@article {12012, title = {Examining variation in state spending on medicaid long-term services and supports for older adults.}, journal = {Home Health Care Services Quarterly}, volume = {41}, year = {2022}, pages = {54-64}, abstract = {

State Medicaid programs are the largest source of funding for long-term services and supports (LTSS). We characterized states across quartiles of mean LTSS spending for individuals >=65 and used the Health and Retirement Study to examine the demographic, functional, and caregiving characteristics across these quartiles. Individuals in states with lower Medicaid spending on LTSS reported more family and friend caregiving hours and were more likely to be from racial and ethnic minority groups. Continued work is needed to improve Medicaid LTSS policy to better support vulnerable populations, particularly in lower quartile states.

}, keywords = {long-term services and support, Medicaid}, issn = {1545-0856}, doi = {10.1080/01621424.2021.2004286}, author = {Mellgard, George and Claire K. Ankuda and Rahman, Omari-Khalid and Amy Kelley} } @article {11594, title = {A national profile of kinlessness at the end of life among older adults: Findings from the Health and Retirement Study.}, journal = {Journal of the American Geriatric Society}, volume = {69}, year = {2021}, pages = {2143-2151}, abstract = {

BACKGROUND/OBJECTIVES: The majority of end-of-life (EOL) caregiving is provided by unpaid family members. An increasing number of older adults are kinless (without close family/partnerships) and may have insufficient caregiver support to remain at home at the EOL. We therefore determined what proportion of older adults are kinless at the EOL and assessed the association of kinlessness with EOL care.

DESIGN: Retrospective analysis of Health and Retirement Study decedents, 2002-2015.

SETTING: US population-based sample.

PARTICIPANTS: Decedents age 51+ who died within 1 year of interview (n = 3844) and subset who are community-dwelling at last interview.

MEASUREMENTS: Kinlessness was defined as lacking a spouse/partner and children. Primary outcome measure was location of death. Secondary outcome measures included contextual EOL measures such as symptom burden and caregiver support.

RESULTS: A total of 7.4\% of decedents were kinless at the EOL. Kinless decedents were more likely to be female, nonwhite, enrolled in Medicaid, living alone, or living in a nursing home prior to death. Although community-dwelling kinless decedents received fewer hours of caregiving per week at the EOL (34.7 vs. 56.2, p < 0.05) and were more likely to die in nursing homes (18.1\% vs. 10.3\%, p < 0.05) than those with kin, they did not have higher EOL symptom burden or treatment intensity (e.g., intensive care unit use). In multinomial logistic analysis controlling for demographic and illness characteristics, kinless decedents living in the community before death had a twofold increased risk of dying in the nursing home (odds ratio [OR] = 2.02 [95\% confidence interval (CI) = 1.09-3.72]) and a trend toward increased risk of hospital death (OR = 1.60 [95\% CI = 0.96-2.69]) versus home setting.

CONCLUSIONS: Kinless individuals are more likely to die in nursing homes, even if they are living in the community in their last year of life. Expanded long-term care services and policies are needed to enable all older adults regardless of their family support systems to receive high-quality EOL care.

