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Objective Despite cross-sectional evidence that persons living with dementia receive disproportionate hours of care, studies of how care intensity progresses over time and differs for those living with and without dementia have been lacking. Method We used the 2011–2018 National Health and Aging Trends Study to estimate growth mixture models to identify incident care hour trajectories ("classes") among older adults (N = 1,780). Results We identified 4 incident care hour classes: "Low, stable," "High, increasing," "24/7 then high, stable," and "Low then resolved." The high-intensity classes had the highest proportions of care recipients with dementia and accounted for nearly half of that group. Older adults with dementia were 3–4 times as likely as other older adults to experience one of the 2 high-intensity trajectories. A substantial proportion of the 4 in 10 older adults with dementia who were predicted to be in the "Low, stable" class lived in residential care settings. Discussion Information on how family caregiving is likely to evolve over time in terms of care hours may help older adults with and without dementia, the family members, friends, and paid individuals who care for them, as well as their health care providers assess and plan for future care needs. [ABSTRACT FROM AUTHOR]

Objectives We provide national estimates of caregiving networks for older adults with and without dementia and examine how these networks develop over time. Most prior research has focused on primary caregivers and rarely on change over time. Method We identify a cohort of older adults continuously followed in the National Health and Aging Trends Study between 2011 and 2015 and receiving help from family members or unpaid caregivers in 2015 (n = 1,288). We examine differences by dementia status in network size, types of assistance and task sharing, and composition—differentiating between "specialist" and "generalist" caregivers helping in one versus multiple activity domains. Multinomial regression is used to estimate change over time in network task sharing and composition. Results In 2015, older adults with dementia had larger caregiving networks involving more task sharing than those without dementia and more often relied on generalist caregivers, especially the subset assisting with medical, household, and mobility or self-care activities. Uniformly greater reliance over time on these more intensely engaged generalist caregivers chiefly accounts for larger dementia networks. Discussion Findings lend support to the need for caregiver training on managing multiple task domains and—for dementia caregivers in particular—task-sharing skills. More generally, the design of new approaches to better support older adults and their caregivers should consider the complexity, heterogeneity, and change over time in caregiving networks. [ABSTRACT FROM AUTHOR]

As baby boomers approach old age, many factors may be driving a growing divide between the demand for family caregivers and the number of available caregivers. This article highlights trends in family caregiving and changing patterns of family life that challenge the family's capacity to carry out its traditional functions in long-term services and supports (LTSS), describes the high cost of LTSS (including out-of-pocket spending), illuminates the future care gap, and explains the implications of these trends in the context of providing and paying for LTSS. [ABSTRACT FROM AUTHOR]

Objectives Studies have reported decreasing dementia prevalence in recent decades in the United States. We explore with a new national data source whether declines have occurred since 2011, whether trends are attributable to shifts in dementia incidence or mortality, and whether trends are related to shifts in population composition or subgroup prevalence. Methods We use the 2011–2015 National Health and Aging Trends Study (N = 27,547) to examine prevalence of probable dementia among the 70 and older population. To minimize the influence of potential learning effects on prevalence rates, we require individuals to meet probable dementia criteria at two consecutive rounds. Results: Prevalence of probable dementia declines over this period by 1.4% to 2.6% per year. Declines are concentrated among women, non-Hispanic white and black groups, and those with no vascular conditions or risk factors. The latter group also has experienced declines in dementia incidence. Declines in prevalence are largely attributable to age- and education-related shifts in population composition. Discussion Given the role of age and educational composition in short-term declines, the United States is likely to continue to experience short-term declines in dementia prevalence. However, persistently high rates among minority groups, especially of Hispanic origin, are concerning, and, barring new treatments, long-run trends may reverse course. [ABSTRACT FROM AUTHOR]

Objectives: To provide a profile of older adults who successfully accommodate declines in capacity by using assistive devices. Method: Using the National Health and Aging Trends Study, we provide national estimates of prevalent, incident, and persistent successful accommodation of mobility and self-care activity limitations. For incident and persistent accommodation groups, we describe their subjective wellbeing and participation restrictions, health and functioning, demographic and socioeconomic characteristics, and acquisition of assistive devices and environmental features. We estimate regression models predicting incident and persistent successful accommodation and the extent of wellbeing and participation restrictions for incident and persistent groups (vs. those who are fully able). Results: Nearly one-quarter of older adults have put in place accommodations that allow them to carry out daily activities with no assistance or difficulty. In adjusted models, incident and persistent successful accommodation is more common for those ages 80-89, those with more children, and those living in homes with environmental features already installed; well-being levels for these groups are similar and participation restrictions only slightly below those who are fully able. Discussion: A focus on facilitating successful accommodation among those who experience declines in capacity may be an effective means of promoting participation and wellbeing in later life. [ABSTRACT FROM AUTHOR]

