Smoking, but Not Other Environmental Exposures, Increases Risk for Advanced Brain Aging

Abstract Exposure to harmful substances and chemicals such as tobacco smoke, chemicals (e.g., herbicides, pesticides, Agent Orange) and metal dust has been associated with increased risk of developing cancer, cardiovascular disease, and other diseases that contribute to shorter life expectancy. Associations with brain health in relation to these exposures are less well studied. We examined the relationship between brain health and prolonged exposure to different harmful substances in 498 male participants average age 68 (range 61 to 73) from the Vietnam Era Twin Study of Aging (VETSA). For self-reported tobacco smoke, herbicides/pesticides, and metal dust we created three groups reflecting recency of exposure (current/former/never). For Agent Orange we examined two exposure groups (ever/never). Brain health, defined as predicted brain age (PBAD), was evaluated by applying Brain-Age Regression Analysis and Computation Utility software (BARACUS) to magnetic resonance images collected at age 68. Tobacco smoking (r=-0.15, p=0.0004 ) was significantly correlated with PBAD and remained significant (F=5.56, p=0.005) in multivariate analyses adjusted for age, socioeconomic status (SES), age 20 general cognitive ability, and non-independence of twins within pairs. Never smokers had significantly younger brains than current or former smokers. PBAD did not differ for current versus former smokers. In other analyses, more advanced PBAD was associated with non-amnestic MCI. In this sample, tobacco smoking had the strongest relationship with overall brain health in late midlife compared with other types of environmental exposures, reinforcing its role in pathological aging and its importance as a public health priority.

primary care (PC). The current PC practice of body mass index (BMI) calculation to screen for disease risk lacks specificity to the older adult habitus. Guided by the Health Belief Model, this study utilized a one-way analysis of covariance to examine the effect of experimental cues, WC measurement and central obesity disease risk education, compared to control cues, BMI and obesity classification, on older adults' health beliefs (perceived susceptibility and health benefits) and behaviors (diet and exercise) 6 weeks post cues/intervention. Of the 99 participants (control group [N=49]; experimental group [N=50]) 92% reported 'never' having WC measurement and 76% reported 'never' having BMI calculation in PC. Both groups reported high levels of perceived susceptibility and exercise at baseline. Changes in perceived susceptibility, diet, and exercise were non-significant in either group. There was a significant increase in perceived health benefits of WC measurement (p=0.01) and BMI calculation (p=0.01) in the experimental group compared to the control group. Willingness to exercise (p=0.007) significantly increased in the experimental group compared to the control group. The lack of BMI experience in both groups may have caused control cues to function as experimental cues in both groups. Thus, this study provides evidence that combined use of WC measurement, central obesity health risk education, BMI calculation, and obesity classification increase perceived benefits of body measurements and motivate physical activity in older adults over BMI and obesity classification alone.

EFFECTS OF MEDICARE DRUG SUBSIDIES ON ADHERENCE FOR DIABETICS: EVIDENCE FROM A REGRESSION DISCONTINUITY DESIGN
Alexandra Glynn, Inmaculada Hernandez, and Eric Roberts, University of Pittsburgh, Pittsburgh, Pennsylvania, United States Out-of-pocket prescription drug costs are rapidly rising, particularly for insulin, which is a life-saving drug used by 3.1 million diabetics on Medicare. High out-of-pocket costs place an accentuated financial strain on older adults with diabetes, many of whom have low incomes, and may impede medication adherence, leading to poor health outcomes. The Medicare Part D Low-Income Subsidy (LIS) program limits drug co-pays to under $8.50 per prescription and caps outof-pocket drug costs for lowest-income recipients (<135% Federal Poverty Level, FPL), resulting in pronounced differences in out-of-pocket costs for those with marginally different incomes. Using detailed income data from the Health and Retirement Study linked to Medicare claims (2008-2016), we employed a regression discontinuity (RD) design to isolate the effects of differences in out-of-pocket costs at eligibility thresholds for the LIS. Diabetic beneficiaries whose income exceeded the LIS eligibility threshold had lower Part D spending (-$945/year, p=0.03, n=2,367) and adherence to oral antidiabetic drugs (-8%, p=0.02). We conducted secondary analyses at the eligibility threshold for Medicaid, as individuals whose income exceeds the eligibility limit for Medicaid (100% of FPL in most states) are significantly less likely to receive the LIS. Above the Medicaid eligibility threshold (n=2,295), annual spending on insulin was $395 lower (p=0.002) and proportion of insulin use was 6% lower (p=0.04). These results suggest low-income Medicare beneficiaries who are not shielded from out-of-pocket costs via the LIS are particularly sensitive to drug costs. Policy proposals to limit out-of-pocket costs could improve medication adherence to high-cost drugs for vulnerable beneficiaries. Studies have suggested that extreme weather events have differential effects by age. By leveraging electronic medical records, we aim to analyze the environmental influence of extreme heat on the health of older adults. From our healthcare system's de-identified data warehouse, we extracted a retrospective cohort of 108,192 patients who were ≥65 years of age as of 1/1/2018 with pre-existing chronic conditions including diabetes, COPD, cardiovascular disease, or kidney disease. Extreme heat event period was defined as 5/1/2018 to 9/1/2018 (79 days with temperature ≥90o; 15 days of moderately poor/poor air quality index (AQI) [≥75] values) and the comparison period was defined as 5/1/2019 to 9/1/2019 (51 days with temperature ≥90o; 0 days with moderately poor/poor AQI values) in the Kansas City area. We randomly partitioned the study cohort into two sets and demonstrated the two patient sets were statistically similar (p>0.05) with respect to their demographic and underlying health conditions. Finally, we compared the respiratory, cardiovascular, and renal health outcomes between the 2018 and the 2019 cohorts. Most patients were Caucasians, female and had comorbid conditions. Results showed significantly higher number of all-cause emergency department visits (p=0.04) and outpatient visits (p=<.001) during the extreme heat event period in 2018. Analyses also showed significantly higher number of outpatient visits due to upper respiratory diseases (p=0.008) and acute renal failure (p=0.01) in 2018. In conclusion, extreme heat increased use of healthcare services in older adults with chronic conditions. Exposure to harmful substances and chemicals such as tobacco smoke, chemicals (e.g., herbicides, pesticides, Agent Orange) and metal dust has been associated with increased risk of developing cancer, cardiovascular disease, and other diseases that contribute to shorter life expectancy. Associations with brain health in relation to these exposures are less well studied. We examined the relationship between brain health and prolonged exposure to different harmful substances in 498 male participants average age 68 (range 61 to 73) from the Vietnam Era Twin Study of Aging (VETSA). For self-reported tobacco smoke, herbicides/pesticides, and metal dust we created three groups reflecting recency of exposure (current/former/never). For Agent Orange we examined two exposure groups (ever/never). Brain health, defined as predicted brain age (PBAD), was evaluated by applying Brain-Age Regression Analysis and Computation Utility software (BARACUS) to magnetic resonance images collected at age 68. Tobacco smoking (r=-0.15, p=0.0004 ) was significantly correlated with PBAD and remained significant (F=5.56, p=0.005) in multivariate analyses adjusted for age, socioeconomic status (SES), age 20 general cognitive ability, and non-independence of twins within pairs. Never smokers had significantly younger brains than current or former smokers. PBAD did not differ for current versus former smokers. In other analyses, more advanced PBAD was associated with non-amnestic MCI. In this sample, tobacco smoking had the strongest relationship with overall brain health in late midlife compared with other types of environmental exposures, reinforcing its role in pathological aging and its importance as a public health priority.

