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1.  Assessing capacity in suspected cases of self-neglect 
Geriatrics  2008;63(2):24-31.
Self-neglect is a serious and burgeoning public health challenge representing the most common problem faced by Adult Protective Services agencies. Among older adults who are vulnerable to self-neglect, the capacity to make decisions may remain intact. However, the capacity to identify and extract oneself from harmful situations, circumstances, or relationships may be diminished. A key ethical and clinical branch point in identifying older adults at risk for self-neglect involves determining whether the individual can both make and implement decisions regarding personal needs, health, and safety. The Articulate Demonstrate method is a practical and efficient way to screen capacity in the setting of suspected self-neglect. Once self-neglect has been identified, common clinical interventions can be targeted to the diagnosed deficits that foster vulnerability to neglect in older adults.
PMCID: PMC2847362  PMID: 18312020
elder abuse and neglect; self-neglect; capacity; geriatric assessment
2.  Exploring Self-neglect in Older Adults: Preliminary Findings of the Self-Neglect Severity Scale and Next Steps 
Journal of the American Geriatrics Society  2008;56(Suppl 2):S253-S260.
Despite the public health implications of self-neglect, no tool exists for characterizing this condition. Self-neglecters often have no caregivers or surrogates to interview regarding the neglect, and are often too cognitively impaired to provide valid self-reports. In response to this need, researchers from the Consortium for Research in Elder Self-neglect of Texas (CREST), collaborated with other experts in the field of elder self-neglect to design the Self-neglect Severity Scale (SSS). The SSS assesses three domains of self-neglect: hygiene, functioning, and environment and relies on observational ratings assigned by trained observers. Following pilot testing and revision, the SSS was field tested in the homes of subjects who had been reported to and substantiated by Texas Adult Protective Services (APS) as self-neglecting, and compared to subjects recruited from a local geriatric clinic who were reported to APS and who had no history of self-neglect.
The first field test demonstrated that the SSS could distinguish elder self-neglecters from community dwellers that do not self-neglect. The SSS exhibited adequate scale reliability (Cronbach’s alpha) and correlation with case status. Interrater reliability also appeared adequate although sensitivity and specificity fell below the conventional acceptable range. Future methods are proposed for refining the SSS to improve its use as the benchmark for identifying elder self-neglect.
doi:10.1111/j.1532-5415.2008.01977.x
PMCID: PMC2743305  PMID: 19016968
screening; self-neglect; environment
3.  Conceptual Challenges and Practical Approaches to Screening Capacity for Self-care and Protection in Vulnerable Older Adults 
Identifying impairments in the capacity to make and execute decisions is critical to the assessment and remediation of elder self-neglect. Few capacity assessment tools are available for use outside of health care settings and none have been validated in the context of elder self-neglect. Health and social services professionals are in need of validated tools to assess capacity for self-care and self protection during initial evaluations of older adults with suspected self-neglect syndrome. Currently, legal and medical declarations of incapacity and guardianship rely on clinical evaluations and instruments developed to assess only decision-making capacity. This paper first describes the conceptual and methodological challenges to assessing the capacity to make and execute decisions regarding safe and independent living. Second, the paper describes the pragmatic obstacles to developing a screening tool for the capacity for self-care and self protection (SC&P). Finally, the paper outlines the process for validation and field testing of the screening tool. A valid and feasible screening tool can then be used during field assessments by social services professionals to screen for potential impairments in the capacity for self-care and protection in vulnerable older adults.
doi:10.1111/j.1532-5415.2008.01979.x
PMCID: PMC3717403  PMID: 19016970
self-neglect syndrome; elder abuse and neglect; capacity; decision making
4.  Association Between Elder Self-Neglect and Hospice Utilization in a Community Population 
Elder self-neglect is associated with substantial 1-year mortality. However, hospice utilization among those with self-neglect remain unclear. The objective of this study is to quantify the prospective relation between self-neglect and risk for hospice utilization in a community population of older adults. Prospective population-based study in a geographically-defined community in Chicago of older adults who participated in the Chicago Health and Aging Project. Of the 8,669 participants in the Chicago Health and Aging Project, a subset of 1,438 participants was reported to social services agency for suspected elder self-neglect. Outcome of interest was the hospice utilization obtained from the Center for Medicare and Medicaid System. Cox proportional hazard models were used to assess independent association of self-neglect with risk of hospice utilization using time-varying covariate analyses. After adjusting for potential confounding factors, elders who self-neglect was associated with increased risk for hospice utilization (HR, 2.43, 95% CI, 2.10-2.81). Greater self-neglect severity (Mild: (HR, 2.12 (1.61-2.79); Moderate: (HR, 2.36 (1.95-2.84); Severe: (HR, 4.66 (2.98-7.30)) were associated with increased risk for hospice utilization. Interaction term analyses suggest that the significant relationship between self-neglect and hospice utilization was not mediated through medical conditions, cognitive impairment and physical disability. Moreover, self-neglect was associated with shorter length of stay in hospice (PE, −0.27, SE, 0.12, p<0.02) and shorter time from hospice admission to death (PE, −0.32, SE, 0.13, p<0.01). Elder self-neglect was associated with increased risk of hospice use in this community population. Elder self-neglect is associated with shorter length of stay in hospice care and shorter time from hospice admission to death.
