Examining Utilization of Formal Supports and Related Impacts on Overall Well-Being Among East Asian American Family Caregivers of Persons With Dementia: A Mixed-Methods Study

BACKGROUND AND OBJECTIVES

Although East Asian American family caregivers are known to underutilize formal support services, there is a lack of evidence regarding the associations of formal service utilization with caregivers' well-being. This study examined the prevalence of different types of home-and community-based formal service utilization among Korean and Chinese American family caregivers of persons with dementia and how utilization of such services was associated with their well-being. We also explored their overall experience in accessing and utilizing formal dementia support services and programs.

RESEARCH DESIGN AND METHODS

We employed a convergent mixed-methods study design. In a convenience sampling method, we recruited 62 family caregivers. Logistic regression and thematic analysis were utilized to analyze data.

RESULTS

The results showed in-home services were mostly utilized among family caregivers of these ethnic groups. Out of 9 different support services, those who utilized nutrition programs and case management were more likely to report higher overall well-being. Four themes were developed: (1) awareness of formal support services but uncertainty on how to access them, (2) language barriers imposing additional challenges in accessing formal support services, (3) traveling to access culturally appropriate services, and (4) desire for culturally tailored medical and long-term care services.

DISCUSSION AND IMPLICATIONS

Findings from this study suggest the importance of case management services to overcome barriers to accessing and utilizing a wide range of formal support services and provision of culturally appropriate food in formal support services to increase East Asian American family caregivers' utilization of long-term care services.

Turning It Over to God: African American Assisted Living Residents' End-of-Life Preferences and Advance Care Planning

OBJECTIVES

Assisted living (AL), a popular long-term care setting for older Americans, increasingly is a site for end-of-life care. Although most residents prefer AL to be their final home, relatively little is known about end-of-life preferences and advance care planning, especially among African American residents. Our research addresses this knowledge gap.

METHODS

Informed by grounded theory, we present an analysis of qualitative data collected over 2 years in a 100-bed AL community catering to African American residents. Data consisted of field notes from participant observation conducted during 310 site visits and 818 observation hours, in-depth interviews with 25 residents, and a review of their AL records.

RESULTS

Residents varied in their end-of-life preferences and advance care planning, but united in the belief that God was in control. We identified "Turning it over to God" as an explanatory framework for understanding how this group negotiated end-of-life preferences and advance care planning. Individual-level resident factors (e.g., age, pain, and function) and factors reflecting broader cultural and societal influences, including health literacy and care experiences, were influential.

DISCUSSION

Contradictions arose from turning it over to God, including those between care preferences, planning, and anticipated or actual end-of-life outcomes.

Migration and Cognitive Health Disparities: The Arab American and Refugee Case

OBJECTIVES

This study investigates whether the year of arrival to the United States (U.S.) and birthplace relate to postmigration cognitive difficulties among foreign- and U.S.-born Arab Americans in later life.

METHODS

We analyzed 19 years (2000-2019) of data from the American Community Survey Public Use Microdata Samples (weighted N = 393,501; ages ≥ 50 years). Cognitive difficulty was based on self-reported data, and weighted means, percentages, adjusted prevalence estimates, and adjusted odds ratio were calculated.

RESULTS

Controlling only for demographics, foreign-born Arabs reported higher odds of cognitive difficulty compared to U.S.-born Arabs across all arrival cohorts (p < .001). After accounting for economic and integration factors, those who arrived between 1991 and 2000 had higher odds (odds ratio [OR] = 1.06, 95% confidence interval [CI] =1.00, 1.19, p < .01), while those who arrived after 2001 had lower odds (OR = 0.87, 95% CI = 0.78, 0.97, p < .001) of cognitive difficulty. Lacking English proficiency (OR = 1.90, 95% CI = 1.82, 1.98, p < .001) was related to higher odds, whereas not being a U.S. citizen was significantly associated with lower odds (OR = 0.89, 95% CI = 0.52, 0.94, p < .001) of cognitive difficulty. Yet, results varied by birthplace. Migrants born in Iraq consistently reported the highest odds of cognitive difficulty across all arrival cohorts.

