Social Isolation and Worsening Health Behaviors Among Older Adults During the COVID-19 Pandemic.

OBJECTIVES: We examine the relationship between social isolation, poor health behaviors, and the perceived worsening of older adults' health behaviors following the coronavirus outbreak. We assess the extent to which psychological pathways mediate the relationship between social isolation and worsening health behaviors. METHODS: Drawing on data from the National Social Life Health and Aging Project Round 3 (2015) and its coronavirus immune disease 2019 (COVID-19) substudy (2020; N = 2,549), we use generalized linear models to explore how indicators of social isolation during the COVID-19 pandemic-infrequent in-person contact with friends and family in 2020 and decreased in-person contact with friends and family since COVID-19 started-are associated with (1) poor health behaviors (low physical activity, drinks per week, smoking, and poor sleep) in 2020 and (2) perceived worsening of health behaviors (reports of decreased physical activity, increased drinking and smoking, and feeling less rested) since the pandemic started. RESULTS: Infrequent in-person contact was not associated with poor health behaviors. Decreases in in-person contact, on the other hand, were associated with worsening health behaviors. Older adults who reported decreases in in-person contact were more likely to perceive a decrease in physical activity, an increase in drinking, and feeling less rested. Emotional well-being, particularly loneliness compared to anxiety or depressive feelings, partially mediated the relationship between perceived worsening of health behaviors and a decrease in in-person contact with friends, and to a lesser extent, with family. DISCUSSION: Our study suggests that in-person contact may play a distinct role in shaping older adults' well-being during the pandemic.

Takes Two to Tango: Cognitive Impairment and Sexual Activity in Older Individuals and Dyads.

OBJECTIVES: This article examines the association between cognitive impairment, including mild cognitive impairment (MCI) and early dementia (ED), and sexual activity in a large, longitudinal sample of community-dwelling older adults. We focus here on sexual activity, which includes both sexual activity with a partner and masturbation. METHODS: We analyzed 3,777 older individuals and members of 955 intimate dyads using the National Social Life, Health, and Aging Project (2010 and 2015). We used ordered probit regression, cross-lagged panels models, and probit regression. RESULTS: We find that older adults with cognitive limitations, either MCI or ED, are about as likely to be sexually active with a partner as those with normal cognitive function. This is the case both in the cross-section and longitudinally. Both men and women with ED are less likely to have masturbated, however. Among married and cohabiting couples, we find no association between cognitive impairment in either the husband, the wife, or in both partners and their joint sexual activity. Women whose measured cognitive function is lower than their husbands are less likely to report any masturbation. DISCUSSION: Sex with a partner, a fundamentally social activity, seems to be conserved in the face of cognitive limitation but masturbation, a solitary activity, does not. We argue that the intimate dyad plays an important role in conserving partnered sexual activity. Results can inform strategies to maintain the sexual well-being of older adults with cognitive impairment and their partners as part of overall strategies to improve quality of life.

Elder Mistreatment Methods and Measures in Round 3 of the National Social Life, Health, and Aging Project.

OBJECTIVES: Elder mistreatment has negative consequences for older adults' health and well-being. As such, scholars aim to understand its causes, the contexts in which it occurs, how to prevent victimization, and how to design interventions for mistreated older adults. This paper provides a detailed overview of the 2015-2016 National Social Life, Health, and Aging Project (NSHAP) Round 3 Elder Mistreatment Module (EMM) to encourage further research on the topic. METHOD: This paper reviews previous elder mistreatment scholarship, describes the EMM, provides descriptive analyses of elder mistreatment among community-dwelling older adults, and discusses promising approaches and limitations to future research with these data. RESULTS: The EMM includes 10 stem questions to measure elder mistreatment behaviors experienced since age 60 and 2 follow-up questions about perceived severity and the identity of the perpetrator. The stem questions can be analyzed individually or combined into a scale, and researchers can account for severity as a robustness check. Analysts can also group the measures into specific types of elder mistreatment. A major strength of the EMM is its ability to identify perpetrators in victims' core social networks. DISCUSSION: The NSHAP Round 3 EMM provides scholars an opportunity to study older Americans' mistreatment experiences, particularly as they relate to their physical and mental health, their social networks and personal relationships, and their broader social contexts.

Resilience and Social Support-Giving Scales: Conceptual and Empirical Validation.

