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The present study used the CDC’s 2017 Behavioral Risk Factor Surveillance System and Structural Equation Modeling (SEM) to test the Meikirch model’s theoretical definition of health and aging. This biopsychosocial and ecological framework considers the dynamic interplay between an individual’s biology, health behavior and health potential, social surroundings, physical environment, and demands of living on both mental and physical health outcomes. A total sample of 96,568 adults were included with a mean age of 66.05 years (SD = 9.91). Individuals were classified in the following age groups: 43% middle-aged (45-64 years), 33% young-old (65-74 years), and 25% old-old adults (75+ years). The sample was largely female (61%), Non-Hispanic White (86%), and urban (67%). A CFA and WLSMV estimation was used to assess each latent construct. The overall SEM model was found to be a good fit (RMSEA=0.05, CFI=0.94, TLI=0.90), explained a significant portion of the variance in the health outcome (65%), and appeared to mimic prior literature on health variable relationships. An important finding within this study suggests the significant relationship between education, personally acquired potential, and health outcome variables. Underscoring health education and health literacy interventions may positively promote a person’s health behavior, resource access, and health outcomes across the lifespan. The Meikirch model can be used as a framework in public health interventions to better understand health adaptation, as well as behavioral risks and systematic hurdles. Overall, the study emphasizes how understanding health is not exclusively an individual hurdle to tackle, but a communal goal.

Alzheimer’s disease and related dementias often begin with symptoms of mild memory loss, eventually leading to more severe cognitive impairment, functional impairment, and ultimately, death. Data from the Behavioral Risk Factor Surveillance System core questions related to chronic diseases and from the cognitive decline optional module on subjective cognitive decline (SCD) from the years 2015-2018 were aggregated across the participating 50 states, D.C., and Puerto Rico for this analysis. Among U.S. adults aged 65 years and older, only 39.8% (95%CI=37.6-42.1) of those experiencing SCD reported discussing their SCD symptoms with a healthcare provider. The prevalence of discussing SCD symptoms with a provider was higher among those with at least one chronic condition than among those with no chronic conditions. 30.7% (28.6-32.8) of those aged 65 years and older reported that their SCD led to functional limitations and 28.8% (26.5-31.2) needed assistance with day-to-day activities. For patients aged 65 years and older, Welcome to Medicare visits and Medicare Annual Wellness Visits are critically underutilized primary care access points. Primary care providers can manage chronic conditions, cognitive health, and initiate referrals for testing. Efforts to promote the use of toolkits and diagnostic codes that are available to primary care providers to initiate conversations about memory loss with patients may be utilized to improve detection, diagnosis, and planning for memory problems. Discussions may lead to earlier detection and diagnosis of cognitive impairment, such as Alzheimer’s disease, or other treatable conditions such as delirium or pressure in the brain and avoid costly hospitalizations.

Achieving meaningful progress against Alzheimer’s disease and related dementias (ADRD) requires an urgent public health response. Since 2005, the Alzheimer’s Association, Centers for Disease Control and Prevention (CDC), and other public health partners collaborated on the Healthy Brain Initiative (HBI). HBI seeks to advance public health awareness of and action on ADRD as a public health issue. The HBI Road Map Series, State and Local Public Health Partnerships to Address Dementia: The 2018–2023 Road Map (S&L RM) and Road Map for Indian Country, provide the public health with concrete steps to respond to the growing burden of ADRD in communities, consistent with the aim of the Building Our Largest Dementia (BOLD) Infrastructure for Alzheimer’s Act (P.L. 115-406). This series of RMs for state, local, and tribal public health provide flexible menus of actions to address cognitive health, including ADRD, and support for dementia caregivers with population-based approaches. The purpose of this session is to illustrate public health’s role with ADRD—past, present, and future. An overview of the evolution of HBI RM series will be provided (McGuire) and preliminary evaluation data of 24 actions from S&L RM will be presented (French, Shean, Beatty). Holt, Reed, & McGuire will share lessons learned and next steps from CDC’s Regional Action Institutes designed to facilitate implementation of the RM series across the US. The intersection between the RM series and Age-Friendly Public Health Systems will be described as a starting point for public health (Wolfe, French, Shean).

