Use of preventive service and potentially preventable hospitalization among American adults with disability: Longitudinal analysis of Traditional Medicare and commercial insurance

Objective

Examine the association between traditional Medicare (TM) vs. commercial insurance and the use of preventive care and potentially preventable hospitalization (PPH) among adults (18+) with disability [cerebral palsy/spina bifida (CP/SB); multiple sclerosis (MS); traumatic spinal cord injury (TSCI)] in the United States.

Methods

Using 2008-2016 Medicare and commercial claims data, we compared adults with the same disability enrolled in TM vs. commercial insurance [Medicare: n = 21,599 (CP/SB); n = 7,605 (MS); n = 4,802 (TSCI); commercial: n = 11,306 (CP/SB); n = 6,254 (MS); n = 5,265 (TSCI)]. We applied generalized estimating equations to address repeated measures, comparing cases with controls. All models were adjusted for age, sex, race/ethnicity, and comorbid conditions.

Results

Compared with commercial insurance, enrolling in TM reduced the odds of using preventive services. For example, adjusted odds ratios (OR) of annual wellness visits in TM vs. commercial insurance were 0.31 (95% confidence interval (CI): 0.28-0.34), 0.32 (95% CI: 0.28-0.37), and 0.19 (95% CI: 0.17-0.22) among adults with CP/SB, TSCI, and MS, respectively. Furthermore, PPH risks were higher in TM vs. commercial insurance. ORs of PPH in TM vs. commercial insurance were 1.50 (95% CI: 1.18-1.89), 1.83 (95% CI: 1.40-2.41), and 2.32 (95% CI: 1.66-3.22) among adults with CP/SB, TSCI, and MS, respectively. Moreover, dual-eligible adults had higher odds of PPH compared with non-dual-eligible adults [CP/SB: OR = 1.47 (95% CI: 1.25-1.72); TSCI: OR = 1.61 (95% CI: 1.35-1.92), and MS: OR = 1.80 (95% CI: 1.55-2.10)].

Conclusions

TM, relative to commercial insurance, was associated with lower receipt of preventive care and higher PPH risk among adults with disability.

The Worst of Times: Depressive Symptoms Among Racialized Groups Living With Dementia and Cognitive Impairment During the COVID-19 Pandemic

Objective: To explore differences in depressive symptoms for older adults (Black, Latinx, and White) by cognitive status during the 2020 COVID-19 pandemic. Methods: Data from the Health and Retirement Study identified older adults as cognitively normal, cognitively impaired without dementia (CIND), and persons living with dementia (PLWD). Multiple linear regression analyses examined associations between cognitive status and depressive symptoms among these racialized groups. Results: Compared to the cognitively normal older adults racialized as Black, those with CIND reported higher depressive symptoms during the pandemic (overall and somatic) and PLWD had higher somatic symptoms (p < .01). Older adults racialized as White with CIND reported higher somatic (p < .01) symptoms compared to cognitively normal older adults racialized as White. Discussion: The COVID-19 pandemic was a challenging event among older adults racialized as Black with CIND and PLWD. Future studies should examine if these depressive symptoms persist over time.

USABILITY AND ACCEPTABILITY OF A PEER-DELIVERED TECHNOLOGY BASED MENTAL HEALTH INTERVENTION FOR FAMILY CAREGIVERS

Family caregivers of people with dementia are critical to the quality of life of care recipients and the sustainability of healthcare systems but face increased risk of emotional distress and negative health outcomes. The purpose of this study was to examine the usability, acceptability, and preliminary effectiveness of a technology-based and caregiver-delivered peer support program, “Caregiver Remote Education and Support” (CARES) smartphone application and to identify barriers and facilitators to the ethical use of former caregivers as technology-based interventionists. Nine family caregivers of people with dementia received the CARES intervention and three former family caregivers of people with dementia were trained to deliver the CARES system. Quantitative data were collected at baseline and at the end of the two-week field usability study. Qualitative data were also collected at the end of the two-week field usability study. The pilot study demonstrated that a two-week, peer- delivered and technology supported mental health intervention designed to improve burden, stress, and strain levels was experienced by former and current family caregivers as usable, acceptable, and ethical. CARES was associated with non-statistically significant improvements in burden, stress, and strain levels. This pre/post field usability study demonstrated it is possible to train former family caregivers of people with dementia to use technology to deliver a mental health intervention to current caregivers. Future studies would benefit from a longer trial, a larger sample size, a randomized controlled design, and a control of covariables such as stages of dementia, years providing care, and the severity of dementia symptoms.

WHEN FAMILIES DISAGREE: CORRELATES AND STRESS PROCESS OUTCOMES OF FAMILY CAREGIVER DISAGREEMENT

Dementia caregiving is a family affair, yet prior research suggests that families often disagree about care provision. We explore correlates of such disagreements and how disagreements relate to stress process outcomes of care. The current study examines 552 family caregivers for Medicare-eligible older adults with dementia from the 2017 National Study of Caregiving. We consider demographic and care characteristics as predictors of family disagreement in a multinomial logistic model, and family disagreement as the key predictor of caregiving overload, emotional difficulty, and gains in linear regressions. Females had greater odds of disagreement, while those with friends and family to talk to and providing assistance with household care activities had lower odds of disagreement. Family disagreement was significantly associated with overload (B=0.95, p<.001) and emotional difficulty (B=0.45, p<.05), but not gains. Interventions to help families manage care disagreements and coordinate care may have great impact on caregiver well-being.

PANDEMIC-SPECIFIC SUPPORTS AND CHALLENGES: ASSOCIATIONS WITH DEMENTIA CAREGIVER WELL-BEING

This study examines the prevalence of pandemic-specific care supports and challenges (e.g., increased support from family and friends, difficulty accessing respite care, confusion on public health guidelines) and associations with stress and well-being among 100 family caregivers for persons living with dementia interviewed in 2021. Pandemic care challenges were common- 52% reported a decrease in support from family and friends, 43% had difficulty accessing medical care, and 31% had difficulty getting needed in-home and out-of-home services. Accounting for demographics and the care context, difficulties accessing various types of respite care (e.g., paid respite care, respite from family/friends) were associated with caregiver stress, burden, and less positive affect. Pandemic supports, including increased support from family and friends and receiving information on COVID-care were associated with greater positive affect, but not caregiver stress. While care-supports enhanced well-being, efforts to help caregivers take breaks from caregiving may have significant impact on reducing stress.

