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1.  Depressive, Functional Status, and Neuropsychiatric Symptom Trajectories Before an Alzheimer’s Disease Diagnosis 
Aging & mental health  2013;18(1):10.1080/13607863.2013.814100.
This short report relied on multi-year data from the National Alzheimer’s Coordinating Center-Uniform Data Set (NACC-UDS) to examine whether significant changes occurred in functional status, neuropsychiatric symptom, and depressive symptoms in the years prior to receiving an Alzheimer’s disease (AD) diagnosis.
The secondary analysis utilized a retrospective cohort design. The NACC-UDS is a publicly accessible, longitudinal database that includes standardized data on neuropsychiatric symptoms, functional status, and depressive symptoms for Alzheimer’s Disease Center (ADC) participants in the United States based on their annual visits from 2005 to 2011. ADC participants were considered diagnosed with AD if a follow-up data form indicated an affirmative response to whether the ADC participant had "Probable AD (NINCDS/ADRDA)" or "Possible AD (NINCDS/ADRDA)." This yielded an analytic sample of 2,478 individuals (139 with an eventual Probable AD diagnosis, 109 individuals with an eventual Possible AD diagnosis, and 2,230 without any AD diagnosis) representing a total of 11,358 visits/points of data.
Multi-level linear models revealed significant decreases (p < .05) in functional status prior to a Probable or Possible AD diagnosis and significant increases in depressive symptoms prior to a Probable AD diagnosis.
Changes in functional and depressive symptoms were partly independent of cognitive decline. The longitudinal results lend additional support to conceptual and empirical models of pre-diagnosis declines in AD.
PMCID: PMC3855584  PMID: 23822174
Alzheimer’s disease; Screening and Diagnosis; Psychological and Behavioral Symptoms; Depression; Functional Status
2.  Parental status and late-life well-being in rural China: The benefits of having multiple children 
Aging & mental health  2013;18(1):10.1080/13607863.2013.799117.
This study examined potential differences among childless elders, elders with one child, and elders with multiple children in rural China in their levels of depression and life satisfaction, and investigated the mechanism behind the potential differences.
The sample consisted of 1,224 older adults in rural Anhui province, China. ANOVA tests were carried out to compare the three groups in depression and life satisfaction, respectively. Multiple regressions were carried out to predict depression and life satisfaction, with 1) parental status, 2) individual attributes (i.e., socio-demographic variables and functional health), and 3) variables representing family relations (i.e., living arrangement, intergenerational contact, and family support) entered sequentially in each regression.
Overall, childless elders in rural China had significantly higher level of depression and lower level of life satisfaction than did older parents. The primary reason for such group differences was lack of monetary support from adult children, the effect of which was conditioned upon the income level of older adults. With a high level of income, the benefit of monetary support from children was negligible. However, the mere presence of multiple children was associated with a higher life satisfaction, independently of personal attributes and potential monetary support form children.
This study contributed to the “missing link” in the explanation by identifying the pathways through which parental status affect individual well-being. The findings indicate that local contexts such as affluence, social norms, and available formal support all play a role in shaping the consequences of childlessness in later life.
PMCID: PMC3841233  PMID: 23711296
Parental status; depression; life satisfaction; rural China; local contexts
3.  Gender differences of social interactions and their effects on subjective well-being among Japanese elders 
Aging & mental health  2013;18(1):10.1080/13607863.2013.788997.
Gender differences of social interactions and their effects on subjective well-being among Japanese elders over three years were examined.
Repeated measurements of 498 elders over a three-year survey interval were obtained from a baseline mail survey and two- and three-year follow-up surveys. Outcomes were analyzed using Hierarchical Linear Modeling.
Male elders were more likely to have a spouse and work at paid jobs, while female elders were likely to have more frequent contacts with their child/children and more interactions with friends. As the elders aged over three years, life satisfaction decreased, while depression did not show any significant overall trend. There were no beneficial effects of social interactions on change in well-being, although social participation, interaction with friends, and conversation with spouse were beneficially related to baseline levels of both depressive tendency and life satisfaction. Among female elders only, the number of children had beneficial effects on life satisfaction.
There are modest gender differences of the impact of social interactions on the well-being of Japanese elders, and the number of children seems to be more important as potential sources of support for female rather than male elders. Spousal conversation and non-obligatory social interaction such as unpaid social activities and friendship seem to be important for both male and female elders in Japan. These findings suggest that social relations among Japanese elders may be moving away from more gender dependent patterns seen in the past.
PMCID: PMC3744606  PMID: 23614456
subjective well-being; growth curve modeling; temporal change; social interaction
4.  The Influence of Social Factors and Health on Depressive Symptoms and Worry: A Study of Older Vietnamese Adults 
Aging & mental health  2012;16(6):780-786.
