Association between Incident Elder Abuse and Trajectories of Cognitive Decline in US Chinese Population: Moderating and Mediating Effects of Resilience Factors

Elder abuse is a burgeoning public health issue that affects about 10% of older adults in the United States each year. Less is known about the relationship between elder abuse and cognitive function, not to mention using longitudinal data to test the effect of incidence of elder abuse on cognitive function across time. Resilience theory indicates resilience asset (individual resilience factor) and resource (external to individual) enable individuals to respond successfully to crises. The stress and coping model highlighted the moderating/mediating role of resilience in the relationship between stressor and health. The broad objective of this project is to understand how violence in later life would influence cognitive function, and whether resilience could buffer this negative mechanism. The specific aim is to examine how incidence of elder abuse will affect cognitive function across time in U.S. Chinese older adults, and further explore whether resilience factors (asset and resource) can protect them from cognitive decline.

Data will be derived from three waves of PINE Study (Co-I Dong) from 2011 to 2017 with sample size 3,157 (response rate 91.9%). Resilience factors include asset and resource. Resilience asset was assessed by mastery. Resilience resources encompass support from family and friend. We also focused on the interactive effect of resilience asset and resource, because resource are believed to enhance individuals’ resilience that comes from feeling valued by meaningful others or embedded in supportive environment. Longitudinal Structural Equation Modeling and Bootstrap will be used to investigate the role of resilience factors in the relationship between incident elder abuse and cognitive outcomes. In the moderating model, we will compare the trajectory of four groups of older adults: 1) high mastery and high social support; 2) high mastery and low social support; 3) low mastery and high social support; and 4) low mastery and low social support. In the mediating model, we will test whether elder abuse exerts effects on cognitive function through the decline of resilience. In addition, the effects of incidence of domains of elder abuse will be examined in this study, including physical, psychological, and sexual abuse, financial exploitation and caregiver neglect. The sociodemographic factors which were related to cognitive function will be controlled in data analysis, such as age, gender, and education. We will also control pre-trauma cognitive function to reveal the cognitive function change resulting from incidence of elder abuse.

Mental health outcomes among LGB and Non-LGB Older Asian Americans: A Mixed Methods Study of the Influence of Minority Stress.

In the U.S., Asian Americans are a growing minority group and although highly educated suffer mental health disparities. A range of socio-cultural factors influence health disparities among Asian Americans. Sexual orientation may interact with these factors to compound risk for LGBT Asian Americans. Our study will address an important gap in the literature by examining minority stress and other forms of trauma and their influences on the mental health of older LGBT and non-LGBT older Asian populations. Specific aims are to: Aim 1: Determine the influence of trauma and other indicators of minority stress on mental health and QOL among older Asian Americans. We hypothesize that trauma and minority stress will be associated with poor mental health and QOL outcomes. Further, we hypothesize that sexual orientation will interact with trauma/minority stress to explain the worse mental health of LGBT respondents compared to non-LGBT respondents. Aim 2. In partnership with Asian LGBT organizations, we will conduct focus groups with older Asian Americans who are LGBT (N = 30) and in-depth interviews with directors of local and national Asian LGBT serving organizations (N = 10) to examine experiences with trauma/minority stress, identify risk and protective influences and to identify culturally acceptable coping resources.

This mixed methods study will be guided by the Minority Stress Model, a framework that is widely used to examine the impact of social stress (e.g., discrimination) that results from belonging to a stigmatized social category. Assumptions associated with the model are that it is: (a) unique—minority stress is additive to general stressors; (b) chronic—minority stress is related to stable underlying social and cultural structures; and (c) socially based —it stems from social processes beyond the individual. Quantitative data will be obtained from the nation's largest state health survey (The California Health Interview Survey, CHIS) that have high promotions of Asian Americans, measure sexual orientation and have similar measures of: (1) stress/trauma, (2) mental health outcomes, and (3) substance abuse behaviors. Qualitative data will be collected to provide more in-depth and contextual information regarding the influence of trauma experiences on the mental health of older LGBT Asian Americans. Specifically, we will examine the influence of minority stressors (discrimination, victimization, internalized homophobia, concealment) and cultural influences on stress experiences and intra and inter-Asian group variations in risk and protective factors. This research is significant as it in line with the IOM Report on LGBT research and the 21st Century Cures Act. Further, it increases the knowledge base regarding mental health among Asian Americans who identify as LGBT, thus enhancing our ability to design effective culturally targeted and trauma informed psychosocial intervention to improve mental health outcomes among LGBT Asian Americans.

