We developed an innovative pilot studies program to foster partnerships between university researchers and agencies serving older people in New York City. The development of researchers willing to collaborate with frontline service agencies and service agencies ready to partner with researchers is critical for translating scientific research into evidence-based practice that benefits community-dwelling older adults.
Design and Methods
We adapted the traditional academic pilot studies model to include key features of community-based participatory research.
In partnership with a network of 265 senior centers and service agencies, we built a multistep program to recruit and educate scientific investigators and agencies in the principles of community-based research and to fund research partnerships that fulfilled essential elements of research translation from university to community: scientific rigor, sensitivity to community needs, and applicability to frontline practice. We also developed an educational and monitoring infrastructure to support projects.
Pilot studies programs developing community-based participatory research require an infrastructure that can supplement individual pilot investigator efforts with centralized resources to ensure proper implementation and dissemination of the research. The financial and time investment required to maintain programs such as those at the Cornell Institute for Translational Research on Aging, or CITRA, may be a barrier to establishing similar programs.
Community-based participatory research; Investigator development; Research to practice
Prior to testing the feasibility/potential efficacy of a newly developed self-management pain program for seniors with back pain, this study sought to: 1) determine prospective consumers’ prior exposure to self-management pain programs, 2) determine their willingness to participate in the new program; and 3) ascertain perceived barriers/facilitators to program participation.
Six senior centers located in New York City.
We enrolled a race/ethnicity stratified (African American, Hispanic, or non-Hispanic White) sample of 90 subjects who were ages 60 years or older and had chronic back pain.
While 60% of non-Hispanic Whites reported prior participation in a self-management pain program, fewer Hispanic (23%) and African Americans (20%) participants reported prior participation. Most participants (80%) were strongly willing to participate in the new program. Multivariate analyses revealed that only pain intensity had a trend toward significance (p=.07), with higher pain scores associated with greater willingness to participate. Few barriers to participation were identified, however, respondents felt that tailoring the course to best meet the needs of those with physical disabilities, providing flexibility in class timing, and informing individuals about program benefits prior to enrollment could help maximize program reach. No race/ethnicity differences were identified with respect to willingness to participate or program participation barriers.
These data support efforts to disseminate self-management pain programs in older populations, particularly minority communities. The recommendations made by participants can help to guide implementation efforts of the newly developed pain program and may help to enhance both their reach and success.
A rapidly expanding number of baby boomers provide care to aging parents. This study examines associations between caregiver status and outcomes related to awareness and anticipation of future long-term care (LTC) needs using 2007 Connecticut Long-Term Care Needs Assessment survey data. Baby boomers who were adult child caregivers (n = 353) vs. baby boomers who were not (n = 1242) were more likely to anticipate some future LTC needs and to have considered certain financing strategies. Although baby boomer adult child caregivers more readily anticipate some future LTC needs, they are not taking specific actions. It is important to address the need for public education directed towards those who are currently (or have recently completed) caring for aging parents.
caregivers; successful aging; baby boomers; expectations
We employed community-based participatory research techniques to adapt an evidence-based Arthritis Self-Help Program (ASHP) for older African American, Hispanic and non-Hispanic white adults. Participants and instructors provided multiple recommendations for program changes in telephone interviews and focus groups. Recommendations were adjudicated and implemented through a collaborative, consensus-based process involving diverse stakeholders. Changes implemented show sensitivity to the preferences and needs of participants, as well as the strengths and constraints of program instructors and host sites. Improved fit for participants may extend the program’s reach and effectiveness for older adults of color. In addition, the adapted ASHP may make the program more feasible and therefore sustainable for the host sites.
Community-based participatory research; program adaptation; program implementation; race/ethnic minority populations
Chronic pain is a debilitating and pervasive health problem, particularly among older adults. Researchers and clinicians acknowledge that pain conditions do not occur in isolation, but rather exact a toll on the individual sufferer and the family system at large. No research, however, has explicitly explored the impact of older parents’ chronic pain symptoms on their adult children. In this article, we present relevant predictions from theoretical models that identify the interpersonal effects of chronic illness and pain on family relationships. Guided by theory and empirical research on these topics, we present a conceptual framework of hypothesized risk factors for adult children of parents with chronic pain. We conclude by offering an agenda for future research.
Intergenerational relationships; adult children; pain; chronic illness
To examine the effects of electronic health information technology (HIT) on nursing home residents.
