Childhood Socioeconomic Status and Later Life Cognition: Evidence From the Wisconsin Longitudinal Study

Objectives:This study examined childhood socioeconomic status (SES) as a predictor of later life cognition and the extent to which midlife SES accounts for associations. Methods: Data came from 5,074 participants in the Wisconsin Longitudinal Study. Measures from adolescence included parents' educational attainment, father's occupational status, and household income. Memory and language/executive function were assessed at ages 65 and 72 years. Results: Global childhood SES was a stronger predictor of baseline levels of language/executive function than baseline memory. Associations involving parents' education were reduced in size and by statistical significance when accounting for participants' midlife SES, whereas associations involving parental income and occupational status became statistically nonsignificant. We found no associations between childhood SES and change in cognition. Discussion: Findings contribute to growing evidence that socioeconomic differences in childhood have potential consequences for later life cognition, particularly in terms of the disparate levels of cognition with which people enter later life.

Family relationships and advance care planning: do supportive and critical relations encourage or hinder planning?

OBJECTIVES

The effectiveness of advance care planning (ACP) may depend on family members' understanding of patient preferences. However, we know of no studies that explore the association between family relationship dynamics and ACP. ACP includes a living will, durable power of attorney for health care (DPAHC) appointment, and discussions. We evaluated the effects of three aspects of family relations--general family functioning, support and criticism from spouse, and support and criticism from children--on both overall ACP and specific DPAHC designations.

METHOD

Using multinomial logistic regression models and data from a sample of 293 older adults, we estimated the effects of family relationship quality on the likelihood of completing ACP and appointing a spouse or adult child as DPAHC. Analyses controlled for demographic and health characteristics.

RESULTS

Better overall family functioning increased the odds of ACP. Higher levels of spousal support increased the odds of holding informal discussions, whereas spousal criticism reduced the odds of naming one's spouse as DPAHC. Both criticism and emotional support from children increased the odds that a child was named as DPAHC.

DISCUSSION

Family dynamics affect ACP in complex ways and should be considered when patients and their families discuss end-of-life care and make DPAHC designations.

Sexual behavior in later life

OBJECTIVE

This research tests the influences of age, biological, and psychosocial factors on sexual expression in later life.

METHOD

The American Association of Retired Persons Modern Maturity Sexuality Survey collected data on diagnosed illnesses, treated illnesses, sexual desire, sexual attitudes, partner circumstances, and sexual behavior from 1,384 persons ages 45 and older. Ordered logistic regression models estimate the associations of age, biological, and psychosocial factors with the frequency of five sexual behaviors.

RESULTS

Diagnosed illnesses and treatments are generally unrelated to frequency of sexual activity. Sexual attitudes are related to frequency of partnered behavior and sexual desire is related to frequency of masturbation among both women and men. Satisfaction with the physical relationship with a partner is strongly related to behavior. Age remains significant after all other factors are controlled.

DISCUSSION

The authors conclude that the nature of sexual expression in later life reflects the interplay of body, mind, and social context.

End-of-life planning in a family context: does relationship quality affect whether (and with whom) older adults plan?

OBJECTIVES

Medical professionals typically approach advance care planning (ACP) as an individual-level activity, yet family members also may play an integral role in making decisions about older adults' end-of-life care. We evaluate the effects of marital satisfaction and parent-child relationship quality on older adults' use of advance directives (i.e., living will and durable power of attorney for health care [DPAHC] appointments) and end-of-life discussions.

METHODS

Using multinomial logistic regression models and data from a sample of 1,883 older adults in the Wisconsin Longitudinal Study, we estimated the effects of marital satisfaction, emotional support and criticism from children, other social support, demographic characteristics, and health on general ACP (i.e., advance directive only, discussions only, both, or neither) and specific DPAHC appointments.

RESULTS

Parents with problematic parent-child relationships were less likely to complete ACP, and marital satisfaction was positively associated with completion of both advance directives and discussions. Happily married persons were more likely to appoint their spouse as DPAHC, whereas persons who received ample emotional support from children were mostly likely to appoint an adult child.

