State COVID-19 Policies and Drug Overdose Mortality Among Working-Age Adults in the United States, 2020

Objectives. To identify relationships between US states' COVID-19 in-person activity limitation and economic support policies and drug overdose deaths among working-age adults in 2020. Methods. We used county-level data on 140 435 drug overdoses among adults aged 25 to 64 years during January 2019 to December 2020 from the National Vital Statistics System and data on states' COVID-19 policies from the Oxford COVID-19 Government Response Tracker to assess US trends in overdose deaths by sex in 3138 counties. Results. Policies limiting in-person activities significantly increased, whereas economic support policies significantly decreased, overdose rates. A 1-unit increase in policies restricting activities predicted a 15% average monthly increase in overdose rates for men (incident rate ratio [IRR] = 1.15; 95% confidence interval [CI] = 1.09, 1.20) and a 14% increase for women (IRR = 1.14; 95% CI = 1.09, 1.20). A 1-unit increase in economic support policies predicted a 3% average monthly decrease for men (IRR = 0.97; 95% CI = 0.95, 1.00) and a 4% decrease for women (IRR = 0.96; 95% CI = 0.93, 0.99). All states' policy combinations are predicted to have increased drug-poisoning mortality. Conclusions. The economic supports that states enacted were insufficient to fully mitigate the adverse relationship between activity limitations and drug overdoses. (Am J Public Health. Published online ahead of print May 2, 2024:e1-e9. https://doi.org/10.2105/AJPH.2024.307621).

The Changing Demography of Late-Life Family Caregiving: A Research Agenda to Understand Future Care Networks for an Aging U.S. Population

Repeated claims that a dwindling supply of potential caregivers is creating a crisis in care for the U.S. aging population have not been well-grounded in empirical research. Concerns about the supply of family care do not adequately recognize factors that may modify the availability and willingness of family and friends to provide care to older persons in need of assistance or the increasing heterogeneity of the older population. In this paper, we set forth a framework that places family caregiving in the context of older adults' care needs, the alternatives available to them, and the outcomes of that care. We focus on care networks, rather than individuals, and discuss the demographic and social changes that may alter the formation of care networks in the future. Last, we identify research areas to prioritize in order to better support planning efforts to care for the aging U.S. population.

U.S. States' COVID-19 physical distancing policies and working-age adult mental health outcomes

In the early months of the COVID-19 pandemic, states enacted multiple policies to reduce in-person interactions. Scholars have speculated that these policies may have contributed to adverse mental health outcomes. This study examines potential associations between states' COVID-19 physical distancing policies and working-age (18-64) adults' self-reported mental health. Mental health outcomes (depression, anxiety, worsened mental health, and sought treatment for anxiety or depression) are from the National Wellbeing Survey collected from working-age adults in the United States (U.S.) February 1 to March 18, 2021 (N = 3,804). Data on 12 state policies are from the COVID-19 U.S. State Policy Database. Analyses included logistic regression and Bayesian group index modeling, which identified sets, or "bundles," of policies that were associated with each mental health outcome. Multiple policies (both separately and in bundles) were associated with adverse mental health outcomes, with certain policies (closures and curfews on retail and other businesses) being particularly important. A one-month increase in exposure to respective model-derived physical distancing policy bundles was associated with a 36% increase in the odds of reporting that COVID-19 worsened one's mental health (odds ratio [OR] = 1·36; 95% credible interval [CRI] = 1·01 to 1·80), a 6% increase in the odds of meeting the clinical threshold for anxiety (OR = 1·06; CRI = 0·99 to 1·16), and a 15% increase in the odds of seeking treatment for anxiety or depression (OR = 1·15; CRI = 1·02 to 1·49). To accurately understand the role of states' COVID-19 policies on mental health during the pandemic, researchers must consider how collections of policies might influence outcomes.

Social isolation and subclinical vascular pathways to cerebrovascular disease

Social isolation and lack of social support are risk factors for cardiovascular and cerebrovascular disease (CVD). This study explored the relationship between measures of social support and subclinical measures of CVD risk. 58 healthy adults ages 18 to 85 years participated in this study. The Berkman-Syme Social Network Inventory (SNI) was used to assess social isolation, with higher scores signifying less isolation. Social support was defined using the 12-Item Interpersonal Support Evaluation List (ISEL-12) with a higher score signifying higher social support. Subclinical CVD measures included carotid-femoral pulse wave velocity (cfPWV), carotid beta-stiffness index, and middle cerebral artery (MCA) pulsatility index. Path analysis models for both the SNI and ISEL appraisal domain predicting cfPWV and cerebrovascular pulsatility fit the data well. Path analyses showed significant direct paths from the SNI (β = -.363, t = -2.91) and ISEL appraisal domain (β = -.264, t = -2.05) to cfPWV. From cfPWV, both models revealed significant direct paths to carotid stiffness (β = .488, t = 4.18) to carotid pulse pressure (β = .311, t = 2.45) to MCA pulsatility (β = .527, t = 4.64). Social isolation and appraisal of social support are related to unfavorably higher aortic stiffness, with subsequent detrimental effects on cerebrovascular hemodynamic pulsatility.

State policies that promote, and that inhibit, improved public health: An exploratory analysis of paid sick leave

The United States has no national requirement that employers provide paid sick leave (PSL) to their employees, despite the many established public health benefits of PSL access. Many states, and some localities, have passed laws requiring PSL within their jurisdictions. Past studies have shown that these PSL mandates are effective in promoting increased PSL access. However, past studies have not considered two other commonly-used state policy initiatives-PSL preemption and right-to-work laws-that could hypothetically influence employers' decisions to provide PSL. During the past few decades, all possible combinations of these policy interventions can be found in one or more U.S. states. This study estimates the combined associations of these 3 policies with PSL access. The estimates support recent research on the positive effects of PSL mandates, but also suggest that PSL preemption and right-to-work laws may have offsetting effects. Failure to take account of these additional policies may lead to an over-estimate of the effectiveness of PSL mandates.