Background and Objectives Subjective cognitive decline (SCD), the self-reported experience of worsening or more frequent confusion or memory loss, may be associated with the development or worsening of chronic conditions or complicating their self-management. The objectives of this study were to (i) establish the prevalence of chronic conditions and multiple chronic conditions among adults with SCD, and (ii) compare the prevalence of chronic conditions among people with and without SCD and SCD-related functional limitations. Research Design and Methods Data were analyzed from the Cognitive Decline module of the Behavioral Risk Factor Surveillance System administered in 49 states, DC, and Puerto Rico during 2015–2017. Analyses included 220,221 respondents aged 45 years or older who answered the SCD screening question and reported their chronic conditions. Weighted estimates were calculated and chi-square tests were used for comparisons. Results Persons with a history of stroke, heart disease, and chronic obstructive pulmonary disorder had significantly higher prevalence of SCD compared to those without. The prevalence of having at least one chronic condition was higher among adults with SCD compared to adults without SCD in each age group (45–64 years: 77.4% vs 47.1%, p < .001; ≥65 years: 86.3% vs 73.5%, p < .001). Among those with SCD, the prevalence of an SCD-related functional limitation was higher among those with at least one chronic condition compared to those with none (45–64 years: 63.3% vs 42.4%, p < .001; ≥65 years: 40.0% vs 25.1%, p < .001). Only half of adults with SCD and a chronic condition had discussed their SCD with a health care professional. Discussion and Implications SCD and chronic conditions commonly co-occur. Having a chronic condition was associated with greater SCD-related functional limitations. SCD might complicate the management of chronic conditions, and patients and providers should be aware of increased risk for cognitive decline in the presence of chronic diseases.

As the proportion of older adults in the United States is projected to increase dramatically in the coming decades, it is imperative that public health address and maintain the cognitive health of this growing population. More than 5 million Americans live with Alzheimer’s disease and related dementias (ADRD) today, and this number is projected to more than double by 2050. The public health community must be proactive in outlining the response to this growing crisis. Promoting cognitive decline risk reduction, early detection and diagnosis, and increasing the use and availability of timely data are critical components of this response. To prepare state, local, and tribal organizations, CDC and the Alzheimer’s Association have developed a series of Road Maps that chart the public health response to dementia. Since the initial Healthy Brain Initiative (HBI) Road Map release in 2007, the Road Map has undergone two new iterations, with the most recent version, The HBI’s State and Local Public Health Partnerships to Address Dementia: The 2018–2023 Road Map, released in late 2018. Over the past several years, significant advances were made in the science of risk reduction and early detection of ADRD. As a result, the public health response requires a life-course approach that focuses on reducing risk and identifying memory issues earlier to improve health outcomes. The most recent Road Map was revised to accommodate these strides in the science and to effect change at the policy, systems, and environment levels. The 2018–2023 Road Map identifies 25 actions that state and local public health agencies and their partners can implement to promote cognitive health and address cognitive impairment and the needs of caregivers. The actions are categorized into four traditional domains of public health, and the Road Map can help public health and its partners chart a course for a dementia-prepared future.

Home- and community-based services (HCBS) can reduce caregiver burden. We compared the prevalence of HCBS unmet needs among caregivers in rural and urban areas and identified factors associated with unmet HCBS needs. We used 2015-2018 Behavioral Risk Factor Surveillance System data, including the optional Caregiver Module, from 44 states, District of Columbia, and Puerto Rico. Caregivers were individuals providing care/assistance to a friend/family member with a long-term illness/disability during the past 30 days. Unmet needs were defined as needing, but not receiving, one or more of the following: caregiving classes, help accessing services, support groups, individual counseling, or respite care. “Rural” was defined as living outside Metropolitan Statistical Areas (available only for landline respondents). We calculated weighted estimates and used log-binomial regression to estimate adjusted prevalence ratios (PR). 19% of 25,180 caregivers lived in a rural area. Rural caregivers were less likely to report unmet HCBS needs (14.4% versus 20.6% urban, p

The Healthy Brain Initiative (HBI) seeks to advance public health awareness of and action on ADRD as a public health issue. The HBI Road Map Series, State and Local Public Health Partnerships to Address Dementia: The 2018–2023 Road Map (S&L RM) and Road Map for Indian Country (RMIC), provide the public health with concrete steps to respond to the growing burden of ADRD in communities, consistent with the aim of the Building Our Largest Dementia (BOLD) Infrastructure for Alzheimer’s Act (P.L. 115-406). This series of RMs for state, local, and tribal public health provide flexible menus of actions to address cognitive health, including ADRD, and support for dementia caregivers with population-based approaches. This session will describe how the initiative evolved over the past 15 years including policy and implementation success stories.

