice experiment (DCE) surveyed 2031 adults aged 50-70 across 12 provinces in China. Each DCE scenario described five attributes: type of caregivers, place of LTC, contents of LTC, out-of-pocket payments, and quality of life (QoL). Preferences and the marginal willingness to pay (WTP) were derived using mixed-logit and latent class models.

RESULTS

Older adults displayed higher preferences for long-term caregivers who improve their QoL, incur lower out-of-pocket payments, and provide medical LTC services at home, with the maximum WTP of $22.832 per month. QoL was rated as the most important LTC factor, followed by the place of LTC and the type of caregivers. When the level of QoL improved from poor to good, respondents would be willing to pay $18.375 per month more (95% confidence interval: 16.858 to 20.137), and the uptake rate increased by 76.47%. There was preference heterogeneity among older people with different sex, education, family size, and knowledge of LTC insurance.

CONCLUSION

QoL was the most important factor in older Chinese adults' preference for caregivers. Home care and medical care from formal caregivers was preferred by older adults. We recommend training family caregivers, raising older people's awareness of LTC insurance, and guiding policymakers in developing people-oriented LTC and a multi-level LTC system.

Technology Use Among Older Adults and Their Caregivers: Cross-Sectional Survey Study

Background

Informal caregivers are called upon to provide substantial care, but more needs to be known about technology use among older adult and caregiver dyads.

Objective

This study described technology use among older adults and their caregivers, explored potential correlates of technology use, and highlighted implications for practice.

Methods

A cross-sectional survey was conducted among unpaid caregivers of older adults (n=486). Primary outcomes were self-reported technology (devices and functions) use among caregivers and their oldest care recipient. The concordance of technology use among caregivers and care recipients was also examined. Multivariable regression models were conducted separately for caregivers and care recipients.

Results

Greater proportions of caregivers used all examined technologies, except for the medication alerts or tracking function, than care recipients. Caregivers used an average of 3.4 devices and 4.2 functions, compared to 1.8 devices and 1.6 functions used by their care recipients. Among caregivers, younger age, higher income, and higher education were associated with more technology use (P<.05). Among care recipients, younger age, not having cognitive dysfunction, and caregiver's technology use were associated with more technology use (P<.05).

Conclusions

Understanding technology use patterns and device adoption across diverse caregiver and care recipient populations is increasingly important for enhancing geriatric care. Findings can guide recommendations about appropriate technology interventions and help providers communicate and share information more effectively with patients and their caregivers.

Longitudinal Care Network Changes and Associated Healthcare Utilization Among Care Recipients

This study examines caregiver networks, including size, composition, and stability, and their associations with the likelihood of hospitalization and skilled-nursing facility (SNF) admissions. Data from the National Health and Aging Trends Study linked to Center for Medicare and Medicaid Services data were analyzed for 3855 older adults across five survey waves. Generalized estimating equation models assessed the associations. The findings indicate each additional paid caregiver was associated with higher adjusted risk ratios (aRR) for hospitalization (aRR = 1.24, 95% CI 1.10-1.41) and SNF admission (aRR = 1.28, 95% CI 1.06-1.54) among care recipients, a pattern that is also observed with the addition of unpaid caregivers (hospitalization: aRR = 1.13, 95% CI 1.06-1.20; SNF: aRR = 1.12, 95% CI 1.02-1.23). These results suggest that policies and approaches to enhance the quality and coordination of caregivers may be warranted to support improved outcomes for care recipients.

Active involvement in scientific research of persons living with dementia and long-term care users: a systematic review of existing methods with a specific focus on good practices, facilitators and barriers of involvement

BACKGROUND

Active involvement of persons living with dementia (PLWD) and long-term care (LTC) users in research is essential but less developed compared to other patient groups. However, their involvement in research is not only important but also feasible. This study aims to provide an overview of methods, facilitators, and barriers for involving PLWD and LTC users in scientific research.

