Unrelenting Growth and Diversification: Using the Health and Retirement Study to Illuminate Cannabis Use Among Aging Americans

BACKGROUND AND OBJECTIVES

Cannabis use among aging Americans continues to increase. We examine correlates of cannabis use including attitudes, state of residence, health status, and service use.

RESEARCH DESIGN AND METHODS

Using the 2018 Health and Retirement Study Cannabis module completed by 1,372 respondents aged 50 and older, we distinguished current cannabis users from those who have never used or have some prior use. We linked 2018 and 2016 core HRS data and used multinomial regressions to identify associations among current use, attitudes, place of residence, as well as current (2018) and past (2016) medical conditions, pain, and sleep issues. We also examined associations among cannabis use, hospital stays, and outpatient medical visits.

RESULTS

Past-year cannabis use reached 10.3% among aging Americans. Attitudes toward cannabis have changed over time with 4 of 5 survey respondents currently holding a favorable attitude. Attitude and state of residence were associated with current use. Cannabis users reported higher levels of pain, were more likely to use prescription opioids, and report activity limitations in both 2016 and 2018. Associations between cannabis use and sleep issues or concurrent healthcare use were not observed.

DISCUSSION AND IMPLICATIONS

Changing attitudes and state legalization appear important for late middle-aged and older persons, and as many as 1 of every 5 persons over 50 may be using cannabis by 2030. Cannabis use among aging Americans warrants increased attention from care providers, program administrators, and policymakers, especially as a prevention or harm reduction strategy relative to prescription opioids.

Autumn in New York: The Case of Long-Term Care Facilities in the "Safe Staffing" Lawsuit With Less Staffing But Similar COVID-19 Outcomes

BACKGROUND AND OBJECTIVES

In 2022, 239 New York state long-term care facilities (LTCFs) challenged a "Safe Staffing" law in court. Our study compares LTCFs involved and not involved in the lawsuit, testing for differences in staffing measures and resident outcomes during the first year of the coronavirus disease 2019 (COVID-19) pandemic.

RESEARCH DESIGN AND METHODS

New York LTCF-level data were obtained from the Centers for Medicare and Medicaid Services 2019 organization and 2020 COVID-19 data files. These data were then linked to data from the Long-Term Care Community Coalition, which identified the LTCFs involved in the "Safe Staffing" lawsuit. We first tested for differences in reported 2019 staffing levels by lawsuit involvement. Second, we specified "Doubly Robust" regression models to test if lawsuit involvement was associated with differences in resident COVID-19 infections, COVID-19 deaths, and overall mortality.

RESULTS

LTCFs involved in the lawsuit reported lower staff ratings and fewer staffing hours compared to LTCFs not involved in the lawsuit. Despite finding higher rates of admissions with COVID-19 in LTCFs involved in the lawsuit, we did not find that COVID-19 infections, COVID-19 deaths, or overall mortality differed by lawsuit involvement.

DISCUSSION AND IMPLICATIONS

LTCFs involved in the lawsuit were deemed by policymakers as reducing staff, earning excess profits, and placing residents at risk. While these LTCFs reported lower staffing levels, we observed no differences in resident outcomes during the first year of the COVID-19 pandemic. Researchers and policymakers should develop more nuanced perspectives concerning the relationship among LTCF staffing, outcomes, and organizational profitability.

Offering an Alternative to Persons with Chronic Pain: How Access to Cannabis May Provide an Off-Ramp from Undesired Prescription Opioid Use

Background

Chronic pain (CP) is experienced by as many as 50 million Americans and can negatively impact physical and mental health. Prescribing opioids is the most common approach to address moderate to severe CP though these potent analgesics are associated with a significant number of side effects. One alternative some Americans are turning to for CP management is cannabis. In addition to serving as an alternative, many individuals with CP use cannabis in addition to using prescription opioids. This study examined individuals with CP who enrolled in the state of Illinois' opioid diversion program, the Opioid Alternative Pilot Program (OAPP), which offers individuals aged 21 and older a separate pathway to access medical cannabis if they have or could receive a prescription for opioids as certified by a licensed physician.

Methods

Cross-sectional survey data were collected from 450 participants. We described participants and compared those who use only cannabis with those who use cannabis and opioids.

Results

While 16% of the respondents were cannabis-only users, 84% of the respondents were co-users of opioids and cannabis. Both groups considered opioid use risky (100% cannabis-only, 89% co-users,). The majority (73%) of respondents sought to completely stop or never start using opioids for CP. Cannabis-only users reported lower levels of pain compared to co-users. Co-users (85%) were more likely to have their routine provider as a cannabis certifying physician than cannabis-only users (69%).

Conclusion

With increasing clinical evidence, legalization and acceptance, researchers should continue to examine how cannabis may be a viable alternative to reduce the risk of prescription opioid side effects, misuse, or dependence. Our findings also inform health care providers and state policymakers who increasingly are being asked to consider how cannabis may reduce the potential for harmful outcomes among persons with CP who use prescription opioids.

Pathways into Assisted Living Communities: Admission Limitations and Assessment Requirements Across the United States

OBJECTIVES

Limitations to admission play a critical role in shaping the composition of residents residing within licensed assisted living (AL) communities.

DESIGN

We document variation across 165 licensure classifications in how state agencies limit who AL communities may admit and what assessments are required to make those determinations.

SETTING AND PARTICIPANTS

AL regulations and licensed AL communities across all 50 states in 2018.

METHODS

We estimated the proportion of all licensed AL communities regulated by admission limitations and identified groups consisting of those that limit admission based on a health-related condition, specified behavior, mental health condition, and/or cognitive impairment as well as those that impose no limitations to admission. We also estimated the proportion of all licensed AL communities required to conduct assessments at time of admission.