OBJECTIVES: This report introduces National Social Life, Health, and Aging Project (NSHAP) data users to 2 new measures-one that assesses older adults' resilience, defined as personal attributes that indicate an adaptive reserve that can be drawn on during adversity, and a second that expands on existing measures of social support received from others to also assess social support given to close others. METHOD: Data from 4,604 NSHAP respondents born 1920-1965 were used to conduct psychometric analyses and validation of our measures of resilience and social support-giving. RESULTS: Scale reliabilities were acceptable for the 4-item resilience scale, and the 2-item scales for family support-giving and friend support-giving. The 2 spousal support-giving items did not cohere well as a single scale. The resilience scale exhibited significant correlations with criterion validation variables, even after adjusting for correlated personality traits. The support-giving scales, and the spousal support-giving items, also exhibited significant correlations with criteria, and with the resilience scale, even after adjusting for social support receipt. Scale means exhibited demographic differences. DISCUSSION: The resilience and social support-giving measures have acceptable psychometric characteristics (with the exception of spousal support-giving), convergent validity, and predictive utility net of related variables. NSHAP data users are offered several suggestions (key points) in the use of these measures in future research.

Childhood Background Measures and Their Associations With Later-Life Physical, Mental, and Social Health in the National Social Life, Health, and Aging Project.

OBJECTIVE: We describe each childhood background measure available in the National Social Life, Health, and Aging Project (NSHAP), report preliminary population estimates for each measure by age and gender, and validate the childhood measures by showing that the associations between the NSHAP childhood measures and later-life health outcomes are consistent with previous studies on this topic. METHOD: Childhood background measures included family life happiness, family structure, parental educational attainment, perceived financial situation, experience of violence, witness of violence, childhood health, and place of birth. We measured self-rated health, depressive symptoms, and social support to assess later-life physical, mental, and social health. Logistic and linear regression models were used for the binary and continuous outcome variables, respectively. RESULTS: Older age groups were more likely than those in younger age groups to report a poor financial situation in childhood, lower parental education, and intact family structure and were less likely to have experienced or witnessed a violent event as a child. Growing up in a happy and well-educated family was associated with better physical, mental, and social health in older ages. DISCUSSION: NSHAP childhood data included a variety of measures assessing the family social environment during childhood, providing a valuable resource for the study of early-life determinants of health and well-being over the life course.

2015-2016 Normative Data for the 3-m Usual Walk, Five Repeated Chair Stands, and Static Balance Components of the SPPB Among U.S. Older Adults Across Two Nationally Representative Data Sets: NSHAP and NHATS.

OBJECTIVES: Our primary objective was to examine the distribution of 3-m usual walk, five repeated chair stands, and three static balance stance performances among age and gender subgroups of adults at least 65 years in two national data sets. We secondarily determined whether demographic-function associations varied across data sets, birth cohorts, or models incorporating data from those "unable to do" tasks. METHODS: Two nationally representative data sets were used to generate survey weight-adjusted performance distributions: the 2015-2016 National Social Life Health and Aging Project and the 2016 National Health and Aging Trends Study. We then regressed walk and chair stand performance on age, gender, and race/ethnicity, examining differences across data sets, birth cohorts (1920-1947, 1948-1965), and before/after incorporating the "unable to do" performers. RESULTS: Findings confirmed the gradual decline in function with age and allowed estimation of "relative" performance within age/gender subgroups. Data set distribution differences were noted, possibly due to recruitment, eligibility, and protocol variations. Demographic associations were similar across data sets but generally weaker among the 1948-1965 cohort and in models including the sizable "unable to do" group. DISCUSSION: We present the largest, most current Short Physical Performance Battery reference data in U.S. adults aged 65 or older. Findings support standardization of administration protocols in research and clinical care and differentiating absolute from relative performance.

Novel Insights From Interviewer Assessments of Personal Attributes, Home Environment, and Residential Context in NSHAP.

OBJECTIVES: This study was aimed to describe the interviewer-assessed measures present in the 2015/2016 Round of National Social Life, Health, and Aging Project (NSHAP), outline strengths of interviewer-assessed measures, and explore how interviewer assessments in the domains of home environment and personal characteristics are associated with older adult health. METHOD: Data come from the 2015/2016 Round of the NSHAP. RESULTS: We provide descriptive results from the interviewer assessments of personal attributes, indoor home environment, and outdoor residential context. We present an illustrative analysis of reports of falls, a health outcome that might be predicted by characteristics assessed by the interviewer, and we suggest directions for further research. DISCUSSION: Interviewer assessments collected in NSHAP are useful as proxy measures and can be used in combination with respondent's reports and ecological measures to generate insights into healthy aging.