Vietnam has a growing older population, many of whom experienced war and social upheavals in their lives. Prior research has described the health of the older population, but little work has explored mental health. The current study examines the frequency and correlates of two mental health indicators: depressive symptoms and worry.
A representative sample of 600 adults 55 and older stratified by gender (50% women), age (mean = 70.33), and rural/urban (50% rural) was recruited in Da Nang, Vietnam and surrounding rural districts. Participants were interviewed in their homes by trained interviewers. Dependent variables were a Vietnamese version of the CES-D and a culturally specific worry scale.
Forty-seven percent of the sample had scores above the cut-off for clinical depression and scores on the worry scale were high. Using multiple linear regressions we found that women, the less educated and individuals with more material hardship had higher depressive symptoms whereas rural residents, women, married, and young-old individuals were more worried. Pain, ADL assistance and emotional support were significant predictors of both depressive symptoms and worry, though the direction of the association for emotional support differed. Illnesses were only a predictor of depressive symptoms.
The high reports of depressive symptoms and worry suggests the need for incorporating mental health screening as part of health programs for older adults in Vietnam. Attention to factors associated with depressive symptoms and worry, such as economic hardship, health problems and lack of emotional support, may contribute to alleviation of symptoms.
PMCID: PMC4233407  PMID: 22486622
depression; worry; older adults; Vietnam
5.  Correlates of Cognitive Impairment in Older Vietnamese 
Aging & mental health  2013;17(8):915-923.
This study examined correlates of cognitive functioning and possible cognitive impairment among older adults living in Da Nang, Vietnam and surrounding rural areas.
The analytic sample consisted of 489 adults 55 and older stratified by gender, age, and rural/urban status. The sample was 46% rural, 44% women, with a mean age of 69.04. Interviews were conducted in individuals’ homes by trained interviewers. The dependent variable was a Vietnamese version of the MMSE. A multiple linear regression was run with the MMSE continuous scores reflecting cognitive functioning, while a binary logistic regression was conducted with an education-adjusted cut-off score reflecting possible cognitive impairment. Age, gender, education, material hardship, depressive symptoms (CES-D), war injury, head trauma, diabetes, cardiovascular and cerebrovascular disease conditions served as correlates, controlling for marital status and rural/urban residence.
About 33% of the sample scored below the standard cutoff of 23 on the MMSE. However only 12.9% of the sample would be considered impaired using the education-adjusted cutoff score. Cognitive functioning and possible cognitive impairment as indicated by MMSE scores were significantly associated with being older, completing fewer years of education, and material hardship. Gender, depressive symptoms, and cerebrovascular disease were associated with cognitive functioning, but not cognitive impairment.
These results show that social characteristics, physical illness, and mental health are associated with cognitive functioning. The study also raises questions about the need for standardization of screening measures on Vietnamese populations.
PMCID: PMC4233409  PMID: 23697847
social context; cognitive functioning; cognitive impairment; Vietnam
6.  Physicians’ Detection of Late-Life Depression: The Roles of Dysphoria and Cognitive Impairment 
Aging & mental health  2013;17(8):10.1080/13607863.2013.805403.
To examine factors that impede or facilitate physicians’ detection of depression in later life, including cognitive impairment and patients’ endorsement of dysphoria.
A population-based sample of 344 adults from the Swedish Adoption/Twin Study of Aging (SATSA) was utilized. Physician detection of depression was determined by (1) outpatient medical records, (2) antidepressant prescription, and/or (3) inpatient hospitalization. Depressive symptoms were measured by highest score on the Center for Epidemiologic Studies-Depression Scale (CES-D), administered on 6 occasions between 1986 and 1994. Endorsement of dysphoria was examined using two items on the CES-D. The Mini-Mental State Examination (MMSE) was used to indicate cognitive impairment.
One-hundred thirty-six individuals were above the cut-off on the CES-D on at least one occasion; however, only 14 of these individuals (10%) were detected as depressed by a physician. Higher CES-D total score was significantly related to physician detection. Furthermore, physicians were most likely to detect depression if the individual endorsed the single CES-D item regarding feeling depressed. A significant interaction was found, such that overall CES-D score was only associated with physician detection among those with higher endorsement of the depressed item. The association between total CES-D and physician detection was not affected by presence of cognitive impairment.
Depression in later life often goes undetected by physicians. Factors associated with detection include the frequency/severity of symptoms and patients’ endorsement specifically of feeling depressed. Results suggest that physicians should routinely assess for other symptoms associated with late-life depression besides dysphoria (e.g., appetite loss, crying spells).
