Health trends, disparities, and determinants; Family and intergenerational supports; Effects of place on health and aging; Effects of social, economic, and healthcare policy on health and aging; Health and aging of specific populations; Disability and long-term care.
2021. Chun-Yo Ho. Elderly Health in Rural America: Impact of Hospital Closure.
Rural areas in the U.S. have been experiencing declines in access to hospital care. Since 2005, there has been 176 rural hospital closure, with considerable variation across states (North Carolina Rural Health Research Program, 2020). More than a fifth of all current rural hospitals are at high risk of closing, in which about two-third of them are considered essential to their community (Navigant 2019). Such trend echoes the access to health care is the top health priority among rural population (Bolin et al. 2015).
Aim 1: To estimate the effect of losing access to hospital care in rural U.S. counties on elderly health outcomes in response to time-sensitive conditions, and to test for disparities by race/ethnicity and by education, using Vital Statistics death certificate records from 2005-2018.
Aim 2: To estimate the magnitudes of policy-relevant factors affecting rural elder’ health outcomes directly as well as indirectly through loss of access to hospital care; these policy-relevant factors include the state’s ACA Medicaid expansion status, hospital characteristics, and local market characteristics.
Priority Research Areas: 11. Effects of place on health and aging, Disability, Health Care and Long-Term Care
2021. Colleen Heflin. Increasing access to SNAP for older adults through the Standard Medical Deduction.
Specific Aims: One of the goals of Healthy People 2020 is to identify and address the social and physical environments that promote good health for all. In 2017, food insecurity was present for 7.7 percent of persons aged 60 and older, or 5.5 million persons (Ziliak & Gundersen, 2019). The consequences of elderly persons’ food insecurity are far-reaching, affecting their health and well-being (Gundersen, Kreider, and Pepper 2011). The Supplemental Nutritional Assistance Program (SNAP) is the largest food and nutrition assistance program in the United States and has been shown to reduce food insecurity. States have the option to adopt the Standard Medical Deduction (SMD), a provision designed to make it easier for older adults to deduct medical expenses from income during the eligibility process which should increases the number of older adults eligible for SNAP as well as the benefit amount for which they qualify. Despite the potential importance of this provision, currently only 21 states adopt the SMD and there are no formal evaluations of its effectiveness.
Aim 1: To explore if and to what extent SNAP outcomes are higher in states that adopt the Standard Medical Deduction.
Aim 2: Because health, out-of-pocket health expenses, and lifetime connection to the SNAP program vary by demographic characteristics, we will document how these effects differ by sex and race/ethnicity.
Priority Research Areas: 12. Effects of social, economic, and healthcare policy on health and aging
2021. Jun Li . Effect of Medicaid expansion on low-income, aging adults’ use of informal care.
More than 44 million Americans receive help from informal caregivers at a societal cost of $522 billion annually, which reflects a health care system that provides limited support for formal long-term services and supports. The Affordable Care Act gave states the opportunity to expand Medicaid, which covers medical care and formal long-term services and supports for low-income and disabled adults under 65, with expansion associated with greater use of health care including increased use of formal long-term services and supports. Greater use of formal medical care (including long-term services and supports) has been observed to substitute for or complement informal care depending on the health of the population and availability of family
and intergenerational supports. Thus, Medicaid expansion could be critical for how low-income, aging adults use informal care.
Aim 1: Examine the association between Medicaid expansion and informal care use among low-income adults. We will examine changes in the total intensity of care (number of weekly hours) received, the type of informal caregiving including activities of daily living (e.g., dressing, eating, bathing, and toileting) and instrumental activities of daily living (e.g., meal preparation, grocery shopping, making phone calls), and the composition of informal care (number of informal caregivers providing care). We hypothesize that expansion will be associated with reduced informal care and changes in the composition of informal care.
Aim 2: Estimate the association of Medicaid expansion with unpaid, informal care costs for low-income adults. We will assess the effects of Medicaid expansion on the monthly costs of informal care borne by care recipients and their caregivers, focusing on the indirect costs of informal care computed using the market price of hourly wages of home health care and personal care aides. We hypothesize that costs of informal care will decrease after expansion.
Aim 3: Examine whether the relationship between Medicaid expansion and informal care use and costs varied by cognitive impairment, heavy informal care use, and low-income status. We will assess whether expansion had a differential effect on individuals who are more disadvantaged and likely to benefit from changes in access to formal long-term services and supports. Specifically, we examine those with cognitive impairment, those with informal care use above the median amount, and individuals in the bottom quartile of the Medicaid expansion-eligible income distribution. We hypothesize that decreases in informal care use and costs will be greater for vulnerable individuals after expansion.