doi:10.1016/j.archger.2012.06.008
PMCID: PMC3495081  PMID: 22770866
elder self-neglect; hospice services utilization; population-based study
5.  Association of Personality Traits with Elder Self-Neglect in a Community Dwelling Population 
Objective
Elder self-neglect is an important public health issue. However, little is known about the association between personality traits and risk of elder self-neglect among community-dwelling populations. The objectives of this study are: 1) to examine the association of personality traits with elder self-neglect and 2) to examine the association of personality traits with elder self-neglect severity.
Methods
Population-based study conducted from 1993–2005 of community-dwelling older adults (N=9,056) participating in the Chicago Health Aging Project (CHAP). Subsets of the CHAP participants (N=1,820) were identified for suspected self-neglect by social services agency, which assessed the severity. Personality traits assessed included neuroticism, extraversion, rigidity and information processing. Logistic and linear regressions were used to assess these associations.
Results
In the bivariate analyses, personality traits (neuroticism, extraversion, information processing, and rigidity) were significantly associated with increased risk of elder self-neglect. However, after adjusting for potential confounders, the above associations were no longer statistically significant. In addition, personality traits were not associated with increased risk of greater self-neglect severity. Furthermore, interaction term analyses of personality traits with health and psychosocial factors were not statistically significant with elder self-neglect outcomes.
Conclusion
Neuroticism, extraversion, rigidity and information processing were not associated with significantly increased risk of elder self-neglect after consideration of potential confounders.
doi:10.1097/JGP.0b013e3182006a53
PMCID: PMC3145969  PMID: 21788924
elder self-neglect; personality traits; population-based study
6.  Prevalence of Self-Neglect across Gender, Race, and Socioeconomic Status: Findings from the Chicago Health and Aging Project 
Gerontology  2011;58(3):258-268.
Background
Self-neglect is the behavior of an elderly person that threatens his/her own health and safety, and it is associated with increased morbidity and mortality. However, the scope of the self-neglect in the community population remains unclear. We examined the prevalence of self-neglect and its specific behaviors of hoarding, hygiene and other environmental hazards in a community-dwelling elderly population.
Methods
A population-based cohort study conducted from 2007 to 2010 in a single cycle in a geographically defined community of 4 adjacent neighborhoods in Chicago, Ill., USA. Participant's personal and home environment was rated on hoarding, personal hygiene, house in need of repair, unsanitary conditions, and inadequate utility. Prevalence estimates were presented across gender, race/ethnicity, education and income levels.
Results
There were 4,627 older adults in the cohort. The prevalence of self-neglect and specific personal and environmental hazards varied significantly by race/ethnicity and by levels of education and income. For race/ethnicity, black older adults (men 13.2%; women 10.9%) had a significantly higher prevalence of self-neglect than white older adults (men 2.4%; women 2.6%). For those with less than high school education, the prevalence of the self-neglect was 14.7% in men and 10.9% in women. For those with an annual income of less than USD 15,000, the prevalence of self-neglect was 21.7% in men and 15.3% in women.
Conclusion
The prevalence of self-neglect and specific behaviors of hoarding, poor hygiene, and other environmental hazards are higher among black older adults and among those with lower levels of education and income.
doi:10.1159/000334256
PMCID: PMC3362301  PMID: 22189358
Self-neglect; Hoarding; Hygiene; Squalor; Environmental hazards; Population-based study
7.  Elder Self-Neglect and Hospitalization: Findings from the Chicago Health and Aging Project 
Objectives
The objective of this study is to quantify the relation between reported elder self-neglect and rate of hospitalization in a community population of older adults.
Design
Prospective population-based study
Setting
Geographically-defined community in Chicago.
Participants
Community-dwelling older adults who participated in the Chicago Health and Aging Project. Of the 6,864 participants in the Chicago Health and Aging Project, a subset of 1,165 participants was reported to social services agency for suspected elder self-neglect.
Measurements
The primary predictor was elder self-neglect reported to social services agency. Outcome of interest was the annual rate of hospitalization obtained from the Center for Medicare and Medicaid System. Poisson regression models were used to assess these longitudinal relationships.
