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1.  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
2.  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
3.  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
4.  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
5.  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
6.  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
7.  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
8.  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
9.  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
10.  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
11.  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
12.  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
13.  The Relationship of Religious Involvement Indicators and Social Support to Current and Past Suicidality among Depressed Older Adults 
Aging & mental health  2012;17(3):366-374.
Elderly people, particularly those with major depression, are at the highest risk for suicide than any other age group. Religious involvement is associated with a range of health outcomes including lower odds of death by suicide. However, not much is known about the effects of religious involvement on suicidal ideation in the elderly or which aspects of religiosity are beneficial. The current study examined the relative influence of various conceptualizations of religious involvement, above and beyond the protective effects of social support, on current and past suicidality among depressed older adults.
Participants were 248 depressed patients 59 years and older enrolled in the Neurocognitive Outcomes of Depression in the Elderly (NCODE) study. A psychiatrist assessed current suicidal ideation using the suicidal thoughts item from the Montgomery-Asberg depression rating scale (MADRS). Past history of suicide attempts, four religious involvement indicators, social support indicators, and control variables were assessed via self-report.
Church attendance, above and beyond importance of religion, private religious practices and social support, was associated with less suicidal ideation; perceived social support partially mediated this relationship. Current religious practices were not predictive of retrospective reports of past suicide attempts.
Church attendance, rather than other religious involvement indicators, has the strongest relationship to current suicidal ideation. Clinicians should consider public religious activity patterns and perceived social support when assessing for other known risk and protective factors for suicide and in developing treatment plans.
PMCID: PMC3596433  PMID: 23121118
Religion; Suicide; Elderly; Depression
14.  Cumulative exposure to traumatic events in older adults 
Aging & mental health  2013;18(3):316-325.
The present study examined the impact of cumulative trauma exposure on current posttraumatic stress disorder (PTSD) symptom severity in a nonclinical sample of adults in their 60s. The predictive utility of cumulative trauma exposure was compared to other known predictors of PTSD, including trauma severity, personality traits, social support, and event centrality.
Community-dwelling adults (n = 2,515) from the crest of the Baby Boom generation completed the Traumatic Life Events Questionnaire, the PTSD Checklist, the NEO Personality Inventory, the Centrality of Event Scale, and rated their current social support.
Cumulative trauma exposure predicted greater PTSD symptom severity in hierarchical regression analyses consistent with a dose-response model. Neuroticism and event centrality also emerged as robust predictors of PTSD symptom severity. In contrast, the severity of individuals’ single most distressing life event, as measured by self-report ratings of the A1 PTSD diagnostic criterion, did not add explanatory variance to the model. Analyses concerning event categories revealed that cumulative exposure to childhood violence and adulthood physical assaults were most strongly associated with PTSD symptom severity in older adulthood. Moreover, cumulative self-oriented events accounted for a larger percentage of variance in symptom severity compared to events directed at others.
Our findings suggest that the cumulative impact of exposure to traumatic events throughout the life course contributes significantly to post-traumatic stress in older adulthood above and beyond other known predictors of PTSD.
PMCID: PMC3944195  PMID: 24011223
cumulative trauma exposure; PTSD symptom severity; personality; event centrality; social support
15.  Improving Access to Dementia Care: Development and Evaluation of a Rural and Remote Memory Clinic 
Aging & mental health  2009;13(1):17-30.
The availability, accessibility, and acceptability of services are critical factors in rural health service delivery. In Canada, the aging population and the consequent increase in prevalence of dementia challenge the ability of many rural communities to provide specialized dementia care. This paper describes the development, operation, and evaluation of an interdisciplinary memory clinic designed to improve access to diagnosis and management of early stage dementia for older persons living in rural and remote areas in the Canadian province of Saskatchewan. We describe the clinic structure, processes, and clinical assessment, as well as the evaluation research design and instruments. Finally, we report the demographic characteristics and geographic distribution of individuals referred during the first three years.
PMCID: PMC3966903  PMID: 19197686 CAMSID: cams4246
16.  Vascular Depression: An Early Warning Sign of Frailty 
Aging & mental health  2012;17(1):85-93.
Frailty is a common geriatric disorder associated with ADL impairment, hospitalization, and death. Phenomenological evidence suggests that late-life depression (Katz, 2004), particularly vascular depression, may be a risk factor for frailty. This study tests that hypothesis.