PMCID: PMC3797862  PMID: 23767897
late-life depression; physician detection; dysphoria; cognitive impairment
7.  Does Co-residence with Adult Children Associate with Better Psychological Well-being among the Oldest Old in China? 
Aging & mental health  2013;18(2):232-239.
Embedded in a traditional culture where filial piety was honored, living with adult children once had been the most prevalent living arrangement and the best option for Chinese elderly people. This study examined whether co-residence with adult children would be still beneficial to the psychological well-being (PWB) among the oldest old (aged 80 and above) in China today.
Using data from the fifth wave of the Chinese Longitudinal Healthy Longevity Survey conducted in 2008, the authors examined living arrangements among the total sample (n = 12,213) and the association between living arrangement and PWB among a sub-sample (n = 7,037) of respondents with normal cognition.
1) More than half (67.1%) of the unmarried oldest old reported being co-resided with their children; while for the married oldest old, the majority of the respondents (62.4%) lived with a spouse only. 2) For the widowed, co-residence with adult children was associated with better PWB compared to living along; but for the married, co-residence did not bring additional benefits to the PWB. 3) Co-residence of the widowed and children was associated with better life satisfaction compared to living with a spouse only, while it was associated with lower emotional well-being compared to living with a spouse (with or without a child).
These findings suggest that living arrangements of Chinese oldest old are partially getting westernized, and the majority of them adapt it well. Government programs need to be developed to assist the Chinese oldest old (especially widowed) to live independently.
PMCID: PMC4158609  PMID: 24053437
psychological well-being; social support; extreme old age; living arrangement; independent living
8.  Effects of home, outside leisure, social, and peer activity on psychological health among Japanese family caregivers 
Aging & mental health  2012;16(4):500-506.
Previous research has indicated that informal caregivers’ personal activities are disrupted by their caregiving role, leading to psychological stress and lower life satisfaction. However, the extent to which engagement in personal activities affects caregivers’ psychological health remains unclear. This study examines the relationship between different types and frequencies of activities and both positive and negative parameters of the psychological health of caregivers.
A mail survey was conducted with 727 family caregivers of older persons using adult day care services in the Tokyo metropolitan area. Perceived caregiver burden, care satisfaction, life satisfaction, and depression were used as psychological health outcomes. Engagement in home, outside leisure, social, and peer activities, as well as caregiver and care-recipient characteristics and caregiving situations, were assessed using a multivariate regression analysis.
Engagement in home activities was related to lower scores on burden and depression and greater care satisfaction after controlling for care needs and caregiver characteristics, and social and peer activities were associated with greater life satisfaction. More frequent engagement was also associated with better psychological health, but a moderate involvement in home activities was most strongly associated with better care satisfaction. The amount of outside leisure activity was not significantly related with any of the outcomes.
This study shows that activity type and frequency are associated with caregivers’ psychological health, extending previous findings and providing practical implications for the support of family caregivers through programs to improve their participation in specific types of activities.
PMCID: PMC4154229  PMID: 22360698
informal caregiving; social activity; leisure activity; burden; depression
9.  Perceived Cognitive Impairment among African American elders: health and functional impairments in daily life 
Aging & mental health  2013;18(4):471-480.
The Center for Disease Control began to assess Perceived Cognitive Impairment in 2009, yet there has been no in-depth study of how perceived decline in thinking or memory skills may be associated to the health and lifestyle of an independent community-dwelling older person. Among urban-dwelling older African Americans who are at elevated risk for cognitive impairment and dementia, we know even less regarding the interaction of these risk factors.
Five hundred and one African American elders (n = 501) between the ages of 55 and 95 with an average age of 70.73 years (SD = 8.6 years) participated in telephone interviews.
Approximately one-third of the elders reported that their memory, thinking skills, or ability to reason was worse than a year ago (n = 150; 29.9%) and 25% of this group (n = 38) reported that this Perceived Cognitive Impairment impacted their daily activities and/or warranted a consultation with their doctor. Bivariate analyses indicated that Perceived Cognitive Impairment was associated with increased health problems, mobility limitations, depressed mood, and lower social functioning.
Elders who reported that cognitive problems impacted their daily functioning reported the greatest health and mental health problems. Perceived Cognitive Impairment is an important health variable with implications for an older adult’s overall health, mobility, and mental health.
PMCID: PMC4151047  PMID: 24328435
African American; mild cognitive impairment; psychological and social aspects of dementia; age associated memory problems; physical health status; functional status
10.  Emotional Benefits of Mindfulness-Based Stress Reduction in Older Adults: The Moderating Roles of Age and Depressive Symptom Severity 
Aging & mental health  2013;17(7):823-829.
