Aging in Time and Place
The 16th Annual
Student Mentoring Conference
on Gerontology and Geriatrics
Keynote Addresses and Posters
Edited by
Bettina Schmid
Aging in Time and Place
The 16th Annual
Student Mentoring Conference
on Gerontology and Geriatrics
Keynote Addresses and Posters
Edited by
Bettina Schmid
Copyright © 2005 by The University of Georgia Institute of Gerontology. All rights
reserved. No portion of this report or the data which it contains may be reproduced
without the express written consent of the authors.
Copies of this report may be obtained from The University of Georgia Institute of
Gerontology, 255 E. Hancock Ave., Athens, GA 30602, and the website http://www.
geron.uga.edu.
Technical Report Number UGAIG-05-002.
Printed in Athens, Georgia, by The University of Georgia Printing Department.
iii
Table of Contents
Preface.............................................................................................................. iv
Dr. Louis D. Burgio
Foreword...........................................................................................................v
Editor, Bettina Schmid
About the Conference................................................................................vi
Co-sponsors...................................................................................................vii
Faculty Keynote Address
Life Extension: New Possibilities for Aging in Time and Place.............1
Dr. Terrie Fox Wetle
Student Keynote Address I
Chronic Conditions and Co-morbid Psychiatric Disorders
among Tennessee Medicare Elderly
Michelle C. Reece and Cynthia D. Jackson.........................................15
Student Keynote Address II
The Graduate School Trajectory................................................................35
Katherina A. Nikzad
Lee Awards.....................................................................................................53
Poster Presentations..................................................................................56
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Preface
The 16th Annual Student Mentoring Conference on Gerontology and Geriatrics
was held on Tybee Island, GA, from April 15th to 17th, 2005. As always, the conference
provided an excellent opportunity for students to present their research to a non-threatening, supportive audience. The “receptive” tenor of the conference is particularly
important to undergraduates and lower-level graduate students, but is beneficial to students at all levels. The conference also offers an opportunity for professional networking - a skill rarely taught but of exceptional importance to career advancement.
The conference continues to grow in popularity, with 93 faculty and student participants in this year’s conference, representing 18 institutions. Some of the farthest
traveling students came from Hiram College in Ohio, University of Louisville, and the
University of Kentucky. Co-sponsors of the conference were Armstrong Atlantic State
University, Health Sciences Department; Brenau University, School of Health and
Science; Georgia Southern University, College of Liberal Arts and Sciences; Georgia
State University, Gerontology Institute; Medical College of Georgia, School of Nursing; North Georgia College and State University, School of Nursing; The University of
Alabama, Center for Mental Health and Aging; The University of Georgia, Gerontology Center, and University of Kentucky, Graduate Center for Gerontology.
The monograph includes papers from our faculty keynote speaker, Terrie Fox
Wetle, Ph.D., of Brown University and immediate past president of the Gerontological Society of America, and by student keynote speakers, Cynthia D. Jackson, M.S.,
and Michelle C. Reece, M.S., of Tennessee State University, and Katherina A. Nikzad,
B.A., from the University of Kentucky.
It is important to note that, like most aspects of this conference, this monograph
was put together almost exclusively by students. Expertly edited and designed by Bettina Schmid, Ph.D. candidate in Clinical Psychology at The University of Alabama,
the monograph documents were reviewed primarily by fellow graduate students who
generously gave of their time. I believe the efforts of the authors, editor, and reviewers
show through in the quality of the papers.
Considering the continuing success of the conference, our plan is to carry-on
while remaining open to suggestions from all (in particular, students) for making the
conference even more responsive to students’ needs. We hope you enjoy reading the
monograph as much as our students enjoyed creating it.
Dr. Louis D. Burgio, Ph.D.
Distinguished Research Professor
Director, Center for Mental Health and Aging
The University of Alabama
Tuscaloosa, Alabama
June 2005
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Forward
The student mentoring conference is a unique milieu in which students in gerontology and related fields hone their skills as professional contributors to the scientific
community. Students participate at many levels: poster preparation, poster presentation,
keynote addresses, preparation of the conference monograph, and informal networking. Faculty and advanced students assume mentoring roles. This activity takes place
in an environment of warmth, support, and encouragement. Returning students have
commented on how their confidence and skills have grown with each passing year of
the conference.
The monograph showcases the three keynote addresses and the poster presentations. The faculty keynote address, given by Terrie Fox Wetle, Ph.D., Associate Dean of
Medicine for Public Health and Public Policy at Brown Medical School, and Professor
of Community Health, presented recent research on healthy life extension. The first
student keynote address, by Michelle C. Reece and Cynthia D. Jackson, presented an
epidemiological approach to comorbid illness in older adults. The second student keynote
address, by Katherine Nikzad, presented an overview of graduate school in which she
provides personal insights and advice on how thoughtful planning can make graduate
school a rewarding and valuable experience, using her own research as an example.
