@article {11156, title = {Factor structure of the Harmonized Cognitive Assessment Protocol neuropsychological battery in the Health and Retirement Study}, journal = {Neuropsychology}, year = {Forthcoming}, abstract = {Objectives: The Harmonized Cognitive Assessment Protocol (HCAP) describes an assessment battery and a family of population-representative studies measuring neuropsychological performance. We describe the factorial structure of the HCAP battery in the US Health and Retirement Study (HRS).Method: The HCAP battery was compiled from existing measures by a cross-disciplinary and international panel of researchers. The HCAP battery used in the 2016 wave of the HRS. We used factor analysis methods to assess and refine a theoretically-driven single and multiple domain factor structure for tests included in the HCAP battery among 3,347 participants with evaluable performance data. Results: For the eight domains of cognitive functioning identified theoretically (orientation, memory [immediate, delayed, \& recognition], set shifting, attention/speed, language/fluency, andvisuospatial), all single factor models fit reasonably well, although four of these domains had either 2 or 3 indicators where good fit is axiomatic. Multidimensional models suggested the eight-domain model was overly complex. A five-domain model (orientation, memory delayed and recognition, executive functioning, language/fluency, visuospatial) was identified as a reasonable model for summarizing performance in this sample (standardized root mean square residual = 0.05, root mean square error of approximation = 0.05, confirmatory fit index = 0.94). Discussion: The HCAP battery conforms adequately to a multidimensional structure of neuropsychological performance. The derived measurement models can be used as anchors for calibrating cross-national studies of cognitive performance, and to identify persons performing atthe low end as part of an algorithmic classification of probable dementia}, keywords = {Cognitive Ability, Confirmatory Factor Analysis, HCAP, Older Adults}, doi = {10.31234/osf.io/rvmhj}, author = {Richard N Jones and Jennifer J Manly and Kenneth M. Langa and Lindsay H Ryan and Deborah A Levine and Ryan J McCammon and David R Weir} } @article {13526, title = {Harmonization of Later-Life Cognitive Function Across National Contexts: Results from the Harmonized Cognitive Assessment Protocols (HCAPs).}, journal = {medRxiv}, year = {Forthcoming}, abstract = {

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{\textperiodcentered}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).

}, keywords = {Cognition, Education, harmonization, HCAP}, doi = {10.1101/2023.06.09.23291217}, author = {Gross, Alden L and LI, CHIHUA and Brice{\~n}o, Emily M and Renter{\'\i}a, Miguel Arce and Richard N Jones and Kenneth M. Langa and Jennifer J Manly and Nichols, Emma L and David R Weir and Wong, Rebeca and Berkman, Lisa and Lee, Jinkook and Lindsay C Kobayashi} } @article {13557, title = {Loneliness and Depressive Symptoms Are High Among Older Adults With Digestive Disease and Associated With Lower Perceived Health.}, journal = {Clin Gastroenterol Hepatol}, year = {Forthcoming}, abstract = {

BACKGROUND \& AIMS: Current approaches to managing digestive disease in older adults fail to consider the psychosocial factors contributing to a person{\textquoteright}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.

}, keywords = {Epidemiology, General Practice, Outcomes Research, Psychiatric Disorders}, issn = {1542-7714}, doi = {10.1016/j.cgh.2023.08.027}, author = {Cohen-Mekelburg, Shirley and Jordan, Ariel and Kenney, Brooke and Burgess, Helen J and Chang, Joy W and Hu, Hsou Mei and Tapper, Elliot and Kenneth M. Langa and Levine, Deborah A and Waljee, Akbar K} } @article {12945, title = {Association Between Loneliness and Postoperative Mortality Among Medicare Beneficiaries.}, journal = {JAMA Surgery}, volume = {158}, year = {2023}, pages = {212-214}, keywords = {Loneliness, Medicare}, issn = {2168-6262}, doi = {10.1001/jamasurg.2022.4784}, author = {Shen, Mary R and Suwanabol, Pasithorn A and Howard, Ryan A and Hu, Hsou Mei and Levine, Deborah A and Kenneth M. Langa and Waljee, Jennifer F} } @article {13650, title = {Association of cumulative loneliness with all-cause mortality among middle-aged and older adults in the United States, 1996 to 2019.}, journal = {PNAS}, volume = {120}, year = {2023}, pages = {e2306819120}, abstract = {

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.

}, keywords = {cumulative loneliness, excess death, Mortality}, issn = {1091-6490}, doi = {10.1073/pnas.2306819120}, author = {Yu, Xuexin and Cho, Tsai-Chin and Westrick, Ashly C and Chen, Chen and Kenneth M. Langa and Lindsay C Kobayashi} } @article {12939, title = {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.}, journal = {Preventive Medicine Reports}, volume = {31}, year = {2023}, pages = {102083}, abstract = {

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.

}, keywords = {alcohol use, Cancer survivorship, Functional aging, Health behaviors, Physical activity, Smoking}, issn = {2211-3355}, doi = {10.1016/j.pmedr.2022.102083}, author = {Westrick, Ashly C and Kenneth M. Langa and Lindsay C Kobayashi} } @article {13452, title = {Comparison of Particulate Air Pollution From Different Emission Sources and Incident Dementia in the US.}, journal = {JAMA Intern Med}, year = {2023}, abstract = {

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.

}, issn = {2168-6114}, doi = {10.1001/jamainternmed.2023.3300}, author = {Zhang, Boya and Weuve, Jennifer and Kenneth M. Langa and D{\textquoteright}Souza, Jennifer and Szpiro, Adam and Jessica Faul and Mendes de Leon, Carlos and Gao, Jiaqi and Kaufman, Joel D and Sheppard, Lianne and Lee, Jinkook and Lindsay C Kobayashi and Hirth, Richard and Adar, Sara D} } @article {12477, title = {A cultural neuropsychological approach to harmonization of cognitive data across culturally and linguistically diverse older adult populations.}, journal = {Neuropsychology}, volume = {37}, year = {2023}, pages = {247-257}, abstract = {

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).

}, keywords = {cognitive data, HCAP, Mex-Cog, neuropsychology}, issn = {1931-1559}, doi = {10.1037/neu0000816}, author = {Brice{\~n}o, Emily M and Arce Renter{\'\i}a, Miguel and Gross, Alden L and Richard N Jones and Gonzalez, Christopher and Wong, Rebeca and David R Weir and Kenneth M. Langa and Jennifer J Manly} } @article {13588, title = {Decision Making for Patients With Severe Dementia Versus Normal Cognition Near the End of Life.}, journal = {Innovation in Aging}, volume = {7}, year = {2023}, pages = {igad081}, abstract = {

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.

}, keywords = {Advance care planning, cognitive impairment, family caregivers}, issn = {2399-5300}, doi = {10.1093/geroni/igad081}, author = {Nicholas, Lauren Hersch and Halpern, Scott D and David R Weir and Baum, Micah Y and Nolan, Marie and Gallo, Joseph and Kenneth M. Langa} } @article {12271, title = {Functional aging trajectories of older cancer survivors: A latent growth analysis of the US Health and Retirement Study.}, journal = {Journal of Cancer Survivorship}, volume = {17}, year = {2023}, pages = {1499-1509}, abstract = {

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.

