The Gerontologist current issue

Negative Impact and Positive Value in Caregiving: Validation of the COPE Index in a Six-Country Sample of Carers

2008-06-30

Purpose: The present study attempts to further validate the COPE Index on a large sample of carers drawn from six European countries. Design and Methods: We used a cross-sectional survey, with approximately 1,000 carers recruited in each of six countries by means of a common standard evaluation protocol. Our saturation recruitment of a designated quota of carers occurred by means of several channels, in identified geographical zones within countries. Interviews were carried out with primary informal carers by use of a common assessment tool. We subjected items of the COPE Index to principal component analysis and we assessed emergent components through the use of Cronbach's alpha reliability procedures. We examined factor components as summative scales for confirmatory correlations with caregiving and psychological variables. Results: Three components emerged, which we identified as the negative impact of caregiving, the positive value of caregiving, and the quality of support for caregiving. Internal consistency was good for negative impact and satisfactory for positive value and quality of support. Negative value was most consistently and strongly correlated with caregiving and psychological variables, although we did find diverse associations between these variables and the COPE Index subscales. Implications: The COPE Index is a brief, first-stage assessment of some sophistication that can enable health and social care professionals to develop appropriately targeted interventions to enhance the positive aspects of the caregiving experience and quality of support, as well as reduce the negative impacts of caregiving.

Effects of Caregiver Status, Coping Styles, and Social Support on the Physical Health of Korean American Caregivers

Kim, J.-H., Knight, B. G. — 2008-06-30

Purpose: This study investigated direct and indirect effects of caregiver status on the physical health of Korean American caregivers in terms of caregiver coping styles and the quantity and the quality of informal social support. Design and Methods: Using a sample of 87 caregivers and 87 matched noncaregivers, we analyzed a path model, employing both subjective (self-reported general health) and objective (blood pressure and cortisol levels) health indicators. For the intervening variables the path model employed coping styles and two aspects of social support (the quantity of informal social support and the quality of informal social support). Results: Our findings supported the association of caregiver status with poor health outcomes among Korean American caregivers. Of interest, the adverse effects of caregiver status on the physical health of caregivers were reported only with objective health markers (blood pressure and cortisol levels), not with subjective health indicators. The proposed indirect effects of caregiver status were supported only for cortisol levels, through the quality of informal social support. Implications: The demonstration of the physical health effects of caregiving in one of the nation's fastest growing ethnic groups, and the finding that these physiological effects occur without self-reported poor health, call attention to a potentially serious health problem in an understudied group providing family care to frail older family members.

More Than Just a Communication Medium: What Older Adults Say About Television and Depression

Nguyen, G. T., Wittink, M. N., Murray, G. F., Barg, F. K. — 2008-06-30

Purpose: Older adults watch more television than younger people do. Television's role in mental health has been described in the general population, but less is known about how older adults think of television in the context of depression. Design and Methods: Using a semistructured interview created to help clinicians understand how older adults conceptualize depression diagnosis and treatment, we conducted a qualitative study of 102 patients aged 65 years or older. We recruited them from primary care offices and interviewed them in their homes. During our analysis, we found that many respondents offered spontaneous thoughts about the relationship between television and depression. We extracted all television-related content from the interview transcripts and identified themes by using grounded theory. Results: Participants cited television as a way to identify depression in themselves or others (either through overuse or lack of interest) or as a way to cope with depressive symptoms. Some felt that television could be harmful, particularly when content was high in negativity. A substantial number of participants discussed more than one of these themes, and a few mentioned all three. Married people were more likely to discuss television's role in identifying depression. Participants with low education more often mentioned that television could be helpful, whereas those with a history of depression treatment were more likely to discuss television's potential harm. Implications: Researchers should conduct further studies to help them better understand the relationship among depression, television viewing, and individual viewpoints concerning television's role in geriatric depression. An exploration of these issues may yield new approaches to help clinicians address depression in late life.