Results
The average annual rate of hospitalization for those without elder self-neglect was 0.6 (1.3) and for those with reported elder self-neglect was 1.8 (3.2). After adjusting for sociodemographic, socioeconomic, medical commorbidities, cognitive function and physical function, elders who self-neglect had significantly higher rate of hospital utilization (RR, 1.47, 95% CI, 1.39–1.55). Greater self-neglect severity (Mild: PE=0.24, SE=0.05, p<0.001; Moderate: PE=0.45, SE=0.03, p<0.001; Severe: PE=0.54, SE=0.11, p<0.001) were associated with increased annual rates of hospital utilization, after considering same confounders. Interaction term analyses suggest that the significant relationship between self-neglect and hospitalization was not mediated through medical conditions, cognitive impairment and physical disability.
Conclusion
Reported elder self-neglect was associated with increased rates of hospitalization in this community population. Greater self-neglect severity was associated with a greater increase in the rate of hospitalization.
doi:10.1111/j.1532-5415.2011.03821.x
PMCID: PMC3288156  PMID: 22283642
elder self-neglect; health services utilization; population-based study
8.  A Prospective Population-Based Study of Differences in Elder Self-Neglect and Mortality Between Black and White Older Adults 
Background.
Self-neglect is the behavior of an elderly person that threatens his or her own health and safety, and it is associated with increased morbidity and mortality. Although report of self-neglect is more common among black older adults, the racial/ethnic differences in mortality remain unclear.
Methods.
The Chicago Healthy Aging Project is a population-based cohort study conducted from 1993 to 2005. A subset of these participants were suspected to self-neglect and were reported to a social services agency. Mortality was ascertained during follow-up and from the National Death Index. Cox proportional hazards models were used to assess the mortality risk.
Results.
In the total cohort, there were 5,963 black and 3,475 white older adults, and of these, 1,479 were reported for self-neglect (21.7% in black and 5.3% in white older adults). In multivariable analyses with extensive adjustments, the interaction term indicated that impact of self-neglect on mortality was significantly stronger in black than in white older adults (parameter estimate, 0.54, SE, 0.14, p < .001). This difference persisted over time. In race/ethnicity-stratified analyses, at 6 months after report of self-neglect, the hazard ratio for black older adults was 5.00 (95% confidence interval, 4.47–5.59) and for white older adults was 2.75 (95% confidence interval, 2.19–3.44). At 3 years after report, the hazard ratios were 2.61 (95% confidence interval, 2.25–3.04) and 1.47 (95% confidence interval, 1.10–1.96) for black older adults and white older adults, respectively.
Conclusions.
Future studies are needed to qualify the casual mechanisms between self-neglect and mortality in black and white older adults in order to devise targeted prevention and intervention strategies.
doi:10.1093/gerona/glr053
PMCID: PMC3110911  PMID: 21498840
Self-neglect; Health disparity; Population-based study; Race/ethnicity; Mortality
9.  Prospective Study of the Elder Self-Neglect and Emergency Department Use in a Community Population 
Purpose
This study aims to quantify the relation between elder self-neglect and rate of emergency department utilization in a community-dwelling population.
Methods
A prospective population-based study is conducted in a geographically-defined community in Chicago of community-dwelling older adults who participated in the Chicago Health and Aging Project. Of the 6,864 participants in the Chicago Health and Aging Project, 1,165 participants were reported to social services agency for suspected elder self-neglect. The primary predictor was elder self-neglect reported to social services agency. The outcome of interest was the annual rate of emergency department utilization obtained from the Center for Medicare and Medicaid Services. Poisson regression models were used to assess these longitudinal relationships.
Results
The average annual rate of emergency department visits for those without elder self-neglect was 0.6 (1.3) and for those with reported elder self-neglect was 1.9 (3.4). After adjusting for sociodemographics, socioeconomic variables, medical conditions, cognitive and physical function, elders who self-neglect had significantly higher rates of emergency department utilization (RR, 1.42, 95% CI, 1.29–1.58). Greater self-neglect severity (Mild: PE=0.27, SE=0.04, p<0.001; Moderate: PE=0.41, SE=0.03, p<0.001; Severe: PE=0.55, SE=0.09, p<0.001) was associated with increased rates of emergency department utilization, after considering the same confounders.
