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Purpose: Family caregivers comprise the backbone of long-term-care provision in the United States, yet little is known about how the composition and experience of family caregiving has changed over time. Design and Methods: Data are drawn from the 1989 and 1999 National Long-Term Care Survey and Informal Caregiver Survey to develop nationally representative profiles of disabled older adults and their primary informal caregivers at two points in time. Results: The proportion of chronically disabled community-dwelling older adults who were receiving informal assistance from family or friends declined over the period of interest, whereas the proportion receiving no human help increased. On average, recipients of informal care were older and more disabled in 1999 than in 1989. Primary caregivers were children (41.3%), spouses (38.4%), and other family or friends (20.4%); children were more likely and others less likely to serve as primary caregivers in 1999 relative to 1989. Primary caregivers provided frequent and high levels of help at both points in time. A striking increase was found (from 34.9% to 52.8%) in the proportion of primary caregivers working alone, without secondary caregiver involvement. Implications:In the context of projected demographic trends and budgetary constraints to public health insurance programs, these data underscore the importance of identifying viable strategies to monitor and support family caregivers in the coming years. (Contains 6 tables.)

Objectives. To examine whether stability of living arrangements and changes in household composition--both types and frequency--influence nursing home placement or timing to entry among older people. Methods. Data from the first 5 waves of the Assets and Health Dynamics of the Elderly (1993-2002) on 8,093 persons aged 70 years or older at baseline are used in probit and hazard models to predict nursing home entry and time to entry. Results. Stable living arrangements carry different risks of institutionalization. Those living continuously alone or with others were at highest risk; at lowest risk were those living continuously with a spouse or the same child (lowest overall). Changes in household composition were protective against nursing home entry and slowed time to entry; types of change were not influential when number of changes was taken into account. Discussion. Results suggest that stability of living arrangements in and of itself is not protective against institutionalization. Having options that allow one to change living arrangements over time in response to changing needs for assistance is of importance if the goal is to avoid institutional care or extend community residence prior to entry. Key Words: Generational studies--Health services use--Living arrangements. doi: 10.1093/geronb/gbq023.

Objectives To understand changes during the coronavirus disease 2019 (COVID-19) pandemic in weekly contact with nonresident family and friends for U.S. adults aged 70 and older in residential care and community settings. Methods Participants in the National Health and Aging Trends Study COVID-19 mail supplement (N = 3,098) reported frequency of phone, electronic, video, and in-person contact with nonresident family and friends in a typical week before and during the pandemic. We examined less than weekly contact by mode for those in residential care settings and community residents with and without limitations. We estimated multinomial logit models to examine predictors of change to less than weekly contact (vs. maintaining weekly or more contact) by mode, overall, and stratified by setting. Results Weekly in-person contact fell substantially (from 61% to 39%) and more so in residential care (from 56% to 22%), where nearly 4 in 10 transitioned to less than weekly in-person contact (doubling to 8 out of 10). Weekly or more contact was largely stable for electronic and telephone modes across settings. Weekly or more video contact increased mainly for community residents without limitations. Compared to community residents without limitations, those in assisted living or nursing homes had more than 5 times the odds (adjusted odds ratio [AOR] = 5.3; p =.01) of changing to less than weekly in-person contact; those in independent living also had higher odds of changing to less than weekly in-person (AOR = 2.6; p =.01) and video (AOR = 3.4; p =.01) contact. Discussion The pandemic revealed the importance of ensuring that communication technologies to maintain social ties are available to and usable by older adults, particularly for those living in residential care settings. [ABSTRACT FROM AUTHOR]

Objective Despite cross-sectional evidence that persons living with dementia receive disproportionate hours of care, studies of how care intensity progresses over time and differs for those living with and without dementia have been lacking. Method We used the 2011–2018 National Health and Aging Trends Study to estimate growth mixture models to identify incident care hour trajectories ("classes") among older adults (N = 1,780). Results We identified 4 incident care hour classes: "Low, stable," "High, increasing," "24/7 then high, stable," and "Low then resolved." The high-intensity classes had the highest proportions of care recipients with dementia and accounted for nearly half of that group. Older adults with dementia were 3–4 times as likely as other older adults to experience one of the 2 high-intensity trajectories. A substantial proportion of the 4 in 10 older adults with dementia who were predicted to be in the "Low, stable" class lived in residential care settings. Discussion Information on how family caregiving is likely to evolve over time in terms of care hours may help older adults with and without dementia, the family members, friends, and paid individuals who care for them, as well as their health care providers assess and plan for future care needs. [ABSTRACT FROM AUTHOR]