We identified a sample of stroke-free women over the age of 80 from the Health and Retirement Survey. The sample included 984 respondents in 2000 (incidence sample). Of these, 459 were non-frail at baseline and still alive in 2004 (prevalence sample). Frail respondents experienced at least three of the following: wasting, exhaustion, weakness, slowness, and falls. Vascular depression was represented using two dummy variables. The first represented respondents with either high CVB (at least two cerebrovascular risk factors) or probable depression (score ≥ 3 on the 8-item CES-D), and the second represented respondents with both high CVB and probable depression.
At baseline, the prevalence of frailty was 31.5%. Over 4 years the incidence of frailty was 31.8%. After controlling for age, education, ADL and IADL disability, arthritis, pulmonary disorders, cancer, and self-rated health, respondents with either high CVB or probable depression were more likely to be frail at baseline, and those with both were at even higher risk. Of those who were not frail at the 2000 wave, respondents who reported both high CVB and probable depression were more likely to become frail by 2004.
These findings suggest that vascular depression is a prodrome for frailty.
PMCID: PMC3492543  PMID: 22724516
Frailty; Vascular Depression; Older Women
17.  A longitudinal study of differences in late and early onset geriatric depression: Depressive symptoms and psychosocial, cognitive, and neurological functioning 
Aging & mental health  2012;17(1):1-11.
Studies suggest early onset depression (EOD) is associated with a more severe course of the depressive disorder, while late onset depression (LOD) is associated with more cognitive and neuroimaging changes. This study examined if older adults with EOD, compared with those with LOD, would exhibit more severe symptoms of depression and, consistent with the glucocorticoid cascade hypothesis, have more hippocampal volume loss. A second goal was to determine if LOD, compared with EOD, would demonstrate more cognitive and neuroimaging changes.
At regular intervals over a four year period non-demented, older, depressed adults were assessed on the Mini Mental Status Examination (MMSE) and the Montgomery-Asberg Depression Rating Scale (MADRS). They were also assessed on Magnetic Resonance Imaging (MRI).
Compared with LOD, EOD had more depressive symptoms, more suicidal thoughts, and less social support. Growth curve analyses indicated that EOD demonstrated higher levels of residual depressive symptoms over time. The LOD group exhibited a greater decrement in cognitive scores. Contrary to the glucocorticoid cascade hypothesis, participants with EOD lost right hippocampal volume at a slower rate than did participants with LOD. Right cerebrum gray matter was initially smaller among participants with LOD.
EOD is associated with greater severity of depressive illness. LOD is associated with more severe cognitive and neurological changes. These differences are relevant to understanding cognitive impairment in geriatric depression.
PMCID: PMC3535510  PMID: 22934752
late-onset depression; early-onset depression; cognition; hippocampus
18.  Alcohol effects on Cognitive Change in Middle-Aged and Older Adults 
Aging & mental health  2012;17(1):12-23.
This study examines cognitive outcomes for alcohol drinking status over time, across cognitive ability and age groups.
Data (1998-2005) from N=571 Seattle Longitudinal Study participants age 45+years (middle-aged: 45-64, young-old: 65-75, old-old: 75+) were analyzed to examine the alcohol drinking status effect (e.g. abstinent, moderate (≤7 drinks/week), at-risk (≥8 drinks/week)) on cognitive ability (e.g., Memory, Reasoning, Spatial, Verbal Number, Speed abilities).
Findings indicated that alcohol drinking status was associated with change in verbal ability, spatial ability, and perceptual speed. Decline in verbal ability was seen among alcohol abstainers and moderate alcohol consumers, but at-risk drinkers displayed relative stability. At-risk old-old adults and middle-aged adults (regardless of drinking status), displayed relative stability in spatial ability. Decline in spatial ability was however present among young-old adults across drinking status, and among abstaining and moderate drinking old-old adults. At-risk drinkers showed the most positive spatial ability trajectory. A gender effect in perceptual speed was detected, with women who abstained from drinking displaying the most decline in perceptual speed compared with women that regularly consumed alcohol, and men displaying decline in perceptual speed across drinking status.
In this study, consuming alcohol is indicative of cognitive stability. This conclusion should be considered cautiously, due to study bias created from survivor effects, analyzing two time points, health/medication change status, and overrepresentation of higher socioeconomic status and white populations in this study. Future research needs to design studies that can make concrete recommendations about the relationship between drinking status and cognition.
PMCID: PMC3561493  PMID: 22934837
alcohol; cognition; aging
19.  Fidelity and Acceptability of an Adaptive Intervention for Caregivers: An Exploratory Study 
Aging & mental health  2012;17(2):197-206.
There has been growing interest in providing tailored or adaptive interventions to family caregivers as a way of addressing their heterogeneity of risk factors and other needs. A particular challenge in an adaptive study is to implement the individualized intervention protocol as planned (program fidelity). This study explores the fidelity of implementation of an adaptive intervention for family caregivers of persons with dementia and its acceptability to caregivers.