To examine the effects of age and depressive symptom severity on changes in positive affect among older adults randomly assigned to a Mindfulness-Based Stress Reduction (MBSR) program or a waitlist control group. Drawing from the Motivational Theory of Life-Span Development, we hypothesized that lower levels of depressive symptom severity and older age would be associated with greater positive affect in response to the MBSR intervention.
Data were collected from a sample of community-dwelling English-speaking adults (n = 200) aged ≥ 65, randomly assigned to an 8-week MBSR program or a Waitlist Control group. Our main outcome variable was a 5-item measure of positive affect, which was measured at study entry as well as 8 weeks and 6-months later.
At 6-month follow-up, we observed group by baseline depressive symptom severity (β = −.17, p = .02) and group by baseline depressive symptom severity by age (β = −.14, p = .05) interactions. Among MBSR participants, greater baseline depressive symptom severity was also associated with less improvement in positive affect at the 6-month follow-up (β = −.30, p = .003). Findings were qualified by a significant depressive symptom severity by age interaction (β = −.25, p = .01), such that MBSR participants who were 70 and over with lower baseline depressive symptom severity had the greatest improvement in positive affect at the 6-month follow-up.
MBSR improves positive affect for older adults with lower depressive symptom severity, perhaps because it capitalizes on naturalistic changes in control strategies.
PMCID: PMC3755021  PMID: 23697871
Mindfulness-based stress reduction; age; depressive symptom severity; positive affect
Aging & mental health  2013;17(7):830-838.
The primary objective of this study was to examine a variety of potential predictors of response to Cognitive Behavioral Therapy (CBT) in depressed older adults.
Sixty older adults with a clinical diagnosis of major or minor depression or dysthymic disorder received 12 individual sessions of CBT over a 3 to 4 month period. The BDI-II was administered pre and post intervention to assess change in level of depression. A cut-off score of 13 or less at post was used to determine positive treatment response. A variety of measures (obtained at baseline) were evaluated using hierarchical regression techniques to predict improvement following treatment
Individuals who showed greater improvement were: a) more open to new experiences; b) less negatively affected by past stressors; c) less inclined to have an external locus of control but more likely to cite others as responsible for negative stress in their lives; and d) were more likely to seek emotional support when symptomatic. Lower education level and reported use of active coping strategies at baseline were associated with less improvement. Other variables (e.g., age, overall physical health, and cognitive status) were not associated with treatment response. Use of logistic regression to predict responders vs. non-responders yielded a similar pattern.
These findings agree with prior research confirming the effectiveness of a brief CBT intervention for older depressed persons and suggest further exploration of several psychosocial factors that may contribute to a stronger response to CBT.
PMCID: PMC3755101  PMID: 23631698
cognitive behavior therapy; CBT; depression; older adults; trauma; response predictors
12.  Vascular depression and frailty: A compound threat to longevity among older-old women 
Aging & mental health  2013;17(7):901-910.
The vascular depression hypothesis posits that cerebrovascular burden contributes to the development of depression symptoms in late life. Building on work that suggests that vascular depression is a prodrome for frailty (Paulson & Lichtenberg, 2011), this paper tests a theoretical framework that vascular depression symptoms are an early marker of a broader pattern of decline characterized by more frailty symptoms and shortened lifespan, and that vascular depression symptoms predict mortality through frailty.
The sample was drawn from the Health and Retirement Study and included 1,361 stroke-free women over the age of 80. Data was included from six biannual waves from 1998 to 2008 (waves 4-9). A vascular depression symptomatology variable was based on CES-D scores and number of cerebrovascular risk factors (hypertension, diabetes, cardiac disease and smoking). Frailty was measured based on wasting, slowness, weakness, fatigue, and falls. Vascular depression and frailty symptoms were modeled using slope and intercept terms. Mortality was modeled using a discrete-time survival term.
The data supported the proposed model (RMSEA=.051; CFI=.971; X2=234.84, p<.001). Higher vascular depression symptom slope and intercept scores significantly predicted higher frailty slope and intercept scores, respectively. Frailty intercept scores significantly predicted mortality. Vascular depression symptoms indirectly predicted mortality through frailty symptoms. A second model testing the competing hypothesis that frailty symptoms lead to vascular depression symptoms and indirectly to mortality was not supported by the data.
Results suggest that vascular depression symptoms are associated with a clinical trajectory that includes greater frailty and shortened remaining lifespan.