U.S. State Preemption Laws and Working-Age Mortality

INTRODUCTION

The goal of this study was to estimate how state preemption laws that prohibit local authority to raise the minimum wage or mandate paid sick leave have contributed to working-age mortality from suicide, homicide, drug overdose, alcohol poisoning, and transport accidents.

METHODS

County-by-quarter death counts by cause and sex for 1999-2019 were regressed on minimum wage levels and hours of paid sick-leave requirements, controlling for time-varying covariates and place- and time-specific fixed effects. The model coefficients were then used to predict expected reductions in mortality if the preemption laws were repealed. Analyses were conducted during January 2022-April 2022.

RESULTS

Paid sick-leave requirements were associated with lower mortality. These associations were statistically significant for suicide and homicide deaths among men and for homicide and alcohol-related deaths among women. Mortality may decline by more than 5% in large central metropolitan counties currently constrained by preemption laws if they were able to mandate a 40-hour annual paid sick-leave requirement.

CONCLUSIONS

State legislatures' preemption of local authority to enact health-promoting legislation may be contributing to the worrisome trends in external causes of death.

Effects of US state preemption laws on infant mortality

Studies show that raising the minimum wage in a US state above the federal minimum wage can reduce infant mortality rates in those states. Some states have raised their minimum wage in recent decades, while many others did not, and have prohibited local authorities from doing so by enacting preemption laws. This study investigates how the recent emergence of state preemption laws that remove local authority to raise the minimum wage has affected infant mortality rates. Using county- and state- level data spanning 2001 through 2018, this study models infant mortality rates as a function of minimum wage levels, controlling for confounders. The estimated model, combined with information on the timing, location, and level of preempted minimum wages, is then used to estimate the number of infant deaths that occurred in 2018 that could be attributed to state preemption of local minimum wage increases. In the 9 largest (pop. > 250,000) metro counties most directly affected by state preemption, we estimate that in 2018, 25 infant deaths were attributable to preemption. This equates to a 5.4% reduction in these counties' infant mortality rate. When considering all large metro counties in preemption states, as many as 605 infant deaths could be attributed to preemption. State preemption laws that remove local authority to enact health-promoting legislation, such as minimum wage increases, are a significant threat to population health. The growing tide of these laws, particularly since 2010, may be contributing to recent troubling trends in US life expectancy.

Division of Parent Care Among Adult Children

OBJECTIVES

Many older adults rely on their children's support to sustain community residence. Although filial norms encourage adult children to help their parents, not every child provides parent care in times of need. The majority of prior studies have adopted an individualistic perspective to examine factors associated with individual children's caregiving behavior. This study complements previous work by using the family systems perspective to understand how caregiving responsibilities are allocated among children in the family and how the pattern of care division evolves over time.

METHOD

Data came from seven rounds of the National Health and Aging Trends Study (2011-2017), in which community-dwelling respondents were asked about all of their children and which children provided them with care. Multilevel models were estimated to examine how caregiving responsibilities were distributed among children and how the children's caregiving efforts responded to changes in their parents' frailty.

RESULTS

About three quarters of older adults reported receiving help from only one child, and the average of monthly care hours was about 50 at baseline. As parents' frailty increased, the proportion of children providing parents rose and the allocation of parent-care hours became more equal.

DISCUSSION

This study underscores the importance of using the family systems perspective to better understand adult children's caregiving behavior. Although just one adult child providing care is the most common caregiving arrangement initially, adult children tend to work with their siblings to support parents' aging in place as parents' need for care increases.

A role for genes in the 'caregiver stress process'?

The stress that accompanies caring for one's parent, and the contribution of that stress to adverse physical and mental-health outcomes, is extensively studied and widely acknowledged. Yet there has been almost no attempt to incorporate the well-documented role of genetic variation in psychological distress into research on caregiving. We use phenotypic data from a large, population-based sample linked to extensive genotype data to develop a polygenic risk score (PRS) for depression, and test for both direct and interactive effects of the PRS in a multilevel repeat-measures model of caregiver-related stress. We distinguish three groups: potential caregivers (those with a living parent who does not need care), noncaregivers (those who do not provide care to their parent that needs care), and caregivers. We also obtain separate estimates according to the gender of both the parent and child. We found that a parent's need for care, and the child's provision of care, are associated with depression in some but not all cases; in contrast the PRS was significantly associated with the risk for increased depressive symptoms (with P ≤ 0.01) in all cases. These findings support an additive genetic contribution to the diathesis-stress model of depression in the context of caregiving.

Estimating the Prevalence of Serious Mental Illness and Dementia Diagnoses Among Medicare Beneficiaries in the Health and Retirement Study

OBJECTIVE

To estimate the prevalence of serious mental illness and dementia among Medicare beneficiaries in the Health and Retirement Study (HRS).

METHODS

This study utilizes HRS-linked Medicare claims data sets and inverse probability weighting to estimate overall and age-specific cumulative prevalence rates of dementia and serious mental illnesses among 18,740 Medicare beneficiaries. Two-way tabulations determine conditional probabilities of dementia diagnoses among beneficiaries diagnosed with specific mental illnesses, and binary logistic regressions determine conditional probabilities of dementia diagnoses among beneficiaries diagnosed with specific mental illnesses, controlling for covariates.