Priority Research Areas: 12. Effects of social, economic, and healthcare policy on health and aging, Disability, Health Care and Long-Term Care
2021. Adriana Reyes. Extension of Health Shocks and Changes in Spatial Proximity between Parents and Children.
Summary of existing project. Adult children provide significant amounts of caregiving to their parents, which is facilitated by relatively close geographic proximity. This project utilizes longitudinal data from the Health and Retirement Study (HRS) to understand how families mobilize in response to a health shock, such an ADRD diagnosis. Using data from 2004-2014, we estimate proximity over time between parents and their adult children using parent’s Census tract and children’s zip codes. Analyses will leverage longitudinal data to assess the time-ordering of health shocks and changes in geographic proximity to children using fixed effects models.
Rationale for broadening existing project. Alzheimer’s disease and related dementias (ADRD) are among the costliest conditions faced by individuals and society . Average out of pocket costs for someone with ADRD is over $10,000, four times as much as for someone without ADRD . Older adults with ADRD are at a greater risk of preventable hospitalizations than those without ADRD, and having higher quality family care may help cut down preventable hospitalizations [2, 3]. Out-of-pocket health care payments for ADRD consumed 32% of household wealth five years before death . Early stage diagnosis of ADRD has been associated with declines in wealth, which may make it difficult to pay for late-stage treatment . Despite the well documented financial toll of ADRD on the families of those living with ADRD, we know less about how family proximity and care may moderate this relationship.
Specific Aims. This project asks whether changes in parent-child proximity in response to ADRD is associated with wealth. In particular, does the proximity of adult children reduce health care-related spending for adults with ADRD? The overall goal of this work is to understand how family proximity and mobilization are associated with wealth trajectories and health care spending by older adults with ADRD. Having family nearby may help reduce hospitalizations and other forms of health care spending that can enable older adults to maintain wealth.
Priority Research Areas: Cognitive Aging and the Demography of Dementia, Family and Intergenerational supports
2021. Ben Shaw . Living alone and risk for the development of Alzheimer’s Disease and related dementias: When does solitary living matter and why.
Background. Existing research shows that living alone in later life is associated with greater risk for the development of ADRD than physical inactivity, hypertension, diabetes, and obesity . Nevertheless, many older adults who live alone are able to maintain high levels of functioning and will not develop ADRD. While some research has identified factors that moderate the mortality risk of living alone , more research is needed to understand the circumstances associated with solitary living in later life that are mostly likely to confer, or buffer, ADRD risk. Social isolation is widely regarded as a key explanatory factor , but other demographic, behavioral, social, and environmental factors may also play important roles, either independently or jointly with social isolation. In addition, the timing of living alone (e.g., age of onset; duration in living alone status) and the circumstances precipitating a transition to solitary living may also be important in determining risk for ADRD.
Aims. This study’s aims are: (1) to determine which specific circumstances defining one’s living alone status (i.e., age of transition to living alone; duration in living alone status; event leading to living alone transition) are associated with ADRD incidence among older adults; (2) to determine the key demographic, behavioral, social, and environmental factors related to living alone during later life that are most strongly associated with ADRD incidence among older adults; and (3) to determine what demographic, behavioral, social, and environmental factors buffer the risk of ADRD among older adults living alone.
Priority Research Areas: Cognitive Aging and the Demography of Dementia, Family and Intergenerational supports
2021. Emily Wiemers . Extension of The Consequences of Disabilities in Late Middle Age for Consumption Well-Being.
Summary of existing project. The existing project uses the rich consumption and health data in Panel Study of Income Dynamics [PSID] to examine the consequences of disability in late middle age for consumption well-being and to assess whether the decline in consumption at the time an individual becomes disabled is predicted by or mediated by reports of poor health in childhood. The supplement exploits the measures of cognition, consumption, labor supply, wealth, and early childhood health in the Health and Retirement Study [HRS] to answer the same set of questions focusing on the impact of the onset of cognitive limitations and dementia on consumption well-being and its correlation with poor health in early childhood.
Specific Aim. To use the HRS to examine the impact of cognitive limitation or dementia onset on consumption well-being paying particular attention to the role of spousal labor supply and wealth as sources of consumption smoothing, and to evaluate the role of poor health in childhood in either exacerbating or mediating dementia-related consumption declines.
Priority Research Areas: Cognitive Aging and the Demography of Dementia, Disability, Health Care and Long-Term Care
2021. Kevin Heffernan. Estimated Arterial Stiffness as a Predictor of Cognitive Decline and Dementia in Middle-Aged and Older Adults.
Background. With aging, large arteries outside of the brain lose elasticity. Elevated levels of arterial stiffness expose the brain to high blood pressure that causes structural damage . Numerous cross-sectional studies now support a strong association between arterial stiffening and β-amyloid plaque deposition and atrophy of key areas of the brain implicated in the pathogenesis of cognitive aging and ADRD development [24-27]. Arterial stiffness also prospectively predicts cognitive decline [28-30] and transition to dementia in older adults [31-33]. As such, arterial stiffness may be a useful vascular biomarker to predict age-related cognitive decline and transition from mild cognitive impairment (MCI) to more severe dementia in the general population.