DISCUSSION

Migration history and birthplace may be important factors explaining cognitive disparities among the diverse group of Arab migrants and Arab Americans. Future research examining mechanisms underlying these associations and the impact of migration on cognitive health is needed to address cognitive disparities in migrants.

Socioeconomic Status, Race/Ethnicity, and Unexpected Variation in Dementia Classification in Longitudinal Survey Data

OBJECTIVES

As dementia affects a growing number of older adults, it is important to understand its detection and progression. We identified patterns in dementia classification over time using a longitudinal, nationally representative sample of older adults. We examined the relationship between socioeconomic status and race/ethnicity, and patterns in dementia classification.

METHODS

Data for 7,218 Medicare beneficiaries from the 2011-2017 National Health and Aging Trends Study (NHATS) were classified into five categories: consistently no dementia, consistently cognitive impairment, "typical" dementia progression, "expected" variation, and "unexpected" variation. Multivariable multinomial logistic regression assessed relative risk of dementia classification by sociodemographic and health factors.

RESULTS

Among NHATS respondents, 59.5% consistently were recorded as having no dementia, 7% consistently cognitively impaired, 13% as having typical progression, 15% as having expected variation, and 5.5% as having unexpected variation. In multivariable models, compared with consistent dementia classification, less education, Medicare-Medicaid-dual enrollment, and identifying as non-Hispanic Black were associated with increased likelihood of unexpected variation (e.g., non-Hispanic Black adjusted risk ratio: 2.12, 95% CI: 1.61-2.78, p < .0001).

DISCUSSION

A significant minority of individuals have unexpected patterns of dementia classification over time, particularly individuals with low socioeconomic status and identifying as non-Hispanic Black. Dementia classification uncertainty may make it challenging to activate resources (e.g., health care, caregiving) for effective disease management, underscoring the need to support persons from at-risk groups and to carefully evaluate cognitive assessment tools to ensure they are equally reliable across groups to avoid magnifying disparities.

Sibling Deaths, Racial/Ethnic Disadvantage, and Dementia in Later Life

OBJECTIVES

Sibling loss is understudied in the bereavement and health literature. The present study considers whether experiencing the death of siblings in mid-to-late life is associated with subsequent dementia risk and how differential exposure to sibling losses by race/ethnicity may contribute to racial/ethnic disparities in dementia risk.

METHODS

We use discrete-time hazard regression models, a formal mediation test, and a counterfactual simulation to reveal how sibling loss in mid-to-late life affects dementia incidence and whether unequal exposures by race/ethnicity mediate the racial/ethnic disparities in dementia. We analyze data from the Health and Retirement Study (2000-2016). The sample includes 13,589 respondents (10,607 non-Hispanic White, 1,761 non-Hispanic Black, and 1,158 Hispanic adults) aged 65 years and older in 2000 who show no evidence of dementia at baseline.

RESULTS

Discrete-time hazard regression results show that sibling loss in mid-to-late life is associated with up to 54% higher risk for dementia. Sibling loss contributes to Black-White disparities in dementia risk. In addition, a simulation analysis shows that dementia rates would be 14% lower for Black adults if they experienced the lower rates of sibling loss experienced by White adults. This pattern was not observed among Hispanic adults.

DISCUSSION

The death of a sibling in mid-to-late life is a stressor that is associated with increased dementia risk. Black adults are disadvantaged in that they are more likely than Whites to experience the death of siblings, and such losses contribute to the already substantial racial/ethnic disadvantage in dementia.

Health Care Access and Utilization for American Indian Elders: A Concept-Mapping Study

OBJECTIVES

Inequities in access to and utilization of health care greatly influence the health and quality of life of American Indian elders (AIEs). This study explores the importance and perceived prevalence of factors affecting health care use within this population and assesses the changeability of these factors to produce a list of action items that are timely and relevant to improving health care access and utilization.

METHOD

Concept mapping was conducted with AIEs (n = 65) and professional stakeholders (n = 50), including tribal leaders, administrators of public-sector health systems, outreach workers, and health care providers. Data were analyzed using multidimensional scaling and cluster analyses.

RESULTS

The final concept-map model comprised nine thematic clusters related to factors affecting elder health care: Difficulties Obtaining and Using Insurance; Insecurity from Lack of Knowledge; Limited Availability of Services; Scheduling Challenges; Provider Issues and Relationships; Family and Emotional Challenges; Health-Related Self-Efficacy and Knowledge; Accessibility and Transportation Barriers; and Tribal/National Policy.