METHODS

A systematic literature search across 12 databases in December 2020 identified studies involving PLWD, LTC users, or their carers beyond research subjects and describing methods or models for involvement. Qualitative descriptions of involvement methods underwent a risk of bias assessment using the Critical Appraisal Skills Programme (CASP) Qualitative Checklist 2018. A data collection sheet in Microsoft Excel and thematic analysis were used to synthesize the results.

RESULTS

The eighteen included studies delineated five core involvement methods spanning all research phases: advisory groups, formal and informal research team meetings, action groups, workshops, and co-conducting interviews. Additionally, two co-research models with PLWD and carers were found, while only two studies detailed LTC user involvement methods. Four distinct involvement roles were identified: consulting and advisory roles, co-analysts, co-researchers, and partners. The review also addressed barriers, facilitators, and good practices in the preparation, execution, and translation phases of research, emphasizing the importance of diversity, bias reduction, and resource allocation. Trust-building, clear roles, ongoing training, and inclusive support were highlighted.

CONCLUSIONS

Planning enough time for active involvement is important to ensure that researchers have time to build a trusting relationship and meet personal needs and preferences of PLWD, LTC users and carers. Researchers are advised not to presume the meaning of burden and to avoid a deficit perspective. A flexible or emergent design could aid involved persons' ownership of the research process.

TRIAL REGISTRATION

Prospero 2021: CRD42021253736.

Race/Ethnicity, Nativity, and Gender Disparities in Unmet Care Needs Among Older Adults in the United States

BACKGROUND AND OBJECTIVES

Although disparities in disability and the unequal distribution of care resources are widely discussed in the literature, there has been less research on disparities in experiencing unmet care needs among older adults. This study aims to investigate how unmet care needs are unevenly distributed across social groups with various intersecting identities, such as race/ethnicity, nativity, and gender, although considering their care needs and care networks, drawing on the conceptual framework of the pathway to unmet needs.

RESEARCH DESIGN AND METHODS

The data for this study came from the National Health and Aging Trends Study (2011-2018), and the study sample consisted of 7,061 Medicare beneficiaries who needed assistance with daily activities. Questions about unmet care needs were in the form of consequences related to difficulty or lack of help with daily activities. Mixed-effects negative binomial regression models were used to predict rates of unmet needs.

RESULTS

Older adults of color, especially women, experienced higher rates of unmet care needs compared with their White and male counterparts. Although Black-White and gender differences in unmet needs were mostly explained by unequal exposures to care needs and differential care networks, Hispanic women and foreign-born Hispanic men were still at a disadvantage even after adjusting for these covariates.

DISCUSSION AND IMPLICATIONS

These results emphasize the importance of adopting an intersectional approach to enhance the quality of long-term services and support for older adults facing social disadvantages.

Social Services Post-discharge and Their Association With Readmission in a 2016 Swedish Geriatric Cohort

OBJECTIVES

To describe the social services received by a 2016 Swedish cohort after discharge from inpatient geriatric care and to analyze the association between level of social services post-discharge and 30-day readmission.

DESIGN

Observational, closed-cohort study.

SETTING AND PARTICIPANTS

All patients admitted to 1 of 3 regionally operated inpatient geriatric care settings in Region Stockholm, Sweden, in 2016 (n = 7453).

METHODS

Individual-level data from medical records and population registries were linked using unique personal identification numbers. Descriptive statistics were reported for 4 levels of municipal social services post-discharge: long-term care, 1 to 50 home help hours per month, >50 home help hours per month, and no home help. Multinomial logistic regression was performed to analyze the association between level of social services post-discharge and 3 outcomes within 30 days: readmission, death without readmission, or neither readmission nor death.

RESULTS

Results show that almost 11% of patients were discharged to long-term care and 54% received municipal home help services. Individuals with no municipal home help or with 1 to 50 hours per month were more likely to be readmitted within 30 days compared with those in long-term care. Living with more than 50 hours of help was not associated with an increased likelihood of 30-day readmission.

