0843 Prospective Associations of Insomnia Symptoms With Health Services Use in Community-Dwelling Older Adults

Introduction

Limited research has examined links of insomnia with health services use, particularly using claims-based data. We investigated the association of insomnia symptoms with costly health services use, measured by Medicare claims, in a nationally representative sample of U.S. older adults.

Methods

Participants were 4,302 community-dwelling Medicare beneficiaries aged ≥65 years from Round 1 (2011) of the National Health and Aging Trends Study who had continuous fee-for-service Medicare coverage 1 year before and after the Round 1 interview. Participants reported past-month insomnia symptoms (i.e., sleep onset latency >30 minutes, difficulty returning to sleep after early awakening) which we categorized as 0, 1, or 2 symptoms. Outcomes were linked Medicare claims occurring after Round 1 interviews: emergency department (ED) visits, all-cause hospitalizations, preventable hospitalizations, all-cause 30-day readmissions, home health care (all measured as yes/no); and number of hospitalizations and ED visits.

Results

Overall, 18.9% of participants were hospitalized, 29.3% visited the ED, 3.1% had a preventable hospitalization, 2.6% had a readmission, and 11.7% used home health care. After adjustment for demographics, compared to participants with no insomnia symptoms, those with 2 symptoms had a higher odds of ED visits (odds ratio (OR)=1.42, p<0.001), all-cause hospitalizations (OR=1.30, p<0.01), preventable hospitalizations (OR=1.83, p<0.05), 30-day readmissions (OR=1.73, p<0.05), and home health care use (OR=1.27, p<0.05). These associations did not hold, however, upon further adjustment for health characteristics (i.e., depressive/anxiety symptoms, medical comorbidities and BMI). After full adjustment, reporting 2 insomnia symptoms, versus no insomnia symptoms, was associated with a greater number of ED visits (Incidence Rate Ratio=1.16, p<0.05).

Conclusion

Among older adults, a greater number of insomnia symptoms is associated with greater health services use. Insomnia symptoms may be a marker of, or exacerbate, health conditions. Targeting insomnia may lower health services use.

Support

National Institute on Aging: R01AG050507 & R01AG050507-02S (PI: Spira); F31-AG058389; U01AG032947 (PI: Kasper) for the National Health and Aging Trends Study. Johns Hopkins Center on Aging and Health Data Use Agreement (PI: Roth, Co-I: Sheehan) with Centers for Medicare & Medicaid Services titled, “Potentially modifiable factors influencing outcomes in NHATS.”

0844 Links of Napping With Subsequent All-Cause Hospitalizations and Emergency Department Visits in Older Adults

Introduction

Few studies have examined whether napping is associated with objective measures of health services use. We investigated links of napping characteristics with all-cause hospitalizations and emergency department (ED) visits in Medicare claims from a nationally representative sample of older adults.

Methods

Participants were 869 community-dwelling Medicare beneficiaries aged ≥65 years from Round 3 (2013) and Round 4 (2014) of the National Health and Aging Trends Study (NHATS) who had continuous fee-for-service coverage 1 year before and after the NHATS interview. Participants reported past-month napping frequency (re-categorized as non-nappers, infrequent nappers, frequent nappers), napping type (intentional, unintentional), and nap duration. Outcomes were from linked Medicare claims measured after napping assessment: all-cause ED visits and hospitalizations (yes vs. no), and number of hospitalizations and ED visits.

Results

Overall, 45.4% of participants were nappers, and 55.2% of the nappers reported taking unintentional naps. After adjustment for demographics, depressive/anxiety symptoms, medical comorbidities and BMI, compared with non-nappers, infrequent and frequent nappers had a higher odds of hospitalization (odds ratio (OR)=1.65 and 1.73, respectively, both p<0.05), as did unintentional nappers (OR=1.85, p<0.05). We found no significant adjusted associations of napping frequency with ED visits. However, compared with non-nappers, unintentional nappers had a higher odds of visiting the ED (OR=1.94, p<0.01). Additionally, compared to nappers taking short naps (≤30 minutes), those with naps >60 minutes had a greater number of ED visits (Incidence Rate Ratio=1.99, p<0.05).