DISCUSSION

Findings suggest that improvements in access to and utilization of health care among AIEs will require actions across multiple domains, including health system navigation services, workforce improvements, and tribal, state, and federal policy. A multilevel socioecological approach is necessary to organize and undertake these actions.

Cumulative Inequality at the End of Life?: Racial Disparities in Impairment in the Time Before Death

OBJECTIVES

Drawing from cumulative inequality (CI) theory, the current study examined racial disparities in impairment as individuals approached death to determine whether proposed mechanisms hypothesized to fuel or diminish racial disparities at late ages were at work at the end of individualized life spans.

METHOD

Black-white disparities were analyzed among decedents using latent growth curves based on the data from the North Carolina Established Populations for Epidemiologic Studies of the Elderly (EPESE) (N = 1,926).

RESULTS

Consistent with previous literature, racial inequalities in functional disparities diminish at late ages. However, significant black-white disparities emerge as older adults approach death, exponentially increasing within the 2 years immediately preceding death. Further, these disparities are not fully mediated by socioeconomic status.

DISCUSSION

The results confirm that CI in health outcomes is observable in late life among individual life spans, suggesting the years surrounding death may be a particularly vulnerable period for health inequality. Future research should examine how advantaged statuses translate to increased access to health-related resources that aid in maintaining greater functional independence until the last stage of life.

Black-White Disparities in Moves to Assisted Living and Nursing Homes Among Older Medicare Beneficiaries

OBJECTIVES

Investigate black-white disparities in older adults' moves to assisted living and nursing homes and draw from the Andersen Healthcare Utilization Model to test explanations for any disparities.

METHODS

Data are from a nationally representative sample of older community-dwelling Medicare beneficiaries from the 2015 (N = 5,212) National Health and Aging Trends Study (NHATS). We use stepwise multinomial logistic regression to examine black-white disparities in moves out of community housing to assisted living or a nursing home over 2 years, before and after adjusting for predisposing (age, gender), enabling (income, housing tenure, Medicaid, living arrangement) and need (activities of daily living [ADL] limitation, physical capacity, self-rated health, and dementia) factors.

RESULTS

Black older adults are less likely to move to assisted living and are more likely to move to a nursing home compared to white older adults. Black-white disparities in moves to nursing homes are explained by black-white differences in enabling and need factors, whereas black-white disparities in moves to assisted living remain even after adjusting for enabling and need factors.

DISCUSSION

Unmeasured factors related to systemic racism (e.g., residential racial segregation, racial discrimination) and/or black-white differences in care preferences might further explain black-white disparities in moves to assisted living and warrant further investigation.

Cultural differences in the intended use of long-term care services in the United States: The role of family ties

OBJECTIVES

In the light of an increasingly diverse older population in the United States, there is an ongoing discussion how cultural factors contribute to individual long-term care (LTC) needs and service use. This study empirically assesses whether the level of acculturation and cultural differences in the importance of the family shape foreign-born immigrants' intention to use certain LTC services.

METHODS

We correlated immigrants' intention to use certain LTC services to the cultural strength of family ties that prevails in their region of origin. We used data from the National Health Interview Survey and the World Values Survey/European Values Study for analysis. Multinomial logit models were estimated and predisposing, enabling, and need factors were controlled for. Estimations were weighted to account for the sampling structure and sensitivity analyses were conducted.

RESULTS

Immigrants from cultures with stronger family ties are significantly more likely to intend the use of LTC options that include the family. Furthermore, immigrants are less likely to intend the use of exclusively family care when having lived in the United States for a longer time.

DISCUSSION

We conclude that cultural differences in family ties shape immigrants' intention to use certain LTC services. If policy makers aim at increasing the provision of specific LTC services or support to family caregivers, there should be a careful evaluation of demand-side factors in an increasingly culturally diverse society.

The Color of COVID-19: Structural Racism and the Disproportionate Impact of the Pandemic on Older Black and Latinx Adults

Objectives

The aim of this evidence-based theoretically informed essay is to provide an overview of how and why the COVID-19 outbreak is particularly detrimental for the health of older Black and Latinx adults.