DISCUSSION

Family dynamics affect ACP in complex ways and should be considered in patient-provider discussions of end-of-life care.

Spouses' effectiveness as end-of-life health care surrogates: accuracy, uncertainty, and errors of overtreatment or undertreatment

PURPOSE

We document the extent to which older adults accurately report their spouses' end-of-life treatment preferences, in the hypothetical scenarios of terminal illness with severe physical pain and terminal illness with severe cognitive impairment. We investigate the extent to which accurate reports, inaccurate reports (i.e., errors of undertreatment or overtreatment), and uncertain reports (responses of "do not know") are associated with spouses' advance care planning and surrogates' involvement in the planning.

DESIGN AND METHODS

We used data from married couples who participated in the Wisconsin Longitudinal Study in 2004. These 2,750 couples were in their mid-60s and in relatively good health. We conducted multinomial logistic regressions.

RESULTS

Surrogates were accurate in the majority of cases, made errors in 12% to 22% of cases, and were uncertain in 11% to 16% of cases. Errors of overtreatment and undertreatment were equally prevalent. For both scenarios, discussing preferences was associated with lower odds of an uncertain surrogate response.

IMPLICATIONS

We suggest ways that health care practitioners could facilitate family-level conversations in order to ensure that patients' preferences are accurately represented in end-of-life care settings.

Persistent problems in end-of-life planning among young- and middle-aged American couples

OBJECTIVES

Guided by the transtheoretical model of health behavior change, this study sought to explain why (a) rates of advance care planning remain low in the general population and (b) surrogate decision makers are often inaccurate about patients' end-of-life preferences.

METHODS

The study used quantitative data from a cross-sectional internet survey conducted between July and October 2010. The 2,150 participants aged 18-64 belonged to 1,075 married or cohabiting heterosexual couples. Participants included members of a nationally representative internet panel and a convenience sample from online advertisements.

RESULTS

Older age was associated with a greater likelihood of having executed a living will and/or appointed a durable power of attorney for health care. Both older age and poorer health were independently associated with a greater likelihood of having discussed end-of-life health care treatment preferences. Completion of one's own end-of-life planning was unrelated to one's ability to accurately report one's partner's treatment preferences.

DISCUSSION

Readiness to plan for end of life appears to differ across planning behaviors. Age and health are related to aspects of one's own advance care planning, but none of these factors are related to accuracy as a partner's surrogate.

Do Older Adults Know Their Spouses' End-of-Life Treatment Preferences?

When terminally ill patients become mentally incapacitated, the patient's surrogate often makes treatment decisions in collaboration with health care providers. We examine how surrogates' errors in reporting their spouse's preferences are affected by their gender, status as durable power of attorney for health care (DPAHC), whether the surrogate and spouse held discussions about end-of-life preferences, and the spouse's health status. We apply structural equation models to data from 2,750 married couples in their mid 60s who participated in the 2004 wave of the Wisconsin Longitudinal Study. Surrogates reported their spouse's preferences incorrectly 13 and 26 percent of the time in end-of-life scenarios involving cognitive impairment and physical pain, respectively. Surrogates projected their own preferences onto the spouse. Similar patterns emerged regardless of surrogate gender, surrogate status as DPAHC, marital discussions about end-of-life, or spousal health status. We discuss implications for the process of surrogate decision-making and for future research.

Life Course Pathways From Childhood Socioeconomic Status to Later-Life Cognition: Evidence From the Wisconsin Longitudinal Study

OBJECTIVES

A growing body of research indicates that older adults are at greater risk for poorer cognition if they experienced low socioeconomic status (SES) as children. Guided by life course epidemiology, this study aimed to advance understanding of processes through which childhood SES influences cognition decades later, with attention to the role of scholastic performance in adolescence and SES in midlife.