The Intersection of Cancer and Culture: Financial Burden and Advanced Care Planning among Filipino, Asian Indian, and Chinese Elders in Chicago

As the costs associated with cancer escalate, financial concerns of patients and families are increasingly common. Cost sharing for cancer patients can lead to the inability to afford basic needs such as food and clothes, non-adherence, spending savings, and even bankruptcy. In response to these concerns, an 11-item patient reported outcome, Comprehensive Score of Financial Toxicity (COST), was developed to assess financial burden due to cancer costs. Little is known about financial burden and advanced care planning needs Asian elders with cancer face, and Asian cancer survivors report poorer care communication, quality, and self-efficacy when compared to white patients. In this project, we aim to 1) validate the questionnaire, Comprehensive Score of Financial Toxicity (COST), to assess patient-reported financial burden among Asians with a diagnosis of cancer (Aim 1). We will also explore perceptions and attitudes towards discussing cost of cancer care and care planning (Aim 2). We hypothesize that traditional cultural values, family duty, and preferences for information disclosure and decision making, will be reflected in their perspectives around the discussing and managing the cost of cancer care.

We will qualitatively explore perceptions and attitudes of patients and caregivers towards cost of cancer care within a population of Chinese and South Asian elders in Chicago. We are focusing on these two minority populations to explore the concept of filial piety, traditional cultural values, and preferences for information disclosure and decision-making. Inclusion criteria include women and men age 55 or greater, of Chinese or South Asian descent, with a diagnosis of any stage malignancy. We plan to conduct one-on-one interviews with fifteen participants from each ethnic background for a total of 30 participants. Once all interviews are completed, translated, and transcribed, data will be entered and analyzed using AtlasTi (version 7, Scientific Software Development GmbH, Berlin, Germany) computer software. Transcripts will be coded and analyzed by Drs. Kircher, Mohindra, and Simon, iteratively, proceeding from descriptive to thematic coding until saturation is achieved. Triangulation will be used to resolve any differences. This study can help to bridge care of older adults with traumatic cancer diagnosis and minimize financial toxicity within their families. The findings from this study will assist a R01 application to design a trauma-informed intervention to assist Asian cancer survivors.

Implementation of a Health-Related Social Needs Screening Tool in Primary Care Settings

Asian American populations in the U, particularly older Asian immigrants, experience higher rates of chronic disease and poorer mental well-being compared to non-minorities. Additional socioeconomic and cultural barriers further contribute to disparities in access to health care, uptake of preventive screenings, and adherence to chronic disease management. Unmet patients’ social needs lead to poorer health outcomes and weaker health system performance. Thus, there has been an increasing effort to measure and address social determinants of health and health-related social needs (HRSN) among underserved clinic populations. Few efforts to screen for HRSNs within clinic settings, however, have focused on Asian American populations or augmented existing screening tools to incorporate measures of acculturation, stress, resilience, and immigration experiences that may uniquely impact the health outcomes of specific Asian American subgroups. In the proposed pilot study, we aim to: (1) implement an expanded HRSN screening tool at the Center for Asian Health to identify the prevalence of food insecurity, transportation barriers, utility needs, interpersonal safety, housing, trauma, and resilience, (2) examine variation in the prevalence of HRSN among elderly and non-elderly patients, across Asian subgroups and compared to populations in other data sources, and (3) explore the relationship between HRSN domains, to health outcomes and health care utilization via medical chart audits in a subsample of study participants. As health care systematically moves towards clinic assessment of patients’ HRSNs, it is important to ensure the needs of older Asian minorities are appropriately and adequately measured. The findings from this pilot study will be highly informative for measurement and health care intervention development for Asian American patients.