Millennials (born 1981-1996), now outnumber Baby Boomers. Millennials have the unique task of potentially providing care for their own children, their aging parents, and grandparents, making them the first “club sandwich” generation. We utilized data from 44 states, the District of Columbia, and Puerto Rico from the 2015-2018 Behavioral Risk Factor Surveillance System to estimate the prevalence of informal caregiving among Millennials (based on age at the time of survey completion: 18-34 in 2015, 19-35 in 2016, 20-36 in 2017, and 21-37 in 2018). We conducted log-binomial regression analyses to compare mental and physical health among Millennials, adjusting for age, sex, education, and race/ethnicity. Among 37,780 Millennials included, 18.7% provided regular care/assistance to a friend/family member with a health problem, long-term illness, or disability in the past month. Of these caregivers, 36.3% provided the most care to a parent/parent-in-law and 21.8% to a grandparent. Half of Millennials had ≥1 children under age 18 in their home, regardless of caregiving status. In adjusted models, Millennial caregivers had higher prevalence of frequent mental distress [≥14 days in the past 30 days when mental health was not good] (prevalence ratio [PR]=1.72, 95% confidence interval [CI]: 1.50-2.00, p

Alzheimer’s disease and related dementias (ADRD) are a significant public health burden. Collectively, ADRD have been called the most expensive chronic conditions in the United States due to outsized health care utilization. Data from the 2016 and 2017 Healthcare Cost Utilization Project National Inpatient Sample, an all-payer representative sample of US hospitalizations, were used to describe hospitalizations in adults ≥65 years with ADRD. Chronic conditions were defined using International Classification of Disease, Tenth Edition, Clinical Modification (ICD-10-CM) code definitions from the Centers for Medicare and Medicaid Services Chronic Conditions Warehouse. Code definitions from the Agency for Healthcare Research and Quality defined potentially preventable hospitalizations where admission might have been avoided by appropriate outpatient primary care management. One in six hospitalizations in adults ≥65 years were for persons with ADRD, including 1 in 3 adults ≥85 years. Among those with ADRD-related admissions, the most common reasons for admission, as defined by the principal diagnosis, were heart disease (18.1%), certain infections (14.5%), injuries (12.7%), respiratory illness (11.2%), and genitourinary conditions (10.4%). In hospitalized adults with ADRD, the prevalence of diagnosed urinary tract infection (37.0%)—a potentially preventable hospitalization—is more than double the prevalence in adults without ADRD (15.5%, prevalence ratio = 2.39, 95% confidence interval: 2.37-2.42). Common comorbidities, injuries, and potentially preventable hospitalizations all contribute to hospitalizations in adults with ADRD. Focusing on injury prevention and appropriate outpatient management of comorbidities in adults with ADRD might reduce the number of hospitalizations, including potentially preventable hospitalizations, among adults with ADRD.

While adults aged 65 years and older are most at risk for chronic conditions, studies show that middle-aged adults aged 45–64 years also have growing numbers of comorbid chronic diseases. Regardless of age, managing chronic conditions requires decision-making abilities to manage treatments effectively. Symptoms of memory loss and confusion may impair a person’s ability to manage their health. This study examined chronic conditions in persons with subjective cognitive decline (SCD), defined as the self-reported experience of increased memory problems or confusion. Behavioral Risk Factor Surveillance System data from 2015–2017 were used to define SCD and disease status for eight chronic conditions (heart disease, stroke, cancer, arthritis, asthma, depression, diabetes, and chronic obstructive pulmonary disease) for adults 45–64 years from 49 states, District of Columbia, and Puerto Rico that collected data on cognitive decline. Among adults aged 45–64 years, 10.8% reported SCD. Among those with SCD, 77.4% had at least one chronic disease compared to 47.1% of those without SCD. Those with SCD had a higher prevalence for all eight conditions compared to those similarly-aged without SCD. Adults with at least one chronic condition were more likely to discuss their symptoms of SCD with a health care professional (54.2%) compared to those with no chronic conditions (30.3%). Poor management of chronic conditions can result in increased health care costs and might worsen existing symptoms of confusion and memory problems. Self-care interventions for chronic disease management should consider the importance of an individual’s cognitive status, including SCD.

