Through Alzheimer's Eyes: A Virtual Pilot Intervention for Family Caregivers of People with Dementia.

OBJECTIVE: To evaluate the feasibility and acceptability of a virtually delivered psychoeducational skill-building intervention for ADRD caregivers. METHODS: A single-arm, pre-posttest pilot study design was employed to evaluate the intervention. Four 90-min group-based weekly sessions were combined with four individual coaching sessions via Zoom. Intervention components covered topics designed to reduce caregiver stress and distress, and a VR experience to help caregivers understand dementia. Data was gathered via REDCap pre- and post-intervention and through post-intervention interviews via Zoom. RESULTS: Results (N = 20) from individual interviews, surveys, and treatment implementation strategies suggest strong feasibility and acceptability. Key change exploration indicated medium effect sizes and statistical significance in preparedness for caregiving (t(19) = 2.69, p = .015, d = 63), communication (t(19) = 2.45, p = .024, d = 0.55), and a medium effect size for the mindful attention awareness scale (t(19) = 0.48, p = (0.637, d = 0.54). Further, participants reported their perceptions of improvement in outcomes such as the ability to care, increased understanding of memory loss, and confidence. CONCLUSIONS: Through Alzheimer's Eyes is a feasible and acceptable intervention that blends technology with skill-building strategies to help caregivers manage their stress and distress regardless of their location. CLINICAL IMPLICATIONS: There is potential for interventions including VR to assist family caregivers in managing caregiving challenges and improve well-being.

Feasibility of the Remembering Warmth and Safeness Intervention in older ADRD caregivers.

BACKGROUND: The number of older adults in the U.S. living with ADRD is projected to increase dramatically by 2060. As older adults increasingly assume informal caregiving responsibilities, community-based intervention to sustain caregiver well-being is a dementia research priority. OBJECTIVE: To evaluate the feasibility of the RWSI among older ADRD caregivers. The RWSI is informed by the Neurovisceral Integration Model, in which memories that engage safety signals cultivate feelings of safety and well-being. METHODS: A within-subjects pre/post-intervention design with older ADRD caregivers to evaluate feasibility (acceptability, demand, fidelity) and empirical promise (well-being). RESULTS: The feasibility of the RWSI, implemented with fidelity, was strongly endorsed, as participants attended each intervention session, after which reported experiencing feelings of warmth and safeness, and provided the highest possible acceptability ratings. Participant narratives provided corroboration. DISCUSSION: Findings support the feasibility of the RWSI in older ADRD caregivers, providing the basis for continued research.

The associations between type 2 diabetes and plasma biomarkers of Alzheimer's disease in the Health and Aging Brain Study: Health Disparities (HABS-HD).

Alzheimer's disease (AD) affects Latinos disproportionately. One of the reasons underlying this disparity may be type 2 diabetes (T2D) that is a risk factor for AD. The purpose of this study was to examine the associations of T2D and AD blood biomarkers and the differences in these associations between Mexican Americans and non-Hispanic Whites. This study was a secondary analysis of baseline data from the observational Health and Aging Brain Study: Health Disparities (HABS-HD) that investigated factors underlying health disparities in AD in Mexican Americans in comparison to non-Hispanic Whites. HABS-HD participants were excluded if they had missing data or were large outliers (z-scores >|4|) on a given AD biomarker. Fasting blood glucose and glycosylated hemoglobin (HbA1c) levels were measured from clinical labs. T2D was diagnosed by licensed clinicians. Plasma amyloid-beta 42 and 40 (Aß42/42) ratio, total tau (t-tau), and neurofilament light (NfL) were measured via ultra-sensitive Simoa assays. The sample sizes were 1,552 for Aß42/40 ratio, 1,570 for t-tau, and 1,553 for NfL. Mexican Americans were younger (66.6±8.7 vs. 69.5±8.6) and had more female (64.9% female vs. 55.1%) and fewer years of schooling (9.5±4.6 vs. 15.6±2.5) than non-Hispanic Whites. Mexican Americans differed significantly from non-Hispanic Whites in blood glucose (113.5±36.6 vs. 99.2±17.0) and HbA1c (6.33±1.4 vs. 5.51±0.6) levels, T2D diagnosis (35.3% vs. 11.1%), as well as blood Aß42/40 ratio (.051±.012 vs. .047±.011), t-tau (2.56±.95 vs. 2.33±.90), and NfL levels (16.3±9.5 vs. 20.3±10.3). Blood glucose, blood HbA1c, and T2D diagnosis were not related to Aß42/40 ratio and t-tau but explained 3.7% of the variation in NfL (p < .001). Blood glucose and T2D diagnosis were not, while HbA1c was positively (b = 2.31, p < .001, ß = 0.26), associated with NfL among Mexican Americans. In contrast, blood glucose, HbA1c, and T2D diagnosis were negatively (b = -0.09, p < .01, ß = -0.26), not (b = 0.34, p = .71, ß = 0.04), and positively (b = 3.32, p < .01, ß = 0.33) associated with NfL, respectively in non-Hispanic Whites. To conclude, blood glucose and HbA1c levels and T2D diagnosis are associated with plasma NfL levels, but not plasma Aß and t-tau levels. These associations differ in an ethnicity-specific manner and need to be further studied as a potential mechanism underlying AD disparities.

