@article {11156, title = {Factor structure of the Harmonized Cognitive Assessment Protocol neuropsychological battery in the Health and Retirement Study}, journal = {Neuropsychology}, year = {Forthcoming}, abstract = {Objectives: The Harmonized Cognitive Assessment Protocol (HCAP) describes an assessment battery and a family of population-representative studies measuring neuropsychological performance. We describe the factorial structure of the HCAP battery in the US Health and Retirement Study (HRS).Method: The HCAP battery was compiled from existing measures by a cross-disciplinary and international panel of researchers. The HCAP battery used in the 2016 wave of the HRS. We used factor analysis methods to assess and refine a theoretically-driven single and multiple domain factor structure for tests included in the HCAP battery among 3,347 participants with evaluable performance data. Results: For the eight domains of cognitive functioning identified theoretically (orientation, memory [immediate, delayed, \& recognition], set shifting, attention/speed, language/fluency, andvisuospatial), all single factor models fit reasonably well, although four of these domains had either 2 or 3 indicators where good fit is axiomatic. Multidimensional models suggested the eight-domain model was overly complex. A five-domain model (orientation, memory delayed and recognition, executive functioning, language/fluency, visuospatial) was identified as a reasonable model for summarizing performance in this sample (standardized root mean square residual = 0.05, root mean square error of approximation = 0.05, confirmatory fit index = 0.94). Discussion: The HCAP battery conforms adequately to a multidimensional structure of neuropsychological performance. The derived measurement models can be used as anchors for calibrating cross-national studies of cognitive performance, and to identify persons performing atthe low end as part of an algorithmic classification of probable dementia}, keywords = {Cognitive Ability, Confirmatory Factor Analysis, HCAP, Older Adults}, doi = {10.31234/osf.io/rvmhj}, author = {Richard N Jones and Jennifer J Manly and Kenneth M. Langa and Lindsay H Ryan and Deborah A Levine and Ryan J McCammon and David R Weir} } @article {5760, title = {Health and Retirement Study Imputation of Cognitive Functioning Measures: 1992-2018}, year = {2022}, institution = {Survey Research Center, University of Michigan}, address = {Ann Arbor, Michigan}, keywords = {Health Conditions and Status, Methodology}, url = {https://hrsdata.isr.umich.edu/sites/default/files/documentation/data-descriptions/1651088507/COGIMP9218_dd.pdf}, author = {Ryan J McCammon and Gwenith G Fisher and Hassan, Halimah and Jessica Faul and Rogers, Willard and David R Weir} } @article {11670, title = {Changes in Health Care Access and Utilization for Low-SES Adults Age 51-64 after Medicaid Expansion.}, journal = {The Journal of Gerontology: Series B}, volume = {76}, year = {2021}, pages = {1218-1230}, abstract = {

OBJECTIVES: Whether the Affordable Care Act (ACA) insurance expansions improved access to care and health for adults age 51-64 has not been closely examined. This study examined longitudinal changes in access, utilization, and health for low-socioeconomic status adults age 51-64 before and after the ACA Medicaid expansion.

METHODS: Longitudinal difference-in-differences (DID) study before (2010-2014) and after (2016) Medicaid expansion, including N=2,088 noninstitutionalized low-education adults age 51-64 (N=633 in Medicaid expansion states, N=1,455 in non-expansion states) from the nationally representative biennial Health and Retirement Study. Outcomes included coverage (any, Medicaid, private), access (usual source of care, difficulty finding doctor, foregone care, cost-related medication nonadherence, out-of-pocket costs), utilization (outpatient visit, hospitalization), and health status.

RESULTS: Low-education adults age 51-64 had increased rates of Medicaid coverage (+10.6 percentage points [pp] in expansion states, +3.2 pp in non-expansion states, DID +7.4 pp, p=0.001) and increased likelihood of hospitalizations (+9.2 pp in expansion states, -1.1 pp in non-expansion states, DID +10.4 pp, p=0.003) in Medicaid expansion compared with non-expansion states after 2014. Those in expansion states also had a smaller increase in limitations in paid work/housework over time, compared to those in non-expansion states (+3.6 pp in expansion states, +11.0 pp in non-expansion states, DID -7.5 pp, p=0.006). There were no other significant differences in access, utilization or health trends between expansion and non-expansion states.

DISCUSSION: After Medicaid expansion, low-education status adults age 51-64 were more likely to be hospitalized, suggesting poor baseline access to chronic disease management and pent-up demand for hospital services.

}, keywords = {Affordable Care Act, Hospitalization, Medicaid, Retirement}, issn = {1758-5368}, doi = {10.1093/geronb/gbaa123}, author = {Tipirneni, Renuka and Helen G Levy and Kenneth M. Langa and Ryan J McCammon and Zivin, Kara and Jamie E Luster and Karmakar, Monita and John Z. Ayanian} } @article {11279, title = {Development and validation of prediction model to estimate 10-year risk of all-cause mortality using modern statistical learning methods: a large population-based cohort study and external validation.}, journal = {BMC Medical Research Methodology}, volume = {21}, year = {2021}, pages = {8}, abstract = {

BACKGROUND: In increasingly ageing populations, there is an emergent need to develop a robust prediction model for estimating an individual absolute risk for all-cause mortality, so that relevant assessments and interventions can be targeted appropriately. The objective of the study was to derive, evaluate and validate (internally and externally) a risk prediction model allowing rapid estimations of an absolute risk of all-cause mortality in the following 10 years.

METHODS: For the model development, data came from English Longitudinal Study of Ageing study, which comprised 9154 population-representative individuals aged 50-75 years, 1240 (13.5\%) of whom died during the 10-year follow-up. Internal validation was carried out using Harrell{\textquoteright}s optimism-correction procedure; external validation was carried out using Health and Retirement Study (HRS), which is a nationally representative longitudinal survey of adults aged >=50 years residing in the United States. Cox proportional hazards model with regularisation by the least absolute shrinkage and selection operator, where optimisation parameters were chosen based on repeated cross-validation, was employed for variable selection and model fitting. Measures of calibration, discrimination, sensitivity and specificity were determined in the development and validation cohorts.