}, keywords = {Activities for daily living, Aging, Cancer, Memory}, issn = {1932-2267}, doi = {10.1007/s11764-022-01185-0}, author = {Westrick, Ashly C and Kenneth M. Langa and Eastman, Marisa and Ospina-Romero, Monica and Mullins, Megan A and Lindsay C Kobayashi} } @article {13546, title = {Hypertension and Stroke as Mediators of Air Pollution Exposure and Incident Dementia.}, journal = {JAMA Network Open}, volume = {6}, year = {2023}, pages = {e2333470}, abstract = {

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{\textquoteright}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.

}, keywords = {Air Pollution, Dementia, Hypertension, Particulate Matter, Stroke}, issn = {2574-3805}, doi = {10.1001/jamanetworkopen.2023.33470}, author = {Zhang, Boya and Kenneth M. Langa and Weuve, Jennifer and D{\textquoteright}Souza, Jennifer and Szpiro, Adam and Jessica Faul and Mendes de Leon, Carlos and Kaufman, Joel D and Lisabeth, Lynda and Hirth, Richard A and Adar, Sara D} } @article {11464, title = {The Influence of Cognitive Impairment on Post-Operative Outcomes.}, journal = {Annals of Surgery}, volume = {277}, year = {2023}, pages = {e212-e217}, abstract = {

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.

}, keywords = {cognition impairment, Postoperative Period}, issn = {1528-1140}, doi = {10.1097/SLA.0000000000004799}, author = {Blair, Emilie M and Deborah A Levine and Hu, Hsou Mei and Kenneth M. Langa and Mohammed U Kabeto and Waljee, Jennifer} } @article {13533, title = {Memory and language cognitive data harmonization across the United States and Mexico.}, journal = {Alzheimer{\textquoteright}s \& Dementia (Amsterdam, Netherlands)}, volume = {15}, year = {2023}, pages = {e12478}, abstract = {

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{\textquoteright}s disease and related dementias.

}, keywords = {Alzheimer{\textquoteright}s disease, cognitive aging, cross-cultural, cultural neuropsychology, harmonization}, issn = {2352-8729}, doi = {10.1002/dad2.12478}, author = {Arce Renter{\'\i}a, Miguel and Brice{\~n}o, Emily M and Chen, Diefei and Saenz, Joseph and Lindsay C Kobayashi and Gonzalez, Christopher and Vonk, Jet M J and Richard N Jones and Jennifer J Manly and Wong, Rebeca and David R Weir and Kenneth M. Langa and Gross, Alden L} } @article {13331, title = {The mode effect of web-based surveying on the 2018 HRS measure of cognitive functioning.}, journal = {J Gerontol B Psychol Sci Soc Sci}, year = {2023}, abstract = {

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.

}, issn = {1758-5368}, doi = {10.1093/geronb/gbad068}, author = {Domingue, Benjamin W and McCammon, Ryan and Brady T. West and Kenneth M. Langa and David R Weir and Jessica Faul} } @article {12358, title = {Addition of Vision Impairment to a Life-Course Model of Potentially Modifiable Dementia Risk Factors in the US.}, journal = {JAMA Neurology}, volume = {79}, year = {2022}, pages = {623-626}, abstract = {

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{\textquoteright}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{\textquoteright}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.

}, keywords = {dementia risk, life-course model, vision impairment}, issn = {2168-6157}, doi = {10.1001/jamaneurol.2022.0723}, author = {Ehrlich, Joshua R and Goldstein, Jenna and Swenor, Bonnie K and Whitson, Heather and Kenneth M. Langa and Veliz, Phillip} } @article {12711, title = {Development and External Validation of a Mortality Prediction Model for Community-Dwelling Older Adults With Dementia.}, journal = {JAMA Internal Medicine}, volume = {182}, year = {2022}, pages = {1161-1170}, abstract = {

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.

}, keywords = {community dwelling, Dementia, mortality risk}, issn = {2168-6114}, doi = {10.1001/jamainternmed.2022.4326}, author = {Deardorff, W James and Barnes, Deborah E and Jeon, Sun Y and Boscardin, W John and Kenneth M. Langa and Covinsky, Kenneth E and Mitchell, Susan L and Whitlock, Elizabeth L and Smith, Alexander K and Lee, Sei J} } @article {10.1001/jamaneurol.2022.3543, title = {Estimating the Prevalence of Dementia and Mild Cognitive Impairment in the US: The 2016 Health and Retirement Study Harmonized Cognitive Assessment Protocol Project}, journal = {JAMA Neurology}, volume = {79}, year = {2022}, pages = {1242-1249}, abstract = {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.}, keywords = {Dementia, HCAP, mild cognitive impairment}, issn = {2168-6149}, doi = {10.1001/jamaneurol.2022.3543}, author = {Jennifer J Manly and Richard N Jones and Kenneth M. Langa and Ryan, Lindsay H. and Levine, Deborah A. and McCammon, Ryan and Heeringa, Steven G. and David R Weir} } @article {13505, title = {Interactions between the apolipoprotein E4 gene and modifiable risk factors for cognitive impairment: a nationally representative panel study.}, journal = {BMC Geriatrics}, volume = {22}, year = {2022}, pages = {938}, abstract = {

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.

}, keywords = {Apolipoprotein E4, Cognitive Dysfunction, Dementia, Risk Factors}, issn = {1471-2318}, doi = {10.1186/s12877-022-03652-w}, author = {Kolli, Ajay and Zhou, Yunshu and Chung, Grace and Ware, Erin B and Kenneth M. Langa and Ehrlich, Joshua R} } @article {12989, title = {MODE EFFECTS ON COGNITIVE FUNCTIONING ASSESSMENTS IN THE HEALTH AND RETIREMENT STUDY}, journal = {Innovation in Aging}, volume = {6}, year = {2022}, pages = {163}, abstract = {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.}, keywords = {Cognition, cognitive functioning assessments}, doi = {10.1093/geroni/igac059.652}, author = {Jessica Faul and Domingue, Ben and Stenhaug, Ben and Brady T. West and Kenneth M. Langa and David R Weir} } @conference {11822, title = {Associations of Long-term Air Pollution Exposure and Incident Late-Life Disability in Older U.S. Adults: The Health Retirement Study}, booktitle = {ISEE Conference Abstracts}, volume = {2021}, year = {2021}, abstract = {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 {\textmu}g/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.}, keywords = {Activities of Daily Living, Air Pollution, Long-Term Exposure}, url = {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}, author = {Gao, Jiaqi and Carlos F. Mendes de Leon and D{\textquoteright}Souza, Jennifer and Zhang, Boya and Szpiro, Adam and Young, Michael and Weuve, Jennifer and Kenneth M. Langa and Jessica Faul and Kaufman, Joel and Richard A Hirth and Sara Dubowsky Adar} } @article {11490, title = {Cumulative Genetic Risk and APOE ε4 Are Independently Associated With Dementia Status in a Multiethnic, Population-Based Cohort}, journal = {Neurology Genetics}, volume = {7}, year = {2021}, pages = {e576}, abstract = {

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.

