Carolina Center for Population Aging and Health (CCPAH)

2022. Carmen Gutierrez, PhD. Criminal Legal System Connections, Health, and Place Safety.

Connections to the criminal legal system (CLS) are known to affect health. Indeed, a large body of
literature documents adverse health consequences associated with being punished by the CLS. However, surprisingly little is known about the ways that the relationship between punishment and health varies across geographic contexts. Even less attention has been dedicated to investigating the health consequences of working for the CLS, although research during the pandemic highlights how
exposure to jail and prison environments has contributed to elevated levels of COVID-19 cases and
deaths among detention center staff. Expanding our knowledge on the relationship between health
and connections to the CLS to include workers and linking these health patterns to spatial contexts will
contribute to our understanding of place-based and racial inequalities in health. People who are both
punished and employed by the CLS are disproportionately Black and Latino men who have been shown
to have worse health and shorter life expectancies compared to people in the general population, and
recent changes across metropolitan areas have altered the spatial distribution of this population.
Nowadays, people connected to the CLS—through both punishment and employment—are increasingly
likely to reside in rural areas. No study to date, however, has examined the health consequences of
being connected to the CLS through both punishment and employment through a contextual
framework. To address these important and timely gaps in the literature, the proposed project seeks to generate original data on CLS connections in eastern North Carolina (ENC)—a predominately rural area where jails and prisons are prominent—and link these connections to health outcomes among working-age adults. This data collection effort will contribute to the existing data collection system of the DEEPP project (Dynamics of Extreme Events, People, and Places), led by Elizabeth Frankenberg. The proposed work would therefore build upon DEEPP’s rich data and support my goal of establishing a unique source of data that will be used for future NIH grant submissions. Specific aims of this foundational work are to:

Aim 1: Map the locations of jails and prisons in ENC and measure their prominence as sites of
employment and punishment.
Aim 2: Collect qualitative data on the stressors associated with CLS connections among people in ENC.
Aim 3: Develop and pilot test a computer-assisted questionnaire to collect information on CLS
connections, health, and place in ENC.

Priority Research Areas: Health Trends and Disparities

2022. Margaret Sheridan, PhD. A Dimensional Approach to Assessing the Impact of Adversity on Age-Related Cognitive Decline.

Exposure to childhood adversity is common, and is associated with risk for numerous negative outcomes in childhood, adolescence, and adulthood. The prevailing approach for examining the developmental consequences of adversity exposure is a cumulative risk model which points to stress as the primary biological pathway through which adversity comes to impact health outcomes. We have articulated an alternative to the cumulative risk model which proposes a set of novel mechanisms explaining how dimensions of adverse experiences, specifically deprivation and threat, influence risk for negative life outcomes and in particular psychopathology (McLaughlin & Sheridan, 2016; McLaughlin, Sheridan, & Lambert, 2014; Sheridan & McLaughlin, 2016; Sheridan & McLaughlin, 2014). Existing data support the hypothesis that exposure to deprivation but not threat disrupts cognitive function and associated neural pathways whereas exposure to threat but not deprivation disrupts emotion regulation in childhood and adolescence (Lambert et al., 2016; Machlin et al., 2019; Manly et al., 1994, 2001; McLaughlin et al., 2019; Sheridan et al., 2017). In addition, these dimensions of adversity are differentially linked with long-term differences in emotion regulation and cognitive function when measured longitudinally from early childhood through late adolescence (Miller et al., 2018, 2020).

Importantly, a robust body of work has documented associations between early life adversity exposure and aging related health concerns (Midei et al., 2013) and recent work indicates that differential effects of deprivation and threat on cognitive function and emotion reactivity may be observable even into late life (Geoffroy et al., 2016b). Given selective associations between deprivation and cognitive function in childhood, we expect that deprivation, but not threat, will increase the rate of age-related cognitive decline and rates of diseases of cognitive aging such as idiopathic dementia. In contrast, we would expect threat but not deprivation exposure to be associated with increased cardiovascular risk and metabolic dysfunction. However, most work examining associations between adversity and aging to date has not delineated dimensions of adversity. Beginning well-designed and novel studies of the impact of early adversity on aging is a long-term investment, prior to initiating this kind of approach preliminary investigations are needed. Here we propose three avenues through which preliminary data will be obtained.

