Depressive Symptoms Partially Mediate the Association of Frailty Phenotype Symptoms and Cognition for Females but Not Males

OBJECTIVES

We aimed to evaluate whether depressive symptoms mediated the relationship between frailty phenotype and cognitive function by sex.

METHODS

Data came from the Health and Retirement Study from 2012-2016. The outcome was measured by Fried's frailty criteria, our outcome was continuous global cognition, and mediator was depressive symptoms. We used mediation analysis, stratified by sex, to estimate the direct and indirect effects of frailty symptoms on cognition mediated by depressive symptoms.

RESULTS

Males had a larger total effect (β= -0.43; 95% CI: -0.66, -0.02) for lower cognitive score for each increase in frailty symptom compared to females (β= -0.28; 95% CI: -0.47, -0.08). A significant indirect effect from frailty phenotype to cognition was found through depressive symptoms for females but not males.

CONCLUSION

These results highlight the importance of identifying individuals with frailty and depressive symptoms to monitor and provide interventions to preserve cognitive function.

The role of frailty in the association between depression and fall risk among older adults

OBJECTIVES

Although there is a recognized association between depression and greater fall risk among older adults, the mechanisms explaining this association are unclear. This study evaluated the role of frailty, a common geriatric syndrome, in determining greater risk of falls among older adults with depression.

METHOD

We used longitudinal data from three biennial waves of the Health and Retirement Study (HRS; 2010-2014). The sample included community-dwelling survey respondents age ≥ 65 who participated in objective physiological measures. Major Depression (MD) was measured using Composite International Diagnostic Interview for depression short form. Frailty was measured using criteria outlined in the frailty phenotype model. Causal mediation analysis was used to differentiate the direct effect of depression and indirect effect mediated by frailty on falls, fall injuries, and multiple falls.

RESULTS

Major depression was associated with significantly greater odds of experiencing a fall (OR: 1.91; 95% CI: 1.31, 2.77), fall injury (OR: 1.86; 95% CI: 1.17, 2.95), and multiple falls (OR: 2.26; 95% CI: 1.52, 3.37) over a two-year period. Frailty was a significant mediator of the effects of depression on falls and multiple falls, accounting for approximately 18.9% and 21.3% of the total effects, respectively. We found no evidence of depression-frailty interaction. Sensitivity analyses showed that results were robust to unmeasured confounding and alternative operationalizations of depression.

CONCLUSION

Frailty explains a significant proportion of increased likelihood of falls among older adults with depression. Treatment and management of frailty symptoms may be an important components of fall prevention among older adults with depression.

Factors contributing to antihypertensive medication adherence among adults with intellectual and developmental disability

Adults with intellectual or developmental disabilities often have hypertension and mental illness, and are prescribed medications for treatment. This study examined psychotropic medication adherence as a mediator between the association of residence type and antihypertensive medication adherence for adults with intellectual or developmental disabilities. We used Medicaid data of adults with intellectual or developmental disabilities who had hypertension and prescribed antihypertensive medication (N = 1,201) to measure the direct effect, indirect effect, and total effect of residence type (home vs. supervised setting) and antihypertensive medication adherence, with a mediator of psychotropic medication adherence. The indirect effect of psychotropic medication adherence on antihypertensive medication adherence was 1.26 (OR = 1.26, CI: 1.08-1.52), holding residency constant. The direct effect of residential type on antihypertensive medication adherence was 3.75 (OR = 3.75, CI: 1.61-8.75). This association may be due to some features of having a mental illness or maybe the result of being prescribed more than one medication.

Genetic Risk Factors for Alzheimer's Disease in Racial/Ethnic Minority Populations in the U.S.: A Scoping Review

Objectives: As the United States (U.S.) population rapidly ages, the incidence of Alzheimer's Disease and Related Dementias (ADRDs) is rising, with racial/ethnic minorities affected at disproportionate rates. Much research has been undertaken to test, sequence, and analyze genetic risk factors for ADRDs in Caucasian populations, but comparatively little has been done with racial/ethnic minority populations. We conducted a scoping review to examine the nature and extent of the research that has been published about the genetic factors of ADRDs among racial/ethnic minorities in the U.S. Design: Using an established scoping review methodological framework, we searched electronic databases for articles describing peer-reviewed empirical studies or Genome-Wide Association Studies that had been published 2005-2018 and focused on ADRD-related genes or genetic factors among underrepresented racial/ethnic minority population in the U.S. Results: Sixty-six articles met the inclusion criteria for full text review. Well-established ADRD genetic risk factors for Caucasian populations including APOE, APP, PSEN1, and PSEN2 have not been studied to the same degree in minority U.S. populations. Compared to the amount of research that has been conducted with Caucasian populations in the U.S., racial/ethnic minority communities are underrepresented. Conclusion: Given the projected growth of the aging population and incidence of ADRDs, particularly among racial/ethnic minorities, increased focus on this important segment of the population is warranted. Our review can aid researchers in developing fundamental research questions to determine the role that ADRD risk genes play in the heavier burden of ADRDs in racial/ethnic minority populations.