Conclusion

Among older adults, napping—and particularly unintentional napping—may be a modifiable risk factor for health services use. More studies that consider multiple napping characteristics (e.g., duration, frequency), and using objective measures (e.g., actigraphy), are needed to advance understanding of how napping might influence health services use.

Support

National Institute on Aging: R01AG050507 & R01AG050507-02S (PI: Spira); F31-AG058389; U01AG032947 (PI: Kasper) for the National Health and Aging Trends Study. Johns Hopkins Center on Aging and Health Data Use Agreement (PI: Roth, Co-I: Sheehan) with Centers for Medicare & Medicaid Services titled, “Potentially modifiable factors influencing outcomes in NHATS.”

Age- and education-adjusted normative data for the Rivermead Behavioural Memory Test (RBMT)

The original Rivermead Behavioural Memory Test (RBMT) suggests a cutoff global score of 10 points. However, this limit may be too stringent for older adults attending memory training programs, particularly for those with low education levels. This study aims to provide appropriately adjusted age and education norms for the RBMT. Data from 711 subjects were grouped based on age (65-67, 68-71, 72-75 and 76-83) and education level (primary school, high school and university studies). The data exhibit a clear trend of scores decreasing with age. The diminution in scores does not reach trend levels of significance between neighboring (< 5 years) age intervals, but it is statistically significant at the designated alpha level (p = .05) when younger and older adults are compared over a range of 5 years of difference. 81.86% of our sample has global scores below the suggested cutoff of 10 points. The present study provides a more accurate representation of RBMT global score performance in older adults for specific age and education stratifications.

Linking depressive symptoms and functional disability in late life

We hypothesized that the relationship of depressive symptoms to functional disability might be mediated by cognitive processes such as memory and problem-solving. The study sample consisted of 147 community-dwelling older adults (mean age = 74.0 years, SD = 5.9). In regression models that included terms for age, gender, and years of education, depressive symptoms were significantly inversely associated with two performance-based measures of functioning: everyday problems test (beta = -0.15, p = 0.04) and observed tasks of daily living (beta = -0.14, p = 0.02). When memory and problem-solving ability were added to the model, the relationship of depressive symptoms with function was attenuated. A structural equation model based on our conceptual framework revealed that both memory and problem-solving abilities were important mediators in the relationship of depressive symptoms and functional disability. The results suggest that intervention studies intended to limit functional disability secondary to depression among older adults may need to consider the effect of depression on cognition.

ACTIVE: a cognitive intervention trial to promote independence in older adults

The Advanced Cognitive Training for Independent and Vital Elderly (ACTIVE) trial is a randomized, controlled, single-masked trial designed to determine whether cognitive training interventions (memory, reasoning, and speed of information processing), which have previously been found to be successful at improving mental abilities under laboratory or small-scale field conditions, can affect cognitively based measures of daily functioning. Enrollment began during 1998; 2-year follow-up will be completed by January 2002. Primary outcomes focus on measures of cognitively demanding everyday functioning, including financial management, food preparation, medication use, and driving. Secondary outcomes include health-related quality of life, mobility, and health-service utilization. Trial participants (n = 2832) are aged 65 and over, and at entry into the trial, did not have significant cognitive, physical, or functional decline. Because of its size and the carefully developed rigor, ACTIVE may serve as a guide for future behavioral medicine trials of this nature.

Factors associated with pilot error in aviation crashes

BACKGROUND

The importance of pilot error in aviation crashes has long been recognized. However, understanding and preventing pilot error remains the foremost challenge in aviation safety.

OBJECTIVE

This study aims to identify pilot characteristics and crash circumstances that are associated with the presence of pilot error in a large sample of aviation crashes.

METHODS

Different data files compiled by the National Transportation Safety Board for 329 major airline crashes, 1,627 commuter/air taxi crashes, and 27,935 general aviation crashes for the years 1983-96 were merged; and the presence of pilot error was analyzed in relation to variables indicating the characteristics of the pilot-in-command, crash circumstance, and aircraft. Multivariate logistic regression modeling was performed to assess the associations of individual variables with the likelihood of pilot error given a crash.