Using a sample of 35 caregivers of person with dementia who participated in a program development study, we gathered information on acceptability and fidelity of the program from multiple sources, including caregiver and counselor reports and ratings of recordings of sessions.
Findings show that caregivers have high levels of acceptance of the intervention plan and high ratings of satisfaction with the program. Ratings of satisfaction and counselor competence were not associated with the amount of treatment provided. Ratings by counselors and independent raters found good fidelity for two of the three program domains.
The results demonstrate that trained counselors can follow a tailored intervention plan and that caregivers’ experience of the program did not differ depending on how much intervention was provided. A next step is to determine how an adaptive protocol would affect caregiver outcomes.
PMCID: PMC3570581  PMID: 22943746
Caregiving; dementia; psychosocial interventions; treatment evaluation
20.  Proactive Aging: A Longitudinal Study of Stress, Resources, Agency and Well-being in Late Life 
Aging & mental health  2012;16(4):10.1080/13607863.2011.644519.
Using the Proactivity Model of Successful Aging, we examined how internal and external resources contribute to the maintenance of psychological well-being and social activities among older adults who experience normative stressors of aging. Outcome variables in this study are collectively referred to as quality of life (QOL). We also examined the mediating role of proactive adaptations between internal and external resources and QOL indicators.
Based on five annual interviews of a sample of 1,000 community dwelling older adults in Florida (effective N = 561), we tested the lagged effects of stressors on two indicators of QOL, four years later. In the full longitudinal model, using structural equations, we estimated the direct effects of internal and external resources on QOL, along with indirect effects through proactive adaptations.
Stressors negatively influenced QOL four years later. Internal and external resources led to better QOL four years later, both directly and indirectly through proactive adaptations of marshaling support and planning for the future.
These findings lend support to the Proactivity Model of Successful Aging by documenting the value of proactive adaptations (i.e., exercise, planning ahead and marshaling support) as proximate influences on QOL outcomes (i.e., depressive symptomatology and social activities). Findings suggest that older adults can maintain successful aging even in the face of health-related and social stressors by invoking accumulated resources to deal actively with the challenges of aging.
PMCID: PMC3825511  PMID: 22299813
Successful aging; adaptation to stress; proactivity; quality of life
21.  The relationship between depressive symptoms and walking among Hispanic older adults: A longitudinal, cross-lagged panel analysis 
Aging & mental health  2010;14(2):10.1080/13607860903191374.
This study examines the relationship between depressive symptoms and walking behavior across 30 months in a prospective study of 217 community-dwelling, Hispanic older adults in Miami, Florida (ages 70–100 years).
Analyses examine the direction of the relationship between depressive symptoms and physical activity (i.e., walking) over time, as well as test for a potential bi-directional or reciprocal relationship between these two variables.
Structural equation modeling (SEM) with a cross-lagged panel design revealed that walking was unrelated to subsequent depressive symptoms. However, depressive symptoms were related to subsequent walking behavior at every time-point, such that higher levels of depressive symptoms were predictive of less walking in the future. Older adults who had clinically-relevant depressive symptoms at the initial assessment had 1.34 times the risk of not walking 30 months later, compared to older adults without clinically-relevant depressive symptoms.
Results support the need for primary care providers to evaluate and address depressive symptoms among older adults, as a means of reducing sedentary behavior and potentially improving health. Further research on the prevention and management of depressive symptoms and sedentary behavior is needed, given the morbidity related to both of these health risks, particularly for minority and low-socio-economic status (SES) older adults.
PMCID: PMC3821697  PMID: 20336553
older adults; Hispanics/Latinos; depressive symptoms; physical activity; longitudinal analyses
22.  Stressful Life Events and Daily Stressors Affect Awakening Cortisol Level in Midlife Mothers of Individuals with Autism Spectrum Disorders 
Aging & mental health  2012;16(8):939-949.
The current study examines the awakening cortisol level in midlife mothers (M=51.4 years old, SD=8.4) of individuals (M=22.1 years old, SD=7.1) with autism spectrum disorders (ASD) under stressful conditions that are not specific to the son or daughter's ASD symptoms.
In addition to completing a set of questionnaires and in-home interviews, 82 mothers from the Adolescents and Adults with Autism Study (AAA) participated in a Daily Diary Study.
Findings from the multilevel models indicated that mothers who previously were exposed to no negative life events in the previous period had an increased awakening cortisol level on days following a greater number and more severe stressors, a normative stress response. In contrast, we observed a flatter cortisol level of daily stressors in mothers who experienced a greater number of negative life events in the previous period.