COVID-19 Incidence and Mortality Among Long-Term Care Facility Residents and Staff in South Carolina

Objectives

This study explored differences in COVID-19 incidence, mortality, and timing among long-term care facility (LTCF) residents and staff with those living in the community in South Carolina (SC).

Design

Longitudinal secondary data analysis.

Setting and Participants

Adults age ≥18 in SC with confirmed COVID-19 diagnosis from 3/15/2020 and 1/2/2021 (n = 307,891).

Methods

COVID-19 data came from the SC Department of Health and Environmental Control (SCDHEC). We included all COVID-19 cases, hospitalizations, and deaths among adult residents. Residence and employment in LTCF were confirmed by SCDHEC. Descriptive statistics and trends for cases, hospitalizations, and deaths were calculated. We used Cox proportional hazards to compare COVID-19 mortality in LTCF residents and staff to community dwelling older adults and adults not employed in LTCF, respectively, controlling for age, gender, race, and pre-existing chronic health conditions.

Results

LTC residents experienced greater incidence of cases throughout the study period until the week ending on 1/2/21. LTCF residents with COVID-19 were more likely to be hospitalized compared to older adults in the community and 74% more likely to die (HR: 1.74, 95% CI: 1.59-1.90), after adjusting. LTC staff experienced greater incidence of cases compared to adults not employed in LTCF until the week ending on 12/26/2020, while experiencing similar incidence of death compared to the similar community members. After adjusting, LTC staff had 0.58 (HR = 0.58; CI: 0.39-0.88) times lower hazard of death compared to community members that did not work in a LTCF.

Conclusions and Implications

Narrowing of the gap between LTCF and community-wide infection and mortality rates over the study period suggests that early detection of COVID-19 in LTCFs could serve as a first indicator of disease spread in the greater community. Results also indicate that policies and regulations addressing staff testing and protection may help to slow or prevent spread within facilities.

Frailty Phenotype and Cause-Specific Mortality in the United States

BACKGROUND

Frailty is a common condition among older adults increasing risk of adverse outcomes including mortality; however, little is known about the incidence or risk of specific causes of death among frail individuals.

METHODS

Data came from the Health and Retirement Study (HRS; 2004-2012), linked to underlying cause-of-death information from the National Death Index (NDI). Community-dwelling HRS participants aged 65 and older who completed a general health interview and physical measurements (n = 10,490) were included in analysis. Frailty was measured using phenotypic model criteria-exhaustion, low weight, low energy expenditure, slow gait, and weakness. Underlying causes of death were determined using International Classification of Diseases, Version 10 codes. We used Cox proportional hazards and competing risks regression models to calculate and compare incidence of cause-specific mortality by frailty status.

RESULTS

During follow-up, prefrail and frail older adults had significantly greater hazard of all-cause mortality compared to individuals without symptoms (adjusted hazard ratio [HR] prefrail: 1.85, 95% CI: 1.51, 2.25; HR frail: 2.75, 95% CI: 2.14, 3.53). Frailty was associated with 2.96 (95% CI: 2.17, 4.03), 2.82 (95% CI: 2.02, 3.94), 3.48 (95% CI: 2.17, 5.59), and 2.87 (95% CI: 1.47, 5.59) times greater hazard of death from heart disease, cancer, respiratory illness, and dementia, respectively.

CONCLUSIONS

Significantly greater risk of mortality from several different causes should be considered alongside the potential costs of screening and intervention for frailty in subspecialty and general geriatric clinical practice. Findings may help investigators estimate the potential impact of frailty reduction approaches on mortality.

An Evaluation of Dementia Dialogues®: A Program for Informal and Formal Caregivers in North and South Carolina

In 2019, the University of South Carolina's Office for the Study of Aging (OSA) remodeled the curriculum for the nationally registered Dementia Dialogues^® program that delivers high-quality education to formal and informal caregivers of persons who exhibit signs and symptoms of Alzheimer's disease and related dementias (ADRD). This study evaluated new knowledge acquired and program satisfaction by North and South Carolina program participants (N = 235) after completing updated modules. Pre/post module survey data were analyzed using means and percentiles, McNemar's test, and paired t tests. Results demonstrated significant positive increases in caregiver knowledge attainment, with differences in overall knowledge change in specific modules among caregivers and noncaregivers (p < .0001-<.05). Dementia Dialogues^® may serve as a useful tool in providing important information that increases caregiver knowledge of persons living with ADRD. Further research is recommended to examine how knowledge improvement translates into caregiving practices.