This study investigates long-term care preferences across three hypothetical scenarios and over one year of time among a sample of disabled older women receiving informal care (n = 420). Unpaid or paid help in one's home was preferred, given scenarios of instrumental activities of daily living (IADL) and activities of daily living (ADL) needs; nursing home care was most preferred for dementia care. While aggregate preferences for long-term care were relatively stable, there was considerable fluctuation in individuals' preferences over time, with just 52.5%, 44.4%, and 44.6% of participants retaining their initial first choice across IADL, ADL, and dementia scenarios, respectively. Implications of study findings are discussed. KEYWORDS. Long-term care, home and community-based care, nursing home, patient preference

ABSTRACT Little is known about the prevalence and correlates of psychotropic drug use in community-dwelling elders with dementia. Baseline data from 285 community-dwelling elders with a research classification of dementia [...]

ABSTRACT Little is known about the prevalence and correlates of psychotropic use in community-dwelling elders with dementia. Baseline data from 285 community-dwelling elders with a research classification of dementia (based [...]

Purpose: Family caregivers comprise the backbone of long-term-care provision in the United States, yet little is known about how the composition and experience of family caregiving has changed over time. Design and Methods: Data are drawn from the 1989 and 1999 National Long-Term Care Survey and Informal Caregiver Survey to develop nationally representative profiles of disabled older adults and their primary informal caregivers at two points in time. Results: The proportion of chronically disabled community-dwelling older adults who were receiving informal assistance from family or friends declined over the period of interest, whereas the proportion receiving no human help increased. On average, recipients of informal care were older and more disabled in 1999 than in 1989. Primary caregivers were children (41.3%), spouses (38.4%), and other family or friends (20.4%); children were more likely and others less likely to serve as primary caregivers in 1999 relative to 1989. Primary caregivers provided frequent and high levels of help at both points in time. A striking increase was found (from 34.9% to 52.8%) in the proportion of primary caregivers working alone, without secondary caregiver involvement. Implications: In the context of projected demographic trends and budgetary constraints to public health insurance programs, these data underscore the importance of identifying viable strategies to monitor and support family caregivers in the coming years. Key Words: Family caregiving, Informal caregiving, Long-term care, Disability

The two programs Medicare or Medicaid, dual eligibles that focus on the health care of the individuals with disabilities and the older people with low-income levels are discussed.

Background. The role of behavioral and psychological symptoms as an independent risk factor of nursing home placement (NHP) in cognitively impaired elders has been controversial. Methods. A community sample of 449 cognitively impaired elders and their knowledgeable informants (KIs) was followed for 1 year. Subjects were classified as having dementia (n = 330) or mild cognitive impairment (MCI) (n = 119) using a neuropsychiatric battery of 4 tests. Subject characteristics (behavioral and psychological symptoms, demographic, health related, and health services use) and KI characteristics were entered into the Cox proportional hazard regression analysis. Results. The incidence rate of NHP was 8.9%. At baseline, 57.7% of subjects had at least 1 behavioral and psychological symptom. Presence of these symptoms was associated with shorter time to NHP only in a univariate analysis. Other factors significant in the multivariate Cox modeling were being white (hazard ratio [HR] = 2.17), having fair or poor physical health rating (HR = 2.12), having greater numbers of difficulties with activities of daily living (HR = 1.46), and having a physician's diagnosis of dementia (HR = 6.76). An interaction was found between the last 2 variables (HR = 0.59), indicating that among those with a diagnosis of dementia, a greater number of difficulties with activities of daily living delayed time to NHP. KI characteristics were not associated with NHP. Conclusions. Behavioral and psychological symptoms were common, but having these symptoms was not an independent risk factor of NHP. Caregiver characteristics may not play as important a role in determining NHP as subject characteristics. Interventions aimed at improving or maintaining physical or cognitive functioning may have better chances of delaying NHP.

