"Relationships, Very Quickly, Turn to Nothing": Loneliness, Social Isolation, and Adaptation to Changing Social Lives Among Persons Living With Dementia and Care Partners

BACKGROUND AND OBJECTIVES

Persons with dementia and their care partners have known risks for loneliness and social isolation throughout the disease trajectory, yet little is described about social lives in a population heterogeneous for disease stage, syndrome type, and setting.

RESEARCH DESIGN AND METHODS

We conducted a secondary analysis of qualitative interviews from multiple studies to triangulate responses from a cohort of persons with dementia (n = 24), and active (n = 33) or bereaved (n = 15) care partners diverse in setting, dementia type and stage, and life experience. Interviews explored challenges related to social lives and were analyzed thematically.

RESULTS

Persons with dementia were on average 80 years old (range: 67-94), 38% female, and 78% diagnosed with Alzheimer's dementia; care partners were on average 67 years old (range: 40-87) and 69% female. We identified 3 primary themes. First, dyads lost external social networks due to complex factors, including discomfort of surrounding social networks, caregiving responsibilities, and progressive cognitive deficits. Second, care partners described disruptions of meaningful dyadic relationships due to progressive cognitive and functional deficits, leading to loneliness and anticipatory grief. Third, adaptive strategies centered on care partners facilitating shared social activities and programs addressing caregiver burden. An overarching theme of disease-course accumulation of barriers to social interactions and constant adaptations was present in all themes.

DISCUSSION AND IMPLICATIONS

Isolation and loneliness are a shared experience and source of distress for persons with dementia and care partners. Results can inform interventions tailored to individual needs and disease stages of dyads that enhance social connectedness.

Supporting technology access for older adults through in-home, intergenerational involvement: The case for ethnographic methods and student service-learning courses

This editorial comments on the article by Hawley et al.

Spouses of individuals living with mild cognitive impairment or dementia in the United States: A descriptive, population-based study

BACKGROUND

Little is known about the population of individuals who live with a spouse with cognitive impairment (CI) or dementia.

METHODS

Using the US Health and Retirement Study, 2000 to 2018, we estimated the population of adults ≥ 50 years old co-residing with a spouse with probable CI/dementia. We described their socio-demographic and health characteristics and quantified socio-demographic inequities.

RESULTS

Among community-dwelling adults ≥ 50 years old, 6% of women and 4% of men co-resided with a spouse with probable CI/dementia. Among those who were married/partnered, the prevalence of spousal dementia was greater for Black and Hispanic adults compared to their White counterparts, and for those with lower versus higher educational attainment. Among spouses, activities of daily living disability, depression, and past 2-year hospitalization was common.

DISCUSSION

Millions of older adults, disproportionately Black and Hispanic people and people with lower levels of educational attainment, live with a spouse with CI while also facing their own major health challenges.

The Role of Digital Technologies in Facilitating Psychosocial Resilience to Sudden Social Isolation Among Older Adults: Lessons Learned from the COVID-19 Pandemic

This study investigated how older adults adopted new technologies in response to sudden social isolation caused by the COVID-19 pandemic and how this adoption was related to their long-term psychosocial well-being. The study involved a 6-month longitudinal survey of 151 older adults and two phone-based focus groups, which informed a semi-structured interview guide and purposive sampling of diverse community-dwelling older adults. We then conducted twenty qualitative interviews and thematic analysis and mapped themes to 6-month quantitative trajectories of psychosocial health. Three themes emerged: first, most participants adopted multiple technologies to maintain social connection and psychosocial well-being. Second, participants felt left behind by certain technologies due to complicated systems or ageist societal norms. Third, pandemic-related community resources promoted technology independence among isolated older adults and those wanting to avoid "burdening" family. Results challenge ageist stereotypes and provide a framework for encouraging access and comfort with multiple technologies to adapt to sudden health crises or disruptive events.

Social Isolation and Worsening Health Behaviors Among Older Adults During the COVID-19 Pandemic

OBJECTIVES

We examine the relationship between social isolation, poor health behaviors, and the perceived worsening of older adults' health behaviors following the coronavirus outbreak. We assess the extent to which psychological pathways mediate the relationship between social isolation and worsening health behaviors.

METHODS

Drawing on data from the National Social Life Health and Aging Project Round 3 (2015) and its coronavirus immune disease 2019 (COVID-19) substudy (2020; N = 2,549), we use generalized linear models to explore how indicators of social isolation during the COVID-19 pandemic-infrequent in-person contact with friends and family in 2020 and decreased in-person contact with friends and family since COVID-19 started-are associated with (1) poor health behaviors (low physical activity, drinks per week, smoking, and poor sleep) in 2020 and (2) perceived worsening of health behaviors (reports of decreased physical activity, increased drinking and smoking, and feeling less rested) since the pandemic started.

RESULTS

Infrequent in-person contact was not associated with poor health behaviors. Decreases in in-person contact, on the other hand, were associated with worsening health behaviors. Older adults who reported decreases in in-person contact were more likely to perceive a decrease in physical activity, an increase in drinking, and feeling less rested. Emotional well-being, particularly loneliness compared to anxiety or depressive feelings, partially mediated the relationship between perceived worsening of health behaviors and a decrease in in-person contact with friends, and to a lesser extent, with family.

DISCUSSION

Our study suggests that in-person contact may play a distinct role in shaping older adults' well-being during the pandemic.

What Are "Social Prescriptions" and How Should They Be Integrated Into Care Plans?