RESULTS

The largest group of ALs (29% nationally) is governed by regulations limiting the admission of persons with a health condition. The next largest group of AL communities (23.6%) limit admissions based on health, specified behavior, mental health conditions, and cognitive impairment. In contrast, 11.1% of licensed AL communities have no regulations restricting admissions. We also found that more than 8 of every 10 licensed communities were required to have residents complete a health assessment at admission, but less than half were required to complete a cognitive assessment.

CONCLUSIONS AND IMPLICATIONS

The variation we observe implies that state agencies have created multiple licensure classifications that serve as a mechanism for sorting types of residents into settings based on their need (eg, health, mental health, cognitive). Although future research should investigate the implications of this regulatory diversity, the categories outlined here may be helpful to clinicians, consumers, and policy makers to better understand the options in their state and how various AL licensure classifications compare to one another.

Promoting Quality of Life and Safety in Assisted Living: A Survey of State Monitoring and Enforcement Agents

Our goal was to learn about monitoring and enforcement of state assisted living (AL) regulations. Using survey responses provided in 2019 from administrative agents across 48 states, we described state agency structures, accounted for operational processes concerning monitoring and enforcement, and documented data collecting and public reporting efforts. In half of the states, oversight of AL was dispersed across three or more agencies, and administrative support varied in terms of staffing and budget allocations. Operations also varied. While most agents could deploy a range of monitoring and enforcement tools, less than half compiled data concerning inspections, violations, and penalties. Less than 10 states shared such information in a manner that was easily accessible to the public. Future research should determine how these varied administrative structures and processes deter or contribute to AL communities' efforts to implement regulations designed to promote quality of life and provide for the safety of residents.

Medical Cannabis and Utilization of Nonhospice Palliative Care Services: Complements and Alternatives at End of Life

Background and Objectives

There is a need to know more about cannabis use among terminally diagnosed older adults, specifically whether it operates as a complement or alternative to palliative care. The objective is to explore differences among the terminal illness population within the Illinois Medical Cannabis Program (IMCP) by their use of palliative care.

Research Design and Methods

The study uses primary, cross-sectional survey data from 708 terminally diagnosed patients, residing in Illinois, and enrolled in the IMCP. We compared the sample on palliative care utilization through logistic regression models, examined associations between palliative care and self-reported outcome improvements using ordinary least squares regressions, and explored differences in average pain levels using independent t-tests.

Results

115 of 708 terminally diagnosed IMCP participants were receiving palliative care. We find increased odds of palliative care utilization for cancer (odds ratio [OR] [SE] = 2.15 [0.53], p < .01), low psychological well-being (OR [SE] = 1.97 [0.58], p < .05), medical complexity (OR [SE] = 2.05 [0.70], p < .05), and prior military service (OR [SE] = 2.01 [0.68], p < .05). Palliative care utilization is positively associated with improvement ratings for pain (7.52 [3.41], p < .05) and ability to manage health outcomes (8.29 [3.61], p < .01). Concurrent use of cannabis and opioids is associated with higher pain levels at initiation of cannabis dosing (p < .05).

Discussion and Implications

Our results suggest that cannabis is largely an alternative to palliative care for terminal patients. For those in palliative care, it is a therapeutic complement used at higher levels of pain.

Comparing Cannabis Use Across Diagnosed Conditions: Apples and Oranges?

Although researchers have identified medications that relieve symptoms of Multiple Sclerosis (MS), none are entirely effective and some persons with multiple sclerosis (PwMS) use alternatives. Our study compared cannabis use among PwMS (N=135) and persons diagnosed with arthritis (N=582) or cancer (N=622) who participated in the Illinois medical cannabis program. We tested for significant differences across psychological well-being, quality of life and three behavioral outcomes, and also considered effects of co-occurring prescription opioid use. A majority of all individuals used cannabis to address pain and improve quality of sleep. PwMS reported lower levels of productivity, exercise and social activity, and cannabis was less helpful with improving these particular outcomes. Most persons used cannabis for sleep or digestive problems and we found no differences across groups in terms of well-being and quality of life. This comparative evaluation suggests cannabis mechanisms are not specific as much as they impact common processes.

The Relationship Between States' Staffing Regulations And Hospitalizations Of Assisted Living Residents

Assisted living provides housing and long-term care services to more than 811,000 older adults in the United States daily and is regulated by the states. This article describes changes in the specificity of state regulations governing the staffing in assisted living settings (that is, requirements for sufficient staffing or staffing ratios or levels) between 2007 and 2018 and the association between these changes and rates of hospitalization among a national sample of assisted living residents, including a subgroup with dementia. We found that increased regulatory specificity for direct care workers (for example, a change from requiring "sufficient" direct care worker staffing to requiring a specific staffing ratio or level) was associated with a 4 percent reduction in the monthly risk for hospitalization among residents in our sample and a 6 percent reduction among the subgroup with dementia. However, an increase in regulatory specificity for licensed practical nurses was associated with a 2.5 percent increase in the monthly risk for hospitalization and a 5 percent increase among the subgroup with dementia. Given that no federal requirements exist for the number of staff members or composition of staff in assisted living, these findings can inform states' policy decisions about staffing requirements for assisted living settings.

Cannabis and End-of-Life Care: A Snapshot of Hospice Planning and Experiences Among Illinois Medical Cannabis Patients With A Terminal Diagnosis

INTRODUCTION

Between 2013 and 2019, Illinois limited cannabis access to certified patients enrolled in the Illinois Medical Cannabis Program (IMCP). In 2016, the state instituted a fast-track pathway for terminal patients. The benefits of medicinal cannabis (MC) have clear implications for patients near end-of-life (EOL). However, little is known about how terminal patients engage medical cannabis relative to supportive care.

METHODS

Anonymous cross-sectional survey data were collected from 342 terminal patients who were already enrolled in (n = 19) or planning to enroll (n = 323) in hospice for EOL care. Logistic regression models compare patients in the sample on hospice planning vs. hospice enrollment, use of palliative care vs. hospice care, and use standard care vs non-hospice palliative care.