These findings highlight the sustained toll that global and everyday stressors have on awakening cortisol level of midlife and aging mothers of individuals with ASD.
PMCID: PMC3434247  PMID: 22640177
Stress; caregivers; cortisol
23.  The Association of Mental Conditions with Blood Glucose Levels in Older Adults with Diabetes 
Aging & mental health  2012;16(8):950-957.
People with diabetes must engage in several self-care activities to manage blood glucose; cognitive function and other affective disorders may affect self-care behaviors. We examined the executive function domain of cognition, depressive symptoms, and symptoms of generalized anxiety disorder (GAD) to determine which common mental conditions that can co-occur with diabetes are associated with blood glucose levels.
We conducted a cross-sectional in-person survey of 563 rural older adults (age 60 years or older) with diabetes that included African Americans, American Indians, and Whites from eight counties in south-central North Carolina. Hemoglobin A1C (A1C) was measured from a finger-stick blood sample to assess blood glucose control. Executive function, depressive symptoms, and symptoms of GAD were assessed using established measures and scoring procedures. Separate multivariate linear regression models were used to examine the association of executive function, depressive symptoms, and symptoms of GAD with A1C.
Adjusting for potential confounders including age, gender, education, ethnicity, marital status, history of stroke, heart disease, hypertension, diabetes knowledge, and duration of diabetes, executive function was significantly associated with A1C levels: every one-unit increase in executive function was associated with a 0.23 lower A1C value (p = 0.02). Symptoms of depression and GAD were not associated with A1C levels.
Low executive function is potentially a barrier to self-care, the cornerstone of managing blood glucose levels. Training aids that compensate for cognitive impairments may be essential for achieving effective glucose control.
PMCID: PMC3434257  PMID: 22640032
A1C; cognitive function; depression; anxiety; aging
Aging & mental health  2012;16(7):902-910.
We investigated patients’ difficulties in managing their diet (i.e., diet setbacks) and associations with change in disease-specific and general emotional distress (diabetes distress and depressive symptoms) among patients with type 2 diabetes and their spouses.
Data for this study were collected in couples’ homes (N = 115 couples) using structured interviews and self-administered questionnaires at three time points: baseline (T1), six months after baseline (T2), and twelve months after baseline (T3).
Patients’ diet setbacks were associated with an increase in their diabetes distress in the shorter-term (over six months). Patients’ diet setbacks were not associated with longer-term change in diabetes distress or with change in depressive symptoms at either time point (six months or one year). In contrast, spouses’ perceptions of patients’ diet setbacks were associated with increases in their own diabetes distress at both time points (over six months and one year), and also with an increase in their depressive symptoms in the longer-term (over one year).
Findings reveal detrimental consequences of patients’ diet nonadherence for emotional well-being that extend to the well-being of their spouses.
PMCID: PMC3416920  PMID: 22533446
chronic illness management; diabetes distress; depressive symptoms
25.  Evaluating the Cornell Scale for Depression in Dementia as a Proxy Measure in Nursing Home Residents With and Without Dementia 
Aging & mental health  2012;16(7):892-901.
We evaluated the use of the Cornell Scale for Depression in Dementia (CSDD) as a proxy measure. Study questions were: How do residents’ self-reports on the CSDD compare with the nurse proxy CSDD ratings of the resident? How do characteristics of depression as rated by the resident CSDD and the nurse CSDD compare? To what extent are demographic and clinical variables associated with resident CSDD, nurse CSDD, and the discrepancy between resident and nurse CSDD scores?
Residents and nurse proxy pairs (n=395 pairs) from 28 nursing homes (NHs) participated. We calculated discrepancy scores for total and subscale CSDD scores, examined correlations between resident and nurse CSDD scores, and described rates of clinical depression using each of the scores. We conducted multivariate analyses to examine factors associated with resident and nurse CSDD and discrepancy scores.
On average, participants had mild cognitive impairment, were White, and female. Associations between resident and nurse CSDD were low (r=.16). The mean discrepancy score was −2.03 (SD=5.28, p<0.001), indicating that nurses evaluated residents as less depressed than residents evaluated themselves. Discrepancy scores were not associated with residents’ cognitive status, but were associated with a measure of self-report reliability. Regression analyses indicated that depression diagnosis accounted for a small but significant association with resident CSDD, but was not significantly associated with nurse CSDD.
These findings underscore the importance of obtaining resident input when assessing depression in NH residents with dementia, and educating NH nurses in the most effective ways to assess depression.
PMCID: PMC3416948  PMID: 22486638
depression; proxy measure; nursing homes; dementia

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