Aim1. We propose taking a meta-analytic approach to understanding the differential impact of deprivation and threat on aging processes. In a previous grant we completed a meta-analysis of the differential impact of deprivation and threat on cardiovascular and metabolic disease indicators. Here we proposed building on that dataset to also examine the impact of these forms of adversity on age related cognitive decline.
Aim2. In an existing dataset (N = 1,252; ages 18-80 years) acquired using the online data collection platform Prolific, Co-Investigator Boettiger assessed adversity and cognitive function via self-report. Utilizing this data we will determine if retrospective reports of exposure to these forms of adversity are differentially linked with age-related decline in self-reported cognitive function.
Aim3. In an ongoing pilot data collection project of participants between 18-80 years (N = 120) cognitive and neural function are directly assessed using cognitive testing and neuroimaging. This project is funded via a National Science Foundation grant to Co-Investigators Lindquist and Giovanello. In collaboration with PI Sheridan, measures of self-reported exposure to deprivation and threat are being collected in this dataset in an ongoing fashion. Utilizing this data we will determine if retrospective reports of exposure to these forms of adversity are differentially linked with age-related decline in cognitive function and associated neural processes such as functional brain connectivity.

These preliminary findings will result in (a) up to three publishable empirical papers and (b) preliminary results which will provide a strong foundation for two subsequent planned grants. First, Co-Investigators Giovanello and Lindquist will build on findings from their current study to apply for an R01 from NICHD to examine life-span changes in emotion and cognitive function. With preliminary data from this application, they will be able to work with PI Sheridan to additionally investigate the link between dimensions of adversity stress reactivity and cognitive function across the life span. Second, Co-Investigator Boettiger will apply for funding from the NIAAA to examine the impact of cognitive aging on risk for alcohol use disorder. With preliminary data from this application, she will be able to work with PI Sheridan to additionally investigate the impact of deprivation and threat as moderators of her planned analyses.

Priority Research Areas: Biology, Genetics and Demography of Aging

2021. Kathleen Mullan Harris, PhD. The Role of Morningness in Sleep Timing and Epigenetic Aging in Young Adulthood.

Being more of a “night owl” has been linked to increased risk of diabetes, hypertension, and
mortality. Evidence suggests that diurnal preference for morningness (versus eveningness) is
affected by both genetic and environmental, as well as developmental factors, with chronotype
(measured as midpoint of sleep on free days) shifting earlier as people age from young adulthood
and beyond. However, not only does aging affect diurnal rhythms, but recent research highlights a
pathway by which diurnal rhythms might affect aging: telomere length (a measure of biological aging,
which shortens as we age) is shorter in people with moderately late compared to intermediate diurnal
preference. Much remains to be understood regarding the relationship between chronotype and
biological aging, and recent epigenetic “clock” measures provide an opportunity to investigate how
diurnal preference affects biological aging processes reflected in DNA methylation (DNAm).
We propose leveraging genetic and recently collected epigenetic data in NIA-funded Add Health to
advance understanding of the relationships between diurnal preference, sleep timing, and epigenetic
aging. We hypothesize that greater genetic propensity for morningness, reflected in polygenic scores
(PGSs), is associated with decreased epigenetic age acceleration (EAA), a measure capturing how
far biological aging reflected in DNAm has progressed beyond levels predicted by chronological age.
Our aims are:
Aim 1: Estimate association of morningness PGSs with sleep timing in young adults using
PGSs constructed from prior morningness GWAS.9 Test whether association changes across young
adulthood.
Aim 2: Identify whether social and environmental schedules moderate association of
morningness PGSs with sleep timing. Test whether association differs between work and free
days and by sunset time, examining extent to which social schedules and sunlight exposure interact
with morningness PGSs.
Aim 3: Estimate association of morningness PGSs with EAA in early mid-adulthood and
identify whether sleep timing moderates this association. Assess whether “mismatch” of
morningness PGSs and sleep timing (e.g. high on morningness PGSs, late sleep timing) predicts
greater EAA.