RESULTS: The model selected 13 prognostic factors of all-cause mortality encompassing information on demographic characteristics, health comorbidity, lifestyle and cognitive functioning. The internally validated model had good discriminatory ability (c-index=0.74), specificity (72.5\%) and sensitivity (73.0\%). Following external validation, the model{\textquoteright}s prediction accuracy remained within a clinically acceptable range (c-index=0.69, calibration slope β=0.80, specificity=71.5\% and sensitivity=70.6\%). The main limitation of our model is twofold: 1) it may not be applicable to nursing home and other institutional populations, and 2) it was developed and validated in the cohorts with predominately white ethnicity.

CONCLUSIONS: A new prediction model that quantifies absolute risk of all-cause mortality in the following 10-years in the general population has been developed and externally validated. It has good prediction accuracy and is based on variables that are available in a variety of care and research settings. This model can facilitate identification of high risk for all-cause mortality older adults for further assessment or interventions.

}, keywords = {Absolute risk, Mortality, Population-based longitudinal study, Prognostic factors, Statistical learning, Survival}, issn = {1471-2288}, doi = {10.1186/s12874-020-01204-7}, author = {Ajnakina, Olesya and Agbedjro, Deborah and Ryan J McCammon and Jessica Faul and Murray, Robin M and Stahl, Daniel and Andrew Steptoe} } @article {12107, title = {HRS 2016 Sampling Weights}, year = {2021}, institution = {Survey Research Center, Institute for Social Research, University of Michigan}, address = {Ann Arbor, MI}, author = {Lee, Sunghee and Nishimura, Raphael and Burton, Paul and Ryan J McCammon} } @article {10355, title = {The Health and Retirement Study Harmonized Cognitive Assessment Protocol Project: Study Design and Methods}, journal = {Neuroepidemiology}, year = {2020}, month = {2019}, abstract = {Introduction: The Harmonized Cognitive Assessment Protocol (HCAP) Project is a substudy within the Health and Retirement Study (HRS), an ongoing nationally representative panel study of about 20,000 adults aged 51 or older in the United States. The HCAP is part of an international research collaboration funded by the National Institute on Aging to better measure and identify cognitive impairment and dementia in representative population-based samples of older adults, in the context of ongoing longitudinal studies of aging in high-, middle-, and low-income countries around the world. Methods: The HCAP cognitive test battery was designed to measure a range of key cognitive domains affected by cognitive aging (including attention, memory, executive function, language, and visuospatial function) and to allow harmonization and comparisons to other studies in the United States and around the world. The HCAP included a pair of in-person interviews, one with the target HRS respondent (a randomly selected HRS sample member, aged 65+) that lasted approximately 1 h and one with an informant nominated by the respondent that lasted approximately 20 min. The final HRS HCAP sample included 3,496 study subjects, representing a 79\% response rate among those invited to participate. Conclusion: Linking detailed HCAP cognitive assessments to the wealth of available longitudinal HRS data on cognition, health, biomarkers, genetics, health care utilization, informal care, and economic resources and behavior will provide unique and expanded opportunities to study cognitive impairment and dementia in a nationally representative US population-based sample. The fielding of similar HCAP projects in multiple countries around the world will provide additional opportunities to study international differences in the prevalence, incidence, and outcomes of dementia globally with comparable data. Like all HRS data, HCAP data are publicly available at no cost to researchers.}, keywords = {Cognition, cognitive assessment, study design}, isbn = {0251-5350}, doi = {10.1159/000503004}, author = {Kenneth M. Langa and Lindsay H Ryan and Ryan J McCammon and Richard N Jones and Jennifer J Manly and Deborah A Levine and Amanda Sonnega and Farron, M. and David R Weir} } @article {9280, title = {Association between spousal caregiver well-being and care recipient healthcare expenditures}, journal = {Journal of the American Geriatrics Society}, volume = {65}, year = {2017}, pages = {2220-2226}, abstract = {Objectives To measure the association between spousal depression, general health, fatigue and sleep, and future care recipient healthcare expenditures and emergency department (ED) use. Design Prospective cohort study. Setting Health and Retirement Study. Participants Home-dwelling spousal dyads in which one individual (care recipient) was aged 65 and older and had one or more activity of daily living or instrumental activity of daily living disabilities and was enrolled in Medicare Part B (N = 3,101). Exposure Caregiver sleep (Jenkins Sleep Scale), depressive symptoms (Center for Epidemiologic Studies Depression-8 Scale), and self-reported general health measures. Measurements Primary outcome was care recipient Medicare expenditures. Secondary outcome was care recipient ED use. Follow-up was 6 months. Results Caregiver depressive symptoms score and six of 17 caregiver well-being measures were prospectively associated with higher care recipient expenditures after minimal adjustment (P < .05). Higher care recipient expenditures remained significantly associated with caregiver fatigue (cost increase, $1,937, 95\% confidence interval (CI) = $770{\textendash}3,105) and caregiver sadness (cost increase, $1,323, 95\% CI = $228{\textendash}2,419) after full adjustment. Four of 17 caregiver well-being measures, including severe fatigue, were significantly associated with care recipient ED use after minimal adjustment (P < .05). Greater odds of care recipient ED use remained significantly associated with caregiver fatigue (odds ratio (OR) = 1.24, 95\% CI = 1.01{\textendash}1.52) and caregiver fair to poor health (OR = 1.23, 95\% CI = 1.04{\textendash}1.45) after full adjustment. Caregiver total sleep score was not associated with care recipient outcomes. Conclusion Poor caregiver well-being, particularly severe fatigue, is independently and prospectively associated with higher care recipient Medicare expenditures and ED use.}, keywords = {Caregiving, Marriage, Medical Expenses, Medicare/Medicaid/Health Insurance, Well-being}, doi = {10.1111/jgs.15039}, url = {http://doi.wiley.com/10.1111/jgs.15039http://onlinelibrary.wiley.com/wol1/doi/10.1111/jgs.15039/fullpdfhttps://api.wiley.com/onlinelibrary/tdm/v1/articles/10.1111\%2Fjgs.15039}, author = {Claire K. Ankuda and Donovan T Maust and Mohammed U Kabeto and Ryan J McCammon and Kenneth M. Langa and Deborah A Levine} } @article {9321, title = {Distress Associated with Dementia-Related Psychosis and Agitation in Relation to Healthcare Utilization and Costs.}, journal = {American Journal of Geriatric Psychiatry}, volume = {25}, year = {2017}, month = {2017 Oct}, pages = {1074-1082}, abstract = {