RESULTS

Pilot error was a probable cause in 38% of the major airline crashes, 74% of the commuter/air taxi crashes, and 85% of the general aviation crashes. Among the factors examined, instrument meteorological condition and on-airport location were each associated with a significantly increased odds of pilot error. The likelihood of pilot error decreased as pilot certificate rating increased in commuter/air taxi and general aviation crashes. Neither pilot age nor gender was independently associated with the odds of pilot error. With adjustment for pilot characteristics and crash circumstances, flight experience as measured in total flight time showed a significant protective effect on pilot error in general aviation crashes.

CONCLUSIONS

The prevalence and correlates of pilot error in aviation crashes vary with the type of flight operations. Adverse weather is consistently associated with a significantly elevated likelihood of pilot error, possibly due to increased performance demand.

The driving habits of adults aged 60 years and older

OBJECTIVES

We describe the driving habits of adults aged 60 years and older who were interviewed in the context of a community survey focused on mental disturbances. Our goal was to identify clinical cues that might signal driving difficulty in older adults who might present to the primary care physician for health care.

DESIGN

A population-based survey.

SETTING

Continuing participants in a follow-up study of community-dwelling adults who were living in East Baltimore in 1981.

PARTICIPANTS

Subjects were 1920 continuing participants of the Baltimore sample of the Epidemiologic Catchment Area Program; 589 were aged 60 years and older and provided information on driving habits.

MEASUREMENTS

Respondents were asked about their driving status: had they made adaptations to driving and had they experienced any adverse driving events in the 2 years before the interview. Driving behaviors were assessed in relation to chronic disease, sensory impairment, functional status, and mental status.

RESULTS

Former drivers were more likely to be older, female, and nonwhite. Diabetes, vision impairment, functional impairment, and making an error on the copy design task of the Mini-Mental State Examination (MMSE) were associated with no longer driving. Women were more likely to report having made adaptations to driving, as were persons with heart disease, arthritis, vision impairment, and those who made an error on the copy design task of the MMSE. Heart disease and hearing impairment were associated with report of an adverse driving event. In multivariate models that included terms for potentially influential characteristics such as age, gender, and miles driven, only the copy design task was associated with driving status, and only heart disease was associated with driving adaptation and adverse driving events.

CONCLUSION

Simple tests that tap visuospatial ability, such as the copy design task of the MMSE, may warrant additional study for use in driving assessment of older adults in primary care. The results underscore the importance of making an inquiry about driving as a separate and independent component of functional assessment.

Effect of concentration problems on the malleability of children's aggressive and shy behaviors

OBJECTIVE

Previous research has demonstrated the central role of early childhood concentration problems in the development of aggression and other maladaptive behaviors. The present study investigated the moderating effect of concentration problems on the impact of a classroom-based preventive intervention directed at aggressive and shy behaviors in an epidemiologically defined sample of 1,084 urban first-grade children.

METHOD

Concentration problems, aggressive behavior, and shy behavior were assessed by a structured teacher interview (the Teacher Observation of Classroom Adaptation-Revised) in the fall and spring of first grade.

RESULTS

Children with high ratings on concentration problems in the fall had higher levels of teacher-rated aggressive and shy behavior in the spring than did children without such problems. The intervention reduced aggressive and shy behavior in children regardless of fall concentration level. Boys, but not girls, in the intervention condition with high concentration problems had higher levels of spring aggression than those without such problems, but they also showed the greatest reductions in aggressive behavior from fall to spring.

CONCLUSIONS

These results suggest that aggressive behavior is malleable in children with concentration problems, provide further evidence on the etiological significance of concentration problems for the development of maladaptive behavior, and highlight the importance of directly targeting concentration problems to maximize preventive intervention impact.

Automobile driving in Huntington's disease

We assessed the influence of the neurological and cognitive impairments of Huntington's disease (HD) on automobile driving. In a group of 73 HD outpatients, 53 (72%) continued to drive after illness onset. Those no longer driving had more severe symptoms than those still driving. Twenty-nine HD patients who were still driving and 16 healthy control subjects underwent a clinical examination, a cognitive examination, a driving-simulator assessment, and completed questionnaires about driving history and habits. HD patients performed significantly worse than control subjects on the driving-simulator tasks and were more likely to have been involved in a collision in the preceding 2 years (58% of HD vs. 11% of control subjects). Patients with collisions were less functionally impaired but had slower simple reaction time scores than did those without collisions. HD patients are at increased risk for accidents, but patients who have accidents are not easily distinguished from those who do not.

