Centers

2022. Carmen Gutierrez, PhD. Criminal Legal System Connections, Health, and Place Safety.

Connections to the criminal legal system (CLS) are known to affect health. Indeed, a large body of
literature documents adverse health consequences associated with being punished by the CLS. However, surprisingly little is known about the ways that the relationship between punishment and health varies across geographic contexts. Even less attention has been dedicated to investigating the health consequences of working for the CLS, although research during the pandemic highlights how
exposure to jail and prison environments has contributed to elevated levels of COVID-19 cases and
deaths among detention center staff. Expanding our knowledge on the relationship between health
and connections to the CLS to include workers and linking these health patterns to spatial contexts will
contribute to our understanding of place-based and racial inequalities in health. People who are both
punished and employed by the CLS are disproportionately Black and Latino men who have been shown
to have worse health and shorter life expectancies compared to people in the general population, and
recent changes across metropolitan areas have altered the spatial distribution of this population.
Nowadays, people connected to the CLS—through both punishment and employment—are increasingly
likely to reside in rural areas. No study to date, however, has examined the health consequences of
being connected to the CLS through both punishment and employment through a contextual
framework. To address these important and timely gaps in the literature, the proposed project seeks to generate original data on CLS connections in eastern North Carolina (ENC)—a predominately rural area where jails and prisons are prominent—and link these connections to health outcomes among working-age adults. This data collection effort will contribute to the existing data collection system of the DEEPP project (Dynamics of Extreme Events, People, and Places), led by Elizabeth Frankenberg. The proposed work would therefore build upon DEEPP’s rich data and support my goal of establishing a unique source of data that will be used for future NIH grant submissions. Specific aims of this foundational work are to:

Aim 1: Map the locations of jails and prisons in ENC and measure their prominence as sites of
employment and punishment.
Aim 2: Collect qualitative data on the stressors associated with CLS connections among people in ENC.
Aim 3: Develop and pilot test a computer-assisted questionnaire to collect information on CLS
connections, health, and place in ENC.

Priority Research Areas: Health Trends and Disparities

2022. Margaret Sheridan, PhD. A Dimensional Approach to Assessing the Impact of Adversity on Age-Related Cognitive Decline.

Exposure to childhood adversity is common, and is associated with risk for numerous negative outcomes in childhood, adolescence, and adulthood. The prevailing approach for examining the developmental consequences of adversity exposure is a cumulative risk model which points to stress as the primary biological pathway through which adversity comes to impact health outcomes. We have articulated an alternative to the cumulative risk model which proposes a set of novel mechanisms explaining how dimensions of adverse experiences, specifically deprivation and threat, influence risk for negative life outcomes and in particular psychopathology (McLaughlin & Sheridan, 2016; McLaughlin, Sheridan, & Lambert, 2014; Sheridan & McLaughlin, 2016; Sheridan & McLaughlin, 2014). Existing data support the hypothesis that exposure to deprivation but not threat disrupts cognitive function and associated neural pathways whereas exposure to threat but not deprivation disrupts emotion regulation in childhood and adolescence (Lambert et al., 2016; Machlin et al., 2019; Manly et al., 1994, 2001; McLaughlin et al., 2019; Sheridan et al., 2017). In addition, these dimensions of adversity are differentially linked with long-term differences in emotion regulation and cognitive function when measured longitudinally from early childhood through late adolescence (Miller et al., 2018, 2020).

Importantly, a robust body of work has documented associations between early life adversity exposure and aging related health concerns (Midei et al., 2013) and recent work indicates that differential effects of deprivation and threat on cognitive function and emotion reactivity may be observable even into late life (Geoffroy et al., 2016b). Given selective associations between deprivation and cognitive function in childhood, we expect that deprivation, but not threat, will increase the rate of age-related cognitive decline and rates of diseases of cognitive aging such as idiopathic dementia. In contrast, we would expect threat but not deprivation exposure to be associated with increased cardiovascular risk and metabolic dysfunction. However, most work examining associations between adversity and aging to date has not delineated dimensions of adversity. Beginning well-designed and novel studies of the impact of early adversity on aging is a long-term investment, prior to initiating this kind of approach preliminary investigations are needed. Here we propose three avenues through which preliminary data will be obtained.

Aim1. We propose taking a meta-analytic approach to understanding the differential impact of deprivation and threat on aging processes. In a previous grant we completed a meta-analysis of the differential impact of deprivation and threat on cardiovascular and metabolic disease indicators. Here we proposed building on that dataset to also examine the impact of these forms of adversity on age related cognitive decline.
Aim2. In an existing dataset (N = 1,252; ages 18-80 years) acquired using the online data collection platform Prolific, Co-Investigator Boettiger assessed adversity and cognitive function via self-report. Utilizing this data we will determine if retrospective reports of exposure to these forms of adversity are differentially linked with age-related decline in self-reported cognitive function.
Aim3. In an ongoing pilot data collection project of participants between 18-80 years (N = 120) cognitive and neural function are directly assessed using cognitive testing and neuroimaging. This project is funded via a National Science Foundation grant to Co-Investigators Lindquist and Giovanello. In collaboration with PI Sheridan, measures of self-reported exposure to deprivation and threat are being collected in this dataset in an ongoing fashion. Utilizing this data we will determine if retrospective reports of exposure to these forms of adversity are differentially linked with age-related decline in cognitive function and associated neural processes such as functional brain connectivity.

These preliminary findings will result in (a) up to three publishable empirical papers and (b) preliminary results which will provide a strong foundation for two subsequent planned grants. First, Co-Investigators Giovanello and Lindquist will build on findings from their current study to apply for an R01 from NICHD to examine life-span changes in emotion and cognitive function. With preliminary data from this application, they will be able to work with PI Sheridan to additionally investigate the link between dimensions of adversity stress reactivity and cognitive function across the life span. Second, Co-Investigator Boettiger will apply for funding from the NIAAA to examine the impact of cognitive aging on risk for alcohol use disorder. With preliminary data from this application, she will be able to work with PI Sheridan to additionally investigate the impact of deprivation and threat as moderators of her planned analyses.

Priority Research Areas: Biology, Genetics and Demography of Aging

2021. Kathleen Mullan Harris, PhD. The Role of Morningness in Sleep Timing and Epigenetic Aging in Young Adulthood.

Being more of a “night owl” has been linked to increased risk of diabetes, hypertension, and
mortality. Evidence suggests that diurnal preference for morningness (versus eveningness) is
affected by both genetic and environmental, as well as developmental factors, with chronotype
(measured as midpoint of sleep on free days) shifting earlier as people age from young adulthood
and beyond. However, not only does aging affect diurnal rhythms, but recent research highlights a
pathway by which diurnal rhythms might affect aging: telomere length (a measure of biological aging,
which shortens as we age) is shorter in people with moderately late compared to intermediate diurnal
preference. Much remains to be understood regarding the relationship between chronotype and
biological aging, and recent epigenetic “clock” measures provide an opportunity to investigate how
diurnal preference affects biological aging processes reflected in DNA methylation (DNAm).
We propose leveraging genetic and recently collected epigenetic data in NIA-funded Add Health to
advance understanding of the relationships between diurnal preference, sleep timing, and epigenetic
aging. We hypothesize that greater genetic propensity for morningness, reflected in polygenic scores
(PGSs), is associated with decreased epigenetic age acceleration (EAA), a measure capturing how
far biological aging reflected in DNAm has progressed beyond levels predicted by chronological age.
Our aims are:
Aim 1: Estimate association of morningness PGSs with sleep timing in young adults using
PGSs constructed from prior morningness GWAS.9 Test whether association changes across young
adulthood.
Aim 2: Identify whether social and environmental schedules moderate association of
morningness PGSs with sleep timing. Test whether association differs between work and free
days and by sunset time, examining extent to which social schedules and sunlight exposure interact
with morningness PGSs.
Aim 3: Estimate association of morningness PGSs with EAA in early mid-adulthood and
identify whether sleep timing moderates this association. Assess whether “mismatch” of
morningness PGSs and sleep timing (e.g. high on morningness PGSs, late sleep timing) predicts
greater EAA.

Priority Research Areas: Biology, Genetics and Demography of Aging

2021. Tonia Poteat, PhD. Meeting the Pandemic Needs of Older Sexual Minority Women: Data to Inform Covid-19 Response.

Sexual minority women (SMW) face unique COVID-19 pandemic-related challenges. Black SMW ≥ 50 years old, in particular, were already experiencing health inequities at the intersection of racism, sexism, ageism, and homophobia. Our prior research with Black lesbian elders identified a heavy burden of poverty, multimorbidity, and poor mental health – factors that increase COVID-19 vulnerability. We also identified resilience strategies, such as community-building and intergenerational learning. However, social-distancing, income loss, and caregiving demands wrought by the pandemic have interrupted many of these strategies, as described during virtual focus groups discussion (FGDs) completed with 100 older Black SMW in late 2020. Our FGDs explored physical and psychosocial health, experiences with COVID-19 testing, illness and loss, and vaccine attitudes – providing data on the importance of addressing mental health and vaccine hesitancy. However, FGDs were limited to Black SMW, precluding comparisons with other racial groups to determine whether tailored interventions are necessary. The nature of FGDs prevented in-depth explorations of participants’ perspectives on potential interventions. The videoconference platform presented barriers to engaging women with low educational attainment and/or low technology skills; therefore, we lack information from these groups. We must address these limitations in order to design an intervention that is feasible and acceptable to diverse older SMW. To gather the preliminary data necessary to develop and test a mental health intervention, we propose a mixed methods study with the following aims:

Aim 1: Assess strategies for recruiting racially and educationally diverse older SMW for participation in a
quantitative survey. These data will inform enrollment approaches for the future intervention.
Aim 2: Characterize vaccine attitudes and psychosocial effects of the COVID-19 pandemic via a quantitative survey among a sample of diverse older SMW that builds on prior FGD results. Findings will provide comparative data by race, education, and socioeconomic status to inform selection of intervention targets.
Aim 3: Identify feasible and acceptable strategies to bolster resilience and mitigate pandemic-related harms among diverse older SMW by conducting in-depth interviews with prior FGD participants and a purposive sample of SMW with low educational attainment and/or low technology skills.

These data will be collected in partnership with ZAMI NOBLA – National Organization of Black Lesbians on Aging, a community-based organization which collaborated on aforementioned FGDs. They will partner on the planned grant application to NIA in February 2022 that will respond to NOT-AG-21-015: Notice of Special Interest: Aging-Relevant Behavioral and Social Research on Coronavirus Disease 2019.

Priority Research Areas: Health Trends and Disparities

2021. Jeremy Moulton, PhD. Property tax exemptions and senior home affordability.

Property tax exemptions are often targeted at seniors to improve home affordability and help them
age in place. In this project, I aim to answer the question of whether these policies affect the
ownership and location decisions of seniors and what impact this has on their health.

Specific Aim 1: How have property tax exemptions for seniors affected home prices across the United
States? Use event study regression analysis and comparative interrupted time series (CITS) methodologies on “big data” from Zillow to estimate the effect of property tax exemptions on home prices.
Specific Aim 1a: Who are the winners and losers of property tax exemptions? Use merged American Community Survey (ACS) demographic data to estimate which demographic groups (age, race, ethnicity, etc.) are the recipients of the price change by stratifying and/or interacting the above models.

Specific Aim 2: How have property tax exemptions affected location and ownership decisions for
seniors? Use spatial methods and amenity location data (such as health facilities) to estimate how seniors
change their location decisions based on the incentives associated with property tax exemption.
Specific Aim 2a: Have other major housing policies affected the location decisions and ownership
decisions of seniors? Use CITS to investigate if major policies like the first-time homebuyer tax credit, that targeted younger buyers, pushed senior homebuyers out of the market.

Specific Aim 3: How have property tax exemptions affected the health of seniors? Investigate the impact on health for those pushed into less desirable locations due to the exemptions as well as those that expect appreciation and tax exemption using similar analysis to aim 1.

Priority Research Areas: Population, Economic and Health Forecasting

2021. Joanna "Asia" Maselko. Optimizing wearable sensing technologies for the measurement of social interactions among older adults.

Social isolation and loneliness are linked with multiple negative mental, cognitive, and physical
health outcomes, including mortality across the lifecourse, while greater social engagement is
linked with significant positive health outcomes. Older age is a unique period of the lifecourse
where social connections undergo a dramatic shift, often characterized by decreases in social
connectedness, which are in turn, linked with declining mental, cognitive, and physical health.
Thus, there is enormous need for effective interventions to alleviate the health and social burdens
associated with social isolation and loneliness among older age persons. Unfortunately,
interventions aiming to engage older persons in activities that are meaningful, enjoyable, and
sustainable have yielded decidedly mixed results. One potential area of focus to ameliorate these negative impacts is the increase of positive social interactions within relationships that the individual is already motivated to engage in. A relationship with unique potential to impact the health of older individuals is the
grandparent-grandchild (GP-GC) relationship. A focus on GP-GC interactions offers a pathway for
preventative interventions, encouraging safe ways for older persons to remain engaged in meaningful
interactions as they age, and thereby optimizing years of healthy life. However, research on the
health implications of grandparenting has been surprisingly inconclusive, even as its positive
potential is clearly acknowledged.

A key challenge to understanding the impact of GP-GC interactions on GP health and well-being is
that measurement of GP-GC interactions has remained coarse, and granular domains of GP-GC
interactions are not as well understood. For example, most studies assess GP-GC interaction by
inquiring about the number of hours spent caregiving or co-residence status. It is also important
to distinguish caregiving burden from GP-GC interactions. A potential area for methodological
breakthrough is to assess these granular social interaction domains in a continuous, passive, and
naturalistic manner, while combining with simultaneous data on GC proximity. Wearable technology
offers such an opportunity. Recent developments in wearable sensing and activity recognition
technologies are revolutionizing behavioral research with their unique potential to unobtrusively
gather comprehensive and meaningful data from the real-world contexts in which individuals
live. However, the feasibility and potential contributions of these approaches to aging
research has not yet been fully examined. Previous funding submissions from our research team have
been hindered by a lack of piloting that has left the feasibility of this method in question.
Our overarching study objective is to pilot the use of a wearable technology-based approach to
measure how domains related to health among the aging vary in the presence of their grandchild. We
focus on the measurement of known correlates of health, including heart-rate variability, physical
activity, and frequency and quality of grandparent speech.

We have two specific hypotheses, one methodological and one substantive. First, we hypothesize that we can successfully use wearable technology in a natural (non-laboratory) setting to measure heart rate variability, physical activity, and pre-specified speech domains of the older individual, as well as grandchild proximity. Second, we hypothesize that the presence of the grandchild will be correlated with higher heart
rate variability, higher frequency of domains such as positive affective speech and physical
activity, and lower frequency of negative affective speech and silence. In our pilot we will obtain data from:
1) The wearable worn by the grandparent and a proximity beacon worn by the grandchild. These will
capture data on (a) heart rate variability (b) physical activity, (c) the auditory environment, and
(d) GC proximity to the GP.
2) Qualitative interviews focusing on the feasibility and accessibility of the tech package.

This is a pilot study and is aimed at determining whether this approach for assessing GP-GC social
actions is feasible; the results will not contribute to generalizable knowledge and do not require
an IRB review.

Priority Research Areas: Biology, Genetics and Demography of Aging

2020. Jennifer Lund, PhD. Social Determinants and Adverse Health Outcomes in Older Adults: The role of inappropriate medication use.