Objectives. To examine changes in active life expectancy in the United States over 30 years for older men and women (aged ≥ 65 years). Methods. We used the 1982 and 2004 National Long Term Care Survey and the 2011 National Health and Aging Trends Study to estimate age-specific mortality and disability rates, the overall chances of survival and of surviving without disability, and years of active life for men and women. Results. For older men, longevity has increased, disability has been postponed to older ages, disability prevalence has fallen, and the percentage of remaining life spent active has increased. However, for older women, small longevity increases have been accompanied by even smaller postponements in disability, a reversal of a downward trend in moderate disability, and stagnation of active life as a percentage of life expectancy. As a consequence, older women no longer live more active years than men, despite their longer lives. Conclusions. Neither a compression nor expansion of late-life disability is inevitable. Public health measures directed at older women to postpone disability may be needed to offset impending long-term care pressures related to population aging. [ABSTRACT FROM AUTHOR]

Objectives. Studies of late-life disablement typically address the role of advancing age as a factor in developing disability, and in some cases have pointed out the importance of time to death (TTD) in understanding changes in functioning. However, few studies have addressed both factors simultaneously, and none have dealt satisfactorily with the problem of missing data on TTD in panel studies. Methods. We fit latent-class trajectory models of disablement using data from the Health and Retirement Study. Among survivors (~20% of the sample), TTD is unknown, producing a missingdata problem. We use an auxiliary regression equation to impute TTD and employ multiple imputation techniques to obtain final parameter estimates and standard errors. Results. Our best-fitting model has 3 latent classes. In all 3 classes, the probability of having a disability increases with nearness to death; however, in only 2 of the 3 classes is age associated with disability. We find gender, race, and educational differences in class-membership probabilities. Discussion. The model reveals a complex pattern of age- and time-dependent heterogeneity in late-life disablement. The techniques developed here could be applied to other phenomena known to depend on TTD, such as cognitive change, weight loss, and health care spending. [ABSTRACT FROM AUTHOR]

Purpose of the Study: Comprehensive measures of disability accommodations have been lacking in national health and aging studies. This article introduces measures of accommodations developed for the National Health and Aging Trends Study, evaluates their reliability, and explores the validity and reliability of hierarchical classification schemes derived from these measures. Design and Methods: We examined test–retest reliability for questions about assistive device use, doing activities less often, and getting help from another person with both percentage agreement and kappa (N = 111). Summary measures across activities and several hierarchical classification schemes (e.g., no accommodation, devices/activity reductions only, help) were developed. For the latter, we also evaluated validity by examining correlations with measures of capacity and demographic characteristics (N = 326). Results: Items about assistive device use and help in the last month were robust (most kappas 0.7–0.9). Activity reduction measures were moderately reliable (around 0.5) but still showed reasonable agreement. Reliabilities for summary measures were good for device use (0.78–0.89) and help (0.62–0.67) but lower, albeit acceptable, for activity reduction (0.53). Hierarchical classifications had acceptable reliability and levels demonstrated hierarchical properties. Implications: National Health and Aging Trends Study’s self-care and mobility accommodation measures offer ample reliability to study adaptation to limitations and can be used to construct a reliable and valid hierarchy. [ABSTRACT FROM PUBLISHER]

Context The cost of late-life dependency is projected to grow rapidly as the number of older adults in the United States increases in the coming decades. To provide a context for framing relevant policy discussions, we investigated activity limitations and assistance, care resources, and unmet need for a national sample of older adults. Methods We analyzed the 2011 National Health and Aging Trends Study, a new national panel study of more than 8,000 Medicare enrollees. Findings Nearly one-half of older adults, or 18 million people, had difficulty or received help in the last month with daily activities. Altogether, 1 in 4 older adults receiving help lived in either a supportive care (15%) or a nursing home (10%) setting. Nearly 3 million received assistance with 3 or more self-care or mobility activities in settings other than nursing homes, and a disproportionate share of persons at this level had low incomes. Nearly all older adults in settings other than nursing homes had at least 1 potential informal care network member (family or household member or close friend), and the average number of network members was 4. Levels of informal assistance, primarily from family caregivers, were substantial for older adults receiving help in the community (164 hours/month) and living in supportive care settings (50 hours/month). Nearly all of those getting help received informal care, and about 3 in 10 received paid care. Of those who had difficulty or received help in settings other than nursing homes, 32% had an adverse consequence in the last month related to an unmet need; for community residents with a paid caregiver, the figure was nearly 60%. Conclusions The older population-especially those with few economic resources-has substantial late-life care needs. Policies to improve long-term services and supports and reduce unmet need could benefit both older adults and those who care for them. [ABSTRACT FROM AUTHOR]

