Publications and Presentations > Gerontological Society of America Conference 2005 - Posters and Presentations

Gerontological Society of America Conference 2005 - Posters and Presentations

Symposium Overview: Enhancing Life Quality of Frail Elders: Effects of a Home Environmental Intervention on Function, Fall Efficacy and Mortality L.N. Gitlin

Functional disability, a major adverse outcome of chronic conditions, represents a sentinel event in the lives of older adults and is associated with depression, increased fear of falling, dependence on others, relocation and mortality. This symposium presents an NIA funded (#R50503) randomized controlled trial that tested an intervention to minimize functional difficulties in elders. The 10-contact intervention (Project ABLE) founded in Competence-Environmental Press and Life Span Theory of Control frameworks introduced control strategies (problem-solving, energy conservation, home modification, and falls prevention and recovery training skills) over 12 months. 319 community elders 70+ years old were randomly assigned to intervention or usual care. Results show that control strategies protect against the depressive effects of functional disability and afford positive mental health. At 6-months, compared with controls, intervention participants reported reduced functional difficulties, greater self-confidence, reduced fear of falling, and fewer home hazards, and these benefits were sustained at 12 months. Moreover, the intervention reduced the risk for mortality among intervention participants by 9%. Women and those 80+ years old benefited the most in select domains. Collectively, these papers suggest that a home-based intervention involving instruction in a wide range of control strategies has a profound effect on life quality for those at risk of functional decline. Next steps and translational challenges are discussed with emphasis on the theoretical and long-term care planning implications of these findings.

• The Role of Engagement Control Strategies in Protecting Against Depressive Symptoms in Elders with Functional Difficulties Dennis, Gitlin, Winter, Hauck, and Schulz
  
  Presented are cross-sectional analyses (N = 319) from Project ABLE which examine relationships between function-oriented engagement control strategies, disengagement, depressive symptomatology, and difficulties with basic (reaching), instrumental (meal preparation, IADLs), and self-care activities (bathing, ADLs). Engagement involved pursuit of attaining daily functional goals using behavioral and cognitive strategies whereas disengagement reflected resignation or giving up on maintaining physical function. Difficulties with Basic, IADL and ADL functioning were associated with higher depressive symptoms. The effect of Basic and ADL difficulties on depressive symptoms was moderated by engagement strategies whereas disengagement mediated relationships between depressive symptoms and Basic, ADL and IADL difficulties. Findings suggest that engagement control strategies protect against depressive effects of functional difficulties whereas disengagement attenuates risk for poor mental health. Engagement strategies reflect behavioral and cognitive strategies that can be taught to older adults. Implications for rehabilitative, home care and other service interventions are discussed.
  
• Short and Long-term Effects of Project ABLE: Reduced Functional Difficulties, Fear of Falling and Mortality L.N.Gitlin, L.Winter, M. Dennis, W. Hauck
  
  This paper presents short (6 months) and long-term (12 months) treatment effects of the Project ABLE intervention. At 6 months, intervention participants compared to controls reported reduced difficulties with ADLs (p = .033), and IADLs (p = .044), enhanced self-efficacy (p = .025), reduced fear of falling (p = .001), less near falls (p = .030), and greater use of control strategies (p = .009). Also, fewer home (p = .050) and bathroom hazards (p = .003) were observed. At 12 months benefits were sustained with no delayed treatment effects found. Also at 12 months, using Kaplan Meier Survival Analysis, we found that the relative risk of dying in 1 year was 8 times higher in the control than treatment group (p = .003). The agent or mechanism of action of the intervention may be control strategy use, which was also associated with reduced risk of mortality.