Optimizing medication use in older adults (age 65+ years) is challenging due to the frequent
co-occurrence of multimorbidity, polypharmacy, and age-related changes in pharmacokinetics and
pharmacodynamics, which together increase the risk for adverse drug events. Adverse drug events are
costly, accounting for approximately $3.5 billion in spending in the United States (US) each year.
Medications whose risks of harm exceed their expected clinical benefits are termed potentially
inappropriate medications (PIMs). PIM use is common, reaching a one-year prevalence of >30% among
Medicare beneficiaries, and is associated with an increased risk of adverse health outcomes of
paramount importance to older adults, including falls, functional and cognitive impairment,
hospitalization, and mortality. While there are several prescribing tools that can be used to
identify PIMs (e.g., the Beers Criteria, the Screening Tool for Older People’s Prescriptions
(STOPP) criteria, and the Drug Burden Index (DBI)), there is a lack of understanding of the
relative merits of these tools and how best to apply them in the context of longitudinal data. In
addition, while social disparities in health, particularly those by race/ethnicity, geography, and
socioeconomic status (SES), are well documented for individuals across the life course, there is
little mechanistic research describing how disparities in PIM use could potentially impact
persistent and ever growing health disparities in late life. Our proposed study will leverage a
novel data resource, the National Health and Aging Trends Study linked with Medicare claims data to
evaluate and compare the performance of contemporary PIM screening tools, document disparities in
use by race/ethnicity, geography, and SES, and disentangle associations between longitudinal PIM
use trajectories and important adverse health outcomes. Our results will inform the development and
refinement of pharmacy- based interventions using PIM screening tools that are better targeted to
high-risk populations in greatest need promote safe and effective medication use among older adults, ultimately leading to reductions in health disparities in late life.

Priority Research Areas: Health Trends and Disparities

2020. Linda Adair, PhD. Effects of health on economic well-being of older adults in the context of rapid modernization.

The relationship between health and economic status is bi-directional. While many studies document poor health outcomes related to poverty, less attention has been paid to how health affects economic outcomes. Physical, cognitive, and mental health can have profound effects on the economic productivity and security of older adults, with consequences not only for them but also for the next generation who may benefit from their financial support or be burdened by the time and costs of caregiving and support. Health conditions which limit physical mobility and stamina may be of importance for productivity in occupations that require physical strength or endurance while cognitive deficits and poor mental health may be more likely to impact occupations which require cognitive skills. These limitations may develop over long periods of time. However, few longitudinal studies in low- and middle-income country (LMIC) contexts provide the long-term data that allow study of the evolution of poor health and its impact on economic outcomes across the life course.  Even fewer studies have the data needed to document intergenerational effects. We plan to conduct interdisciplinary, comparative research using data from extremely rich cohort studies spanning several decades in China, Indonesia, and the Philippines. The principal investigators represent ESI and senior CPC fellows (Adair, Gordon-Larsen, Frankenberg) from different disciplines and who have collaborated on other projects. The overall goal of this project is to enhance understanding of how economic productivity and security in older adults is influenced by trajectories of physical, mental, and cognitive health beginning earlier in life, and in turn, how the health and economic well-being of older adults affects the next generation. The cohort studies for this project include: The China Health and Nutrition Survey (CHNS) is a multipurpose panel survey following all members of more than 41,000 households in 360 communities throughout China across 10 exams from 1990 to 2019. The 2015 survey includes 19,525 individuals of whom 5,173 were age 60+. The Cebu Longitudinal Health and Nutrition Study (CLHNS) recruited pregnant women from urban and rural communities of Metro Cebu in 1983-4 and followed them and an index child during bimonthly visits for the first 2 years, then in 8 subsequent surveys through 2016, when the women ranged in age from 45-78 (n=1659, 596 age 60+). The Indonesia Study of the Tsunami, Aftermath and Recovery (STAR) includes a representative population from Aceh, Sumatra, first recruited in 2004, with 6 follow-up visits through 2017. The most recent survey includes 9,707 individuals age 40 and above, of whom 2481 were age 60 and older. The three studies span time periods of rapid modernization and concomitant dramatic health and economic changes. Of note in all settings is the transition in types of work and labor markets from more to less physically demanding jobs benefitting from modern technology, and changes in health profiles with the emergence of obesity and chronic diseases. Comparative research across these settings can take advantage of the high diversity, pace of development and level of disparities within and between countries. The aims include: 1) Harmonization and preparation of data for comparative analysis, by harnessing substantial similarities in the questionnaires and data collected in the surveys. This harmonization work will be guided by principles established by Fortier et al in their work with multiple British and European cohorts(https://academic.oup.com/ije/article/40/5/1314/658348) ; 2) Estimate the pathways through which disparities in middle adulthood nutritional status represented as underweight, overweight, and obesity affect subsequent development and patterns of cardiometabolic health, impairment in physical and cognitive functioning, and in turn, changes in type of work, work hours, and earnings. We will use longitudinal marginal structural models to address likely bidirectional associations and take advantage of repeated surveys to focus on predictors of changes in economic outcomes subsequent to changes in health status.

Priority Research Areas: Determinants of Health, Well-Being and Longevity

2020. Robert Hummer, PhD. Life Course Cognition: Multimodal Measurement of Cognitive Functioning among Diverse Midlife Americans.

Understanding cognitive functioning is a critical national priority as the United States prepares for the rapid aging of its population. Recent scholarship makes it clear, though, that population-based study of cognitive functioning must begin long before old age; focused attention on midlife (i.e., ages 40-49) is essential. The National Longitudinal Study of Adolescent to Adult Health (Add Health) is poised to make a critical contribution to the understanding of midlife cognitive functioning in the United States. Our research team is in the process of developing the application to secure funding for Wave VI of Add Health, which will include in-depth attention to cognitive health in midlife. Add Health is a longitudinal study of a nationally representative sample of Americans that began following 20,000 adolescents in grades 7-12 during the 1994-95 school year. Add Health respondents are now reaching middle-age; as currently scheduled, the average age of Wave VI respondents will be 44. Add Health is thus exceptionally unique in having such a rich, multi-level, longitudinal array of data among a large nationally representative and diverse cohort of Americans as they approach midlife. These data also set the stage for rigorously studying risk and protective factors that occur earlier in the life course prior to the age-related conditions that will begin to affect this cohort, including cognitive decline and—in the future—dementia. This pilot project will assist in our preparation for cognitive data collection in Wave VI. The overall goal of this pilot is to develop, test, and evaluate potential measures of cognitive functioning among a diverse convenience sample of midlife subjects. We will work with our Add Health field contractor (RTI, International), to draw a diverse (by race/ethnicity, gender, and educational attainment) sample of North Carolina residents between the ages of 40-49. Because the plans for Wave VI of Add Health include both in-person and web-based cognitive assessments, this pilot project will develop, test, and evaluate potential measures of cognition in both the in-home and web-based data collection modes. The pilot project will address the following aims: 1) Using available tools (e.g., NIH Toolbox, Harmonized Cognitive Aging Project, Montreal Cognitive Assessment, Mini-Mental State Examination, PhenX Toolkit, and more), develop a range of in-person and web-based cognitive assessments to pilot among our convenience sample. 2) Collect pilot data on a range of cognitive functioning batteries from our convenience sample, using both the in-home and web-based modes of data collection. We will aim to collect data from as many subjects as our budget allows, with the sample balanced according to race/ethnicity (Black, Hispanic, Asian, White), gender (women, men), and educational attainment (high school degree or less, some college, college degree or more). 3) Compare the in-person with the web-based assessments and test for differences across the two modes. We will make these comparisons across both the full sample, as well as within subgroups defined by race/ethnicity, gender, and educational attainment. This pilot project stands to provide innovative and useful information for measuring cognition in middle age in large scale demographic and population-based studies, including Add Health.

Priority Research Areas: Biology, Genetics and Demography of Aging

2022. Anna Wu, PhD. Risk of ADRD among first-, second-, and third-generation Latinos in the Multiethnic Cohort (MEC).

The overall objective of this pilot study is to better understand factors driving purported variation in Alzheimer’s disease and related dementia (ADRD) risk across Latino populations.  This prospective analysis will be conducted among 20,093 California Latinos in the well-established Multiethnic Cohort (MEC) Study.  The three specific aims are: (1)  To determine the age and sex-adjusted diagnostic incidence rates of ADRD for 11,413 first-, 6,125 second-, and 2,555 third-generation Latinos. (2) To investigate ADRD risk associations with outdoor air pollution (gaseous and particulate matter pollutants) and to compare associations of established lifestyle factors (education, neighborhood socioeconomic status, marital status, history of hypertension, stroke, diabetes and heart disease, smoking status, physical activity, short/long sleep, body mass index, and diet quality) across first-, second-, and third-generation Latinos. We will also compare hazard ratio (HR) and 95% confidence interval (CI) from Cox regression models for these Latino populations to those of White California MEC participants.  (3)  To estimate the ADRD population attributable risk for lifestyle factors and outdoor air pollution among first-, second-, and third-generation Latinos.  Completion of this pilot project should provide new information on the incidence, as well as lifestyle and environmental determinants of late-onset ADRD for Latinos by generation status.

Priority Research Areas: Cognitive Aging and the Demography of Dementia

2022. Annie Chen. Dynamic Microsimulation Projections of ADRD and Associated Functional Limitations in Taiwan and the United States.

This pilot project develops the Taiwan Future Elderly Model (TFEM) to model cognitive function, functional limitations and informal caregiving; validate the model with observed data; and conduct an initial comparison of ADRD disease burden between Taiwan and the US.  It addresses three of the research priorities of the Center for Advancing Sociodemographic and Economic Study of Alzheimer’s Disease and Related Dementias for the 2022-2023 funding cycle: Health, social and economic costs of ADRD for individuals, families and generations; factors driving variation in ADRD risk and outcomes across populations; international and national trends in and projections of ADRD. This pilot adds an additional country to the growing network of international microsimulation models built on local health and retirement surveys and the Future Elderly Microsimulation software.

Priority Research Areas: Population, Economic and Health Forecasting

2022. Katherine Miller, PhD. The Mediating Role of State Policies Supporting Care Partners of Persons with Dementia on Care Partner Outcomes.

Over six million persons living with dementia in the U.S received unpaid care from nearly 16 million care partners. Demand for care provided in the home by family care partners is expected to increase. Care partners of persons living with dementia generally report worse physical health and high levels of depressive symptoms and care partner burden. Variation in state policies supporting care partners yields heterogenous access to and generosity of services for care partners. Unpacking the potential mediating role of polices intended to benefit care partners is critical to support and improve the health of care partners of persons living with dementia. Our objectives are to: (1) provide systematic documentation of policies supporting care partners of persons living with dementia; and (2) examine association of policies and care partners’ outcomes. This study leverages an existing dataset of policies supporting care partners to expand upon and survey data of nationally representative sample of care partners. This research will advance our understanding of the effects of dementia caregiving on care partners and persons living with dementia by building a database for future research to examine persons living with dementia and care partner outcomes. Moreover, understanding the pathways by which policies and policy interactions impact these outcomes is essential to inform the policy discussions regarding evidence-based supports for care partners of persons living with dementia.

Priority Research Areas: Disability, Health Care and Long-Term Care

2021. Bryan Tysinger, Research Assistant Professor, USC. Dynamic Microsimulation Projections of ADRD in Ireland and the United States .

Projecting the future burden of Alzheimer’s Disease and Related Diseases (ADRD) is of critical importance to understand implications for individuals, families, health systems, and government planning.  Previously, the applicants have developed dynamic microsimulation models in longitudinal panel data to estimate statistical models of aging and predict future outcomes. This pilot has five Aims:  1. Extend and validate the TILDA-based microsimulation to model new outcomes: cognitive function, depressive behavior, functional limitations and time spent in residential care; 2. Extend and validate the HRS-based microsimulation to model the depressive behavioral domain of ADRD; 3. Produce population and subpopulation (gender, education, and race) projections, and compare these projections within and between countries; 4. Recommend best practices for projecting cognition, depressive behavior, functional status, and ADRD to guide other researchers using panel studies similar to HRS and TILDA.  Scope the potential for novel inclusion of biomarkers and laboratory measures in projections; 5. Use the results as a basis for large-scale international study proposal to project future needs, estimate future health and social care costs, and evaluate the effect of different systems and payment models on care, health and economic outcomes. We anticipate three outcomes associated with the pilot aims: (a) Projections of ADRD prevalence, associated depressive symptoms and functional limitations, and associated residential care use in the United States and Ireland, for the population and for subgroups of interest (Aims 1-3); (b) Lessons learned in validating the domains of ADRD will be documented to inform other modelers undertaking similar work, including assessment of how biomarkers and lab data may improve prediction (Aim 4); (c) An R01 proposal for modeling future ADRD prevalence and associated costs in different countries covered by the g2aging family of longitudinal studies (Aim 5).

Priority Research Areas: Population, Economic and Health Forecasting

2021. Karen Fingerman, Professor, University of Texas at Austin. Young Adult Caregivers of Aging Family Members.

More than 40 million adults in the U.S. provide caregiving to older adults and 1 in 4 of these caregivers are young adults aged 18 to 34. Research and interventions for Alzheimer’s Disease caregiving have focused on middle aged and older caregivers. Young adults may have distinct experiences in caregiving and providing care for older family members may be detrimental to future goals (e.g., education) with lasting repercussions on well-being throughout the life course. This pilot study will develop survey instruments and research methodologies to examine this under-researched group. Aim 1 Develop research battery to assess young adults’ caregiving experiences. We will assess the frequency and types of tasks young adult caregivers perform, their role in the family caregiving system and cultural beliefs about caregiving. Aim 2 Develop of assessments of young adults’ caregiving burdens and well-being We will assess implications of caregiving (positive and negative), including burden, loss of goal-directed statuses (e.g., educational pursuits) and subjective perceptions of control. Aim 3 Generate methodologies of daily sampling of caregiving. Intensive data collection will provide insights into caregiving close to the time these tasks occur. Across all aims, we will consider race/ethnicity, gender, relationship to care recipient and intergenerational coresidence. We will recruit a sample of 80 Hispanic, African American or Asian young adults (aged 18 to 34) who identify as caregivers for an older relative with ADRD (i.e., aged 65+). They will complete a 30 minute baseline survey to adapt existing measures and develop new ones to assess young adults’ caregiving experiences. Then, participants will complete brief surveys every week for 5 weeks. Our research team has extensive experience analyzing data intensive assessments. The proposed study may fundamentally shift the paradigm for understanding how family caregiving occurs, embedded in cultural and socioeconomic contexts.

Priority Research Areas: Caregiving

2021. Leah Richmond-Rakerd, Assistant Professor, University of Michigan. Do Mental Disorders Forecast ADRD in Nationwide Administrative Registers?.

Neurodegenerative conditions, including Alzheimer’s disease and related dementias (ADRD), have an outsized impact on disability and loss of independence in older adults. As such, there is a growing need to identify modifiable factors that drive variation in ADRD risk at the population level. We propose to investigate mental disorders as a potential preventable risk factor for later-life ADRD. Using three decades of nationwide health-register data on 1.7 million New Zealand citizens aged 21-60 at baseline, we will test whether mental disorders forecast the development of ADRD in the subsequent 30 years. We will test whether these associations hold across sex and age, across different types of mental disorders, within pairs of siblings matched on family-level risk factors, and after controlling for pre-existing physical-health conditions. Through this project, we will (1) quantify the degree to which preventing mental-health problems in young people might reduce the health and social burden of neurodegenerative diseases, and (2) create exportable tools, including a new linked-sibling data resource and a method for ascertaining ADRD across multiple health registers, that can be used by other ADRD researchers employing linked administrative data in their work. If results of the proposed project indicate that mental disorders forecast neurodegenerative diseases, this would also suggest novel hypotheses about mechanisms that underlie the development of ADRD and that may drive variation in ADRD risk across populations (e.g., inflammation, low education, poor health behaviors, social isolation, or psychiatric medications), to be tested in future basic-science and administrative-register studies.

2021. Sarah Mawhorter, Assistant Professor, University of Gronigen. Housing Transitions Associated with Cognitive Decline.

While existing research addresses the suitability of various housing alternatives for persons with dementia (PWD), little is known about PWDs’ housing transitions over the course of cognitive decline. This study investigates PWDs’ housing transitions using Health and Retirement study data from 2002 through 2016. We find that over half (56%) of PWD move in the years around dementia onset: 28% move once, and 28% move twice or more. Examining various types of moves, we see that slightly over a third of respondents move to another home at some point during cognitive decline, just under a third move into nursing homes, and around ten percent move in with relatives, with overlap between these categories since some PWD move more than once. We find strong patterns by educational attainment and race/ethnicity: Black and Hispanic PWD and those with lower education levels are less likely to move to another home or enter a nursing home than White and college-educated PWD. This suggests the importance of providing support for PWD and their families to transition into different living arrangements as their housing needs change.