}, keywords = {Aging, Alzheimer disease, Cognition, genetic risk}, issn = {2376-7839}, doi = {10.1212/NXG.0000000000000576}, author = {Kelly M Bakulski and Vadari, Harita S and Jessica Faul and Steven G Heeringa and Sharon L R Kardia and Kenneth M. Langa and Jennifer A. Smith and Jennifer J Manly and Colter Mitchell and Benke, Kelly S and Erin B Ware} } @article {12598, title = {Development, Validation, and Performance of a New Physical Functioning-Weighted Multimorbidity Index for Use in Administrative Data.}, journal = {Journal of General Internal Medicine}, volume = {36}, year = {2021}, pages = {2427-2433}, keywords = {Activities of Daily Living, multimorbidity}, issn = {1525-1497}, doi = {10.1007/s11606-020-06486-7}, author = {Wei, Melissa Y and Luster, Jamie E and Ratz, David and Mukamal, Kenneth J and Kenneth M. Langa} } @article {11817, title = {Development, Validation, and Performance of a New Physical Functioning{\textendash}Weighted Multimorbidity Index for Use in Administrative Data}, journal = {Journal of General Internal Medicine}, volume = {36}, year = {2021}, pages = {2427{\textendash}2433}, keywords = {Medicaid, Medicare, multimorbidity index, physical functioning}, doi = {10.1007/s11606-020-06486-7}, author = {Melissa Y Wei and Jamie E Luster and Ratz, David and Kenneth J Mukamal and Kenneth M. Langa} } @article {11675, title = {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.}, journal = {The Journals of Gerontology: Series B }, volume = {76}, year = {2021}, pages = {S51-S63}, abstract = {

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.

}, keywords = {Cognition, Cross-national comparison, Early origins of health, Education, ELSA, Life course analysis}, issn = {1758-5368}, doi = {10.1093/geronb/gbaa138}, author = {Jessica Faul and Erin B Ware and Mohammed U Kabeto and Fisher, Jonah and Kenneth M. Langa} } @article {10355, title = {The Health and Retirement Study Harmonized Cognitive Assessment Protocol Project: Study Design and Methods}, journal = {Neuroepidemiology}, year = {2020}, month = {2019}, abstract = {Introduction: The Harmonized Cognitive Assessment Protocol (HCAP) Project is a substudy within the Health and Retirement Study (HRS), an ongoing nationally representative panel study of about 20,000 adults aged 51 or older in the United States. The HCAP is part of an international research collaboration funded by the National Institute on Aging to better measure and identify cognitive impairment and dementia in representative population-based samples of older adults, in the context of ongoing longitudinal studies of aging in high-, middle-, and low-income countries around the world. Methods: The HCAP cognitive test battery was designed to measure a range of key cognitive domains affected by cognitive aging (including attention, memory, executive function, language, and visuospatial function) and to allow harmonization and comparisons to other studies in the United States and around the world. The HCAP included a pair of in-person interviews, one with the target HRS respondent (a randomly selected HRS sample member, aged 65+) that lasted approximately 1 h and one with an informant nominated by the respondent that lasted approximately 20 min. The final HRS HCAP sample included 3,496 study subjects, representing a 79\% response rate among those invited to participate. Conclusion: Linking detailed HCAP cognitive assessments to the wealth of available longitudinal HRS data on cognition, health, biomarkers, genetics, health care utilization, informal care, and economic resources and behavior will provide unique and expanded opportunities to study cognitive impairment and dementia in a nationally representative US population-based sample. The fielding of similar HCAP projects in multiple countries around the world will provide additional opportunities to study international differences in the prevalence, incidence, and outcomes of dementia globally with comparable data. Like all HRS data, HCAP data are publicly available at no cost to researchers.}, keywords = {Cognition, cognitive assessment, study design}, isbn = {0251-5350}, doi = {10.1159/000503004}, author = {Kenneth M. Langa and Lindsay H Ryan and Ryan J McCammon and Richard N Jones and Jennifer J Manly and Deborah A Levine and Amanda Sonnega and Farron, M. and David R Weir} } @article {10155, title = {Multimorbidity and cognitive decline over 14 years in older Americans.}, journal = {Journals of Gerontology. Series A, Biological Sciences \& Medical Sciences}, year = {2020}, abstract = {

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.

}, keywords = {Cognitive Ability, Comorbidity, Longitudinal data}, issn = {1758-535X}, doi = {10.1093/gerona/glz147}, author = {Melissa Y Wei and Deborah A Levine and Laura B Zahodne and Mohammed U Kabeto and Kenneth M. Langa} } @article {10782, title = {The Relationship of Loneliness to End-of-Life Experience in Older Americans: A Cohort Study}, journal = {Journal of the American Geriatrics Society}, volume = {68}, year = {2020}, pages = {1064-1071}, abstract = {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{\textendash}1071, 2020}, keywords = {Advance care planning, aggressive care, end of life, Loneliness, symptoms}, doi = {10.1111/jgs.16354}, url = {https://pubmed.ncbi.nlm.nih.gov/32128789/}, author = {Nauzley C Abedini and Choi, Hwajung and Melissa Y Wei and Kenneth M. Langa and Vineet Chopra} } @article {10669, title = {The Relationship of Loneliness to End-of-Life Experience in Older Americans: A Cohort Study}, journal = {Journal of the American Geriatrics SocietyJournal of the American Geriatrics SocietyJ Am Geriatr Soc}, year = {2020}, note = {doi: 10.1111/jgs.16354}, type = {Journal}, abstract = {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.}, keywords = {Advance care planning, aggressive care, end of life, Loneliness, symptoms}, isbn = {0002-8614}, doi = {10.1111/jgs.16354}, url = {https://onlinelibrary.wiley.com/doi/abs/10.1111/jgs.16354}, author = {Nauzley C Abedini and Choi, Hwajung and Melissa Y Wei and Kenneth M. Langa and Vineet Chopra} } @article {9548, title = {Physical Functioning Decline and Mortality in Older Adults with Multimorbidity: Joint Modeling of Longitudinal and Survival Data.}, journal = {Journals of Gerontology Series A: Biological Sciences \& Medical Sciences}, volume = {74}, year = {2019}, pages = {226-232}, abstract = {

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.

}, keywords = {Comorbidity, Mortality, Physical Ability}, issn = {1758-535X}, doi = {10.1093/gerona/gly038}, author = {Melissa Y Wei and Mohammed U Kabeto and Andrzej T Galecki and Kenneth M. Langa} } @inbook {9830, title = {Cognitive Functioning of U.S. Adults by Race and Hispanic Origin}, booktitle = {Contextualizing Health and Aging in the Americas}, year = {2018}, pages = {85 - 107}, publisher = {Springer International Publishing}, organization = {Springer International Publishing}, address = {Cham}, abstract = {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{\textquoteright}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.}, keywords = {Alzheimer{\textquoteright}s disease, Cognitive Ability, Hispanics, Racial/ethnic differences}, isbn = {978-3-030-00583-2}, doi = {10.1007/978-3-030-00584-910.1007/978-3-030-00584-9_5}, url = {https://link.springer.com/chapter/10.1007/978-3-030-00584-9_5}, author = {D{\'\i}az-Venegas, Carlos and Brian Downer and Kenneth M. Langa and Rebeca Wong}, editor = {William A. Vega and Jacqueline L. Angel and Guti{\'e}rrez Robledo, Luis Miguel F. and Kyriakos S Markides} } @article {9158, title = {Multimorbidity and physical and cognitive function: performance of a new multimorbidity-weighted index.}, journal = {Journals of Gerontology Series A: Biological Sciences \& Medical Sciences}, volume = {73}, year = {2018}, pages = {225}, abstract = {

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{\textquoteright}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.