The study evaluated the impact of implementing a comprehensive HIT system on resident clinical, functional, and quality of care outcome indicators, as well as measures of resident awareness of and satisfaction with the technology. The study used a prospective, quasi-experimental design, directly assessing 761 nursing home residents in 10 urban and suburban nursing homes in the greater New York City area.
No statistically significant impact of the introduction of HIT on residents was found on any outcomes, with the exception of a significant negative effect on behavioral symptoms. Residents' subjective assessment of the HIT intervention were generally positive.
The absence of effects on most indicators is encouraging for the future development of HIT in nursing homes. The single negative finding suggests that further investigation is needed on possible impact on resident behavior.
Long-Term Care; Technology; Quality of Care
Elder abuse in long term care has received considerable attention; however, resident-to-resident elder mistreatment (R-REM) has not been well researched. Preliminary findings from studies of R-REM suggest that it is sufficiently widespread to merit concern, and is likely to have serious detrimental outcomes for residents. However, no evidence-based training, intervention and implementation strategies exist that address this issue.
The objective was to evaluate the impact of a newly developed R-REM training intervention for nursing staff on knowledge, recognition and reporting of R-REM.
The design was a prospective cluster randomized trial with randomization at the unit level.
A sample of 1405 residents (685 in the control and 720 in the intervention group) from 47 New York City nursing home units (23 experimental and 24 control) in 5 nursing homes was assessed. Data were collected at three waves: baseline, 6 and 12 months. Staff on the experimental units received the training and implementation protocols, while those on the comparison units did not. Evaluation of outcomes was conducted on an intent-to-treat basis using mixed (random and fixed effects) models for continuous knowledge variables and Poisson regressions for longitudinal count data measuring recognition and reporting.
There was a significant increase in knowledge post-training, controlling for pre-training levels for the intervention group (p<0.001), significantly increased recognition of R-REM (p<0.001), and longitudinal reporting in the intervention as contrasted with the control group (p=0.0058).
A longitudinal evaluation demonstrated that the training intervention was effective in enhancing knowledge, recognition and reporting of R-REM. It is recommended that this training program be implemented in long term care facilities.
Resident-to-resident elder mistreatment (R-REM); nursing homes; long term care; older people; elder abuse; staff education; staff training
Evidence exists suggesting that most sexual aggression against older adults occurs in long-term care facilities. Fellow residents are the most common perpetrators, often due to inappropriate hypersexual behavior caused by dementing illness. This resident-to-resident sexual aggression (RRSA) is defined as sexual interactions between long-term care residents that in a community setting would likely be construed as unwelcome by at least one of the recipients and have high potential to cause physical or psychological distress in one or both of the involved. Although RRSA may be common and physical and psychological consequences for victims may be significant, this phenomenon has received little direct attention from researchers to date. We review the existing literature and relevant related research examining elder sexual abuse and hypersexual behavior to describe the epidemiologic features of this phenomenon, including risk factors for perpetrators and victims. Preventing and managing sexual aggression in nursing homes is made more challenging due to the legitimate and recognized need for nursing home residents, even those with advanced dementing illness, to sexually express themselves. We discuss the ethical dilemma this situation creates and the need to evaluate the capacity to consent to sexual activity among residents with dementing illness and to re-evaluate capacity as the diseases progress. We offer suggestions for managing RRSA incidents and for future research, including the importance of designing effective interventions.
aggressive behavior; sexual abuse; nursing homes; sexual behavior; dementia
As Baby Boomers enter late life, relationships with family members gain importance. This review article highlights two aspects of their intergenerational relationships: (a) caregiving for aging parents and (b) interactions with adult children in the context of changing marital dynamics.
Design and Methods:
The researchers describe three studies: (a) the Within Family Differences Study (WFDS) of mothers aged 65–75 and their multiple grown children (primarily Baby Boomers) ongoing since 2001; (b) the Family Exchanges Study (FES) of Baby Boomers aged 42–60, their spouses, parents, and multiple grown children ongoing since 2008; and (c) the Longitudinal Study of Generations (LSoG) of 351 three-generation families started when the Baby Boomers were teenagers in 1971, with interviews every 3–5 years from 1985 to 2005.
These studies show that the Baby Boomers in midlife navigate complex intergenerational patterns. The WFDS finds aging parents differentiate among Baby Boomer children in midlife, favoring some more than others. The FES shows that the Baby Boomers are typically more involved with their children than with their aging parents; Boomers’ personal values, family members’ needs, and personal rewards shape decisions about support. The LSoG documents how divorce and remarriage dampen intergenerational obligations in some families. Moreover, loosening cultural norms have weakened family bonds in general.