UNEXPECTED CAREGIVING: LIFE AFTER A COVID-19 INTENSIVE CARE UNIT HOSPITALIZATION

The coronavirus pandemic has led to an exceptional number of critical care hospitalizations followed by extended recovery periods that necessitate familial support. Using a qualitative descriptive approach, this study aimed to examine the strategies used by families to adjust to the caregiving role. Semi-structured interviews of patients who had been recently discharged from the Intensive Care Unit (ICU) (n=16) along with their family caregivers (n=16) were thematically analyzed. Three major themes were identified that highlight how family caregivers adapt to the caregiving role following an ICU COVID-19 related hospitalization including 1) engaging the support of family and friends, 2) shifting responsibilities to accommodate caregiving, and 3) managing one’s emotions. Additional themes more specifically related to managing COVID-19 care included: 1) managing infection control, 2) care recipient’s need for independence, and 3) managing support services. Flexibility and sufficient support allowed family caregivers to manage their new caregiving role and function optimally.

DEMENTIA FAMILY CAREGIVERS EXPERIENCES USING COMMUNITY-BASED AND HEALTHCARE SERVICES DURING COVID-19

Family caregivers are key medical decision makers for persons living with dementia (PLwD) and play a critical role in interfacing with community-based services and the health care system. The COVID-19 pandemic, however, had dramatic impact on service utilization, with many suspended, delayed, or moved to telehealth. Emerging data suggests the pandemic posed challenges to service use for family caregivers, yet how this impacted caregiver’s care practice is unknown. An in-depth qualitative interview was conducted with 100 primary family caregivers for PLwD in 2021 on care management during the COVID-19 pandemic. Watkins’ rigorous and accelerated data reduction technique was used to analyze qualitative data through open and focused coding and identify themes specific to family caregiver’s access to and use of community-based and health care services. Themes emerged regarding challenges and benefits of service use during the pandemic. Caregivers struggled with not being allowed to attend medical appointments with the PLwD or to speak confidentially with the physician over a PLwD’s telehealth appointment. Caregivers felt physicians couldn’t always read the care situation over telehealth, but appreciated not having to leave the house. Losing the consistency of in-home caregivers or respite programs put additional strain on caregivers, but many found virtual programming engaging. Grocery delivery/pickup was a new service used by many caregivers and found to be supportive of in-home care. As the pandemic evolves, finding ways to support caregivers through continued involvement in health care visits and as they access community services is critical to caregiver and PLwD health and well-being.

Exploring dementia care in acute care settings: Perspectives of nurses and social workers on caring for patients with behavioral and psychological symptoms

This qualitative study compares perspectives of nurses (n = 5) and social workers (n = 12) about their role in caring for patients with dementia with behavioral and psychological problems in an acute care setting. A thematic qualitative analysis was conducted using the Rigorous and Accelerated Data Reduction Technique (RADaR). Three themes emerged: engagement of the patient and coordination with family and professionals, treatment and medical management of behavioral and psychological symptoms of dementia (BPSD) in the hospital, and barriers to care. Barriers to care are identified by both professions, with each having its own care niche. Social workers and nurses work as a team with the understanding that they face care challenges. Person centered care is a successful approach for the care team working with patients with BPSD.

The Changing Tides of Caregiving During the COVID-19 Pandemic: How Decreasing and Increasing Care Provision Relates to Caregiver Well-Being

OBJECTIVES

Pandemic-specific changes to the caregiving context (e.g., attempts to reduce exposure, physical distancing requirements) may lead to changes in care provision. This study uses the 2020 National Health and Aging Trends Study Family Members and Friends coronavirus disease 2019 (COVID-19) questionnaire to explore changes in the amount of care provision during COVID-19 and associations with stress process outcomes of caregiving.

METHODS

The sample includes 1,020 caregivers who provided care for an older adult during COVID-19. Caregivers indicated whether their hours of care decreased, stayed stable, or increased during the pandemic. We describe reasons for change in care and compare changes in care by demographic and care-related characteristics using chi-squares and analyses of variance, and relate changes in care with stress process outcomes (e.g., overload, COVID-related anxiety) using multivariable linear regression.

RESULTS

Caregivers were 60.7 years old on average, 69.3% were female, and 18.6% were non-White. While most caregivers reported no change, 30.5% reported an increase and 11.5% reported a decrease in the amount of pandemic care provided. Relative to maintaining stable care provision, an increase was associated broadly with worse mental health and care-related stress, whereas a decrease was associated with greater emotional difficulty related to care and lower levels of positive affectivity.

DISCUSSION

Those who changed their care provision during the pandemic predominantly did so to protect their care recipient from COVID-19 exposure. Increasing one's care provision was strongly associated with worse mental health and well-being. Supports for caregivers who take on additional care tasks during the pandemic could have great public health benefit.

Early Trauma and Later Health: Examining the Mediation of Social Relationships in Adulthood in HRS

Early trauma is associated with compromised health and well-being in later life, but whether social functioning mediates the association is unclear. Participants in the Health and Retirement Study (n = 15,946) had baseline surveys in years 2006 and 2008 (T1), and were followed up twice (T2-3) every 4 years. Health outcomes included depressive symptoms, chronic health conditions, and subjective memory complaints. Social relationships were measured by contacts, relationship strains, and feelings of loneliness. Early trauma was measured by parental physical abuse and alcohol and drug problems in the family before the age of 16. Social contacts decreased over time, while relationship strains and loneliness increased especially for older adults with early trauma, which in turn mediated the associations between early trauma and poorer health in later life. The findings suggested that maintaining positive social relationships are beneficial for better health in late life, especially for individuals with early trauma exposures.

Caregiving Challenges During the COVID-19 Pandemic: Findings From the National Poll on Healthy Aging

The COVID-19 pandemic posed new challenges for caregivers. This study examines the prevalence of pandemic care challenges (e.g., decreasing care to reduce virus spread, difficulty accessing medical care) and their associations with caregiver mental health and interpersonal well-being in a nationally representative sample of 311 caregivers who participated in the June 2020 National Poll on Healthy Aging. We consider seven care challenges and supports as key predictors of caregiver mental health (care-related stress, self-reported mental health, three depressive symptoms) and interpersonal well-being (lack of companionship, isolation) in bivariate tests and ordinary least squares regressions. Each care challenge/support was endorsed by between 13-23% of caregivers. Difficulty getting needed medical care was the most predictive challenge associated with increased caregiver stress, depressive symptoms, and worsened interpersonal well-being. All care challenges predicted an increase in caregiver stress. Effective caregiver tools and supports must consider changing policies and care needs, especially during a pandemic.

