Associations Between Visual Impairment and Homebound Status, Home Hazards, and Support Service Utilization: The National Health and Aging Trends Study.

In the coming years, inevitably growing numbers of older populations will yield more older Americans with extensive medical and long-term care needs. This will lead to an increasing need for long-term services and supports (LTSS) to assist older adults with routine daily activities (e.g., bathing, dressing, medication management). There is a growing interest in understanding how social and physical environments contribute to health outcomes and the provision of services and resources for older persons with disabilities requiring assistance from LTSS. Decisions about care and subsequent experiences are likely a result of factors that extend beyond personal preference or individual factors, such as neighborhood quality, housing context, and living situations (i.e., homebound status) among community-dwelling older adults. Given population aging and the shift of LTSS from nursing homes toward community settings, there is a pressing need for more information about contextual factors that might help better develop supports for vulnerable older adults. This symposium will feature four presentations that provide novel insight regarding social and physical contextual factors contributing to LTSS. Presentations leverage data from the National Health and Aging Trends Study (NHATS), a nationally representative survey of Medicare beneficiaries aged 65 and older, and will describe: 1) associations between individual and home environment risk-factors, neighborhood-level social deprivation, and falls; 2) the relationship between neighborhood-level social deprivation and caregiving intensity (number of hours of caregiving per week) among community-dwelling older adults; 3) associations between living in single-family vs. multi-unit housing and social networks; and 4) community tenure among homebound older adults.

Homebound status is associated with multiple risk factors and worse health outcomes. However, limited knowledge exists about the association between vision impairment (VI) and becoming homebound. Therefore, this study examined the associations between VI and homebound status, utilization of home-based care, presence of tripping hazards, and likelihood of transitioning to homebound status in United States (US) older adults. Longitudinal data was collected from the 2021-2023 National Health and Aging Trends Study and included Medicare beneficiaries ≥71 years. The main exposure was any VI, defined as impairment in either distance (DVA) or near (NVA) visual acuity (>0.3 logMAR), or contrast sensitivity (CS;< 1.55 logCS). Outcomes included homebound status, presence of safety hazards, and utilization of home-based care. 3,002 participants (mean [SD] age, 78.8 [5.6] years; 55.3% female; 81.8% non-Hispanic White) were included in our study. The prevalence of being homebound was higher among those with any VI (9.2%,95%CI:7.3-11.5%) compared to no VI (4.0%,95%CI:3.0-5.3%). In multivariable logistic regression models, individuals with any VI had a significantly higher risk of becoming homebound or semi-homebound (HR = 1.35,95%CI:1.04-1.74,p=.02) compared to peers without any VI. Likewise, participants with any VI had a greater likelihood of having home hazards (OR = 1.88,95%CI:1.32-2.69, p=.001) and utilizing home-based care (OR = 1.31,95%CI:1.06-1.62,p=.01) compared to those without any VI. In conclusion, older US adults with VI were more often homebound, more likely to become homebound, had more home hazards, and more often utilized home-based care, highlighting the need to holistically evaluate a patient when determining the need for home care and tailoring interventions to maximize independence.

Black-White Differences in Long-Term Services and Supports (LTSS) Deserts: Implications for Unmet Care Needs.