Changes in visual fixation and saccadic eye movements in Alzheimer's disease

Visual fixation and saccadic eye movements were assessed in 31 mild to moderately demented patients with probable Alzheimer's disease (AD) and 31 age- and education-matched nondemented elderly control subjects. Seventeen AD and 17 matched control subjects were reassessed after a 9-month interval. On a fixation task, duration of fixation and number of intrusive saccades were not different between groups at baseline or follow-up. Both AD patients and control subjects showed more intrusive saccades at follow-up than at baseline. AD patients showed increased latency to initiation of saccades at baseline and on follow-up. Amplitude and velocity of saccades were not different between groups at any visit. Changes in measures of fixation, but no saccade measure, correlated with changes in MMSE scores over testing sessions. These data suggest that fixation is more sensitive than are saccades to the progession of AD.

The course and malleability of aggressive behavior from early first grade into middle school: results of a developmental epidemiologically-based preventive trial

The course and malleability of aggressive behavior from beginning elementary school through transition into middle school was investigated. In a developmental epidemiologically defined population of 1000 urban first graders, a two year classroom-based randomized preventive trial was aimed at reducing aggressive behavior, an antecedent of delinquency, violent behavior, and heavy drug use in adolescence and adulthood. Earlier we reported impact in first grade on teacher and peer ratings and on classroom observations. We report here on the course and on sixth grade teacher ratings of aggressive behavior. Improvement was observable during transition times, in first grade and in middle school, among the males in the preventive intervention who were more aggressive in first grade.

The effects of Alzheimer disease on driving-related abilities

Ten Alzheimer disease (AD) patients and 12 healthy elderly controls were evaluated on two tests of driving-related abilities: the Driver Performance Test (DPT) and the Driving Advisement System (DAS). Subjects were administered a battery of neuropsychological tests to determine if severity of dementia in AD correlates with driving performance. On the DPT, the AD patients scored in the average range in two of five skill areas (predicting the effects of a hazard, deciding how to avoid it); below average in two areas (searching for a hazard, executing evasive actions); and poorly in one area (identifying hazards). The elderly controls scored at an average level in all five skill areas. On the DAS, AD patients were significantly slower than the elderly controls on simple, two-choice, and conditional reaction time tests and were much slower than drivers in general. The AD patients' performances on two cognitive tests, the Mini-Mental State Examination (MMSE) and the Category Fluency Test, correlated significantly with aspects of performance on the DPT and the DAS. Although these are preliminary results from a pilot investigation, they suggest that AD patients' driving-related abilities are adversely affected by the disease and that driving-related performance tests and neuropsychological tests may be useful in assessing the impact of AD on driving.

Long-term retention of implicit learning in Huntington's disease

Implicit learning was examined in 15 Huntington's disease (HD) patients and 15 control subjects (NC) using a semantic decision-making task. HD patients demonstrated only slightly reduced priming; like NC subjects, their decision times decreased over repeated presentations, though to a somewhat lesser degree. On explicit recognition testing, the HD group made significantly more false positive errors than did the control group, suggesting an impairment of effortful retrieval. The groups displayed equivalent retention of implicitly learned material after 6 months. The striatal neuronal loss of early Huntington's disease does not markedly affect priming or retention of primed stimuli, but may alter explicit memory judgements.

Sleep disturbance and Alzheimer's disease: relationship to behavioral problems

We studied the sleep characteristics of 108 outpatients with probable Alzheimer's disease and found that sleep disturbance was significantly related to daytime behavioral disturbance but not to cognitive impairment. Possible treatment strategies and neuropathological and neurochemical mechanisms are discussed.