Objectives. To inform public health efforts to promote independent functioning among older adults, we have provided new national estimates of late-life disability that explicitly recognize behavioral adaptations. Methods. We analyzed the 2011 National Health and Aging Trends Study, a study of Medicare enrollees aged 65 years and older (n = 8077). For 7 mobility and self-care activities we identified 5 hierarchical stages-fully able, successful accommodation with devices, activity reduction, difficulty despite accommodations, and receipt of help-and explored disparities and associations with quality of life measures. Results. Among older adults, 31% were fully able to complete self-care and mobility activities. The remaining groups successfully accommodated with devices (25%), reduced their activities (6%), reported difficulty despite accommodations (18%), or received help (21%). With successive stages, physical and cognitive capacity decreased and symptoms and multimorbidity increased. Successful accommodation was associated with maintaining participation in valued activities and high well-being, but substantial disparities by race, ethnicity, and income existed. Conclusions. Increased public health attention to behavioral adaptations to functional change can promote independence for older adults and may enhance quality of life. [ABSTRACT FROM AUTHOR]

Background. Measurement gaps continue to hamper fuller understanding of late-life disability trends and dynamics. This article reports findings that validate the self-reported components of the disability protocol to be used in the new National Health and Aging Trends Study. The protocol was designed to redress existing measures by attending to environmental aspects of disability, capturing a broader range of capacity to perform tasks and including participation restriction items. Methods. We undertook an in-person validation study to determine the reliability, validity, and initial measurement properties of the National Health and Aging Trends Study self-reported disability protocol (n = 326). A random subset (n = 111) was readministered the protocol within 2–4 weeks. The interview and reinterview included new self-reported measures of physical capacity, activity limitations, and participation restrictions, as well as established performance and cognitive tests. We calculated percent agreement and kappa between interviews for all self-reported items and summary measures. We also assessed the construct validity of summary measures through correlations with demographic characteristics, frailty, memory, and performance-based mobility and confirmed whether activity limitations and participation restrictions were distinct domains. Results. New items and derived summary measures demonstrate robustness over a short time period, with kappas for retained/recommended items in the .60–.80 range. The summary measures correlate as expected with age, sex, residential status, and established performance-based constructs. Two factors, representing activity limitations and participation restrictions, were confirmed. Conclusions. The National Health and Aging Trends Study protocol preserves the ability to examine more traditional measures of functioning while offering new insights into how activities are performed and preserving key conceptual distinctions. [ABSTRACT FROM PUBLISHER]

Objectives. We estimated national and state-level potential medical care cost savings achievable through modest reductions in the prevalence of several diseases associated with the same lifestyle-related risk factors. Methods. Using Medical Expenditure Panel Survey Household Component data (2003-2005), we estimated the effects on medical spending over time of reductions in the prevalence of diabetes, hypertension, and related conditions amenable to primary prevention by comparing simulated counterfactual morbidity and medical care expenditures to actual disease and expenditure patterns.We produced state-level estimates of spending by using multivariate reweighting techniques. Results. Nationally, we estimated that reducing diabetes and hypertension prevalence by 5% would save approximately $9 billion annually in the near term. With resulting reductions in comorbidities and selected related conditions, savings could rise to approximately $24.7 billion annually in the medium term. Returns were greatest in absolute terms for private payers, but greatest in percentage terms for public payers. State savings varied with demographic makeup and prevailing morbidity. Conclusions. Well-designed interventions that achieve improvements in lifestyle-related risk factors could result in sufficient savings in the short and medium term to substantially offset intervention costs. [ABSTRACT FROM AUTHOR]

Although the prevalence of late-life disability has been declining, how best to promote further reductions remains unclear. This article develops and then demonstrates an approach for comparing the effects of interventions on the prevalence of late-life disability. We review evidence for three potentially high-impact strategies: physical activity, depression screening and treatment, and fall prevention. Because of the large population at risk for falling, the demonstrated efficacy of multi-component interventions in preventing falls, and the strong links between falls and disability, we conclude that, in the short run, multi-component fall-prevention efforts would likely have a higher impact than either physical activity or depression screening and treatment. However, longer-term comparisons cannot be made based on the current literature and may differ from short-run conclusions, since increases in longevity may temper the influences of these interventions on prevalence. Additional research is needed to evaluate longer-term outcomes of interventions, including effects on length and quality of life. [ABSTRACT FROM AUTHOR]

In September 2002, a technical working group met to resolve previously published inconsistencies across national surveys in trends in activity limitations among the older population. The 12-person panel prepared estimates from five national data sets and investigated methodological sources of the inconsistencies among the population aged 70 and older from the early 1980s to 2001. Although the evidence was mixed for the 1980s and it is difficult to pinpoint when in the 1990s the decline began, during the mid- and late 1990s, the panel found consistent declines on the order of 1%-2.5% per year for two commonly used measures in the disability literature: difficulty with daily activities and help with daily activities. Mixed evidence was found for a third measure: the use of help or equipment with daily activities. The panel also found agreement across surveys that the proportion of older persons who receive help with bathing has declined at the same time as the proportion who use only equipment (but not personal care) to bathe has increased. In comparing findings across surveys, the panel found that the period, definition of disability, treatment of the institutionalized population, and age standardizing of results were important to consider. The implications of the findings for policy, national survey efforts, and further research are discussed. [ABSTRACT FROM AUTHOR]