}, keywords = {Caregiving, end of life, Families, kinlessness, location of death}, issn = {1532-5415}, doi = {10.1111/jgs.17171}, author = {Natalie Plick and Claire K. Ankuda and Christine A Mair and Husain, Mohammed and Katherine A Ornstein} } @article {11649, title = {Patterns of Material Hardship and Food Insecurity Among Older Adults During the COVID-19 Pandemic.}, journal = {Journal of General Internal Medicine}, volume = {36}, year = {2021}, pages = {3639-3641}, abstract = {The coronavirus (COVID-19) pandemic has major economic consequences across the USA.1 Along with heightened risk for severe COVID-19,2 older adults have less digital access which may be a barrier to mobilizing supports including grocery delivery.3,4 While people with lower incomes and from racial and ethnic minoritized groups have faced high levels of material hardship due to COVID-19,1 little is known about the experience of older adults. We aim to assess the prevalence and risk factors for material hardship and food insecurity among older adults in the USA.}, keywords = {COVID-19, Food insecurity, material hardship, race}, issn = {1525-1497}, doi = {10.1007/s11606-021-06905-3}, author = {Claire K. Ankuda and Fogel, Joyce and Amy Kelley and Byhoff, Elena} } @article {10002, title = {Caregiving, recovery, and death after incident ADL/IADL disability among older adults in the United States}, journal = {Journal of Applied Gerontology}, volume = {39}, year = {2020}, type = {Journal}, abstract = {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.}, keywords = {Activities of Daily Living, Caregiving, Disabilities}, issn = {0733-4648}, doi = {10.1177/0733464819826842}, url = {https://journals.sagepub.com/doi/10.1177/0733464819826842}, author = {Claire K. Ankuda and Deborah A Levine and Kenneth M. Langa and Katherine A Ornstein and Amy Kelley} } @article {11293, title = {Kinlessness at the End of Life in the United States: Implications for Place of Death, and Quality of Life Among Older Adults}, journal = {Innovation in Aging}, volume = {4}, year = {2020}, pages = {604 }, abstract = {We used the Health and Retirement Study, a large nationally representative study of U.S. older adults from 2002-2015, to identify decedents and assess quality of EOL care by availability of kin. 7.9\% of participants were kinless at EOL (no adult children or spouses), reflecting national estimates of 1,027,600 older adults. Those who were kinless at EOL were more likely to be female (61.2\% vs 51.5\%), from the lowest wealth quartile (53.6\% vs 35.6\%), and less likely to be white and non-Hispanic (75.6\% vs 81.8\%). Among the community-dwelling population, individuals with kin received 2.4 times as much hours of help from informal caregivers per month, compared to those without kin. We did not observe differences in rates of hospital death by kin status in adjusted models. More work is needed to assess any unmet needs in the EOL period for kinless older adults, especially as healthcare moves towards increased in-home supports.}, keywords = {end of life, kinless}, isbn = {2399-5300}, doi = {https://doi.org/10.1093/geroni/igaa057.2037}, author = {Katherine A Ornstein and Natalie Plick and Claire K. Ankuda} } @article {10557, title = {Lifetime History of Traumatic Brain Injury is Associated with Increased Loneliness in Adults: A U.S. Nationally Representative Study}, journal = {International Journal of Geriatric Psychiatry}, volume = {35}, year = {2020}, pages = {553-563}, abstract = {Background/Objectives: An estimated 55 million individuals worldwide live with chronic disability associated with Traumatic Brain Injury (TBI) which may include cognitive, behavioral and social impairments. Reduced participation in social activities is common after TBI, however few studies have evaluated loneliness among survivors of TBI. The current study aimed to evaluate the association between history of TBI and loneliness, and to identify mediators of this association. Methods/Design: Retrospective cohort study. Nationally representative sample of N=724 adults over age 50 (Health and Retirement Study). Loneliness was evaluated using the 11-item Revised UCLA (R-UCLA) Loneliness Scale (range 11-33). Lifetime history of TBI evaluated retrospectively using the Ohio State University TBI Identification Method. We included the following covariates: age, sex, race, education; and mediators: depressive symptoms, number of comorbidities, chronic pain, difficulty with activities of daily living, and social network index. Results: History of TBI was associated with a 1.28 point (95\% CI: 0.46, 2.11, p<0.05; Cohen{\textquoteright}s D=0.284) increase in R-UCLA loneliness scale scores, after covariate adjustment. Individuals with more recent injuries (within 10 years) and multiple lifetime TBIs reported the highest loneliness scores. In the structural equation model, depressive symptoms and comorbidity burden partially mediated the relationship between TBI and loneliness. All models were adjusted for United States (U.S.) population sampling weights. Conclusions: History of TBI was associated with greater loneliness compared to individuals without TBI in a representative sample of U.S. adults. Managing depressive symptoms and medical consequences of TBI may be a target to ameliorate reporting of loneliness in this population. This article is protected by copyright. All rights reserved.}, keywords = {Loneliness, Older Adults, Traumatic Brain Injury}, doi = {10.1002/gps.5271}, author = {Raj G. Kumar and Katherine A Ornstein and Bollens-Lund, Evan and Watson, Eric M. and Claire K. Ankuda and Amy Kelley and Dams-O{\textquoteright}Connor, Kristen} } @article {doi:10.1111/jgs.16197, title = {The Epidemiology of Depressive Symptoms in the Last Year of Life}, journal = {Journal of the American Geriatrics Society}, volume = {n/a}, year = {2019}, abstract = {BACKGROUND/OBJECTIVE Depression impacts quality of life at all life stages, but the epidemiology of depression in the last year of life is unknown. This study{\textquoteright}s objectives were to document the epidemiology of depressive symptoms in the year prior to death and to assess how the trajectory of depressive symptoms varies by sociodemographic and clinical factors. DESIGN Observational, cross-sectional, cohort study using the Health and Retirement Study. SETTING Population-based survey. PARTICIPANTS A total of 3274 individuals who died within 12 months after assessment. MEASURES Primary outcome: eight-item Center for Epidemiologic Studies Depression Scale (CESD-8). Covariates included sociodemographics, self-reported illnesses, and activity of daily living (ADL) limitations. RESULTS Average CESD-8 score increased over the last year of life, with 59.3\% screening positive for depression in the last month before death. Depression symptoms increased gradually from 12 to 4 months before death (increase of 0.05 points/month; 95\% confidence interval [CI] = 0.01-0.08 points/month) and then escalated from 4 to 1 months before death (increase of 0.29 points/month; 95\% CI = 0.16-0.39 points/month). Women, younger adults, and nonwhite adults all demonstrated higher rates of depressive symptoms. Individuals with cancer reported escalating rates of depressive symptoms at the end of life, while individuals with lung disease and ADL impairment demonstrated persistently high rates throughout the year before death. CONCLUSIONS This study revealed high rates of depressive symptoms in the last year of life as well as differences in the burden of depressive symptoms. A public health approach must be taken to screen for and appropriately treat symptoms of depression across the lifespan.}, keywords = {depression, end of lifemental health}, doi = {10.1111/jgs.16197}, url = {https://onlinelibrary.wiley.com/doi/abs/10.1111/jgs.16197}, author = {Kozlov, Elissa and Dong, XinQi and Amy Kelley and Claire K. Ankuda} } @article {9809, title = {Association Between Purpose in Life and Glucose Control Among Older Adults.}, journal = {Annals of Behavioral Medicine}, volume = {52}, year = {2018}, pages = {309-318}, abstract = {