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

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

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

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

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

}, keywords = {Dementia, Depressive symptoms, Healthcare, Stress}, issn = {1545-7214}, doi = {10.1016/j.jagp.2017.02.025}, author = {Donovan T Maust and Helen C Kales and Ryan J McCammon and Frederic C. Blow and Amanda N Leggett and Kenneth M. Langa} } @conference { ISI:000388585000170, title = {Internet Usage Among Older Adults: Findings from the Health and Retirement Study 2002-2014}, booktitle = {Gerontological Society of America}, year = {2016}, month = {NOV}, publisher = {Oxford}, organization = {Oxford}, keywords = {Internet usage, Older Adults, Societal changes}, issn = {0016-9013}, author = {Gwenith G Fisher and Wallace, L. E. and Lindsay H Ryan and Ryan J McCammon and John J McArdle} } @article {6438, title = {Mapping the Two Levels of Digital Divide: Internet Access and Social Network Site Adoption among Older Adults in the USA}, journal = {Information, Communication and Society}, volume = {19}, year = {2016}, pages = {1445-1464}, chapter = {1445}, abstract = {Older adults have increasingly adopted Internet and social network sites (SNSs), but little communication scholarship has explored systematic differences in access within this population. Using a nationally representative sample of Americans over the age of 50 years from the 2012 Health and Retirement Study, we examine Internet access (N?=?18,851) and SNS adoption patterns (N?=?869) among this sample and explore how these patterns vary by age. Regarding Internet access, results suggest that while the gender divide has reversed in favor of women, older adults who are economically, socioculturally, or physically disadvantaged are less likely to have reliable Internet access. In addition, the view that the various divides in Internet access are less of a concern for those who are younger is only partially supported, as some access-related divides do not vary by age or even decrease with age. For SNS adoption, we found that access to technological resources (diversity of online activities) positively predicts SNS use. Moreover, SNS users are more likely to be younger, female, widowed, and homemakers, perhaps because these individuals are more motivated to use SNSs to complement or compensate for their existing social status. These findings reveal unique challenges and motivations in relation to Internet access and SNS adoption patterns across the later life span.}, keywords = {Demographics, Health Conditions and Status}, doi = {10.1080/1369118X.2015.1109695}, url = {http://dx.doi.org/10.1080/1369118X.2015.1109695}, author = {Rebecca P. Yu and Nicole B. Ellison and Ryan J McCammon and Kenneth M. Langa} } @article {8514, title = {Neuroimaging overuse is more common in Medicare compared with the VA.}, journal = {Neurology}, volume = {87}, year = {2016}, month = {2016 Aug 23}, pages = {792-8}, abstract = {

OBJECTIVE: To inform initiatives to reduce overuse, we compared neuroimaging appropriateness in a large Medicare cohort with a Department of Veterans Affairs (VA) cohort.

METHODS: Separate retrospective cohorts were established in Medicare and in VA for headache and neuropathy from 2004 to 2011. The Medicare cohorts included all patients enrolled in the Health and Retirement Study (HRS) with linked Medicare claims (HRS-Medicare; n = 1,244 for headache and 998 for neuropathy). The VA cohorts included all patients receiving services in the VA (n = 93,755 for headache and 183,642 for neuropathy). Inclusion criteria were age over 65 years and an outpatient visit for incident neuropathy or a primary headache. Neuroimaging use was measured with Current Procedural Terminology codes and potential overuse was defined using published criteria for use with administrative data. Increasingly specific appropriateness criteria excluded nontarget conditions for which neuroimaging may be appropriate.

RESULTS: For both peripheral neuropathy and headache, potentially inappropriate imaging was more common in HRS-Medicare compared with the VA. Forty-nine percentage of all headache patients received neuroimaging in HRS-Medicare compared with 22.1\% in the VA (p < 0.001) and differences persist when analyzing more specific definitions of overuse. A total of 23.7\% of all HRS-Medicare incident neuropathy patients received neuroimaging compared with 9.0\% in the VA (p < 0.001), and the difference persisted after excluding nontarget conditions.

CONCLUSIONS: Overuse of neuroimaging is likely less common in the VA than in a Medicare population. Better understanding the reasons for the more selective use of neuroimaging in the VA could help inform future initiatives to reduce overuse of diagnostic testing.

}, keywords = {Aged, Aged, 80 and over, Cohort Studies, Female, Headache Disorders, Primary, Humans, Male, Medicare, Neuroimaging, Peripheral Nervous System Diseases, United States, United States Department of Veterans Affairs, Unnecessary Procedures}, issn = {1526-632X}, doi = {10.1212/WNL.0000000000002963}, url = {http://www.ncbi.nlm.nih.gov/pubmed/27402889}, author = {James F. Burke and Eve A Kerr and Ryan J McCammon and Holleman, Rob and Kenneth M. Langa and Brian C. Callaghan} } @article {8287, title = {Antidepressant Use and Cognitive Decline: The Health and Retirement Study.}, journal = {Am J Med}, volume = {128}, year = {2015}, month = {2015 Jul}, pages = {739-46}, publisher = {128}, abstract = {

BACKGROUND: Depression is associated with cognitive impairment and dementia, but whether treatment for depression with antidepressants reduces the risk for cognitive decline is unclear. We assessed the association between antidepressant use and cognitive decline over 6 years.

METHODS: Participants were 3714 adults aged 50 years or more who were enrolled in the nationally representative Health and Retirement Study and had self-reported antidepressant use. Depressive symptoms were assessed using the 8-item Center for Epidemiologic Studies Depression Scale. Cognitive function was assessed at 4 time points (2004, 2006, 2008, 2010) using a validated 27-point scale. Change in cognitive function over the 6-year follow-up period was examined using linear growth models, adjusted for demographics, depressive symptoms, comorbidities, functional limitations, and antidepressant anticholinergic activity load.