2020. Alice Chen, Associate Professor, USC. ADRD Care in New Delivery and Payment Methods.

This study estimates the impact of new payment and delivery models—including accountable care organization models, patient-centered medical care homes, value-based payment modifiers, and merit-based incentive payments – on the health care and drug use and cost for ADRD patients. Results from this research will identify which delivery and payment models are most effective in improving dementia care. They will also inform an R01 proposals that seek to uncover mechanisms for observed improvements in dementia care, such as the restructuring of ADRD care teams, care coordination, and the placement of higher-risk ADRD patients into care management programs.

Priority Research Areas: Care for Persons Living with Dementia

2020. Bryan Tysinger, Research Assistant Professor, USC; Rebeca Wong, Professor, UT Medical Branch. Harmonized Cognitive Measures for International Microsimulation Modeling of ADRD.

This project will extend two existing microsimulation models, the United States Future Elderly Model (US-FEM, based on the HRS) and the FEM-Mexico (based on the MHAS) to incorporate measures from the HCAP supplement and produce population and subpopulation estimates of dementia today and in the future. It will inform an R01 proposal for modeling ADRD that will extend the analysis to potentially include microsimulation models for England, India, and China.

2020. Chandra Muller, Professor, University of Texas, Austin. National Longitudinal Study, 1972 (NLS-72) Record Matching to Centers for Medicare and Medicaid Services (CMS) Records.

This study addresses the social or skill aspects of education that shape cognitive functioning. The study will create new data for analysis of education and early cognition effects on economic security among older people. The matching and analyses will lay the foundation for an R01 proposal to follow-up the NLS-72 cohort to study cognitive aging and AD.

Priority Research Areas: Determinants of Health, Well-Being and Longevity

2020. Karen Eggleston, Senior Fellow; Jay Bhattacharya, Professor, Stanford. Trends and Projections of ADRD in Asia.

This project will extend the current Japanese Future Elderly Model (JFEM) microsimulation model to include cognitive function and dementia. It will use this expanded JFEM to study the social and economic burden of ADRD in Japan, and compare to other FEM for North America and Europe. Existing Asia microsimulation models include those for South Korea and Singapore, with a model under development for Taiwan, and in the planning stages for Hong Kong, the rest of China, and India. The study will project the health and cost implications of cognitive decline and ADRD and implications of long-term care insurance (LTCI) programs in Japan and South Korea.

Priority Research Areas: Population, Economic and Health Forecasting

2020. Mireille Jacobson, Associate Professor; Jason Doctor, Professor; Julie Zissimopoulos, Associate Professor, USC. The Impact of Cognitive Screening on Early ADRD Diagnosis, Treatment and Spending.

This study examines how Medicare plan type affects the likelihood of an early ADRD diagnosis combining both Traditional Medicare Fee-for-service claims and MA plan encounter files. The study will also fill a gap in our understanding of the impact of ADRD diagnosis on differences in health care utilization and spending in MA and Traditional Medicare. It will inform an R01 proposal to improve screening, diagnosis and care for person living with dementia.

Priority Research Areas: Cognitive Aging and the Demography of Dementia

2023. Kelly Musick. Family Complexity and Economic Resources Within and Across Households.

Increases in childbearing outside of marriage, divorce, repartnering, and childbearing across partnerships have increased the complexity and diversity of families (McLanahan, 2004). Changes in family composition and living arrangements raise challenges for measuring family relationships that our study designs are often ill-equipped to address. This is critically important because families provide a vital safety net for their members across the life course, from childhood through older ages. In Judith Seltzer’s recent address to the Population Association of America (2019), she argued that to better understand how families meet the obligations defined by kinship, demographers need to do a better job identifying family ties that extend beyond the household. Our project answers this call.
Evidence to date shows that family complexity is common, particularly among racialized and less advantaged groups (Amorim & Tach, 2019; Cancian et al., 2011; Carlson & Furstenberg, 2006). Family complexity is associated with reduced resources for children (Brown et al., 2015; Fomby et al., 2016; Halpern-Meekin & Tach, 2008; Harknett & Knab, 2007) and weaker relationships between parents and their adult children (Cherlin & Seltzer, 2014; Furstenberg, 2014). Emerging
work in this area has shed new light on the prevalence and potential implications of family complexity for children and older adults, but our current accounting is incomplete. Prior research has focused largely on the presence and composition of parents in the household (e.g., Kennedy and Bumpass 2008; Raley and Wildsmith 2004), limiting our understanding of family ties over the life course and missing key components of kinship that make up the private social safety net. We address this gap by leveraging the genealogical design of the Panel Study of Income
Dynamics (PSID, 1985-2017). Traditional household-based surveys fail to capture relationships and resource flows between children and nonresident parents and siblings, and administrative data have limited measures of family and household characteristics. The PSID is uniquely suited to advancing our understanding of family complexity and its links to resource flows within and across households, and how these resource flows change within and across cohorts. Our project
follows a conceptual framework in which family complexity has implications for economic resources, which in turn shape the support and well-being of family members from childhood through the older adult years. It advances CAPS research on family and intergenerational supports and reflects the cross-cutting theme of distinctive circumstances of specific populations, as defined by race and social disadvantage. We use multiple waves of data from the PSID 1985-2017. The unique design of the PSID follows “gened” family members even when they leave the original household. This makes it possible to collect detailed information on nonresident parents that is typically not available in household surveys. In particular, we have information on the marriage and fertility histories of these
nonresident parents; income sources from labor, kin, public, and other sources for all members of their households; and the full set of biological, adoptive, half, and step siblings residing in their households. We follow changes in residential and nonresidential family composition from the perspective of children, as their parents’ relationships evolve and new children are brought into the family. We address four specific aims:

Aims 1 and 2: We will identify complex parent and sibling relationships within and beyond the household, and we will estimate differences in their prevalence as children age, across cohorts, and by race and socioeconomic status. To do so, we will rely on household roster data collected at each wave, which includes move-in and move-out dates for all new and departed household members; comprehensive marriage and birth histories collected from all sample members ages 15 years and older since 1985; and PSID’s family composition file (early release, 1968-2017) with identifiers for biological, adoptive, half, and step sibling relationships.

Aims 3 and 4: We will examine the income sources of households linked by nonresidential parent and sibling relationships, and we will estimate differences as children age, across cohorts, and by race and socioeconomic status in the resources potentially available to children in complex families within and beyond the household. For a subset of children (N=3,065), we have a complete
fertility history for both parents, thus enabling accurate estimates of half and step siblings on the mother’s and father’s side. We will use this subset of children as a starting sample for our analysis of resources within and across households. We will merge information on family composition to information on household income sources at multiple waves from the core PSID family files. Our project makes several innovative contributions to the literature: First, we rely on the unique
genealogical design of the PSID that follows family members as they leave the household, making it possible to map changes in both residential and nonresidential sibship composition prospectively as children age. Second, we examine change across a broader span of cohorts, including more recent cohorts of children (born 1985-2004) than those included in the 1997 NLSY (born 1980-1984). Third, we provide among the first estimates based on a national sample of
differences in patterns of change by parents’ union status, education, and race/ethnicity. The inclusion of a low-income oversample in PSID’s original design enables us to evaluate the extent to which social class differences in sibship composition emerged within and between cohorts against the backdrop of rising social inequality. Finally, we provide the first estimates of detailed income sources of households linked by nonresidential parent and sibling relationships, and our
accounting differentiates by cohort, child age, race/ethnicity, and socioeconomic status. The descriptive work proposed here will inform a larger project proposal to the National Institute on Aging to investigate associations between family complexity, economic resources, and multiple dimensions of parent and child well-being over the life course. We plan to link our detailed file on childhood family composition and economic resources to data from the Child Development
Supplement, the Transition to Adulthood Supplement, and the Rosters and Transfers module. These links will allow us to map childhood experiences onto indicators of child well-being and relationships between parents and their adult children. For the parent generation, this includes transfers of time and money with their adult children, as well as help given to children for school, a home purchase, or other financial help. This extension directly addresses critical questions
about family complexity and the functioning of the family as a safety net for their members across the life course. This project is a collaboration between CAPS affiliate Kelly Musick at Cornell University and Paula Fomby at the University of Pennsylvania. The funding will support a Research Assistantship for an emerging aging scholar with interests in family relationships and well-being over the life course. Musick and Fomby have a long record of collaboration on topics related to family investments, child well-being, and family complexity, including a recently completed R01 on the emergence and social patterning of family complexity over historical time. Fomby led PSID data collection and training initiatives for a decade and is an expert in all aspects of PSID design and content required to achieve the study aims.

Priority Research Areas: Health Trends and Disparities, Determinants of Health, Well-Being and Longevity

2023. Marc Garcia. U.S. State Policy Contexts and Disability Risk Among Older Latino Adults in the United States.

The main objective of this project is to generate insights into the role of U.S. state policy contexts on disability risks among Latino adults (as a pan-ethnic category) ages 65 and older, and among subgroups of Latino adults (i.e., by nativity status, country of origin, and gender). The project will also provide insights into which domains of state policy (e.g., labor, environment, immigration) appear to be particularly important for disability risk among Latino adults. The findings will provide new evidence on the potential role of state policy contexts on disability
among the growing and increasingly diverse population of Latino adults in the United States. This project contributes to CAPS’ signature theme of health and well-being and its cross-cutting themes of place and specific populations. It has two specific aims:

Aim 1: Estimate the associations between U.S. states’ policy contexts and disability risk among older Latino adults and subgroups of Latino adults. The analyses will focus on two measures of disability. One measure assesses difficulty with activities of daily living such as bathing and eating (ADL) or instrumental activities of daily living such as shopping and running errands (IADL). Another measure assesses cognitive difficulty. State policy contexts will be measured with a single, well-established summary score of over 120 state-level policies [5].

Aim 2: Examine how 16 specific state policy domains, such as labor and immigration, are associated with disability risk among Latino adults in midlife. This aim will analyze the same measures of disability as in Aim 1. The 16 policy domains are components of the overall state policy measure used in Aim 1.

Priority Research Areas: Cognitive Aging and the Demography of Dementia, Determinants of Health, Well-Being and Longevity

2023. Pinka Chatterji. Consolidation in the Medicare Part D market and racial disparities in access to prescription drugs.

The Medicare prescription drug program (Part D) was launched in 2006. Since then, the Part D market has experienced significant consolidation, driven by mergers and acquisitions (M&A) and regulatory changes [1]. The overarching goal of this project is to examine how this industry consolidation has affected Part D utilization and out-of-pocket spending, and racial disparities in these outcomes, through reducing plan variety and competition.

Aim 1:  Document geographic variation in Medicare Part D market characteristics from 2006-2021 using maps and descriptive tables. We will examine Part D market characteristics across geography and time, focusing on Centers for Medicare and Medicaid Services (CMS) markets with the largest shares of minority racial/ethnic elderly populations. This approach will allow us to gauge descriptively whether trends in market consolidation are different in geographic areas with vs. without high minority elderly populations.

Aim 2:  Formally test whether Part D market consolidation affects market-level plan characteristics (e.g., premiums, quality), as well as racial disparities in prescription drug use and out-of-pocket spending on drugs among elderly individuals.

Priority Research Areas: Determinants of Health, Well-Being and Longevity, Disability, Health Care and Long-Term Care

2022. Kate Strully . Exclusionary and inclusionary residential zoning laws and health disparities among metropolitan older adults.

Aim 1: Draws on data from the 2020 Medicare Disparities Database to conduct an ecological-level analysis of how DZ and IZ policies are associated with health disparities in populations 65+ in the 50 most populous core-based statistical areas (CBSAs) in the U.S., and proposes to test for endogeneity in DZ policies using an instrumental variable strategy.
Aim 2: Uses data on respondents 65+ from the 2020 Behavioral Risk Factor Surveillance Study to conduct a multi-level analysis at the individual and CBSA level of how DZ and IZ policies are associated with health outcomes across racial-ethnic and income groups.
Aim 3: Involves a review and preliminary analysis of IZ programs within large CBSAs to identify significant policy changes and comparison locations in order to design a longitudinal study of effects of changes in IZ policies on income and racial-ethnic health disparities for individuals 65+.

Priority Research Areas: Determinants of Health, Well-Being and Longevity, Effects of Policy and Place on Health

2022. Maria Brown . Biological Aging and Functional Limitations: Moderation by Discrimination.

Aim 1: Examine how accelerated biological aging, as measured by epigenetic clocks, is associated with functional limitations in older adults.
Aim 2: Evaluate how the relationship between epigenetic clocks and functional limitations is impacted by perceived discrimination in later life among Black, Hispanic, and White older adults.

Priority Research Areas: Biology, Genetics and Demography of Aging, Health and Aging of Specific Populations

2022. Samantha Friedman. Redlining Policy and Later-Life Mortality: An Exploratory Analysis of the Linked HRS-1940 Census Data.

Aim 1: To link the HRS-1940 data at the ED level to the redlining data from the digitized HOLC maps. Mapping the HOLC information onto the EDs is an arduous process because a complete set of ED shapefiles is not readily available. Once ED shapefiles are created, we will overlay the HOLC maps and create a redlining score for each neighborhood. Then, we will link these data to the HRS public use data and code the project variables.
Aim 2: Using the harmonized dataset, we will estimate a hazard model of all-cause mortality as a function of early-life-neighborhood redlined status, control variables, and mediating variables for the full sample and by race to address the following research questions: a) Does residence in a redlined neighborhood in early life contribute directly to mortality in later life, controlling for other factors? b) Is the impact of residence in a redlined neighborhood in early life on mortality in later life mediated by mid-to-late life income, wealth, and education? and c) Does the impact of redlining in early life differ by race?

Priority Research Areas: Determinants of Health, Well-Being and Longevity, Effects of Policy and Place on Health

2022. Vida Maralani . Marital Sorting and Health Inequalities in Later Life.

Aim 1: To investigate how couples’ joint education- smoking portfolios established at the time of marriage inform their functional limitations at older ages.
Aim 2: To examine differences in smoking and exposure to second-hand smoke across the marital years as potential mechanisms linking assortative mating to inequalities in functional limitations at older ages.
Aim 3: To examine whether the association between assortative mating and health at older ages has changed across birth cohorts. This helps to illuminate one potential family-level mechanism underlying increasing educational disparities in health in the U.S.

Priority Research Areas: Determinants of Health, Well-Being and Longevity, Health Trends and Disparities

2021. Chun-Yo Ho. Elderly Health in Rural America: Impact of Hospital Closure.

Specific Aims:
Rural areas in the U.S. have been experiencing declines in access to hospital care. Since 2005, there has been 176 rural hospital closure, with considerable variation across states (North Carolina Rural Health Research Program, 2020). More than a fifth of all current rural hospitals are at high risk of closing, in which about two-third of them are considered essential to their community (Navigant 2019). Such trend echoes the access to health care is the top health priority among rural population (Bolin et al. 2015).

Aim 1: To estimate the effect of losing access to hospital care in rural U.S. counties on elderly health outcomes in response to time-sensitive conditions, and to test for disparities by race/ethnicity and by education, using Vital Statistics death certificate records from 2005-2018.

Aim 2: To estimate the magnitudes of policy-relevant factors affecting rural elder’ health outcomes directly as well as indirectly through loss of access to hospital care; these policy-relevant factors include the state’s ACA Medicaid expansion status, hospital characteristics, and local market characteristics.

Priority Research Areas: Determinants of Health, Well-Being and Longevity, Disability, Health Care and Long-Term Care

2021. Colleen Heflin. Increasing access to SNAP for older adults through the Standard Medical Deduction.

Specific Aims: One of the goals of Healthy People 2020 is to identify and address the social and physical environments that promote good health for all. In 2017, food insecurity was present for 7.7 percent of persons aged 60 and older, or 5.5 million persons (Ziliak & Gundersen, 2019). The consequences of elderly persons’ food insecurity are far-reaching, affecting their health and well-being (Gundersen,
Kreider, and Pepper 2011). The Supplemental Nutritional Assistance Program (SNAP) is the largest food and nutrition assistance program in the United States and has been shown to reduce food insecurity. States have the option to adopt the Standard Medical Deduction (SMD), a provision designed to make it easier
for older adults to deduct medical expenses from income during the eligibility process which should increases the number of older adults eligible for SNAP as well as the benefit amount for which they qualify. Despite the potential importance of this provision, currently only 21 states adopt the SMD and there are no formal evaluations of its effectiveness.