}, keywords = {Cognition \& Reasoning, Comorbidity}, issn = {1758-535X}, doi = {10.1093/gerona/glx114}, author = {Melissa Y Wei and Mohammed U Kabeto and Kenneth M. Langa and Kenneth J Mukamal} } @article {9391, title = {Secular Trends in Dementia and Cognitive Impairment of U.S. Rural and Urban Older Adults}, journal = {American Journal of Preventive Medicine}, volume = {54}, year = {2018}, pages = {164-172}, abstract = {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{\textquoteright} 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.}, keywords = {Cognitive Ability, Dementia, Religion, Rural Settings, urban life}, issn = {07493797}, doi = {10.1016/j.amepre.2017.10.021}, url = {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}, author = {Margaret M Weden and Regina A Shih and Mohammed U Kabeto and Kenneth M. Langa} } @article {8805, title = {Associations between community-level disaster exposure and individual-level changes in disability and risk of death for older Americans.}, journal = {Soc Sci Med}, volume = {173}, year = {2017}, month = {2017 01}, pages = {118-125}, abstract = {

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{\textquoteright}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 {\textquoteright}joint modelling{\textquoteright} 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.

}, keywords = {Aged, Aged, 80 and over, Cohort Studies, Community Participation, Continental Population Groups, Disabled Persons, Disaster Planning, Disasters, Female, Humans, Income, Longitudinal Studies, Male, Middle Aged, Mortality, United States}, issn = {1873-5347}, doi = {10.1016/j.socscimed.2016.12.007}, url = {https://www.sciencedirect.com/science/article/abs/pii/S0277953616306785?via\%3Dihub}, author = {Samuel L. Brilleman and Wolfe, Rory and Moreno-Betancur, Margarita and Anne E Sales and Kenneth M. Langa and Yun Li and Elizabeth L. Daugher Biddison and Rubinson, Lewis and Theodore J Iwashyna} } @article {8813, title = {A Comparison of the Prevalence of Dementia in the United States in 2000 and 2012.}, journal = {JAMA Intern Med}, volume = {177}, year = {2017}, month = {2017 01 01}, pages = {51-58}, abstract = {

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.

}, keywords = {Aged, Dementia, Female, Humans, Male, Prevalence, Risk Factors, United States}, issn = {2168-6114}, doi = {10.1001/jamainternmed.2016.6807}, url = {http://archinte.jamanetwork.com/article.aspx?doi=10.1001/jamainternmed.2016.6807http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2587084}, author = {Kenneth M. Langa and Eric B Larson and Eileen M. Crimmins and Jessica Faul and Deborah A Levine and Mohammed U Kabeto and David R Weir} } @article {9006, title = {The Hispanic paradox: Race/ethnicity and nativity, immigrant enclave residence and cognitive impairment among older US adults.}, journal = {Journal of the American Geriatrics Society}, volume = {65}, year = {2017}, pages = {1085-1091}, abstract = {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.}, keywords = {Cognitive Ability, Racial/ethnic differences, Socioeconomic factors, Women and Minorities}, issn = {1532-5415}, doi = {10.1111/jgs.14806}, author = {Margaret M Weden and Jeremy Miles and Esther M Friedman and Jos{\'e} J Escarce and Peterson, Christine and Kenneth M. Langa and Regina A Shih} } @article {9465, title = {The obesity paradox and incident cardiovascular disease: A population-based study.}, journal = {PLoS One}, volume = {12}, year = {2017}, month = {2017}, pages = {e0188636}, abstract = {

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.

}, keywords = {BMI, Cardiovascular disease, Obesity}, issn = {1932-6203}, doi = {10.1371/journal.pone.0188636}, author = {Virginia W Chang and Kenneth M. Langa and David R Weir and Theodore J Iwashyna} } @article {8905, title = {The Relationship of Obesity to Hospice Use and Expenditures: A Cohort Study.}, journal = {Annals of Internal Medicine}, year = {2017}, month = {2017 Feb 07}, abstract = {

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.

}, keywords = {Hospice, Medicare/Medicaid/Health Insurance, Obesity, Older Adults}, issn = {1539-3704}, doi = {10.7326/M16-0749}, author = {Tamara B Harris and Byhoff, Elena and Chithra R Perumalswami and Kenneth M. Langa and Alexi A Wright and Jennifer J Griggs} } @article {9950, title = {2016 Harmonized Cognitive Assessment Protocol (HCAP) Study Protocol Summary}, year = {2016}, month = {03/2018}, pages = {1-15}, institution = {Health and Retirement Study, Survey Research Center, Institute for Social Research, University of Michigan}, address = {Ann Arbor, MI}, author = {David R Weir and Kenneth M. Langa and Lindsay H Ryan} } @article {8481, title = {Racial and ethnic differences in cognitive function among older adults in the USA.}, journal = {International Journal of Geriatric Psychiatry}, volume = {31}, year = {2016}, pages = {1004-1012}, abstract = {

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 {\textcopyright} 2016 John Wiley \& Sons, Ltd.

}, keywords = {African Americans, Aged, Aged, 80 and over, Cognition, Ethnic Groups, European Continental Ancestry Group, Female, Hispanic Americans, Humans, Male, Middle Aged, United States}, issn = {1099-1166}, doi = {10.1002/gps.4410}, author = {D{\'\i}az-Venegas, Carlos and Brian Downer and Kenneth M. Langa and Rebeca Wong} } @article {8660, title = {Factors associated with cognitive evaluations in the United States.}, journal = {Neurology}, volume = {84}, year = {2015}, month = {2015 Jan 06}, pages = {64-71}, abstract = {

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.

}, keywords = {Aged, Aged, 80 and over, Cognition Disorders, Cohort Studies, Dementia, Female, Humans, Logistic Models, Male, Marital Status, Multivariate Analysis, Neuropsychological tests, Severity of Illness Index, United States}, issn = {1526-632X}, doi = {10.1212/WNL.0000000000001096}, url = {http://www.neurology.org/cgi/doi/10.1212/WNL.0000000000001096}, author = {Vikas Kotagal and Kenneth M. Langa and Brenda L Plassman and Gwenith G Fisher and Bruno J Giordani and Robert B Wallace and James F. Burke and David C Steffens and Mohammed U Kabeto and Roger L. Albin and Norman L Foster} } @article {5851, title = {Racial Difference in the Use of VA Health Services}, year = {2015}, institution = {Ann Arbor, MI, Michigan Reirement Research Center, University of Michigan}, abstract = {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.}, url = {http://www.mrrc.isr.umich.edu/publications/papers/pdf/wp334.pdf}, author = {Fang, Chichun and Kenneth M. Langa and Helen G Levy and David R Weir} } @article {8928, title = {Advance directives and nursing home stays associated with less aggressive end-of-life care for patients with severe dementia.}, journal = {Health Affairs}, volume = {33}, year = {2014}, month = {2014 Apr}, pages = {667-74}, abstract = {

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.

