TY - JOUR T1 - Development and External Validation of Models to Predict Need for Nursing Home Level of Care in Community-Dwelling Older Adults With Dementia. JF - JAMA Internal Medicine Y1 - Forthcoming A1 - Deardorff, W James A1 - Jeon, Sun Y A1 - Barnes, Deborah E A1 - Boscardin, W John A1 - Kenneth M. Langa A1 - Covinsky, Kenneth E A1 - Mitchell, Susan L A1 - Lee, Sei J A1 - Smith, Alexander K KW - Community-dwelling KW - Dementia KW - home care KW - Nursing AB -

IMPORTANCE: Most older adults living with dementia ultimately need nursing home level of care (NHLOC).

OBJECTIVE: To develop models to predict need for NHLOC among older adults with probable dementia using self-report and proxy reports to aid patients and family with planning and care management.

DESIGN, SETTING, AND PARTICIPANTS: This prognostic study included data from 1998 to 2016 from the Health and Retirement Study (development cohort) and from 2011 to 2019 from the National Health and Aging Trends Study (validation cohort). Participants were community-dwelling adults 65 years and older with probable dementia. Data analysis was conducted between January 2022 and October 2023.

EXPOSURES: Candidate predictors included demographics, behavioral/health factors, functional measures, and chronic conditions.

MAIN OUTCOMES AND MEASURES: The primary outcome was need for NHLOC defined as (1) 3 or more activities of daily living (ADL) dependencies, (2) 2 or more ADL dependencies and presence of wandering/need for supervision, or (3) needing help with eating. A Weibull survival model incorporating interval censoring and competing risk of death was used. Imputation-stable variable selection was used to develop 2 models: one using proxy responses and another using self-responses. Model performance was assessed by discrimination (integrated area under the receiver operating characteristic curve [iAUC]) and calibration (calibration plots).

RESULTS: Of 3327 participants with probable dementia in the Health and Retirement Study, the mean (SD) age was 82.4 (7.4) years and 2301 (survey-weighted 70%) were female. At the end of follow-up, 2107 participants (63.3%) were classified as needing NHLOC. Predictors for both final models included age, baseline ADL and instrumental ADL dependencies, and driving status. The proxy model added body mass index and falls history. The self-respondent model added female sex, incontinence, and date recall. Optimism-corrected iAUC after bootstrap internal validation was 0.72 (95% CI, 0.70-0.75) in the proxy model and 0.64 (95% CI, 0.62-0.66) in the self-respondent model. On external validation in the National Health and Aging Trends Study (n = 1712), iAUC in the proxy and self-respondent models was 0.66 (95% CI, 0.61-0.70) and 0.64 (95% CI, 0.62-0.67), respectively. There was excellent calibration across the range of predicted risk.

CONCLUSIONS AND RELEVANCE: This prognostic study showed that relatively simple models using self-report or proxy responses can predict need for NHLOC in community-dwelling older adults with probable dementia with moderate discrimination and excellent calibration. These estimates may help guide discussions with patients and families in future care planning.

ER - TY - JOUR T1 - Factor structure of the Harmonized Cognitive Assessment Protocol neuropsychological battery in the Health and Retirement Study JF - Neuropsychology Y1 - Forthcoming A1 - Richard N Jones A1 - Jennifer J Manly A1 - Kenneth M. Langa A1 - Lindsay H Ryan A1 - Deborah A Levine A1 - Ryan J McCammon A1 - David R Weir KW - Cognitive Ability KW - Confirmatory Factor Analysis KW - HCAP KW - Older Adults AB - 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 ER - TY - JOUR T1 - Harmonization of Later-Life Cognitive Function Across National Contexts: Results from the Harmonized Cognitive Assessment Protocols (HCAPs). JF - medRxiv Y1 - Forthcoming A1 - Gross, Alden L A1 - LI, CHIHUA A1 - Briceño, Emily M A1 - Rentería, Miguel Arce A1 - Richard N Jones A1 - Kenneth M. Langa A1 - Jennifer J Manly A1 - Nichols, Emma L A1 - David R Weir A1 - Wong, Rebeca A1 - Berkman, Lisa A1 - Lee, Jinkook A1 - Lindsay C Kobayashi KW - Cognition KW - Education KW - harmonization KW - HCAP AB -

BACKGROUND: The Harmonized Cognitive Assessment Protocol (HCAP) is an innovative instrument for cross-national comparisons of later-life cognitive function, yet its suitability across diverse populations is unknown. We aimed to harmonize general and domain-specific cognitive scores from HCAPs across six countries, and evaluate precision and criterion validity of the resulting harmonized scores.

METHODS: We statistically harmonized general and domain-specific cognitive function across the six publicly available HCAP partner studies in the United States, England, India, Mexico, China, and South Africa (N=21,141). We used an item banking approach that leveraged common cognitive test items across studies and tests that were unique to studies, as identified by a multidisciplinary expert panel. We generated harmonized factor scores for general and domain- specific cognitive function using serially estimated graded-response item response theory (IRT) models. We evaluated precision of the factor scores using test information plots and criterion validity using age, gender, and educational attainment.

FINDINGS: IRT models of cognitive function in each country fit well. We compared measurement reliability of the harmonized general cognitive function factor across each cohort using test information plots; marginal reliability was high (r> 0·90) for 93% of respondents across six countries. In each country, general cognitive function scores were lower with older ages and higher with greater levels of educational attainment.

INTERPRETATION: We statistically harmonized cognitive function measures across six large, population-based studies of cognitive aging in the US, England, India, Mexico, China, and South Africa. Precision of the estimated scores was excellent. This work provides a foundation for international networks of researchers to make stronger inferences and direct comparisons of cross-national associations of risk factors for cognitive outcomes.

FUNDING: National Institute on Aging (R01 AG070953, R01 AG030153, R01 AG051125, U01 AG058499; U24 AG065182; R01AG051158).

ER - TY - JOUR T1 - Loneliness and Depressive Symptoms Are High Among Older Adults With Digestive Disease and Associated With Lower Perceived Health. JF - Clin Gastroenterol Hepatol Y1 - Forthcoming A1 - Cohen-Mekelburg, Shirley A1 - Jordan, Ariel A1 - Kenney, Brooke A1 - Burgess, Helen J A1 - Chang, Joy W A1 - Hu, Hsou Mei A1 - Tapper, Elliot A1 - Kenneth M. Langa A1 - Levine, Deborah A A1 - Waljee, Akbar K KW - Epidemiology KW - General Practice KW - Outcomes Research KW - Psychiatric Disorders AB -

BACKGROUND & AIMS: Current approaches to managing digestive disease in older adults fail to consider the psychosocial factors contributing to a person's health. We aimed to compare the frequency of loneliness, depression, and social isolation in older adults with and without a digestive disease and to quantify their association with poor health.

METHODS: We conducted an analysis of Health and Retirement Study data from 2008 to 2016, a nationally representative panel study of participants 50 years and older and their spouses. Bivariate analyses examined differences in loneliness, depression, and social isolation among patients with and without a digestive disease. We also examined the relationship between these factors and health.

RESULTS: We identified 3979 (56.0%) respondents with and 3131 (44.0%) without a digestive disease. Overall, 60.4% and 55.6% of respondents with and without a digestive disease reported loneliness (P < .001), 12.7% and 7.5% reported severe depression (P < .001), and 8.9% and 8.7% reported social isolation (P = NS), respectively. After adjusting for covariates, those with a digestive disease were more likely to report poor or fair health than those without a digestive disease (odds ratio [OR], 1.25; 95% CI, 1.11-1.41). Among patients with a digestive disease, loneliness (OR, 1.43; 95% CI, 1.22-1.69) and moderate and severe depression (OR, 2.93; 95% CI, 2.48-3.47; and OR, 8.96; 95% CI, 6.91-11.63, respectively) were associated with greater odds of poor or fair health.

CONCLUSIONS: Older adults with a digestive disease were more likely than those without a digestive disease to endorse loneliness and moderate to severe depression and these conditions are associated with poor or fair health. Gastroenterologists should feel empowered to screen patients for depression and loneliness symptoms and establish care pathways for mental health treatment.

ER - TY - JOUR T1 - Pre-Analytical Variables Influencing Stability of Blood-Based Biomarkers of Neuropathology. JF - Journal of Alzheimer's Disease Y1 - Forthcoming A1 - Panikkar, Daniel A1 - Vivek, Sithara A1 - Crimmins, Eileen A1 - Jessica Faul A1 - Kenneth M. Langa A1 - Bharat Thyagarajan KW - Alzheimer KW - amyloid-β KW - blood-based biomarkers KW - pre-analytical variables KW - Simoa assay KW - stability AB -

BACKGROUND: Sample collection and preanalytical protocols may significantly impact the results of large-scale epidemiological studies incorporating blood-based biomarkers of neuropathology.

OBJECTIVE: To evaluate the stability and assay variability of several blood-based biomarkers of neuropathology for common preanalytical conditions.

METHODS: We collected serum and plasma samples from 41 participants and evaluated the effect of processing delay of up to 72 h when stored at 4∘C, three freeze-thaw cycles, and a combination of 48-h processing delay when stored at 4∘C and three freeze-thaw cycles on biomarker stability. Using the Simoa assay (Quanterix Inc.), we measured amyloid-β 40 (Aβ40), amyloid-β 42 (Aβ42), neurofilament light (NfL), glial fibrillary acidic protein (GFAP), and phosphorylated tau 181 (p-tau-181).

RESULTS: We found that Aβ40 and Aβ42 levels significantly decreased after a 24-h processing delay in both plasma and serum samples, and a single freeze-thaw cycle (p < 0.0001). Nevertheless, serum Aβ42/40 ratio remained stable with a processing delay up to 48 h while plasma Aβ42/40 ratio showed only small but significant increase with a delay up to 72 h. Both plasma and serum GFAP and NfL levels were only modestly affected by processing delay and freeze-thaw cycles. Plasma p-tau-181 levels notably increased with a 24-, 48-, and 72-h processing delay, but remained stable in serum. Intra-individual variation over two weeks was minimal for all biomarkers and their levels were substantially lower in serum when compared with plasma.

CONCLUSION: These results suggest that standardizing preanalytical variables will allow robust measurements of biomarkers of neuropathology in population studies.

ER - TY - JOUR T1 - Treatment preferences among adults with normal cognition and cognitive impairment. JF - Journal of American Geriatrics Society Y1 - Forthcoming A1 - Owsley, Kelsey M A1 - Kenneth M. Langa A1 - Macis, Mario A1 - Nicholas, Lauren Hersch KW - cognitive impairment KW - Dementia KW - observational study KW - treatment preference AB -

BACKGROUND: Although patient participation in treatment decisions is important for preference-concordant care delivery, it is largely unknown how cognitive impairment influences treatment preferences. We investigated whether treatment preferences for the care of serious illness differ between adults with and without cognitive impairment in hypothetical clinical scenarios.

METHODS: Data from the 2018 Health and Retirement Study were used. The sample included 1291 self-respondents (201 respondents with cognitive impairment, and 1090 with normal cognition). We examined treatment preferences for life-extending, limited, and comfort care options in two hypothetical clinical scenarios where the respondent imagines a patient with (1) good physical health with severe cognitive impairment consistent with dementia; and (2) with physical impairment due to a heart attack, but normal cognition. Respondents specified whether they were unsure, or if they would want or not want each treatment option. Linear probability models were used to compare treatment preferences by cognitive status.

RESULTS: Respondents with cognitive impairment were more likely to report that they were unsure about treatment options across both clinical scenarios compared to those with normal cognition. For the limited treatment option, cognitive impairment was associated with a lower rate of expressing a treatment preference by 7.3 (p = 0.070) and 8.5 (p = 0.035) percentage points for dementia and heart attack scenarios, respectively. Among those who articulated preferences, cognitive impairment was associated with a higher rate of preference for life-extending treatment in both dementia (30.1% vs. 20.0%, p = 0.044) and heart attack scenarios (30.0% vs. 20.2%, p = 0.033).

CONCLUSIONS: Compared to those with normal cognition, cognitive impairment was associated with greater uncertainty about treatment preferences and higher rates of aggressive care preferences among those who specified preferences. Further research should assess whether preferences for aggressive care become more common as cognition declines in order to improve preference-concordant care delivery for patients with cognitive impairment.

ER - TY - JOUR T1 - Association Between Loneliness and Postoperative Mortality Among Medicare Beneficiaries. JF - JAMA Surgery Y1 - 2023 A1 - Shen, Mary R A1 - Suwanabol, Pasithorn A A1 - Howard, Ryan A A1 - Hu, Hsou Mei A1 - Levine, Deborah A A1 - Kenneth M. Langa A1 - Waljee, Jennifer F KW - Loneliness KW - Medicare VL - 158 IS - 2 ER - TY - JOUR T1 - Association of Arts Event Attendance With Cognitive Function Among Older Adults Enrolled in the Health and Retirement Study. JF - Innov Aging Y1 - 2023 A1 - Ike, John David A1 - Choi, Hwa Jung A1 - Cho, Tsai-Chin A1 - Howell, Joel D A1 - Kenneth M. Langa KW - Arts engagement; Cognition; Community activity; Geriatrics; Humanities AB -

BACKGROUND AND OBJECTIVES: Among the cognitively impaired, arts engagement is associated with improved neurocognitive symptoms. Less is known about arts engagement as a potentially modifiable lifestyle factor to prevent or slow cognitive decline. Our aim was to evaluate the association between arts event attendance and cognition.

RESEARCH DESIGN AND METHODS: We used data from the 2014 and 2016 waves of the Health and Retirement Study to evaluate the association between arts event attendance and cognition using multivariable linear regressions. Arts event attendance in 2014 was our exposure of interest and included visiting an art museum or art gallery; attending an arts or crafts fair; attending a live performance (concert, play, or reading); and/or going to a movie theater. Cognitive function in 2016 measured on a 27-point scale by the Telephone Interview for Cognitive Status was our main outcome of interest.

RESULTS: Of the 1,149 participants included in the final analysis, 70.7% attended an arts event. The mean baseline cognitive score was higher among those who attended art events (16.8 [standard deviation {}, ±3.8] vs 13.8 [, ±5.0]; < .001). In our multivariable regressions, those who attended arts events in 2014 exhibited higher cognitive scores in 2016 after controlling for demographic, socioeconomic, health, and baseline cognitive covariates (β, 1.07 [95% confidence interval {CI}, 0.50-1.64]; < .001). This association was primarily observed in those with lower baseline cognitive function (β, 1.19 [95% CI, 0.33-2.06]; = .008).

DISCUSSION AND IMPLICATIONS: Arts event attendance may be associated with better cognitive function. Given concerns for residual confounding and reverse causality, this association warrants further study.

VL - 7 IS - 3 ER - TY - JOUR T1 - Association of cumulative loneliness with all-cause mortality among middle-aged and older adults in the United States, 1996 to 2019. JF - PNAS Y1 - 2023 A1 - Yu, Xuexin A1 - Cho, Tsai-Chin A1 - Westrick, Ashly C A1 - Chen, Chen A1 - Kenneth M. Langa A1 - Lindsay C Kobayashi KW - cumulative loneliness KW - excess death KW - Mortality AB -

Loneliness is a growing public health concern worldwide. We characterized the association between cumulative loneliness and subsequent all-cause mortality, using data from 9,032 participants aged 50+ in the population-based US Health and Retirement Study (HRS) from 1996 to 2019. Loneliness status (yes; no) was measured biennially from 1996 to 2004, and we categorized the experience of cumulative loneliness over the 8-y period as never, one time point, two time points, and ≥three time points. A multivariable-adjusted age-stratified Cox proportional hazards regression model was fitted to examine the association between cumulative loneliness from 1996 to 2004 and all-cause mortality from 2004 to 2019. Excess deaths due to each category of cumulative loneliness were calculated. Compared to those who never reported loneliness from 1996 to 2004, participants experiencing loneliness at one time point, two time points, and ≥three time points respectively had 1.05 (95% CI: 0.96 to 1.15), 1.06 (95% CI: 0.95 to 1.19), and 1.16 (95% CI: 1.02 to 1.33) times higher hazards of mortality from 2004 to 2019 ( trend = 0.01). These results correspond to 106 (95% CI: 68 to 144), 202 (95% CI: 146 to 259), and 288 (95% CI: 233 to 343) excess deaths per 10,000 person-years, for those experiencing loneliness at each of one, two, or ≥three time points from 1996 to 2004. Cumulative loneliness in mid-to-later life may thus be a mortality risk factor with a notable impact on excess mortality. Loneliness may be an important target for interventions to improve life expectancy in the United States.

VL - 120 IS - 51 ER - TY - JOUR T1 - The association of health behaviors prior to cancer diagnosis and functional aging trajectories after diagnosis: Longitudinal cohort study of middle-aged and older US cancer survivors. JF - Preventive Medicine Reports Y1 - 2023 A1 - Westrick, Ashly C A1 - Kenneth M. Langa A1 - Lindsay C Kobayashi KW - alcohol use KW - Cancer survivorship KW - Functional aging KW - Health behaviors KW - Physical activity KW - Smoking AB -

We aimed to determine the influence of modifiable health behaviors prior to a cancer diagnosis on functional aging trajectories after diagnosis among middle-aged and older cancer survivors in the United States. Data were from biennial interviews with 2,717 survivors of a first incident cancer diagnosis after age 50 in the population-based US Health and Retirement Study from 1998 to 2016. Smoking status, alcohol use, and vigorous physical activity frequency were assessed at the interview prior to cancer diagnosis. Confounder-adjusted multinomial logistic regression was used to determine the associations between each pre-diagnosis health behavior and post-diagnosis trajectories of memory function and limitations to activities of daily living (ADLs), which were identified using group-based trajectory modeling. Overall, 20.7 % of cancer survivors were current smokers, 30.6 % drank alcohol, and 27.1 % engaged in vigorous physical activity >=once a week prior to their diagnosis. In the years following diagnosis, those who had engaged in vigorous physical activity > once a week were less likely to have a medium-high (OR: 0.5; 95 % CI: 0.2-0.9) or medium-low memory loss trajectories (OR: 0.6; 95 % CI: 0.3-1.0) versus very low memory loss trajectory, and were less likely to have a high, increasing ADL limitation trajectory (OR: 0.3; 95 % CI: 0.2, 0.6) versus no ADL limitation trajectory. Vigorous physical activity, but not smoking or alcohol use, was associated with better post-diagnosis functional aging trajectories after a first incident cancer diagnosis in mid-to-later life in this population-based study. Identification of modifiable risk factors can inform targeted interventions to promote healthy aging among cancer survivors.

VL - 31 ER - TY - JOUR T1 - Comparison of Particulate Air Pollution From Different Emission Sources and Incident Dementia in the US. JF - JAMA Intern Med Y1 - 2023 A1 - Zhang, Boya A1 - Weuve, Jennifer A1 - Kenneth M. Langa A1 - D'Souza, Jennifer A1 - Szpiro, Adam A1 - Jessica Faul A1 - Mendes de Leon, Carlos A1 - Gao, Jiaqi A1 - Kaufman, Joel D A1 - Sheppard, Lianne A1 - Lee, Jinkook A1 - Lindsay C Kobayashi A1 - Hirth, Richard A1 - Adar, Sara D AB -

IMPORTANCE: Emerging evidence indicates that exposure to fine particulate matter (PM2.5) air pollution may increase dementia risk in older adults. Although this evidence suggests opportunities for intervention, little is known about the relative importance of PM2.5 from different emission sources.

OBJECTIVE: To examine associations of long-term exposure of total and source-specific PM2.5 with incident dementia in older adults.

DESIGN, SETTING, AND PARTICIPANTS: The Environmental Predictors of Cognitive Health and Aging study used biennial survey data from January 1, 1998, to December 31, 2016, for participants in the Health and Retirement Study, which is a nationally representative, population-based cohort study in the US. The present cohort study included all participants older than 50 years who were without dementia at baseline and had available exposure, outcome, and demographic data between 1998 and 2016 (N = 27 857). Analyses were performed from January 31 to May 1, 2022.

EXPOSURES: The 10-year mean total PM2.5 and PM2.5 from 9 emission sources at participant residences for each month during follow-up using spatiotemporal and chemical transport models.

MAIN OUTCOMES AND MEASURES: The main outcome was incident dementia as classified by a validated algorithm incorporating respondent-based cognitive testing and proxy respondent reports. Adjusted hazard ratios (HRs) were estimated for incident dementia per IQR of residential PM2.5 concentrations using time-varying, weighted Cox proportional hazards regression models with adjustment for the individual- and area-level risk factors.

RESULTS: Among 27 857 participants (mean [SD] age, 61 [10] years; 15 747 [56.5%] female), 4105 (15%) developed dementia during a mean (SD) follow-up of 10.2 [5.6] years. Higher concentrations of total PM2.5 were associated with greater rates of incident dementia (HR, 1.08 per IQR; 95% CI, 1.01-1.17). In single pollutant models, PM2.5 from all sources, except dust, were associated with increased rates of dementia, with the strongest associations for agriculture, traffic, coal combustion, and wildfires. After control for PM2.5 from all other sources and copollutants, only PM2.5 from agriculture (HR, 1.13; 95% CI, 1.01-1.27) and wildfires (HR, 1.05; 95% CI, 1.02-1.08) were robustly associated with greater rates of dementia.

CONCLUSION AND RELEVANCE: In this cohort study, higher residential PM2.5 levels, especially from agriculture and wildfires, were associated with higher rates of incident dementia, providing further evidence supporting PM2.5 reduction as a population-based approach to promote healthy cognitive aging. These findings also indicate that intervening on key emission sources might have value, although more research is needed to confirm these findings.

ER - TY - JOUR T1 - A cultural neuropsychological approach to harmonization of cognitive data across culturally and linguistically diverse older adult populations. JF - Neuropsychology Y1 - 2023 A1 - Briceño, Emily M A1 - Arce Rentería, Miguel A1 - Gross, Alden L A1 - Richard N Jones A1 - Gonzalez, Christopher A1 - Wong, Rebeca A1 - David R Weir A1 - Kenneth M. Langa A1 - Jennifer J Manly KW - cognitive data KW - HCAP KW - Mex-Cog KW - neuropsychology AB -

OBJECTIVE: To describe a cultural neuropsychological approach to prestatistical harmonization of cognitive data across the United States (U.S.) and Mexico with the Harmonized Cognitive Assessment Protocol (HCAP).

METHOD: We performed a comprehensive review of the administration, scoring, and coding procedures for each cognitive test item administered across the English and Spanish versions of the HCAP in the Health and Retirement Study (HRS) in the U.S. and the Ancillary Study on Cognitive Aging in Mexico (Mex-Cog). For items that were potentially equivalent across studies, we compared each cognitive test item for linguistic and cultural equivalence and classified items as confident or tentative linking items, based on the degree of confidence in their comparability across cohorts and language groups. We evaluated these classifications using differential item functioning techniques.

RESULTS: We evaluated 132 test items among 21 cognitive instruments in the HCAP across the HRS and Mex-Cog. We identified 72 confident linking items, 46 tentative linking items, and 14 items that were not comparable across cohorts. Measurement invariance analysis revealed that 64% of the confident linking items and 83% of the tentative linking items showed statistical evidence of measurement differences across cohorts.

CONCLUSIONS: Prestatistical harmonization of cognitive data, performed by a multidisciplinary and multilingual team including cultural neuropsychologists, can identify differences in cognitive construct measurement across languages and cultures that may not be identified by statistical procedures alone. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

VL - 37 IS - 3 ER - TY - JOUR T1 - Decision Making for Patients With Severe Dementia Versus Normal Cognition Near the End of Life. JF - Innovation in Aging Y1 - 2023 A1 - Nicholas, Lauren Hersch A1 - Halpern, Scott D A1 - David R Weir A1 - Baum, Micah Y A1 - Nolan, Marie A1 - Gallo, Joseph A1 - Kenneth M. Langa KW - Advance care planning KW - cognitive impairment KW - family caregivers AB -

BACKGROUND AND OBJECTIVES: The clinical progression of severe dementia frequently leads to situations where surrogate decision makers must quickly make choices about potentially burdensome treatments that offer limited clinical benefit. We examined whether the number of decision makers and their access to advance directives were related to treatment choice for patients with severe dementia in comparison to those with normal cognition.

RESEARCH DESIGN AND METHODS: We retrospectively linked survey responses about end-of-life treatment decisions to Medicare claims for Health and Retirement Study respondents dying between 2002 and 2015 whose next-of-kin reported a need for surrogate decision making. We estimated multivariable logistic regression models to study measures of aggressive care in the last 6 months of life; in-hospital death, burdensome transfers, and burdensome treatments.

RESULTS: Compared to patients who were cognitively normal near the end of life ( = 1 198), patients with severe dementia ( = 722) were less likely to experience burdensome treatments (18% [95% confidence interval {CI} 14-21] vs 32% [95% CI 29-35]), burdensome transfers (20% [95% CI 17-24] vs 30% [95% CI 27-33]), and in-hospital death (24% [95% CI 20-28] vs 30% [95% CI 26-33]) when surrogates were involved. Rates of burdensome treatments, transfers, or in-hospital death for decedents with severe dementia did not vary with single versus multiple decision makers or when decision makers were informed by advance directives. However, among decedents with normal cognition, a single decision maker informed by an advance directive was associated with the lowest rates of burdensome treatments and in-hospital death.

DISCUSSION AND IMPLICATIONS: Surrogate decision makers made similar choices around end-of-life care for patients with severe dementia regardless of the number of decision makers and availability of advance directives. However, both advance directives and single decision makers were associated with less aggressive care for cognitively normal decedents.

VL - 7 IS - 7 ER - TY - JOUR T1 - The devil's in the details: Variation in estimates of late-life activity limitations across national cohort studies. JF - J of the American Geriatric Society Y1 - 2023 A1 - Ankuda, Claire K A1 - Covinsky, Kenneth A1 - Freedman, Vicki A A1 - Kenneth M. Langa A1 - Aldridge, Melissa D A1 - Yee, Cynthia A1 - Kelley, Amy S KW - Activities of Daily Living KW - Cohort Studies KW - Disabled Persons KW - Medicare KW - Self Care AB -

BACKGROUND: Assessing activity limitations is central to aging research. However, assessments of activity limitations vary, and this may have implications for the populations identified. We aim to compare measures of activities of daily living (ADLs) and their resulting prevalence and mortality across three nationally-representative cohort studies: the National Health and Aging Trends Study (NHATS), the Health and Retirement Survey (HRS), and the Medicare Current Beneficiary Survey (MCBS).

METHODS: We compared the phrasing and context of questions around help and difficulty with six self-care activities: eating, bathing, toileting, dressing, walking inside, and transferring. We then compared the prevalence and 1-year mortality for difficulty and help with eating and dressing.

RESULTS: NHATS, HRS, and MCBS varied widely in phrasing and framing of questions around activity limitations, impacting the proportion of the population found to experience difficulty or receive help. For example, in NHATS 12.4% [95% confidence interval (CI) 11.5%-13.4%] of the cohort received help with dressing, while in HRS this figure was 6.4% [95% CI 5.7%-7.2%] and MCBS 5.3% [95% CI 4.7%-5.8%]. When combined with variation in sampling frame and survey approach of each survey, such differences resulted in large variation in estimates of the older population of older adults with ADL disability.

CONCLUSIONS: In order to take late-life activity limitations seriously, we must clearly define the measures we use. Further, researchers and clinicians seeking to understand the experience of older adults with activity limitations should be careful to interpret findings in light of the framing of the question asked.

VL - 71 IS - 3 ER - TY - JOUR T1 - Estimating the Prevalence of Dementia in India Using a Semi-Supervised Machine Learning Approach. JF - Neuroepidemiology Y1 - 2023 A1 - Jin, Haomiao A1 - Crimmins, Eileen A1 - Kenneth M. Langa A1 - Dey, A B A1 - Lee, Jinkook KW - Aged KW - Aging KW - Dementia KW - Female KW - Humans KW - India KW - Male KW - Middle Aged KW - Prevalence KW - supervised machine learning AB -

INTRODUCTION: Accurate estimation of dementia prevalence is essential for making effective public and social care policy to support individuals and families suffering from the disease. The purpose of this paper is to estimate the prevalence of dementia in India using a semi-supervised machine learning approach based on a large nationally representative sample.

METHODS: The sample of this study is adults 60 years or older in the wave 1 (2017-2019) of the Longitudinal Aging Study in India (LASI). A subsample in LASI received extensive cognitive assessment and clinical consensus ratings and therefore has diagnoses of dementia. A semi-supervised machine learning model was developed to predict the status of dementia for LASI participants without diagnoses. After obtaining the predictions, sampling weights and age standardization to the World Health Organization (WHO) standard population were applied to generate the estimate for prevalence of dementia in India.

RESULTS: The prevalence of dementia for those aged 60 years and older in India was 8.44% (95% CI: 7.89%-9.01%). The age-standardized prevalence was estimated to be 8.94% (95% CI: 8.36%-9.55%). The prevalence of dementia was greater for those who were older, were females, received no education, and lived in rural areas.

DISCUSSION: The prevalence of dementia in India may be higher than prior estimates derived from local studies. These prevalence estimates provide the information necessary for making long-term planning of public and social care policy. The semi-supervised machine learning approach adopted in this paper may also be useful for other large population aging studies that have a similar data structure.

VL - 57 IS - 1 ER - TY - JOUR T1 - Functional aging trajectories of older cancer survivors: A latent growth analysis of the US Health and Retirement Study. JF - Journal of Cancer Survivorship Y1 - 2023 A1 - Westrick, Ashly C A1 - Kenneth M. Langa A1 - Eastman, Marisa A1 - Ospina-Romero, Monica A1 - Mullins, Megan A A1 - Lindsay C Kobayashi KW - Activities for daily living KW - Aging KW - Cancer KW - Memory AB -

PURPOSE: We aimed to identify prototypical functional aging trajectories of US cancer survivors aged 50 and older, overall and stratified by sociodemographic and health-related characteristics.

METHODS: Data were from 2986 survivors of a first incident cancer diagnosis (except non-melanoma skin cancer) after age 50 in the population representative U.S. Health and Retirement Study from 1998-2016. Cancer diagnoses, episodic memory function, and activity of daily living (ADL) limitations were assessed at biennial study interviews. Using time of cancer diagnosis as the baseline, we used group-based trajectory modeling to identify trajectories of memory function and ADL limitations following diagnosis.

RESULTS: We identified five memory loss trajectories (high: 8.4%; medium-high: 18.3%; medium-low: 21.5%; low: 25.5%; and, very low: 26.2%), and four ADL limitation trajectories (high/increasing limitations: 18.7%; medium limitations: 18.7%; low limitations: 8.14%; no limitations: 60.0). The high memory loss and high/increasing ADL limitation trajectories were both characterized by older age, being female (52% for memory, 58.9% for ADL), having lower pre-cancer memory scores, and a higher prevalence of pre-cancer comorbidities including stroke (30.9% for memory and 29.7% for ADL), hypertension (64.7% for memory and 69.8 for ADL), and depressive symptoms. In joint analyses, we found that generally those with higher memory were more likely to have fewer ADL limitations and vice versa.

CONCLUSION: Older cancer survivors experience heterogeneous trajectories of functional aging that are largely characterized by comorbidities prior to diagnosis.

IMPLICATION FOR CANCER SURVIVORS: Results can help identify older cancer survivors at increased risk for accelerated functional decline.

VL - 17 IS - 5 ER - TY - JOUR T1 - Hypertension and Stroke as Mediators of Air Pollution Exposure and Incident Dementia. JF - JAMA Network Open Y1 - 2023 A1 - Zhang, Boya A1 - Kenneth M. Langa A1 - Weuve, Jennifer A1 - D'Souza, Jennifer A1 - Szpiro, Adam A1 - Jessica Faul A1 - Mendes de Leon, Carlos A1 - Kaufman, Joel D A1 - Lisabeth, Lynda A1 - Hirth, Richard A A1 - Adar, Sara D KW - Air Pollution KW - Dementia KW - Hypertension KW - Particulate Matter KW - Stroke AB -

IMPORTANCE: Fine particulate matter air pollution (PM2.5) has been consistently associated with cardiovascular disease, which, in turn, is associated with an increased risk of dementia. As such, vascular dysfunction might be a mechanism by which PM2.5 mediates dementia risk, yet few prior epidemiological studies have examined this potential mechanism.

OBJECTIVE: To investigate whether hypertension and stroke serve as mediators and modifiers of the association of PM2.5 with incident dementia.

DESIGN, SETTING, AND PARTICIPANTS: As part of the Environmental Predictors of Cognitive Health and Aging (EPOCH) Project, this cohort study used biennial survey data collected between 1998 and 2016 from respondents of the Health and Retirement Study (HRS), a nationally representative, population-based, cohort in the US. Eligible participants were those over 50 years of age who were free of dementia at baseline and had complete exposure, mediator, outcome, and demographic data from the HRS. Data analysis was conducted from August to November 2022.

EXPOSURES: Exposure to PM2.5, calculated for the 10 years preceding each person's baseline examination according to residential histories and spatiotemporal models.

MAIN OUTCOMES AND MEASURES: Incident dementia was identified using a validated algorithm based on cognitive testing and informant reports. The 4-way decomposition causal mediation analysis method was used to quantify the degree to which hypertension and stroke mediated or modified the association of PM2.5 with incident dementia after adjustment for individual-level and area-level covariates.

RESULTS: Among 27 857 participants (mean [SD] age at baseline, 61 [10] years; 15 747 female participants [56.5%]; 19 249 non-Hispanic White participants [69.1%]), 4105 (14.7%) developed dementia during the follow-up period (mean [SD], 10.2 [5.6] years). Among participants with dementia, 2204 (53.7%) had a history of hypertension at baseline and 386 (9.4%) received a diagnosis of hypertension during the follow up. A total of 378 participants (9.2%) had a history of stroke at baseline and 673 (16.4%) developed stroke over the follow-up period. The IQR of baseline PM2.5 concentrations was 10.9 to 14.9 μg/m3. In fully adjusted models, higher levels of PM2.5 (per IQR) were not associated with increased risk of incident dementia (HR, 1.04; 95% CI, 0.98 to 1.11). Although there were positive associations of prevalent stroke (HR, 1.67; 95% CI, 1.48 to 1.88) and hypertension (HR, 1.15; 95% CI, 1.08 to 1.23) with incident dementia compared with those free of stroke and hypertension during follow-up, there was no statistically significant association of PM2.5 with stroke (odds ratio per IQR increment in PM2.5, 1.08; 95%CI, 0.91 to 1.29) and no evidence of an association of PM2.5 with hypertension (odds ratio per IQR increment in PM2.5, 0.99; 95%CI, 0.92 to 1.07). Concordantly, there was no evidence that hypertension or stroke acted as mediators or modifiers of the association of PM2.5 with incident dementia. Although the nonmediated interaction between PM2.5 and hypertension accounted for 39.2% of the total excess association (95% CI, -138.5% to 216.9%), the findings were not statistically significant.

CONCLUSIONS AND RELEVANCE: These findings suggest that although hypertension may enhance the susceptibility of individuals to air pollution, hypertension and stroke do not significantly mediate or modify the association of PM2.5 with dementia, indicating the need to investigate other pathways and potential mediators of risk.

VL - 6 IS - 9 ER - TY - JOUR T1 - The Influence of Cognitive Impairment on Post-Operative Outcomes. JF - Annals of Surgery Y1 - 2023 A1 - Blair, Emilie M A1 - Deborah A Levine A1 - Hu, Hsou Mei A1 - Kenneth M. Langa A1 - Mohammed U Kabeto A1 - Waljee, Jennifer KW - cognition impairment KW - Postoperative Period AB -

OBJECTIVE: To examine differences in rates of elective surgery, postoperative mortality, and readmission by pre-existing cognitive status among Medicare beneficiaries undergoing surgery.

BACKGROUND: Mild cognitive impairment (MCI) is common among older adults, but the impact of MCI on surgical outcomes is understudied.

METHODS: We conducted a retrospective cohort study of individuals ≥65 who underwent surgery between 2001 and 2015 using data from the nationally-representative Health and Retirement Study linked with Medicare claims. Cognitive status was assessed by the modified Telephone Interview for Cognitive Status score and categorized as normal cognition (score: 12-27), MCI (7-11), and dementia (<7). Outcomes were 30- and 90-day postoperative mortality and readmissions. We used Cox proportional hazard models to estimate the risk of each outcome by cognition, adjusting for patient characteristics.

RESULTS: In 6,590 patients, 69.9% had normal cognition, 20.1% had MCI, and 9.9% had dementia. Patients with MCI (79.9%) and dementia (73.6%) were less likely to undergo elective surgery than patients with normal cognition (85.9%). Patients with MCI had similar postoperative mortality and readmissions rates as patients with normal cognition. However, patients with dementia had significantly higher postoperative 90-day mortality (5.2% vs. 8.4%, p=0.002) and readmission rates (13.9% vs. 17.3%, p=0.038).

CONCLUSION: Patients with self-reported MCI are less likely to undergo elective surgery but have similar postoperative outcomes compared with patients with normal cognition. Despite the variability of defining MCI, our findings suggest that MCI may not confer additional risk for older individuals undergoing surgery, and should not be a barrier for surgical care.

VL - 277 IS - 1 ER - TY - JOUR T1 - Measurement differences in the assessment of functional limitations for cognitive impairment classification across geographic locations. JF - Alzheimers Dement Y1 - 2023 A1 - Nichols, Emma A1 - Ng, Derek K A1 - Hayat, Shabina A1 - Kenneth M. Langa A1 - Lee, Jinkook A1 - Steptoe, Andrew A1 - Deal, Jennifer A A1 - Gross, Alden L KW - Activities of Daily Living KW - Aged KW - Cognitive Dysfunction KW - Dementia KW - England KW - Humans KW - Surveys and Questionnaires KW - United States AB -

INTRODUCTION: The measurement of dementia in cross-national contexts relies on the assessment of functional limitations. We aimed to evaluate the performance of survey items on functional limitations across culturally diverse geographic settings.

METHODS: We used data from the Harmonized Cognitive Assessment Protocol Surveys (HCAP) in five countries (total N = 11,250) to quantify associations between items on functional limitations and cognitive impairment.

RESULTS: Many items performed better in the United States and England compared to South Africa, India, and Mexico. Items on the Community Screening Instrument for Dementia (CSID) had the least variability across countries (SD = 0.73 vs. 0.92 [Blessed] and 0.98 [Jorm IQCODE]), but also the weakest associations with cognitive impairment (median odds ratio [OR] = 2.23 vs. 3.01 [Blessed] and 2.75 [Jorm IQCODE]).

DISCUSSION: Differences in cultural norms for reporting functional limitations likely influences performance of items on functional limitations and may affect the interpretation of results from substantive studies.

HIGHLIGHTS: There was substantial cross-country variation in item performance. Items from the Community Screening Instrument for Dementia (CSID) had less cross-country variability but lower performance. There was more variability in performance of instrumental activities of daily living (IADL) compared to activities of daily living (ADL) items. Variability in cultural expectations of older adults should be taken into account. Results highlight the need for novel approaches to assessing functional limitations.

VL - 19 IS - 5 ER - TY - JOUR T1 - Memory and language cognitive data harmonization across the United States and Mexico. JF - Alzheimer's & Dementia (Amsterdam, Netherlands) Y1 - 2023 A1 - Arce Rentería, Miguel A1 - Briceño, Emily M A1 - Chen, Diefei A1 - Saenz, Joseph A1 - Lindsay C Kobayashi A1 - Gonzalez, Christopher A1 - Vonk, Jet M J A1 - Richard N Jones A1 - Jennifer J Manly A1 - Wong, Rebeca A1 - David R Weir A1 - Kenneth M. Langa A1 - Gross, Alden L KW - Alzheimer's disease KW - cognitive aging KW - cross‐cultural KW - cultural neuropsychology KW - harmonization AB -

INTRODUCTION: We used cultural neuropsychology-informed procedures to derive and validate harmonized scores representing memory and language across population-based studies in the United States and Mexico.

METHODS: Data were from the Health and Retirement Study Harmonized Cognitive Assessment Protocol (HRS-HCAP) and the Mexican Health and Aging Study (MHAS) Ancillary Study on Cognitive Aging (Mex-Cog). We statistically co-calibrated memory and language domains and performed differential item functioning (DIF) analysis using a cultural neuropsychological approach. We examined relationships among harmonized scores, age, and education.

RESULTS: We included 3170 participants from the HRS-HCAP (age = 76.6 [standard deviation (SD): 7.5], 60% female) and 2042 participants from the Mex-Cog (age = 68.1 [SD: 9.0], 59% female). Five of seven memory items and one of twelve language items demonstrated DIF by study. Harmonized memory and language scores showed expected associations with age and education.

DISCUSSION: A cultural neuropsychological approach to harmonization facilitates the generation of harmonized measures of memory and language function in cross-national studies.

HIGHLIGHTS: We harmonized memory and language scores across studies in the United States and Mexico.A cultural neuropsychological approach to data harmonization was used.Harmonized scores showed minimal measurement differences between cohorts.Future work can use these harmonized scores for cross-national studies of Alzheimer's disease and related dementias.

VL - 15 IS - 3 ER - TY - JOUR T1 - The mode effect of web-based surveying on the 2018 HRS measure of cognitive functioning. JF - J Gerontol B Psychol Sci Soc Sci Y1 - 2023 A1 - Domingue, Benjamin W A1 - McCammon, Ryan A1 - Brady T. West A1 - Kenneth M. Langa A1 - David R Weir A1 - Jessica Faul AB -

OBJECTIVES: Measuring cognition in an aging population is a public health priority. A move towards survey measurement via the web (as opposed to phone or in-person) is cost effective but challenging as it may induce bias in cognitive measures. We examine this possibility using an experiment embedded in the 2018 wave of data collection for the US Health and Retirement Study (HRS).

METHODS: We utilize techniques from multiple group item response theory to assess the effect of survey mode on performance on the HRS cognitive measure. We also study the problem of attrition by attempting to predict dropout and via approaches meant to minimize bias in subsequent inferences due to attrition.

RESULTS: We find evidence of an increase in scores for HRS respondents who are randomly assigned to the web-based mode of data collection in 2018. Web-based respondents score higher in 2018 than do phone-based respondents, and they show much larger gains relative to 2016 performance and subsequently larger declines in 2020. The bias in favor of web-based responding is observed across all items, but most pronounced for the serial 7 task and numeracy items. Due to the relative ease of the web-based mode, we suggest a cutscore of 12 being used to indicate CIND (cognitively impaired but not demented) status when using the web-based version rather than 11.

DISCUSSION: The difference in mode may be non-ignorable for many uses of the HRS cognitive measure. In particular, it may require reconsideration of some cutscore-based approaches to identify impairment.

ER - TY - JOUR T1 - Negative wealth shocks in later life and subsequent cognitive function in older adults in China, England, Mexico, and the USA, 2012-18: a population-based, cross-nationally harmonised, longitudinal study. JF - Lancet Healthy Longev Y1 - 2023 A1 - Cho, Tsai-Chin A1 - Yu, Xuexin A1 - Gross, Alden L A1 - Zhang, Yuan S A1 - Lee, Jinkook A1 - Kenneth M. Langa A1 - Lindsay C Kobayashi AB -

BACKGROUND: Household wealth is positively related to cognitive health outcomes in later life. However, the association between negative wealth shocks and cognitive function in later life, and whether this association might differ across countries at different levels of economic development, is unclear. We aimed to investigate whether negative wealth shocks in later life are associated with cognitive function in older adults in China, England, Mexico, and the USA, and whether this association is modified by country income level.

METHODS: For this population-based, cross-nationally harmonised, longitudinal study, data were analysed from core interviews of the population-based US Health and Retirement Study (2012 and 2016) and its partner studies in China (the China Health and Retirement Longitudinal Study; 2015 and 2018), England (the English Longitudinal Study of Ageing; 2012 and 2016), and Mexico (Mexican Health and Aging Study; 2012 and 2015-16), and their respective Harmonized Cognitive Assessment Protocols (HCAPs). Negative wealth shocks over the follow-up periods of the respective cohorts were defined in two ways: an extreme loss of 75% or greater from the baseline amount of wealth, and a decline in within-population wealth quintile rank. The primary outcome was the harmonised general cognitive function (GCF) factor score, which was constructed with factor analysis on the HCAP neuropsychological assessments of memory, orientation, attention, executive function, and verbal fluency performance (mean 0; SD 1). We used sampling-weighted, multivariable-adjusted linear models to examine associations.

FINDINGS: Data from 9465 participants were included in this analysis: 3796 from China, 1184 from England, 1193 from Mexico, and 3292 from the USA. The mean baseline age of participants was 68·5 (SD 5·4) years in China (49·8% women), 72·0 (7·0) years in England (54·6% women), 70·6 (6·8) years in Mexico (55·1% women), and 72·7 (7·5) years in the USA (60·4% women). A wealth loss of 75% or greater was negatively associated with subsequent cognitive function in the USA (β -0·16 SD units; 95% CI -0·29 to -0·04) and China (-0·14; -0·21 to -0·07), but not in England (-0·01; -0·24 to 0·22) or Mexico (-0·11; -0·24 to 0·03). Similarly, within-population wealth quintile rank declines were negatively associated with subsequent cognitive function in the USA (β -0·07 per quintile rank decline; 95% CI -0·11 to -0·03) and China (β -0·07; -0·09 to -0·04), but not in England (-0·05; -0·11 to 0·01) or Mexico (-0·03; -0·07 to 0·01).

INTERPRETATION: The impact of wealth shocks in later life on subsequent lower level of cognitive function of older adults in China, England, Mexico, and the USA differed across macro-level socioeconomic structures. These findings suggest that government policies and social safety nets in countries with different levels of economic development might have a role in protecting older adults from adverse health effects of wealth losses in later life.

FUNDING: US National Institute on Aging, US National Institutes of Health.

ER - TY - JOUR T1 - Addition of Vision Impairment to a Life-Course Model of Potentially Modifiable Dementia Risk Factors in the US. JF - JAMA Neurology Y1 - 2022 A1 - Ehrlich, Joshua R A1 - Goldstein, Jenna A1 - Swenor, Bonnie K A1 - Whitson, Heather A1 - Kenneth M. Langa A1 - Veliz, Phillip KW - dementia risk KW - life-course model KW - vision impairment AB -

Importance: Dementia prevention is a high priority, given the large impact of dementia on the well-being of individuals and society. The number of older adults with dementia in the US and globally is projected to increase as a result of population aging and growth. Thus, it is vital to identify potentially modifiable dementia risk factors. Vision impairment has been identified as a risk factor for accelerated cognitive decline and incident dementia. An estimated 90% of vision impairment is preventable or has yet to be treated. Nevertheless, vision impairment has not been included in the dominant life-course model of dementia risk factors, developed by the Lancet Commission, used to shape public health policy and research priorities.

Objective: To strengthen an existing model of potentially modifiable dementia risk factors through the inclusion of vision impairment and to estimate the contributions of those risk factors in the US population.

Design, Setting, and Participants: Population-based, cross-sectional study using data from the 2018 round of the Health and Retirement Study. Analyses were conducted from March 11 through September 24, 2021. The study population was a probability sample of US adults aged 50 years and older.

Exposures: Potentially modifiable dementia risk factors, including vision impairment.

Main Outcomes and Measures: The estimated population attributable fractions (PAFs) of dementia associated with vision impairment and other dementia risk factors (11 of those included in the Lancet Commission's life-course model) were calculated. The PAF represents the number of cases of dementia that would potentially be prevented if a risk factor were eliminated.

Results: The probability sample from the Health and Retirement Study included 16 690 participants (weighted demographic characteristics: 54.0% female, 52.0% age ≥65, 10.6% Black, 80% White, and 9.2% identified as other [including American Indian or Alaska Native, Asian, and Hawiian Native or Pacific Islander, although specific data were not available]). The 12 dementia risk factors in the PAF model were associated with an estimated 62.4% of dementia cases in the US. The risk factor with the highest weighted PAF for dementia was hypertension (12.4%). The PAF of vision impairment was 1.8%, suggesting that more than 100 000 prevalent dementia cases in the US could potentially have been prevented through healthy vision.

Conclusions and Relevance: Existing life-course models of potentially modifiable dementia risk factors, such as the Lancet Commission's, may consider including vision impairment. Since a large majority of vision impairment can be treated with cost-effective but underused interventions, this may represent a viable target for future interventional research that aims to slow cognitive decline and prevent incident dementia.

VL - 79 IS - 6 ER - TY - JOUR T1 - Association of Perceived Job Insecurity With Subsequent Memory Function and Decline Among Adults 55 Years or Older in England and the US, 2006 to 2016. JF - JAMA Network Open Y1 - 2022 A1 - Yu, Xuexin A1 - Kenneth M. Langa A1 - Cho, Tsai-Chin A1 - Lindsay C Kobayashi KW - COVID-19 KW - ELSA KW - Employment KW - England KW - Female KW - Male KW - Memory Disorders KW - Pandemics KW - Prospective Studies AB -

Importance: Intensified global economic competition and recent financial crises, including those associated with the COVID-19 pandemic, have contributed to uncertainty about job security. However, little is known about the association of perceived job insecurity with memory function and decline among older adults.

Objectives: To investigate the association between perceived job insecurity and subsequent memory function and rate of memory decline among older adults in the US and England.

Design, Setting, and Participants: This 10-year prospective population-based cohort study used data from the US Health and Retirement Study (HRS) and the English Longitudinal Study of Ageing (ELSA) collected from 2006 to 2016. Participants included 9538 adults 55 years or older. Data were analyzed from August 1 to 31, 2021.

Exposures: Perceived job insecurity (yes vs no) at baseline.

Main Outcomes and Measures: Episodic memory z scores at baseline and rate of decline during the follow-up.

Results: Among the 9538 study participants, the mean (SD) age at baseline was 60.97 (6.06) years, and 4981 (52.22%) were women. A total of 2320 participants (24.32%) reported job insecurity at baseline (1088 of 3949 [27.55%] in England and 1232 of 5589 [22.04%] in the US). Perceived job insecurity after 55 years of age was associated with lower baseline memory z scores in the fully adjusted model (β = -0.04 [95% CI, -0.08 to -0.01]) but not with rate of memory decline (β = 0.01 [95% CI, -0.01 to 0.01]). The association appeared to be stronger in the US than in England (job insecurity × US, β = -0.05 [95% CI, -0.11 to 0.02]), but the estimate was imprecise, potentially owing to low statistical power.

Conclusions and Relevance: The findings of this cohort study suggest that exposure to job insecurity in middle to late life was associated with worse memory function among older adults in the US and England. This association may vary across socioeconomic and social welfare contexts, although future studies with large samples from diverse socioeconomic settings are warranted.

VL - 5 IS - 4 ER - TY - JOUR T1 - Development and External Validation of a Mortality Prediction Model for Community-Dwelling Older Adults With Dementia. JF - JAMA Internal Medicine Y1 - 2022 A1 - Deardorff, W James A1 - Barnes, Deborah E A1 - Jeon, Sun Y A1 - Boscardin, W John A1 - Kenneth M. Langa A1 - Covinsky, Kenneth E A1 - Mitchell, Susan L A1 - Whitlock, Elizabeth L A1 - Smith, Alexander K A1 - Lee, Sei J KW - community dwelling KW - Dementia KW - mortality risk AB -

Importance: Estimating mortality risk in older adults with dementia is important for guiding decisions such as cancer screening, treatment of new and chronic medical conditions, and advance care planning.

Objective: To develop and externally validate a mortality prediction model in community-dwelling older adults with dementia.

Design, Setting, and Participants: This cohort study included community-dwelling participants (aged ≥65 years) in the Health and Retirement Study (HRS) from 1998 to 2016 (derivation cohort) and National Health and Aging Trends Study (NHATS) from 2011 to 2019 (validation cohort).

Exposures: Candidate predictors included demographics, behavioral/health factors, functional measures (eg, activities of daily living [ADL] and instrumental activities of daily living [IADL]), and chronic conditions.

Main Outcomes and Measures: The primary outcome was time to all-cause death. We used Cox proportional hazards regression with backward selection and multiple imputation for model development. Model performance was assessed by discrimination (integrated area under the receiver operating characteristic curve [iAUC]) and calibration (plots of predicted and observed mortality).

Results: Of 4267 participants with probable dementia in HRS, the mean (SD) age was 82.2 (7.6) years, 2930 (survey-weighted 69.4%) were female, and 785 (survey-weighted 12.1%) identified as Black. Median (IQR) follow-up time was 3.9 (2.0-6.8) years, and 3466 (81.2%) participants died by end of follow-up. The final model included age, sex, body mass index, smoking status, ADL dependency count, IADL difficulty count, difficulty walking several blocks, participation in vigorous physical activity, and chronic conditions (cancer, heart disease, diabetes, lung disease). The optimism-corrected iAUC after bootstrap internal validation was 0.76 (95% CI, 0.75-0.76) with time-specific AUC of 0.73 (95% CI, 0.70-0.75) at 1 year, 0.75 (95% CI, 0.73-0.77) at 5 years, and 0.84 (95% CI, 0.82-0.85) at 10 years. On external validation in NHATS (n = 2404), AUC was 0.73 (95% CI, 0.70-0.76) at 1 year and 0.74 (95% CI, 0.71-0.76) at 5 years. Calibration plots suggested good calibration across the range of predicted risk from 1 to 10 years.

Conclusions and Relevance: We developed and externally validated a mortality prediction model in community-dwelling older adults with dementia that showed good discrimination and calibration. The mortality risk estimates may help guide discussions regarding treatment decisions and advance care planning.

VL - 182 IS - 11 ER - TY - JOUR T1 - Differential trends in disability among rich and poor adults in the US and England from 2002 to 2016. JF - The Journals of Gerontology, Series B Y1 - 2022 A1 - Choi, Hwa Jung A1 - Robert F. Schoeni A1 - Andrew Steptoe A1 - Cho, Tsai-Chin A1 - Kenneth M. Langa KW - ADL limitation KW - Disability trend KW - ELSA KW - health disparity KW - IADL limitation AB -

OBJECTIVE: Disability in the US has not improved in recent decades. Comparing temporal trends in disability prevalence across different income groups, both within and between the US and England, would inform public policy aimed at reducing disparities in disability.

METHODS: Using the Health and Retirement Study (HRS) and the English Longitudinal Study of Ageing (ELSA), we estimated annual percent change from 2002 to 2016 in disability among community dwelling adults (197,021 person-years of observations). Disability was defined based on self-report of limitations with five instrumental activities of daily living (IADLs) and six activities of daily living (ADLs). We examined the trends by age and income quintile and adjusted for individual-level sociodemographic status and survey design.

RESULTS: The adjusted annual percent change (AAPC) in disability prevalence declined significantly in both countries for ages 75 and older during 2002--2016. For ages 55-64 and 65-74, disability prevalence was unchanged in the US but declined in England. Both countries experienced a widening gap in disability between low- and high-income adults among the younger age groups. For example, for those ages 55-64 in each country, there was no significant improvement in disability for the low-income group but a significant improvement for the high-income group (AAPC=-3.60 95% CI [-6.57,-0.63] for the US; AAPC=-6.06 95% CI [-8.77,-3.35] for England).

DISCUSSION: Improvements in disability were more widespread in England than in the US between 2002 and 2016. In both countries, the disparity in disability between low- and high-income adults widened for middle-aged adults. Policies targeted at preventing disability among low-income adults should be a priority in both countries.

VL - 77 IS - Supplement_2 ER - TY - JOUR T1 - EDUCATION GRADIENTS IN LATER-LIFE COGNITIVE FUNCTION ACROSS LOW-, MIDDLE-, AND HIGH-INCOME COUNTRIES JF - Innovation in Aging Y1 - 2022 A1 - Yuan Zhang A1 - Brendan O'Shea A1 - Xuexin Yu A1 - Tsai-Chin Cho A1 - Kenneth M. Langa A1 - Alden Gross A1 - Lindsay C Kobayashi KW - Education gradient AB - Education is positively related to cognitive function. However, educational gradients in cognitive function may vary across older populations with different educational compositions and physical and social environments. We conducted one of the first cross-national comparative studies on educational differences in later-life cognitive function using harmonized data. Multivariable linear regressions were employed to estimate the association between education according to International Standard Classification of Education (ISCED) categories and cognitive function for adults ages 60+ from the United States, England, Mexico, South Africa, India, and China. Cross-country differences were tested using fully interacted models. Controlling for demographics and parental education, we found significant educational gradients in cognitive function in low- and middle-income countries; however, in high-income countries, only those with upper secondary education and above had a consistent cognitive advantage over those with primary education. This study suggests substantial country-level differences in cognitive benefits of educational attainment. VL - 6 IS - Supplement_1 ER - TY - JOUR T1 - Estimating the Prevalence of Dementia and Mild Cognitive Impairment in the US: The 2016 Health and Retirement Study Harmonized Cognitive Assessment Protocol Project JF - JAMA Neurology Y1 - 2022 A1 - Jennifer J Manly A1 - Richard N Jones A1 - Kenneth M. Langa A1 - Ryan, Lindsay H. A1 - Levine, Deborah A. A1 - McCammon, Ryan A1 - Heeringa, Steven G. A1 - David R Weir KW - Dementia KW - HCAP KW - mild cognitive impairment AB - Nationally representative data are critical for understanding the causes, costs, and outcomes associated with dementia and mild cognitive impairment (MCI) in the US and can inform policies aimed at reducing the impact of these conditions on patients, families, and public programs. The nationally representative Health and Retirement Study (HRS) is an essential resource for such data, but the HRS substudy providing dementia diagnostic information was fielded more than 20 years ago and more recent data are needed.The Harmonized Cognitive Assessment Protocol (HCAP) was developed to update national estimates of the prevalence of MCI and dementia in the US and examine differences by age, race, ethnicity, and sex.HRS is an ongoing longitudinal nationally representative study of people 51 years and older with staggered entry dates from 1992 to 2022 and follow-up ranging from 4 to 30 years. HCAP is a cross-sectional random sample of individuals in HRS who were 65 years or older in 2016. Of 9972 age-eligible HRS participants, 4425 were randomly selected for HCAP, and 3496 completed a comprehensive neuropsychological test battery and informant interview, none of whom were excluded. Dementia and MCI were classified using an algorithm based on standard diagnostic criteria and comparing test performance to a robust normative sample.Groups were stratified by age, sex, education, race, and ethnicity.National prevalence estimates using population weights.The mean (SD) age of the study population sample (N = 3496) was 76.4 (7.6) years, and 2095 participants (60\%) were female. There were 551 participants who self-identified as Black and not Hispanic (16\%), 382 who self-identified as Hispanic regardless of race (16\%), 2483 who self-identified as White and not Hispanic (71\%), and 80 who self-identified as another race (2\%), including American Indian or Alaska Native, Asian, Native Hawaiian or Pacific Islander, or another self-described race. A total of 393 individuals (10\%; 95\% CI, 9-11) were classified as having dementia and 804 (22\%; 95\% CI, 20-24) as having MCI. Every 5-year increase in age was associated with higher risk of dementia (weighted odds ratio [OR], 1.95 per 5-year age difference; 95\%, CI, 1.77-2.14) and MCI (OR, 1.17 per 5-year age difference, 95\% CI, 1.09-1.26). Each additional year of education was associated with a decrease in risk of dementia (OR, 0.93 per year of school, 95\% CI, 0.89-0.97) and MCI (OR, 0.94, 95\% CI, 0.91-0.97). Dementia was more common among non-Hispanic Black individuals (OR, 1.81; 95\% CI, 1.20-2.75) and MCI in Hispanic individuals (OR, 1.42; 95\% CI, 1.03-1.96) compared with non-Hispanic White individuals. Other group comparisons by race and ethnicity were not possible owing to small numbers. No differences in prevalence were found between female individuals and male individuals.Using a comprehensive neuropsychological test battery and large sample, the national prevalence of dementia and MCI in 2016 found in this cross-sectional study was similar to that of other US-based studies, indicating a disproportionate burden of dementia and MCI among older Black and Hispanic adults and those with lower education. VL - 79 IS - 12 ER - TY - JOUR T1 - Glaucoma and cognitive function trajectories in a population-based study: Findings from the health and retirement study. JF - Journal of the American Geriatrics Society Y1 - 2022 A1 - Kolli, Ajay A1 - Kabeto, Mohammed A1 - McCammon, Ryan A1 - Kenneth M. Langa A1 - Ehrlich, Joshua R KW - cognitive function KW - Glaucoma KW - Ophthalmology KW - vision AB -

INTRODUCTION: Prior studies on the association of glaucoma and cognitive function have reported mixed results.

