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Objectives Early-life disadvantage (ELD) relates to lower late-life cognition. However, personality factors, including having an internal locus of control (LOC) or a conscientious personality, relate to resilience and effective stress coping. We explore whether personality factors convey resilience against the negative effects of ELD on cognition, by gender, in Mexico. Methods Using the 2015 Mexican Health and Aging Study, we estimated expected cognition using multiple ELD markers to identify a subsample in the lowest quartile of expected cognition given ELD (n = 2,086). In this subsample, we estimated cross-sectional associations between personality and having above-median observed cognitive ability (n = 522) using logistic regression. Results Among those in the lowest quartile of expected cognition, a more internal LOC (β = 0.32 [men] and β = 0.44 [women]) and conscientious personality (β = 0.39 [men] and β = 0.17 [women]) were significantly associated with having above-median cognitive ability in models adjusted for demographic confounders. Larger benefits of conscientiousness were observed for men than women. Associations between personality and having above-median cognitive ability remained statistically significant after further adjustment for health, stress, and cognitive stimulation variables, regardless of gender. Discussion Personality factors may convey resilience among individuals who experienced ELD, potentially breaking the link between ELD and worse late-life cognition. Structural factors and gender roles may affect how much women benefit from personality factors.

OBJECTIVES Mexico has a rapidly aging population at risk for cognitive impairment. Social and leisure activities may protect against cognitive decline in older adults. The benefits of these behaviors may vary by patterns of cognitive impairment. The objectives of this study were to identify latent states of cognitive functioning, model the incidence of transitions between these states, and investigate how social and leisure activities were associated with state transitions over a 6-year period in Mexican adults aged 60 and older. METHODS We performed latent transition analyses to identify distinct cognitive statuses in the 2012 and 2018 waves of the Mexican Health and Aging Study (N = 9,091). We examined the transition probabilities between these states and their associations with social and leisure activities. RESULTS We identified 4 cognitive statuses at baseline: normal cognition (43%), temporal disorientation (30%), perceptual-motor function impairment (7%), and learning and memory impairment (20%). Various social and leisure activities were associated with reduced odds of death and disadvantageous cognitive transitions, as well as increased odds of beneficial transitions. DISCUSSION Mapping the effects of popular social and leisure activities onto common patterns in cognitive functioning may inform the development of more enjoyable and effective health-protective behavioral interventions.

Background Pain is associated with cognitive decline among older adults, but few studies have investigated bidirectional associations between pain and cognitive decline, especially in older Hispanic populations. Our objective was to assess the bidirectional association between pain interference and cognitive performance in a sample of older Puerto Rican adults. Methods Data came from baseline and 4-year follow-up of the Puerto Rican Elderly: Health Conditions Study, a longitudinal representative study of Puerto Rican older adults aged 60 and older. Pain and cognitive performance were assessed at each wave. A pain interference variable was created using the sum of pain status (yes/no) and pain interference (yes/no; range 0–2). Global cognitive performance was assessed with the Mini-Mental Cabán. We tested bidirectional associations using a path model with concurrent and cross-lagged paths between pain and cognitive performance, adjusting for sociodemographic and health factors (n = 2 349). Results Baseline pain interference was not associated with baseline cognitive performance (p = .636) or with cognitive performance at follow-up (p = .594). However, increased pain interference at follow-up was associated with greater cognitive decline at follow-up (β = −0.07, standard error [SE] = 0.02, p = .003). Greater baseline cognitive performance was associated with lower pain interference at follow-up (β = −0.07, SE = 0.02, p = .007). Conclusions These findings highlight the importance of worsening pain interference as a potentially modifiable risk factor for cognitive decline, as pain treatment options exist. Additionally, better baseline cognitive performance may be a protective factor for pain, providing further evidence of the dynamic relationship between pain and cognitive performance.