}, keywords = {Advance directives, Dementia, Disabilities, End-of-life care, Nursing homes, Older Adults}, issn = {1544-5208}, doi = {10.1377/hlthaff.2013.1258}, author = {Lauren Hersch Nicholas and Julie P W Bynum and Theodore J Iwashyna and David R Weir and Kenneth M. Langa} } @article {7966, title = {Aging children of long-lived parents experience slower cognitive decline}, journal = {Alzheimer{\textquoteright}s and Dementia}, volume = {10}, year = {2014}, pages = {S315-S322}, publisher = {10}, keywords = {Adult children, Expectations, Genetics, Health Conditions and Status}, doi = {10.1016/j.jalz.2013.07.002}, url = {http://www.sciencedirect.com/science/article/pii/S1552526013024965}, author = {Ambarish Dutta and Henley, William and Robine, Jean-Marie and David J Llewellyn and Kenneth M. Langa and Robert B Wallace and David Melzer} } @article {8517, title = {Cognitive Test Selection for the Harmonized Cognitive Assessment Protocol (HCAP)}, year = {2014}, month = {10/2014}, institution = {Institute for Social Research, University of Michigan}, address = {Ann Arbor, Michigan}, abstract = {The goal of this effort, set by the National Institute on Aging (NIA), is to devise a cognitive assessment that meets the following criteria: 1) Can be administered in the home by a survey interviewer in about one hour, 2) Has sufficient overlap with the 2002/03 HRS-ADAMS study that it can be used to establish trends in prevalence of dementia and cognitive impairment without dementia, and 3) Can be administered comparably and lead to comparably valid diagnoses in other developed and developing countries where HRS-type surveys are conducted. This goal is achievable because of substantial investment by the NIA in data collection in population studies focused on dementia. There is thus now an empirical basis for making test selection. Informant reports are a key element of most population-based approaches to assessment to establish the presence or absence of change in cognitive ability and of limitation in activity resulting from change. We intend to include informant reports in our data collection protocol and in the diagnostic algorithm. This document is focused on cognitive testing of the subject.}, keywords = {Cognitive Ability, HCAP, Meta-analyses, Survey Methodology}, author = {David R Weir and Ryan J McCammon and Lindsay H Ryan and Kenneth M. Langa} } @article {8046, title = {Cohort Profile: the Health and Retirement Study (HRS).}, journal = {Int J Epidemiol}, volume = {43}, year = {2014}, month = {2014 Apr}, pages = {576-85}, publisher = {43}, abstract = {

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{\textquoteright}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).

}, keywords = {Aged, Female, Genetic Predisposition to Disease, Health Status, Humans, Longitudinal Studies, Male, Mental Health, Middle Aged, Physical Fitness, Retirement, United States}, issn = {1464-3685}, doi = {10.1093/ije/dyu067}, author = {Amanda Sonnega and Jessica Faul and Mary Beth Ofstedal and Kenneth M. Langa and John W R Phillips and David R Weir} } @article {7996, title = {Development and validation of a brief dementia screening indicator for primary care.}, journal = {Alzheimers Dement}, volume = {10}, year = {2014}, note = {Export Date: 21 April 2014 Source: Scopus Article in Press}, month = {2014 Nov}, pages = {656-665.e1}, publisher = {10}, abstract = {

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

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

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

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

}, keywords = {Aged, Cohort Studies, Dementia, Female, Humans, Male, Mass Screening, Predictive Value of Tests, Primary Health Care, Proportional Hazards Models, Risk Assessment}, issn = {1552-5279}, doi = {10.1016/j.jalz.2013.11.006}, url = {http://www.scopus.com/inward/record.url?eid=2-s2.0-84893186546andpartnerID=40andmd5=3b617dce24578e022db389d90ad9ddd1}, author = {Deborah E Barnes and Alexa S. Beiser and Anne Lee and Kenneth M. Langa and Alain Koyama and Sarah R Preis and John Neuhaus and Ryan J McCammon and Kristine Yaffe and Seshadri, Sudha and Mary Haan and David R Weir} } @article {8926, title = {Economic development and gender inequality in cognition: a comparison of China and India, and of SAGE and the HRS sister studies.}, journal = {Journal of Economics of Ageing}, volume = {4}, year = {2014}, month = {2014 Dec 01}, pages = {114-125}, abstract = {

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.

}, keywords = {CHARLS, Economics, Gender Differences, LASI, Older Adults, SAGE, Sister studies}, issn = {2212-828X}, doi = {10.1016/j.jeoa.2014.08.002}, author = {David R Weir and Margaret Lay and Kenneth M. Langa} } @article {8088, title = {History of alcohol use disorders and risk of severe cognitive impairment: a 19-year prospective cohort study.}, journal = {Am J Geriatr Psychiatry}, volume = {22}, year = {2014}, month = {2014 Oct}, pages = {1047-54}, publisher = {22}, abstract = {

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.

}, keywords = {Alcohol-Related Disorders, Cognition Disorders, Diagnosis, Dual (Psychiatry), Female, Humans, Incidence, Male, Memory Disorders, Middle Aged, Prospective Studies, Risk Factors, United States}, issn = {1545-7214}, doi = {10.1016/j.jagp.2014.06.001}, url = {http://www.sciencedirect.com/science/article/pii/S1064748114001675}, author = {Ku{\'z}ma, El{\.z}bieta and David J Llewellyn and Kenneth M. Langa and Robert B Wallace and Iain A Lang} } @article {5954, title = {Documentation of Biomarkers in the 2006 and 2008 Health and Retirement Study}, year = {2013}, institution = {Institute for Social Research, University of Michigan}, address = {Ann Arbor, Michigan}, abstract = {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.}, keywords = {Health Conditions and Status, Healthcare, Methodology}, author = {Eileen M. Crimmins and Jessica Faul and Jung K Kim and Heidi M Guyer and Kenneth M. Langa and Mary Beth Ofstedal and Amanda Sonnega and Robert B Wallace and David R Weir} } @article {7892, title = {Impact of cigarette smoking on utilization of nursing home services.}, journal = {Nicotine Tob Res}, volume = {15}, year = {2013}, month = {2013 Nov}, pages = {1902-9}, abstract = {

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

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

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

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

}, keywords = {Age Factors, Aged, Aged, 80 and over, Black or African American, Cross-Sectional Studies, Female, Hispanic or Latino, Humans, Length of Stay, Logistic Models, Longitudinal Studies, Male, Middle Aged, Nursing homes, Risk, Self Report, Smoking, Socioeconomic factors, United States, White People}, issn = {1469-994X}, doi = {10.1093/ntr/ntt079}, url = {http://ntr.oxfordjournals.org/content/early/2013/06/18/ntr.ntt079.abstract}, author = {Kenneth E. Warner and Ryan J McCammon and Brant E Fries and Kenneth M. Langa} } @article {7955, title = {Longer lived parents: protective associations with cancer incidence and overall mortality.}, journal = {J Gerontol A Biol Sci Med Sci}, volume = {68}, year = {2013}, note = {Times Cited: 0}, month = {2013 Nov}, pages = {1409-18}, publisher = {68}, abstract = {

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{\textquoteright}s and father{\textquoteright}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{\textquoteright}s or father{\textquoteright}s attained ages, adjusted for each other.

RESULTS: With increasing mother{\textquoteright}s or father{\textquoteright}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.