Priority Research Areas: Biology, Genetics and Demography of Aging

2021. Tonia Poteat, PhD. Meeting the Pandemic Needs of Older Sexual Minority Women: Data to Inform Covid-19 Response.

Sexual minority women (SMW) face unique COVID-19 pandemic-related challenges. Black SMW ≥ 50 years old, in particular, were already experiencing health inequities at the intersection of racism, sexism, ageism, and homophobia. Our prior research with Black lesbian elders identified a heavy burden of poverty, multimorbidity, and poor mental health – factors that increase COVID-19 vulnerability. We also identified resilience strategies, such as community-building and intergenerational learning. However, social-distancing, income loss, and caregiving demands wrought by the pandemic have interrupted many of these strategies, as described during virtual focus groups discussion (FGDs) completed with 100 older Black SMW in late 2020. Our FGDs explored physical and psychosocial health, experiences with COVID-19 testing, illness and loss, and vaccine attitudes – providing data on the importance of addressing mental health and vaccine hesitancy. However, FGDs were limited to Black SMW, precluding comparisons with other racial groups to determine whether tailored interventions are necessary. The nature of FGDs prevented in-depth explorations of participants’ perspectives on potential interventions. The videoconference platform presented barriers to engaging women with low educational attainment and/or low technology skills; therefore, we lack information from these groups. We must address these limitations in order to design an intervention that is feasible and acceptable to diverse older SMW. To gather the preliminary data necessary to develop and test a mental health intervention, we propose a mixed methods study with the following aims:

Aim 1: Assess strategies for recruiting racially and educationally diverse older SMW for participation in a
quantitative survey. These data will inform enrollment approaches for the future intervention.
Aim 2: Characterize vaccine attitudes and psychosocial effects of the COVID-19 pandemic via a quantitative survey among a sample of diverse older SMW that builds on prior FGD results. Findings will provide comparative data by race, education, and socioeconomic status to inform selection of intervention targets.
Aim 3: Identify feasible and acceptable strategies to bolster resilience and mitigate pandemic-related harms among diverse older SMW by conducting in-depth interviews with prior FGD participants and a purposive sample of SMW with low educational attainment and/or low technology skills.

These data will be collected in partnership with ZAMI NOBLA – National Organization of Black Lesbians on Aging, a community-based organization which collaborated on aforementioned FGDs. They will partner on the planned grant application to NIA in February 2022 that will respond to NOT-AG-21-015: Notice of Special Interest: Aging-Relevant Behavioral and Social Research on Coronavirus Disease 2019.

Priority Research Areas: Health Trends and Disparities

2021. Jeremy Moulton, PhD. Property tax exemptions and senior home affordability.

Property tax exemptions are often targeted at seniors to improve home affordability and help them
age in place. In this project, I aim to answer the question of whether these policies affect the
ownership and location decisions of seniors and what impact this has on their health.

Specific Aim 1: How have property tax exemptions for seniors affected home prices across the United
States? Use event study regression analysis and comparative interrupted time series (CITS) methodologies on “big data” from Zillow to estimate the effect of property tax exemptions on home prices.
Specific Aim 1a: Who are the winners and losers of property tax exemptions? Use merged American Community Survey (ACS) demographic data to estimate which demographic groups (age, race, ethnicity, etc.) are the recipients of the price change by stratifying and/or interacting the above models.

Specific Aim 2: How have property tax exemptions affected location and ownership decisions for
seniors? Use spatial methods and amenity location data (such as health facilities) to estimate how seniors
change their location decisions based on the incentives associated with property tax exemption.
Specific Aim 2a: Have other major housing policies affected the location decisions and ownership
decisions of seniors? Use CITS to investigate if major policies like the first-time homebuyer tax credit, that targeted younger buyers, pushed senior homebuyers out of the market.