Priority Research Areas: 12. Effects of social, economic, and healthcare policy on health and aging

2021. Jun Li . Effect of Medicaid expansion on low-income, aging adults’ use of informal care.

Specific Aims:
More than 44 million Americans receive help from informal caregivers at a societal cost of $522 billion annually, which reflects a health care system that provides limited support for formal long-term services and supports. The Affordable Care Act gave states the opportunity to expand Medicaid, which covers medical care and formal long-term services and supports for low-income and disabled adults under 65, with expansion associated with greater use of health care including increased use of formal long-term services and supports. Greater use of formal medical care (including long-term services and supports) has been observed to substitute for or complement informal care depending on the health of the population and availability of family
and intergenerational supports. Thus, Medicaid expansion could be critical for how low-income, aging adults use informal care.

Aim 1: Examine the association between Medicaid expansion and informal care use among low-income adults. We will examine changes in the total intensity of care (number of weekly hours) received, the type of informal caregiving including activities of daily living (e.g., dressing, eating, bathing, and toileting) and instrumental activities of daily living (e.g., meal preparation, grocery shopping, making phone calls), and the composition of informal care (number of informal caregivers providing care). We hypothesize that expansion will be associated with reduced informal care and changes in the composition of informal care.

Aim 2: Estimate the association of Medicaid expansion with unpaid, informal care costs for low-income adults. We will assess the effects of Medicaid expansion on the monthly costs of informal care borne by care recipients and their caregivers, focusing on the indirect costs of informal care computed using the market price of hourly wages of home health care and personal care aides. We hypothesize that costs of informal care will decrease after expansion.

Aim 3: Examine whether the relationship between Medicaid expansion and informal care use and costs varied by cognitive impairment, heavy informal care use, and low-income status. We will assess whether expansion had a differential effect on individuals who are more disadvantaged and likely to benefit from changes in access to formal long-term services and supports. Specifically, we examine those with cognitive impairment, those with informal care use above the median amount, and individuals in the bottom quartile of the Medicaid expansion-eligible income distribution. We hypothesize that decreases in informal care use and costs will be greater for vulnerable individuals after expansion.

Priority Research Areas: 12. Effects of social, economic, and healthcare policy on health and aging, Disability, Health Care and Long-Term Care

2021. Adriana Reyes. Extension of Health Shocks and Changes in Spatial Proximity between Parents and Children.

Summary of existing project. Adult children provide significant amounts of caregiving to their parents, which is facilitated by relatively close geographic proximity. This project utilizes longitudinal data from the Health and Retirement Study (HRS) to understand how families mobilize in response to a health shock, such an ADRD diagnosis. Using data from 2004-2014, we estimate proximity over time between parents and their adult children using parent’s Census tract and children’s zip codes. Analyses will leverage longitudinal data to assess the time-ordering of health shocks and changes in geographic proximity to children using fixed effects models.

Rationale for broadening existing project. Alzheimer’s disease and related dementias (ADRD) are among the costliest conditions faced by individuals and society [1]. Average out of pocket costs for someone with ADRD is over $10,000, four times as much as for someone without ADRD [2]. Older adults with ADRD are at a greater risk of preventable hospitalizations than those without ADRD, and having higher quality family care may help cut down preventable hospitalizations [2, 3]. Out-of-pocket health care payments for ADRD consumed 32% of household wealth five years before death [4].  Early stage diagnosis of ADRD has been associated with declines in wealth, which may make it difficult to pay for late-stage treatment [5]. Despite the well documented financial toll of ADRD on the families of those living with ADRD, we know less about how family proximity and care may moderate this relationship.

Specific Aims. This project asks whether changes in parent-child proximity in response to ADRD is associated with wealth. In particular, does the proximity of adult children reduce health care-related spending for adults with ADRD? The overall goal of this work is to understand how family proximity and mobilization are associated with wealth trajectories and health care spending by older adults with ADRD. Having family nearby may help reduce hospitalizations and other forms of health care spending that can enable older adults to maintain wealth.

Priority Research Areas: Cognitive Aging and the Demography of Dementia, Family and Intergenerational supports

2021. Ben Shaw . Living alone and risk for the development of Alzheimer’s Disease and related dementias: When does solitary living matter and why.

Background. Existing research shows that living alone in later life is associated with greater risk for the development of ADRD than physical inactivity, hypertension, diabetes, and obesity [53]. Nevertheless, many older adults who live alone are able to maintain high levels of functioning and will not develop ADRD. While some research has identified factors that moderate the mortality risk of living alone [54], more research is needed to understand the circumstances associated with solitary living in later life that are mostly likely to confer, or buffer, ADRD risk. Social isolation is widely regarded as a key explanatory factor [55], but other demographic, behavioral, social, and environmental factors may also play important roles, either independently or jointly with social isolation. In addition, the timing of living alone (e.g., age of onset; duration in living alone status) and the circumstances precipitating a transition to solitary living may also be important in determining risk for ADRD.

Aims. This study’s aims are: (1) to determine which specific circumstances defining one’s living alone status (i.e., age of transition to living alone; duration in living alone status; event leading to living alone transition) are associated with ADRD incidence among older adults; (2) to determine the key demographic, behavioral, social, and environmental factors related to living alone during later life that are most strongly associated with ADRD incidence among older adults; and (3) to determine what demographic, behavioral, social, and environmental factors buffer the risk of ADRD among older adults living alone.

Priority Research Areas: Cognitive Aging and the Demography of Dementia, Family and Intergenerational supports

2021. Emily Wiemers . Extension of The Consequences of Disabilities in Late Middle Age for Consumption Well-Being.

Summary of existing project. The existing project uses the rich consumption and health data in Panel Study of Income Dynamics [PSID] to examine the consequences of disability in late middle age for consumption well-being and to assess whether the decline in consumption at the time an individual becomes disabled is predicted by or mediated by reports of poor health in childhood. The supplement exploits the measures of cognition, consumption, labor supply, wealth, and early childhood health in the Health and Retirement Study [HRS] to answer the same set of questions focusing on the impact of the onset of cognitive limitations and dementia on consumption well-being and its correlation with poor health in early childhood.

Specific Aim. To use the HRS to examine the impact of cognitive limitation or dementia onset on consumption well-being paying particular attention to the role of spousal labor supply and wealth as sources of consumption smoothing, and to evaluate the role of poor health in childhood in either exacerbating or mediating dementia-related consumption declines.

Priority Research Areas: Cognitive Aging and the Demography of Dementia, Disability, Health Care and Long-Term Care

2021. Kevin Heffernan. Estimated Arterial Stiffness as a Predictor of Cognitive Decline and Dementia in Middle-Aged and Older Adults.

Background. With aging, large arteries outside of the brain lose elasticity. Elevated levels of arterial stiffness expose the brain to high blood pressure that causes structural damage [23]. Numerous cross-sectional studies now support a strong association between arterial stiffening and β-amyloid plaque deposition and atrophy of key areas of the brain implicated in the pathogenesis of cognitive aging and ADRD development [24-27]. Arterial stiffness also prospectively predicts cognitive decline [28-30] and transition to dementia in older adults [31-33]. As such, arterial stiffness may be a useful vascular biomarker to predict age-related cognitive decline and transition from mild cognitive impairment (MCI) to more severe dementia in the general population.

The gold standard method for assessing arterial stiffness, carotid-femoral pulse wave velocity (cfPWV), requires specialized, relatively expensive equipment and considerable technical proficiency, which limits its widespread adoption [34]. cfPWV can be estimated from two commonly measured clinical variables – age and blood pressure – and we have shown this estimated pulse wave velocity (ePWV) is an independent predictor of cardiovascular and cerebrovascular events in the general population [35,36].This pilot project will extend our ongoing work on vascular aging to consider the relationship between ePWV, cognitive decline, and dementia.

Specific Aims. As the NIA acknowledges that “MCI research is perceived by experts as Alzheimer’s Disease prevention research,” this pilot project will leverage the strong longitudinal study design of the HRS to address two specific aims and associated hypotheses: (1) examine ePWV as a predictor of cognitive decline in middle-aged and older adults. We hypothesize that higher arterial stiffness will predict a steeper age-related decline in cognitive function. (2) Examine ePWV as a predictor of the transition from MCI to dementia in middle-aged and older adults. We hypothesize higher arterial stiffness will be associated with a higher risk of transitioning from MCI to having dementia.

Priority Research Areas: Cognitive Aging and the Demography of Dementia, Health Trends and Disparities

2021. Scott Landes . Comparing Alzheimer’s Related Mortality Among People with and without Down Syndrome.

Background and Significance. Over the past 50 years, the age of death for people with Down syndrome in the Unites States has improved markedly, from an average age at death of 25 in 1983, to 49 in 1997, to 56 in 2017 [39,40]. The increase in longevity for this population is typically ascribed to improvements in early intervention efforts, as well as social supports and medical care for people that often coincided with a transition away from institutional and toward community-based supports [41,42]. With the advent of people with Down syndrome now living into and beyond their 40s, research has documented high rates of early onset Alzheimer’s disease among this population, with some researchers claiming that a majority of individual’s with Down syndrome exhibit neuropathological characteristics of Alzheimer’s disease by age 40 [43-47].

Three studies utilize US death certificate data to document that adults with Down syndrome have higher rates of death from Alzheimer’s disease and or dementia that adults in the general population [40,48,49], with the most recent reporting adults with Down syndrome were 25 times more likely to die from these diseases [49]. While informative, there are limitations to this research that need to be addressed. The first is that all three studies rely on analysis of the underlying cause of death, as opposed to conducting broader analysis of multiple cause of death. Thus, while they accurately identify that people with Down syndrome were more likely to have Alzheimer’s/dementia identified as their underlying cause of death, they do not address whether people with Down syndrome were more/less likely to have been diagnosed with Alzheimer’s disease by their time of death. This is an important distinction. As people with Alzheimer’s disease can die from various other diseases [50], focusing solely on the underlying cause of death leads to underestimates of the prevalence of this disease at time of death that may vary between people with/without Down syndrome. In comparison, utilizing multiple cause of death files, which provide information on comorbidities present at the time of death, would provide a more accurate accounting of the prevalence of Alzheimer’s disease among both populations at the time of death. In addition, analysis of multiple cause of death files would allow for examination of whether causes of death are similar or different among people with and without Down syndrome who have Alzheimer’s disease, an important research question that has not been addressed to date.

Specific Aims. This project has two aims: (1) to analyze differences in the prevalence of Alzheimer’s disease among people with and without Down syndrome at the time of death; and (2) to document causes of death among people with and without Down syndrome who had Alzheimer’s disease reported on their death certificate.

Priority Research Areas: Cognitive Aging and the Demography of Dementia, Health and aging of specific populations

2020. Adriana Reyes. Health Shocks and Changes in Spatial Proximity between Parents and Children.

Background: Over half of caregivers who provide substantial help to older adults are adult children [1]. However, family caregiving is facilitated by relatively close geographic proximity, especially because children provide an average of 77 hours of assistance a month [2]. Living near children enables a wide range of support, and therefore older adults may migrate to be closer to children in response to or in anticipation of health declines [3]. Previous research has found that when adult children move, they are more likely to choose locations close to their parents compared to other locations, especially when parents are very old [4]. Similarly, elderly adults’ migration patterns are motivated by a desire for close geographic proximity to their children [5]. Recent estimates suggest that a majority of parents and children live near each other, especially those with fewer socioeconomic resources [6]. Yet, the number of older adults without an adult child nearby is projected to increase dramatically over the next two decades [7]. As many rural areas experience an out-migration of young people and declining economic opportunities, the ability of older adults to rely on children for caregiving may be compromised in these areas. We know that children play a significant role in caring for their aging parents; however, we know less about how health shocks associated with Alzheimer’s disease and other conditions may alter the geographic location of children and parents. Building on this context, this project will pursue two specific aims:
Aim 1: Construct a panel dataset of spatial proximity between parents and their adult children. The data will document, at each wave, the distance between parents and their adult children and changes across waves.
Aim 2: Identify the correlates of changes in proximity and co-residence. The project will examine how changes in proximity evolve relative to changes in health, such as an Alzheimer’s diagnosis.

Priority Research Areas: Determinants of Health, Well-Being and Longevity, Family and Intergenerational Dynamics

2020. Emily Wiemers. The Consequences of Disabilities in Late Middle Age for Consumption Well-Being.

Background: This project will use the rich data in the Panel Study of Income Dynamics (PSID) to examine the consequences of disability in late middle age for economic well-being using consumption-based measures (e.g., food, housing, services) rather than income-based measures. It will exploit the long health histories in the PSID to examine whether declines in consumption at the time an adult becomes disabled are predicted by or mediated by reports of poor health earlier in life, particularly in childhood. The project will address two specific aims:
Aim 1: Examine the impact of the onset of work-limiting disabilities in late middle age on health, non-durable, and non-health service consumption, focusing on spousal labor supply and wealth as sources of smoothing consumption. This aim will recognize that, for married people, there is a tension between providing care to a disabled spouse and increasing labor supply to smooth consumption after the onset of a spouse’s disability.
Aim 2: Examine whether adverse childhood health conditions explain declines in consumption for those experiencing a work-limiting disability in late middle age. Individuals with poor health in childhood may save to insure their consumption against expected future adverse health shocks. Alternatively, they may be unable to self-insure because poor health in childhood limits earnings. Adverse childhood health conditions may also predict the severity of disabilities later in life, even in the absence of insurance effects.

Priority Research Areas: Family and Intergenerational Dynamics, Disability, Health Care and Long-Term Care

2020. Pinka Chatterji. 3. Medicare Part D and Disparities in Chronic Disease among the U.S. Elderly Population .

Background: Health insurance may be a key factor underlying disparities in chronic disease among the U.S. elderly population. Notably, a study that used data from 1999 to 2006 found that racial/ethnic disparities in control of blood pressure and diabetes become smaller after age 65, suggesting that Medicare reduces disparities in chronic disease [13]. Medicare introduced optional prescription drug coverage in 2006 (Part D). The introduction of Part D may have made Medicare an even more important factor in remediating disparities given the important role of prescription drugs in controlling chronic disease. Prior work suggests that there are racial/ethnic differences in medication adherence for chronic diseases [14, 15], and Part D has increased medication usage overall among the elderly population [16, 17]. To our knowledge, however, no studies have investigated the potentially strong effects of Part D on older adults’ awareness and control of chronic disease, or the effects of Part D on racial/ethnic and education-related disparities in chronic disease. The project will address two specific aims:
Aim 1: Test whether the introduction of Medicare Part D affected disparities in awareness and control of hypertension, diabetes, and hyperlipidemia using national data sets that include biomarkers.
Aim 2: Test whether Part D affected disparities in prescription drug use and out-of-pocket spending on drugs among elderly individuals with chronic diseases.

Priority Research Areas: Determinants of Health, Well-Being and Longevity, Effects of Policy and Place on Health

2020. Shannon Monnat. Demographic, Geographic, and Temporal Trends in Co-Occurring Use Disorders and Mortality from Opioids, Other Drugs, and Alcohol among Middle-Age and Older Adults in the United States.

Background: Opioid use disorders (OUD) and overdose death rates have grown to unprecedented levels [18, 19]. The U.S. has also experienced large increases in cocaine, methamphetamine, and non-opioid prescription (especially benzodiazepines) overdoses over the past decade. Deaths from alcohol use and use disorders (AUD) are also rising, especially among older adults, women, and low-SES individuals [20, 21]. These crises are costly, getting worse, and interdependent. Excessive alcohol use is common among individuals who misuse opioids [22], with more than half of individuals with OUD also meeting criteria for AUD [23]; more than half of opioid-related deaths involve alcohol or another drug [24]. Use disorders and overdose rates are also geographically patterned [25, 26]. Moreover, while drug and alcohol mortality rates have increased across many demographic groups over the past 20 years, increases in the middle-age cohort (35-64 years) have been startling. Thus, we focus on the relationship between drug- and alcohol- use disorders and between drug- and alcohol- related mortality among middle-aged and older adults. The specific aims of this two-year study are to:
Aim 1: Characterize demographic, geographic, and temporal trends (2000-2017) in the relationships between opioids, other drugs, and alcohol—in terms of use disorders and mortality—among middle-aged and older adults.
Aim 2: Identify typologies of counties based on use disorders and mortality from opioids, other drugs, and alcohol.
Aim 3: Compare the county groups found in Aim 2 by sociodemographic, economic, and other characteristics.