RESULTS

In our sample, cancer patients (OR = 0.21 (0.11), p < .01), and those who used the fast-track application into the IMCP (OR = 0.11 (0.06), p < .001) were less likely to be enrolled in hospice. Compared to patients in palliative care, hospice patients were less likely to report cancer as their qualifying condition (OR = 0.16 (0.11), p < .01), or entered the IMCP via the fast-track (OR = 0.23 (0.15), p < .05).

DISCUSSION

Given low hospice enrollment in a fairly large EOL sample, cannabis use may operate as an alternative to supportive forms of care like hospice and palliation. Clinicians should initiate conversations about cannabis use with their patients while also engaging EOL Care planning discussions as an essential part of the general care plan.

Biopsychosocial factors and health outcomes associated with cannabis, opioids and benzodiazepines use among older veterans

Background: Older Veterans may experience injuries that result in chronic pain and mental health conditions. Given the increasing availability of medical cannabis, it is important to examine if it serves as a viable or undesirable form of care relative to existing approaches.Objectives: We compared cannabis, prescription opioids, and benzodiazepines use between older Veteran and non-Veterans, and identified outcomes of cannabis use among Veterans. Because of the physical and mental conditions experienced by older Veterans we expected Veterans to report higher use of opioids and benzodiazepines compared to non-Veterans.Methods: We collected surveys from individuals aged 60 and older enrolled in the Illinois Medical Cannabis Patient Program and conducted logistic regression to identify factors associated with cannabis, opioids and benzodiazepines use between Veterans (N = 514, 90.2% male) and Non-Veterans (N = 2758, 41.1% male) across biopsychosocial factors.Results: Both groups reported similar levels of pain, quality of life, social satisfaction, and sleep quality. Veterans were more likely to use cannabis for mental health conditions (p = <.001) while they reported lower use for pain-related conditions (p = <.001) than non-Veterans. Veterans were less likely to use opioids (p = .013) and benzodiazepines (p < .01) compared to non-Veterans. Veterans also reported desirable health outcomes of cannabis use for pain, sleep quality, health conditions, and quality of life.Conclusions: Our work provides insights for clinicians and policy makers to consider whether cannabis can be a viable option to reduce or replace opioid and benzodiazepine use by older Veterans with chronic physical and mental health conditions.

Connecting policy to licensed assisted living communities, introducing health services regulatory analysis

OBJECTIVE

To document dementia-relevant state assisted living regulations and their changes over time as they pertain to licensed care settings.

DATA SOURCES

For all states, current directories of licensed assisted living communities and state regulations for each year, 2007-2018, were obtained from state agency websites and Nexis Uni, respectively.

STUDY DESIGN

We identified multiple types of regulatory classifications for each state and documented the presence or absence of specific dementia care provisions in the regulations for each type by study year. Maps and summary statistics were used to compare results to previous research and document change longitudinally.

DATA COLLECTION/EXTRACTION METHODS

We used a policy analysis approach to connect communities listed in directories to applicable regulatory text. Then, we employed policy surveillance and question-based coding to record the presence or absence of specific policies for each classification and study year.

PRINCIPAL FINDINGS

Our team empirically documented provisions requiring dementia-specific training for administrators and direct care staff, and cognitive impairment screening for each study year. We found that 23 states added one or more of these requirements for one or more license types, but the states that had these provisions for all types of licensed assisted living declined from four to two.

CONCLUSIONS

We identified significant, previously undocumented, within-state policy variation for assisted living licensed settings between 2007 and 2018. Using the regulatory classification instead of the state as the unit of analysis revealed that many policy adoptions were limited to dementia-designated settings. This suggests that people living with dementia in general assisted living are not afforded the same protections. We call our approach health services regulatory analysis and argue that it has the potential to identify gaps in existing policies, an important endeavor for health services research in assisted living and other care settings.

Cannabis Use among Persons with Dementia and Their Caregivers: Lighting up an Emerging Issue for Clinical Gerontologists

Objectives: Our goal is to illuminate cannabis use among persons with dementia (PwD) and their informal caregivers relative to the use of evidence-based as well as other complementary and alternative care practices. Methods: We analyzed focus group (FG) narratives provided by 26 caregivers of PwD and identified five themes concerning the provision of cannabis to PwD and caregivers' self-use. Results: Three of the 26 caregivers provided PwD cannabis and also used themselves, another 3 of the 26 used themselves only, and all but two of the remaining FG participants indicated they would consider providing cannabis to PwD or using for themselves. These caregivers expressed a desire to obtain more empirically-based information about cannabis and to discuss options with their clinical care providers. Conclusions: A small but significant proportion of caregivers are providing cannabis to PwD as a possible treatment for agitation, sleep disturbances and other problematic secondary symptoms and using for themselves as way to relieve stress. Many other caregivers may start using cannabis upon receiving information and guidance from a credible source. Clinical Implications: Notwithstanding the need for more research, clinical gerontologists and other dementia care specialists are being looked upon to provide information and guidance about the benefits and harms of cannabis use among PwD and their caregivers.

Assessing Health-Related Outcomes of Medical Cannabis Use among Older Persons: Findings from Colorado and Illinois

OBJECTIVES

To assess health-related outcomes associated with medical cannabis use among older patients in Colorado and Illinois enrolled in their home state's medical cannabis program.

METHODS

Cross-sectional data from anonymous surveys were collected from 139 persons over the age of 60 using medical cannabis in the past year. We used structural equation modeling (SEM) to confirm the hypothesized four-factor structure that includes health-related quality of life (HRQL), health-care utilization (HCU), symptom effects, and adverse events. We then examined associations between cannabis use and self-reported outcome changes using linear regression.

RESULTS

The four-factor model was the best fitting structure (X2(df) = 81.63 (67), p> X2 = 0.108) relative to reduced structures. We also found that using cannabis 1-4 times per week is associated with 3.30 additional points on the HRQL scale (p < .001), 2.72 additional points on the HCU scale (p < .01), and 1.13 points on pain (p < .001). The frequency of use reported at 5-7 times per week is associated with 4.71 additional HRQL score points (p < .001). No significant associations were observed between the frequency of use and adverse events.