Social Health in the National Social Life, Health, and Aging Project.

OBJECTIVES: In this article, we present the theoretical framework that guided the development of the National Social Life, Health, and Aging Project (NSHAP) including the measures of social health. We discuss the literature that links social measures to other outcomes, and we discuss in detail how researchers might construct common measures of social health, including those that reflect social relationships, sexuality, social networks, social resources, and social participation. METHODS: The NSHAP includes multiple detailed measures of social health, collected in the rounds of data collection carried out in 2005, 2010, and 2015, allowing for study of changes over time and as people age among a nationally representative sample of the community-dwelling population of older adults in the United States. RESULTS: We define indicators of social health, describe measures of each in the 2015 round of NSHAP, and show the distribution of the measures by gender and age. We present scales of dimensions of social health that have been developed elsewhere and describe their properties. DISCUSSION: We briefly discuss the distribution of these measures by age and gender in the 2015 round of NSHAP. Simple analyses of these categorized measures reveal differences by age and gender that deserve closer attention in future investigations using the NSHAP data.

Analyzing Birth Cohorts With the National Social Life, Health, and Aging Project.

OBJECTIVES: In this article, we seek to provide assistance to those who might want to use data from the National Social Life, Health, and Aging Project (NSHAP) Rounds 1-3 to compare those born in different cohorts. We outline 2 theoretical models that underlie the design of NSHAP-the life course model and the birth cohorts model-and review examples of social and political changes that may have differentially affected cohorts of older adults. Then we present 2 ways that NSHAP data might be used to compare cohorts, show examples of analyses of cohort differences in measures in NSHAP, and discuss features of the data that might affect their use for this purpose. METHODS: Round 3 of the NSHAP added a group of respondents born between 1948 and 1965, the Baby Boom. Together with data from an earlier cohort, interviewed in Rounds 1-3, these data allow analysis of birth cohorts of older adults in the United States. We show examples of some approaches. RESULTS: Our age-matched cohort differences approach included all observations where the respondent was aged 57-67 at the time of interview in different time periods (3,816 observations overall; 2,316 for the Silent Generation cohort and 1,500 for the Baby Boom cohort). Our second approach, age, period, and cohort effects, models the effects of age and birth year using restricted cubic splines, with one model excluding the linear effect of birth year, and the other excluding the linear effect of period. We present examples of analyses using each of these methods. DISCUSSION: We describe features of the NSHAP data of which researchers should be aware when conducting cohort analyses with these data.

The epidemiology of social isolation and loneliness among older adults during the last years of life.

BACKGROUND: Social isolation and loneliness are critical to the health of older adults, but they have not been well-described at the end of life. OBJECTIVES: To determine the prevalence and correlates of social isolation and loneliness among older adults in the last years of life. DESIGN: Nationally representative, cross-sectional survey. SETTING: Health and Retirement Study, 2006-2016 data. PARTICIPANTS: Adults age > 50 interviewed once in the last 4 years of life (n = 3613). MEASUREMENTS: We defined social isolation using a 15-item scale measuring household contacts, social network interaction, and community engagement, and frequent loneliness using the 3-item UCLA Loneliness Scale. We used multivariable logistic regression to determine their adjusted prevalence by time prior-to-death and by subgroups of interest. RESULTS: Approximately 19% experienced social isolation, 18% loneliness, and 5% both in the last 4 years of life (correlation = 0.11). The adjusted prevalence of social isolation was higher for individuals nearer to death (4 years: 18% vs 0-3 months: 27%, p = 0.05) and there was no significant change in loneliness (4 years: 19% vs 0-3 months: 23%, p = 0.13). Risk factors for both isolation and loneliness included (p < 0.01): low net-worth (Isolation: 34% vs 14%; Loneliness: 29% vs 13%), hearing impairment (Isolation: 26% vs 20%; Loneliness: 26% vs 17%), and difficulty preparing meals (Isolation: 27% vs 19%; Loneliness: 29% vs 15%). Factors associated with loneliness, but not social isolation, included being female, pain, incontinence, and cognitive impairment. CONCLUSIONS: Social isolation and loneliness are common at the end of life, affecting 1 in 4 older adults, but few experience both. Rates were higher for older adults who were poor and experienced functional or sensory impairments. Results can inform clinical efforts to identify and address end-of-life psychosocial suffering and health policies which prioritize social needs at the end of life.