Priority Research Areas: Health Trends and Disparities, Effects of Policy and Place on Health

2022. Corinne Engelman. Identification of Gene–Environment Interactions in Cognitive Decline During the Preclinical Stage of Alzheimer’s.

The overall objective of this proposal is to use the life-course approach, combined with a novel Alzheimer’s disease (AD) modeling strategy and rich Health and Retirement Study (HRS) and Wisconsin Registry for Alzheimer’s Prevention (WRAP) data, to identify potential interactions between social and behavioral factors, biomarkers, and genetic variants influencing cognitive aging during the preclinical stage of AD. Findings from this research will provide preliminary data for an NIH R01 application to the NIA to evaluate these candidate interactions in other NIA-funded datasets we have access to through collaborators, including expanding this research to African Americans recruited by WRAP, who were targeted in a later phase of WRAP and have just undergone genome-wide genotyping, HRS, and the Washington Heights-Inwood Community Aging Project (WHICAP).

Priority Research Areas: Biology, Genetics and Demography of Aging

2022. Lauren Schmitz. Assessing Measures of Biological Age in a Low-Income Context: The Malawi Longitudinal Study of Families and Health.

This pilot supports in-depth research on the creation and evaluation of biological (or phenotypic) aging measures in a low-income countries (LIC) context. This project has two aims: (1) construct measures of biological age (BA) in the Malawi Longitudinal Study of Families and Health (MLSFH) and test whether they are stronger predictors of age-related disease than chronological age (CA) and (2) compare BA measures and related findings with results from high-income countries (HICs) to evaluate the context-dependence of biological aging measures. This project includes the analysis of pilot data for an R01 resubmission or submission of a new R01 as well as collaborative research opportunities for students that are interested in working with the MLSFH data.

Priority Research Areas: Biology, Genetics and Demography of Aging

2022. Qiongshi Lu. Polygenic Gene-environment Interaction Analysis for Human Complex Traits.

This study will assess the interaction between genetics and education reform (i.e., a well-known natural experiment on compulsory schooling age reform) in the UK. This project will explore two recent statistical advances as alternative approaches to estimating gene-environment interaction (GxE). This project will pursue the following two aims: (1) estimate GxE using genetic variants associated with trait variability (vQTL) and variance polygenic scores (vPGS) and (2) estimate polygenic GxE interaction using genetic correlation analysis. The analysis conducted in this project will benefit the method paper describing the PIGEON approach and will lead to at least one other manuscript on GxE analysis.

Priority Research Areas: Biology, Genetics and Demography of Aging

2022. Rebecca Myerson. Informing Health Insurance Policy to Improve Lung Cancer Screening.

This project aims to: (1) compare the effect of nearly-universal access to Medicare insurance coverage on lung cancer screening by race, sex, and ethnicity to evaluate the impact on disparities and (2) document the characteristics of screened Medicare patients who lack documentation of shared decision-making, including race, sex, and ethnicity. The findings will inform coverage policy as well as policy related to shared decision-making to improve access to lung cancer screening among older adults, women, and racial/ethnic minorities. As such, the project will increase the evidence base to improve diagnosis and make health care more accessible and equitable. Furthermore, this research will open new horizons for R01-level work on shared decision-making policy, including Medicare’s recent shared decision-making mandates for two other conditions.

Priority Research Areas: Population, Economic and Health Forecasting

2022. Wei Xu. Uncovering the Impact of Birth Place on Mid-Life All-Cause and Cause-Specific Mortality.

This project aims to provide new evidence of the contribution of early life geographic context to variation in mid-life mortality in the US and potential mechanisms through which the contribution may be realized. Specifically, this project seeks to: (1) determine the magnitude of contribution of birth place to mid-life mortality, (2) determine the influence of birth place on patterns of mid-life cause-specific mortality, and (3) uncover mechanisms linking birth place and mid-life mortality by focusing early life exposures to epidemiologic and socioeconomic contexts and residential mobility. Findings will inform policy interventions aimed at reducing mid-life mortality inequalities.

Priority Research Areas: Population, Economic and Health Forecasting

2021. Eric Grodsky. The Nation’s High School Class of 1972 at Retirement: Education and Cognitive Aging Among Mid-Cohort Baby Boomers.

The research team will collect data from the ~14,500 sample members of the precursor to High School and Beyond, the National Longitudinal Study of the High School Class of 1972. Born mainly in 1953-55, sample members are now in their mid to late 60s. This proposed project would collect, analyze and disseminate data about their current cognition and life circumstances as well as their physiological status as indicated by whole blood, plasma, serum, and other biomarkers. The project has four aims:

1. Estimate the effects of education from adolescence forward
2. Assess the role of different aspects of education in producing racial and ethnic disparities in cognitive functioning and impairment in the transition from midlife to older ages
3. Assess the role of different aspects of education in the relationship between physiology and ADRD captured in blood- and saliva-based biomarkers as individuals transition from midlife to older ages
4. Prepare for distribution the resulting database and associated documentation and metadata to facilitate scholarship on the factors that affect cognitive functioning and cognitive impairment.

Priority Research Areas: Cognitive Aging and the Demography of Dementia

2021. Jessica Cao. Post-acute Care Access and Disparities among ACO Medicare Beneficiaries during the COVID-19 Pandemic.

This pilot project aims to gauge the changes and disparities in post-acute care (PAC) access among Medicare beneficiaries in the UW Health system, a local Medicare Accountable Care Organization (ACO), during the COVID-19 pandemic. Results from this pilot project will be used as the baseline for R01- level studies regarding the effects of the pandemic on PAC utilizations, health outcomes and subsequent health care utilizations and costs among Medicare beneficiaries. The ultimate goal is to make recommendations to the local ACO and beyond on how to improve equitable care access and quality of care for older adults.

Priority Research Areas: Health Trends and Disparities

2021. John Eason. Frailty, Aging, and Cancer Survival.

The goal of this project is to investigate the role of frailty/aging at the individual level and community level factors in pancreatic ductal adenocarcinoma survival. In addition to measuring the effect of community disadvantage (e.g. poverty and unemployment), researchers will examine how/if the presence of healthcare organizations in a community mitigate the effect of disadvantage incidence and survival. Eason and colleagues will investigate the role of individual level determinants of health disparities, but will also investigate how access to health care may alleviate cancer survival disparities.

Priority Research Areas: Effects of Interventions on Population Health

2021. Kristen Litzelman. “Jumping through A New Set of Hoops Each Time” – Conceptualization and Assessment of Socioeconomic Disparities in Caregivers’ Access to Resources.

In order to advance research and intervention efforts focused on resource use among caregivers, this project will conceptualize the process of accessing resources and assess socioeconomic disparities in resource use. The researchers will draw on previous theoretical and conceptual models to frame this work. The project’s overarching hypothesis is that service use is driven not only by need, but by caregivers’ existing resources of time, money, and emotional energy, compounded by sequential challenges in the systems navigation process. Conceptualizing this process and assessing how socioeconomic factors are linked to service utilization is a critical first step to understanding disparities in resource allocation and identifying targets for intervention

Priority Research Areas: Health Trends and Disparities

2021. Lauren Schmitz and Valentina Duque (University of Sydney). The Impact of Early Life Exposure to Extreme Weather and Temperature Shocks on Late Life Cardiovascular and Cognitive Health: Evidence from the Longitudinal Aging Study in India (LAS).

This project will contribute to our understanding of how early life conditions affect aging patterns in developing countries. Specifically, since agriculture remains the main source of income for a large fraction of households in these contexts, we will focus on two shocks that largely affect their economic, health, and psychological wellbeing: 1) the occurrence of adverse weather and temperature shocks, and 2) policies aimed at reducing food insecurity, poverty, and promoting economic growth. Understanding life course impacts of extreme weather patterns on aging outcomes is particularly imperative in the modern climate era; the number of record high temperatures and intense rainfall events has been increasing globally and these trends are expected to continue to rise over the next few decades.

Priority Research Areas: Determinants of Health, Well-Being and Longevity

2020. Jason Fletcher. Deploying Machine Learning Tools to Predict Mortality Outcomes in the General Population.

Utilizing machine learning to predict mortality outcomes at the population level has thus far proven a tough nut to crack: the existing small samples sizes too small, the large samples lacking the proper type of data. This project aims to find the middle ground between these extremes by linking large population-based data from the National Longitudinal Mortality Study and the American Community Survey (ACS) to data from the National Death Index (NDI) and Medicare claims. Utilizing these linkages, the researchers will look for interactions that lead to mortality, and create risk scores based off of these interactions.

Priority Research Areas: Determinants of Health, Well-Being and Longevity

2020. Jooyoung Kong. Adverse Childhood Experiences and Physiological, Affective, and Cardiovascular Reactivity to Family Caregiving Stress.

Longer life spans have helped advent the “sandwich generation” – middle-aged adults who find themselves caring for their children and their own aging parents. This position, stressful for anyone, may be especially stressful for adults who had Adverse Childhood Experiences (ACEs) while growing up. Primarily using the data from the Midlife in the United States (MIDUS) study, this project will explore how caregiving adults with ACES in their histories respond and react to daily stressors.

Priority Research Areas: Determinants of Health, Well-Being and Longevity

2020. Judith Simcox. Improving Biomarkers of Metabolic Disease in African American Populations.

Studies have shown that the most widely used clinical markers for diabetes — HDL, LDL, and triglycerides — are not accurate predictors of the disease in African-Americans. This pilot project will examine the promise of two potential alternatives in African-American females: C reactive protein and arachidonic acid containing lipids. African Americans are 60% more likely than Caucasians to have diabetes and twice as likely to die from diabetes-related complications. With better diagnostic tools, healthcare professionals have a better chance of bringing about positive health care outcomes.

Priority Research Areas: Biology, Genetics and Demography of Aging

2020. Philipp Koellinger. Understanding Socio-economic Influences on Health and Longevity.

Scientists have already discovered that low socio-economic status (SES) is linked to an array of physical and mental health conditions and reduced longevity, but the mechanisms behind these correlations have proven elusive thus far. If they could be discovered, scientists may be able to predict and prevent some of the poor outcomes associated with low SES. This project will utilize the over 500,000 genomic samples within the UK Biobank to complete analyses.

Priority Research Areas: Determinants of Health, Well-Being and Longevity

2020. ZhengZheng Tang. Investigating the Interactions between Inflammatory Biomarkers and Gut Microbiome in the Wisconsin Longitudinal Study.

Persistent inflammation has emerged as a consistent marker of aging and aging-related diseases. This pilot project seeks to investigate the connection between these inflamed biomarkers and changes in the gut microbiome among older adults, using the Wisconsin Longitudinal Study, a rich longitudinal data source that has tracked individuals from the 1957 high school class throughout Wisconsin.

Priority Research Areas: Biology, Genetics and Demography of Aging

2024. Avshalom Caspi. The links between mental and physical disorders across the life course: A whole nation analysis .

By launching this project with nationwide registry data we will pave the way for a grant application of a three-nation study that will bring together physical health, mental health, and socioeconomic data across the life span (from birth to age 100) in three nations (New Zealand, Denmark, and Norway) for >14 million people. These three nations have unique nationwide data registries. We have already established the feasibility of working with the New Zealand and the Danish data. Our goal is to become sufficiently familiar with a new data resource from Norway, and to generate an initial publication, that will document feasibility for a grant application of a three-nation study. The three nations offer access to complementary nationwide health records, including prescription records, hospital records, and, in Norway, primary-care encounters.

Our aim is to identify the links between mental disorders and physical diseases in the population. To do so, we will leverage a unique data resource that to our knowledge is not available anywhere else in the world: every primary care health encounter over a 17-year period from 2006-2022 in Norway, where all residents are assigned a primary-care physician. By exploring the connections between mental disorders and physical diseases within primary care context, we strive to deepen our understanding of the interplay between mental and physical health, from childhood to old age. Using pilot grant funds, we will prepare and code the nationwide data from primary-care records, and also prepare an initial report which will serve as a ‘preliminary study’ for an extramural grant application.

Priority Research Areas: Determinants of Health, Well-Being and Longevity, Population, Economic and Health Forecasting

2024. Herman Pontzer. Allostatic Load and Cardiometabolic Health in a Rural Population.

This project directly examines foundations of lifelong health by testing hypotheses linking early life adversity and physiological (dys)regulation (allostatic load) to cardiometabolic health in adults. It also involves biodemography by integrating biological indicators of health into a life course perspective to examine how the interactions between life events and physiology contribute to population health disparities and mortality differentials. Accordingly, this project engages life course studies through focusing on the cumulative effects of early life experiences on long-term health consequences. The project’s goals include advancing our understanding of how chronic stress influences health across an individual’s health and lifespan, and how these relationships impact differences in population health.

The Great Smoky Mountain Study (GSMS) provides a unique opportunity to investigate longitudinal effects of early life experience and adversity on cardiometabolic health over the life course. Previous work with GSMS has focused on psychosocial and environmental sources of adversity. With banked dried blood spots for all participants beginning at their enrollment into the study, there are numerous opportunities to expand these analyses to examine biomarkers of physiological stress and dysregulation, including allostasis. This project is a first step in this direction. Results will provide pilot data for grant proposals examining physiological measures of early life stress, their changes over the life course, and their association with adult health outcomes.

Priority Research Areas: Determinants of Health, Well-Being and Longevity, Biology, Genetics and Demography of Aging

2024. M. Giovanna Merli. Data Collection Innovations to Study the Health of African Immigrants in the United States.

The topics and methods featured in this study are consistent with DUPRI’s support for data innovations and with the signature themes of the P30-funded CPHA and P2C-funded DPRC (demography of health, life course studies, foundations of lifelong health and interconnected social systems and population health). This project is the first in a collaboration among the following teams:
(1) the Duke-UNC team composed of Giovanna Merli (Professor of Public Policy at Duke), Ted Mouw (Professor of Sociology at UNC) and colleagues, who have invested significant effort in the empirical testing and evaluation of an innovative link-tracing sampling design, Network Sampling with Memory (NSM), which traces the links (social ties) of respondents to recruit subsequent waves of respondents into the sample according to probability sampling principles. Merli and Mouw have successfully tested this approach among Chinese immigrant populations in the US, Africa and Europe as well as Mexican immigrants in the US. They have shown that NSM is able to generate representative samples of immigrant populations, when compared with the American Community Survey, and that peer referral driving sample recruitment increases response rates; (2) the University of Pennsylvania team composed by Irma Elo, Professor of Sociology and Jere Behrman, Professor of Economics (3) the University of Ghana team led by Ayaga Bawah, Associate Professor and Director of the Regional Institute for Population Studies at the University of Ghana.
The Penn and Ghana teams have significant expertise in the study of immigrant health and mortality, African health, human resources, economic demography, incentive systems and household behaviors, as well as in the design and conduct of longitudinal data collections in Africa and other low and middle income areas. These two teams have already worked together on a small pilot study of a convenience sample of Ghanaian immigrants in Philadelphia.

The purpose of this collaboration is to extend the NSM methodology to recruit binational samples of Ghanaian migrants to the U.S. to better understand the impact of migration on the health and wellbeing of African migrants and their families at both origin and destination. The Duke-UNC’s team successfully evaluated NSM with support from grants from NICHD and France National Research Council. We are now planning an NIH R01 grant application to apply and extend this tested methodology to recruit a binational sample of Ghanaian migrants that captures the contexts at origin and destination and to use the peer-referral approach embedded in NSM techniques to follow members of the recruited sample over time. A DUPRI pilot award would help us collect preliminary data and test the feasibility of collecting the network data required by the implementation of NSM among Ghanaian migrants. The new R01 grant application will thus follow from previous NIH investments in this methodology, which would increase the probability of success.