Health consequences of social isolation and loneliness include worsened morbidity and mortality. Despite wide recognition of this fact, little is understood about how to intervene successfully. "Social prescribing" is one approach by which clinicians can intervene on social determinants of health, which include social isolation and loneliness. This commentary on a case defines social prescribing and suggests how to integrate it into practice.

Disparities in advance care planning among older US immigrants

BACKGROUND

Despite known racial disparities in advance care planning (ACP), little is known about ACP disparities experienced by US immigrants.

METHODS

We used data from the 2016 wave of the Health and Retirement Study. We defined ACP engagement as self-reported end-of-life (EOL) discussions, designation of a power of attorney (DPOA), documented living will, or "any" of the three behaviors. Immigration status was determined by respondent-reported birth outside the United States. Time in the United States was calculated by subtracting the year of arrival in the United States from the survey year of 2016. We used multivariable logistic regression to estimate the association between ACP engagement and immigration status and the relationship of acculturation to ACP engagement, adjusting for sociodemographics, religiosity, and life expectancy.

RESULTS

Of the total cohort (N = 9928), 10% were immigrants; 45% of immigrants identified as Hispanic. After adjustment, immigrants had significantly lower adjusted probability of any ACP engagement (immigrants: 74% vs. US-born: 83%, p < 0.001), EOL discussions (67% vs. 77%, p < 0.001), DPOA designation (50% vs. 59%, p = 0.001) and living will documentation (50% vs. 56%, p = 0.03). Among immigrants, each year in the United States was associated with a 4% increase in the odds of any ACP engagement (aOR 1.04, 95% CI 1.03-1.06), ranging from 36% engaged 10 years after immigration to 78% after 70 years.

CONCLUSION

ACP engagement was lower for US immigrants compared to US-born older adults, particularly for those that recently immigrated. Future studies should explore strategies to reduce disparities in ACP and the unique ACP needs among different immigrant populations.

Association of Social Isolation With Hospitalization and Nursing Home Entry Among Community-Dwelling Older Adults

Importance

Social isolation is associated with adverse health outcomes, yet its implications for hospitalization and nursing home entry are not well understood.

Objective

To evaluate whether higher levels of social isolation are associated with overnight hospitalization, skilled nursing facility stays, and nursing home placement among a nationally representative sample of community-dwelling older adults after adjusting for key health and social characteristics, including loneliness and depressive symptoms.

Design, Setting, and Participants

This observational cohort study included 7 waves of longitudinal panel data from the Health and Retirement Study, with community-dwelling adults aged 65 years or older interviewed between March 1, 2006, and June 30, 2018 (11 517 respondents; 21 294 person-years). Data were analyzed from May 25, 2022, to May 4, 2023.

Main Outcomes and Measures

Social isolation was measured with a multidomain 6-item scale (range, 0-6, in which a higher score indicates greater isolation). Multivariate logistic regressions were performed on survey-weighted data to produce national estimates for the odds of self-reported hospitalization, skilled nursing facility stays, and nursing home placement over time.

Results

A total of 57% of this study's 11 517 participants were female, 43% were male, 8.4% were Black, 6.7% were Hispanic or Latino, 88.1% were White, 3.5% were other ("other" includes American Indian or Alaska Native, Asian or Pacific Islander, and other race, which has no further breakdown available because this variable was obtained directly from the Health and Retirement Study), and 58.2% were aged 65 to 74 years. Approximately 15% of community-dwelling older adults in the US experienced social isolation. Higher social isolation scores were significantly associated with increased odds of nursing home placement (odds ratio, 2.01; 95% CI, 1.21-3.32) and skilled nursing facility stays (odds ratio, 1.16; 95% CI, 1.06-1.28) during 2 years. With each point increase in an individual's social isolation score, the estimated probability of nursing home placement or a skilled nursing facility stay increased by 0.5 and 0.4 percentage points, respectively, during 2 years. Higher levels of social isolation were not associated with 2-year hospitalization rates.

Conclusions and Relevance

This cohort study found that social isolation was a significant risk factor for nursing home use among older adults. Efforts to deter or delay nursing home entry should seek to enhance social contact at home or in community settings. The design and assessment of interventions that optimize the social connections of older adults have the potential to improve their health trajectories and outcomes.

Perceptions of the Role of Living Alone in Providing Services to Patients With Cognitive Impairment

Importance

The potential role of living alone in either facilitating or hampering access to and use of services for older adults with cognitive impairment is largely unknown. Specifically, it is critical to understand directly from health care and social services professionals how living alone creates barriers to the access and use of supportive health care and social services for racially and ethnically diverse patients with cognitive impairment.

Objective

To identify the potential role of living alone in the access and use of health care and social services for diverse patients with cognitive impairment by investigating professionals' perceptions of caring for such patients who live alone in comparison with counterparts living with others.

Design, Setting, and Participants

This qualitative study of 76 clinicians, social workers, and other professionals used semistructured interviews conducted between February 8, 2021, and June 8, 2022, with purposively sampled professionals providing services to diverse patients with cognitive impairment in Michigan, California, and Texas.

Main Outcomes and Measures

Clinicians, social workers, and other professionals compared serving patients with cognitive impairment and living alone vs counterparts living with others. An inductive content analysis was used to analyze the interview transcripts.

Results

A total of 76 professionals were interviewed (mean [SD] age, 49.3 [12.7] years); 59 were female (77.6%), 8 were Black or African American (11%), and 35 were White (46%). Participants included physicians, nurses, social workers, and home-care aides, for a total of 20 professions. Participants elucidated specific factors that made serving older adults living alone with cognitive impairment more challenging than serving counterparts living with others (eg, lacking an advocate, incomplete medical history, requiring difficult interventions), as well as factors associated with increased concerns when caring for older adults living alone with cognitive impairment, such as isolation and a crisis-dominated health care system. Participants also identified reasons for systematic unmet needs of older adults living alone with cognitive impairment for essential health care and social services, including policies limiting access and use to public home-care aides.