CONCLUSIONS

We observed how cannabis use outcomes fall into four independent factors, and those using more frequently reported higher values on HRQL, HCU, and pain measures. However, we are cautious about the generalizability of our findings.

CLINICAL IMPLICATIONS

Clinicians should consider how older patients using medical cannabis can experience positive and negative outcomes simultaneously or separately and assess these outcomes directly along with considering patient self-reports.

The Intersection of Medicaid and Assisted Living for Residents with Dementia

Medicaid has increasingly offered coverage to persons residing in assisted living (AL). However, the scope of coverage across states is unknown. We sourced 2019 state administrative regulations specific to Medicaid and AL and determined forty-five (45) states link Medicaid with AL. Twenty-seven (27) do so as part of their state plan, 32 use a §1915(c) waiver, and 11 use a §1115 waiver. Forty-four states limit Medicaid coverage to a specific population, 16 limit coverage to those with a diagnosed disability, and 1 state limits coverage to a specific geographic region. In addition, 33 states provide payment for room and board with 28 states upholding a payment cap. In regards to services, 13 states reimburse a limited range of services while 32 offer a more expansive range of services. As Medicaid programs have extended coverage to residents of AL, researchers must now consider the impact on AL access and residents’ outcomes. Part of a symposium sponsored by Assisted Living Interest Group.

Measuring Attitudes Toward Medical and Recreational Cannabis Among Older Adults in Colorado

BACKGROUND AND OBJECTIVES

Cannabis use among older adults is on the rise. Despite growing interest in the topic, there exists a paucity of standardized measures capturing cannabis-specific attitudes among older adults. Using data from a survey of older Coloradans, we create two scales that separately measure medical and recreational cannabis attitudes. We also examine how these two attitudes relate to individual-level characteristics.

RESEARCH DESIGN AND METHODS

We assess reliability using Cronbach's alpha and item-rest correlations and perform confirmatory factor analyses to test the two attitude models. We conduct a seemingly unrelated regression estimation to assess how individual characteristics predict medical and recreational cannabis attitude scores.

RESULTS

Twelve indicators combined into two valid and reliable scales. Both scales had a three-factor structure with affect, cognition and social perception as latent dimensions. For both scales, fit indices for the three-factor model were statistically superior when compared with other models. The three-factor structure for both scales was invariant across age groups. Age, physical health, and being a caregiver differentially predicted medical and recreational cannabis attitude scores.

DISCUSSION AND IMPLICATIONS

Medical and recreational cannabis attitude scales can inform the development and evaluation of tailored interventions targeting older adult attitudes that aim to influence cannabis use behaviors. These scales also enable researchers to measure cannabis-specific attitudes among older adults more accurately and parsimoniously, which in turn can facilitate a better understanding of the complex interplay between cannabis policy, use, and attitudes.

Medicaid managed care in Iowa: Experiences of older adults and people with disabilities

BACKGROUND

A growing number of states are turning to managed care arrangements to provide care to senior and disabled Medicaid beneficiaries. Despite their complex care needs, very little is known about the experience of these individuals in managed care.

OBJECTIVE

To document experiences of a sample of aged and disabled Medicaid beneficiaries receiving long-term services and supports through managed care in Iowa and to assess whether these experiences changed over time.

METHODS

A purposive sample of 49 aged and disabled beneficiaries enrolled in one of seven HCBS waivers in Iowa was recruited in 2017. Telephone surveys were conducted in 2017 and 2019. A conventional content analysis was used to generate themes, which were then ranked by frequency proportions. Thematic frequencies were compared across waves among repeat respondents.

RESULTS

Content analysis yielded seven themes in the following areas: system navigation; service approvals; provider relations; customer service; case management; perception of Iowa's transition to managed care; and oversight. Concerns with service approvals was the most frequently reported theme and within this, issues related to changes in approved services or hours and quality of newly approved services comprised the largest number of references. Beneficiary concerns appeared to grow over time among respondents participating in both survey interview waves.

CONCLUSION

The results of this study point to serious and persistent concerns related to access and quality of care under managed care for at least some HCBS waiver participants in Iowa, underscoring the need for a comprehensive evaluation of the program.

Preserving stroke care during the COVID-19 pandemic: Potential issues and solutions

The coronavirus 2019 (COVID-19) pandemic requires drastic changes in allocation of resources, which can affect the delivery of stroke care, and many providers are seeking guidance. As caregivers, we are guided by 3 distinct principles that will occasionally conflict during the pandemic: (1) we must ensure the best care for those stricken with COVID-19, (2) we must provide excellent care and advocacy for patients with cerebrovascular disease and their families, and (3) we must advocate for the safety of health care personnel managing patients with stroke, with particular attention to those most vulnerable, including trainees. This descriptive review by a diverse group of experts in stroke care aims to provide advice by specifically addressing the potential impact of this pandemic on (1) the quality of the stroke care delivered, (2) ethical considerations in stroke care, (3) safety and logistic issues for providers of patients with stroke, and (4) stroke research. Our recommendations on these issues represent our best opinions given the available information, but are subject to revision as the situation related to the COVID-19 pandemic continues to evolve. We expect that ongoing emergent research will offer additional insights that will provide evidence that could prompt the modification or removal of some of these recommendations.

State Variability in the Prevalence and Healthcare Utilization of Assisted Living Residents with Dementia

OBJECTIVES

Almost 1 million older and disabled adults who require long-term care reside in assisted living (AL), approximately 40% of whom have a diagnosis of Alzheimer's disease and related dementias (ADRD). States vary in their regulations specific to dementia care that may influence the presence of residents with ADRD in AL and their outcomes. The objectives of this study were to describe the state variability in the prevalence of ADRD among Medicare beneficiaries residing in larger (25+ bed) ALs and their healthcare utilization.

