A Scenario-Based Investigation of Surrogate Decision Making for Older Adults

Abstract Surrogate decisions involve complex, challenging choices; surrogate decision-makers make treatment decisions for approximately 40% of hospitalized adults and 70% of older adults, and up to 95% of critically ill adults of any age. The purpose of our study was to understand how people make decisions for others and how surrogate decision making is linked to people’s cognition, self-efficacy, and demographics, especially differences in acute (e.g., health and medical care, financial management, and end of life) versus general scenarios (spending time with family, contacting an insurance company on behalf of a family member). Participants were recruited through Amazon’s Mechanical Turk. We collected data from 290 adult participants aged 18 years or older. On average, people reported a higher level of confidence in general versus acute scenario. The differences of confidence in scenario-based surrogate decision-making links to decision-makers’ cognition, self-efficacy, the experience of decision-making, the experience of caregiving, and demographic factors.

involved a prior substantiated APS report. This presentation highlights how surrogates perpetuate abuse and outcomes on older adult victims. Our findings inform practice and policy for better prevention, detection, investigation, and intervention in these challenging cases.

SELF-NEGLECT: ONE PATHWAY TO SURROGATE DECISION-MAKING
Holly Ramsey-Klawsnik, 1 and Jason Burnett, 2 , 1. Canton,Massachusetts,United States,2. McGovern Medical School at UTHealth,Houston,Texas,United States Self-neglect, the most frequently reported allegation to Adult Protective Services (APS), involves profoundly harmful behaviors often due to functional or cognitive limitations, health problems, and insufficient resources that result in older adults insufficiently meeting their basic needs. Outcomes include high risk of illness, hospitalization and readmission, hospice and nursing home use, early mortality, and placement under surrogate decision-making authority of either well-intended or opportunistic others. APS staff are charged with assessing self-neglect and intervening to reduce client danger. A nationwide APS survey revealed program policies, procedures, resources, and needs affecting the client welfare. For example, 92% of APS programs have provisions for seeking guardianship for self-neglecting individuals, in 25% of programs staff serve as court-appointed guardians, and a wide variety of tools are used within APS programs to assess clients' mental capacity. Key study findings, implications, and recommendations will be presented.

A SCENARIO-BASED INVESTIGATION OF SURROGATE DECISION MAKING FOR OLDER ADULTS
Yuxin Zhao, 1 Benjamin Katz, 2 and Pamela Teaster, 3 1. Booz Allen Hamilton, Bethesda, Maryland, United States,2. Virginia Tech,Blacksburg,Virginia,United States,3. Virginia Tech,BLACKSBURG,Virginia,United States Surrogate decisions involve complex, challenging choices; surrogate decision-makers make treatment decisions for approximately 40% of hospitalized adults and 70% of older adults, and up to 95% of critically ill adults of any age. The purpose of our study was to understand how people make decisions for others and how surrogate decision making is linked to people's cognition, self-efficacy, and demographics, especially differences in acute (e.g., health and medical care, financial management, and end of life) versus general scenarios (spending time with family, contacting an insurance company on behalf of a family member). Participants were recruited through Amazon's Mechanical Turk. We collected data from 290 adult participants aged 18 years or older. On average, people reported a higher level of confidence in general versus acute scenario. The differences of confidence in scenario-based surrogate decision-making links to decision-makers' cognition, self-efficacy, the experience of decision-making, the experience of caregiving, and demographic factors.

PERCEPTION VERSUS REALITY: SUBJECTIVE AND OBJECTIVE NEIGHBORHOOD CHARACTERISTICS AND COGNITIVE FUNCTION IN REGARDS Chair: Jessica Finlay Co-Chair: Philippa Clarke Discussant: Lisa Barnes
Does the world shrink as we age? The neighborhood captures a spatial area someone inhabits and moves through on a daily basis. It reflects a balance between internal perceptions and abilities, and the external environment which may enable or restrict participation in everyday life. We frequently hear that older adults have shrinking neighborhoods given declining functional mobility. This is associated with declines in physical and cognitive functioning, depression, poorer quality of life, and mortality. Knowledge of the interplay between objective and subjective neighborhood measurement remains limited. This symposium will explore these linked yet distinct constructs based on secondary data analyses of the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study, a racially diverse sample of 30,000+ aging Americans. Finlay investigates how someone's perceived neighborhood size (in number of blocks) varies by individual and geographic characteristics including age, cognitive function, self-rated health, and urban/rural context. Esposito's analyses focus on neighborhood size in relation to race and residential segregation. Clarke compares subjective perceptions of neighborhood parks and safety from crime to objective indicators, and examines variations by health and cognitive status. Barnes will critically consider implications for how older adults interpret and engage with their surrounding environments. The symposium questions the validity of neighborhood-based metrics to reflect the perspectives and experiences of older residents, particularly those navigating cognitive decline. It informs policy-making efforts to improve physical neighborhood environments and social community contexts, which are critical to the health and well-being of older adults aging in place.

MY NEIGHBORHOOD IS FUZZY, NOT HARD AND FAST: A MIXED-METHODS STUDY OF NEIGHBORHOOD SIZE AMONG AGING AMERICANS
Jessica Finlay, Joy Bohyun Jang, Michael Esposito, Sandra Tang, Anam Khan, and Philippa Clarke, University of Michigan, Ann Arbor, Michigan, United States In this exploratory sequential mixed-methods study, interviews with 125 adults aged 55-92 living in the Minneapolis (Minnesota) metropolitan area suggest that neighborhood boundaries are "fuzzy". Qualitative analysis of neighborhood perceptions identified race, mobility, driving status, social connections, housing insecurity, land use, urbanicity, and crime as key themes. Over 8,000 REGARDS participants (mean age 72) indicated how many blocks composed their neighborhoods (mean=9.9, SD=35.4). Linear regression models showed that being over the age of 85, white, less educated, lower income, less physically and cognitively healthy, and living outside of a metropolitan area significantly GSA 2020Annual Scientific Meeting Innovation in Aging, 2020