Conclusions and Relevance

In this qualitative study of professionals' perspectives, findings suggest that living alone is a social determinant of health among patients with cognitive impairment owing to substantial barriers in access to services. Results raised considerable concerns about safety because the US health care system is not well equipped to address the unique needs of older adults living alone with cognitive impairment.

The association of gait speed and self-reported difficulty walking with social isolation: A nationally-representative study

BACKGROUND

Mobility assessments are commonly used among older adults as risk stratification for falls, preoperative function, frailty, and mortality. We determined if gait speed and self-reported difficulty walking are similarly associated with social isolation and loneliness, which are key markers of social well-being and linked to health outcomes.

METHODS

We used 2015-2016 data from the National Social life Health and Aging Project (NSHAP), an in-person nationally-representative survey of 2640 community-dwelling adults ≥65 years old. We measured gait speed (timed 3-m walk: unable to walk, ≥5.7 s, and <5.7 s), and self-reported difficulty walking one block or across the room (unable, "much," "some," or "no" difficulty). Social measures included loneliness (3-item UCLA scale), social isolation (12-item scale), and individual social activities (frequency socializing, religious participation, community participation, and volunteering). We used logistic regression to determine the adjusted probability of each social measure by gait speed and difficulty walking, adjusting for sociodemographic and health characteristics, and tested for interaction terms with age.

RESULTS

Participants were on average 75 years old (SD = 7.1), 54% female, 9% Black/African American, and 6% Hispanic. Difficulty walking one block was associated with (p < 0.05): social isolation (much difficulty: 26% vs no difficulty: 18%), low socializing (33% vs 19%), low volunteering (67% vs 53%), low community participation (54% vs 43%), low religious participation (51% vs 46%), and loneliness (25% vs 14%). Difficulty walking across the room was similarly strongly associated with social isolation and individual activities. The association between self-reported difficulty walking and social isolation was stronger at older ages (p-value of interaction <0.001).

CONCLUSIONS

Self-reported mobility difficulty is a widely used clinical assessment that is strongly associated with loneliness and social isolation, particularly at older ages. Among persons with limited mobility, clinicians should consider a careful social history to identify social needs and interventions addressing mobility to enhance social connections.

End-of-life health care use among socially isolated and cognitively impaired older adults

BACKGROUND

Social isolation is common in the last years of life, especially among individuals with cognitive impairment (CI), but it is unknown if social isolation is related to end-of-life health care use.

METHODS

We used nationally-representative 2006-2018 Health and Retirement Study (HRS) data linked to Medicare claims, including adults age ≥65 interviewed in the last 4 years of life (N = 2380). We used a validated social isolation scale and three social isolation subscales: (1) household contacts (marital status, household size, nearby children), (2) social network interaction (with children, family, and friends), and (3) community engagement. End-of-life health outcomes included 2+ emergency department (ED) visits in the last month of life, hospitalizations or ICU stays in the last 6 months of life, and any hospice use. CI was defined using the validated Langa-Weir methodology. We used logistic regression to test the association of each social isolation measure with each end-of-life outcome, adjusted for sociodemographic covariates, and tested for interaction terms with CI (p < 0.2).

RESULTS

The mean age of our sample of decedents was 81.2 (SD = 9.9), 53% were female, 8% Black, and 4% Hispanic. Overall, social isolation and the community engagement subscale were not associated with end-of-life health care use. Fewer household contacts were associated with lower hospice use (aOR = 0.74, p = 0.005). There were significant interaction terms between the social network interaction subscale and CI for ED use (p = 0.009) and hospitalizations (p = 0.04), and a trend for ICU stays (p = 0.15); individuals with both low social network interaction and CI had lower health care use across all three outcomes compared to other groups.

CONCLUSIONS

Individuals with fewer household contacts had lower hospice use, and cognitively impaired individuals with low social network interaction had fewer end-of-life ED visits, hospitalizations, and ICU stays. Clinicians should consider mobilizing external support services to ensure access to goal-concordant care for older adults with limited end-of-life social contact when needed.

Persistent loneliness due to COVID-19 over 18 months of the pandemic: A prospective cohort study

BACKGROUND

Loneliness was common early in the COVID-19 pandemic due to physical distancing measures, but little is known about how loneliness persisted into later stages of the pandemic. We therefore examined longitudinal trajectories of loneliness over 18 months of the pandemic and subgroups at risk for persistent loneliness.

METHODS

We used data from the COVID-19 & Chronic Conditions study collected between March 27, 2020 to December 10, 2021, including 641 predominantly older adults with ≥1 chronic condition who completed six interviews at approximately 3 month intervals. Participants reported loneliness (defined as some, most, or all of the time) during the past week due to COVID-19. We used trajectory mixture models to identify clusters of individuals following similar trajectories of loneliness, then determined subgroups likely to be classified in different loneliness trajectories using multivariable regression models adjusted for sociodemographic and clinical covariates.