METHOD

We used data from the Wisconsin Longitudinal Study (WLS), which has followed a cohort of high school graduates since they were 18 years old in 1957. Childhood SES was measured prospectively in adolescence, and measures of memory and language/executive functioning were based on neurocognitive assessments at age 72. We used participants' scores on a statewide standardized test in high school as an indicator of scholastic performance in adolescence. The measure of SES in midlife included years of postsecondary education, income, and occupation status at age 53.

RESULTS

Findings from structural equation models indicated that scholastic performance in adolescence and midlife status attainment together fully mediated associations between childhood SES and both memory and language/executive functioning at age 72. Adolescent scholastic performance was directly associated with later-life cognition, as well as indirectly through midlife status attainment.

DISCUSSION

Findings provide support for both latency and social pathway processes when considering how SES in childhood influences later-life cognition. Results contribute to growing calls for social policies and programs to support optimal brain health at multiple phases throughout the life course, especially among individuals with lower SES as children.

Older adults' preferences for independent or delegated end-of-life medical decision making

OBJECTIVE

This study assesses the proportions of participants who prefer independent or delegated medical decision making at the end of life and examines the relationships of personal beliefs, affiliative beliefs, and end-of-life planning behaviors to decision-making preference.

METHOD

Data are drawn from the Wisconsin Longitudinal Study, a sample of nearly 4,500 healthy White Midwestern high school graduates in their mid-60s.

RESULTS

Four fifths of participants wanted to make decisions independently. Valuing independence, being less avoidant of thoughts of death, and valuing quality of life over length of life had strong associations with a preference for independent decision making. Those concerned about burdening a caregiver wanted to make independent decisions. Persons who both executed a living will and appointed a durable power of attorney for health care preferred independent decision making.

DISCUSSION

Older adults cite personal and affiliative beliefs, not lack of autonomy, as reasons for their choice to decide independently or delegate.

Solidarity in the Grandparent-Adult Grandchild Relationship and Trajectories of Depressive Symptoms

PURPOSE OF THE STUDY

Grandparent-adult grandchild relationships are becoming longer and more common, and therefore potentially more influential in the lives of individuals. This study examined the influence of solidarity (i.e., affinity, contact, and functional exchange) in the grandparent-adult grandchild relationship upon the depressive symptoms of both members of the dyad.

DESIGN AND METHODS

The study used data from the Longitudinal Study of Generations, a survey of 3- and 4-generation U.S. families that included 7 waves of data collection between 1985 and 2004. The sample was comprised of 374 grandparents and 356 adult grandchildren. We analyzed the data using multilevel growth curve models.

RESULTS

For both grandparents and adult grandchildren, greater affinity reduced depressive symptoms and more frequent contact increased symptoms. For grandparents only, receiving functional support without also providing it increased depressive symptoms.

IMPLICATIONS

The average grandparent-adult grandchild relationship is a source of both support and strain to both generations. These relationships exhibit great diversity, however, with large amounts of variation between dyads and within a single dyad over time. We suggest how policy makers and practitioners can identify the relational contexts that best promote the well-being of members of both generations.

Childhood socioeconomic status and genetic risk for poorer cognition in later life

The ε4 allele of the APOE gene is associated with poorer cognition in later life. This study aimed to advance understanding of how environments potentially moderate this genetic risk by focusing on childhood socioeconomic status (SES). Previous research across diverse national contexts has found that older adults from higher-SES families in childhood demonstrate better cognitive functioning than their lower-SES counterparts. Nevertheless, few studies have examined whether higher childhood SES might also promote later life cognition by mitigating the effects of ε4 carrier status. To address this gap, we used data from 3017 participants in the Wisconsin Longitudinal Study, which has followed a random sample of people who graduated from Wisconsin high schools in 1957. Childhood SES included parents' educational attainment, father's occupational status, and household income in adolescence. We constructed measures of memory and of language/executive functioning using scores from neurocognitive tests administered when participants were approximately ages 65 and 72. APOE ε4 status was measured through saliva samples. Results from cross-controlled multilevel models indicated that APOE ε4 status-and not childhood SES-independently predicted memory, whereas childhood SES-and not APOE ε4 status-independently predicted language/executive functioning. Moreover, a statistical interaction between APOE ε4 status and childhood SES for memory indicated that at baseline, higher childhood SES protected against the risk of APOE ε4 status, whereas lower childhood SES exacerbated the risk of APOE ε4 status. However, by follow-up, these moderating effects dissipated, and APOE ε4 status alone was associated with memory. We interpret these results in light of theorizing on differential susceptibility for poorer cognition across the life course.