Perceived Balance, Balance Performance, and Falls Among Community-Dwelling Older Adults: A Retrospective, Cross-Sectional Study.

Objectives: To examine the extent to which older adults' perceived balance, a balance performance test, and fear of falling (FOF) were associated with falls in the last month. Methods: The Health Belief Model served as the theoretical framework. A retrospective, cross-sectional, secondary analysis using data from the National Health and Aging Trends Study was conducted (N = 7499). Results: Multiple logistic regression analysis revealed that the odds of reporting a fall in the past month were 3.3 times (p < .001) greater for participants who self-reported having a balance problem compared to those who did not. The Short Physical Performance Battery and FOF were not uniquely associated with falls. Discussion: Our findings support limited evidence suggesting that older adults' perceived balance is a better predictor of falls than balance performance. Assessing older adults' perceived balance may be a new way to assess older adults' fall risk to prevent future falls.

Perceived balance and self-reported falls: A retrospective cross-sectional study using the National Health and Aging Trend Study.

AIMS: To examine how perceived balance problems are associated with self-reported falls in the past month after controlling for known correlates of falls among older adults. BACKGROUND: Approximately 30% of adults age 65 and older fall each year. Most accidental falls are preventable, and older adults' engagement in fall prevention is imperative. Limited research suggest that older adults do not use the term 'fall risk' to describe their risk for falls. Instead, they commonly use the term 'balance problems'. Yet, commonly used fall risk assessment tools in both primary and acute care do not assess older adults' perceived balance. DESIGN AND METHOD: The Health Belief Model and the concept of perceived susceptibility served as the theoretical framework. A retrospective, cross-sectional secondary analysis using data from the National Health and Aging Trends Study from year 2015 was conducted. The outcome variable was self-reported falls in the last month. RESULTS: A subsample of independently living participants (N = 7499) was selected, and 10.3% of the sample reported a fall. Multiple logistic regression analysis revealed that the odds of reporting a fall in the past month was 3.4 times (p < .001) greater for participants who self-reported having a balance problem compared to those who did not. In contrast, fear of falling and perceived memory problems were not uniquely associated with falls. Using a mobility device, reporting pain, poor self-rated health status, depression and anxiety scores were also associated with falling. CONCLUSION AND IMPLICATIONS: Older adults' perceived balance problem is strongly associated with their fall risk. Perceived balance may be important to discuss with older adults to increase identification of fall risk. Older adults' perceived balance should be included in nursing fall risk assessments and fall prevention interventions. A focus on balance may increase older adults' engagement in fall prevention.

The Provider's Role in Retaining Black Women With HIV in Care: A Scoping Review.

Black/African American women represent 54% of new HIV cases among all women in the United States, face higher rates of morbidity and mortality, and are often understudied. The patient-provider relationship is an important motivator to keeping people who live with HIV retained in care and adherent to a medical regimen, thereby improving chances for viral suppression and maintaining overall better health. This scoping review sought to determine the extent of documented provider actions that encourage Black women with HIV to stay engaged in care. The review investigated five databases for peer-reviewed studies in the United States that included Black women from 2009 to 2023 and specifically described beneficial provider actions or behaviors. Of 526 records, 12 met the criteria. Studies revealed that women are motivated by providers who create a respectful, nonjudgmental emotionally supportive relationship with them rather than those who rely on an authoritative transactional exchange of information and orders.