The gold standard method for assessing arterial stiffness, carotid-femoral pulse wave velocity (cfPWV), requires specialized, relatively expensive equipment and considerable technical proficiency, which limits its widespread adoption . cfPWV can be estimated from two commonly measured clinical variables – age and blood pressure – and we have shown this estimated pulse wave velocity (ePWV) is an independent predictor of cardiovascular and cerebrovascular events in the general population [35,36].This pilot project will extend our ongoing work on vascular aging to consider the relationship between ePWV, cognitive decline, and dementia.
Specific Aims. As the NIA acknowledges that “MCI research is perceived by experts as Alzheimer’s Disease prevention research,” this pilot project will leverage the strong longitudinal study design of the HRS to address two specific aims and associated hypotheses: (1) examine ePWV as a predictor of cognitive decline in middle-aged and older adults. We hypothesize that higher arterial stiffness will predict a steeper age-related decline in cognitive function. (2) Examine ePWV as a predictor of the transition from MCI to dementia in middle-aged and older adults. We hypothesize higher arterial stiffness will be associated with a higher risk of transitioning from MCI to having dementia.
Priority Research Areas: Cognitive Aging and the Demography of Dementia, Health Trends and Disparities
2021. Scott Landes . Comparing Alzheimer’s Related Mortality Among People with and without Down Syndrome.
Background and Significance. Over the past 50 years, the age of death for people with Down syndrome in the Unites States has improved markedly, from an average age at death of 25 in 1983, to 49 in 1997, to 56 in 2017 [39,40]. The increase in longevity for this population is typically ascribed to improvements in early intervention efforts, as well as social supports and medical care for people that often coincided with a transition away from institutional and toward community-based supports [41,42]. With the advent of people with Down syndrome now living into and beyond their 40s, research has documented high rates of early onset Alzheimer’s disease among this population, with some researchers claiming that a majority of individual’s with Down syndrome exhibit neuropathological characteristics of Alzheimer’s disease by age 40 [43-47].
Three studies utilize US death certificate data to document that adults with Down syndrome have higher rates of death from Alzheimer’s disease and or dementia that adults in the general population [40,48,49], with the most recent reporting adults with Down syndrome were 25 times more likely to die from these diseases . While informative, there are limitations to this research that need to be addressed. The first is that all three studies rely on analysis of the underlying cause of death, as opposed to conducting broader analysis of multiple cause of death. Thus, while they accurately identify that people with Down syndrome were more likely to have Alzheimer’s/dementia identified as their underlying cause of death, they do not address whether people with Down syndrome were more/less likely to have been diagnosed with Alzheimer’s disease by their time of death. This is an important distinction. As people with Alzheimer’s disease can die from various other diseases , focusing solely on the underlying cause of death leads to underestimates of the prevalence of this disease at time of death that may vary between people with/without Down syndrome. In comparison, utilizing multiple cause of death files, which provide information on comorbidities present at the time of death, would provide a more accurate accounting of the prevalence of Alzheimer’s disease among both populations at the time of death. In addition, analysis of multiple cause of death files would allow for examination of whether causes of death are similar or different among people with and without Down syndrome who have Alzheimer’s disease, an important research question that has not been addressed to date.
Specific Aims. This project has two aims: (1) to analyze differences in the prevalence of Alzheimer’s disease among people with and without Down syndrome at the time of death; and (2) to document causes of death among people with and without Down syndrome who had Alzheimer’s disease reported on their death certificate.
Priority Research Areas: Cognitive Aging and the Demography of Dementia, Health and aging of specific populations
2020. Adriana Reyes. Health Shocks and Changes in Spatial Proximity between Parents and Children.
Background: Over half of caregivers who provide substantial help to older adults are adult children . However, family caregiving is facilitated by relatively close geographic proximity, especially because children provide an average of 77 hours of assistance a month . Living near children enables a wide range of support, and therefore older adults may migrate to be closer to children in response to or in anticipation of health declines . Previous research has found that when adult children move, they are more likely to choose locations close to their parents compared to other locations, especially when parents are very old . Similarly, elderly adults’ migration patterns are motivated by a desire for close geographic proximity to their children . Recent estimates suggest that a majority of parents and children live near each other, especially those with fewer socioeconomic resources . Yet, the number of older adults without an adult child nearby is projected to increase dramatically over the next two decades . As many rural areas experience an out-migration of young people and declining economic opportunities, the ability of older adults to rely on children for caregiving may be compromised in these areas. We know that children play a significant role in caring for their aging parents; however, we know less about how health shocks associated with Alzheimer’s disease and other conditions may alter the geographic location of children and parents. Building on this context, this project will pursue two specific aims:
Aim 1: Construct a panel dataset of spatial proximity between parents and their adult children. The data will document, at each wave, the distance between parents and their adult children and changes across waves.