Specific Aim 3: How have property tax exemptions affected the health of seniors? Investigate the impact on health for those pushed into less desirable locations due to the exemptions as well as those that expect appreciation and tax exemption using similar analysis to aim 1.

Priority Research Areas: Population, Economic and Health Forecasting

2021. Joanna "Asia" Maselko. Optimizing wearable sensing technologies for the measurement of social interactions among older adults.

Social isolation and loneliness are linked with multiple negative mental, cognitive, and physical
health outcomes, including mortality across the lifecourse, while greater social engagement is
linked with significant positive health outcomes. Older age is a unique period of the lifecourse
where social connections undergo a dramatic shift, often characterized by decreases in social
connectedness, which are in turn, linked with declining mental, cognitive, and physical health.
Thus, there is enormous need for effective interventions to alleviate the health and social burdens
associated with social isolation and loneliness among older age persons. Unfortunately,
interventions aiming to engage older persons in activities that are meaningful, enjoyable, and
sustainable have yielded decidedly mixed results. One potential area of focus to ameliorate these negative impacts is the increase of positive social interactions within relationships that the individual is already motivated to engage in. A relationship with unique potential to impact the health of older individuals is the
grandparent-grandchild (GP-GC) relationship. A focus on GP-GC interactions offers a pathway for
preventative interventions, encouraging safe ways for older persons to remain engaged in meaningful
interactions as they age, and thereby optimizing years of healthy life. However, research on the
health implications of grandparenting has been surprisingly inconclusive, even as its positive
potential is clearly acknowledged.

A key challenge to understanding the impact of GP-GC interactions on GP health and well-being is
that measurement of GP-GC interactions has remained coarse, and granular domains of GP-GC
interactions are not as well understood. For example, most studies assess GP-GC interaction by
inquiring about the number of hours spent caregiving or co-residence status. It is also important
to distinguish caregiving burden from GP-GC interactions. A potential area for methodological
breakthrough is to assess these granular social interaction domains in a continuous, passive, and
naturalistic manner, while combining with simultaneous data on GC proximity. Wearable technology
offers such an opportunity. Recent developments in wearable sensing and activity recognition
technologies are revolutionizing behavioral research with their unique potential to unobtrusively
gather comprehensive and meaningful data from the real-world contexts in which individuals
live. However, the feasibility and potential contributions of these approaches to aging
research has not yet been fully examined. Previous funding submissions from our research team have
been hindered by a lack of piloting that has left the feasibility of this method in question.
Our overarching study objective is to pilot the use of a wearable technology-based approach to
measure how domains related to health among the aging vary in the presence of their grandchild. We
focus on the measurement of known correlates of health, including heart-rate variability, physical
activity, and frequency and quality of grandparent speech.

We have two specific hypotheses, one methodological and one substantive. First, we hypothesize that we can successfully use wearable technology in a natural (non-laboratory) setting to measure heart rate variability, physical activity, and pre-specified speech domains of the older individual, as well as grandchild proximity. Second, we hypothesize that the presence of the grandchild will be correlated with higher heart
rate variability, higher frequency of domains such as positive affective speech and physical
activity, and lower frequency of negative affective speech and silence. In our pilot we will obtain data from:
1) The wearable worn by the grandparent and a proximity beacon worn by the grandchild. These will
capture data on (a) heart rate variability (b) physical activity, (c) the auditory environment, and
(d) GC proximity to the GP.
2) Qualitative interviews focusing on the feasibility and accessibility of the tech package.

This is a pilot study and is aimed at determining whether this approach for assessing GP-GC social
actions is feasible; the results will not contribute to generalizable knowledge and do not require
an IRB review.

Priority Research Areas: Biology, Genetics and Demography of Aging

2020. Jennifer Lund, PhD. Social Determinants and Adverse Health Outcomes in Older Adults: The role of inappropriate medication use.

