Interventions to Modify Psychological Well-Being: Progress, Promises, and an Agenda for Future Research.

Psychological well-being, characterized by feelings, cognitions, and strategies that are associated with positive functioning (including hedonic and eudaimonic well-being), has been linked with better physical health and greater longevity. Importantly, psychological well-being can be strengthened with interventions, providing a strategy for improving population health. But are the effects of well-being interventions meaningful, durable, and scalable enough to improve health at a population-level? To assess this possibility, a cross-disciplinary group of scholars convened to review current knowledge and develop a research agenda. Here we summarize and build on the key insights from this convening, which were: (1) existing interventions should continue to be adapted to achieve a large-enough effect to result in downstream improvements in psychological functioning and health, (2) research should determine the durability of interventions needed to drive population-level and lasting changes, (3) a shift from individual-level care and treatment to a public-health model of population-level prevention is needed and will require new infrastructure that can deliver interventions at scale, (4) interventions should be accessible and effective in racially, ethnically, and geographically diverse samples. A discussion examining the key future research questions follows.

The association of psychological protective factors with caregiver mental health outcomes.

The primary objectives were to investigate the association of resilience, purpose-in-life, and social connections in additive combinations with mental health outcomes of caregivers: 1) reduced levels of loneliness and/or depression; and 2) higher levels of positive perception of aging and quality of life. The study sample was identified from adults age ≥65, who had completed a survey during May-June 2018 or May-June 2019, and self-identified as caregivers (N=1,015; 15.4%). Resilience, purpose-in-life, and social connections were dichotomized as high/low; then counted with equal weighting 0 to 3. Among caregiver respondents, 24%, 29%, 32%, and 15% had 0, 1, 2, or 3 of these protective factors, respectively. As the number of protective factors increased, loneliness and depression decreased and positive perception of aging and quality of life increased. Caregiver interventions that include a focus on psychological protective factors may help to buffer caregiving-related stress thereby improving mental health and quality of life.

The association of resilience, social connections, and internal locus of control with pain outcomes among older adults.

Our objective was to investigate the hypothesis that psychological resources, including resilience, social connections, and internal locus of control, separately and in additive combinations, would be associated with selected pain outcomes: 1) days of opioid use and 2) medical/drug expenditures over 2 years. A mailed survey was sent to a stratified sample of older adults age≥65 with diagnosed back pain, osteoarthritis, and/or rheumatoid arthritis. Each of the resources was dichotomized as high/low and/or counted with equal weighting. Among respondents (N=3,131), the prevalence of mild/no and moderate/severe pain severity was 59% and 41%, respectively. As hypothesized, each resource was associated with lower levels of pain; additively, reported pain severity decreased as the number of resources increased. For moderate/severe pain, there was reduced opioid use among those with more resources; and, for mild/no pain, decreased medical/drug expenditures among those with ≥2 resources. Interventions that integrate psychological resources may enhance their effectiveness.

The association of physical activity with loneliness, social isolation, and selected psychological protective factors among older adults.

The primary objectives were to investigate the association of physical activity levels with 1) loneliness and social isolation; 2) protective factors: resilience, purpose-in-life, and perception of aging; and 3) the impact of these factors on healthcare expenditure patterns across physical activity levels. The study sample was identified from adults age ≥65 who completed a health survey in 2018 or 2019 (N=6,652). Among survey respondents, the prevalence of low, moderate, and high physical activity levels was 29%, 31%, and 41%, respectively. Moderate and high physical activity were associated with 15%-30% lower likelihoods of loneliness and social isolation; and with 27% to 150% higher protective factors. In addition, physical activity was associated with the mitigation of increased healthcare expenditures associated with loneliness, social isolation, and low levels of protective factors. Thus, physical activity could serve as an intervention to reduce loneliness and social isolation, augment protective factors, and mitigate excess healthcare expenditures.

Loneliness, Social Isolation, and All-Cause Mortality in a Large Sample of Older Adults.

OBJECTIVES: Using data from a large random sample of U.S. older adults (N = 7982), the effect of loneliness and social isolation on all-cause mortality was examined considering their separate and combined effects. METHODS: The UCLA-3 Loneliness Scale and the Social Network Index (SNI) were used to define loneliness and social isolation. Cox proportional hazards regression models were performed. RESULTS: Among study participants, there were 548 deaths. In separate, adjusted models, loneliness (severe and moderate) and social isolation (limited and moderate social network) were both associated with all-cause mortality. When modeled together, social isolation (limited and moderate social network) along with severe loneliness remained significantly associated with mortality. DISCUSSION: Results demonstrate that both loneliness and social isolation contribute to greater risk of mortality within our population of older adults. As the COVID-19 pandemic continues, loneliness and social isolation should be targeted safely in efforts to reduce mortality risk among older adults.