Informal caregivers can provide assistance that can help family members and friends live in the community longer but can place caregivers at increased risk for poorer health outcomes. Subjective cognitive decline (SCD) is the self-reported experience of worsening or more frequent confusion or memory loss. The objective of this study is to describe SCD in caregivers. Data were analyzed from 21 states, Puerto Rico, and District of Columbia who administered both the Caregiver and Cognitive Decline modules of the Behavioral Risk Factor Surveillance System in the same year for 2015–2017. A higher proportion of caregivers reported SCD (13.4%) compared to non-caregivers (10.2%). Of those who did need assistance with daily activities due to SCD, 1 in 8 non-caregivers were unable to the necessary assistance compared to 1 in 4 caregivers. SCD among caregivers is of particular concern because it affects both the caregiver and care recipient.

The Centers for Disease Control and Prevention’s (CDC) Behavioral Risk Factor Surveillance System (BRFSS) is the world’s largest ongoing health survey, administered in all 50 U.S. states, as well as the District of Columbia and the three U.S. territories, with data collected from more than 400,000 respondents. The BRFSS collects data on cognitive decline and caregiving as well as many health behaviors, annually. In 2015-2017, the 6-item cognitive decline module has been administered in 49 states, DC, and Puerto Rico, while the 9-item caregiving has been administered in 44 states, DC, and Puerto Rico. CDC’s Alzheimer’s Disease and Healthy Aging Program has developed many data for action resources for use by states and other partners to help identify populations and communities most at need. This presentation will describe the series of resources to facilitate data utilization among Tribal Communities, including state and race/ethnicity-specific infographics, topic-specific briefs, and the online portal.

Alzheimer’s disease (AD) is the most common form of dementia. Subjective cognitive decline (SCD) is the self-reported experience of worsening or more frequent confusion or memory loss and it is one of the earliest noticeable symptoms of AD. Data from respondents aged 45 years and older to the Centers for Disease Control and Prevention’s Behavioral Risk Factor Surveillance System Cognitive Decline module were examined to identify race and ethnicity disparities in SCD. This module was administered by 49 participating states, District of Columbia, and Puerto Rico from 2015-2018. Data were analyzed using SAS statistical software and methods that accounted for survey design and weighted data. Prevalence of SCD by race/ethnicity with 95% confidence intervals (CI) was calculated. Among adults aged 45 years and older, one in nine (10.8%; CI=10.5-11.2) non-Hispanic white adults experienced SCD. In comparison, among adults aged 45 years and older, one in nine (11.2%; CI=9.8-12.7) Hispanic, one in eight (13.2%; CI=12.0-14.3) African American/black, and one in five (19.6%; CI=16.0-23.2) American Indian/Alaska Native (AI/AN) adults experienced SCD. These numbers are expected to increase significantly over time, especially for some minority groups. More specifically, Hispanics and African Americans are expected to constitute a large proportion of older adults in the coming decades. There are implications in how communities are reached with respect to awareness of cognitive decline (this includes AI/AN adults, as well). Race and ethnicity disparities in SCD may be influenced by differences in chronic diseases and other risk factors that are also disparate between communities.

The Centers for Disease Control and Prevention (CDC), through its Behavioral Risk Factor Surveillance System (BRFSS), collects data on caregivers and the caregiving situation as well as many health behaviors, annually. The BRFSS is the world’s largest ongoing health survey, administered in all 50 U.S. states, as well as the District of Columbia and the three U.S. territories, with data collected from more than 400,000 respondents. In 2015-2017, the 9-item caregiving module was administered in 44 states, DC, and Puerto Rico on the BRFSS. CDC’s Alzheimer’s Disease and Healthy Aging Program has developed many data for action resources for use by states and other partners to help identify populations and communities most at need. This presentation will describe future enhancements with the BRFSS caregiving module and the series CDC developed resources to facilitate date utilization, including state-specific infographics, data briefs, and the online data portal.

