Showing papers in "Gerontologist in 2003"

The Impact of Hearing Loss on Quality of Life in Older Adults

Abstract: Purpose: The authors investigate the impact of hearing loss on quality of life in a large population of older adults. Design and Methods: Data are from the 5-year follow-up Epidemiology of Hearing Loss Study, a population-based longitudinal study of agerelated hearing impairment conducted in Beaver Dam, WI. Participants (N ¼ 2,688) were 53–97 years old (mean ¼ 69 years) and 42% were male. Difficulties with communication were assessed by using the Hearing Handicap for the Elderly—Screening version (HHIE-S), with additional questions regarding communication difficulties in specific situations. Health-related quality of life was assessed by using measures of activities of daily living (ADLs), instrumental ADLs (IADLs) and the Short Form 36 Health Survey (SF-36). Hearing loss measured by audiometry was categorized on the basis of the puretone average of hearing thresholds at 0.5, 1, 2, and 4 kHz. Results: Of participants, 28% had a mild hearing loss and 24% had a moderate to severe hearing loss. Severity of hearing loss was significantly associated with having a hearing handicap and with self-reported communication difficulties. Individuals with moderate to severe hearing loss were more likely than individuals without hearing loss to have impaired ADLs and IADLs. Severity of hearing loss was significantly associated with decreased function in both the Mental Component Summary score and the Physical Component Summary score of the SF-36 as well as with six of the eight individual domain scores. Implications: Severity of hearing loss is associated with reduced quality of life in older adults.

Self, Society, and the “New Gerontology”

Abstract: The "new gerontology," built on the concept of successful aging, sets forth the preconditions for and the end product of the process of aging successfully. Focused on health and active participation in life, it vests largely within individuals the power to achieve this normatively desirable state. While acknowledging the contributions of the scientific base for Rowe and Kahn's successful aging model, we emphasize the need for a more careful examination of the model itself. Using critical gerontology as a primary filter, we critique this normative vision by focusing on its unarticulated (and perhaps unexplored) values, assumptions, and consequences. We argue that these unexamined features may further harm older people, particularly older women, the poor, and people of color who are already marginalized. We conclude by suggesting forms of resistance to this univocal standard.

Environmental Correlates to Behavioral Health Outcomes in Alzheimer's Special Care Units

Abstract: Purpose: We systematically measured the associations between environmental design features of nursing home special care units and the incidence of aggression, agitation, social withdrawal, depression, and psychotic problems among persons living there who have Alzheimer’s disease or a related disorder. Design and Methods: We developed and tested a model of critical health-related environmental design features in settings for people with Alzheimer’s disease. We used hierarchical linear modeling statistical techniques to assess associations between seven environmental design features and behavioral health measures for 427 residents in 15 special care units. Behavioral health measures included the Cohen-Mansfield physical agitation, verbal agitation, and aggressive behavior scales, the Multidimensional Observation Scale for Elderly Subjects depression and social withdrawal scales, and BEHAVE-AD (psychotic symptom list) misidentification and paranoid delusions scales. Statistical controls were included for the influence of, among others, cognitive status, need for assistance with activities of daily living, prescription drug use, amount of Alzheimer’s staff training, and staff-to-resident ratio. Although hierarchical linear modeling minimizes the risk of Type II—false positive—error, this exploratory study also pays special attention to avoiding Type I error— the failure to recognize possible relationships between behavioral health characteristics and independent variables. Results: We found associations between each behavioral health measure and particular environmental design features, as well as between behavioral health measures and both resident and nonenvironmental facility variables. Implications: This research demonstrates the potential that environment has for contributing to the improvement of Alzheimer’s symptoms. A balanced combination of pharmacologic, behavioral, and environmental approaches is likely to be most effective in improving the health, behavior, and quality of life of people with Alzheimer’s disease.

Conducting Research on Home Environments: Lessons Learned and New Directions

Abstract: The study of home environments is a research domain within the field of environmental gerontology that addresses issues related to aging in place. Despite the importance of aging at home, there are few recent studies in this area and most are descriptive and lack theoretical direction. This article examines the current state of research on home environments from which methodological challenges and new directions for future research are identified. Three broad research queries are posed: What should we measure and why in home environments? How do older people and their family members use the home environment in health, illness, and caregiving? What are the interrelationships between the home environment, psychological well-being, and daily functioning throughout the aging process? Suggestions for future research on home environments are discussed and the implications for advancing environmental gerontology highlighted. Specifically, the home environment offers a testing ground for generic environmental constructs and their measurement as well as a unique setting from which new understandings and constructs of person-environment fit can emerge.