Effects of age and training on memory for pragmatic implications in advertising

Young adults (M age = 20.19 years) and old adults (M age = 67.58 years) were tested for their immediate memory of implicit and explicit information in commercial advertising. All participants read advertising passages for various fictitious products and evaluated the truthfulness of test sentences that paraphrased the critical claims pragmatically implied or directly asserted in the ad. In addition, half of the participants in each age group received individualized training in making implication-assertion discriminations. For both types of ad forms (implied, asserted), young and old adults produced an equivalent number of truth ratings, suggesting that both age groups are equally likely to interpret implied information as directly asserted fact. Analysis of the training results indicated that old as well as young adults learned to discriminate successfully between implied and asserted ad claims, although training had only a small effect on the participants' tendency to draw unwarranted inferences.

Adult age differences in the use of story structure in delayed free recall

Thirty-six young adults (M age = 24.3 years) and 36 old adults (M age = 71.8 years) listened to four double-episode stories having either standard, interleaved, or scrambled structure. Two days later they were asked to recall the stories. Analysis of the mean number of nodes recalled revealed no age differences in the recall of standard and scrambled stories with both groups recalling the standard stories equally well and the scrambled stories equally poorly. However, for interleaved stories, young adults followed their pattern of recall for standard stories while old adults followed their pattern for scrambled stories. Also, the age groups differed in their pattern of additions and distortions, with old adults giving more for standard stories and young adults giving more for scrambled stories. Results appear to support models of age-related differences in memory processes and/or strategies when material must be reorganized or hierarchized. Possible metacognitive differences were also discussed; i.e., old adults may aim to tell the story interestingly, while young adults aim to tell it accurately.

Planfulness and problem solving in older adults

The applicability of problem solving concepts such as planfulness and depth of search to older adult cognitive behavior was considered. Eighteen males (sixty to eighty-nine years) and eighteen females (sixty to eighty-two years) solved isomorphic inquiry problems involving elimination of number and letter alternatives from a twenty-four item stimulus array. Half of the participants were given planning instructions designed to deepen their search through existing knowledge, while half received no instructions. Analyses of the total number of questions to solution and the percentage reduction in number of alternatives produced by each question revealed no reliable gender-related differences. Planning instructions, however, reduced the number of questions prior to solution and increased the informational value of most inquiries. The results were interpreted in terms of a metacognitive strategy deficiency in later life. Theoretical issues related to the construction and validation of information-processing models that depend on "real-world" knowledge were discussed.

Age effects in problem solving in relation to irrelevant information, dimensional preference, and feedback

Forty middle-aged (M age=41.62 years) and forty elderly (M age= 72.22 years) women solved matrix problems that varied according to levels of irrelevant information and dimensional preferences. One-half of the women within each age group received corrective verbal feedback while solving the problems. Increasing levels of irrelevant information affected processing times and accuracy scores for both age groups, but middle-aged were significantly faster and more accurate than elderly. There was also evidence for the effects of dimensional preferences. On multidimensional matrix problems subjects made more errors by processing only a most preferred rather than only a least-preferred stimulus dimension. Feedback improved matrix performance, although its effects on the accuracy scores of the elderly were attenuated by the presence of less preferred dimensions. The findings were discussed in terms of an age-related, selective-attention deficit.

Effects of varying irrelevant information on adult age differences in problem solving

Sixty young (M = 20.6), middle-aged (M = 52.4), and elderly (M = 72.6) men and women solved problems which required them to match one of two stimulus arrays to a standard. On each problem one dimension (color, form, number, or position) was relevant to correct matching, and three dimensions, which were either variable or constant, were irrelevant to solution. Age and the number of variable irrelevant dimensions were the best predictors of reaction time and error scores. Young were significantly faster than middle-aged and the middle-aged were faster than the elderly. The elderly made most errors, but the young and middle-aged were not significantly different from each other. Reaction times and errors increased as the number of variable irrelevant dimensions increased. For the elderly there was a disproportionate increase in both reaction times and errors as levels of irrelevancy increased. No reliable differences were found with regard to gender. The results were discussed in terms of an age-related decline in the ability to ignore irrelevant information.

Dimensional preferences in middle and old age

Dimensional preferences in 40 middle-aged (M = 41.62 years) and 40 elderly (M = 72.22 years) females were assessed using a dimensional choice task. Significant age differences in reaction times of choice but not in number of dimensional choices were obtained. There was a perfect rank-order correspondence between the two age groups in dimensional choices with form being the most preferred and color the least preferred perceptual dimension.