RESULTS

Weighted prevalence estimates for dementia, schizophrenia (SZP), bipolar disorder (BPD), and major depressive disorder (MDD) are similar to previous studies. Odds of dementia diagnosis are significantly greater for beneficiaries diagnosed with SZP, BPD, or MDD.

CONCLUSIONS

Co-occurring mental disabilities require further investigation, as in the near future increasing numbers of mentally ill older adults will need appropriate and affordable community-based services and supports.

Does Paid Family Leave Reduce Nursing Home Use? The California Experience

The intent of Paid Family Leave (PFL) is to make it financially easier for individuals to take time off from paid work to care for children and seriously ill family members. Given the linkages between care provided by family members and the usage of paid services, we examine whether California's PFL program influenced nursing home utilization in California during the 1999 to 2008 period. This is the first empirical study to examine the effects of PFL on long-term care patterns. Multivariate difference-indifference estimates across alternative comparison groups provide consistent evidence that the implementation of PFL reduced the proportion of the elderly population in nursing homes by 0.5 to 0.7 percentage points. Our preferred estimate, employing an empirically-matched group of control states, finds that PFL reduced nursing home usage by about 0.65 percentage points. For California, this represents an 11 percent relative decline in elderly nursing home utilization.

Disability Measurement in the Health and Retirement Study

The Health and Retirement Study (HRS) has provided extensive and detailed national data on disability since it began in 1992, and has been used extensively in studies of disability trends and trajectories. We summarize conceptual frameworks used to characterize disability and review the HRS measures of functioning, work disability, and employer accommodations. HRS survey questions have experienced changes in wording, skip logic, or other design features over the life of the study, and we comment on the analytic challenges posed by those changes. Among our conclusions are (1) work disability and benefit eligibility are important concepts that should be considered for redesign to better reflect current concepts and policy issues; (2) methodological studies of changes in wording or skip logic should be undertaken; and (3) minor additions to survey content in areas such as temporal reference periods or changes in social-participation activities would improve measurement.

Do U.S. states' socioeconomic and policy contexts shape adult disability?

Growing disparities in adult mortality across U.S. states point to the importance of assessing disparities in other domains of health. Here, we estimate state-level differences in disability, and draw on the WHO socio-ecological framework to assess the role of ecological factors in explaining these differences. Our study is based on data from 5.5 million adults aged 25-94 years in the 2010-2014 waves of the American Community Survey. Disability is defined as difficulty with mobility, independent living, self-care, vision, hearing, or cognition. We first provide estimates of age-standardized and age-specific disability prevalence by state. We then estimate multilevel models to assess how states' socioeconomic and policy contexts shape the probability of having a disability. Age-standardized disability prevalence differs markedly by state, from 12.9% in North Dakota and Minnesota to 23.5% in West Virginia. Disability was lower in states with stronger economic output, more income equality, longer histories of tax credits for low-income workers, and higher cigarette taxes (for middle-age women), net of individuals' socio-demographic characteristics. States' socioeconomic and policy contexts appear particularly important for older adults. Findings underscore the importance of socio-ecological influences on disability.

Kinship and Family Support in Taiwan

By 1983, Taiwan had reached the final stage of its population transition, with both mortality and fertility at low rates. Such demographic change will increasingly affect the capacity of families to maintain their caregiving role. Due to reduced fertility, by the 21st century, many elderly persons may have few or no children available to care for them in old age. This article focuses on the family network as a potential source of support for Taiwanese elderly, using microsimulation techniques. The results indicate that the proportion of aged parents without working-age children can be expected to rise substantially. The decline in fertility that has already occurred will reduce the extent of children available to share parental support obligations and increase the support burden on individual offspring. As a result, continued dependence on children as the major form of support will leave a substantial proportion of elderly without resources and a large proportion of the younger generation with difficult financial burdens.

Declining Eligibility for Social Security Spouse and Widow Benefits in the United States?

Currently, two thirds of older women receive Social Security spouse and widow benefits, which are distributed on the basis of marital rather than employment status. But marriage rates are down, particularly among Black women. This study used June 1985, 1990, and 1995 Current Population Survey data to trace trends in marriage for women from five birth cohorts and to predict marital patterns for the latter three cohorts. The authors found that the proportion of women who will reach age 62 without 10-year marriages, and thus be ineligible for spouse and widow benefits, is increasing modestly for Whites and Hispanics but dramatically for African Americans. When women who were born in the 1960s reach age 62, 82% of Whites, 85% of Hispanics, and just 50% of Blacks will be eligible. The authors discuss alternative mechanisms for distributing benefits.

Traditionality, Modernity, and Household Composition

This article investigates the patterns and correlates of currently married adult children’s coresidence with their parents in Turkey using data from the 1993 Turkish Demographic and Health Survey. The authors are particularly interested in traditional patterns of coresidence (i.e., coresidence with one or both of the husband’s parents) and the effect of variables measuring traditionality at the individual and contextual levels on coresidence with any parent and with the husband’s parents. The results indicate that coresidence among currently married children is not the norm. However, the odds of coresidence with the husband’s parents, given that a couple coresides with any parent, are very high. In addition, the authors find substantial effects of traditionality measures on coresidence, especially with the husband’s parents. Continued economic development, and the social changes that accompany it, can be expected to reduce the prevalence of parent-child coresidence in Turkey.