A QUALITATIVE STUDY ON MAKING RURAL COMMUNITIES MORE DEMENTIA-FRIENDLY Melissa OConnor, Megan Pedersen, and Rachel Grace, North Dakota State University, Fargo, North Dakota, United States
Recent studies on attitudes toward dementia in the United States, such as the World Alzheimer Report 2019, have found that fear and stigma are still widespread among the general public. This may be particularly true in rural communities. In the current study, community-dwelling adults in small Midwestern communities responded to the open-ended survey question, "What do you think could be done to make your community more welcoming for people with Alzheimer's disease and other forms of dementia?" Participants (N=242) ranged in age from 18-88 (M=40, SD=21). The sample was 68% female, and 61% lived in communities of 50,000-150,000 people, while 39% lived in smaller towns. Most participants (61.2%) did not personally know someone with dementia. Data were collected via paper and telephone surveys.
Responses to the open-ended question were analyzed using open, axial, and selective coding. The following themes emerged: greater exposure to individuals with dementia; educational workshops about dementia; more intergenerational programs; greater accessibility of respite care and other services; more fundraising efforts; and community leaders talking about dementia. Responses included, "Have more intergenerational programs that bring together Alzheimer's patients and children in a positive environment." "When I was in school, we visited an Alzheimer's unit. That was a great experience." "I know what it is, but I don't know anything else. I wish I was more informed. I don't know how to help." These findings indicate that residents of rural communities are motivated to help individuals with dementia, but need more guidance, education, and personal connections/exposure.

A SYSTEMATIC REVIEW OF OBSERVATIONAL DYADIC PERSONS LIVING WITH DEMENTIA: CAREGIVER COMMUNICATION INSTRUMENTS Sohyun Kim, University of Iowa, Iowa City, Iowa, United States
To facilitate social interaction and providing quality care in persons living with dementia (PLWD), an effective means of evaluating communication quality between PLWD and their caregiver is needed. However, there is no systematic review of current instruments to assess dyadic PLWD-caregiver interactions in various care settings. The purpose of this review was to critically evaluate existing dyadic observational communication instruments used to provide recommendations. A systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Guideline was conducted. Literature that were published by May 2019 in English were searched from CINAHL, AgeLine, PsychINFO, Communication and Mass Media Complete, ProQuest Dissertations and Theses Global, and Scopus. Keywords were "communication strategy," "communication," "caregivers," "dementia," and any combination of these terms or MeSH terms. Data were extracted including development process, operational concept, target population and setting, items/scoring format, psychometric properties, and research/ clinical use. A total of 3042 articles were identified and 15 instruments from 29 studies were evaluated by the scoring of 12 psychometrics: participants/items ratio, reliability (internal consistency, intra-rater, inter-rater), and validity (content, concurrent, predictive, known group difference, divergent/discriminant, convergent, structural). The total score was ranged from 0 to 22 (high quality: 16-22, moderate: 8-15, low: 0-7). There was no instrument with high quality assessing dyadic interaction. Only one instrument was evaluated as moderate quality (modified Behavioral Observation Scoring System, BOSS). While existing instruments are still in the early stages of development and testing, they demonstrate potential evidence that may require further testing before application in research and clinical practice.