Integration of an Objective Cognitive Assessment Into a Prognostic Index for 5-Year Mortality Prediction.

BACKGROUND/OBJECTIVES: Prognostic indices rarely include cognition. We determined if a comprehensive cognitive screen or brief individual items were associated with improved mortality predictions of a widely used prognostic index. DESIGN, SETTING, AND PARTICIPANTS: The National Social Life Health and Aging Project Wave 2, a nationally representative, cross-sectional, in-home survey conducted in 2010 to 2011 on 3,199 community-dwelling adults aged 60 to 99 years. MEASUREMENTS: Cognition was measured using a Survey-Adapted Montreal Cognitive Assessment (MoCA-SA) grouped into three screened categories: screen normal (≥24 points), screen positive for mild cognitive impairment (18-23 points), and screen positive for dementia (<18 points). Single-item cognitive measures included clock-draw and five-word delayed recall. We constructed a modified Lee Prognostic Index (range = 0-18 points) based on age, behavior, function, and comorbidities shown to predict long-term mortality. We used logistic regression and the fraction of new information provided to determine if each cognitive measure improved the Lee index's 5-year mortality prediction. RESULTS: The sample was 54% female and had a mean age of 72 years, MoCA-SA score of 22 (SD = 4.5), and Lee index of 7 (SD = 3). Regression analysis indicated the MoCA-SA modestly improved the Lee index's mortality prediction (P < .001; fraction of new information provided = 0.06); for low Lee index scores (<4 points), the absolute mortality rate difference was 7% by cognitive status; and for higher Lee index scores (4-7 points or 8-12 points), the absolute mortality rate difference was 15% by cognitive status. The clock-draw and delayed-recall items added similar value to mortality predictions as the longer MoCA-SA. Cognition had the third highest fraction of new information of all 13 Lee index items. CONCLUSION: Incorporating a brief measure of cognition into a modified Lee index, even with single items, resulted in more accurate 5-year mortality risk predictions. Cognition should be included in prognostic calculators in older adults given its independent association with mortality risk. J Am Geriatr Soc 68:1796-1802, 2020.

The Social Relationship Context of Elder Mistreatment.

BACKGROUND AND OBJECTIVES: Elder mistreatment victims at risk of poor physical and psychological health may benefit from increased social support. This article identifies mistreatment victims among community-dwelling older Americans and maps their social networks to guide the design of social support interventions. RESEARCH DESIGN AND METHODS: Using nationally representative survey data from Wave 3 (2015-2016) of the National Social Life, Health, and Aging Project (N = 2,334) and descriptive, latent class, and regression analyses, we estimate the prevalence of mistreatment since age 60, identify the alleged perpetrators' relationships to the victims, and examine victims' social networks. RESULTS: Self-reported lifetime prevalence of elder mistreatment is as high as 21%, depending on the mistreatment behavior measured. Latent class analysis reveals two mistreatment classes: 12% of older adults experienced multiple types of mistreatment (polyvictimization), and 6% experienced primarily financial mistreatment. Although alleged perpetrators are unlikely to appear in older adults' core social networks, the most commonly reported perpetrators are children and relatives. Regression analyses show that experiencing mistreatment since age 60 is associated with having less current social support, more social strain, and fewer kin in the core social network. Older adults reporting polyvictimization also have less-dense core networks. DISCUSSION AND IMPLICATIONS: Increasing family support should be done cautiously because children and relatives are frequently named as mistreatment perpetrators. Increasing communication across polyvictimization victims' network members may support their well-being. Providing outside assistance with financial management could benefit financial mistreatment victims.

Cognitive Function and its Risk Factors Among Older US Adults Living at Home.