In addition, there were over 40 poster presentations by students at undergraduate,
graduate, and postgraduate levels. The top three poster presentations received awards.
The abstracts covered a wide variety of relevant topics including palliative and end-oflife care, housing and care for older adults, and advocacy and legal issues pertaining
to older adults.
Many people contributed to this monograph. The hard work of the keynote presenters in transforming their presentations into polished manuscripts is deeply appreciated.
In addition, several people have provided indispensable assistance and support in this
endeavor (listed in alphabetical order):
Rebecca Allen
Louis Burgio
Jayne Clamp
Ellen Cotter
Carrie Dubose
Marie Durden
Margaret Ege
Susan Fisher
Anne Glass
Michelle Hilgeman
Misti Johnson
Pat Norton
Megan O’Laughlin
Katie Petro
Leonard Poon
Samantha Schmid
It has been an honor to serve as the editor for the monograph of the 16th Annual Student Mentoring Conference on Gerontology and Geriatrics.
Bettina Schmid, M.S.
Center for Mental Health and Aging
The University of Alabama
Tuscaloosa, AL
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About the Conference
Aging in Time and Place
The organizers chose “Aging in Time and Place” as the theme of this year’s
conference in order to encourage submissions that focus on the temporal and spatial
context of the aging experience.
Each of us grows old at a particular time and place or places. Our aging experience is conditioned not only by physiological changes and health that tends to decline
in advanced old age, but by the particular age cohort into which we were born that
shaped our life experience. The complex interrelationships between time and space,
between “then” and “now” and between “here” and “there,” that shape and enrich our
lives in old age are represented in the photograph on the cover of this monograph.
Students and faculty have come together to address some of the mysteries of time and
place in the lives of old and young alike.
Thanks to all of the individuals involved in planning, organizing, and working on the 16th Annual Student Mentoring Conference on Gerontology and Geriatrics.
In Memory
The monograph of the 16th Annual Student Mentoring Conference on Gerontology
and Geriatrics is dedicated in memory of Amber Heuerman.
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Co-Sponsors
The 16th Annual Student Mentoring Conference on Gerontology and Geriatrics is
cosponsored by the following institutions:
Armstrong Atlantic State University
Health Sciences Department
Savannah, GA 31419
Brenau University
School of Health and Science
Gainsville, GA 30501
Georgia Southern University
College of Liberal Arts and
Social Sciences
Statesboro, GA 30460
Georgia State University
Gerontology Institute
Atlanta, GA 30303
Medical College of Georgia
School of Nursing
Augusta, GA 30912
North Georgia College
and State University
School of Nursing
Dahlonega, GA 30597
The University of Alabama
Center for Mental Health and Aging
Tuscaloosa, AL 35487
The University of Georgia
Institute of Gerontology
(formerly Gerontology Center)
Athens, GA 30602
University of Kentucky
Graduate Center for Gerontology
Lexington, KY 40536
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Faculty Keynote Address
Faculty Keynote Address
Dr. Terrie Fox Wetle is Associate Dean of Medicine for Public Health and Public
Policy at Brown Medical School and is Professor of Community Health. She was most
recently Deputy Director at the National Institute on Aging at the National Institutes
of Health. Formerly, she was Director for the Braceland Center for Mental Health and
Aging at the Institute of Living, and Associate Professor of Community Medicine and
Health Care, University of Connecticut Health Center, School of Medicine. She is
former Associate Director of the Division on Aging and Assistant Professor of Medicine
at Harvard Medical School. At Yale, she was Director of the Program in Long Term
Care Administration and Assistant Professor of Epidemiology and Public Health.
She also previously worked in federal government as a Social Policy Analyst for the
Administration on Aging, Department of Health and Human Services, and in local
government as director of an Area Agency on Aging in Portland, Oregon. She is the
past President of the Gerontological Society of America. Dr. Wetle’s research interests
include social gerontology, the organization and finance of health care and ethical issues
in geriatric care and public health, and end of life care. She has more than 150 scientific
publications and serves on the editorial boards of several journals. Her most recent edited
book is Financing Long Term Care: The Integration of Public and Private Roles.
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Life Extension:
New Possibilities for Aging in Time and Place
Terrie Fox Wetle, M.S., Ph.D.