DESIGN

Retrospective observational national study.

PARTICIPANTS

National cohort of 293,336 Medicare fee-for-service enrollees residing in larger (25+ bed) ALs in 2016 and 2017 including 88,867 (30.3%) residents with ADRD. We compared this cohort's characteristics and healthcare utilization with that of individuals with ADRD who resided in nursing homes (NHs; n = 602,521) and the community (n = 2,074,420).

METHODS

Medicare enrollment data, claims, and the NH Minimum Data Set were used to describe differences among ADRD patients in AL, NHs, and the community. We present rates of NH admission and hospitalization, by state, adjusting for age, sex, race, dual eligibility, and chronic conditions.

RESULTS

The prevalence of ADRD among AL residents varied by state, ranging from 24% to 47%. In 2017, AL residents with ADRD had higher rates of NH admission than their community-dwelling counterparts (adjusted national average = 24%, ranging from 14% to 35% among states). AL residents with ADRD had higher rates of hospitalization (38%) than populations in either NHs (29%) or the community (34%), and ranged from 29% to 45% of residents among states.

CONCLUSION

These findings have implications for states as they regulate AL and for healthcare professionals whose patients reside in AL. Future work is needed to understand specific elements of states' regulatory environments and local markets that may impact access and outcomes for this vulnerable population of residents with ADRD. J Am Geriatr Soc 68:1504-1511, 2020.

Older Cannabis Users Are Not All Alike: Lifespan Cannabis Use Patterns

Although several studies have examined individual-level correlates of cannabis use in later life, there is scant evidence identifying heterogeneity among older users. Using data from Colorado, this study examines variability in lifespan patterns of cannabis use among individuals aged 60 years and older. Sample respondents reported cannabis use in the past year and frequency of use in four periods of adulthood. Analyses used a multi-way contingency table to identify mutually exclusive subgroups of cannabis users based on lifetime reports of use and linear probability models to identify predictors of group identity. Three subgroups of older cannabis users were identified: new users, stop-out or intermittent users, and consistent users. The three groups varied on current use frequency and method of ingestion, as well as social and health characteristics. Screening for past history of cannabis use may help health care providers identify older adults who need health information and monitoring related to cannabis use.

TWELVE YEARS OF CHANGES IN STATES’ ASSISTED LIVING REQUIREMENTS FOR DEMENTIA-SPECIFIC STAFF TRAINING

We describe two categories of dementia-specific AL requirements: staff training and admission/discharge criteria. We reviewed current requirements for all states and the District of Columbia, and amendments made over 12 years. Current and historic regulations were collected and analyzed using policy surveillance and qualitative coding. Twenty-three states currently require dementia-specific training, and 22 require continuing education. Nearly all states (49) require administrators to complete dementia-specific training. Of these, 13 states specified 7 to 120 hours of dementia care training. Some states added pre-admission screening for cognitive impairment; a few require a dementia diagnosis for admission. We describe state variation longitudinally in direct care staff training requirements, including: number of training hours, training content, and use of examinations or other tests of knowledge, skills and abilities. In addition, we categorize changes in admission/discharge criteria over time, including the use of medical versus behavioral health symptoms.

ASSESSING HEALTH-RELATED OUTCOMES OF MEDICAL CANNABIS USE AMONG OLDER PERSONS IN COLORADO AND ILLINOIS

The use of cannabis is increasing among older Americans. A growing body of evidence shows cannabis and cannabinoids effective for treating chronic pain, spasticity, nausea, and sleep disturbances. States seeking to respond to the treatment needs of specific patient populations have legalized the use of cannabis for medical purposes. Few instruments offer standard outcomes for understanding the use of medial cannabis from the patient perspective, particularly focusing on older persons. Using cross-sectional survey data from a sample of older persons in Colorado and Illinois, we validate two scales to consistently measure patient-reported health related outcomes of medical cannabis use. We confirmed the validity of two separate, reliable outcome scales: a three-factor scale for measuring global health outcomes and a single-factor scale for capturing adverse health events. The COPS questionnaire revealed strong construct validity and internal consistency, and a lack of meaningful factor variance.

EXPLORING STRUCTURAL BARRIERS TO MEDICAL CANNABIS ACCESS AMONG OLDER ADULTS

A growing number of older persons are using cannabis to treat medical conditions and symptoms. Preliminary work examining survey responses from persons over age 60 in Colorado and revealed the presence of structural barriers in safe and effective access to MC. In particular, older adults reported a gap in their expectations as a patient and current healthcare provider practice in counseling and educating them on MC use. To examine this from the provider perspective, we aim to survey Illinois state physicians and assess current knowledge, training needs, attitudes and practices associated with MC and older adults. Multivariate regression analysis will be conducted to predict current practice associated with MC (for example, whether physician ever certified a patient for MC) as a function of provider characteristics, as well as their knowledge and attitudes on the topic. We will also conduct sub-group analysis to understand practice patterns by specialty and experience.

LIFESPAN CANNABIS USE PATTERNS IN OLDER USERS

The rapidly rising rates of cannabis use among older adults may reflect a rise in late-onset users, re-engagement after a period without use, or a continuous use pattern since young adulthood that is more visible after legalization of cannabis. Older (age 60+) cannabis users (n=82) provided retrospective ratings on their frequency of use across adulthood. Approximately 28% were not using cannabis when young adults, with a larger percentage (40%) reporting non-use while ages 31-49 and 37% reported non-use when ages 50-64. Approximately 21% of older users were first time users, with 60% low frequency and 35% daily/weekly users. High frequency users generally were high frequency users throughout adulthood, but the pattern varied substantially by gender and mode of consumption. Women were more likely first-time users than men, and more likely non-smokers. Among non-smokers, about 40% were first-time users. Implications are explored for research, policy, and clinical practice.