Effectiveness of Problem-Solving Therapy for Older, Primary Care Patients With Depression: Results From the IMPACT Project

Arean, P., Hegel, M., Vannoy, S., Fan, M.-Y., Unuzter, J. — 2008-06-30

Purpose: We compared a primary-care-based psychotherapy, that is, problem-solving therapy for primary care (PST-PC), to community-based psychotherapy in treating late-life major depression and dysthymia. Design and Methods: The data here are from the IMPACT study, which compared collaborative care within a primary care clinic to care as usual in the treatment of 1,801 primary care patients, 60 years of age or older, with major depression or dysthymia. This study is a secondary data analysis (n = 433) of participants who received either PST-PC (by means of collaborative care) or community-based psychotherapy (by means of usual care). Results: Older adults who received PST-PC had more depression-free days at both 12 and between 12 and 24 months (β = 47.5, p <.001; β = 47.0, p <.001), and they had fewer depressive symptoms and better functioning at 12 months (β_dep = –0.36, p <.001; β_func = –0.94, p <.001), than those who received community-based psychotherapy. We found no differences at 24 months. Implications: Results suggest that PST-PC as delivered in primary care settings is an effective method for treating late-life depression.

MDS-Based State Medicaid Reimbursement and the ADL-Decline Quality Indicator

Bellows, N. M., Halpin, H. A. — 2008-06-30

Purpose: We examined the relationship between the quality indicator for decline in activities of daily living (ADL) and the use of the Minimum Data Set (MDS) for determining Medicaid skilled nursing facility reimbursement. Design and Methods: We conducted a cross-sectional analysis using the 2004 National MDS Facility Quality Indicator reports as the dependent variable in a multilevel regression model. Our primary explanatory variable was a state-level binary variable distinguishing whether or not the state used an MDS-based Medicaid-reimbursement system in 2004. We obtained control variables through the Online Survey, Certification, and Reporting System. Results: Skilled nursing facilities located in states that used the MDS for Medicaid reimbursement reported more ADL decline than did facilities in states that did not use the MDS for reimbursement. Implications: The finding suggests that the ADL-decline quality indicator captures more than just quality, including state-level policy differences. Therefore, the ADL-decline quality indicator should be investigated and refined prior to being relied on for pay-for-performance initiatives.

To What Degree Does Provider Performance Affect a Quality Indicator? The Case of Nursing Homes and ADL Change

Phillips, C. D., Chen, M., Sherman, M. — 2008-06-30

Purpose: This research investigates what factors affect the degree to which nursing home performance explains variance in residents' change in status of activities of daily living (ADL) after admission. Design and Methods: The database included all residents admitted in 2002 to a 10% random sample of nursing homes in the United States. Longitudinal analyses of outcomes at 3 months after admission test the ability of individual characteristics and nursing home identifiers to explain variance in ADL change for different groups of residents. Results: As we compared the best and worst providers (top 20% vs bottom 20%, then 10%, then 5%) and we restricted analyses to more homogeneous groups of residents, we found that more of the variance in ADL change was attributable to provider performance. Cognitive function and race also affected the degree to which home performance had an impact on outcomes. Implications: The results imply that some quality indicators may be most useful in distinguishing between nursing homes that provide the best or the worst care. Futhermore, the degree to which a quality indicator is driven by a nursing home's performance may vary considerably, depending on the characteristics of the consumer. These findings raise questions about the usefulness of performance measures that focus on heterogeneous groups of consumers or entire provider populations. "How much of the variance in a quality indicator does provider performance explain?" is an issue we think has not received the attention it deserves in current discussions of performance-measurement strategies and pay-for-performance models.