}, keywords = {Aged, Aged, 80 and over, Female, Humans, Incidence, Longevity, Male, Middle Aged, Mortality, Neoplasms, Parents}, issn = {1758-535X}, doi = {10.1093/gerona/glt061}, author = {Ambarish Dutta and Henley, William and Robine, Jean-Marie and Kenneth M. Langa and Robert B Wallace and David Melzer} } @article {7631, title = {Assessment of cognition using surveys and neuropsychological assessment: the Health and Retirement Study and the Aging, Demographics, and Memory Study.}, journal = {J Gerontol B Psychol Sci Soc Sci}, volume = {66 Suppl 1}, year = {2011}, note = {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.}, month = {2011 Jul}, pages = {i162-71}, publisher = {66 Suppl 1}, abstract = {

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.

}, keywords = {Age Factors, Aged, Aged, 80 and over, Cognition, Cognition Disorders, Dementia, Educational Status, Female, Humans, Interviews as Topic, Logistic Models, Longitudinal Studies, Male, Multivariate Analysis, Neuropsychological tests, Odds Ratio, Prevalence, Sex Factors, United States}, issn = {1758-5368}, doi = {10.1093/geronb/gbr048}, author = {Eileen M. Crimmins and Jung K Kim and Kenneth M. Langa and David R Weir} } @article {7586, title = {Incidence of dementia and cognitive impairment, not dementia in the United States.}, journal = {Ann Neurol}, volume = {70}, year = {2011}, month = {2011 Sep}, pages = {418-26}, abstract = {

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

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

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

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

}, keywords = {Aged, Aged, 80 and over, Alzheimer disease, Cognition Disorders, Cohort Studies, Dementia, Diagnostic and Statistical Manual of Mental Disorders, disease progression, Female, Humans, Logistic Models, Longitudinal Studies, Male, Models, Statistical, United States}, issn = {1531-8249}, doi = {10.1002/ana.22362}, author = {Brenda L Plassman and Kenneth M. Langa and Ryan J McCammon and Gwenith G Fisher and Guy G Potter and James R Burke and David C Steffens and Norman L Foster and Bruno J Giordani and Frederick W Unverzagt and Kathleen A Welsh-Bohmer and Steven G Heeringa and David R Weir and Robert B Wallace} } @article {7563, title = {Operationalizing diagnostic criteria for Alzheimer{\textquoteright}s disease and other age-related cognitive impairment-Part 2.}, journal = {Alzheimers Dement}, volume = {7}, year = {2011}, month = {2011 Jan}, pages = {35-52}, publisher = {7}, abstract = {

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{\textquoteright}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.

}, keywords = {Age Factors, Aging, Alzheimer disease, Cognition Disorders, Community Health Planning, Humans, Incidence, Longitudinal Studies, Neuropsychological tests, Prevalence, United States}, issn = {1552-5279}, doi = {10.1016/j.jalz.2010.12.002}, author = {Seshadri, Sudha and Alexa S. Beiser and Au, Rhoda and Philip A Wolf and Robert S Wilson and Ronald C Petersen and David S Knopman and Walter A Rocca and Claudia H Kawas and Maria M Corrada and Brenda L Plassman and Kenneth M. Langa and Helena C Chui} } @article {7652, title = {Proxy interviews and bias in the distribution of cognitive abilities due to non-response in longitudinal studies: a comparison of HRS and ELSA.}, journal = {Longit Life Course Stud}, volume = {2}, year = {2011}, month = {2011 May}, pages = {170-184}, publisher = {2}, issn = {1757-9597}, doi = {10.14301/llcs.v2i2.116}, author = {David R Weir and Jessica Faul and Kenneth M. Langa} } @article {7566, title = {Reducing case ascertainment costs in U.S. population studies of Alzheimer{\textquoteright}s disease, dementia, and cognitive impairment-Part 1.}, journal = {Alzheimers Dement}, volume = {7}, year = {2011}, month = {2011 Jan}, pages = {94-109}, publisher = {7}, abstract = {

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.

}, keywords = {Aging, Algorithms, Alzheimer disease, Cognition Disorders, Community Health Planning, Cost-Benefit Analysis, Dementia, Health Surveys, Humans, Internet, Reproducibility of Results, United States}, issn = {1552-5279}, doi = {10.1016/j.jalz.2010.11.004}, url = {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 }, author = {David R Weir and Robert B Wallace and Kenneth M. Langa and Brenda L Plassman and Robert S Wilson and David A Bennett and Duara, Ranjan and Loewenstein, David and Ganguli, Mary and Sano, Mary} } @article {7687, title = {Regional variation in the association between advance directives and end-of-life Medicare expenditures.}, journal = {JAMA}, volume = {306}, year = {2011}, month = {2011 Oct 05}, pages = {1447-53}, publisher = {112}, abstract = {

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{\textquoteright}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.

}, keywords = {Advance directives, Aged, Aged, 80 and over, Data collection, Female, Health Expenditures, Hospice Care, Hospital Mortality, Hospitals, Humans, Kidney Failure, Chronic, Male, Medicare, Palliative care, Prospective Studies, Regression Analysis, Terminal Care, United States}, issn = {1538-3598}, doi = {10.1001/jama.2011.1410}, url = {http://proquest.umi.com.proxy.lib.umich.edu/pqdweb?did=2590187421andFmt=7andclientId=17822andRQT=309andVName=PQD}, author = {Lauren Hersch Nicholas and Kenneth M. Langa and Theodore J Iwashyna and David R Weir} } @article {7565, title = {Sources of variability in estimates of the prevalence of Alzheimer{\textquoteright}s disease in the United States.}, journal = {Alzheimers Dement}, volume = {7}, year = {2011}, month = {2011 Jan}, pages = {74-9}, publisher = {7}, abstract = {

BACKGROUND: The prevalence of Alzheimer{\textquoteright}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.

}, keywords = {Aged, Aged, 80 and over, Alzheimer disease, Community Health Planning, Comorbidity, Dementia, Diagnosis, Differential, Female, Humans, Incidence, Male, Prevalence, United States}, issn = {1552-5279}, doi = {10.1016/j.jalz.2010.11.006}, author = {Robert S Wilson and David R Weir and Sue E Leurgans and Denis A Evans and Liesi Hebert and Kenneth M. Langa and Brenda L Plassman and Brent J. Small and David A Bennett} } @article {7567, title = {Trends in the incidence and prevalence of Alzheimer{\textquoteright}s disease, dementia, and cognitive impairment in the United States.}, journal = {Alzheimers Dement}, volume = {7}, year = {2011}, month = {2011 Jan}, pages = {80-93}, publisher = {7}, abstract = {

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.

}, keywords = {Age Factors, Alzheimer disease, Cognition Disorders, Cohort Studies, Community Health Planning, Dementia, Humans, Incidence, Prevalence, Residence Characteristics, Retrospective Studies, Time Factors, United States}, issn = {1552-5279}, doi = {10.1016/j.jalz.2010.11.002}, author = {Walter A Rocca and Ronald C Petersen and David S Knopman and Liesi Hebert and Denis A Evans and Kathleen S Hall and Gao, Sujuan and Frederick W Unverzagt and Kenneth M. Langa and Eric B Larson and Lon R White} } @article {7452, title = {Clinical complexity in middle-aged and older adults with diabetes: the Health and Retirement Study.}, journal = {Med Care}, volume = {48}, year = {2010}, month = {2010 Apr}, pages = {327-34}, publisher = {48}, abstract = {

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.