Aim 2: Identify the correlates of changes in proximity and co-residence. The project will examine how changes in proximity evolve relative to changes in health, such as an Alzheimer’s diagnosis.
Priority Research Areas: Determinants of Health, Well-Being and Longevity, Family and Intergenerational Dynamics
2020. Emily Wiemers. The Consequences of Disabilities in Late Middle Age for Consumption Well-Being.
Background: This project will use the rich data in the Panel Study of Income Dynamics (PSID) to examine the consequences of disability in late middle age for economic well-being using consumption-based measures (e.g., food, housing, services) rather than income-based measures. It will exploit the long health histories in the PSID to examine whether declines in consumption at the time an adult becomes disabled are predicted by or mediated by reports of poor health earlier in life, particularly in childhood. The project will address two specific aims:
Aim 1: Examine the impact of the onset of work-limiting disabilities in late middle age on health, non-durable, and non-health service consumption, focusing on spousal labor supply and wealth as sources of smoothing consumption. This aim will recognize that, for married people, there is a tension between providing care to a disabled spouse and increasing labor supply to smooth consumption after the onset of a spouse’s disability.
Aim 2: Examine whether adverse childhood health conditions explain declines in consumption for those experiencing a work-limiting disability in late middle age. Individuals with poor health in childhood may save to insure their consumption against expected future adverse health shocks. Alternatively, they may be unable to self-insure because poor health in childhood limits earnings. Adverse childhood health conditions may also predict the severity of disabilities later in life, even in the absence of insurance effects.
Priority Research Areas: Family and Intergenerational Dynamics, Disability, Health Care and Long-Term Care
2020. Pinka Chatterji. 3. Medicare Part D and Disparities in Chronic Disease among the U.S. Elderly Population .
Background: Health insurance may be a key factor underlying disparities in chronic disease among the U.S. elderly population. Notably, a study that used data from 1999 to 2006 found that racial/ethnic disparities in control of blood pressure and diabetes become smaller after age 65, suggesting that Medicare reduces disparities in chronic disease . Medicare introduced optional prescription drug coverage in 2006 (Part D). The introduction of Part D may have made Medicare an even more important factor in remediating disparities given the important role of prescription drugs in controlling chronic disease. Prior work suggests that there are racial/ethnic differences in medication adherence for chronic diseases [14, 15], and Part D has increased medication usage overall among the elderly population [16, 17]. To our knowledge, however, no studies have investigated the potentially strong effects of Part D on older adults’ awareness and control of chronic disease, or the effects of Part D on racial/ethnic and education-related disparities in chronic disease. The project will address two specific aims:
Aim 1: Test whether the introduction of Medicare Part D affected disparities in awareness and control of hypertension, diabetes, and hyperlipidemia using national data sets that include biomarkers.
Aim 2: Test whether Part D affected disparities in prescription drug use and out-of-pocket spending on drugs among elderly individuals with chronic diseases.
Priority Research Areas: Determinants of Health, Well-Being and Longevity, Effects of Policy and Place on Health
2020. Shannon Monnat. Demographic, Geographic, and Temporal Trends in Co-Occurring Use Disorders and Mortality from Opioids, Other Drugs, and Alcohol among Middle-Age and Older Adults in the United States.
Background: Opioid use disorders (OUD) and overdose death rates have grown to unprecedented levels [18, 19]. The U.S. has also experienced large increases in cocaine, methamphetamine, and non-opioid prescription (especially benzodiazepines) overdoses over the past decade. Deaths from alcohol use and use disorders (AUD) are also rising, especially among older adults, women, and low-SES individuals [20, 21]. These crises are costly, getting worse, and interdependent. Excessive alcohol use is common among individuals who misuse opioids , with more than half of individuals with OUD also meeting criteria for AUD ; more than half of opioid-related deaths involve alcohol or another drug . Use disorders and overdose rates are also geographically patterned [25, 26]. Moreover, while drug and alcohol mortality rates have increased across many demographic groups over the past 20 years, increases in the middle-age cohort (35-64 years) have been startling. Thus, we focus on the relationship between drug- and alcohol- use disorders and between drug- and alcohol- related mortality among middle-aged and older adults. The specific aims of this two-year study are to:
Aim 2: Identify typologies of counties based on use disorders and mortality from opioids, other drugs, and alcohol.
Aim 3: Compare the county groups found in Aim 2 by sociodemographic, economic, and other characteristics.
Priority Research Areas: Health Trends and Disparities, Effects of Policy and Place on Health
Center Administrator/Media Contact: Kathy Forrest