Nursing Home Care Quality: Insights From a Bayesian Network Approach

Goodson, J., Jang, W., Rantz, M. — 2008-06-30

Purpose: The purpose of this research is twofold. The first purpose is to utilize a new methodology (Bayesian networks) for aggregating various quality indicators to measure the overall quality of care in nursing homes. The second is to provide new insight into the relationships that exist among various measures of quality and how such measures affect the overall quality of nursing home care as measured by the Observable Indicators of Nursing Home Care Quality Instrument. In contrast to many methods used for the same purpose, our method yields both qualitative and quantitative insight into nursing home care quality. Design and Methods: We construct several Bayesian networks to study the influences among factors associated with the quality of nursing home care; we compare and measure their accuracy against other predictive models. Results: We find the best Bayesian network to perform better than other commonly used methods. We also identify key factors, including number of certified nurse assistant hours, prevalence of bedfast residents, and prevalence of daily physical restraints, that significantly affect the quality of nursing home care. Furthermore, the results of our analysis identify their probabilistic relationships. Implications: The findings of this research indicate that nursing home care quality is most accurately represented through a mix of structural, process, and outcome measures of quality. We also observe that the factors affecting the quality of nursing home care collectively determine the overall quality. Hence, focusing on only key factors without addressing other related factors may not substantially improve the quality of nursing home care.

Everyday Physical Activity as a Predictor of Late-Life Mortality

Chipperfield, J. G. — 2008-06-30

Purpose: The present study hypothesized that simple, everyday physical activity (EPA) would decline with advancing age; that women would have a more favorable EPA profile than would men; and that EPA would have a survival benefit. Design and Methods: Community-dwelling participants (aged 80–98 years, n = 198) wore mechanical actigraphs in order for EPA to be assessed. Individuals were classified as active, inactive, and sedentary based on their level of EPA exhibited over a substantial part of the day. Survival status was available at approximately 2 years. Results: Mean EPA scores decreased with advancing age and, in contrast to men, women in their early eighties appeared to be protected from declining EPA. This partially supported the hypothesis that women would have a more favorable EPA profile. What is most important is that mean EPA scores predicted mortality. Moreover, when compared with their less sedentary counterparts, sedentary adults were more than three times as likely to be deceased 2 years later. Implications: Researchers need to conduct new trials to determine whether or how physical activity is associated with mortality.

Long-Term Effects of a Stage-Based Intervention for Changing Exercise Intentions and Behavior in Older Adults

2008-06-30

Purpose: We examined the efficacy of an intervention tailored to the individual's stage of change for exercise adoption on exercise stage of change, physical activity, and physical function in community-dwelling older adults. Design and Methods: We randomized participants to a print and telephone intervention or a contact comparison group. Through the use of longitudinal analyses we examined the intervention's effectiveness in promoting stage progression, altering decisional balance and the processes of change, increasing self-efficacy and physical activity, and improving physical function among older adults who completed the 24-month study (N = 966). We conducted similar analyses that excluded individuals who were in maintenance at baseline and 24 months. Results: At the end of the study, there were no differences in stage progression, self-efficacy, decisional balance, the processes of change, physical activity, or physical function by intervention assignment. When the analyses excluded those participants (n = 358) who were in the maintenance stage for exercise throughout the intervention, we found that, compared with the comparison group, a greater proportion of individuals who received the exercise intervention progressed in stage by 24 months. Conversely, more individuals in the comparison group remained stable or regressed in stage compared with the intervention group. Implications: Results indicate that a tailored intervention is effective in increasing motivational readiness for exercise in individuals who were in stages of change other than maintenance.

Civic Engagement as a Retirement Role for Aging Americans

Kaskie, B., Imhof, S., Cavanaugh, J., Culp, K. — 2008-06-30

Purpose: Public attention directed toward the civic engagement of retired Americans has increased considerably. The purpose of this research was to define civic engagement as a retirement role and differentiate individuals who met this role definition from other retirees. Design and Methods: Retirees who met our definition of civic engagement were identified from a sample of 683 retired older adults living in a rural Midwestern state. Using a multinomial logistic regression analysis, we contrasted this group of engaged retirees to three other groups of retirees: (a) those who were neither working nor volunteering, (b) those who had returned to work in part-time or seasonal occupations, and (c) those who volunteered for fewer than 5 hours each week. Results: The analyses indicated that individuals assigned to the group of engaged retirees were similar across 24 variables. This group of engaged retirees differed from the other groups by gender, education level, and health status; retirement motives and planning efforts; primary retirement activities; and attitudes about volunteering and returning to work. Implications: This research supported the contention that civic engagement could be defined as a formal retirement role, as engaged retirees differ significantly from those who volunteer less, work in noncivic roles, or do neither. Further, we resolved that associating the act of volunteering, in itself, with civic engagement may no longer be appropriate for retired older adults. The definition of civic engagement as a retirement role should also include those individuals who return to work in organizations that pursue specific civic activities.