The association of increasing resilience with positive health outcomes among older adults.

Our objective was to investigate three levels of resilience (low, medium, and high), identify associated characteristics, and measure the impact of increasing resilience on quality of life (QOL), healthcare utilization and expenditures, and preventive services compliance. The study sample was identified from adults age ≥65 who completed surveys during May-June 2019 (N=3,573). Other protective factors, including purpose-in-life, optimism, locus of control, and social connections, were dichotomized as high/low and counted with equal weighting (0 to 4). Among survey respondents, the prevalence of low, medium, and high resilience levels was 27%, 29%, and 44%, respectively. The strongest predictors of medium and high resilience included increasing number of other protective factors, lower stress, and no depression. Individuals with medium and high resilience had significantly higher QOL and lower healthcare utilization and expenditures. Resilience strategies integrated into healthy aging programming could be associated with improvements in QOL and/or healthcare utilization and expenditure outcomes.

Cumulative effect of loneliness and social isolation on health outcomes among older adults.

OBJECTIVES: Loneliness and social isolation are described similarly yet are distinct constructs. Numerous studies have examined each construct separately; however, less effort has been dedicated to exploring the impacts in combination. This study sought to describe the cumulative effects on late-life health outcomes. METHOD: Survey data collected in 2018-2019 of a randomly sampled population of US older adults, age 65+, were utilized (N = 6,994). Survey measures included loneliness and social isolation using the UCLA-3 Loneliness Scale and Social Network Index. Participants were grouped into four categories based on overlap. Groups were lonely only, socially isolated only, both lonely and socially isolated, or neither. Bivariate and adjusted associations were examined. RESULTS: Among participants (mean age = 76.5 years), 9.8% (n = 684) were considered lonely only, 20.6% (n = 1,439) socially isolated only, 9.1% (n = 639) both lonely and socially isolated, and 60.5% (n = 4,232) neither. Those considered both lonely and socially isolated were more likely to be older, female, less healthy, depressed, with lower quality of life and greater medical costs in bivariate analyses. In adjusted results, participants who were both lonely and socially isolated had significantly higher rates of ER visits and marginally higher medical costs. CONCLUSION: Results demonstrate cumulative effects of these constructs among older adults. Findings not only fill a gap in research exploring the impacts of loneliness and social isolation later in life, but also confirm the need for approaches targeting older adults who are both lonely and socially isolated. As the COVID-19 pandemic continues, this priority will continue to be urgent for older adults.

COVID-19 Era Social Isolation among Older Adults.

Risk of COVID-19 exposure and more severe illness are serious concerns for older adults. Social distancing has worsened existing social isolation, with severe impacts on connectedness among seniors. The pandemic is threatening to cause an extended health crisis, with impacts including serious health consequences. Our primary purpose is to summarize emerging research describing the impacts of the pandemic on social isolation among older adults. A streamlined search was conducted to fit the scope of this literature review. Common research databases and mainstream resources and websites were utilized to identify research published or released in 2020 to align with the pandemic. Early research indicates that the pandemic has worsened social isolation among older adults. Social isolation has become urgent, as seniors have lost their usual connections due to social distancing. While safety measures are critical to prevent virus exposure, this approach must be balanced with maintaining social connectedness. The pandemic highlights the importance of social connections, with significant impacts on both community-living older adults and those in nursing facilities. Safety protocols have created a paradox of reduced risk along with greater harm. Consequently, adapted approaches are urgently needed to address the consequences of a long-term social recession.

The additive impact of multiple psychosocial protective factors on selected health outcomes among older adults.

Our objective was to investigate the additive properties of five psychosocial protective factors: purpose-in-life, resilience, optimism, internal locus of control and social connections. Self-reported psychological (depression, stress) and physical (health status, functionality) health outcomes and measured healthcare utilization and expenditures were included. The study sample was identified from adults age ≥65 who completed a health survey during May-June 2019 (N = 3,577). Each of the five protective factors was dichotomized as high/low (1/0) and counted with equal weighting. The protective factors were additive such that significant improvements in psychological and physical health outcomes were evident across factor subgroups: as the number of factors increased, health outcomes improved. The magnitude of the improvements was greatest between 0 and 1 factor. In addition, a significant linear trend for reduced healthcare expenditures ($1,356 reduction per factor added) was evident. Interventions promoting at least one protective factor would be beneficial for older adult populations.