PMCID: PMC4148075  PMID: 23683113
Longitudinal modeling; Clinical trajectory; Aging; Mood; Disability
13.  Systematic Review of Non-Pharmacologic Interventions to Delay Functional Decline in Community-Dwelling Patients with Dementia 
Aging & mental health  2013;17(6):655-666.
Older adults with dementia experience progressive functional decline, which contributes to caregiver burden and nursing home placement. The goal of this systematic review was to determine if any non-pharmacologic interventions have delayed functional decline among community-dwelling dementia patients.
We completed a systematic literature review to identify controlled clinical trials reporting the impact of non-pharmacologic interventions on any measure of functional impairment or disability among community-dwelling dementia patients. We included studies that reported any proxy-respondent, self-reported, or performance-based standardized assessments.
We identified 18 published clinical trials that met inclusion criteria and found that study interventions fell into three different groups: occupational therapy, exercise, and multi-faceted (“other”) interventions. The three groups of studies tended to vary systematically regarding the conceptual framework for the disabling process, target of intervention, and type of outcome measure. Approximately half the studies were conducted in the US with mean sample size of 99 (from 27 to 1131) and follow-up periods between three months and two years. Instruments used to measure functional impairment or disability varied widely with 55 instruments across 18 studies. Nine studies reported a statistically significant improvement in functional decline in the intervention group.
The current literature provides clinical trial evidence that non-pharmacologic interventions can delay progression of functional impairment or disability among community-dwelling dementia patients. The clinical significance of this early evidence is uncertain. These early studies provide rationale for larger and longer-term studies to determine if these interventions are sufficiently potent to delay institutionalization.
PMCID: PMC3723698  PMID: 23611141
occupational therapy; physical function; aged
14.  Well-Being among Older Adults with OA: Direct and Mediated Patterns of Control Beliefs, Optimism and Pessimism 
Aging & mental health  2013;17(5):595-608.
To assess the contribution of important psychological resources (i.e., optimism, pessimism, control beliefs) to the psychological well-being of older adults with Osteoarthritis (OA); to assess the direct and mediated association of these psychosocial resources to outcomes (depressive symptoms, life satisfaction, and self-esteem). These objectives are important because OA is a significant stressor, treatments are limited, and psychological functioning is at risk for those coping with the condition, even compared to other chronic illnesses.
A cross-sectional survey of 160 community-dwelling older adults with OA (81% women). Participants were not randomly selected, but nonetheless reflected the demographic makeup of the selection area.
Ordinary least squares regression analyses using the PROCESS macro (Hayes, 2012) revealed that optimism and pessimism were associated with higher depressive symptoms and lower self-esteem indirectly through constraints beliefs. The analysis of life satisfaction showed that optimism and pessimism were each partially mediated through mastery and constraints beliefs.
These results suggest that prior research, which has assessed these psychological resources as having singular relationships to outcomes, may have underestimated the importance of the relationship between these variables. We discuss possible points of intervention for older adults with OA who may experience increasing constraints beliefs over time.
PMCID: PMC3694999  PMID: 23418813
personality; older adults; osteoarthritis; mediation
15.  Exploring the Effectiveness of an Internet-Based Program for Reducing Caregiver Distress Using the iCare Stress Management e-Training Program 
Aging & mental health  2013;17(5):544-554.
Determine if the online iCare Stress Management e-Training Program reduces stress, bother depression and poor life quality for dementia family caregivers (CGs).
CGs (N=150) were randomly assigned to the iCare Condition (ICC) or to the Education/Information-Only Condition (EOC) for a 3-month periodChange in self-report measures of stress (PSS) (primary outcome), caregiver bother(RMBPC), depression (CES-D) and quality of life (PQOL) (secondary outcomes) was determined, along with usage of new information in one’s own caregiving.
A mixed ANOVA revealed that change in perceived stress was significant for the ICC but not the EOC (p = .017). Changes in the other measures were not significant. More caregivers in the ICC used the materials in their own caregiving situation than those in the EOC. Roughly one-third of the caregivers enrolled in the study dropped prior to completion.
Results are promising, but the high dropout is a concern. Future efforts to improve dropout rate and increase participant engagement are warranted. To our knowledge this is the first attempt to present an evidence-based intervention for CGs via the Internet.
PMCID: PMC3695021  PMID: 23461355
Alzheimer’s Disease; caregiving; nonpharmacological treatments; Internet-based program; dementia
16.  Olfaction and Apathy in Alzheimer’s Disease, Mild Cognitive Impairment, and Healthy Older Adults 
Aging & mental health  2013;17(5):564-570.