The provider's role in retaining Black women with HIV in care: A scoping reviewThis review sought the perspectives of Black women with HIV on actions their providers take that help retain them in medical care.

Predictors of Usual and Peak Gait Speed in Community-Dwelling Older Adults With Mild-to-Moderate Alzheimer's Dementia.

Gait speed significantly affects functional status and health outcomes in older adults. This cross-sectional study evaluated cognitive and physical fitness contributors to usual and peak gait speed in persons with Alzheimer's dementia. Multiple hierarchal linear regression was used to obtain squared semipartial correlation coefficients (sr2) and effect sizes (Cohen's ƒ2). Participants (n = 90; 56% male) averaged 77.1 ± 6.6 years of age and 21.8 ± 3.4 on Mini-Mental State Examination. Demographic/clinical, physical fitness, and cognition variables explained 45% and 39% of variance in usual and peak gait speed, respectively. Muscle strength was the only significant contributor to both usual (sr2 = .175; Cohen's ƒ2 = 0.31; p < .001) and peak gait speed (sr2 = .11; Cohen's ƒ2 = 0.18; p < .001). Women who were "slow" walkers (usual gait speed <1.0 m/s) had significantly lower cardiorespiratory fitness and executive functioning compared with "fast" walkers. In conclusion, improving muscle strength may modify gait and downstream health outcomes in Alzheimer's dementia.

Behind the Scenes of a Technologically Enhanced Intervention for Caregivers of People With Dementia: Protocol for a Feasibility and Acceptability Study.

BACKGROUND: Alzheimer's disease affects 55 million people worldwide. As the disease progresses, these individuals require a devoted caregiver, often a family member, who provides evolving complex care. Caregivers can experience a variety of ongoing stressors, resulting in reductions in caregiver emotional well-being (and other quality-of-life indicators). Information and communication technologies provide an excellent opportunity to train caregivers remotely and help them to manage these stressors and related distress. OBJECTIVE: This protocol describes the theoretical rationale, study design, and methods of a new, technologically enhanced psychoeducational skill-building intervention for caregivers of people with dementia that includes a virtual reality component. METHODS: Through Alzheimer's Eyes is a 4-week, single-arm, pre-post test pilot study consisting of 4 sessions of 90 minutes each that are delivered by videoconferencing. These sessions include a weekly virtual reality experience characterizing the journey of an older Latina with Alzheimer's disease from her perspective to help caregivers see through the eyes of a person with dementia. The 4 sessions cover the skill-training topics of communication, managing challenging behaviors and unhelpful thoughts, the importance of self-care, and mindfulness-all of which are key components designed to reduce stress and distress in family caregivers. Individual interviews conducted before and after the intervention gather participant insights into the intervention, evaluate its feasibility and acceptability, and assess its impact on key outcomes. RESULTS: Data collection for the study started in January 2022, and the results are expected to be submitted for publication in the second half of 2023. Twenty caregivers from the United States have completed the workshop to date. Preliminary data gathered from these participants support the intervention's feasibility and acceptability. CONCLUSIONS: Through Alzheimer's Eyes leverages existing technology combined with psychoeducational skill building to help caregivers manage their stress, regardless of their location. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/42655.

Modifiable Risk Factors for Brain Health and Dementia and Opportunities for Intervention: A Brief Review.

Maintaining brain health and promoting healthy lifestyle strategies to manage modifiable risk factors is vital to ensuring well-being for all - not only for the individuals with memory challenges but also their family caregivers and professional providers. In this brief review paper, we highlight modifiable risk and protective factors and opportunities for dementia risk reduction (e.g., limited alcohol use and reduced exposure to air pollution, secondhand smoke, and excessive noise); provide an overview of the World-Wide FINGERS Network and its goal to adapt the original Finnish Geriatric Intervention Study to Prevent Cognitive Impairment and Disability (FINGER) multidomain lifestyle approach in various settings to determine whether the protocol is effective across different populations in varied geographic, cultural, and economic settings and to optimize the model across a continuum of cognitive decline; and, comment on challenges and opportunities for researchers and clinicians including opportunities for risk reduction and intervention in primary care settings and the need to establish linkages across multiple levels of intervention to sustain behavior change in prevention, treatment, and care.

Feeling Safe and Nostalgia in Healthy Aging.