Safety Events Associated with Tramadol Use Among Older Adults with Osteoarthritis.

Tramadol is a low-level opioid increasingly recommended to treat moderate-to-severe acute and chronic pain. Although characterized as having fewer opioid-related adverse events, the longer term safety of tramadol use among older adults has not been thoroughly documented. Thus, the primary objective was to examine the risk of safety events associated with chronic tramadol use compared to other chronic opioid use or no opioids among older adults with osteoarthritis. Safety events considered included: ≥3 emergency room (ER) visits, falls/hip fractures, cardiovascular (CVD) hospitalization, composite safety event hospitalization, and all-cause mortality. The study population included older adults ages ≥65 years diagnosed with osteoarthritis and classified into new or continuing tramadol use, new or continuing other opioid use, or nonuse. Inclusion criteria included: 6-month pre period and up to 33 months post period. Tramadol, other opioid, and no opioid users were 1:1 propensity-matched providing study populations of 25,899 within each category; 72% were new chronic opioid users. Multiple logistic regression or Cox proportional hazard ratios were used to document risk. Generally, tramadol users had fewer adverse event risks compared to other opioid users but higher risks than nonusers. New users of tramadol or other opioids had higher risks than continuing users. Tramadol use was associated with increased risk of multiple ER utilizations, falls/fractures, CVD hospitalizations, safety event hospitalizations, and mortality (new users only) compared to nonuse. Thus, although tramadol use may be appropriately recommended within a pain management strategy for older adults with osteoarthritis, careful monitoring for adverse safety events is warranted.

Reducing loneliness and improving well-being among older adults with animatronic pets.

BACKGROUND: Studies consistently demonstrate that older adults who are lonely have higher rates of depression and increased mortality risk. Pet ownership may be a solution for loneliness; however, challenges related to pet ownership exist for older adults. Therefore, researchers and practitioners are examining the use of animatronic pets to reduce loneliness. OBJECTIVE: To determine the feasibility of an animatronic pet program, and whether ownership of animatronic pets would decrease loneliness and improve well-being among lonely older adults. METHODS: Eligible individuals were identified as lonely through a prior survey. Participants were provided with the choice of an animatronic pet and completed T1/T2/T3 surveys. RESULTS: Attrition was high; 168 (63%) participants completed T1/T2 surveys, and 125 (48%) also completed a T3 survey. Post survey data indicated that loneliness decreased, while mental well-being, resilience, and purpose in life improved. Frequent interactions with the pets were associated with greater improvement in mental well-being and optimism. CONCLUSIONS: Animatronic pets appear to provide benefits for the well-being of lonely older adults. Future studies should employ randomized controlled designs examining the impact of animatronic pets.

Psychosocial Factors Associated with Sleep Quality and Duration Among Older Adults with Chronic Pain.

Sleep complaints are common among older adults with chronic pain. Because of the risk of significant side effects, sleep medications are not recommended as first-line treatments. Little is known about the association between positive psychosocial factors and sleep, but further awareness could support non-drug strategies to minimize poor sleep. The purpose of this study was to (1) determine the prevalence of self-reported poor sleep quality and short/long sleep duration in a population of older adults with chronic pain, and (2) examine the associations of negative risk factors, sleep-inducing medications, and positive psychosocial characteristics on sleep outcomes in this population. This study analyzed survey responses from 4201 adults ages ≥65 years with diagnosed back pain, osteoarthritis, and/or rheumatoid arthritis, and at least 1 year of continuous medical and drug plan enrollment. The most commonly reported sleep outcome was short sleep duration (39%), followed by poor sleep quality (22%), and long sleep duration (9%). Based on pharmaceutical claims, prescriptions for opioids (59%) or benzodiazepines (22%) were common. Perceived stress, depression, and pain or sleep prescription medications were independently associated with poor sleep quality and short or long sleep durations. The positive psychosocial factors of higher resilience and more diverse social networks were independently associated with good sleep quality and optimal sleep duration. These results underscore the importance of social and coping factors to sleep, which may provide new opportunities to improve sleep and well-being in older adults with chronic pain.

Limited Health Literacy and Hearing Loss Among Older Adults.