METHODS: The Health and Retirement Study (HRS) is a nationally representative panel survey of Americans age ≥ 51 years. HRS-linked Medicare claims data were used to identify incident glaucoma cases (by glaucoma type). Cognitive function was measured using the Telephone Interview for Cognitive Status (TICS), administered in each wave (every 2 years). Separate linear mixed models were fitted with either prevalent or incident glaucoma as a predictor of TICS trajectories and adjusting for age, race/ethnicity, educational attainment, gender, and medical history. Negative model estimates indicate associations of glaucoma with worse cognitive function scores or steeper per-year declines in cognitive function scores.

RESULTS: Analyses of prevalent glaucoma cases included 1344 cases and 5729 controls. Analyses of incident glaucoma included 886 cases and 4385 controls. In fully-adjusted models, those with prevalent glaucoma had similar TICS scores to controls (β = 0.01; 95% Confidence Interval [CI]: -0.15, 0.18; p = 0.86). However, in those with incident glaucoma, we detected a statistically significant association between glaucoma and lower TICS scores (β = -0.29; 95% CI: -0.50, -0.08; p = 0.007). However, there was no statistically significant association between either prevalent or incident glaucoma and per-year rates of change in TICS scores. When categorizing glaucoma by type (primary open angle glaucoma, normal tension glaucoma, or other glaucoma), no significant associations were detected between either prevalent or incident glaucoma and levels of or rates of change in TICS scores in fully covariate adjusted models.

CONCLUSION: The observed associations between glaucoma and cognitive function were small and unlikely to be clinically meaningful. Compared to prior studies on this topic, this investigation provides robust evidence based on its larger sample size, longitudinal follow-up, and repeated measures of cognitive function in a population-based sample.

VL - 70 IS - 10 ER - TY - JOUR T1 - Housing status, mortgage debt and financial burden as barriers to health among older adults in the U.S JF - Housing and Society Y1 - 2022 A1 - Mehdipanah, Roshanak A1 - Martin, Jaclyn A1 - Eisenberg, Alexa K. A1 - Amy J Schulz A1 - Lewis B Morgenstern A1 - Kenneth M. Langa KW - health KW - Housing KW - housing tenure KW - mortgage KW - Older adult AB - ABSTRACT We examine relations between housing status, mortgage, financial burden, and healthy aging among older U.S. adults. We combine cross-sectional data from 2012 to 2014 Health and Retirement Study cohorts. Using regression models, we examined associations between owners and renters, mortgage and non-mortgage holders, financial strain, and difficulty paying bills, and poor self-rated health (SRH), heart condition (HC) and hospitalization (past two years). We find that compared to owners, renters had greater likelihood of poor SRH and hospitalization. Regardless of tenure, financial strain was associated with greater likelihood of poor SRH, HC and hospitalization, while difficulty paying bills was associated with poor SRH and HC. Mortgage holders had lower likelihood of poor SRH. Accounting for mortgage status, financial strain was associated with greater likelihood of poor SRH, HC and hospitalization, while difficulty paying bills was associated with poor SRH and HC. Associations between tenure or mortgage status and health were not modified by either financial burden factors. We conclude that there need to be more robust and inclusive programs that assist older populations with housing could improve self-rated health, with particular attention to renters, mortgage holders and those experiencing financial burden. VL - 49 SN - 0888-2746 IS - 1 ER - TY - JOUR T1 - Interactions between the apolipoprotein E4 gene and modifiable risk factors for cognitive impairment: a nationally representative panel study. JF - BMC Geriatrics Y1 - 2022 A1 - Kolli, Ajay A1 - Zhou, Yunshu A1 - Chung, Grace A1 - Ware, Erin B A1 - Kenneth M. Langa A1 - Ehrlich, Joshua R KW - Apolipoprotein E4 KW - Cognitive Dysfunction KW - Dementia KW - Risk Factors AB -

BACKGROUND: Few studies using rigorous clinical diagnosis have considered whether associations with cognitive decline are potentiated by interactions between genetic and modifiable risk factors. Given the increasing burden of cognitive impairment (CI) and dementia, we assessed whether Apolipoprotein E ε4 (APOE4) genotype status modifies the association between incident CI and key modifiable risk factors .

METHODS: Older adults (70+) in the US were included. APOE4 status was genotyped. Risk factors for CI were self-reported. Cognitive status (normal, CI, or dementia) was assigned by clinical consensus panel. In eight separate Cox proportional hazard models, we assessed for interactions between APOE4 status and other CI risk factors.

RESULT: The analytical sample included 181 participants (mean age 77.7 years; 45.9% male). APOE4 was independently associated with a greater hazard of CI in each model (Hazard Ratios [HR] between 1.81-2.66, p < 0.05) except the model evaluating educational attainment (HR 1.65, p = 0.40). The joint effects of APOE4 and high school education or less (HR 2.25, 95% CI: 1.40-3.60, p < 0.001), hypertension (HR 2.46, 95% CI: 1.28-4.73, p = 0.007), elevated depressive symptoms (HR 5.09, 95% CI: 2.59-10.02, p < 0.001), hearing loss (HR 3.44, 95% CI: 1.87-6.33, p < 0.0001), vision impairment (HR 5.14, 95% CI: 2.31-11.43, p < 0.001), smoking (HR 2.35, 95% CI: 1.24-4.47, p = 0.009), or obesity (HR 3.80, 95% CI: 2.11-6.85, p < 0.001) were associated with the hazard of incident CIND (compared to no genetic or modifiable risk factor) in separate models. The joint effect of Apolipoprotein ε4 and type 2 diabetes was not associated with CIND (HR 1.58, 95% CI: 0.67-2.48, p = 0.44).

DISCUSSION: The combination of APOE4 and selected modifiable risk factors conveys a stronger association with incident CI than either type of risk factor alone.

VL - 22 IS - 1 ER - TY - JOUR T1 - MODE EFFECTS ON COGNITIVE FUNCTIONING ASSESSMENTS IN THE HEALTH AND RETIREMENT STUDY JF - Innovation in Aging Y1 - 2022 A1 - Jessica Faul A1 - Domingue, Ben A1 - Stenhaug, Ben A1 - Brady T. West A1 - Kenneth M. Langa A1 - David R Weir KW - Cognition KW - cognitive functioning assessments AB - As the population of the US ages, there is interest in assessing health conditions associated with age and longevity, such as age-related decline in cognitive functioning. As a result, there is an increased focus on measuring cognitive functioning in surveys of older populations. One challenge relates to conducting comparable measurement across survey modes (e.g., phone vs. web). Compounding this is that mode of survey administration is often not assigned randomly making inter-group comparison more difficult. This paper addresses these issues using a novel experiment embedded within the Health and Retirement Study (HRS). The HRS, a US-based cohort of people over 50, has measured cognition since its inception using both in-person and telephone modes. In 2018, a sample of approximately 3700 respondents was identified as web-eligible based on a prior report of internet access along with other selection criteria. Of these, 60% were randomly selected for the web sample with the remainder serving as controls, assigned to telephone mode for comparison purposes. We deploy techniques from item response theory (IRT) and differential item functioning (DIF) to estimate the difference in cognitive functioning between web and phone respondents in 2018 based on longitudinal cognition data collected prior to 2018. Second, we estimate the overall effect of taking the survey via the web as compared to the phone. Third, we examine item-level variation in the magnitude of the mode effect and suggest possible methods for adjustment to support longitudinal consistency. These results are important in guiding future research that utilizes web-based cognitive measures. VL - 6 IS - Suppl 1 ER - TY - JOUR T1 - Time to dementia diagnosis by race: a retrospective cohort study. JF - Journal of the American Geriatrics Society Y1 - 2022 A1 - Davis, Matthew A A1 - Lee, Kathryn A A1 - Harris, Melissa A1 - Ha, Jinkyung A1 - Kenneth M. Langa A1 - Bynum, Julie P W A1 - Hoffman, Geoffrey J KW - Dementia KW - Diagnosis KW - Disparities KW - Medicare KW - race AB -

BACKGROUND: Non-Hispanic Black individuals may be less likely to receive a diagnosis of dementia compared to non-Hispanic White individuals. These findings raise important questions regarding which factors may explain this observed association and any differences in the time to which disparities emerge following dementia onset.

METHODS: We conducted a retrospective cohort study using survey data from the 1995 to 2016 Health and Retirement Study linked with Medicare fee-for-service claims. Using the Hurd algorithm (a regression-based approach), we identified dementia onset among older adult respondents (age ≥65 years) from the Telephone Interview for Cognitive Status and proxy respondents. We determined date from dementia onset to diagnosis using Medicare data up to 3 years following onset using a list of established diagnosis codes. Cox Proportional Hazards modeling was used to examine the association between an individual's reported race and likelihood of diagnosis after accounting for sociodemographic characteristics, income, education, functional status, and healthcare use.

RESULTS: We identified 3435 older adults who experienced a new onset of dementia. Among them, 30.1% received a diagnosis within 36 months of onset. In unadjusted analyses, the difference in cumulative proportion diagnosed by race continued to increase across time following onset, p-value <0.001. 23.8% of non-Hispanic Black versus 31.4% of non-Hispanic White participants were diagnosed within 36 months of dementia onset, Hazard Ratio = 0.73 (95% CI: 0.61, 0.88). The association persisted after adjustment for functional status and healthcare use; however, these factors had less of an impact on the strength of the association than income and level of education.

CONCLUSION: Lower diagnosis rates of dementia among non-Hispanic Black individuals persists after adjustment for sociodemographic characteristics, functional status, and healthcare use. Further understanding of barriers to diagnosis that may be related to social determinants of health is needed to improve dementia-related outcomes among non-Hispanic Black Americans.

ER - TY - JOUR T1 - Validation of Claims Algorithms to Identify Alzheimer's Disease and Related Dementias. JF - The Journals of Gerontology, Series A Y1 - 2022 A1 - Ellen P McCarthy A1 - Chang, Chiang-Hua A1 - Tilton, Nicholas A1 - Mohammed U Kabeto A1 - Kenneth M. Langa A1 - Julie P W Bynum KW - Accuracy KW - algorithm KW - Dementia KW - Diagnosis KW - Medicare AB -

BACKGROUND: Using billing data generated through healthcare delivery to identify individuals with dementia has become important in research. To inform tradeoffs between approaches, we tested the validity of different Medicare claims-based algorithms.

METHODS: We included 5,784 Medicare-enrolled, Health and Retirement Study participants aged >65 years in 2012 clinically assessed for cognitive status over multiple waves and determined performance characteristics of different claims-based algorithms.

RESULTS: Positive predictive value (PPV) of claims ranged from 53.8-70.3% and was highest using a revised algorithm and 1-year of observation. The trade-off of greater PPV was lower sensitivity; sensitivity could be maximized using 3-years of observation. All algorithms had low sensitivity (31.3-56.8%) and high specificity (92.3-98.0%). Algorithm test performance varied by participant characteristics, including age and race.

CONCLUSIONS: Revised algorithms for dementia diagnosis using Medicare administrative data have reasonable accuracy for research purposes, but investigators should be cognizant of the trade-offs in accuracy among the approaches they consider.

VL - 77 IS - 6 ER - TY - CONF T1 - Associations of Long-term Air Pollution Exposure and Incident Late-Life Disability in Older U.S. Adults: The Health Retirement Study T2 - ISEE Conference Abstracts Y1 - 2021 A1 - Gao, Jiaqi A1 - Carlos F. Mendes de Leon A1 - D'Souza, Jennifer A1 - Zhang, Boya A1 - Szpiro, Adam A1 - Young, Michael A1 - Weuve, Jennifer A1 - Kenneth M. Langa A1 - Jessica Faul A1 - Kaufman, Joel A1 - Richard A Hirth A1 - Sara Dubowsky Adar KW - Activities of Daily Living KW - Air Pollution KW - Long-Term Exposure AB - Late-life disability is of critical concern to older adults and can reflect the cumulative burden of chronic disease over the lifespan. Although air pollution has been associated with many common chronic conditions, associations with disability are understudied. We aimed to quantify associations between long-term exposures to air pollution and late-life disability. METHODS: We used biennial data between 2000 and 2016 on self-reported Activities of Daily Living (ADL) from participants 65 years from the nationally representative Health and Retirement Study. Using a spatiotemporal prediction model, we estimated 10-year PM2.5, PM10-2.5, NO2, and O3 concentrations at participant residences. We then estimated the risk of incident ADL disability as a function of time-varying air pollution, adjusting for individual and area-level confounders and sampling weights in a Cox model. We fitted single- and two-pollutant models. RESULTS:Our study population of 16,927 adults (70+6.4 years) was predominantly non-Hispanic White (76%), Non-Hispanic Black (14%), and Hispanic White (8%) and 32% reported a new disability during follow-up. Overall, we found some evidence that air pollution was associated with an increased risk of ADL disability. After adjustment for place and PM2.5, we found that interquartile increases in PM10-2.5 and NO2 were associated with 8% (HR: 1.08 per 5 µg/m3, 95% CI: 1.01, 1.17) and 9% (HR: 1.09 per 6 ppb, 95% CI: 1.00, 1.19) greater hazards of ADL, respectively, with similar findings in the single pollutant models. PM2.5 and O3 were not associated with higher hazards of ADL in single or multipollutant models after detailed adjustment for place. CONCLUSIONS:This prospective study in a nationally representative sample of older adults found some evidence that higher levels of some but not all long-term air pollutants assessed are associated with increased risk of late-life disability. JF - ISEE Conference Abstracts VL - 2021 UR - https://ehp.niehs.nih.gov/action/doSearch?AllField=Associations+of+Long-term+Air+Pollution+Exposure+and+Incident+Late-Life+Disability+in+Older+U.S.+Adults%3A+The+Health+Retirement+Study IS - 1 ER - TY - JOUR T1 - Changes in Health Care Access and Utilization for Low-SES Adults Age 51-64 after Medicaid Expansion. JF - The Journal of Gerontology: Series B Y1 - 2021 A1 - Tipirneni, Renuka A1 - Helen G Levy A1 - Kenneth M. Langa A1 - Ryan J McCammon A1 - Zivin, Kara A1 - Jamie E Luster A1 - Karmakar, Monita A1 - John Z. Ayanian KW - Affordable Care Act KW - Hospitalization KW - Medicaid KW - Retirement AB -

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.

VL - 76 IS - 6 ER - TY - JOUR T1 - Cumulative Genetic Risk and APOE ε4 Are Independently Associated With Dementia Status in a Multiethnic, Population-Based Cohort JF - Neurology Genetics Y1 - 2021 A1 - Kelly M Bakulski A1 - Vadari, Harita S A1 - Jessica Faul A1 - Steven G Heeringa A1 - Sharon L R Kardia A1 - Kenneth M. Langa A1 - Jennifer A. Smith A1 - Jennifer J Manly A1 - Colter Mitchell A1 - Benke, Kelly S A1 - Erin B Ware KW - Aging KW - Alzheimer disease KW - Cognition KW - genetic risk AB -

Objective: Alzheimer disease (AD) is a common and costly neurodegenerative disorder. A large proportion of AD risk is heritable, and many genetic risk factors have been identified. The objective of this study was to test the hypothesis that cumulative genetic risk of known AD markers contributed to odds of dementia in a population-based sample.

Methods: In the US population-based Health and Retirement Study (waves 1995-2014), we evaluated the role of cumulative genetic risk of AD, with and without the alleles, on dementia status (dementia, cognitive impairment without dementia, borderline cognitive impairment without dementia, and cognitively normal). We used logistic regression, accounting for demographic covariates and genetic principal components, and analyses were stratified by European and African genetic ancestry.

Results: In the European ancestry sample (n = 8,399), both AD polygenic score excluding the genetic region (odds ratio [OR] = 1.10; 95% confidence interval [CI]: 1.00-1.20) and the presence of any alleles (OR = 2.42; 95% CI: 1.99-2.95) were associated with the odds of dementia relative to normal cognition in a mutually adjusted model. In the African ancestry sample (n = 1,605), the presence of any alleles was associated with 1.77 (95% CI: 1.20-2.61) times higher odds of dementia, whereas the AD polygenic score excluding the genetic region was not significantly associated with the odds of dementia relative to normal cognition 1.06 (95% CI: 0.97-1.30).

Conclusions: Cumulative genetic risk of AD and are both independent predictors of dementia in European ancestry. This study provides important insight into the polygenic nature of dementia and demonstrates the utility of polygenic scores in dementia research.

VL - 7 IS - 2 ER - TY - JOUR T1 - Development, Validation, and Performance of a New Physical Functioning–Weighted Multimorbidity Index for Use in Administrative Data JF - Journal of General Internal Medicine Y1 - 2021 A1 - Melissa Y Wei A1 - Jamie E Luster A1 - Ratz, David A1 - Kenneth J Mukamal A1 - Kenneth M. Langa KW - Medicaid KW - Medicare KW - multimorbidity index KW - physical functioning VL - 36 ER - TY - JOUR T1 - Development, Validation, and Performance of a New Physical Functioning-Weighted Multimorbidity Index for Use in Administrative Data. JF - Journal of General Internal Medicine Y1 - 2021 A1 - Wei, Melissa Y A1 - Luster, Jamie E A1 - Ratz, David A1 - Mukamal, Kenneth J A1 - Kenneth M. Langa KW - Activities of Daily Living KW - multimorbidity VL - 36 IS - 8 ER - TY - JOUR T1 - Does it Matter Who Decides? Outcomes of Surrogate Decision-Making for Community-Dwelling, Cognitively Impaired Older Adults Near the End of Life. JF - Journal of Pain and Symptom Management Y1 - 2021 A1 - Micah Y. Baum A1 - Gallo, Joseph J A1 - Nolan, Marie T A1 - Kenneth M. Langa A1 - Halpern, Scott D A1 - Macis, Mario A1 - Lauren Hersch Nicholas KW - end-of-life decisions KW - Family KW - surrogate decision-making AB -

CONTEXT: Cognitively impaired older adults frequently need surrogate decision-making near the end-of-life. It is unknown whether differences in the surrogate's relationship to the decedent are associated with different end-of-life treatment choices.

OBJECTIVES: To describe differences in end-of-life care for community dwelling, cognitively impaired older adults when children and spouses are involved in decision-making.

METHODS: Retrospective observational study.

RESULTS: Among 742 community-dwelling adults with cognitive impairment (mild cognitive impairment or dementia) prior to death, children participated in end-of-life decisions for 615 patients (83%) and spouses participated in decisions for 258 patients (35%), with both children and spouses participating for 131 patients (18%). When controlling for demographic characteristics, decedents with only a spouse decision-maker were less likely to undergo a life-sustaining treatment than decedents with only children decision-makers (P < 0.05). There was no difference in the probability of in-hospital death or burdensome transfers across facilities across decedent-decision-maker relationships. Differences in rates of life-sustaining treatment were greater when we restricted to decedents with dementia.

CONCLUSION: Decedents with cognitive impairment or dementia were less likely to receive life-sustaining treatments when spouses versus children were involved with end-of-life treatment decisions but were no less likely to experience other measures of potentially burdensome end-of-life care.

VL - 62 IS - 6 ER - TY - JOUR T1 - The Effect of Childhood Socioeconomic Position and Social Mobility on Cognitive Function and Change Among Older Adults: A Comparison Between the United States and England. JF - The Journals of Gerontology: Series B Y1 - 2021 A1 - Jessica Faul A1 - Erin B Ware A1 - Mohammed U Kabeto A1 - Fisher, Jonah A1 - Kenneth M. Langa KW - Cognition KW - Cross-national comparison KW - Early origins of health KW - Education KW - ELSA KW - Life course analysis AB -

OBJECTIVES: This study aims to examine the relationship between childhood socioeconomic position (SEP) and cognitive function in later life within nationally representative samples of older adults in the United States and England, investigate whether these effects are mediated by later-life SEP, and determine whether social mobility from childhood to adulthood affects cognitive function and decline.

METHOD: Using data from the Health and Retirement Study (HRS) and the English Longitudinal Survey of Ageing (ELSA), we examined the relationships between measures of SEP, cognitive performance and decline using individual growth curve models.

RESULTS: High childhood SEP was associated with higher cognitive performance at baseline in both cohorts and did not affect the rate of decline. This benefit dissipated after adjusting for education and adult wealth in the United States. Respondents with low childhood SEP, above median education, and high adult SEP had better cognitive performance at baseline than respondents with a similar childhood background and less upward mobility in both countries.

DISCUSSION: These findings emphasize the impact of childhood SEP on cognitive trajectories among older adults. Upward mobility may partially compensate for disadvantage early in life but does not protect against cognitive decline.

VL - 76 IS - Supplement_1 ER - TY - JOUR T1 - Family Care Availability And Implications For Informal And Formal Care Used By Adults With Dementia In The US. JF - Health Affairs Y1 - 2021 A1 - Choi, Hwajung A1 - Michele M Heisler A1 - Edward C Norton A1 - Kenneth M. Langa A1 - Cho, Tsai-Chin A1 - Cathleen M. Connell KW - Dementia KW - family caregivers KW - formal care KW - Informal care AB -

Despite the important role that family members can play in dementia care, little is known about the association between the availability of family members and the type of care, informal (unpaid) or formal (paid), that is actually delivered to older adults with dementia in the US. Using data about older adults with dementia from the Health and Retirement Study, we found significantly lower spousal availability but greater adult child availability among women versus men, non-Hispanic Blacks versus non-Hispanic Whites, and people with lower versus higher socioeconomic status. Adults with dementia and disability who have greater family availability were significantly more likely to receive informal care and less likely to use formal care. In particular, the predicted probability of a community-dwelling adult moving to a nursing home during the subsequent two years was substantially lower for those who had a co-resident adult child (11 percent) compared with those who did not have a co-resident adult child but had at least one adult child living close (20 percent) and with those who have all children living far (23 percent). Health care policies on dementia should consider potential family availability in predicting the type of care that people with dementia will use and the potential disparities in consequences for them and their families.

VL - 40 IS - 9 ER - TY - JOUR T1 - Identifying cohabiting couples in administrative data: evidence from Medicare address data JF - Health Services and Outcomes Research Methodology Y1 - 2021 A1 - Matta, Sasmira A1 - Joanne W. Hsu A1 - Theodore J Iwashyna A1 - Micah Y. Baum A1 - Kenneth M. Langa A1 - Lauren Hersch Nicholas KW - Cohabitation KW - Couples KW - Marriage KW - Medicare AB - Marital status is recognized as an important social determinant of health, income, and social support, but is rarely available in administrative data. We assessed the feasibility of using exact address data and zip code history to identify cohabiting couples using the 2018 Medicare Vital Status file and ZIP codes in the 2011–2014 Master Beneficiary Summary Files. Medicare beneficiaries meeting our algorithm displayed characteristics consistent with assortative mating and resembled known married couples in the Health and Retirement Study linked to Medicare claims. Address information represents a promising strategy for identifying cohabiting couples in administrative data including healthcare claims and other data types. VL - 21 SN - 1572-9400 IS - 2 ER - TY - JOUR T1 - The Longitudinal Association of Vision Impairment with Transitions to Cognitive Impairment and Dementia: Findings from The Aging, Demographics and Memory Study. JF - The Journals of Gerontology - Series A Y1 - 2021 A1 - Joshua R Ehrlich A1 - Bonnielin K Swenor A1 - Zhou, Yunshu A1 - Kenneth M. Langa KW - blindness KW - cognitive transitions KW - Epidemiology AB -

BACKGROUND: Vision impairment (VI) is associated with incident cognitive decline and dementia. However, it is not known whether VI is associated only with the transition to cognitive impairment, or whether it is also associated with later transitions to dementia.

METHODS: We used data from the population-based Aging, Demographics and Memory Study (ADAMS) to investigate the association of visual acuity impairment (VI; defined as binocular presenting visual acuity <20/40) with transitions from cognitively normal (CN) to cognitive impairment no dementia (CIND) and from CIND to dementia. Multivariable Cox proportional hazards models and logistic regression were used to model the association of VI with cognitive transitions, adjusted for covariates.

RESULTS: There were 351 participants included in this study (weighted percentages: 45% male, 64% age 70-79 years) with a mean follow-up time of 4.1 years. In a multivariable model, the hazard of dementia was elevated among those with VI (HR=1.63, 95%CI=1.04-2.58). Participants with VI had a greater hazard of transitioning from CN to CIND (HR=1.86, 95%CI=1.09-3.18). However, among those with CIND and VI a similar percentage transitioned to dementia (48%) and remained CIND (52%); there was no significant association between VI and transitioning from CIND to dementia (HR=0.94, 95%CI=0.56-1.55). Using logistic regression models, the same associations between VI and cognitive transitions were identified.

CONCLUSIONS: Poor vision is associated with the development of CIND. The association of VI and dementia appears to be due to the higher risk of dementia among individuals with CIND. Findings may inform the design of future interventional studies.

VL - 76 IS - 12 ER - TY - JOUR T1 - Same-Sex Couples and Cognitive Impairment: Evidence from the Health and Retirement Study. JF - The Journals of Gerontology: Series B Y1 - 2021 A1 - Hui Liu A1 - Hsieh, Ning A1 - Zhang, Zhenmei A1 - Zhang, Yan A1 - Kenneth M. Langa KW - cognitive impairment KW - gender KW - Marital Status KW - same-sex couples KW - sexual minorities AB -

OBJECTIVES: We provide the first nationally representative population-based study of cognitive disparities among same-sex and different-sex couples in the United States.

METHOD: We analyzed data from the Health and Retirement Study (2000-2016). The sample included 23,669 respondents (196 same-sex partners and 23,473 different-sex partners) aged 50 and older who contributed to 85,117 person-period records (496 from same-sex partners and 84,621 from different-sex partners). Cognitive impairment was assessed using the modified version of the Telephone Interview for Cognitive Status (TICS). Mixed-effects discrete-time hazard regression models were estimated to predict the odds of cognitive impairment.

RESULTS: The estimated odds of cognitive impairment were 78% (p < .01) higher for same-sex partners than for different-sex partners. This disparity was mainly explained by differences in marital status and, to a much lesser extent, by differences in physical and mental health. Specifically, a significantly higher proportion of same-sex partners than different-sex partners were cohabiting rather than legally married (72.98% vs. 5.42% in the study sample), and cohabitors had a significantly higher risk of cognitive impairment than their married counterparts (OR = 1.53, p < .001).

DISCUSSION: The findings indicate that designing and implementing public policies and programs that work to eliminate societal homophobia, especially among older adults, is a critical step in reducing the elevated risk of cognitive impairment among older same-sex couples.

VL - 76 IS - 7 ER - TY - JOUR T1 - Subtle mistakes in self-report surveys predict future transition to dementia JF - Alzheimer's & Dementia: Diagnosis, Assessment & Disease Monitoring Y1 - 2021 A1 - Stefan Schneider A1 - Junghaenel, Doerte U. A1 - Elizabeth Zelinski A1 - Erik Meijer A1 - Arthur A. Stone A1 - Kenneth M. Langa A1 - Arie Kapteyn KW - cognitive impairment KW - Dementia KW - early detection KW - Epidemiology KW - functional abilities KW - self-report surveys AB - Introduction We investigate whether indices of subtle reporting mistakes derived from responses in self-report surveys are associated with dementia risk. Methods We examined 13,831 participants without dementia from the prospective, population-based Health and Retirement Study (mean age 69 ± 10 years, 59% women). Participants’ response patterns in 21 questionnaires were analyzed to identify implausible responses (multivariate outliers), incompatible responses (Guttman errors), acquiescent responses, random errors, and the proportion of skipped questions. Subsequent incident dementia was determined over up to 10 years of follow-up. Results During follow-up, 2074 participants developed dementia and 3717 died. Each of the survey response indices was associated with future dementia risk controlling for confounders and accounting for death as a competing risk. Stronger associations were evident for participants who were younger and cognitively normal at baseline. Discussion Mistakes in the completion of self-report surveys in longitudinal studies may be early indicators of dementia among middle-aged and older adults. VL - 13 ER - TY - JOUR T1 - Caregiving, recovery, and death after incident ADL/IADL disability among older adults in the United States JF - Journal of Applied Gerontology Y1 - 2020 A1 - Claire K. Ankuda A1 - Deborah A Levine A1 - Kenneth M. Langa A1 - Katherine A Ornstein A1 - Amy Kelley KW - Activities of Daily Living KW - Caregiving KW - Disabilities AB - This study assesses patterns of caregiving, death, and recovery after incident disability in older adults. We used the Health and Retirement Study to follow of a cohort of adults age ≥65 years in the United States with incident disability in activities of daily living (ADLs) or instrumental activities of daily living (IADLs; n = 8,713). Rates of care and function state were assessed biennially: deceased, nursing home dwelling, at home with paid help, at home with both paid and unpaid help, at home with unpaid help, at home with no assistance and recovered. In the 2 years after incident disability, 22.1% recovered and 46.8% died. Transitions between care and function states occurred frequently, with more than 20% of the cohort living at home with no assistance despite disability at least once. This study demonstrates the high levels of care and function state fluctuation and unmet needs after functional disability. VL - 39 UR - https://journals.sagepub.com/doi/10.1177/0733464819826842 IS - 4 JO - J Appl Gerontol ER - TY - JOUR T1 - Comparison of Health Outcomes Among High- and Low-Income Adults Aged 55 to 64 Years in the US vs England JF - JAMA Intern Med Y1 - 2020 A1 - Choi, Hwajung A1 - Andrew Steptoe A1 - Michele M Heisler A1 - Philippa J Clarke A1 - Robert F. Schoeni A1 - Jivraj, Stephen A1 - Cho, Tsai-Chin A1 - Kenneth M. Langa KW - Demographics KW - ELSA KW - Income KW - socioeconomic status AB - Socioeconomic differences in life expectancy, health, and disability have been found in European countries as well as in the US. Identifying the extent and pattern of health disparities, both within and across the US and England, may be important for informing public health and public policy aimed at reducing these disparities.To compare the health of US adults aged 55 to 64 years with the health of their peers in England across the high and low ranges of income in each country.Using data from the Health and Retirement Study (HRS) and the English Longitudinal Study of Ageing (ELSA) for 2008-2016, a pooled cross-sectional analysis of comparably measured health outcomes, with adjustment for demographic characteristics and socioeconomic status, was conducted. The analysis sample included community-dwelling adults aged 55 to 64 years from the HRS and ELSA, resulting in 46 887 person-years of observations. Data analysis was conducted from September 17, 2019, to May 12, 2020.Residence in the US or England and yearly income.Sixteen health outcomes were compared, including 5 self-assessed outcomes, 3 directly measured outcomes, and 8 self-reported physician-diagnosed health conditions.This cross-sectional study included 12 879 individuals and 31 928 person-years from HRS (mean [SD] age, 59.2 [2.8] years; 51.9% women) and 5693 individuals and 14 959 person-years from ELSA (mean [SD] age, 59.3 [2.9] years; 51.0% women). After adjusting for individual-level demographic characteristics and socioeconomic status, a substantial health gap between lower-income and higher-income adults was found in both countries, but the health gap between the bottom 20% and the top 20% of the income distribution was significantly greater in the US than England on 13 of 16 measures. The adjusted US-England difference in the prevalence gap between the bottom 20% and the top 20% ranged from 3.6 percentage points (95% CI, 2.0-5.2 percentage points) in stroke to 9.7 percentage points (95% CI, 5.4-13.9 percentage points) for functional limitation. Among individuals in the lowest income group in each country, those in the US group vs the England group had significantly worse outcomes on many health measures (10 of 16 outcomes in the bottom income decile); the significant differences in adjusted prevalence of health problems in the US vs England for the bottom income decile ranged from 7.6% (95% CI, 6.0%-9.3%) vs 3.8% (95% CI, 2.6%-4.9%) for stroke to 75.7% (95% CI, 72.7%-78.8%) vs 59.5% (95% CI, 56.3%-62.7%) for functional limitation. Among individuals in the highest income group, those in the US group vs England group had worse outcomes on fewer health measures (4 of 16 outcomes in the top income decile); the significant differences in adjusted prevalence of health problems in the US vs England for the top income decile ranged from 36.9% (95% CI, 33.4%-40.4%) vs 30.0% (95% CI, 27.2%-32.7%) for hypertension to 35.4% (95% CI, 32.0%-38.7%) vs 22.5% (95% CI, 19.9%-25.1%) for arthritis.For most health outcomes examined in this cross-sectional study, the health gap between adults with low vs high income appeared to be larger in the US than in England, and the health disadvantages in the US compared with England are apparently more pronounced among individuals with low income. Public policy and public health interventions aimed at improving the health of adults with lower income should be a priority in the US. SN - 2168-6106 ER - TY - JOUR T1 - The Health and Retirement Study Harmonized Cognitive Assessment Protocol Project: Study Design and Methods JF - Neuroepidemiology Y1 - 2020 A1 - Kenneth M. Langa A1 - Lindsay H Ryan A1 - Ryan J McCammon A1 - Richard N Jones A1 - Jennifer J Manly A1 - Deborah A Levine A1 - Amanda Sonnega A1 - Farron, M. A1 - David R Weir KW - Cognition KW - cognitive assessment KW - study design AB - 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. SN - 0251-5350 ER - TY - JOUR T1 - Marital status and dementia: Evidence from the Health and Retirement Study. JF - Journals of Gerontology. Series B, Psychological Sciences and Social Sciences Y1 - 2020 A1 - Hui Liu A1 - Zhang, Zhenmei A1 - Kenneth M. Langa KW - Cognitive Ability KW - Dementia KW - Marriage AB -

OBJECTIVES: We provide one of the first population-based studies of variation in dementia by marital status in the U.S.

METHOD: We analyzed data from the Health and Retirement Study (2000-2014). The sample included 15,379 respondents (6,650 men and 8,729 women) age 52 and over in 2000 who showed no evidence of dementia at the baseline survey. Dementia was assessed using either the modified version of the Telephone Interview for Cognitive Status (TICS) or the proxy's assessment. Discrete-time hazard regression models were estimated to predict odds of dementia.

RESULTS: All unmarried groups, including the cohabiting, divorced/separated, widowed, and never married, had significantly higher odds of developing dementia over the study period than their married counterparts; economic resources and, to a lesser degree, health-related factors accounted for only part of the marital status variation in dementia. For divorced/separated and widowed respondents, the differences in the odds of dementia relative to married respondents were greater among men than among women.

DISCUSSION: These findings will be helpful for health policy makers and practitioners who seek to better identify vulnerable subpopulations and to design effective intervention strategies to reduce dementia risk.

ER - TY - JOUR T1 - Methods and Early Recruitment of a Community-Based Study of Cognitive Impairment Among Mexican Americans and Non-Hispanic Whites: The BASIC-Cognitive Study JF - Journal of Alzheimer's Disease Y1 - 2020 A1 - Emily Briceño A1 - Mehdipanah, Roshanak A1 - Gonzales, Xavier A1 - Steven G Heeringa A1 - Deborah A Levine A1 - Kenneth M. Langa A1 - Garcia, Nelda A1 - Longoria, Ruth A1 - Lewis B Morgenstern KW - Caregivers KW - Dementia KW - Epidemiology KW - Health Resources KW - mexican american KW - mild cognitive impairment AB - Background: As the Mexican American (MA) population grows and ages, there is an urgent need to estimate the prevalence of cognitive impairment or dementia (CID), cognitive trajectories, and identify community resource needs. The Brain Attack Surveillance in Corpus Christi (BASIC)-Cognitive project is a population-based study to address these issues among older MAs and non-Hispanic whites (NHW) and their informal care providers. Objective: Present the methodology and initial recruitment findings for the BASIC-Cognitive project. Method: Random, door-to-door case ascertainment is used in Nueces County, Texas, to recruit community-dwelling and nursing home residents ≥65 and informal care providers. Households are identified from a two-stage area probability sample, using Census data to aim for equal balance of MAs and NHWs. Individuals with cognitive screens indicative of possible CID complete neuropsychological assessment (Harmonized Cognitive Assessment Protocol from the Health and Retirement Study). Informal care providers complete comprehensive interview and needs assessment. Study pairs repeat procedures at 2-year follow-up. Asset and concept mapping are performed to identify community resources and study care providers’ perceptions of needs for individuals with CID. Results: 1,030 age-eligible households were identified, or 27% of households for whom age could be determined. 1,320 individuals were age-eligible, corresponding to 1.3 adults per eligible household. Initial recruitment yielded robust participation in the MA eligible population (60% of 689 individuals that completed cognitive screening). Conclusion: The BASIC-Cognitive study will provide critical information regarding the prevalence of CID in MAs, the impact of caregiving, and allocation of community resources to meet the needs of this population. VL - 73 SN - 1875-8908 UR - https://content.iospress.com/articles/journal-of-alzheimers-disease/jad190761 IS - 1 ER - TY - JOUR T1 - Mild cognitive impairment and receipt of procedures for acute ischemic stroke in older adults JF - Journal of Stroke and Cerebrovascular Diseases Y1 - 2020 A1 - Deborah A Levine A1 - Andrzej T Galecki A1 - Mohammed U Kabeto A1 - Nallamothu, Brahmajee K. A1 - Zahuranec, Darin B. A1 - Lewis B Morgenstern A1 - Lynda D Lisabeth A1 - Bruno J Giordani A1 - Kenneth M. Langa KW - Aging KW - cognitive impairment KW - Health policy/outcomes research KW - Ischemic stroke AB - Background and purpose Older patients with pre-existing mild cognitive impairment (MCI) receive less evidence-based care after acute myocardial infarction, however, whether they receive less care after acute ischemic stroke (AIS) is unknown. We compared receipt of guideline-concordant procedures after AIS between older adults with pre-existing MCI and normal cognition. Methods Prospective study of 591 adults ≥65 hospitalized for AIS between 2000 and 2014, and followed through 2015 using data from the nationally representative Health and Retirement Study, Medicare and American Hospital Association. We assessed pre-existing MCI (modified Telephone Interview for Cognitive Status score of 7–11) and normal cognition (score of 12–27). Primary outcome was a composite quality measure representing the number of 4 procedures (carotid imaging, cardiac monitoring, echocardiogram, and rehabilitation assessment) received within 30 days after AIS (ordinal scale with values of 0, 1, 2, 3–4). Results Among survivors of AIS, 26.9% had pre-existing MCI (62.9% were women, with a mean [SD] age of 82.4 [7.7] years), and 73.1% had normal cognition (51.4% were women, with a mean age of 78.4 [7.2] years). Patients with pre-existing MCI, compared to cognitively normal patients, had 39% lower cumulative odds of receiving the composite quality measure (unadjusted cumulative odds ratio, OR, 0.61 [95% CI, 0.43–0.87]; P=0.006). However, this association became non-significant after adjusting for patient and hospital factors (adjusted cumulative OR, 0.83 [95% CI, 0.56–1.24]; P=0.37). Lower cumulative odds of receiving the composite quality measure were associated with older patient age (adjusted cumulative OR per 1-year older age, 0.97 [95% CI, 0.95–0.99]; P=0.01) and Southern hospitals (adjusted cumulative OR for South vs North, 0.54 [95% CI, 0.31–0.94]; P=0.03). Conclusions Differences in receipt of guideline-concordant procedures after AIS exist between patients with pre-existing MCI and normal cognition. These differences were largely explained by patient and regional factors associated with receiving less AIS care. VL - 29 SN - 1052-3057 IS - 10 ER - TY - JOUR T1 - Mild Cognitive Impairment and Receipt of Treatments for Acute Myocardial Infarction in Older Adults JF - Journal of General Internal Medicine Y1 - 2020 A1 - Deborah A Levine A1 - Kenneth M. Langa A1 - Andrzej T Galecki A1 - Mohammed U Kabeto A1 - Lewis B Morgenstern A1 - Zahuranec, Darin B. A1 - Bruno J Giordani A1 - Lynda D Lisabeth A1 - Nallamothu, Brahmajee K. KW - Cognitive Ability KW - Heart disease KW - Medicare/Medicaid/Health Insurance AB - Background Older adults with mild cognitive impairment (MCI) should receive evidence-based treatments when indicated. Providers and patients may overestimate the risk of dementia in patients with MCI leading to potential under-treatment. However, the association between pre-existing MCI and receipt of evidence-based treatments is uncertain. Objective To compare receipt of treatments for acute myocardial infarction (AMI) between older adults with pre-existing MCI and cognitively normal patients. Design Prospective study using data from the nationally representative Health and Retirement Study, Medicare, and American Hospital Association. Participants Six hundred nine adults aged 65 or older hospitalized for AMI between 2000 and 2011 and followed through 2012 with pre-existing MCI (defined as modified Telephone Interview for Cognitive Status score of 7–11) and normal cognition (score of 12–27). Main Measures Receipt of cardiac catheterization and coronary revascularization within 30 days and cardiac rehabilitation within 1 year of AMI hospitalization. Key Results Among the survivors of AMI, 19.2% had pre-existing MCI (55.6% were women and 44.4% were male, with a mean [SD] age of 82.3 [7.5] years), and 80.8% had normal cognition (45.7% were women and 54.3% were male, with a mean age of 77.1 [7.1] years). Survivors of AMI with pre-existing MCI were significantly less likely than those with normal cognition to receive cardiac catheterization (50% vs 77%; P < 0.001), coronary revascularization (29% vs 63%; P < 0.001), and cardiac rehabilitation (9% vs 22%; P = 0.001) after AMI. After adjusting for patient and hospital factors, pre-existing MCI remained associated with lower use of cardiac catheterization (adjusted hazard ratio (aHR), 0.65; 95% CI, 0.48–0.89; P = 0.007) and coronary revascularization (aHR, 0.55; 95% CI, 0.37–0.81; P = .003), but not cardiac rehabilitation (aHR, 1.01; 95% CI, 0.49–2.07; P = 0.98). Conclusions Pre-existing MCI is associated with lower use of cardiac catheterization and coronary revascularization but not cardiac rehabilitation after AMI. VL - 35 UR - https://link.springer.com/article/10.1007%2Fs11606-019-05155-8#citeas JO - J GEN INTERN MED ER - TY - JOUR T1 - Multimorbidity and cognitive decline over 14 years in older Americans. JF - Journals of Gerontology. Series A, Biological Sciences & Medical Sciences Y1 - 2020 A1 - Melissa Y Wei A1 - Deborah A Levine A1 - Laura B Zahodne A1 - Mohammed U Kabeto A1 - Kenneth M. Langa KW - Cognitive Ability KW - Comorbidity KW - Longitudinal data AB -

BACKGROUND: Multimorbidity is associated with greater disability and accelerated declines in physical functioning over time in older adults. However, less is known about its effect on cognitive decline.

METHODS: Participants without dementia from the Health and Retirement Study were interviewed about physician-diagnosed conditions, from which their multimorbidity-weighted index (MWI) that weights diseases to physical functioning was computed. We used linear mixed-effects models to examine the predictor MWI with the modified Telephone Interview for Cognitive Status (TICSm, global cognition), 10-word immediate recall and delayed recall, and serial 7s outcomes biennially after adjusting for baseline cognition and covariates.

RESULTS: 14,265 participants, 60% female, contributed 73,700 observations. Participants had a meanSD age 679.3 years and MWI 4.43.9 at baseline. Each point increase in MWI was associated with declines in global cognition (0.04, 95%CI: 0.03-0.04 TICSm), immediate recall (0.01, 95%CI: 0.01-0.02 words), delayed recall (0.01, 95%CI: 0.01-0.02 words), and working memory (0.01, 95%CI: 0.01-0.02 serial 7s) (all P<0.001). Multimorbidity was associated with faster declines in global cognition (0.003 points/year faster, 95%CI: 0.002-0.004), immediate recall (0.001 words/year faster, 95%CI: 0.001-0.002), and working memory (0.006 incorrect serial 7s/year faster, 95%CI: 0.004-0.009) (all P<0.001), but not delayed recall compared with premorbid slopes.

CONCLUSIONS: Multimorbidity using a validated index weighted to physical functioning was associated with acute decline in cognition and accelerated and persistent cognitive decline over 14 years. This study supports an ongoing geriatric syndrome of coexisting physical and cognitive impairment in adults with multimorbidity. Clinicians should monitor and address both domains in older multimorbid adults.

U1 - http://www.ncbi.nlm.nih.gov/pubmed/31173065?dopt=Abstract ER - TY - JOUR T1 - Physical and Functional Impairment Among Older Adults With a History of Traumatic Brain Injury. JF - Journal of Head Trauma Rehabilitation Y1 - 2020 A1 - Erica S Kornblith A1 - Kenneth M. Langa A1 - Kristine Yaffe A1 - Raquel C Gardner KW - Brain injury KW - functional impairment KW - physical impairment AB -

OBJECTIVES: To examine the association of lifetime history of traumatic brain injury (TBI) with later-life physical impairment (PI) and functional impairment (FI) and to evaluate the impact of neurobehavioral symptoms that frequently co-occur with TBI on these relations.

PARTICIPANTS: A total of 1148 respondents to the 2014 Wave of the Health and Retirement Study, a nationally representative survey of older community-dwelling adults, randomly selected to participate in a TBI exposure survey. They reported no prior TBI (n = 737) or prior TBI (n = 411).

DESIGN: Cross-sectional survey study.

MAIN MEASURES: Physical impairment (self-reported difficulty with ≥1 of 8 physical activities); FI (self-reported difficulty with ≥1 of 11 activities of daily living); self-reported current neurobehavioral symptoms (pain, sleep problems, depression, subjective memory impairment); The Ohio State University TBI Identification Method (OSU-TBI-ID)-short form.

ANALYSES: Stepwise logistic regression models ([1] unadjusted; [2] adjusted for demographics and medical comorbidities; [3] additionally adjusted for neurobehavioral symptoms) compared PI and FI between TBI groups.

RESULTS: Traumatic brain injury-exposed (mean: 33.6 years postinjury) respondents were younger, less likely to be female, and reported more comorbidities and neurobehavioral symptoms. Although TBI was significantly associated with increased odds of PI and FI in unadjusted models and models adjusted for demographics/comorbidities (adjusted odds ratio, 95% confidence interval: PI 1.62, 1.21-2.17; FI 1.60, 1.20-2.14), this association was no longer statistically significant after further adjustment for neurobehavioral symptoms.

CONCLUSION: History of TBI is associated with substantial PI and FI among community-dwelling older adults. Further research is warranted to determine whether aggressive management of neurobehavioral symptoms in this population may mitigate long-term PI and FI in this population.