CONCLUSIONS AND IMPLICATIONS

Patients who received inpatient geriatric care are significant users of municipal social services post-discharge. Living in long-term care or with extensive home help appears to be a protective factor in preventing readmission compared with more limited or no home help services. Care transitions for this frail patient group require careful social care planning. Supporting individuals discharged with fewer social service hours may help reduce readmissions.

Characteristics and Range of Reviews About Technologies for Aging in Place: Scoping Review of Reviews

BACKGROUND

It is a contemporary and global challenge that the increasing number of older people requiring care will surpass the available caregivers. Solutions are needed to help older people maintain their health, prevent disability, and delay or avoid dependency on others. Technology can enable older people to age in place while maintaining their dignity and quality of life. Literature reviews on this topic have become important tools for researchers, practitioners, policy makers, and decision makers who need to navigate and access the extensive available evidence. Due to the large number and diversity of existing reviews, there is a need for a review of reviews that provides an overview of the range and characteristics of the evidence on technology for aging in place.

OBJECTIVE

This study aimed to explore the characteristics and the range of evidence on technologies for aging in place by conducting a scoping review of reviews and presenting an evidence map that researchers, policy makers, and practitioners may use to identify gaps and reviews of interest.

METHODS

The review was conducted in accordance with the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews). Literature searches were conducted in Web of Science, PubMed, and Scopus using a search string that consisted of the terms "older people" and "technology for ageing in place," with alternate terms using Boolean operators and truncation, adapted to the rules for each database.

RESULTS

A total of 5447 studies were screened, with 344 studies included after full-text screening. The number of reviews on this topic has increased dramatically over time, and the literature is scattered across a variety of journals. Vocabularies and approaches used to describe technology, populations, and problems are highly heterogeneous. We have identified 3 principal ways that reviews have dealt with populations, 5 strategies that the reviews draw on to conceptualize technology, and 4 principal types of problems that they have dealt with. These may be understood as methods that can inform future reviews on this topic. The relationships among populations, technologies, and problems studied in the reviews are presented in an evidence map that includes pertinent gaps.

CONCLUSIONS

Redundancies and unexploited synergies between bodies of evidence on technology for aging in place are highly likely. These results can be used to decrease this risk if they are used to inform the design of future reviews on this topic. There is a need for an examination of the current state of the art in knowledge on technology for aging in place in low- and middle-income countries, especially in Africa.

Lived experiences of older male caregivers: "That was the Worst!"

INTRODUCTION

Although caregiving is a traditional female role, older men represent an increasing proportion of family caregivers. This study's aim was to describe lived experiences of men who engaged in later-life caregiving.

METHOD

Streubert's phenomenological method, inclusive of unstructured interviews and respondent validation of a single formalized description, was applied to explore lived experiences of eight older male caregivers.

RESULTS

Three overarching themes characterized older male caregiving: 1) role and life changes, 2) "taking care of business," and 3) getting over "the worst". All caregivers spent extensive time in anticipatory planning for potential problems and were dissatisfied with existing resources and services. Each man described a profound, mentally-challenging caregiving crisis that triggered important caregiving decisions.

DISCUSSION

Study findings support an urgent need for research to clarify the mental health needs of older male caregivers and to test interventions that better meet the unique needs of this growing caregiver demographic.

Family Ties and Older Adult Well-Being: Incorporating Social Networks and Proximity

OBJECTIVES

This paper examines the family ties of older adults in the United States and how they are associated with mental health and social activity. We compare older adults with 4 types of family ties: adults "close" to family in proximity and social network, "kinless" older adults without a partner or children, "distanced" adults who live far from close kin, and "disconnected" older adults who do not report kin in their social network or do not report a location for some kin.