BACKGROUND: Effective communications between health care providers and patients are critical for high-quality health care. OBJECTIVE: This study sampled adults age 65 years and older to explore (1) characteristics associated with limited health literacy (LHL) and (2) medical costs and gaps in care based on health literacy, hearing loss, and hearing aid use status. METHODS: The study included 19,223 adults age 65 years and older who completed a health survey that was linked to his or her medical claims that were generated after medical care provided in the year prior to survey completion. Health literacy, hearing loss, and hearing aid use were assessed through self-reports. Health literacy was coded as limited and adequate. Hearing loss and hearing aid use were coded into five categories: no hearing loss, unaided mild, aided mild, unaided severe, and aided severe hearing loss. KEY RESULTS: Seven percent reported LHL and 41% reported hearing loss. Hearing loss, especially unaided severe, was associated with LHL, as were memory loss, depression, loneliness, older age, and male gender. People with aided severe hearing loss and LHL had higher annual medical costs than those with adequate health literacy. Similarly, those with no hearing loss and LHL had higher annual medical costs than those with adequate health literacy. CONCLUSIONS: Unaided mild, aided severe, and unaided severe hearing loss were positively associated with LHL, although the association was reduced among hearing aid users. Specifically, aided mild or severe hearing loss had lower odds of LHL, compared to unaided mild or severe hearing loss, respectively. We also observed that people with both hearing loss and LHL were more likely to have higher medical costs. Continued focus on solutions to address both LHL and hearing loss remains warranted. [HLRP: Health Literacy Research and Practice. 2020;4(2):e129-e137.] PLAIN LANGUAGE SUMMARY: Health survey and medical claims data were used for this study. Hearing loss, especially unaided severe, was associated with limited health literacy, as were memory loss, depression, loneliness, older age, and male gender. Those with both limited health literacy and hearing loss had the highest medical costs. Health literacy and hearing loss can affect health care communications, warranting further study.

The association of pain locus of control with pain outcomes among older adults.

Our primary objective was to 1) determine the prevalence of pain locus of control (LOC) subscales in a population of older adults with pain conditions, and 2) estimate their associated protective effects on pain outcomes. A mailed survey was sent to a stratified sample of older adults age≥65 with diagnosed back pain, osteoarthritis and/or rheumatoid arthritis. Multivariate logistic regression modeling was used to determine the relative protective associations of positive resources, including LOC, resilience and social networks, on pain outcomes. Among respondents (N = 3,824), 31% were identified as internal; 34% as powerful others; and 35% as chance. In adjusted models, internal was associated with outcomes of lower pain severity, reduced chronic opioid use and increased physical functionality. Powerful others was partially protective; chance was associated with the poorest outcomes. Multidimensional pain programs should incorporate the enhancement of positive resources, including LOC, to maximize the effectiveness of pain management strategies.

Characteristics and Health Outcomes Associated With Hearing Loss and Hearing Aid Use Among Older Adults.

Background: This study recruited older adults to explore physical and psychosocial conditions and other health outcomes associated with hearing loss (HL) and hearing aid use. Method: Survey data were used to categorize 20,244 participants into five groups: no HL, unaided mild HL, aided mild HL, unaided severe HL, and aided severe HL. Results: Individuals with unaided severe HL were more likely to report poor-fair self-rated health and were less likely to leave the home, or exercise 4 to 7 days per week, while there were no such associations for those with aided mild or severe HL. In addition, those with aided hearing were less likely to report depression, low social support, or mobility limitations. Discussion: In several instances, hearing aid use reduced associations between HL and negative psychosocial and physical characteristics, and health outcomes. More research using longitudinal study designs is needed to better understand the true implications of these findings.

Concurrent Use of Opioids with Other Central Nervous System-Active Medications Among Older Adults.

The primary objective was to determine the prevalence and characteristics of older adults concurrently using opioids and other central nervous system (CNS)-active medications, and the specialties of providers who ordered the medications. A secondary objective was to document medication-related adverse effects associated with such concurrent drug use. Study populations were identified as older adults aged ≥65 years with 1 year continuous medical and drug plan enrollment during 2017 and opioid use of ≥2 prescriptions for ≥15 days' supply. CNS-active medications included benzodiazepines, non-benzodiazepine hypnotics, muscle relaxants, antipsychotics, and gabapentinoids. Provider specialties were identified from the National Provider Identification database. Characteristics associated with opioids only, opioids plus 1, and opioids plus ≥2 additional CNS-active medications were determined using multinomial logistic regression. Outcome measures during 2017 included injurious falls/fractures and ≥3 emergency room (ER) visits. Among eligible insureds (N = 209,947), 57% used opioids only, 28% used opioids plus 1 additional CNS medication, and 15% used ≥2 additional medications. About 60% of opioids and other concurrent CNS medications were prescribed by the same provider, generally a primary care provider. Benzodiazepines and gabapentinoids were most often used concurrently with opioids. Health status, insomnia, anxiety, depression, and low back pain had the strongest associations with concurrent medication use. Overall, concurrent use with ≥2 CNS medications increased the likelihood of injurious falls/fractures or ≥3 ER visits in this population by about 18% and 21%, respectively. Both patients and providers may benefit from an awareness of adverse outcomes associated with concurrent opioid and other CNS-active medication use.