Environmental Gerontology at the Beginning of the New Millennium: Reflections on Its Historical, Empirical, and Theoretical Development

Abstract: Over the past four decades the environmental context of aging has come to play an important role in gerontological theory, research, and practice. Environmental gerontology (EG)--focused on the description, explanation, and modification or optimization of the relation between elderly persons and their sociospatial surroundings--has emerged as a subfield in its own right. The aim of this article is to reflect on the historical, empirical, and theoretical development of recent EG, following Parmelee and Lawton's diagnosis from 1990 that there is a need to move the field beyond its current languishing state. From a historical perspective, EG has clearly played an important and successful role within the gerontology enterprise in terms of explicit consideration of the sociophysical environment in theory and research. A literature analysis of empirical studies supports the view that research has continued on a substantial quantitative level during the 1990s. Findings of these research studies address the whole diversity of classic EG research questions, but mostly in the sense of replication and extension. In terms of theoretical discussion, our analysis leads to the insight that EG may be described as a field high in conceptual aspiration ("world views"), but low with regard to making research and application-productive use of its theoretical achievements.

The Effect of a Family Therapy and Technology-Based Intervention on Caregiver Depression

Abstract: Purpose The majority of persons with Alzheimer's disease (AD) are cared for at home by a family member such as a spouse or daughter. Caregiving places enormous demands on these caregivers, and the negative consequences associated with caregiving are well documented. This paper reports results from the Miami site of the REACH (Resources for Enhancing Alzheimer's Caregiver Health) program that examined the efficacy of a family therapy and technology-based intervention in reducing depressive symptoms (according to the Center for Epidemiological Studies Depression scale) among family caregivers of AD patients at 6 months and 18 months follow-up. Design and methods There were 225 White American and Cuban American caregivers that were randomized into a structural ecosystems therapy, structural ecosystems therapy + computer-telephone integrated system, or minimal support control condition. Results Caregivers in the combined family therapy and technology intervention experienced a significant reduction in depressive symptoms at 6 months. The 18-month follow-up data indicated that the intervention was particularly beneficial for Cuban American husband and daughter caregivers. Implications The results indicate that information technology has a promising role in alleviating distress and depression among groups of AD caregivers. The data also demonstrate that interventions have differential impacts according to ethnic group and the caregiver-patient relationship.

Definition, Measurement, and Correlates of Quality of Life in Nursing Homes: Toward a Reasonable Practice, Research, and Policy Agenda

Abstract: Purpose: This article identifies challenges in defining, measuring, and studying quality of life of nursing home residents. Design and Method: A theoretical analysis was conducted based on literature and the author’s own large-scale studies of quality of life of nursing home residents. Results: Measuring quality of life is a relatively low priority in nursing homes because of focus on markers of poor quality of care, pervasive sense that nursing homes are powerless to influence quality of life, and impatience with research among those dedicated to culture change. The research argues that the resident voice must be sought in reaching operational definitions for quality of life and as reporters on the quality of their own lives, and that resident burden is a spurious concern that should not deter direct interviews with residents. Five challenges in measuring quality of life were identified: (a) designing questions with appropriate response categories and time frames, (b) developing a sampling strategy, (c) aggregating information at the individual andfacilitylevel,(d)validatingwhatare ultimately subjective constructs, and (e) developing an approach using observations and proxies to assess quality of life for approximately the 40% of the residents who will be impossible to interview. Implications: Although residents’ perceived quality of life is partly a product of their health, social supports, and personalities, nursing homes can directly influence quality of life through their polices, practices, and environments, and, indirectly, through their approaches to family and community. A research agenda is needed, which includes both methodological research and studies of the correlates of quality of life.

The Health and Social Service Needs of Gay and Lesbian Elders and Their Families in Canada

Abstract: Purpose: This article reports the findings of a study, undertaken in 2000, whose purpose was to gather information about the experiences and realities of gay and lesbian seniors and their families from across Canada in accessing a broad range of health and social services in the community, and to examine the role of health care and social service organizations in shaping access and service delivery. Design and Methods: This study used a qualitative exploratory design based on focus group interviews. Perspectives of older gay men and lesbians and their families involved in organizations addressing these issues, as well as professionals from both gay and lesbian health organizations and mainstream elder care organizations were sought. Results: Specific reference was made to the impact of discrimination on the health and access to health services of these populations. Issues relating to invisibility, historic and current barriers to care, and the nature of service options are identified. Implications: Recommendations for change are highlighted, including those related to best practice programs and policies in the long-term care sector.