Apathy is a prevalent neuropsychiatric manifestation in individuals with Alzheimer’s disease (AD) that is associated with decreased social functioning and increased caregiver burden. Olfactory deficits are also commonly observed in AD, and prior work has indicated a link between increased apathy and olfactory dysfunction in individuals with Parkinson’s disease. Here, we examined odor identification performance in patients with probable AD (n = 172), individuals with mild cognitive impairment (MCI; n = 112), and neurologically and psychiatrically healthy older adults (n = 132) and its relation to apathy, depression, and overall psychopathology.
Participants were administered the Sniffin’ Sticks odor identification test and measures assessing severity of apathy, depression, and overall neuropsychiatric symptomatology.
Consistent with previous research, AD and MCI patients were significantly worse at identifying odors than healthy older adults. Additionally, a sex by diagnosis interaction was observed. AD patients had significantly higher levels of apathy relative to MCI and control participants. Of note, across the entire sample odor identification deficits were correlated with level of apathy at the level of p < 0.01, but not with depression or neuropsychiatric symptom severity, when controlling for MMSE score.
Collectively, these data suggest that olfactory disturbance and apathy in AD may result from the progression of disease pathology in shared neural substrates.
PMCID: PMC3664659  PMID: 23398350
olfactory; smell; apathy; neuropsychiatry; sex differences
17.  Sex differences in trajectories of depressive symptoms among older Taiwanese: the contribution of selected stressors and social factors 
Aging & mental health  2013;17(6):773-783.
We assessed female-male differences in depressive symptoms among older Taiwanese and quantified the contribution of sex differences in exposure and response to selected covariates in explaining the gap.
Using data from six survey waves over 18 years for a nationally representative cohort of 4049 Taiwanese aged 60+, we employed growth curve analysis to model individual-level trajectories of depressive symptoms across age.
Among older Taiwanese, women’s disadvantage with respect to social position and employment accounted for about 40% of the sex difference in depressive symptoms. Sex differences in decision control and exposure to widowhood and financial decline played surprisingly little role. Although we found no evidence that the effects of marriage, recent widowhood or recent child death varied by sex, living apart from one’s children appeared to be more detrimental for women than for men in this society. Moreover, the effect of living with children depended on the arrangement: living with an unmarried son was more strongly associated with depressive symptoms than living with a married son and daughter-in-law.
Sex differentials in social position and employment are major contributors to the sex difference in depressive symptoms among older Taiwanese, yet sex differences in exposure or response to selected stressors appear to play little role. Differential vulnerabilities to particular living arrangements may also contribute to women’s excess psychological distress, although more research is needed to elucidate the mechanisms by which living arrangements influence depressive symptoms in Taiwan.
PMCID: PMC4074914  PMID: 23557213
Depression; sex differences; socioeconomic status; Taiwan; living arrangements
18.  Medical conditions and depressive, anxiety, and somatic symptoms in older adults with and without generalized anxiety disorder 
Aging & mental health  2010;14(6):764-768.
The objective of this study was to examine medical illness and anxiety, depressive, and somatic symptoms in older medical patients with generalized anxiety disorder (GAD).
A case-control study was designed and conducted in the University of California, San Diego (UCSD) Geriatrics Clinics. A total of fifty-four older medical patients with GAD and 54 matched controls participated.
The measurements used for this study include: Brief Symptom Inventory – 18, Mini International Neuropsychiatric Interview, and the Anxiety Disorders Interview Schedule.
Older medical patients with GAD reported higher levels of somatic symptoms, anxiety, and depression than other older adults, as well as higher rates of diabetes and gastrointestinal conditions. In a multivariate model that included somatic symptoms, medical conditions, and depressive and anxiety symptoms, anxiety symptoms were the only significant predictors of GAD.
These results suggest first, that older medical patients with GAD do not primarily express distress as somatic symptoms; second, that anxiety symptoms in geriatric patients should not be discounted as a byproduct of medical illness or depression; and third, that older adults with diabetes and gastrointestinal conditions may benefit from screening for anxiety.
PMCID: PMC4066633  PMID: 20635235
elderly; somatization; depression
19.  Therapist and patient perspectives on cognitive-behavioral therapy for older adults with hoarding disorder: A collective case study 
Aging & mental health  2012;16(7):915-921.
Utilizing a qualitative approach, the current study explored therapist and patient perspectives on a specialized cognitive-behavioral therapy (CBT) protocol for clinically significant hoarding in older adult patients. Data were derived from the following sources: (1) therapist observation; (2) CBT consultant observation; (3) clinical treatment notes; (4) participant feedback, including a focus group; and (5) participant in-session notes and completed homework assignments. Our findings showed that the value of homework, treatment session compliance, and deficits in executive functioning (prospective memory, planning, problem solving, and cognitive flexibility) were common themes among participants as viewed by the therapist. Patients reported that exposure exercises and the therapeutic relationship were the most helpful aspects of their treatment, while cognitive strategies had limited success. Our results suggest that treatment for hoarding in older adults may be improved by focusing on exposure therapy elements, remediating executive function deficits, providing simplified homework assignments, and decreasing the emphasis or modifying cognitive restructuring techniques.