Time-Varying Insomnia Symptoms and Incidence of Cognitive Impairment and Dementia among Older US Adults

There is conflicting evidence regarding the association between insomnia and the onset of mild cognitive impairment (MCI) or dementia. This study aimed to evaluate if time-varying insomnia is associated with the development of MCI and dementia. Data from the Health and Retirement Study (n = 13,833) from 2002 to 2014 were used (59.4% female). The Brief Insomnia Questionnaire was used to identify insomnia symptoms which were compiled in an insomnia severity index, ranging from 0 to 4. In analysis, participants' symptoms could vary from wave-to-wave. Dementia was defined using results from the Health and Retirement Study (HRS) global cognitive assessment tool. Respondents were classified as either having dementia, MCI, or being cognitively healthy. Cox proportional hazards models with time-dependent exposure using the counting process (start-stop time) were used for analysis. For each one-unit increase in the insomnia symptom index, there was a 5-percent greater hazard of MCI (HR = 1.05; 95% CI: 1.04-1.06) and dementia (HR = 1.05; 95% CI: 1.03-1.05), after fully adjusting. Using a nationally representative sample of adults age 51 and older, this study found that time-varying insomnia symptoms are associated with risk of MCI and dementia. This highlights the importance of identifying sleep disturbances and their change over time as potentially important risk factors for MCI and dementia.

A systematic review of interventions for loneliness among older adults living in long-term care facilities

OBJECTIVES

This study aimed to review loneliness interventions for older adults living in long-term care (LTC) facilities over the past 10 years, to categorize interventions by type, and to compare effectiveness of loneliness interventions in these settings.

METHODS

Systematic review followed PRISMA guidelines. Articles matching search criteria were collected from PubMed, PsycINFO, and Web of Science from 2009 to 2019. The inclusion criteria were as follows: 1) English language, 2) intervention studies with a quantitative measure that compares pre-trial to post-trial changes, 3) loneliness as a primary or secondary outcome 4) subjects age >65, and 5) subjects living in a LTC facility, such as a nursing home, assisted-living, or hospice.

RESULTS

A total of 15 intervention studies qualified for systematic review. Most of these interventions were psychological therapies and leisure/skill development interventions. Approximately, 87% of studies reported significant decreases in loneliness following intervention. Laughter therapy, horticultural therapy, and reminiscence therapy were associated with the greatest decreases in loneliness.

DISCUSSION

Results suggest that, although less common than interventions in the community, there are several effective interventions to reduce loneliness among older adults living in LTC facilities. Lack of standardized measures and high-quality studies limits comparisons between intervention types and generalizability to different populations.

Knowledge evaluation instruments for dementia caregiver education programs: A scoping review

With the increase in our older adult population, there is a need for dementia training for informal and formal dementia caregivers. The objective of this scoping study is to assess dementia knowledge instruments utilized in educational programs and interventions intended for formal and informal dementia caregivers. Scoping review methodology was used to search PubMed, PsycInfo, CINAHL and Web of Science with tailored database search terms. The search yielded 8101 results, with 35 studies meeting inclusion. Studies were conducted in eight countries, had varying study designs (randomized controlled trials [RCTs] = 9, non-RCTs = 6, one-group study design = 20) and utilized previously published (19) and author developed (16) instruments. Furthermore, the studies were internationally diverse, conducted in the United States (n = 18), Australia (n = 7), UK (n = 3), China (n = 2), Canada (n = 2), Taiwan (n = 1), Brazil (n = 1) and multi-country (n = 1). Only two studies focused on minority populations. While author-developed instruments may be more relevant and timesaving, studies should strive to validate instruments or use previously published instruments to help standardize findings across studies and understand better the effects of educational programs on caregiver knowledge. Geriatr Gerontol Int 2020; 20: 397-413.

A SCOPING REVIEW OF KNOWLEDGE EVALUATION INSTRUMENTS FOR FORMAL AND INFORMAL DEMENTIA CAREGIVER PROGRAMS

With the increase in our older adult population there is a need for dementia training for informal and formal dementia caregivers. The objective of this scoping study was to assess dementia knowledge instruments utilized in educational programs and interventions intended for formal and informal dementia caregivers. Scoping review methodology was used to search PubMed, PsycInfo, CINAHL, and Web of Science with tailored database search terms. The search yielded 8,101 results, with 35 studies meeting inclusion criteria. Studies were conducted in eight countries, had varying study designs (RCTs=9, non-RCTs=6, one-group study design=20), and utilized previously published (19) and author-developed (16) instruments. Only two studies focused on minority populations. While author-developed instruments may be more relevant and time-saving, studies should strive to validate instruments or use previously published instruments to help standardize findings across studies and better understand the effects of education programs on caregiver knowledge.