• Who Benefits from the Project ABLE Intervention? Age, Race and Gender Differences in Treatment Effects L. Winter, L. N. Gitlin, M. Dennis, W. Hauck
  
  This paper examines whether treatment effects of Project ABLE differed for whites or non-whites, men or women, young old (<80) or old old (> 80). In two domains at 6-months, activities of daily living (ADL) and mobility difficulties, treatment benefits differed by participants' age and gender, but not race. Older participants (80+ years of age) showed a greater benefit from treatment such that less difficulty was reported compared to participants under 80 (ADL difficulty, p =.015; mobility difficulty, p =.003). This interaction may be the result of higher difficulty levels with ADL and mobility in the older group at baseline. Similarly, women derived greater treatment benefits in ADL and mobility difficulty than did men (ADL difficulty, p =.034; mobility, p =.050). This may reflect women's greater tendency to comply with treatments involving behavioral modification and skills training as compared with men.

Symposium Overview: It Takes an Interdisciplinary Team: Translating Evidence-Based Practice into Community Based Health Promotion Programs

This symposium will feature four ongoing projects funded by the U.S. Administration on Aging (AoA) that share the goal of implementing and evaluating disease or injury prevention programs for older adults in community settings based on models found to be efficacious in randomized clinical trials (RCTs) as part of a larger effort to build a public/private partnership focused on increasing older Americans' access to effective health promotion programs at the community level. Each project presented at this symposium involves an interdisciplinary team drawn from aging services providers, area agencies on aging, health care providers and research organizations. Projects selected for this session are implementing translations of evidence-based programs that address heart disease self-management, chronic disease self-management with African American older adults, falls prevention, and medication management. The four AoA-funded projects are located in Albany, NY; Los Angeles, CA; Philadelphia, PA, and Portland, ME. Session presenters are primarily responsible for the evaluation of these local initiatives. They will provide a description of how each respective interdisciplinary team worked to maintain fidelity to the original research while enacting necessary adaptations for establishing a sustainable community based model. Preliminary findings will be presented concerning the achievement of outcomes comparable to the original RCTs

• Outcomes of Harvest Health: A Chronic Disease Self-Management Program for African American Older Adults. L. N. Gitlin, N.L. Chernett, M.P. Dennis
  
  Harvest Health, an interdisciplinary collaboration between an Area Agency for Aging, a senior center, a health care provider and a research institution is an evidence-based health program (Lorig's Chronic Disease Self-Management Program (CDSMP) implemented with 500 community-dwelling African American elders. The four-month evaluation for the first 94 participants shows statistically significant improvement in time spent in strengthening/stretching (p = .000); decreased health distress (p = .000); and reduced illness intrusion (physical well-being/diet (p = .006); work and finances (p = .047). Most important 95% reported continued use of disease self-management strategies. Evaluation results suggest it is possible to implement the CDSMP with elderly African Americans and retain treatment fidelity. Although other outcomes found by Lorig's research were not shown in this population (e.g., improved self-rated health and service utilization), the retention of healthy behaviors is promising. Lessons learned and implementation challenges will also be highlighted.

J. Rhoades, H. Black, Center for Applied Research on Aging and Health, Jefferson University, Suite 500, 130 S. 9 th Street, Philadelphia, PA 19107, Jennifer.Rhoades@Jefferson.edu.

This poster explores the concepts of religious and gender identity and their link to an individual's life-long self-view. It is based on ongoing research that investigates the personal meaning of suffering to a group of 120 community-dwelling elders aged 80 and above. Individuals are recruited from the Philadelphia area for in-depth, open-ended interviews and are stratified by self-reported health, gender, and ethnicity. In three sessions with each elder, interviewers elicit respondents' life story and story of suffering. Using a case study method we introduce an elderly woman whose gender and religious identities merge in her story of suffering: an incident of clergy abuse that occurred over seventy years previously, at age 13. Her reaction to this incident and to the ‘conspiracy of silence' by other authority figures throughout her life highlights her core identity. She consistently rejected gender and religious customs that encouraged women's submission to authority, despite abuse. Despite their censure, she remains outspoken in reporting this abuse to significant others, such as church authorities and family members. This research shows that elders need a voice for abuses they have experienced, and that have never been publicly acknowledged. Researchers and other health care professionals can provide a variety of forums for doing so.