RESULTS

Participants were on average 63 years old, 61% female, 30% Black, 20% Latinx, and 29% were living below the poverty level. There was an overall reduction in loneliness over time (March to April/2020: 51% to September to December/2021: 31%, p = 0.01). Four distinct trajectory groups emerged: (1) "Persistent Loneliness" (n = 101, 16%); (2) "Adapted" (n = 141, 22%), individuals who were initially lonely, with feelings of loneliness decreasing over time; (3) "Occasional loneliness" (n = 189, 29%); and (4) "Never lonely" (n = 211, 33%). Subgroups at highest risk of the "Persistently Lonely" trajectory included those identifying as Latinx (aOR 2.5, 95% CI: 1.2, 5.2), or living in poverty (aOR 2.5; 95% CI: 1.4, 4.6).

CONCLUSIONS

Although loneliness declined for a majority of older adults during the pandemic in our sample, persistent loneliness attributed to the COVID-19 pandemic was common (1 in 6 adults), particularly among individuals identifying as Hispanic/Latinx or living in poverty. Interventions addressing loneliness can ease pandemic-related suffering, and may mitigate long-term mental and physical health consequences.

Key Elements and Mechanisms of a Peer-Support Intervention to Reduce Loneliness and Isolation among Low-Income Older Adults: A Qualitative Implementation Science Study

This paper describes the evaluation of a longitudinal peer-support program developed to address loneliness and isolation among low-income, urban community-dwelling older adults in San Francisco. Our objective was to determine barriers, challenges, and successful strategies in implementation of the program. In-depth qualitative interviews with clients (n = 15) and peers (n = 6) were conducted and analyzed thematically by program component. We identified barriers and challenges to engagement and outlined strategies used to identify clients, match them with peers, and provide support to both peers and clients. We found that peers played a flexible, non-clinical role and were perceived as friends. Connections to community resources helped when clients needed additional support. We also documented creative strategies used to maintain inter-personal connections during the COVID-19 pandemic. This study fills a gap in understanding how a peer-support program can be designed to address loneliness and social isolation, particularly in low-income, urban settings.

Analyzing Birth Cohorts With the National Social Life, Health, and Aging Project

OBJECTIVES

In this article, we seek to provide assistance to those who might want to use data from the National Social Life, Health, and Aging Project (NSHAP) Rounds 1-3 to compare those born in different cohorts. We outline 2 theoretical models that underlie the design of NSHAP-the life course model and the birth cohorts model-and review examples of social and political changes that may have differentially affected cohorts of older adults. Then we present 2 ways that NSHAP data might be used to compare cohorts, show examples of analyses of cohort differences in measures in NSHAP, and discuss features of the data that might affect their use for this purpose.

METHODS

Round 3 of the NSHAP added a group of respondents born between 1948 and 1965, the Baby Boom. Together with data from an earlier cohort, interviewed in Rounds 1-3, these data allow analysis of birth cohorts of older adults in the United States. We show examples of some approaches.

RESULTS

Our age-matched cohort differences approach included all observations where the respondent was aged 57-67 at the time of interview in different time periods (3,816 observations overall; 2,316 for the Silent Generation cohort and 1,500 for the Baby Boom cohort). Our second approach, age, period, and cohort effects, models the effects of age and birth year using restricted cubic splines, with one model excluding the linear effect of birth year, and the other excluding the linear effect of period. We present examples of analyses using each of these methods.

DISCUSSION

We describe features of the NSHAP data of which researchers should be aware when conducting cohort analyses with these data.

Social Health in the National Social Life, Health, and Aging Project

OBJECTIVES

In this article, we present the theoretical framework that guided the development of the National Social Life, Health, and Aging Project (NSHAP) including the measures of social health. We discuss the literature that links social measures to other outcomes, and we discuss in detail how researchers might construct common measures of social health, including those that reflect social relationships, sexuality, social networks, social resources, and social participation.

METHODS

The NSHAP includes multiple detailed measures of social health, collected in the rounds of data collection carried out in 2005, 2010, and 2015, allowing for study of changes over time and as people age among a nationally representative sample of the community-dwelling population of older adults in the United States.

RESULTS

We define indicators of social health, describe measures of each in the 2015 round of NSHAP, and show the distribution of the measures by gender and age. We present scales of dimensions of social health that have been developed elsewhere and describe their properties.

DISCUSSION

We briefly discuss the distribution of these measures by age and gender in the 2015 round of NSHAP. Simple analyses of these categorized measures reveal differences by age and gender that deserve closer attention in future investigations using the NSHAP data.

Use of High-risk Medications Among Lonely Older Adults: Results From a Nationally Representative Sample

This cross-sectional study investigates the relationship between loneliness and high-risk medication use in adults older than 65 years.

Engaging Diverse Older Adults With Cognitive Impairment and Caregivers in Advance Care Planning: A Pilot Study of the Interactive PREPARE Website

INTRODUCTION

Engaging patients with cognitive impairment in advance care planning (ACP), including completing advance directives and naming health care proxies, before they lose decision-making capacity is important.

METHODS

We determined the feasibility of the PREPAREforYourCare.org ACP program among 20 diverse older adults with mild-to-moderate cognitive impairment and their caregivers in a 1-week, pre-post pilot. We examined ease-of-use, satisfaction, and feasibility using validated scales, and change in ACP Engagement scores, including knowledge, contemplation, self-efficacy, and readiness subscales (5-point scales), from baseline to 1-week.

RESULTS

Participants were on average 70 years old (SD=9.0), 45% Spanish-speaking, 60% had limited health literacy, and 15% felt comfortable using the internet. Patients and caregivers rated PREPARE a mean of 8.6 (SD=1.6) and 9.4 (SD=1.1) on the 10-point ease-of-use scale, 4.7 (SD=0.4) and 4.7 (SD=0.3) on the 5-point satisfaction scale, and 4.9 (SD=0.4) and 4.8 (SD=0.6) on the 5-point feasibility scale, respectively. ACP engagement scores increased for 16 of 20 (80%) patients (P=0.03) and 16 of 20 (80%) caregivers (P=0.18). Caregivers experienced increased knowledge (3.8 to 4.7, P=0.002) and self-efficacy (3.6 to 4.5, P=0.034) for ACP.