Patterns of Marijuana Use and Health Impact: A Survey Among Older Coloradans

Access to recreational and medical marijuana is common in the United States, particularly in states with legalized use. Here, we describe patterns of recreational and medical marijuana use and self-reported health among older persons using a geographically sampled survey in Colorado. The in-person or online survey was offered to community-dwelling older persons aged above 60 years. We assessed past-year marijuana use including recreational, medical, or both; methods of use; marijuana source; reasons for use; sociodemographic and health factors; and self-reported health. Of 274 respondents (mean age = 72.5 years, 65% women), 45% reported past-year marijuana use. Of these, 54% reported using marijuana both medically and recreationally. Using more than one marijuana method or preparation was common. Reasons for use included arthritis, chronic back pain, anxiety, and depression. Past-year marijuana users reported improved overall health, quality of life, day-to-day functioning, and improvement in pain. Odds of past-year marijuana use decreased with each additional year of age. The odds were lower among women and those with higher self-reported health status; odds of use were higher with past-year opioid use. Older persons with access to recreational and medical marijuana described concurrent use of medical and recreational marijuana, use of multiple preparations, and overall positive health impacts.

Defining doctoral gerontologists: Who are they and how are they contributing to the field of gerontology?

More than 300 individuals have earned doctoral degrees in gerontology since 1993, yet little is known about their training, professional placement, and contributions to the field. Given this lack of information, the authors sought to define the emerging mass of doctoral gerontologists. In this study, the authors analyzed results from the 2014 Gerontology Education Longitudinal Study survey sample of 84 individuals who earned a doctoral degree in gerontology between 1993 and 2013. Results revealed doctoral gerontologists completed training requirements that were consistent across eight programs offering doctorates in gerontology. The authors also found doctoral gerontologists have been successful in securing jobs in academic and nonacademic organizations, creating gerontological knowledge, and translating their work into other fields. The authors concluded by considering how the successful integration of doctoral gerontologists might continue, and they propose directions for future research.

The Academy Is Aging in Place: Assessing Alternatives for Modifying Institutions of Higher Education

Institutions of higher education employ a greater proportion of persons over 65 relative to the general labor force, and the median age of the professorate has now surpassed all other occupational groups. Such a novel demographic change in the academic workforce presents several unique challenges. Should institutions modify policies and programs that provide more opportunities for aging faculty to remain healthy and productive, or should efforts focus on facilitating retirement? How universities and colleges choose to retain or retire their aging faculty certainly has become a point for consideration. This forum presents what is known about the aging academic workforce and describes current institutional responses. The discussion then builds on the notion of aging in place, presenting a more holistic approach to the modification of institutional policies and programs that support continued faculty engagement as well as mutually agreeable retirements. In particular, institutions should consider making modifications that increase targeted health and wellness programs, expand retirement counseling services, and offer varied retirement pathway options as viable responses to the continued aging of the academic workforce.

Impact of Stroke Call on the Stroke Neurology Workforce in the United States: Possible Challenges and Opportunities

BACKGROUND

The Stroke & Vascular Neurology Section of the American Academy of Neurology was charged to identify challenges to the recruitment and retention of stroke neurologists and to make recommendations to address any identified problems. The Section initiated this effort by determining the impact of stroke on-call requirements as a barrier to the recruitment and retention of vascular neurologists.

METHODS

This is a cross-sectional survey of a sample of US Neurologists providing acute stroke care.

RESULTS

Of the 900 neurologists who were sent surveys, 313 (35%) responded. Of respondents from institutions providing stroke coverage, 71% indicated that general neurologists and 45% indicated that vascular neurologists provided that service. Of those taking stroke call, 36% agreed with the statement, "I spent too much time on stroke call," a perception that was less common among those who took less than 12-hour shifts (P < .0001); 21% who participated in stroke call were dissatisfied with their current job. Forty-six percent indicated that their stroke call duties contributed to their personal feeling of "burnout."

CONCLUSIONS

Although the reasons are likely multifactorial, our survey of neurologists providing stroke care suggests that over-burdensome on-call responsibilities may be contributing to the vascular neurology workforce burnout and could be affecting recruitment and retention of vascular neurologists. Strategies to reduce the lifestyle impact of stroke call may help address this problem.

Chiropractic episodes and the co-occurrence of chiropractic and health services use among older Medicare beneficiaries

OBJECTIVE

The purpose of this study was to define and characterize episodes of chiropractic care among older Medicare beneficiaries and to evaluate the extent to which chiropractic services were used in tandem with conventional medicine.

METHODS

Medicare Part B claims histories for 1991 to 2007 were linked to the nationally representative survey on Assets and Health Dynamics among the Oldest Old baseline interviews (1993-1994) to define episodes of chiropractic sensitive care using 4 approaches. Chiropractic and nonchiropractic patterns of service use were examined within these episodes of care. Of the 7447 Assets and Health Dynamics among the Oldest Old participants, 971 used chiropractic services and constituted the analytic sample.

RESULTS

There were substantial variations in the number and duration of episodes and the type and volume of services used across the 4 definitions. Depending on how the episode was constructed, the mean number of episodes per chiropractic user ranged from 3.74 to 23.12, the mean episode duration ranged from 4.7 to 28.8 days, the mean number of chiropractic visits per episode ranged from 0.88 to 2.8, and the percentage of episodes with co-occurrent use of chiropractic and nonchiropractic providers ranged from 4.9% to 10.9% over the 17-year period.

CONCLUSION

Treatment for back-related musculoskeletal conditions was sought from a variety of providers, but there was little co-occurrent service use or coordinated care across provider types within care episodes. Chiropractic treatment dosing patterns in everyday practice were much lower than that used in clinical trial protocols designed to establish chiropractic efficacy for back-related conditions.

Older adults who persistently present to the emergency department with severe, non-severe, and indeterminate episode patterns

Background

It is well known that older adults figure prominently in the use of emergency departments (ED) across the United States. Previous research has differentiated ED visits by levels of clinical severity and found health status and other individual characteristics distinguished severe from non-severe visits. In this research, we classified older adults into population groups that persistently present with severe, non-severe, or indeterminate patterns of ED episodes. We then contrasted the three groups using a comprehensive set of covariates.