Recent research indicates declining age-adjusted chronic disability among older Americans, which might moderate health care costs in the coming decades. This study examines the trend's underlying components using data from the 1984–1999 National Long-Term Care Surveys to better understand the reasons for the declines and potential implications for acute and long-term care. The reductions occurred primarily for activities like financial management and shopping. Assistance with personal care activities associated with greater frailty fell less, and independence with assistive devices rose. Institutional residence was stable. More needs to be known about the extent to which these declines reflect environmental improvements allowing greater independence at any level of health, rather than improvements in health, before concluding that the declines will mean lower costs. [ABSTRACT FROM AUTHOR]

Considers an integrated income and disability annuity as an alternative framework for long-term care financing and shows that pooling disability and mortality risks can reduce the need for medical underwriting. Annuity approach to financing long-term care; Results from a study simulating the implications of combining an immediate income annuity and a cash disability policy for the potential size of the market and for adverse selection in both types of insurance.

Examines changes in the population of chronically disabled elderly, their sources of care and the characteristics of family caregivers. Decline in number of active family caregivers; Constant number of primary caregivers who look after severely disabled recipients; Participation of members of the sandwich generation and full-time workers as caregivers.

When private resources are defined broadly to include informal care as well as private expenditures, 73 percent of the elderly long term care population rely entirely on private resources for their care. The emphasis of current programs on institutional care directs public resources toward those with more serious disability and less family to care for them. Among those with four or five disabilities in ADLS, 35 percent of those without a spouse or children currently receive no public support, compared with nearly 80 percent of those with both spouse and chiidren. Thus, even if restricted to seriously disabled persons, a new program expanding public long term care financing would increase eligibiity for public benefits disproportionately among those with greater informal care resources. [ABSTRACT FROM PUBLISHER]

A correction to the article "Change OverTime in Caregiving Networks for Older Adults With and Without Dementia," by Brenda C. Spillman, Vicki A. Freedman, Judith D. Kasper, and Jennifer L. Wolff, which was published in a 2019 issue of the journal is presented.

The authors comment on the connection between remaining lifetime and the trajectory of late-life disability. Few critics have argued that using time to death (TTD) as a predictor of disability confuses the direction of causality. They said the author's our approach to imputation of TTD among censored observations is not valid because TTD is not missing at random (MAR).

Objectives. Older adults with care needs live in a variety of settings—from traditional community housing to nursing homes. This analysis provides new estimates of the size and characteristics of the older population across settings and examines unmet needs for assistance. Method. Data are from the 2011 National Health and Aging Trends Study (N = 8,077). Multinomial logistic regressions focus on people in settings other than nursing homes who are at risk for unmet needs, defined as receiving help or having difficulty with household, self-care, or mobility activities (N = 4,023). Results. Of 38.1 million Medicare beneficiaries ages 65 and older, 5.5 million (15%) live in settings other than traditional housing: 2.5 million in retirement or senior housing communities, nearly 1 million in independent- and 1 million in assisted-living settings, and 1.1 million in nursing homes. The prevalence of assistance is higher and physical and cognitive capacity lower in each successive setting. Unmet needs are common in traditional community housing (31%), but most prevalent in retirement or senior housing (37%) and assisted living settings (42%). After controlling for differences in resident characteristics across settings, those in retirement or senior housing communities have a higher likelihood of unmet needs than those in traditional community housing, while those in independent or assisted living settings have a lower relative likelihood. Discussion. Substantial numbers of older adults, many with care needs, live in a continuum of settings other than traditional community housing. Unmet needs are prevalent among older adults with limitations across all settings and warrant further investigation and monitoring. [ABSTRACT FROM AUTHOR]

Private insurance is one strategy for financing the large and growing cost of long-term care. Little is known, however, about the extent to which medical underwriting may limit the potential of private insurance to cover nursing home care, or whether the underwriting criteria used in this relatively new market successfully identify high-cost groups. Data from the National Mortality Followback Survey are used to address these two questions. It is estimated that between 12 and 23 percent of the population would be rejected from private long-term care insurance because of their health if everyone applied at 65. These figures rise to between 20 and 31 percent at age 75. The simulation results suggest that long-term care insurance underwriting criteria identify individuals who vary substantially in the financial risk they pose to insurers. In most cases, whether a criterion identifies a high-cost group is sensitive to the policy individuals are assumed to buy. [ABSTRACT FROM AUTHOR]