The association of pain and depression has not been evaluated in low- and middle-income countries, which have a disproportionate burden of pain compared to high-income countries.Using data from the Mexican Health and Aging Study (baseline, 2012; follow-up, 2015), we examined the bidirectional relationship between pain and depressive symptoms and identified shared predictors among community-dwelling participants ≥60 years (n = 7237). Multivariable logistic regressions models evaluated the association between (1) baseline pain and incident elevated depressive symptoms and (2) baseline depressive symptoms and incident pain, adjusting for demographic, socioeconomic, and health-related factors. Models included inverse probability weights and evaluated interactions by gender.Participants (55.0% women) were on average 69.1 years old. Over half reported no pain (60.7%) and low/no depressive symptoms (67.9%) in 2012, of which, 20.2% reported elevated depressive symptoms and 25.3% self-reported pain in 2015. Baseline pain was associated with higher odds of incident elevated depressive symptoms (aOR 1.65; 95% CI, 1.41-1.93). Baseline elevated depressive symptoms were associated with higher odds of developing pain (aOR 1.57; 95% CI, 1.32-1.87). Age, gender, self-rated health, and activity of daily living limitations were shared risk factors for pain and elevated depressive symptomatology onset. Although the incidence of elevated depressive symptoms and pain was higher in women, there were no statistically significant interactions.Older adults with pain or depression may be at risk for developing the other. These shared predictors could help identify patients in clinical settings, where pain and depression are often overlooked, reducing the cascading risk of this comorbidity.

Supplemental Digital Content is Available in the Text. Older Mexicans had 2 trajectories of activity-limiting pain (low-stable and moderate-increasing) over 17 years. Compared with men, women were more likely to have moderate-increasing pain., Pain increases with age, disproportionately affects women, and is a major contributor to decreased quality of life. Because pain is dynamic, trajectories are important to consider. Few studies have examined longitudinal trajectories of pain, by gender, in Mexico. We used data from 5 waves (over 2001–2018) of the Mexican Health and Aging Study, a nationally representative sample of Mexicans aged 50 years and older. Pain was categorized as self-reported frequent pain that makes it difficult to do usual activities. Latent class mixture models were used to create pain trajectories (n = 9824). The sample was majority female (56.15%), with a mean age of 61.72 years. We identified 2 pain trajectories: low-stable (81.88%) and moderate-increasing (18.12%). Women had 1.75 times the odds of being in the moderate-increasing group compared with men (95% confidence interval= 1.41, 2.17). In addition, having zero years of education was associated with higher odds of being in the moderate-increasing group, compared with having any years of education. Fair/poor self-rated health, obesity, arthritis, elevated depressive symptoms, and falls were positively associated with pain for both trajectory groups. Being married was positively associated with pain in the low-stable group. Insurance status was negatively associated with pain in the low-stable group, but positively associated with pain in the moderate-increasing group. We identified 2 trajectories of activity-limiting pain, among older Mexican adults (50+) over 17 years of follow-up. Understanding gender differences in pain trajectories in later life and the factors associated with trajectory development is crucial to improve quality of life, especially in vulnerable populations.

Introduction Older adults, including racial and ethnic minorities, are underrepresented in research. As the US population ages, the number of older racial and ethnic minority individuals will increase. Including these individuals in research is an important step towards reducing health disparities. Methods We used data from HealthStreet, a University of Florida community engagement program which uses community health workers to assess the health of the community, to assess willingness to participate in different types of health research by race/ethnicity. Descriptive statistics and logistic regression models were used to assess willingness to participate among adults aged 50 and older, by race/ethnicity (n = 4694). Results Our sample was 42.0% non-Hispanic White, 52.8% non-Hispanic Black, and 5.2% Hispanic. Non-Hispanic White participants reported more past research participation than non-Hispanic Black and Hispanic participants (28.7% vs. 19.0% and 19.2%, respectively). Compared with non-Hispanic White participants, non-Hispanic Black participants were less willing to participate in most types of studies, while Hispanic participants were less willing to participate in studies that might be seen as invasive (required blood sample, genetic sample, or participants to take medicine, or use of medical equipment). Conclusions Our study provides investigators with a general profile of research preferences by race/ethnicity; compared with non-Hispanic White individuals, non-Hispanic Black individuals are less willing to participate in most studies, while Hispanic individuals are less willing to participate in studies that may be seen as invasive or demanding. It is imperative to include diverse older adults in health research. By tailoring research based on preferences we can improve recruitment in underrepresented populations.