Anger and Depression Management: Psychoeducational Skill Training Interventions for Women Caregivers of a Relative With Dementia

Abstract: Purpose: This study examines the short-term impact of two theoretically based psychoeducational small group interventions with distressed caregivers, and it also examines the role of specific moderator and mediator variables on caregiver outcomes. Design and Methods: Female participants (N ¼ 169) aged 50 and older who were caring for a communitydwelling relative with a dementing illness were randomly assigned to one of three treatment interventions: anger management, depression management, or a wait-list control group. These interventions took place over a 3- to 4-month period. The primary outcomes examined were anger or hostile mood, depressed mood, frequency of use of positive and negative coping strategies, and perceived caregiving self-efficacy. Results: Significant main effects in the expected direction were found for changes in most of these measures. Participants in both anger management and depression management groups had significant reductions in their levels of anger or hostility and depression from Time 1 to Time 2 in comparison to participants in the wait-list control group. Use of positive cognitive coping strategies increased in the anger management group only. Self-efficacy significantly increased for participants in both intervention groups, and it was also demonstrated to function as a mediator of intervention effects. Pretreatment levels of depressive symptoms and anger expression style (Anger Expression-Out) moderated the relative effects of the two interventions on mood and coping. Implications: These data are consistent with a growing body of evidence supporting the effectiveness of skills training, in small groups, to improve both the affective states and the type of coping strategies used by caregivers. In addition, this study underscores the need to evaluate key pretreatment variables in order to determine which form of treatment may be more compatible with caregiver characteristics and thus more likely to be beneficial to individuals.

Gender Differences in the Self-Rated Health–Mortality Association: Is It Poor Self-Rated Health That Predicts Mortality or Excellent Self-Rated Health That Predicts Survival?

Abstract: Purpose: This study investigates gender differences in the association between self-rated health (SRH) and mortality. This association has been well-documented, but findings regarding gender differences are inconsistent. The specific objectives were (a) to examine these differences in a short and a long time frame (b) to examine these differences among old and old-old people, and (c) to address the question of whether this association is based on the accuracy of poor SRH as a predictor of future decline, and/or of better SRH as a predictor of longevity. Design and Methods: The study is based on an Israeli nationally representative sample of 622 women and 730 mere who were interviewed about their SRH, as well as sociodemographic information and other measures of health, physical functioning, cognitive status, and depression. Results: For both genders, SRH was associated only with shorter term mortality (within the next 4 years) and not with longer-term mortality (9 years of follow-up). This association was strongest among the old (ages 75-84) women, compared with the old men and with the old-old (85-94) women and men. A possible explanation may be related to differences in the accuracy of excellent SRH at very old age. Implications: The SRH-mortality association may differ among age and gender groups. Identifying the conditions under which it is more accurate will enable researchers and practitioners to know when it can be utilized. It is important to assess differences in the accuracy of poor SRH as well as of excellent SRH as predictors of future health outcomes.

Effects of the home environmental skill-building program on the caregiver-care recipient dyad: 6-month outcomes from the Philadelphia REACH Initiative.

Abstract: Purpose We examine 6-month effects of the Environmental Skill-Building Program on caregiver well-being and care recipient functioning and whether effects vary by caregiver gender, race (White or non-White), and relationship (spouse or nonspouse) Design and methods We enrolled 255 family caregivers of community-residing persons with Alzheimer's disease or related disorders, of whom 190 participated in a follow-up interview Caregivers were randomized to a usual care control group or intervention group that received five home contacts and one telephone contact by occupational therapists, who provided education, problem-solving training, and adaptive equipment Baseline and 6-month follow-up included self-report measures of caregiver objective and subjective burden, caregiver well-being, and care recipient problem behaviors and physical function Results Compared with controls (n = 101), intervention caregivers (n = 89) reported less upset with memory-related behaviors, less need for assistance from others, and better affect Intervention spouses reported less upset with disruptive behaviors; men reported spending less time in daily oversight; and women reported less need for help from others, better affect, and enhanced management ability, overall well-being, and mastery relative to control group counterparts Statistically significant treatment differences were not found for hours helping with instrumental activities of daily living, upset with providing assistance with instrumental activities of daily living and activities of daily living, perceived change in somatic symptoms, White versus non-White caregivers, or care recipient outcomes Implications The Environmental Skill-Building Program reduces burden and enhances caregiver well-being in select domains and has added benefit for women and spouses