Priority Research Areas: Migration and health

2023. Jen'nan Read. Implications of White Diversity for U.S. Black-White Health Disparities.

The overarching goal of this project is to examine how demographic changes in the ethnic origins of whites impact knowledge on U.S. racial disparities in health over time. Specifically, the project will decompose non-Hispanic whites by nativity and region of birth using nationally-representative data from the National Health Interview Survey and the American Community Survey and then replicate studies on black-white health disparities. The replication will first use the standard aggregate white category in comparisons to blacks and then substitute alternative definitions of whites that isolate those of western European descent from those of eastern European, Middle Eastern and North African descent.

Findings from this study will have implications across DUPRI’s priority areas and contribute to ongoing debates on potential revisions to federal standards on race and ethnicity. The common practice across population health sciences is to treat Whites in the aggregate in studies of U.S. racial inequality, particularly research that focuses on gaps in resources and health outcomes between groups. Studies that focus on within-group diversity among Whites, including my own, are illustrative for identifying vulnerable subpopulations that are masked by the aggregate category. However, they do not address whether changes in the composition of whites over time impact knowledge on intergroup racial inequalities between blacks and whites. Answers to this question would inform research on racial inequality and guide policies that seek to alleviate them.

Priority Research Areas: Health Trends and Disparities

2023. Hanzhang Xu. Characterizing Caregiving Networks among Persons with ADRD in a Global Context.

The proposed study is consistent with two priority areas at CPHA as indicated above. First, our study will identify the caregiving networks shared by persons with Alzheimer’s disease and related dementia (ADRD). Some of the caregiving networks likely will include family members across different generations. For example, in China, the cultural expectation of caregiving within the home/family (e.g. filial piety) may contribute to the multigenerational living environment. Therefore, the proposed project is consistent with the intergenerational studies priority area. Furthermore, while the current study will focus on the heterogeneity of caregiving networks and factors associated with it, our ultimate goal is to assess whether certain caregiving networks are associated better well-being, personhood, and quality of life among persons with ADRD. As family and friends are vital to the health and well-being of persons with ADRD, this project’s focus on linked lives is also consistent with the life course studies priority area.

The PI has been working closely with the Worldwide Elements To Harmonize Research In long-term care liVing Environments (WE-THRIVE) consortium since 2018. In brief, this consortium aims to establish common data elements (CDE) that are relevant to person-centered long-term dementia care. Recently this consortium was invited by the NIA to submit a P01 application that focuses on advancing the identification and use of dementia CDEs that can serve as the springboard for numerous additional studies of the structure, functioning, quality, and equity of dementia care. This proposed project will provide much needed preliminary evidence for one of the P01 projects (R01 equivalence) that focuses on profiling dementia caregiving networks using existing data. This line of work is closely aligned with several NIA’s special interests: ADRD, family caregiving, HRS and HRS International Family of Studies.

Priority Research Areas: Consequences of U.S. and Global Aging, Determinants of Health, Well-Being and Longevity

2023. Matthew Dupre. Racial Differences in Age-Related Hearing Loss in Middle-Aged and Older Adults.

Decades of research has documented racial differences in the health and well-being of older adults in the United States. However, much less is known about the life course patterning and predictors of racial differences in hearing loss among U.S. older adults. Evidence from population-based studies indicates that Black Americans have a 40-70% lower prevalence of hearing loss and better pure-tone thresholds compared to White Americans. The reasons for these racial differences in hearing sensitivity are not well understood and appear paradoxical in the context of the large literature on racial disparities in health. Drawing on the life course perspective and biodemography, Black adults may have greater age-related hearing loss than previously observed, but these racial differences may be obscured by failing to account for the life course patterning of hearing loss and the accumulation of risks that Black adults face. Research shows that Black adults experience greater lifetime exposure to risk factors for hearing loss than White adults. For example, Black individuals are much more likely to work in jobs that place them at increased risk for noise-induced hearing loss and live in areas exposed to greater levels of environmental noise pollution or infectious diseases associated with hearing loss (e.g., cytomegalovirus). However, previous research has not examined how the accumulation of a wide range of social, behavioral, and/or physiological factors may contribute to age-related patterns of hearing loss among White and Black older adults. Moreover, most studies that have examined hearing loss are primarily limited to White populations or do not disaggregate Black populations from other minority racial/ethnic groups (i.e., focusing on “non-White” groups).

To date, there is limited and conflicting evidence to inform the development of clinical and public health interventions to address hearing loss among racial minorities. This pilot project will lay the groundwork to begin addressing this gap by leveraging multiple data sources to understand how a wide array of factors may be contributing to age-related patterns of hearing loss among White and Black middle-aged and older adults. Results from this pilot project will be used to develop an NIH Diversity Supplement (PA-21-071) to examine the implications of age-related hearing loss for differences in hospitalizations in older adults and an NIH/R21 proposal to develop the preliminary evidence needed to support a tailored intervention to improve hearing healthcare among racial minorities.

Priority Research Areas: Cognitive Aging and the Demography of Dementia, Determinants of Health, Well-Being and Longevity

2022. Charles Nunn. Quantifying the gradient of market integration in relation to health across the life course in northeast Madagascar.

The pilot research engages with (1) “Foundations of Lifelong Health” by investigating the impact of interactions among biological, behavioral and environmental factors on human health throughout the life course, and (2) “Interconnected Social Systems and Population Health” by considering how
social connections influence aging and health. The pilot research will form a foundation for building a rich understanding of ongoing market integration in the Sava region of northeast Madagascar where people are transitioning from a lifestyle based on subsistence farming to a lifestyle based on
market activities, including buying and selling goods. This research will further understanding of the effects of economic change on health across the lifecourse.

The proposed pilot work will help secure external funding in three main ways: (1) by developing methods to quantify market integration that are appropriate for the cultural, economic, and social context of the area (northeast Madagascar); (2) by expanding our existing research to capture a wider spectrum of variation in market integration across villages; and (3) by conducting initial tests that investigate whether market integration covaries with age, health outcomes, and contact patterns in the region. Previous work studying health in three villages has revealed that agriculturalists are
increasingly farming a key cash crop (vanilla). This work has demonstrated variation in market integration within these villages; we also expect to document variation across villages, which range from subsistence farmers far from transportation networks to hubs of market activity along major
roadways. In the context of larger grant applications (R21s or R01s), we will propose to investigate how market integration influences infectious disease exposure, cardiovascular disease, sleep and health disparities, social networks and health, and stress across the life course. We anticipate that
initial funding applications in the next 24 months will focus on the first two of these topics and incorporate interactions between age and market integration.

Priority Research Areas: Population, Economic and Health Forecasting, Determinants of Health, Well-Being and Longevity

2021. Elizabeth Gifford . Characterizing Accelerated Aging in Veterans of the Gulf War using Epigenetic Biomarkers.

Gulf War illness (GWI) is a chronic multisymptom illness (CMI) like fibromyalgia, irritable bowel syndrome, and chronic fatigue syndrome. GWI affects an estimated 25-32% of veterans who were deployed in support of the first Gulf War (1990-91) who continue to experience a host of persistent and reoccurring symptoms (e.g., fatigue, pain, rashes, and gastrointestinal issues) that cannot be explained by other diagnosed medical conditions. An unanswered question for Gulf War veterans is whether or not individuals who experience GWI are also at- risk for experiencing accelerated aging as evidenced by older “epigenetic clocks” and younger age of onset for various chronic conditions. The overarching aim of this pilot is to leverage rich data collected on Gulf War era veterans including self-reported survey data, GWAS (genome wide association study) data, and electronic medical records to create generalizable knowledge regarding aging and disease progression. Specifically, utilizing the Gulf War Era Cohort and Biorepository data repository, this pilot will develop four estimates of epigenetic physiologic age for participants of the Gulf War Era Cohort and Biorepository in support of testing the following hypotheses: (1) Epigenetic age estimates will be higher in Veterans with GWI compared to those without GWI; (2) Epigenetic age estimates will be higher in Veterans with chronic health conditions compared to those without chronic health conditions; (3) Epigenetic age estimates will be higher in Veterans with psychosocial stress, as measured by post-traumatic stress disorder (PTSD).

Priority Research Areas: Biology, Genetics and Demography of Aging, Health Trends and Disparities

2021. Tyson Brown . Structural Racism and Trajectories of Disease and Disability in Later Life.

Health inequities along racial lines are broad and deep. Black Americans have a greater prevalence and severity of an array of illnesses, including chronic diseases and disability. While the vast majority of research on racial inequalities in health has focused on the role of individual-level factors such as socioeconomic resources (e.g., education, insurance, income, and wealth), a nascent line of research has begun to examine how health inequities are shaped by contextual factors stemming from structural racism (SR)—i.e., systemic racial exclusion from power, resources, opportunities, and well-being due to societal policies, practices, ideologies and institutions. Prior research has not examined whether racialized socioeconomic inequality is a mediating mechanism linking macro-level structural racism and individual-level health trajectories among older adults. This information is critical for understanding and addressing pathways through which SR affects health in later life. To address these critical gaps, this pilot will create and disseminate a dataset on SR, spanning economic, social, political, and judicial domains as well as over time between 2000 and 2020. This data resource will be a valuable tool for the research community to efficiently build the knowledge base on how SR shapes population health and aging processes. Second, the pilot will provide novel information about the longitudinal relationships between SR and trajectories of health. Finally, the pilot will test the following: a) whether higher levels of SR exposure are predictive of worse health trajectories (levels and rates of accumulation of chronic diseases and disability), b) the extent to which cumulative (and changes in) exposure to SR impacts trajectories of health, and c) whether there are lagged effects of SR exposure on chronic disease and disability trajectories.

Priority Research Areas: Health Trends and Disparities, Determinants of Health, Well-Being and Longevity

2021. Gregory Samanez-Larkin. Adult age differences in learning and decision making related to differences in sensitivity to different types of reward.

Neuroscientific research on decision making and aging has focused almost exclusively on monetary incentives. Despite evidence for intact processing of and motivation by monetary gains in old age, preserved function does not extend to learning-based decision making where these incentives must be applied. Here older adults learn more slowly from monetary gains and losses compared to younger adults. These age deficits in learning have been linked to the structure and function of frontostriatal brain circuits, and some studies suggest that enhancement of this neural network via pharmacological increases in dopamine levels selectively improves reward learning in older adults. Although age differences in incentive motivation have been suggested to be due to motivation to maximize well-being (i.e., based on socioemotional selectivity theory), almost no studies have examined age differences in social incentive processing. An interesting possibility is that social incentives may provide a non-pharmaceutical and non-invasive enhancement of frontostriatal networks thus improving learning in old age. The goal of the proposed pilot studies is to examine adult age differences in behavioral and neural sensitivity to social and monetary incentives and examine the behavioral and neural effects of these incentives on learning-based decision making. For the proposed studies we have developed cognitive tasks that will investigate subjective emotional responses during anticipation and receipt of social and monetary incentives (Aim 1), neural sensitivity to the anticipation and receipt of social and monetary incentives (Aim 2), and learning from probabilistic social and monetary outcomes during decision making (Aim 3). One behavioral pilot study (Study 1) and one behavioral and neuroimaging pilot study (Study 2) will be conducted.

Priority Research Areas: Cognitive Aging and the Demography of Dementia, Disability, Health Care and Long-Term Care

2021. Terrie Moffitt . Psychological and mental health determinants of COVID-19 vaccine hesitancy and vaccine resistance.

This pilot aims to deliver a comprehensive psychological description of groups who differed in their vaccine intentions in the months just before vaccines became available to them utilizing a cohort on all 1037 births (1972-1973) in one city from the Dunedin Study in New Zealand. Public health professionals aspire to tailor pro-vaccination messaging to the values, motives, lifestyles, and background of people who are hesitant or resistant toward vaccination. This tailoring has called for a “marketing approach” to messaging. However, there is a wide social gap between highly-educated public health professionals and most unvaccinated citizens, who tend to be secondary-school educated, or less. This gap impedes effective messaging. For example, prior US surveys report that unvaccinated individuals tend to be Republicans, or southerners, or not college graduates, but these are crude proxies for people’s actual beliefs, attitudes, preferences, cognitive abilities, and motivations. This pilot harnesses psychologically rich prospective data from a 5-decade longitudinal cohort study to provide insights about the personal psychologies associated with vaccine-hesitance and vaccine-resistance, and whether those personal psychologies emerged early in life and are longstanding. Dunedin cohort members have reported whether they definitely or probably intended to be vaccinated ; definitely or probably did not intend to be vaccinated, or did not know enough to decide. The pilot will compare these 3 groups on prospective antecedents of vaccine intentions, including: (1) adverse childhood experiences; (2) adolescent personality and locus of control over health; (3) cognitive abilities and health knowledge and comprehension of health concepts; and (4) detailed mental disorder histories.

Priority Research Areas: Determinants of Health, Well-Being and Longevity, Health Trends and Disparities

2021. V. Joseph Hotz . Assessing New Data Source for Measuring Income Volatility to Study Its Relationship with Mortality in the U.S.

This pilot will assess the use of data from a commercial consumer database on all households in the U.S. to construct reliable measures of the volatility of household income. If successful, the resulting data will be used to assess the relationships between income volatility and mortality in the U.S. and how that relationship varies by race/ethnicity, age and gender of heads of households in the U.S. Study of the latter relationship has been hampered by the lack of availability of samples of households in the U.S. that contain longitudinal data on income and that are of sufficient size to form reliable estimates for all or most counties in the U.S. for different race/ethnic, age and gender groups. If this assessment of the measures of income volatility produced by this data source are positive, others will be able to conduct the first large-scale assessment of the role that income volatility may have played in explaining the recent declines in life expectancy for working age adults in the U.S. and may explain differences in mortality rates by regions of the U.S., and disparities in mortality across racial and ethnic groups.

Priority Research Areas: Determinants of Health, Well-Being and Longevity, Consequences of U.S. and Global Aging

2020. Susan Alberts . Early adversity in a wild primate model: Physiological mediation and social mitigation.

Adversity in early life has far-reaching effects on health, well-being, and survival in adulthood, especially when multiple adverse events co-occur. This association is seen not only in humans, but also in captive and wild nonhuman primates. Captive primates exposed to nutritional deficits or maternal neglect show decreased survival in adulthood compared to control animals. Wild baboons who experienced multiple forms of early adversity show reduced adult survival compared to unaffected individuals. Studies of humans and captive animals suggest that immune processes may mediate the effects of early adversity on survival. Early social and physical adversity in humans and captive animals is associated with increased risk of cardiovascular disease, diabetes, mental illness, and allostatic load. In several studies of humans, early-life trauma is also associated with chronic inflammation or heightened inflammatory response to an immune threat. Population-based, prospective, longitudinal studies with multiple repeated measures of adult traits are necessary to fully understand the developmental and physiological underpinnings of early adversity. Innovation. This pilot offers a solution to these challenges by using existing prospective, full life-course data, with real-time, direct observations of both early life adversity and adult sociality, as well as repeated noninvasive measures of adult immune function measured in biological samples that have already been collected. Investigators anticipate the development of a novel dataset that will generate a large number of repeated measures of immunity for each subject in our study; this pilot will be one of the first to measure baseline and acute inflammation in serum from wild animals, a method that may be useful for other wild animal and human research. It will also be one of the first to leverage repeated measures within subjects to quantify baseline versus acute inflammation levels

Priority Research Areas: Determinants of Health, Well-Being and Longevity

2020. Herman Ponzer . The Daasanach pastoralist population of northern Kenya: A model for healthy aging—specifically the avoidance of non-communicable disease and frailty.

Small-scale subsistence populations like the pastoralist population of northern Kenya, the Daasanach, have remarkably low prevalence of age-related frailty and cardiometabolic disease, diseases strongly associated with aging and responsible for the vast majority of morbidity and mortality in the U.S. and other industrialized populations. This pilot will investigate which aspects of lifestyle (physical activity, diet, etc.) promote healthy aging among the Daasanach. Two aspects of Daasanach life are of particular relevance to the study of aging. First, like many rural populations across the developing world, the Daasanach are moving from active traditional lifestyles to more sedentary, market-integrated village life. Second, the Daasanach have a largely animal- based diet (blood, milk, and meat). The Daasanach are at the epicenter of the epidemiological transition. Understanding lifestyle changes affecting their life course will help shape strategies to promote healthy aging and other positive health outcomes for them and for other populations in transition and post-transition. This pilot takes advantage of a societal transition in a pastoral environment to capture biosocial processes over the life course that lead to differential aging

Priority Research Areas: Consequences of U.S. and Global Aging

2023. Crystal Yee To Ng. The Role of Friends in the Lives of Dementia Caregivers: Implications for Daily Cardiovascular Health.