Methods

Using a unique dataset linking individual characteristics with Medicare claims for calendar years 1991-2007, we identified patterns of ED use among the large, nationally representative AHEAD sample consisting of 5,510 older adults. We then classified one group of older adults who persistently presented to the ED with clinically severe episodes and another group who persistently presented to the ED with non-severe episodes. These two groups were contrasted using logistic regression, and then contrasted against a third group with a persistent pattern of ED episodes with indeterminate levels of severity using multinomial logistic regression. Variable selection was based on Andersen's behavioral model of health services use and featured clinical status, demographic and socioeconomic characteristics, health behaviors, health service use patterns, local health care supply, and other contextual effects.

Results

We identified 948 individuals (17.2% of the entire sample) who presented a pattern in which their ED episodes were typically defined as severe and 1,076 individuals (19.5%) who typically presented with non-severe episodes. Individuals who persistently presented to the ED with severe episodes were more likely to be older (AOR 1.52), men (AOR 1.28), current smokers (AOR 1.60), experience diabetes (AOR (AOR 1.80), heart disease (AOR 1.70), hypertension (AOR 1.32) and have a greater amount of morbidity (AOR 1.48) than those who persistently presented to the ED with non-severe episodes. When contrasted with 1,177 individuals with a persistent pattern of indeterminate severity ED use, persons with severe patterns were older (AOR 1.36), more likely to be obese (AOR 1.36), and experience heart disease (AOR 1.49) and hypertension (AOR 1.36) while persons with non-severe patterns were less likely to smoke (AOR 0.63) and have diabetes (AOR 0.67) or lung disease (AOR 0.58).

Conclusions

We distinguished three large, readily identifiable groups of older adults which figure prominently in the use of EDs across the United States. Our results suggest that one group affects the general capacity of the ED to provide care as they persistently present with severe episodes requiring urgent staff attention and greater resource allocation. Another group persistently presents with non-severe episodes and creates a considerable share of the excess demand for ED care. Future research should determine how chronic disease management programs and varied co-payment obligations might impact the use of the ED by these two large and distinct groups of older adults with consistent ED use patterns.

A prospective cohort study of long-term cognitive changes in older Medicare beneficiaries

Background

Promoting cognitive health and preventing its decline are longstanding public health goals, but long-term changes in cognitive function are not well-documented. Therefore, we first examined long-term changes in cognitive function among older Medicare beneficiaries in the Survey on Assets and Health Dynamics among the Oldest Old (AHEAD), and then we identified the risk factors associated with those changes in cognitive function.

Methods

We conducted a secondary analysis of a prospective, population-based cohort using baseline (1993-1994) interview data linked to 1993-2007 Medicare claims to examine cognitive function at the final follow-up interview which occurred between 1995-1996 and 2006-2007. Besides traditional risk factors (i.e., aging, age, race, and education) and adjustment for baseline cognitive function, we considered the reason for censoring (entrance into managed care or death), and post-baseline continuity of care and major health shocks (hospital episodes). Residual change score multiple linear regression analysis was used to predict cognitive function at the final follow-up using data from telephone interviews among 3,021 to 4,251 (sample size varied by cognitive outcome) baseline community-dwelling self-respondents that were ≥ 70 years old, not in managed Medicare, and had at least one follow-up interview as self-respondents. Cognitive function was assessed using the 7-item Telephone Interview for Cognitive Status (TICS-7; general mental status), and the 10-item immediate and delayed (episodic memory) word recall tests.

Results

Mean changes in the number of correct responses on the TICS-7, and 10-item immediate and delayed word recall tests were -0.33, -0.75, and -0.78, with 43.6%, 54.9%, and 52.3% declining and 25.4%, 20.8%, and 22.9% unchanged. The main and most consistent risks for declining cognitive function were the baseline values of cognitive function (reflecting substantial regression to the mean), aging (a strong linear pattern of increased decline associated with greater aging, but with diminishing marginal returns), older age at baseline, dying before the end of the study period, lower education, and minority status.

Conclusions

In addition to aging, age, minority status, and low education, substantial and differential risks for cognitive change were associated with sooner vs. later subsequent death that help to clarify the terminal drop hypothesis. No readily modifiable protective factors were identified.

Long-term declines in ADLs, IADLs, and mobility among older Medicare beneficiaries

Background

Most prior studies have focused on short-term (≤ 2 years) functional declines. But those studies cannot address aging effects inasmuch as all participants have aged the same amount. Therefore, the authors studied the extent of long-term functional decline in older Medicare beneficiaries who were followed for varying time lengths, and the authors also identified the risk factors associated with those declines.

Methods

The analytic sample included 5,871 self- or proxy-respondents who had complete baseline and follow-up survey data that could be linked to their Medicare claims for 1993-2007. Functional status was assessed using activities of daily living (ADLs), instrumental ADLs (IADLs), and mobility limitations, with declines defined as the development of two of more new difficulties. Multiple logistic regression analysis was used to focus on the associations involving respondent status, health lifestyle, continuity of care, managed care status, health shocks, and terminal drop.

Results

The average amount of time between the first and final interviews was 8.0 years. Declines were observed for 36.6% on ADL abilities, 32.3% on IADL abilities, and 30.9% on mobility abilities. Functional decline was more likely to occur when proxy-reports were used, and the effects of baseline function on decline were reduced when proxy-reports were used. Engaging in vigorous physical activity consistently and substantially protected against functional decline, whereas obesity, cigarette smoking, and alcohol consumption were only associated with mobility declines. Post-baseline hospitalizations were the most robust predictors of functional decline, exhibiting a dose-response effect such that the greater the average annual number of hospital episodes, the greater the likelihood of functional status decline. Participants whose final interview preceded their death by one year or less had substantially greater odds of functional status decline.