VL - 35 IS - 4 ER - TY - JOUR T1 - Prevalence of Lifetime History of Traumatic Brain Injury among Older Male Veterans Compared to Civilians: A Nationally Representative Study JF - Journal of NeurotraumaJournal of Neurotrauma Y1 - 2020 A1 - Erica S Kornblith A1 - Kristine Yaffe A1 - Kenneth M. Langa A1 - Raquel C Gardner KW - Brain Injuries KW - Dementia KW - Traumatic AB - Traumatic brain injury (TBI) is common among older adults as well as among Veterans in the United States and can increase risk for dementia. We compared prevalence of TBI in older male Veterans and civilians using a nationally representative sample. We examined data from 599 male respondents to the 2014 Wave of the Health and Retirement Study (HRS), a nationally representative survey of older adults, randomly selected to participate in a comprehensive TBI survey. Respondents self-reported no injury, non-TBI head/neck injury (NTI), or TBI. We used weighted analyses to examine prevalence of injury and relative risk of injury sub-types. Among male Veterans, we found a national prevalence of over 70% for lifetime history of any head/neck injury (TBI plus NTI), 14.3% for multiple NTI, and 36% for lifetime history of at least one TBI. In contrast, prevalence estimates for male civilians were 58% for lifetime history of head/neck injury, 4.8% for multiple NTI, and 45% for lifetime history of at least one TBI (all comparisons p<0.001). Male civilians have higher self-reported TBI prevalence, while male Veterans have higher self-reported NTI and multiple-NTI prevalence. Further research on drivers of the unexpectedly higher prevalence of lifetime history of TBI in male civilians, as well as on mechanisms and sequelae of the highly prevalent non-TBI head/neck injuries among older male Veterans, is warranted.Traumatic brain injury (TBI) is common among older adults as well as among Veterans in the United States and can increase risk for dementia. We compared prevalence of TBI in older male Veterans and civilians using a nationally representative sample. We examined data from 599 male respondents to the 2014 Wave of the Health and Retirement Study (HRS), a nationally representative survey of older adults, randomly selected to participate in a comprehensive TBI survey. Respondents self-reported no injury, non-TBI head/neck injury (NTI), or TBI. We used weighted analyses to examine prevalence of injury and relative risk of injury sub-types. Among male Veterans, we found a national prevalence of over 70% for lifetime history of any head/neck injury (TBI plus NTI), 14.3% for multiple NTI, and 36% for lifetime history of at least one TBI. In contrast, prevalence estimates for male civilians were 58% for lifetime history of head/neck injury, 4.8% for multiple NTI, and 45% for lifetime history of at least one TBI (all comparisons p<0.001). Male civilians have higher self-reported TBI prevalence, while male Veterans have higher self-reported NTI and multiple-NTI prevalence. Further research on drivers of the unexpectedly higher prevalence of lifetime history of TBI in male civilians, as well as on mechanisms and sequelae of the highly prevalent non-TBI head/neck injuries among older male Veterans, is warranted. SN - 0897-7151 ER - TY - JOUR T1 - The Relationship of Loneliness to End-of-Life Experience in Older Americans: A Cohort Study JF - Journal of the American Geriatrics Society Y1 - 2020 A1 - Nauzley C Abedini A1 - Choi, Hwajung A1 - Melissa Y Wei A1 - Kenneth M. Langa A1 - Vineet Chopra KW - Advance care planning KW - aggressive care KW - end of life KW - Loneliness KW - symptoms AB - OBJECTIVES Little is known about the relationship between loneliness and end-of-life (EOL) experience including symptom burden, intensity of care, and advance care planning among older adults. DESIGN Secondary analysis of the Health and Retirement Study (HRS). SETTING Population based. PARTICIPANTS Decedents older than 50 years who died between 2004 and 2014 (n = 8700). Exclusions included those who were ineligible for surveys assessing loneliness (n = 2932) or had missing or incomplete loneliness or symptom data (n = 2872). MEASUREMENTS Individuals were characterized as lonely based on responses to the three-item Revised University of California, Los Angeles Loneliness Scale in the most recent HRS survey before death. Outcomes were proxy reports of total EOL symptom burden, intensity of EOL care (eg, late hospice enrollment, place of death, hospitalizations, use of life support), and advance care planning. Results were expressed as adjusted odds ratios (aORs) with 95% confidence intervals (CIs). RESULTS One-third of 2896 decedents (n = 942) were lonely. After adjusting for demographics, socioeconomic status, multimorbidity, depressive symptoms, family and friends, and social support, loneliness was independently associated with increased total symptom burden at EOL (ß = .13; P = .004). Compared with nonlonely individuals, lonely decedents were more likely to use life support in the last 2 years of life (35.5% vs 29.4%; aOR = 1.36; 95% CI = 1.08-1.71) and more likely to die in a nursing home (18.4% vs 14.2%; aOR = 1.78; 95% CI = 1.30-2.42). No significant differences in other measures of intense care (late hospice enrollment, number of hospitalizations, or dialysis use) or likelihood of advance care planning were observed. CONCLUSION Lonely older people may be burdened by more symptoms and may be exposed to more intense EOL care compared with nonlonely people. Interventions aiming to screen for, prevent, and mitigate loneliness during the vulnerable EOL period are necessary. J Am Geriatr Soc 68:1064–1071, 2020 VL - 68 UR - https://pubmed.ncbi.nlm.nih.gov/32128789/ IS - 5 ER - TY - JOUR T1 - The Relationship of Loneliness to End-of-Life Experience in Older Americans: A Cohort Study JF - Journal of the American Geriatrics SocietyJournal of the American Geriatrics SocietyJ Am Geriatr Soc Y1 - 2020 A1 - Nauzley C Abedini A1 - Choi, Hwajung A1 - Melissa Y Wei A1 - Kenneth M. Langa A1 - Vineet Chopra KW - Advance care planning KW - aggressive care KW - end of life KW - Loneliness KW - symptoms AB - OBJECTIVES Little is known about the relationship between loneliness and end-of-life (EOL) experience including symptom burden, intensity of care, and advance care planning among older adults. DESIGN Secondary analysis of the Health and Retirement Study (HRS). SETTING Population based. PARTICIPANTS Decedents older than 50?years who died between 2004 and 2014 (n = 8700). Exclusions included those who were ineligible for surveys assessing loneliness (n = 2932) or had missing or incomplete loneliness or symptom data (n = 2872). MEASUREMENTS Individuals were characterized as lonely based on responses to the three-item Revised University of California, Los Angeles Loneliness Scale in the most recent HRS survey before death. Outcomes were proxy reports of total EOL symptom burden, intensity of EOL care (eg, late hospice enrollment, place of death, hospitalizations, use of life support), and advance care planning. Results were expressed as adjusted odds ratios (aORs) with 95% confidence intervals (CIs). RESULTS One-third of 2896 decedents (n = 942) were lonely. After adjusting for demographics, socioeconomic status, multimorbidity, depressive symptoms, family and friends, and social support, loneliness was independently associated with increased total symptom burden at EOL (ß = .13; P =?.004). Compared with nonlonely individuals, lonely decedents were more likely to use life support in the last 2?years of life (35.5% vs 29.4%; aOR = 1.36; 95% CI = 1.08-1.71) and more likely to die in a nursing home (18.4% vs 14.2%; aOR = 1.78; 95% CI = 1.30-2.42). No significant differences in other measures of intense care (late hospice enrollment, number of hospitalizations, or dialysis use) or likelihood of advance care planning were observed. CONCLUSION Lonely older people may be burdened by more symptoms and may be exposed to more intense EOL care compared with nonlonely people. Interventions aiming to screen for, prevent, and mitigate loneliness during the vulnerable EOL period are necessary. SN - 0002-8614 UR - https://onlinelibrary.wiley.com/doi/abs/10.1111/jgs.16354 N1 - doi: 10.1111/jgs.16354 JO - Journal of the American Geriatrics Society ER - TY - JOUR T1 - Sleep Difficulties and Cognition over a 10-Year Period in a National Sample of U.S. Older Adults JF - Innovation in Aging Y1 - 2020 A1 - Robbins, Rebecca A1 - Amanda Sonnega A1 - Robert W. Turner A1 - Jean-Louis, Girardin A1 - Butler, Mark A1 - Osorio, Ricardo M A1 - Kenneth M. Langa KW - cognitive function KW - Gerontology KW - healthy aging KW - Sleep KW - Translational medicine AB - Sleep difficulties are common among older adults and are associated with cognitive decline. We used data from a large, nationally representative longitudinal survey of adults over the age of 50 in the U.S. to examine the relationship between specific sleep difficulties and cognitive function over time.Longitudinal data from the 2004-2014 waves of the Health and Retirement Study were used in the current study. We examined sleep difficulties and cognitive function within participants and across time (n=16,201). Sleep difficulty measures included difficulty initiating sleep, nocturnal awakenings, early morning awakenings, and waking feeling rested from rarely/never (1) to most nights (3). The modified Telephone Interview for Cognitive Status (TICS-m) was used to measure cognitive function. Generalized Linear Mixed Models (GLMM) were used with time varying covariates to examine the relationship between sleep difficulties and cognitive function over time.In covariate-adjusted models, compared to “never” reporting sleep difficulty, difficulty initiating sleep “most nights” was associated with worse cognitive function over time (Year 2014: b=-0.40, 95%CI: -0.63 to -0.16, p<.01) as was difficulty waking up too early “most nights” (Year 2014: b=-0.31, 95%CI: -0.56 to -0.07, p<.05). In covariate-adjusted analyses, compared to “never” reporting waking up feeling rested, cognitive function was higher among those who reported waking up feeling rested “some nights” (Year 2010: b=0.21, 95%CI: 0.02 to 0.40, p<.05).Our findings highlight an association between early morning awakenings and worse cognitive function, but also an association between waking feeling rested and better cognitive function over time.Sleep difficulties are common among older adults yet reduce quality of life and also contribute to the development of and potentially accelerate cognitive decline. This study examines specific sleep difficulties (e.g., difficulty falling asleep) and their unique relationship to cognition over time among older adults in the U.S. The primary aim of this work is to illuminate the specific sleep difficulties that are most concerning from the standpoint of cognitive impairment so as to inform the design of future tailored sleep improvement programs for older adults. SN - 2399-5300 ER - TY - JOUR T1 - Is social capital protective against hospital readmissions? JF - BMC Health Services Research Y1 - 2020 A1 - Zlotnick, Hanna A1 - Geoffrey J Hoffman A1 - Nuliyalu, Ushapoorna A1 - Engler, Tedi A. A1 - Kenneth M. Langa A1 - Ryan, Andrew M. KW - Aging KW - Cohort Analysis KW - health policy AB - To evaluate the association between social capital and 30-day readmission to the hospital among Medicare beneficiaries overall, beneficiaries with dementia and related memory disorders, and beneficiaries with dual eligibility for Medicaid. VL - 20 SN - 1472-6963 IS - 1 ER - TY - JOUR T1 - Trends in Disability Among Adults 55-64 in the United States and England From 2002 to 2016 JF - Innovation in Aging Y1 - 2020 A1 - Choi, Hwajung A1 - Robert F. Schoeni A1 - Cho, Tsai-Chin A1 - Kenneth M. Langa KW - Disability KW - ELSA AB - The paper’s goal is to assess whether and, if so, the extent to which prevalence in disability of adults near retirement ages in the US increased over time compared to their peers in England and examine income group differences in the relative trends. This study uses 2002-2016 Health and Retirement Study (HRS) and English Longitudinal Study of Ageing (ELSA) focusing on adults aged 55-64. Annual percent changes over the period of 2002-2016 for limitations in instrumental activities of daily living (IADL) and activities of daily living (ADL) are estimated for each survey (HRS and ELSA) using multivariable logistic regressions to adjust for individual-level characteristics While disability prevalence of adults ages 55-64 in England improved over the years of 2002-2016 (annual % change= -2.01 for IADL; - 2.53 for ADL), disability prevalence of US adults has not improved and in fact even worsened in terms of IADL (annual % change= +1.35). There are substantial variations in the IADL/ADL trends by income groups. In the US, the adverse trends in disability were more pronounced among the lowest income groups (annual % change in IADL=1.76 for bottom 20% vs. -2.08 for top 20%; annual % change in ADL=1.08 for bottom 20% vs. -2.08 for top 20%). In England, the disability status improved over time for all but the lowest income group. We will examine further to identify specific factors contributing to divergent/convergent trends in disability between the US and England. VL - 4 SN - 2399-5300 IS - Suppl 1 ER - TY - Generic T1 - COGNITIVE IMPAIRMENT AND SLEEP DIFFICULTIES OVER 10 YEARS IN A NATIONAL SAMPLE OF OLDER ADULTS T2 - Innovation in Aging Y1 - 2019 A1 - Robbins, Rebecca A1 - Amanda Sonnega A1 - Turner II, Robert W A1 - Jean-Louis, Girardin A1 - Kenneth M. Langa KW - Cognition KW - cognitive impairment KW - Sleep AB - Prior studies suggest that sleep difficulties (e.g., trouble falling asleep) may be associated with cognitive impairment. We used a large, nationally representative longitudinal survey of adults over the age of 50 in the US to examine the relationship between sleep difficulties and cognitive functioning. Generalized estimation equation (GEE) linear regression models were used to analyze data from the 2004-2014 waves of the Health and Retirement Study. We examined sleep difficulties and cognitive functioning within participants and across time (n=17,642). Sleep difficulty was measured as trouble falling asleep, nocturnal awakenings, and waking too early scored as 1= rarely/never, 2=sometimes, and 3=most of the time. A summary score indicated cognitive functioning (range 0-27). Models controlled for age, gender, race/ethnicity, marital status, education, chronic medical conditions, depressive symptoms, and body mass index (BMI). Compared to those with no sleep difficulties, those who reported difficulty falling asleep [“sometimes” OR=0.83,95%CI:0.71-0.96 and “most of the time” OR=0.79,95%CI: 0.64-0.98] and waking too early [“most of the time” OR=0.79,95%CI: 0.63-0.98] had worse cognitive functioning. Compared to those with no sleep difficulties, those who reported nocturnal awakenings [“most of the time” OR=1.29,95%CI:1.08-1.54] had higher cognitive functioning. Over time, lower cognitive function was more likely among those reporting difficulty falling asleep (OR=0.73,95%CI:0.54-0.97), nocturnal awakenings (OR=0.77,95%CI:0.61-0.97) and waking too early (OR=0.65,95%CI: 0.47-0.88). In this nationally representative, longitudinal sample of older US adults, we found that over time lower cognitive function was more likely among those who reported difficulty falling asleep, nocturnal awakenings, and waking too early. JF - Innovation in Aging VL - 3 SN - 2399-5300 UR - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6840199/ IS - Suppl 1 JO - Innov Aging ER - TY - JOUR T1 - Does home equity affect decisions on long-term care insurance purchases? Evidence from the United States. JF - Research on Aging Y1 - 2019 A1 - Richard A Hirth A1 - Acharya, Yubraj A1 - Helen G Levy A1 - Kenneth M. Langa KW - Decision making KW - Homeownership KW - Long-term care insurance AB - The low uptake of private long-term care insurance (LTCI) by the elderly in the United States, despite visible risks, has left economists puzzled. Prior studies have hypothesized that home equity can be a substitute for LTCI and hence may partly explain the low uptake. We test this hypothesis empirically. We utilize exogenous variation in house prices at the level of the metropolitan statistical area (MSA) as an instrument for home equity for individuals residing in that MSA and data from the Health and Retirement Study. In the most robust specifications, we find no evidence that the elderly change their decision on LTCI based on variation in their home equity, and even specifications requiring stronger identification assumptions imply only small effect magnitudes. Home equity as a substitute for LTCI does not appear to be a major contributing factor to low LTCI take up. VL - 41 IS - 6 U1 - http://www.ncbi.nlm.nih.gov/pubmed/30803354?dopt=Abstract ER - TY - JOUR T1 - Health Risk Behaviors after Disaster Exposure Among Older Adults JF - Prehospital and Disaster Medicine Y1 - 2019 A1 - Bell, Sue Anne A1 - Choi, Hwajung A1 - Kenneth M. Langa A1 - Theodore J Iwashyna KW - BMI KW - Health behaviors KW - Risk Factors VL - 34 UR - https://www.cambridge.org/core/product/identifier/S1049023X18001231/type/journal_articlehttps://www.cambridge.org/core/services/aop-cambridge-core/content/view/S1049023X18001231 IS - 1 JO - Prehosp. Disaster med. ER - TY - JOUR T1 - Measurement of Fall Injury With Health Care System Data and Assessment of Inclusiveness and Validity of Measurement Models JF - JAMA Network Open Y1 - 2019 A1 - Lillian C. Min A1 - Mary Tinetti A1 - Kenneth M. Langa A1 - Ha, Jinkyung A1 - Neil B. Alexander A1 - Geoffrey J Hoffman KW - Fall injury KW - Health Care KW - Inclusiveness AB - National injury surveillance systems use administrative data to collect information about severe fall-related trauma and mortality. Measuring milder injuries in ambulatory clinics would improve comprehensive outcomes measurement across the care spectrum.To assess a flexible set of administrative data–only algorithms for health systems to capture a greater breadth of injuries than traditional fall injury surveillance algorithms and to quantify the algorithm inclusiveness and validity associated with expanding to milder injuries.In this longitudinal diagnostic study of 13 939 older adults (≥65 years) in the nationally representative Health and Retirement Study, a survey was conducted every 2 years and was linked to hospital, emergency department, postacute skilled nursing home, and outpatient Medicare claims (2000-2012). During each 2-year observation period, participants were considered to have sustained a fall-related injury (FRI) based on a composite reference standard of having either an external cause of injury (E-code) or confirmation by the Health and Retirement Study patient interview. A framework involving 3 algorithms with International Classification of Diseases, Ninth Revision codes that extend FRI identification with administrative data beyond the use of fall-related E-codes was developed: an acute care algorithm (head and face or limb, neck, and trunk injury reported at the hospital or emergency department), a balanced algorithm (all acute care algorithm injuries plus severe nonemergency outpatient injuries), and an inclusive algorithm (almost all injuries). Data were collected from January 1, 1998, through December 31, 2012, and statistical analysis was performed from August 1, 2016, to March 1, 2019.Validity, measured as the proportion of potential FRI diagnoses confirmed by the reference standard, and inclusiveness, measured as the proportion of reference-standard FRIs captured by the potential FRI diagnoses.Of 13 939 participants, 1672 (42.4\%) were male, with a mean (SD) age of 77.56 (7.63) years. Among 50 310 observation periods, 9270 potential FRI diagnoses (18.4\%) were identified; these were tested against 8621 reference-standard FRIs (17.1\%). Compared with the commonly used method of E-coded–only FRIs (2-year incidence, 8.8\% [95\% CI, 8.6\%-9.1\%]; inclusion of 51.5\% [95\% CI, 50.4\%-52.5\%] of the reference-standard FRIs), FRI inclusion was increased with use of the study framework of algorithms. With the acute care algorithm (2-year incidence, 12.6\% [95\% CI, 12.4\%-12.9\%]), validity was prioritized (88.6\% [95\% CI, 87.4\%-89.8\%]) over inclusiveness (62.1\% [95\% CI, 61.1\%-63.1\%]). The balanced algorithm showed a 2-year incidence of 14.6\% (95\% CI, 14.3\%-14.9\%), inclusion of 65.3\% (95\% CI, 64.3\%-66.3\%), and validity of 83.2\% (95\% CI, 81.9\%-84.6\%). With the inclusive algorithm, the number of potential FRIs increased compared with the E-code–only method (2-year incidence, 17.4\% [95\% CI, 17.1\%-17.8\%]; inclusion, 68.4\% [95\% CI, 67.4\%-69.3\%]; validity, 75.2\% [95\% CI, 73.7\%-76.6\%]).The findings suggest that use of algorithms with International Classification of Diseases, Ninth Revision codes may increase inclusion of FRIs by health care systems compared with E-codes and that these algorithms may be used by health systems to evaluate interventions and quality improvement efforts. VL - 2 IS - 8 ER - TY - JOUR T1 - Paths into sepsis: Trajectories of presepsis healthcare use. JF - Annals of the American Thoracic Society Y1 - 2019 A1 - Hallie C Prescott A1 - Alicia G Carmichael A1 - Kenneth M. Langa A1 - Gonzalez, Richard A1 - Theodore J Iwashyna KW - Hospitalization KW - Risk Factors KW - Sepsis AB -

RATIONALE: Sepsis is a leading cause of death and disability whose heterogeneity is often cited as a key impediment to translational progress.

OBJECTIVES: To test the hypothesis that there are consequential and significant differences in sepsis outcomes that result from differences in a patient's clinical course leading up to sepsis hospitalization.

METHODS: We conducted an observational cohort study of U.S. Health and Retirement Study (HRS) participants in Medicare (1998-2012) and U.S. Department of Veterans Affairs beneficiaries (2009). Using latent profile analysis, we identified patient subtypes based on trajectory of presepsis healthcare facility use. Subtypes were identified in the derivation cohort (1,512 sepsis hospitalizations among earlier HRS participants), then validated them in two additional cohorts (1,992 sepsis hospitalizations among later HRS participants; 32,525 sepsis hospitalizations among U.S. Department of Veterans Affairs beneficiaries). We measured the association between presepsis path and 90-day mortality using chi-square tests and multivariable logistic regression.

RESULTS: We identified three subtypes: low use of inpatient healthcare facilities, comprising 84% of the derivation cohort; rising use, 12%; and high use, 4%. The shape and distribution of presepsis trajectories were similar in all three cohorts. In the derivation cohort, 90-day mortality differed by presepsis trajectory as follows: 38% (low use), 63% (rising use), and 48% (high use) (P < 0.001). This association persisted in the validation cohorts (P < 0.001 for each). The rising use class remained an independent predictor of mortality after adjustment for potential confounders, including detailed physiologic data.

CONCLUSIONS: In national cohorts of patients with sepsis, we have shown that several distinct paths into sepsis exist. These paths, identified by trajectories of presepsis healthcare use, are predictive of 90-day mortality.

VL - 16 IS - 1 U1 - http://www.ncbi.nlm.nih.gov/pubmed/30212640?dopt=Abstract ER - TY - JOUR T1 - Physical Functioning Decline and Mortality in Older Adults with Multimorbidity: Joint Modeling of Longitudinal and Survival Data. JF - Journals of Gerontology Series A: Biological Sciences & Medical Sciences Y1 - 2019 A1 - Melissa Y Wei A1 - Mohammed U Kabeto A1 - Andrzej T Galecki A1 - Kenneth M. Langa KW - Comorbidity KW - Mortality KW - Physical Ability AB -

Background: Multimorbidity is common among older adults and strongly associated with physical functioning decline and increased mortality. However, the full spectrum of direct and indirect effects of multimorbidity on physical functioning and survival has not been quantified. We aimed to determine the longitudinal relationship of multimorbidity on physical functioning and quantify the impact of multimorbidity and multimorbidity-attributed changes in physical functioning on mortality risk.

Methods: The Health and Retirement Study is a nationally-representative population-based prospective cohort of adults aged 51 or older. In 2000, participants were interviewed about physician-diagnosed chronic conditions, from which their multimorbidity-weighted index (MWI) was computed. Between 2000-2011, participants reported their current physical functioning using a modified Short Form-36. With MWI as a time-varying exposure, we jointly modeled its associations with physical functioning and survival.

Results: The final sample included 74,037 observations from 18,174 participants. At baseline, participants had a weighted mean MWI of 4.64.2 (range 0-36.8). During follow-up, physical functioning declined -1.72 (95% CI: -1.77, -1.67, p<0.001) HRS physical functioning units per point MWI in adjusted models. Over follow-up, 6,362 (34%) participants died. Mortality risk increased 8% (HR 1.08, 95% CI 1.07-1.08, p<0.001) per point MWI in adjusted models. Across all population subgroups, MWI was associated with greater physical functioning decline and mortality risk.

Conclusions: Multimorbidity and its associated decline in physical functioning were significantly associated with increased mortality. These associations can be predicted with an easily interpreted and applied multimorbidity index that can better identify and target adults at increased risk for disability and death.

VL - 74 IS - 2 U1 - http://www.ncbi.nlm.nih.gov/pubmed/29529179?dopt=Abstract ER - TY - JOUR T1 - Reducing Disparities in Healthy Aging Through an Enhanced Medicare Annual Wellness Visit JF - Public Policy & Aging Report Y1 - 2019 A1 - Tipirneni, Renuka A1 - Ganguli, Ishani A1 - John Z. Ayanian A1 - Kenneth M. Langa KW - Health Disparities KW - Medicare KW - Well-being AB - In its current form, the Medicare annual wellness visit (AWV) is not reaching most older Americans, particularly lower-income or minority adults and those served by safety-net providers (Ganguli, Souza, McWilliams, & Mehrotra, 2018). Yet these underserved seniors face disparities in healthy aging, likely due to individual, social, and behavioral determinants of health, such as low income, limited education, social isolation, food insecurity, poor housing quality, and difficulty affording medications. New AWV models should move beyond traditional assessments of cognition, balance, and vision to identify and address important root causes of poor health, such as individual, social, and behavioral determinants of health. Incorporating these key determinants of health into AWVs has the potential to promote healthy aging among underserved seniors. In this paper, we present local opportunities for AWV-related practice transformation, including screening tools, electronic health record templates, care team member roles, and workflows. At the national level, we suggest updates to Medicare’s current AWV policy guidelines with regard to visit elements and funding models. VL - 29 UR - https://academic.oup.com/ppar/advance-article/doi/10.1093/ppar/pry048/5251985http://academic.oup.com/ppar/advance-article-pdf/doi/10.1093/ppar/pry048/27184822/pry048.pdf IS - 1 ER - TY - JOUR T1 - Association of a Negative Wealth Shock With All-Cause Mortality in Middle-aged and Older Adults in the United States. JF - JAMA Y1 - 2018 A1 - Lindsay R Pool A1 - Sarah A. Burgard A1 - Belinda L Needham A1 - Michael R. Elliott A1 - Kenneth M. Langa A1 - Carlos F. Mendes de Leon KW - Mortality KW - NDI KW - Wealth Shocks AB -

Importance: A sudden loss of wealth-a negative wealth shock-may lead to a significant mental health toll and also leave fewer monetary resources for health-related expenses. With limited years remaining to regain lost wealth in older age, the health consequences of these negative wealth shocks may be long-lasting.

Objective: To determine whether a negative wealth shock was associated with all-cause mortality during 20 years of follow-up.

Design, Setting, and Participants: The Health and Retirement Study, a nationally representative prospective cohort study of US adults aged 51 through 61 years at study entry. The study population included 8714 adults, first assessed for a negative wealth shock in 1994 and followed biennially through 2014 (the most recent year of available data).

Exposures: Experiencing a negative wealth shock, defined as a loss of 75% or more of total net worth over a 2-year period, or asset poverty, defined as 0 or negative total net worth at study entry.

Main Outcomes and Measures: Mortality data were collected from the National Death Index and postmortem interviews with family members. Marginal structural survival methods were used to account for the potential bias due to changes in health status that may both trigger negative wealth shocks and act as the mechanism through which negative wealth shocks lead to increased mortality.

Results: There were 8714 participants in the study sample (mean [SD] age at study entry, 55 [3.2] years; 53% women), 2430 experienced a negative wealth shock during follow-up, 749 had asset poverty at baseline, and 5535 had continuously positive wealth without shock. A total of 2823 deaths occurred during 80 683 person-years of follow-up. There were 30.6 vs 64.9 deaths per 1000 person-years for those with continuously positive wealth vs negative wealth shock (adjusted hazard ratio [HR], 1.50; 95% CI, 1.36-1.67). There were 73.4 deaths per 1000 person-years for those with asset poverty at baseline (adjusted HR, 1.67; 95% CI, 1.44-1.94; compared with continuously positive wealth).

Conclusions and Relevance: Among US adults aged 51 years and older, loss of wealth over 2 years was associated with an increased risk of all-cause mortality. Further research is needed to better understand the possible mechanisms for this association and determine whether there is potential value for targeted interventions.

VL - 319 IS - 13 U1 - http://www.ncbi.nlm.nih.gov/pubmed/29614178?dopt=Abstract ER - TY - CHAP T1 - Cognitive Functioning of U.S. Adults by Race and Hispanic Origin T2 - Contextualizing Health and Aging in the Americas Y1 - 2018 A1 - Díaz-Venegas, Carlos A1 - Brian Downer A1 - Kenneth M. Langa A1 - Rebeca Wong ED - William A. Vega ED - Jacqueline L. Angel ED - Gutiérrez Robledo, Luis Miguel F. ED - Kyriakos S Markides KW - Alzheimer's disease KW - Cognitive Ability KW - Hispanics KW - Racial/ethnic differences AB - The U.S. older adult population is becoming increasingly diverse. The evidence from research using data from diverse older adult populations indicates that Hispanics have poorer performance on cognitive tests than older non-Hispanic whites (NHW). However, the evidence that older Hispanics are at an increased risk for Alzheimer’s disease or related dementia (ADRD) than NHW is less clear. Interpreting the evidence from existing research on disparities between NHWs and Hispanics is complicated by the fact that few studies have differentiated between Hispanic subgroups by country of origin. In this chapter, we use the ethnic descriptor of Hispanic as interchangeable with Latino. We summarize the current evidence on disparities between Hispanics and NHW in cognitive functioning and ADRD, and factors that may contribute to these disparities. This summary focuses on the rationale for considering specific Hispanic populations when studying differences in cognitive functioning between Hispanics and NHWs. Finally, we present and discuss the findings from an analysis of data from the 2010 wave of the Health and Retirement Study (n = 18,982) in which we examine differences in three cognitive domains by race/ethnicity, including four Hispanic subgroups. In this analysis, all Hispanic subgroups, except Cubans, had significantly lower scores for all cognitive domains compared to NHWs, with Puerto Ricans showing the lowest scores among Hispanics. JF - Contextualizing Health and Aging in the Americas PB - Springer International Publishing CY - Cham SN - 978-3-030-00583-2 UR - https://link.springer.com/chapter/10.1007/978-3-030-00584-9_5 ER - TY - JOUR T1 - Impact of In-Hospital Death on Spending for Bereaved Spouses. JF - Health Services Research Y1 - 2018 A1 - Katherine A Ornstein A1 - Melissa M Garrido A1 - Albert L Siu A1 - Bollens-Lund, Evan A1 - Kenneth M. Langa A1 - Amy Kelley KW - Bereavement KW - End of life decisions KW - Medicare linkage KW - Medicare/Medicaid/Health Insurance AB -

OBJECTIVE: To examine how patients' location of death relates to health care utilization and spending for surviving spouses.

DATA SOURCES/STUDY SETTING: Health and Retirement Study (HRS) 2000-2012 linked to the Dartmouth Atlas and Medicare claims data.

STUDY DESIGN: This was an observational study. We matched bereaved spouses whose spouses died in a hospital to those whose spouses died outside the hospital using propensity scores based on decedent and spouse demographic and clinical characteristics, care preferences, and regional practice patterns.

DATA COLLECTION/EXTRACTION METHODS: We identified 1,348 HRS decedents with surviving spouses. We linked HRS data from each dyad with Medicare claims and regional characteristics.

PRINCIPAL FINDINGS: In multivariable models, bereaved spouses of decedents who died in the hospital had $3,106 higher Medicare spending 12 months postdeath (p = .04) compared to those whose spouses died outside a hospital. Those surviving spouses were also significantly more likely to have an ED visit (OR = 1.5; p < .01) and hospital admission (OR = 1.4; p = .02) in the year after their spouse's in-hospital death. Increased Medicare spending for surviving spouses persisted through the 24-month period postdeath ($5,310; p = .02).

CONCLUSIONS: Bereaved spouses of decedents who died in the hospital had significantly greater Medicare spending and health care utilization themselves after their spouses' death.

VL - 53 IS - Suppl_1 U1 - http://www.ncbi.nlm.nih.gov/pubmed/29488621?dopt=Abstract ER - TY - JOUR T1 - Multimorbidity and physical and cognitive function: performance of a new multimorbidity-weighted index. JF - Journals of Gerontology Series A: Biological Sciences & Medical Sciences Y1 - 2018 A1 - Melissa Y Wei A1 - Mohammed U Kabeto A1 - Kenneth M. Langa A1 - Kenneth J Mukamal KW - Cognition & Reasoning KW - Comorbidity AB -

Background: Multimorbidity is an important health outcome but is difficult to quantify. We recently developed a multimorbidity-weighted index (MWI) and herein assess its performance in an independent nationally-representative cohort.

Methods: Health and Retirement Study (HRS) participants completed an interview on physician-diagnosed chronic conditions and physical functioning. We determined the relationship of chronic conditions on physical functioning and validated these weights with the original, independently-derived MWI. We then determined the association between MWI with physical functioning, grip strength, gait speed, basic and instrumental activities of daily living (ADL/IADL) limitations, and the modified Telephone Interview for Cognitive Status (TICS-m) in adjusted models.

Results: Among 20,509 adults, associations between chronic conditions and physical functioning varied several-fold. MWI values based on weightings in the HRS and original cohorts correlated strongly (Pearson's r=0.92) and had high classification agreement (Kappa statistic=0.80, p<0.0001). Participants in the highest vs. lowest MWI quartiles had weaker grip strength (-2.91 kg, 95%CI: -3.51, -2.30), slower gait speed (-0.29 m/s, 95%CI: -0.35, -0.23), more ADL (0.79, 95%CI: 0.71, 0.87) and IADL (0.49, 95%CI: 0.44, 0.55) limitations, and lower TICS-m (-0.59, 95%CI: -0.77, -0.41) (all P<0.001). We observed monotonic graded relationships for all outcomes with increasing MWI quartiles.

Conclusion: A multimorbidity index weighted to physical functioning performed nearly identically in a nationally-representative cohort as it did in its development cohorts, confirming broad generalizability. MWI was strongly associated with subjective and objective physical and cognitive performance. Thus, MWI serves as a valid patient-centered measure of multimorbidity, an important construct in research and clinical practice.

VL - 73 IS - 2 U1 - http://www.ncbi.nlm.nih.gov/pubmed/28605457?dopt=Abstract ER - TY - JOUR T1 - Secular Trends in Dementia and Cognitive Impairment of U.S. Rural and Urban Older Adults JF - American Journal of Preventive Medicine Y1 - 2018 A1 - Margaret M Weden A1 - Regina A Shih A1 - Mohammed U Kabeto A1 - Kenneth M. Langa KW - Cognitive Ability KW - Dementia KW - Religion KW - Rural Settings KW - urban life AB - Introduction This is a nationally representative study of rural−urban disparities in the prevalence of probable dementia and cognitive impairment without dementia (CIND). Methods Data on non-institutionalized U.S. adults from the 2000 (n=16,386) and 2010 (n=16,311) cross-sections of the Health and Retirement Study were linked to respective Census assessments of the urban composition of residential census tracts. Relative risk ratios (RRR) for rural−urban differentials in dementia and CIND respective to normal cognitive status were assessed using multinomial logistic regression. Analyses were conducted in 2016. Results Unadjusted prevalence of dementia and CIND in rural and urban tracts converged so that rural disadvantages in the relative risk of dementia (RRR=1.42, 95% CI=1.10, 1.83) and CIND (RRR=1.35, 95% CI=1.13, 1.61) in 2000 no longer reached statistical significance in 2010. Adjustment for the strong protective role of educational attainment reduced rural disadvantages in 2000 to statistical nonsignificance, whereas adjustment for race/ethnicity resulted in a statistically significant increase in RRRs in 2010. Full adjustment for sociodemographic and health factors revealed persisting rural disadvantages for dementia and CIND in both periods with RRR in 2010 for dementia of 1.79 (95% CI=1.31, 2.43) and for CIND of 1.38 (95% CI=1.14, 1.68). Conclusions Larger gains in rural adults’ cognitive functioning between 2000 and 2010 that are linked with increased educational attainment demonstrate long-term public health benefits of investment in secondary education. Persistent disadvantages in cognitive functioning among rural adults compared with sociodemographically similar urban peers highlight the importance of public health planning for more rapidly aging rural communities. VL - 54 UR - http://linkinghub.elsevier.com/retrieve/pii/S074937971730644Xhttp://api.elsevier.com/content/article/PII:S074937971730644X?httpAccept=text/xmlhttp://api.elsevier.com/content/article/PII:S074937971730644X?httpAccept=text/plain IS - 2 JO - American Journal of Preventive Medicine ER - TY - JOUR T1 - Trends in the Prevalence and Disparity in Cognitive Limitations of Americans 55-69 Years Old. JF - Journals of Gerontology Series B: Psychological Sciences & Social Sciences Y1 - 2018 A1 - Choi, Hwajung A1 - Robert F. Schoeni A1 - Linda G Martin A1 - Kenneth M. Langa KW - Cognitive Ability KW - Functional limitations AB -

Objectives: To determine whether the prevalence of cognitive limitation (CL) among Americans ages 55 to 69 years changed between 1998 and 2014, and to assess the trends in socioeconomic disparities in CL among groups defined by race/ethnicity, education, income, and wealth.

Method: Logistic regression using 1998-2014 data from the biennial Health and Retirement Study, a nationally representative data set. CL is defined as a score of 0-11 on a 27-point cognitive battery of items focused on memory. Socioeconomic status (SES) measures are classified as quartiles.

Results: In models controlling for age, gender, and previous cognitive testing, we find no significant change over time in the overall prevalence of CL, widening disparities in limitation by income and, in some cases, wealth, and improvements among non-Hispanic whites but not other racial/ethnic groups.

Discussion: Among people 55-69, rates of CL are many times higher for groups with lower SES than those with higher SES, and recent trends show little indication that the gaps are narrowing.

VL - 73 IS - suppl_1 U1 - http://www.ncbi.nlm.nih.gov/pubmed/29669102?dopt=Abstract ER - TY - JOUR T1 - Underreporting of Fall Injuries of Older Adults: Implications for Wellness Visit Fall Risk Screening. JF - Journal of the American Geriatrics Society Y1 - 2018 A1 - Geoffrey J Hoffman A1 - Ha, Jinkyung A1 - Neil B. Alexander A1 - Kenneth M. Langa A1 - Mary Tinetti A1 - Lillian C. Min KW - Doctor visits KW - Falls KW - Medicare linkage KW - Medicare/Medicaid/Health Insurance AB -

OBJECTIVES: To compare the accuracy of and factors affecting the accuracy of self-reported fall-related injuries (SFRIs) with those of administratively obtained FRIs (AFRIs).

DESIGN: Retrospective observational study SETTING: United States PARTICIPANTS: Fee-for-service Medicare beneficiaries aged 65 and older (N=47,215).

MEASUREMENTS: We used 24-month self-report recall data from 2000-2012 Health and Retirement Study data to identify SFRIs and linked inpatient, outpatient, and ambulatory Medicare data to identify AFRIs. Sensitivity and specificity were assessed, with AFRIs defined using the University of California at Los Angeles/RAND algorithm as the criterion standard. Logistic regression models were used to identify sociodemographic and health predictors of sensitivity.

RESULTS: Overall sensitivity and specificity were 28% and 92%. Sensitivity was greater for the oldest adults (38%), women (34%), those with more functional limitations (47%), and those with a prior fall (38%). In adjusted results, several participant factors (being female, being white, poor functional status, depression, prior falls) were modestly associated with better sensitivity and specificity. Injury severity (requiring hospital care) most substantively improved SFRI sensitivity (73%).

CONCLUSION: An overwhelming 72% of individuals who received Medicare-reimbursed health care for FRIs failed to report a fall injury when asked. Future efforts to address underreporting in primary care of nonwhite and healthier older adults are critical to improve preventive efforts. Redesigned questions-for example, that address stigma of attributing injury to falling-may improve sensitivity.

VL - 66 IS - 6 ER - TY - JOUR T1 - Association between spousal caregiver well-being and care recipient healthcare expenditures JF - Journal of the American Geriatrics Society Y1 - 2017 A1 - Claire K. Ankuda A1 - Donovan T Maust A1 - Mohammed U Kabeto A1 - Ryan J McCammon A1 - Kenneth M. Langa A1 - Deborah A Levine KW - Caregiving KW - Marriage KW - Medical Expenses KW - Medicare/Medicaid/Health Insurance KW - Well-being AB - 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) = $770–3,105) and caregiver sadness (cost increase, $1,323, 95% CI = $228–2,419) 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 = 1.01–1.52) and caregiver fair to poor health (OR = 1.23, 95% CI = 1.04–1.45) 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. VL - 65 UR - 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 IS - 10 JO - J Am Geriatr Soc ER - TY - JOUR T1 - Associations between community-level disaster exposure and individual-level changes in disability and risk of death for older Americans. JF - Soc Sci Med Y1 - 2017 A1 - Samuel L. Brilleman A1 - Wolfe, Rory A1 - Moreno-Betancur, Margarita A1 - Anne E Sales A1 - Kenneth M. Langa A1 - Yun Li A1 - Elizabeth L. Daugher Biddison A1 - Rubinson, Lewis A1 - Theodore J Iwashyna KW - Aged KW - Aged, 80 and over KW - Cohort Studies KW - Community Participation KW - Continental Population Groups KW - Disabled Persons KW - Disaster Planning KW - Disasters KW - Female KW - Humans KW - Income KW - Longitudinal Studies KW - Male KW - Middle Aged KW - Mortality KW - United States AB -

Disasters occur frequently in the United States (US) and their impact on acute morbidity, mortality and short-term increased health needs has been well described. However, barring mental health, little is known about the medium or longer-term health impacts of disasters. This study sought to determine if there is an association between community-level disaster exposure and individual-level changes in disability and/or the risk of death for older Americans. Using the US Federal Emergency Management Agency's database of disaster declarations, 602 disasters occurred between August 1998 and December 2010 and were characterized by their presence, intensity, duration and type. Repeated measurements of a disability score (based on activities of daily living) and dates of death were observed between January 2000 and November 2010 for 18,102 American individuals aged 50-89 years, who were participating in the national longitudinal Health and Retirement Study. Longitudinal (disability) and time-to-event (death) data were modelled simultaneously using a 'joint modelling' approach. There was no evidence of an association between community-level disaster exposure and individual-level changes in disability or the risk of death. Our results suggest that future research should focus on individual-level disaster exposures, moderate to severe disaster events, or higher-risk groups of individuals.

VL - 173 UR - https://www.sciencedirect.com/science/article/abs/pii/S0277953616306785?via%3Dihub U1 - http://www.ncbi.nlm.nih.gov/pubmed/27960126?dopt=Abstract JO - Social Science & Medicine ER - TY - JOUR T1 - A Comparison of the Prevalence of Dementia in the United States in 2000 and 2012. JF - JAMA Intern Med Y1 - 2017 A1 - Kenneth M. Langa A1 - Eric B Larson A1 - Eileen M. Crimmins A1 - Jessica Faul A1 - Deborah A Levine A1 - Mohammed U Kabeto A1 - David R Weir KW - Aged KW - Dementia KW - Female KW - Humans KW - Male KW - Prevalence KW - Risk Factors KW - United States AB -

Importance: The aging of the US population is expected to lead to a large increase in the number of adults with dementia, but some recent studies in the United States and other high-income countries suggest that the age-specific risk of dementia may have declined over the past 25 years. Clarifying current and future population trends in dementia prevalence and risk has important implications for patients, families, and government programs.

Objective: To compare the prevalence of dementia in the United States in 2000 and 2012.

Design, Setting, and Participants: We used data from the Health and Retirement Study (HRS), a nationally representative, population-based longitudinal survey of individuals in the United States 65 years or older from the 2000 (n = 10 546) and 2012 (n = 10 511) waves of the HRS.

Main Outcomes and Measures: Dementia was identified in each year using HRS cognitive measures and validated methods for classifying self-respondents, as well as those represented by a proxy. Logistic regression was used to identify socioeconomic and health variables associated with change in dementia prevalence between 2000 and 2012.

Results: The study cohorts had an average age of 75.0 years (95% CI, 74.8-75.2 years) in 2000 and 74.8 years (95% CI, 74.5-75.1 years) in 2012 (P = .24); 58.4% (95% CI, 57.3%-59.4%) of the 2000 cohort was female compared with 56.3% (95% CI, 55.5%-57.0%) of the 2012 cohort (P < .001). Dementia prevalence among those 65 years or older decreased from 11.6% (95% CI, 10.7%-12.7%) in 2000 to 8.8% (95% CI, 8.2%-9.4%) (8.6% with age- and sex-standardization) in 2012 (P < .001). More years of education was associated with a lower risk for dementia, and average years of education increased significantly (from 11.8 years [95% CI, 11.6-11.9 years] to 12.7 years [95% CI, 12.6-12.9 years]; P < .001) between 2000 and 2012. The decline in dementia prevalence occurred even though there was a significant age- and sex-adjusted increase between years in the cardiovascular risk profile (eg, prevalence of hypertension, diabetes, and obesity) among older US adults.

Conclusions and Relevance: The prevalence of dementia in the United States declined significantly between 2000 and 2012. An increase in educational attainment was associated with some of the decline in dementia prevalence, but the full set of social, behavioral, and medical factors contributing to the decline is still uncertain. Continued monitoring of trends in dementia incidence and prevalence will be important for better gauging the full future societal impact of dementia as the number of older adults increases in the decades ahead.

VL - 177 UR - http://archinte.jamanetwork.com/article.aspx?doi=10.1001/jamainternmed.2016.6807http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2587084 IS - 1 U1 - http://www.ncbi.nlm.nih.gov/pubmed/27893041?dopt=Abstract JO - JAMA Intern Med ER - TY - JOUR T1 - Distress Associated with Dementia-Related Psychosis and Agitation in Relation to Healthcare Utilization and Costs. JF - American Journal of Geriatric Psychiatry Y1 - 2017 A1 - Donovan T Maust A1 - Helen C Kales A1 - Ryan J McCammon A1 - Frederic C. Blow A1 - Amanda N Leggett A1 - Kenneth M. Langa KW - Dementia KW - Depressive symptoms KW - Healthcare KW - Stress AB -

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.

VL - 25 IS - 10 U1 - http://www.ncbi.nlm.nih.gov/pubmed/28754586?dopt=Abstract ER - TY - JOUR T1 - The Hispanic paradox: Race/ethnicity and nativity, immigrant enclave residence and cognitive impairment among older US adults. JF - Journal of the American Geriatrics Society Y1 - 2017 A1 - Margaret M Weden A1 - Jeremy Miles A1 - Esther M Friedman A1 - José J Escarce A1 - Peterson, Christine A1 - Kenneth M. Langa A1 - Regina A Shih KW - Cognitive Ability KW - Racial/ethnic differences KW - Socioeconomic factors KW - Women and Minorities AB - Hispanics, and particularly foreign-born Mexican Americans, have been shown to fare better across a range of health outcomes than might be expected given the generally higher levels of socioeconomic disadvantage in this population, a phenomena termed the "Hispanic Paradox". Previous research on social disparities in cognitive aging, however, has been unable to address both race/ethnicity and nativity (REN) in a nationally-representative sample of US adults leaving unanswered questions about potentially "paradoxical" advantages of Mexican ethnic-origins and the role of nativity, socioeconomic status (SES), and enclave residence. We employ biennial assessments of cognitive functioning to study prevalent and incident cognitive impairment (CI) within the three largest US REN groups: US-born non-Hispanic whites (US-NHW), US-born non-Hispanic blacks (US-NHB), US-born Mexican Americans (US-MA), and foreign-born Mexican Americans (FB-MA). Data come from a nationally-representative sample of community-dwelling older adults in the Health and Retirement Study linked with the 2000 Census and followed over 10 years (N = 8,433). Large disadvantages in prevalent and incident CI were observed for all REN minorities respective to US-born non-Hispanic whites. Individual and neighborhood SES accounted substantially for these disadvantages and revealed an immigrant advantage: FB-MA odds of prevalent CI were about half those of US-NHW and hazards of incident CI were about half those of US-MA. Residence in an immigrant enclave was protective of prevalent CI among FB-MA. The findings illuminate important directions for research into the sources of cognitive risk and resilience and provide guidance about CI screening within the increasingly diverse aging US population. VL - 65 IS - 5 ER - TY - JOUR T1 - The Impact of Disability and Social Determinants of Health on Condition-Specific Readmissions beyond Medicare Risk Adjustments: A Cohort Study. JF - J Gen Intern Med Y1 - 2017 A1 - Meddings, Jennifer A1 - Reichert, Heidi A1 - Shawna N Smith A1 - Theodore J Iwashyna A1 - Kenneth M. Langa A1 - Timothy P Hofer A1 - Laurence F McMahon KW - Activities of Daily Living KW - Cognitive Dysfunction KW - Comorbidity KW - Disability Evaluation KW - Female KW - Heart Failure KW - Humans KW - Logistic Models KW - Male KW - Myocardial Infarction KW - Patient Readmission KW - Pneumonia KW - Retrospective Studies KW - Risk Adjustment KW - Social determinants of health AB -

BACKGROUND: Readmission rates after pneumonia, heart failure, and acute myocardial infarction hospitalizations are risk-adjusted for age, gender, and medical comorbidities and used to penalize hospitals.

OBJECTIVE: To assess the impact of disability and social determinants of health on condition-specific readmissions beyond current risk adjustment.

DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study of Medicare patients using 1) linked Health and Retirement Study-Medicare claims data (HRS-CMS) and 2) Healthcare Cost and Utilization Project State Inpatient Databases (Florida, Washington) linked with ZIP Code-level measures from the Census American Community Survey (ACS-HCUP). Multilevel logistic regression models assessed the impact of disability and selected social determinants of health on readmission beyond current risk adjustment.

MAIN MEASURES: Outcomes measured were readmissions ≤30 days after hospitalizations for pneumonia, heart failure, or acute myocardial infarction. HRS-CMS models included disability measures (activities of daily living [ADL] limitations, cognitive impairment, nursing home residence, home healthcare use) and social determinants of health (spouse, children, wealth, Medicaid, race). ACS-HCUP model measures were ZIP Code-percentage of residents ≥65 years of age with ADL difficulty, spouse, income, Medicaid, and patient-level and hospital-level race.

KEY RESULTS: For pneumonia, ≥3 ADL difficulties (OR 1.61, CI 1.079-2.391) and prior home healthcare needs (OR 1.68, CI 1.204-2.355) increased readmission in HRS-CMS models (N = 1631); ADL difficulties (OR 1.20, CI 1.063-1.352) and 'other' race (OR 1.14, CI 1.001-1.301) increased readmission in ACS-HCUP models (N = 27,297). For heart failure, children (OR 0.66, CI 0.437-0.984) and wealth (OR 0.53, CI 0.349-0.787) lowered readmission in HRS-CMS models (N = 2068), while black (OR 1.17, CI 1.056-1.292) and 'other' race (OR 1.14, CI 1.036-1.260) increased readmission in ACS-HCUP models (N = 37,612). For acute myocardial infarction, nursing home status (OR 4.04, CI 1.212-13.440) increased readmission in HRS-CMS models (N = 833); 'other' patient-level race (OR 1.18, CI 1.012-1.385) and hospital-level race (OR 1.06, CI 1.001-1.125) increased readmission in ACS-HCUP models (N = 17,496).

CONCLUSIONS: Disability and social determinants of health influence readmission risk when added to the current Medicare risk adjustment models, but the effect varies by condition.

VL - 32 UR - http://link.springer.com/10.1007/s11606-016-3869-xhttp://link.springer.com/content/pdf/10.1007/s11606-016-3869-x.pdfhttp://link.springer.com/content/pdf/10.1007/s11606-016-3869-x.pdfhttp://link.springer.com/article/10.1007/s11606-016-3869-x/fulltext.html IS - 1 U1 - http://www.ncbi.nlm.nih.gov/pubmed/27848189?dopt=Abstract JO - J GEN INTERN MED ER - TY - JOUR T1 - Late mortality after acute hypoxic respiratory failure. JF - Thorax Y1 - 2017 A1 - Hallie C Prescott A1 - Sjoding, Michael W A1 - Kenneth M. Langa A1 - Theodore J Iwashyna A1 - Daniel F McAuley KW - Health Shocks KW - Mortality KW - Respiratory Disease AB -

BACKGROUND: Acute hypoxic respiratory failure (AHRF) is associated with significant acute mortality. It is unclear whether later mortality is predominantly driven by pre-existing comorbid disease, the acute inciting event or is the result of AHRF itself.

METHODS: Observational cohort study of elderly US Health and Retirement Study (HRS) participants in fee-for-service Medicare (1998-2012). Patients hospitalised with AHRF were matched 1:1 to otherwise similar adults who were not currently hospitalised and separately to patients hospitalised with acute inciting events (pneumonia, non-pulmonary infection, aspiration, trauma, pancreatitis) that may result in AHRF, here termed at-risk hospitalisations. The primary outcome was late mortality-death in the 31 days to 2 years following hospital admission.

RESULTS: Among 15 075 HRS participants, we identified 1268 AHRF and 13 117 at-risk hospitalisations. AHRF hospitalisations were matched to 1157 non-hospitalised adults and 1017 at-risk hospitalisations. Among patients who survived at least 30 days, AHRF was associated with a 24.4% (95%CI 19.9% to 28.9%, p<0.001) absolute increase in late mortality relative to adults not currently hospitalised and a 6.7% (95%CI 1.7% to 11.7%, p=0.01) increase relative to adults hospitalised with acute inciting event(s) alone. At-risk hospitalisation explained 71.2% of the increased odds of late mortality, whereas the development of AHRF itself explained 28.8%. Risk for death was equivalent to at-risk hospitalisation beyond 90 days, but remained elevated for more than 1 year compared with non-hospitalised controls.

CONCLUSIONS: In this national sample of older Americans, approximately one in four survivors with AHRF had a late death not explained by pre-AHRF health status. More than 70% of this increased risk was associated with hospitalisation for acute inciting events, while 30% was associated with hypoxemic respiratory failure.

U1 - http://www.ncbi.nlm.nih.gov/pubmed/28780503?dopt=Abstract ER - TY - JOUR T1 - Neuroprotective diets are associated with better cognitive function: The Health and Retirement Study. JF - Journal of the American Geriatrics Society Y1 - 2017 A1 - Claire T McEvoy A1 - Heidi M Guyer A1 - Kenneth M. Langa A1 - Kristine Yaffe KW - Cognitive Ability KW - Eating habits AB -

OBJECTIVES: To evaluate the association between the Mediterranean diet (MedDiet) and the Mediterranean-DASH diet Intervention for Neurodegeneration Delay (MIND diet) and cognition in a nationally representative population of older U.S. adults.

DESIGN: Population-based cross-sectional study.

SETTING: Health and Retirement Study.

PARTICIPANTS: Community-dwelling older adults (N = 5,907; mean age 67.8 ± 10.8).

MEASUREMENTS: Adherence to dietary patterns was determined from food frequency questionnaires using criteria determined a priori to generate diet scores for the MedDiet (range 0-55) and MIND diet (range 0-15). Cognitive performance was measured using a composite test score of global cognitive function (range 0-27). Linear regression was used to compare cognitive performance according to tertiles of dietary pattern. Logistic regression was used to examine the association between dietary patterns and clinically significant cognitive impairment. Models were adjusted for age, sex, race, educational attainment, and other health and lifestyle covariates.

RESULTS: Participants with mid (odds ratio (OR) = 0.85, 95% confidence interval (CI) = 0.71-1.02, P = .08) and high (OR 0.65, 95% CI = 0.52-0.81, P < .001) MedDiet scores were less likely to have poor cognitive performance than those with low scores in fully adjusted models. Results for the MIND diet were similar. Higher scores in each dietary pattern were independently associated with significantly better cognitive function (P < .001) in a dose-response manner (P trend  < .001).

CONCLUSION: In a large nationally representative population of older adults, greater adherence to the MedDiet and MIND diet was independently associated with better cognitive function and lower risk of cognitive impairment. Clinical trials are required to elucidate the role of dietary patterns in cognitive aging.

VL - 65 IS - 8 U1 - http://www.ncbi.nlm.nih.gov/pubmed/28440854?dopt=Abstract ER - TY - JOUR T1 - The obesity paradox and incident cardiovascular disease: A population-based study. JF - PLoS One Y1 - 2017 A1 - Virginia W Chang A1 - Kenneth M. Langa A1 - David R Weir A1 - Theodore J Iwashyna KW - BMI KW - Cardiovascular disease KW - Obesity AB -

BACKGROUND: Prior work suggests that obesity may confer a survival advantage among persons with cardiovascular disease (CVD). This obesity "paradox" is frequently studied in the context of prevalent disease, a stage in the disease process when confounding from illness-related weight loss and selective survival are especially problematic. Our objective was to examine the association of obesity with mortality among persons with incident CVD, where biases are potentially reduced, and to compare these findings with those based on prevalent disease.

METHODS: We used data from the Health and Retirement Study, an ongoing, nationally representative longitudinal survey of U.S. adults age 50 years and older initiated in 1992 and linked to Medicare claims. Cox proportional hazard models were used to estimate the association between weight status and mortality among persons with specific CVD diagnoses. CVD diagnoses were established by self-reported survey data as well as Medicare claims. Prevalent disease models used concurrent weight status, and incident disease models used pre-diagnosis weight status.

RESULTS: We examined myocardial infarction, congestive heart failure, stroke, and ischemic heart disease. A strong and significant obesity paradox was consistently observed in prevalent disease models (hazard of death 18-36% lower for obese class I relative to normal weight), replicating prior findings. However, in incident disease models of the same conditions in the same dataset, there was no evidence of this survival benefit. Findings from models using survey- vs. claims-based diagnoses were largely consistent.

CONCLUSION: We observed an obesity paradox in prevalent CVD, replicating prior findings in a population-based sample with longer-term follow-up. In incident CVD, however, we did not find evidence of a survival advantage for obesity. Our findings do not offer support for reevaluating clinical and public health guidelines in pursuit of a potential obesity paradox.

VL - 12 IS - 12 U1 - http://www.ncbi.nlm.nih.gov/pubmed/29216243?dopt=Abstract ER - TY - JOUR T1 - Psychotropic use and associated neuropsychiatric symptoms among patients with dementia in the USA. JF - International Journal of Geriatric Psychiatry Y1 - 2017 A1 - Donovan T Maust A1 - Kenneth M. Langa A1 - Frederic C. Blow A1 - Helen C Kales KW - ADAMS KW - Antidepressants KW - Dementia KW - Drug use KW - Older Adults KW - Psychiatry AB -

OBJECTIVE: To determine the national prevalence of psychotropic use and association with neuropsychiatric symptoms among patients with dementia.

METHODS: Participants diagnosed with dementia (n = 414) in the Aging, Demographics, and Memory Study, a nationally representative survey of US adults >70 years old. Diagnosis was based on in-person clinical assessment and informant interview. Information collected included demographics, place of residence, 10-item Neuropsychiatric Inventory (NPI), and prescribed medications (antipsychotic, sedative-hypnotic, antidepressant, mood stabilizer).

RESULTS: Of 414 participants with dementia, 41.4% were prescribed a psychotropic medication, including 84.0% of nursing home residents and 28.6% of community-dwellers. Of participants, 23.5% were prescribed an antidepressant. Compared with the total NPI score of those on no medication (4.5), those on antipsychotics and those on sedative-hypnotics had much higher scores (respectively: 12.6, p < 0.001; 11.8, p = 0.03), although those antidepressants did not (6.9, p = 0.15). A larger proportion of patients on antipsychotics exhibited psychosis and agitation compared with those on no medication, while those on antidepressants exhibited more depressive symptoms. In multivariable logistic regression that included dementia severity and nursing home residence, nursing home residence was the characteristic most strongly associated with psychotropic use (odds ratio ranging from 8.96 [p < 0.001] for antipsychotics to 15.59 [p < 0.001] for sedative-hypnotics). More intense psychotic symptoms and agitation were associated with antipsychotic use; more intense anxiety and agitation were associated with sedative-hypnotic use. More intense depression and apathy were not associated with antidepressant use.

CONCLUSIONS: In this nationally representative sample, 41.4% of patients were taking psychotropic medication. While associated with neuropsychiatric symptoms, nursing home residence was most strongly tied to use. Copyright © 2016 John Wiley & Sons, Ltd.

VL - 32 IS - 2 ER - TY - JOUR T1 - The Relationship of Obesity to Hospice Use and Expenditures: A Cohort Study. JF - Annals of Internal Medicine Y1 - 2017 A1 - Tamara B Harris A1 - Byhoff, Elena A1 - Chithra R Perumalswami A1 - Kenneth M. Langa A1 - Alexi A Wright A1 - Jennifer J Griggs KW - Hospice KW - Medicare/Medicaid/Health Insurance KW - Obesity KW - Older Adults AB -

Background: Obesity complicates medical, nursing, and informal care in severe illness, but its effect on hospice use and Medicare expenditures is unknown.

Objective: To describe the associations between body mass index (BMI) and hospice use and Medicare expenditures in the last 6 months of life.

Design: Retrospective cohort.

Setting: The HRS (Health and Retirement Study).

Participants: 5677 community-dwelling Medicare fee-for-service beneficiaries who died between 1998 and 2012.

Measurements: Hospice enrollment, days enrolled in hospice, in-home death, and total Medicare expenditures in the 6 months before death. BMI was modeled as a continuous variable with a quadratic functional form.

Results: For decedents with BMI of 20 kg/m2, the predicted probability of hospice enrollment was 38.3% (95% CI, 36.5% to 40.2%), hospice duration was 42.8 days (CI, 42.3 to 43.2 days), probability of in-home death was 61.3% (CI, 59.4% to 63.2%), and total Medicare expenditures were $42 803 (CI, $41 085 to $44 521). When BMI increased to 30 kg/m2, the predicted probability of hospice enrollment decreased by 6.7 percentage points (CI, -9.3 to -4.0 percentage points), hospice duration decreased by 3.8 days (CI, -4.4 to -3.1 days), probability of in-home death decreased by 3.2 percentage points (CI, -6.0 to -0.4 percentage points), and total Medicare expenditures increased by $3471 (CI, $955 to $5988). For morbidly obese decedents (BMI ≥40 kg/m2), the predicted probability of hospice enrollment decreased by 15.2 percentage points (CI, -19.6 to -10.9 percentage points), hospice duration decreased by 4.3 days (CI, -5.7 to -2.9 days), and in-home death decreased by 6.3 percentage points (CI, -11.2 to -1.5 percentage points) versus decedents with BMI of 20 kg/m2.

Limitation: Baseline data were self-reported, and the interval between reported BMI and time of death varied.

Conclusion: Among community-dwelling decedents in the HRS, increasing obesity was associated with reduced hospice use and in-home death and higher Medicare expenditures in the last 6 months of life.

Primary Funding Source: Robert Wood Johnson Foundation Clinical Scholars Program.

ER - TY - ICOMM T1 - Rich American seniors are getting healthier, leaving the poor behind Y1 - 2017 A1 - Matthew A. Davis A1 - Kenneth M. Langa KW - Editorial KW - Income inequality KW - News JF - The Conversation US PB - The Conversation US CY - Cambridge, MA UR - https://theconversation.com/rich-american-seniors-are-getting-healthier-leaving-the-poor-behind-83012 ER - TY - JOUR T1 - Subjective and objective cognitive function among older adults with a history of traumatic brain injury: A population-based cohort study. JF - PLoS Medicine Y1 - 2017 A1 - Raquel C Gardner A1 - Kenneth M. Langa A1 - Kristine Yaffe KW - Brain injury KW - Cognitive Ability KW - Older Adults AB -

BACKGROUND: Traumatic brain injury (TBI) is extremely common across the lifespan and is an established risk factor for dementia. The cognitive profile of the large and growing population of older adults with prior TBI who do not have a diagnosis of dementia, however, has not been well described. Our aim was to describe the cognitive profile associated with prior TBI exposure among community-dwelling older adults without dementia-an understudied but potentially vulnerable population.

METHODS AND FINDINGS: In this population-based cohort study, we studied 984 community-dwelling older adults (age 51 y and older and their spouses) without dementia who had been randomly selected from respondents to the 2014 wave of the Health and Retirement Study to participate in a comprehensive TBI survey and who either reported no prior TBI (n = 737) or prior symptomatic TBI resulting in treatment in a hospital (n = 247). Mean time since first TBI was 38 ± 19 y. Outcomes assessed included measures of global cognitive function, verbal episodic memory, semantic fluency, and calculation as well as a measure of subjective memory ("How would you rate your memory at the present time?"). We compared outcomes between the two TBI groups using regression models adjusting for demographics, medical comorbidities, and depression. Sensitivity analyses were performed stratified by TBI severity (no TBI, TBI without loss of consciousness [LOC], and TBI with LOC). Respondents with TBI were younger (mean age 64 ± 10 y versus 68 ± 11 y), were less likely to be female, and had higher prevalence of medical comorbidities and depression than respondents without TBI. Respondents with TBI did not perform significantly differently from respondents without TBI on any measure of objective cognitive function in either raw or adjusted models (fully adjusted: global cognitive function score 15.4 versus 15.2, p = 0.68; verbal episodic memory score 4.4 versus 4.3, p = 0.79; semantic fluency score 15.7 versus 14.0, p = 0.21; calculation impairment 22% versus 26%, risk ratio [RR] [95% CI] = 0.86 [0.67-1.11], p = 0.24). Sensitivity analyses stratified by TBI severity produced similar results. TBI was associated with significantly increased risk for subjective memory impairment in models adjusted for demographics and medical comorbidities (29% versus 24%; RR [95% CI]: 1.26 [1.02-1.57], p = 0.036). After further adjustment for active depression, however, risk for subjective memory impairment was no longer significant (RR [95% CI]: 1.18 [0.95-1.47], p = 0.13). Sensitivity analyses revealed that risk of subjective memory impairment was increased only among respondents with TBI with LOC and not among those with TBI without LOC. Furthermore, the risk of subjective memory impairment was significantly greater among those with TBI with LOC versus those without TBI even after adjustment for depression (RR [95% CI]: partially adjusted, 1.38 [1.09-1.74], p = 0.008; fully adjusted, 1.28 [1.01-1.61], p = 0.039).

CONCLUSIONS: In this population-based study of community-dwelling older adults without dementia, those with prior TBI with LOC were more likely to report subjective memory impairment compared to those without TBI even after adjustment for demographics, medical comorbidities, and active depression. Lack of greater objective cognitive impairment among those with versus without TBI may be due to poor sensitivity of the cognitive battery or survival bias, or may suggest that post-TBI cognitive impairment primarily affects executive function and processing speed, which were not rigorously assessed in this study. Our findings show that among community-dwelling non-demented older adults, history of TBI is common but may not preferentially impact cognitive domains of episodic memory, attention, working memory, verbal semantic fluency, or calculation.

VL - 14 IS - 3 ER - TY - JOUR T1 - The Use of Life-Sustaining Procedures in the Last Month of Life Is Associated With More Depressive Symptoms in Surviving Spouses. JF - J Pain Symptom Manage Y1 - 2017 A1 - Katherine A Ornstein A1 - Melissa D. Aldridge A1 - Melissa M Garrido A1 - Rebecca Jean Gorges A1 - Bollens-Lund, Evan A1 - Albert L Siu A1 - Kenneth M. Langa A1 - Amy Kelley KW - Aged KW - Aged, 80 and over KW - Caregivers KW - depression KW - Female KW - Humans KW - Intubation KW - Longitudinal Studies KW - Male KW - Mental Health KW - Respiration, Artificial KW - Spouses KW - Survivors KW - Terminal Care AB -

CONTEXT: Family caregivers of individuals with serious illness who undergo intensive life-sustaining medical procedures at the end of life may be at risk of negative consequences including depression.

OBJECTIVES: The objective of this study was to determine the association between patients' use of life-sustaining procedures at the end of life and depressive symptoms in their surviving spouses.