This study aims to examine the role of friends in the daily experiences of African American (AA) and European American (EA) ADRD caregivers. This pilot study uses data from the Stress and Well-Being in the Everyday Lives of Caregivers study (SWELCare), a study of AA and EA men and women who are primary caregivers and co-reside with their family member or friend who is living with ADRD.2

2023. Jennifer Ailshire. Colombian Survey of Aging (COSA) Biomarker Pilot.

2023. Jessica Faul. Understanding the Speed of Aging Among Adults with Cerebral Palsy.

2023. Kate Duchowny. The Relationship Between Neighborhoods, Muscle Strength and Physical Disability in the National Health & Aging Trends Study (NHATS).

2022. Helen Meier. Immune Aging Phenotypes and COVID-19 Risk in the Health and Retirement Study.

The goal of this pilot project is to determine if pre-pandemic features of immune aging (i.e., age associated T-cell subsets, inflammation, and epigenetic age) are associated with COVID-19 infection and disease severity.  The pilot draws upon data from the Health and Retirement Study, a nationally representative longitudinal study of adults over 55 years.

Priority Research Areas: Biology, Genetics and Demography of Aging

2022. Iliya Gutin, University of Texas at Austin. Life Expectancy Trends among U.S. States and Peer Countries, 1980-2020: Estimating the Impact of the 2020 COVID-19 Pandemic on Widening Differences.

This project uses restricted access state-level vital statistics data from the National Center for Health Statistics as well as national-level data for 18 high-income peer countries in the Human Mortality Database to help point to similarities in key structural advantages and social policies shared by specific states and peer countries that allowed for the COVID-19 pandemic to be managed more effectively and mitigated avoidable deaths at all ages.

Priority Research Areas: Health Trends and Disparities

2022. Theresa Andrasfay, University of Southern California. Impact of the COVID-19 Pandemic on Physical Functioning, Disability, and Associated Risk Factors among Older Adults in the United States.

This project assesses the early impact of the COVID-19 pandemic on population-level trends in mobility and ADL limitations and their risk factors among older adults in the United States. Analyses draw upon four nationally representative data sources: the Health and Retirement Study, the National Health Interview Survey, the National Health and Aging Trends Study and the Understanding America Study.

2021. Joelle Abramowitz. Effects of California’s Paid Family Leave on Work and Caregiving of Older Adults.

Paid family leave laws have the potential to alter older adults’ allocation of time spent in work and caregiving, which can in turn affect their own physical, emotional, and financial wellbeing. In 2004, California became the first state to require that employers provide paid family leave to their employees.  Using data from the Health and Retirement Study, this pilot project examines changes in older adults’ time spent in work and caregiving before and after California’s 2004 paid family leave law.

2021. Joshua Ehrlich. The Synergistic Impact of Late Life Vision Impairment and Genetic Risk on Cognitive Decline and Dementia.

This pilot study will test the central hypothesis that vision impairments is a “second hit” that potentiates the risk of cognitive decline and dementia among those that carry the APOE ε4 allele. This hypothesis will be tested using data from the nationally-representative Health and Retirement Study and its sub-study, the Aging, Demographics and Memory Study.

2021. Sarah E. Patterson. When Family Care Isn’t Available: Examining Unmet Care Needs of Kinless, Distanced, and Disconnected Older Adults.

2021. Yulya Truskinovsky, Wayne State University. The Lasting Impacts of COVID-19 on Long-Term Care Expectations and Outcomes for High-Need Older Adults.

Documenting changes related to the pandemic in long-term services and supports and family care is crucial in understanding the immediate impact of COVID-19 on vulnerable older adults and for establishing a nationally representative baseline to study longer-run effects.  This pilot project will use data from the Health and Retirement Study to examine the effect of the COVID-19 on long-term services and supports and care decisions among older adults who need help with at least two activities of daily living (ADLs) or with probable dementia (high need older adults).

2021. Mengyao Hu. Dementia Diagnosis Classification Using Deep Learning Neural Networks Based on Clock Drawing Test (CDT) and Medicare claims.

This pilot study will develop advanced deep learning neural networks to analyze Clock-Drawing Test images to predict dementia diagnosis. The pilot will draw upon Medicare claims linked with a large, publicly available repository of clock images from the 2011-2019 National Health and Aging Trends Study, a panel study of Medicare beneficiaries ages 65 and older.

2020. Hwajung Choi. Care Allocation among Adult Children of Older People with Dementia.

Adult children often take on central roles in caring for aging parents-especially when a parent develops dementia. How families allocate care among adult children, how this allocation changes over the course of dementia, and implications for the course of the disease remain largely unexplored. Using nearly 20 years of data from the Health and Retirement Study, the proposed pilot project will explore new measures of care allocation among adult children in families in which a parent has dementia.

2020. Jessica Faul, Colter Mitchell. The Effects of Collection Procedures on DNA Methylation Measurement in Population-based Surveys of Aging.

Epigenetics—the study of gene modifications that do not involve changes to the nucleotide sequence—holds great promise as a potential indicator of molecular change from contextual effects and aging and consequently an early signal of health disparities. Over the last few years aging studies have assayed thousands of genetic samples at great expense. However, despite evidence suggesting sensitivity of epigenetics assays to external stimuli, no research has explored the effects of collection and storage conditions on epigenetic data. This pilot project extends prior work on DNA quality and genomic assay stability to include DNA methylation—the most widely used (and most stable) measure of epigenetics in aging studies.

2020. Lindsay Kobayashi. Investigating Cross-National Variation in Later-Life Cognitive Health Inequalities.

By 2050, nearly 70% of global dementia cases are projected to occur in lower- and middle-income countries (LMICs). There is an urgent need to build up scientific evidence and resources to understand the etiology of cognitive aging outcomes in LMICs. A first step is to understand the measurement properties of various cognitive tests administered in these countries. This pilot project will use new data from five internationally harmonized longitudinal studies of aging using the Harmonized Cognitive Assessment Protocol (HCAP), including three LMICs and two high-income countries. Psychometric methods will be used to equate cognitive test item scores across countries so that cross-national comparisons may proceed.

2020. Yajuan Si, David S. Johnson. Confidentiality and Privacy Protection after Record Linkage: Laying the Groundwork for Synthetic Record Linkage.

Augmenting surveys with information about the places sample members have lived can enhance the value of survey data. Restricted enclaves with remote access are valuable for sharing such data, yet barriers to use outside such environments remain because of confidentiality and privacy concerns. The Census Bureau has recently taken steps to create synthetic versions of some of its data products, but the robustness of such data to answer questions not explicitly considered by the synthetic data generation technique has been questioned. Using the Panel Study of Income Dynamics, this pilot project will develop and evaluate procedures to create survey data linked with synthetic geographic data designed to address confidential and privacy as well as analytic concerns.

2023. A. Hamedani. Identifying visual impairment in older adults using administrative claims data.

Visual impairment is common in older adults and is associated with negative outcomes such as falls,
depression, anxiety, and cognitive impairment. Because half of all vision loss in the U.S. is
preventable or treatable, identifying the burden and consequences of age-related visual impairment
can lead to interventions to promote access to eye care and improve population health.
Administrative claims data (e.g. Medicare) are an important tool in public health research and have
been used to study disease prevalence, healthcare utilization, costs, effectiveness, and outcomes
across many areas of medicine. However, their application to the study of visual impairment and eye
disease has been limited by the fact that the most important clinical outcomes in ophthalmology
(namely, visual acuity and vision-related quality of life) are not captured in administrative claims data.
In this study, we will link Medicare claims data with questionnaire and examination data from the
National Health and Nutrition Examination Survey (NHANES) to develop and validate a novel visual
impairment comorbidity index to predict age-related visual impairment using Medicare diagnosis and
procedure codes. This tool will facilitate a new generation of population-based research on the
prevalence and health effects of age-related visual impairment using administrative claims datasets.

Priority Research Areas: Health Trends and Disparities

2023. C. Ma. Understanding the Dynamic Process of Older Adult Behavior Changes for Disaster Preparedness: An Application of the Integrated Transtheoretical Model with Social Cognitive Theory and Protection Motivation Theory.

Conceptualized as a dynamic process of individual health protective mechanism, disaster
preparedness is defined as individual behavior changes in this study, from “not prepared” (NP) stage
to “having an intention to prepare” (IP) stage, and ultimately to “already prepared” (AP) stage.
Although older adults are much more vulnerable to the health effects of disasters than their middle
age and young adult counterparts, the extent to which behavioral transitions from one stage to
another differ across the two groups has not been explored. Integrating the Transtheoretical Model
(TTM) with Social Cognitive Theory (SCT) and Protection Motivation Theory (PMT), we propose a
new model to examine a series of specific reasons behind behavior changes for disaster
preparedness. Using 2022 National Household Survey data (FEMA, 2022), this U.S. population study
will address the following questions.
1. Are there disparities in behavior changes for disaster preparedness between older adults and
non-older adults?
2. If so, to what extent are these disparities accounted for by income differences between the two
groups?
3. To what extent does personal disaster experience, preparedness awareness, self-efficacy,
and risk perception each contribute to behavior changes for disaster preparedness, especially when
people are at different income levels?
The study also seeks to provide a new statistical method to estimate individual behavior changes in
departure from the NP stage and in arrival to the AP stage, respectively. To fill the research gap with
respect to disaster preparedness for older adults (as recently discussed by NIH/NIA [2002]), the
proposed study aims to identify the specific reasons behind older adults’ decision-making process for
all-hazards disaster preparedness. We aim to publish our findings from this study in peer-reviewed
academic journals. Using these results, we will then employ the present process-oriented approach
and subsequent measurement to study how to support older adults’ preparedness when they are
exposed in specific hazards (e.g., floodings, wildfires, heatwaves, earthquakes), through extramural
funding from NIH and/or NSF.

Priority Research Areas: Consequences of U.S. and Global Aging

2023. I. Elo. Predictors of Cognitive Health in Sub-Saharan Africa: Comparative Perspective from Ghana and Malawi.

The overall aim of this pilot project is to conduct comparative analyses and generate findings on the
predictors of cognitive health among older individuals in Ghana and Malawi, two Sub-Saharan African
countries at different levels of development, Ghana being low-middle-income country and Malawi a
low-income country. Importantly, these findings will inform planned pilot data collection activities to
test the Harmonized Cognitive Assessment Protocol (HCAP) in both countries and the integration of
HCAP in the nationally representative WHO SAGE survey in Ghana. The proposed analyses will
examine similarities and differences in the association between demographic, socioeconomic, and
health-related predictors of cognition in Ghana and Malawi. The project activities will also provide an
opportunity to engage and train a post-doctoral fellow in aging-related research.

Priority Research Areas: Cognitive Aging and the Demography of Dementia

2023. K. Britt. Spirituality and Brain Health in Older Adults.

Historically underrepresented populations experience a disproportionate burden of age-related
cognitive disorders compared to non-White populations. As a salient resource for coping in Black
communities, spirituality may be associated with better brain health, yet research is limited, especially
in this population. This study aims to examine: 1) associations between spirituality and cognition, 2)
identify possible differences across racial groups and, 3) explore the role of spirituality as a
moderator between AD blood biomarkers and cognition. I hypothesize a relationship exists between
(a) spirituality and specific cognitive domains including executive function and memory, (b) the
protective effect of spirituality on cognition will be stronger in Black individuals, and (c) higher
spirituality will attenuate the association between AD blood biomarkers and cognition. Using
secondary data from the Penn AD Research Center and Memory Centers, we will use multivariate
regression with moderation analyses to elucidate spirituality as a potential resilience factor in minority
brain health.

Priority Research Areas: Cognitive Aging and the Demography of Dementia

2023. P. Ho. Alcohol Use, Genetics, and Cognitive Decline.

Alcohol use disorder (AUD) is one of the most pronounced public health concerns in the U.S. and
cause an enormous burden to the society. In 2019, 14.5 million people of age 12 and older have AUD
but only 7.2% of them had received treatment in the past year. Moreover, AUD may be correlated with
cognitive decline and dementia could be a onerous burden to Individuals, family members, and the
society. Both alcohol consumption and cognitive decline are often correlated to many unoberved
factors such as genetics, personality traits, and risk perception therefore resulting in endogneity
concerns. To tackle the endogeneity concerns, this project proposes to study the alcohol consumption
of individuals of age 50 and older from the genetic perspective, which is pre-determined, and its
association with cognitive decline. The development in genome-wide association studies (GWAS) in
past decades provide a straightforward method to summarize the genetic tendency of a certain trait
(e.g., alcohol consumption) by calculating a Polygenic score (PGS). A higher PGS refers to a higher
genetic tendency of a trait. We first aim to establish the association between alcohol consumption
PGS and the rate of cognitive decline to alleviate the endogeneity of drinking behaviors. To further
characterize the effects of alcohol consumption on cognitive decline, we identify stressful events (e.g.,
unemployment, divorce) and investigate how individuals respond to stressful events by changing their
alcohol consumption. The frequencies and spacingof stressful events can facilitate dose response
analyses. We then explore the genetic correlations between alcohol consumption and other traits
(e.g., depression, bipolar, smoking behaviors, and personality traits) that often co-exist with AUD to
obtain a clear picture of AUD, common comorbidities of AUD, and cognitive decline. Alcohol
consumption, as a risk factor of many diseases, is modifiable via behavior modifications. Thus, we
next investigate how education and social interactions may interact with alcohol consumption, which
may shed light on behavior modification targets.

Priority Research Areas: Biology, Genetics and Demography of Aging

2022. C. Leonard. Effect of outdoor temperature and air pollution on the comparative safety of antihyperglycemic therapies.

Diabetes exacts a profound societal cost in terms of morbidity, disability, and mortality. As climate
change progresses and further magnifies the negative impacts of extreme outdoor temperatures and air
pollution on health, there is urgency in the need for adaptable and personalized diabetes care. Natural
environmental factors like extreme temperatures and pollution are known to be associated with serious adverse
health outcomes in persons with type 2 diabetes; these include hypoglycemia (very low blood sugar), diabetic
ketoacidosis (very high blood ketones), and cardiovascular events (like heart arrhythmias). The most vulnerable
and disadvantaged populations tend to be hardest hit by climate change and are least equipped to combat its
effects, and there is substantial overlap between these populations and Medicaid recipients. Furthermore,
Medicaid recipients are diagnosed with diabetes and hospitalized for diabetes-related adverse health outcomes
at higher rates than the general US population.
Personalized diabetes care involves selecting the best therapy based on patient characteristics.
Unfortunately, clinical trials comparing diabetes drugs have not examined interactions with outdoor temperature
or air pollution, and are underpowered to do so. This presents a major knowledge gap for efforts to incorporate
natural environmental factors into personalized diabetes care. While innovative, the inclusion of environmental
factors in clinical decision-making has precedent, and is even anticipated in the treatment of diabetes.
To address this knowledge gap, we recently submitted an R01 application to examine the roles of outdoor
temperature and air pollution on the comparative safety of diabetes drugs in persons with type 2 diabetes. We
proposed to conduct pharmacoepidemiologic studies by linking federal environmental datasets to Department
of Health and Human Services healthcare data for the entire US Medicaid (and Medicare) populations residing
in the conterminous US. We proposed to examine the effects of outdoor temperature and air pollution on rates
of serious hypoglycemia, diabetic ketoacidosis, and serious arrhythmia, within and among incident users of
different diabetes drug classes. Our Quartet application proposes to generate pilot data to bolster an R01
resubmission, recommended by our NIDDK Program Official, by demonstrating proof-of-concept by linking
environmental to healthcare data for Medicaid beneficiaries with type 2 diabetes, then using this dataset to: a)
examine temperature and pollution variability by beneficiary ZIP code of residence; b) examine rates of the
above-named health outcomes by temperature and pollution; and c) demonstrate variability in outcome rates
among users of different diabetes drug regimens. These pilot data will enable us to directly respond to
summary statement feedback and improve the fundability of our proposed, innovative R01 that would
incorporate natural environmental factors to improve health in persons with diabetes.