RESULTS: At baseline, cognitive function did not differ significantly between the 445 (12.1\%) participants taking antidepressants and those not taking antidepressants (mean, 14.9\%; 95\% confidence interval, 14.3-15.4 vs mean, 15.1\%; 95\% confidence interval, 14.9-15.3). During the 6-year follow up period, cognition declined in both users and nonusers of antidepressants, ranging from -1.4 change in mean score in those with high depressive symptoms and taking antidepressants to -0.5 change in mean score in those with high depressive symptoms and not taking antidepressants. In adjusted models, cognition declined in people taking antidepressants at the same rate as those not taking antidepressants. Results remained consistent across different levels of baseline cognitive function, age, and duration of antidepressant use (prolonged vs short-term).

CONCLUSIONS: Antidepressant use did not modify the course of 6-year cognitive change in this nationally representative sample.

}, keywords = {Age Distribution, Aged, Aged, 80 and over, Antidepressive Agents, Cognition, Cross-Sectional Studies, Depressive Disorder, Female, Follow-Up Studies, Geriatric Assessment, Humans, Incidence, Male, Middle Aged, Reference Values, Risk Assessment, Sex Distribution, Surveys and Questionnaires, United States}, issn = {1555-7162}, doi = {10.1016/j.amjmed.2015.01.007}, author = {Jane S Saczynski and Allison B Rosen and Ryan J McCammon and Zivin, Kara and Susan E. Andrade and Kenneth M. Langa and Sandeep Vijan and Paul A Pirraglia and Becky A. Briesacher} } @article {8332, title = {Longitudinal patient-oriented outcomes in neuropathy: Importance of early detection and falls.}, journal = {Neurology}, volume = {85}, year = {2015}, month = {2015 Jul 07}, pages = {71-9}, publisher = {85}, abstract = {

OBJECTIVE: To evaluate longitudinal patient-oriented outcomes in peripheral neuropathy over a 14-year time period including time before and after diagnosis.

METHODS: The 1996-2007 Health and Retirement Study (HRS)-Medicare Claims linked database identified incident peripheral neuropathy cases (ICD-9 codes) in patients >=65 years. Using detailed demographic information from the HRS and Medicare claims, a propensity score method identified a matched control group without neuropathy. Patient-oriented outcomes, with an emphasis on self-reported falls, pain, and self-rated health (HRS interview), were determined before and after neuropathy diagnosis. Generalized estimating equations were used to assess differences in longitudinal outcomes between cases and controls.

RESULTS: We identified 953 peripheral neuropathy cases and 953 propensity-matched controls. The mean (SD) age was 77.4 (6.7) years for cases, 76.9 (6.6) years for controls, and 42.1\% had diabetes. Differences were detected in falls 3.0 years before neuropathy diagnosis (case vs control; 32\% vs 25\%, p = 0.008), 5.0 years for pain (36\% vs 27\%, p = 0.002), and 5.0 years for good to excellent self-rated health (61\% vs 74\%, p < 0.0001). Over time, the proportion of fallers increased more rapidly in neuropathy cases compared to controls (p = 0.002), but no differences in pain (p = 0.08) or self-rated health (p = 0.9) were observed.

CONCLUSIONS: In older persons, differences in falls, pain, and self-rated health can be detected 3-5 years prior to peripheral neuropathy diagnosis, but only falls deteriorates more rapidly over time in neuropathy cases compared to controls. Interventions to improve early peripheral neuropathy detection are needed, and future clinical trials should incorporate falls as a key patient-oriented outcome.

}, keywords = {Accidental Falls, Aged, Aged, 80 and over, Early Diagnosis, Female, Humans, International Classification of Diseases, Longitudinal Studies, Male, Medicare, Patient-Centered Care, Peripheral Nervous System Diseases, Treatment Outcome, United States}, issn = {1526-632X}, doi = {10.1212/WNL.0000000000001714}, author = {Brian C. Callaghan and Kevin Kerber and Kenneth M. Langa and Banerjee, Mousumi and Rodgers, Ann and Ryan J McCammon and James F. Burke and Eva L Feldman} } @article {8213, title = {The relationships that matter: social network site use and social wellbeing among older adults in the United States of America}, journal = {Ageing and Society}, year = {2015}, note = {Export Date: 9 September 2015 Article in Press}, abstract = {An increasing number of middle-aged and older Americans are using social network sites (SNSs), but little research has addressed how SNS use is associated with social wellbeing outcomes in this population. Using a nationally representative sample of 1,620 Americans older than 50 from the 2012 Health and Retirement Study (HRS), we examine the relationship between older adults SNS use and social wellbeing associated with non-kin and kin relations and explore how these associations vary by age. Results of ordinary least-squares regression analyses suggest that SNS use is positively associated with non-kin-related social wellbeing outcomes, including perceived support from friends ( = 0.13; p 0.001; N = 460) and feelings of connectedness ( = 0.10; p 0.001; N = 463). Regression models employing interaction terms of age and SNS use further reveal that SNS use contributes to feelings of connectedness to a greater extent as people age ( = 0.10; p 0.001; N = 463). Of all kin-related social wellbeing outcomes, SNS use only predicts increased perceived support from children ( = 0.08; p 0.05; N = 410), and age negatively shapes this relationship ( = 0.14; p 0.001; N = 410). As older people engage with an increasingly smaller and narrower network with a greater proportion of kin contacts, our results suggest that SNS use may help older adults access differential social benefits throughout later life. Copyright Cambridge University Press 2015 This is a work of the U.S. Government and is not subject to copyright protection in the United States.}, keywords = {Adult children, Health Conditions and Status}, doi = {10.1017/S0144686X15000677}, url = {http://www.scopus.com/inward/record.url?eid=2-s2.0-84934325062andpartnerID=40andmd5=4576f4f7c6bbe43a40f9370e613cde7a}, author = {R. P. Yu and Ryan J McCammon and Nicole B. Ellison and Kenneth M. Langa} } @article {8517, title = {Cognitive Test Selection for the Harmonized Cognitive Assessment Protocol (HCAP)}, year = {2014}, month = {10/2014}, institution = {Institute for Social Research, University of Michigan}, address = {Ann Arbor, Michigan}, abstract = {The goal of this effort, set by the National Institute on Aging (NIA), is to devise a cognitive assessment that meets the following criteria: 1) Can be administered in the home by a survey interviewer in about one hour, 2) Has sufficient overlap with the 2002/03 HRS-ADAMS study that it can be used to establish trends in prevalence of dementia and cognitive impairment without dementia, and 3) Can be administered comparably and lead to comparably valid diagnoses in other developed and developing countries where HRS-type surveys are conducted. This goal is achievable because of substantial investment by the NIA in data collection in population studies focused on dementia. There is thus now an empirical basis for making test selection. Informant reports are a key element of most population-based approaches to assessment to establish the presence or absence of change in cognitive ability and of limitation in activity resulting from change. We intend to include informant reports in our data collection protocol and in the diagnostic algorithm. This document is focused on cognitive testing of the subject.}, keywords = {Cognitive Ability, HCAP, Meta-analyses, Survey Methodology}, author = {David R Weir and Ryan J McCammon and Lindsay H Ryan and Kenneth M. Langa} } @article {7996, title = {Development and validation of a brief dementia screening indicator for primary care.}, journal = {Alzheimers Dement}, volume = {10}, year = {2014}, note = {Export Date: 21 April 2014 Source: Scopus Article in Press}, month = {2014 Nov}, pages = {656-665.e1}, publisher = {10}, abstract = {