Background: Physical frailty and cognitive impairment have been separately associated with falls. The purpose of the study is to examine the associations of physical frailty and cognitive impairment separately and jointly with incident recurrent falls among older adults.Methods: The analysis included 6000 older adults in community or non-nursing home residential care settings who were at least 65 years old and participated in the National Health and Aging Trends Study. Frailty was assessed using the physical frailty phenotype; cognitive impairment was defined by bottom quintile of the clock-drawing test or immediate and delayed 10-word recall, or self/proxy-report of diagnosis of dementia, or AD8 score at least 2. The marginal means/rates models were used to analyze the associations of frailty and cognitive impairment with recurrent falls over 6 years of follow-up between 2011 and 2017.Results: Of the 6000 older adults, 1787 (29.8%) had cognitive impairment only, 334 (5.6%) had frailty only, 615 (10.3%) had both, and 3264 (54.4%) had neither. After adjusting for age, sex, race, education, living alone, obesity, disease burden, and mobility disability, those with frailty (with or without cognitive impairment) at baseline had higher rates of recurrent falls than those without cognitive impairment and frailty (frailty only: rate ratio [RR] = 1.31, 95% confidence interval [CI] = 1.18-1.44; both: RR = 1.28, 95% CI = 1.17-1.40). The association was marginally significant for those with cognitive impairment only (RR = 1.07, 95% CI = 1.00-1.13).Conclusions: Frailty and cognitive impairment were independently associated with recurrent falls in noninstitutionalized older adults. There was a lack of synergistic effect between frailty and cognitive impairment. [ABSTRACT FROM AUTHOR]

Objectives. This study examines the association of disability and social interaction, measured as in-person contact with non-household members and home confinement, and identifies sociodemographic, socioeconomic, and health-related factors that modify this relationship. Methods. Participants were 1,002 moderately to severely disabled community-dwelling women aged 65 and older from the Women's Health and Aging Study, identified by screening an age-stratified random sample of Medicare beneficiaries in Baltimore, Maryland. Logistic regression models were used to estimate the odds of low social interaction associated with disability and each independent modifier. Results. In a typical week, 23% did not visit with anyone residing outside their households and 17% did not leave their homes. In addition to and independent of disability level, older age, not completing high school, having a driver in the home, hearing difficulties and incontinence were associated with low social contact; older age and African American race were related to home confinement. African American women living alone are especially vulnerable to home confinement. Discussion. Physical disability is not necessarily socially disabling, as many of the most severely disabled in our study had at least daily social interaction. Improvements in social interaction appear possible through more effective management of certain health conditions and attention to potential sociocultural barriers.

Employers are increasingly concerned by the cost of health benefits provided to retired workers. One reason is that the Financial Accounting Standards Board (FASB), the organization that establishes "generally accepted accounting principles," has proposed altering the way firms report expenditures for retiree medical coverage on financial statements. We recently completed a national survey of business firms offering retiree health benefits to address three issues: 1) What is the current structure of retiree health benefit plans? 2) What changes are firms planning to implement in the structure of their retiree health benefits? 3) To what extent are these changes due to the FASB proposal? The FASB reporting proposal is only one factor underlying these changes. More important is the real financial pressure on firms due to the accelerating cost of retiree health care.

Objectives: To investigate the rate and patterns of accumulation of frailty manifestations in relationship to all‐cause mortality and whether there is a point in the progression of frailty beyond which the process becomes irreversible and death becomes imminent (a.k.a. point of no return). Design Longitudinal observational study. Setting: Community or a non‐nursing home residential care setting. Participants: Two thousand five hundred and fifty seven robust older adults identified at baseline in 2011 with follow‐up for all‐cause mortality between 2011 and 2018. Measurements Frailty was measured by the physical frailty phenotype. Cox models were used to study the relationships of the number of frailty criteria (0–5) at each point in time and its accumulation patterns with all‐cause mortality. Markov state‐transition models were used to study annual transitions between health states (i.e., frailty, recovery, and death) after becoming frail among those with frailty onset (n = 373). Results: There was a nonlinear association between greater number of frailty criteria and increasing risk of mortality, with a notable risk acceleration after having accumulated all five criteria (hazard ratio (HR) = 32.6 vs none, 95% confidence interval (CI) = 15.7–67.5). In addition, the risk of one‐year mortality tripled, and the likelihood of recovery (i.e., reverting to be robust or pre‐frail) halved among those with five frailty criteria compared to those with three or four criteria. A 50% increase in mortality risk was also associated with frailty onset without (vs with) a prior history of pre‐frailty (HR = 1.51, 95% CI = 1.20–1.90). Conclusion: Both the number and rate of accumulation of frailty criteria were associated with mortality risk. Although there was insufficient evidence to declare a point of no return, having all five‐frailty criteria signals the beginning of a transition toward a point of no return. Ongoing monitoring of frailty progression could aid clinical and personal decision‐making regarding timing of intervention and eventual transition from curative to palliative care. [ABSTRACT FROM AUTHOR]