DISCUSSION

The PREPARE website was feasible and may facilitate ACP engagement among diverse older adults with cognitive impairment and their caregivers.

A peer intervention reduces loneliness and improves social well-being in low-income older adults: A mixed-methods study

BACKGROUND

Evidence-based interventions addressing loneliness and social isolation are needed, including among low-income, community-dwelling older adults of diverse racial and ethnic backgrounds. Our objective was to assess the effect of a peer intervention in addressing loneliness, isolation, and behavioral health needs in this population.

METHODS

We conducted a mixed-method, two-year longitudinal study of a peer-outreach intervention in 74 low-income older adults recruited via an urban senior center in San Francisco. Structured participant surveys were conducted at baseline and every 6 months for up to 2 years. Outcomes included loneliness (3-item UCLA loneliness scale), social interaction (10-item Duke index), self-perceived socializing barriers (range: 0-10), and depression (PHQ-2 screen). Data were analyzed using mixed-effects linear and logistic regression adjusted for age and gender. Qualitative, semi-structured interviews with participants (N = 15) and peers (N = 6) were conducted in English and Spanish and analyzed thematically.

RESULTS

Participants were on average 71 years old (range: 59-96 years), with 58% male, 15% LGBT, 18% African American, 19% Latinx, 8% Asian, 86% living alone, and 36% with an ADL impairment. On average, 43 contact visits (IQR: 31-97 visits) between participants and peers occurred over the first year. Loneliness scores decreased by, on average, 0.8 points over 24 months (p = 0.015). Participants reported reduced depression (38%-16%, p < 0.001) and fewer barriers to socializing (1.5 fewer, p < 0.001). Because of the longitudinal relationship and matching of characteristics of peers to participants, participants reported strong feelings of kinship, motivations to reach out in other areas of life, and improved mood.

CONCLUSION

Diverse older adults in an urban setting participating in a longitudinal peer program experienced reduced loneliness, depression, and barriers to socializing. Matching by shared backgrounds facilitated rapport and bonding between participants and peers.

The epidemiology of social isolation and loneliness among older adults during the last years of life

BACKGROUND

Social isolation and loneliness are critical to the health of older adults, but they have not been well-described at the end of life.

OBJECTIVES

To determine the prevalence and correlates of social isolation and loneliness among older adults in the last years of life.

DESIGN

Nationally representative, cross-sectional survey.

SETTING

Health and Retirement Study, 2006-2016 data.

PARTICIPANTS

Adults age > 50 interviewed once in the last 4 years of life (n = 3613).

MEASUREMENTS

We defined social isolation using a 15-item scale measuring household contacts, social network interaction, and community engagement, and frequent loneliness using the 3-item UCLA Loneliness Scale. We used multivariable logistic regression to determine their adjusted prevalence by time prior-to-death and by subgroups of interest.

RESULTS

Approximately 19% experienced social isolation, 18% loneliness, and 5% both in the last 4 years of life (correlation = 0.11). The adjusted prevalence of social isolation was higher for individuals nearer to death (4 years: 18% vs 0-3 months: 27%, p = 0.05) and there was no significant change in loneliness (4 years: 19% vs 0-3 months: 23%, p = 0.13). Risk factors for both isolation and loneliness included (p < 0.01): low net-worth (Isolation: 34% vs 14%; Loneliness: 29% vs 13%), hearing impairment (Isolation: 26% vs 20%; Loneliness: 26% vs 17%), and difficulty preparing meals (Isolation: 27% vs 19%; Loneliness: 29% vs 15%). Factors associated with loneliness, but not social isolation, included being female, pain, incontinence, and cognitive impairment.

CONCLUSIONS

Social isolation and loneliness are common at the end of life, affecting 1 in 4 older adults, but few experience both. Rates were higher for older adults who were poor and experienced functional or sensory impairments. Results can inform clinical efforts to identify and address end-of-life psychosocial suffering and health policies which prioritize social needs at the end of life.

Formal and informal social participation and elder mistreatment in a national sample of older adults

BACKGROUND/OBJECTIVES

Older adults' susceptibility to mistreatment may be affected by their participation in social activities, but little is known about relationships between social participation and elder mistreatment.

DESIGN

Cross-sectional analysis.

SETTING/PARTICIPANTS

National probability sample of older community-dwelling U.S. adults interviewed in 2015-2016, including 1268 women and 973 men (mean age 75 years and 76 years, respectively; 82% non-Hispanic white).

MEASUREMENTS

Frequency of participation in formal activities (organized meetings, religious services, and volunteering) and informal social activities (visiting friends and family) was assessed by questionnaire. Elder mistreatment included emotional (four items), physical (two items), and financial mistreatment (two items) since age 60. Multivariable logistic regression examined associations between each type of social participation and elder mistreatment among men and women, adjusting for age, race/ethnicity, education, and comorbidity.