BACKGROUND: Non-medical use of prescription drugs is a major public health concern in the United States. Prescription opioids and sedatives are among the most widely abused drugs and their combined use can be lethal. Increasingly rigid prescribing guidelines may contribute to the changing context of opioid use and increase drug diversion. OBJECTIVE: To examine gender differences in diversion of prescription opioids and sedatives among non-medical prescription opioid and sedative polysubstance users. We hypothesize that men will be more likely than women to engage in incoming diversion. METHODS: Data from the Prescription Drug Abuse, Misuse, and Dependence Study, a cross-sectional study focused on prescription drug users, were analyzed. Non-medical use was defined as use of a drug that was not prescribed or use in a way other than prescribed. Individuals who reported past 12-month non-medical opioid and sedative use were included; diversion was defined as incoming (obtaining drugs from a source other than a health professional) and outgoing (giving away/selling/trading prescription drugs). RESULTS: Among the 198 polysubstance users, 41.4% were female. Men were 2.85 times as likely as women to report incoming diversion (95% CI: 1.21–6.72). Women were more likely to obtain opioids from a healthcare professional; men were more likely to obtain sedatives from a roommate, coworker, or friend. Over half of men and women reported outgoing diversion opioids or sedatives. CONCLUSION: Drug diversion highlights an important point of intervention. Current prevention efforts that target prescribers should be expanded to include users and diversion activities; these interventions should be gender-specific.

Background and Objectives To assess gender differences in prevalence of neuropsychiatric symptoms (NPS) among community-dwelling Mexican Americans ≥80 years. Research Design and Methods Using data from Wave 7 (2010–2011) of the Hispanic Established Population for the Epidemiological Study of the Elderly, we analyzed the NPS of 914 participants as determined by the Neuropsychiatric Inventory (NPI) with assessments conducted by their caregivers. Multivariate logistic regression models were used to test the association of individual NPS with gender, adjusting for relevant characteristics. Results The average age of our sample was 86.1 years, and 65.3% were women. Over 60% of participants had at least one informant/caregiver reported NPS. After adjustment, women had lower odds than men of agitation/aggression but higher odds of dysphoria/depression and anxiety. Discussion Recognizing gender differences in NPS phenotype could help guide development of culturally appropriate NPS screening and treatment programs.

Introduction The Montreal Cognitive Assessment (MoCA) is a popular screening tool for Mild Cognitive Impairment (MCI). The psychometric properties of the MoCA have not been widely examined in minority groups. We aimed to analyze the discriminate ability of subtests and items by race and ethnicity given gold-standard clinical diagnosis of cognitive status. Methods We analyzed data from the National Alzheimer Coordinating Center Uniform Data Set March 2018 data freeze. Stepwise regression was used to determine which subtests predicted cognitive status (normal cognition, MCI, or dementia), by race/ethnicity. Item discrimination and difficulty was calculated by race/ethnicity and cognitive status. Results In our sample (n=3895), with an average age of 69.7, 80.7% were non-Hispanic white, 15.0% were non-Hispanic black, and 4.2% were Hispanic. Among non-Hispanic whites all subtests, education, and age predicted clinician diagnosis, while visuospatial/executive, attention, language, delayed recall, and orientation subtests were predictive among non-Hispanic blacks and visuospatial/executive, delayed recall, and orientation subtests and education were predictive among Hispanics. Item discrimination and difficulty varied by race/ethnicity and cognitive status. Conclusions By understanding the psychometric properties of MoCA subtests, we can focus on subtests that have higher discrimination and more diagnostic utility. Subtests should be further evaluated for use in screening of minority individuals.

Background Diabetes is a risk factor for dementia and mortality, while obesity later in life is associated with a reduced risk. Their co-occurrence, diabesity, is common, but its association with dementia and mortality is unclear. Methods Using data from the Mexican Health and Aging Study, we used multinomial logistic regression to examine the associations of diabetes and body mass index (BMI), and diabesity, in 2012, with cognitive impairment and mortality in 2018, among participants aged ≥60 years with normal cognition at baseline (n = 7,885). Results Diabetes was associated with cognitive impairment, compared to not having diabetes (RRR=1.83, 95% CI=1.48–2.26). BMI was not associated with cognitive impairment. Regarding mortality, diabetes was associated with an increased risk (RRR=2.28, 95% CI=1.98–2.63) and being overweight or having obesity was associated with a reduced risk (RRR=0.74, 95% CI=0.65–0.86; RRR=0.79, 95% CI= 0.66–0.95). When BMI and diabetes were combined, having diabetes only (RRR=2.01, 95% CI=1.40–2.87), being overweight with diabetes (RRR=1.42, 95% CI=1.02–1.97) or having diabesity (RRR=1.50, 95% CI=1.08–2.06) were associated with cognitive impairment, compared to having a normal BMI without diabetes. Diabetes, regardless of BMI, was associated with an increased risk of mortality, while being overweight or having obesity was associated with a reduced risk of mortality. Conclusions With the increase in the prevalence of obesity and diabetes among Mexicans, it is important to understand how these conditions and their co-occurrence impact cognitive impairment and mortality. Among older Mexicans, diabesity is associated with 6-year mortality and cognitive impairment onset, likely driven by the effect of diabetes.