New Methods for Analyzing Active Life Expectancy

The increment-decrement life-table methods used in several recent analyses of active life expectancy depend on parameters representing rates of movement between functional states such as "active" or "disabled." Available data often pose severe problems for the derivation of these parameters. For example, panel-survey data typically fail to record functional status between interviews. The time intervals between interviews also tend to vary across respondents, often substantially. The Longitudinal Study of Aging, used in this research, exhibits these problems. The authors develop a discrete-time Markov chain model of functional status dynamics that accommodates these features of the data and present maximum-likelihood estimates of the model. Also introduced is a new technique for the calculation of active life expectancy: microsimulation of functional status histories. The microsimulation technique permits the derivation of several new indexes of late life-course outcomes.

Disability-Free Life Expectancy Over 30 Years: A Growing Female Disadvantage in the US Population

OBJECTIVES

To examine changes in active life expectancy in the United States over 30 years for older men and women (aged ≥ 65 years).

METHODS

We used the 1982 and 2004 National Long Term Care Survey and the 2011 National Health and Aging Trends Study to estimate age-specific mortality and disability rates, the overall chances of survival and of surviving without disability, and years of active life for men and women.

RESULTS

For older men, longevity has increased, disability has been postponed to older ages, disability prevalence has fallen, and the percentage of remaining life spent active has increased. However, for older women, small longevity increases have been accompanied by even smaller postponements in disability, a reversal of a downward trend in moderate disability, and stagnation of active life as a percentage of life expectancy. As a consequence, older women no longer live more active years than men, despite their longer lives.

CONCLUSIONS

Neither a compression nor expansion of late-life disability is inevitable. Public health measures directed at older women to postpone disability may be needed to offset impending long-term care pressures related to population aging.

Parental disability, parent care, and offspring mental health outcomes

Decades of research supports a widely held view that providing parent care is stressful, and that these stresses are associated with adverse mental health outcomes. However, some recent studies suggest an additional possibility, namely that "noncaregiver stress"-a consequence of having a parent with major care needs, but not being an active caregiver-may be a serious problem as well. This finding emerges in data which permit separate controls for parental needs for care and offspring provision of parent care. We extend these results using Generations and Gender Programme data from five countries-Bulgaria, France, Georgia, Romania, and Russia-for which the necessary variables can be comparably measured. Our outcome variable is a depression score based on a 7-item scale. In country-specific regressions, we find two instances of statistically significant associations of depression with the regular provision of personal care to a parent with care needs, i.e., the usual "caregiver stress" result. However, we also find two instances of statistically significant differences in respondents' depressive symptoms that are associated with having a parent with care needs, i.e., instances of "noncaregiver stress." We find limited evidence of gender-specific responses to both forms of stress. Our evidence supports both the typical caregiver stress response and the less-studied noncaregiver stress response, which suggests the need for additional research.

Disability Trajectories at the End of Life: A "Countdown" Model

OBJECTIVES

Studies of late-life disablement typically address the role of advancing age as a factor in developing disability, and in some cases have pointed out the importance of time to death (TTD) in understanding changes in functioning. However, few studies have addressed both factors simultaneously, and none have dealt satisfactorily with the problem of missing data on TTD in panel studies.

METHODS

We fit latent-class trajectory models of disablement using data from the Health and Retirement Study. Among survivors (~20% of the sample), TTD is unknown, producing a missing-data problem. We use an auxiliary regression equation to impute TTD and employ multiple imputation techniques to obtain final parameter estimates and standard errors.

RESULTS

Our best-fitting model has 3 latent classes. In all 3 classes, the probability of having a disability increases with nearness to death; however, in only 2 of the 3 classes is age associated with disability. We find gender, race, and educational differences in class-membership probabilities.

DISCUSSION

The model reveals a complex pattern of age- and time-dependent heterogeneity in late-life disablement. The techniques developed here could be applied to other phenomena known to depend on TTD, such as cognitive change, weight loss, and health care spending.

Getting help from others: the effects of demand and supply

OBJECTIVES

This article investigates whether the help with care needs that is received from others depends on the potential supply of family helpers.

METHODS

Data from the first round of survey data collected in the National Health and Aging Trends Study are used to create measures of whether help is received, the number of helpers, and the hours of help received. Regression analysis is used to relate these outcomes to indicators of the demand for and supply of helpers.

RESULTS

Analyses suggest limited evidence that the receipt of help is a supply-driven phenomenon. Although the measures of child-caregiver supply are not associated with a binary indicator of help received, caregiver-supply factors are associated with the number of helpers and the total hours of help received.

DISCUSSION

Findings on the total number of helpers and total hours of care have implications for the division of care labor within families and between families and nonfamily members. Foreseeable trends in the demand for and the supply of help suggest further evolution in patterns of elders' receipt of help with care needs. Even if those with needs for care continue to have their needs addressed by one or more helpers, the number of helpers, and the aggregate amount of help they provide, is likely to undergo adjustment in response to changing family patterns.

An Evaluation of Recent Old-Age Policy Innovations in South Korea

In 2008, South Korea launched a Basic Old-Age Pension program, which provides income support for the bottom 60% of the population, and a universal Long-Term Care Insurance (LTCI) program. We investigate the effect of both policies on subjective well-being of the elderly. We use panel data from the Korean Longitudinal Study of Aging, with the 2006 data representing the “pretreatment” and the 2008 data the “posttreatment” situations. We use regression methods for purposes of inferring program impacts. Our findings suggest that satisfaction with economic status was slightly improved by LTCI alone, and by LTCI and basic old-age pension in combination, depending on the estimator used. We found no policy impacts on satisfaction with health conditions. The benefits provided by the two programs may be insufficient to raise well-being in the population as a whole; alternatively, the outcomes may have been measured too soon after the policies were implemented.

Behavioral adaptation and late-life disability: a new spectrum for assessing public health impacts

OBJECTIVES

To inform public health efforts to promote independent functioning among older adults, we have provided new national estimates of late-life disability that explicitly recognize behavioral adaptations.