PMCID: PMC4048715  PMID: 22548463
older adults; qualitative approach; exposure exercise; provider perspectives; executive function
20.  Knowledge about aging and worry in older adults: Testing the mediating role of intolerance of uncertainty 
Aging & mental health  2009;13(1):135-141.
This study aims to explore the relationship between knowledge about aging and severity of worry in older adults, and to test the potential mediational role of intolerance of uncertainty.
The sample was composed of 120 community-dwelling older adults, with a mean of age of 71.0 years (SD = 6.3). Mediational analyses and structural equation modeling were used to analyze and compare different models.
Greater knowledge about aging was negatively related to both intolerance of uncertainty and worry, and its effect on worry was partially mediated by intolerance of uncertainty. The mediational model obtained an excellent fit to the data (i.e. Goodness of fit index (GFI) = 0.995) and clearly had a better fit than alternative models.
These results suggest that a good knowledge of the aging process could help decrease aversive uncertainty and thus reduce the level of worry among older adults. Thus, educational programs to increase knowledge about aging could serve as one preventive strategy for anxiety in old age.
PMCID: PMC4048718  PMID: 19197699
stereotypes; GAD; beliefs about aging; FAQ
21.  A Preliminary Typology of Caregivers and Effects on Service Utilization of Caregiver Counseling 
Aging & mental health  2013;17(4):495-507.
Caregivers (CGs) of older adults have unique and diverse needs for intervention. The present studies describe the characteristics of CGs and caregiving situations and how these relate to CG therapy utilization patterns in a community mental health setting.
Study 1: Through chart review, the researchers explored service utilization patterns and identified preliminary typologies of Caregiver Family Therapy (CFT) clients, N = 23. Study 2: By conducting a second chart review, the researchers sought to determine whether the categories that emerged in Study 1 applied to a second group of CFT clients, N = 36.
Study 1: Four distinct categories of caregivers emerged: High-Distress (high disorganization, high complexity), Resourceful but At-Risk (low disorganization, high complexity), Non-Committal (high disorganization, low complexity), and Model CGs (low disorganization, low complexity). Study 2: While the ability to classify CGs into category proved to have some inconsistencies, preliminary evidence suggests the ability to predict utilization once CGs were placed into category was good. In Study 2 a fifth category emerged: High Functioning but Static, which suggests CGs were on a continuum ranging from high to low on family organizational style and CG situation complexity.
While caregiving situations vary widely among families and across time, this paper provides a preliminary typology of CGs that may assist clinicians in tailoring CG interventions to meet the needs of their clients based on information garnered early in therapy, perhaps as early as the intake process.
PMCID: PMC4038971  PMID: 23336319
Caregiver Family Therapy; typology; service utilization
22.  Caregiving Spouses’ Attachment Orientations and the Physical and Psychological Health of Individuals with Alzheimer’s Disease 
Aging & mental health  2012;17(4):508-516.
Attachment theory is a useful framework for understanding how caregiving dyads regulate emotions and maintain feelings of security in reaction to a loved one’s chronic illness. In this study we examined the extent to which the attachment orientations (anxiety and avoidance) of persons with Alzheimer’s disease (AD) and their spousal caregivers were associated with each partner’s report of the physical and psychological health symptoms of the person with AD.
Fifty-eight individuals with AD and their spousal caregivers each completed a 12-item self-report measure of trait attachment orientation and rated the physical and psychological health symptoms of the person with AD over the past two weeks. Data from the persons with AD were used after determining that they were able to provide reliable responses.
As predicted, individuals with AD who were high in anxious attachment self-reported more physical and psychological symptoms, particularly when their caregivers were high in anxious attachment. Also, caregivers perceived more physical symptoms in individuals with AD who were high in avoidant attachment.
This study highlights the importance of considering the attachment security of both caregivers and persons with AD when considering how each partner views the psychological and physical health symptoms of the person with AD. Our results have implications for providing care-recipients and caregivers with improved, tailored care.
PMCID: PMC3596494  PMID: 23215899
attachment; Alzheimer’s disease; caregiving
23.  Association of Cortisol with Neuropsychological Assessment in Older Adults with Generalized Anxiety Disorder 
Aging & mental health  2013;17(4):432-440.