Cognitive-Behavioral Styles of Dementia Care Management: Targeting and Tailoring to Style

Despite an extensive literature on the stress process of caregiving, little attention has focused on how caregivers provide care (caregiving styles). To explore caregiving styles among 100 primary caregivers for persons living with dementia, we utilize k-modes machine learning analysis. This technique clusters caregiver’s use of behavioral (Dementia Management Strategies Scale; criticism, active management, encouragement) and cognitive (Caregiver Readiness Scale; understanding, adaptability) approaches into style profiles. Three styles were identified: Managers (n=25; high use of criticism, moderate use of active management and encouragement, poor understanding and adaptability), Adapters (n=48; low use of criticism, high use of adaptive management and encouragement, good understanding and adaptability), and Avoiders (n=27; low use of all behavioral strategies, moderate adaptability and understanding). Styles differ by demographic and care characteristics. Findings suggest that caregivers have variable approaches to care that are measurable, thus, targeting/tailoring interventions to caregiver style could be an effective approach.

Cognitive-Behavioral Dementia Caregiving Styles: Associations With Care Stress and Well-Being

Some caregivers of persons with Alzheimer’s Disease and related dementias (ADRD) are known to be under high levels of burden, which is associated with higher levels of anxiety, depression, and stress. Previous research has established anxiety, depression, and stress are associated with binge drinking, but little research has examined binge drinking rates among ADRD caregivers. Binge drinking could influence the ability of ADRD caregivers to provide care. The purpose of this study was to explore the prevalence and prevalence correlates of binge drinking among ADRD caregivers using the 2019 Behavior Risk Factor Surveillance Survey (BRFSS). We identified N = 1,642 persons who were the primary informal caregivers of a person with ADRD. Among them, the prevalence of binge drinking was 14 per 100 persons. Bivariable analyses suggested male caregivers and caregivers with 14 or more days of poor mental health in the past 30 days had the highest prevalence of binge drinking at 18 per 100 persons. Caregivers who were 65 or older or had the lowest prevalence at 3 per 100 persons. Caregiving characteristics revealed providing 20 to 39 hours of care per week had the highest prevalence of binge drinking (17 per 100) whereas spousal caregivers (9 per 100) had the lowest prevalence. Smoking status and hours per week providing care were associated with higher odds of binge drinking in multivariable analyses. Future research should examine if binge drinking by ADRD caregivers is related caregiver burden and the quality of care provided to the persons with ADRD.

Early Adversity and Later Health: The Pathway of Social Relationships in Adulthood in HRS and ELSA

Early adversity is associated with compromised health and well-being in later life, but whether social functioning mediate the association is unclear. We examined 2 longitudinal samples of older adults (&gt;= 50 years) whose baseline surveys were between 2006 and 2008 with follow-up until 2016 in the Health and Retirement Study (HRS, n = 15,946) and its sister study in England (ELSA, n = 9,692). Health outcomes included depressive symptoms, chronic health conditions, and subjective memory complaints. Social relationships were measured by contacts, relationship strains, and feelings of loneliness. Early adversity was measured by parental physical abuse and alcohol and drug problems in the family before the age of 16. Patterns of association were similar in these 2 samples, where social contacts decreased over time, while relationship strains and loneliness increased especially for older adults with early trauma, which in turn mediated the associations between early adversity and poorer later health.

Caregivers' Medical Care Provision at Patient End-of-Life: Associations with Emotional Difficulty and Gains

Family caregivers play crucial roles in patient care and medical decision making, especially at end-of-life (EOL). Yet, most research focuses on caregivers’ burden, with little attention to rewards that make for a fulfilling EOL care experience. We consider caregiver involvement at EOL and associations with caregiver stress and gains. Data are drawn from the 2017 National Study of Caregiving’s last month of life and core interviews which includes caregivers (n=283) for a nationally representative sample of Medicare eligible older adults, and questions caregivers about their care provision and EOL experience. We consider indicators of caregivers’ involvement in medical decision making and support received from providers as predictors of caregivers’ emotional difficulty and gains at EOL utilizing linear regressions controlling for demographic characteristics. Caregivers were 60.7 years of age on average, 72.5% female, 21.3% non-white, and 11% were spousal partners. Making medical decisions was associated with increased emotional difficulty at EOL (B=0.93, SE=0.24, p<.001). In contrast, more caregiving gains were associated with having care decisions align with the CG’s wishes (B=-0.64, SE=0.30, p<.05), being more informed by providers (B=0.41, SE=0.16, p<.05), helping the care recipient with anxiety or sadness (B=0.69, SE=0.28, p<. 05), and surprisingly, feeling that care decisions were made without their input (B=0.82, SE=0.29, p<.01). Being more involved and informed in care was associated with both positive and negative caregiver outcomes at EOL. Understanding caregiver emotional difficulty and gains at EOL are critical for identifying how clinicians can better support caregivers at EOL and improving the caregiving experience.

Older Adults’ Worry about COVID-19: Associations with Experiences of COVID-19 Among Social Connections

The COVID-19 pandemic has challenged the physical and mental health of older adults, yet it is unknown how much older adults worry about their own exposure. As older adults are at increased risk for severe complications from COVID-19, understanding patterns of worry may inform public health guidelines and interventions for this age group. We investigated older adults’ worry about COVID-19 in the early months of the pandemic and associations with familial/friend’s diagnosis or disease symptoms. Data comes from the baseline (April/May 2020), one-month, and two-month follow-up surveys from the COVID-19 Coping Study, a national longitudinal cohort study of US adults aged ≥55. We used linear regression models to investigate the association between self-reported familial/friend diagnosis or symptoms with pandemic worry, accounting for demographic factors and individual diagnosis or experience of COVID-19 symptoms. Participants (Baseline=4379, 1 month= 2553, 2 month=2682) were 67 years old on average, 72% were female, 5.7% were non-White, and 80.5% had a college degree. At baseline, 26.6% of participants had friends or family who had been diagnosed or experienced symptoms of COVID-19. Having friends or family diagnosed or with symptoms of COVID-19 (B=0.08, SE=0.04, p&lt;.05), being female (B=0.42, SE=0.03, p&lt;.001), and having higher educational attainment (B=0.06, SE=0.02, p&lt;.001) were significantly associated with greater worry about COVID-19. These associations were consistent over 3 months. Understanding if worry about the pandemic correlates with following public health guidelines is a key next step so intervention strategies can prioritize older adults and their social networks.