The impact of internal locus of control on healthcare utilization, expenditures, and health status across older adult income levels.

Our objectives were to 1) determine the prevalence of locus of control (LOC) dimensions stratified by older adult income levels; 2) characterize internal LOC attributes within income subgroups; and 3) investigate LOC associations with healthcare utilization and expenditures; self-rated health and functionality. The survey sample was identified from adults age ≥65 years with diagnosed pain conditions. Internal LOC characteristics were determined from logistic regressions; outcomes regression-adjusted. Among respondents, internal prevalence for low (N = 554), medium (N = 1,394) and high income (N = 2040) was 27%, 30% and 30%, respectively. Internal was associated with high resilience, less stress, exercise and less opioid use across income levels. Lower-income internal was additionally associated with diverse social networks, physical therapy and less drug use. Those with high internal generally had lower healthcare utilization and expenditures; better self-rated health and functionality. Internal LOC is a powerful positive resource associated with better health outcomes, especially influential for lower income.

Association of Resilience and Social Networks with Pain Outcomes Among Older Adults.

Depression, stress, and poor sleep have been associated with increased pain among older adults; positive resources, such as resilience and social networks, may help to buffer the impacts of these negative attributes on pain outcomes. The primary objective was to determine the relative effects of positive resources and negative attributes on pain outcomes among older adults with diagnosed back pain, osteoarthritis, and rheumatoid arthritis. The stratified study sample was identified from older adults ages ≥65 years. Members received a survey assessing positive resources (resilience, social networks), negative attributes (depression, stress, poor sleep), and pain outcomes (severity, interference). Opioid and other medication use was determined from pharmaceutical claims. After weighting to representative distributions of pain conditions and adjusting for survey response bias, multinomial logistic regressions were used to determine the relative associations of positive and negative attributes on pain outcomes. Among survey respondents (N = 4161), prevalence of self-reported pain severity and interference for no/mild, moderate, and severe categories was 61%, 21%, and 18%, and 67%, 16%, and 17%, respectively. In bivariate models, negative attributes of depression, stress, and poor sleep had stronger associations with pain severity and interference than the moderating effects of positive resources of high resilience and diverse social networks. In fully adjusted multivariate models, the strongest associations with moderate and severe pain severity and interference remained depression, stress, and poor sleep. Based on these results, multidimensional pain management strategies should include management of negative attributes along with enhancement of positive resources for effective management of chronic pain.

Using Pain Medication Intensity to Stratify Back Pain Among Older Adults.

OBJECTIVE: To examine the prevalence of musculoskeletal back pain among older adults stratified by pain medication intensity to 1) review treatment patterns and 2) consider targeted back pain prevention interventions. METHODS: A random sample of older adults age 64 years and older was utilized to identify new and recurring back pain. Prescription pain medications from drug claims were used to stratify to five unique intensity levels. The characteristics of each level were determined using regression models. RESULTS: About 10% had musculoskeletal back pain. Of these, 54% (N = 20,645) had new back pain and 46% (N = 17,252) had recurring back pain. Overall, about 35% received physical therapy. Pain medication intensity levels included no prescription pain medications, nonsteroidal anti-inflammatory drugs (NSAIDs), muscle relaxants, low-dose opioids, and high-dose opioids (new back pain: 39%, 10%, 6%, 23%, and 23%, respectively; recurring back pain 32%, 9%, 4%, 17%, and 38%, respectively). NSAID and muscle relaxant users were younger, healthier, and received physical therapy. Opioid users were younger, in poorer health, used sleep medications, received physical therapy, and had more falls and higher health care utilization and expenditures. CONCLUSIONS: New and recurring back pain patients can be stratified by pain medication intensity to review treatment patterns and target back pain prevention programs. Those with back pain but taking no prescription pain medications may benefit from back pain prevention programs. More research on guidelines for treatment options for those on high levels of pain medications is warranted.