METHODS: We used data from the Health and Retirement Study, a longitudinal survey of U.S. residents, linked to Medicare claims data. We included married Medicare beneficiaries aged 65 years and older who died between 2000 and 2011 (n = 1258) and their surviving spouses. The use of life-sustaining procedures (i.e., intubation/mechanical ventilation, tracheostomy, gastrostomy tube insertion, enteral/parenteral nutrition, and cardiopulmonary resuscitation) in the last month of life was measured via claims data. Using propensity score matching, we compared change in depressive symptoms of surviving spouses.

RESULTS: Eighteen percent of decedents underwent one or more life-sustaining procedures in the last month of life. Those whose spouses underwent life-sustaining procedures had a 0.32-point increase in depressive symptoms after death (scale range = 0-8) and a greater likelihood of clinically significant depression (odds ratio = 1.51) compared with a matched sample of spouses of those who did not have procedures (P < 0.05).

CONCLUSION: Surviving spouses of those who undergo intensive life-sustaining procedures at the end of life experience a greater magnitude of increase in depressive symptoms than those whose spouses do not undergo such procedures. Further study of the circumstances and decision making surrounding these procedures is needed to understand their relationship with survivors' negative mental health consequences and how best to provide appropriate support.

VL - 53 UR - http://linkinghub.elsevier.com/retrieve/pii/S0885392416307850http://api.elsevier.com/content/article/PII:S0885392416307850?httpAccept=text/plainhttp://api.elsevier.com/content/article/PII:S0885392416307850?httpAccept=text/xml IS - 2 U1 - http://www.ncbi.nlm.nih.gov/pubmed/27864126?dopt=Abstract JO - Journal of Pain and Symptom Management ER - TY - JOUR T1 - What’s the “Take Home” from Research on Dementia Trends? JF - PLOS Medicine Y1 - 2017 A1 - Eric B Larson A1 - Kenneth M. Langa KW - Cognitive Ability KW - Dementia VL - 14 UR - http://dx.plos.org/10.1371/journal.pmed.1002236http://dx.plos.org/10.1371/journal.pmed.1002236 IS - 3 JO - PLoS Med ER - TY - RPRT T1 - 2016 Harmonized Cognitive Assessment Protocol (HCAP) Study Protocol Summary Y1 - 2016 A1 - David R Weir A1 - Kenneth M. Langa A1 - Lindsay H Ryan PB - Health and Retirement Study, Survey Research Center, Institute for Social Research, University of Michigan CY - Ann Arbor, MI ER - TY - JOUR T1 - Dispositional Optimism and Incidence of Cognitive Impairment in Older Adults. JF - Psychosom Med Y1 - 2016 A1 - Katerina A B Gawronski A1 - Eric S Kim A1 - Kenneth M. Langa A1 - Laura D Kubzansky KW - Aged KW - Aged, 80 and over KW - Cognitive Dysfunction KW - Female KW - Humans KW - Incidence KW - Male KW - Optimism KW - Protective factors KW - United States AB -

OBJECTIVE: Higher levels of optimism have been linked with positive health behaviors, biological processes, and health conditions that are potentially protective against cognitive impairment in older adults. However, the association between optimism and cognitive impairment has not been directly investigated. We examined whether optimism is associated with incident cognitive impairment in older adults.

METHODS: Data are from the Health and Retirement Study. Optimism was measured by using the Life Orientation Test-R and cognitive impairment with a modified version of the Telephone Interview for Cognitive Status derived from the Mini-Mental State Examination. Using multiple logistic regression models, we prospectively assessed whether optimism was associated with incident cognitive impairment in 4624 adults 65 years and older during a 4-year period.

RESULTS: Among participants, 312 women and 190 men developed cognitive impairment during the 4-year follow-up. Higher optimism was associated with decreased risk of incident cognitive impairment. When adjusted for sociodemographic factors, each standard deviation increase in optimism was associated with reduced odds (odds ratio [OR] = 0.70, 95% confidence interval [CI] = 0.61-0.81) of becoming cognitively impaired. A dose-response relationship was observed. Compared with those with the lowest levels of optimism, people with moderate levels had somewhat reduced odds of cognitive impairment (OR = 0.78, 95% CI = 0.59-1.03), whereas people with the highest levels had the lowest odds of cognitive impairment (OR = 0.52, 95% CI = 0.36-0.74). These associations remained after adjusting for health behaviors, biological factors, and psychological covariates that could either confound the association of interest or serve on the pathway.

CONCLUSIONS: Optimism was prospectively associated with a reduced likelihood of becoming cognitively impaired. If these results are replicated, the data suggest that potentially modifiable aspects of positive psychological functioning such as optimism play an important role in maintaining cognitive functioning.

VL - 78 UR - https://www.ncbi.nlm.nih.gov/pubmed/27284699 IS - 7 U1 - http://www.ncbi.nlm.nih.gov/pubmed/27284699?dopt=Abstract ER - TY - JOUR T1 - Lagged Associations of Metropolitan Statistical Area- and State-Level Income Inequality with Cognitive Function: The Health and Retirement Study. JF - PLoS One Y1 - 2016 A1 - Kim, Daniel A1 - Griffin, Beth Ann A1 - Mohammed U Kabeto A1 - José J Escarce A1 - Kenneth M. Langa A1 - Regina A Shih ED - M. Maria Glymour KW - Cities KW - Cognition KW - Female KW - health KW - Humans KW - Income KW - Interviews as Topic KW - Linear Models KW - Male KW - Middle Aged KW - Multivariate Analysis KW - Residence Characteristics KW - Retirement KW - Socioeconomic factors KW - Statistics as Topic KW - Telephone KW - United States AB -

PURPOSE: Much variation in individual-level cognitive function in late life remains unexplained, with little exploration of area-level/contextual factors to date. Income inequality is a contextual factor that may plausibly influence cognitive function.

METHODS: In a nationally-representative cohort of older Americans from the Health and Retirement Study, we examined state- and metropolitan statistical area (MSA)-level income inequality as predictors of individual-level cognitive function measured by the 27-point Telephone Interview for Cognitive Status (TICS-m) scale. We modeled latency periods of 8-20 years, and controlled for state-/metropolitan statistical area (MSA)-level and individual-level factors.

RESULTS: Higher MSA-level income inequality predicted lower cognitive function 16-18 years later. Using a 16-year lag, living in a MSA in the highest income inequality quartile predicted a 0.9-point lower TICS-m score (β = -0.86; 95% CI = -1.41, -0.31), roughly equivalent to the magnitude associated with five years of aging. We observed no associations for state-level income inequality. The findings were robust to sensitivity analyses using propensity score methods.

CONCLUSIONS: Among older Americans, MSA-level income inequality appears to influence cognitive function nearly two decades later. Policies reducing income inequality levels within cities may help address the growing burden of declining cognitive function among older populations within the United States.

VL - 11 UR - http://dx.doi.org/10.1371/journal.pone.0157327 IS - 6 U1 - http://www.ncbi.nlm.nih.gov/pubmed/27332986?dopt=Abstract JO - PLoS ONE ER - TY - JOUR T1 - Late mortality after sepsis: propensity matched cohort study. JF - BMJ Y1 - 2016 A1 - Hallie C Prescott A1 - Osterholzer, John J A1 - Kenneth M. Langa A1 - Angus, Derek C A1 - Theodore J Iwashyna KW - Aged KW - Aged, 80 and over KW - Case-Control Studies KW - Cause of Death KW - Female KW - Hospital Mortality KW - Hospitalization KW - Humans KW - Longitudinal Studies KW - Male KW - Medicare KW - Propensity Score KW - Prospective Studies KW - Sepsis KW - Time Factors KW - United States AB -

OBJECTIVES:  To determine whether late mortality after sepsis is driven predominantly by pre-existing comorbid disease or is the result of sepsis itself.

DEIGN:  Observational cohort study.

SETTING:  US Health and Retirement Study.

PARTICIPANTS:  960 patients aged ≥65 (1998-2010) with fee-for-service Medicare coverage who were admitted to hospital with sepsis. Patients were matched to 777 adults not currently in hospital, 788 patients admitted with non-sepsis infection, and 504 patients admitted with acute sterile inflammatory conditions.

MAIN OUTCOME MEASURES:  Late (31 days to two years) mortality and odds of death at various intervals.

RESULTS:  Sepsis was associated with a 22.1% (95% confidence interval 17.5% to 26.7%) absolute increase in late mortality relative to adults not in hospital, a 10.4% (5.4% to 15.4%) absolute increase relative to patients admitted with non-sepsis infection, and a 16.2% (10.2% to 22.2%) absolute increase relative to patients admitted with sterile inflammatory conditions (P<0.001 for each comparison). Mortality remained higher for at least two years relative to adults not in hospital.

CONCLUSIONS:  More than one in five patients who survives sepsis has a late death not explained by health status before sepsis.

VL - 353 UR - https://www.ncbi.nlm.nih.gov/pubmed/27189000 U1 - http://www.ncbi.nlm.nih.gov/pubmed/27189000?dopt=Abstract ER - TY - JOUR T1 - Mapping the Two Levels of Digital Divide: Internet Access and Social Network Site Adoption among Older Adults in the USA JF - Information, Communication and Society Y1 - 2016 A1 - Rebecca P. Yu A1 - Nicole B. Ellison A1 - Ryan J McCammon A1 - Kenneth M. Langa KW - Demographics KW - Health Conditions and Status AB - 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. VL - 19 UR - http://dx.doi.org/10.1080/1369118X.2015.1109695 IS - 10 U4 - Social network site/Internet access/digital divide/older adults ER - TY - JOUR T1 - Neuroimaging overuse is more common in Medicare compared with the VA. JF - Neurology Y1 - 2016 A1 - James F. Burke A1 - Eve A Kerr A1 - Ryan J McCammon A1 - Holleman, Rob A1 - Kenneth M. Langa A1 - Brian C. Callaghan KW - Aged KW - Aged, 80 and over KW - Cohort Studies KW - Female KW - Headache Disorders, Primary KW - Humans KW - Male KW - Medicare KW - Neuroimaging KW - Peripheral Nervous System Diseases KW - United States KW - United States Department of Veterans Affairs KW - Unnecessary Procedures AB -

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.

VL - 87 UR - http://www.ncbi.nlm.nih.gov/pubmed/27402889 IS - 8 U1 - http://www.ncbi.nlm.nih.gov/pubmed/27402889?dopt=Abstract ER - TY - JOUR T1 - Racial and ethnic differences in cognitive function among older adults in the USA. JF - International Journal of Geriatric Psychiatry Y1 - 2016 A1 - Díaz-Venegas, Carlos A1 - Brian Downer A1 - Kenneth M. Langa A1 - Rebeca Wong KW - African Americans KW - Aged KW - Aged, 80 and over KW - Cognition KW - Ethnic Groups KW - European Continental Ancestry Group KW - Female KW - Hispanic Americans KW - Humans KW - Male KW - Middle Aged KW - United States AB -

OBJECTIVE: Examine differences in cognition between Hispanic, non-Hispanic black (NHB), and non-Hispanic white (NHW) older adults in the United States.

DATA/METHODS: The final sample includes 18 982 participants aged 51 or older who received a modified version of the Telephone Interview for Cognitive Status during the 2010 Health and Retirement Study follow-up. Ordinary least squares will be used to examine differences in overall cognition according to race/ethnicity.

RESULTS: Hispanics and NHB had lower cognition than NHW for all age groups (51-59, 60-69, 70-79, 80+). Hispanics had higher cognition than NHB for all age groups but these differences were all within one point. The lower cognition among NHB compared to NHW remained significant after controlling for age, gender, and education, whereas the differences in cognition between Hispanics and NHW were no longer significant after controlling for these covariates. Cognitive scores increased with greater educational attainment for all race/ethnic groups, but Hispanics exhibited the least benefit.

DISCUSSION: Our results highlight the role of education in race/ethnic differences in cognitive function during old age. Education seems beneficial for cognition in old age for all race/ethnic groups, but Hispanics appear to receive a lower benefit compared to other race/ethnic groups. Further research is needed on the racial and ethnic differences in the pathways of the benefits of educational attainment for late-life cognitive function. Copyright © 2016 John Wiley & Sons, Ltd.

VL - 31 IS - 9 U4 - Racial differences Whites Hispanics Non-Hispanic Whites Non-Hispanic Blacks Older Adults Cognitive function ER - TY - JOUR T1 - Racial and Ethnic Differences in End-of-Life Medicare Expenditures. JF - Journal of the American Geriatrics Society Y1 - 2016 A1 - Byhoff, Elena A1 - Tamara B Harris A1 - Kenneth M. Langa A1 - Theodore J Iwashyna KW - African Continental Ancestry Group KW - Aged KW - Aged, 80 and over KW - Cohort Studies KW - Comorbidity KW - Cross-Cultural Comparison KW - Ethnic Groups KW - European Continental Ancestry Group KW - Female KW - Health Care Surveys KW - Health Expenditures KW - Hispanic Americans KW - Humans KW - Life Support Care KW - Longitudinal Studies KW - Male KW - Medicare KW - Rate Setting and Review KW - Social Support KW - Socioeconomic factors KW - Terminal Care KW - United States AB -

OBJECTIVES: To determine to what extent demographic, social support, socioeconomic, geographic, medical, and End-of-Life (EOL) planning factors explain racial and ethnic variation in Medicare spending during the last 6 months of life.

DESIGN: Retrospective cohort study.

SETTING: Health and Retirement Study (HRS).

PARTICIPANTS: Decedents who participated in HRS between 1998 and 2012 and previously consented to survey linkage with Medicare claims (N = 7,105).

MEASUREMENTS: Total Medicare expenditures in the last 180 days of life according to race and ethnicity, controlling for demographic factors, social supports, geography, illness burden, and EOL planning factors, including presence of advance directives, discussion of EOL treatment preferences, and whether death had been expected.

RESULTS: The analysis included 5,548 (78.1%) non-Hispanic white, 1,030 (14.5%) non-Hispanic black, and 331 (4.7%) Hispanic adults and 196 (2.8%) adults of other race or ethnicity. Unadjusted results suggest that average EOL Medicare expenditures were $13,522 (35%, P < .001) more for black decedents and $16,341 (42%, P < .001) more for Hispanics than for whites. Controlling for demographic, socioeconomic, geographic, medical, and EOL-specific factors, the Medicare expenditure difference between groups fell to $8,047 (22%, P < .001) more for black and $6,855 (19%, P < .001) more for Hispanic decedents than expenditures for non-Hispanic whites. The expenditure differences between groups remained statistically significant in all models.

CONCLUSION: Individuals-level factors, including EOL planning factors do not fully explain racial and ethnic differences in Medicare spending in the last 6 months of life. Future research should focus on broader systemic, organizational, and provider-level factors to explain these differences.

VL - 64 IS - 9 ER - TY - JOUR T1 - Unfinished business in preventing Alzheimer Disease. JF - JAMA Internal Medicine Y1 - 2016 A1 - Jason H. Karlawish A1 - Kenneth M. Langa KW - Alzheimer's disease KW - Commentary VL - 176 IS - 12 U1 - http://www.ncbi.nlm.nih.gov/pubmed/27749947?dopt=Abstract ER - TY - JOUR T1 - Antidepressant Use and Cognitive Decline: The Health and Retirement Study. JF - Am J Med Y1 - 2015 A1 - Jane S Saczynski A1 - Allison B Rosen A1 - Ryan J McCammon A1 - Zivin, Kara A1 - Susan E. Andrade A1 - Kenneth M. Langa A1 - Sandeep Vijan A1 - Paul A Pirraglia A1 - Becky A. Briesacher KW - Age Distribution KW - Aged KW - Aged, 80 and over KW - Antidepressive Agents KW - Cognition KW - Cross-Sectional Studies KW - Depressive Disorder KW - Female KW - Follow-Up Studies KW - Geriatric Assessment KW - Humans KW - Incidence KW - Male KW - Middle Aged KW - Reference Values KW - Risk Assessment KW - Sex Distribution KW - Surveys and Questionnaires KW - United States AB -

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.

PB - 128 VL - 128 IS - 7 U1 - http://www.ncbi.nlm.nih.gov/pubmed/25644319?dopt=Abstract U2 - PMC4618694 U4 - Antidepressants/Cognition/Depression/CES Depression Scale/CES Depression Scale/COMORBIDITY/Depressive Symptoms ER - TY - JOUR T1 - The association of depression, cognitive impairment without dementia, and dementia with risk of ischemic stroke: a cohort study. JF - Psychosom Med Y1 - 2015 A1 - Dimitry S Davydow A1 - Deborah A Levine A1 - Zivin, Kara A1 - Wayne J Katon A1 - Kenneth M. Langa KW - Aged KW - Aged, 80 and over KW - Cognitive Dysfunction KW - Cohort Studies KW - Dementia KW - depression KW - Female KW - Humans KW - Male KW - Middle Aged KW - Psychiatric Status Rating Scales KW - Retrospective Studies KW - Risk Factors KW - Stroke KW - United States AB -

OBJECTIVE: To determine if depression, cognitive impairment without dementia (CIND), and/or dementia are each independently associated with risk of ischemic stroke and to identify characteristics that could modify these associations.

METHODS: This retrospective-cohort study examined a population-based sample of 7031 Americans older than 50 years participating in the Health and Retirement Study (1998-2008) who consented to have their interviews linked to their Medicare claims. The eight-item Center for Epidemiologic Studies Depression Scale and/or International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) depression diagnoses were used to identify baseline depression. The Modified Telephone Interview for Cognitive Status and/or ICD-9-CM dementia diagnoses were used to identify baseline CIND or dementia. Hospitalizations for ischemic stroke were identified via ICD-9-CM diagnoses.

RESULTS: After adjusting for demographics, medical comorbidities, and health-risk behaviors, CIND alone (odds ratio [OR] = 1.37, 95% confidence interval [CI] = 1.11-1.69) and co-occurring depression and CIND (OR = 1.65, 95% CI = 1.24-2.18) were independently associated with increased odds of ischemic stroke. Depression alone was not associated with odds of ischemic stroke (OR = 1.11, 95% CI = 0.88-1.40) in unadjusted analyses. Neither dementia alone (OR = 1.09, 95% CI = 0.82-1.45) nor co-occurring depression and dementia (OR = 1.25, 95% CI = 0.89-1.76) were associated with odds of ischemic stroke after adjusting for demographics.

CONCLUSIONS: CIND and co-occurring depression and CIND are independently associated with increased risk of ischemic stroke. Individuals with co-occurring depression and CIND represent a high-risk group that may benefit from targeted interventions to prevent stroke.

PB - 77 VL - 77 IS - 2 U1 - http://www.ncbi.nlm.nih.gov/pubmed/25647752?dopt=Abstract ER - TY - JOUR T1 - Does Stroke Contribute to Racial Differences in Cognitive Decline? JF - Stroke Y1 - 2015 A1 - Deborah A Levine A1 - Mohammed U Kabeto A1 - Kenneth M. Langa A1 - Lynda D Lisabeth A1 - Mary A M Rogers A1 - Andrzej T Galecki KW - African Continental Ancestry Group KW - Aged KW - Aged, 80 and over KW - Cognition Disorders KW - European Continental Ancestry Group KW - Female KW - Humans KW - Longitudinal Studies KW - Male KW - Risk Factors KW - Stroke AB -

BACKGROUND AND PURPOSE: It is unknown whether blacks' elevated risk of dementia is because of racial differences in acute stroke, the impact of stroke on cognitive health, or other factors. We investigated whether racial differences in cognitive decline are explained by differences in the frequency or impact of incident stroke between blacks and whites, controlling for baseline cognition.

METHODS: Among 4908 black and white participants aged ≥65 years free of stroke and cognitive impairment in the nationally representative Health and Retirement Study with linked Medicare data (1998-2010), we examined longitudinal changes in global cognition (modified version of the Telephone Interview for Cognitive Status) by race, before and after adjusting for time-dependent incident stroke followed by a race-by-incident stroke interaction term, using linear mixed-effects models that included fixed effects of participant demographics, clinical factors, and cognition, and random effects for intercept and slope for time.

RESULTS: We identified 34 of 453 (7.5%) blacks and 300 of 4455 (6.7%) whites with incident stroke over a mean (SD) of 4.1 (1.9) years of follow-up (P=0.53). Blacks had greater cognitive decline than whites (adjusted difference in modified version of the Telephone Interview for Cognitive Status score, 1.47 points; 95% confidence interval, 1.21 to 1.73 points). With further adjustment for cumulative incidence of stroke, the black-white difference in cognitive decline persisted. Incident stroke was associated with a decrease in global cognition (1.21 points; P<0.001) corresponding to ≈7.9 years of cognitive aging. The effect of incident stroke on cognition did not statistically differ by race (P=0.52).

CONCLUSIONS: In this population-based cohort of older adults, incident stroke did not explain black-white differences in cognitive decline or impact cognition differently by race.

PB - 46 VL - 46 UR - http://stroke.ahajournals.org/content/early/2015/05/20/STROKEAHA.114.008156.abstract IS - 7 U1 - http://www.ncbi.nlm.nih.gov/pubmed/25999389?dopt=Abstract U4 - dementia/Medicare/stroke/African American/cognitive status/decline ER - TY - JOUR T1 - Factors associated with cognitive evaluations in the United States. JF - Neurology Y1 - 2015 A1 - Vikas Kotagal A1 - Kenneth M. Langa A1 - Brenda L Plassman A1 - Gwenith G Fisher A1 - Bruno J Giordani A1 - Robert B Wallace A1 - James F. Burke A1 - David C Steffens A1 - Mohammed U Kabeto A1 - Roger L. Albin A1 - Norman L Foster KW - Aged KW - Aged, 80 and over KW - Cognition Disorders KW - Cohort Studies KW - Dementia KW - Female KW - Humans KW - Logistic Models KW - Male KW - Marital Status KW - Multivariate Analysis KW - Neuropsychological tests KW - Severity of Illness Index KW - United States AB -

OBJECTIVE: We aimed to explore factors associated with clinical evaluations for cognitive impairment among older residents of the United States.

METHODS: Two hundred ninety-seven of 845 subjects in the Aging, Demographics, and Memory Study (ADAMS), a nationally representative community-based cohort study, met criteria for dementia after a detailed in-person study examination. Informants for these subjects reported whether or not they had ever received a clinical cognitive evaluation outside of the context of ADAMS. Among subjects with dementia, we evaluated demographic, socioeconomic, and clinical factors associated with an informant-reported clinical cognitive evaluation using bivariate analyses and multivariable logistic regression.

RESULTS: Of the 297 participants with dementia in ADAMS, 55.2% (representing about 1.8 million elderly Americans in 2002) reported no history of a clinical cognitive evaluation by a physician. In a multivariable logistic regression model (n = 297) controlling for demographics, physical function measures, and dementia severity, marital status (odds ratio for currently married: 2.63 [95% confidence interval: 1.10-6.35]) was the only significant independent predictor of receiving a clinical cognitive evaluation among subjects with study-confirmed dementia.

CONCLUSIONS: Many elderly individuals with dementia do not receive clinical cognitive evaluations. The likelihood of receiving a clinical cognitive evaluation in elderly individuals with dementia associates with certain patient-specific factors, particularly severity of cognitive impairment and current marital status.

VL - 84 UR - http://www.neurology.org/cgi/doi/10.1212/WNL.0000000000001096 IS - 1 U1 - http://www.ncbi.nlm.nih.gov/pubmed/25428689?dopt=Abstract JO - Neurology ER - TY - JOUR T1 - Future Monetary Costs of Dementia in the United States under Alternative Dementia Prevalence Scenarios. JF - Journal of Population Ageing Y1 - 2015 A1 - Michael D Hurd A1 - Martorell, Paco A1 - Kenneth M. Langa KW - Dementia KW - Forecasting KW - Health Conditions and Status KW - Older Adults AB -

Population aging will likely lead to increases is health care spending and the ability of governments to support entitlement programs such as Medicare and Medicaid. Dementia is a chronic condition that is especially pertinent because of its strong association with old age and because care for dementia is labor intensive and expensive. Indeed, prior research has found that if current dementia prevalence rates persist population aging will generate very large increases in health care spending for dementia. In this study we considered two alternative assumptions or scenarios about future prevalence. The first adjusts the prevalence projections using recent research that suggests dementia prevalence may be declining. The second uses growth hypertension, obesity and diabetes, and the relationship between dementia and these conditions to adjust future prevalence rates. We find under the first scenario that if the rates of decline in age-specific dementia rates persist, future costs will be much less than previous estimates, about 40% lower. Under the second scenario, the growth in those conditions makes only small differences in costs.

VL - 8 IS - 1-2 ER - TY - JOUR T1 - Health literacy and the digital divide among older Americans. JF - J Gen Intern Med Y1 - 2015 A1 - Helen G Levy A1 - Alexander T Janke A1 - Kenneth M. Langa KW - Age Factors KW - Aged KW - Aged, 80 and over KW - Cohort Studies KW - Digital Divide KW - Female KW - Health Literacy KW - Humans KW - Internet KW - Male KW - Prospective Studies KW - Retrospective Studies KW - Surveys and Questionnaires KW - United States AB -

BACKGROUND: Among the requirements for meaningful use of electronic medical records (EMRs) is that patients must be able to interact online with information from their records. However, many older Americans may be unprepared to do this, particularly those with low levels of health literacy.

OBJECTIVE: The purpose of the study was to quantify the relationship between health literacy and use of the Internet for obtaining health information among Americans aged 65 and older.

DESIGN: We performed retrospective analysis of 2009 and 2010 data from the Health and Retirement Study, a longitudinal survey of a nationally representative sample of older Americans.

PARTICIPANTS: Subjects were community-dwelling adults aged 65 years and older (824 individuals in the general population and 1,584 Internet users).

MAIN MEASURES: Our analysis included measures of regular use of the Internet for any purpose and use of the Internet to obtain health or medical information; health literacy was measured using the Rapid Estimate of Adult Literacy in Medicine-Revised (REALM-R) and self-reported confidence filling out medical forms.

KEY RESULTS: Only 9.7% of elderly individuals with low health literacy used the Internet to obtain health information, compared with 31.9% of those with adequate health literacy. This gradient persisted after controlling for sociodemographic characteristics, health status, and general cognitive ability. The gradient arose both because individuals with low health literacy were less likely to use the Internet at all (OR = 0.36 [95% CI 0.24 to 0.54]) and because, among those who did use the Internet, individuals with low health literacy were less likely to use it to get health or medical information (OR = 0.60 [95% CI 0.47 to 0.77]).

CONCLUSION: Low health literacy is associated with significantly less use of the Internet for health information among Americans aged 65 and older. Web-based health interventions targeting older adults must address barriers to substantive use by individuals with low health literacy, or risk exacerbating the digital divide.

VL - 30 UR - http://www.scopus.com/inward/record.url?eid=2-s2.0-84914171477andpartnerID=40andmd5=41b0823f4329aba89308dad7c476949a IS - 3 N1 - Export Date: 20 January 2015 Article in Press U1 - http://www.ncbi.nlm.nih.gov/pubmed/25387437?dopt=Abstract U4 - health literacy/health literacy/electronic health records/internet use/sociodemographic characteristics/sociodemographic characteristics ER - TY - JOUR T1 - Hospitalization Type and Subsequent Severe Sepsis. JF - Am J Respir Crit Care Med Y1 - 2015 A1 - Hallie C Prescott A1 - Dickson, R. P. A1 - Mary A M Rogers A1 - Kenneth M. Langa A1 - Lwashyna, T. J. KW - Aged KW - Aged, 80 and over KW - Anti-Bacterial Agents KW - Clostridioides difficile KW - Dysbiosis KW - Enterocolitis, Pseudomembranous KW - Female KW - Hospitalization KW - Humans KW - Incidence KW - Information Storage and Retrieval KW - Longitudinal Studies KW - Male KW - Medicare KW - Patient Readmission KW - Retrospective Studies KW - Risk Factors KW - Sepsis KW - United States AB -

RATIONALE: Hospitalization is associated with microbiome perturbation (dysbiosis), and this perturbation is more severe in patients treated with antimicrobials.

OBJECTIVES: To evaluate whether hospitalizations known to be associated with periods of microbiome perturbation are associated with increased risk of severe sepsis after hospital discharge.

METHODS: We studied participants in the U.S. Health and Retirement Study with linked Medicare claims (1998-2010). We measured whether three hospitalization types associated with increasing severity of probable dysbiosis (non-infection-related hospitalization, infection-related hospitalization, and hospitalization with Clostridium difficile infection [CDI]) were associated with increasing risk for severe sepsis in the 90 days after hospital discharge. We used two study designs: the first was a longitudinal design with between-person comparisons and the second was a self-controlled case series design using within-person comparison.

MEASUREMENTS AND MAIN RESULTS: We identified 43,095 hospitalizations among 10,996 Health and Retirement Study-Medicare participants. In the 90 days following non-infection-related hospitalization, infection-related hospitalization, and hospitalization with CDI, adjusted probabilities of subsequent admission for severe sepsis were 4.1% (95% confidence interval [CI], 3.8-4.4%), 7.1% (95% CI, 6.6-7.6%), and 10.7% (95% CI, 7.7-13.8%), respectively. The incidence rate ratio (IRR) of severe sepsis was 3.3-fold greater during the 90 days after hospitalizations than during other observation periods. The IRR was 30% greater after an infection-related hospitalization versus a non-infection-related hospitalization. The IRR was 70% greater after a hospitalization with CDI than an infection-related hospitalization without CDI.

CONCLUSIONS: There is a strong dose-response relationship between events known to result in dysbiosis and subsequent severe sepsis hospitalization that is not present for rehospitalization for nonsepsis diagnoses.

PB - 192 VL - 192 IS - 5 U1 - http://www.ncbi.nlm.nih.gov/pubmed/26016947?dopt=Abstract U4 - humans/microbiota/self-controlled case series/patient readmission/dysbiosis/CLOSTRIDIUM-DIFFICILE INFECTION/RESPIRATORY SYSTEM/COMMUNITY/PNEUMONIA/CRITICAL CARE MEDICINE/METAANALYSIS/INTESTINAL MICROBIOTA/GUT MICROBIOTA/ANTIBIOTIC-TREATMENT/DISEASE/PREMATURE-INFANTS/FECAL MICROBIOTA TRANSPLANTATION/Enterocolitis, Pseudomembranous - epidemiology/Dysbiosis - epidemiology/Sepsis - epidemiology/Anti-Bacterial Agents - therapeutic use/Hospitalization - statistics/numerical data/Patient Readmission - statistics/numerical data ER - TY - JOUR T1 - Longitudinal patient-oriented outcomes in neuropathy: Importance of early detection and falls. JF - Neurology Y1 - 2015 A1 - Brian C. Callaghan A1 - Kevin Kerber A1 - Kenneth M. Langa A1 - Banerjee, Mousumi A1 - Rodgers, Ann A1 - Ryan J McCammon A1 - James F. Burke A1 - Eva L Feldman KW - Accidental Falls KW - Aged KW - Aged, 80 and over KW - Early Diagnosis KW - Female KW - Humans KW - International Classification of Diseases KW - Longitudinal Studies KW - Male KW - Medicare KW - Patient-Centered Care KW - Peripheral Nervous System Diseases KW - Treatment Outcome KW - United States AB -

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.

PB - 85 VL - 85 IS - 1 U1 - http://www.ncbi.nlm.nih.gov/pubmed/26019191?dopt=Abstract U2 - PMC4501944 U4 - Peripheral neuropathy/Peripheral neuropathy/Medicare/Propensity score ER - TY - JOUR T1 - Older Adults' Residential Proximity to Their Children: Changes After Cardiovascular Events. JF - Journals of Gerontology Series B: Psychological Sciences and Social Sciencess Y1 - 2015 A1 - Choi, Hwajung A1 - Robert F. Schoeni A1 - Kenneth M. Langa A1 - Michele M Heisler KW - Cardiovascular health KW - Heart disease KW - Older Adults KW - Proximity KW - Social Support AB -

OBJECTIVES: To assess changes in family residential proximity after a first cardiovascular (CV) event among older adults and to identify families most likely to experience such moves.

METHOD: Using a nationally representative longitudinal study of older adults in the United States, we identified respondents with no prior diagnosis of CV disease (CVD). We examined subsequent development of stroke, heart attack, and/or heart failure among these older adults and examined changes in their residential proximity to their closest child before and after the CV event. We then compared the likelihood of changes in proximity between families with and without CV events. Finally, we determined which types of families are most likely to relocate following a CV event.

RESULTS: Having a first CV event increases the 2-year predicted probability of children and adult parents moving in with and closer to each other (relative risk ratio = 1.61 and 1.55, respectively). Families are especially likely to move after a first CV event if the older person experiencing the event is spouseless or has a daughter.

DISCUSSION: CVD is a leading cause of disability, which in turn creates a significant need for personal care among older adults. Assessment of changes in family residential proximity responding to CV events is important to fully understand the consequences of older adults' CV events including the cost of caregiving.

VL - 70 IS - 6 ER - TY - RPRT T1 - Racial Difference in the Use of VA Health Services Y1 - 2015 A1 - Fang, Chichun A1 - Kenneth M. Langa A1 - Helen G Levy A1 - David R Weir AB - We study the factors that affect the utilization of health care services administered by the Department of Veterans Affairs (VA) and its racial differences. Due to data limitation, previous research in this regard mostly only focuses on veterans who are VA users or at least eligible for VA services. We fill in the gap in literature with a random sample of veterans 51 and older from the Health and Retirement Study. We find that, among all veterans, those who are black and less healthy are more likely to use VA health services. These factors, nevertheless, are no longer statistically significant after the sample is restricted to veterans who are eligible for VA services. We also find that VA health services and services provided through other channels are at least partial substitutes: VA usage drops when a veteran becomes age eligible for Medicare or when a veteran has health insurance coverage through employment. This drop in usage holds not only among all veterans, but also among veterans eligible for VA services. Finally, perception about the quality of services delivered in VA versus non-VA facilities strongly predicts VA services usage. Those who have favorable views toward VA use VA services more, and the results from variance decomposition suggests a majority part of the racial difference in VA usage can be attributed to the racial difference in such perception. PB - Ann Arbor, MI, Michigan Reirement Research Center, University of Michigan UR - http://www.mrrc.isr.umich.edu/publications/papers/pdf/wp334.pdf U4 - Demographics ER - TY - JOUR T1 - Readmission diagnoses after hospitalization for severe sepsis and other acute medical conditions. JF - JAMA Y1 - 2015 A1 - Hallie C Prescott A1 - Kenneth M. Langa A1 - Theodore J Iwashyna KW - Acute Disease KW - Hospitalization KW - Humans KW - Patient Readmission KW - Sepsis PB - 313 VL - 313 UR - http://dx.doi.org/10.1001/jama.2015.1410 IS - 10 N1 - 10.1001/jama.2015.1410 U1 - http://www.ncbi.nlm.nih.gov/pubmed/25756444?dopt=Abstract ER - TY - JOUR T1 - The relationships that matter: social network site use and social wellbeing among older adults in the United States of America JF - Ageing and Society Y1 - 2015 A1 - R. P. Yu A1 - Ryan J McCammon A1 - Nicole B. Ellison A1 - Kenneth M. Langa KW - Adult children KW - Health Conditions and Status AB - 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. UR - http://www.scopus.com/inward/record.url?eid=2-s2.0-84934325062andpartnerID=40andmd5=4576f4f7c6bbe43a40f9370e613cde7a N1 - Export Date: 9 September 2015 Article in Press U4 - feelings of connectedness/feelings of isolation/social network site/social support/social wellbeing ER - TY - JOUR T1 - Spouse and Child Availability for Newly Disabled Older Adults: Socioeconomic Differences and Potential Role of Residential Proximity. JF - J Gerontol B Psychol Sci Soc Sci Y1 - 2015 A1 - Choi, Hwajung A1 - Robert F. Schoeni A1 - Kenneth M. Langa A1 - Michele M Heisler KW - Activities of Daily Living KW - Adult children KW - Aged KW - Aged, 80 and over KW - Aging KW - Disabled Persons KW - Female KW - Home Nursing KW - Humans KW - Male KW - Middle Aged KW - Nursing homes KW - Residence Characteristics KW - Social Class KW - Spouses AB -

OBJECTIVES: To examine the potential role of child and spousal availability in facilitating community-based care for disabled older adults.

METHOD: We used the Health and Retirement Study, a nationally representative longitudinal study of older adults. The analysis sample included older adults who were nondisabled at baseline, but who then developed at least one activity of daily living (ADL) limitation over the subsequent 2-year period (N = 2,094). Using multivariate, multinomial logistic regression, we examined the association of child and spouse availability prior to disablement of the older adults with ADL care receipt status after the onset of disablement, after adjusting for other sociodemographic and clinical characteristics.

RESULTS: Lower socioeconomic status (SES) was associated with less availability of a spouse but greater availability of children at baseline. Compared with older adults who had no children nearby (i.e., all children lived further than 30 miles), older adults who had at least one child living with or near them prior to the onset of the ADL limitation were less likely to go to a nursing home (adjusted odds ratio [AOR]: 0.26 for coresident; AOR: 0.44 for 1- 30 miles) and less likely to depend on formal care (AOR: 0.39 for coresident; AOR: 0.51 for 1-30 miles) after the onset of new ADL limitation/s.

DISCUSSION: Understanding SES variations in the informal care resources, and potential role of child geographic availability, may inform the development of cost-effective community-based care programs and policies.

PB - 70 VL - 70 UR - http://psychsocgerontology.oxfordjournals.org/content/early/2014/03/06/geronb.gbu015.abstract IS - 3 U1 - http://www.ncbi.nlm.nih.gov/pubmed/24607786?dopt=Abstract U4 - Disability/Disability/Geographic proximity/Informal care/Socioeconomic status/community-based care/activities of daily living ER - TY - JOUR T1 - US Prevalence And Predictors Of Informal Caregiving For Dementia. JF - Health Affairs Y1 - 2015 A1 - Esther M Friedman A1 - Regina A Shih A1 - Kenneth M. Langa A1 - Michael D Hurd KW - Caregiving KW - Dementia KW - Demographics KW - Long-term Care KW - Older Adults AB - In 2010, 5.5 million US adults ages seventy and older received informal care, including 3.6 million with cognitive impairment or probable dementia. Adults with probable dementia received 171 hours of monthly informal care, versus 89 and 66 hours for cognitively impaired without dementia and cognitively normal adults, respectively. VL - 34 IS - 10 ER - TY - JOUR T1 - Acute infection contributes to racial disparities in stroke mortality. JF - Neurology Y1 - 2014 A1 - Deborah A Levine A1 - Kenneth M. Langa A1 - Mary A M Rogers KW - Black or African American KW - Case-Control Studies KW - Female KW - Health Status Disparities KW - Healthcare Disparities KW - Hispanic or Latino KW - Humans KW - Infections KW - Male KW - Odds Ratio KW - Retrospective Studies KW - Risk Factors KW - Stroke KW - White People AB -

OBJECTIVE: It is unknown whether racial differences in exposure to acute precipitants of stroke, specifically infection, contribute to racial disparities in stroke mortality.

METHODS: Among participants in the nationally representative Health and Retirement Study with linked Medicare data (1991-2007), we conducted a case-crossover study employing within-person comparisons to study racial/ethnic differences in the risks of death and hospitalization from ischemic stroke following acute infection.

RESULTS: There were 964 adults hospitalized for ischemic stroke. Acute infection increased the 30-day risks of ischemic stroke death (5.82-fold) and ischemic stroke hospitalization (1.87-fold). Acute infection was a more potent trigger of acute ischemic stroke death in non-Hispanic blacks (odds ratio [OR] 39.21; 95% confidence interval [CI] 9.26-166.00) than in non-Hispanic whites (OR 4.50; 95% CI 3.14-6.44) or Hispanics (OR 5.18; 95% CI 1.34-19.95) (race-by-stroke interaction, p = 0.005). When adjusted for atrial fibrillation, infection remained more strongly associated with stroke mortality in blacks (OR 34.85) than in whites (OR 3.58) and Hispanics (OR 3.53). Acute infection increased the short-term risk of incident stroke similarly across racial/ethnic groups. Infection occurred often before stroke death in non-Hispanic blacks, with 70% experiencing an infection in the 30 days before stroke death compared to a background frequency of 15%.

CONCLUSIONS: Acute infection disproportionately increases the risk of stroke death for non-Hispanic blacks, independently of atrial fibrillation. Stroke incidence did not explain this finding. Acute infection appears to be one factor that contributes to the black-white disparity in stroke mortality.

PB - 82 VL - 82 IS - 11 N1 - Times Cited: 0 U1 - http://www.ncbi.nlm.nih.gov/pubmed/24510494?dopt=Abstract U4 - Racial and ethnic difference/Stroke/Medicare/hospitalization/ischemic stroke/atrial fibrillation ER - TY - JOUR T1 - Advance directives and nursing home stays associated with less aggressive end-of-life care for patients with severe dementia. JF - Health Affairs Y1 - 2014 A1 - Lauren Hersch Nicholas A1 - Julie P W Bynum A1 - Theodore J Iwashyna A1 - David R Weir A1 - Kenneth M. Langa KW - Advance directives KW - Dementia KW - Disabilities KW - End-of-life care KW - Nursing homes KW - Older Adults AB -

The number of older adults with cognitive impairment is increasing, and such adults often require a surrogate to make decisions about health care. However, little is known about the aggressiveness of end-of-life care for these people, especially those who reside in the community. We found that cognitive impairment is common among older adults approaching the end of life, whether they live in the community or in a nursing home, and that nearly 30 percent of patients with severe dementia remained in the community until death. Among those patients, having an advance directive in the form of a living will was associated with significantly less aggressive care at the end of life, compared to similar patients without an advance directive-as measured by Medicare spending ($11,461 less per patient), likelihood of in-hospital death (17.9 percentage points lower), and use of the intensive care unit (9.4 percentage points lower). In contrast, advance directives were not associated with differences in care for people with normal cognition or mild dementia, whether they resided in the community or in a nursing home. Timely advance care planning after a diagnosis of cognitive impairment may be particularly important for older adults who reside in the community.

VL - 33 IS - 4 ER - TY - JOUR T1 - Aging children of long-lived parents experience slower cognitive decline JF - Alzheimer's and Dementia Y1 - 2014 A1 - Ambarish Dutta A1 - Henley, William A1 - Robine, Jean-Marie A1 - David J Llewellyn A1 - Kenneth M. Langa A1 - Robert B Wallace A1 - David Melzer KW - Adult children KW - Expectations KW - Genetics KW - Health Conditions and Status PB - 10 VL - 10 UR - http://www.sciencedirect.com/science/article/pii/S1552526013024965 IS - 5 U4 - Dementia/Memory disorder/Aging/Parental longevity/Extreme survival/Cognitive impairment/Heritability ER - TY - RPRT T1 - Cognitive Test Selection for the Harmonized Cognitive Assessment Protocol (HCAP) Y1 - 2014 A1 - David R Weir A1 - Ryan J McCammon A1 - Lindsay H Ryan A1 - Kenneth M. Langa KW - Cognitive Ability KW - HCAP KW - Meta-analyses KW - Survey Methodology AB - 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. PB - Institute for Social Research, University of Michigan CY - Ann Arbor, Michigan ER - TY - JOUR T1 - Cohort Profile: the Health and Retirement Study (HRS). JF - Int J Epidemiol Y1 - 2014 A1 - Amanda Sonnega A1 - Jessica Faul A1 - Mary Beth Ofstedal A1 - Kenneth M. Langa A1 - John W R Phillips A1 - David R Weir KW - Aged KW - Female KW - Genetic Predisposition to Disease KW - Health Status KW - Humans KW - Longitudinal Studies KW - Male KW - Mental Health KW - Middle Aged KW - Physical Fitness KW - Retirement KW - United States AB -

The Health and Retirement Study (HRS) is a nationally representative longitudinal survey of more than 37 000 individuals over age 50 in 23 000 households in the USA. The survey, which has been fielded every 2 years since 1992, was established to provide a national resource for data on the changing health and economic circumstances associated with ageing at both individual and population levels. Its multidisciplinary approach is focused on four broad topics-income and wealth; health, cognition and use of healthcare services; work and retirement; and family connections. HRS data are also linked at the individual level to administrative records from Social Security and Medicare, Veteran's Administration, the National Death Index and employer-provided pension plan information. Since 2006, data collection has expanded to include biomarkers and genetics as well as much greater depth in psychology and social context. This blend of economic, health and psychosocial information provides unprecedented potential to study increasingly complex questions about ageing and retirement. The HRS has been a leading force for rapid release of data while simultaneously protecting the confidentiality of respondents. Three categories of data-public, sensitive and restricted-can be accessed through procedures described on the HRS website (hrsonline.isr.umich.edu).

PB - 43 VL - 43 IS - 2 U1 - http://www.ncbi.nlm.nih.gov/pubmed/24671021?dopt=Abstract U4 - administrative data/Restricted data ER - TY - JOUR T1 - Death certificates underestimate infections as proximal causes of death in the U.S. JF - PLoS One Y1 - 2014 A1 - Govindan, Sushant A1 - Shapiro, Letitia A1 - Kenneth M. Langa A1 - Theodore J Iwashyna KW - Cause of Death KW - Death Certificates KW - Hospitalization KW - Humans KW - Infections KW - Medicare KW - United States AB -

BACKGROUND: Death certificates are a primary data source for assessing the population burden of diseases; however, there are concerns regarding their accuracy. Diagnosis-Related Group (DRG) coding of a terminal hospitalization may provide an alternative view. We analyzed the rate and patterns of disagreement between death certificate data and hospital claims for patients who died during an inpatient hospitalization.

METHODS: We studied respondents from the Health and Retirement Study (a nationally representative sample of older Americans who had an inpatient death documented in the linked Medicare claims from 1993-2007). Causes of death abstracted from death certificates were aggregated to the standard National Center for Health Statistics List of 50 Rankable Causes of Death. Centers for Medicare and Medicaid Services (CMS)-DRGs were manually aggregated into a parallel classification. We then compared the two systems via 2×2, focusing on concordance. Our primary analysis was agreement between the two data sources, assessed with percentages and Cohen's kappa statistic.

RESULTS: 2074 inpatient deaths were included in our analysis. 36.6% of death certificate cause-of-death codes agreed with the reason for the terminal hospitalization in the Medicare claims at the broad category level; when re-classifying DRGs without clear alignment as agreements, the concordance only increased to 61%. Overall Kappa was 0.21, or "fair." Death certificates in this cohort redemonstrated the conventional top 3 causes of death as diseases of the heart, malignancy, and cerebrovascular disease. However, hospitalization claims data showed infections, diseases of the heart, and cerebrovascular disease as the most common diagnoses for the same terminal hospitalizations.

CONCLUSION: There are significant differences between Medicare claims and death certificate data in assigning cause of death for inpatients. The importance of infections as proximal causes of death is underestimated by current death certificate-based strategies.

PB - 9 VL - 9 IS - 5 N1 - Times Cited: 0 U1 - http://www.ncbi.nlm.nih.gov/pubmed/24878897?dopt=Abstract U2 - PMC4039437 U4 - Medicare claims/Infection/death certificate/cause of death/survey methods ER - TY - JOUR T1 - Depression and risk of hospitalization for pneumonia in a cohort study of older Americans. JF - J Psychosom Res Y1 - 2014 A1 - Dimitry S Davydow A1 - Catherine L Hough A1 - Zivin, Kara A1 - Kenneth M. Langa A1 - Wayne J Katon KW - Aged KW - Aged, 80 and over KW - Cohort Studies KW - Comorbidity KW - depression KW - Depressive Disorder KW - Female KW - Hospitalization KW - Humans KW - Logistic Models KW - Male KW - Middle Aged KW - Odds Ratio KW - Pneumonia KW - Risk Assessment KW - Risk Factors KW - United States AB -

OBJECTIVE: The aim of this study is to determine if depression is independently associated with risk of hospitalization for pneumonia after adjusting for demographics, medical comorbidity, health-risk behaviors, baseline cognition and functional impairments.

METHODS: This secondary analysis of prospectively collected data examined a population-based sample of 6704 Health and Retirement Study (HRS) (1998-2008) participants>50years old who consented to have their interviews linked to their Medicare claims and were without a dementia diagnosis. The eight-item Center for Epidemiologic Studies Depression Scale and/or International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) depression diagnoses were used to identify baseline depression. ICD-9-CM diagnoses were used to identify hospitalizations for which the principal discharge diagnosis was for bacterial or viral pneumonia. The odds of hospitalization for pneumonia for participants with depression relative to those without depression were estimated using logistic regression models. Population attributable fractions were calculated to determine the extent that hospitalizations for pneumonia could be attributable to depression.

RESULTS: After adjusting for demographic characteristics, clinical factors, and health-risk behaviors, depression was independently associated with increased odds of hospitalization for pneumonia (odds ratio [OR]: 1.28, 95% confidence interval [95%CI]: 1.08, 1.53). This association persisted after adjusting for baseline cognition and functional impairments (OR: 1.24, 95%CI: 1.03, 1.50). In this cohort, 6% (95%CI: 2%, 10%) of hospitalizations for pneumonia were potentially attributable to depression.

CONCLUSION: Depression is independently associated with increased odds of hospitalization for pneumonia. This study provides additional rationale for integrating mental health care into medical settings in order to improve outcomes for older adults.

PB - 77 VL - 77 IS - 6 N1 - Times Cited: 0 0 U1 - http://www.ncbi.nlm.nih.gov/pubmed/25139125?dopt=Abstract U2 - PMC4259844 U4 - Depression/Pneumonia/Hospitalization/Outcome assessment (health care)/health Care Utilization/mental Health ER - TY - JOUR T1 - Development and validation of a brief dementia screening indicator for primary care. JF - Alzheimers Dement Y1 - 2014 A1 - Deborah E Barnes A1 - Alexa S. Beiser A1 - Anne Lee A1 - Kenneth M. Langa A1 - Alain Koyama A1 - Sarah R Preis A1 - John Neuhaus A1 - Ryan J McCammon A1 - Kristine Yaffe A1 - Seshadri, Sudha A1 - Mary Haan A1 - David R Weir KW - Aged KW - Cohort Studies KW - Dementia KW - Female KW - Humans KW - Male KW - Mass Screening KW - Predictive Value of Tests KW - Primary Health Care KW - Proportional Hazards Models KW - Risk Assessment AB -

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'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.

PB - 10 VL - 10 UR - http://www.scopus.com/inward/record.url?eid=2-s2.0-84893186546andpartnerID=40andmd5=3b617dce24578e022db389d90ad9ddd1 IS - 6 N1 - Export Date: 21 April 2014 Source: Scopus Article in Press U1 - http://www.ncbi.nlm.nih.gov/pubmed/24491321?dopt=Abstract U2 - PMC4119094 U4 - Dementia/Primary care/Risk prediction modeling/Screening/Cognitive Impairment ER - TY - JOUR T1 - Economic development and gender inequality in cognition: a comparison of China and India, and of SAGE and the HRS sister studies. JF - Journal of Economics of Ageing Y1 - 2014 A1 - David R Weir A1 - Margaret Lay A1 - Kenneth M. Langa KW - CHARLS KW - Economics KW - Gender Differences KW - LASI KW - Older Adults KW - SAGE KW - Sister studies AB -

This paper examines cognition measures by age and gender from two types of studies in China and India. It finds that despite some notable differences in samples and measures, a general strong association of cognition in older ages with education emerges as a potential explanation for gender gaps and cohort differences. Female disadvantage in cognition is greater in India, both before and after controlling for education. The process of rural-urban migration draws more cognitively able women to cities in China but not in India. The advent of modern longitudinal studies of aging in these developing countries holds great promise for future work.

VL - 4 ER - TY - JOUR T1 - Education, brain health, and improving life opportunities for women JF - The Journal of the Economics of Ageing Y1 - 2014 A1 - Kenneth M. Langa A1 - Eric B Larson KW - Education KW - Gender Differences KW - Life opportunities KW - Older Adults KW - Women and Minorities AB - The paper by Lei et al. in this issue adds to the growing body of empirical evidence that education and cognitive stimulation, both in early-life and in later-life, seem especially important for cognitive health and the prevention of cognitive decline with aging. The expanding educational opportunities for girls and women in developing countries such as China over the last few decades appear to have played an important role in improving their cognitive health and, in turn, have likely expanded their opportunities to participate more fully and successfully in both work and social roles. While “curing” dementia in the coming decades seems unlikely, decreasing the risk of cognitive impairment and disability in both developed and developing countries through increasing education, life-long cognitive stimulation, and improved control of cardiovascular risk appears achievable. Success would benefit people of all ages by keeping older adults more independent and productive, and minimizing the burden of support on younger generations. VL - 4 UR - http://linkinghub.elsevier.com/retrieve/pii/S2212828X14000176http://api.elsevier.com/content/article/PII:S2212828X14000176?httpAccept=text/xmlhttp://api.elsevier.com/content/article/PII:S2212828X14000176?httpAccept=text/plain JO - The Journal of the Economics of Ageing ER - TY - JOUR T1 - Functional disability and cognitive impairment after hospitalization for myocardial infarction and stroke. JF - Circ Cardiovasc Qual Outcomes Y1 - 2014 A1 - Deborah A Levine A1 - Dimitry S Davydow A1 - Catherine L Hough A1 - Kenneth M. Langa A1 - Mary A M Rogers A1 - Theodore J Iwashyna KW - Activities of Daily Living KW - Cognition KW - Cognition Disorders KW - Disability Evaluation KW - Disabled Persons KW - Female KW - Follow-Up Studies KW - Hospitalization KW - Humans KW - Incidence KW - Male KW - Middle Aged KW - Myocardial Infarction KW - Odds Ratio KW - Retrospective Studies KW - Stroke KW - Time Factors KW - United States AB -

BACKGROUND: We assessed the acute and long-term effect of myocardial infarction (MI) and stroke on postevent functional disability and cognition while controlling for survivors' changes in functioning over the years before the event.

METHODS AND RESULTS: Among participants in the nationally representative Health and Retirement Study with linked Medicare data (1998-2010), we determined within-person changes in functional limitations (basic and instrumental activities of daily living) and cognitive impairment after hospitalization for stroke (n=432) and MI (n=450), controlling for premorbid functioning using fixed-effects regression. In persons without baseline impairments, an acute MI yielded a mean acute increase of 0.41 functional limitations (95% confidence interval [CI], 0.18-0.63) with a linear increase of 0.14 limitations/year in the following decade. These increases were 0.65 limitations (95% CI, 0.07-1.23) and 0.27 limitations/year afterward for those with mild-to-moderate impairment at baseline. Stroke resulted in an acute increase of 2.07 (95% CI, 1.51-2.63) limitations because of the acute event and an increase of 0.15 limitations/year afterward for those unimpaired at baseline. There were 2.65 new limitations (95% CI, 1.86-3.44) and 0.19/year afterward for those with baseline mild-to-moderate impairment. Stroke hospitalization was associated with greater odds of moderate-to-severe cognitive impairment (odds ratio, 3.86; 95% CI, 2.10-7.11) at the time of the event, after adjustment for premorbid cognition but MI hospitalization was not.

CONCLUSIONS: In this population-based cohort, most MI and stroke hospitalizations were associated with significant increases in functional disability at the time of the event and in the decade afterward. Survivors of MI and stroke warrant screening for functional disability over the long-term.

PB - 7 VL - 7 IS - 6 N1 - Times Cited: 1 0 1 U1 - http://www.ncbi.nlm.nih.gov/pubmed/25387772?dopt=Abstract U4 - activities of daily living/cognitive impairment/myocardial infarction/stroke/functional decline/functional decline/Transient Ischemic Attack/Coronary Artery Disease/quality of life/medicare ER - TY - JOUR T1 - Geographic variation in out-of-pocket expenditures of elderly Medicare beneficiaries. JF - J Am Geriatr Soc Y1 - 2014 A1 - Lena M. Chen A1 - Edward C Norton A1 - Kenneth M. Langa A1 - Le, Sidney A1 - Arnold M. Epstein KW - Aged KW - Aged, 80 and over KW - Cohort Studies KW - Female KW - Geography KW - Health Care Costs KW - Health Expenditures KW - Humans KW - Male KW - Medicare KW - Retrospective Studies KW - United States AB -

OBJECTIVES: To examine whether out-of-pocket expenditures (OOPEs) exhibit the same geographic variation as Medicare claims, given wide variation in the costs of U.S. health care, but no information on how that translates into OOPEs or financial burden for older Americans.

DESIGN: Retrospective cohort study.

SETTING: Data from the Health and Retirement Study linked to Medicare claims.

PARTICIPANTS: A nationally representative cohort of 4,657 noninstitutionalized, community-dwelling, fee-for-service elderly Medicare beneficiaries interviewed in 2006 and 2008.

MEASUREMENTS: The primary predictor was per capita Medicare spending quintile according to hospital referral region. The primary outcome was a self-reported, validated measure of annual OOPEs excluding premiums.

RESULTS: Mean and median adjusted per capita Medicare payments were $5,916 and $2,635, respectively; mean and median adjusted OOPEs were $1,525 and $779, respectively. Adjusted median Medicare payments were $3,474 in the highest cost quintile and $1,942 in the lowest cost quintile (ratio 1.79, P < .001 for difference). In contrast, adjusted median OOPEs were not higher in the highest than in the lowest Medicare cost quintile ($795 vs $764 for a Q5:Q1 ratio of 1.04, P = .42). The Q5:Q1 ratio was 1.48 for adjusted mean Medicare payments and 1.04 for adjusted mean OOPEs (both P < .001).

CONCLUSION: Medicare payments vary widely between high- and low-cost regions, but OOPEs do not.

PB - 62 VL - 62 IS - 6 N1 - Times Cited: 0 U1 - http://www.ncbi.nlm.nih.gov/pubmed/24852182?dopt=Abstract U4 - Medicare/geographic variation/out-of-pocket expenditures ER - TY - JOUR T1 - History of alcohol use disorders and risk of severe cognitive impairment: a 19-year prospective cohort study. JF - Am J Geriatr Psychiatry Y1 - 2014 A1 - Kuźma, Elżbieta A1 - David J Llewellyn A1 - Kenneth M. Langa A1 - Robert B Wallace A1 - Iain A Lang KW - Alcohol-Related Disorders KW - Cognition Disorders KW - Diagnosis, Dual (Psychiatry) KW - Female KW - Humans KW - Incidence KW - Male KW - Memory Disorders KW - Middle Aged KW - Prospective Studies KW - Risk Factors KW - United States AB -

OBJECTIVE: To assess the effects of a history of alcohol use disorders (AUDs) on risk of severe cognitive and memory impairment in later life.