Maintenance of visual and auditory function is important for preventing the onset of activity limitations and preserving quality of life in later life. To date, national panel studies focused on health and aging have mostly collected subjective (self-reported) measures of visual and auditory function. The National Health and Aging Trends Study (NHATS), a study of Medicare beneficiaries ages sixty-five and older, recently developed a protocol for measuring objective visual and auditory function for its annual, in-home data collection conducted by trained interviewers. The protocol includes three vision tests—distance and near acuity and contrast sensitivity—and one hearing test—pure-tone audiometry—conducted using a tablet platform with results recorded in a scannable booklet. To identify operational issues and evaluate data quality for the proposed set of vision and hearing tests, NHATS incorporated a pilot study into its 2019 round (N  = 417 participants and N  = 9 interviewers). Using these pilot study data, the objectives of this paper are to: (1) describe the NHATS protocols to collect objective measures of visual and auditory function; (2) evaluate the quality of the data collected; and (3) assess whether results are influenced by interviewers. We found that respondents were highly likely to participate, with cooperation rates for each test about 90 percent. Data were high quality, with low rates of missingness, test results significantly associated with age and self-reported items, and percentages with poor vision or hearing consistent with prior population-based studies. Objective measures were more likely than self-reports to classify participants as having visual and auditory impairments and had stronger relationships with demographic correlates. Interviewer effects were small and not statistically significant in this small sample. Results of this study have demonstrated that objective visual and auditory functioning can be successfully incorporated into an interviewer-administered home-based protocol. [ABSTRACT FROM AUTHOR]

Background: Racial/ethnic frailty prevalence disparities have been documented. Better elucidating how these operate may inform interventions to eliminate them. We aimed to determine whether physical frailty phenotype (PFP) prevalence disparities (i) are explained by health aspects, (ii) vary by income, or (iii) differ in degree across individual PFP criteria.Methods: Data came from the 2011 National Health and Aging Trends Study baseline evaluation. The study sample (n = 7,439) included persons in all residential settings except nursing homes. Logistic regression was used to achieve aims (i)-(iii) listed above. In (i), health aspects considered were body mass index (BMI) status and number of chronic diseases. Analyses incorporated sampling weights and adjusted for sociodemographic factors.Results: Comparisons are versus non-Hispanic whites: Non-Hispanic blacks (odds ratio [OR] = 1.46, 95% confidence interval [CI]: 1.21-1.76) and Hispanics (1.56, 1.20-2.03) continued to have higher odds of frailty after accounting for BMI status and number of chronic diseases. Non-Hispanic blacks had elevated odds of frailty in all income quartiles, including the highest (OR = 2.19, 1.24-3.397). Racial/ethnic disparities differed considerably across frailty criteria, ranging from a twofold increase in odds of slowness to a 25%-30% decrease in odds of self-reported exhaustion.Conclusions: BMI and disease burden do not explain racial/ethnic frailty disparities. Black-white disparities are not restricted to low-income groups. Racial/ethnic differences vary considerably by NHATS PFP criteria. Our findings support the need to better understand mechanisms underlying elevated frailty burden in older non-Hispanic black and Hispanic Americans, how phenotypic measures capture frailty in racial/ethnic subgroups and, potentially, how to create assessments more comparable by race/ethnicity. [ABSTRACT FROM AUTHOR]