Medically complex home care and caregiver strain

PURPOSE OF THE STUDY

To examine (a) whether the content of caregiving tasks (i.e., nursing vs. personal care) contributes to variation in caregivers' strain and (b) whether the level of complexity of nursing tasks contributes to variation in strain among caregivers providing help with such tasks.

DESIGN AND METHODS

The data came from the Cash and Counseling Demonstration and Evaluation study conducted in Arkansas, Florida, and New Jersey. The paper analyzes the physical and emotional strain of 1,926 paid American caregivers who helped adult Medicaid recipients with personal and nursing care in the home.

RESULTS

Over 80% of home caregivers were providing assistance with nursing care, and over 50% of those were providing help with moderate or high complexity tasks. Caregivers who were providing any type of nursing care reported significantly more strain than caregivers who were providing only personal care. Those providing highly or moderately complex nursing care exhibited more caregiver strain than did those providing low-complexity nursing care.

IMPLICATIONS

Medical complexity is an important contributor to caregiver strain. Policymakers should consider medical complexity in the development of practices to assist the caregivers of Medicaid long-term care recipients, especially through consumer-directed supportive service programs.

Patient-Physician End-of-Life Discussions in the Routine Care of Medicare Beneficiaries

OBJECTIVE

Medicare reimbursement for physicians who discussed end-of-life care and planning with a patient during an office visit was cut from the 2010 Affordable Care Act. We assessed the characteristics of patients who reported having had such discussions, and whether these discussions are associated with trust in one's physicians and with rates of family advance care planning (FACP).

METHOD

The sample consisted of 5,199 Medicare beneficiaries who reported having an ongoing relationship with a primary care physician. We estimated ordinal and multinomial logistic regressions that controlled for health care utilization, current health, and recent family deaths.

RESULTS

Less than 1% (n = 310) reported an end-of-life conversation with a physician during the course of routine care. However, conversations were associated with greater trust in one's physician and higher rates of completion of FACP.

DISCUSSION

Findings support renewed efforts to reimburse physicians for discussing end of life with their Medicare patients.

Influence of the Social Network on Married and Unmarried Older Adults' Mental Health

Purpose of the Study

In later life, adults' social networks grow smaller through a combination of intentional selection and involuntary loss. This study examined whether older adults who lack a high-quality marriage compensate for this using support from other ties. We analyzed how relationships with family and friends are associated with depressive symptoms across multiple marital statuses.

Design and Methods

Data from 3,371 older adults who participated in the most recent wave of the National Social Life, Health, and Aging Project (NSHAP) were analyzed using analysis of variance (ANOVA) and ordinary least squares (OLS) regression.

Results

Individuals in high-quality marriages experienced fewer depressive symptoms than the widowed, never married, divorced/separated, and those in lower-quality marriages. Older adults' perceived family support, family strain, and friend strain were all significantly associated with depressive symptoms. The only difference in these effects according to marital status was for perceived family support, which was strongest for the never married.

Implications

The never married may depend more on family and friends than the previously or unhappily married. Any compensation efforts among the latter failed to reduce depressive symptoms relative to happily married others. Older adults in high-quality marriages benefit from their marital relationship, and also benefit from supportive family and friend ties.

School Context in Adolescence and Cognitive Functioning 50 Years Later

To advance understanding of how social inequalities from childhood might contribute to cognitive aging, we examined the extent to which school context in adolescence was associated with individuals' cognitive performance more than 50 years later. Using data from 3,012 participants in the Wisconsin Longitudinal Study (WLS), we created an aggregate measure of school-level structural advantage, with indicators such as the proportion of teachers who had at least five years of teaching experience and spending per pupil. Multilevel models indicated that secondary school advantage was associated with small benefits in language/executive function at age 65 among older adults who had lower academic achievement in secondary school. Findings suggest that school advantage is a developmental context of adolescence that has modest implications for intracohort differences in aspects of later life cognition.