BACKGROUND: Detection of "any cognitive impairment" is mandated as part of the Medicare annual wellness visit, but screening all patients may result in excessive false positives.

METHODS: We developed and validated a brief Dementia Screening Indicator using data from four large, ongoing cohort studies (the Cardiovascular Health Study [CHS]; the Framingham Heart Study [FHS]; the Health and Retirement Study [HRS]; the Sacramento Area Latino Study on Aging [SALSA]) to help clinicians identify a subgroup of high-risk patients to target for cognitive screening.

RESULTS: The final Dementia Screening Indicator included age (1 point/year; ages, 65-79 years), less than 12~years of education (9 points), stroke (6 points), diabetes mellitus (3 points), body mass index less than 18.5~kg/m(2) (8 points), requiring assistance with money or medications (10 points), and~depressive symptoms (6 points). Accuracy was good across the cohorts (Harrell{\textquoteright}s C statistic: CHS, 0.68; FHS, 0.77; HRS, 0.76; SALSA, 0.78).

CONCLUSIONS: The Dementia Screening Indicator is a simple tool that may be useful in primary care settings to identify high-risk patients to target for cognitive screening.

}, keywords = {Aged, Cohort Studies, Dementia, Female, Humans, Male, Mass Screening, Predictive Value of Tests, Primary Health Care, Proportional Hazards Models, Risk Assessment}, issn = {1552-5279}, doi = {10.1016/j.jalz.2013.11.006}, url = {http://www.scopus.com/inward/record.url?eid=2-s2.0-84893186546andpartnerID=40andmd5=3b617dce24578e022db389d90ad9ddd1}, author = {Deborah E Barnes and Alexa S. Beiser and Anne Lee and Kenneth M. Langa and Alain Koyama and Sarah R Preis and John Neuhaus and Ryan J McCammon and Kristine Yaffe and Seshadri, Sudha and Mary Haan and David R Weir} } @article {8930, title = {Expenditures in the elderly with peripheral neuropathy: Where should we focus cost-control efforts?}, journal = {Neurology. Clinical Practice}, volume = {3}, year = {2013}, month = {2013 Oct}, pages = {421-430}, abstract = {

To optimize care in the evaluation of peripheral neuropathy, we sought to define which tests drive expenditures and the role of the provider type. We investigated test utilization and expenditures by provider type in those with incident neuropathy in a nationally representative elderly, Medicare population. Multivariable logistic regression was used to determine predictors of MRI and electrodiagnostic utilization. MRIs of the neuroaxis and electrodiagnostic tests accounted for 88\% of total expenditures. Mean and aggregate diagnostic expenditures were higher in those who saw a neurologist. Patients who saw a neurologist were more likely to receive an MRI and an electrodiagnostic test. MRIs and electrodiagnostic tests are the main contributors to expenditures in the evaluation of peripheral neuropathy, and should be the focus of future efficiency efforts.

}, keywords = {Medical Expenses, Medicare/Medicaid/Health Insurance, Older Adults, Peripheral Neuropathy}, issn = {2163-0402}, doi = {10.1212/CPJ.0b013e3182a78fb1}, author = {Brian C. Callaghan and James F. Burke and Rodgers, Ann and Ryan J McCammon and Kenneth M. Langa and Eva L Feldman and Kevin Kerber} } @article {7892, title = {Impact of cigarette smoking on utilization of nursing home services.}, journal = {Nicotine Tob Res}, volume = {15}, year = {2013}, month = {2013 Nov}, pages = {1902-9}, abstract = {

INTRODUCTION: Few studies have examined the effects of smoking on nursing home utilization, generally using poor data on smoking status. No previous study has distinguished utilization for recent from long-term quitters.

METHODS: Using the Health and Retirement Study, we assessed nursing home utilization by never-smokers, long-term quitters (quit >3 years), recent quitters (quit <=3 years), and current smokers. We used logistic regression to evaluate the likelihood of a nursing home admission. For those with an admission, we used negative binomial regression on the number of nursing home nights. Finally, we employed zero-inflated negative binomial regression to estimate nights for the full sample.

RESULTS: Controlling for other variables, compared with never-smokers, long-term quitters have an odds ratio (OR) for nursing home admission of 1.18 (95\% CI: 1.07-1.2), current smokers 1.39 (1.23-1.57), and recent quitters 1.55 (1.29-1.87). The probability of admission rises rapidly with age and is lower for African Americans and Hispanics, more affluent respondents, respondents with a spouse present in the home, and respondents with a living child. Given admission, smoking status is not associated with length of stay (LOS). LOS is longer for older respondents and women and shorter for more affluent respondents and those with spouses present.

CONCLUSIONS: Compared with otherwise identical never-smokers, former and current smokers have a significantly increased risk of nursing home admission. That recent quitters are at greatest risk of admission is consistent with evidence that many stop smoking because they are sick, often due to smoking.