METHODS

We analyzed the 2011 National Health and Aging Trends Study, a study of Medicare enrollees aged 65 years and older (n = 8077). For 7 mobility and self-care activities we identified 5 hierarchical stages--fully able, successful accommodation with devices, activity reduction, difficulty despite accommodations, and receipt of help--and explored disparities and associations with quality of life measures.

RESULTS

Among older adults, 31% were fully able to complete self-care and mobility activities. The remaining groups successfully accommodated with devices (25%), reduced their activities (6%), reported difficulty despite accommodations (18%), or received help (21%). With successive stages, physical and cognitive capacity decreased and symptoms and multimorbidity increased. Successful accommodation was associated with maintaining participation in valued activities and high well-being, but substantial disparities by race, ethnicity, and income existed.

CONCLUSIONS

Increased public health attention to behavioral adaptations to functional change can promote independence for older adults and may enhance quality of life.

Uses of Panel Study of Income Dynamics Data in Research on Aging

The Panel Study of Income Dynamics (PSID) has, over its 50-year history, proven to be a useful source of data for research on virtually all of the major topics in the area of social gerontology. This usefulness reflects three of the leading features of the PSID: its longitudinality, its content, and its tracking rules, which permit users to develop family-based and generationally-linked measures. This paper summarizes key areas of survey content, including both routinely-collected data and several one-time or occasional supplements to the routine items. The paper also illustrates how these data elements have been used, providing examples of published papers in several areas of social gerontology. Finally, the paper points out some methodological issues associated with the PSID design; these methodological issues arise, in varying degrees, in longitudinal studies other than the PSID, and should be acknowledged by both the producers and consumers of longitudinal-data research.

National collegiate athletic association division I athletes' use of nonprescription medication

Background:

Athletes are known to use over-the-counter pain medication. However, the frequency of such use among National Collegiate Athletic Association (NCAA) Division I-A football athletes is unknown.

Hypothesis:

NCAA Division I-A football athletes who use nonprescription analgesics for pain misuse these medications.

Study Design:

Cross-sectional study.

Methods:

The football players (N, 144) who met the criteria and agreed to participate were from 8 NCAA Division I-A schools. The participants were administered the Over the Counter Drug Screen for Athletes, which measures attitudes toward the use of a spectrum of substances.

Results:

Among football athletes surveyed who took nonprescription analgesics for football-related pain, 37% reported taking more than the recommended dose. This was slightly higher than the 28% of players who stated they have not taken nonprescription analgesics for football-related pain. Thirty-four percent of all athletes reported using more than the recommended dose of nonprescription analgesics. Athletes who purchased their own nonprescription analgesics communicated poorly regarding nonprescription analgesics use. Those lacking knowledge about nonprescription analgesics and those using nonprescription analgesics in anticipation of pain or to avoid missing a practice or game were most likely to misuse nonprescription analgesics.

Conclusion:

NCAA Division I-A football athletes who use nonprescription analgesics for athletic competition do not misuse nonprescription analgesics.

Family structure and the reproduction of inequality: Parents' contribution to children's college costs

This article examines the role of family structure in the financial support parents provide for their children's college education. Data are from the Health and Retirement Study. We focus on aspects of family structure that affect parental support and estimate shared family variance in investments as well as within-family variation using a multilevel model. Family membership accounts for about 60% of the variance in payment of college costs. Small family size, living with both biological parents (compared to one biological parent and a stepparent), higher parental education, and having older parents are associated with greater parental expenditures.

Increased longevity and metabolic correction following syngeneic BMT in a murine model of mucopolysaccharidosis type I

Mucopolysaccharidosis type I (MPS I) is an autosomal recessive inherited disease caused by deficiency of the glycosidase α-L-iduronidase (IDUA). Deficiency of IDUA leads to lysosomal accumulation of the glycosaminoglycans (GAG) heparan and dermatan sulfate and associated multi-systemic disease, the most severe form known as Hurler syndrome. Since 1981, the treatment of Hurler patients has often included allogeneic bone marrow transplantation (BMT) from a matched donor. However, mouse models of the disease were not developed until 1997. To further characterize the MPS I mouse model and to study the effectiveness of BMT in these animals, we engrafted a cohort (n=33) of 4–8 week-old Idua^−/− animals with high levels (88.4 ± 10.3%) of wild-type donor marrow. Engrafted animals displayed an increased lifespan, preserved cardiac function, partially restored IDUA activity in peripheral organs, and decreased GAG accumulation in both peripheral organs and in the brain. However, levels of GAG and GM3 ganglioside in the brain remained elevated in comparison to unaffected animals. Since these results are similar to those observed in Hurler patients following BMT, this murine transplantation model can be used to evaluate the effects of novel, more effective methods of delivering IDUA to the brain as an adjunct to BMT.

Validation of new measures of disability and functioning in the National Health and Aging Trends Study

BACKGROUND

Measurement gaps continue to hamper fuller understanding of late-life disability trends and dynamics. This article reports findings that validate the self-reported components of the disability protocol to be used in the new National Health and Aging Trends Study. The protocol was designed to redress existing measures by attending to environmental aspects of disability, capturing a broader range of capacity to perform tasks and including participation restriction items.

METHODS

We undertook an in-person validation study to determine the reliability, validity, and initial measurement properties of the National Health and Aging Trends Study self-reported disability protocol (n = 326). A random subset (n = 111) was readministered the protocol within 2-4 weeks. The interview and reinterview included new self-reported measures of physical capacity, activity limitations, and participation restrictions, as well as established performance and cognitive tests. We calculated percent agreement and kappa between interviews for all self-reported items and summary measures. We also assessed the construct validity of summary measures through correlations with demographic characteristics, frailty, memory, and performance-based mobility and confirmed whether activity limitations and participation restrictions were distinct domains.