Exploring Dementia Care in an Acute Care Setting: Perspectives of Social Workers and Nurses

Nurses and social workers in acute care settings have unique perspectives about providing care to persons living with dementia (PLwD) who experience behavioral and psychological symptoms of dementia (BPSD). Their distinctive roles and training have important implications for the recovery and well-being of PLwDs during hospital stays. This study utilized the "rigorous and accelerated data reduction" (RADaR) technique to compare perspectives of social workers (n=12) and nurses (n=5) in a Midwestern tertiary care facility about their caring for PLwds with BPSD. Three major themes were identified: 1) patient engagement and coordination with family and professionals, 2) treatment and medical management, and 3) barriers to care. Similarities between social workers and nurses emerged within the themes, including the importance of family involvement and providing person centered care. Differences emerged particularly within the treatment and medical management theme, as nurses utilize medications to treat BPSD and social workers were more likely to use redirection. While there is distinctive training for nurses and social workers, both identified similar barriers to providing care to PLwDs with BPSD, including time constraints, competing demands, and lack of training on BPSD management. Results demonstrate how an understanding of the critical and complementary roles that nurses and social workers play in dementia care and work together to build a care team can inform best practices to support symptom management and quality of life in PLwDs. Continuing education and training could be beneficial for both professionals to improve the quality of care for PlwDs.

Different Statistical Approaches to Develop a Guideline for Improvement of Caregiver’s Mental Health

Caregiver burden is common, and improvement of caregivers’ mental health could lead to better quality of care and well-being for both caregivers and care recipients. We investigate ways to develop a guideline to enhance caregiver’s mental well-being by applying and comparing regression tree and ensemble tree models. Data comes from the 2017 National Health and Aging Trends Study and National Study of Caregiving. Dementia caregivers’ (n=945) aspects of caregiving, care activities, support environment, and participation along with basic demographics and health are considered. First, insignificant predictors are preselected using linear regression with backward selection, which will not be included in the tree models. Using the predetermined predictors that are not excluded in the backward selection method, regression tree and ensemble tree models are generated to predict emotional difficulty of caregivers. The regression tree with the preselected predictors predicts caregivers with low to moderate levels of overload and high levels of joy being with their care recipient associated with the lowest level of emotional difficulty. On the other hand, if caregivers have high levels of overload and low to moderately high levels of positive affect, this is linked with the highest level of emotional difficulty. Ensemble tree models showed similar results with lower error measures. Using tree-based methods can help determine the most important predictors of caregiver mental health. Easily interpretable results with applicable decision rules can provide a guideline for intervention developers.

An Action Research Method for Generating Human-Centered COVID-19 Caregiving Interventions

Caregiving for post-intensive care COVID-19 patients is an important determinant of successful recovery, including the reduced likelihood of ICU readmission. With possible ICU readmissions coinciding with a second wave of the pandemic, researchers and clinicians at the University of Michigan sought to develop a patient and caregiver-informed intervention that was remote, accessible, and could be immediately delivered. The resulting study, Health Enhanced by Adjusting and Recovering Together, reinforces these imperatives common in action research frameworks. Action research, emerging itself from a tumultuous time (1930s-40s) paralleling the COVID-19 pandemic, is a pragmatic research approach with the explicit goal of resolving a community problem or enacting social change--and doing so quickly. Here, we demonstrate a unique method for rapid intervention development that intertwines elements of (a) Human-centered design, for the purpose of a people-focused outlook, (b) Action research, for the purpose of rapid intervention, and (c) Traditional qualitative analysis, for the purpose of knowledge creation. The result of this combined method is an efficiently developed intervention that, while imperfect, is a user-centered, contextually-relevant viable product that can be quickly disseminated, tested, and further refined. The method presented is timely and relevant to other clinical and research teams addressing caregiving during the COVID-19 pandemic.

The Influence of Dementia Caregiving Styles on Caregiver Distress and the Person With Dementia’s Quality of Life

Building vertically upon the Stress Process Model, dementia caregivers’ cognitive-behavioral management styles are an understudied area with implications for dyadic care outcomes and tailoring of care interventions. We consider whether membership in five previously classified caregiving styles (Externalizers, Individualists, Learners, Adapters, Nurturers- which vary in their adaptability, dementia understanding, and behavioral management practices) impacts caregivers’ experiences of care-related stress and the quality of life of the person with dementia (PWD). Participants included 100 primary family caregivers for PWDs who were 74% female, 18% non-White, and on average 64 years old. Utilizing linear regressions, each caregiving style was considered as a key predictor (reference: Externalizers- poor understanding, non-adaptable approach, and punitive behavioral strategies) of the Caregiver Assessment of Function and Upset (CAFU) upset score, Neuropsychiatric Inventory (NPI-C) distress scale, Zarit Burden Interview (ZBI), and PWD quality of life (QOL-AD) scale controlling for demographics, care duration, co-residency, and dementia severity. Relative to Externalizers, Nurturers (understanding, adaptability, positive engagements) had less CAFU upset (β=-0.4, p<.01), less NPI-C distress (β=-0.3, p<.05), and greater QOL-AD for the PWD (β=0.4, p<.01). Learners (recognize need to change care approach, attempting adaptability, trial-and-error behavioral care) also showed significantly lower NPI-C distress than Externalizers (β=-0.5, p<.01). Thus caregiving styles with more dementia understanding, adaptability and positive behavioral strategies showed less distress and better PWD QOL. Corresponding with recent dementia care summits calling for identification of caregivers at greatest risk for poor outcomes, targeting and tailoring interventions based on caregiving styles may lead to great public health impact.

