Outcomes of advance care directives after admission to a long-term care home: DNR the DNH?

Background Residents of long-term care homes (LTCH) often experience unnecessary and non-beneficial hospitalizations and interventions near the end-of-life. Advance care directives aim to ensure that end-of-life care respects resident needs and wishes. Methods In this retrospective cohort study, we used multistate models to examine the health trajectories associated with Do-Not-Resuscitate (DNR) and Do-Not-Hospitalize (DNH) directives of residents admitted to LTCH in Ontario, Alberta, and British Columbia, Canada. We adjusted for baseline frailty-related health instability. We considered three possible end states: change in health, hospitalization, or death. For measurements, we used standardized RAI-MDS 2.0 LTCH assessments linked to hospital records from 2010 to 2015. Results We report on 123,003 LTCH residents. The prevalence of DNR and DNH directives was 71 and 26% respectively. Both directives were associated with increased odds of transitioning to a state of greater health instability and death, and decreased odds of hospitalization. The odds of hospitalization in the presence of a DNH directive were lowered, but not eliminated, with odds of 0.67 (95% confidence interval 0.65–0.69), 0.63 (0.61–0.65), and 0.47 (0.43–0.52) for residents with low, moderate and high health instability, respectively. Conclusion Even though both DNR and DNH orders are associated with serious health outcomes, DNH directives were not frequently used and often overturned. We suggest that policies recommending DNH directives be re-evaluated, with greater emphasis on advance care planning that better reflects resident values and wishes.

Parent and child mental health trajectories April 2020 to May 2021: Strict lockdown versus no lockdown in Australia

Objective: To control a second-wave COVID-19 outbreak, the state of Victoria in Australia experienced one of the world’s first long and strict lockdowns over July–October 2020, while the rest of Australia experienced ‘COVID-normal’ with minimal restrictions. We (1) investigate trajectories of parent/child mental health outcomes in Victoria vs non-Victoria and (2) identify baseline demographic, individual and COVID-19-related factors associated with mental health trajectories. Methods: Online community sample of 2004 Australian parents with rapid repeated assessment over 14 time-points over April 2020 to May 2021. Measures assessed parent mental health (Depression, Anxiety and Stress Scales-21), child depression symptoms (13-item Short Mood and Feelings Questionnaire) and child anxiety symptoms (four items from Brief Spence Children’s Anxiety Scale). Results: Mental health trajectories shadowed COVID-19 infection rates. Victorians reported a peak in mental health symptoms at the time of the second-wave lockdown compared to other states. Key baseline predictors, including parent and child loneliness (standardized regression coefficient [β] = 0.09–0.46), parent/child diagnoses (β = 0.07–0.21), couple conflict (β = 0.07–0.18) and COVID-19 stressors, such as worry/concern about COVID-19, illness and loss of job (β = 0.12–0.15), predicted elevated trajectories. Effects of predictors on parent and child mental health trajectories are illustrated in an online interactive app for readers ( https://lingtax.shinyapps.io/CPAS_trend/ ). Conclusion: Our findings provide evidence of worse trajectories of parent and child mental health symptoms at a time coinciding with a second COVID-19 outbreak involving strict lockdown in Victoria, compared to non-locked states in Australia. We identified several baseline factors that may be useful in detecting high-risk families who are likely to require additional support early on in future lockdowns.

NIA Priorities on Emotional Well-Being

In 2021, NIH funded six high-priority research networks designed to develop resources to support and advance the study of emotional well-being (EWB) and its core components. These research networks aim to advance the field by facilitating transdisciplinary research in the social, behavioral, psychological, biological, and neurobiological sciences. The National Institute on Aging (NIA) co-sponsored the RFA, and provided funding for NEW Brain Aging, because of the central importance of EWB to health trajectories across the adult lifespan. In this presentation, Dr. Simmons, Chief of the Individual Behavioral Processes Branch within the NIA Division of Behavioral and Social Research (BSR), will discuss how EWB research fits within NIA priorities. She will then facilitate open discussion about NIA and BSR’s vision for the EWB ‘network of networks,’ the synergy of NEW Brain Aging with other members of the larger network, and the opportunities these networks will provide for investigators interested in EWB.

Food Insecurity and Mental Health Trajectories During the COVID-19 Pandemic: Longitudinal Evidence

The extent to which food insecurity impacts changes in mental health outcomes over time in the context of Covid-19 remains unknown. Using longitudinal data from a nationally representative survey, the objectives of the present study were to: (1) assess the prevalence of food insecurity among U.S. adults amid the Covid-19 pandemic; and (2) investigate the relationships between food insecurity statuses and changes in mental health outcomes over time as the pandemic unfolds. Longitudinal data from the Internet-based Understanding Coronavirus in America survey collected bi-weekly between April and December 2020 were used (n=4,068, 15 repeated measures). Adult respondents (aged ≥18) were asked about their food insecurity experiences and stress/anxiety/depressive symptoms. Linear mixed-effect models examined changes in mental health outcomes over time among groups with various food insecurity statuses. Overall prevalence of food insecurity was 8%. Food insecurity was consistently associated with higher levels of stress/anxiety/depressive symptoms (p<0.001). Stress/anxiety/depressive symptoms declined over time among food-secured U.S adults. However, mental health trajectories of respondents with various food insecurity categories, including food insecurity status, persistent food insecurity, and food insecurity of higher severity and longer duration, remained stable or worsened over time. Moreover, the mental health gap between food-secured and food-unsecured participants widened over time. Food insecurity represents a pressing public health problem during the Covid-19 pandemic with substantial mental health implications. Persistent and severe food insecurity may contribute to mental health disparity in the long term. Food insecurity reduction interventions may alleviate the estimated alarming mental health burden as the pandemic unfolds.

Moves to age-restricted housing and functional health trajectories among independent living older adults

Where independent living older adults live has been found to have strong links with disability. For example, older adults living in age-restricted housing contexts (e.g., retirement communities) have been found to have worse functional health compared to those living in non-age-restricted settings. Theories and empirical research demonstrate positive and negative aspects of living in age-restricted housing. Recent availability of population-level longitudinal data with sufficiently large samples has made examination of this heterogeneity possible. In this study we examine whether a move to age-restricted housing is associated with functional health trajectories and whether age at time of move moderates this link. We examine these questions using nine waves of longitudinal data from a representative sample of 8,687 U.S. adults age 65 and older from the National Health and Aging Trends Study. Spline-like growth curve models were estimated to determine the intercept, slope prior to move to age-restricted housing, and slope after the move. We also tested whether these processes are conditional on age at time of move. Results indicate that regardless of age all respondents experienced a decline in functional health following a move to age-restricted housing. However, there is variation in the steepness of this decline by age at time of the move. People who move to age-restricted housing earlier experience a less steep decline in functional health post-move compared to those who move later. Findings suggest moving to age-restricted housing earlier may enable older adults to utilize resources often available in these settings to prevent steep health declines.