The Role of Spiritual Well-being in Moderating Frail Elders' Affective Response to Functional Difficulty M. P. Dennis, L. N. Gitlin, L. Winter, Y. K. Chee

Anxiety and depression have been well documented as affective consequences of functional impairment. Little research, however, has examined factors that moderate these associations. The present cross-sectional study examined the role of spiritual well-being in buffering the impact of functional difficulty on the anxiety and depressive symptoms of 319 functionally vulnerable community-dwelling elders, aged 70 or older, participating in a 6-month randomized controlled trial designed to enhance function. As demonstrated in recent research on spirituality and health, we expected that spiritual well-being would moderate the association between functional difficulty and anxiety as well as the relationship between functional difficulty and depression. Functional difficulty was significantly associated with anxiety (r = .27, p = .000) and depression (r = .33, p = .000) such that anxiety and depression increased as did functional difficulty. Spiritual well-being was assessed using an 8-item subscale of Lawton et al.'s (2001) Valuation of Life scale (e.g., “Life has meaning for me.”). After controlling for demographic and health conditions, results of separate regression analyses indicated that spiritual well-being had a moderating effect on the association between functional difficulty and depression (R 2 = .42, p [interaction] = .041), i.e., elders with greater functional difficulty and greater spiritual well-being experienced less depression. Contrary to expectations, spiritual well-being did not buffer the effect of functional difficulty on anxiety. Spiritual well-being has a differential effect on mental health. It appears to afford protection against the depressive consequences of functional impairment in frail elders but not anxiety. (NIA funded #AG 13687).

Social Support and Self-Management of Diabetes. AJ Schwartz, JM Kinney, & CS Kart, Miami University, Oxford, OH 45056.

Day-to-day management of diabetes mellitus (DM) rests with the individual with DM, as well as those in her/his social constellation. Yet, little is known about the impact of social support on self-management of this disease. Surveys were distributed to 112 adults 40 years of age and older and diagnosed with DM who were recruited at meetings of the Fraternal Order of Eagles in locations across Ohio . Social support was measured using the Perceived Social Support from Friends and Family Scale; the Summary of Diabetes Self-Care Activities (SDSCA) measured the frequency of self-management activities in 5 regimen areas (e.g. diet, exercise, foot care, glucose testing, and medication use) over the prior 7 days. Two regimen areas were added measuring alcohol/smoking behavior and use of complementary medicine (i.e., use of herbs, vitamins). Selected demographic characteristics and DM experiences were also collected. When surveys were returned, participants were provided with an FDA-approved at-home kit to collect a dried blood sample for HbA1c testing. The median age of respondents was 62 years and the median age at which they report being first diagnosed with DM was 52 years. On average, respondents report significantly more support from family (14.13, sd = 5.4) than from friends (12.74, sd = 4.3). Although relationships between perceived social support from family/friends and selected SDSCA regimen areas approached statistical significance, respondents with high perceived social support from family did show significantly higher HbA1c tests (= 7.3). Mechanisms through which family social support might inhibit effective self-management of DM are discussed.

The Tension of Loss in Old Age

C.Caruso & H.Black Thomas Jefferson University, Center for Applied Research in Aging and Health (CARAH), 130 South 9 th Street, Philadelphia, PA 19107 cjm107@jefferson.edu.

Our poster is based on a larger qualitative study that explores the personal meaning of suffering to 122 community-dwelling elders. Because loss in old age emerges as a significant aspect of suffering in elders' narratives, we focus on suffering as loss. We are recruiting community dwelling elders aged 80 and above, stratified by ethnicity, gender and self-reported health for extended qualitative interviews. Respondents tell their life story and story of suffering along with personal definitions of suffering. Through narrative analysis we examine responses to the many losses experienced during a long life and the suffering that results from loss. By old age, elders have endured many significant losses (jobs, education, friendships, death) and are considered more familiar with loss than younger persons. Most respondents use personal tools, such as strong self-view, optimism, or keeping busy in order to manage the suffering that results from loss. In this poster we use a case study to demonstrate how one elderly woman's standard of accepting loss failed in the face of her daughter's death. Mrs. W's case study reveals the tension between a theory about loss, and the lived experience of loss that results in suffering. Her narrative has implications for health care professionals involved in any type of grief work. If a world or self view has ‘worked' for an individual throughout their life, it may be difficult to alter that viewpoint in old age.