Social isolation is associated with adverse health outcomes among older adults but can be attenuated through increased social contact and support. Long-term services and supports (LTSS) are a potential mechanism to increase social contact and provide socially isolated older adults with the help needed to perform routine activities. Using a nationally representative sample of 6,705 community-dwelling older adults from the 2015 National Health and Aging Trends Study (NHATS), we examined associations between social isolation, functional difficulty, adverse consequences due to unmet needs, and indicators of the LTSS environment (e.g., Meals on Wheels). About 22% of older adults were socially isolated. Socially isolated older adults had greater functional difficulty compared to those who were not socially isolated (45.3% vs 38.3%; p<0.0001). Socially isolated older adults were more likely to be Medicaid enrollees (17.5% vs 8.4%; p<0.0001) and use LTSS including SNAP benefits (12.7% vs 5.5%; p<0.0001), Meals on Wheels (4.1% vs 1.6%; p<0.0001), energy/gas financial assistance (7.5% vs 4.2%; p<0.0001), and transportation services for older adults or people with disabilities (4.6% vs 2.7%; p=0.001). Despite greater LTSS use, socially isolated older adults more often experienced adverse consequences due to unmet needs compared to those who were not socially isolated (12.5% vs 7.7%; p<0.0001). Findings suggest that LTSS in the form of social and senior services are critical in supporting those lacking social connection, but they may not be adequate to support aging in place in the absence of informal support.

Medicaid-funded long-term services and supports (LTSS) are foundational in helping older dual-enrollees with disabilities remain in the community. Over the past decade, nearly half of U.S. states have transformed LTSS delivery through managed LTSS (MLTSS) with the goal of improving care coordination and avoiding unnecessary health care utilization. Despite this rapid growth, no prior studies describe whether characteristics and care experiences of older dual-enrollees differ between counties with and without MLTSS. We draw on the nationally representative 2015 National Health and Aging Trends Study (NHATS) linked to the census tract of participants’ place of residence to examine differences in demographic characteristics, health, and care experiences of older dual-enrollees with LTSS need (n=462) by county-level presence of MLTSS. We broadly defined LTSS need as receiving assistance with one or more self-care or mobility activity or having probable dementia. More than half (56.9%) of older dual-enrollees with LTSS need lived in counties with MLTSS. Hispanic/other individuals were three times more likely to live in counties with (versus without) MLTSS presence (54.2% vs. 15.8%, p<0.0001) while individuals living in rural regions less likely to live in counties with MLTSS presence (8.8% vs. 31.8%, p<0.05). There were no differences in age, gender, self-reported health, dementia status, or number of chronic conditions of the sample population by MLTSS presence. Similarly, no differences were observed in experiencing adverse consequences from unmet care needs or social participation restrictions by MLTSS presence. These results are a foundational step toward building evidence and understanding who MLTSS programs are serving.

Personality is associated with predictors of homebound status like frailty, incident falls, and depression. It has been rarely investigated whether personality predicts homebound status among older adults. Using the combining cross-sectional data of the Year 2013 and Year 2014 data from the National Health and Aging Trends Study (NHATS), this study examined the association between personality traits and homebound status in a sample of community-dwelling older adults aged 65 years and older (N=2,788). Homebound status (non-homebound, semi-homebound, and homebound) was determined by the frequency, difficulty, and help of outdoor mobility. Personality traits, including conscientiousness, agreeableness, openness, extraversion, and neuroticism were assessed using the 10-item Midlife Development Inventory on a rating scale from 1 (not at all) to 4 (a lot). Each personality trait was included as a predictor in an ordinal logistic regression model to examine its association with homebound status after adjusting demographic and health-related covariates. The sample was on average 79±7.53 years old, non-Hispanic White (72.0%), female (58.6%), living alone (35.4%) or with spouse/partner only (37.4%). Seventy-four percent, 18%, and 8% of participants were non-homebound, semi-homebound, and homebound, respectively. Homebound participants tended to be less-educated older females. The average scores of conscientiousness, agreeableness, openness, extraversion, and neuroticism were 3.19±0.75, 3.57±0.56, 2.81±0.83, 3.13±0.75, and 2.22±0.86, respectively. Among these five personality traits, high conscientiousness (OR=1.34, p<0.001) and extraversion (OR=1.16, p=.03) were associated with a reduced likelihood of being homebound. These findings provided a basis for potential personality assessment to identify and protect individuals with high homebound risk.