The population of older adults worldwide is growing, with an urgent need for approaches that develop and maintain intrinsic capacity consistent with healthy aging. Theory and empirical research converge on feeling safe as central to healthy aging. However, there has been limited attention to resources that cultivate feeling safe to support healthy aging. Nostalgia, "a sentimental longing for one's past," is established as a source of comfort in response to social threat, existential threat, and self-threat. Drawing from extant theory and research, we build on these findings to position nostalgia as a regulatory resource that cultivates feeling safe and contributes to intrinsic capacity to support healthy aging. Using a narrative review method, we: (a) characterize feeling safe as a distinct affective dimension, (b) summarize the character of nostalgia in alignment with feeling safe, (c) propose a theoretical account of the mechanisms through which nostalgia cultivates feeling safe, (d) highlight the contribution of nostalgia to feeling safe and emotional, physiological, and behavioral regulatory capabilities in healthy aging, and (e) offer conclusions and direction for research.

Physical Activity Among Predominantly White Middle-Aged and Older US Adults During the SARS-CoV-2 Pandemic: Results From a National Longitudinal Survey.

Background: The first COVID-19 case in the US was diagnosed late January 2020. In the subsequent months, cases grew exponentially. By March 2020, SARS-CoV-2 (the novel coronavirus that causes COVID-19) was a global pandemic and the US declared a national emergency. To mitigate transmission, federal guidelines were established for social and physical distancing. These events disrupted daily routines of individuals around the world, including Americans. The impact of the pandemic on PA patterns of Americans is largely unknown, especially among those at greater risk for severe COVID-19 outcomes. The aim of this study was to assess levels of PA over time during the pandemic among US adults aged >50 years. Methods: Data were collected as part of a web-based, longitudinal, 3-wave study examining health and well-being among adults aged > 50. PA data were collected at Waves 2 and 3 using the International Physical Activity Questionnaire-Short Form (IPAQ-SF). At Wave 2 (conducted mid-May to early June, 2020), participants completed the IPAQ-SF twice, once in reference to a typical 7-day period before the pandemic, and again in reference to the past 7 days. At Wave 3 (conducted mid-June to early July 2020), participants completed the IPAQ-SF once, with reference to the past 7 days. Potential predictors of PA change were collected using items from previously established surveys and included demographic characteristics, pre-pandemic PA levels, perceived COVID-19 threat, self-rated general health, and number of chronic disease conditions. Results: Respondents (N = 589) had a mean age of 63 ± 7.39 years and were mostly female (88%) and non-Hispanic White (96%). Mean MET-min/week across the three time-referents were 2,904 (pre-pandemic), 1,682 (Wave 2 past 7-days), and 2,001 (Wave 3 past 7-days), with PA declining between the first and second time referents (d = -0.45, p < 0.001) and remaining below pre-pandemic levels at the third (d = -0.34, p < 0.001). Changes over time were predicted by pre-pandemic PA and self-rated general health (p's < .05). Conclusions: Effective strategies are needed to promote safe and socially-distanced PA among adults aged >50 years until the risk of contracting COVID-19 subsides. In the post-pandemic era, PA programming will be imperative to address pandemic-associated declines in PA.

Development of a Nostalgic Remembering Intervention: Feeling Safe in Dyads Receiving Palliative Care for Advanced Heart Failure.

BACKGROUND: Dyads receiving palliative care for advanced heart failure are at risk for the loss of feeling safe, experienced as a fractured sense of coherence, discontinuity in sense of self and relationships, and strained social connections and altered roles. However, few theory-based interventions have addressed feeling safe in this vulnerable population. PURPOSE: The purpose of this article is to describe the development of the Nostalgic Remembering Intervention to strengthen feeling safe and promote adaptive physiological and psychological regulation in dyads receiving palliative care for heart failure. CONCLUSIONS: Systematic intervention development is essential to understand what, for whom, why, and how an intervention works in producing outcomes. Program theory provided a systematic approach to the development of the Nostalgic Remembering Intervention, including conceptualization of the problem targeted by the intervention, specification of critical inputs and conditions that operationalize the intervention, and understanding the mediating processes leading to expected outcomes. CLINICAL IMPLICATIONS: Creating a foundation for cardiovascular nursing research and practice requires continued, systematic development of theory-based interventions to best meet the needs of dyads receiving palliative care for heart failure. The development of the Nostalgic Remembering Intervention to strengthen feeling safe in dyads provides a novel and relevant approach.