Conclusion
Elder self-neglect was associated with increased rates of emergency department utilization in this community population. Greater self-neglect severity was associated with a greater increase in the rate of emergency department utilization.
doi:10.1016/j.ajem.2011.02.008
PMCID: PMC3131483  PMID: 21411263
elder self-neglect; emergency department utilization; population-based study
10.  Advancing the Field Elder Abuse: Future Directions and Policy Implications 
Elder abuse, sometime called elder mistreatment or elder maltreatment, includes psychological, physical, and sexual abuse, neglect (caregiver neglect and self-neglect), and financial exploitation. Evidence suggests that 1 out of 10 older adult experiences some form of elder abuse, and only 1 of out 25 cases are actually reported to social services agencies. At the same time, elder abuse is associated with significant morbidity and premature mortality. Despite these findings, there is a great paucity in research, practice, and policy dealing with the pervasive issues of elder abuse. Through my experiences as a American Political Sciences Association Congressional Policy Fellow/Health and Aging Policy Fellow working with Administration on Community Living (ACL) (Previously known at Administration on Aging (AoA)) for the last two years, I will describe the major functions of the ACL; and highlight on two major pieces of federal legislation: The Older Americans Act (OAA) and the Elder Justice Act (EJA). Moreover, I will highlight major research gaps and future policy relevant research directions for the field of elder abuse.
doi:10.1111/j.1532-5415.2012.04211.x
PMCID: PMC3498608  PMID: 23110488
elder abuse; health policy; national health and aging policy fellow
11.  Cross-Sectional Study of the Characteristics of Reported Elder Self-Neglect in a Community-Dwelling Population: Findings from a Population-Based Cohort 
Gerontology  2009;56(3):325-334.
Background
Elder self-neglect is an important public health issue. However, little is known about the characteristics of self-neglect and its association with social factors among community-dwelling populations. Objectives: (1) To examine the sociodemographic, health-related and psychosocial characteristics of reported elder self-neglect; (2) to examine the association of social network and social engagement with reported self-neglect.
Methods
Population-based study conducted from 1993 to 2005 of community-dwelling subjects (n = 9,056) participating in the Chicago Health and Aging Project (CHAP). Subsets of the CHAP subjects (n = 1,812) were identified for suspected self-neglect by the social services agency, which also assessed the severity. This reported group was compared with the unreported group in the CHAP across the sociodemographic, health-related and psychosocial variables. Logistical regressions were used to assess the association of social factors and self-neglect.
Results
Older age, women, African-Americans, and those with lower education or lower income were more likely to be reported for self-neglect. Those reported for self-neglect were more likely to have lower levels of cognitive and physical function, nutritional status, psychosocial function and a higher number of medical comorbidities. After adjusting for confounders, lower levels of social network and social engagement were significantly associated with an increased risk of reported self-neglect. Among the reported cases of self-neglect, the study found increased trends of older age, women, African-American, lower income, lower cognitive and physical function, lower social engagement and a higher number of chronic medical conditions with self-neglect severity.
Conclusion
Reported self-neglect elders have multiple sociodemographic, health-related and psychosocial characteristics that are different than elders not reported. Lower levels of social network and social engagement were associated with increased risk of self-neglect.
doi:10.1159/000243164
PMCID: PMC2865493  PMID: 19786733
Self-neglect; Social network; Social engagement; Aging; Elderly; Cross-sectional study; Population-based study
12.  The Walking Egg Project: Universal access to infertility care – from dream to reality 
Facts, Views & Vision in ObGyn  2013;5(2):161-175.
Childlessness and infertility care are neglected aspects of family planning in resource-poor countries, although the consequences of involuntary childlessness are much more dramatic and can create more wide ranging societal problems compared to Western societies, particularly for women. Because many families in developing countries completely depend on children for economic survival, childlessness has to be regarded as a social and public health issue and not only as an individual medical problem.
In the Walking Egg Project we strive to raise awareness surrounding childlessness in resource-poor countries and to make infertility care in all its aspects, including assisted reproductive technologies, available and accessible for a much larger part of the world population.
We hope to achieve this goal through innovation and research, advocacy and networking, training and capacity building and service delivery. The Walking Egg non-profit organization has chosen a holistic approach of reproductive health and therefore strengthening infertility care should go together with strengthening other aspects of family planning and mother care.
Right from the start The Walking Project has approached the problem of infertility in a multidisciplinary and global manner. It gathers medical, social, ethical, epidemiological, juridical and economical scientists and experts along with artists and philosophers to discuss and work together towards its goal.
We recently developed a simplified tWE lab IVF culture system with excellent results. According to our first cost calculation, the price of a single IVF cycle using the methodologies and protocols we described, seems to be less than 200 Euros.
We realize that universal access to infertility care can only be achieved when good quality but affordable infertility care is linked to effective family planning and safe motherhood programmes. Only a global project with respect to sociocultural, ethical, economical and political differences can be successful.
PMCID: PMC3987356  PMID: 24753941
Assisted reproduction; developing countries; infertility care; intrauterine insemination; IVF; medical education; one-step diagnostic phase; resource-poor countries; simplified IVF; sociocultural factors
13.  Manifestations of Indirect Self-destructiveness and Methods of Suicide Attempts 
The Psychiatric Quarterly  2012;84(2):197-208.