To determine the effect of home-based primary care (HBPC) for frail older adults, operating under Independence at Home (IAH) incentive alignment on long-term institutionalization (LTI). Case-cohort study using HBPC site, Medicare administrative data, and National Health and Aging Trends Study (NHATS) benchmarks. Three IAH-participating HBPC sites in Philadelphia, PA, Richmond, VA, and Washington, DC. HBPC integrated with long-term services and supports (LTSS) cases (n = 721) and concurrent comparison groups (HBPC not integrated with LTSS: n = 82; no HBPC: n = 573). Cases were eligible if enrolled at one of the three HBPC sites from 2012 to 2015. Independence at Home-qualified (IAH-Q) concurrent comparison groups were selected from Philadelphia, PA; Richmond, VA; and Washington, DC. HBPC integrated with LTSS under IAH demonstration incentives. Measurements include LTI rate and mortality rates, community survival, and LTSS costs. The LTI rate in the three HBPC programs (8%) was less than that of both concurrent comparison groups (IAH-Q beneficiaries not receiving HBPC, 16%; patients receiving HBPC but not in the IAH demonstration practices, 18%). LTI for patients at each HBPC site declined over the three study years (9.9%, 9.4%, and 4.9%, respectively). Costs of home- and community-based services (HCBS) were nonsignificantly lower among integrated care patients ($2151/mo; observed-to-expected ratio = .88 [.68-1.09]). LTI-free survival in the IAH HBPC group was 85% at 36 months, extending average community residence by 12.8 months compared with IAH-q participants in NHATS. HBPC integrated with long-term support services delays LTI in frail, medically complex Medicare beneficiaries without increasing HCBS costs.

Digital Technology Use in US Community-Dwelling Seniors With and Without Homebound Status

Vision and hearing impairments are highly prevalent conditions among older adults, and well-established links exist between sensory impairment and household, mobility, and self-care activity limitations. However, studies examining the impact of unmet long-term services and supports (LTSS) needs have not considered the role of vision and hearing impairment on the risk of experiencing adverse consequences, including wetting or soiling oneself. Using Rounds 1 and 5 of the National Health and Aging Trends Study, a nationally representative survey of Medicare beneficiaries aged 65 and older, we examine the association of vision and hearing impairment on the odds of experiencing an adverse consequence while accounting for other sociodemographic and health status factors. Among a weighted population of 49,770,947 community-living older adults with limitations in household, mobility, or self-care activities, 20.1% (95% CI: 19.2-21.0) experienced an adverse consequence as a result of unmet LTSS needs. In the fully adjusted regression, individuals with vision or hearing impairment had 96% (odds ratio [OR]: 1.96; 95% CI: 1.64-2.34) and 43% increased odds (OR: 1.43; 95% CI: 1.24-1.65), respectively, of experiencing any adverse consequence. Hearing impairment was associated with higher odds of household or self-care adverse consequences, while vision impairment was associated with higher odds of mobility or self-care adverse consequences. Sensory impairment may increase the risk for adverse consequences for older adults with unmet LTSS needs. Activities that support older adults living safely in the community should consider the role of sensory impairment and how to address the unique needs of those with hearing or vision impairment.

Use of Home-Based Clinical Care and Long-Term Services and Supports Among Homebound Older Adults.