Older adults with Generalized Anxiety Disorder (GAD) have elevated diurnal cortisol patterns and show an increased cortisol stress response, which may increase risk for cognitive dysfunction. The current secondary data analysis examined how neuropsychological assessment as a possible laboratory stressor affects cortisol levels in late-life GAD and, in turn, how cortisol levels affect cognitive performance.
The current sample consisted of 69 individuals with late-life GAD and 39 psychiatrically-healthy group-matched comparison participants. Cognitive performance was measured with a neuropsychological battery and salivary cortisol was collected at several time points. Hierarchical regressions were performed to assess the moderating role of cortisol in the relationship between GAD status and cognitive performance.
The results revealed that older adults with GAD showed significantly lower cortisol levels during neuropsychological assessment, compared to their baseline levels. Further, there was a significant interaction between post-neuropsychological assessment cortisol levels and GAD status on several measures of cognitive performance. The interaction indicated that there is a significant negative relationship between cortisol level and cognitive performance in the GAD participants and no such relationship in the comparison participants.
Our results revealed that participating in a neuropsychological assessment was associated with reduced cortisol in GAD participants, suggesting that refocusing attention such as engaging in cognitive tasks had a cortisol-lowering effect. Further, a higher cortisol level appears to have a detrimental effect on cognitive performance for individuals with GAD but not psychiatrically-healthy comparison participants. The methodological and treatment implications of these findings are discussed.
PMCID: PMC3625449  PMID: 23336532
Generalized anxiety disorder (GAD); HPA axis; neuropsychological assessment; cortisol; stress
24.  Comparison of Major Depressive Disorder and Subthreshold Depression among Older Adults in Community Long-Term Care 
Aging & mental health  2012;17(4):461-469.
This study extends existing knowledge regarding the continuum between major depression (MD) and subthreshold depression (SD) by examining differences in symptomology and associative factors for a subpopulation of older adults with functional disability.
Our sample consisted of clients age 60 and above entering public community long term care derived from the baseline survey of a longitudinal study (315 non-depressed, 74 MD, and 221 SD). We used the Diagnostic Interview Schedule to establish diagnoses of MD, the Center for Epidemiological Studies Depression Scale (CES-D) to assess SD, and other self-report measures to explore potential associative factors of demographics, comorbidity, social support, and stressors.
No differences in CES-D identified symptoms occurred between the two groups. MD and SD were both associated with lower education, poorer social support, more severe medical conditions, and higher stress when compared to non-depressed older adults. Younger age, and being female were associated solely with MD; whereas, worse perceived health and more trouble affording food were associated solely with SD. The only associative factor significantly different between MD and SD was age. Those with MD were more likely to be younger than those with SD.
Our findings of symptom profiles and associative factors lend support to the continuum notion of depression. Identification of only older adults within the community long-term care service system who meet criteria for MD would leave many older adults, who also face multiple comorbidities, high levels of stress and social isolation, and substantial depressive symptoms undiagnosed and untreated.
PMCID: PMC3605212  PMID: 23227913
depressive symptoms; diagnosis; homecare; functional impairment
25.  The Longitudinal and Dyadic Effects of Mutuality on Perceived Stress for Stroke Survivors and their Spousal Caregivers 
Aging & mental health  2013;17(4):423-431.
Functional impairment resulting from a stroke frequently requires the care of a family caregiver, often the spouse. This change in the relationship can be stressful for the couple. Thus, this study examined the longitudinal, dyadic relationship between caregivers’ and stroke survivors’ mutuality and caregivers’ and stroke survivors’ perceived stress.
This secondary data analysis of 159 stroke survivors and their spousal caregivers utilized a cross-lagged, mixed models analysis with the Actor-Partner Interdependence Model (APIM) to examine the dyadic relationship between mutuality and perceived stress over the first year post discharge from inpatient rehabilitation.
Caregivers’ mutuality showed an actor effect (β = −3.82, p < .0001) but not a partner effect. Thus, caregivers’ mutuality influenced one’s own perceived stress but not the stroke survivors’ perceived stress. Stroke survivors’ perceived stress showed a partner effect and affected caregivers’ perceived stress (β=.13, p=.047). Caregivers’ perceived stress did not show a partner effect and did not significantly affect stroke survivors’ perceived stress.
These findings highlight the interpersonal nature of stress in the context of caregiving for a spouse. Caregivers are especially influenced by perceived stress in the spousal relationship. Couples should be encouraged to focus on positive aspects of the caregiving relationship to mitigate stress.
PMCID: PMC3646563  PMID: 23323629
stroke; caregiving; perceived stress; mutuality; dyadic analysis

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