BACKGROUND/OBJECTIVES: Hospitalization is common among older adults with disability, many of whom receive help from a caregiver and have dementia. Our objective was to evaluate the association between caregiver factors and risk of hospitalization and whether associations differ by dementia status. DESIGN: Longitudinal observational study. SETTING: The 1999 and 2004 National Long‐Term Care Survey and the 2011 and 2015 National Health and Aging Trends Study, linked caregiver surveys, and Medicare claims. PARTICIPANTS: A total of 2,589 community‐living Medicare fee‐for‐service beneficiaries, aged 65 years or older (mean age = 79 years; 63% women; 31% with dementia), with self‐care or mobility disability and their primary family or unpaid caregiver. MEASUREMENTS: Self‐reported characteristics of older adults and their caregivers were assessed from older adult and caregiver survey interviews. Older adult hospitalization over the subsequent 12 months was identified in Medicare claims. Multivariable Cox proportional hazards models adjusted for older adult characteristics and were stratified by dementia status. RESULTS: In this nationally representative cohort, 38% of older adults with disabilities were hospitalized over 12 months following interview. Increased hospitalization risk was associated with having a primary caregiver who helped with healthcare tasks (adjusted hazard ratio (aHR) = 1.22; 95% confidence interval (CI) = 1.05–1.40), reported physical strain (aHR = 1.21; 95% CI = 1.04–1.42), and provided more than 40 hours of care weekly (aHR = 1.26; 95% CI = 1.04–1.54 vs ≤20 hours). Having a caregiver who had helped for 4 years or longer (vs <1 year) was associated with 38% lower risk of hospitalization (aHR = 0.62; 95% CI = 0.49–0.79). Older adults with and without dementia had similar rates of hospitalization (39.5% vs 37.3%; P =.4), and caregiving factors were similarly associated with hospitalization regardless of older adults' dementia status. CONCLUSION: Select caregiving characteristics are associated with hospitalization risk among older adults with disability. Hospitalization risk reduction strategies may benefit from understanding and addressing caregiving circumstances. [ABSTRACT FROM AUTHOR]

BACKGROUND/OBJECTIVES: To obtain national and regional estimates of prevalence of frailty with or without cognitive impairment, and cognitive impairment with or without frailty among older adults in the United States, and to identify profiles of characteristics that distinguish their joint versus separate occurrence. DESIGN: Cross‐sectional. SETTING: Community or non–nursing home residential care settings. PARTICIPANTS: A U.S. nationally representative sample of 7,497 older adults aged 65 and older from the National Health and Aging Trends Study. MEASUREMENTS: Frailty was measured by the physical frailty phenotype. Cognitive impairment was assessed by cognitive performance testing of executive function and memory or by proxy reports. Multinomial logistic regression was used to identify profiles of demographic, socioeconomic, health, behavioral, and psychosocial characteristics that distinguish four subgroups: not‐frail and cognitively intact ("neither"), not‐frail and cognitively impaired ("Cog. only"), frail and cognitively intact ("frailty only"), and frail and cognitively impaired ("both"). RESULTS: The prevalence of "Cog. only," "frailty only," and "both" was 25.5%, 5.6%, and 8.7%, respectively. Individuals with"frailty only" had the highest prevalence of obesity, current smoking, comorbidity, lung disease, and history of surgery. The "both" group had the highest prevalence of dementia, depression, cardiovascular diseases, and disability. No significant differences were found between the "Cog. only" group and the "neither" group with respect to history of surgery and comorbidity burden. The prevalence of dementia in the "Cog. only" was less than half of that in the "both" group. CONCLUSION: The finding of sizable subgroups having physical frailty but not cognitive impairment, and vice versa, suggests that the two cannot be considered necessarily as antecedent or sequela of one another. The study provided empirical data supporting the prioritization of comorbidity, obesity, surgery history, and smoking status in clinical screening of frailty and cognitive impairment before formal diagnostic assessments. [ABSTRACT FROM AUTHOR]

Background and Objectives Racial disparities in health and socioeconomic characteristics of older adults have implications for the experiences of their family and unpaid caregivers, but knowledge to date has primarily drawn from convenience samples. Using a population-based sample, we examine associations between caregiver race and caregiving-related effects. Research Design and Methods Study participants include white (n = 992) and black (n = 556) respondents to the 2015 National Study of Caregiving who assisted community-dwelling older adults with disabilities who participated in the National Health and Aging Trends Study. Guided by Pearlin's Stress Process Model, hierarchical logistic regression models were constructed to examine race differences in caregiving-related effects after adjusting for caregiving context, stressors, and resources. Results Relative to white caregivers, blacks more often provided in excess of 40 hr of care per week (54.3% vs 38.6%) and more often cared for an older adult with dementia (27.1% vs 20.7%) who was living below the federal poverty line (31.7% vs 11.9%) or was Medicaid-eligible (42.2% vs 11.8%). Black caregivers more often used supportive services (32.9% vs 24.8%). In fully adjusted regression models, black caregivers were more likely to report gains and less likely to report emotional difficulty than whites. Service utilization did not attenuate caregiving-related emotional difficulty or participation restrictions, regardless of race. Discussion and Implications Findings highlight caregiving disparities and counterintuitive differences in experiences and indicate the importance of identifying supports such as paid family leave and faith and community-based programming to better support community-dwelling low-income older adults and their family and unpaid caregivers. [ABSTRACT FROM AUTHOR]