Optimizing medication use in older adults (age 65+ years) is challenging due to the frequent
co-occurrence of multimorbidity, polypharmacy, and age-related changes in pharmacokinetics and
pharmacodynamics, which together increase the risk for adverse drug events. Adverse drug events are
costly, accounting for approximately $3.5 billion in spending in the United States (US) each year.
Medications whose risks of harm exceed their expected clinical benefits are termed potentially
inappropriate medications (PIMs). PIM use is common, reaching a one-year prevalence of >30% among
Medicare beneficiaries, and is associated with an increased risk of adverse health outcomes of
paramount importance to older adults, including falls, functional and cognitive impairment,
hospitalization, and mortality. While there are several prescribing tools that can be used to
identify PIMs (e.g., the Beers Criteria, the Screening Tool for Older People’s Prescriptions
(STOPP) criteria, and the Drug Burden Index (DBI)), there is a lack of understanding of the
relative merits of these tools and how best to apply them in the context of longitudinal data. In
addition, while social disparities in health, particularly those by race/ethnicity, geography, and
socioeconomic status (SES), are well documented for individuals across the life course, there is
little mechanistic research describing how disparities in PIM use could potentially impact
persistent and ever growing health disparities in late life. Our proposed study will leverage a
novel data resource, the National Health and Aging Trends Study linked with Medicare claims data to
evaluate and compare the performance of contemporary PIM screening tools, document disparities in
use by race/ethnicity, geography, and SES, and disentangle associations between longitudinal PIM
use trajectories and important adverse health outcomes. Our results will inform the development and
refinement of pharmacy- based interventions using PIM screening tools that are better targeted to
high-risk populations in greatest need promote safe and effective medication use among older adults, ultimately leading to reductions in health disparities in late life.

Priority Research Areas: Health Trends and Disparities

2020. Linda Adair, PhD. Effects of health on economic well-being of older adults in the context of rapid modernization.

The relationship between health and economic status is bi-directional. While many studies document poor health outcomes related to poverty, less attention has been paid to how health affects economic outcomes. Physical, cognitive, and mental health can have profound effects on the economic productivity and security of older adults, with consequences not only for them but also for the next generation who may benefit from their financial support or be burdened by the time and costs of caregiving and support. Health conditions which limit physical mobility and stamina may be of importance for productivity in occupations that require physical strength or endurance while cognitive deficits and poor mental health may be more likely to impact occupations which require cognitive skills. These limitations may develop over long periods of time. However, few longitudinal studies in low- and middle-income country (LMIC) contexts provide the long-term data that allow study of the evolution of poor health and its impact on economic outcomes across the life course.  Even fewer studies have the data needed to document intergenerational effects. We plan to conduct interdisciplinary, comparative research using data from extremely rich cohort studies spanning several decades in China, Indonesia, and the Philippines. The principal investigators represent ESI and senior CPC fellows (Adair, Gordon-Larsen, Frankenberg) from different disciplines and who have collaborated on other projects. The overall goal of this project is to enhance understanding of how economic productivity and security in older adults is influenced by trajectories of physical, mental, and cognitive health beginning earlier in life, and in turn, how the health and economic well-being of older adults affects the next generation. The cohort studies for this project include: The China Health and Nutrition Survey (CHNS) is a multipurpose panel survey following all members of more than 41,000 households in 360 communities throughout China across 10 exams from 1990 to 2019. The 2015 survey includes 19,525 individuals of whom 5,173 were age 60+. The Cebu Longitudinal Health and Nutrition Study (CLHNS) recruited pregnant women from urban and rural communities of Metro Cebu in 1983-4 and followed them and an index child during bimonthly visits for the first 2 years, then in 8 subsequent surveys through 2016, when the women ranged in age from 45-78 (n=1659, 596 age 60+). The Indonesia Study of the Tsunami, Aftermath and Recovery (STAR) includes a representative population from Aceh, Sumatra, first recruited in 2004, with 6 follow-up visits through 2017. The most recent survey includes 9,707 individuals age 40 and above, of whom 2481 were age 60 and older. The three studies span time periods of rapid modernization and concomitant dramatic health and economic changes. Of note in all settings is the transition in types of work and labor markets from more to less physically demanding jobs benefitting from modern technology, and changes in health profiles with the emergence of obesity and chronic diseases. Comparative research across these settings can take advantage of the high diversity, pace of development and level of disparities within and between countries. The aims include: 1) Harmonization and preparation of data for comparative analysis, by harnessing substantial similarities in the questionnaires and data collected in the surveys. This harmonization work will be guided by principles established by Fortier et al in their work with multiple British and European cohorts(https://academic.oup.com/ije/article/40/5/1314/658348) ; 2) Estimate the pathways through which disparities in middle adulthood nutritional status represented as underweight, overweight, and obesity affect subsequent development and patterns of cardiometabolic health, impairment in physical and cognitive functioning, and in turn, changes in type of work, work hours, and earnings. We will use longitudinal marginal structural models to address likely bidirectional associations and take advantage of repeated surveys to focus on predictors of changes in economic outcomes subsequent to changes in health status.