Resources for Enhancing Alzheimer's Caregiver Health (REACH): Overview, Site-Specific Outcomes, and Future Directions

Abstract: Established in 1995, Resources for Enhancing Alzheimer’s Caregiver Health (REACH) is a unique, multisite research program sponsored by the National Institute on Aging and the National Institute on Nursing Research. The primary purpose of REACH is to carry out social and behavioral research on interventions designed to enhance family caregiving for Alzheimer’s disease (AD) and related disorders. Specifically, REACH has two goals: to test the effectiveness of multiple different interventions and to evaluate the pooled effect of REACH interventions overall. REACH developed from a National Institutes of Health initiative that acknowledged the well-documented burdens associated with family caregiving as well as the existence of promising family caregiver interventions reported in the literature.

Lessons Learned About Minority Recruitment and Retention From the Centers on Minority Aging and Health Promotion

Abstract: Purpose: This article presents a summary of an earlier monograph on the recruitment and retention of older ethnic minority individuals. Design and Methods: The authors provide an overview of recruitment and retention efforts made by six National Institutes of Health Office of Minority Reseorch/ National Institute on Aging-funded Centers on Minority Aging and Health Promotion. We rely on a model that focuses on barriers and enablers to recruitment that stem from the minority community as well as the research community. Results: The summary of findings suggests that recruitment and retention success occurs when there is a match between the goals of the ethnic minority communities and the research community. Implications: Recognizing and understanding the culture of each ethnic minority community as well the research perspectives is essential to successful recruitment and retention of ethnic minority elderly individuals.

Caregiving and Institutionalization of Cognitively Impaired Older People: Utilizing Dynamic Predictors of Change

Abstract: Purpose: The purpose of this study was to identify reliable predictors of nursing home entry over a 3-year period in a sample of 3,944 persons with dementia who resided in a home setting at baseline. Strengths of the analysis include a multiregional recruitment strategy, incorporation of salient caregiver characteristics, and a 3-year prospective design that allows for the modeling of change in important variables (e.g., care recipient functional status or caregiving indicators) when time to institutionalization is predicted. Design and Methods: Data were derived from the control sample of the Medicare Alzheimer's Disease Demonstration Evaluation (MADDE). A Cox proportional hazards model was used to predict time to institutionalization among individuals with dementia (baseline was enrollment into MADDE). Predictors included care recipient demographics, caregiver demographics, and time-varying measurements of care recipient functional status, caregiving indicators, and service utilization. Indicators of change were also incorporated to capitalize on the prospective data available. Results: Although several results were consistent with prior findings, caregiving indicators (i.e., burden and self-rated health) and community-based service use were significant predictors of earlier placement. Change in caregiver instrumental activities of daily living and care recipient activities of daily living were also related to expedited institutionalization. Implications: The findings emphasize the importance of incorporating both care recipient and caregiver function and service use patterns when targeting programs designed to prevent or delay institutionalization for people with dementia.

Definition of Successful Aging by Elderly Canadian Males: The Manitoba Follow-Up Study

Abstract: Purpose Although the concept of successful aging is used widely in the field of gerontology, there is no agreed-on standard or common underlying definition for measuring success in aging. Our recent survey of an elderly male population asked respondents to define "successful aging." This paper describes the themes that evolved from those definitions, explores interrelationships between the themes, and examines the association between characteristics of respondents and the themes provided in their definition. Design and methods The Manitoba Follow-up Study has followed a cohort of 3,983 World War II Royal Canadian Air Force male aircrew recruits since July 1, 1948. At a mean age of 78 years in 1996, the survivors were surveyed and asked, "What is your definition of successful aging?" and "Would you say you have aged successfully?" A content analysis identified themes emerging from their definitions. Results The most frequent of the 20 component themes from the definitions of successful aging as provided by 30% of the 1,771 respondents related to "health and disease"; "physical," "mental," and "social activity" were more likely to be found in a definition including "interest," "having goals," "family," or "diet," and they were less likely to be mentioned with themes of "independence" or "health." Many of the themes reflect an individual's attitudes toward life and the aging process. Current life satisfaction, self-rated health, and limitation in activities of daily living were significantly associated with an increased likelihood of reporting specific themes in definitions. Implications As health care professionals adapt to the changing demographic composition of society, it should be of interest to understand what successful aging might mean to the elderly males to whom they are attending.