METHODS: We studied the association between history of AUDs and the onset of severe cognitive and memory impairment in 6,542 middle-aged adults born 1931 through 1941 who participated in the Health and Retirement Study, a prospective nationally representative U.S. cohort. Participants were assessed at 1992 baseline and follow-up cognitive assessments were conducted biannually from 1996 through 2010. History of AUDs was identified using the three-item modified CAGE questionnaire. Cognitive outcomes were assessed using the 35-item modified Telephone Interview for Cognitive Status at last follow-up with incident severe cognitive impairment defined as a score ≤ 8, and incident severe memory impairment defined as a score ≤ 1 on a 20-item memory subscale.

RESULTS: During up to 19 years of follow-up (mean: 16.7 years, standard deviation: 3.0, range: 3.5-19.1 years), 90 participants experienced severe cognitive impairment and 74 participants experienced severe memory impairment. History of AUDs more than doubled the odds of severe memory impairment (odds ratio [OR] = 2.21, 95% confidence interval [CI] = 1.27-3.85, t = 2.88, df = 52, p = 0.01). The association with severe cognitive impairment was statistically non-significant but in the same direction (OR = 1.80, 95% CI = 0.97-3.33, t = 1.92, df = 52, p = 0.06).

CONCLUSION: Middle-aged adults with a history of AUDs have increased odds of developing severe memory impairment later in life. These results reinforce the need to consider the relationship between alcohol consumption and cognition from a multifactorial lifespan perspective.

PB - 22 VL - 22 UR - http://www.sciencedirect.com/science/article/pii/S1064748114001675 IS - 10 U1 - http://www.ncbi.nlm.nih.gov/pubmed/25091517?dopt=Abstract U2 - PMC4165640 U4 - Alcohol use disorders/memory impairment/cognitive impairment/cognitive ability/alcohol consumption ER - TY - JOUR T1 - Increased 1-year healthcare use in survivors of severe sepsis. JF - Am J Respir Crit Care Med Y1 - 2014 A1 - Hallie C Prescott A1 - Kenneth M. Langa A1 - Liu, Vincent A1 - Gabriel J. Escobar A1 - Theodore J Iwashyna KW - Aged KW - Female KW - Health Facilities KW - Humans KW - Insurance Claim Review KW - Long-term Care KW - Male KW - Medical Record Linkage KW - Medicare KW - Mortality KW - Outcome Assessment, Health Care KW - Patient Readmission KW - Prospective Studies KW - Sepsis KW - Skilled Nursing Facilities KW - Survivors KW - United States AB -

RATIONALE: Hospitalizations for severe sepsis are common, and a growing number of patients survive to hospital discharge. Nonetheless, little is known about survivors' post-discharge healthcare use.

OBJECTIVES: To measure inpatient healthcare use of severe sepsis survivors compared with patients' own presepsis resource use and the resource use of survivors of otherwise similar nonsepsis hospitalizations.

METHODS: This is an observational cohort study of survivors of severe sepsis and nonsepsis hospitalizations identified from participants in the Health and Retirement Study with linked Medicare claims, 1998-2005. We matched severe sepsis and nonsepsis hospitalizations by demographics, comorbidity burden, premorbid disability, hospitalization length, and intensive care use.

MEASUREMENTS AND MAIN RESULTS: Using Medicare claims, we measured patients' use of inpatient facilities (hospitals, long-term acute care hospitals, and skilled nursing facilities) in the 2 years surrounding hospitalization. Severe sepsis survivors spent more days (median, 16 [interquartile range, 3-45] vs. 7 [0-29]; P < 0.001) and a higher proportion of days alive (median, 9.6% [interquartile range, 1.4-33.8%] vs. 1.9% [0.0-7.9%]; P < 0.001) admitted to facilities in the year after hospitalization, compared with the year prior. The increase in facility-days was similar for nonsepsis hospitalizations. However, the severe sepsis cohort experienced greater post-discharge mortality (44.2% [95% confidence interval, 41.3-47.2%] vs. 31.4% [95% confidence interval, 28.6-34.2%] at 1 year), a steeper decline in days spent at home (difference-in-differences, -38.6 d [95% confidence interval, -50.9 to 26.3]; P < 0.001), and a greater increase in the proportion of days alive spent in a facility (difference-in-differences, 5.4% [95% confidence interval, 2.8-8.1%]; P < 0.001).

CONCLUSIONS: Healthcare use is markedly elevated after severe sepsis, and post-discharge management may be an opportunity to reduce resource use.

PB - 190 VL - 190 IS - 1 N1 - Times Cited: 1 U1 - http://www.ncbi.nlm.nih.gov/pubmed/24872085?dopt=Abstract U4 - healthcare facilities/sepsis/hospitalization/patient outcomes assessment/patient readmission/skilled nursing facility ER - TY - JOUR T1 - Leveraging the health and retirement study to advance palliative care research. JF - J Palliat Med Y1 - 2014 A1 - Amy Kelley A1 - Kenneth M. Langa A1 - John G. Cagle A1 - Katherine A Ornstein A1 - Maria J Silveira A1 - Lauren Hersch Nicholas A1 - Kenneth E Covinsky A1 - Christine S Ritchie KW - Aged KW - Caregivers KW - Evidence-Based Practice KW - Health Services Research KW - Health Surveys KW - Humans KW - Longitudinal Studies KW - Needs Assessment KW - Pain Management KW - Palliative care KW - Quality of Life KW - Retirement KW - Sociological Factors KW - United States AB -

BACKGROUND: The critical need to expand and develop the palliative care evidence base was recently highlighted by the Journal of Palliative Medicine's series of articles describing the Research Priorities in Geriatric Palliative Care. The Health and Retirement Study (HRS) is uniquely positioned to address many priority areas of palliative care research. This nationally representative, ongoing, longitudinal study collects detailed survey data every 2 years, including demographics, health and functional characteristics, information on family and caregivers, and personal finances, and also conducts a proxy interview after each subject's death. The HRS can also be linked with Medicare claims data and many other data sources, e.g., U.S. Census, Dartmouth Atlas of Health Care.

SETTING: While the HRS offers innumerable research opportunities, these data are complex and limitations do exist. Therefore, we assembled an interdisciplinary group of investigators using the HRS for palliative care research to identify the key palliative care research gaps that may be amenable to study within the HRS and the strengths and weaknesses of the HRS for each of these topic areas.

CONCLUSION: In this article we present the work of this group as a potential roadmap for investigators contemplating the use of HRS data for palliative care research.

PB - 17 VL - 17 IS - 5 U1 - http://www.ncbi.nlm.nih.gov/pubmed/24694096?dopt=Abstract U2 - PMC4012620 U4 - Caregivers/Evidence-Based Practice/Needs Assessment/Pain Management/Palliative Care ER - TY - JOUR T1 - Neuropsychiatric disorders and potentially preventable hospitalizations in a prospective cohort study of older Americans. JF - J Gen Intern Med Y1 - 2014 A1 - Dimitry S Davydow A1 - Zivin, Kara A1 - Wayne J Katon A1 - Gregory M Pontone A1 - Lydia Chwastiak A1 - Kenneth M. Langa A1 - Theodore J Iwashyna KW - Aged KW - Aged, 80 and over KW - Cognition Disorders KW - Cohort Studies KW - Dementia KW - depression KW - Female KW - Hospitalization KW - Humans KW - Male KW - Mental Disorders KW - Prospective Studies KW - Risk Factors KW - United States AB -

BACKGROUND: The relative contributions of depression, cognitive impairment without dementia (CIND), and dementia to the risk of potentially preventable hospitalizations in older adults are not well understood.

OBJECTIVE(S): To determine if depression, CIND, and/or dementia are each independently associated with hospitalizations for ambulatory care-sensitive conditions (ACSCs) and rehospitalizations within 30 days after hospitalization for pneumonia, congestive heart failure (CHF), or myocardial infarction (MI).

DESIGN: Prospective cohort study.

PARTICIPANTS: Population-based sample of 7,031 Americans > 50 years old participating in the Health and Retirement Study (1998-2008).

MAIN MEASURES: The eight-item Center for Epidemiologic Studies Depression Scale and/or International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) depression diagnoses were used to identify baseline depression. The Modified Telephone Interview for Cognitive Status and/or ICD-9-CM dementia diagnoses were used to identify baseline CIND or dementia. Primary outcomes were time to hospitalization for an ACSC and presence of a hospitalization within 30 days after hospitalization for pneumonia, CHF, or MI.

KEY RESULTS: All five categories of baseline neuropsychiatric disorder status were independently associated with increased risk of hospitalization for an ACSC (depression alone: Hazard Ratio [HR]: 1.33, 95% Confidence Interval [95%CI]: 1.18, 1.52; CIND alone: HR: 1.25, 95%CI: 1.10, 1.41; dementia alone: HR: 1.32, 95%CI: 1.12, 1.55; comorbid depression and CIND: HR: 1.43, 95%CI: 1.20, 1.69; comorbid depression and dementia: HR: 1.66, 95%CI: 1.38, 2.00). Depression (Odds Ratio [OR]: 1.37, 95%CI: 1.01, 1.84), comorbid depression and CIND (OR: 1.98, 95%CI: 1.40, 2.81), or comorbid depression and dementia (OR: 1.58, 95%CI: 1.06, 2.35) were independently associated with increased odds of rehospitalization within 30 days after hospitalization for pneumonia, CHF, or MI.

CONCLUSIONS: Depression, CIND, and dementia are each independently associated with potentially preventable hospitalizations in older Americans. Older adults with comorbid depression and cognitive impairment represent a particularly at-risk group that could benefit from targeted interventions.

PB - 29 VL - 29 IS - 10 N1 - Export Date: 6 August 2014 Article in Press U1 - http://www.ncbi.nlm.nih.gov/pubmed/24939712?dopt=Abstract U2 - PMC4175651 U4 - depression/dementia/ambulatory care-sensitive/condition/hospitalization/rehospitalization/cognitive impairment ER - TY - JOUR T1 - Obesity and 1-year outcomes in older Americans with severe sepsis. JF - Crit Care Med Y1 - 2014 A1 - Hallie C Prescott A1 - Virginia W Chang A1 - James M. O'Brien Jr A1 - Kenneth M. Langa A1 - Theodore J Iwashyna KW - Aged KW - Aged, 80 and over KW - Body Mass Index KW - Cohort Studies KW - Comorbidity KW - Critical Illness KW - Delivery of Health Care KW - Female KW - Health Expenditures KW - Hospitalization KW - Humans KW - Male KW - Medicare KW - Middle Aged KW - Obesity KW - Sepsis KW - Survival Rate KW - Survivors KW - United States AB -

OBJECTIVES: Although critical care physicians view obesity as an independent poor prognostic marker, growing evidence suggests that obesity is, instead, associated with improved mortality following ICU admission. However, this prior empirical work may be biased by preferential admission of obese patients to ICUs, and little is known about other patient-centered outcomes following critical illness. We sought to determine whether 1-year mortality, healthcare utilization, and functional outcomes following a severe sepsis hospitalization differ by body mass index.

DESIGN: Observational cohort study.

SETTING: U.S. hospitals.

PATIENTS: We analyzed 1,404 severe sepsis hospitalizations (1999-2005) among Medicare beneficiaries enrolled in the nationally representative Health and Retirement Study, of which 597 (42.5%) were normal weight, 473 (33.7%) were overweight, and 334 (23.8%) were obese or severely obese, as assessed at their survey prior to acute illness. Underweight patients were excluded a priori.

INTERVENTIONS: None.

MEASUREMENTS AND MAIN RESULTS: Using Medicare claims, we identified severe sepsis hospitalizations and measured inpatient healthcare facility use and calculated total and itemized Medicare spending in the year following hospital discharge. Using the National Death Index, we determined mortality. We ascertained pre- and postmorbid functional status from survey data. Patients with greater body mass indexes experienced lower 1-year mortality compared with nonobese patients, and there was a dose-response relationship such that obese (odds ratio = 0.59; 95% CI, 0.39-0.88) and severely obese patients (odds ratio = 0.46; 95% CI, 0.26-0.80) had the lowest mortality. Total days in a healthcare facility and Medicare expenditures were greater for obese patients (p < 0.01 for both comparisons), but average daily utilization (p = 0.44) and Medicare spending were similar (p = 0.65) among normal, overweight, and obese survivors. Total function limitations following severe sepsis did not differ by body mass index category (p = 0.64).

CONCLUSIONS: Obesity is associated with improved mortality among severe sepsis patients. Due to longer survival, obese sepsis survivors use more healthcare and result in higher Medicare spending in the year following hospitalization. Median daily healthcare utilization was similar across body mass index categories.

PB - 42 VL - 42 IS - 8 N1 - Export Date: 21 April 2014 Source: Scopus Article in Press U1 - http://www.ncbi.nlm.nih.gov/pubmed/24717466?dopt=Abstract U2 - PMC4205159 U4 - body mass index/critical care/outcomes assessment/prognosis/sepsis/utilization ER - TY - JOUR T1 - Adults with cardiovascular disease who help others: a prospective study of health outcomes. JF - J Behav Med Y1 - 2013 A1 - Michele M Heisler A1 - Choi, Hwajung A1 - John D Piette A1 - Ann Marie Rosland A1 - Kenneth M. Langa A1 - Stephanie Brown KW - Activities of Daily Living KW - Aged KW - Cardiovascular Diseases KW - depression KW - Female KW - Health Status KW - Helping Behavior KW - Humans KW - Longitudinal Studies KW - Male KW - Middle Aged KW - Prospective Studies KW - Time Factors AB -

Little is known about the health impact of helping behaviors among individuals with high-risk chronic diseases such as cardiovascular disease (CVD). Using a nationally representative, longitudinal survey, we examined the subsequent health of adults with CVD (n = 4,491) who spent time providing non-paid assistance to family and friends outside of their households compared with those who had provided no assistance. After both adjusting for baseline characteristics and using propensity score matching methods, spending up to 200 h over the prior 12 months helping others was associated with lower odds of experiencing a new CVD event or dying in the subsequent 2 years. Providing up to 100 h of assistance was associated with reporting fewer depressive symptoms. This threshold effect raises the question of whether assistance beyond a certain number of hours may impose a burden that mitigates health benefits from helping others. Health care providers could play an important role exploring ways that patients with CVD can provide beneficial levels of assistance to others in their own social networks or communities, thereby possibly also improving their own health.

PB - 36 VL - 36 UR - http://search.proquest.com.proxy.lib.umich.edu/docview/1318045378?accountid=14667 IS - 2 N1 - Copyright - Springer Science Business Media New York 2013 Last updated - 2013-04-30 DOI - 2922261571; 76454332; 69709; BVMD; 22481214; SPVLBVMD108653629414 U1 - http://www.ncbi.nlm.nih.gov/pubmed/22481214?dopt=Abstract U4 - Psychology/Cardiovascular disease/Chronic conditions/caregivers/Depressive Symptoms/health care policy ER - TY - JOUR T1 - Dementia and out-of-pocket spending on health care services. JF - Alzheimers Dement Y1 - 2013 A1 - Delavande, Adeline A1 - Michael D Hurd A1 - Martorell, Paco A1 - Kenneth M. Langa KW - Aged KW - Dementia KW - Female KW - Financing, Personal KW - Health Expenditures KW - Humans KW - Male AB -

BACKGROUND: High levels of out-of-pocket (OOP) spending for health care may lead patients to forego needed services and medications as well as hamper their ability to pay for other essential goods. Because it leads to disability and the loss of independence, dementia may put patients and their families at risk for high OOP spending, especially for long-term care services.

METHODS: We used data from the Aging, Demographics, and Memory Study, a nationally representative subsample (n = 743) of the Health and Retirement Study, to determine whether individuals with dementia had higher self-reported OOP spending compared with those with cognitive impairment without dementia and those with normal cognitive function. We also examined the relationship between dementia and utilization of dental care and prescription medications-two types of health care that are frequently paid for OOP. Multivariate and logistic regression models were used to adjust for the influence of potential confounders.

RESULTS: After controlling for demographics and comorbidities, those with dementia had more than three times the yearly OOP spending compared with those with normal cognition ($8216 for those with dementia vs. $2570 for those with normal cognition, P < .01). Higher OOP spending for those with dementia was mainly driven by greater expenditures on nursing home care (P < .01). Dementia was not associated with the likelihood of visiting the dentist (P = .76) or foregoing prescription medications owing to cost (P = .34).

CONCLUSIONS: Dementia is associated with high levels of OOP spending but not with the use of dental care or foregoing prescription medications, suggesting that excess OOP spending among those with dementia does not "crowd out" spending on these other health care services.

PB - 9 VL - 9 IS - 1 N1 - Times Cited: 0 U1 - http://www.ncbi.nlm.nih.gov/pubmed/23154049?dopt=Abstract U3 - 23154049 U4 - Out of pocket costs/health Care/Long Term Care/Dementia/dental Care/COMORBIDITY/health care services ER - TY - JOUR T1 - Depression, antidepressant medications, and risk of Clostridium difficile infection. JF - BMC Medicine Y1 - 2013 A1 - Mary A M Rogers A1 - M. Todd Greene A1 - Vincent B Young A1 - Sanjay Saint A1 - Kenneth M. Langa A1 - John Y Kao A1 - David M. Aronoff KW - Antidepressants KW - Clostridium KW - Depressive symptoms KW - Infection KW - Older Adults AB -

BACKGROUND: An ancillary finding in previous research has suggested that the use of antidepressant medications increases the risk of developing Clostridium difficile infection (CDI). Our objective was to evaluate whether depression or the use of anti-depressants altered the risk of developing CDI, using two distinct datasets and study designs.

METHODS: In Study 1, we conducted a longitudinal investigation of a nationally representative sample of older Americans (n = 16,781), linking data from biennial interviews to physician and emergency department visits, stays in hospital and skilled nursing facilities, home health visits, and other outpatient visits. In Study 2, we completed a clinical investigation of hospitalized adults who were tested for C. difficile (n = 4047), with cases testing positive and controls testing negative. Antidepressant medication use prior to testing was ascertained.

RESULTS: The population-based rate of CDI in older Americans was 282.9/100,000 person-years (95% confidence interval (CI)) 226.3 to 339.5) for individuals with depression and 197.1/100,000 person-years for those without depression (95% CI 168.0 to 226.1). The odds of CDI were 36% greater in persons with major depression (95% CI 1.06 to 1.74), 35% greater in individuals with depressive disorders (95% CI 1.05 to 1.73), 54% greater in those who were widowed (95% CI 1.21 to 1.95), and 25% lower in adults who did not live alone (95% CI 0.62 to 0.92). Self-reports of feeling sad or having emotional, nervous or psychiatric problems at baseline were also associated with the later development of CDI. Use of certain antidepressant medications during hospitalization was associated with altered risk of CDI.

CONCLUSIONS: Adults with depression and who take specific anti-depressants seem to be more likely to develop CDI. Older adults who are widowed or who live alone are also at greater risk of CDI.

VL - 11 ER - TY - RPRT T1 - Documentation of Biomarkers in the 2006 and 2008 Health and Retirement Study Y1 - 2013 A1 - Eileen M. Crimmins A1 - Jessica Faul A1 - Jung K Kim A1 - Heidi M Guyer A1 - Kenneth M. Langa A1 - Mary Beth Ofstedal A1 - Amanda Sonnega A1 - Robert B Wallace A1 - David R Weir KW - Health Conditions and Status KW - Healthcare KW - Methodology AB - Biomarkers refer to the general range of physiological, metabolic, biochemical, endocrine and genetic measures that can be obtained in living organisms. The term is most commonly used to refer to one-time biochemical or hematological measures made on blood or other available bodily fluids, but perhaps the term should be used for a broader range of measures. In 2006 and 2008, HRS included the following biomarkers measurements, administered in this order: Saliva collection for DNA extraction; Blood spot collection for cholesterol, hemoglobin A1C, CRP and cystatin C analysis (results for C-reactive protein and cystatin C are forthcoming). This report describes the following for each of the measures listed above: Rationale and key citations; Sample description; Measure description; Equipment; Protocol description; Special instructions. PB - Institute for Social Research, University of Michigan CY - Ann Arbor, Michigan U4 - Biomarker data/survey Methods/health measures ER - TY - JOUR T1 - Expenditures in the elderly with peripheral neuropathy: Where should we focus cost-control efforts? JF - Neurology. Clinical Practice Y1 - 2013 A1 - Brian C. Callaghan A1 - James F. Burke A1 - Rodgers, Ann A1 - Ryan J McCammon A1 - Kenneth M. Langa A1 - Eva L Feldman A1 - Kevin Kerber KW - Medical Expenses KW - Medicare/Medicaid/Health Insurance KW - Older Adults KW - Peripheral Neuropathy AB -

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.

VL - 3 IS - 5 ER - TY - JOUR T1 - Fall-associated difficulty with activities of daily living in functionally independent individuals aged 65 to 69 in the United States: a cohort study. JF - J Am Geriatr Soc Y1 - 2013 A1 - Nishant K. Sekaran A1 - Choi, Hwajung A1 - Rodney A. Hayward A1 - Kenneth M. Langa KW - Accidental Falls KW - Activities of Daily Living KW - Aged KW - Aging KW - Disability Evaluation KW - Disabled Persons KW - Female KW - Follow-Up Studies KW - Geriatric Assessment KW - Health Status KW - Humans KW - Male KW - Odds Ratio KW - Retrospective Studies KW - Risk Factors KW - United States KW - Wounds and Injuries AB -

OBJECTIVES: To determine whether falling would be a marker for future difficulty with activities of daily (ADLs) that would vary according to fall frequency and associated injury.

DESIGN: Longitudinal analysis.

SETTING: Community.

PARTICIPANTS: Nationally representative cohort of 2,020 community-living, functionally independent older adults aged 65 to 69 at baseline followed from 1998 to 2008.

MEASUREMENTS: ADL difficulty.

RESULTS: Experiencing one fall with injury (odds ratio (OR) = 1.78, 95% confidence interval (CI) = 1.29-2.48), at least two falls without injury (OR = 2.36, 95% CI = 1.80-3.09), or at least two falls with at least one injury (OR = 3.75, 95% CI = 2.55-5.53) in the prior 2 years was independently associated with higher rates of ADL difficulty after adjustment for sociodemographic, behavioral, and clinical covariates.

CONCLUSION: Falling is an important marker for future ADL difficulty in younger, functionally independent older adults. Individuals who fall frequently or report injury are at highest risk.

PB - 61 VL - 61 IS - 1 U1 - http://www.ncbi.nlm.nih.gov/pubmed/23311555?dopt=Abstract U4 - falls/Fall prevention/disability/disability/older adults/ADL/IADL/activities of daily living/Mobility/functional impairment/health Status ER - TY - JOUR T1 - Functional disability, cognitive impairment, and depression after hospitalization for pneumonia. JF - Am J Med Y1 - 2013 A1 - Dimitry S Davydow A1 - Catherine L Hough A1 - Deborah A Levine A1 - Kenneth M. Langa A1 - Theodore J Iwashyna KW - Activities of Daily Living KW - Aged KW - Aged, 80 and over KW - Cognitive Dysfunction KW - depression KW - Hospitalization KW - Humans KW - Logistic Models KW - Longitudinal Studies KW - Middle Aged KW - Myocardial Infarction KW - Pneumonia KW - Stroke AB -

OBJECTIVE: The study objective was to examine whether hospitalization for pneumonia is associated with functional decline, cognitive impairment, and depression, and to compare this impairment with that seen after known disabling conditions, such as myocardial infarction or stroke.

METHODS: We used data from a prospective cohort of 1434 adults aged more than 50 years who survived 1711 hospitalizations for pneumonia, myocardial infarction, or stroke drawn from the Health and Retirement Study (1998-2010). Main outcome measures included the number of Activities and Instrumental Activities of Daily Living requiring assistance and the presence of cognitive impairment and substantial depressive symptoms.

RESULTS: Hospitalization for pneumonia was associated with 1.01 new impairments in Activities and Instrumental Activities of Daily Living (95% confidence interval [CI], 0.71-1.32) among patients without baseline functional impairment and 0.99 new impairments in Activities and Instrumental Activities of Daily Living (95% CI, 0.57-1.41) among those with mild-to-moderate baseline limitations, as well as moderate-to-severe cognitive impairment (odds ratio, 2.46; 95% CI, 1.60-3.79) and substantial depressive symptoms (odds ratio, 1.63; 95% CI, 1.06-2.51). Patients without baseline functional impairment who survived pneumonia hospitalization had more subsequent impairments in Activities and Instrumental Activities of Daily Living than those who survived myocardial infarction hospitalization. There were no significant differences in subsequent moderate-to-severe cognitive impairment or substantial depressive symptoms between patients who survived myocardial infarction or stroke and those who survived pneumonia.

CONCLUSIONS: Hospitalization for pneumonia in older adults is associated with subsequent functional and cognitive impairment. Improved pneumonia prevention and interventions to ameliorate adverse sequelae during and after hospitalization may improve outcomes.

VL - 126 IS - 7 U1 - http://www.ncbi.nlm.nih.gov/pubmed/23499326?dopt=Abstract U2 - PMC3690157 U4 - Functional decline/Functional decline/cognitive Impairment/Depression/myocardial Infarction/Stroke/pneumonia/ADL/IADL/depressive symptoms/HOSPITALIZATION ER - TY - JOUR T1 - Functional limitations in older adults who have cognitive impairment without dementia. JF - J Geriatr Psychiatry Neurol Y1 - 2013 A1 - Tanya R Gure A1 - Kenneth M. Langa A1 - Gwenith G Fisher A1 - John D Piette A1 - Brenda L Plassman KW - Activities of Daily Living KW - Age Factors KW - Aged KW - Aged, 80 and over KW - Cognitive Dysfunction KW - Dementia KW - Female KW - Humans KW - Male KW - Neuropsychological tests KW - Severity of Illness Index KW - Surveys and Questionnaires AB -

OBJECTIVE: To characterize the prevalence of functional limitations among older adults with cognitive impairment without dementia (CIND).

METHODS: Secondary data analysis was performed using the Aging, Demographics, and Memory Study data set. A total of 856 individuals aged ≥ 71 years were assigned to 3 diagnostic cognitive categories. A questionnaire was completed by a proxy informant regarding functional limitations for 744 of the 856 respondents.

RESULTS: Of the 744 patients, 263 (13.9%) had dementia, 201 (21.3%) had CIND, and 280 (64.8%) had normal cognition. Informants reported ≥1 instrumental activities of daily living (ADLs) limitation in 45% of the patients with CIND compared to 13% of the patients with normal cognition and 85% of the patients with dementia (P < .001). The ADL impairments among individuals with CIND were primarily attributed to physical health problems (n = 41; 40%).

CONCLUSIONS: Many individuals with CIND have impairment in a range of complex and basic daily activities, largely due to physical health problems.

VL - 26 IS - 2 N1 - NLM Title Abbreviation: J Geriatr Psychiatry Neurol U1 - http://www.ncbi.nlm.nih.gov/pubmed/23559664?dopt=Abstract U2 - PMC3726208 U4 - ADAMS/Cognitive Impairment/ADL and IADL Impairments/Physical health/Dementia/Functional limitation ER - TY - JOUR T1 - Hospital and nursing home use from 2002 to 2008 among U.S. older adults with cognitive impairment, not dementia in 2002. JF - Alzheimer Dis Assoc Disord Y1 - 2013 A1 - Daniel O. Clark A1 - Timothy E. Stump A1 - Tu, Wanzhu A1 - Douglas K Miller A1 - Kenneth M. Langa A1 - Frederick W Unverzagt A1 - Christopher M. Callahan KW - Aged KW - Aged, 80 and over KW - Aging KW - Cognition Disorders KW - Dementia KW - Female KW - Homes for the Aged KW - Hospitalization KW - Humans KW - Male KW - Nursing homes KW - United States AB -

Little is known about health care use in the cognitive impairment, not dementia (CIND) subpopulation. Using a cohort of 7130 persons aged 71 years or over from the Health and Retirement Survey, we compared mean and total health care use from 2002 to 2008 for those with no cognitive impairment, CIND, or dementia in 2002. Cognitive status was determined using a validated method based on self or proxy interview measures. Health care use was also based on self or proxy reports. On the basis of the Health and Retirement Survey, the CIND subpopulation in 2002 was 5.3 million or 23% of the total population 71 years of age or over. Mean hospital nights was similar and mean nursing home nights was less in persons with CIND compared with persons with dementia. The CIND subpopulation, however, had more total hospital and nursing home nights--71,000 total hospital nights and 223,000 total nursing home nights versus 32,000 hospital nights and 138,000 nursing home nights in the dementia subpopulation. A relatively large population and high health care use result in a large health care impact of the CIND subpopulation.

VL - 27 UR - http://content.wkhealth.com/linkback/openurl?sid=WKPTLP:landingpage&an=00002093-201310000-00012 IS - 4 U1 - http://www.ncbi.nlm.nih.gov/pubmed/23151595?dopt=Abstract JO - Alzheimer Disease & Associated Disorders ER - TY - JOUR T1 - Impact of cigarette smoking on utilization of nursing home services. JF - Nicotine Tob Res Y1 - 2013 A1 - Kenneth E. Warner A1 - Ryan J McCammon A1 - Brant E Fries A1 - Kenneth M. Langa KW - Age Factors KW - Aged KW - Aged, 80 and over KW - Black or African American KW - Cross-Sectional Studies KW - Female KW - Hispanic or Latino KW - Humans KW - Length of Stay KW - Logistic Models KW - Longitudinal Studies KW - Male KW - Middle Aged KW - Nursing homes KW - Risk KW - Self Report KW - Smoking KW - Socioeconomic factors KW - United States KW - White People AB -

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.

VL - 15 UR - http://ntr.oxfordjournals.org/content/early/2013/06/18/ntr.ntt079.abstract IS - 11 U1 - http://www.ncbi.nlm.nih.gov/pubmed/23803394?dopt=Abstract ER - TY - JOUR T1 - Longer lived parents: protective associations with cancer incidence and overall mortality. JF - J Gerontol A Biol Sci Med Sci Y1 - 2013 A1 - Ambarish Dutta A1 - Henley, William A1 - Robine, Jean-Marie A1 - Kenneth M. Langa A1 - Robert B Wallace A1 - David Melzer KW - Aged KW - Aged, 80 and over KW - Female KW - Humans KW - Incidence KW - Longevity KW - Male KW - Middle Aged KW - Mortality KW - Neoplasms KW - Parents AB -

BACKGROUND: Children of centenarians have lower cardiovascular disease prevalence and live longer. We aimed to estimate associations between the full range of parental attained ages and health status in a middle-aged U.S. representative sample.

METHODS: Using Health and Retirement Study data, models estimated disease incidence and mortality hazards for respondents aged 51-61 years at baseline, followed up for 18 years. Full adjustment included sex, race, smoking, wealth, education, body mass index, and childhood socioeconomic status. Mother's and father's attained age distributions were used to define short-, intermediate-, and long-lived groups, yielding a ranked parental longevity score (n = 6,055, excluding short-long discordance). Linear models (n = 8,340) tested mother's or father's attained ages, adjusted for each other.

RESULTS: With increasing mother's or father's survival (>65 years), all-cause mortality declined 19% (hazard ratio [HR] = 0.81, 95% CI: 0.76-0.86, p < .001) and 14% per decade (HR = 0.87, 95% CI: 0.81-0.92, p < .001). Estimates changed only modestly when fully adjusted. Parent-in-law survival was not associated with mortality (n = 1,809, HR = 1.00, 95% CI: 0.90-1.12, p = .98). Offspring with one or two long-lived parents had lower cancer incidence (938 cases, HR per parental longevity score = 0.76, 95% CI: 0.61-0.94, p = .01) versus two intermediate parents. Similar HRs for diabetes (HR = 0.89, 95% CI: 0.84-0.96, p = .001), heart disease (HR = 0.88, 95% CI: 0.82-0.93, p < .001), and stroke (HR = 0.86, 95% CI: 0.78-0.95, p = .002) were significant, but there was no trend for arthritis.

CONCLUSIONS: The results provide the first robust evidence that increasing parental attained age is associated with lower cancer incidence in offspring. Health advantages of having centenarian parents extend to a wider range of parental longevity and may provide a quantitative trait of slower aging.

PB - 68 VL - 68 IS - 11 N1 - Times Cited: 0 U1 - http://www.ncbi.nlm.nih.gov/pubmed/23685624?dopt=Abstract U4 - Family History/Parental Longevity/Cancer/Cardiovascular Disease/Centenarian/Lower Risk/Biomarkers ER - TY - JOUR T1 - Monetary costs of dementia in the United States. JF - N Engl J Med Y1 - 2013 A1 - Michael D Hurd A1 - Martorell, Paco A1 - Delavande, Adeline A1 - Kathleen J Mullen A1 - Kenneth M. Langa KW - Aged KW - Aged, 80 and over KW - Cost of Illness KW - Dementia KW - Female KW - Health Care Costs KW - Home Care Services KW - Home Nursing KW - Humans KW - Longitudinal Studies KW - Male KW - Medicare KW - Middle Aged KW - Nursing homes KW - United States AB -

BACKGROUND: Dementia affects a large and growing number of older adults in the United States. The monetary costs attributable to dementia are likely to be similarly large and to continue to increase.

METHODS: In a subsample (856 persons) of the population in the Health and Retirement Study (HRS), a nationally representative longitudinal study of older adults, the diagnosis of dementia was determined with the use of a detailed in-home cognitive assessment that was 3 to 4 hours in duration and a review by an expert panel. We then imputed cognitive status to the full HRS sample (10,903 persons, 31,936 person-years) on the basis of measures of cognitive and functional status available for all HRS respondents, thereby identifying persons in the larger sample with a high probability of dementia. The market costs associated with care for persons with dementia were determined on the basis of self-reported out-of-pocket spending and the utilization of nursing home care; Medicare claims data were used to identify costs paid by Medicare. Hours of informal (unpaid) care were valued either as the cost of equivalent formal (paid) care or as the estimated wages forgone by informal caregivers.

RESULTS: The estimated prevalence of dementia among persons older than 70 years of age in the United States in 2010 was 14.7%. The yearly monetary cost per person that was attributable to dementia was either $56,290 (95% confidence interval [CI], $42,746 to $69,834) or $41,689 (95% CI, $31,017 to $52,362), depending on the method used to value informal care. These individual costs suggest that the total monetary cost of dementia in 2010 was between $157 billion and $215 billion. Medicare paid approximately $11 billion of this cost.

CONCLUSIONS: Dementia represents a substantial financial burden on society, one that is similar to the financial burden of heart disease and cancer. (Funded by the National Institute on Aging.).

PB - 386 VL - 368 UR - http://www.nejm.org/doi/full/10.1056/NEJMsa1204629 IS - 14 U1 - http://www.ncbi.nlm.nih.gov/pubmed/23550670?dopt=Abstract U3 - 23550670 U4 - ADAMS/Dementia/Cognitive Impairment/cognitive assessment/PREVALENCE/Medicare/Out of pocket costs/nursing homes/Informal care/public policy ER - TY - JOUR T1 - New insights into the dementia epidemic. JF - New England Journal of Medicine Y1 - 2013 A1 - Eric B Larson A1 - Kristine Yaffe A1 - Kenneth M. Langa KW - Aging KW - Cognitive Ability KW - Dementia KW - Health Conditions and Status KW - Older Adults VL - 369 IS - 24 ER - TY - JOUR T1 - Personality profile of the children of long-lived parents. JF - J Gerontol B Psychol Sci Soc Sci Y1 - 2013 A1 - Evangelia E Antoniou A1 - Ambarish Dutta A1 - Kenneth M. Langa A1 - David Melzer A1 - David J Llewellyn KW - Aged KW - Extraversion, Psychological KW - Fathers KW - Female KW - Health Status KW - Humans KW - Interviews as Topic KW - Longevity KW - Longitudinal Studies KW - Male KW - Mothers KW - Parents KW - Personality KW - Personality Inventory KW - Sex Factors AB -

OBJECTIVES: Past research has shown that parental longevity is related to offspring physical health and longevity. Preliminary studies suggest that parental longevity may be linked to the offspring's personality traits. A comprehensive 5-factor personality model has been related to physical health, but the association with parental longevity has not yet been investigated. We used a 5-factor personality model to investigate the relationship between parental longevity and offspring personality.

METHOD: Data from the longitudinal Health and Retirement Study (HRS) was used in the analyses. Using the Midlife Development Inventory and the Life Orientation test, the relationship between parental attained age and offspring personality was assessed using regression models for both men and women.

RESULTS: Male offspring of long-lived fathers and mothers were more likely to be open to new experiences (p < .01) and be more extroverted (p = .03) compared with male offspring of short-lived fathers or mothers. Maternal or paternal attained age had no effect on the female offspring personality traits.

DISCUSSION: Personality is an important phenotype to consider when investigating genetic and environmental determinants of longevity. Further research is needed to investigate the potential of gender-specific mechanisms.

VL - 68 IS - 5 U1 - http://www.ncbi.nlm.nih.gov/pubmed/23419869?dopt=Abstract U3 - 23419869 U4 - physical health/Longevity/personality/personality/Midlife Development Inventory/Life Orientatin Test ER - TY - JOUR T1 - Symptoms of depression in survivors of severe sepsis: a prospective cohort study of older Americans. JF - Am J Geriatr Psychiatry Y1 - 2013 A1 - Dimitry S Davydow A1 - Catherine L Hough A1 - Kenneth M. Langa A1 - Theodore J Iwashyna KW - Aged KW - Aged, 80 and over KW - Cohort Studies KW - depression KW - Female KW - Hospitalization KW - Humans KW - Longitudinal Studies KW - Male KW - Poisson Distribution KW - Prospective Studies KW - Regression Analysis KW - Risk Factors KW - Sepsis KW - Severity of Illness Index KW - Survivors KW - United States AB -

OBJECTIVES: To examine if incident severe sepsis is associated with increased risk of subsequent depressive symptoms and to assess which patient characteristics are associated with increased risk of depressive symptoms.

DESIGN: Prospective longitudinal cohort study.

SETTING: Population-based cohort of older U.S. adults interviewed as part of the Health and Retirement Study (1998-2006).

PARTICIPANTS: A total of 439 patients who survived 471 hospitalizations for severe sepsis and completed at least one follow-up interview.

MEASUREMENTS: Depressive symptoms were assessed with a modified version of the Center for Epidemiologic Studies Depression Scale. Severe sepsis was identified using a validated algorithm in Medicare claims.

RESULTS: The point prevalence of substantial depressive symptoms was 28% at a median of 1.2 years before sepsis, and remained 28% at a median of 0.9 years after sepsis. Neither incident severe sepsis (relative risk [RR]: 1.00; 95% confidence interval [CI]: 0.73, 1.34) nor severe sepsis-related clinical characteristics were significantly associated with subsequent depressive symptoms. These results were robust to potential threats from missing data or alternative outcome definitions. After adjustment, presepsis substantial depressive symptoms (RR: 2.20; 95% CI: 1.66, 2.90) and worse postsepsis functional impairment (RR: 1.08 per new limitation; 95% CI: 1.03, 1.13) were independently associated with substantial depressive symptoms after sepsis.

CONCLUSIONS: The prevalence of substantial depressive symptoms in severe sepsis survivors is high but is not increased relative to their presepsis levels. Identifying this large subset of severe sepsis survivors at increased risk for major depression, and beginning interventions before hospital discharge, may improve outcomes.

PB - 21 VL - 21 IS - 9 U1 - http://www.ncbi.nlm.nih.gov/pubmed/23567391?dopt=Abstract U2 - PMC3462893 U4 - Critical care/Depression/Outcome assessment (healthcare)/Sepsis/health Care Utilization/HOSPITALIZATION ER - TY - JOUR T1 - Trends in depressive symptom burden among older adults in the United States from 1998 to 2008. JF - J Gen Intern Med Y1 - 2013 A1 - Zivin, Kara A1 - Paul A Pirraglia A1 - Ryan J McCammon A1 - Kenneth M. Langa A1 - Sandeep Vijan KW - Age Factors KW - Aged KW - Aged, 80 and over KW - Cohort Studies KW - Cost of Illness KW - Cross-Sectional Studies KW - depression KW - Female KW - Humans KW - Male KW - Middle Aged KW - United States AB -

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.

PB - 28 VL - 28 IS - 12 U1 - http://www.ncbi.nlm.nih.gov/pubmed/23835787?dopt=Abstract U2 - PMC3832736 U4 - Depression/Risk-Factors/Retirement/Older Adults/Depressive Symptoms ER - TY - JOUR T1 - Antigenic challenge in the etiology of autoimmune disease in women. JF - J Autoimmun Y1 - 2012 A1 - Mary A M Rogers A1 - Deborah A Levine A1 - Neil Blumberg A1 - Gwenith G Fisher A1 - Mohammed U Kabeto A1 - Kenneth M. Langa KW - Aged KW - Aged, 80 and over KW - Antigens KW - Autoimmune Diseases KW - Female KW - Humans KW - Incidence KW - Middle Aged KW - Prevalence KW - Risk Factors KW - United States AB -

Infection has long been implicated as a trigger for autoimmune disease. Other antigenic challenges include receipt of allogeneic tissue or blood resulting in immunomodulation. We investigated antigenic challenges as possible risk factors for autoimmune disease in women using the Health and Retirement Study, a nationally representative longitudinal study, linked to Medicare files, years 1991-2007. The prevalence of autoimmune disease (rheumatoid arthritis, Hashimoto's disease, Graves' disease, systemic lupus erythematosus, celiac disease, systemic sclerosis, Sjögren syndrome and multiple sclerosis) was 1.4% in older women (95% CI: 1.3%, 1.5%) with significant variation across regions of the United States. The risk of autoimmune disease increased by 41% (95% CI of incidence rate ratio (IRR): 1.10, 1.81) with a prior infection-related medical visit. The risk of autoimmune disease increased by 90% (95% CI of IRR: 1.36, 2.66) with a prior transfusion without infection. Parity was not associated with autoimmune disease. Women less than 65 years of age and Jewish women had significantly elevated risk of developing autoimmune disease, as did individuals with a history of heart disease or end-stage renal disease. Antigenic challenges, such as infection and allogeneic blood transfusion, are significant risk factors for the development of autoimmune disease in older women.

PB - 38 VL - 38 IS - 2-3 N1 - Rogers, Mary A M Levine, Deborah A Blumberg, Neil Fisher, Gwenith G Kabeto, Mohammed Langa, Kenneth M 5R21HL093129-02/HL/NHLBI NIH HHS/ HL078603/HL/NHLBI NIH HHS/ HL095467/HL/NHLBI NIH HHS/ HL100051/HL/NHLBI NIH HHS/ R21 HL093129-01A1/HL/NHLBI NIH HHS/ R21 HL093129-02/HL/NHLBI NIH HHS/ U01AG009740/AG/NIA NIH HHS/ England J Autoimmun. 2012 May;38(2-3):J97-J102. Epub 2011 Aug 30. U1 - http://www.ncbi.nlm.nih.gov/pubmed/21880464?dopt=Abstract U2 - PMC3242155 U4 - infection/autoimmune disease/allogeneic blood transfusion/risk Factors/WOMEN ER - TY - JOUR T1 - Burden of cirrhosis on older Americans and their families: analysis of the health and retirement study. JF - Hepatology Y1 - 2012 A1 - M. O. Rakoski A1 - Ryan J McCammon A1 - John D Piette A1 - Theodore J Iwashyna A1 - J. A. Marrero A1 - Lok, Anna S A1 - Kenneth M. Langa A1 - Volk, Michael L KW - Aged KW - Black People KW - Caregivers KW - Comorbidity KW - Cost of Illness KW - Databases, Factual KW - Disability Evaluation KW - Female KW - Health Care Costs KW - Health Status KW - Hispanic or Latino KW - Humans KW - Incidence KW - Liver Cirrhosis KW - Male KW - Medicaid KW - Medicare KW - Prevalence KW - Prospective Studies KW - Retirement KW - United States KW - White People AB -

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' 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.

PB - 55 VL - 55 IS - 1 U1 - http://www.ncbi.nlm.nih.gov/pubmed/21858847?dopt=Abstract U2 - PMC3462487 U4 - alcohol Abuse/cirrhosis/cirrhosis/Self assessed health/COMORBIDITY/health care/HOSPITALIZATION/physician visits/physician visits ER - TY - JOUR T1 - Chemotherapy was not associated with cognitive decline in older adults with breast and colorectal cancer: findings from a prospective cohort study. JF - Med Care Y1 - 2012 A1 - Victoria A. Shaffer A1 - Edgar C. Merkle A1 - Angela Fagerlin A1 - Jennifer J Griggs A1 - Kenneth M. Langa A1 - Theodore J Iwashyna KW - Age Factors KW - Aged KW - Aged, 80 and over KW - Aging KW - Antineoplastic Agents KW - Antineoplastic Protocols KW - Bayes Theorem KW - Breast Neoplasms KW - Cognition Disorders KW - Colorectal Neoplasms KW - Female KW - Health Behavior KW - Humans KW - Interviews as Topic KW - Male KW - Memory KW - Prospective Studies AB -

OBJECTIVES: This study tested 2 hypotheses: (1) chemotherapy increases the rate of cognitive decline in breast and colorectal cancer patients beyond what is typical of normal aging and (2) chemotherapy results in systematic cognitive declines when compared with breast and colorectal cancer patients who did not receive chemotherapy.

SUBJECTS: Data came from personal interviews with a prospective cohort of patients with breast (n=141) or colorectal cancer (n=224) with incident disease drawn from the nationally representative Health and Retirement Study (1998-2006) with linked Medicare claims.

MEASURES: The 27-point modified Telephone Interview for Cognitive Status was used to assess cognitive functioning, focusing on memory and attention. We defined the smallest clinically significant change as 0.4 points per year.

RESULTS: We used Bayesian hierarchical linear models to test the hypotheses, adjusting for multiple possible confounders. Eighty-eight patients were treated with chemotherapy; 277 were not. The mean age at diagnosis was 75.5. Patients were followed for a median of 3.1 years after diagnosis, with a range of 0 to 8.3 years. We found no differences in the rates of cognitive decline before and after diagnosis for patients who received chemotherapy in adjusted models (P=0.86, one-sided 95% posterior intervals lower bound: 0.09 worse after chemotherapy), where patients served as their own controls. Moreover, the rate of cognitive decline after diagnosis did not differ between patients who had chemotherapy and those who did not (P=0.84, one-sided 95% posterior intervals lower bound: 0.11 worse for chemotherapy group in adjusted model).

CONCLUSIONS: There was no evidence of cognitive decline associated with chemotherapy in this sample of older adults with breast and colorectal cancer.

VL - 50 IS - 10 U1 - http://www.ncbi.nlm.nih.gov/pubmed/22683591?dopt=Abstract U2 - PMC3444668 U4 - chemotherapy/Cognitive decline/CANCER/Medicare claims/Linear Models/Linear Models ER - TY - JOUR T1 - Depressive symptoms in spouses of older patients with severe sepsis. JF - Crit Care Med Y1 - 2012 A1 - Dimitry S Davydow A1 - Catherine L Hough A1 - Kenneth M. Langa A1 - Theodore J Iwashyna KW - Age Factors KW - Aged KW - depression KW - Female KW - Hospitalization KW - Humans KW - Male KW - Multivariate Analysis KW - Prospective Studies KW - Psychiatric Status Rating Scales KW - Sepsis KW - Sex Factors KW - Spouses KW - Time Factors KW - United States AB -

OBJECTIVE: To examine whether spouses of patients with severe sepsis are at increased risk for depression independent of the spouse's presepsis history, whether this risk differs by sex, and is associated with a sepsis patient's disability after hospitalization.

DESIGN: Prospective longitudinal cohort study.

SETTING: Population-based cohort of U.S. adults over 50 yrs old interviewed as part of the Health and Retirement Study (1993-2008).

PATIENTS: Nine hundred twenty-nine patient-spouse dyads comprising 1,212 hospitalizations for severe sepsis.

MEASUREMENTS AND MAIN RESULTS: Severe sepsis was identified using a validated algorithm in Medicare claims. Depression was assessed with a modified version of the Center for Epidemiologic Studies Depression Scale. All analyses were stratified by gender. The prevalence of substantial depressive symptoms in wives of patients with severe sepsis increased by 14 percentage points at the time of severe sepsis (from 20% at a median of 1.1 yrs presepsis to 34% at a median of 1 yr postsepsis) with an odds ratio of 3.74 (95% confidence interval: 2.20, 6.37), in multivariable regression. Husbands had an 8 percentage point increase in the prevalence of substantial depressive symptoms, which was not significant in multivariable regression (odds ratio 1.90, 95% confidence interval 0.75, 4.71). The increase in depression was not explained by bereavement; women had greater odds of substantial depressive symptoms even when their spouse survived a severe sepsis hospitalization (odds ratio 2.86, 95% confidence interval 1.06, 7.73). Wives of sepsis survivors who were disabled were more likely to be depressed (odds ratio 1.35 per activities of daily living limitation of sepsis survivor, 95% confidence interval 1.12, 1.64); however, controlling for patient disability only slightly attenuated the association between sepsis and wives' depression (odds ratio 2.61, 95% confidence interval 0.93, 7.38).

CONCLUSIONS: Older women may be at greater risk for depression if their spouse is hospitalized for severe sepsis. Spouses of patients with severe sepsis may benefit from greater support and depression screening, both when their loved one dies and when their loved one survives.

VL - 40 IS - 8 U1 - http://www.ncbi.nlm.nih.gov/pubmed/22635049?dopt=Abstract U2 - PMC3670798 U4 - sepsis/DISABILITY/DISABILITY/HOSPITALIZATION/medicare claims/depression/Depressive Symptoms/respondent incentives/Spousal care/WOMEN ER - TY - JOUR T1 - The influence of diabetes psychosocial attributes and self-management practices on change in diabetes status. JF - Patient Educ Couns Y1 - 2012 A1 - Donna M Zulman A1 - Ann Marie Rosland A1 - Choi, Hwajung A1 - Kenneth M. Langa A1 - Michele M Heisler KW - Aged KW - Blood Glucose Self-Monitoring KW - Cross-Sectional Studies KW - Diabetes Mellitus, Type 1 KW - Diabetes Mellitus, Type 2 KW - Disease Management KW - Female KW - Glycated Hemoglobin KW - Health Knowledge, Attitudes, Practice KW - Health Status KW - Humans KW - Interviews as Topic KW - Male KW - Middle Aged KW - Multivariate Analysis KW - Risk Factors KW - Self Care KW - Self Efficacy KW - Severity of Illness Index KW - Social Support KW - Stress, Psychological KW - Surveys and Questionnaires KW - Treatment Outcome AB -

OBJECTIVE: To examine the influence of diabetes psychosocial attributes and self-management on glycemic control and diabetes status change.

METHODS: Using data from the Health and Retirement Study, a nationally representative longitudinal study of U.S. adults >51 years, we examined cross-sectional relationships among diabetes psychosocial attributes (self-efficacy, risk awareness, care understanding, prioritization of diabetes, and emotional distress), self-management ratings, and glycemic control. We then explored whether self-management ratings and psychosocial attributes in 2003 predicted change in diabetes status in 2004.

RESULTS: In multivariate analyses (N=1834), all diabetes psychosocial attributes were associated with self-management ratings, with self-efficacy and diabetes distress having the strongest relationships (adj coeff=8.1, p<0.01 and -4.1, p<0.01, respectively). Lower self-management ratings in 2003 were associated cross-sectionally with higher hemoglobin A1C (adj coeff=0.16, p<0.01), and with perceived worsening diabetes status in 2004 (adj OR=1.36, p<0.05), with much of this latter relationship explained by diabetes distress.

CONCLUSION: Psychosocial attributes, most notably diabetes-related emotional distress, contribute to difficulty with diabetes self-management, poor glycemic control, and worsening diabetes status over time.

PRACTICE IMPLICATIONS: Self-management and adherence interventions should target psychosocial attributes such as disease-related emotional distress.

PB - 87 VL - 87 UR - http://www.ncbi.nlm.nih.gov/pubmed/21840149 IS - 1 N1 - Zulman, Donna M Rosland, Ann-Marie Choi, Hwajung Langa, Kenneth M Heisler, Michele U01 AG09740/AG/NIA NIH HHS/ Ireland Patient Educ Couns. 2012 Apr;87(1):74-80. Epub 2011 Aug 15. U1 - http://www.ncbi.nlm.nih.gov/pubmed/21840149?dopt=Abstract U2 - PMC3229832 U4 - Diabetes/glycemic control/glycemic control/psycho-social/self-management ER - TY - JOUR T1 - Predictors of self-report of heart failure in a population-based survey of older adults. JF - Circ Cardiovasc Qual Outcomes Y1 - 2012 A1 - Tanya R Gure A1 - Ryan J McCammon A1 - Christine T Cigolle A1 - Todd M Koelling A1 - Caroline S Blaum A1 - Kenneth M. Langa KW - Age Factors KW - Aged KW - Aged, 80 and over KW - Algorithms KW - Awareness KW - Chi-Square Distribution KW - Comorbidity KW - Female KW - Health Knowledge, Attitudes, Practice KW - Health Status KW - Health Surveys KW - Heart Failure KW - Humans KW - Insurance Claim Review KW - Logistic Models KW - Male KW - Medicare KW - Odds Ratio KW - Patients KW - Predictive Value of Tests KW - Self Report KW - Socioeconomic factors KW - United States AB -

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.

PB - 5 VL - 5 IS - 3 U1 - http://www.ncbi.nlm.nih.gov/pubmed/22592753?dopt=Abstract U2 - PMC3370939 U4 - medicare claims/heart disease/self-reported health ER - TY - JOUR T1 - Presepsis depressive symptoms are associated with incident cognitive impairment in survivors of severe sepsis: a prospective cohort study of older Americans. JF - J Am Geriatr Soc Y1 - 2012 A1 - Dimitry S Davydow A1 - Catherine L Hough A1 - Kenneth M. Langa A1 - Theodore J Iwashyna KW - Aged KW - Aged, 80 and over KW - Cognition Disorders KW - Cohort Studies KW - depression KW - Female KW - Humans KW - Longitudinal Studies KW - Male KW - Sepsis KW - Survivors AB -

OBJECTIVES: To test the hypothesis that presepsis depressive symptoms are associated with risk of new cognitive impairment in survivors of severe sepsis.

DESIGN: Prospective longitudinal cohort study.

SETTING: Population-based cohort of older U.S. adults interviewed as part of the Health and Retirement Study (1998-2006).

PARTICIPANTS: Four hundred forty-seven individuals with normal presepsis cognition who survived 540 hospitalizations for severe sepsis and completed at least one follow-up interview.

MEASUREMENTS: Severe sepsis was identified using a validated algorithm in Medicare claims. Depressive symptoms were assessed prospectively using a modified version of the Center for Epidemiologic Studies Depression Scale. Cognitive function was assessed using versions of the Telephone Interview for Cognitive Status (TICS). Logistic regression with robust standard errors was used to examine associations between substantial depressive symptoms at any interview before sepsis and incident cognitive impairment (mild or moderate to severe cognitive impairment) at any interview after sepsis.

RESULTS: The prevalence of substantial depressive symptoms in participants with normal cognition before sepsis was 38% (95% confidence interval (CI) = 34-42%). After severe sepsis, 18% (95% CI = 15-20%) of survivors had incident cognitive impairment. In unadjusted analyses, presepsis substantial depressive symptoms were associated with postsepsis incident cognitive impairment (odds ratio (OR) = 2.56, 95% CI = 1.53-4.27). After adjustment for demographics, health-risk behaviors, clinical characteristics of the sepsis episode, and presepsis TICS scores, substantial presepsis depressive symptoms remained the strongest factor associated with postsepsis incident cognitive impairment (OR = 2.58, 95% CI = 1.45-4.59).

CONCLUSION: Substantial presepsis depressive symptoms are independently associated with incident postsepsis cognitive impairment. Depressed older adults may be particularly at risk of developing cognitive impairment after a serious medical illness.

PB - 60 VL - 60 IS - 12 U1 - http://www.ncbi.nlm.nih.gov/pubmed/23176643?dopt=Abstract U2 - PMC3521098 U4 - Depression/sepsis/Cognition/Cognitive Impairment/CES Depression Scale/CES Depression Scale/TICS Scale/Older Adults ER - TY - JOUR T1 - Prevalence of cognitive impairment in older adults with heart failure. JF - J Am Geriatr Soc Y1 - 2012 A1 - Tanya R Gure A1 - Caroline S Blaum A1 - Bruno J Giordani A1 - Todd M Koelling A1 - Andrzej T Galecki A1 - Susan J Pressler A1 - Scott L Hummel A1 - Kenneth M. Langa KW - Aged KW - Aged, 80 and over KW - Algorithms KW - Chi-Square Distribution KW - Cognition Disorders KW - Cross-Sectional Studies KW - Demography KW - Female KW - Heart Failure KW - Humans KW - Logistic Models KW - Male KW - Medicare KW - Prevalence KW - United States AB -

OBJECTIVES: To determine the prevalence of cognitive impairment in older adults with heart failure (HF).

DESIGN: Cross-sectional analysis of the 2004 wave of the nationally representative Health and Retirement Study linked to 2002 to 2004 Medicare administrative claims.

SETTING: United States, community.

PARTICIPANTS: Six thousand one hundred eighty-nine individuals aged 67 and older.

MEASUREMENTS: An algorithm was developed using a combination of self- and proxy report of a heart problem and the presence of one or more Medicare claims in administrative files using standard HF diagnostic codes. On the basis of the algorithm, three categories were created to characterize the likelihood of a HF diagnosis: high or moderate probability of HF, low probability of HF, and no HF. Cognitive function was assessed using a screening measure of cognitive function or according to proxy rating. Age-adjusted prevalence estimates of cognitive impairment were calculated for the three groups.