Priority Research Areas: Determinants of Health, Well-Being and Longevity

2020. Robert Hummer, PhD. Life Course Cognition: Multimodal Measurement of Cognitive Functioning among Diverse Midlife Americans.

Understanding cognitive functioning is a critical national priority as the United States prepares for the rapid aging of its population. Recent scholarship makes it clear, though, that population-based study of cognitive functioning must begin long before old age; focused attention on midlife (i.e., ages 40-49) is essential. The National Longitudinal Study of Adolescent to Adult Health (Add Health) is poised to make a critical contribution to the understanding of midlife cognitive functioning in the United States. Our research team is in the process of developing the application to secure funding for Wave VI of Add Health, which will include in-depth attention to cognitive health in midlife. Add Health is a longitudinal study of a nationally representative sample of Americans that began following 20,000 adolescents in grades 7-12 during the 1994-95 school year. Add Health respondents are now reaching middle-age; as currently scheduled, the average age of Wave VI respondents will be 44. Add Health is thus exceptionally unique in having such a rich, multi-level, longitudinal array of data among a large nationally representative and diverse cohort of Americans as they approach midlife. These data also set the stage for rigorously studying risk and protective factors that occur earlier in the life course prior to the age-related conditions that will begin to affect this cohort, including cognitive decline and—in the future—dementia. This pilot project will assist in our preparation for cognitive data collection in Wave VI. The overall goal of this pilot is to develop, test, and evaluate potential measures of cognitive functioning among a diverse convenience sample of midlife subjects. We will work with our Add Health field contractor (RTI, International), to draw a diverse (by race/ethnicity, gender, and educational attainment) sample of North Carolina residents between the ages of 40-49. Because the plans for Wave VI of Add Health include both in-person and web-based cognitive assessments, this pilot project will develop, test, and evaluate potential measures of cognition in both the in-home and web-based data collection modes. The pilot project will address the following aims: 1) Using available tools (e.g., NIH Toolbox, Harmonized Cognitive Aging Project, Montreal Cognitive Assessment, Mini-Mental State Examination, PhenX Toolkit, and more), develop a range of in-person and web-based cognitive assessments to pilot among our convenience sample. 2) Collect pilot data on a range of cognitive functioning batteries from our convenience sample, using both the in-home and web-based modes of data collection. We will aim to collect data from as many subjects as our budget allows, with the sample balanced according to race/ethnicity (Black, Hispanic, Asian, White), gender (women, men), and educational attainment (high school degree or less, some college, college degree or more). 3) Compare the in-person with the web-based assessments and test for differences across the two modes. We will make these comparisons across both the full sample, as well as within subgroups defined by race/ethnicity, gender, and educational attainment. This pilot project stands to provide innovative and useful information for measuring cognition in middle age in large scale demographic and population-based studies, including Add Health.

Priority Research Areas: Biology, Genetics and Demography of Aging