The Efficacy of General Practitioner Assessment of Cognition in Chinese Elders Aged 80 and Older.

OBJECTIVES: This study examined the efficacy of the General Practitioner Assessment of Cognition-Chinese version (GPCOG-C) in screening dementia and mild cognitive impairment (MCI) among older Chinese. METHODS: Survey questionnaires were administered to 293 participants aged 80 or above from a university hospital in mainland China. Alzheimer disease and MCI were diagnosed in light of the National Institute on Aging and the Alzheimer's Association (NIA/AA) criteria. The sensitivity and specificity of GPCOG-C and Mini-Mental State Examination (MMSE) in screening dementia and MCI were compared to the NIA/AA criteria. RESULTS: The GPCOG-C had the sensitivity of 62.3% and specificity of 84.6% in screening MCI, which had comparable efficacy as the NIA/AA criteria. In screening dementia, GPCOG-C had a lower sensitivity (63.7%) than the MMSE and a higher specificity (82.6%) higher than the MMSE. CONCLUSIONS: The GPCOG-C is a useful and efficient tool to identify dementia and MCI in older Chinese in outpatient clinical settings.

Trajectory and variability characterization of the Montreal cognitive assessment in older adults.

BACKGROUND: The Montreal cognitive assessment (MoCA) has become one of the most widely used cognitive screening instruments since its initial publication. To date, only a handful of studies have explored longitudinal characteristics of the MoCA. AIM: The aim of this study is to characterize the trajectory of MoCA performance across a broad age continuum of older adults. METHODS: Data from 467 cognitively normal participants were used in this analysis. The sample was grouped into four strata based on the participants' age at baseline (60-69, 70-79, 80-89, and 90-99). Mixed model repeated measures (MMRM) analysis and mixed-effects spline models were used to characterize the trajectory of MoCA scores in each age stratum and in the entire sample. Intrasubject standard deviation (ISD) was used to characterize the natural variability of individual MoCA performance over time. RESULTS: The ISD values for each of the age strata indicated that year-to-year individual variation on the MoCA ranged from zero to three points. MMRM analysis showed that the 60-69 stratum remained relatively stable over time while the 70-79 and 80-89 strata both showed notable decline relative to baseline performance. The mixed-effects spline model showed that MoCA performance declines linearly across the older adult age span. DISCUSSION: Among cognitively normal older adults MoCA performance remains relatively stable over time, however across the older adult age-span MoCA performance declines in a linear fashion. These results will help clinicians better understand the normal course of MoCA change in older adults while researchers may use these results to inform sample size estimates for intervention studies. CONCLUSION: This study provides an enhanced view of the MoCA's intraindividual trajectory in normal elderly aged 60 and older.

Collective Care: Multiple Caregivers and Multiple Care Recipients in Mexican American Families.

PURPOSE: Specific stressors associated with caregiving in Mexican American (MA) families are not well documented, yet caregiving issues are paramount because informal care for parents is central to their culture. Although MA families who band together to provide care for one member are not unique, the literature does not describe the phenomenon of collective caregiving, which may be widespread but unrecognized. This article describes these understudied families who are poorly served by contemporary health systems because their characteristics are unknown. DESIGN: Descriptive, multisite, longitudinal mixed-methods study of MA caregiving families. FINDINGS: We identified three types of collective caregivers: those providing care for multiple family members simultaneously, those providing care successively to several family members, and/or those needing care themselves during their caregiving of others. DISCUSSION AND CONCLUSIONS: Collective caregiving of MA elders warrants further investigation. IMPLICATIONS FOR PRACTICE: Exploration of collective caregiving may provide a foundation for tailored family interventions.

The Impact of Mild Cognitive Impairment on Gait and Balance: A Systematic Review and Meta-Analysis of Studies Using Instrumented Assessment.