Using the Meikirch model as a theoretical underpinning, the present study aimed to examine population health disparities by discerning age variations within and across rural urban areas. Secondary data analysis was conducted using the CDC’s 2017 Behavioral Risk Factor Surveillance System. The study’s outcome variables included physical health and mental health burden (zero days, 1-13 days, 14+ days). A total sample of 96,568 adults were included with a mean age of 66.05 years (SD = 9.91). Individuals were classified in the following age groups: 43% middle-aged (45-64 years), 33% young-old (65-74 years), and 25% old-old adults (75+ years). The sample was largely female (61%), Non-Hispanic White (86%), and urban (67%). A series of chi-square tests of independence – post hoc tests when applicable – were completed. Overall, rural residents reported a higher prevalence of severe physical and mental health symptom burden. Regarding physical health burden, a significant difference was found within urban settings (X2(4) = 50.74, p < .001), where, unexpectedly, young-old adults reported the best physical health. Regarding mental health burden, a significant difference was found for both urban (X2(4) = 1661.72, p < .001)) and rural settings (X2(4) = 820.65, p < .001), with middle-aged adults reporting greater mental illness and the old-old adults reporting greater mental health resiliency. Findings suggest that a multidimensional framework of health usefully informs public health and clinical service interventions, identifying populations and locations in need (i.e., targeting rural physical health across age groups and mental health among the middle-age, regardless of location).

Family and friends who provide care to people with chronic conditions or disability (caregivers) are a critical component of community-based care in the US. Falls could negatively impact a caregiver’s ability to provide care. In 2016, 15 states, DC, and Puerto Rico included the optional Caregiver Module on the Behavioral Risk Factor Surveillance System. We used these data to estimate fall and injurious fall prevalence among caregivers age ≥45 who had provided care for ≥2 years. Among 71,541 respondents, 11.8% provided care for ≥2 years. One-third of caregivers had fallen in the past year (16.6% once; 16.4% more than once), and 47.3% of caregivers who fell reported at least one resulted in an injury that limited activity or required treatment. Caregivers were significantly more likely to fall (p=0.02) and to experience injury (p=0.002) compared to non-caregivers. Falls are common among caregivers and potentially harmful to them and their care recipients.

As caregiving is becoming a leading public health issue, we used the BRFSS to better understand who caregivers are as well as features of their caregiving experience. We combined BRFSS data from three years (2015-2017) to examine demographic characteristics including gender, race, age, education, employment, and marital status. Slightly more than one in five BRFSS respondents (20.7%) were caregivers. The majority were women, had at least some college, were employed, and married or living with a partner. Most caregivers were under 45 years old, but a substantial proportion (20.7%) were 65 years or older. There was significant state variation by every demographic characteristic. These data underscore that caregiving is a common feature of U.S. family life, and caregivers’ concerns should be considered in healthcare, employment, and service provision. Important state-level variations uncovered by use of the BRFSS Caregiving Module could lead to better targeting of caregiver support programs.

One priority action in “The Healthy Brain Initiative: The Public Health Road Map for State and National Partnerships, 2013–2018” is surveillance of cognitive health issues. CDC’s Healthy Aging Program (HAP) has developed and promulgated the use of two modules, on subjective cognitive decline and caregiving, in the Behavioral Risk Factor Surveillance System (BRFSS). The BRFSS is the world’s largest ongoing telephone health-related survey, collecting data in 50 states and three U.S. territories. The HAP enlisted the help of subject matter experts and used cognitive testing to refine and improve these modules.

With the graying of the U.S. population, there has been an increased recognition in public health to promote healthy aging and address major problems afflicting older Americans. The Centers for Disease Control and Prevention (CDC) has established the Healthy Aging Program (HAP) to serve as the focal point for cross-cutting public health action. Housed in the CDC’s National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP), Program staff work with a variety of partners to increase the reach of their programs and broaden dissemination of their efforts.