RESULTS

Forty percent of women and 22% of men reported at least one form of mistreatment (emotional, physical, or financial). Women reporting at least monthly engagement in formal social activities were more likely to report emotional mistreatment (adjusted odds ratio (AOR) 1.59, 95% confidence interval (CI) 1.09-2.33). Among men, monthly organized meeting attendance was associated with increased odds of emotional mistreatment (AOR 1.34, 95% CI 1.01-1.93). Weekly informal socializing was inversely associated with emotional mistreatment (AOR 0.59, 95% CI 0.44-0.78) and financial mistreatment (AOR 0.59, 95% CI 0.42-0.85) among women.

CONCLUSION

In this national cohort, older adults who were frequently engaged in formal social activities reported similar or higher levels of mistreatment than those with less frequent organized social participation. Older women with regular informal contact with family or friends were less likely to report some kinds of mistreatment. Strategies for detecting and mitigating elder mistreatment should consider differences in patterns of formal and informal social participation and their potential contribution to mistreatment risk.

Cancer Screening in Older Adults: Individualized Decision-Making and Communication Strategies

Cancer screening decisions in older adults can be complex due to the unclear cancer-specific mortality benefits of screening and several known harms including false positives, overdiagnosis, and procedural complications from downstream diagnostic interventions. In this review, we provide a framework for individualized cancer screening decisions among older adults, involving accounting for overall health and life expectancy, individual values, and the risks and benefits of specific cancer screening tests. We then discuss strategies for effective communication of recommendations during clinical visits that are considered more effective, easy to understand, and acceptable by older adults and clinicians.

Social Isolation and Loneliness Among San Francisco Bay Area Older Adults During the COVID-19 Shelter-in-Place Orders

BACKGROUND/OBJECTIVES

Physical distancing during the COVID‐19 pandemic may have unintended, detrimental effects on social isolation and loneliness among older adults. Our objectives were to investigate (1) experiences of social isolation and loneliness during shelter‐in‐place orders, and (2) unmet health needs related to changes in social interactions.

DESIGN

Mixed‐methods longitudinal phone‐based survey administered every 2 weeks.

SETTING

Two community sites and an academic geriatrics outpatient clinical practice.

PARTICIPANTS

A total of 151 community‐dwelling older adults.

MEASUREMENTS

We measured social isolation using a six‐item modified Duke Social Support Index, social interaction subscale, that included assessments of video‐based and Internet‐based socializing. Measures of loneliness included self‐reported worsened loneliness due to the COVID‐19 pandemic and loneliness severity based on the three‐item University of California, Los Angeles (UCLA) Loneliness Scale. Participants were invited to share open‐ended comments about their social experiences.

RESULTS

Participants were on average aged 75 years (standard deviation = 10), 50% had hearing or vision impairment, 64% lived alone, and 26% had difficulty bathing. Participants reported social isolation in 40% of interviews, 76% reported minimal video‐based socializing, and 42% minimal Internet‐based socializing. Socially isolated participants reported difficulty finding help with functional needs including bathing (20% vs 55%; P = .04). More than half (54%) of the participants reported worsened loneliness due to COVID‐19 that was associated with worsened depression (62% vs 9%; P < .001) and anxiety (57% vs 9%; P < .001). Rates of loneliness improved on average by time since shelter‐in‐place orders (4–6 weeks: 46% vs 13–15 weeks: 27%; P = .009), however, loneliness persisted or worsened for a subgroup of participants. Open‐ended responses revealed challenges faced by the subgroup experiencing persistent loneliness including poor emotional coping and discomfort with new technologies.

CONCLUSION

Many older adults are adjusting to COVID‐19 restrictions since the start of shelter‐in‐place orders. Additional steps are critically needed to address the psychological suffering and unmet medical needs of those with persistent loneliness or barriers to technology‐based social interaction.

Integration of an Objective Cognitive Assessment Into a Prognostic Index for 5-Year Mortality Prediction

BACKGROUND/OBJECTIVES

Prognostic indices rarely include cognition. We determined if a comprehensive cognitive screen or brief individual items were associated with improved mortality predictions of a widely used prognostic index.

DESIGN, SETTING, AND PARTICIPANTS

The National Social Life Health and Aging Project Wave 2, a nationally representative, cross-sectional, in-home survey conducted in 2010 to 2011 on 3,199 community-dwelling adults aged 60 to 99 years.

MEASUREMENTS

Cognition was measured using a Survey-Adapted Montreal Cognitive Assessment (MoCA-SA) grouped into three screened categories: screen normal (≥24 points), screen positive for mild cognitive impairment (18-23 points), and screen positive for dementia (<18 points). Single-item cognitive measures included clock-draw and five-word delayed recall. We constructed a modified Lee Prognostic Index (range = 0-18 points) based on age, behavior, function, and comorbidities shown to predict long-term mortality. We used logistic regression and the fraction of new information provided to determine if each cognitive measure improved the Lee index's 5-year mortality prediction.

RESULTS

The sample was 54% female and had a mean age of 72 years, MoCA-SA score of 22 (SD = 4.5), and Lee index of 7 (SD = 3). Regression analysis indicated the MoCA-SA modestly improved the Lee index's mortality prediction (P < .001; fraction of new information provided = 0.06); for low Lee index scores (<4 points), the absolute mortality rate difference was 7% by cognitive status; and for higher Lee index scores (4-7 points or 8-12 points), the absolute mortality rate difference was 15% by cognitive status. The clock-draw and delayed-recall items added similar value to mortality predictions as the longer MoCA-SA. Cognition had the third highest fraction of new information of all 13 Lee index items.

CONCLUSION

Incorporating a brief measure of cognition into a modified Lee index, even with single items, resulted in more accurate 5-year mortality risk predictions. Cognition should be included in prognostic calculators in older adults given its independent association with mortality risk. J Am Geriatr Soc 68:1796-1802, 2020.