Priority Research Areas: Health Trends and Disparities

2022. G. Nave. Biological age and its value for behavioral and decision science.

The proposed project draws on recent advances in bio-informational research, with an aim to
investigate how a new type of measurement—called “epigenetic clocks”, which quantifies biological
processes related to aging (i.e., biological age)—can better our understanding of individuals’
judgments and decisions. At this time, epigenetic clocks have been previously used in medical
research to understand the aging process and human lifespan, and such measures have been shown
to be better at capturing variability in biological aging processes than chronological age. In this
project, we will partner with one of the largest firms in the US selling epigenetic testing kits,
TruDiagnostic, and, leveraging their existing customer base (~15,000 individuals with epigenetic
data), survey participants on a variety of psychological tasks relevant to the aging process, such as
temporal discounting, risk taking, cognitive reflection, and personality change over the lifespan. Using
survey measures combined with epigenetic data, we seek to differentiate the contribution of biological
aging from other non-biological aging-related measures (such as chronological age), and empirically
disentangle their effects on psychological well-being as well as other meaninful outcomes. Funding
from this grant will be used for participant incentives.

2022. K. Auriemma. Using hospital-free days to understand the impact of lung allocation policy changes on older lung transplant recipients.

Background: Changes in US lung allocation policies in 2005 and 2017 increased transplants among
the sickest and oldest candidates on the waitlist. The impacts of these policy changes on health care
utilization and quality of life are not known. Assessing hospital-free days (HFDs) among transplant
recipients will provide a better assessment of the post-transplant survivorship experience than simple
measures of mortality.
Objectives: To better understand the consequences of changes in lung allocation policy and inform
future decision making.
Specific Aims: (1) To quantify temporal changes in HFDs among lung transplant recipients. (2) To
determine the impact of May 2005 and November 2017 lung allocation score policy changes on HFDs
in older relative to younger lung transplant recipients.
Design: We will create a retrospective cohort of Penn lung transplant recipients from 2000 to 2020 by
merging Penn data with regional utilization data and data from the Lung Transplant Outcomes Group.
Methods: Median HFDs, defined as all days alive spent outside of an acute-care hospital, long-term
acute-care hospital, or emergency department, will be calculated at 365 days post-transplant for each
year of the study. We will identify patient characteristics associated with greater attainment of HFDs.
We will use an interrupted time-series design to compare HFDs before and after major lung allocation
policy changes and determine how these changes differed among older relative to younger patients.
Impact: This study will generate key preliminary data for a planned NIH R01 proposal to assess the
impact of previous and future LAS policy changes on HFDs nationally and to assess changes in
patient function and quality of life. Future work will integrate those measures into quality-weighted
HFDs.

Priority Research Areas: Disability, Health Care and Long-Term Care

2022. K. Miller. Impacts of the COVID-19 Pandemic on Youth and Young Adult Caregivers.

A growing proportion of individuals provide unpaid care to family members and friends (i.e., are family
caregivers). Among younger individuals, an estimated 12.7 million young adults (ages 18-34) and 5.4
million youth (aged <18) are family caregivers. As the ongoing COVID-19 pandemic has increased
disability and comorbidities, it follows an increasing number of young adults and youths may
undertake the role of family caregiver. Potential increases in young adult/youth caregiving
responsibilities are of major concern because caregiving is associated with adverse mental, physical,
and financial outcomes. Additionally, because the pandemic has disproportionately impacted
historically marginalized communities, younger adults/youth of historically marginalized populations
may disproportionately become family caregivers; thus, existing mental, physical, and financial
disparities may be exacerbated. Little evidence exists quantifying the impact of the COVID-19
pandemic on the proportion of young adults/youths acting as caregivers and the intensity of their
caregiving. The overall objectives of this pilot study are to estimate the prevalence of and describe
the impact of the COVID-19 pandemic on young adult/youth caregivers. This research will advance
our understanding of young adult/youths acting as family caregivers.

Priority Research Areas: Health Trends and Disparities

2022. M. Dougherty. Improving the Outcomes of Older Adult Surgical Patients with Prolonged Surgical Time: Evaluating Modifiable Hospital Nursing Resources.

More older adults in the United States are undergoing inpatient surgery than ever before. Older age is a risk factor for greater morbidity and mortality following surgery; therefore, improving the surgical care and outcomes of older adults warrants attention. In this proposal, we focus on one concerning adverse surgical event which is particularly threatening to the postoperative recovery of older adults—prolonged surgical time. Prolonged surgical time is associated with complications including a greater risk of death, longer stays in the hospital, and other poor outcomes including venous thromboembolism, anemia, and sepsis. The current literature on outcomes of older adults with prolonged surgical time is limited to descriptive research and offers no evidence about prevention or early intervention of complications should they occur. The proposed study seeks to examine the outcomes of older adult surgical patients that experience prolonged surgical time and modifiable nursing resources within hospitals. Decades of research has shown that when nurses at the bedside are adequately staffed and practice in environments that allow for nurse autonomy and teamwork with physician colleagues, patients are more likely to have favorable postoperative outcomes. The benefits of these good nursing resources are most pronounced among patients with the highest clinical risk, which lends credence to our hypothesis that favorable staffing ratios and supportive work environments will be especially beneficial to older adults with prolonged surgical time. The proposed study addresses the following aims: 1) to evaluate whether and to what extent differences in hospital nursing resources (i.e., patient-to-nurse staffing ratios, work environment) are associated with outcomes of older adult surgical patients with and without prolonged surgical time and 2) to determine whether the effects of hospital nursing resources on older adult surgical patient outcomes are conditional on surgical time. This study will use multiple linked secondary data sources including patient data from the Centers from Medicare and Medicaid Services (CMS), hospital data about nursing resources from the RN4CAST survey of nurses, and data of hospital structural characteristics from the American Hospital Association Annual Survey. Datasets will be linked by hospital identifiers common to all datasets. We anticipate the patient sample will include 800,000 older adult surgical patients, 65 years old or older, which will be representative of approximately 160 surgical procedures and approximately 500 hospitals. Findings obtained from this study will support a burgeoning program of research to inform targeted interventions for improving the care and outcomes of high-risk older adult surgical patients.

Priority Research Areas: Disability, Health Care and Long-Term Care

2021. C. Boen. Uneven Spillover Effects of Police Violence: Police Shootings and Disparities in Emotional Well-Being.

In 2018, 992 people were shot and killed by the police in the United States. Black men are at particularly high risk of deadly police violence relative to other groups. In addition to direct consequences of this violence, studies document a host of spill-over effects of police violence, including decreased trust in the police and increased legal cynicism. Given racial disparities in risk of police violence and a broader context of structural racism in the U.S., the collateral consequences of this violence are magnified for Black communities. Now, with the rise of portable video recorders and social media, police violence that was only observed in situ is recorded and broadcast to a global audience, made viral, and viewed repeatedly, broadening the potential reach of these spillover effects. At the same time, forms of social connectivity like Twitter offer individuals platforms for expressing their emotions in real time, offering researchers valuable insight into the effects of widely publicized events, including police violence. A growing body of research aims to identify the spillover effects of police violence, but critical gaps in scientific understanding of the role of police violence in shaping emotional and psychological outcomes—as well as population disparities in well-being—remain. The proposed project improves scientific understanding of the population impacts of police violence by using a corpus of text data from Twitter and computational text analysis to evaluate the emotional spillover effects of police violence and assess racial-ethnic, gender, age, and geographic variation in the associations between police violence and emotional well-being. The project uses longitudinal data, a quasi-natural experiment design, and two cases—the shootings of Michael Brown and Tamir Rice—to assess whether and how police violence affects the emotional well-being of individuals, paying particular attention to the stress-related psychological processes undergirding these links as well as differential vulnerability to these events. This project will expand and shift scholarship on police violence and population disparities in well-being in three key ways. First, this study leverages big data and cutting-edge computational methods to examine the impacts of police violence on population well-being. While most research in this area relies on survey data, our use of Twitter data will allow for improved understanding of how these events shape individual and population well-being in real time. Second, we use a quasi-experimental design and difference-in-difference models to assess the links between police violence and emotional well-being, thereby improving our ability to make causal inferences. Finally, we use a variety of techniques to code sociodemographic characteristics and test for differential vulnerability of exposure to police violence by race, gender, age, and geography, providing new evidence of the role of police violence in shaping inequities in emotional and psychological well-being. Findings from this study will generate new understandings of the spillover effects of police violence, particularly as these events shape individual emotions in ways that relate to individual health and contribute to population health disparities. Results from this project will be inform applications for subsequent extramural funding focused on the links between police violence, emotions, and population disparities in psychological well-being.

Priority Research Areas: Determinants of Health, Well-Being and Longevity

2021. C. Low. Reproductive Disability: The Link Between Infertility and Economic Well-Being for Women in Zambia.

It is widely acknowledged that disability results in a permanent downward shift in worker’s incomes, and thus consumption. In other words, workers are not fully insured against these negative shocks in labor market productivity. There is much less attention to another form of disability, that of secondary infertility, which may affect women economically if they are partly dependent on male partners for economic support. In this project, I will test whether infertility materially impacts women’s economic well-being similarly to how worker disability affects their earnings. The long-term plan for this project is to collect longitudinal data over a two-year period on 1,000 women in Zambia to measure how consumption, health, and economic wellbeing co-move with fecundity and spousal expectations of fecundity. The longitudinal data will allow an event study analysis with individual fixed effects to show that the onset of infertility, or “reproductive disability” is associated with a loss of consumption and economic wellbeing. In the initial pilot phase, I will begin enrolling the first 400 women in the survey, as well as analyze existing DHS data in Zambia to demonstrate the connection between infertility and loss of consumption.

Priority Research Areas: Disability, Health Care and Long-Term Care

2021. R. Greysen. Gamification to Improve Physical Activity in Seniors at Risk for Alzheimer's.

Increased physical activity by walking further or more vigorously may delay the development of Alzheimer’s Disease and Related Dementias (ADRD) and associated cognitive decline but reaching higher levels of activity and maintaining it as a long-term habit is difficult to do. This project will use concepts from behavioral science to create a mobility game that people at risk for developing ADRD can play in order to increase their levels of activity while having fun doing it. The game is played with a support partner who is a spouse, family member, or close friend who provides feedback and encouragement to help the game-player reach activity goals and maintain them as habits over time. Participants in the game will use their own smartphone and a wristwatch that tracks activity (such as a FitBit, provided by this study) to set goals, get feedback, and play the game for 12 weeks. Participants will be asked to continue wearing the wristwatch for another 6 weeks to track activity after the game is over. To determine the effectiveness of this game, we will randomly assign 50 people to the game and 50 people to only get the wristwatch but no game component. All participants in this study will be recruited from the GeneMatch registry which offers genetic testing on risk for ADRD to all participants. We will recruit participants to our study who have elevated genetic risk as well as those without specific genetic risks to see if either group responds differently to the game. The short-term goal of this study is to determine the feasibility of remotely recruiting and engaging older adults at high risk for developing ADRD from an existing Alzheimer’s cohort study. We hypothesize that we will be able demonstrate the efficacy of gamification to increase physical activity in this pilot population as well as explore differential effects of high-risk genotypes and demonstrate the ability to collect functional and cognitive measures remotely. These results will enable competitive applications for larger studies (NIA R01) immediately after the completion of this pilot. The long-term goal for this project is to launch a successful new line of inquiry into physical activity in patients with ADRD by adapting and applying behavioral economics approaches such as gamification which have been successfully developed for other populations.

Priority Research Areas: Effects of Interventions on Population Health

2021. W. Roth. How Does Genetic Ancestry Testing Affect Perceptions of Race?.

The proposed research will evaluate the relative influence of genomic, phenotypic, social attributes, and social context in shaping how individuals perceive other people’s race, to determine how genomic information is influencing societal norms of racial classification. The larger project will conduct a conjoint survey experiment that includes unique morphed photographs, information about genetic ancestry test (GAT) results, and social attributes like racial self-identification before and after testing, to influence the racial classification of others by White, Black, Hispanic, and Asian respondents. The pilot project will develop and test the morphed photographs to be used as the visual stimuli in the experiment. GATs are one of the most common ways that genomic awareness has increased in the public sphere. Many scholars believe GATs will shape individuals’ beliefs about race, including beliefs in essential racial differences and that races are genetically determined. Recent research shows that GATs lead some people to change their racial identity based on the reported genetic information. However, we know little about whether those genetically-influenced identity claims are accepted by others or whether information about an individual’s genetic ancestry influences how their race is perceived. Increased genomic knowledge may be shifting norms of racial classification. This could have significant social implications ranging from demographic shifts and identity-based political mobilization to changing patientprovider interactions and assessments in healthcare settings. In everyday life, people typically rely on phenotype to racially classify others, often using it as a proxy for ancestry. However, we know little about how the perception of phenotype interacts with information about ancestry, which we will test using photographs of human faces and hypothetical GAT results. In addition, an abundant scholarship has shown that race is shaped by social context. Nevertheless, most studies have been observational and may be afflicted by endogeneity. We will provide rigorous experimental evidence for how the social context influences racial classifications: some respondents will be asked to categorize individuals seeking membership in a cultural affinity group; others will be told the individual is applying to college, priming a context of competition for scarce resources; the remainder will be given a neutral context. Last, our nationally representative survey will sample Black, White, Asian, and Hispanic respondents, which will allow us to test how racial perceptions vary across the U.S. and among the nation’s largest ethnoracial groups. This project will develop a research protocol and preliminary data for a larger future study focusing on how genomic information shapes healthcare providers’ racial perceptions and clinical assessments of patients.

Priority Research Areas: Biology, Genetics and Demography of Aging

2020. I. Kohler. Comparative Cognitive Health Changes in Low-Income Settings.

This projects overall aim is to lay foundations for a program application to examine for the first time individual variation and age-related changes in cognitive health in mature adults across non-WEIRD (Western, Educated, Industrialized, Rich, Democratic), low-income populations with the ultimate goal to understand if cognitive aging follows universal trajectories and/or is determined by environmentally dependent mechanisms. The project focuses on comparative analysis of longitudinal data on cognition among mature adults using data sets covering substantial segments (at least two decades) of the life-cycle in three very distinct relatively low-income populations in Bolivia, Guatemala, and Malawi.

Priority Research Areas: Cognitive Aging and the Demography of Dementia

2020. M. Candon. Understanding Nursing Turnover: The Case of Home Health.

High levels of turnover in professions that rely heavily on skill acquisition is a major source of inefficiency due to productivity loss, termination costs, vacancy, orientation and training, and other spillovers. Turnover among nurses, a bedrock in health care, is a particular concern given the amount of direct care they provide patients – indeed, compromised nursing care has been associated with longer lengths of stay and higher rates of adverse outcomes, including mortality. To date, most studies of nursing turnover have focused on inpatient nurses in hospitals using self-reported survey data and are therefore limited in scope. No projects have been able to cleanly connect nurses to patients, making it impossible to understand the full impact of nursing turnover. This project will leverage a collaborative agreement between the University of Pennsylvania and Encompass Home Health, which is one of the largest home health agencies in the country, currently operating in 30 states. We will acquire a host of different datasets from Encompass to answer two main questions: first, which factors drive nursing turnover in home health; and second, how does nursing turnover in home health affect patient outcomes such as hospitalizations and mortality? Using variables constructed from human resources, payroll, visit logs, and other secondary data sources, we will include a host of potential factors that may drive turnover, e.g., driving time, patient acuity, and outside labor market opportunities, in order to construct an algorithm that can flag nurses at high risk of turnover. This will allow for more tailored personnel interventions to improve retention among home health nurses at Encompass. Next, we will use these unique data to explore the confounded relationship between nursing turnover and patient outcomes. Because home health nurses work alone or in tandem with other provider types, we are able to connect individual nurses to individual patients. That, along with more rigorous statistical approaches, gives us an unprecedented opportunity to pin down the causal pathway between nursing turnover and patient care.

Priority Research Areas: Disability, Health Care and Long-Term Care