RESULTS: The prevalence of cognitive impairment consistent with dementia in older adults with HF was 15%, and the prevalence of mild cognitive impairment was 24%. The odds of dementia in those with HF were significantly higher, even after adjustment for age, education level, net worth, and prior stroke (odds ratio = 1.52, 95% confidence interval = 1.14-2.02).

CONCLUSION: Cognitive impairment is common in older adults with HF and is independently associated with risk of dementia. A cognitive assessment should be routinely incorporated into HF-focused models of care.

PB - 60 VL - 60 IS - 9 U1 - http://www.ncbi.nlm.nih.gov/pubmed/22882000?dopt=Abstract U2 - PMC3445700 U4 - Cognition/Cognitive impairment/Cardiovascular disease/heart Diseases/epidemiology/dementia/PREVALENCE ER - TY - JOUR T1 - Spurious inferences about long-term outcomes: the case of severe sepsis and geriatric conditions. JF - Am J Respir Crit Care Med Y1 - 2012 A1 - Theodore J Iwashyna A1 - Netzer, Giora A1 - Kenneth M. Langa A1 - Christine T Cigolle KW - Aged KW - Aged, 80 and over KW - Body Mass Index KW - Chronic pain KW - Cohort Studies KW - Comorbidity KW - Critical Illness KW - Disabled Persons KW - disease progression KW - Female KW - Geriatric Assessment KW - Hearing Disorders KW - Hospitalization KW - Humans KW - Incidence KW - Male KW - Musculoskeletal Diseases KW - Prognosis KW - Retrospective Studies KW - Risk Assessment KW - Sepsis KW - Survival Analysis KW - Survivors KW - Thinness KW - Time KW - Treatment Outcome KW - Urinary incontinence KW - Vision Disorders AB -

RATIONALE: Survivors of critical illness suffer significant limitations and disabilities.

OBJECTIVES: Ascertain whether severe sepsis is associated with increased risk of so-called geriatric conditions (injurious falls, low body mass index [BMI], incontinence, vision loss, hearing loss, and chronic pain) and whether this association is measured consistently across three different study designs.

METHODS: Patients with severe sepsis were identified in the Health and Retirement Study, a nationally representative cohort interviewed every 2 years, 1998 to 2006, and in linked Medicare claims. Three comparators were used to assess an association of severe sepsis with geriatric conditions in survivors: the prevalence in the United States population aged 65 years and older, survivors' own pre-sepsis levels assessed before hospitalization, or survivors' own pre-sepsis trajectory.

MEASUREMENTS AND MAIN RESULTS: Six hundred twenty-three severe sepsis hospitalizations were followed a median of 0.92 years. When compared with the 65 years and older population, surviving severe sepsis was associated with increased rates of low BMI, injurious falls, incontinence, and vision loss. Results were similar when comparing survivors to their own pre-sepsis levels. The association of low BMI and severe sepsis persisted when controlling for patients' pre-sepsis trajectories, but there was no association of severe sepsis with injurious falls, incontinence, vision loss, hearing loss, and chronic pain after such controls.

CONCLUSIONS: Geriatric conditions are common after severe sepsis. However, severe sepsis is associated with increased rates of only a subset of geriatric conditions, not all. In studying outcomes after acute illness, failing to measure and control for both preillness levels and trajectories may result in erroneous conclusions.

PB - 185 VL - 185 IS - 8 N1 - Iwashyna, Theodore J Netzer, Giora Langa, Kenneth M Cigolle, Christine K08 AG031837/AG/NIA NIH HHS/ K08 HL091249/HL/NHLBI NIH HHS/ K12 RR023250/RR/NCRR NIH HHS/ P30-AG028747/AG/NIA NIH HHS/ P60 DK-20572/DK/NIDDK NIH HHS/ R01 AG030155/AG/NIA NIH HHS/ U01 AG09740/AG/NIA NIH HHS/ UL1RR024986/RR/NCRR NIH HHS/ Am J Respir Crit Care Med. 2012 Apr 15;185(8):835-41. Epub 2012 Feb 9. U1 - http://www.ncbi.nlm.nih.gov/pubmed/22323301?dopt=Abstract U2 - PMC3360570 U4 - Body Mass Index/Cohort Studies/Comorbidity/DISABILITY/DISABILITY/Geriatric Assessment/Hearing Disorders/Hospitalization/Musculoskeletal Diseases/Risk Assessment/Sepsis/Survival Analysis/body Weight/Treatment Outcome/Urinary Incontinence/Vision Disorders ER - TY - JOUR T1 - Tests and expenditures in the initial evaluation of peripheral neuropathy. JF - Arch Intern Med Y1 - 2012 A1 - Brian C. Callaghan A1 - Ryan J McCammon A1 - Kevin Kerber A1 - Xiao Xu A1 - Kenneth M. Langa A1 - Eva L Feldman KW - Aged KW - Antibodies, Antinuclear KW - Blood Cell Count KW - Blood Protein Electrophoresis KW - Blood Sedimentation KW - Brain KW - Diagnostic Tests, Routine KW - Electromyography KW - Female KW - Glucose Tolerance Test KW - Glycated Hemoglobin KW - Health Expenditures KW - Humans KW - International Classification of Diseases KW - Magnetic Resonance Imaging KW - Male KW - Medicare KW - Neural Conduction KW - Peripheral Nervous System Diseases KW - Quality Assurance, Health Care KW - Spine KW - Thyrotropin KW - United States KW - Vitamin B 12 AB -

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.

PB - 172 VL - 172 IS - 2 U1 - http://www.ncbi.nlm.nih.gov/pubmed/22271119?dopt=Abstract U2 - PMC3694340 U4 - Peripheral neuropathy/Peripheral neuropathy/diagonistic practice patterns/health Services/Medicare/Medicare claims/glucose tolerance test ER - TY - JOUR T1 - Triggers of hospitalization for venous thromboembolism. JF - Circulation Y1 - 2012 A1 - Mary A M Rogers A1 - Deborah A Levine A1 - Neil Blumberg A1 - Scott A Flanders A1 - Vineet Chopra A1 - Kenneth M. Langa KW - Aged KW - Ambulatory Care Facilities KW - Comorbidity KW - Cross-Over Studies KW - Emergency Service, Hospital KW - Female KW - Hematinics KW - Home Care Services KW - Hospitalization KW - Humans KW - Immobilization KW - Incidence KW - Infections KW - Male KW - Medicare KW - Middle Aged KW - Office Visits KW - Postoperative Complications KW - Pulmonary Embolism KW - Risk Factors KW - Skilled Nursing Facilities KW - Transfusion Reaction KW - United States KW - Venous Thrombosis AB -

BACKGROUND: The rate of hospitalization for venous thromboembolism (VTE) is increasing in the United States. Although predictors of hospital-acquired VTE are well-known, triggers of VTE before hospitalization are not as clearly defined. The objective of this study was to evaluate triggers of hospitalization for VTE.

METHODS AND RESULTS: A case-crossover study was conducted. Subjects were participants in the Health and Retirement Study, a nationally representative sample of older Americans. Data were linked to Medicare files for hospital and nursing home stays, emergency department visits, outpatient visits including physician visits, and home health visits from years 1991 to 2007 (n=16 781). The outcome was hospitalization for venous thromboembolism (n=399). Exposures during the 90-day period before hospitalization for VTE were compared with exposures occurring in 4 comparison periods. Infection was the most common trigger of hospitalization for VTE, occurring in 52.4% of the risk periods before hospitalization. The adjusted incidence rate ratios (IRRs; 95% confidence interval) were 2.90 (2.13, 3.94) for all infection, 2.63 (1.90, 3.63) for infection without a previous hospital or skilled nursing facility stay, and 6.92 (4.46, 10.72) for infection with a previous hospital or skilled nursing facility stay. Erythropoiesis-stimulating agents and blood transfusion were also associated with VTE hospitalization (IRR=9.33, 95% confidence interval: 1.19, 73.42; IRR=2.57, 95% confidence interval: 1.17, 5.64; respectively). Other predictors included major surgeries, fractures (IRR=2.81), immobility (IRR=4.23), and chemotherapy (IRR=5.70). These predictors, combined, accounted for a large proportion (69.7%) of exposures before VTE hospitalization as opposed to 35.3% in the comparison periods.

CONCLUSIONS: Risk prediction algorithms for VTE should be reevaluated to include infection, erythropoiesis-stimulating agents, and blood transfusion.

PB - 125 VL - 125 UR - http://www.ncbi.nlm.nih.gov/pubmed/22474264 IS - 17 N1 - Rogers, Mary A M Levine, Deborah A Blumberg, Neil Flanders, Scott A Chopra, Vineet Langa, Kenneth M 5R21HL093129-02/HL/NHLBI NIH HHS/ R01 HL095467/HL/NHLBI NIH HHS/ U01AG009740/AG/NIA NIH HHS/ Circulation. 2012 May 1;125(17):2092-9. Epub 2012 Apr 3. U1 - http://www.ncbi.nlm.nih.gov/pubmed/22474264?dopt=Abstract U2 - PMC3342773 U4 - medicare claims/HOSPITALIZATION/venous thromboembolism/pulmonary embolism ER - TY - JOUR T1 - Assessment of cognition using surveys and neuropsychological assessment: the Health and Retirement Study and the Aging, Demographics, and Memory Study. JF - J Gerontol B Psychol Sci Soc Sci Y1 - 2011 A1 - Eileen M. Crimmins A1 - Jung K Kim A1 - Kenneth M. Langa A1 - David R Weir KW - Age Factors KW - Aged KW - Aged, 80 and over KW - Cognition KW - Cognition Disorders KW - Dementia KW - Educational Status KW - Female KW - Humans KW - Interviews as Topic KW - Logistic Models KW - Longitudinal Studies KW - Male KW - Multivariate Analysis KW - Neuropsychological tests KW - Odds Ratio KW - Prevalence KW - Sex Factors KW - United States AB -

OBJECTIVES: This study examines the similarity of cognitive assessments using 1 interview in a large population study, the Health and Retirement Study (HRS), and a subsample in which a detailed neuropsychiatric assessment has been performed (Aging, Demographics, and Memory Study [ADAMS]).

METHODS: Respondents are diagnosed in ADAMS as demented, cognitively impaired without dementia (CIND), or as having normal cognitive function. Multinomial logistic analysis is used to predict diagnosis using a variety of cognitive and noncognitive measures from the HRS and additional measures and information from ADAMS.

RESULTS: The cognitive tests in HRS predict the ADAMS diagnosis in 74% of the sample able to complete the HRS survey on their own. Proxy respondents answer for a large proportion of HRS respondents who are diagnosed as demented in ADAMS. Classification of proxy respondents with some cognitive impairment can be predicted in 86% of the sample. Adding a small number of additional tests from ADAMS can increase each of these percentages to 84% and 93%, respectively.

DISCUSSION: Cognitive assessment appropriate for diagnosis of dementia and CIND in large population surveys could be improved with more targeted information from informants and additional cognitive tests targeting other areas of brain function.

PB - 66 Suppl 1 VL - 66 Suppl 1 IS - Suppl 1 N1 - Crimmins, Eileen M Kim, Jung Ki Langa, Kenneth M Weir, David R P30 AG17265/AG/NIA NIH HHS/United States U01 AG009740/AG/NIA NIH HHS/United States Research Support, N.I.H., Extramural United States The journals of gerontology. Series B, Psychological sciences and social sciences J Gerontol B Psychol Sci Soc Sci. 2011 Jul;66 Suppl 1:i162-71. U1 - http://www.ncbi.nlm.nih.gov/pubmed/21743047?dopt=Abstract U2 - PMC3165454 U4 - Age Factors/Aged, 80 and over/Cognition/Cognition Disorders/ diagnosis/epidemiology/psychology/Cognition Disorders/ diagnosis/epidemiology/psychology/Dementia/ diagnosis/epidemiology/psychology/Dementia/ diagnosis/epidemiology/psychology/Educational Status/Female/Logistic Models/Longitudinal Studies/Multivariate Analysis/Neuropsychological Tests/Odds Ratio/Prevalence/Sex Factors/United States/epidemiology/United States/epidemiology ER - TY - JOUR T1 - Caregiver burden and neuropsychiatric symptoms in older adults with cognitive impairment: the Aging, Demographics, and Memory Study (ADAMS). JF - Alzheimer Dis Assoc Disord Y1 - 2011 A1 - Okura, Toru A1 - Kenneth M. Langa KW - Aged KW - Aged, 80 and over KW - Caregivers KW - Cognition Disorders KW - Cost of Illness KW - Cross-Sectional Studies KW - Female KW - Humans KW - Male KW - Neuropsychological tests AB -

OBJECTIVES: To estimate the quantity of informal care associated with neuropsychiatric symptoms in older adults with cognitive impairment.

DESIGN: Cross-sectional analysis.

SETTING: The Aging, Demographics, and Memory Study.

PARTICIPANTS: A sample (n=450) of adults aged 71 years and older with cognitive impairment drawn form the Health and Retirement Study.

MEASUREMENTS: The presence of neuropsychiatric symptoms (delusions, hallucinations, agitation, depression, apathy, elation, anxiety, disinhibition, irritation, and aberrant motor behaviors) was identified using the neuropsychiatric inventory. Cognitive category [normal, cognitive impairment without dementia (CIND), or dementia] was assigned by a consensus panel. The hours per week of active help and supervision were ascertained by informant questionnaire.

RESULTS: Among older adults with CIND or dementia, those with no neuropsychiatric symptoms received an average of 10.2 hours of active help and 10.9 hours of supervision per week from informal caregivers. Those with 1 or 2 neuropsychiatric symptoms received an additional 10.0 hours of active help and 12.4 hours of supervision per week, while those with 3 or more symptoms received an additional 18.2 hours of active help and 28.7 hours of supervision per week (P<0.001). The presence of irritation (14.7 additional hours) was associated with the greatest number of additional hours of active help. The presence of aberrant motor behaviors (17.7 additional hours) and disinhibition (17.5 additional hours) were associated with the greatest number of additional hours of supervision.

CONCLUSIONS: Neuropsychiatric symptoms among those with CIND or dementia are associated with a significant increase in the provision of informal care. This care represents a significant time commitment for families and a significant economic cost to society.

PB - 25 VL - 25 IS - 2 N1 - Okura, Toru Langa, Kenneth M R01 AG027010/AG/NIA NIH HHS/United States R01 AG030155-01/AG/NIA NIH HHS/United States R01 AG030155-02/AG/NIA NIH HHS/United States R01 AG030155-03/AG/NIA NIH HHS/United States R01 AG030155-04/AG/NIA NIH HHS/United States R01 AG030155-05/AG/NIA NIH HHS/United States U01 AG09740/AG/NIA NIH HHS/United States Research Support, N.I.H., Extramural United States Alzheimer disease and associated disorders Nihms259646 Alzheimer Dis Assoc Disord. 2011 Apr-Jun;25(2):116-21. U1 - http://www.ncbi.nlm.nih.gov/pubmed/21192239?dopt=Abstract U2 - PMC3100441 U4 - Aged, 80 and over/Caregivers/ statistics/Caregivers/ statistics/numerical data/Cognition Disorders/ psychology/Cognition Disorders/ psychology/Cost of Illness/Cross-Sectional Studies/Female/Humans/Neuropsychological Tests ER - TY - JOUR T1 - Caring for individuals with dementia and cognitive impairment, not dementia: findings from the aging, demographics, and memory study. JF - J Am Geriatr Soc Y1 - 2011 A1 - Gwenith G Fisher A1 - Melissa M Franks A1 - Brenda L Plassman A1 - Stephanie Brown A1 - Guy G Potter A1 - David J Llewellyn A1 - Mary A M Rogers A1 - Kenneth M. Langa KW - Activities of Daily Living KW - Aged KW - Analysis of Variance KW - Caregivers KW - Cognition Disorders KW - Cross-Sectional Studies KW - Dementia KW - Female KW - Humans KW - Linear Models KW - Male KW - Neuropsychological tests KW - Time Factors KW - United States AB -

OBJECTIVES: To compare the characteristics and outcomes of caregivers of adults with dementia with those of caregivers of adults with cognitive impairment, not dementia (CIND).

DESIGN: Cross-sectional.

SETTING: In-home assessment for cognitive impairment and self-administered caregiving questionnaire.

PARTICIPANTS: One hundred sixty-nine primary family caregivers of participants in the Aging, Demographics, and Memory Study (ADAMS). ADAMS participants were aged 71 and older drawn from the nationally representative Health and Retirement Study.

MEASUREMENTS: Neuropsychological testing, neurological examination, clinical assessment, and medical history were used to assign a diagnosis of normal cognition, CIND, or dementia. Caregiving measures included caregiving time, functional limitations, depressive symptoms, physical and emotional strain, caregiving rewards, caregiver health, and demographic characteristics.

RESULTS: Dementia caregivers spent approximately 9 hours per day providing care, compared with 4 hours per day for CIND caregivers (P=.001). Forty-four percent of dementia caregivers exhibited depressive symptoms, compared with 26.5% of CIND caregivers (P=.03). Physical and emotional strains were similar in both groups of caregivers. Regardless of the strains, nearly all caregivers reported some benefits from providing care. Behavioral problems (P=.01) and difficulty with instrumental activities of daily living (P=.01) in persons with CIND partially explained emotional strain experienced by CIND caregivers. For those with dementia, behavioral problems predicted caregiver emotional strain (P<.001) and depressive symptoms (P=.01).

CONCLUSION: Although support services are available to dementia caregivers, CIND caregivers also expend considerable time and experience strains. The real caregiver burden of cognitive impairment in the U.S. population may therefore be greatly underestimated if people who have reached the diagnostic threshold for dementia are focused on exclusively.

PB - 59 VL - 59 UR - http://onlinelibrary.wiley.com/doi/10.1111/j.1532-5415.2010.03304.x/full IS - 3 U1 - http://www.ncbi.nlm.nih.gov/pubmed/21391939?dopt=Abstract U2 - PMC3646395 U4 - Activities of Daily Living/Analysis of Variance/Caregivers/ psychology/Caregivers/ psychology/Cognition Disorders/ nursing/Cognition Disorders/ nursing/Cross-Sectional Studies/Dementia/ nursing/Dementia/ nursing/Female/Humans/Linear Models/Linear Models/Neuropsychological Tests/Time Factors ER - TY - JOUR T1 - Development and validation of a brief cognitive assessment tool: the sweet 16. JF - Arch Intern Med Y1 - 2011 A1 - Tamara G Fong A1 - Richard N Jones A1 - James L Rudolph A1 - Frances Margaret Yang A1 - Tommet, Douglas A1 - Habtemariam, Daniel A1 - Edward R Marcantonio A1 - Kenneth M. Langa A1 - Sharon K Inouye KW - Aged KW - Aged, 80 and over KW - Cognition Disorders KW - Cohort Studies KW - Dementia KW - Female KW - Humans KW - Male KW - Neuropsychological tests KW - Surveys and Questionnaires AB -

BACKGROUND: Cognitive impairment is often unrecognized among older adults. Meanwhile, current assessment instruments are underused, lack sensitivity, or may be restricted by copyright laws. To address these limitations, we created a new brief cognitive assessment tool: the Sweet 16.

METHODS: The Sweet 16 was developed in a cohort from a large post-acute hospitalization study (n=774) and compared with the Mini-Mental State Examination (MMSE). Equipercentile equating identified Sweet 16 cut points that correlated with widely used MMSE cut points. Sweet 16 performance characteristics were independently validated in a cohort from the Aging, Demographics, and Memory Study (n=709) using clinical consensus diagnosis, the modified Blessed Dementia Rating Scale, and the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE).

RESULTS: The Sweet 16 correlated highly with the MMSE (Spearman r, 0.94; P<.001). Validated against the IQCODE, the area under the curve was 0.84 for the Sweet 16 and 0.81 for the MMSE (P=.06). A Sweet 16 score of less than 14 (approximating an MMSE score <24) demonstrated a sensitivity of 80% and a specificity of 70%, whereas an MMSE score of less than 24 showed a sensitivity of 64% and a specificity of 86% against the IQCODE. When compared with clinical diagnosis, a Sweet 16 score of less than 14 showed a sensitivity of 99% and a specificity of 72% in contrast to an MMSE score with a sensitivity of 87% and a specificity of 89%. For education of 12 years or more, the area under the curve was 0.90 for the Sweet 16 and 0.84 for the MMSE (P=.03).

CONCLUSIONS: The Sweet 16 is simple, quick to administer, and will be available open access. The performance of the Sweet 16 is equivalent or superior to that of the MMSE.

PB - 171 VL - 171 IS - 5 U1 - http://www.ncbi.nlm.nih.gov/pubmed/21059967?dopt=Abstract U3 - 21059967 U4 - Older people/Cognition/reasoning/Correlation analysis/Medical diagnosis/Dementia/Hospitalization ER - TY - JOUR T1 - Geriatric conditions develop in middle-aged adults with diabetes. JF - J Gen Intern Med Y1 - 2011 A1 - Christine T Cigolle A1 - Pearl G. Lee A1 - Kenneth M. Langa A1 - Lee, Yuo-Yu A1 - Zhiyi Tian A1 - Caroline S Blaum KW - Accidental Falls KW - Age Factors KW - Aged KW - Aged, 80 and over KW - Aging KW - Diabetes Mellitus KW - Dizziness KW - Female KW - Geriatric Assessment KW - Health Status KW - Health Surveys KW - Humans KW - Longitudinal Studies KW - Male KW - Middle Aged KW - pain KW - Urinary incontinence AB -

BACKGROUND: Geriatric conditions, collections of symptoms common in older adults and not necessarily associated with a specific disease, increase in prevalence with advancing age. These conditions are important contributors to the complex health status of older adults. Diabetes mellitus is known to co-occur with geriatric conditions in older adults and has been implicated in the pathogenesis of some conditions.

OBJECTIVE: To investigate the prevalence and incidence of geriatric conditions in middle-aged and older-aged adults with diabetes.

DESIGN: Secondary analysis of nationally-representative, longitudinal health interview survey data (Health and Retirement Study waves 2004 and 2006).

PARTICIPANTS: Respondents 51 years and older in 2004 (n=18,908).

MAIN MEASURES: Diabetes mellitus. Eight geriatric conditions: cognitive impairment, falls, incontinence, low body mass index, dizziness, vision impairment, hearing impairment, pain.

KEY RESULTS: Adults with diabetes, compared to those without, had increased prevalence and increased incidence of geriatric conditions across the age spectrum (p< 0.01 for each age group from 51-54 years old to 75-79 years old). Differences between adults with and without diabetes were most marked in middle-age. Diabetes was associated with the two-year cumulative incidence of acquiring new geriatric conditions (odds ratio, 95% confidence interval: 1.8, 1.6-2.0). A diabetes-age interaction was discovered: as age increased, the association of diabetes with new geriatric conditions decreased.

CONCLUSIONS: Middle-aged, as well as older-aged, adults with diabetes are at increased risk for the development of geriatric conditions, which contribute substantially to their morbidity and functional impairment. Our findings suggest that adults with diabetes should be monitored for the development of these conditions beginning at a younger age than previously thought.

PB - 26 VL - 26 IS - 3 U1 - http://www.ncbi.nlm.nih.gov/pubmed/20878496?dopt=Abstract U2 - PMC3043187 U4 - geriatric conditions/diabetes/cognitive Impairment/falls/Incontinence/Vision Disorders/Hearing Disorders ER - TY - JOUR T1 - Incidence of dementia and cognitive impairment, not dementia in the United States. JF - Ann Neurol Y1 - 2011 A1 - Brenda L Plassman A1 - Kenneth M. Langa A1 - Ryan J McCammon A1 - Gwenith G Fisher A1 - Guy G Potter A1 - James R Burke A1 - David C Steffens A1 - Norman L Foster A1 - Bruno J Giordani A1 - Frederick W Unverzagt A1 - Kathleen A Welsh-Bohmer A1 - Steven G Heeringa A1 - David R Weir A1 - Robert B Wallace KW - Aged KW - Aged, 80 and over KW - Alzheimer disease KW - Cognition Disorders KW - Cohort Studies KW - Dementia KW - Diagnostic and Statistical Manual of Mental Disorders KW - disease progression KW - Female KW - Humans KW - Logistic Models KW - Longitudinal Studies KW - Male KW - Models, Statistical KW - United States AB -

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.

VL - 70 IS - 3 U1 - http://www.ncbi.nlm.nih.gov/pubmed/21425187?dopt=Abstract U2 - PMC3139807 U4 - Dementia/Cognitive Impairment/Alzheimer disease/vascular dementia/incident dementia ER - TY - JOUR T1 - National estimates of the prevalence of Alzheimer's disease in the United States. JF - Alzheimers Dement Y1 - 2011 A1 - Brookmeyer, Ron A1 - Denis A Evans A1 - Liesi Hebert A1 - Kenneth M. Langa A1 - Steven G Heeringa A1 - Brenda L Plassman A1 - Walter Kukull KW - Age Factors KW - Alzheimer disease KW - Community Health Planning KW - Data collection KW - Humans KW - Incidence KW - Models, Statistical KW - Prevalence KW - Sampling Studies KW - United States AB -

Several methods of estimating prevalence of dementia are presented in this article. For both Brookmeyer and the Chicago Health and Aging project (CHAP), the estimates of prevalence are derived statistically, forward calculating from incidence and survival figures. The choice of incidence rates on which to build the estimates may be critical. Brookmeyer used incidence rates from several published studies, whereas the CHAP investigators applied the incidence rates observed in their own cohort. The Aging, Demographics, and Memory Study (ADAMS) and the East Boston Senior Health Project (EBSHP) were sample surveys designed to ascertain the prevalence of Alzheimer's disease and dementia. ADAMS obtained direct estimates by relying on probability sampling nationwide. EBSHP relied on projection of localized prevalence estimates to the national population. The sampling techniques of ADAMS and EBSHP were rather similar, whereas their disease definitions were not. By contrast, EBSPH and CHAP have similar disease definitions internally, but use different calculation techniques, and yet arrive at similar prevalence estimates, which are considerably greater than those obtained by either Brookmeyer or ADAMS. Choice of disease definition may play the larger role in explaining differences in observed prevalence between these studies.

PB - 7 VL - 7 IS - 1 U1 - http://www.ncbi.nlm.nih.gov/pubmed/21255744?dopt=Abstract U2 - PMC3052294 U4 - Alzheimer disease/Dementia/Cognitive impairment/Prevalence/Population-based/Projection/Probability/sampling ER - TY - JOUR T1 - Neuropsychiatric symptoms and the risk of institutionalization and death: the aging, demographics, and memory study. JF - J Am Geriatr Soc Y1 - 2011 A1 - Okura, Toru A1 - Brenda L Plassman A1 - David C Steffens A1 - David J Llewellyn A1 - Guy G Potter A1 - Kenneth M. Langa KW - Activities of Daily Living KW - Aged KW - Aged, 80 and over KW - Behavioral Symptoms KW - Caregivers KW - Cognition Disorders KW - Female KW - Humans KW - Institutionalization KW - Male KW - Neuropsychological tests KW - Proportional Hazards Models AB -

OBJECTIVES: To examine the association between neuropsychiatric symptoms and risk of institutionalization and death.

DESIGN: Analysis of longitudinal data.

SETTING: The Aging, Demographics, and Memory Study (ADAMS).

PARTICIPANTS: Five hundred thirty-seven adults aged 71 and older with cognitive impairment drawn from the Health and Retirement Study (HRS).

MEASUREMENTS: Neuropsychiatric symptoms (delusions, hallucinations, agitation, depression, apathy, elation, anxiety, disinhibition, irritation, and aberrant motor behaviors) and caregiver distress were identified using the Neuropsychiatric Inventory. A consensus panel in the ADAMS assigned cognitive category. Date of nursing home placement and information on death, functional limitations, medical comorbidity, and sociodemographic characteristics were obtained from the HRS and ADAMS.

RESULTS: Overall, the presence of one or more neuropsychiatric symptoms was not associated with a significantly higher risk for institutionalization or death during the 5-year study period, although when assessing each symptom individually, depression, delusions, and agitation were each associated with a significantly higher risk of institutionalization (hazard rate (HR)=3.06, 95% confidence interval (CI)=1.09-8.59 for depression; HR=5.74, 95% CI=1.94-16.96 for clinically significant delusions; HR=4.70, 95% CI=1.07-20.70 for clinically significant agitation). Caregiver distress mediated the association between delusions and agitation and institutionalization. Depression and hallucinations were associated with significantly higher mortality (HR=1.56, 95% CI=1.08-2.26 for depression; HR=2.59, 95% CI=1.09-6.16 for clinically significant hallucinations).

CONCLUSION: Some, but not all, neuropsychiatric symptoms are associated with a higher risk of institutionalization and death in people with cognitive impairment, and caregiver distress also influences institutionalization. Interventions that better target and treat depression, delusions, agitation, and hallucinations, as well as caregiver distress, may help delay or prevent these negative clinical outcomes.

PB - 59 VL - 59 IS - 3 U1 - http://www.ncbi.nlm.nih.gov/pubmed/21391937?dopt=Abstract U2 - PMC3088883 U4 - Mental disorders/Cognition/reasoning/Caregivers/Risk factors/Nursing homes/Mortality/Older people ER - TY - JOUR T1 - Operationalizing diagnostic criteria for Alzheimer's disease and other age-related cognitive impairment-Part 2. JF - Alzheimers Dement Y1 - 2011 A1 - Seshadri, Sudha A1 - Alexa S. Beiser A1 - Au, Rhoda A1 - Philip A Wolf A1 - Robert S Wilson A1 - Ronald C Petersen A1 - David S Knopman A1 - Walter A Rocca A1 - Claudia H Kawas A1 - Maria M Corrada A1 - Brenda L Plassman A1 - Kenneth M. Langa A1 - Helena C Chui KW - Age Factors KW - Aging KW - Alzheimer disease KW - Cognition Disorders KW - Community Health Planning KW - Humans KW - Incidence KW - Longitudinal Studies KW - Neuropsychological tests KW - Prevalence KW - United States AB -

This article focuses on the effects of operational differences in case ascertainment on estimates of prevalence and incidence of cognitive impairment and/or dementia of the Alzheimer type. Experience and insights are discussed by investigators from the Framingham Heart Study, the East Boston Senior Health Project, the Chicago Health and Aging Project, the Mayo Clinic Study of Aging, the Baltimore Longitudinal Study of Aging, and the Aging, Demographics, and Memory Study. There is a general consensus that the single most important factor determining prevalence estimates of Alzheimer's disease (AD) is the severity of cognitive impairment used as a threshold to define cases. Studies that require a level of cognitive impairment in which persons are unable to provide self-care will have much lower estimates than the studies aimed at identifying persons in the earliest stages of AD. There are limited autopsy data from the aforementioned epidemiological studies to address accuracy in the diagnosis of etiological subtype, namely the specification of AD alone or in combination with other types of pathology. However, other community-based cohort studies show that many persons with mild cognitive impairment and also some persons without dementia or mild cognitive impairment meet pathological criteria for AD, thereby suggesting that the number of persons who would benefit from an effective secondary prevention intervention is probably higher than the published prevalence estimates. Improved accuracy in the clinical diagnosis of AD is anticipated with the addition of molecular and structural biomarkers in the next generation of epidemiological studies.

PB - 7 VL - 7 IS - 1 U1 - http://www.ncbi.nlm.nih.gov/pubmed/21255742?dopt=Abstract U2 - PMC3039838 U4 - Alzheimer disease/cognitive Impairment/PREVALENCE/Incidence/Dementia ER - TY - JOUR T1 - Proxy interviews and bias in the distribution of cognitive abilities due to non-response in longitudinal studies: a comparison of HRS and ELSA. JF - Longit Life Course Stud Y1 - 2011 A1 - David R Weir A1 - Jessica Faul A1 - Kenneth M. Langa PB - 2 VL - 2 IS - 2 U1 - http://www.ncbi.nlm.nih.gov/pubmed/25360159?dopt=Abstract U4 - Cognitive ability/Methodology/longitudinal Studies/proxy interviews/proxy interviews/ELSA_/cross-national ER - TY - JOUR T1 - Reducing case ascertainment costs in U.S. population studies of Alzheimer's disease, dementia, and cognitive impairment-Part 1. JF - Alzheimers Dement Y1 - 2011 A1 - David R Weir A1 - Robert B Wallace A1 - Kenneth M. Langa A1 - Brenda L Plassman A1 - Robert S Wilson A1 - David A Bennett A1 - Duara, Ranjan A1 - Loewenstein, David A1 - Ganguli, Mary A1 - Sano, Mary KW - Aging KW - Algorithms KW - Alzheimer disease KW - Cognition Disorders KW - Community Health Planning KW - Cost-Benefit Analysis KW - Dementia KW - Health Surveys KW - Humans KW - Internet KW - Reproducibility of Results KW - United States AB -

Establishing methods for ascertainment of dementia and cognitive impairment that are accurate and also cost-effective is a challenging enterprise. Large population-based studies often using administrative data sets offer relatively inexpensive and reliable estimates of severe conditions including moderate to advanced dementia that are useful for public health planning, but they can miss less severe cognitive impairment which may be the most effective point for intervention. Clinical and epidemiological cohorts, intensively assessed, provide more sensitive detection of less severe cognitive impairment but are often costly. In this article, several approaches to ascertainment are evaluated for validity, reliability, and cost. In particular, the methods of ascertainment from the Health and Retirement Study are described briefly, along with those of the Aging, Demographics, and Memory Study (ADAMS). ADAMS, a resource-intense sub-study of the Health and Retirement Study, was designed to provide diagnostic accuracy among persons with more advanced dementia. A proposal to streamline future ADAMS assessments is offered. Also considered are algorithmic and Web-based approaches to diagnosis that can reduce the expense of clinical expertise and, in some contexts, can reduce the extent of data collection. These approaches are intended for intensively assessed epidemiological cohorts where goal is valid and reliable case detection with efficient and cost-effective tools.

PB - 7 VL - 7 UR - http://mgetit.lib.umich.edu/sfx_local?ctx_enc=info 3Aofi 2Fenc 3AUTF-8;ctx_id=10_1;ctx_tim=2011-03-28T16 3A26 3A0EDT;ctx_ver=Z39.88-2004;rfr_id=info 3Asid 2Fsfxit.com 3Acitation;rft.genre=article;rft_id=info 3Apmid 2F21255747;rft_val_fmt=info 3Aofi 2Ffmt IS - 1 U1 - http://www.ncbi.nlm.nih.gov/pubmed/21255747?dopt=Abstract U2 - PMC3044596 U4 - Alzheimers disease/Dementia/Mild cognitive impairment/Cognitive impairment not dementia/Diagnostic algorithms/Cognition/Epidemiology/Screening/Technology/Education/Ethnicity ER - TY - JOUR T1 - Regional variation in the association between advance directives and end-of-life Medicare expenditures. JF - JAMA Y1 - 2011 A1 - Lauren Hersch Nicholas A1 - Kenneth M. Langa A1 - Theodore J Iwashyna A1 - David R Weir KW - Advance directives KW - Aged KW - Aged, 80 and over KW - Data collection KW - Female KW - Health Expenditures KW - Hospice Care KW - Hospital Mortality KW - Hospitals KW - Humans KW - Kidney Failure, Chronic KW - Male KW - Medicare KW - Palliative care KW - Prospective Studies KW - Regression Analysis KW - Terminal Care KW - United States AB -

CONTEXT: It is unclear if advance directives (living wills) are associated with end-of-life expenditures and treatments.

OBJECTIVE: To examine regional variation in the associations between treatment-limiting advance directive use, end-of-life Medicare expenditures, and use of palliative and intensive treatments.

DESIGN, SETTING, AND PATIENTS: Prospectively collected survey data from the Health and Retirement Study for 3302 Medicare beneficiaries who died between 1998 and 2007 linked to Medicare claims and the National Death Index. Multivariable regression models examined associations between advance directives, end-of-life Medicare expenditures, and treatments by level of Medicare spending in the decedent's hospital referral region.

MAIN OUTCOME MEASURES: Medicare expenditures, life-sustaining treatments, hospice care, and in-hospital death over the last 6 months of life.

RESULTS: Advance directives specifying limits in care were associated with lower spending in hospital referral regions with high average levels of end-of-life expenditures (-$5585 per decedent; 95% CI, -$10,903 to -$267), but there was no difference in spending in hospital referral regions with low or medium levels of end-of-life expenditures. Directives were associated with lower adjusted probabilities of in-hospital death in high- and medium-spending regions (-9.8%; 95% CI, -16% to -3% in high-spending regions; -5.3%; 95% CI, -10% to -0.4% in medium-spending regions). Advance directives were associated with higher adjusted probabilities of hospice use in high- and medium-spending regions (17%; 95% CI, 11% to 23% in high-spending regions, 11%; 95% CI, 6% to 16% in medium-spending regions), but not in low-spending regions.

CONCLUSION: Advance directives specifying limitations in end-of-life care were associated with significantly lower levels of Medicare spending, lower likelihood of in-hospital death, and higher use of hospice care in regions characterized by higher levels of end-of-life spending.

PB - 112 VL - 306 UR - http://proquest.umi.com.proxy.lib.umich.edu/pqdweb?did=2590187421andFmt=7andclientId=17822andRQT=309andVName=PQD IS - 13 U1 - http://www.ncbi.nlm.nih.gov/pubmed/21972306?dopt=Abstract U2 - PMC3332047 U4 - Advance directives/Palliative care/Health care expenditures/Medicare ER - TY - JOUR T1 - Sources of variability in estimates of the prevalence of Alzheimer's disease in the United States. JF - Alzheimers Dement Y1 - 2011 A1 - Robert S Wilson A1 - David R Weir A1 - Sue E Leurgans A1 - Denis A Evans A1 - Liesi Hebert A1 - Kenneth M. Langa A1 - Brenda L Plassman A1 - Brent J. Small A1 - David A Bennett KW - Aged KW - Aged, 80 and over KW - Alzheimer disease KW - Community Health Planning KW - Comorbidity KW - Dementia KW - Diagnosis, Differential KW - Female KW - Humans KW - Incidence KW - Male KW - Prevalence KW - United States AB -

BACKGROUND: The prevalence of Alzheimer's disease (AD) in the United States was estimated at 2.3 million in 2002 by the Aging, Demographics, and Memory Study (ADAMS), which is almost 50% less than the estimate of 4.5 million in 2000 derived from the Chicago Health and Aging Project.

METHODS: We considered how differences in diagnostic criteria may have contributed to these differences in AD prevalence.

RESULTS: We identified several important differences in diagnostic criteria that may have contributed to the differing estimates of AD prevalence. Two factors were especially noteworthy. First, the Diagnostic and Statistical Manual of Mental Disorders III-R and IV criteria of functional limitation documented by an informant used in ADAMS effectively concentrated the diagnosis of dementia toward a relatively higher level of cognitive impairment. ADAMS separately identified a category of cognitive impairment not dementia and within that group there were a substantial number of cases with "prodromal" AD (a maximum of 1.95 million with upweighting). Second, a substantial proportion of dementia in ADAMS was attributed to either vascular disease (representing a maximum of 0.59 million with upweighting) or undetermined etiology (a maximum of 0.34 million), whereas most dementia, including mixed dementia, was attributed to AD in the Chicago Health and Aging Project.

CONCLUSION: The diagnosis of AD in population studies is a complex process. When a diagnosis of AD excludes persons meeting criteria for vascular dementia, when not all persons with dementia are assigned an etiology, and when a diagnosis of dementia requires an informant report of functional limitations, the prevalence is substantially lower and the diagnosed cases most likely have a relatively higher level of impairment.

PB - 7 VL - 7 IS - 1 U1 - http://www.ncbi.nlm.nih.gov/pubmed/21255745?dopt=Abstract U2 - PMC3145367 U4 - Epidemiology/Dementia/Alzheimers disease/Vascular dementia/Mild cognitive impairment/Cognitive impairment no dementia ER - TY - JOUR T1 - Trends in the incidence and prevalence of Alzheimer's disease, dementia, and cognitive impairment in the United States. JF - Alzheimers Dement Y1 - 2011 A1 - Walter A Rocca A1 - Ronald C Petersen A1 - David S Knopman A1 - Liesi Hebert A1 - Denis A Evans A1 - Kathleen S Hall A1 - Gao, Sujuan A1 - Frederick W Unverzagt A1 - Kenneth M. Langa A1 - Eric B Larson A1 - Lon R White KW - Age Factors KW - Alzheimer disease KW - Cognition Disorders KW - Cohort Studies KW - Community Health Planning KW - Dementia KW - Humans KW - Incidence KW - Prevalence KW - Residence Characteristics KW - Retrospective Studies KW - Time Factors KW - United States AB -

Declines in heart disease and stroke mortality rates are conventionally attributed to reductions in cigarette smoking, recognition and treatment of hypertension and diabetes, effective medications to improve serum lipid levels and to reduce clot formation, and general lifestyle improvements. Recent evidence implicates these and other cerebrovascular factors in the development of a substantial proportion of dementia cases. Analyses were undertaken to determine whether corresponding declines in age-specific prevalence and incidence rates for dementia and cognitive impairment have occurred in recent years. Data spanning 1 or 2 decades were examined from community-based epidemiological studies in Minnesota, Illinois, and Indiana, and from the Health and Retirement Study, which is a national survey. Although some decline was observed in the Minnesota cohort, no statistically significant trends were apparent in the community studies. A significant reduction in cognitive impairment measured by neuropsychological testing was identified in the national survey. Cautious optimism appears justified.

PB - 7 VL - 7 IS - 1 U1 - http://www.ncbi.nlm.nih.gov/pubmed/21255746?dopt=Abstract U2 - PMC3026476 U4 - Alzheimers disease/Dementia/Cognitive impairment/Prevalence/Incidence/Time trends ER - TY - JOUR T1 - Utilization of blood transfusion among older adults in the United States. JF - Transfusion Y1 - 2011 A1 - Mary A M Rogers A1 - Neil Blumberg A1 - Heal, Joanna M A1 - Kenneth M. Langa KW - Age Distribution KW - Aged KW - Aged, 80 and over KW - Black or African American KW - Blood Transfusion KW - Female KW - Humans KW - Male KW - United States KW - White People AB -

BACKGROUND: While there have been epidemiologic studies of blood donors, the characteristics of individuals who receive transfusions have not been well described for the US population.

STUDY DESIGN AND METHODS: Subjects were from the nationally representative Health and Retirement Study whose data were linked to Medicare files from 1991 through 2007 (n = 16,377). A cohort study was conducted to assess the frequency of transfusion in older Americans over time and to describe the characteristics of blood recipients.

RESULTS: Thirty-one percent (95% confidence interval [CI], 30%-33%) of older Americans received at least one transfusion within a 10-year period and 5.8% (95% CI, 5.4%-6.2%) experienced repeated transfusion-related visits within 30 days. The mean number of transfusion-related visits was 2.3 over a 10-year period (95% CI, 2.2-2.4). Older Americans who lived in the South were most likely to receive a transfusion (34%), independent of demographic and health-related factors, while those who lived in the western United States were the least likely (26%). Predictors of transfusion included smoking, low body mass index, and a history of cancer, diabetes mellitus, end-stage renal disease, and heart disease. African-Americans and Mexican-Americans had greater rates of blood utilization than other races and other Hispanics (respectively). There were also differences in transfusion utilization by education, marital status, religion, and alcohol use.

CONCLUSIONS: Transfusion is common in older Americans. Regional variations in blood use are not explained by patient characteristics alone.

PB - 51 VL - 51 IS - 4 U1 - http://www.ncbi.nlm.nih.gov/pubmed/21087284?dopt=Abstract U2 - PMC3078991 U4 - health services/blood transfusions/blood transfusions ER - TY - JOUR T1 - Advance directives and outcomes of surrogate decision making before death. JF - N Engl J Med Y1 - 2010 A1 - Maria J Silveira A1 - Scott Y H Kim A1 - Kenneth M. Langa KW - Advance directives KW - Aged KW - Aged, 80 and over KW - Decision making KW - Female KW - Humans KW - Living Wills KW - Logistic Models KW - Male KW - Mental Competency KW - Middle Aged KW - Proxy KW - Terminal Care KW - United States AB -

BACKGROUND: Recent discussions about health care reform have raised questions regarding the value of advance directives.

METHODS: We used data from survey proxies in the Health and Retirement Study involving adults 60 years of age or older who had died between 2000 and 2006 to determine the prevalence of the need for decision making and lost decision-making capacity and to test the association between preferences documented in advance directives and outcomes of surrogate decision making.

RESULTS: Of 3746 subjects, 42.5% required decision making, of whom 70.3% lacked decision-making capacity and 67.6% of those subjects, in turn, had advance directives. Subjects who had living wills were more likely to want limited care (92.7%) or comfort care (96.2%) than all care possible (1.9%); 83.2% of subjects who requested limited care and 97.1% of subjects who requested comfort care received care consistent with their preferences. Among the 10 subjects who requested all care possible, only 5 received it; however, subjects who requested all care possible were far more likely to receive aggressive care as compared with those who did not request it (adjusted odds ratio, 22.62; 95% confidence interval [CI], 4.45 to 115.00). Subjects with living wills were less likely to receive all care possible (adjusted odds ratio, 0.33; 95% CI, 0.19 to 0.56) than were subjects without living wills. Subjects who had assigned a durable power of attorney for health care were less likely to die in a hospital (adjusted odds ratio, 0.72; 95% CI, 0.55 to 0.93) or receive all care possible (adjusted odds ratio, 0.54; 95% CI, 0.34 to 0.86) than were subjects who had not assigned a durable power of attorney for health care.

CONCLUSIONS: Between 2000 and 2006, many elderly Americans needed decision making near the end of life at a time when most lacked the capacity to make decisions. Patients who had prepared advance directives received care that was strongly associated with their preferences. These findings support the continued use of advance directives.

PB - 362 VL - 362 IS - 13 U1 - http://www.ncbi.nlm.nih.gov/pubmed/20357283?dopt=Abstract U2 - PMC2880881 U4 - Right to die/Powers of attorney/Decision making/Health care/Advance directives ER - TY - JOUR T1 - The case for involving adult children outside of the household in the self-management support of older adults with chronic illnesses. JF - Chronic Illn Y1 - 2010 A1 - John D Piette A1 - Ann Marie Rosland A1 - Maria J Silveira A1 - Mohammed U Kabeto A1 - Kenneth M. Langa KW - Adult KW - Chronic disease KW - Family Relations KW - Female KW - Humans KW - Male KW - Middle Aged KW - Self Care KW - Social Support AB -

OBJECTIVES: This study sought to (1) identify barriers to spousal support for chronic illness self-care among community-dwelling older adults; and (2) describe the potential availability of self-care support from adult children living outside of the household.

METHODS: Nationally representative US sample of chronically ill adults aged 51+ were interviewed as part of the Health and Retirement Study (N = 14,862). Both participants and their spouses (when available) reported information about their health and functioning. Participants also reported information about their contact with adult children and the quality of those relationships.

RESULTS: More than one-third (38%) of chronically ill older adults in the US are unmarried; and when spouses are available, the majority of them have multiple chronic diseases and functional limitations. However, the vast majority of chronically ill older adults (93%, representing roughly 60 million Americans) have adult children, with half having children living over 10 miles away. Most respondents with children (78%) reported at least weekly telephone contact and that these relationships were positive. Roughly 19 million older chronically ill Americans have adult children living at a distance but none nearby; these children are in frequent telephone contact and respondents (including those with multiple chronic diseases) report that the relationships are positive.

DISCUSSION: As the gap between available health services for disease management and the need among community-dwelling patients continues to grow, adult children-including those living at a distance-represent an important resource for improving self-care support for people with chronic diseases.

PB - 6 VL - 6 IS - 1 U1 - http://www.ncbi.nlm.nih.gov/pubmed/20308349?dopt=Abstract U2 - PMC2864454 U4 - self-care/Chronic Disease ER - TY - JOUR T1 - Clinical complexity in middle-aged and older adults with diabetes: the Health and Retirement Study. JF - Med Care Y1 - 2010 A1 - Caroline S Blaum A1 - Christine T Cigolle A1 - Cynthia Boyd A1 - Jennifer L. Wolff A1 - Zhiyi Tian A1 - Kenneth M. Langa A1 - David R Weir KW - Aged KW - Cross-Sectional Studies KW - Diabetes Complications KW - Diabetes Mellitus, Type 2 KW - Female KW - Glycemic Index KW - Health Status KW - Health Surveys KW - Humans KW - Male KW - Middle Aged KW - Quality of Health Care KW - Self Care KW - Severity of Illness Index KW - Treatment Failure KW - United States AB -

BACKGROUND: Some patients with diabetes may have health status characteristics that could make diabetes self-management (DSM) difficult and lead to inadequate glycemic control, or limit the benefit of some diabetes management interventions.

OBJECTIVE: To investigate how many older and middle-aged adults with diabetes have such health status characteristics.

DESIGN: Secondary data analysis of a nationally representative health interview survey, the Health and Retirement Study, and its diabetes mail-out survey.

SETTING/PARTICIPANTS: Americans aged 51 and older with diabetes (n = 3506 representing 13.6 million people); aged 56 and older in diabetes survey (n = 1132, representing 9.9 million).

MEASUREMENTS: Number of adults with diabetes and (a) relatively good health; (b) health status that could make DSM difficult (eg, comorbidities, impaired instrumental activities of daily living; and (c) characteristics like advanced dementia and activities of daily living dependency that could limit benefit of some diabetes management. Health and Retirement Study measures included demographics. Diabetes Survey included self-measured HbA1c.

RESULTS: Nearly 22% of adults > or =51 with diabetes (about 3 million people) have health characteristics that could make DSM difficult. Another 10% (1.4 million) may receive limited benefit from some diabetes management. Mail-out respondents with health characteristics that could make DSM difficult had significantly higher mean HbA1c compared with people with relatively good health (7.6% vs. 7.3%, P < 0.04.).

CONCLUSIONS: Some middle-aged as well as older adults with diabetes have health status characteristics that might make DSM difficult or of limited benefit. Current diabetes quality measures, including measures of glycemic control, may not reflect what is possible or optimal for all patient groups.

PB - 48 VL - 48 IS - 4 U1 - http://www.ncbi.nlm.nih.gov/pubmed/20355264?dopt=Abstract U2 - PMC3153504 U4 - Data analysis/Patients/Diabetes/Glycemic index/Older people/Middle age ER - TY - JOUR T1 - Depression among older adults in the United States and England. JF - Am J Geriatr Psychiatry Y1 - 2010 A1 - Zivin, Kara A1 - David J Llewellyn A1 - Iain A Lang A1 - Sandeep Vijan A1 - Mohammed U Kabeto A1 - Erin M Miller A1 - Kenneth M. Langa KW - Aged KW - Aged, 80 and over KW - depression KW - England KW - Female KW - Health Behavior KW - Health Status KW - Health Surveys KW - Humans KW - Male KW - Prevalence KW - Risk Factors KW - United States KW - White People AB -

CONTEXT: Depression negatively affects health and well being among older adults, but there have been no nationally representative comparisons of depression prevalence among older adults in England and the United States.

OBJECTIVE: The authors sought to compare depressive symptoms among older adults in these countries and identify sociodemographic and clinical correlates of depression in these countries.

DESIGN AND SETTING: The authors assessed depressive symptoms in non-Hispanic whites aged 65 years and older in 2002 in two nationally representative, population-based studies: the U.S. Health and Retirement Study and English Longitudinal Study of Ageing.

PARTICIPANTS: A total of 8,295 Health and Retirement Study respondents and 5,208 English Longitudinal Study of Ageing respondents.

MAIN OUTCOME MEASURES: The authors measured depressive symptoms using the eight-item Center for Epidemiologic Studies Depression Scale. The authors determined whether depressive symptom differences between the United States and England were associated with sociodemographic characteristics, chronic health conditions, and health behaviors.

RESULTS: Significant depressive symptoms (Center for Epidemiologic Studies Depression Scale score ≥4) were more prevalent in English than U.S. adults (17.6% versus 14.6%, adjusted Wald test F([1, 1593]) = 11.4, p < 0.001). Adjusted rates of depressive symptoms in England were 19% higher compared with the United States (odds ratio: 1.19, 95% confidence interval: 1.01-1.40). U.S. adults had higher levels of education, and net worth, but lower levels of activities of daily living/instrumental activities of daily living impairments, tobacco use, and cognitive impairment, which may have contributed to relatively lower levels of depressive symptoms in the United States.

CONCLUSIONS: Older adults in the United States had lower rates of depressive symptoms than their English counterparts despite having more chronic health conditions. Future cross-national studies should identify how depression treatment influences outcomes in these populations.

PB - 11 VL - 18 IS - 11 U1 - http://www.ncbi.nlm.nih.gov/pubmed/20808088?dopt=Abstract U2 - PMC3786867 U4 - Aged, 80 and over/Depression/Health Behavior/Health Status/Health Surveys/Prevalence/Risk Factors/epidemiology ER - TY - JOUR T1 - Differences in functional impairment across subtypes of dementia. JF - J Gerontol A Biol Sci Med Sci Y1 - 2010 A1 - Tanya R Gure A1 - Mohammed U Kabeto A1 - Brenda L Plassman A1 - John D Piette A1 - Kenneth M. Langa KW - Activities of Daily Living KW - Aged KW - Alzheimer disease KW - Dementia KW - Dementia, Vascular KW - Humans AB -

BACKGROUND: Dementia is a cause of disability in later life. Despite the importance of functional status to the diagnosis of dementia, limited information exists on differences in functional limitations by dementia subtype. We conducted a cross-sectional analysis using the Aging, Demographics, and Memory Study (ADAMS) to determine the extent of functional impairment among older adults with dementia due to different etiologies.

METHODS: The ADAMS sample consisted of 856 individuals aged 71 years and older originally surveyed as part of the Health and Retirement Study. Based on a comprehensive in-person cognitive evaluation, respondents were assigned to diagnostic categories of normal cognition, cognitive impairment not demented, and demented. Dementia subtypes were grouped into three categories: vascular dementia (VaD), Alzheimer's dementia (AD), and dementia due to other etiologies. For 744 of the 856 respondents, a proxy informant completed a questionnaire asking whether the respondent had difficulty completing instrumental activities of daily living and activities of daily living (ADLs).

RESULTS: Of 744 ADAMS participants, 263 had dementia: 199 (70.5%) with AD, 42 (16.9%) with VaD, and 22 (12.6%) were demented due to other etiologies. After adjustment for demographics, chronic illnesses, and dementia severity, participants with VaD (odds ratio [OR] 5.74; 95% confidence interval [CI] 2.60-12.69) and other etiologies of dementia (OR 21.23; 95% CI 7.25-62.16) were more likely to have greater than or equal to four ADL limitations compared with those with AD.

CONCLUSIONS: VaD is associated with significantly more ADL limitations than AD. These physical limitations should be considered when designing adult day care programs, which adequately accommodate the needs of non-AD patients.

PB - 65A VL - 65 IS - 4 U1 - http://www.ncbi.nlm.nih.gov/pubmed/20018827?dopt=Abstract U2 - PMC2844058 U4 - Aging/Dementia/Demographics/Memory/Older people/Alzheimers disease/Questionnaires/Disability/Disability ER - TY - JOUR T1 - Factors influencing cost-related nonadherence to medication in older adults: a conceptually based approach. JF - Value Health Y1 - 2010 A1 - Zivin, Kara A1 - Scott M Ratliff A1 - Michele M Heisler A1 - Kenneth M. Langa A1 - John D Piette KW - Aged KW - Aged, 80 and over KW - Chronic disease KW - Female KW - Financing, Personal KW - Health Status KW - Humans KW - Logistic Models KW - Male KW - Medication Adherence KW - Models, Econometric KW - Multivariate Analysis KW - Prescription Fees KW - Risk Factors KW - Socioeconomic factors KW - United States AB -

OBJECTIVE: Although multiple noncost factors likely influence a patient's propensity to forego treatment in the face of cost pressures, little is known about how patients' sociodemographic characteristics, physical and behavioral health comorbidities, and prescription regimens influence cost-related nonadherence (CRN) to medications. We sought to determine both financial and nonfinancial factors associated with CRN in a nationally representative sample of older adults.

METHODS: We used a conceptual model developed by Piette and colleagues that describes financial and nonfinancial factors that could increase someone's risk of CRN, including income, comorbidities, and medication regimen complexity. We used data from the 2004 wave of the Health and Retirement Study and the 2005 HRS Prescription Drug Study to examine the influence of factors within each of these domains on measures of CRN (including not filling, stopping, or skipping doses) in a nationally representative sample of Americans age 65+ in 2005.

RESULTS: Of the 3071 respondents who met study criteria, 20% reported some form of CRN in 2005. As in prior studies, indicators of financial stress such as higher out-of-pocket payments for medications and lower net worth were significantly associated with CRN in multivariable analyses. Controlling for these economic pressures, relatively younger respondents (ages 65-74) and depressive symptoms were consistent independent risk factors for CRN.

CONCLUSIONS: Noncost factors influenced patients' propensity to forego treatment even in the context of cost concerns. Future research encompassing clinician and health system factors should identify additional determinants of CRN beyond patients' cost pressures.

PB - 13 VL - 13 IS - 4 U1 - http://www.ncbi.nlm.nih.gov/pubmed/20070641?dopt=Abstract U2 - PMC3013351 U4 - health Care Costs/socioeconomic Status/cost-related nonadherence/risk factors ER - TY - JOUR T1 - Hospitalizations and deaths among adults with cardiovascular disease who underuse medications because of cost: a longitudinal analysis. JF - Med Care Y1 - 2010 A1 - Michele M Heisler A1 - Choi, Hwajung A1 - Allison B Rosen A1 - Sandeep Vijan A1 - Mohammed U Kabeto A1 - Kenneth M. Langa A1 - John D Piette KW - Aged KW - Aged, 80 and over KW - Cardiovascular Diseases KW - Female KW - Financing, Personal KW - Health Care Costs KW - Health Services Accessibility KW - Health Status Disparities KW - Hospitalization KW - Humans KW - Logistic Models KW - Longitudinal Studies KW - Male KW - Medication Adherence KW - Middle Aged KW - Multivariate Analysis KW - Risk Factors KW - United States AB -

CONTEXT: It is well-documented that the financial burden of out-of-pocket expenditures for prescription drugs often leads people with medication-sensitive chronic illnesses to restrict their use of these medications. Less is known about the extent to which such cost-related medication underuse is associated with increases in subsequent hospitalizations and deaths.