Effects of an Automated Telephone Support System on Caregiver Burden and Anxiety: Findings From the REACH for TLC Intervention Study.

Abstract: Purpose: We determine the main outcome effects of a 12-month computer-mediated automated interactive voice response (IVR) intervention designed to assist family caregivers managing persons with disruptive behaviors related to Alzheimer’s disease (AD). Design and Methods: We conducted a randomized controlled study of 100 caregivers, 51 in the usual care control group and 49 in the technology intervention group, who received yearlong access to an IVR-mediated system. The system provided caregiver stress monitoring and counseling information, personal voice-mail linkage to AD experts, a voice-mail telephone support group, and a distraction call for care recipients. We conducted analyses by using a repeated measures approach for longitudinal data and an intention-to-treat analytic approach. Outcomes included the caregiver’s appraisal of the bothersome nature of caregiving, anxiety, depression, and mastery at baseline, 6, 12, and 18 months. Results: There was a significant intervention effect as hypothesized for participants with lower mastery at baseline on all three outcomes: bother (p 5 .04), anxiety (p 5 .01), and depression (p 5 .007). Additionally, wives exhibited a significant intervention effect in the reduction of the bothersome nature of caregiving (p 5 .02). Implications: Wives who exhibited low mastery and high anxiety benefited the most from the automated telecare intervention. Findings suggest that, to optimize outcome effects, similar interventions should be tailored to match the users’ characteristics and preferences.

Change in Indices of Distress Among Latino and Anglo Female Caregivers of Elderly Relatives With Dementia: Site-Specific Results From the REACH National Collaborative Study

Abstract: Purpose: Few empirical studies have compared the efficacy between psychoeducational (skill-building) approaches for reducing caregivers’ psychological distress and interventions modeled after typical community-based support groups. We compare the impact of two distinct interventions on Anglo and Latino caregivers of elderly relatives with dementia. Design and Methods: The change from preassessment to postassessment (baseline to 3 months) for 213 female caregivers (122 Anglo and 91 Latino) is presented. They were seen weekly for 10 weeks in either the Coping With Caregiving psychoeducational program (instruction and practice in small groups to learn specific cognitive and behavioral skills) or in the Enhanced Support Group condition (guided discussion and empathic listening to develop reciprocal support within the group). Both programs were tailored to be sensitive to the cultural concerns of Anglo and Latino caregivers, and they were delivered in either English or Spanish by trained interventionists. Results: Overall, participants in the Coping With Caregiving condition reported a significant reduction in depressive symptoms, increased use of adaptive coping strategies, and a trend toward decreased use of negative coping strategies when compared with those in the Enhanced Support Group condition. Results were similar for both ethnic groups: there were no main effects for ethnicity, and no significant ethnicity by treatment interaction effects. Implications: This study provides empirical support that female caregivers benefit more from a skillbuilding approach to managing their distress than from support group membership alone. We find it very encouraging that the Latino caregivers responded well on key outcome variables, suggesting that Latinos will participate in clinical research and will benefit from their involvement when services are provided to meet their specific needs.

Assisted Living and Nursing Homes: Apples and Oranges?

Abstract: Purpose: The goals of this study are to describe the current state of residential care/assisted living (RC/ AL) care and residents in comparison with nursing home (NH) care and residents, identify different types of RC/AL care and residents, and consider how variation in RC/AL case-mix reflects differences in care provision and/or consumer preference. Design and Methods: Data were derived from the Collaborative Studies of Long-Term Care, a four-state study of 193 RC/AL facilities and 40 NHs. Multivariate analyses examined differences in ten process of care measures between RC/AL facilities with less than 16 beds; traditional RC/AL with 16 or more beds; newmodel RC/AL; and NHs. Generalized estimating equation models determined differences in resident case-mix across RC/AL facilities using data for 2,078 residents. Results: NHs report provision of significantly more health services and have significantly more lenient admission policies than RC/AL facilities, but provide less privacy. They do not differ from larger RC/AL facilities in policy clarity or resident control. Differences within RC/AL types are evident, with smaller and for-profit facilities scoring lower than other facilities across multiple process measures, including those related to individual freedom and institutional order. Resident impairment is substantial in both NHs and RC/AL settings, but differs by RC/AL facility characteristics. Implications: Differences in process of care and resident characteristics by facility type highlight the importance of considering: (1) the adequacy of existing process measures for evaluating smaller facilities; (2) resident case-mix when comparing facility types and outcomes; and (3) the complexity