ASSOCIATION BETWEEN FRAILTY AND DEVELOPMENT OF COGNITIVE IMPAIRMENT: EVIDENCE FROM THE HEALTH AND RETIREMENT STUDY

Research has shown there is currently an increasing prevalence of cognitive impairment and dementia in older adults. To date, there remains a paucity of research to explain this increase and research on early markers and risk factors are warranted. This study aims to assess the association of cognitively normal older adults who are frail and the development of cognitive impairment four years later. Data from the Health and Retirement Study – a nationally representative sample of older US adults – was used from 2004-2008 for individuals 65 and older (n=8,377). Frailty was categorized by using Fried’s phenotype model: individuals were grouped into frail, pre-frail, and robust. Cognitive impairment – a composite score that assessed memory recall and global mental status – was classified as scoring eight or less on a 35-point scale. After restricting to cognitively healthy individuals, logistic regression with weights was used to assess the association between frailty status and the development of cognitive impairment four years later. The model was adjusted for baseline age, gender, race, education years, smoking status, and chronic health issues (high blood pressure, diabetes, cancer, lung disease, heart disease, stroke, psychiatric problems, and arthritis). Frail individuals, compared to those who were robust, had increased odds of cognitive impairment (OR=1.74; 95% CI: 1.48-2.16), after fully adjusting. Evidence from this study suggest that frail individuals are more likely to become cognitively impaired over time. This provides a potential pathway of intervention to help delay or prevent the development of cognitive impairment in older US adults.

Obesity, Dietary inflammation, and Frailty among Older Adults: Evidence from the National Health and Nutrition Examination Survey

Knowledge related to the relationship between obesity and frailty is limited. This study aimed to investigate associations between obesity, dietary inflammation, and frailty among older adults. Study data came from National Health and Nutrition Examination Survey (2007-2014) examinations of adults age ≥60 years (n = 7182). Dietary inflammatory potential was determined using the Dietary Inflammatory Index (DII^®) derived from 24-h dietary recall. We analyzed independent and joint associations of obesity and DII with frailty to evaluate interaction. Multivariable logistic regression revealed that both obesity (Odds Ratio [OR] = 2.24, 95% CI: 1.68, 2.99) and moderately pro-inflammatory DII (OR = 1.68, 95% CI: 1.10, 2.58) were independently associated with greater frailty prevalence. A negative multiplicative interaction between obesity and highest pro-inflammatory diet also was found (adjusted odds in non-obese and obese were 2.07 and 2.37, respectively; p = 0.046). Results indicate the importance of considering obesity and dietary inflammatory potential when screening for frailty or developing treatments.

Dietary Inflammatory Index, Pre-Frailty and Frailty among Older US Adults: Evidence from the National Health and Nutrition Examination Survey, 2007-2014

OBJECTIVE

This study aimed to investigate the association between dietary inflammation, pre-frailty and frailty among older US adults. Additionally, effect modification of gender on the association between dietary inflammation and frailty was assessed.

DESIGN

Study data came from the National Health and Nutrition Examination Survey (2007-2014) - a nationally representative, cross-sectional study of adults.

PARTICIPANTS

The analytic sample included adults ≥60 years (n=7,182).

MEASUREMENTS

Dietary Inflammatory Index (DII®) scores were calculated from 24-hour dietary recalls; DII was categorized into quintiles from Quintile 1 (Q1) (least inflammatory) to Q5 (most inflammatory). Frailty was assessed by four criteria: exhaustion, weakness, low body mass, and low physical activity. Individuals were then categorized into robust (0 criteria), pre-frail (1-2 criteria), or frail (3-4 criteria). Multinomial logistic regression was used to examine the odds of frailty categories (pre-frail vs. robust; frail vs. robust).

RESULTS

After adjusting for potential confounders, individuals in DII quintile 5 (vs Q1) were more likely to be pre-frail (OR = 1.71; 95% CI: 1.36-2.15) and frail (OR = 1.70; 95% CI: 1.02-2.85). Individuals in Q4 had greater odds of frailty only (OR = 1.82; 95% CI: 1.13, 2.93). No evidence of effect modification by gender on the association of DII and frailty was found.

CONCLUSION

This study expands upon previous evidence of a relationship between dietary inflammation and frailty. When designing nutrition-based frailty interventions, inflammatory properties of diets should be considered.