Methods

We draw upon current events, academic literature, and numerous data sources to illustrate how biopsychosocial factors place older adults at higher risk for COVID-19 relative to younger adults, and how structural racism magnifies these risks for older Black and Latinx adults.

Results

We identify three proximate mechanisms through which structural racism operates as a fundamental cause of racial/ethnic inequalities in COVID-19 burden among older adults: (1) Risk of exposure; (2) Weathering processes; and (3) Health care access and quality.

Discussion

While the ongoing COVID-19 pandemic is an unprecedented crisis, the racial/ethnic health inequalities among older adults it has exposed are long-standing and deeply rooted in structural racism within American society. This knowledge presents both challenges and opportunities for researchers and policymakers as they seek to address the needs of older adults. It is imperative that federal, state, and local governments collect and release comprehensive data on the number of confirmed COVID-19 cases and deaths by race/ethnicity and age to better gauge the impact of outbreak across minority communities. We conclude with a discussion of incremental steps to be taken to lessen the disproportionate burden of COVID-19 among older Black and Latinx adults, as well as the need for transformative actions that address structural racism in order to achieve population health equity.

Death of a Child Prior to Midlife, Dementia Risk, and Racial Disparities

OBJECTIVES

This study considers whether experiencing the death of a child prior to midlife (by parental age 40) is associated with subsequent dementia risk, and how such losses, which are more common for black than for white parents, may add to racial disparities in dementia risk.

METHODS

We use discrete-time event history models to predict dementia incidence among 9,276 non-Hispanic white and 2,182 non-Hispanic black respondents from the Health and Retirement Study, 2000-2014.

RESULTS

Losing a child prior to midlife is associated with increased risk for later dementia, and adds to disparities in dementia risk associated with race. The death of a child is associated with a number of biosocial variables that contribute to subsequent dementia risk, helping to explain how the death of child may increase risk over time.

DISCUSSION

The death of a child prior to midlife is a traumatic life course stressor with consequences that appear to increase dementia risk for both black and white parents, and this increased risk is explained by biosocial processes likely activated by bereavement. However, black parents are further disadvantaged in that they are more likely than white parents to experience the death of a child, and such losses add to the already substantial racial disadvantage in dementia risk.

Disablement in Context: Neighborhood Characteristics and Their Association With Frailty Onset Among Older Adults

OBJECTIVES

Frailty, an aggregate expression of risk resulting from age- or disease-associated physiologic accumulation, is responsible for large economic and societal costs. Little is known about how the context in which older adult's live may contribute to differences in frailty. This study clarifies the role of neighborhood structural characteristics and social processes for understanding declines in health status.

METHOD

Data from two waves of the National Social Life, Health and Aging Project were linked to tract-level information from the 2000 Census (n = 1,925). Frailty was measured with in-home assessments and self-report. Ordered logistic regressions were employed to estimate the role of tract-level structural and social process indicators at baseline on frailty at follow-up.

RESULTS

Living in a neighborhood characterized with a higher density of African Americans and with more residential instability was associated with higher odds of frailty. Adults in neighborhoods with increasing levels of physical disorder had higher odds of frailty (adjusted odds ratio [AOR]: 1.20, 95% confidence interval [CI]: 1.03, 1.39), while those exposed to more social cohesion had lower odds (AOR: 0.87, CI: 0.78, 0.97).

DISCUSSION

For older adults, both neighborhood structural and social process characteristics appear to be independently associated with frailty.

Double Disadvantage in the Process of Disablement: Race as a Moderator in the Association Between Chronic Conditions and Functional Limitations

OBJECTIVES

This study evaluated (a) whether the association between chronic conditions and functional limitations vary by race/ethnicity, and (b) whether socioeconomic status accounted for any observed racial variation in the association between chronic conditions and functional limitations.

METHOD

The Health and Retirement Study data were used to assess whether race/ethnicity moderated the association between chronic conditions and functional limitations, and whether education, income, and/or wealth mediated any of the observed moderation by race/ethnicity.