Barriers and Challenges Faced by Social Workers Caring for Dementia Patients in Acute Care Settings

The nature of dementia care provided by social workers across various hospital settings is unexplored. This study utilized the “rigorous and accelerated data reduction” (RADaR) qualitative analysis technique to explore the process of care among social workers for persons with dementia (PWDs) across a Midwestern tertiary care system with two aims: 1) to identify environmental barriers and supports to quality dementia care in two hospital settings (medical and psychiatric emergency departments (ED), and the main inpatient hospital (IP)), and 2) to identify existing strengths and challenges to high quality social work dementia care within these settings. Twelve qualitative interviews were conducted with a purposive, snowball sample of social workers in dementia care in a large, academic health care system in 2016. Results identify environmental barriers in both settings (physical space design, patient-environment interactions, safety, and discharge disposition). Environmental aspects that promote quality care include supportive staff and family in the patient environment in the IP and ED hospital sections while the discharge disposition is more relevant in the IP. While there are some areas of social work involvement (discharge, psycho-social needs, treatment/management issues) that promote quality of care across locales, the pattern of performing roles varied, e.g. there is more focus on discharge planning and less management of competing demands in the IP than in the ED. Also, social workers were more involved in the diagnosis of dementia in the ED than other settings. We offer policy and practice recommendations to improve care for PWDs in academic hospital settings.

Family Caregivers on the Frontline: Challenges of Providing Care to Post-ICU COVID-19 Patients

Family caregivers are essential care providers helping to ensure the sometimes complicated recovery of recently hospitalized COVID-19 patients. COVID-19 caregivers face pandemic-specific challenges such as not being at patient bedside throughout the hospital stay and managing social distancing post-discharge. The current study aims to explore the unique experiences of family caregivers of Intensive Care Unit (ICU) COVID-19 patients. In-depth qualitative interviews were conducted by web conference with 13 dyads of adults who were in an ICU for COVID-19 between March and August 2020 and their primary caregiver (n=26). Participants were interviewed about the care recipient’s hospitalization and recovery journey, supports received, challenges experienced, and gaps in the system of care. Thematic qualitative analysis was conducted utilizing Watkins’ (2017) rigorous and accelerated data reduction (RADaR) technique. Caregivers played a critical role in patient admission, discharge, and recovery. Themes of caregiving challenges included self-management of COVID-19 infection, knowledge deficits of available resources and post-discharge care needs, post-infection stigma, separation guilt, deprioritized self-care, financial challenges, and lengthy recoveries with some ongoing health needs. While receipt of emotional support was considered an advantage, some caregivers expressed contact fatigue. Understanding how COVID caregivers experience illness management across the recovery journey can aid our understanding of the COVID caregiving process and identify intervention targets to improve overall health and well-being of the care dyad.

Differences in Cause-Specific Mortality Between Frail Men and Women in the United States

While frailty is associated with risk of numerous adverse health outcomes including mortality, little is known about the most common specific causes of death among frail older adults or how these causes might differ by gender. This information may be important to understanding the frailty syndrome and to informing screening and treatment. We used linked data from the Health and Retirement Study (2004 – 2012) and the National Death Index (NDI). We analyzed data from HRS participants age 65 and older who completed a general health interview and physiological measures (n=10,490). Frailty was operationalized using the phenotype criteria – low weight, low energy expenditure, exhaustion, slow gait, and weakness. Causes of death were determined using International Classification of Diseases (v10) codes from death certificates. We used Cox proportional hazards to compare incidence of cause-specific mortality by frailty status and gender. The attributable risk of mortality due to frailty in the sample was 16.6% among women and 17.3% among men. Overall, frail older adults had greater risk of death from heart disease (hazard ratio (HR): 2.97; 95% CI: 2.18, 4.04), cancer (HR: 2.81; 95% CI: 2.01, 3.93), and dementia 2.86 (95% CI: 1.46, 5.58) but not cerebrovascular disease or accidents. Frail women were more approximately 29% more likely to die from heart disease than frail men. Findings suggest that frailty is a significant risk factor for mortality from several different causes, especially among women. Findings may help inform screening and treatment decisions for older adults at risk for frailty.

Physical Activity and Insomnia Symptoms Over 10 Years in a U.S. National Sample of Late-Middle-Age and Older Adults: Age Matters

Research suggests that physical activity may influence sleep, yet more research is needed before it can be considered a frontline treatment for insomnia. Less is known about how this relationship is moderated by age. Using multilevel modeling, we examined self-reported physical activity and insomnia symptoms in 18,078 respondents from the U.S. nationally representative Health and Retirement Study (2004-2014). The mean baseline age was 64.7 years, with 53.9% female. Individuals who reported more physical activity (B = -0.005, p < .001) had fewer insomnia symptoms. Over 10 years, the respondents reported fewer insomnia symptoms at times when they reported more physical activity than was average for them (B = -0.003, p < .001). Age moderated this relationship (B = 0.0002, p < .01). Although modest, these findings concur with the literature, suggesting moderate benefits of physical activity for sleep in older adults. Future research should aim to further elucidate this relationship among adults at advanced ages.

Dementia Care Across a Tertiary Care Health System: What Exists Now and What Needs to Change

OBJECTIVES

This study explored the process of care for persons living with dementia (PLWDs) in various care settings across a tertiary care system and considers challenges and opportunities for change.

DESIGN

Aimed at quality improvement, qualitative interviews were conducted with key stakeholders in dementia care across geriatric outpatient clinics, medical and psychiatric emergency departments, and the main hospital in 2016.

SETTING AND PARTICIPANTS

Forty-nine interactive interviews were conducted with a purposive and snowball sampling of health care professionals (physicians, nurses, social workers, administrators) and families in a large, academic health care system.

MEASURES

Qualitative interview guides were developed by the study team to assess the process of care for PLWDs and strengths and challenges to delivering that care.

RESULTS

Key themes emerging from the interviews in each care setting are presented. The outpatient setting offers expertise, a multidisciplinary clinic, and research opportunities, but needs to respond to long waitlists, space limitations, and lack of consensus about who owns dementia care. The emergency department offers a low nurse/patient ratio and expertise in acute medical problems, but experiences competing demands and staff turnover; additionally, dementia does not appear on medical records, which can impede care. The hospital offers consultative services and resources, yet the physical space is confined and chaotic; sitters and antipsychotics can be overused, and placement outside of the hospital for PLWDs can be a challenge.

CONCLUSIONS AND IMPLICATIONS

Five key recommendations are provided to help health systems proactively prepare for the coming boom of PLWD and their caregivers, including outpatient education, a dementia care management program to link services, Internet-based training for providers, and repurposing sitters as Elder Life specialists.