End-of-Life Treatment Preferences Among Older Adults: An Assessment of Psychosocial Influences

We explore the content and correlates of older adults' end-of-life treatment preferences in two hypothetical terminal illness scenarios: severe physical pain with no cognitive impairment, and severe cognitive impairment with no physical pain. For each scenario, we assess whether participants would reject life-prolonging treatment, accept treatment, or do not know their preferences. Using data from the 2004 wave of the Wisconsin Longitudinal Study (N = 5,106), we estimate multinomial logistic regression models to evaluate whether treatment preferences are associated with direct experience with end-of-life issues, personal beliefs, health, and sociodemographic characteristics. Persons who have made formal end-of-life preparations, persons with no religious affiliation, mainline Protestants, and persons who are pessimistic about their own life expectancy are more likely to reject treatment in both scenarios. Women and persons who witnessed the painful death of a loved one are more likely to reject treatment in the cognitive impairment scenario only. Consistent with rational choice perspectives, our results suggest that individuals prefer treatments that they perceive to have highly probable desirable consequences for both self and family.

The Role of Relationship Biography in Advance Care Planning

Objective: We examine the ways that romantic relationship biographies are related to whether, how, and with whom individuals complete advance care planning (ACP), preparations for end-of-life medical care. Method: Data are from an Internet survey of 2,144 adults aged 18 to 64, all of whom were either married to or cohabiting with an opposite-sex partner. Results: Cohabitors were less likely than married people to complete ACP. Relationship quality was an important influence on ACP, but did not account for the differences between married and cohabiting persons. Differences were largely explained by the age composition of the groups. Discussion: Couples who foresee a long and stable future together are those most likely to engage in end-of-life planning, a preventative health behavior with long-term consequences for well-being.

Beyond the Individual: Evidence Linking Neighborhood Trust and Social Isolation Among Community-Dwelling Older Adults

Loneliness and social isolation are significant public health problems. However, the community and neighborhood factors that contribute to this pandemic are less examined. Adopting a neighborhood resource-based social capital theory, we examined whether neighborhood trust was associated with older Americans' loneliness, number of friends, and perceived support from friends. We analyzed two waves of longitudinal data from the Health and Retirement Study, with a sample of 5,817 Americans aged 50 years and older. We used first difference models to analyze the data and controlled for potential confounders including perceived support from family and health status. Increases in the perception that neighbors are trustworthy and helpful were associated with statistically significant decreases in loneliness and increases in perceived social support from friends over a 4-year period. Findings have implications for conceptualizing social capital and for potential interventions targeting interpersonal trust and reducing loneliness and social isolation.

The Role of Current Family Relationships in Associations Between Childhood Abuse and Adult Psychological Functioning

OBJECTIVES

Childhood abuse has long-term negative effects on adult psychological well-being. This study examined whether and how adults with a history of childhood abuse may experience poor psychological functioning partly due to aspects of current family relationships.

METHOD

We estimated multilevel mediation models using 3 waves of longitudinal data from 3,487 participants in the study of Midlife Development in the United States. Outcomes measured included negative affect, life satisfaction, and psychological well-being. We included aspects of family relationships as mediators: perceived support, perceived strain, frequency of contact, and hours of providing instrumental and emotional support.

RESULTS

Multilevel mediation models showed that childhood verbal and physical abuse negatively affected diverse aspects of family relationships in later adulthood (i.e., less perceived support, more perceived strain, less frequent contact, and fewer hours of providing instrumental support). We also found that less perceived support and more family strain significantly mediated the associations between childhood abuse and all 3 psychological functioning outcomes.