Background and Objectives Depression among older Mexican adults is underrecognized and of increasing concern due to its association with comorbidities including cognitive and functional impairments. Prior studies have found an association between low involvement levels in social activities and depression. We aimed to examine the association of time-use activities and depressive symptomatology by sex. Research Design and Methods We used data from the 2012 and 2015 waves of the Mexican Health and Aging Study. Participants aged 60 and older who had low or no depressive symptoms in 2012 were included in these analyses (N = 4,309). Factor analysis was used to group activities and logistic regression models were used to assess the association of baseline time use with depressive symptomatology in 2015. Results Among those with low or no depressive symptomatology in 2012, 21.0% reported elevated symptoms (5+) in 2015. Those with elevated depressive symptoms were more likely to be women, older, lower educated, and with at least one activity of daily living limitation. Four time-use domains emerged from the factor analysis including hobbies and indoor activities, volunteering, caregiving, and working. The hobbies and indoor activities domain was associated with lower odds of elevated symptoms for men and women (odds ratio [OR]: 0.76, 95% confidence interval [CI]: 0.61–0.96; and OR: 0.75, 95% CI: 0.61–0.91, respectively). Additionally, the volunteer and community activities domain was associated with lower odds of depressive symptoms for women (OR: 0.72, 95% CI: 0.58–0.89) and men (OR: 0.77, 95% CI: 0.60–0.99). Discussion and Implications Understanding how older Mexicans distribute their time among different activities and its associations with depressive symptoms can help guide policy and sex-specific interventions for psychological well-being. Certain domains had lower odds for elevated depressive symptomatology; future work should examine this association in other countries as well as the context of the built environment.

Key Points Question What are the changes in prescribing rates in men and women of benzodiazepines, Z-hypnotics, and serotonergic drugs during the COVID-19 pandemic (2020 and 2021) compared with prior years (2018 and 2019)? Findings This cohort study of US adults (15.1 million to 17.3 million depending on the year studied) found an increase in Z-hypnotic and serotonergic drug prescriptions in both men and women along with an increase in benzodiazepine prescriptions in women at the start of the COVID-19 pandemic. Meaning These findings suggest a substantial association of COVID-19–associated social isolation, stay-at-home orders, and other COVID-related mitigation measures with mental health issues, especially among women., Importance The ongoing COVID-19 pandemic and associated mitigation measures have disrupted access to psychiatric medications, particularly for women. Objective To assess the sex differences in trends in the prescribing of benzodiazepines, Z-hypnotics and serotonergic (selective serotonin reuptake inhibitors [SSRIs] and serotonin and norepinephrine reuptake inhibitors [SNRIs]), which are commonly prescribed for anxiety, insomnia, and depression. Design, Setting, and Participants This cohort study used data from Clinformatics Data Mart, one of the largest commercial health insurance databases in the US. Enrollees 18 years or older were required to have complete enrollment in a given month during our study period, January 1, 2018, to March 31, 2021, to be included for that month. Main Outcomes and Measures Prescription of a benzodiazepine, Z-hypnotic, or SSRI or SNRI. For each month, the percentage of patients with benzodiazepine, Z-hypnotic, or SSRI or SNRI prescriptions by sex was calculated. Results The records of 17 255 033 adults (mean [SD] age, 51.7 [19.5] years; 51.3% female) were examined in 2018, 17 340 731 adults (mean [SD] age, 52.5 [19.7] years; 51.6% female) in 2019, 16 916 910 adults (mean [SD] age, 53.7 [19.8] years; 51.9% female) in 2020, and 15 135 998 adults (mean [SD] age, 56.2 [19.8] years; 52.5% female) in 2021. Compared with men, women had a higher rate of prescriptions for all 3 drugs classes and had larger changes in prescription rates over time. Benzodiazepine prescribing decreased from January 2018 (women: 5.61%; 95% CI, 5.60%-5.63%; men: 3.03%; 95% CI, 3.02%-3.04%) to March 2021 (women: 4.91%; 95% CI, 4.90%-4.93%; men: 2.66%; 95% CI, 2.65%-2.67%), except for a slight increase in April 2020 among women. Z-hypnotic prescribing increased from January 2020 for women (1.39%; 95% CI, 1.38%-1.40%) and February 2020 for men (0.97%; 95% CI, 0.96%-0.98%) to October 2020 (women: 1.46%; 95% CI, 1.46%-1.47%; men: 1.00%; 95% CI, 0.99%-1.01%). Prescribing of SSRIs and SNRIs increased from January 2018 (women: 12.77%; 95% CI; 12.75%-12.80%; men: 5.56%; 95% CI, 5.44%-5.58%) to April 2020 for men (6.73%; 95% CI, 6.71%-6.75%) and October 2020 for women (15.18%; 95% CI, 15.16%-15.21%). Conclusions and Relevance In this cohort study, coinciding with the COVID-19 pandemic onset was an increase in Z-hypnotic as well as SSRI and SNRI prescriptions in both men and women along with an increase in benzodiazepine prescriptions in women, findings that suggest a substantial mental health impact of COVID-19–associated mitigation measures., This cohort study examines trends in the prescribing of benzodiazepines, serotonergic drugs, and Z-hypnotics among US adults during the COVID-19 pandemic.