}, keywords = {Age Factors, Aged, Aged, 80 and over, Black or African American, Cross-Sectional Studies, Female, Hispanic or Latino, Humans, Length of Stay, Logistic Models, Longitudinal Studies, Male, Middle Aged, Nursing homes, Risk, Self Report, Smoking, Socioeconomic factors, United States, White People}, issn = {1469-994X}, doi = {10.1093/ntr/ntt079}, url = {http://ntr.oxfordjournals.org/content/early/2013/06/18/ntr.ntt079.abstract}, author = {Kenneth E. Warner and Ryan J McCammon and Brant E Fries and Kenneth M. Langa} } @article {5959, title = {New Measures of Fluid Intelligence in the HRS}, year = {2013}, institution = {Institute for Social Research, University of Michigan}, address = {Ann Arbor, Michigan}, abstract = {This user guide describes how measures designed to test quantitative reasoning, verbal reasoning and verbal fluency were implemented in the 2010 and 2012 waves of the Health and Retirement Study. The Number Series test and Retrieval Fluency test were administered in the 2010 and 2012 waves of HRS to the full sample. The Verbal Analogies test was administered to a 10 percent random sample of the full HRS sample in 2012. Number Series measures quantitative reasoning, a specific type of fluid cognitive ability or fluid intelligence. Quantitative reasoning ability involves reasoning with concepts that depend upon mathematical relationships. The number series task requires the respondent to look at a series of numbers with a number missing from the series. The respondent must determine the numerical pattern and then provide the missing number in the series. Retrieval Fluency measures an aspect of long-term retrieval : fluency of retrieval from stored knowledge. It was first incorporated in the HRS in the 2010 wave . This test is a typical neuropsychology test and was adapted by McArdle and Woodcock from the WJ-III Tests of Achievement: Retrieval Fluency ( Riverside Publishing). The measure consisted of a single item in which respondents were asked to name as many animals as they could within a 60-second time limit. This measure is consistent with animal fluency measures commonly administered in other neuropsychological exams (e.g., the CERAD animal fluency measure; Morris et al., 1989) . Administration protocols, test scoring, and data quality review procedures are discussed for each measure.}, keywords = {Health Conditions and Status, Methodology}, author = {Gwenith G Fisher and John J McArdle and Ryan J McCammon and Amanda Sonnega and David R Weir} } @article {7911, title = {Trends in depressive symptom burden among older adults in the United States from 1998 to 2008.}, journal = {J Gen Intern Med}, volume = {28}, year = {2013}, month = {2013 Dec}, pages = {1611-9}, publisher = {28}, abstract = {

CONTEXT: Diagnosis and treatment of depression has increased over the past decade in the United States. Whether self-reported depressive symptoms among older adults have concomitantly declined is unknown.

OBJECTIVE: To examine trends in depressive symptoms among older adults in the US between 1998 and 2008.

DESIGN: Serial cross-sectional analysis of six biennial assessments.

SETTING: Health and Retirement Study (HRS), a nationally-representative survey. PATIENTS OR OTHER PARTICIPANTS Adults aged 55 and older (N = 16,184 in 1998).

MAIN OUTCOME MEASURE: The eight-item Center for Epidemiologic Studies Depression scale (CES-D8) assessed three levels of depressive symptoms (none = 0, elevated = 4+, severe = 6+), adjusting for demographic and clinical characteristics.

RESULTS: Having no depressive symptoms increased over the 10-year period from 40.9~\% to 47.4~\% (prevalence ratio [PR]: 1.16, 95 \% CI: 1.13-1.19), with significant increases in those aged >= 60 relative to those aged 55-59. There was a 7~\% prevalence reduction of elevated symptoms from 15.5~\% to 14.2~\% (PR: 0.93, 95 \% CI: 0.88-0.98), which was most pronounced among those aged 80-84 in whom the prevalence of elevated symptoms declined from 14.3~\% to 9.6~\%. Prevalence of having severe depressive symptoms increased from 5.8~\% to 6.8~\% (PR: 1.17, 95 \% CI: 1.06-1.28); however, this increase was limited to those aged 55-59, with the probability of severe symptoms increasing from 8.7~\% to 11.8~\%. No significant changes in severe symptoms were observed for those aged >= 60.

CONCLUSIONS: Overall late-life depressive symptom burden declined significantly from 1998 to 2008. This decrease appeared to be driven primarily by greater reductions in depressive symptoms in the oldest-old, and by an increase in those with no depressive symptoms. These changes in symptom burden were robust to physical, functional, demographic, and economic factors. Future research should examine whether this decrease in depressive symptoms is associated with improved treatment outcomes, and if there have been changes in the treatment received for the various age cohorts.

}, keywords = {Age Factors, Aged, Aged, 80 and over, Cohort Studies, Cost of Illness, Cross-Sectional Studies, depression, Female, Humans, Male, Middle Aged, United States}, issn = {1525-1497}, doi = {10.1007/s11606-013-2533-y}, author = {Zivin, Kara and Paul A Pirraglia and Ryan J McCammon and Kenneth M. Langa and Sandeep Vijan} } @article {7683, title = {Burden of cirrhosis on older Americans and their families: analysis of the health and retirement study.}, journal = {Hepatology}, volume = {55}, year = {2012}, month = {2012 Jan}, pages = {184-91}, publisher = {55}, abstract = {

UNLABELLED: Prevalence of cirrhosis among older adults is expected to increase; therefore, we studied the health status, functional disability, and need for supportive care in a large national sample of individuals with cirrhosis. A prospective cohort of individuals with cirrhosis was identified within the longitudinal, nationally representative Health and Retirement Study. Cirrhosis cases were identified in linked Medicare data via ICD-9-CM (International Classification of Diseases, Ninth Revision, Clinical Modification) codes and compared to an age-matched cohort without cirrhosis. Two primary outcome domains were assessed: (1) patients{\textquoteright} health status (perceived health status, comorbidities, health care utilization, and functional disability as determined by activities of daily living and instrumental activities of daily living), and (2) informal caregiving (hours of caregiving provided by a primary informal caregiver and associated cost). Adjusted negative binomial regression was used to assess the association between cirrhosis and functional disability. A total of 317 individuals with cirrhosis and 951 age-matched comparators were identified. Relative to the comparison group, individuals with cirrhosis had worse self-reported health status, more comorbidities, and used significantly more health care services (hospitalizations, nursing home stays, physician visits; P < 0.001 for all bivariable comparisons). They also had greater functional disability (P < 0.001 for activities of daily living and instrumental activities of daily living), despite adjustment for covariates such as comorbidities and health care utilization. Individuals with cirrhosis received more than twice the number of informal caregiving hours per week (P < 0.001), at an annual cost of US $4700 per person.