BACKGROUND: The Montreal Cognitive Assessment (MoCA) has not been administered to a representative national sample, precluding comparison of patient scores to the general population and for risk factor identification. METHODS: A validated survey-based adaptation of the MoCA (MoCA-SA) was administered to a probability sample of home-dwelling US adults aged 62 to 90, using the National Social Life, Health, and Aging Project (n=3129), yielding estimates of prevalence in the United States. The association between MoCA-SA scores and sociodemographic and health-related risk factors were determined. RESULTS: MoCA-SA scores decreased with age, and there were substantial differences among sex, education, and race/ethnicity groups. Poor physical health, functional status, and depression were also associated with lower cognitive performance; current health behaviors were not. Using the recommended MoCA cut-point score for Mild Cognitive Impairment (MoCA score <26; MoCA-SA score <17), 72% (95% confidence interval, 69% to 74%) of older US adults would be classified as having some degree of cognitive impairment. CONCLUSIONS: Our results provide an important national estimate for interpreting MoCA scores from individual patients, and establish wide variability in cognition among older home-dwelling US adults. Care should be taken in applying previously-established MoCA cut-points to the general population, especially when evaluating individuals from educationally and ethnically diverse groups.

Cognition in Context: The Role of Objective and Subjective Measures of Neighborhood and Household in Cognitive Functioning in Later Life.

Background and Objectives: Although the role of place on health is not new, less is known about how place matters for cognition. By investigating both neighborhood and home as the sociospatial realms of older adults, we explore associations between health and place across multiple contexts. We also distinguish objective and subjective measures of place and disentangle their differential associations with cognition. Research Design and Methods: We analyzed place effects on cognition from the National Social Life, Health, and Aging Project (N = 2,260) linked to neighborhood characteristics and crime data. We measured place in four ways: (a) objective indicators of neighborhood such as police-reported crime rates and interviewer-reported on presence of disordered conditions on the streets; (b) perceptions of neighborhood by respondents (perceived danger and social cohesion); (c) objective conditions of home (interviewer's report on presence of clutters, odor, and messiness); (4) perceived social support, strain, and threat by household members. The MoCA-SA was used to assess cognitive functioning. Results: Subjective interpretations appeared to have more direct effects on cognition than did objective indicators of neighborhood or home. When examining these living environments together, we found the association between neighborhood and cognition is partially explained by characteristics of home environment, especially perceived social support. We found a buffering effect of social support on cognition for women, not for men. Discussion and Implications: Late life living environments are important contexts for aging. Aging-in-Place interventions should address subjective interpretations of place to reduce future risks of cognitive decline.

Response to Acierno's comments on Wong and Waite, "Elder mistreatment predicts later physical and psychological health: Results from a national longitudinal study".

We respond to Dr. Acierno's concerns about the measurement of elder mistreatment and social support in the National Social Life, Health, and Aging Project. We made our analytic decisions carefully and conducted systematic robustness checks and believe our findings are theoretically important.

Elder mistreatment predicts later physical and psychological health: Results from a national longitudinal study.

Stress process theory predicts that elder mistreatment leads to declines in health, and that social support buffers its ill effects. We test this theory using nationally representative, longitudinal data from 2,261 older adults in the National Social Life Health and Aging Project. We regress psychological and physical health in 2010/2011 on verbal and financial mistreatment experience in 2005/2006 and find that the mistreated have more anxiety symptoms, greater feelings of loneliness, and worse physical and functional health 5 years later than those who did not report mistreatment. In particular, we show a novel association between financial mistreatment and functional health. Contrary to the stress buffering hypothesis, we find little evidence that social support moderates the relationship between mistreatment and health. Our findings point to the lasting impact of mistreatment on health but show little evidence of a buffering role of social support in this process.

Sexuality in Older Couples: Individual and Dyadic Characteristics.

Sexuality is a key component of health and functioning that changes with age. Although most sexual activity takes place with a partner, the majority of research on sexuality has focused on individuals. In this paper, we focused on the sexual dyad. We proposed and tested a conceptual model of the predictors of partnered sexual activity in older adulthood. This model began with the personality of each of the partners, which affects individuals' views of sex and characteristics of the partnership, which in turn affected sexual expression in the couple. We measured a key feature of personality, Positivity, which reflected the individual's tendency to present his or herself positively in social situations. This trait, we posited, increased frequency of sex through increased desire for sex, and the subjective importance of sex to each member of the couple. In this model, Positivity also impacted characteristics of the relationship that promoted dyadic sexual behavior. These processes differed for men and women in the model. We tested this model with data from the National Social Life, Health and Aging Project, which conducted personal interviews with both partners in 940 American dyads (average male age 72; average female age 69). We found that couples in which the husbands' (but not wives') were high in Positivity show higher levels of sexual activity, and that this association was partially mediated by dimensions of relationship quality, but more so by individual factors such as thinking about sex and believing sex is important.