RESULTS

New items and derived summary measures demonstrate robustness over a short time period, with kappas for retained/recommended items in the .60-.80 range. The summary measures correlate as expected with age, sex, residential status, and established performance-based constructs. Two factors, representing activity limitations and participation restrictions, were confirmed.

CONCLUSIONS

The National Health and Aging Trends Study protocol preserves the ability to examine more traditional measures of functioning while offering new insights into how activities are performed and preserving key conceptual distinctions.

Fiscal externalities of becoming a parent

Theoretical and empirical results suggest that there are externalities to childbearing, but those results usually assume that these externalities accrue uniformly within a homogeneous population. We advance this argument by developing separate estimates of the fiscal externalities associated with parents—those who devote time or material resources to minor children—and nonparents. Our analysis uses data from the US Panel Study of income Dynamics on the age profiles of taxes paid and publicly funded benefits consumed by parents and nonparents, together with a previously developed intertemporal economic-demographic accounting model. The accounting framework takes into account the net fiscal impacts of future generations as well as the present population. Our findings indicate that, with a 3 percent discount rate, parents produce a substantial net fiscal externality, about $217,000 in 2009 dollars. This is equivalent to a lifetime annuity of nearly $8,100 per year beginning at age 18. The results are sensitive to both the discount rate used and the proportion of parents within the cohort.

Modeling transition rates using panel current-status data: how serious is the bias?

Studies of disability dynamics and active life expectancy often rely on transition rates or probabilities that are estimated using panel survey data in which respondents report on current health or functional status. If respondents are contacted at intervals of one or two years, then relatively short periods of disability or recovery between surveys may be missed. Much published research that uses such data assumes that there are no unrecorded transitions, applying event-history techniques to estimate transition rates. In recent years, a different approach based on embedded Markov chains has received growing use. We assessed the performance of both approaches, using as a criterion their ability to reproduce the parameters of a "true" model based on panel data collected at one-month intervals. Neither of the widely used approaches performs particularly well, and neither is uniformly superior to the other.

Mixed results in a transitional planning program for alternative school students

Disciplinary alternative schools have a reputation as gateways to the juvenile and criminal justice systems. The authors conducted an evaluation of an intervention (Strategies for Success) designed to divert seventh-, eighth-, and ninth-grade alternative school students from this gateway. They used propensity score matching and a multivariate random effects model to estimate program impacts and found that the program not only increased attendance rates, at least in the short term, but also increased the likelihood of reassignment to alternative schools. The discussion focuses on possible reasons and solutions for high rates of return to alternative school and for the erosion of program effects.

Trends in rates of onset of and recovery from disability at older ages: 1982-1994

OBJECTIVES

Although there is substantial evidence of declining prevalence of disability among the older population during the late 1980s and 1990s, evidence on trends in the underlying dynamics of disability is lacking. For this study, we estimated models of transitions between discrete disability and vital states that incorporated simple linear time trends.

METHODS

We analyzed data from the 1982-1994 interviews of the New Haven Established Populations for Epidemiologic Studies of the Elderly study and used three alternative measures of disability status. We estimated separate models of disability prevalence and disability transitions by gender.

RESULTS

Eleven of 12 estimated trends in transition rates were statistically significant. For men and women, and for three alternative disability indicators, we found downward trends in rates of both onset of and recovery from disability among people aged 75 and older. We did not find any consistent pattern of trends in disability among those aging into the 75 and older group during this period.

DISCUSSION

Our findings are consistent with declining population-level disability prevalence only if any downward trend in onset outweighs the downward trend in recovery. These findings are also consistent with a trend toward more severe disability problems among the disabled population.

Improving knowledge about disability transitions by adding retrospective information to panel surveys. Population health metrics

Background

Panel data are often used to estimate key measures of public health, such as years lived with and without disability. Panel surveys commonly measure disability at intervals of one or two years, and occasionally more than two. It is likely that these intervals often include unreported changes in functional status. Unreported changes may bias estimates of disability transition probabilities, which are commonly used to estimate years lived with and without disability. Most surveys do not ask participants about periods with and without disability in the time since they last responded to the survey. We examined a way to improve the usefulness of panel surveys and our understanding of disability processes, by eliciting retrospective disability information.

Methods

Data were from the United States' National Long Term Care Survey. At each wave, this survey asks disabled respondents how long they have been disabled. We tested whether estimates of probabilities predicting changes in disability status can be improved by making use of this retrospective disability information. Methods included embedded Markov Chain analysis, microsimulation, and the Hausman specification test.

Results

Estimates based on data that include retrospective information are significantly different from those that use only the more limited information that is contemporaneous to the surveys. They are also more efficient. At age 65, all estimated probabilities for becoming disabled were higher when retrospective information was used, and all probabilities for remaining disabled were lower. Microsimulation revealed that using retrospective information increased the number of functional status transitions. For example, for women the mean number of transitions from nondisabled to disabled or dead was 52.7% greater when retrospective information was added to the analysis.

Conclusion

Our results suggest that the value of future panel studies for estimating transitions in disability could be notably enhanced by adding a small number of questions asking respondents for details about their disabilities–and lack of disabilities–in the period since a preceding survey wave. Information provided by such questions could substantially improve both the measurement of disability histories and estimates of disability processes.