Transitions in Spousal Caregiving

Abstract: Purpose This study describes transitions over 5 years among community-dwelling elderly spouses into and within caregiving roles and associated health outcomes. Design and methods Participants in the Caregiver Health Effects Study (n = 818) were interviewed four times over 5 years with changes in their caregiving status described. Analyses of the effect on health outcomes of transitions were performed on those for whom four observations were available (n = 428). Results Only half (49.5%) of noncaregivers at baseline remained noncaregivers at 5-year follow-up. The remainder experienced one or more transitions, including moving into the caregiving role, their own or their spouse's death, or placement of their spouse in a long-term care facility. The trajectory of health outcomes associated with caregiving was generally downward. Those who transitioned to heavy caregiving had more symptoms of depression, and poorer self-reported health and health behaviors. Implications Transitions into and within the caregiving role should be monitored for adverse health effects on the caregiver, with interventions tailored to the individual's location in the caregiving trajectory.

A National Survey of Assisted Living Facilities

Abstract: Purpose: Throughout the 1990s, assisted living was the most rapidly growing form of senior housing. The purpose of this paper is to describe the existing supply of assisted living facilities (ALFs) and examine the extent to which they matched the philosophy of assisted living. Design and Methods: The study involved a multistage sample design to produce nationally representative estimates for the ALF industry. Administrators of nearly 1,500 eligible ALFs were interviewed by telephone. Results: As of 1998, there were an estimated 11,459 ALFs nationwide, with 611,300 beds and 521,500 residents. Nearly 60% offered a combination of low services and low or minimal privacy, whereas only 11% offered relatively high services and high privacy. Seventy-three percent of the resident rooms or apartments were private. Aging-in-place was limited by discharge policies in most ALFs for residents who needed help with transfers, had moderate to severe cognitive impairment, had any behavioral symptoms, or needed nursing care. The industry is largely private pay and unaffordable for low- or moderate-income persons aged >75 unless they use assets as well as income to pay. Implications: ALFs differed widely in ownership, size, policies, and the degree to which they manifested the philosophy of assisted living. This diversity represents a challenge for consumers in terms of selecting an appropriate facility and for policy makers in terms of deciding what role they want assisted living to play in long-term care.

The quality of quality measurement in U.S. nursing homes.

Abstract: Purpose This article examines various technical challenges inherent in the design, implementation, and dissemination of health care quality performance measures. Design and methods Using national and state-specific Minimum Data Set data from 1999, we examined sample size, measure stability, creation of ordinal ranks, and risk adjustment as applied to aggregated facility quality indicators. Results Nursing home Quality Indicators now in use are multidimensional and quarterly estimates of incidence-based measures can be relatively unstable, suggesting the need for some averaging of measures over time. Implications Current public reports benchmarking nursing homes' performances may require additional technical modifications to avoid compromising the fairness of comparisons.

Relating Medical Students' Knowledge, Attitudes, and Experience to an Interest in Geriatric Medicine

Abstract: Purpose This study examined medical students' interest in geriatrics: Are knowledge, positive attitudes, and prior experience with older adults associated with an interest in geriatric medicine? Design and methods Entering University of Michigan medical students completed three surveys: the Revised Facts on Aging Quiz, the University of California at Los Angeles Geriatric Attitudes Scale, and the Maxwell-Sullivan Attitudes Scale. The students were also asked questions about their prior experience with older adults and their interest in geriatric medicine. Results The results indicate that incoming medical students have minimal knowledge about aging, moderately positive attitudes toward older adults, and low interest in geriatric medicine. Having more positive attitudes toward older adults (ss =.28) and having cared for older persons prior to medical school (ss =.14) were associated with greater interest in geriatric medicine. Implications These findings suggest that interventions to increase the number of geriatric-oriented physicians should focus on influencing learners' attitudes through experiences in the care of older adults.