The method of suicide attempt is related to motivational processes and the psycho(patho)logical mechanisms and traits of an individual. Indirect self-destructiveness is related to direct self-destructiveness. It is presumed that it can transform to the latter thus leading to suicide attempts or death by suicide. The study objective was to examine the relationship between individual manifestations of indirect self-destructiveness and the methods of suicide attempt as well as to explore the indirect predictors of particular suicide methods. The study was conducted among 147 persons (114 females, 33 males) who attempted suicide. The research instrument was the Polish version of the “Chronic Self-Destructiveness Scale” (CS-DS), including Transgression and Risk, Poor Health Maintenance, Personal and Social Neglects, Lack of Planfulness, and Helplessness and Passiveness in the face of problems. Correlation and regression analyses were applied. A number of statistically significant correlations were found between indirect self-destructiveness, or its manifestations, and the methods of suicide attempt. Moreover, the particular categories of indirect self-destructive behaviour were found to largely determine the choice of the method of suicide attempt. Among these categories, the strongest predictor appeared to be Helplessness and Passiveness in the face of problems. The method of suicide attempt is a variable related to psychosocial determinants of suicidal behaviour. The findings of this study may prove useful in the design and implementation of therapeutic activities focused on persons who attempted suicide. Recognising the particular manifestations of indirect self-destructive behaviours of an attempter can guide implementation of therapeutic measures, for him/her e.g. via strengthening coping skills and eliminating risk factors for self-harm.
doi:10.1007/s11126-012-9239-x
PMCID: PMC3656246  PMID: 23054261
Indirect self-destructiveness; Transgression and Risk; Poor health maintenance; Personal and social neglects; Lack of planfulness; Helplessness and passiveness; Suicide attempt methods
14.  Ethical problems in pediatrics: what does the setting of care and education show us? 
BMC Medical Ethics  2012;13:2.
Background
Pediatrics ethics education should enhance medical students' skills to deal with ethical problems that may arise in the different settings of care. This study aimed to analyze the ethical problems experienced by physicians who have medical education and pediatric care responsibilities, and if those problems are associated to their workplace, medical specialty and area of clinical practice.
Methods
A self-applied semi-structured questionnaire was answered by 88 physicians with teaching and pediatric care responsibilities. Content analysis was performed to analyze the qualitative data. Poisson regression was used to explore the association of the categories of ethical problems reported with workplace and professional specialty and activity.
Results
210 ethical problems were reported, grouped into five areas: physician-patient relationship, end-of-life care, health professional conducts, socioeconomic issues and health policies, and pediatric teaching. Doctors who worked in hospitals as well as general and subspecialist pediatricians reported fewer ethical problems related to socioeconomic issues and health policies than those who worked in Basic Health Units and who were family doctors.
Conclusions
Some ethical problems are specific to certain settings: those related to end-of-life care are more frequent in the hospital settings and those associated with socioeconomic issues and public health policies are more frequent in Basic Health Units. Other problems are present in all the setting of pediatric care and learning and include ethical problems related to physician-patient relationship, health professional conducts and the pediatric education process. These findings should be taken into consideration when planning the teaching of ethics in pediatrics.
Trial registration
This research article didn't reports the results of a controlled health care intervention. The study project was approved by the Institutional Ethical Review Committee (Report CEP-HIJG 032/2008).
doi:10.1186/1472-6939-13-2
PMCID: PMC3317842  PMID: 22424271
15.  Older Adults with Multi-Morbidity: Medication Management Processes and Design Implications for Personal Health Applications 
Background
Older adults often have multiple chronic problems requiring them to manage complex medication regimens overseen by various clinicians. Personal health applications (PHAs) show promise assisting in medication self-management, but adoption of new computer technologies by this population is challenging. Optimizing the utility of PHAs requires a thorough understanding of older adults’ needs, preferences, and practices.
Objective
The objective of our study was to understand the medication self-management issues faced by older adults and caregivers that can be addressed by an electronic PHA.
Methods
We conducted a qualitative analysis of a series of individual and group semistructured interviews with participants who were identified through purposive sampling.
Results
We interviewed 32 adult patients and 2 adult family caregivers. We identified 5 core themes regarding medication self-management challenges: seeking reliable medication information, maintaining autonomy in medication treatment decisions, worrying about taking too many medications, reconciling information discrepancies between allopathic and alternative medical therapies, and tracking and coordinating health information between multiple providers.
Conclusions
This study provides insights into the latent concerns and challenges faced by older adults and caregivers in managing medications. The results suggest that PHAs should have the following features to accommodate the management strategies and information preferences of this population: (1) provide links to authoritative and reliable information on side effects, drug interactions, and other medication-related concerns in a way that is clear, concise, and easy to navigate, (2) facilitate communication between patients and doctors and pharmacists through electronic messaging and health information exchange, and (3) provide patients the ability to selectively disclose medication information to different clinicians.
doi:10.2196/jmir.1813
PMCID: PMC3221383  PMID: 21715286
Older adults; medication management; health records, personal
16.  Assessing barriers to the identification of elder abuse and neglect: a communitywide survey of primary care physicians. 