Vision impairment (VI) is associated with falls in older adults. However, past studies have relied on geographically constrained samples with limited generalizability or self-reports of visual difficulty. To date, there have not been nationally representative studies on the association of objective measures of visual function and falls outcomes. We used cross-sectional data from Round 11 of National Health and Aging Trends Study (NHATS), a nationally representative panel study of age-eligible Medicare beneficiaries (N = 2951). We performed Poisson regression to calculate the prevalence and prevalence ratio (PR) of >1 fall in the past year, any fall in the past month, fear of falling (FoF), and activity limitation due to FoF as a function of distance visual acuity, near visual acuity, and contrast sensitivity. Models were adjusted for demographic and health covariates and were weighted to make nationally representative parameter estimates. The weighted proportion of participants with VI was 27.6% (95% CI, 25.4%-29.9%). Individuals with any VI had a higher prevalence of falls compared with those without VI (18.5% vs. 14.1%, PR = 1.25, 95% CI 1.02-1.53). Specifically, contrast sensitivity impairment was associated with a higher prevalence of recurrent falls (20.8% vs. 14.7%; PR = 1.30, 95% CI 1.01-1.67) and recent falls (17.1% vs. 9.9%; PR = 1.40, 95% CI 1.01-1.94). This relationship existed even independent of near and distance visual acuity. Distance and near visual acuity were not significantly associated with falls. Having any VI was also associated with a higher prevalence of FoF (38.4% vs. 30.5%, PR = 1.17, 95% CI 1.02-1.34). The prevalence of falls is associated with poor contrast sensitivity but not with near or distance visual acuity. Findings suggest greater collaboration between geriatricians and eye care providers may be warranted to assess and address fall risk in older adults with VI.

Estimates of the association between visual impairment (VI) and dementia in the US population are based on self-reported survey data or measures of visual function that are at least 15 years old. Older adults are at high risk of VI and dementia so there is a need for up-to-date national estimates based on objective assessments. To estimate the association between VI and dementia in older US adults based on objective visual and cognitive function testing. This secondary analysis of the 2021 National Health and Aging Trends Study (NHATS), a population-based, nationally representative panel study, included 3817 respondents 71 years and older. Data were analyzed from January to March 2023. In 2021, NHATS incorporated tablet-based tests of distance and near visual acuity and contrast sensitivity (CS) with habitual correction. VI was defined as distance visual acuity more than 0.30 logMAR, near visual acuity more than 0.30 logMAR, and CS more than 1 SD below the sample mean. Dementia was defined as scoring 1.5 SDs or more below the mean in 1 or more cognitive domains, an AD8 Dementia Screening Interview Score indicating probable dementia, or diagnosed dementia. Poisson regression estimated dementia prevalence ratios adjusted for covariates. Of 2967 included participants, 1707 (weighted percentage, 55.3%) were female, and the median (IQR) age was 76.9 (77-86) years. The weighted prevalence of dementia was 12.3% (95% CI, 10.9-13.7) and increased with near VI (21.5%; 95% CI, 17.7-25.3), distance VI (mild: 19.1%; 95% CI, 13.0-25.2; moderate, severe, or blind: 32.9%; 95% CI, 24.1- 41.8), and CS impairment (25.9%; 95% CI, 20.5-31.3). Dementia prevalence was higher among participants with near VI and CS impairment than those without (near VI prevalence ratio: 1.40; 95% CI, 1.16-1.69; CS impairment prevalence ratio: 1.31; 95% CI, 1.04-1.66) and among participants with moderate to severe distance VI or blindness (prevalence ratio: 1.72; 95% CI, 1.26-2.35) after adjustment for covariates. In this survey study, all types of objectively measured VI were associated with a higher dementia prevalence. As most VI is preventable, prioritizing vision health may be important for optimizing cognitive function.

There is growing interest in the role of “place” in the provision of long-term services and supports (LTSS) for older adults with disabilities, who receive ~16 billion hours of care per year from family and unpaid caregivers, but information is lacking. Using data from the 2015 National Health and Aging Trends Study (NHATS) linked to census-tract-level information from the American Community Survey, we described the association between caregiving intensity (hours of care received per week) and neighborhood social deprivation among N=2125 community-dwelling older adults with disabilities. Individuals receiving 40 hours or more of help per week had greater levels of functional impairment and dementia, and more often lived in neighborhoods at the highest quartile of social deprivation compared to those receiving fewer than 20 hours of care (26.8% vs. 21.7%, respectively). Findings have policy implications for targeting LTSS strategies toward addressing inequities in social determinants of health for vulnerable populations.