Improving Access to Healthcare in Asian Americans: the Role of Individual and Contextual Factors

The present study is to examine a model that integrates individual and environmental dimensions in healthcare access among Asian Americans, using a sample that reflects cultural, ethnic, and linguistic diversities. The approach of the proposed study is based on the premise that (1) immigration-related factors are a unique vulnerability of Asian Americans that poses a significant risk to health and healthcare and that (2) environmental contexts strongly influence their healthcare access. Guided by Andersen’s behavioral health model, Aim 1 is to explore individual factors, specifically immigration-related factors (e.g., life course immigration trauma, resilience, nativity, length of stay in the U.S., English proficiency, and acculturation) that contribute to healthcare access. While a sizeable body of literature has identified major barriers and facilitators of healthcare access by focusing on the independent effects of those factors with using a variable-centered method, we will use a person-centered method with latent profile/class analysis to directly identify groups/clusters of individuals who share a profile based on multiple risk factors. Aim 2 explores the effect of neighborhood and community contexts (e.g., availability of culturally and linguistically appropriate healthcare services and ethnic density in local communities) on healthcare access. Putting health and healthcare into environmental (i.e., neighborhood/ community characteristics) contexts adds an important dimension to predicting and remediating health/healthcare disparities for Asian Americans. Geographic Information Systems (GIS) technology will serve as a methodological tool to construct variables on neighborhood/community context. The overall approach and findings will inform how to effectively address inequality in healthcare access and will have direct relevance for Asian Americans.

Health Outcomes in Asian Older Adults under Extreme Heat and Medication Use

Heat waves kill more people than floods, tornadoes, and earthquakes combined and lead to excess emergency room visits and hospitalizations. The health impacts of extreme heat will only intensify due to the changing climate, urbanization, and aging population. Older adults are vulnerable to extreme heat, not only due to low adaptive capacity, but also because of the multiple medications they take. Although older adults make up only 13% of the population, they account for more than one-third of medication use in the US. However, current evidence assessing health effects of extreme heat lacks consideration of this important and modifiable risk factor. Minority populations are also vulnerable to extreme heat due to low socioeconomic status and related comorbidities. The Asian population is the fastest growing minority population among the US elderly with demonstrated disparities in poverty rates, insurance coverage, and health status. Yet, little evidence exists addressing the impact of extreme heat and medications in Asian older adults. We aim to assess the independent and synergistic effects of extreme heat and medications on health outcomes 1) in Asian older adults vs. non-Hispanic White and 2) in US Chinese Asian subgroup vs. older adults in Taiwan and identify mediating resilience factors by linking climate and healthcare data the US and Taiwan. The proposed study will quantify casualties of extreme heat and medication side effects in older adults and shed lights on the potential disparities on health outcomes in the US Asian older adults comparing to non-Hispanic White or Taiwanese population.

Exploring the associations between risk and protective factors and the health of older sexual and gender minority Asian Americans

There are more than 6 million sexual and gender minorities or individuals who identify as lesbian, gay, bisexual, transgender and/or queer adults over age 50 currently living in the United States. This number will likely double by 2030. Not a lot is known about the health of older Asian Americans who identify as sexual and gender minorities. This study will describe the physical and mental health conditions experienced by older sexual and gender minority Asian Americans who are age 50 and older. It will also identify factors that may increase or decrease these problems, such as experiences of stigma, discrimination, and resiliency or coping skills. This study plans to use existing data from the Kaiser Northern California’s Research Program for Genes, Environment, and Health to explore the physical and mental health conditions of older sexual and gender minority Asian Americans, and then compare to a similar group of older heterosexual Asian Americans. This will help us to find health problems that need more attention. We will also ask older sexual and gender minority Asian Americans who identify a lesbian, gay, bisexual, transgender, and/or queer and live in San Francisco, CA to share their experiences and the ways that they have coped with their health problems. We will do this by asking about experiences and habits that are good and bad for health. This study hopes to find new ways to improve the health and future healthcare of older sexual and gender minority Asian Americans and other diverse groups.