Reviews of these studies provide insights into how the Baby Boomers may negotiate caregiving for aging parents as well as the likelihood of family care they will receive when their own health declines in the future.
Baby Boomer; Caregiving; Family; Intergenerational relationships; Parent; Social support
Evidence-based interventions (EBIs) are an important tool for community health practitioners, but there is often a mismatch between the population in which the EBI was validated and the target population in which it will be used. Methods of planned adaptation identify differences in the new target population and attempt to make changes to the EBI that accommodate these differences without diluting the program’s effectiveness. This article outlines an innovative method for eliciting ideas for program modifications and deciding on program changes. The Method for Program Adaptation through Community Engagement (M-PACE) uses systematic and detailed feedback from program participants to guide adaptation. The authors describe procedures for obtaining high-quality participant feedback and adjudicating recommendations to decide on program changes. M-PACE was developed as part of the adaptation of an evidence-based, arthritis self-management program for older adults. The application and results of the M-PACE method are presented using this case as an example.
evidence-based interventions; program adaptation; cultural adaptation; community-based participatory research; self-management programs
Despite its prevalence and negative consequences, research on elder abuse has rarely considered resident-to-resident aggression (RRA) in nursing homes. This study employed a qualitative event reconstruction methodology to identify the major forms of RRA that occur in nursing homes.
Design and methods:
Events of RRA were identified within a 2-week period in all units (n = 53) in nursing homes located in New York City. Narrative reconstructions were created for each event based on information from residents and staff who were involved as well as other sources. The event reconstructions were analyzed using qualitative methods to identify common features of RRA events.
Analysis of the 122 event reconstructions identified 13 major forms of RRA, grouped under five themes. The resulting framework demonstrated the heterogeneity of types of RRA, the importance of considering personal, environmental, and triggering factors, and the potential emotional and physical harm to residents.
These results suggest the need for person-centered and environmental interventions to reduce RRA, as well as for further research on the topic.
Abuse/neglect; Behavior; Long-term care; Aggression
The goal of this paper is to demonstrate a process by which qualitative and quantitative approaches are combined to reveal patterns in the data that are unlikely to be detected and confirmed by either method alone. Specifically, we take a sequential approach to combining qualitative and quantitative data to explore race differences in how mothers differentiate among their adult children. We began with a standard multivariate analysis examining race differences in mothers’ differentiation among their adult children regarding emotional closeness and confiding. Finding no race differences in this analysis, we conducted an in-depth comparison of the Black and White mothers’ narratives to determine whether there were underlying patterns that we had been unable to detect in our first analysis. Using this method, we found that Black mothers were substantially more likely than White mothers to emphasize interpersonal relationships within the family when describing differences among their children. In our final step, we developed a measure of familism based on the qualitative data and conducted a multivariate analysis to confirm the patterns revealed by the in-depth comparison of the mother’s narratives. We conclude that using such a sequential mixed methods approach to data analysis has the potential to shed new light on complex family relations.
Maternal Differentiation; Parent-Adult Child Relations; Race; Within-Family Differences; Later Life Families; Sequential Mixed Methods Designs
This study examines the influence of race on perceived similarity and conflict between nursing home staff and family members of residents. Despite evidence that the caregiving experience varies by race for both family and professional caregivers, little is known about how race plays a role in staff conflict with residents’ family members.
We used a representative sample of Certified Nursing Assistants (CNAs) to test relationships between race, treatment from family members, similarity to family members in expectations for care by CNAs, and conflicts with family members concerning aspects of resident care.
Results of structural equation modeling indicated that race was not a predictor of staff perception of conflict with family members or of poor treatment from residents’ families. However, Black nursing assistants were more likely to perceive that their own expectations of nursing care are dissimilar from those of residents’ family members. Dissimilarity predicted reports of poor treatment from family members, and poor treatment was a positive predictor of perception of conflict.
The personal long-term nature of nursing home care necessitates a high level of connectedness between family caregivers and nursing home staff. Results highlight the importance of establishing organizational pathways for communication of expectations between nursing staff and residents’ families.
conflict; long-term care; race
In this paper, we explored the association between direct and indirect measures of intergenerational ambivalence, making comparisons by generational position and child’s gender; furthermore, we examined whether these measures were similarly strong predictors of depressive symptoms and positive affect.
Data for the analysis were collected from 254 mothers aged 72–82 years and a randomly selected adult child as part of a larger study of within-family differences in parent–adult child relations.