METHODS

Using pooled data from the National Health and Aging Trends Study 2015-2019 for older adults aged 70 and older (N = 24,818 person-waves), we examine how family ties are associated with mental health and social activity, and whether lacking family is tied to poor well-being because older adults' needs are not being met.

RESULTS

Kinless older adults and disconnected older adults have poorer outcomes (lower mental health scores and less social activity), compared to those close to their family. These findings suggest that both the presence and quality of the connection, as measured here via both location and social network, are critical for understanding which older adults are "at risk." Older adults who were not geographically proximate to their close kin (i.e., distanced) were not disadvantaged relative to those close to their families. Unmet needs do not help explain these patterns.

DISCUSSION

Our results highlight that family ties are important for older adults well-being, not just through their existence but also their quality and strength.

The Mediating Effect of Caregiving Relationship Quality on the Association Between Caregiving Stressors and Mental Health Problems Among Older Spousal Caregivers

Providing care to a spouse can be especially challenging for older adults given their compounding stressors resulting from aging and caregiving. This cross-sectional study examines the relationships between caregiving stressors and caregiver mental health problems and the potential mediator (i.e., caregiving relationship quality) of these associations. A total of 431 Americans (≥65 years) were selected from the National Study of Caregiving. Path analysis shows that care assistance was positively associated with caregiver mental health problems, and this association was mediated by negative relationship quality (Indirect effect  =  .14, p  =  .016). Moreover, role overload was positively associated with caregiver mental health problems, which was mediated by negative relationship quality (indirect effect  =  .13, p  =  .002). Findings suggest that caregiving stressors can adversely affect mental health by exacerbating negative relationship quality. Interventions that limit negative exchanges and increase compassionate communications between older spousal caregivers and their care-receiving partners are needed.

The Care Gap in Later Life Across European Countries

OBJECTIVES

Do adults without kin experience a care gap where they need help with activities of daily living but get no help from any source? We examine the prevalence of the care gap across Europe, and test whether those without partners or children substitute for their lack of close kin with help from broader networks, or whether they disproportionately experience care gaps.

METHODS

Using data from the Survey on Health, Ageing and Retirement in Europe, we estimate the care gap in 28 European countries and Israel, how it varies, and who provides help for respondents with different family structures.

RESULTS

The care gap is substantial, with 6.1% of all respondents ages 50 and above reporting a gap. It is highest in Western and Eastern Europe and lowest in Southern Europe and Israel. Respondents without partners or children are significantly more likely to have care gaps than those with close kin. However, respondents without close kin draw more often on more diverse networks of friends and relatives and use nursing home care.

DISCUSSION

Our study introduces the concept of the care gap and shows that although it is most common among unpartnered adults without children it is also quite common for those with immediate family. A broader network partially but not completely substitutes for care gaps among those without immediate family. Our results offer new insights into the demand for public care services in countries with diverse welfare states.

Malnutrition-related mortality trends in older adults in the United States from 1999 to 2020

BACKGROUND

Malnutrition mortality in older adults is underrepresented in scientific literature. This obscures any recent changes and hinders needed social change. This study aims to assess malnutrition mortality trends in older adults (≥ 65 years old) from 1999 to 2020 in the United States (U.S.).

METHODS

Mortality data from the Centers for Disease Control and Prevention's (CDC) Wide-Ranging Online Data for Epidemiology Research (WONDER) database were extracted. The ICD-10 Codes E40 - E46 were used to identify malnutrition deaths. Crude mortality rates (CMR) and age-adjusted mortality rates (AAMR) were extracted by gender, age, race, census region, and urban-rural classification. Joinpoint regression analysis was used to calculate annual percentage changes (APC) of AAMR by the permutation test and the parametric method was used to calculate 95% confidence intervals. Average Annual Percentage Changes (AAPC) were calculated as the weighted average of APCs.