Promoting declines in the prevalence of late-life disability: comparisons of three potentially high-impact interventions

Although the prevalence of late-life disability has been declining, how best to promote further reductions remains unclear. This article develops and then demonstrates an approach for comparing the effects of interventions on the prevalence of late-life disability. We review evidence for three potentially high-impact strategies: physical activity, depression screening and treatment, and fall prevention. Because of the large population at risk for falling, the demonstrated efficacy of multi-component interventions in preventing falls, and the strong links between falls and disability, we conclude that, in the short run, multi-component fall-prevention efforts would likely have a higher impact than either physical activity or depression screening and treatment. However, longer-term comparisons cannot be made based on the current literature and may differ from short-run conclusions, since increases in longevity may temper the influences of these interventions on prevalence. Additional research is needed to evaluate longer-term outcomes of interventions, including effects on length and quality of life.

Parent care and the stress process: findings from panel data

OBJECTIVE

The purpose of this study was to test with panel data an extended model of the stress process recognizing the separate effects of a parent's need for care and an adult child's caring activities.

METHODS

Using data from the 1996, 1998, and 2000 waves of the Health and Retirement Study, we estimated nonlinear mixed models of mental health outcomes. We assessed mental health for separate samples of 3,350 men and 3,659 women by using an 8-item scale of depressive symptoms. We also explored the sensitivity of results to alternative measures and model specifications.

RESULT

We found that female, but not male, caregivers whose parents needed care exhibited adverse mental health consequences. However, we found that, generally, both male and female non-caregivers whose parents needed care were more likely to report symptoms of depression than were non-caregivers without disabled parents. Additional findings suggest that the stress process is still more complex among married couples.

DISCUSSION

This study distinguishes the outcomes of parental care needs from those attributable to caregiving activities. Adverse psychological outcomes appear to be dispersed throughout the family. To focus narrowly on active caregivers is to underestimate the social burdens of disability at older ages.

Perspectives on the recent decline in disability at older ages

A decline has been found in the prevalence of disability among the older U.S. population during the 1980s and 1990s. One source of evidence for this decline is data from the National Long-Term Care Survey (NLTCS). This article investigates possible ambiguities in measuring disability using large-scale household surveys, illustrating the consequences of such problems with new analyses of NLTCS data. The reanalysis suggests a more gradual decline in disability than that found in prior research. The article also discusses three societal trends in areas other than health or functioning that might contribute to declines in disability levels: a reduced supply of informal care, changes in the technology of self-care, and changes in the definition and perception of both "ability" and "disability."

Reconsidering substitution in long-term care: when does assistive technology take the place of personal care?

OBJECTIVE

Assistive technology (AT) may improve quality of life and reduce dependence for older persons with disabilities. In this article, we examine tradeoffs between the use of AT and reliance on personal care, with attention to factors that may influence those relationships.

METHODS

We jointly modeled hours of formal and informal care with use of AT in order to address the interdependence of these outcomes in ways not taken into account in previous studies. We analyzed a national sample of older persons with difficulty in activities of daily living drawn from Phase 2 of the 1994-1995 National Health Interview Survey (NHIS) Disability Supplement.

RESULTS

Our findings show that the use of AT was associated with reductions in informal care hours, especially for those who were unmarried, better educated, or had better cognitive abilities, but appeared to supplement formal care services for these groups. Individuals with cognitive impairment were less likely than others to substitute AT with either type of personal care.

DISCUSSION

These models raise the possibility that reductions of informal care hours may be accomplished with a combination of formal care and assistive devices, rather than from either alternative alone.

Our “Increasingly Mobile Society”? The Curious Persistence of a False Belief

PURPOSE

We call attention to the widespread belief that the United States is an "increasingly mobile society," despite the fact that overall mobility has generally declined since about 1950, and interstate mobility has generally not increased during the same period. We review and extend past research documenting these mobility trends.

DESIGN AND METHODS

We describe population-level mobility for people of all ages as well as for several adult age groups, using published data from the U.S. Current Population Survey. We use simple regression methods to estimate the size and significance of mobility trends.

RESULTS

Overall mobility rates have declined for individuals of all ages and among all age groups. The largest average annual declines occur for 20- to 29-year-olds, although the rate of decline for those aged 65 and older is also large. Interstate mobility has declined slightly or remained constant, except among adults between 45 and 64 years old.

IMPLICATIONS

Although there may be good reasons to worry about the future of family care provided to elderly individuals, increased geographic mobility does not appear to be one of them. We speculate on reasons why the false belief persists.

Disability and home care dynamics among older unmarried Americans

OBJECTIVES

We describe how paid and unpaid home care hours received by older unmarried Americans change in response to disability dynamics. We test whether responses to disability declines and improvements are symmetric; that is, we test whether reductions in care hours that are due to disability improvements are of similar magnitude to increases in care hours that are due to disability declines.

METHODS

Using a national sample of older unmarried Americans, we examine changes in total hours, paid hours, and unpaid hours of care in response to declines and improvements in personal care (activities of daily living, or ADLs) and routine care (instrumental ADLs, or IADLs) disability. We model changes in the total hours of care received in the past month and jointly model changes in unpaid and paid hours, using Tobit models.

RESULTS

Changes in the total hours of care received respond to both increases and decreases in the count of ADL limitations and appear close to symmetric. In contrast, responses to IADL disability dynamics appear to be far less symmetric: Although increases in the count of IADL limitations are met with substantial increases in the total hours of care, decreases are not met with correspondingly large declines in care. The same general pattern is found for unpaid and paid care, and for Medicaid-funded home care.

DISCUSSION

Disability and care are not static constructs in old age. Older unmarried persons experience worsening, stabilizing, and recovery of function, and their care hours change accordingly. Evaluations of home care programs must be cognizant of such dynamic realities.