OBJECTIVE: We compared the risk of hospitalizations among 5401 and of death among 6135 middle-aged and elderly adults with one or more cardiovascular diseases (diabetes, coronary artery disease, heart failure, and history of stroke) according to whether participants did or did not report restricting prescription medications because of cost.

DESIGN AND SETTING: A retrospective biannual cohort study across 4 cross-sectional waves of the Health and Retirement Study, a nationally representative survey of adults older than age 50. Using multivariate logistic regression to adjust for baseline differences in sociodemographic and health characteristics, we assessed subsequent hospitalizations and deaths between 1998 and 2006 for respondents who reported that they had or had not taken less medicine than prescribed because of cost.

RESULTS: Respondents with cardiovascular disease who reported underusing medications due to cost were significantly more likely to be hospitalized in the next 2 years, even after adjusting for other patient characteristics (adjusted predicted probability of 47% compared with 38%, P < 0.001). The more survey waves respondents reported cost-related medication underuse during 1998 to 2004, the higher the probability of being hospitalized in 2006 (adjusted predicted probability of 54% among respondents reporting cost-related medication underuse in all 4 survey waves compared with 42% among respondents reporting no underuse, P < 0.001). There was no independent association of cost-related medication underuse with death.

CONCLUSIONS: In this nationally representative cohort, middle-aged and elderly adults with cardiovascular disease who reported cutting back on medication use because of cost were more likely to report being hospitalized over a subsequent 2-year period after they had reported medication underuse. The more extensively respondents reported cost-related underuse over time, the higher their adjusted predicted probability of subsequent hospitalization.

PB - 48 VL - 48 IS - 2 N1 - Using Smart Source Parsing Feb Comment In: Med Care. 2010 Feb;48(2):85-6 20057326 Index Medicus U1 - http://www.ncbi.nlm.nih.gov/pubmed/20068489?dopt=Abstract U2 - PMC3034735 U4 - Cardiovascular Diseases: drug therapy/Cardiovascular Diseases: economics/mortality/Health Care Costs/Services Accessibility: economics/Health Status Disparities/Hospitalization: economics/Hospitalization: statistics and numerical data/Logistic Models/Longitudinal Studies/Medication Adherence/Multivariate Analysis/Risk Factors ER - TY - JOUR T1 - Long-term cognitive impairment and functional disability among survivors of severe sepsis. JF - JAMA Y1 - 2010 A1 - Theodore J Iwashyna A1 - E Wesley Ely A1 - Dylan M Smith A1 - Kenneth M. Langa KW - Activities of Daily Living KW - Aged KW - Aged, 80 and over KW - Case-Control Studies KW - Cognition Disorders KW - Disabled Persons KW - Female KW - Health Status KW - Hospitalization KW - Humans KW - Male KW - Prospective Studies KW - Sepsis KW - Severity of Illness Index KW - Survivors KW - United States AB -

CONTEXT: Cognitive impairment and functional disability are major determinants of caregiving needs and societal health care costs. Although the incidence of severe sepsis is high and increasing, the magnitude of patients' long-term cognitive and functional limitations after sepsis is unknown.

OBJECTIVE: To determine the change in cognitive impairment and physical functioning among patients who survive severe sepsis, controlling for their presepsis functioning.

DESIGN, SETTING, AND PATIENTS: A prospective cohort involving 1194 patients with 1520 hospitalizations for severe sepsis drawn from the Health and Retirement Study, a nationally representative survey of US residents (1998-2006). A total of 9223 respondents had a baseline cognitive and functional assessment and had linked Medicare claims; 516 survived severe sepsis and 4517 survived a nonsepsis hospitalization to at least 1 follow-up survey and are included in the analysis.

MAIN OUTCOME MEASURES: Personal interviews were conducted with respondents or proxies using validated surveys to assess the presence of cognitive impairment and to determine the number of activities of daily living (ADLs) and instrumental ADLs (IADLs) for which patients needed assistance.

RESULTS: Survivors' mean age at hospitalization was 76.9 years. The prevalence of moderate to severe cognitive impairment increased 10.6 percentage points among patients who survived severe sepsis, an odds ratio (OR) of 3.34 (95% confidence interval [CI], 1.53-7.25) in multivariable regression. Likewise, a high rate of new functional limitations was seen following sepsis: in those with no limits before sepsis, a mean 1.57 new limitations (95% CI, 0.99-2.15); and for those with mild to moderate limitations before sepsis, a mean of 1.50 new limitations (95% CI, 0.87-2.12). In contrast, nonsepsis general hospitalizations were associated with no change in moderate to severe cognitive impairment (OR, 1.15; 95% CI, 0.80-1.67; P for difference vs sepsis = .01) and with the development of fewer new limitations (mean among those with no limits before hospitalization, 0.48; 95% CI, 0.39-0.57; P for difference vs sepsis <.001 and mean among those with mild to moderate limits, 0.43; 95% CI, 0.23-0.63; P for difference = .001). The declines in cognitive and physical function persisted for at least 8 years.

CONCLUSIONS: Severe sepsis in this older population was independently associated with substantial and persistent new cognitive impairment and functional disability among survivors. The magnitude of these new deficits was large, likely resulting in a pivotal downturn in patients' ability to live independently.

PB - 304 VL - 304 UR - http://jama.ama-assn.org/content/304/16/1787.abstract IS - 16 U1 - http://www.ncbi.nlm.nih.gov/pubmed/20978258?dopt=Abstract U2 - PMC3345288 U4 - Sepsis/Cognitive psychology/Disability/Disability/Survivor/Inpatient care ER - TY - JOUR T1 - Prevalence of neuropsychiatric symptoms and their association with functional limitations in older adults in the United States: the aging, demographics, and memory study. JF - J Am Geriatr Soc Y1 - 2010 A1 - Okura, Toru A1 - Brenda L Plassman A1 - David C Steffens A1 - David J Llewellyn A1 - Guy G Potter A1 - Kenneth M. Langa KW - Activities of Daily Living KW - Aged KW - Aged, 80 and over KW - Behavioral Symptoms KW - Cognition Disorders KW - Cross-Sectional Studies KW - Dementia KW - Female KW - Humans KW - Male KW - Mental Disorders KW - Prevalence KW - United States AB -

OBJECTIVES: To estimate the prevalence of neuropsychiatric symptoms and examine their association with functional limitations.

DESIGN: Cross-sectional analysis.

SETTING: The Aging, Demographics, and Memory Study (ADAMS).

PARTICIPANTS: A sample of adults aged 71 and older (N=856) drawn from Health and Retirement Study (HRS), a nationally representative cohort of U.S. adults aged 51 and older.

MEASUREMENTS: The presence of neuropsychiatric symptoms (delusions, hallucinations, agitation, depression, apathy, elation, anxiety, disinhibition, irritation, and aberrant motor behaviors) was identified using the Neuropsychiatric Inventory. A consensus panel in the ADAMS assigned a cognitive category (normal cognition; cognitive impairment, no dementia (CIND); mild, moderate, or severe dementia). Functional limitations, chronic medical conditions, and sociodemographic information were obtained from the HRS and ADAMS.

RESULTS: Forty-three percent of individuals with CIND and 58% of those with dementia exhibited at least one neuropsychiatric symptom. Depression was the most common individual symptom in those with normal cognition (12%), CIND (30%), and mild dementia (25%), whereas apathy (42%) and agitation (41%) were most common in those with severe dementia. Individuals with three or more symptoms and one or more clinically significant symptoms had significantly higher odds of having functional limitations. Those with clinically significant depression had higher odds of activity of daily living limitations, and those with clinically significant depression, anxiety, or aberrant motor behaviors had significantly higher odds of instrumental activity of daily living limitations.

CONCLUSION: Neuropsychiatric symptoms are highly prevalent in older adults with CIND and dementia. Of those with cognitive impairment, a greater number of total neuropsychiatric symptoms and some specific individual symptoms are strongly associated with functional limitations.

PB - 58 VL - 58 IS - 2 U1 - http://www.ncbi.nlm.nih.gov/pubmed/20374406?dopt=Abstract U2 - PMC2875937 U4 - dementia/functional limitations/Functional Assessment/depression/Neuropsychiatric symptoms ER - TY - JOUR T1 - Untreated poor vision: a contributing factor to late-life dementia. JF - Am J Epidemiol Y1 - 2010 A1 - Mary A M Rogers A1 - Kenneth M. Langa KW - Aged, 80 and over KW - Cognition Disorders KW - Dementia KW - Female KW - Humans KW - Logistic Models KW - Male KW - Medicare KW - Ophthalmology KW - Patient Acceptance of Health Care KW - Risk Factors KW - United States KW - Vision Disorders AB -

Ophthalmologic abnormalities have been described in patients with dementia, but the extent to which poor vision and treatment for visual disorders affect cognitive decline is not well defined. Linked data from the Health and Retirement Study and Medicare files (1992-2005) were used to follow the experiences of 625 elderly US study participants with normal cognition at baseline. The outcome was a diagnosis of dementia, cognitively impaired but no dementia, or normal cognition. Poor vision was associated with development of dementia (P = 0.0048); individuals with very good or excellent vision at baseline had a 63% reduced risk of dementia (95% confidence interval (CI): 20, 82) over a mean follow-up period of 8.5 years. Participants with poorer vision who did not visit an ophthalmologist had a 9.5-fold increased risk of Alzheimer disease (95% CI: 2.3, 39.5) and a 5-fold increased risk of cognitively impaired but no dementia (95% CI: 1.6, 15.9). Poorer vision without a previous eye procedure increased the risk of Alzheimer disease 5-fold (95% CI: 1.5, 18.8). For Americans aged 90 years or older, 77.9% who maintained normal cognition had received at least one previous eye procedure compared with 51.7% of those with Alzheimer disease. Untreated poor vision is associated with cognitive decline, particularly Alzheimer disease.

PB - 171 VL - 171 IS - 6 U1 - http://www.ncbi.nlm.nih.gov/pubmed/20150357?dopt=Abstract U2 - PMC2842219 U4 - Alzheimer disease/delirium/dementia/amnestic/cognitive disorders/health services research/Medicare/memory disorders/ophthalmology/vision disorders ER - TY - JOUR T1 - Vascular health, diabetes, APOE and dementia: the Aging, Demographics, and Memory Study. JF - Alzheimers Res Ther Y1 - 2010 A1 - David J Llewellyn A1 - Iain A Lang A1 - Fiona E Matthews A1 - Brenda L Plassman A1 - Mary A M Rogers A1 - Lewis B Morgenstern A1 - Gwenith G Fisher A1 - Mohammed U Kabeto A1 - Kenneth M. Langa AB -

INTRODUCTION: Evidence from clinical samples and geographically limited population studies suggests that vascular health, diabetes and apolipoprotein epsilon4 (APOE) are associated with dementia.

METHODS: A population-based sample of 856 individuals aged 71 years or older from all contiguous regions of the United States received an extensive in-home clinical and neuropsychological assessment in 2001-2003. The relation of hypertension, diabetes, heart disease, stroke, medication usage, and APOE epsilon4 to dementia was modelled using adjusted multivariable logistic regression.

RESULTS: Treated stroke (odds ratio [OR] 3.8, 95% confidence interval [CI] 2.0, 7.2), untreated stroke (OR 3.5, 95% CI 1.7, 7.3), and APOE epsilon4 (OR 2.8, 95% CI 1.7, 4.5) all increased the odds of dementia. Treated hypertension was associated with lower odds of dementia (OR 0.5, 95% CI 0.3, 1.0). Diabetes and heart disease were not significantly associated with dementia. A significant interaction was observed between APOE epsilon4 and stroke (P = 0.001).

CONCLUSIONS: Data from the first dementia study that is representative of the United States population suggest that stroke, the APOE epsilon4 allele and their interaction are strongly associated with dementia.

PB - 2 VL - 2 UR - http://alzres.com/content/2/3/19 IS - 3 U1 - http://www.ncbi.nlm.nih.gov/pubmed/20576093?dopt=Abstract U2 - PMC2919699 U4 - Dementia/Vascular dementia/Stroke ER - TY - JOUR T1 - The accuracy of Medicare claims as an epidemiological tool: the case of dementia revisited. JF - J Alzheimers Dis Y1 - 2009 A1 - Donald H. Taylor Jr. A1 - Østbye, Truls A1 - Kenneth M. Langa A1 - David R Weir A1 - Brenda L Plassman KW - Aged KW - Aged, 80 and over KW - Alzheimer disease KW - Cohort Studies KW - Dementia KW - Female KW - Health Care Costs KW - Humans KW - Insurance Claim Reporting KW - Male KW - Medicare KW - Prevalence KW - Sensitivity and Specificity KW - United States AB -

Our study estimates the sensitivity and specificity of Medicare claims to identify clinically-diagnosed dementia, and documents how errors in dementia assessment affect dementia cost estimates. We compared Medicare claims from 1993-2005 to clinical dementia assessments carried out in 2001-2003 for the Aging Demographics and Memory Study (ADAMS) cohort (n = 758) of the Health and Retirement Study. The sensitivity and specificity of Medicare claims was 0.85 and 0.89 for dementia (0.64 and 0.95 for AD). Persons with dementia cost the Medicare program (in 2003) $7,135 more than controls (P < 0.001) when using claims to identify dementia, compared to $5,684 more when using ADAMS (P < 0.001). Using Medicare claims to identify dementia results in a 110% increase in costs for those with dementia as compared to a 68% increase when using ADAMS to identify disease, net of other variables. Persons with false positive Medicare claims notations of dementia were the most expensive group of subjects ($11,294 versus $4,065, for true negatives P < 0.001). Medicare claims overcount the true prevalence of dementia, but there are both false positive and negative assessments of disease. The use of Medicare claims to identify dementia results in an overstatement of the increase in Medicare costs that are due to dementia.

PB - 17 VL - 17 IS - 4 U1 - http://www.ncbi.nlm.nih.gov/pubmed/19542620?dopt=Abstract U2 - PMC3697480 U4 - Medicare/dementia/Cost of Illness ER - TY - RPRT T1 - Aging, Demographics and Memory Study (ADAMS): Sample Design, Weighting and Analysis for ADAMS Y1 - 2009 A1 - Steven G Heeringa A1 - Gwenith G Fisher A1 - Michael D Hurd A1 - Kenneth M. Langa A1 - Mary Beth Ofstedal A1 - Brenda L Plassman A1 - Rogers, Willard A1 - David R Weir KW - Health Conditions and Status KW - Methodology AB - This technical report describes the sample design, design-based weighting and analysis procedures for the Aging, Demographics and Memory Study (ADAMS), a national study that recruited Health and Retirement Study (HRS) panel members to undergo a psychometric evaluation and clinical assessment visit. Langa et al. (2005) describe the general design and methods for the ADAMS including relevant background on the HRS longitudinal sample. This document provides additional detail on the sample design for the ADAMS including a description of survey sample selection, sample attrition and nonresponse, population weights, design-based variance estimation and related topics of importance to analysts of the ADAMS data. PB - Institute for Social Research, University of Michigan CY - Ann Arbor, Michigan U4 - survey Methods/Sample Design/Cognition ER - TY - JOUR T1 - Association between cognitive function and social support with glycemic control in adults with diabetes mellitus. JF - J Am Geriatr Soc Y1 - 2009 A1 - Okura, Toru A1 - Michele M Heisler A1 - Kenneth M. Langa KW - Aged KW - Blood Glucose KW - Cognition KW - Cross-Sectional Studies KW - Diabetes Mellitus KW - Female KW - Humans KW - Male KW - Middle Aged KW - Social Support AB -

OBJECTIVES: To examine whether cognitive impairment in adults with diabetes mellitus is associated with worse glycemic control and to assess whether level of social support for diabetes mellitus care modifies this relationship.

DESIGN: Cross-sectional analysis.

SETTING: The 2003 Health and Retirement Study (HRS) Mail Survey on Diabetes and the 2004 wave of the HRS.

PARTICIPANTS: Adults aged 50 and older with diabetes mellitus in the United States (N=1,097, mean age 69.2).

MEASUREMENTS: Glycosylated hemoglobin (HbA1c) level; cognitive function, measured with the 35-point HRS cognitive scale (HRS-cog); sociodemographic variables; duration of diabetes mellitus; depressed mood; social support for diabetes mellitus care; self-reported knowledge of diabetes mellitus; treatments for diabetes mellitus; components of the Total Illness Burden Index related to diabetes mellitus; and functional limitations.

RESULTS: In an ordered logistic regression model for the three ordinal levels of HbA1c (<7.0, 7.0-7.9, >or=8.0 mg/dL), respondents with HRS-cog scores in the lowest quartile had significantly higher HbA1c levels than those in the highest cognitive quartile (adjusted odds ratio=1.80, 95% confidence interval=1.11-2.92). A high level of social support for diabetes mellitus care modified this association; for respondents in the lowest cognitive quartile, those with high levels of support had significantly lower odds of having higher HbA1c than those with low levels of support (1.11 vs 2.87, P=.02).

CONCLUSION: Although cognitive impairment was associated with worse glycemic control, higher levels of social support for diabetes mellitus care ameliorated this negative relationship. Identifying the level of social support available to cognitively impaired adults with diabetes mellitus may help to target interventions for better glycemic control.

PB - 57 VL - 57 IS - 10 U1 - http://www.ncbi.nlm.nih.gov/pubmed/19682129?dopt=Abstract U2 - PMC2810258 U4 - Cognitive Function/Social Support/Diabetes Mellitus/Health care management ER - TY - JOUR T1 - "Below average" self-assessed school performance and Alzheimer's disease in the Aging, Demographics, and Memory Study. JF - Alzheimers Dement Y1 - 2009 A1 - Kala M. Mehta A1 - Anita L Stewart A1 - Kenneth M. Langa A1 - Kristine Yaffe A1 - Sandra Y. Moody-Ayers A1 - Brie A Williams A1 - Kenneth E Covinsky KW - Aged KW - Aged, 80 and over KW - Aging KW - Alzheimer disease KW - Apolipoprotein E4 KW - Cognition Disorders KW - Educational Status KW - Female KW - Geriatric Assessment KW - Humans KW - Male KW - Memory KW - Neuropsychological tests KW - Risk Factors AB -

BACKGROUND: A low level of formal education is becoming accepted as a risk factor for Alzheimer's disease (AD). Although increasing attention has been paid to differences in educational quality, no previous studies addressed participants' own characterizations of their overall performance in school. We examined whether self-assessed school performance is associated with AD beyond the effects of educational level alone.

METHODS: Participants were drawn from the population-representative Aging, Demographics, and Memory Study (ADAMS, 2000-2002). The ADAMS participants were asked about their performance in school. Possible response options included "above average," "average," or "below average." The ADAMS participants also underwent a full neuropsychological battery, and received a research diagnosis of possible or probable AD.

RESULTS: The 725 participants (mean age, 81.8 years; 59% female; 16% African-American) varied in self-assessed educational performance: 29% reported "above average," 64% reported "average," and 7% reported "below average" school performance. Participants with a lower self-assessed school performance had higher proportions of AD: 11% of participants with "above average" self-assessed performance had AD, as opposed to 12% of participants with "average" performance and 26% of participants with "below average" performance (P < 0.001). After controlling for subjects' years in school, a literacy test score (Wide-Range Achievement Test), age, sex, race/ethnicity, apolipoprotein E-epsilon4 status, socioeconomic status, and self-reported comorbidities, respondents with "below average" self-assessed school performance were four times more likely to have AD compared with those of "average" performance (odds ratio, 4.0; 95% confidence interval, 1.2-14). "Above average" and "average" self-assessed school performance did not increase or decrease the odds of having AD (odds ratio, 0.9; 95% confidence interval, 0.5-1.7).

CONCLUSIONS: We suggest an association between "below average" self-assessed school performance and AD beyond the known association with formal education. Efforts to increase cognitive reserve through better school performance, in addition to increasing the number of years of formal education in early life, may be important in reducing vulnerability throughout the life course.

PB - 5 VL - 5 UR - http://www.sciencedirect.com/science?_ob=ArticleURLand_udi=B7W6D-4X6VH7W-7and_user=99318and_coverDate=09 2F30 2F2009and_rdoc=1and_fmt=highand_orig=searchand_origin=searchand_sort=dand_docanchor=andview=cand_acct=C000007678and_version=1and_urlVersion=0and_ IS - 5 U1 - http://www.ncbi.nlm.nih.gov/pubmed/19751917?dopt=Abstract U2 - PMC2787515 U4 - alzheimer disease/cognition Disorders/educational Status/Geriatric Assessment/neuropsychological Tests/risk Factors ER - TY - JOUR T1 - Caregiving behavior is associated with decreased mortality risk. JF - Psychol Sci Y1 - 2009 A1 - Stephanie Brown A1 - Dylan M Smith A1 - Schulz, Richard A1 - Mohammed U Kabeto A1 - Peter A. Ubel A1 - Poulin, Michael A1 - Yi, Jaehee A1 - Kim, Catherine A1 - Kenneth M. Langa KW - Altruism KW - Caregivers KW - Humans KW - Mortality AB -

Traditional investigations of caregiving link it to increased caregiver morbidity and mortality, but do not disentangle the effects of providing care from those of being continuously exposed to an ailing loved one with serious health problems. We explored this possible confound in a national, longitudinal survey of elderly married individuals (N= 3,376). Results showed that spending at least 14 hr per week providing care to a spouse predicted decreased mortality for the caregiver, independently of behavioral and cognitive limitations of the care recipient (spouse), and of other demographic and health variables. These findings suggest that it may be premature to conclude that health risks for caregivers are due to providing active help. Indeed, under some circumstances, caregivers may actually benefit from providing care.

PB - 20 VL - 20 UR - http://pss.sagepub.com/content/20/4/4 IS - 4 U1 - http://www.ncbi.nlm.nih.gov/pubmed/19320860?dopt=Abstract U2 - PMC2865652 U4 - Caregivers/Mortality/Risk assessment/Psychology/Older people ER - TY - JOUR T1 - Cognitive health among older adults in the United States and in England. JF - BMC Geriatr Y1 - 2009 A1 - Kenneth M. Langa A1 - David J Llewellyn A1 - Iain A Lang A1 - David R Weir A1 - Robert B Wallace A1 - Mohammed U Kabeto A1 - Felicia A Huppert KW - Aged KW - Aged, 80 and over KW - Aging KW - Cognition KW - Cognition Disorders KW - Cohort Studies KW - Cross-Sectional Studies KW - England KW - Female KW - Health Status KW - Humans KW - Longitudinal Studies KW - Male KW - Neuropsychological tests KW - United States AB -

BACKGROUND: Cognitive function is a key determinant of independence and quality of life among older adults. Compared to adults in England, US adults have a greater prevalence of cardiovascular risk factors and disease that may lead to poorer cognitive function. We compared cognitive performance of older adults in the US and England, and sought to identify sociodemographic and medical factors associated with differences in cognitive function between the two countries.

METHODS: Data were from the 2002 waves of the US Health and Retirement Study (HRS) (n = 8,299) and the English Longitudinal Study of Ageing (ELSA) (n = 5,276), nationally representative population-based studies designed to facilitate direct comparisons of health, wealth, and well-being. There were differences in the administration of the HRS and ELSA surveys, including use of both telephone and in-person administration of the HRS compared to only in-person administration of the ELSA, and a significantly higher response rate for the HRS (87% for the HRS vs. 67% for the ELSA). In each country, we assessed cognitive performance in non-hispanic whites aged 65 and over using the same tests of memory and orientation (0 to 24 point scale).

RESULTS: US adults scored significantly better than English adults on the 24-point cognitive scale (unadjusted mean: 12.8 vs. 11.4, P < .001; age- and sex-adjusted: 13.2 vs. 11.7, P < .001). The US cognitive advantage was apparent even though US adults had a significantly higher prevalence of cardiovascular risk factors and disease. In a series of OLS regression analyses that controlled for a range of sociodemographic and medical factors, higher levels of education and wealth, and lower levels of depressive symptoms, accounted for some of the US cognitive advantage. US adults were also more likely to be taking medications for hypertension, and hypertension treatment was associated with significantly better cognitive function in the US, but not in England (P = .014 for treatment x country interaction).

CONCLUSION: Despite methodological differences in the administration of the surveys in the two countries, US adults aged >/= 65 appeared to be cognitively healthier than English adults, even though they had a higher burden of cardiovascular risk factors and disease. Given the growing number of older adults worldwide, future cross-national studies aimed at identifying the medical and social factors that might prevent or delay cognitive decline in older adults would make important and valuable contributions to public health.

PB - 9 VL - 9 N1 - PMID: 19555494 U1 - http://www.ncbi.nlm.nih.gov/pubmed/19555494?dopt=Abstract U2 - PMC2709651 U4 - Cross Cultural Comparison/Cognitive Function/Hypertension/Medicine/ELSA_/cross-national comparison ER - TY - JOUR T1 - Cognitive performance and informant reports in the diagnosis of cognitive impairment and dementia in African Americans and whites. JF - Alzheimers Dement Y1 - 2009 A1 - Guy G Potter A1 - Brenda L Plassman A1 - James R Burke A1 - Mohammed U Kabeto A1 - Kenneth M. Langa A1 - David J Llewellyn A1 - Mary A M Rogers A1 - David C Steffens KW - Activities of Daily Living KW - Age of Onset KW - Aged KW - Aged, 80 and over KW - Black or African American KW - Caregivers KW - Cognition Disorders KW - Cohort Studies KW - Culture KW - Dementia KW - Disability Evaluation KW - Female KW - Geriatric Assessment KW - Health Surveys KW - Humans KW - Male KW - Neuropsychological tests KW - Observer Variation KW - Population Surveillance KW - Predictive Value of Tests KW - Prevalence KW - Psychiatric Status Rating Scales KW - Psychometrics KW - Registries KW - Sensitivity and Specificity KW - Surveys and Questionnaires KW - White People AB -

BACKGROUND: The diagnosis of cognitive impairment and dementia must reflect an increasingly diverse and aging United States population. This study compared direct testing and informant reports of cognition with clinical diagnoses of cognitive impairment and dementia between African Americans and whites.

METHODS: Participants in the Aging, Demographics, and Memory Study completed in-person dementia evaluations, and were assigned clinical diagnoses (by a consensus panel of dementia experts) of normal; cognitive impairment, not demented (CIND); and dementia. The Consortium to Establish a Registry for Alzheimer's Disease (CERAD) total score and the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) were used to assess cognitive performance and reported cognitive decline.

RESULTS: A higher CERAD total score was associated with lower odds of CIND and dementia, at comparable ratios between African Americans and whites. Higher IQCODE scores were associated with increased odds of dementia in both African Americans and whites. Higher IQCODE scores were associated with increased odds of CIND among whites, but not among African Americans.

CONCLUSIONS: Cultural differences may influence informant reports of prevalent CIND and dementia. Our findings also highlight the need for more comparative research to establish the cultural validity of measures used to diagnose these conditions.

PB - 5 VL - 5 IS - 6 U1 - http://www.ncbi.nlm.nih.gov/pubmed/19896583?dopt=Abstract U2 - PMC2805266 U4 - CERAD/IQCODE/Cognitive decline/Dementia/African American ER - TY - JOUR T1 - Does caring for your spouse harm one's health? Evidence from a United States nationally-representative sample of older adults. JF - Ageing Soc Y1 - 2009 A1 - Kristi Rahrig Jenkins A1 - Mohammed U Kabeto A1 - Kenneth M. Langa AB -

The purpose of this article is to investigate the relationship between spousal care-giving and declines in functioning and self-rated health among older care-givers. The authors used data from the 2000 and 2002 waves of the United States Health and Retirement Study, a biennial longitudinal survey of a nationally representative cohort of adults aged 50 or more years. Two outcomes were examined, declines in functioning and declines in self-rated health. Care-givers were classified into three groups: no care-giving, less than 14 hours of care-giving per week, and 14 or more hours care-giving per week. To assess declines in functioning, two summary scores were created of limitations in basic and instrumental Activities of Daily Living. To assess declines in self-rated health, we compared responses from 2000 and 2002. In the fully adjusted models, care-giving hours did not have an independent effect on declines in functioning or self-rated health. The relationship between care-giving hours and declines in functioning and self-rated health is probably attributable to socio-demographic characteristics, mainly age. The findings suggest that spousal care-giving does not of itself harm functional health or perceived health among older adult care-givers. Understanding the differential effects of these socio-economic characteristics with care-giving hours on health will be useful in promoting the health of older adult care-givers and treating their disorders.

PB - 29 VL - 29 IS - 2 U1 - http://www.ncbi.nlm.nih.gov/pubmed/24567660?dopt=Abstract U4 - Couples/Caregiving/Health Status--ADL limitations ER - TY - JOUR T1 - The effect of depression and cognitive impairment on enrollment in Medicare Part D. JF - J Am Geriatr Soc Y1 - 2009 A1 - Zivin, Kara A1 - Mohammed U Kabeto A1 - Helen C Kales A1 - Kenneth M. Langa KW - Aged KW - Aged, 80 and over KW - Chi-Square Distribution KW - Cognition Disorders KW - depression KW - Female KW - Humans KW - Logistic Models KW - Longitudinal Studies KW - Male KW - Medicare Part D KW - Middle Aged KW - Patient Participation KW - Risk Factors KW - United States AB -

OBJECTIVES: To examine concerns that vulnerable populations, such as depressed or cognitively impaired beneficiaries would have challenges accessing Part D coverage.

DESIGN: Logistic regression analysis was used to assess whether elderly Medicare beneficiaries with depression or cognitive impairment differentially planned to and actually signed up for Part D.

SETTING: 2004 and 2006 data from the Health and Retirement Study (HRS) were used, including a subsample that completed the Prescription Drug Study (PDS) in 2005.

PARTICIPANTS: Nine thousand five hundred ninety-three HRS respondents and 3,567 PDS respondents.

MEASUREMENTS: The outcome variables of interest were planned and actual enrollment in Part D. The independent variables were depression and cognitive impairment status. The analyses were adjusted using clinical and demographic predictors including age, sex, race or ethnicity, educational attainment, net worth, marital status, health status, number of health conditions being treated with prescription medications, and presence of a caregiver.

RESULTS: Although having depression or cognitive impairment was associated with a higher likelihood of planning to and actually signing up for Part D in unadjusted analyses, in adjusted analyses, having depression or cognitive impairment was not significantly associated with whether Medicare beneficiaries planned to enroll in or actually enrolled in Part D.

CONCLUSION: Vulnerable Medicare beneficiaries with depression or cognitive impairment were able to access Part D benefits to the same extent as nonvulnerable beneficiaries. More research is needed to determine how well Part D meets the needs of these populations.

PB - 57 VL - 57 IS - 8 U1 - http://www.ncbi.nlm.nih.gov/pubmed/19515100?dopt=Abstract U2 - PMC2810264 U4 - Depression/Cognition/Medicare ER - TY - JOUR T1 - Effect of Medicare home health care payment on informal care. JF - Inquiry Y1 - 2009 A1 - Ezra Golberstein A1 - David C Grabowski A1 - Kenneth M. Langa A1 - M.E. Chernew KW - Caregivers KW - Confidence Intervals KW - Female KW - Health Care Surveys KW - Home Care Services KW - Humans KW - Male KW - Medicare KW - Organizational Policy KW - Reimbursement Mechanisms KW - United States AB -

This paper assesses the effect of payment caps for Medicare home health care on the use of informal care by older adults with functional limitations. We find that individuals exposed to more restrictive payment caps offset reductions in Medicare home health care with increased informal care, although we only observe this effect for lower-income individuals. This suggests that home care payment restrictions may have increased the caregiving burden on some low-income families, but that many higher-income families were able to either forgo the care or finance it privately. Home care payment policies should recognize these effects, balancing costs of the program with the desire to protect families from the burdens associated with providing informal home care.

PB - 46 VL - 46 IS - 1 U1 - http://www.ncbi.nlm.nih.gov/pubmed/19489484?dopt=Abstract U2 - PMC3092523 U4 - Medicare/Home Care Services/Caregiver Status/home health care ER - TY - JOUR T1 - The influence of long-term care insurance on the likelihood of nursing home admission. JF - J Am Geriatr Soc Y1 - 2009 A1 - Tanya R Gure A1 - Mohammed U Kabeto A1 - Kenneth M. Langa KW - Aged KW - Aged, 80 and over KW - Female KW - Humans KW - Insurance, Long-Term Care KW - Longitudinal Studies KW - Male KW - Middle Aged KW - Nursing homes AB -

OBJECTIVES: To determine the effect of long-term care (LTC) insurance on nursing home use.

DESIGN: Longitudinal analysis, 1998 to 2006 waves of the Health Retirement Study.

SETTING: Community-dwelling nationally representative sample.

PARTICIPANTS: Nineteen thousand one hundred seventy adults aged 50 and older, 1998 wave.

METHODS: Two groups of respondents were created at baseline: those with and without an LTC insurance policy. Respondents admitted to the nursing home from 1998 to 2006 were identified. Propensity scores were used to control for known predictors of LTC insurance possession. A Cox proportional hazards model was used to compare the probability of nursing home admission over 8 years of follow-up for respondents possessing LTC insurance and those without a policy.

RESULTS: Of the 19,170 respondents aged 50 and older in 1998, 1,767 (9.2%) possessed LTC insurance. A total of 1,778 (8.5%) were admitted to a nursing home during the 8-year period: 149 (8.7%) of those with LTC insurance and 1,629 (8.4%) of those without LTC insurance. The hazard ratio, adjusted for propensity score, for those with LTC insurance entering a nursing home compared with those without was 1.07 (95% confidence interval=0.83-1.38). Likelihood of nursing home admission was relatively low because the low-risk population included in the study, limiting the power to detect small differences in risk of nursing home utilization between groups.

CONCLUSION: There was no difference in nursing home utilization between low-risk older adults who did and did not possess an LTC insurance policy.

PB - 57 VL - 57 IS - 10 U1 - http://www.ncbi.nlm.nih.gov/pubmed/19694868?dopt=Abstract U2 - PMC2810263 U4 - Long-Term Care/Insurance, Long Term Care/Nursing Homes ER - TY - JOUR T1 - Parental education and late-life dementia in the United States. JF - J Geriatr Psychiatry Neurol Y1 - 2009 A1 - Mary A M Rogers A1 - Brenda L Plassman A1 - Mohammed U Kabeto A1 - Gwenith G Fisher A1 - John J McArdle A1 - David J Llewellyn A1 - Guy G Potter A1 - Kenneth M. Langa KW - Age Distribution KW - Aged KW - Aged, 80 and over KW - Apolipoproteins E KW - Biomarkers KW - Cognition Disorders KW - Dementia KW - Educational Status KW - Fathers KW - Female KW - Genetic Predisposition to Disease KW - Humans KW - Longitudinal Studies KW - Male KW - Mothers KW - Odds Ratio KW - Parents KW - Prevalence KW - Prospective Studies KW - Racial Groups KW - Risk Factors KW - Sex Distribution KW - United States AB -

We investigated the relation between parental education and dementia in the United States. Participants in the Aging, Demographics, and Memory Study were included, with information regarding parental education obtained from the Health and Retirement Study. The odds of dementia in elderly Americans whose mothers had less then 8 years of schooling were twice (95% CI, 1.1-3.8) that of individuals with higher maternal education, when adjusted for paternal education. Of elderly Americans with less educated mothers, 45.4% (95% CI, 37.4-53.4%) were diagnosed with dementia or ;;cognitive impairment, no dementia'' compared to 31.2% (95% CI, 25.0-37.4%) of elderly Americans whose mothers had at least an 8th grade education. The population attributable risk of dementia due to low maternal education was 18.8% (95% CI, 9.4-28.2%). The education of girls in a population may be protective of dementia in the next generation.

PB - 22 VL - 22 IS - 1 U1 - http://www.ncbi.nlm.nih.gov/pubmed/19073840?dopt=Abstract U2 - PMC2670459 U4 - Dementia/Education/Women ER - TY - JOUR T1 - Prevalence of depression among older Americans: the Aging, Demographics and Memory Study. JF - Int Psychogeriatr Y1 - 2009 A1 - David C Steffens A1 - Gwenith G Fisher A1 - Kenneth M. Langa A1 - Guy G Potter A1 - Brenda L Plassman KW - Aged KW - Aged, 80 and over KW - Alzheimer disease KW - Black People KW - Cohort Studies KW - Comorbidity KW - Cross-Sectional Studies KW - Depressive Disorder KW - Female KW - Health Status KW - Hispanic or Latino KW - Humans KW - Male KW - Neuropsychological tests KW - Personality Assessment KW - Sex Factors KW - Socioeconomic factors KW - United States KW - White People AB -

BACKGROUND: Previous studies have attempted to provide estimates of depression prevalence in older adults. The Aging, Demographics and Memory Study (ADAMS) is a population-representative study that included a depression assessment, providing an opportunity to estimate the prevalence of depression in late life in the U.S.A.

METHODS: The ADAMS sample was drawn from the larger Health and Retirement Study. A total of 851 of 856 ADAMS participants aged 71 and older had available depression data. Depression was measured using the Composite International Diagnostic Interview - Short Form (CIDI-SF) and the informant depression section of the Neuropsychiatric Inventory (NPI). We estimated the national prevalence of depression, stratified by age, race, sex, and cognitive status. Logistic regression analyses were performed to examine the association of depression and previously reported risk factors for the condition.

RESULTS: When combining symptoms of major or minor depression with reported treatment for depression, we found an overall depression prevalence of 11.19%. Prevalence was similar for men (10.19%) and women (11.44%). Whites and Hispanics had nearly three times the prevalence of depression found in African-Americans. Dementia diagnosis and pain severity were associated with increased depression prevalence, while black race was associated with lower rates of depression.

CONCLUSIONS: The finding of similar prevalence estimates for depression in men and women was not consistent with prior research that has shown a female predominance. Given the population-representativeness of our sample, similar depression rates between the sexes in ADAMS may result from racial, ethnic and socioeconomic diversity.

PB - 21 VL - 21 IS - 5 N1 - PMID: 19519984 U1 - http://www.ncbi.nlm.nih.gov/pubmed/19519984?dopt=Abstract U2 - PMC2747379 U4 - Depression/PREVALENCE/Elderly ER - TY - JOUR T1 - Surrogate consent for dementia research: a national survey of older Americans. JF - Neurology Y1 - 2009 A1 - Scott Y H Kim A1 - H.M. Kim A1 - Kenneth M. Langa A1 - Jason H. Karlawish A1 - David S Knopman A1 - Appelbaum, P S KW - Advance directives KW - Age Factors KW - Aged KW - Aged, 80 and over KW - Alzheimer disease KW - Biomedical Research KW - Caregivers KW - Clinical Trials as Topic KW - Data collection KW - ethnicity KW - Female KW - Humans KW - Informed Consent KW - Legal Guardians KW - Male KW - Mental Competency KW - Middle Aged KW - Patient Participation KW - Proxy KW - Research Subjects KW - Surveys and Questionnaires KW - Therapeutic Human Experimentation KW - Third-Party Consent AB -

BACKGROUND: Research in novel therapies for Alzheimer disease (AD) relies on persons with AD as research subjects. Because AD impairs decisional capacity, informed consent often must come from surrogates, usually close family members. But policies for surrogate consent for research remain unsettled after decades of debate.

METHODS: We designed a survey module for a random subsample (n = 1,515) of the 2006 wave of the Health and Retirement Study, a biennial survey of a nationally representative sample of Americans aged 51 and older. The participants answered questions regarding one of four randomly assigned surrogate-based research (SBR) scenarios: lumbar puncture study, drug randomized control study, vaccine study, and gene transfer study. Each participant answered three questions: whether our society should allow family surrogate consent, whether one would want to participate in the research, and whether one would allow one's surrogate some or complete leeway to override stated personal preferences.

RESULTS: Most respondents stated that our society should allow family surrogate consent for SBR (67.5% to 82.5%, depending on the scenario) and would themselves want to participate in SBR (57.4% to 79.7%). Most would also grant some or complete leeway to their surrogates (54.8% to 66.8%), but this was true mainly of those willing to participate. There was a trend toward lower willingness to participate in SBR among those from ethnic or racial minority groups.

CONCLUSIONS: Family surrogate consent-based dementia research is broadly supported by older Americans. Willingness to allow leeway to future surrogates needs to be studied further for its ethical significance for surrogate-based research policy.

PB - 72 VL - 72 IS - 2 N1 - PMID 19139366 U1 - http://www.ncbi.nlm.nih.gov/pubmed/19139366?dopt=Abstract U2 - PMC2663398 U4 - Dementia/Surrogate-based research/Surrogate-based research ER - TY - JOUR T1 - Degree of disability and patterns of caregiving among older Americans with congestive heart failure. JF - J Gen Intern Med Y1 - 2008 A1 - Tanya R Gure A1 - Mohammed U Kabeto A1 - Caroline S Blaum A1 - Kenneth M. Langa KW - Activities of Daily Living KW - Aged KW - Aged, 80 and over KW - Caregivers KW - Coronary Disease KW - Cross-Sectional Studies KW - Disabled Persons KW - Female KW - Health Surveys KW - Heart Failure KW - Hospitalization KW - Humans KW - Male KW - Nursing homes KW - United States AB -

OBJECTIVES: Although congestive heart failure (CHF) is a common condition, the extent of disability and caregiving needs for those with CHF are unclear. We sought to determine: (1) prevalence of physical disability and geriatric conditions, (2) whether CHF is independently associated with disability, (3) rates of nursing home admission, and (4) formal and informal in-home care received in the older CHF population.

METHODS: We used cross-sectional data from the 2000 wave of the Health and Retirement Study. We compared outcomes among three categories of older adults: (1) no coronary heart disease (CHD), (2) CHD, without CHF, and (3) CHF. Compared to those without CHF, respondents reporting CHF were more likely to be disabled (P < 0.001) and to have geriatric conditions (P < 0.001). Respondents reporting CHF were more likely to have been admitted to a nursing home (P < 0.05). CHF respondents were more functionally impaired than respondents without CHF.

RESULTS: The adjusted average weekly informal care hours for respondents reporting CHF was higher than for those reporting CHD but without CHF and those reporting no CHD (6.7 vs 4.1 vs 5.1, respectively; P < 0.05). Average weekly formal caregiving hours also differed among the three groups (1.3 CHF vs 0.9 CHD without CHF vs 0.7 no CHD; P > 0.05).

CONCLUSIONS: CHF imposes a significant burden on patients, families, and the long-term care system. Older adults with CHF have higher rates of disability, geriatric conditions, and nursing home admission.

PB - 23 VL - 23 IS - 1 U1 - http://www.ncbi.nlm.nih.gov/pubmed/18030537?dopt=Abstract U2 - PMC2173919 U4 - Heart Diseases/DISABILITY/DISABILITY/Caregiving ER - TY - RPRT T1 - Documentation of Physical Measures, Anthropometrics and Blood Pressure in the Health and Retirement Study Y1 - 2008 A1 - Eileen M. Crimmins A1 - Heidi M Guyer A1 - Kenneth M. Langa A1 - Mary Beth Ofstedal A1 - Robert B Wallace A1 - David R Weir KW - Health Conditions and Status KW - Healthcare KW - Methodology AB - The assessment of physical performance is an important component of the evaluation of functioning of older persons. The HRS has employed a set of standardized assessments of lung function, grip strength, balance, and walking speed. In addition, HRS collected measures of blood pressure, height, weight, and waist circumference. In 2006, HRS included the following measurements, administered in this order: Blood pressure; Lung function; Hand grip strength; Balance tests; Timed walk; Height; Weight; Waist circumference. This report describes the following for each of the measures listed above: Rationale and key citations; Sample description; Measure description; Equipment; Protocol description; Special instructions PB - Institute for Social Research, University of Michigan CY - Ann Arbor, Michigan U4 - health measures/survey Methods/Physical Activity ER - TY - JOUR T1 - Prevalence of cognitive impairment without dementia in the United States. JF - Ann Intern Med Y1 - 2008 A1 - Brenda L Plassman A1 - Kenneth M. Langa A1 - Gwenith G Fisher A1 - Steven G Heeringa A1 - David R Weir A1 - Mary Beth Ofstedal A1 - James R Burke A1 - Michael D Hurd A1 - Guy G Potter A1 - Willard L Rodgers A1 - David C Steffens A1 - John J McArdle A1 - Robert J. Willis A1 - Robert B Wallace KW - Aged KW - Aged, 80 and over KW - Cognition Disorders KW - Dementia KW - disease progression KW - Humans KW - Longitudinal Studies KW - Prevalence KW - United States AB -

BACKGROUND: Cognitive impairment without dementia is associated with increased risk for disability, increased health care costs, and progression to dementia. There are no population-based prevalence estimates of this condition in the United States.

OBJECTIVE: To estimate the prevalence of cognitive impairment without dementia in the United States and determine longitudinal cognitive and mortality outcomes.

DESIGN: Longitudinal study from July 2001 to March 2005.

SETTING: In-home assessment for cognitive impairment.

PARTICIPANTS: Participants in ADAMS (Aging, Demographics, and Memory Study) who were age 71 years or older drawn from the nationally representative HRS (Health and Retirement Study). Of 1770 selected individuals, 856 completed initial assessment, and of 241 selected individuals, 180 completed 16- to 18-month follow-up assessment.

MEASUREMENTS: Assessments, including neuropsychological testing, neurologic examination, and clinical and medical history, were used to assign a diagnosis of normal cognition, cognitive impairment without dementia, or dementia. National prevalence rates were estimated by using a population-weighted sample.

RESULTS: In 2002, an estimated 5.4 million people (22.2%) in the United States age 71 years or older had cognitive impairment without dementia. Prominent subtypes included prodromal Alzheimer disease (8.2%) and cerebrovascular disease (5.7%). Among participants who completed follow-up assessments, 11.7% with cognitive impairment without dementia progressed to dementia annually, whereas those with subtypes of prodromal Alzheimer disease and stroke progressed at annual rates of 17% to 20%. The annual death rate was 8% among those with cognitive impairment without dementia and almost 15% among those with cognitive impairment due to medical conditions.

LIMITATIONS: Only 56% of the nondeceased target sample completed the initial assessment. Population sampling weights were derived to adjust for at least some of the potential bias due to nonresponse and attrition.

CONCLUSION: Cognitive impairment without dementia is more prevalent in the United States than dementia, and its subtypes vary in prevalence and outcomes.

PB - 148 VL - 148 IS - 6 U1 - http://www.ncbi.nlm.nih.gov/pubmed/18347351?dopt=Abstract U2 - PMC2670458 U4 - Cognitive Functioning/Dementia/Health Risk/PREVALENCE ER - TY - JOUR T1 - Trends in the prevalence and mortality of cognitive impairment in the United States: is there evidence of a compression of cognitive morbidity? JF - Alzheimers Dement Y1 - 2008 A1 - Kenneth M. Langa A1 - Eric B Larson A1 - Jason H. Karlawish A1 - David M Cutler A1 - Mohammed U Kabeto A1 - Scott Y H Kim A1 - Allison B Rosen KW - Aged KW - Aged, 80 and over KW - Cognition Disorders KW - Female KW - Humans KW - Male KW - Neurology KW - Prevalence KW - Quality of Life KW - Socioeconomic factors KW - United States AB -

BACKGROUND: Recent medical, demographic, and social trends might have had an important impact on the cognitive health of older adults. To assess the impact of these multiple trends, we compared the prevalence and 2-year mortality of cognitive impairment (CI) consistent with dementia in the United States in 1993 to 1995 and 2002 to 2004.

METHODS: We used data from the Health and Retirement Study (HRS), a nationally representative population-based longitudinal survey of U.S. adults. Individuals aged 70 years or older from the 1993 (N = 7,406) and 2002 (N = 7,104) waves of the HRS were included. CI was determined by using a 35-point cognitive scale for self-respondents and assessments of memory and judgment for respondents represented by a proxy. Mortality was ascertained with HRS data verified by the National Death Index.

RESULTS: In 1993, 12.2% of those aged 70 or older had CI compared with 8.7% in 2002 (P < .001). CI was associated with a significantly higher risk of 2-year mortality in both years. The risk of death for those with moderate/severe CI was greater in 2002 compared with 1993 (unadjusted hazard ratio, 4.12 in 2002 vs 3.36 in 1993; P = .08; age- and sex-adjusted hazard ratio, 3.11 in 2002 vs 2.53 in 1993; P = .09). Education was protective against CI, but among those with CI, more education was associated with higher 2-year mortality.

CONCLUSIONS: These findings support the hypothesis of a compression of cognitive morbidity between 1993 and 2004, with fewer older Americans reaching a threshold of significant CI and a more rapid decline to death among those who did. Societal investment in building and maintaining cognitive reserve through formal education in childhood and continued cognitive stimulation during work and leisure in adulthood might help limit the burden of dementia among the growing number of older adults worldwide.

PB - 4 VL - 4 IS - 2 U1 - http://www.ncbi.nlm.nih.gov/pubmed/18631957?dopt=Abstract U2 - PMC2390845 U4 - Dementia/Epidemiology/heart disease/Education ER - TY - JOUR T1 - Beyond comorbidity counts: how do comorbidity type and severity influence diabetes patients' treatment priorities and self-management? JF - J Gen Intern Med Y1 - 2007 A1 - Eve A Kerr A1 - Michele M Heisler A1 - Sarah L. Krein A1 - Mohammed U Kabeto A1 - Kenneth M. Langa A1 - David R Weir A1 - John D Piette KW - Aged KW - Attitude to Health KW - Cohort Studies KW - Comorbidity KW - Cross-Sectional Studies KW - Diabetes Mellitus KW - Female KW - Health Priorities KW - Heart Failure KW - Humans KW - Male KW - Middle Aged KW - Self Care KW - Severity of Illness Index KW - United States AB -

BACKGROUND: The majority of older adults have 2 or more chronic conditions and among patients with diabetes, 40% have at least three.

OBJECTIVE: We sought to understand how the number, type, and severity of comorbidities influence diabetes patients' self-management and treatment priorities.

DESIGN: Cross-sectional observation study.

PATIENTS: A total of 1,901 diabetes patients who responded to the 2003 Health and Retirement Study (HRS) diabetes survey.

MEASUREMENTS: We constructed multivariate models to assess the association between presence of comorbidities and each of 2 self-reported outcomes, diabetes prioritization and self-management ability, controlling for patient demographics. Comorbidity was characterized first by a count of all comorbid conditions, then by the presence of specific comorbidity subtypes (microvascular, macrovascular, and non-diabetes related), and finally by severity of 1 serious comorbidity: heart failure (HF).

RESULTS: 40% of respondents had at least 1 microvascular comorbidity, 79% at least 1 macrovascular comorbidity, and 61% at least 1 non-diabetes-related comorbidity. Patients with a greater overall number of comorbidities placed lower priority on diabetes and had worse diabetes self-management ability scores. However, only macrovascular and non-diabetes-related comorbidities, but not microvascular comorbidities, were associated with lower diabetes prioritization, whereas higher numbers of microvascular, macrovascular, and non-diabetes-related conditions were all associated with lower diabetes self-management ability scores. Severe, but not mild, HF was associated with lower diabetes prioritization and self-management scores.

CONCLUSIONS: The type and severity of comorbid conditions, and not just the comorbidity count, influence diabetes patients' self-management. Patients with severely symptomatic comorbidities and those with conditions they consider to be unrelated to diabetes may need additional support in making decisions about care priorities and self-management activities.

PB - 22 VL - 22 IS - 12 U1 - http://www.ncbi.nlm.nih.gov/pubmed/17647065?dopt=Abstract U2 - PMC2219819 U4 - diabetes/COMORBIDITY/Chronic Illness ER - TY - JOUR T1 - Geriatric conditions and disability: the Health and Retirement Study. JF - Ann Intern Med Y1 - 2007 A1 - Christine T Cigolle A1 - Kenneth M. Langa A1 - Mohammed U Kabeto A1 - Zhiyi Tian A1 - Caroline S Blaum KW - Accidental Falls KW - Activities of Daily Living KW - Age Factors KW - Aged KW - Aged, 80 and over KW - Body Mass Index KW - Chronic disease KW - Cognition Disorders KW - Comorbidity KW - Cross-Sectional Studies KW - Disability Evaluation KW - Dizziness KW - Female KW - Geriatric Assessment KW - Geriatrics KW - Hearing Disorders KW - Humans KW - Male KW - Prevalence KW - Retirement KW - Urinary incontinence KW - Vision Disorders AB -

BACKGROUND: Geriatric conditions, such as incontinence and falling, are not part of the traditional disease model of medicine and may be overlooked in the care of older adults. The prevalence of geriatric conditions and their effect on health and disability in older adults has not been investigated in population-based samples.

OBJECTIVE: To investigate the prevalence of geriatric conditions and their association with dependency in activities of daily living by using nationally representative data.

DESIGN: Cross-sectional analysis.

SETTING: Health and Retirement Study survey administered in 2000.

PARTICIPANTS: Adults age 65 years or older (n = 11 093, representing 34.5 million older Americans) living in the community and in nursing homes.

MEASUREMENTS: Geriatric conditions (cognitive impairment, falls, incontinence, low body mass index, dizziness, vision impairment, hearing impairment) and dependency in activities of daily living (bathing, dressing, eating, transferring, toileting).

RESULTS: Of adults age 65 years or older, 49.9% had 1 or more geriatric conditions. Some conditions were as prevalent as common chronic diseases, such as heart disease and diabetes. The association between geriatric conditions and dependency in activities of daily living was strong and significant, even after adjustment for demographic characteristics and chronic diseases (adjusted risk ratio, 2.1 [95% CI, 1.9 to 2.4] for 1 geriatric condition, 3.6 [CI, 3.1 to 4.1] for 2 conditions, and 6.6 [CI, 5.6 to 7.6] for > or =3 conditions).

LIMITATIONS: The study was cross-sectional and based on self-reported data. Because measures were limited by the survey questions, important conditions, such as delirium and frailty, were not assessed. Survival biases may influence the estimates.

CONCLUSIONS: Geriatric conditions are similar in prevalence to chronic diseases in older adults and in some cases are as strongly associated with disability. The findings suggest that geriatric conditions, although not a target of current models of health care, are important to the health and function of older adults and should be addressed in their care.

PB - 147 VL - 147 IS - 3 U1 - http://www.ncbi.nlm.nih.gov/pubmed/17679703?dopt=Abstract U4 - ADL and IADL Impairments/Geriatrics/Chronic Disease/Health care ER - TY - JOUR T1 - Informal caregiving and Body Mass Index among older adults. JF - J Gerontol Nurs Y1 - 2007 A1 - Kristi Rahrig Jenkins A1 - Mohammed U Kabeto A1 - Fultz, Nancy H. A1 - Kenneth M. Langa KW - Activities of Daily Living KW - Aged KW - Aged, 80 and over KW - Body Mass Index KW - Body Weight KW - Caregivers KW - Female KW - Geriatric Assessment KW - Humans KW - Male KW - Social Class AB -

The authors sought to obtain nationally representative estimates of the time of informal caregiving provided to older adults classified into the four standard Body Mass Index (BMI) classifications. They estimated multivariate regression models using data from the 2000 Health and Retirement Study to determine the weekly hours of informal caregiving for older adults classified into the four standard BMI classifications. In the fully adjusted models, being underweight was associated with receiving significantly more informal care, however, obesity was not associated with more informal care. The implications of these findings are discussed in terms of nursing practice and research to prevent weight loss and frailty.

PB - 33 VL - 33 IS - 4 U1 - http://www.ncbi.nlm.nih.gov/pubmed/17436868?dopt=Abstract U4 - Caregiving/Body Mass Index/Obesity ER - TY - JOUR T1 - Mechanisms for racial and ethnic disparities in glycemic control in middle-aged and older Americans in the health and retirement study. JF - Arch Intern Med Y1 - 2007 A1 - Michele M Heisler A1 - Jessica Faul A1 - Rodney A. Hayward A1 - Kenneth M. Langa A1 - Caroline S Blaum A1 - David R Weir KW - Aged KW - Aged, 80 and over KW - Black People KW - Diabetes Mellitus KW - Female KW - Glycated Hemoglobin KW - Health Services Accessibility KW - Hispanic or Latino KW - Humans KW - Longitudinal Studies KW - Male KW - Middle Aged KW - Patient Compliance KW - Socioeconomic factors KW - Treatment Refusal KW - United States KW - White People AB -

BACKGROUND: Mechanisms for racial/ethnic disparities in glycemic control are poorly understood.

METHODS: A nationally representative sample of 1901 respondents 55 years or older with diabetes mellitus completed a mailed survey in 2003; 1233 respondents completed valid at-home hemoglobin A(1c) (HbA(1c)) kits. We constructed multivariate regression models with survey weights to examine racial/ethnic differences in HbA(1c) control and to explore the association of HbA(1c) level with sociodemographic and clinical factors, access to and quality of diabetes health care, and self-management behaviors and attitudes.

RESULTS: There were no significant racial/ethnic differences in HbA(1c) levels in respondents not taking antihyperglycemic medications. In 1034 respondents taking medications, the mean HbA(1c) value (expressed as percentage of total hemoglobin) was 8.07% in black respondents and 8.14% in Latino respondents compared with 7.22% in white respondents (P < .001). Black respondents had worse medication adherence than white respondents, and Latino respondents had more diabetes-specific emotional distress (P < .001). Adjusting for hypothesized mechanisms accounted for 14.0% of the higher HbA(1c) levels in black respondents and 19.0% in Latinos, with the full model explaining 22.0% of the variance. Besides black and Latino ethnicity, only insulin use (P < .001), age younger than 65 years (P = .007), longer diabetes duration (P = .004), and lower self-reported medication adherence (P = .04) were independently associated with higher HbA(1c) levels.

CONCLUSIONS: Latino and African American respondents had worse glycemic control than white respondents. Socioeconomic, clinical, health care, and self-management measures explained approximately a fifth of the HbA(1c) differences. One potentially modifiable factor for which there were racial disparities--medication adherence--was among the most significant independent predictors of glycemic control.