}, keywords = {Aged, Cross-Sectional Studies, Diabetes Complications, Diabetes Mellitus, Type 2, Female, Glycemic Index, Health Status, Health Surveys, Humans, Male, Middle Aged, Quality of Health Care, Self Care, Severity of Illness Index, Treatment Failure, United States}, issn = {1537-1948}, doi = {10.1097/mlr.0b013e3181ca4035}, author = {Caroline S Blaum and Christine T Cigolle and Cynthia Boyd and Jennifer L. Wolff and Zhiyi Tian and Kenneth M. Langa and David R Weir} } @article {7403, title = {The accuracy of Medicare claims as an epidemiological tool: the case of dementia revisited.}, journal = {J Alzheimers Dis}, volume = {17}, year = {2009}, month = {2009}, pages = {807-15}, publisher = {17}, abstract = {

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.

}, keywords = {Aged, Aged, 80 and over, Alzheimer disease, Cohort Studies, Dementia, Female, Health Care Costs, Humans, Insurance Claim Reporting, Male, Medicare, Prevalence, Sensitivity and Specificity, United States}, issn = {1875-8908}, doi = {10.3233/JAD-2009-1099}, author = {Donald H. Taylor Jr. and {\O}stbye, Truls and Kenneth M. Langa and David R Weir and Brenda L Plassman} } @article {5761, title = {Aging, Demographics and Memory Study (ADAMS): Sample Design, Weighting and Analysis for ADAMS}, year = {2009}, institution = {Institute for Social Research, University of Michigan}, address = {Ann Arbor, Michigan}, abstract = {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.}, keywords = {Health Conditions and Status, Methodology}, author = {Steven G Heeringa and Gwenith G Fisher and Michael D Hurd and Kenneth M. Langa and Mary Beth Ofstedal and Brenda L Plassman and Rogers, Willard and David R Weir} } @article {7408, title = {"Below average" self-assessed school performance and Alzheimer{\textquoteright}s disease in the Aging, Demographics, and Memory Study.}, journal = {Alzheimers Dement}, volume = {5}, year = {2009}, month = {2009 Sep}, pages = {380-7}, publisher = {5}, abstract = {

BACKGROUND: A low level of formal education is becoming accepted as a risk factor for Alzheimer{\textquoteright}s disease (AD). Although increasing attention has been paid to differences in educational quality, no previous studies addressed participants{\textquoteright} 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{\textquoteright} 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.

}, keywords = {Aged, Aged, 80 and over, Aging, Alzheimer disease, Apolipoprotein E4, Cognition Disorders, Educational Status, Female, Geriatric Assessment, Humans, Male, Memory, Neuropsychological tests, Risk Factors}, issn = {1552-5279}, doi = {10.1016/j.jalz.2009.07.039}, url = {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_}, author = {Kala M. Mehta and Anita L Stewart and Kenneth M. Langa and Kristine Yaffe and Sandra Y. Moody-Ayers and Brie A Williams and Kenneth E Covinsky} } @article {7346, title = {Cognitive health among older adults in the United States and in England.}, journal = {BMC Geriatr}, volume = {9}, year = {2009}, note = {PMID: 19555494}, month = {2009 Jun 25}, pages = {23}, publisher = {9}, abstract = {

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.

}, keywords = {Aged, Aged, 80 and over, Aging, Cognition, Cognition Disorders, Cohort Studies, Cross-Sectional Studies, England, Female, Health Status, Humans, Longitudinal Studies, Male, Neuropsychological tests, United States}, issn = {1471-2318}, doi = {10.1186/1471-2318-9-23}, author = {Kenneth M. Langa and David J Llewellyn and Iain A Lang and David R Weir and Robert B Wallace and Mohammed U Kabeto and Felicia A Huppert} } @article {5734, title = {Documentation of Physical Measures, Anthropometrics and Blood Pressure in the Health and Retirement Study}, year = {2008}, institution = {Institute for Social Research, University of Michigan}, address = {Ann Arbor, Michigan}, abstract = {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}, keywords = {Health Conditions and Status, Healthcare, Methodology}, author = {Eileen M. Crimmins and Heidi M Guyer and Kenneth M. Langa and Mary Beth Ofstedal and Robert B Wallace and David R Weir} } @article {7201, title = {Prevalence of cognitive impairment without dementia in the United States.}, journal = {Ann Intern Med}, volume = {148}, year = {2008}, month = {2008 Mar 18}, pages = {427-34}, publisher = {148}, abstract = {

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.

}, keywords = {Aged, Aged, 80 and over, Cognition Disorders, Dementia, disease progression, Humans, Longitudinal Studies, Prevalence, United States}, issn = {1539-3704}, doi = {10.7326/0003-4819-148-6-200803180-00005}, author = {Brenda L Plassman and Kenneth M. Langa and Gwenith G Fisher and Steven G Heeringa and David R Weir and Mary Beth Ofstedal and James R Burke and Michael D Hurd and Guy G Potter and Willard L Rodgers and David C Steffens and John J McArdle and Robert J. Willis and Robert B Wallace} } @article {7173, title = {Beyond comorbidity counts: how do comorbidity type and severity influence diabetes patients{\textquoteright} treatment priorities and self-management?}, journal = {J Gen Intern Med}, volume = {22}, year = {2007}, month = {2007 Dec}, pages = {1635-40}, publisher = {22}, abstract = {

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{\textquoteright} 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{\textquoteright} 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.

}, keywords = {Aged, Attitude to Health, Cohort Studies, Comorbidity, Cross-Sectional Studies, Diabetes Mellitus, Female, Health Priorities, Heart Failure, Humans, Male, Middle Aged, Self Care, Severity of Illness Index, United States}, issn = {1525-1497}, doi = {10.1007/s11606-007-0313-2}, author = {Eve A Kerr and Michele M Heisler and Sarah L. Krein and Mohammed U Kabeto and Kenneth M. Langa and David R Weir and John D Piette} } @article {7168, title = {Mechanisms for racial and ethnic disparities in glycemic control in middle-aged and older Americans in the health and retirement study.}, journal = {Arch Intern Med}, volume = {167}, year = {2007}, month = {2007 Sep 24}, pages = {1853-60}, publisher = {167}, abstract = {

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.

}, keywords = {Aged, Aged, 80 and over, Black People, Diabetes Mellitus, Female, Glycated Hemoglobin, Health Services Accessibility, Hispanic or Latino, Humans, Longitudinal Studies, Male, Middle Aged, Patient Compliance, Socioeconomic factors, Treatment Refusal, United States, White People}, issn = {0003-9926}, doi = {10.1001/archinte.167.17.1853}, author = {Michele M Heisler and Jessica Faul and Rodney A. Hayward and Kenneth M. Langa and Caroline S Blaum and David R Weir} } @article {7164, title = {Prevalence of dementia in the United States: the aging, demographics, and memory study.}, journal = {Neuroepidemiology}, volume = {29}, year = {2007}, month = {2007}, pages = {125-32}, publisher = {29}, abstract = {

AIM: To estimate the prevalence of Alzheimer{\textquoteright}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.