Effectiveness of Continuing Education in Long-Term Care: A Literature Review

Abstract: Purpose: This review of the literature examines the effectiveness of continuing education programs in long-term care facilities. Design and Methods: A comprehensive literature search was made for evaluation studies and included computerized bibliographic databases, manual searches of journals, the bibliographies of retrieved articles, and information from key informants. Results: Forty-eight studies met our selection criteria. Rigorous research in this area has been limited. Because of the lack of follow-up evaluation, there is minimal evidence that knowledge gained from training programs is sustained in the long term. Most studies do not consider organizational and system factors when planning and implementing training initiatives. This may account for difficulties encountered in the sustained transfer of knowledge to practice. Implications: There is a need for further rigorous research on the effectiveness of continuing education in long-term care, with systematic attention to the role of organizational and system factors. Training staff in the long-term care setting is a relatively new phenomenon. In the early 1980s, researchers in the United States were reporting that nursing assistants were providing up to 90% of resident care and receiving little or no training (Waxman, Carmen, & Berkenstock, 1984). The primary treatment model was based on a custodial model of care in which staff met the basic needs of residents. Burgio and Burgio (1990) noted, in an early review of the nursing assistant training literature, that the few articles published on this topic prior to 1987, with two notable exceptions, debated whether resources should even be invested in training these workers. The paramount need for staff training was realized in the mid to late 1980s as the organization of long-term care underwent significant change. First, there was a shift in societal attitudes about health and aging toward support for a more therapeutic model of care for elderly people. The current custodial model began to give way to a new, more restorative or rehabilitative model of care. New learning and development was required to effect this change (Burgio & Scilley, 1994).

Conceptualizing Time and Behavior in Environmental Gerontology: A Pair of Old Issues Deserving New Thought

Abstract: Architects, environmental designers, occupational therapists, and human service professionals are variously engaged in efforts to create settings for older persons that better fit their changing lifestyles and abilities. This theoretical article argues that to explain and predict more effectively the appropriateness of the settings occupied and used by their older occupants requires models and empirical inquiries that better conceptualize two areas of inquiry: (a) the temporal properties of environments and individuals and (b) the conceptualization of environmental behaviors or activities describing how individuals use, manipulate, or perform tasks in their settings. The types of constructs and relationships necessary for this inquiry are reviewed and their practical applications considered.

Primary Care Interventions for Dementia Caregivers: 2-Year Outcomes From the REACH Study

Abstract: Purpose This study developed and tested two 24-month primary care interventions to alleviate the psychological distress suffered by the caregivers of those with Alzheimer's disease The interventions, using targeted educational materials, were patient behavior management only, and patient behavior management plus caregiver stress-coping management We hypothesized that the addition of the stress-coping component would improve caregiver outcomes Design and methods A randomized clinical trial of 167 caregiver-care recipient dyads was run, of whom 76 completed the study without bereavement or placement Results During 24 months, caregivers who received the patient behavior management component only, compared with those who also received the stress-coping component, had significantly worse outcomes for general well-being and a trend toward increased risk of depression (ie, a score of >16 on the Center for Epidemiological Studies Depression scale) There was a studywide improvement for bother associated with care recipient behaviors (according to the Revised Memory and Behavior Problems Checklist) Implications Our data suggest that brief primary care interventions may be effective in reducing caregiver distress and burden in the long-term management of the dementia patient They further suggest that interventions that focus only on care recipient behavior, without addressing caregiving issues, may not be as adequate for reducing caregiver distress

Discussion: Gender Differences in Self-Rated Health, in Mortality, and in the Relationship Between the Two

Abstract: The set of articles making up this special section were all driven by the authors’ interest in self-ratings of health and these ratings’ potential for indicating risk for mortality. Studies of this association began to appear in the mid 1980s, and in a relatively short time, dozens had been published, primarily in North America, Europe, and Asia. There was a consistent finding, with few exceptions, that respondents to health surveys who rated their health as ‘‘poor,’’ ‘‘fair,’’ or sometimes just ‘‘good’’ had a significantly higher risk of mortality than those who considered their health ‘‘excellent’’ or the equivalent, even when other measures of health were considered. In some of these studies, the effects were similar for men and women; in others, there were differences. Contributors to this special section have chosen to look at their data with an eye to the differences and with the hope that an analysis of the differences may help reseachers better understand the similarities. Should one expect a gender difference? For multiple reasons, beginning with the dependent variable (mortality), the answer would be yes. Life expectancy is greater for women in virtually every country on earth, at birth and at every other age. It is certainly true for all of the countries for which there are published reports of self-rated health–mortality analyses (Benyamini & Idler, 1999; Idler & Benyamini, 1997). As a result, the age-adjusted risk of mortality in these samples will be lower for the women than for the men, and the number of deaths among women will be proportionately fewer given the number of women in the sample. Another consequence of gender differentials in mortality risk is that (unless sampling weights are used) the number of women in a representative sample will be larger, providing more statistical power and reducing the possibility of Type II errors in subsamples of women compared with subsamples

Impact of Two Psychosocial Interventions on White and African American Family Caregivers of Individuals With Dementia