RESULTS

Between 1999 and 2020, 93,244 older adults died from malnutrition. Malnutrition AAMR increased from 10.7 per 100,000 in 1999 to 25.0 per 100,000 in 2020. The mortality trend declined from 1999 to 2006 (APC = -8.8; 95% CI: -10.0, -7.5), plateaued till 2013, then began to rise from 2013 to 2020 with an APC of 22.4 (95% CI: 21.3, 23.5) and an overall AAPC of 3.9 (95% CI: 3.1, 4.7). Persons ≥ 85 years of age, females, Non-Hispanic Whites, residents of the West region of the U.S., and urban areas had the highest AAPCs in their respective groups.

CONCLUSION

Despite some initial decrements in malnutrition mortality among older adults in the U.S., the uptrend from 2013 to 2020 nullified all established progress. The end result is that malnutrition mortality rates represent a historical high. The burden of the mortality uptrends disproportionately affected certain demographics, namely persons ≥ 85 years of age, females, Non-Hispanic Whites, those living in the West region of the U.S., and urban areas. Effective interventions are strongly needed. Such interventions should aim to ensure food security and early detection and remedy of malnutrition among older adults through stronger government-funded programs and social support systems, increased funding for nursing homes, and more cohesive patient-centered medical care.

"I Didn't Know I Needed to Be Still": Experiences of Black Dementia Caregivers Attending Tailored Online Worship Services

The current study aimed to determine the feasibility and preliminary efficacy of culturally appropriate online worship services for Black dementia caregivers. Researchers met online with families six times over 8 weeks. Each meeting consisted of families viewing a short, uniquely tailored worship service. Preand post-surveys were conducted, and caregivers participated in in-depth, semi-structured interviews to discuss their experiences with the online worship services. All caregivers (N = 24) identified as Christian and African American. There was no significant mean difference between pre- and post-survey results, but there was a trend toward improving perception of caregiver role, caregiver burden, and dyadic relationship. Observations and interviews revealed two themes, Experiences and Feasibility of Engaging With Culturally Appropriate Online Worship Services. Although the preliminary efficacy of the online worship services remains to be investigated, our results suggest resources developed for caregivers of people living with dementia should be carefully tailored to ensure they are culturally appropriate and responsive. [Research in Gerontological Nursing, 16(6), 273-282.].

Paid care among older adults with long-term care needs declined in the first year of COVID-19 while families stepped in

Separate strands of research have documented impacts of the COVID-19 pandemic in nursing homes and among paid and family caregivers, yet there is little evidence connecting changes in the residential decisions of older adults with the provision of paid and family care, limiting our ability to identify potential substitutions and gaps in care. Using the 2020 wave of the Health and Retirement Study linked to county-level COVID-19 mortality rates, we found that, among older adults with long-term care needs, higher county-level mortality rates were associated with a decline in nursing home residence and an increase in co-residence with adult children. These changes were coupled with a decline in the likelihood of receiving paid care and in the number of paid caregivers and an increase in the hours of unpaid care received. This analysis documents a reduction in nursing home residence and paid care during the first year of the pandemic and shows that families filled some of the resulting care gaps. Policymaking around long-term care should consider whether declines in the use of paid care are permanent and how they will affect the health of older Americans and their caregivers over the next decade.

Racial, Ethnic, Nativity, and Educational Disparities in Cognitive Impairment and Activity Limitations in the United States, 1998-2016