Elder abuse and neglect represents an extensive medical and social problem in the United States with an estimated prevalence of 4-10% of older persons. Physicians are mandated to report suspected abuse, but <2% of Adult Protective Service reports are filed by physicians. A knowledge or attitude survey was mailed to all adult primary care physicians in the study community. The intent was to explore possible knowledge deficits and perceived barriers to physician reporting. Regarding the attitude measure, physicians expressed that a lack of understanding of reporting mechanisms represented the most significant obstacle. Regarding the knowledge measure, a majority of the responding physicians were unable to recognize key risk factors for abuse. Study findings will be used to develop local educational programs to enhance physician understanding of elder abuse.
PMCID: PMC2576103  PMID: 16573305
17.  Elder Self-neglect and Abuse and Mortality Risk in a Community-Dwelling Population 
Context
Both elder self-neglect and abuse have become increasingly prominent public health issues. The association of either elder self-neglect or abuse with mortality remains unclear.
Objective
To examine the relationship of elder self-neglect or abuse reported to social services agencies with all-cause mortality among a community-dwelling elderly population.
Design, Setting, and Participants
Prospective, population-based cohort study (conducted from 1993 to 2005) of residents living in a geographically defined community of 3 adjacent neighborhoods in Chicago, Illinois, who were participating in the Chicago Health and Aging Project (CHAP; a longitudinal, population-based, epidemiological study of residents aged ≥65 years). A subset of these participants had suspected elder self-neglect or abuse reported to social services agencies.
Main Outcome Measures
Mortality ascertained during follow-up and by use of the National Death Index. Cox proportional hazard models were used to assess independent associations of self-neglect or elder abuse reporting with the risk of all-cause mortality using time-varying covariate analyses.
Results
Of 9318 CHAP participants, 1544 participants were reported for elder self-neglect and 113 participants were reported for elder abuse from 1993 to 2005. All CHAP participants were followed up for a median of 6.9 years (interquartile range, 7.4 years), during which 4306 deaths occurred. In multivariable analyses, reported elder self-neglect was associated with a significantly increased risk of 1-year mortality (hazard ratio [HR], 5.82; 95% confidence interval [CI], 5.20–6.51). Mortality risk was lower but still elevated after 1 year (HR, 1.88; 95% CI, 1.67–2.14). Reported elder abuse also was associated with significantly increased risk of overall mortality (HR, 1.39; 95% CI, 1.07–1.84). Confirmed elder self-neglect or abuse also was associated with mortality. Increased mortality risks associated with either elder self-neglect or abuse were not restricted to those with the lowest levels of cognitive or physical function.
Conclusion
Both elder self-neglect and abuse reported to social services agencies were associated with increased risk of mortality.
doi:10.1001/jama.2009.1109
PMCID: PMC2965589  PMID: 19654386
18.  Gender Differentiation in Indirect Self-Destructiveness and Suicide Attempt Methods (Gender, Indirect Self-Destructiveness, and Suicide Attempts) 
The Psychiatric Quarterly  2013;85:197-209.
The objective of this study is to examine the gender (sex) differentiation of indirect self-destructiveness and its manifestations as well as its relationships with suicide attempt methods in females and males. The study was conducted among 147 persons (114 females, 33 males) who attempted suicide. The research instrument was the polish version of the Chronic Self-Destructiveness Scale including Transgression and Risk, Poor Health Maintenance, Personal and Social Neglects, Lack of Planfulness, and Helplessness and Passiveness in the face of problems. Differences testing and correlation analyses were applied. Females scored higher on poor health maintenance and males scored significantly higher on personal and social neglects, lack of planfulness, and helplessness. Noteworthy is that the intensity of indirect self-destructiveness in females reached the same magnitude as in males. A number of statistically significant correlations were found between indirect self-destructiveness, or its manifestations, and the methods of suicide attempt in the two groups. Among these categories, the highest contribution was of helplessness and passiveness (both of groups), poor health maintenance (males), and personal and social neglects (females). Results of this study can be useful in the therapeutic efforts and prevention of not only indirectly self-destructive behaviours but also possible suicide attempts. Both preventive and therapeutic activities can take into account the specificity of those phenomena resulting from one’s sex/gender. It is important to adapt preventive and therapeutic measures to psychological (personal) features that arise from an individual’s sex/gender.
doi:10.1007/s11126-013-9283-1
PMCID: PMC3991825  PMID: 24302076
Indirect self-destructiveness; Gender; Sex; Suicide attempt methods
19.  John Snow’s legacy: epidemiology without borders 
Lancet  2013;381(9874):1302-1311.