Background Many older adults become physically and cognitively impaired. However, it is unclear whether unimpaired older adults are more likely to become physically or cognitively impaired first and if this sequence impacts mortality risk. Methods Data came from the Mexican Health and Aging Study. The sample included 1,283 participants aged ≥60 years who were physically and cognitively unimpaired in 2001. Multinomial logistic regression was used to estimate probabilities of being unimpaired, cognitively impaired only, physically impaired only, or cognitively-physically impaired in 2003. Proportional hazard models were used to estimate mortality risk through 2015 according to physical and cognitive status in 2003. Results The probabilities for being unimpaired, physically impaired only, cognitively impaired only, and cognitively-physically impaired in 2003 were 0.45, 0.22, 0.19, and 0.13, respectively. Older age, female sex, and arthritis were associated with significantly greater probability of becoming physically impaired only than cognitively impaired only in 2003. Cognitive impairment only (hazard ratio [HR] = 1.42, 95% confidence interval [CI] = 1.09–1.85) in 2003 but not physical impairment only (HR = 1.22, 95% CI = 0.94–1.58) was associated with greater mortality than being unimpaired in 2003. Cognitively-physically impaired participants had higher mortality risk than participants who were physically (HR = 1.58, 95% CI = 1.18–2.12) or cognitively (HR = 1.36, 95% CI = 1.01–1.84) impaired only. Discussion The likelihood of becoming only physically or cognitively impaired over 2 years varies by demographic and health characteristics. The mortality risk for unimpaired older adults who become cognitively impaired only is similar to those who become physically impaired only. Research should determine if the sequence of cognitive and physical impairments is associated with other outcomes.

Objective: To compare Alzheimer’s disease (AD) knowledge by race and ethnicity in a community sample of middle-aged and older adults aged 50 and over in Florida. Method: Data from HealthStreet, a University of Florida community engagement program, which uses community health workers to assess the health conditions, concerns, and knowledge of community members, was used ( n = 842). A multivariate regression model was used to quantify differences in AD knowledge by race and ethnicity. Results: Older age and recruitment from Miami were associated with higher AD knowledge while being non-Hispanic Black, reporting male sex, having less than high school diploma, and reporting food insecurity were associated with lower AD knowledge. Discussion: Hispanics had comparable AD knowledge to non-Hispanic Whites and more knowledge than non-Hispanic Blacks after adjusting for other factors that could differentiate these groups. Almost half of the participants did not know hypertension is a risk factor for AD, highlighting a point of intervention.

Introduction The Montreal Cognitive Assessment (MoCA), scored from 0 to 30, is used as a screening tool for mild cognitive impairment (MCI). The current cutoff (26) may not be optimal among minorities. Methods Data from the National Alzheimer's Coordinating Center Uniform Data Set March 2018 data freeze was used to calculate optimal cutoffs for detection of MCI and dementia by race/ethnic group and education. Results Of the 3895 individuals included, 80.7% were non-Hispanic White, 15.0% were non-Hispanic Black, and 4.2% were Hispanic. Optimal cutoffs for detection of MCI were 25 among non-Hispanic Whites, 24 among Hispanics, and 23 among non-Hispanic Blacks. Optimal cutoffs for detection of dementia were 19 among non-Hispanic Whites and 16 for both non-Hispanic Blacks and Hispanics. Lower educational attainment produced lower optimal cutoffs. Discussion Our findings suggest cutoffs may need to be stratified by race/ethnicity and education to ensure detecting MCI from normal and MCI from dementia., Highlights • The current MoCA cutoff of 26 is too global and too high for detection of MCI. • Optimal MoCA cutoffs vary by race/ethnicity. • Cutoffs also vary by educational attainment. • Cutoffs should be stratified by race/ethnicity and education before they are applied.