Finding fault: Criticism as a care management strategy and its impact on outcomes for dementia caregivers

BACKGROUND

Despite a large literature on the stress process, little attention has focused on how caregivers for persons living with dementia (PLWDs) provide care and how this may impact care outcomes. Criticism is a management strategy caregivers may use to respond to behavioral symptoms. We consider whether criticism is associated with caregivers' mental health and service utilization.

METHODS

Data are drawn from the Advancing Caregiver Training intervention study including 256 informal caregivers living with a PLWD. In multiple linear regressions controlling for caregivers' demographics and PLWDs' clinical factors, we consider criticism (criticism subscale of the Dementia Management Strategies Scale) as a predictor of caregiver burden, depressive symptoms, desire to institutionalize the PLWD, level of frustration with care, and the number of home-based, social, and health services utilized.

RESULTS

On average, 15% of the sample sometimes reported using criticism as a management strategy to manage the challenges of care. Greater use of criticism was associated with significantly more caregiver burden (β = 0.26, P < 0.001) and frustration with caregiving (β = 0.66, P < 0.001), but not depressive symptoms or a desire to institutionalize the PLWD. Criticism was also associated with significantly greater utilization of home-based (β = 0.14, P < 0.05) and social services (β = 0.15, P < 0.05), but not health care services.

CONCLUSION

Criticism appears to be used by more burdened and frustrated caregivers. The association of criticism with social and home-based services potentially reflects a need for greater support among this group of caregivers. Behavioral interventions that can help caregivers manage behavioral symptoms with positive, empirically validated strategies may be helpful.

Recent Improvements in Cognitive Functioning Among Older U.S. Adults: How Much Does Increasing Educational Attainment Explain?

OBJECTIVES

Recent interest has been generated about reports of declining incidence in cognitive impairment among more recently born cohorts. At the same time, attained education, which is related to cognition, has increased in recent cohorts of older adults. We examined cohort differences in cognitive function in a nationally representative sample of Americans aged 25 and older followed for 25 years (1986-2011) and considered the extent to which cohort differences in education account for differences.

METHOD

Data come from the Americans' Changing Lives Study (N = 3,617). Multiple cohort latent growth models model trajectories of cognition (errors on the Short Portable Mental Status Questionnaire) across four 15-year birth cohorts. Demographic factors, educational attainment, and time-varying health conditions were covariates.

RESULTS

Significant cohort differences were found in the mean number of cognitive errors (e.g., 0.26 more errors at age 65 in cohort born pre-1932 vs cohort born 1947-1961, p < .001). Although demographic and health conditions were associated with level and rate of change in cognitive dysfunction, education solely accounted for cohort differences.

DISCUSSION

Compression of cognitive morbidity is seen among the highly educated, and increasing educational opportunities may be an important strategy for decreasing the risk for cognitive impairment in later life.

"What Hath Night to Do with Sleep?": The Caregiving Context and Dementia Caregivers' Nighttime Awakenings

OBJECTIVES

Care provision for persons with dementia can be rewarding yet may disrupt caregiver's sleep health. Using the National Health & Aging Trends Study and the National Study of Caregiving, we examine care receiver and caregiver contextual factors, caregiver health and psychological wellbeing as predictors of caregivers' nighttime awakenings.

METHODS

The sample for this cross-sectional study included 451 caregivers for individuals with dementia surveyed by telephone.

RESULTS

Nighttime awakenings (1 item measure of waking and not being able to return to sleep) almost every night were reported by 16% of caregivers and 10% reported that helping the care receiver caused their sleep to be interrupted most nights. In a multinomial logistic regression, caregivers' greater nighttime awakenings were associated with caring for care recipients with higher fall risk, as well as caregiver characteristics of more chronic medical conditions and emotional difficulty of the care role.

CONCLUSIONS

Emotional caregiving difficulties were associated with nighttime awakenings even accounting for caregivers' health and care receivers' disability. Thus, interventions improving caregiver distress may improve sleep health.

CLINICAL IMPLICATIONS

Clinicians should screen caregivers for nighttime awakenings so that evidence-based interventions and treatments can be implemented to prevent persistent sleep disturbances.

Distress Associated with Dementia-Related Psychosis and Agitation in Relation to Healthcare Utilization and Costs

OBJECTIVES

Explore the relationship between behavioral and psychological symptoms of dementia (BPSD; specifically, delusions, hallucinations, and agitation/aggression) and associated caregiver distress with emergency department (ED) utilization, inpatient hospitalization, and expenditures for direct medical care.

DESIGN/SETTING/PARTICIPANTS

Retrospective cross-sectional cohort of participants with dementia (N = 332) and informants from the Aging, Demographics, and Memory Study, a nationally representative survey of U.S. adults >70 years old.

MEASUREMENTS

BPSD of interest and associated informant distress (trichotomized as none/low/high) were assessed using the Neuropsychiatric Inventory (NPI). Outcomes were determined from one year of Medicare claims and examined according to presence of BPSD and associated informant distress, adjusting for participant demographics, dementia severity, and comorbidity.

RESULTS

Fifty-eight (15%) participants with dementia had clinically significant delusions, hallucinations, or agitation/aggression. ED visits, inpatient admissions, and costs were not significantly higher among the group with significant BPSD. In fully adjusted models, a high level of informant distress was associated with all outcomes: ED visit incident rate ratio (IRR) 3.03 (95% CI: 1.98-4.63; p < 0.001), hospitalization IRR 2.78 (95% CI: 1.73-4.46; p < 0.001), and relative cost ratio 2.00 (95% CI: 1.12-3.59; p = 0.02).

CONCLUSIONS

A high level of informant distress related to participant BPSD, rather than the symptoms themselves, was associated with increased healthcare utilization and costs. Effectively identifying, educating, and supporting distressed caregivers may help reduce excess healthcare utilization for the growing number of older adults with dementia.

Residual Effects of Restless Sleep over Depressive Symptoms on Chronic Medical Conditions: Race by Gender Differences

BACKGROUND

Sleep and depression are comorbid problems that contribute to the development of chronic medical conditions (CMC) over time. Although racial and gender differences in the bidirectional associations between sleep, depression, and CMC are known, very limited information exists on heterogeneity of the residual effects of sleep problems over depressive symptoms on CMC across race by gender groups.