Imagining the Alternative to Life-sustaining Treatments: Beliefs about the Dying Experience Laraine Winter, Ph.D. and Barbara Parker, B.A .

In advance care documents people express preferences regarding medical interventions (e.g., tube feeding) should they become decisionally incapacitated. Since the treatments are understood to be life-sustaining, such questions implicitly pose choices between treatment and death. But, although the treatments may be explained, the experience of dying without them is seldom described, leaving individuals to supply their own assumptions about the dying experience. What do people imagine a death without the treatments would be like? In a qualitative study, 37 elderly men and woman told us their beliefs about dying without each treatment described in the Life-Prolonging Treatment Preferences Questionnaire (antibiotics, gall bladder surgery, CPR, tube feeding) – how painful it would be, how long it would take, how lonely it would be, whether palliative care would be available, and (if so) how effective it would be. Open-ended responses were coded and tallied. Percentages who believed the death would be terrible or unbearable varied by treatment: 75.7% for antibiotics, 84% for surgery, 40% for tube feeing, 38% for CPR. Beliefs that the death would be lonely were 68% for antibiotics, 57% for surgery, 54% for tube feeding. Only one elder ever independently mentioned palliative care. Yet, when explicitly asked, at least 75% thought it would probably be available, and most thought it would be effective. These results indicate the need for improved public understanding of palliative care services. People's ideas about the alternatives to life-sustaining treatment should inform how advance care documents are written and discussions conducted.

What is Valuation of Life for Frail Community-dwelling Older Adults: Factor Structure and Criterion Validity of the VOL M. P. Dennis, L. Winter, H. Black, L. N. Gitlin

Lawton et al. (1999) defined valuation of life (VOL) as a cognitive-affective schema consisting of complex judgments, emotions and projections influenced by demographic and QOL factors. However, little is known about what constitutes VOL for frail elders. The present study evaluated the psychometric properties of a 13-item version of Lawton et al's. (2001) VOL Scale and examined correlational evidence in support of its construct validity with 319 elders enrolled in the Project ABLE study. Responses of half the sample (N=159) were submitted to principal axis factoring, yielding two factors (spiritual well-being, a = .88 and goal-related self-efficacy, a = .84), accounting for 56% of the variance. For remaining elders (N = 160), reliability analyses indicated that the 13-item VOL was internally consistent (a = .91). We expected and found that low depression (p = .000), high mastery (p = .000) and greater use of control strategies (p = .000) were predictive of VOL (R 2 = .42, p = .000), spiritual well-being (R 2 = .38, p = .000) and goal-related self-efficacy (R 2 = .31, p = .000), but falls and cognitive status were not. Participants' social support and race were also associated with VOL with non-whites scoring higher on VOL (M = 53.6 vs. M = 48.2).VOL is a complex construct composed of two dimensions, spiritual well-being and confidence in goal pursuit. These dimensions suggest that behavioral and cognitive activation is central to understanding how older adults appraise or value their life. (Study funded by NIA #AG 13687)

From Randomized Controlled Trials to Real-Life: Models for Moving Caregiver Intervention Research to Community and Home L.N. Gitlin

Despite 15 years of intervention research to support family caregivers, with studies showing positive results, the gap in transition from research to practice persists. Factors contributing to the gap include the lack of appropriate reimbursement funding streams, staff training, and effective models for translating interventions tested in research environments to real-world settings. This paper presents three models for translating family caregiver interventions into practice settings as illustrated by case studies of proven interventions. One model, referred to as "embedded", involves testing interventions within practice settings for which it is intended. The second model, "forced" or top down, involves moving through translational steps to implement the intervention in the aging network. The third model, "hybrid" involves moving reimburseable components of interventions to practice. The elements of each model, their relative strengths and evaluative needs are explored.