Resilience in the Face of Adversity: The Case of U.S. Chinese Older Adults

As the American society becomes multicultural, it is increasingly important to understand the process through which individuals from diverse cultural, ethic, and racial backgrounds achieve resilient adaptation when encountering adversity. The ability to recover from adversity and stress is particularly important for successful aging of older immigrants. But how resilience manifests in older immigrants and why it is realized by some individuals but not others is still unclear. Using two wave data from the Population Study of Chinese Elders in the United States (PINE), the proposed study aims to address a central question: what is the optimal coping structure of US Chinese elderly in the face of adversity, indicated by loss of key social relationships (widowhood), loss of autonomy (significant decline in physical/cognitive health), and economic hardship (significant decline in income)? Using latent class analysis (LCA), a statistical tool that identifies unobserved subgroups (classes) based on observed behaviors, this study aims to 1) identify different classes of aging immigrants in terms of their overall individual, family, and community “coping repertoire” and 2) the most optimal “coping repertoire” that predicts the best mental health outcomes. The findings will provide foundation for a subsequent R01 proposal that extends the investigation to include additional time points and more comprehensive indicators of adversities, resilience, and health outcomes. The findings will also help develop tailored interventions to minimize vulnerability and promote resiliency in older immigrants who experience adversity.

Resilience, Gut Microbiota, Inflammation and Symptoms in Asian Older Adults with Stroke

There is a fundamental gap in our understanding of the underlying mechanisms of highly prevalent co-occurring symptoms (post-traumatic stress disorder [PTSD], depression, anxiety, stroke symptoms, pain, and, fatigue) that occur post-stroke and the role of resilience in their development and persistence in Asian older adults. My goal in seeking this pilot grant is to become an independent investigator focused on identifying mechanisms triggering the development of these symptoms. Further, I wish to explore differences in physiological and physiological (e.g., gut microbiota, inflammatory resilience) resilience and symptoms between Asian and White older adults with stroke. Stroke survivors experience significant changes in gut microbiome composition and bacterial counts. It is known that ischemic stroke triggers the immune response, resulting in brain inflammation. Asian older adults with lower resilience, gut dysbiosis (e.g., reduced diversity and bacterial overgrowth of bacteroidetes) and elevated inflammatory biomarkers may be at risk for developing symptoms after stroke. A cross sectional pilot study using a convenience sample of two age- and gender-matched groups, 10 Asian and 10 White older adults with stroke, will be conducted. Specific aims are to 1) Determine overall feasibility of the study; 2) Explore differences in psychological (Connor–Davidson Resilience Scale) and physiological resilience (gut microbiota; inflammatory biomarkers, matrix metalloproteinases-9, C-reactive protein, tumor necrosis factor-alpha, interleukin 6, and lipopolysaccharide), psychological (PTSD, depression and anxiety) and physical (stroke symptoms, pain and fatigue) symptoms between the Asian and White older adults with stroke; and 3) Explore associations of psychological and physiological resilience with physical and psychological symptoms.

Stress Coping Process among Homebound Chinese and Korean American Older Adults: How do Internet Use and Acculturation matter?

Though social isolation and its adverse impacts on physical and mental health among homebound older adults has been well documented, there is a paucity of work on homebound older Asian Americans, which leads to the scarcity of culturally-sensitive interventions designed for this population. Recent studies show that internet-based interventions are promising in promoting social engagement and improving physical and mental health of homebound older adults. This proposed study will explore whether and to what extent Internet use and acculturation influence stress coping process (including social isolation, self-mastery and physical and mental health outcomes) by collecting and analyzing primary quantitative data from 200 homebound older adults in the two largest groups of Asian Americans in New York City. The findings of this study will help to design an internet-based and culturally-sensitive intervention to address social isolation and improve resilience and health outcomes among homebound Asian Americans. A NIH R34 proposal will be submitted by the end of this RCMAR grant to test the feasibility of the internet-based intervention. Guided by two mentors, the PI will lead the procedure of measurement validation, recruitment, data collection and analysis, and the R34 proposal preparation and manuscript writing. This proposal is responsive to the goal of RCMAR by (1) providing critical knowledge on the homebound older Asian Americans who are largely understudied, (2) exploring the possibility of internet-based interventions to promote social engagement and improve physical and mental health of this population, and (3) guiding the development of effective interventions for this population.