Are We Choosing Wisely? Older Adults' Cancer Screening Intentions and Recalled Discussions with Physicians About Stopping

BACKGROUND

National guidelines recommend against cancer screening for older individuals with less than a 10-year life expectancy, but it is unknown if this population desires ongoing screening.

OBJECTIVE

To determine (1) if older individuals with < 10-year life expectancy have future intentions for cancer screening, (2) if they recall a doctor previously suggesting that screening is no longer needed, and (3) individual characteristics associated with intentions to seek screening.

DESIGN

National Social life Health and Aging Project (2015-2016), a nationally representative, cross-sectional survey.

PARTICIPANTS

Community-dwelling adults 55-97 years old (n = 3816).

MAIN MEASURES

Self-reported: (1) mammography and PSA testing within the last 2 years, (2) future intentions to be screened, and (3) discussion with a doctor that screening is no longer needed. Ten-year life expectancy was estimated using the Lee prognostic index. Multivariate logistic regression analysis examined intentions to pursue future screening, adjusting for sociodemographic and health covariates.

KEY RESULTS

Among women 75-84 with < 10-year life expectancy, 59% intend on future mammography and 81% recall no conversation with a doctor that mammography may no longer be necessary. Among men 75-84 with < 10-year life expectancy, 54% intend on future PSA screening and 77% recall no discussions that PSA screening may be unnecessary. In adjusted analyses, those reporting recent cancer screening or no recollection that screening may not be necessary were more likely to want future mammography or PSA screening (p < 0.001).

CONCLUSION

Over 75% of older individuals with limited life expectancy intend to continue cancer screening, and less than 25% recall discussing with physicians the need for these tests. In addition to public health and education efforts, these results suggest that older adults' recollection of being told by physicians that screening is not necessary may be a modifiable risk factor for reducing overscreening in older adults with limited life expectancy.

'Til Death Do Us Part: End-of-Life Experiences of Married Couples in a Nationally Representative Survey

OBJECTIVES

To determine whether end-of-life (EOL) experiences in the first spouse in a marriage are associated with EOL experiences in the other spouse.

DESIGN

Nationally representative, longitudinal survey.

SETTING

Health and Retirement Study, Waves 1992-2012 linked to Medicare claims PARTICIPANTS: Community-dwelling older adults who died (N=4,558), representing 2,279 married heterosexual couples.

MEASUREMENTS

We examined 3 EOL experiences: enrollment in hospice for >3 days before death, lack of advance care planning (ACP) before death, and intensive care unit (ICU) use during the last 30 days of life. We used multiple logistic regression to determine whether the EOL experience of the first spouse was a significant predictor of the EOL experience of the second spouse after adjusting for demographic characteristics, socioeconomic status, health status, and time between the first and second spouses' deaths.

RESULTS

First spouses who died were on average 80 years old, and 62% were male; second spouses were on average 85 years old, and 62% were female. After adjustment, second spouses were more likely to use hospice if the first spouse used hospice (odds ratio (OR)=1.68, 95% confidence interval (CI)=1.29-2.20). Second spouses were less likely to have ACP when the first spouse did not have ACP (OR=2.91, 95% CI=2.02-4.21). Hospice and ACP associations were stronger when deaths were closer in time to one another (p-value for interaction < .05). Second spouses were more likely to use ICU services if the first spouse did (OR=1.80, 95% CI=1.27-2.55).

CONCLUSIONS

The EOL experiences of older spouses are strongly associated, which may be relevant when framing ACP discussions. J Am Geriatr Soc 66:2360-2366, 2018.

Cancer Screening in the Elderly: A Review of Breast, Colorectal, Lung, and Prostate Cancer Screening

There are relatively limited data on outcomes of screening older adults for cancer; therefore, the decision to screen older adults requires balancing the potential harms of screening and follow-up diagnostic tests with the possibility of benefit. Harms of screening can be amplified in older and frail adults and include discomfort from undergoing the test itself, anxiety, potential complications from diagnostic procedures resulting from a false-positive test, false reassurance from a false-negative test, and overdiagnosis of tumors that are of no threat and may result in overtreatment. In this paper, we review the evidence and guidelines on breast, colorectal, lung and prostate cancer as applied to older adults. We also provide a general framework for approaching cancer screening in older adults by incorporating evidence-based guidelines, patient preferences, and patient life expectancy estimates into shared screening decisions.

Development of a screening tool to assess prostate cancer health literacy

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Background: Poor comprehension of prostate cancer (PCa) related terms can create barriers to informed discussions on screening, treatment, and measuring outcomes, and contribute to disparities in African American (AA) men. We developed a screening tool to assess for low PCa-related health literacy. Methods: We assessed PCa-related literacy in a sample of 189 AA men, age >40 years from diverse socioeconomic status (SES) using a 27-item scale derived comprehension of commonly used terms for urinary, bowel and sexual function. Using item-response models we examined differential item functioning by education. We developed rapid screening tools based on understanding of 1 or 2 words to predict overall comprehension. Receiver operating characteristic curves assessed the sensitivity and specificity for individuals understanding less than a pre-specified threshold of 70% on the overall scale, defined as “low literacy.” Results are being tested in an independent sample of 110 AA men. Results: The 27-item scale had good internal reliability (Cronbach alpha = 0.93). 47% of the sample met criteria for low literacy. Lower education groups had relatively poor comprehension of sexual function terms compared to higher education groups. 1-item scales using comprehension of the term “rectal urgency” had a sensitivity of 95% for identifying low literacy, “erection” had a specificity of 98%, and “vaginal intercourse” had a sensitivity of 91% and specificity of 81%. Combining “vaginal intercourse” and “rectal urgency” yielded a 2-item scale with strong characteristics (sensitivity 88%, specificity 89%), as did combining “vaginal intercourse” and “erection” (sensitivity 94%, specificity 81%). Conclusions: Rapid screening tools assessing PCa-related literacy performed well in a community sample of AA men with varied SES. Providers can use these tools to identify those at risk of poor comprehension to tailor outcome measurement and shared decision making. [Table: see text]