Conclusions

Both the additive and interactive (with functional status) effects of respondent status should be taken into consideration whenever proxy-reports are used. Encouraging exercise could broadly reduce the risk of functional decline across all three outcomes, although interventions encouraging weight reduction and smoking cessation would only affect mobility declines. Reducing hospitalization and re-hospitalization rates could also broadly reduce the risk of functional decline across all three outcomes.

A longitudinal study of chiropractic use among older adults in the United States

Background

Longitudinal patterns of chiropractic use in the United States, particularly among Medicare beneficiaries, are not well documented. Using a nationally representative sample of older Medicare beneficiaries we describe the use of chiropractic over fifteen years, and classify chiropractic users by annual visit volume. We assess the characteristics that are associated with chiropractic use versus nonuse, as well as between different levels of use.

Methods

We analyzed data from two linked sources: the baseline (1993-1994) interview responses of 5,510 self-respondents in the Survey on Assets and Health Dynamics Among the Oldest Old (AHEAD), and their Medicare claims from 1993 to 2007. Binomial logistic regression was used to identify factors associated with chiropractic use versus nonuse, and conditional upon use, to identify factors associated with high volume relative to lower volume use.

Results

There were 806 users of chiropractic in the AHEAD sample yielding a full period prevalence for 1993-2007 of 14.6%. Average annual prevalence between 1993 and 2007 was 4.8% with a range from 4.1% to 5.4%. Approximately 42% of the users consumed chiropractic services only in a single calendar year while 38% used chiropractic in three or more calendar years. Chiropractic users were more likely to be women, white, overweight, have pain, have multiple comorbid conditions, better self-rated health, access to transportation, higher physician utilization levels, live in the Midwest, and live in an area with fewer physicians per capita. Among chiropractic users, 16% had at least one year in which they exceeded Medicare's "soft cap" of 12 visits per calendar year. These over-the-cap users were more likely to have arthritis and mobility limitations, but were less likely to have a high school education. Additionally, these over-the-cap individuals accounted for 58% of total chiropractic claim volume. High volume users saw chiropractors the most among all types of providers, even more than family practice and internal medicine combined.

Conclusion

There is substantial heterogeneity in the patterns of use of chiropractic services among older adults. In spite of the variability of use patterns, however, there are not many characteristics that distinguish high volume users from lower volume users. While high volume users accounted for a significant portion of claims, the enforcement of a hard cap on annual visits by Medicare would not significantly decrease overall claim volume. Further research to understand the factors causing high volume chiropractic utilization among older Americans is warranted to discern between patterns of "need" and patterns of "health maintenance".

Defining emergency department episodes by severity and intensity: A 15-year study of Medicare beneficiaries

Background

Episodes of Emergency Department (ED) service use among older adults previously have not been constructed, or evaluated as multi-dimensional phenomena. In this study, we constructed episodes of ED service use among a cohort of older adults over a 15-year observation period, measured the episodes by severity and intensity, and compared these measures in predicting subsequent hospitalization.

Methods

We conducted a secondary analysis of the prospective cohort study entitled the Survey on Assets and Health Dynamics among the Oldest Old (AHEAD). Baseline (1993) data on 5,511 self-respondents ≥70 years old were linked to their Medicare claims for 1991-2005. Claims then were organized into episodes of ED care according to Medicare guidelines. The severity of ED episodes was measured with a modified-NYU algorithm using ICD9-CM diagnoses, and the intensity of the episodes was measured using CPT codes. Measures were evaluated against subsequent hospitalization to estimate comparative predictive validity.

Results

Over 15 years, three-fourths (4,171) of the 5,511 AHEAD participants had at least 1 ED episode, with a mean of 4.5 episodes. Cross-classification indicated the modified-NYU severity measure and the CPT-based intensity measure captured different aspects of ED episodes (kappa = 0.18). While both measures were significant independent predictors of hospital admission from ED episodes, the CPT measure had substantially higher predictive validity than the modified-NYU measure (AORs 5.70 vs. 3.31; p < .001).

Conclusions

We demonstrated an innovative approach for how claims data can be used to construct episodes of ED care among a sample of older adults. We also determined that the modified-NYU measure of severity and the CPT measure of intensity tap different aspects of ED episodes, and that both measures were predictive of subsequent hospitalization.

Prior hospitalization and the risk of heart attack in older adults: a 12-year prospective study of Medicare beneficiaries

BACKGROUND

We investigated whether prior hospitalization was a risk factor for heart attacks among older adults in the survey on Assets and Health Dynamics among the Oldest Old.

METHODS

Baseline (1993-1994) interview data were linked to 1993-2005 Medicare claims for 5,511 self-respondents aged 70 years and older and not enrolled in managed Medicare. Primary hospital International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) 410.xx discharge codes identified postbaseline hospitalizations for acute myocardial infarctions (AMIs). Participants were censored at death or postbaseline managed Medicare enrollment. Traditional risk factors and other covariates were included. Recent postbaseline non-AMI hospitalizations (ie, prior hospitalizations) were indicated by a time-dependent marker, and sensitivity analyses identified their peak effect.

RESULTS

The total number of person-years of surveillance was 44,740 with a mean of 8.1 (median = 9.1) per person. Overall, 483 participants (8.8%) suffered postbaseline heart attacks, with 423 participants (7.7%) having their first-ever AMI. As expected, significant traditional risk factors were sex (men); race (whites); marital status (never being married); education (noncollege); geography (living in the South); and reporting a baseline history of angina, arthritis, diabetes, and heart disease. Risk factors were similar for both any postbaseline and first-ever postbaseline AMI analyses. The time-dependent recent non-AMI hospitalization marker did not alter the effects of the traditional risk factors but increased AMI risk by 366% (adjusted hazards ratio = 4.66, p < .0001). Discussion. Our results suggest that some small percentage (<3%) of heart attacks among older adults might be prevented if effective short-term postdischarge planning and monitoring interventions were developed and implemented.