Existing estimates of the prevalence of vision impairment (VI) in the United States are based on self-reported survey data or measures of visual function that are at least 14 years old. Older adults are at high risk for VI and blindness. There is a need for up-to-date, objectively measured, national epidemiological estimates. To present updated national epidemiological estimates of VI and blindness in older US adults based on objective visual function testing. This survey study presents a secondary data analysis of the 2021 National Health and Aging Trends Study (NHATS), a population-based, nationally representative panel study of Medicare beneficiaries 65 years and older. NHATS includes community-dwelling older adults or their proxies who complete in-person interviews; annual follow-up interviews are conducted regardless of residential status. Round 11 NHATS data were collected from June to November 2021, and data were analyzed in August 2022. In 2021, NHATS incorporated tablet-based tests of distance and near visual acuity and contrast sensitivity with habitual correction. National prevalence of impairment in presenting distance visual acuity (>0.30 logMAR, Snellen equivalent worse than 20/40), presenting near visual acuity (>0.30 logMAR, Snellen equivalent worse than 20/40), and contrast sensitivity (>1 SD below the sample mean). Prevalence estimates stratified by age and socioeconomic and demographic data were calculated. In the 2021 round 11 NHATS sample, there were 3817 respondents. After excluding respondents who did not complete the sample person interview (n = 429) and those with missing vision data (n = 362), there were 3026 participants. Of these, 29.5% (95% CI, 27.3%-31.8%) were 71 to 74 years old, and 55.2% (95% CI, 52.8%-57.6%) were female respondents. The prevalence of VI in US adults 71 years and older was 27.8% (95% CI, 25.5%-30.1%). Distance and near visual acuity and contrast sensitivity impairments were prevalent in 10.3% (95% CI, 8.9%-11.7%), 22.3% (95% CI, 20.3%-24.3%), and 10.0% (95% CI, 8.5%-11.4%), respectively. Older age, less education, and lower income were associated with all types of VI. A higher prevalence of near visual acuity and contrast sensitivity impairments was associated with non-White race and Hispanic ethnicity. More than 1 in 4 US adults 71 years and older had VI in 2021, higher than prior estimates. Differences in the prevalence of VI by socioeconomic and demographic factors were observed. These data could inform public health planning.

We examined caregiving relationships for individuals with vision impairment (VI) and dementia, using 2011 National Health and Aging Trends Study (NHATS) data, a survey of Medicare beneficiaries, linked to the National Study of Caregiving, a survey of family/unpaid helpers to NHATS participants. VI was defined as self-reported blindness or difficulty recognizing someone across the street, watching television or reading newspaper print. Dementia was defined as probable dementia based on survey-report or AD8 criteria. Caregiving outcomes included: (1) hours of care provided in the last month and (2) number of valued activities affected by caregiving. Among 1,196 caregivers, 617 assisted older adults without dementia or VI (D-/VI-), 298 with dementia but without VI (D+/VI-), 143 without dementia but with VI (D-/VI+), and 138 with dementia and VI (D+/VI+). In fully-adjusted regression models, caregivers of older adults D+/VI+ spent twice as many hours (IRR=2.0; 95%CI: 1.5-2.7) providing care than caregivers of older adults D-/VI-; however, caregivers of adults D+/VI- and those providing to older adults D-/VI+ spent 1.5-times more hours (95% CI=1.2-1.7; 95% CI=1.1-2.0, respectively). Additionally, caregivers of older adults D+/VI+ reported 4 times as many valued activities were affected (95%CI=2.8-5.6) then caregivers of those D-/VI-, while caregivers of those D+/VI- reported 1.9-times (95% CI=1.3-2.8) and D-/VI+ 1.6-times (95% CI=1.1-2.3) more activities were affected. Our results suggest that caring for older adults with VI has similar demands as caring for older adults with dementia, but that these implications may be magnified when caring for older adults with both dementia and VI.