Associate Dean of Medicine for Public Health and Public Policy
Brown Medical School
This paper addresses several topics related to the concept of life extension. First, I
will present the primary goals of life extension research. Second, I will clarify several
key terms, including the concepts of average life expectancy, maximum life span,
life extension, and longevity. Third, I will discuss promising science relevant to life
extension, including research on interventions to increase the human life span. Last, I
will conclude with a discussion on some of the significant social implications of life
extension.
Primary Goals
The foundational goal in life extension research is the extension of healthy life, not
simply adding more disabled years onto the end of life. Jonathan Swift (1726/1938),
in Gulliver’s Travels, discussed the implications of life extension as Gulliver travels
among the Struldbrugs:
One day, in much good company, I was asked by a person of quality, “whether
I had seen any of their STRULDBRUGS, or immortals?” I said, “I had not;”
and desired he would explain to me “what he meant by such an appellation,
applied to a mortal creature.” He told me “that sometimes, though very rarely,
a child happened to be born in a family, with a red circular spot in the forehead,
directly over the left eyebrow, which was an infallible mark that it (the child)
should never die.” (p. 223)
After this preface, he gave me a particular account of the STRULDBRUGS
among them. He said, “they commonly acted like mortals till about thirty years
old; after which, by degrees, they grew melancholy and dejected, increasing
in both till they came to fourscore.” . . . When they came to fourscore years,
which is reckoned the extremity of living in this country, they had not only all
the follies and infirmities of other old men, but many more which arose from
the dreadful prospect of never dying. They were not only opinionative, peevish,
covetous, morose, vain, talkative, but incapable of friendship, and dead to all
natural affection, which never descended below their grandchildren. Envy and
impotent desires are their prevailing passions. . . . The least miserable among
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Faculty Keynote Address
them appear to be those who turn to dotage, and entirely lose their memories;
these meet with more pity and assistance, because they want many bad qualities
which abound in others. (pp. 228-229)
At ninety, they lose their teeth and hair; they have at that age no distinction of
taste, but eat and drink whatever they can get, without relish or appetite. The
diseases they were subject to still continue, without increasing or diminishing.
In talking, they forget the common appellation of things, and the names of
persons, even of those who are their nearest friends and relations. For the same
reason, they never can amuse themselves with reading, because their memory
will not serve to carry them from the beginning of a sentence to the end; and
by this defect, they are deprived of the only entertainment whereof they might
otherwise be capable. (p. 230)
The reader will easily believe, that from what I had heard and seen, my keen
appetite for perpetuity of life was much abated. (p. 231)
Thus, the emphasis in life extension is not on living forever, but rather the promise
of extending healthy life span and exploring the likelihood and social implications of
life extension.
Key Terms
Average life expectancy is usually defined as the average age of death of a cohort
born in a given year. However, a more technical definition is the age at which 50% of
the members of a population have died, when plotted on a standard survival curve. This
statistic is normally calculated from birth, but may be recomputed in terms of expected
years remaining at any age.
Maximum life span is the theoretical length of time an individual can survive under
optimal conditions. The alternative definition is the age of the oldest known survivor of
a species. For humans, we currently believe that maximum lifespan is 122 years, noting
the long life of Jeanne Louise Calment. Madame Calment was born in Arles, France
on February 21, 1875, and died on August 4, 1997. Her genes may have contributed to
her longevity, as her father lived to the age of 94 and her mother to the age of 86. She
attributed her long life to eating a good deal of olive oil and enjoying chocolate every
day. She rode a bicycle to the age of 100. There have been claims of longer lives, but
none have been substantiated by official records.
Life extension is the increase in maximum life span. This is not simply increasing
average life expectancy. Increases in life expectancy have occurred as more infants
have survived to childhood, children have survived to adulthood, and more adults have
survived to old age. Rather, life extension is extending the maximum life span of our
species.
Longevity is a term used to describe variability in life span by species and by family
lines. For example, the bristlecone pine lives as long as 5,000 years. A tortoise can live
about 150 years; a human, 122 years; a parrot, 90 years; a lobster, greater than 50 years;
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a queen bee, 5 years; a drone or worker bee, 1 year. From this information, we can
conclude that there is a genetic influence. Furthermore, when we look within a specific
species, we can see that there are family lines that live longer or shorter periods of time,
so we know that genetics is involved in maximum life span (Wachtel & Finch, 1997).
Figure 1. Comparison of life spans of selected species (Wachtel & Finch, 1997).
Focusing on humans for a moment, we know that life expectancy has increased
from about 40 years at the turn of the last century up to about 77.6 years in the United
States today. Moreover, females tend to live longer than males. We also know that
environmental influences can have a huge impact on life expectancy in any given year.