Background: Greater purpose in life is associated with lower rates of certain chronic diseases. Whether purpose in life can protect against development of prediabetes or type 2 diabetes is unknown.

Purpose: To examine the association between purpose in life and blood glucose control among adults >=50 years.

Methods: We conducted a longitudinal cohort study of 3,907 participants of the Health and Retirement Study who at baseline did not have type 2 diabetes or prediabetes. Baseline purpose in life was measured using the Ryff and Keyes{\textquoteright} Scales of Psychological Well-Being and grouped into tertiles (high, medium, and low). We used multivariable linear regression to examine the association between baseline purpose in life and HbA1c over 4 years. Multivariable logistic regression was used to examine the association between baseline purpose and incident prediabetes or type 2 diabetes over the same period.

Results: After adjusting for sociodemographic factors, body mass index, physical activity, and physical and mental health factors, HbA1c was 0.07 percentage points lower among participants with high purpose than those with low purpose (95\% confidence interval [CI] -0.12 to -0.02; p = .011). Participants with high purpose had lower odds of developing prediabetes or type 2 diabetes than those with low purpose (adjusted odds ratio 0.78; 95\% CI 0.62 to 0.98; p = .037).

Conclusions: Among older adults, greater purpose in life is associated with a lower incidence of prediabetes or type 2 diabetes. Strategies to promote greater purpose in life should be tested as a part of type 2 diabetes prevention efforts.

}, keywords = {Biomarkers, Diabetes, Glutamic Acid, Purpose in life}, issn = {1532-4796}, doi = {10.1093/abm/kax012}, author = {Hafez, Dina and Michele M Heisler and Choi, Hwajung and Claire K. Ankuda and Winkelman, Tyler and Jeffrey T Kullgren} } @article {9280, title = {Association between spousal caregiver well-being and care recipient healthcare expenditures}, journal = {Journal of the American Geriatrics Society}, volume = {65}, year = {2017}, pages = {2220-2226}, abstract = {Objectives To measure the association between spousal depression, general health, fatigue and sleep, and future care recipient healthcare expenditures and emergency department (ED) use. Design Prospective cohort study. Setting Health and Retirement Study. Participants Home-dwelling spousal dyads in which one individual (care recipient) was aged 65 and older and had one or more activity of daily living or instrumental activity of daily living disabilities and was enrolled in Medicare Part B (N = 3,101). Exposure Caregiver sleep (Jenkins Sleep Scale), depressive symptoms (Center for Epidemiologic Studies Depression-8 Scale), and self-reported general health measures. Measurements Primary outcome was care recipient Medicare expenditures. Secondary outcome was care recipient ED use. Follow-up was 6 months. Results Caregiver depressive symptoms score and six of 17 caregiver well-being measures were prospectively associated with higher care recipient expenditures after minimal adjustment (P < .05). Higher care recipient expenditures remained significantly associated with caregiver fatigue (cost increase, $1,937, 95\% confidence interval (CI) = $770{\textendash}3,105) and caregiver sadness (cost increase, $1,323, 95\% CI = $228{\textendash}2,419) after full adjustment. Four of 17 caregiver well-being measures, including severe fatigue, were significantly associated with care recipient ED use after minimal adjustment (P < .05). Greater odds of care recipient ED use remained significantly associated with caregiver fatigue (odds ratio (OR) = 1.24, 95\% CI = 1.01{\textendash}1.52) and caregiver fair to poor health (OR = 1.23, 95\% CI = 1.04{\textendash}1.45) after full adjustment. Caregiver total sleep score was not associated with care recipient outcomes. Conclusion Poor caregiver well-being, particularly severe fatigue, is independently and prospectively associated with higher care recipient Medicare expenditures and ED use.}, keywords = {Caregiving, Marriage, Medical Expenses, Medicare/Medicaid/Health Insurance, Well-being}, doi = {10.1111/jgs.15039}, url = {http://doi.wiley.com/10.1111/jgs.15039http://onlinelibrary.wiley.com/wol1/doi/10.1111/jgs.15039/fullpdfhttps://api.wiley.com/onlinelibrary/tdm/v1/articles/10.1111\%2Fjgs.15039}, author = {Claire K. Ankuda and Donovan T Maust and Mohammed U Kabeto and Ryan J McCammon and Kenneth M. Langa and Deborah A Levine} }