CONCLUSION: Older Americans with cirrhosis have high rates of disability, health care utilization, and need for informal caregiving. Improved care coordination and caregiver support is necessary to optimize management of this frail population.

}, keywords = {Aged, Black People, Caregivers, Comorbidity, Cost of Illness, Databases, Factual, Disability Evaluation, Female, Health Care Costs, Health Status, Hispanic or Latino, Humans, Incidence, Liver Cirrhosis, Male, Medicaid, Medicare, Prevalence, Prospective Studies, Retirement, United States, White People}, issn = {1527-3350}, doi = {10.1002/hep.24616}, author = {M. O. Rakoski and Ryan J McCammon and John D Piette and Theodore J Iwashyna and J. A. Marrero and Lok, Anna S and Kenneth M. Langa and Volk, Michael L} } @article {7710, title = {Predictors of self-report of heart failure in a population-based survey of older adults.}, journal = {Circ Cardiovasc Qual Outcomes}, volume = {5}, year = {2012}, month = {2012 May}, pages = {396-402}, publisher = {5}, abstract = {

BACKGROUND: Little research has been conducted on the predictors of self-report or patient awareness of heart failure (HF) in a population-based survey. The objective of this study was to (1) test the agreement between Medicare administrative and Health and Retirement Study (HRS) survey data and (2) determine predictors associated with self-report of HF, using a validated Medicare claims algorithm as the reference standard. We hypothesized that those who self-reported HF were more likely to have a higher number of HF-related claims.

METHODS AND RESULTS: Secondary data analysis was conducted using the 2004 wave of the HRS linked to 2002 to 2004 Medicare claims (n=5573 respondents aged >= 67 years). Concordance between self-report of HF in the HRS and Medicare claims was calculated. Logistic regression was performed to identify predictors associated with self-report HF. HF prevalence by self-report was 4.6\%. Self-report of HF and claims agreement was 87\% (κ=0.34). The presence of >1 HF inpatient claims was associated with greater odds of self-report (odds ratio [OR], 1.92; 95\% CI, 1.23-3.00). Greater odds of self-reporting HF was also associated with >= 4 HF claims (OR, 2.74; 95\% CI, 1.36-5.52). Blacks (OR, 0.28; 95\% CI, 0.14-0.55) and Hispanics (OR, 0.30; 95\% CI, 0.11-0.83) were less likely to self-report HF compared with whites in the final model.

CONCLUSIONS: Self-report of HF is an insensitive method for accurately identifying HF cases, especially in those with less-severe disease and who are nonwhite. There may be limited awareness of HF among older minority patients despite having clinical encounters during which HF is coded as a diagnosis.

}, keywords = {Age Factors, Aged, Aged, 80 and over, Algorithms, Awareness, Chi-Square Distribution, Comorbidity, Female, Health Knowledge, Attitudes, Practice, Health Status, Health Surveys, Heart Failure, Humans, Insurance Claim Review, Logistic Models, Male, Medicare, Odds Ratio, Patients, Predictive Value of Tests, Self Report, Socioeconomic factors, United States}, issn = {1941-7705}, doi = {10.1161/CIRCOUTCOMES.111.963116}, author = {Tanya R Gure and Ryan J McCammon and Christine T Cigolle and Todd M Koelling and Caroline S Blaum and Kenneth M. Langa} } @article {7768, title = {Tests and expenditures in the initial evaluation of peripheral neuropathy.}, journal = {Arch Intern Med}, volume = {172}, year = {2012}, month = {2012 Jan 23}, pages = {127-32}, publisher = {172}, abstract = {

BACKGROUND: Peripheral neuropathy is a common disorder in which an extensive evaluation is often unrevealing.

METHODS: We sought to define diagnostic practice patterns as an early step in identifying opportunities to improve efficiency of care. The 1996-2007 Health and Retirement Study Medicare claims-linked database was used to identify individuals with an incident diagnosis of peripheral neuropathy using International Classification of Diseases, Ninth Revision, codes and required no previous neuropathy diagnosis during the preceding 30 months. Focusing on 15 relevant tests, we examined the number and patterns of tests and specific test utilization 6 months before and after the incident neuropathy diagnosis. Medicare expenditures were assessed during the baseline, diagnostic, and follow-up periods.

RESULTS: Of the 12, 673 patients, 1031 (8.1\%) received a new International Classification of Diseases, Ninth Revision, diagnosis of neuropathy and met the study inclusion criteria. Of the 15 tests considered, a median of 4 (interquartile range, 2-5) tests were performed, with more than 400 patterns of testing. Magnetic resonance imaging of the brain or spine was ordered in 23.2\% of patients, whereas a glucose tolerance test was rarely obtained (1.0\%). Mean Medicare expenditures were significantly higher in the diagnostic period than in the baseline period ($14,362 vs $8067, P < .001).

CONCLUSIONS: Patients diagnosed as having peripheral neuropathy typically undergo many tests, but testing patterns are highly variable. Almost one-quarter of patients receiving neuropathy diagnoses undergo high-cost, low-yield magnetic resonance imaging, whereas few receive low-cost, high-yield glucose tolerance tests. Expenditures increase substantially in the diagnostic period. More research is needed to define effective and efficient strategies for the diagnostic evaluation of peripheral neuropathy.

}, keywords = {Aged, Antibodies, Antinuclear, Blood Cell Count, Blood Protein Electrophoresis, Blood Sedimentation, Brain, Diagnostic Tests, Routine, Electromyography, Female, Glucose Tolerance Test, Glycated Hemoglobin, Health Expenditures, Humans, International Classification of Diseases, Magnetic Resonance Imaging, Male, Medicare, Neural Conduction, Peripheral Nervous System Diseases, Quality Assurance, Health Care, Spine, Thyrotropin, United States, Vitamin B 12}, issn = {1538-3679}, doi = {10.1001/archinternmed.2011.1032}, author = {Brian C. Callaghan and Ryan J McCammon and Kevin Kerber and Xiao Xu and Kenneth M. Langa and Eva L Feldman} } @article {7586, title = {Incidence of dementia and cognitive impairment, not dementia in the United States.}, journal = {Ann Neurol}, volume = {70}, year = {2011}, month = {2011 Sep}, pages = {418-26}, abstract = {

OBJECTIVE: Estimates of incident dementia, and cognitive impairment, not dementia (CIND) (or the related mild cognitive impairment) are important for public health and clinical care policy. In this paper, we report US national incidence rates for dementia and CIND.