Pain increases with age, disproportionately affects females, and is a major contributor to decreased quality of life. Because pain is dynamic, trajectories are important to consider. However, few studies have looked at longitudinal trajectories of pain, by sex, using population data. We used data from the 2001, 2003, 2012, and 2015 waves of the Mexican Health and Aging Study, a nationally representative sample of Mexicans aged 50 and older. Individuals who had direct interviews at each time point and complete information on analytical variables were included (n=5,135). Pain reported at these time points was used to define pain trajectories as persistent pain, development of pain, diminishing pain, fluctuating pain, and never pain, by sex. Multinomial logistic regression was used to assess the association of sex with pain trajectories, adjusting for baseline demographic, behavioral, and health factors. Females had a higher prevalence of persistent pain (25.1% vs. 11.5%) while males had a higher prevalence of never pain (35.8% vs. 22.2%). Development of pain, diminishing pain, and fluctuating pain was similar between males and females (14.4% and 14.6%; 14.8% and 15.8%; 23.9% and 22.4%, respectively). Females had higher odds of persistent pain (OR: 2.13; 95%CI 1.67-2.70) and development of pain (OR: 1.40; 95%CI 1.11-1.75) compared to males. Overall, females had a much higher burden of persistent pain compared to males. Understanding trajectories of pain in later life and life course mechanisms for this large sex difference observed is crucial to improve quality of life.

Objectives The objectives were to examine the association between multimorbid chronic disease and frequency of past 6 months emergency department (ED) visits, by sex, in a community sample of adults from North Florida (N = 7143). Methods Data came from HealthStreet, a community engagement program at the University of Florida which uses the Community Health Worker Model to assess community member health conditions and concerns, and willingness to participate in health research. Using logistic regression, we estimated associations between multimorbid chronic disease and frequent ED use using sex as an effect modifier. Results Multimorbid chronic disease was associated with frequent ED use overall, with a stronger association among men. Of the 7143 respondents, 14.4% were frequent ED users, 58.0% were female, and 61.5% were black non-Hispanic. Major findings included that women with 3+ chronic diseases were 2.49 (95% confidence interval, 1.7-3.6) times as likely as women without chronic diseases to report frequent ED use, compared with men with 3+ chronic diseases, who were 4.98 (95% confidence interval, 2.9-8.6) times as likely as men without chronic disease to report frequent ED use. Conclusions Multimorbid chronic disease is very strongly associated with frequent ED use among all, but the association is especially strong among men. Future research is needed to further understand this association and its implication for health care.

In Mexico, palliative care and pain relief was recently added to the essential health services offered through Seguro Popular. Pain is more frequent in older adults, a growing segment of this population, and is a major contributor to decreased quality of life and increased morbidity. However, Mexico only has enough opioid analgesics to treat 36% of those in need. We used logistic regression models to examine correlates of pain using data from the 2012 wave of the Mexican Health and Aging Study, which includes Mexicans aged 50 and older (n=13,727). Overall, 38.2% of individuals reported that they often suffered from pain. Those who reported pain were more likely to be female (OR: 1.56; 95% CI: 1.41, 1.72), insured (OR: 1.17; 95% CI: 1.03, 1.33), live in a semi-rural locality (OR: 1.18; 95% CI: 1.04, 1.34), report their health as fair or poor (OR: 2.99; 95% CI: 2.73, 3.29), be a past smoker (OR: 1.17; 95% CI: 1.06, 1.29), have at least one ADL limitation (OR: 2.58; 95% CI: 2.27, 2.93), report depression (OR: 2.19; 95% CI: 2.02, 2.37), or report arthritis (OR: 2.74; 95% CI: 2.45, 3.07). Those who did not report pain were more likely to be widowed or have higher education. Diabetes, stroke, and cancer were not significantly associated with pain. Given that Mexico does not have the resources to treat over half of individuals living with pain, understanding the high burden of pain in this population is important to inform interventions and improve quality of life.

A letter to the editor is presented in response to the article "Frequent Emergency Department Visits and Hospitalizations Among Homeless People With Medicaid: Implications for Medicaid Expansion" by W-C Lin, M. Bharel, E. O'Connell, and R.E. Clark which appears in a 2015 issue of the journal.