Despite extensive research on cognitive impairment and limitations in basic activities of daily living, no study has investigated the burden of their co-occurrence (co-impairment). Using the Health and Retirement Study data and incidence-based multistate models, we study the population burden of co-impairment using three key indicators: mean age at onset, lifetime risk, and health expectancy. We examine patterns by gender, race, ethnicity, nativity, education, and their interactions for U.S. residents aged 50-100. Furthermore, we analyze what fractions of racial, ethnic, and nativity disparities in co-impairment are attributable to inequalities in educational attainment. Results reveal that an estimated 56% of women and 41% of men aged 50 will experience co-impairment in their remaining life expectancy. Men experience an earlier onset of co-impairment than women (74 vs. 77 years), and women live longer in co-impairment than men (3.4 vs. 1.9 years). Individuals who are Black, Latinx, and lower educated, especially those experiencing intersecting disadvantages, have substantially higher lifetime risk of co-impairment, earlier co-impairment onset, and longer life in co-impairment than their counterparts. Up to 75% of racial, ethnic, and nativity disparity is attributable to inequality in educational attainment. This study provides novel insights into the burden of co-impairment and offers evidence of dramatic disparities in the older U.S. population.

Community-Led, Cross-Sector Partnership of Housing and Health Care to Promote Aging in Place (Unite Health Project): Protocol for a Prospective Observational Study

BACKGROUND

For many older Americans, aging in place is their preferred living arrangement. Minoritized and socioeconomically disadvantaged older adults are up to 3 times more likely to experience disability than other groups, which increases their likelihood of being unable to age in place. Bold ideas to facilitate aging in place, particularly among vulnerable populations, are needed. One such idea is the Unite care model, a community-initiated, academic-supported, cross-sector initiative that combines 2 sectors: housing and health care. The Unite care model colocates a federally qualified health center clinic on an older adult affordable housing campus in Flint, Michigan.

OBJECTIVE

There are two aims to this study. Aim 1 is to evaluate the implementation of the Unite care model in terms of acceptability, adoption, and penetration. Aim 2 is to determine which older adults use the care model and whether the care model promotes aging in place through risk factor reduction and improvement in the physical and social environment.

METHODS

We will assess the care model using a concurrent, exploratory mixed methods design. For aim 1, acceptability will be assessed through semistructured interviews with key stakeholder groups; adoption and penetration will be assessed using housing and health care records. For aim 2, residents residing in the Unite clinic building will participate in structured outcome assessments at 6 and 12 months. Risk factor reduction will be measured by change in systolic blood pressure from baseline to 12 months and change in the physical and social environment (item counts) will also be assessed from baseline to 12 months.

RESULTS

Data collection for aim 1 began in July 2021 and is anticipated to end in April 2023. Data collection for aim 2 began in June 2021 and concluded in November 2022. Data analysis for aim 1 is anticipated to begin in the summer of 2023 and analysis for aim 2 will begin in the spring of 2023.

CONCLUSIONS

If successful, the Unite care model could serve as a new care model to promote aging in place among older adults living in poverty and older Black Americans. The results of this proposal will inform whether larger scale testing of this new model of care is warranted.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/47855.

Gatekeepers: The Association of Caregiving Network Characteristics With Emergency Department Use by Persons Living With Dementia

OBJECTIVES

Caregivers are typically enmeshed in networks of family and friends who assist with care, yet this network is largely neglected in research. In light of the fact that caregivers are key medical decision makers and play a critical role in how persons living with dementia (PLwDs) interface with the health care system, this study explores how features of the caregiver network relate to PLwD emergency department (ED) use.

METHODS

Using 2015 National Health and Aging Trends Study data linked with fee-for-service Medicare claims, we examine ED use in a nationally representative sample of community-dwelling persons aged 65 and older with dementia and at least 1 caregiver. We consider aspects of the caregiver network including membership (e.g., daughter in network), network size, hours of care received, and the presence of generalists and specialists (i.e., broad vs narrow functional assistance) as predictors of ED encounters among PLwD.

RESULTS

PLwDs were 81.5 years old on average, 50% were female, and 33% were non-White. Care networks including nonimmediate family members involved in task sharing for mobility and self-care difficulties and those with more generalists had significantly higher odds of an ED visit. Networks that only consisted of specialist caregivers had significantly lower odds of an ED visit.