The findings provided evidence that direct and indirect measures were strongly associated among mothers but only weakly associated among adult children, particularly sons. The two measures were similarly strong predictors of mothers’, but not children’s, depressive symptoms and positive affect. The most pronounced differences in congruence between direct and indirect measures were found when comparing mothers and sons.
The analyses presented here suggest that direct and indirect measures of intergenerational ambivalence may not be tapping the same underlying construct, particularly in the case of adult children and especially sons. Furthermore, direct measures may have an advantage over indirect measures when including sons in the study design. We conclude that direct and indirect measures cannot be used interchangeably across the combination of generation and gender.
Intergenerational ambivalence; Parent-child relations; Parent-child relations and psychological well-being
Despite high prevalence rates of pain among older adults, relatively few studies have examined the impact of the Arthritis Foundation Self-Help Program (ASHP) in this age group, particularly older minorities. This study compared the effects of the ASHP on groups of older Hispanic, African American and non-Hispanic whites.
Individuals age 60 and over with diverse non-cancer pain disorders were recruited from 3 senior centers in New York City. Participants were surveyed before and after course completion (in person) and at 18 weeks (by telephone). Demographic and clinical data were collected at baseline; outcomes included pain, mood, self-efficacy, and number of days per week spent exercising.
A total of 112 (37 African American, 38 Hispanic and 37 non-Hispanic white) participants (mean age = 75 years) enrolled in the program. All 3 groups experienced significant decreases in pain intensity (p ≤0.05). Significant improvements were also found in mood scores for non-Hispanic white (p=0.01) and Hispanic participants (p=0.03). Hispanic participants also evidenced significant improvement in their confidence to self-manage pain (p=0.003) and reported fewer arthritis-related symptoms (p=0.02). All three race/ethnicity groups reported substantial increases in the number of days spent doing stretching, endurance and relaxation exercises (p≤0.01).
Positive results were noted for all 3 race/ethnicity groups, particularly in the areas of pain reduction and uptake of stretching, endurance and relaxation exercises. Our findings support efforts to disseminate broadly the ASHP in community settings that serve older African American, Hispanic and non-Hispanic white adults with persistent pain disorders.
Self-management strategies for pain hold substantial promise as a means of reducing pain and improving function among older adults with chronic pain, but their use in this age group has not been well defined.
To review the evidence regarding self-management interventions for pain due to musculoskeletal disorders among older adults.
We searched the Medline and Cumulative Index to Nursing and Allied Health Literature databases to identify relevant articles for review and analyzed English-language articles that presented outcome data on pain, function, and/or other relevant endpoints and evaluated programs/strategies that could be feasibly implemented in the community. Abstracted information included study sample characteristics, estimates of treatment effect, and other relevant outcomes when present.
Retained articles (N = 27) included those that evaluated programs sponsored by the Arthritis Foundation and other programs/strategies including yoga, massage therapy, Tai Chi, and music therapy. Positive outcomes were found in 96% of the studies. Proportionate change in pain scores ranged from an increase of 18% to a reduction of 85% (median = 23% reduction), whereas change in disability scores ranged from an increase of 2% to a reduction of 70% (median = 19% reduction). Generalizability issues identified included limited enrollment of ethnic minority elders, as well as non-ethnic elders aged 80 and above.
Our results suggest that a broad range of self-management programs may provide benefits for older adults with chronic pain. Research is needed to establish the efficacy of the programs in diverse age and ethnic groups of older adults and identify strategies that maximize program reach, retention, and methods to ensure continued use of the strategies over time.
Chronic Non-Malignant Pain; Older Adults; Community Setting; Self-Management Programs; Arthritis
This article presents recommendations from expert practitioners and researchers regarding future directions for research on elder abuse prevention. Using the Research-to-Practice Consensus Workshop model, participants critiqued academic research on the prevention of elder mistreatment and identified practice-based suggestions for a research agenda on this topic. The practitioners’ critique resulted in 10 key recommendations for future research that include the following priority areas: defining elder abuse, providing researchers with access to victims and abusers, determining the best approaches in treating abusers, exploiting existing data sets, identifying risk factors, understanding the impact of cultural factors, improving program evaluation, establishing how cognitive impairment affects legal investigations, promoting studies of financial and medical forensics, and improving professional reporting and training. It is hoped that these recommendations will help guide future research in such a way as to make it more applicable to community practice.
elder mistreatment research; consensus workshop; research-practice collaboration
Despite evidence of the importance of value similarity in predicting parent-adult child relations, little attention has been given to the unique role of religious similarity. Using 1,407 dyads nested within 390 families, we examine whether religious similarity predicts the quality of mother-child relations in later life, and whether the strength of this association differs by race. Consistent with our hypotheses, religious similarity was found to be an important factor in predicting both closeness and conflict, particularly in Black families. These findings suggest that it may be important to give greater attention to religion when studying patterns of interaction and support in the later years, especially among Black families.