PB - 167 VL - 167 IS - 17 U1 - http://www.ncbi.nlm.nih.gov/pubmed/17893306?dopt=Abstract U4 - Racial Differences/Diabetes Mellitus ER - TY - JOUR T1 - Prevalence of dementia in the United States: the aging, demographics, and memory study. JF - Neuroepidemiology Y1 - 2007 A1 - Brenda L Plassman A1 - Kenneth M. Langa A1 - Gwenith G Fisher A1 - Steven G Heeringa A1 - David R Weir A1 - Mary Beth Ofstedal A1 - James R Burke A1 - Michael D Hurd A1 - Guy G Potter A1 - Willard L Rodgers A1 - David C Steffens A1 - Robert J. Willis A1 - Robert B Wallace KW - Age Distribution KW - Aged KW - Aged, 80 and over KW - Cohort Studies KW - Dementia KW - Female KW - Geriatric Assessment KW - Health Surveys KW - Humans KW - Logistic Models KW - Male KW - Prevalence KW - Sex Distribution KW - United States AB -

AIM: To estimate the prevalence of Alzheimer's disease (AD) and other dementias in the USA using a nationally representative sample.

METHODS: The Aging, Demographics, and Memory Study sample was composed of 856 individuals aged 71 years and older from the nationally representative Health and Retirement Study (HRS) who were evaluated for dementia using a comprehensive in-home assessment. An expert consensus panel used this information to assign a diagnosis of normal cognition, cognitive impairment but not demented, or dementia (and dementia subtype). Using sampling weights derived from the HRS, we estimated the national prevalence of dementia, AD and vascular dementia by age and gender.

RESULTS: The prevalence of dementia among individuals aged 71 and older was 13.9%, comprising about 3.4 million individuals in the USA in 2002. The corresponding values for AD were 9.7% and 2.4 million individuals. Dementia prevalence increased with age, from 5.0% of those aged 71-79 years to 37.4% of those aged 90 and older.

CONCLUSIONS: Dementia prevalence estimates from this first nationally representative population-based study of dementia in the USA to include subjects from all regions of the country can provide essential information for effective planning for the impending healthcare needs of the large and increasing number of individuals at risk for dementia as our population ages.

PB - 29 VL - 29 IS - 1-2 U1 - http://www.ncbi.nlm.nih.gov/pubmed/17975326?dopt=Abstract U4 - aging/Dementia/Epidemiology ER - TY - JOUR T1 - The Aging, Demographics and Memory Study: Study Design and Methods JF - Neuroepidemiology Y1 - 2005 A1 - Kenneth M. Langa A1 - Brenda L Plassman A1 - Robert B Wallace A1 - A. Regula Herzog A1 - Steven G Heeringa A1 - Mary Beth Ofstedal A1 - James F. Burke A1 - Gwenith G Fisher A1 - Fultz, Nancy H. A1 - Michael D Hurd A1 - Guy G Potter A1 - Willard L Rodgers A1 - David C Steffens A1 - David R Weir KW - Health Conditions and Status KW - Healthcare AB - Objective: We describe the design and methods of the Aging, Demographics, and Memory Study (ADAMS), a new national study that will provide data on the antecedents, prevalence, outcomes, and costs of dementia and cognitive impairment, not demented (CIND) using a unique study design based on the nationally representative Health and Retirement Study (HRS). We also illustrate potential uses of the ADAMS data and provide information to interested researchers on obtaining ADAMS and HRS data. Methods: The ADAMS is the first population-based study of dementia in the United States to include subjects from all regions of the country, while at the same time using a single standardized diagnostic protocol in a community-based sample. A sample of 856 individuals aged 70 or older who were participants in the on-going HRS received an extensive in-home clinical and neuropsychological assessment to determine a diagnosis of normal, CIND, or dementia. Within the CIND and dementia categories, subcategories (e.g., Alzheimer disease, vascular dementia) were assigned to denote the etiology of cognitive impairment. Conclusion: Linking the ADAMS dementia clinical assessment data to the wealth of available longitudinal HRS data on health, health care utilization, informal care, and economic resources and behavior, will provide a unique opportunity to study the onset of CIND and dementia in a nationally-representative population-based sample, as well as the risk factors, prevalence, outcomes, and costs of CIND and dementia. PB - 25 VL - 25 U4 - Aging/Dementia/Epidemiology ER - TY - JOUR T1 - Differences in Amount of Informal Care Received by Non-Hispanic Whites and Latinos in a Nationally Representative Sample of Older Americans JF - Journal of the American Geriatrics Society Y1 - 2005 A1 - Weiss, Carlos O. A1 - Hector M González A1 - Mohammed U Kabeto A1 - Kenneth M. Langa KW - Healthcare KW - Women and Minorities AB - The objective of this study was to evaluate informal (unpaid) care and its broad determinants for Latinos in a nationally representative sample. A cross-sectional analysis of the 1993 Asset and Health Dynamics Study, a national probability sample of 7,443 older adults aged 70 and older, was performed to determine the independent effect of Latino ethnicity on the receipt of informal care by disabled older individuals. Self-reported race/ethnicity was used to predict the mean daily hours of informal care received for activity of daily living (ADL) or instrumental activity of daily living (IADL) assistance after adjustment for predisposing, need, and enabling variables. There was a significant association between informal home care and ethnic group, with 44.3 of Latinos receiving informal care, compared with 33.9 of African Americans and 24.6 of non-Hispanic whites (Po.001). After adjustment, Latinos received 11.0 weekly hours of informal care, compared with 7.5 hours for non-Hispanic whites and 6.3 hours for African Americans (Po.001). The results from this nationally representative sample indicate that Latinos receive significantly more hours of informal care on average than African Americans or non-Hispanic whites for ADL and IADL disability. Clinicians should be alert to the significant amount of informal care and possible associated strain in caregivers of older Latinos. PB - 53 VL - 53 IS - 1 U4 - Hispanic Americans/Caregiving ER - TY - JOUR T1 - The Effect of Diabetes on Diability in Middle-Aged and Older Adults JF - The Journals of Gerontology, Series A: Medical Sciences Y1 - 2005 A1 - Linda A. Wray A1 - Mary Beth Ofstedal A1 - Kenneth M. Langa A1 - Caroline S Blaum KW - Demographics KW - Disabilities KW - Health Conditions and Status AB - Background. Physical disability is increasingly recognized as an adverse health consequence of type 2 diabetes in older adults. We studied the effect of diabetes on disability in middle-aged and older adults to: 1) characterize the association of diabetes with physical disability in middle-aged adults, and 2) determine the extent to which the effect of diabetes is explained by related covariates in either or both age groups. Methods. We used data from two parallel national panel studies of middle-aged and older adults to study the effect of self-reported diabetes at baseline on disability 2 years later, adjusting for baseline covariates. Results. Diabetes was strongly associated with subsequent physical disability (measured by a composite variable combining activities of daily living, mobility, and strength tasks) in middle-aged and older adults. Controlling for socioeconomic characteristics and common diabetes-related and unrelated comorbidities and conditions reduced the diabetes effect substantially, but it remained a significant predictor of disability in both groups. Conclusions. Our analyses demonstrated that disability is an important diabetes-related health outcome in middle-aged and older adults that should be prevented or mitigated through appropriate diabetes management. PB - 60A VL - 60A UR - http://biomedgerontology.oxfordjournals.org/content/60/9/1206.long IS - 9 U4 - Diabetes/Disability/Disability/Middle Aged Adults ER - TY - JOUR T1 - Health, wealth, and happiness: financial resources buffer subjective well-being after the onset of a disability. JF - Psychol Sci Y1 - 2005 A1 - Dylan M Smith A1 - Kenneth M. Langa A1 - Mohammed U Kabeto A1 - Peter A. Ubel KW - Activities of Daily Living KW - Cross-Sectional Studies KW - Disability Evaluation KW - Female KW - Follow-Up Studies KW - Happiness KW - Health Status KW - Humans KW - Male KW - Middle Aged KW - Quality of Life KW - Socioeconomic factors AB -

We examined the hypothesis that the relationship between financial status and subjective well-being, typically found to be very small in cross-sectional studies, is moderated by health status. Specifically, we predicted that wealth would buffer well-being after the onset of a disability. Using data from the Health and Retirement Study, a longitudinal study of people at and approaching retirement age, we employed within-subjects analyses to test whether wealth measured prior to the onset of a disability protected participants' well-being from some of the negative effects of a new disability. We found support for this hypothesis: Participants who were above the median in total net worth reported a much smaller decline in well-being after a new disability than did participants who were below the median. We also found some evidence that the buffering effect of wealth faded with time, as below-median participants recovered some of their well-being.

PB - 16 VL - 16 IS - 9 U1 - http://www.ncbi.nlm.nih.gov/pubmed/16137249?dopt=Abstract U4 - Health Status/Subjective/Wealth/Disability/Disability ER - TY - JOUR T1 - The impact of own and spouse's urinary incontinence on depressive symptoms. JF - Soc Sci Med Y1 - 2005 A1 - Fultz, Nancy H. A1 - Kristi Rahrig Jenkins A1 - Truls Ostbye A1 - Donald H. Taylor Jr. A1 - Mohammed U Kabeto A1 - Kenneth M. Langa KW - Aged KW - Caregivers KW - Cohort Studies KW - depression KW - Female KW - Humans KW - Male KW - Middle Aged KW - United States KW - Urinary incontinence AB -

This study investigated the impact of own and spouse's urinary incontinence on depressive symptoms. Attention was paid to the possibility that gender and caregiving might be important factors in understanding significant effects. We used negative binomial regression to analyze survey data for 9974 middle-aged and older respondents to the Health and Retirement Study in the USA. Results supported the hypothesis that the respondents' own urinary incontinence was associated with depressive symptoms (unadj. IRR = 1.73, 95% CIs = 1.53, 1.95 for men; unadj. IRR = 1.50, 95% CIs = 1.38, 1.63 for women). Controlling sociodemographic and health variables reduced this relationship, but it remained statistically significant for both men and women. Having an incontinent wife put men at greater risk for depressive symptoms (unadj. IRR = 1.13, 95% CIs = 1.02, 1.25), although this relation became nonsignificant with the addition of control variables. No relation between women's depressive symptoms and husbands' (in)continence status was found. Caregiving was not a significant variable in the adjusted analyses, but spouses' depressive symptoms emerged as a significant predictor of the respondents' own depressive symptoms. Health care providers must be sensitive to the emotional impact of urinary incontinence. Our findings also suggest the importance of considering the patient's mental health within a wider context, particularly including the physical and mental health of the patient's spouse.

PB - 60 VL - 60 IS - 11 U1 - http://www.ncbi.nlm.nih.gov/pubmed/15814179?dopt=Abstract U4 - Depression Symptoms/Incontinence/Health Services/Mental Health ER - TY - JOUR T1 - Net worth predicts symptom burden at the end of life. JF - J Palliat Med Y1 - 2005 A1 - Maria J Silveira A1 - Mohammed U Kabeto A1 - Kenneth M. Langa KW - Aged KW - Aged, 80 and over KW - Data collection KW - Female KW - Humans KW - Logistic Models KW - Male KW - Severity of Illness Index KW - Social Class KW - Terminally Ill KW - United States AB -

OBJECTIVES: To explore the predictors of symptom burden at the end of life.

DESIGN: Observational, secondary analysis of Health and Retirement Study (HRS) data.

SETTING: USA.

PARTICIPANTS: Two thousand six hundred four deceased, older adults.

METHODS: Multivariate Poisson and logistic regression to explore the relationship between sociodemographic and clinical factors with symptoms.

RESULTS: Fatigue, pain, dyspnea, depression, and anorexia were common and severe; 58% of participants experienced more than 3 of these during their last year of life. Sociodemographic and clinical factors were associated with the number of symptoms as well as the presence of pain, depression, and dyspnea alone. Decedents in the highest quartile of net worth had fewer symptoms (incident rate ratio [IRR] 0.90, confidence interval [CI] 0.85-0.96) and less pain (odds ratio [OR] 0.66, CI 0.51-0.85) than comparisons did. Patients with cancer experienced more pain (OR 2.02, CI 1.62-2.53) and depression (OR 1.31, CI 1.07-1.61). Patients experienced more depression (OR 2.37, CI 1.85-3.03) and dyspnea (OR 1.40, CI 1.09-1.78).

LIMITATION: Use of proxy reports for primary data.

CONCLUSION: Older Americans experience a large symptom burden in the last year of life, largely with treatable symptoms such as pain, dyspnea, and depression. The adequacy of symptom control relates to clinical factors as well as net worth. This association between symptoms and wealth suggests that access to health care and other social services beyond those covered by Medicare may be important in decreasing symptom burden at the end of life.

PB - 8 VL - 8 IS - 4 U1 - http://www.ncbi.nlm.nih.gov/pubmed/16128657?dopt=Abstract U4 - Quality of Life/Net Worth ER - TY - JOUR T1 - Setting eligibility criteria for a care-coordination benefit. JF - J Am Geriatr Soc Y1 - 2005 A1 - Christine T Cigolle A1 - Kenneth M. Langa A1 - Mohammed U Kabeto A1 - Caroline S Blaum KW - Activities of Daily Living KW - Aged KW - Aged, 80 and over KW - Case Management KW - Chronic disease KW - Cognition Disorders KW - Comorbidity KW - Cross-Sectional Studies KW - Disability Evaluation KW - Disease Management KW - Eligibility Determination KW - Female KW - Geriatric Assessment KW - Health Surveys KW - Humans KW - Longitudinal Studies KW - Male KW - Medicare KW - Middle Aged KW - Retirement KW - United States AB -

OBJECTIVES: To examine different clinically relevant eligibility criteria sets to determine how they differ in numbers and characteristics of individuals served.

DESIGN: Cross-sectional analysis of the 2000 wave of the Health and Retirement Study (HRS), a nationally representative longitudinal health interview survey of adults aged 50 and older.

SETTING: Population-based cohort of community-dwelling older adults, subset of an ongoing longitudinal health interview survey.

PARTICIPANTS: Adults aged 65 and older who were respondents in the 2000 wave of the HRS (n=10,640, representing approximately 33.6 million Medicare beneficiaries).

MEASUREMENTS: Three clinical criteria sets were examined that included different combinations of medical conditions, cognitive impairment, and activity of daily living/instrumental activity of daily living (ADL/IADL) dependency.

RESULTS: A small portion of Medicare beneficiaries (1.3-5.8%) would be eligible for care coordination, depending on the criteria set chosen. A criteria set recently proposed by Congress (at least four severe complex medical conditions and one ADL or IADL dependency) would apply to 427,000 adults aged 65 and older in the United States. Criteria emphasizing cognitive impairment would serve an older population.

CONCLUSION: Several criteria sets for a Medicare care-coordination benefit are clinically reasonable, but different definitions of eligibility would serve different numbers and population groups of older adults.

PB - 53 VL - 53 IS - 12 U1 - http://www.ncbi.nlm.nih.gov/pubmed/16398887?dopt=Abstract U4 - Chronic Disease/Cognition Disorders/ADL and IADL Impairments/Caregiving ER - TY - JOUR T1 - What is perfect health to an 85-year-old?: evidence for scale recalibration in subjective health ratings. JF - Med Care Y1 - 2005 A1 - Peter A. Ubel A1 - Jankovic, Aleksandra A1 - Dylan M Smith A1 - Kenneth M. Langa A1 - Angela Fagerlin KW - Activities of Daily Living KW - Age Factors KW - Aged KW - Aged, 80 and over KW - Analysis of Variance KW - Attitude to Health KW - Calibration KW - Female KW - Geriatric Assessment KW - Health Status KW - Humans KW - Interviews as Topic KW - Male KW - Prospective Studies KW - Psychometrics KW - Self Concept AB -

BACKGROUND: If an 85-year-old man rates his health as 90 on a scale in which 100 represents "perfect health," would his rating mean the same thing as a 90 rating from a 25-year-old? We conducted a randomized trial of 3 different ways of eliciting subjective health ratings from participants in the Health and Retirement Study to test whether the meaning of perfect health changes as people age, causing people to recalibrate their self-reported health ratings to account for their age.

METHODS: The Health and Retirement Study (HRS) is a nationally representative, prospective study of 22,000 persons born in 1947 or earlier. The data analyzed in this study come from the self-assessed health utilities module administered in 2002 to 1031 randomly selected HRS respondents. Respondents were randomized to receive one of 3 versions of a subjective health rating task. In the perfect health version, they were asked how they would rate their "current health on a scale from 0 to 100, in which 0 represents death and 100 represents perfect health." In the your-age version, the phrase "for someone your age" was added to the end of the question to encourage people to recalibrate their responses based on age, and in the 20-year-old version, the phrase "for a 20-year-old" was added to minimize recalibration.

RESULTS: A total of 1015 subjects responded to the rating task (98% response rate). Health ratings varied significantly across versions, with subjects responding to the 20-year-old version reporting lower health (mean rating 66 of 100) than those responding to the your-age version (mean rating of 73, P<0.001) or the perfect health version (mean rating of 73, P<0.001). This result suggests that subjects interpret perfect health to mean "perfect health for someone your age." However, additional analysis showed that the interpretation of the phrase perfect health lies somewhere between the other 2 versions. For example, responses to the perfect health and 20-year-old versions varied significantly by respondent age (both P's<0.075), whereas responses to the your-age scale did not (P=0.8).

CONCLUSION: The phrase "perfect health" is ambiguous, causing some people to recalibrate their responses based on their age. Such ambiguity threatens the validity of common subjective health ratings, thereby reducing the comparability of responses across people of different ages or different circumstances.

PB - 43 VL - 43 IS - 10 U1 - http://www.ncbi.nlm.nih.gov/pubmed/16166876?dopt=Abstract U4 - Subjective phenomena/Methodology ER - TY - JOUR T1 - Extent and cost of informal caregiving for older Americans with symptoms of depression. JF - Am J Psychiatry Y1 - 2004 A1 - Kenneth M. Langa A1 - Marcia A. Valenstein A1 - A. Mark Fendrick A1 - Mohammed U Kabeto A1 - Sandeep Vijan KW - Activities of Daily Living KW - Aged KW - Aged, 80 and over KW - Caregivers KW - Comorbidity KW - Costs and Cost Analysis KW - Depressive Disorder KW - Fees and Charges KW - Female KW - Health Care Costs KW - Home Nursing KW - Humans KW - Longitudinal Studies KW - Male KW - Personality Inventory KW - Workload AB -

OBJECTIVE: The purpose of this study was to obtain nationally representative estimates of the additional time and cost associated with informal caregiving for older Americans with depressive symptoms.

METHOD: Data from the 1993 Asset and Health Dynamics Among the Oldest Old Study, a nationally representative survey of people age 70 years or older (N=6,649), were used to determine the weekly hours and imputed costs of informal caregiving for elderly people with no depressive symptoms in the last week, one to three depressive symptoms in the last week, and four to eight depressive symptoms in the last week.

RESULTS: Forty-four percent of survey respondents reported one to three depressive symptoms, and 18% reported four to eight depressive symptoms. In multivariate regression analyses that adjusted for sociodemographics, caregiver network, and coexisting chronic health conditions, respondents with no depressive symptoms received an average of 2.9 hours per week of informal care, compared with 4.3 hours per week for those with one to three symptoms and 6.0 hours per week for those with four to eight symptoms. Caregiving associated with depressive symptoms in elderly Americans represented a yearly cost of about $9 billion.

CONCLUSIONS: Depressive symptoms in elderly persons are independently associated with significantly higher levels of informal caregiving, even after the effects of major coexisting chronic conditions are adjusted. The additional hours of care attributable to depressive symptoms represent a significant time commitment for family members and, therefore, a significant societal economic cost. Further research should evaluate the causal pathways by which depressive symptoms lead to high levels of caregiving and should examine whether successful treatment of depression reduces the need for informal care.

PB - 161 VL - 161 IS - 5 U1 - http://www.ncbi.nlm.nih.gov/pubmed/15121651?dopt=Abstract U4 - Depression Symptoms/Caregiving ER - TY - JOUR T1 - The health effects of restricting prescription medication use because of cost. JF - Med Care Y1 - 2004 A1 - Michele M Heisler A1 - Kenneth M. Langa A1 - Eby, Elizabeth L. A1 - A. Mark Fendrick A1 - Mohammed U Kabeto A1 - John D Piette KW - Aged KW - Chronic disease KW - Female KW - Financing, Personal KW - Health Services Accessibility KW - Health Status KW - Humans KW - Male KW - Middle Aged KW - Multivariate Analysis KW - Patient Compliance KW - Prospective Studies KW - Risk KW - United States AB -

BACKGROUND: High out-of-pocket expenditures for prescription medications could lead people with chronic illnesses to restrict their use of these medications. Whether adults experience adverse health outcomes after having restricted medication use because of cost is not known.

METHODS: We analyzed data from 2 prospective cohort studies of adults who reported regularly taking prescription medications using 2 waves of the Health and Retirement Study (HRS), a national survey of adults aged 51 to 61 in 1992, and the Asset and Health Dynamics Among the Oldest Old (AHEAD) Study, a national survey of adults aged 70 or older in 1993 (n = 7991). We used multivariable logistic and Poisson regression models to assess the independent effect on health outcomes over 2 to 3 years of follow up of reporting in 1995-1996 having taken less medicine than prescribed because of cost during the prior 2 years. After adjusting for differences in sociodemographic characteristics, health status, smoking, alcohol consumption, body mass index (BMI), and comorbid chronic conditions, we determined the risk of a significant decline in overall health among respondents in good to excellent health at baseline and of developing new disease-related adverse outcomes among respondents with cardiovascular disease, diabetes, arthritis, and depression.

RESULTS: In adjusted analyses, 32.1% of those who had restricted medications because of cost reported a significant decline in their health status compared with 21.2% of those who had not (adjusted odds ratio [AOR], 1.76; confidence interval [CI], 1.27-2.44). Respondents with cardiovascular disease who restricted medications reported higher rates of angina (11.9% vs. 8.2%; AOR, 1.50; CI, 1.09-2.07) and experienced higher rates of nonfatal heart attacks or strokes (7.8% vs. 5.3%; AOR, 1.51; CI, 1.02-2.25). After adjusting for potential confounders, we found no differences in disease-specific complications among respondents with arthritis and diabetes, and increased rates of depression only among the older cohort.

CONCLUSIONS: Cost-related medication restriction among middle-aged and elderly Americans is associated with an increased risk of a subsequent decline in their self-reported health status, and among those with preexisting cardiovascular disease with higher rates of angina and nonfatal heart attacks or strokes. Such cost-related medication restriction could be a mechanism for worse health outcomes among low-income and other vulnerable populations who lack adequate insurance coverage.

PB - 42 VL - 42 IS - 7 N1 - Comment in: Med Care. 2004 Jul;42(7):623-5 AN=15213485 U1 - http://www.ncbi.nlm.nih.gov/pubmed/15213486?dopt=Abstract U4 - Health Insurance/Health Care Costs/Prescription Fees/Female/Multivariate Analysis/Prospective Studies/United States/Health Status/Health Services ER - TY - JOUR T1 - The impact of diabetes on workforce participation: results from a national household sample. JF - Health Serv Res Y1 - 2004 A1 - Sandeep Vijan A1 - Rodney A. Hayward A1 - Kenneth M. Langa KW - Chronic disease KW - Cohort Studies KW - Cost of Illness KW - Cross-Sectional Studies KW - Diabetes Mellitus KW - Disabled Persons KW - Efficiency KW - Employment KW - Female KW - Health Services Research KW - Health Status Indicators KW - Humans KW - Longitudinal Studies KW - Male KW - Middle Aged KW - United States AB -

OBJECTIVE: Diabetes is a highly prevalent condition that results in substantial morbidity and premature mortality. We investigated how diabetes-associated mortality, disability, early retirement, and work absenteeism impacts workforce participation.

DATA SOURCE: We used the Health and Retirement Study (HRS), a national household sample of adults aged 51-61 in 1992, as a data source.

STUDY DESIGN: We conducted cross-sectional analyses on the baseline HRS data, and longitudinal analyses using data from eight years of follow-up. We used two-part regression models to estimate the adjusted impact of diabetes on workforce participation, and then estimated the economic impact of diabetes-related losses in productivity.

PRINCIPAL FINDINGS: Diabetes is a significant predictor of lost productivity. The incremental lost income due to diabetes by 1992 was 60.0 billion US dollars over an average diabetes duration of 9.7 years. From 1992 to 2000, diabetes was responsible for 4.4 billion US dollars in lost income due to early retirement, 0.5 billion US dollars due to increased sick days, 31.7 billion US dollars due to disability, and 22.0 US dollars billion in lost income due to premature mortality, for a total of 58.6 billion dollars in lost productivity, or 7.3 billion US dollars per year.

CONCLUSIONS: In the U.S. population of adults born between 1931 and 1941, diabetes is associated with a profound negative impact on economic productivity. By 1992, an estimated 60 billion US dollars in lost productivity was associated with diabetes; additional annual losses averaged 7.3 billion US dollars over the next eight years, totaling about 120 billion US dollars by the year 2000. Given the rising prevalence of diabetes, these costs are likely to increase substantially unless countered by better public health or medical interventions.

PB - 39 VL - 39 IS - 6 Pt 1 N1 - Social Security Administration/Michigan Retirement Research Center Grant UM01-11 U1 - http://www.ncbi.nlm.nih.gov/pubmed/15533180?dopt=Abstract U4 - diabetes/Labor Supply ER - TY - JOUR T1 - Out-of-pocket health care expenditures among older Americans with dementia. JF - Alzheimer Dis Assoc Disord Y1 - 2004 A1 - Kenneth M. Langa A1 - Eric B Larson A1 - Robert B Wallace A1 - A. Mark Fendrick A1 - Norman L Foster A1 - Mohammed U Kabeto A1 - David R Weir A1 - Robert J. Willis A1 - A. Regula Herzog KW - Aged KW - Aged, 80 and over KW - Alzheimer disease KW - Costs and Cost Analysis KW - Data Interpretation, Statistical KW - Female KW - Financing, Personal KW - Health Care Costs KW - Health Expenditures KW - Health Surveys KW - Humans KW - Insurance Coverage KW - Longitudinal Studies KW - Male AB -

The number of older individuals with dementia will likely increase significantly in the next decades, but there is currently limited information regarding the out-of-pocket expenditures (OOPE) for medical care made by cognitively impaired individuals and their families. We used data from the 1993 and 1995 Asset and Health Dynamics Study, a nationally representative longitudinal survey of older Americans, to determine the OOPE for individuals with and without dementia. Dementia was identified in 1993 using a modified version of the Telephone Interview for Cognitive Status for self-respondents, and proxy assessment of memory and judgment for proxy respondents. In 1995, respondents reported OOPE over the prior 2 years for: 1) hospital and nursing home stays, 2) outpatient services, 3) home care, and 4) prescription medications. The adjusted mean annual OOPE was 1,350 US dollars for those without dementia, 2,150 US dollars for those with mild/moderate dementia, and 3,010 US dollars for those with severe dementia (p < 0.01). Expenditures for hospital/nursing home care (1,770 per year US dollars) and prescription medications (800 per year US dollars) were the largest OOPE components for those with severe dementia. We conclude that dementia is independently associated with significantly higher OOPE for medical care compared with those with normal cognitive function. Severe dementia is associated with a doubling of OOPE, mainly due to higher payments for long-term care. Given that the number of older Americans with dementia will likely increase significantly in the coming decades, changes in public funding aimed at reducing OOPE for both long-term care and prescription medications would have considerable impact on individuals with dementia and their families.

PB - 18 VL - 18 IS - 2 U1 - http://www.ncbi.nlm.nih.gov/pubmed/15249853?dopt=Abstract U4 - Dementia/Health Expenditures ER - TY - JOUR T1 - Out-of-pocket health-care expenditures among older Americans with cancer. JF - Value Health Y1 - 2004 A1 - Kenneth M. Langa A1 - A. Mark Fendrick A1 - M.E. Chernew A1 - Mohammed U Kabeto A1 - Paisley, Kerry L. A1 - Hayman, James A. KW - Aged KW - Aged, 80 and over KW - Cost of Illness KW - Family Characteristics KW - Female KW - Financing, Personal KW - Health Expenditures KW - Health Services Research KW - Humans KW - Insurance, Health KW - Longitudinal Studies KW - Male KW - Medicaid KW - Medicare KW - Michigan KW - Neoplasms AB -

OBJECTIVE: There is currently limited information regarding the out-of-pocket expenditures (OOPE) for medical care made by elderly individuals with cancer. We sought to quantify OOPE for community-dwelling individuals age 70 or older with: 1) no cancer (No CA), 2) a history of cancer, not undergoing current treatment (CA/No Tx), and 3) a history of cancer, undergoing current treatment (CA/Tx).

METHODS: We used data from the 1995 Asset and Health Dynamics Study, a nationally representative survey of community-dwelling elderly individuals. Respondents identified their cancer status and reported OOPE for the prior 2 years for: 1) hospital and nursing home stays, 2) outpatient services, 3) home care, and 4) prescription medications. Using a multivariable two-part regression model to control for differences in sociodemographics, living situation, functional limitations, comorbid chronic conditions, and insurance coverage, the additional cancer-related OOPE were estimated.

RESULTS: Of the 6370 respondents, 5382 (84%) reported No CA, 812 (13%) reported CA/No Tx, and 176 (3%) reported CA/Tx. The adjusted mean annual OOPE for the No CA, CA/No Tx, and CA/Tx groups were 1210 dollars, 1450 dollars, and 1880 dollars, respectively (P < .01). Prescription medications (1120 dollars per year) and home care services (250 dollars) accounted for most of the additional OOPE associated with cancer treatment. Low-income individuals undergoing cancer treatment spent about 27% of their yearly income on OOPE compared to only 5% of yearly income for high-income individuals with no cancer history (P < .01).

CONCLUSIONS: Cancer treatment in older individuals results in significant OOPE, mainly for prescription medications and home care services. Economic evaluations and public policies aimed at cancer prevention and treatment should take note of the significant OOPE made by older Americans with cancer.

PB - 7 VL - 7 IS - 2 U1 - http://www.ncbi.nlm.nih.gov/pubmed/15164808?dopt=Abstract U4 - Health Care Costs/Health Expenditures ER - TY - JOUR T1 - Predicting Nursing Home Admission: Estimates from a seven-year follow-up of a nationally representative sample of older Americans JF - Alzheimer Disease and Associated Disorders Y1 - 2004 A1 - Banaszak-Holl, Jane A1 - A. Mark Fendrick A1 - Norman L Foster A1 - A. Regula Herzog A1 - Mohammed U Kabeto A1 - Kent, David A1 - Walter L. Straus A1 - Kenneth M. Langa KW - Demographics KW - Health Conditions and Status KW - Healthcare KW - Methodology AB - This study determines whether prevalence and predictors of nursing home admission changed in the 1990s, during a period of dramatic changes in the service provision for and medical care of chronic impairments. Data from the 1993-2000 surveys of the Asset and Health Dynamics Among the Oldest Old (AHEAD) Study, a longitudinal and nationally representative sample, were used. Proportional hazard models were used to determine the effects of dementia, physical functioning, clinical conditions, and sociodemographics on the likelihood of nursing home admission. Of the 6,676 respondents, 17 were admitted to a nursing home. Models excluding functional impairment demonstrated significant effects of chronic medical conditions and dementia on the risk of institutionalization. After controlling for functional impairment, dementia still had significant and strong effects on institutionalization but clinical conditions did not, suggesting that the impact of dementia goes beyond its effect on physical functioning. Nursing home admissions did not decrease during the study period, and the impact of dementia on the risk of nursing home admission did not decrease. Interventions for individuals with dementia should impact the behavioral aspects of the condition and slow disease progression in addition to improving physical functioning. PB - 18 VL - 18 IS - 2 U4 - Nursing Homes/Dementia/Sociodemographic/Proportional Hazards Models ER - TY - JOUR T1 - Quality of preventive clinical services among caregivers in the health and retirement study. JF - J Gen Intern Med Y1 - 2004 A1 - Kim, Catherine A1 - Mohammed U Kabeto A1 - Robert B Wallace A1 - Kenneth M. Langa KW - Aged KW - Caregivers KW - Cohort Studies KW - Cross-Sectional Studies KW - Female KW - Health Care Surveys KW - Humans KW - Male KW - Middle Aged KW - Patient Acceptance of Health Care KW - Preventive Health Services KW - Quality of Health Care KW - Time Factors KW - United States AB -

We examined the association between caregiving for a spouse and preventive clinical services (self-reported influenza vaccination, cholesterol screening, mammography, Pap smear, and prostate cancer screening over 2 years and monthly self-breast exam) for the caregiver in a cross-sectional analysis of the Health and Retirement Study, a nationally representative sample of U.S. adults aged > or = 50 years (N = 11,394). Spouses engaged in 0, 1-14, or > or = 14 hours per week of caregiving. Each service was examined in logistic regression models adjusting for caregiver characteristics. After adjustment for covariates, there were no significant associations between spousal caregiving and likelihood of caregiver receipt of preventive services.

PB - 19 VL - 19 IS - 8 U1 - http://www.ncbi.nlm.nih.gov/pubmed/15242474?dopt=Abstract U4 - Caregiving/Spouses/Health Care Utilization/Caregivers/Health Services ER - TY - JOUR T1 - Additive effects of cognitive function and depressive symptoms on mortality in elderly community-living adults. JF - J Gerontol A Biol Sci Med Sci Y1 - 2003 A1 - Kala M. Mehta A1 - Kristine Yaffe A1 - Kenneth M. Langa A1 - Laura Sands A1 - Whooley, Mary A1 - Kenneth E Covinsky KW - Aged KW - Cognition KW - depression KW - Female KW - Humans KW - Male KW - Mortality KW - Proportional Hazards Models KW - Risk Factors AB -

BACKGROUND: Poor cognitive function and depressive symptoms are common in the elderly, frequently coexist, and are interrelated. Both risk factors are independently associated with mortality. Few studies have comprehensively described how the combination of poor cognitive function and depressive symptoms affect the risk for mortality. Our aim was to examine whether the combination of varying levels of cognitive function and depressive symptoms affect the risk of mortality in community-living elderly adults.

METHODS: We studied 6301 elderly adults (mean age, 77 years; 62% women; 81% white) enrolled in the Asset and Health Dynamics Among the Oldest Old (AHEAD) study, a prospective study of community-living participants conducted from 1993 to 1995. Cognitive function and depressive symptoms were measured using two validated measures developed for the AHEAD study. On each measure, participants were divided into tertiles representing the best, middle, and worst scores, and then placed into one of nine mutually exclusive groups ranging from best functioning on both measures to worst functioning on both measures. Mortality rates were assessed in each of the nine groups. Cox proportional hazards models were used to control for potentially confounding characteristics such as demographics, education, income, smoking, alcohol consumption, comorbidity, and baseline functional impairment.

RESULTS: During 2 years of follow-up, 9% (548) of the participants died. Together, cognitive function and depressive symptoms differentiated between elderly adults at markedly different risk for mortality, ranging from 3% in those with the best function on both measures to 16% in those with the worst function on both measures (p <.001). Furthermore, for each level of cognitive function, more depressive symptoms were associated with higher mortality rates, and for each level of depressive symptoms, worse cognitive function was associated with higher mortality rates. In participants with the best cognitive function, mortality rates were 3%, 5%, and 9% in participants with low, middle, and high depressive symptoms, respectively (p <.001 for trend). The corresponding rates were 6%, 7%, and 12% in participants with the middle level of cognitive function (p <.001 for trend), and 10%, 13%, and 16% in participants with the worst level of cognitive function (p <.001 for trend). After adjustment for confounders, participants with the worst function on both measures remained at considerably higher risk for death than participants with the best function on both measures (adjusted hazard ratio, 3.1; 95% confidence interval, 2.0-4.7).

CONCLUSIONS: Cognitive function and depressive symptoms can be used together to stratify elderly adults into groups that have significantly different rates of death. These two risk factors are associated with an increased risk in mortality in a progressive, additive manner.

PB - 58A VL - 58 IS - 5 U1 - http://www.ncbi.nlm.nih.gov/pubmed/12730257?dopt=Abstract U4 - Cognitive Function/Depressive Symptoms/Mortality ER - TY - JOUR T1 - Functional Status and Health Outcomes in Older Americans with Diabetes: Should diabetes management be targeted to health status? JF - Journal of the American Geriatrics Society Y1 - 2003 A1 - Caroline S Blaum A1 - Mary Beth Ofstedal A1 - Kenneth M. Langa A1 - Linda A. Wray KW - Diabetes Mellitus KW - Functional status KW - Older Adults AB - OBJECTIVES: To determine how baseline functional status affects health outcomes in older adults with diabetes mellitus (DM). DESIGN: Nationally representative cross‐sectional and longitudinal health interview survey. SETTING: Waves I (1993) and II (1995) of the Assets and Health Dynamics of the Oldest Old Survey (AHEAD) in the United States. PARTICIPANTS: AHEAD respondents aged 70 and older (n = 7,447, including 995 with DM). MEASUREMENTS: At baseline, the entire sample was divided into three groups: high‐functioning group, defined as having no physical limitations or instrumental activities of daily living/activities of daily living (IADL/ADL) disabilities (39%); low‐functioning group, having three or more limitations or IADL/ADL disabilities (24%); and intermediate‐functioning group, those in the middle (36%). Older adults with and without DM, within each of the functioning groups, were compared at 2‐year follow‐up with respect to demographic characteristics, weight/body mass index, baseline and incident chronic diseases and conditions, and follow‐up functioning. RESULTS: Of people aged 70 and older, 28% with DM and 41% without were high functioning; 38% with DM and 22% without were low functioning (both P < .001). High‐functioning people with DM remained high functioning at 2 years but had a significantly higher incidence of heart disease and mortality than high‐functioning people without DM. Low‐functioning people with DM were significantly more likely to have vascular comorbidities at baseline than low‐functioning people without DM, but their 2‐year outcomes were similar. The intermediate‐functioning group showed the most differences between those with and without DM; those with DM were significantly (P < .01) more likely to have baseline vascular disease, low cognitive performance, increased incident vascular disease, and significantly worse 2‐year functioning and to have experienced falls (P < .001). CONCLUSION: Differences in baseline functional status in older adults with DM were associated with outcome differences. High‐functioning older people with DM tended to remain high functioning but demonstrated significantly higher incidence of heart disease and mortality than those without DM, whereas low‐functioning people with and without DM had similar outcomes. However, intermediate‐functioning older diabetics had worse health and functioning outcomes than a similarly impaired group without DM. DM management adjusted to functional status can potentially address the most‐relevant outcomes in the heterogeneous older population with DM. PB - 51 VL - 51 IS - 6 U4 - Diabetes/Health Status ER - TY - RPRT T1 - The Impact of Poor Health Behaviors on Workforce Disability Y1 - 2003 A1 - Richardson, Caroline R. A1 - Jennifer T. Hanlon A1 - Hillary J. Mull A1 - Sandeep Vijan A1 - Rodney A. Hayward A1 - Linda A. Wray A1 - Kenneth M. Langa KW - Disabilities KW - Health Behavior KW - Labor force participation KW - Older Adults AB - The effects of poor health habits on mortality have been studied extensively. However, few studies have examined the impact of these health behaviors on workforce disability. In the Health and Retirement Study, a nationally representative cohort of 6044 Americans who were between the ages of 51 and 61 and who were working in 1992, we found that both baseline smoking status and a sedentary lifestyle predict workforce disability six years later. If this relationship is causal, cost-benefit analyses of health behavior intervention that neglect workforce disability may substantially underestimate the benefits of such interventions. PB - University of Michigan Retirement Research Center CY - Ann Arbor UR - https://core.ac.uk/download/pdf/7189096.pdf ER - TY - JOUR T1 - Informal caregiving for diabetes and diabetic complications among elderly americans. JF - J Gerontol B Psychol Sci Soc Sci Y1 - 2002 A1 - Kenneth M. Langa A1 - Sandeep Vijan A1 - Rodney A. Hayward A1 - M.E. Chernew A1 - Caroline S Blaum A1 - Mohammed U Kabeto A1 - David R Weir A1 - Steven J. Katz A1 - Robert J. Willis A1 - A. Mark Fendrick KW - Aged KW - Aged, 80 and over KW - Caregivers KW - Cost of Illness KW - Costs and Cost Analysis KW - Diabetes Complications KW - Diabetes Mellitus KW - Disabled Persons KW - Female KW - Health Surveys KW - Humans KW - Hypoglycemic Agents KW - Insulin KW - Male KW - Time Factors AB -

OBJECTIVES: Little is known regarding the amount of time spent by unpaid caregivers providing help to elderly individuals for disabilities associated with diabetes mellitus (DM). We sought to obtain nationally representative estimates of the time, and associated cost, of informal caregiving provided to elderly individuals with diabetes, and to determine the complications of DM that contribute most significantly to the subsequent need for informal care.

METHODS: We estimated multivariable regression models using data from the 1993 Asset and Health Dynamics Among the Oldest Old Study, a nationally representative survey of people aged 70 or older (N = 7,443), to determine the weekly hours of informal caregiving and imputed cost of caregiver time for community-dwelling elderly individuals with and without a diagnosis of DM.

RESULTS: Those without DM received an average of 6.1 hr per week of informal care, those with DM taking no medications received 10.5 hr, those with DM taking oral medications received 10.1 hr, and those with DM taking insulin received 14.4 hr of care (p <.01). Disabilities related to heart disease, stroke, and visual impairment were important predictors of diabetes-related informal care. The total cost of informal caregiving for elderly individuals with diabetes in the United States was between $3 and $6 billion per year, similar to previous estimates of the annual paid long-term care costs attributable to DM.

DISCUSSION: Diabetes imposes a substantial burden on elderly individuals, their families, and society, both through increased rates of disability and the significant time that informal caregivers must spend helping address the associated functional limitations. Future evaluations of the costs of diabetes, and the cost-effectiveness of diabetes interventions, should consider the significant informal caregiving costs associated with the disease.

PB - 57B VL - 57 IS - 3 U1 - http://www.ncbi.nlm.nih.gov/pubmed/11983744?dopt=Abstract U4 - Aged, 80 and Over/Caregivers/Cost of Illness/Costs and Cost Analysis/Diabetes Mellitus/Complications/Therapy/Disabled Persons/Female/Health Surveys/Hypoglycemic Agents/Insulin/Support, Non U.S. Government/Support, U.S. Government--non PHS/Support, U.S. Government--PHS/Time Factors ER - TY - JOUR T1 - Informal caregiving time and costs for urinary incontinence in older individuals in the United States. JF - J Am Geriatr Soc Y1 - 2002 A1 - Kenneth M. Langa A1 - Fultz, Nancy H. A1 - Sanjay Saint A1 - Mohammed U Kabeto A1 - A. Regula Herzog KW - Aged KW - Caregivers KW - Comorbidity KW - Confounding Factors, Epidemiologic KW - Female KW - Humans KW - Incontinence Pads KW - Male KW - Regression Analysis KW - Time Factors KW - United States KW - Urinary incontinence AB -

OBJECTIVES: To obtain nationally representative estimates of the additional time, and related cost, of informal caregiving associated with urinary incontinence in older individuals.

DESIGN: Multivariate regression models using data from the 1993 Asset and Health Dynamics Study, a nationally representative survey of people aged 70 and older (N = 7,443).

SETTING: Community-dwelling older people.

PARTICIPANTS: National population-based sample of community-dwelling older people.

MEASUREMENTS: Weekly hours of informal caregiving, and imputed cost of caregiver time, for community-dwelling older people who reported (1) no unintended urine loss, (2) incontinence that did not require the use of absorbent pads, and (3) incontinence that required the use of absorbent pads.

RESULTS: Thirteen percent of men and 24% of women reported incontinence. After adjusting for sociodemographics, living situation, and comorbidities, continent men received 7.4 hours per week of care, incontinent men who did not use pads received 11.3 hours, and incontinent men who used pads received 16.6 hours (P <.001). Women in these groups received 5.9, 7.6, and 10.7 hours (P <.001), respectively. The additional yearly cost of informal care associated with incontinence was $1,700 and $4,000 for incontinent men who did not and did use pads, respectively, whereas, for women in these groups, the additional yearly cost was $700 and $2,000. Overall, this represents a national annual cost of more than $6 billion for incontinence-related informal care.

CONCLUSIONS: The quantity of informal caregiving for older people with incontinence and its associated economic cost are substantial. Future analyses of the costs of incontinence, and the cost-effectiveness of interventions to prevent or treat incontinence, should consider the significant informal caregiving costs associated with this condition.

PB - 50 VL - 50 IS - 4 U1 - http://www.ncbi.nlm.nih.gov/pubmed/11982676?dopt=Abstract U4 - Caregivers/Comorbidity/Confounding Factors (Epidemiology)/Female/Incontinence Pads/Regression Analysis/Support, U.S. Government--PHS/Time Factors/United States/Epidemiology/Urinary Incontinence ER - TY - JOUR T1 - A national study of the quantity and cost of informal caregiving for the elderly with stroke. JF - Neurology Y1 - 2002 A1 - Hickenbottom, S.L. A1 - A. Mark Fendrick A1 - Kutcher, J.S. A1 - Mohammed U Kabeto A1 - Steven J. Katz A1 - Kenneth M. Langa KW - Aged KW - Aged, 80 and over KW - Caregivers KW - Confidence Intervals KW - Female KW - Humans KW - Longitudinal Studies KW - Male KW - Multivariate Analysis KW - Stroke KW - United States AB -

BACKGROUND: As the US population ages, increased stroke incidence will result in higher stroke-associated costs. Although estimates of direct costs exist, little information is available regarding informal caregiving costs for stroke patients.

OBJECTIVE: To determine a nationally representative estimate of the quantity and cost of informal caregiving for stroke.

METHODS: The authors used data from the first wave of the Asset and Health Dynamics (AHEAD) Study, a longitudinal study of people over 70, to determine average weekly hours of informal caregiving. Two-part multivariable regression analyses were used to determine the likelihood of receiving informal care and the quantity of caregiving hours for those with stroke, after adjusting for important covariates. Average annual cost for informal caregiving was calculated.

RESULTS: Of 7,443 respondents, 656 (8.8%) reported a history of stroke. Of those, 375 (57%) reported stroke-related health problems (SRHP). After adjusting for cormorbid conditions, potential caregiver networks, and sociodemographics, the proportion of persons receiving informal care increased with stroke severity, and there was an association of weekly caregiving hours with stroke +/- SRHP (p < 0.01). Using the median 1999 home health aide wage (8.20 dollars/hour) as the value for family caregiver time, the expected yearly caregiving cost per stroke ranged from 3,500 dollars to 8,200 dollars. Using conservative prevalence estimates from the AHEAD sample (750,000 US elderly patients with stroke but no SRHP and 1 million with stroke and SRHP), this would result in an annual cost of up to 6.1 billion dollars for stroke-related informal caregiving in the United States.

CONCLUSIONS: Informal caregiving-associated costs are substantial and should be considered when estimating the cost of stroke treatment.

PB - 58 VL - 58 IS - 12 U1 - http://www.ncbi.nlm.nih.gov/pubmed/12084872?dopt=Abstract U4 - Aged, 80 and Over/Caregivers/Economics/Statistics and Numerical Data/Cerebrovascular Accident/Economics/Epidemiology/Confidence Intervals/Female/Human/Longitudinal Studies/Multivariate Analysis/Support, Non U.S. Government/Support, U.S. Government--PHS/United States/Epidemiology ER - TY - JOUR T1 - Estimating the cost of informal caregiving for elderly patients with cancer. JF - J Clin Oncol Y1 - 2001 A1 - Hayman, James A. A1 - Kenneth M. Langa A1 - Mohammed U Kabeto A1 - Steven J. Katz A1 - DeMonner, Sonya M. A1 - M.E. Chernew A1 - Slavin, Mitchell B. A1 - A. Mark Fendrick KW - Activities of Daily Living KW - Aged KW - Aged, 80 and over KW - Caregivers KW - Cost of Illness KW - Family KW - Female KW - Home Nursing KW - Humans KW - Male KW - Multivariate Analysis KW - Neoplasms KW - Regression Analysis KW - United States AB -

PURPOSE: As the United States population ages, the increasing prevalence of cancer is likely to result in higher direct medical and nonmedical costs. Although estimates of the associated direct medical costs exist, very little information is available regarding the prevalence, time, and cost associated with informal caregiving for elderly cancer patients.

MATERIALS AND METHODS: To estimate these costs, we used data from the first wave (1993) of the Asset and Health Dynamics (AHEAD) Study, a nationally representative longitudinal survey of people aged 70 or older. Using a multivariable, two-part regression model to control for differences in health and functional status, social support, and sociodemographics, we estimated the probability of receiving informal care, the average weekly number of caregiving hours, and the average annual caregiving cost per case (assuming an average hourly wage of $8.17) for subjects who reported no history of cancer (NC), having a diagnosis of cancer but not receiving treatment for their cancer in the last year (CNT), and having a diagnosis of cancer and receiving treatment in the last year (CT).

RESULTS: Of the 7,443 subjects surveyed, 6,422 (86%) reported NC, 718 (10%) reported CNT, and 303 (4%) reported CT. Whereas the adjusted probability of informal caregiving for those respondents reporting NC and CNT was 26%, it was 34% for those reporting CT (P <.05). Those subjects reporting CT received an average of 10.0 hours of informal caregiving per week, as compared with 6.9 and 6.8 hours for those who reported NC and CNT, respectively (P <.05). Accordingly, cancer treatment was associated with an incremental increase of 3.1 hours per week, which translates into an additional average yearly cost of $1,200 per patient and just over $1 billion nationally.

CONCLUSION: Informal caregiving costs are substantial and should be considered when estimating the cost of cancer treatment in the elderly.

PB - 19 VL - 19 IS - 13 U1 - http://www.ncbi.nlm.nih.gov/pubmed/11432889?dopt=Abstract U4 - Activities of Daily Living/Aged, 80 and Over/Caregivers/Cost of Illness/Family/Psychology/Female/Home Nursing/Economics/Statistics and Numerical Data/Human/Multivariate Analysis/Neoplasms/Complications/Therapy/Regression Analysis/United States ER - TY - JOUR T1 - The explosion in paid home health care in the 1990s: who received the additional services? JF - Med Care Y1 - 2001 A1 - Kenneth M. Langa A1 - M.E. Chernew A1 - Mohammed U Kabeto A1 - Steven J. Katz KW - Activities of Daily Living KW - Aged KW - Aged, 80 and over KW - Chronic disease KW - Family Characteristics KW - Female KW - Financing, Government KW - Frail Elderly KW - Geriatric Assessment KW - Health Care Surveys KW - Health Expenditures KW - health policy KW - Home Care Services KW - Home Nursing KW - Humans KW - Longitudinal Studies KW - Male KW - Marital Status KW - Multivariate Analysis KW - Social Support KW - Socioeconomic factors KW - Surveys and Questionnaires KW - United States KW - Utilization Review AB -

OBJECTIVE: Public expenditures for home health care grew rapidly in the 1990s, but it remains unclear to whom the additional services were targeted. This study tests whether the rapidly increasing expenditures were targeted to the elderly with high levels of disability and low levels of social support, 2 groups that have historically been higher users of paid home health and nursing home services.

METHODS: The Asset and Health Dynamics Study, a nationally representative, longitudinal survey of people > or = 70 years of age (n = 7,443), was used to determine the association of level of disability and level of social support with the use of paid home care services in both 1993 and 1995. Multivariable regression models were used to adjust for sociodemographics, recent hospital or nursing home admissions, chronic medical conditions, and receipt of informal care from family members.

RESULTS: Those with higher levels of disability received more adjusted weekly hours of paid home care in both 1993 and 1995. In 1993, users of paid home care with the least social support (unmarried living alone) received more adjusted weekly hours of care than the unmarried elderly living with others (24 versus 13 hours, P < 0.01) and the married (24 versus 18 hours, P = 0.06). However, by 1995, those who were unmarried and living with others were receiving the most paid home care: 40 versus 26 hours for the unmarried living alone (P < 0.05) and 24 hours for the married (P < 0.05).

CONCLUSIONS: The recent large increase in formal home care services went disproportionately to those with greater social support. Home care policy changes in the early 1990s resulted in a shift in the distribution of home care services toward the elderly living with their children.

PB - 39 VL - 39 IS - 2 U1 - http://www.ncbi.nlm.nih.gov/pubmed/11176552?dopt=Abstract U4 - Activities of Daily Living/Classification/Aged, 80 and Over/Chronic Disease/Family Characteristics/Female/Financing, Government/Frail Elderly/Geriatric Assessment/Health Care Surveys/Health Expenditures/Health Policy/Home Care Services/Home Nursing/Longitudinal Studies/Marital Status/Multivariate Analysis/Questionnaires/Social Support/Socioeconomic Factors/Support, Non U.S. Government/United States/Utilization Review ER - TY - JOUR T1 - National estimates of the quantity and cost of informal caregiving for the elderly with dementia. JF - J Gen Intern Med Y1 - 2001 A1 - Kenneth M. Langa A1 - M.E. Chernew A1 - Mohammed U Kabeto A1 - A. Regula Herzog A1 - Mary Beth Ofstedal A1 - Robert J. Willis A1 - Robert B Wallace A1 - Mucha, L.M. A1 - Walter L. Straus A1 - A. Mark Fendrick KW - Aged KW - Aged, 80 and over KW - Caregivers KW - Cost of Illness KW - Dementia KW - Female KW - Health Care Costs KW - Humans KW - Male KW - Multivariate Analysis KW - Regression Analysis KW - Severity of Illness Index KW - Time Factors KW - United States AB -

OBJECTIVE: Caring for the elderly with dementia imposes a substantial burden on family members and likely accounts for more than half of the total cost of dementia for those living in the community. However, most past estimates of this cost were derived from small, nonrepresentative samples. We sought to obtain nationally representative estimates of the time and associated cost of informal caregiving for the elderly with mild, moderate, and severe dementia.

DESIGN: Multivariable regression models using data from the 1993 Asset and Health Dynamics Study, a nationally representative survey of people age 70 years or older (N = 7,443).

SETTING: National population-based sample of the community-dwelling elderly.

MAIN OUTCOME MEASURES: Incremental weekly hours of informal caregiving and incremental cost of caregiver time for those with mild dementia, moderate dementia, and severe dementia, as compared to elderly individuals with normal cognition. Dementia severity was defined using the Telephone Interview for Cognitive Status.

RESULTS: After adjusting for sociodemographics, comorbidities, and potential caregiving network, those with normal cognition received an average of 4.6 hours per week of informal care. Those with mild dementia received an additional 8.5 hours per week of informal care compared to those with normal cognition (P < .001), while those with moderate and severe dementia received an additional 17.4 and 41.5 hours (P < .001), respectively. The associated additional yearly cost of informal care per case was 3,630 dollars for mild dementia, 7,420 dollars for moderate dementia, and 17,700 dollars for severe dementia. This represents a national annual cost of more than 18 billion dollars.

CONCLUSION: The quantity and associated economic cost of informal caregiving for the elderly with dementia are substantial and increase sharply as cognitive impairment worsens. Physicians caring for elderly individuals with dementia should be mindful of the importance of informal care for the well-being of their patients, as well as the potential for significant burden on those (often elderly) individuals providing the care.

PB - 16 VL - 16 IS - 11 U1 - http://www.ncbi.nlm.nih.gov/pubmed/11722692?dopt=Abstract U4 - Aged, 80 and Over/Caregivers/Economics/Cost of Illness/Dementia/Economics/Therapy/Female/Health Care Costs/Multivariate Analysis/Regression Analysis/Severity of Illness Index/Support, Non U.S. Government/Support, U.S. Government--PHS/Time Factors/United States ER - TY - JOUR T1 - Gender disparities in the receipt of home care for elderly people with disability in the United States. JF - JAMA Y1 - 2000 A1 - Steven J. Katz A1 - Mohammed U Kabeto A1 - Kenneth M. Langa KW - Activities of Daily Living KW - Aged KW - Disabled Persons KW - Family KW - Female KW - Geriatrics KW - Home Care Services KW - Home Nursing KW - Humans KW - Male KW - Regression Analysis KW - Sex Distribution KW - United States AB -

CONTEXT: Projected demographic shifts in the US population over the next 50 years will cause families, health care practitioners, and policymakers to confront a marked increase in the number of people with disabilities living in the community. Concerns about the adequacy of community support are particularly salient to women, who make up a disproportionate number of disabled elderly people and who may be particularly vulnerable because they are more likely to live alone with limited financial resources.

OBJECTIVE: To address gender differences in receipt of informal and formal home care.

DESIGN, SETTING, AND PARTICIPANTS: Nationally representative survey conducted in 1993 among 7443 noninstitutionalized people (4538 women and 2905 men) aged 70 years or older.

MAIN OUTCOME MEASURE: Number of hours per week of informal (generally unpaid) and formal (generally paid) home care received by survey participants who reported any activity of daily living (ADL) or instrumental activity of daily living (IADL) impairment (n = 3109) compared by gender and living arrangement and controlling for other factors.

RESULTS: Compared with disabled men, disabled women were much more likely to be living alone (45.4% vs 16.8%, P<.001) and much less likely to be living with a spouse (27.8% vs 73.6%, P<.001). Overall, women received fewer hours of informal care per week than men (15.7 hours; 95% confidence interval [CI], 14.5-16.9 vs 21.2 hours; 95% CI, 19. 7-22.8). Married disabled women received many fewer hours per week of informal home care than married disabled men (14.8 hours; 95% CI, 13.7-15.8 vs 26.2 hours; 95% CI, 24.6-27.9). Children (>80% women) were the dominant caregivers for disabled women while wives were the dominant caregivers of disabled men. Gender differences in formal home care were small (2.8 hours for women; 95% CI, 2.5-3.1 vs 2.1 hours for men; 95% CI, 1.7-2.4).

CONCLUSION: Large gender disparities appear to exist in the receipt of informal home care for disabled elderly people in the United States, even within married households. Programs providing home care support for disabled elderly people need to consider these large gender disparities and the burden they impose on families when developing intervention strategies in the community.

PB - 284 VL - 284 IS - 23 U1 - http://www.ncbi.nlm.nih.gov/pubmed/11122589?dopt=Abstract U4 - Activities of Daily Living/Disabled Persons/Family/Female/Geriatrics/Home Care Services/Utilization/Home Nursing/Utilization/Regression Analysis/Sex Distribution/Support, Non U.S. Government/Support, U.S. Government--PHS/United States/Epidemiology ER -