AIM

Using a life-course perspective, the present study compared race by gender groups for residual effects of restless sleep over depressive symptoms on CMC.

METHODS

We used data from waves 1 (year 1986), 4 (year 2001), and 5 (year 2011) of the Americans' Changing Lives Study (ACL). The study followed 294 White men, 108 Black men, 490 White women, and 237 Black women for 25 years. Restless sleep, depressive symptoms (Center for Epidemiological Studies-Depression scale [CES-D]), and number of chronic medical conditions (hypertension, diabetes, chronic lung disease, heart disease, stroke, cancer, and arthritis) were measured in 1986, 2001, and 2011. We employed multi-group cross-lagged modeling, with chronic medical conditions as the outcome and race by gender as the groups.

RESULTS

Major group differences were found in the residual effect of restless sleep on CMC over depressive symptoms across race by gender groups. Restless sleep in 2001 predicted CMC 10 years later in 2011 among Black women (standardized adjusted B = .135, P < .05) and White men (standardized adjusted = .145, P < .01) and White women (standardized adjusted B = .171, P < .001) but not Black men (standardized adjusted B = .001, P > .05).

CONCLUSION

Race by gender heterogeneity in the residual effect of restless sleep over depressive symptoms on CMC over 25 years suggests that comorbid poor sleep and depressive symptoms differently contribute to development of multi-morbidity among subpopulations based on the intersection of race and gender. Thus, interventions that try to prevent comorbid sleep problems and depression as a strategy to prevent medical conditions may benefit from tailoring based on the intersection of race and gender.

The Effect of Sleep Disturbance on the Association between Chronic Medical Conditions and Depressive Symptoms Over Time

Chronic medical conditions (CMC) and sleep disturbances are common among adults and associated with depression. We tested sleep disturbance as a moderator of the effect of CMC on depressive symptoms. The sample includes 3597 adults surveyed up to five times over 25 years (1986-2012) from the nationally representative American's Changing Lives Study (ACL). A multi-level model was estimated to examine sleep disturbance as a moderator of the CMC and depressive symptom association, with a second interaction tested for age as a moderator of the within-person level variability in CMC and depressive symptom association. Sleep disturbance and CMC were associated with depressive symptoms at the between-person level, while only sleep disturbance was associated with depressive symptoms at the within-person level. Sleep disturbance significantly interacted with CMC such that more CMCs were associated with more depressive symptoms among individuals sleeping well, but poor sleep was associated with worse depression regardless of CMC. A second interaction between age and within-person variability in CMC was found significant, suggesting that younger adults had higher symptoms of depression at times of below average CMC relative to older adults. The effect of CMC on depressive symptoms may depend on sleep as well as age. Sleeping restfully may allow individuals with CMC the rejuvenation needed to cope with illness adaptively.

Predictors of Pharmacy-Based Measurement and Self-Report of Antidepressant Adherence: Are Individuals Overestimating Adherence?

OBJECTIVE

This study considered various factors as predictors of antidepressant adherence over time as assessed by self-report and medication possession ratios (MPRs) derived from administrative pharmacy data.

METHODS

Adherence was assessed at six and 12 months among 443 veterans in ongoing treatment for depression in a trial of peer support. Logistic regression models were utilized to consider predictors of adequate adherence.

RESULTS

At six and 12 months, respectively, 36% and 35% of patients had poor adherence on the basis of MPRs and 24% and 18% had poor adherence on the basis of self-report. MPRs indicating poor adherence were more likely among men, members of racial groups other than white, and patients with Hispanic ethnicity. Poor self-reported adherence was associated with increased depressive symptoms and unemployment.

CONCLUSIONS

These adherence measures may be complementary. Strategies to improve adherence might target specific demographic groups, unemployed persons, and persons with higher levels of depressive symptoms.

Predictors of New Onset Sleep Medication and Treatment Utilization Among Older Adults in the United States

BACKGROUND

Sleep disturbances are common among older adults resulting in frequent sleep medication utilization, though these drugs are associated with a number of risks. We examine rates and predictors of new prescription sleep medications and sleep treatments, as well as sleep treatments without a doctor's recommendation.

METHODS

Participants were 8,417 adults aged 50 and older from two waves of the nationally representative Health and Retirement Study (HRS) who were not using a sleep medication or treatment at baseline (2006). Logistic regression analyses are run with sociodemographic, health, and mental health factors as predictors of three outcomes: new prescription medication use, sleep treatment use, and sleep treatment out of a doctor's recommendation in 2010.

RESULTS

New sleep medication prescriptions were started by 7.68%, 12.62% started using a new sleep treatment, and 31.93% were using the treatment outside of their doctor's recommendation. Common predictors included greater severity of insomnia, worsening insomnia, older age, and use of psychiatric medications. New prescription medication use was also associated with poorer mental and physical health, whereas new sleep treatment was associated with being White, higher educated, and drinking less alcohol.

CONCLUSIONS

Starting a new prescription sleep medication may reflect poorer health and higher health care utilization, whereas beginning a sleep treatment may reflect an individual's awareness of treatments and determination to treat their problem. Clinicians should be aware of predictors of new sleep medication and treatment users and discuss various forms of treatment or behavioral changes to help patients best manage sleep disturbance.

The Association Between Benzodiazepine Use and Depression Outcomes in Older Veterans

Benzodiazepines (BZDs) are commonly prescribed to older adults with depression, but it is unknown whether they improve antidepressant (AD) adherence or depressive symptoms. We followed 297 older veterans diagnosed with depression and provided a new AD medication prospectively for 4 months. Data include validated self-report measures and VA pharmacy records. At initial assessment, 20.5% of participants were prescribed a BZD. Those with a BZD prescription at baseline were significantly more likely than those without to have a personality disorder, schizophrenia spectrum disorder, or other anxiety disorder, and higher depressive symptom and anxiety symptom scale scores on average. In adjusted regressions, BZD use was not significantly associated with AD adherence, any improvement in depressive symptoms, or a 50% reduction in depressive symptoms. Our results suggest BZD use concurrent with AD treatment does not significantly improve depressive outcomes in older veterans.