Change in Fruit and Vegetable Intake Over 24 Months in Older Adults: Results of the SENIOR Project Intervention

2008-06-30

Purpose: We test the efficacy of an intervention based on the transtheoretical model to increase the intake of fruits and vegetables and to describe differences in psychosocial variables based on the achievement of the 5 A Day Program target. Design and Methods: This study is a randomized controlled trial comparing a 12-month fruit and vegetable intervention to a control condition with a 12-month follow-up. Participants included 1,277 community-residing persons who were 60 years of age or older; 834 provided dietary data at all three time points and are included in our outcome analyses. Results: The intervention group increased intake by 0.5 to 1.0 serving more than the control group over 24 months as measured by the NCI Fruit and Vegetable Screener and the 5 A Day Program screener. The majority of the participants (58%) perceived that they maintained 5 or more servings per day for 24 months. These maintainers had a higher intake at each time point for all dietary measures and differed from those who failed to progress (11%) for most transtheoretical model variables. Implications: The intervention was effective in increasing the intake of fruits and vegetables in older adults. Those who maintained their level of perceived intake as 5 or more servings per day consumed 2–4 servings per day more than those who failed to progress.

Impairment in Instrumental Activities of Daily Living and the Geriatric Syndrome of Self-Neglect

Naik, A. D., Burnett, J., Pickens-Pace, S., Dyer, C. B. — 2008-06-30

Purpose: We sought to characterize self-neglect definitively as a geriatric syndrome by identifying an association with functional impairment. Design and Methods: We performed a cross-sectional home evaluation of 100 community-living older adults referred by Adult Protective Services for geriatric self-neglect and 100 matched adults from a community geriatrics clinic. We made our assessments by using two manual muscle tests, a timed-gait test, a modified Physical Performance Test (mPPT), and the Kohlman Evaluation of Living Skills (KELS). Results: Participants in the self-neglect group had impaired mPPT (p <.077) and KELS (p <.001) scores compared with community-controls. Using analysis of covariance models, we found that self-neglect referral explained a significant proportion of the variance in KELS scores (32%; p <.001) but not in mPPT scores (22%; p =.49). Implications: The geriatric syndrome of self-neglect is associated with increased morbidity and mortality and appears to be independently associated with impairments in instrumental activities of daily living. The evaluation and treatment of geriatric self-neglect should be consistent with that of other geriatric syndromes.

Measuring Worker Turnover in Long-Term Care: Lessons From the Better Jobs Better Care Demonstration: Kathleen Walsh Piercy, PhD, Editor

Barry, T. T., Kemper, P., Brannon, S. D. — 2008-06-30

Purpose: Turnover among direct-care workers (DCWs) continues to be a challenge in long-term care. Both policy makers and provider organizations recognize this issue as a major concern and are designing efforts to reduce turnover among these workers. However, there is currently no standardized method of measuring turnover to define the scope of the problem or to assess the effectiveness of interventions. This article draws on our experience of the Better Jobs Better Care Demonstration (BJBC) to explicate some important issues in measuring and interpreting turnover related to interventions designed to improve DCW jobs. Design and Methods: We used turnover data from a selected group of BJBC providers (N = 9) to demonstrate some of the measurement issues we uncovered in developing a turnover tracking system for BJBC. We also illustrate how the data elements collected in the tracking system make it possible to construct measures that are useful at both policy and practice levels. Results: Differences in definitions of turnover and the data elements used to construct the measure can have large effects on turn over rates, how they are used, and what they mean. Implications: Policy makers, researchers, and managers who need comparative turnover information to address the impending demand for DCWs should be aware that turnover measures differ, and they should take steps to ensure that measures they use have common definitions and data elements.

THE POTENTIAL OF RETIREMENT: Frank J. Whittington, PhD, Editor

Henretta, J. C. — 2008-06-30

BACK TO THE FUTURE: RESTORING ECONOMIC SECURITY FOR WORKERS AND RETIREES

Polivka, L. — 2008-06-30