RESULTS

Results from structural equation models of latent growth curves with random onset indicated that (a) the positive association between chronic conditions and functional limitations onset was larger for African Americans and Hispanics than it was for Whites, but (b) this difference largely persisted net of socioeconomic status.

DISCUSSION

African Americans and Hispanics endure a multiplicative double disadvantage in the early stages of the disablement process where they experience (a) a more rapid onset and higher levels of functional limitations, and (b) greater risk of functional limitation onset associated with chronic conditions compared to their White counterparts. Moreover, basic economic policies are unlikely to curtail the greater risk of functional limitations onset associated with chronic conditions encountered by African Americans and Hispanics.

A New Look at the Living Arrangements of Older Americans Using Multistate Life Tables

OBJECTIVES

We extend existing research on the living arrangements of older Americans by focusing on geographic proximity to children, examining transitions in living arrangements across older ages, and describing differences by both race/ethnicity and educational attainment.

METHOD

We use data from the Health and Retirement Study (HRS) over a period of 10 years (2000-2010) to construct multistate life tables. These analyses allow us to describe the lives of older Americans between ages 65 and 90 in terms of the number of expected years of life in different living arrangements, reflecting both mortality and living arrangement transitions.

RESULTS

Americans spend a substantial proportion of later life living near, but not with, adult children. There is a good deal of change in living arrangements at older ages and living arrangement-specific life expectancy differs markedly by race/ethnicity and educational attainment. However, overall life expectancy is not strongly related to living arrangements at age 65.

DISCUSSION

Multistate life tables, constructed separately by sex, race/ethnicity, and educational attainment, provide a comprehensive description of sociodemographic differences in living arrangements across older ages in the United States. We discuss the potential implications of these differences for access to support and the exacerbation or mitigation of inequalities at older ages.

U.S. Immigration Policy Regimes and Physical Disability Trajectories Among Mexico-U.S. Immigrants

OBJECTIVES

Although immigration policies have shifted dramatically over the course of U.S. history, few have examined their role as a source of health heterogeneity among immigrants. We address this gap by evaluating whether exposure to U.S. Immigration Policy Regimes (IPRs) corresponds with later-life disability disparities among Mexico-U.S. migrant women and men, and assess the degree to which observed differences may also be associated with immigration policies and occupational composition.

METHOD

We analyze 8 waves of data from the Hispanic Established Populations for the Epidemiologic Study of the Elderly (3,044 individuals and 14,474 observations from 1993/1994-2013). Using hierarchical linear models, we estimate trajectories of physical disability associated with gender, occupation, and IPR.

RESULTS

We find differences in disability trajectories by IPR. Associations are not different between men and women, and are not mediated by occupational composition. We also observe an additive effect for certain occupations among women, but not among men.

DISCUSSION

Findings demonstrate that exposure to different IPRs is associated with disparate disability trajectories among Mexico-U.S. migrants. Future research is needed to contextualize the role of IPRs amid other mechanisms of gendered racialization that powerfully contribute to cumulative health differences across the life course.

Childhood Adversity and Men's Relationships in Adulthood: Life Course Processes and Racial Disadvantage

OBJECTIVES

Prior U.S. population studies have found that childhood adversity influences the quality of relationships in adulthood, with emerging research suggesting that this association might be especially strong for black men. We theorize psychosocial and behavioral coping responses to early life adversity and how these responses may link early life adversity to strain in men's relationships with their indeterminate partners and children across the life course, with attention to possible racial variation in these experiences and implications for later life well-being.

METHOD

We analyze in-depth interviews with 15 black men and 15 white men. We use qualitative analysis techniques to connect childhood experiences to psychosocial processes in childhood and behavioral coping strategies associated with relationship experiences throughout adulthood.

RESULTS

Black men describe much stronger and more persistent childhood adversity than do white men. Findings further suggest that childhood adversity contributes to psychosocial processes (e.g., diminished sense of mastery) that may lead to ways of coping with adversity (e.g., self-medication) that are likely to contribute to relationship difficulties throughout the life span.

DISCUSSION

A life course perspective directs attention to the early life origins of cumulative patterns of social disadvantage, patterns that extend to later life. Our findings suggest psychosocial and behavioral pathways through which early life adversity may constrain and strain men's relationships, possibly contributing to racial inequality in family relationships across the life span.