This Review provides abstracts from a meeting held at the London School of Hygiene and Tropical Medicine, on April 11–12, 2013, to celebrate the legacy of John Snow. They describe conventional and unconventional applications of epidemiological methods to problems ranging from diarrhoeal disease, mental health, cancer, and accident care, to education, poverty, financial networks, crime, and violence. Common themes appear throughout, including recognition of the importance of Snow’s example, the philosophical and practical implications of assessment of causality, and an emphasis on the evaluation of preventive, ameliorative, and curative interventions, in a wide variety of medical and societal examples. Almost all self-described epidemiologists nowadays work within the health arena, and this is the focus of most of the societies, journals, and courses that carry the name epidemiology. The range of applications evident in these contributions might encourage some of these institutions to consider broadening their remits. In so doing, they may contribute more directly to, and learn from, non-health-related areas that use the language and methods of epidemiology to address many important problems now facing the world.
doi:10.1016/S0140-6736(13)60771-0
PMCID: PMC3730273  PMID: 23582396
20.  A survey of the 16 Canadian child and youth protection programs: A threadbare patchwork quilt 
Paediatrics & Child Health  2007;12(3):205-209.
BACKGROUND
Child abuse and neglect (CAN) represents an international public health and societal problem, the extent and nature of which are inadequately understood. Child and youth protection programs (CYPPs), based in 16 Canadian paediatric academic health science centres, identify, manage, treat and prevent cases of CAN.
OBJECTIVES
To ascertain the structure, resources and functioning of Canadian CYPPs.
METHODS
Telephone interviews were conducted with the directors of the 16 CYPPs.
RESULTS
Full-time equivalent staffing ranged from 0.25 to 18.7 people. All programs were staffed with physicians. The majority of programs had social workers (14 of 16) and administrative staff (12 of 16), while fewer programs had a dedicated nurse (nine of 16) or psychologists (six of 16). All CYPPs provided medical examinations and psychosocial assessments, consultation and coordination of CAN cases within the hospital and with community professionals, expert medico-legal opinions and representation in court, and hospital in-service and community outreach education and advocacy. Nine centres participated in regular multi-agency reviews of cases. Fourteen centres had specialized teams for acute sexual assault. Academic activities include lectures to medical students (16 of 16), undergraduate clinical electives (11 of 16), mandatory clinical rotations for paediatric residents (10 of 16) and/or electives (15 of 16), a fellowship (one of 16) and research on CAN-related issues (11 of 16). CAN documentation was inconsistent and limited, underestimating the number of cases assessed within the CYPPs.
CONCLUSION
CYPPs appear to need further resources to care for maltreated children and their families. A national, standardized database to document CAN cases would aid in the allocation of resources to help develop policies and programs that effectively address the needs of CAN victims and their families, and to prevent CAN.
PMCID: PMC2528694  PMID: 19030360
Abuse; Child; Documentation; Neglect; Programs
21.  Neglected diseases of neglected populations: Thinking to reshape the determinants of health in Latin America and the Caribbean 
BMC Public Health  2005;5:119.
Background
People living in poverty throughout the developing world are heavily burdened with neglected communicable diseases and often marginalized by the health sector. These diseases are currently referred to as Neglected Diseases of Neglected Populations. The neglected diseases create social and financial burdens to the individual, the family, the community, and the nation.
Discussion
Numerous studies of successful individual interventions to manage communicable disease determinants in various types of communities have been published, but few have applied multiple interventions in an integrated, coordinated manner. We have identified a series of successful interventions and developed three hypothetical scenarios where such interventions could be applied in an integrated, multi-disease, inter-programmatic, and/or inter-sectoral approach for prevention and control of neglected diseases in three different populations: a slum, an indigenous community, and a city with a mix of populations.
Summary
The objective of this paper is to identify new opportunities to address neglected diseases, improve community health and promote sustainable development in neglected populations by highlighting examples of key risk and protective factors for neglected diseases which can be managed and implemented through multi-disease-based, integrated, inter-programmatic, and/or inter-sectoral approaches. Based on a literature review, analysis and development of scenarios we visualize how multiple interventions could manage multiple disease problems and propose these as possible strategies to be tested. We seek to stimulate intra- and inter-sectoral dialogue which will help in the construction of new strategies for neglected diseases (particularly for the parasitic diseases) which could benefit the poor and marginalized based on the principle of sustainability and understanding of key determinants of health, and lead to the establishment of pilot projects and activities which can contribute to the achievement of the Millennium Development Goals.
doi:10.1186/1471-2458-5-119
PMCID: PMC1318484  PMID: 16283932
22.  Late middle-aged and older men living with HIV/AIDS: race differences in coping, social support, and psychological distress. 