The Impact of Sleep Disturbance on the Association Between Stressful Life Events and Depressive Symptoms

OBJECTIVES

Sleep problems are common across the adult life span and may exacerbate depressive symptoms and the effect of common risk factors for depressive symptoms such as life stress. We examine sleep disturbance as a moderator of the association between stressful life events and depressive symptoms across five waves (25 years) of the nationally representative, longitudinal American Changing Lives Study.

METHOD

The sample includes 3,597 adults aged 25 years or older who were surveyed up to five times over 25 years. Multilevel models were run to examine between- and within-person variability in sleep disturbance and life event stress as predictors of depressive symptoms, and an interaction to test sleep disturbance as a moderator is included in a second step.

RESULTS

Life events and sleep disturbance were associated with elevated depressive symptoms at the between- and within-person levels. A significant sleep disturbance by interaction of life events was found, indicating that when individuals experienced an above average number of life events and slept more restlessly than usual, they had a higher risk for depressive symptoms than individuals who experienced above average stress but slept well.

DISCUSSION

Sleeping restfully may allow individuals the rejuvenation needed to manage stress adaptively and reduce depressive symptom burden.

Prevention of Mental Disorder in Older Adults: Recent Innovations and Future Directions

As the global population is aging, increased efforts should be placed on preventing mental disorders in older adults, as opposed to just focusing on sickness and treatment. We provide an overview of existing innovations in prevention in the domains of pharmacotherapy, psychotherapy, and psychosocial interventions. These programs have shown that depression and anxiety can be prevented from recurring, incidence of new disorder can be reduced, and general mental health can be promoted. We also give direction for future research to move the field of geriatric mental health prevention forward.

Correlates of cognitive impairment in older Vietnamese

OBJECTIVES

This study examined correlates of cognitive functioning and possible cognitive impairment among older adults living in Da Nang, Vietnam and surrounding rural areas.

METHODS

The analytic sample consisted of 489 adults, 55 and older stratified by gender, age, and residence in a rural or urban area. The sample was 46% rural, 44% women, with a mean age of 69.04. Interviews were conducted in individuals' homes by trained interviewers. The dependent variable was a Vietnamese version of the mini mental status examination (MMSE). A multiple linear regression was run with the MMSE continuous scores reflecting cognitive functioning, while a binary logistic regression was conducted with an education-adjusted cut-off score reflecting possible cognitive impairment. Age, gender, education, material hardship, depressive symptoms Center for Epidemiologic Studies - Depression Scale, war injury, head trauma, diabetes, cardiovascular and cerebrovascular disease conditions served as correlates, controlling for marital status and rural/urban residence.

RESULTS

About 33% of the sample scored below the standard cutoff of 23 on the MMSE. However, only 12.9% of the sample would be considered impaired using the education-adjusted cut-off score. Cognitive functioning and possible cognitive impairment as indicated by MMSE scores were significantly associated with being older, completing fewer years of education, and material hardship. Gender, depressive symptoms, and cerebrovascular disease were associated with cognitive functioning, but not cognitive impairment.

CONCLUSION

These results show that social characteristics, physical illness, and mental health are associated with cognitive functioning. The study also raises questions about the need for standardization of screening measures on Vietnamese populations.

The influence of social factors and health on depressive symptoms and worry: a study of older Vietnamese adults

OBJECTIVES

Vietnam has a growing older population, many of whom experienced war and social upheavals in their lives. Prior research has described the health of the older population, but little work has explored mental health. The current study examines the frequency and correlates of two mental health indicators: depressive symptoms and worry.

METHOD

A representative sample of 600 adults 55 and older stratified by gender (50% women), age (mean=70.33), and rural/urban (50% rural) was recruited in Da Nang, Vietnam and surrounding rural districts. Participants were interviewed in their homes by trained interviewers. Dependent variables were a Vietnamese version of the CES-D and a culturally specific worry scale.

RESULTS

Forty-seven percent of the sample had scores above the cut-off for clinical depression and scores on the worry scale were high. Using multiple linear regressions we found that women, the less educated and individuals with more material hardship had higher depressive symptoms whereas rural residents, women, married, and young-old individuals were more worried. Pain, ADL assistance and emotional support were significant predictors of both depressive symptoms and worry, though the direction of the association for emotional support differed. Illnesses were only a predictor of depressive symptoms.

CONCLUSION

The high reports of depressive symptoms and worry suggests the need for incorporating mental health screening as part of health programs for older adults in Vietnam. Attention to factors associated with depressive symptoms and worry, such as economic hardship, health problems and lack of emotional support, may contribute to alleviation of symptoms.

Nramp2 expression is associated with pH-dependent iron uptake across the apical membrane of human intestinal Caco-2 cells

The absorption of dietary non-heme iron by intestinal enterocytes is crucial to the maintenance of body iron homeostasis. This process must be tightly regulated since there are no distinct mechanisms for the excretion of excess iron from the body. An insight into the cellular mechanisms has recently been provided by expression cloning of a divalent cation transporter (DCT1) from rat duodenum and positional cloning of its human homologue, Nramp2. Here we demonstrate that Nramp2 is expressed in the apical membrane of the human intestinal epithelial cell line, Caco 2 TC7, and is associated with functional iron transport in these cells with a substrate preference for iron over other divalent cations. Iron transport occurs by a proton-dependent mechanism, exhibiting a concurrent intracellular acidification. Taken together, these data suggest that the expression of the Nramp2 transporter in human enterocytes may play an important role in intestinal iron absorption.

Origins and development of the injunction prohibiting sexual relationships with patients

This paper addresses the historical context, both ancient and modern, of the injunction prohibiting sexual relationships with patients. Reference is made to the increasing knowledge of factors predisposing to such breaches of ethical conduct and to the common dangers and consequences of sexual relationships with patients. Such research findings demonstrate adequate cause for the application of the injunction in all of the health care professions. The modern social context of liberal humanism and feminism, along with the recognised analogy with child sexual abuse, are considered as influences in the current resurgence of interest in the injunction itself.

A survey of Australian psychiatrists' attitudes and practices regarding physical contact with patients

A brief review of the ethics of psychiatrists' and psychotherapists' physical contact with patients is followed by a more detailed review of the major North American studies using self report surveys to measure attitudes and behaviour regarding physical contact with patients. The methodology and results of a recent sample survey of Australian psychiatrists' attitudes and behaviour regarding such physical contact are presented and discussed by comparison with the North American literature. Issues pertaining to both "erotic" and "non-erotic" contact are explored.