}, keywords = {Age Distribution, Aged, Aged, 80 and over, Cohort Studies, Dementia, Female, Geriatric Assessment, Health Surveys, Humans, Logistic Models, Male, Prevalence, Sex Distribution, United States}, issn = {1423-0208}, doi = {10.1159/000109998}, author = {Brenda L Plassman and Kenneth M. Langa and Gwenith G Fisher and Steven G Heeringa and David R Weir and Mary Beth Ofstedal and James R Burke and Michael D Hurd and Guy G Potter and Willard L Rodgers and David C Steffens and Robert J. Willis and Robert B Wallace} } @article {7002, title = {The Aging, Demographics and Memory Study: Study Design and Methods}, journal = {Neuroepidemiology}, volume = {25}, year = {2005}, pages = {181-191}, publisher = {25}, abstract = {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.}, keywords = {Health Conditions and Status, Healthcare}, author = {Kenneth M. Langa and Brenda L Plassman and Robert B Wallace and A. Regula Herzog and Steven G Heeringa and Mary Beth Ofstedal and James F. Burke and Gwenith G Fisher and Fultz, Nancy H. and Michael D Hurd and Guy G Potter and Willard L Rodgers and David C Steffens and David R Weir} } @article {7048, title = {Differences in Amount of Informal Care Received by Non-Hispanic Whites and Latinos in a Nationally Representative Sample of Older Americans}, journal = {Journal of the American Geriatrics Society}, volume = {53}, year = {2005}, pages = {146-151}, publisher = {53}, abstract = {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.}, keywords = {Healthcare, Women and Minorities}, author = {Weiss, Carlos O. and Hector M Gonz{\'a}lez and Mohammed U Kabeto and Kenneth M. Langa} } @article {7005, title = {The Effect of Diabetes on Diability in Middle-Aged and Older Adults}, journal = {The Journals of Gerontology, Series A: Medical Sciences}, volume = {60A}, year = {2005}, pages = {1206-1211}, publisher = {60A}, abstract = {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.}, keywords = {Demographics, Disabilities, Health Conditions and Status}, doi = {10.1093/gerona/60.9.1206}, url = {http://biomedgerontology.oxfordjournals.org/content/60/9/1206.long}, author = {Linda A. Wray and Mary Beth Ofstedal and Kenneth M. Langa and Caroline S Blaum} } @article {6921, title = {Out-of-pocket health care expenditures among older Americans with dementia.}, journal = {Alzheimer Dis Assoc Disord}, volume = {18}, year = {2004}, month = {2004 Apr-Jun}, pages = {90-8}, publisher = {18}, abstract = {

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.

}, keywords = {Aged, Aged, 80 and over, Alzheimer disease, Costs and Cost Analysis, Data Interpretation, Statistical, Female, Financing, Personal, Health Care Costs, Health Expenditures, Health Surveys, Humans, Insurance Coverage, Longitudinal Studies, Male}, issn = {0893-0341}, doi = {10.1097/01.wad.0000126620.73791.3e}, author = {Kenneth M. Langa and Eric B Larson and Robert B Wallace and A. Mark Fendrick and Norman L Foster and Mohammed U Kabeto and David R Weir and Robert J. Willis and A. Regula Herzog} } @article {6922, title = {Quality of preventive clinical services among caregivers in the health and retirement study.}, journal = {J Gen Intern Med}, volume = {19}, year = {2004}, month = {2004 Aug}, pages = {875-8}, publisher = {19}, abstract = {

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.

}, keywords = {Aged, Caregivers, Cohort Studies, Cross-Sectional Studies, Female, Health Care Surveys, Humans, Male, Middle Aged, Patient Acceptance of Health Care, Preventive Health Services, Quality of Health Care, Time Factors, United States}, issn = {0884-8734}, doi = {10.1111/j.1525-1497.2004.30411.x}, author = {Kim, Catherine and Mohammed U Kabeto and Robert B Wallace and Kenneth M. Langa} } @article {6848, title = {Additive effects of cognitive function and depressive symptoms on mortality in elderly community-living adults.}, journal = {J Gerontol A Biol Sci Med Sci}, volume = {58}, year = {2003}, month = {2003 May}, pages = {M461-7}, publisher = {58A}, abstract = {

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.

}, keywords = {Aged, Cognition, depression, Female, Humans, Male, Mortality, Proportional Hazards Models, Risk Factors}, issn = {1079-5006}, doi = {10.1093/gerona/58.5.m461}, author = {Kala M. Mehta and Kristine Yaffe and Kenneth M. Langa and Laura Sands and Whooley, Mary and Kenneth E Covinsky} } @article {6886, title = {Functional Status and Health Outcomes in Older Americans with Diabetes: Should diabetes management be targeted to health status?}, journal = {Journal of the American Geriatrics Society}, volume = {51}, year = {2003}, pages = {745-53}, publisher = {51}, abstract = {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.}, keywords = {Diabetes Mellitus, Functional status, Older Adults}, doi = {10.1046/j.1365-2389.2003.51256.x}, author = {Caroline S Blaum and Mary Beth Ofstedal and Kenneth M. Langa and Linda A. Wray} } @article {8753, title = {The Impact of Poor Health Behaviors on Workforce Disability }, number = {WP 2003-057 }, year = {2003}, month = {06/2003}, pages = {1-22}, institution = {University of Michigan Retirement Research Center}, address = {Ann Arbor}, abstract = {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. }, keywords = {Disabilities, Health Behavior, Labor force participation, Older Adults}, url = {https://core.ac.uk/download/pdf/7189096.pdf}, author = {Richardson, Caroline R. and Jennifer T. Hanlon and Hillary J. Mull and Sandeep Vijan and Rodney A. Hayward and Linda A. Wray and Kenneth M. Langa} } @article {6790, title = {Informal caregiving for diabetes and diabetic complications among elderly americans.}, journal = {J Gerontol B Psychol Sci Soc Sci}, volume = {57}, year = {2002}, month = {2002 May}, pages = {S177-86}, publisher = {57B}, abstract = {

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.

}, keywords = {Aged, Aged, 80 and over, Caregivers, Cost of Illness, Costs and Cost Analysis, Diabetes Complications, Diabetes Mellitus, Disabled Persons, Female, Health Surveys, Humans, Hypoglycemic Agents, Insulin, Male, Time Factors}, issn = {1079-5014}, doi = {10.1093/geronb/57.3.s177}, author = {Kenneth M. Langa and Sandeep Vijan and Rodney A. Hayward and M.E. Chernew and Caroline S Blaum and Mohammed U Kabeto and David R Weir and Steven J. Katz and Robert J. Willis and A. Mark Fendrick} } @article {6738, title = {National estimates of the quantity and cost of informal caregiving for the elderly with dementia.}, journal = {J Gen Intern Med}, volume = {16}, year = {2001}, month = {2001 Nov}, pages = {770-8}, publisher = {16}, abstract = {

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.

}, keywords = {Aged, Aged, 80 and over, Caregivers, Cost of Illness, Dementia, Female, Health Care Costs, Humans, Male, Multivariate Analysis, Regression Analysis, Severity of Illness Index, Time Factors, United States}, issn = {0884-8734}, doi = {10.1111/j.1525-1497.2001.10123.x}, author = {Kenneth M. Langa and M.E. Chernew and Mohammed U Kabeto and A. Regula Herzog and Mary Beth Ofstedal and Robert J. Willis and Robert B Wallace and Mucha, L.M. and Walter L. Straus and A. Mark Fendrick} }