DISCUSSION

Greater complexity of care networks increases risk of presenting to the ED for care. Better understanding how caregiving networks help PLwD interact with the health care system can inform intervention design and targeting in order to help care networks improve care coordination, management, and shared decision making.

Prevalence and risk factors of burden among caregivers of older emergency department patients

The number of older individuals that live independently at home is rising. These older individuals often rely on caregivers who have a similar age and health status. Therefore, caregivers may experience a high burden. We determined the prevalence and associating factors of burden among caregivers of older patients in the emergency department (ED). A cross-sectional study of primary caregivers of patients aged ≥ 70 years visiting the ED of a Dutch teaching hospital was performed. Structured interviews were conducted with patients and their caregivers. Caregiver burden was measured using the caregiver strain index (CSI). Additionally, data from questionnaires and medical records were extracted to determine potential associating factors. Univariate and multivariate regression analyses were conducted to identify independent determinants for burden. Seventy-eight caregivers (39%) experienced a high burden. Multivariate analysis showed a significant association between high caregiver burden and patients with cognitive impairment or dependency for instrumental activities of daily living (IADL) and more self-reported hours of care per day. Almost 40% of older patients in the ED have a caregiver who experiences a high burden. Formal assessment in the ED may help provide adequate care to the patients and their caregivers.

Quality of life and its associated factors among home-dwelling older people residing in the District of Colombo, Sri Lanka: a community-based cross-sectional study

INTRODUCTION

This community-based cross-sectional study explored the factors affecting overall and domain-specific (physical health, psychological health, social relationships and environmental) quality of life (QOL) of home-dwelling older residents of the District of Colombo, Sri Lanka.

METHODS

A representative sample (n=723) of older adults aged >65 years was obtained by the multistage cluster sampling technique. QOL was assessed using the validated Sinhala version of WHOQOL BREF Questionnaire. Data analysis was done using SPSS V.20.

RESULTS

The mean±SD age was 72.23±6.3 years with the overall QOL score being (mean±SD) 56.73±12.57/100. The mean±SD QOL score of physical health, psychological health, social relationships and environmental domains were 55.81±15.80, 59.25±14.68, 46.36±20.08 and 64.61±11.96, respectively. The overall QOL in the adjusted model showed a significant positive association with the educational status, living conditions (with spouse, with spouse and children), participation in religious activities, being visited by friends or relatives and financial independence. The overall QOL was negatively associated with limitations in activities of daily living and instrumental activities of daily living, chronic arthritis and heart disease in the adjusted model. Living with the spouse was positively associated with the psychological domain of QOL. Osteoporosis and chronic arthritis affected the physical health domain, while cancer and disabling stroke affected the psychological domain of QOL negatively. All statistical significances were considered at p<0.05.

CONCLUSION

The overall QOL of home-dwelling elders of the Colombo District is moderate, with the lowest score being in social relationships and the highest in the environmental domain. Educational status, engaging in religious activities and financial independence are key factors associated with a better QOL. Limitations in physical activity and chronic diseases are associated with a reduced QOL. Living with the spouse is a key factor associated with the psychological health domain.

The Effects of Increasing State Minimum Wage on Family and Paid Caregiving

Older adults may receive either or a combination of unpaid family/friend and paid caregiving. The consumption of family/friend and paid caregiving may be sensitive to minimum wage policies. We used data (n = 11,698 unique respondents) from the Health and Retirement Study and a difference-in-differences design to evaluate associations between increases in state minimum wage between 2010 and 2014 and family/friend and paid caregiving consumed by adults age 65+ years. We also examined responses to increases in minimum wage for respondents with dementia or Medicaid beneficiaries. People living in states that increased their minimum wage did not consume substantially different hours of family/friend, paid, or any family/friend or paid caregiving. We did not observe differential responses between increases in minimum wage and hours of family/friend or paid caregiving among people with dementia or Medicaid beneficiaries. Increases in state minimum wage were not associated with changes in caregiving consumed by adults age 65+.