Nursing home entry in Germany and the United States

This paper investigates the transition into a nursing home in old age, using recent panel survey data from Germany and the United States. Among the questions addressed are: what is the incidence of nursing home entry, and how does it vary by age and sex; and to what extent are differentials in nursing home entry attributable to variations in family composition? Although the percentage of older persons living in nursing homes is similar in these two countries, the age-specific rates of movement into them appear to be much lower in Germany than in the USA, possibly due to the effects of public policies. The correlates of nursing home entry appear to be similar across countries as well, although data limitations limit our ability to make definitive comparisons.

Living arrangements among older people: an overview of trends in Europe and the USA

This article compares the trends in living arrangements of older people in several European countries and in the United States. Trends and cross-country variability in several factors that could account for these cross-national differences, including marital status, fertility, labour force participation and attitudes, are also examined. In most countries the proportion of older people living alone increased substantially between 1970 and 1990. However the increase in living alone stabilised or even declined between 1990 and 2000 in most of the countries analysed indicating a possible reversal in the trend. Increases in proportions of older women who are married and reductions in the proportions childless may partially explain this. Considerable variability in both trends and levels of older people's living arrangements was seen especially between north-western and southern European countries. These variations mirrored contrasts in attitudes towards residential care and parent-child coresidence between the countries.

Caregiver Stress and Noncaregiver Stress: Exploring the Pathways of Psychiatric Morbidity

PURPOSE

This study examines depressive symptoms among adult children of elderly parents; it views the parents' care needs and child's care activities as two separate stressors, different combinations of which may affect both caregiving and noncaregiving family members.

DESIGN AND METHODS

A sample of 4,380 women and 3,965 men from the first wave of the Health and Retirement Study was analyzed by use of four alternative forms of multiple regression analysis. Using the Center for Epidemiological Studies Depression scale, respondents reported on their depressive symptoms, as well as on parental disability and care provided by themselves, their spouses, and siblings.

RESULTS

Noncaregivers reporting severe parental disability were significantly more likely to experience depression symptoms. Evidence of increased manifestations of depression was not found among those caring for severely disabled relatives; nor was it found among those providing care in the absence of severe parental care needs. Having a caregiving sibling was associated with increased CES-D scores among noncaregivers.

IMPLICATIONS

In the current literature, personal care needs of a close relative are named among significant disturbances in the lives of caregivers. By extending this approach to members of a family network regardless of caregiver status, this study allows us to distinguish the magnitude of negative outcomes of serious parental care needs while clarifying the impact uniquely attributable to caregiving activities.

Place characteristics and residential location choice among the retirement-age population

OBJECTIVES

We investigate the association between an extensive set of location-specific factors and the propensity of retirement-age individuals to remain in, or relocate to, those locations. In particular we investigate whether state and local fiscal factors influence the migration decisions of retirees, and we study the relative importance of fiscal and other factors in these decisions.

METHODS

We place decisions regarding whether to move and where to locate in a single discrete-choice framework. We estimate an individual-level location-choice model by using a combination of place-characteristics data and Census county-to-county migration data for the period 1985-1990.

RESULTS

We find that levels of tax burdens and public services can affect location decisions. Of the fiscal variables, income taxes have the largest relative effects. However, other factors, including climate, economic conditions, and population characteristics, appear to play much larger roles in migration and location decisions.

DISCUSSION

Although income tax reductions might influence the location decisions of recent retirees, whether or not the economic benefits associated with these population gains outweigh the accompanying revenue losses is an important area for further research. A more cost-effective strategy may be for states to focus on marketing their amenities rather than using fiscal policy to recruit retirees.

Patterns of active life among older women: differences within and between groups

This study examines the distribution of total, unimpaired, and impaired life for several groups of older women defined by race, education, and marital history. Using data from the 1984-1990 Longitudinal Study of Aging, we model transitions among functional statuses using discrete-time Markov chains, and use microsimulation to produce summary indices of active life. Remaining years of life and the proportion of remaining years with disability vary substantially, both within each group of women studied and between pairs of groups. Of all groups studied, never-married, more-educated white women live the longest, healthiest lives. Ever-married nonwhite women with low education have the shortest life expectancy, and experience the most disability. Our findings show that life expectancy is an incomplete indicator of the time women, in particular sub-groups, can expect to live with and without impairment. These findings highlight the heterogeneity of disability processes and life expectancy for older women.

Functionally relevant thresholds of quadriceps femoris strength

The purpose of this study was to identify quadriceps femoris strength thresholds below which performance on ambulatory tasks is compromised. A second purpose was to evaluate whether self-reported functioning matches evaluated performance of the activities. Subjects (N = 100; age 73 +/- 0.9 years) participated in isometric knee extension strength tests, performed three functional ambulatory tasks (chair rise, gait speed, and stair ascent and descent), and answered standard survey questions assessing physical function. Significant relationships were observed between functional performance and the ratio of isometric leg extension peak torque to body weight (STR/WT) for each activity (p <.0001). For each activity, thresholds of STR/WT between 3.0 and 3.5 N m/kg were observed, below which the likelihood for success was reduced. Thresholds were determined by calculating the value of STR/WT that minimized the classification error. Individuals with a STR/WT < 3.0 N m/kg are at a substantial risk for impaired function in chair rise, gait speed, and stair ascent and descent. Sensitivity and specificity of STR/WT as a predictor of functional success ranged from 76% to 81% and from 78% to 94%, respectively, depending on activity. This is of clinical significance, as the STR/WT thresholds can identify individuals with preclinical disability (beginning to have difficulty with ambulatory tasks) as opposed to those in whom an outright disability is observed. This may be useful for targeting individuals for strengthening interventions and developing specific intervention goals.