Abstract: Purpose: We developed manual-guided, replicable interventions based on common needs and cultural preferences of White and African American family caregivers (CGs) of individuals with dementia, and we evaluated these interventions after a 6-month follow-up. Design and Methods: We randomly assigned White (n = 70) and African American (n = 48) CGs of individuals with dementia to either a skills training condition or a minimal support control condition. Results: The degree of treatment implementation was methodically assessed, and findings demonstrated that both interventions were delivered according to protocol and were well received by CGs. CGs in both groups reported decreasing levels of problem behaviors and appraisals of behavioral bother, and increased satisfaction with leisure activities over time. On a measure of appraisal of distress related to behavior problems, White CGs showed more improvement in the minimal support control condition, and African American CGs showed the greatest improvements in the skills training condition. Spouse and nonspouse CGs also showed differential responses to intervention. Implications: Brief manual-guided interventions can be effective with White and African American CGs, and greater attention should be paid to possible differential responses to

Willingness to Participate in Clinical Treatment Research Among Older African Americans and Whites

Abstract: Purpose Using a health services utilization conceptual framework, the purpose of this analysis was to examine race differences in factors predictive of the behavioral intention of older persons to participate in a clinical treatment trial should they have a diagnosis of cancer. In addition, the analysis sought to determine if older African Americans were less likely than Whites to express willingness to participate, given knowledge of the Tuskegee syphilis study and greater fatalistic cancer beliefs. Design and methods Data were drawn from a community-based telephone survey of 216 African Americans and 222 Whites, 50 years of age and older. Results Findings show that willingness to participate was significantly higher among males, persons of younger age, higher incomes, and with nonfatalistic cancer beliefs. Race differences were only apparent for the two significant interactions of race with age and high income. Neither knowledge of the Tuskegee study nor fatalistic cancer beliefs were more important for African Americans than for Whites. Implications Study findings suggest that recruitment strategies need to be tailored to racial differences in factors affecting willingness to participate, particularly those related to age and income level.

Concepts of Self-Rated Health: Specifying the Gender Difference in Mortality Risk

Abstract: Purpose: This study addresses the question of how the relation between self-rated health (SRH) and mortality differs between genders. In addition to the general question, four specific concepts of SRH are distinguished: SRH in comparison with age peers, SRH in comparison with one’s own health 10 years ago, and current and future health perceptions. For these concepts, the gender-specific risks of mortality were evaluated for a short and a longer follow-up period. Design and Methods: Baseline and mortality data from the Longitudinal Aging Study Amsterdam (N ¼ 1917, initial ages 55‐85 years) were used. Mortality risks were evaluated in Cox regression models at 3 and 7.5 years of follow-up, both adjusted for age and for sociodemographic characteristics, indicators of functional and mental health, lifestyle, and social involvement. All SRH measures were scaled from 1 (positive) to 5 (negative). Results: Baseline correlations between SRH concepts were similar for men and women. After 3 years, 12% of the men and 7% of the women had died; after 7.5 years, these percentages were 27 and 15, respectively. In fully adjusted models, current health perceptions predicted 3-year mortality in men (risk ratio of 1.33). At 7.5 years, mortality in men was predicted by current health perceptions and by SRH compared with age peers (risk ratios of 1.25 and 1.23, respectively). In women, no SRH concept predicted either 3-year or 7.5-year mortality. Implications: SRH was a predictor of mortality only in men, not in women. The gender difference showed most clearly at longer follow-up, in the SRH concept ‘‘comparison with age peers.’’

Recruitment and Retention of Latino Dementia Family Caregivers in Intervention Research: Issues to Face, Lessons to Learn

Abstract: Purpose: This article reviews and critiques several issues of importance to those whose goal is to make intervention research with Latino caregivers more "user-friendly." Issues range from current demographic trends showing the ever-increasing number of Latino caregivers to discussion of cultural values that influence their help-seeking behavior. Design and Methods: This article presents a review of current published information on this topic. The gerontological literature was searched for the past decade for relevant material; in addition, the authors' own experience in this area is described. Results: Although limited information was found that derived from actual empirical studies, a number of articles describe potential barriers to research involvement and provide suggestions for making participation more attractive and culturally appropriate for Latinos. Implications: Clinical researchers need to increase their sensitivity to such issues as cultural values and language preference and develop effective collaborations with the Latino community so that intervention research programs can be designed and implemented successfully with Latinos caring for cognitively impaired elderly family members at home.