Differences between husbands and wives in colonoscopy use: Results from a national sample of married couples

Marriage is linked to improved colorectal cancer-related health, likely in part through preventive health behaviors, but it is unclear what role spouses play in colorectal cancer screening. We therefore determine whether self-reported colonoscopy rates are correlated within married couples and the characteristics of spouses associated with colonoscopy use in each partner. We use US nationally-representative 2010 data which includes 804 male-female married couples drawn from a total sample of 3137 community-dwelling adults aged 55-90years old. Using a logistic regression model in the full sample (N=3137), we first find married men have higher adjusted colonoscopy rates than unmarried men (61% versus 52%, p=0.023), but women's rates do not differ by marital status. In the couples' sample (N=804 couples), we use a bivariate probit regression model to estimate multiple regression equations for the two spouses simultaneously as a function of individual and spousal covariates, as well as the adjusted correlation within couples. We find that individuals are nearly twice as likely to receive a colonoscopy if their spouse recently has had one (OR=1.94, 95% CI: 1.39, 2.67, p<0.001). Additionally, we find that husbands have higher adjusted colonoscopy rates whose wives are: 1) happier with the marital relationship (65% vs 51%, p=0.020); 2) more highly educated (72% vs 51%, p=0.020), and 3) viewed as more supportive (65% vs 52%, p=0.020). Recognizing the role of marital status, relationship quality, and spousal characteristics on colonoscopy uptake, particularly in men, could help physicians increase guideline adherence.

Interventions to improve decision making and reduce racial and ethnic disparities in the management of prostate cancer: a systematic review

OBJECTIVES

Ethnic minorities are disproportionately impacted by prostate cancer (PCa) and are at risk for not receiving informed decision making (IDM). We conducted a systematic literature review on interventions to improve: (1) IDM about PCa in screening-eligible minority men, and (2) quality of life (QOL) in minority PCa survivors.

DATA SOURCES

MeSH headings for PCa, ethnic minorities, and interventions were searched in MEDLINE, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, CINAHL, and PsycINFO. SUBJECT ELIGIBILITY CRITERIA: We identified U.S.-based, English-language articles (1985 - 2010) on interventions to improve PCa IDM and QOL that included 50% or more minority patients or analyses stratified by race/ethnicity.

STUDY APPRAISAL AND SYNTHESIS METHODS

Articles (n = 19) were evaluated and scored for quality using a Downs and Black (DB) system. Interventions were organized by those enhancing 1) IDM about PCa screening and 2) improving QOL and symptom among PCa survivors. Outcomes were reported by intervention type (educational seminar, printed material, telephone-based, video and web-based).

RESULTS

Fourteen studies evaluated interventions for enhancing IDM about PCa screening and five evaluated programs to improve outcomes for PCa survivors. Knowledge scores were statistically significantly increased in 12 of 13 screening studies that measured knowledge, with ranges of effect varying across intervention types: educational programs (13% - 48% increase), print (11% - 18%), videotape/DVD (16%), and web-based (7% - 20%). In the final screening study, an intervention to improve decision-making about screening increased decisional self-efficacy by 9%. Five cognitive-behavioral interventions improved QOL among minority men being treated for localized PCa through enhancing problem solving and coping skills.

LIMITATIONS

Weak study designs, small sample sizes, selection biases, and variation in follow-up intervals across studies.

CONCLUSIONS

Educational programs were the most effective intervention for improving knowledge among screening-eligible minority men. Cognitive behavioral strategies improved QOL for minority men treated for localized PCa.

Remaining Life Expectancy Measurement and PSA Screening of Older Men

BACKGROUND: Guidelines recommend informed decision-making regarding prostate specific antigen (PSA) screening for men with at least 10 years of remaining life expectancy (RLE). Comorbidity measures have been used to judge RLE in previous studies, but assessments based on other common RLE measures are unknown. We assessed whether screening rates varied based on four clinically relevant RLE measures, including comorbidities, in a nationally-representative, community-based sample. METHODS: Using the National Social Life, Health and Aging Project (NSHAP), we selected men over 65 without prostate cancer (n=709). They were stratified into three RLE categories (0-7 years, 8-12 years, and 13+ years) based on validated measures of comorbidities, self-rated health status, functional status, and physical performance. The independent relationship of each RLE measure and a combined measure to screening was determined using multivariable logistic regressions. RESULTS: Self-rated health (OR = 6.82; p < 0.01) most closely correlated with RLE-based screening, while the comorbidity index correlated the least (OR = 1.50; p = 0.09). The relationship of RLE to PSA screening significantly strengthened when controlling for the number of doctor visits, particularly for comorbidities (OR= 43.6; p < 0.001). Men who had consistent estimates of less than 7 years RLE by all four measures had an adjusted PSA screening rate of 43.3%. CONCLUSIONS: Regardless of the RLE measure used, men who were estimated to have limited RLE had significant PSA screening rates. However, different RLE measures have different correlations with PSA screening. Specific estimates of over-screening should therefore carefully consider the RLE measure used.