BACKGROUND: In addition to cognitive deficits, people with mild cognitive impairment (MCI) can experience motor dysfunction, including deficits in gait and balance. Objective, instrumented motor performance assessment may allow the detection of subtle MCI-related motor deficits, allowing early diagnosis and intervention. Motor assessment under dual-task conditions may increase diagnostic accuracy; however, the sensitivity of different cognitive tasks is unclear. OBJECTIVE: To systematically review the extant literature focusing on instrumented assessment of gait and balance parameters for discriminating MCI patients from cognitively intact peers. METHODS: Database searches were conducted in PubMed, EMBASE, Cochrane Library, PsycINFO and Web of Science. Inclusion criteria were: (1) clinically confirmed MCI; (2) instrumented measurement of gait and/or balance; (3) English language, and (4) reporting gait or balance parameters which could be included in a meta-analysis for discriminating between MCI patients and cognitively intact individuals based on weighted effect size (d). RESULTS: Fourteen studies met the inclusion criteria and reported quantitative gait (n = 11) or postural balance (n = 4) parameters to be included in the meta-analysis. The meta-analysis revealed that several gait parameters including velocity (d = -0.74, p < 0.01), stride length (d = -0.65, p < 0.01), and stride time (mean: d = 0.56, p = 0.02; coefficient of variation: d = 0.50, p < 0.01) discriminated best between MCI and healthy controls under single-task conditions. Importantly, dual-task assessment increased the discriminative power of gait variables wherein gait variables with counting tasks appeared to be more sensitive (range d = 0.84-1.35) compared to verbal fluency tasks such as animal naming (range d = 0.65-0.94). Balance parameters identified as significant discriminators were anterior-posterior (d = 0.49, p < 0.01) and mediolateral (d = -0.34, p = 0.04) sway position in the eyes-open condition but not eyes-closed condition. CONCLUSION: Existing studies provide evidence that MCI affects specific gait parameters. MCI-related gait changes were most pronounced when subjects are challenged cognitively (i.e., dual task), suggesting that gait assessment with an additional cognitive task is useful for diagnosis and outcome analysis in the target population. Static balance seems to also be affected by MCI, although limited evidence exists. Instrumented motor assessment could provide a critical opportunity for MCI diagnosis and tailored intervention targeting specific deficits and potentially slowing progression to dementia. Further studies are required to confirm our findings.

Latino/Hispanic Alzheimer's caregivers experiencing dementia-related dressing issues: corroboration of the Preservation of Self model and reactions to a "smart dresser" computer-based dressing aid.

OBJECTIVE: To gain an understanding of Latino/Hispanic caregivers' dementia-related dressing issues, their impressions of using a "smart" context-aware dresser to coach dressing, and recommendations to improve its acceptability. METHOD: The same Latina moderator conducted all the caregiver focus groups. She followed a semi-structured interview guide that was previously used with White and African American family caregivers who experienced Alzheimer's disease related dressing challenges. From that study, the Preservation of Self model emerged. Using a deductive qualitative analytic approach, we applied the thematic domains from the Preservation of Self model to ascertain relevance to Latino/Hispanic caregivers. RESULTS: Twenty Latino/Hispanic experienced caregivers were recruited, enrolled, and participated in one of three focus groups. The majority were female (75%) and either the spouse (25%) or adult child (35%). Striking similarities occurred with the dressing challenges and alignment with the Preservation of Self model. Ethnic differences arose in concerns over assimilation weakening the Latino culture of family caregiving. Regional clothing preferences were noted. Technology improvement recommendations for our system, called DRESS, included developing bilingual prompting dialogs and video modules using the local vernacular to improve cultural sensitivity. Caregivers identified the potential for the technology to enable user privacy, empowerment, and exercise as well as offering respite time for themselves. CONCLUSION: Findings suggest dementia-related dressing issues were shared in common by different racial/ethnic groups but the response to them was influenced by cultural dynamics. For the first time Latino/Hispanic voices are heard to reflect their positive technology impressions, concerns, and recommendations in order to begin to address the cultural digital disparities divide.

The "Reckoning Point" as a Marker for Formal Palliative and End-of-Life Care in Mexican American Families.

Palliative and end-of-life care (PEOLC) in Mexican American (MA) caregiving families remains unexplored. Its onset was uncovered in our mixed methods, multisite, interdisciplinary, qualitative descriptive study of 116 caregivers, most of whom had provided long-term informal home care for chronically ill, disabled older family members. This subanalysis used Life Course Perspective to examine the "point of reckoning" in these families, where an older person is taken in for care, or care escalates until one recognizes oneself as the primary caregiver. Ninety-three of 116 caregivers recognized and spontaneously reported a "reckoning point" that initiated the caregiving trajectory, while eight cited "gradual decline" into caregiving for elders in their homes. This "reckoning point," which marks the assumption of this role, may afford a fertile opportunity for referral to community resources or initiation of formal PEOLC, thereby improving the quality of life for these older individuals and their families.