Although AIDS mental health research has recently devoted more attention to the psychosocial needs of older adults living with human immunodeficiency virus (HIV) disease, studies of this population have typically combined older African-American and white participants into one large sample, thereby neglecting potential race differences. The current study examined race differences in stressor burden, ways of coping, social support, and psychological distress among late middle-aged and older men living with HIV/AIDS. Self-administered surveys were completed by 72 men living with HIV/AIDS in New York City and Milwaukee, WI (mean age = 53.4 years). Older African-American and white men experienced comparable levels of stress associated with AIDS-related discrimination, AIDS-related bereavement, financial dilemmas, lack of information and support, relationship difficulties, and domestic problems. However, in responses to these stressors, older African-American men more frequently engaged in adaptive coping strategies, such as greater positive reappraisal and a stronger resolve that their future would be better. Compared to their African-American counterparts, HIV-infected older white men reported elevated levels of depression, anxiety, interpersonal hostility, and somatization. African-American men also received more support from family members and were less likely to disclose their HIV serostatus to close friends. As AIDS becomes more common among older adults, mental health-interventions will increasingly be needed for this group. The development of intervention programs for this group should pay close attention to race-related differences in sociodemographic, psychosocial, and behavioral characteristics.
PMCID: PMC2608530  PMID: 11052457
23.  Social Determinants of Health and Depression: A Preliminary Investigation from Rural China 
PLoS ONE  2012;7(1):e30553.
Background
In the last several years, research related to social determinants of health (SDH) has begun to resonate in the medical, behavioral, social and political sciences arena. The aim of the present study was to explore the relationship between SDH and depression, and to provide new evidences and clues for depression control and prevention.
Methodology/Principal Findings
This research was a cross-sectional survey executed door to door from October 2006 to April 2008, with a sample of 3,738 individuals aged 18 and older in rural China. The three variables of SDH were socioeconomic status (years of schooling and self-reported economic status of family), social cohesion and negative life events. Demographic variables and self-perceived physical health were taken as potential confounders. The cross-table analysis showed that variations in levels of depression were associated with variations in SDH, and logistic regression analysis confirmed the association even after adjusting for potential confounding variables.
Conclusions
Although there were some limitations, the current study provides initial evidence of the importance of SDH in depression. Findings indicate that social inequity and the role of policy action emphasized by SDH should be considered high priorities when addressing the issue of depression. In addition, cell-to-society and pill-to-policy approaches should be encouraged in the future.
doi:10.1371/journal.pone.0030553
PMCID: PMC3261904  PMID: 22276213
24.  Functional Decline in Older Adults 
American family physician  2013;88(6):388-394.
Functional disability is common in older adults. It is often episodic and is associated with a high risk of subsequent health decline. The severity of disability is determined by physical impairments caused by underlying medical conditions, and by external factors such as social support, financial support, and the environment. When multiple health conditions are present, they often result in greater disability than expected because the patient’s ability to compensate for one problem may be affected by comorbid conditions. Evaluation of functional disability is most effective when the physician determines the course of the disability, associated symptoms, effects on specific activities, and coping mechanisms the patient uses to compensate for the functional problem. Underlying health conditions, impairments, and contextual factors (e.g., finances, social support) should be identified using validated screening tools. Interventions should focus on increasing the patient’s capacity to cope with task demands and reducing the demands of the task itself. Interventions for functional decline in older adults are almost always multifactorial because they must address multiple conditions, impairments, and contextual factors.
PMCID: PMC3955056  PMID: 24134046
25.  Psychosocial Rehabilitation and Quality of Life for Older Adults with Serious Mental Illness: Recent Findings and Future Research Directions 
Current opinion in psychiatry  2009;22(4):381-385.
Purpose of Review
The projected increase of Americans age 65 years and older will have an unprecedented impact on the health care delivery system. As a result, new models to support individuals with serious mental illness (SMI) will become increasingly more important. This selective overview highlights recent reports addressing psychosocial functioning and interventions for older adults with SMI.
Recent Findings
Recently published descriptive studies suggest that poor functional outcomes and lower quality of life among older people with SMI are strongly associated with social isolation, depression, cognitive impairment, and chronic medical illness. Recent research on psychosocial interventions include evaluations of three different models of skills training, a supported employment intervention, and cognitive remediation. This research establishes psychosocial rehabilitation as feasible and potentially effective in improving functioning and quality of life in older adults with SMI.
Summary
Several important directions for future research focused on older adults with SMI are suggested by this overview. They include: individually tailored rehabilitation, interventions that optimize social integration and decrease depressive symptoms, techniques that blend cognitive remediation with vocational rehabilitation, and integration of health promotion with psychosocial rehabilitation.
doi:10.1097/YCO.0b013e32832c9234
PMCID: PMC3163501  PMID: 19417666
Psychosocial rehabilitation; quality of life; serious mental illness; functional capacity; older adults

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