Purpose: This study tested the hypothesis that volunteering in environmental organizations in midlife is associated with greater physical activity and improved mental and physical health over a 20-year period. Design and Methods: The study used data from two waves (1974 and 1994) of the Alameda County Study, a longitudinal study of health and mortality that has followed a cohort of 6,928 adults since 1965. Using logistic and multiple regression models, we examined the prospective association between environmental and other volunteerism and three outcomes (physical activity, self-reported health, and depression), with 1974 volunteerism predicting 1994 outcomes, controlling for a number of relevant covariates. Results: Midlife environmental volunteering was significantly associated with physical activity, self-reported health, and depressive symptoms. Implications: This population-based study offers the first epidemiological evidence for a significant positive relationship between environmental volunteering and health and well-being outcomes. Further research, including intervention studies, is needed to confirm and shed additional light on these initial findings.
Volunteerism and civic engagement; Health; Well-being
Parents’ differentiation has been linked to negative psychological and behavioral outcomes in children, adolescents, and young adults. This line of research, however, has not been extended to families in later life. In this article, we use data from 671 mother-child dyads in 275 families in the greater Boston area to explore whether mothers’ differentiation among their children is related to psychological well-being among offspring. We examined actual and perceived maternal differentiation in the domains of closeness, expectations for care, and conflict. We hypothesized that depressive symptoms would be higher when mothers differentiated among their children and when adult children perceived differentiation. Although the specific patterns varied somewhat by mothers’ and children's reports, the findings indicated that across all three domains, maternal differentiation was related to higher depression scores.
Parent-child relations; families in middle and later life; intergenerational relations; adult siblings
Data were collected from 708 adult children nested within 274 later-life families from the Within-Family Differences Study to explore the role of perceived maternal favoritism in the quality of sibling relations in midlife. Mixed-model analyses revealed that regardless of which sibling was favored, perceptions of current favoritism and recollections of favoritism in childhood reduced closeness among siblings. Recollections of maternal favoritism in childhood were more important than perceptions of current favoritism in predicting tension among adult siblings, regardless of age. Taken together, the findings from this investigation are consistent with childhood studies showing that siblings have better relationships when they believe that they are treated equitably by their parents.
Adult siblings < Sibling Relations; Mother-child relations < Parenting < Parenting and Parenthood; Parental favoritism; Within-family design < Method
To more fully characterize the spectrum of RRA.
A focus group study of nursing home staff members and residents who could reliably self-report.
A large urban, not-for-profit long-term care facility in New York City
7 residents and 96 staff members from multiple clinical and non-clinical occupational groups.
16 focus groups were conducted. Content was analyzed with nVivo 7 software for qualitative data.
35 different types of physical, verbal and sexual RRA were described, with screaming and/or yelling being the most common. Calling out and making noise were the most frequent of 29 antecedents identified as instigating episodes of RRA. RRA was most frequent in dining and residents’ rooms, and in the afternoon, though it occurred regularly throughout the facility at all times. While no proven strategies exist to manage RRA, staff described 25 self-initiated techniques to address the issue.
RRA is a ubiquitous phenomenon in nursing home settings with important consequences for affected individuals and facilities. Further epidemiologic research is necessary to more fully describe the phenomenon and identify risk factors and preventative strategies.
nursing home; dementia-related behaviors; focus groups
Resident-to-resident aggression (RRA) between long-term care residents includes negative and aggressive physical, sexual, or verbal interactions that in a community setting would likely be construed as unwelcome and have high potential to cause physical or psychological distress in the recipient. Although this problem potentially has high incidence and prevalence and serious consequences for aggressors and victims, it has received little direct attention from researchers to date. This article reviews the limited available literature on this topic as well as relevant research from related areas including: resident violence toward nursing home staff, aggressive behaviors by elderly persons, and community elder abuse. We present hypothesized risk factors for aggressor, victim, and nursing home environment, including issues surrounding cognitive impairment. We discuss methodological challenges to studying RRA and offer suggestions for future research. Finally, we describe the importance of designing effective interventions, despite the lack currently available, and suggest potential areas of future research.
aggressive behavior; nursing homes; dementia; epidemiology