METHODS: Participants in the Aging, Demographic, and Memory Study (ADAMS) were evaluated for cognitive impairment using a comprehensive in-home assessment. A total of 456 individuals aged 72 years and older, who were not demented at baseline, were followed longitudinally from August 2001 to December 2009. An expert consensus panel assigned a diagnosis of normal cognition, CIND, or dementia and its subtypes. Using a population-weighted sample, we estimated the incidence of dementia, Alzheimer disease (AD), vascular dementia (VaD), and CIND by age. We also estimated the incidence of progression from CIND to dementia.

RESULTS: The incidence of dementia was 33.3 (standard error [SE], 4.2) per 1,000 person-years and 22.9 (SE, 2.9) per 1,000 person-years for AD. The incidence of CIND was 60.4 (SE, 7.2) cases per 1,000 person-years. An estimated 120.3 (SE, 16.9) individuals per 1,000 person-years progressed from CIND to dementia. Over a 5.9-year period, about 3.4 million individuals aged 72 and older in the United States developed incident dementia, of whom approximately 2.3 million developed AD, and about 637,000 developed VaD. Over this same period, almost 4.8 million individuals developed incident CIND.

INTERPRETATION: The incidence of CIND is greater than the incidence of dementia, and those with CIND are at high risk of progressing to dementia, making CIND a potentially valuable target for treatments aimed at slowing cognitive decline.

}, keywords = {Aged, Aged, 80 and over, Alzheimer disease, Cognition Disorders, Cohort Studies, Dementia, Diagnostic and Statistical Manual of Mental Disorders, disease progression, Female, Humans, Logistic Models, Longitudinal Studies, Male, Models, Statistical, United States}, issn = {1531-8249}, doi = {10.1002/ana.22362}, author = {Brenda L Plassman and Kenneth M. Langa and Ryan J McCammon and Gwenith G Fisher and Guy G Potter and James R Burke and David C Steffens and Norman L Foster and Bruno J Giordani and Frederick W Unverzagt and Kathleen A Welsh-Bohmer and Steven G Heeringa and David R Weir and Robert B Wallace} } @article {7106, title = {Social status, risky health behaviors, and diabetes in middle-aged and older adults.}, journal = {J Gerontol B Psychol Sci Soc Sci}, volume = {61}, year = {2006}, month = {2006 Nov}, pages = {S290-8}, publisher = {61B}, abstract = {

OBJECTIVE: This article investigates: (a) how social status influences diabetes prevalence and incidence; (b) how risky health behaviors contribute to the prediction of incident diabetes; (c) if the effects of health behaviors mediate the effects of social status on incident diabetes; and (d) if these effects differ in midlife and older age.

METHODS: We examined nationally representative data from the 1992/1993-1998 panels of the Health and Retirement Study for middle-aged and older adults using logistic regression analyses.

RESULT: The odds of prevalent diabetes were higher for people of older age, men, Black adults, and Latino adults. Higher early-life social status (e.g., parental schooling) and achieved social status (e.g., respondent schooling, economic resources) reduced the odds in both age groups. We observed similar patterns for incident diabetes in midlife but not in older age. Risky health behaviors--particularly obesity--increased the odds of incident diabetes in both age groups independent of social status. The increased odds of incident diabetes in midlife persisted for Black and Latino adults net of other social status factors.

DISCUSSION: Risky health behaviors are key predictors of incident diabetes in both age groups. Economic resources also play an important protective role in incident diabetes in midlife but not in older age.

}, keywords = {Aged, Body Mass Index, Diabetes Mellitus, Female, Follow-Up Studies, Health Behavior, Humans, Incidence, Male, Middle Aged, Prevalence, Risk-Taking, Social Behavior, Social Class, Surveys and Questionnaires}, issn = {1079-5014}, doi = {10.1093/geronb/61.6.s290}, author = {Linda A. Wray and Duane F. Alwin and Ryan J McCammon and Manning, Timothy and Best, Latrica E.} } @article {7042, title = {Social status and risky health behaviors: results from the health and retirement study.}, journal = {J Gerontol B Psychol Sci Soc Sci}, volume = {60 Spec No 2}, year = {2005}, month = {2005 Oct}, pages = {85-92}, publisher = {60B}, abstract = {

OBJECTIVES: We focus on a hypothesized mechanism that may underlie the well-documented link between social status and health-behavioral health risks.

METHODS: We use longitudinal data from representative samples of 6,106 middle-aged and 3,636 older adults from the Health and Retirement Study to examine the relationships between social status-including early life social status (e.g., parental schooling), ascribed social status (e.g., sex, race-ethnicity), and achieved social status (e.g., schooling, economic resources)-and behavioral health risks (e.g., weight, smoking, drinking, physical activity) to (1) assess how early life and ascribed social statuses are linked to behavioral health risks, (2) investigate the role of achieved factors in behavioral health risks, (3) test whether achieved status explains the contributions of early life and ascribed status, and (4) examine whether the social status and health risk relationships differ at midlife and older age.

RESULTS: We find that early life, achieved, and ascribed social statuses strongly predict behavioral health risks, although the effects are stronger in midlife than they are in older age.

DISCUSSION: Ascribed social statuses (and interactions of sex and race-ethnicity), which are important predictors of behavioral health risks even net of early life and achieved social status, should be explored in future research.

}, keywords = {Aged, Aging, Alcohol Drinking, Body Weight, Exercise, Female, Health Behavior, Humans, Life Style, Likelihood Functions, Logistic Models, Longitudinal Studies, Male, Middle Aged, Smoking, Social Class, United States}, issn = {1079-5014}, doi = {10.1093/geronb/60.special_issue_2.s85}, author = {Linda A. Wray and Duane F. Alwin and Ryan J McCammon} }