DISCUSSION

Childhood abuse appears to hinder perceived availability of family support in adulthood, which may undermine the psychological functioning of adults with a history of childhood abuse. To improve their psychological health, interventions should focus on facilitating supportive and functional family relationships.

Who Are the People in Your Neighborhood? Neighborhood Age Composition and Age Discrimination

Age discrimination is pervasive in the United States, yet little is known about the social contexts in which it occurs. Older persons spend much of their time in their neighborhoods, where a density of other older persons may protect against age discrimination. Extending group density theory to age, we analyze data from 1,561 older adults from the second wave of the National Survey of Midlife Development in the United States, using neighborhood-level data from the 2010 U.S. census. We examine (1) whether the concentration of older neighborhood residents influences perceived age discrimination and (2) whether that influence varies by age. Results indicate that the density of older residents protects against age discrimination for individuals entering old age but it is decreasingly influential as individuals approach oldest-old age and report less age discrimination regardless of neighborhood age composition. We discuss the implications of these findings for theory on age discrimination.

Extracurricular Involvement in High School and Later-Life Participation in Voluntary Associations

Objectives

Scholars have identified participation in voluntary associations as a central component of civic engagement for younger and older people alike. However, there has been little longitudinal examination of how such participation potentially fluctuates across multiple periods of the life course, as well as the extent to which involvement in youth is associated with participation in later life.

Method

We used data from the Wisconsin Longitudinal Study-which is among the oldest and most comprehensive cohort studies in the United States to date. Respondents reported their voluntary association participation periodically between the ages of approximately 36 and 72 years. Data collected from high school yearbooks were used to examine whether histories of extracurricular involvement in adolescence were associated with patterns of voluntary association participation across adulthood.

Results

Results from growth curve models indicated that, on average, voluntary association participation peaked in midlife and declined into the 60s and early 70s. Nevertheless, levels of participation were consistently higher among individuals with greater extracurricular involvement in high school, and the rate of decline in participation from midlife to young-old age was also less steep for these individuals.

Discussion

Findings support conceptualizing voluntary association participation among older adults as part of life course trajectories of participation, with influences originating as early as adolescence.

An assessment of social diffusion in the Respecting Choices advance care planning program

This study examines the potential social diffusion effects of the Respecting Choices advance care planning program administered in La Crosse, Wisconsin, since 1991. The program produces educational materials for patients, trains facilitators to help patients prepare for end of life, and ensures that advance directives are connected to patients' medical records. Using data from a survey of more than 5,000 White Wisconsin high school graduates in their mid-60s, we found that participants who were living in the La Crosse area were significantly less likely than their peers living elsewhere to have executed a living will or appointed a health care power of attorney. This pattern may reflect psychological reactance, where individuals reject a message or lesson when they perceive compliance as a threat to their autonomy. There was no evidence of social diffusion effects; participants who lived in the La Crosse region themselves or who had social network members residing in the area were no more likely than those with no known ties to the region to have engaged in advance care planning. Future studies should explore the processes through which individuals learn and share with others their knowledge of advance care planning.

Mechanisms Linking Neighborhood Age Composition to Health

Purpose of the Study

Age integration theory posits that the age composition of spaces affects the social interactions in which people can engage. This study aimed to examine whether social interactions perceived to involve generativity (i.e., commitment to younger generations), daily discrimination, and/or social cohesion mediate associations between neighborhood age composition, self-reported health, and psychological well-being.

Design and Methods

We applied multilevel structural equation models to data from 4,017 participants aged 30-84 who participated in the 2004-2006 wave of National Survey of Midlife Development in the United States, merged with data on their 3,714 neighborhoods from the 2010U.S. Census.

Results

Neighborhoods that represented the age distribution of the United States and neighborhoods that overrepresented older adults were contexts in which residents reported the most generativity and social cohesion. In turn, generativity and social cohesion were associated with better self-reported health and higher psychological well-being.

Implications

The nature of social interaction links neighborhood age composition to health and well-being. These results clarify the results of prior studies, advance measurement, suggest elaborations to age integration theory, and point to new directions for aging-in-place initiatives.