For example, the Spanish Flu pandemic in 1918 caused a major dip in life expectancy,
because it killed not just the old, but also previously healthy young people. Another
example is the AIDS epidemic in sub-Saharan Africa, where entire generations of
persons in their 20s and 30s are dying of the disease. It is more typical, however, that
populations around the world are experiencing steady increases in life expectancy, as
greater numbers of individuals survive childhood and live to grow old.
These increases are attributed to many factors, but the conventional wisdom is that
much of this change over the past century is related to public health efforts such as
clean water, improved sanitation, and vaccination of children. It is also believed that
increases in life expectancy may be due to changes in human behavior, such as health
promotion activities, healthier diets, and other factors that have an influence on how
long individuals within a population live.
Demographers predict that life expectancy will continue to increase, and what once
was referred to as the “population age pyramid,” with many young people represented at
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Faculty Keynote Address
the bottom and fewer persons represented in the top tiers as age increases, will eventually
become an “age rectangle” in which a majority of the world population will live to later
life. Additionally, it should be noted that U.S. demographers have systematically and
consistently underestimated life expectancy and survival rates of the very old for the
last 30 years.
Given this information, many scientists are asking whether the maximum life span
of humans is increasing. While there is currently no clear-cut answer, this question has
evoked considerable debate (Olshansky, Carnes, & Desquelles, 2001). For example, at
the 2003 meeting of the Gerontological Society of America, there was a panel discussion
on this topic, involving James Vaupel, Leonard Hayflick, and others, in which strong
opinions were heatedly discussed, on whether or not a change in maximum life span is
occurring. James Vaupel, a noted demographer at Duke University and the Karolinska
Institute, expressed conviction and provided data that he believed demonstrated increases
in maximum life span. Leonard Hayflick and others questioned whether this is the case.
While the debate continues for humans, we have strong data from other species that
maximum life span can be altered and extended.
Science of Life Extension
I will discuss two areas of promising research helping us to understand potential
strategies for life extension. The first involves genetic control of longevity and the
other addresses interventions to increase life span. This will not be a discussion of
magic elixirs, growth hormone, or snake oil. Over the centuries and continuing into the
present, vast amounts of money have been spent on interventions believed to extend
life – ranging from yogurt and monkey glands, to growth hormones and antioxidants.
As yet, there are no data to demonstrate that any of these sorts of interventions have an
effect on length of life. Nonetheless, billions upon billions of dollars are being spent to
forestall the effects of aging, and the anti-aging medication market is very big business,
both here in the U.S. and abroad.
Genetic Control of Longevity
As mentioned earlier, there is strong observational evidence (i.e., different life
spans of various species) that a genetic component influences longevity. Moreover, we
know that there are long-lived families, and, if we look at various subgroups within the
U.S. population, we know that there are areas of the country in which certain genetic
groups live much longer than other genetic groups and that these differences cannot be
explained by lifestyle choices.
The basic science about genetic control of longevity comes from several streams
of thinking. One of the earliest was Leonard Hayflick’s observation that cells living in
culture have a finite number of possible cell divisions -- about 50 for human epithelial
cells -- and then the colony of cells dies (Hayflick, 1965). At the time Dr. Hayflick made
this discovery, it was a major revelation because it was generally believed that cells in
culture lived forever.
Another stream of basic science evidence comes from the deliberate development
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of long-lived populations among a variety of species, such as fruit flies and C. elegans.
For fruit fly populations, long-lived populations are obtained by selecting for late
breeders. In other words, the longer that reproduction is delayed, the more likely that
the offspring will be long-lived. Michael Rose (1997) has been a leader in this work,
and by repeatedly selecting late breeders in subsequent generations, he has developed
populations of fruit flies with life spans double that of the usual wild-type fruit fly.
Another line of thinking in genetics research is the telomere story. At each end
of every chromosome arm is a telomere. In cell division, the chromosome replicates
itself and splits, resulting in two new sets of chromosomes. Each time the chromosome
replicates itself and divides, it loses a bit of its endpoint, and the telomere gets just a
little shorter. In the drawing below, moving from left to right, one can see that, with
the replication of the chromosome in the absence of telomerase, the telomeres at the
ends of the chromosome (black) get shorter. Eventually, as the telomere shortens the
population of cells no longer grows properly (chromosome at lower right). However,
when telomerase is expressed, the telomere retains its length. This occurs in most cancer
cells and in our reproductive cells. This makes sense, of course, because if chromosomes
in our reproductive cells grew shorter with each division, our species would soon perish.
The trick is to be able to turn telomerase on for aging cells and off for cancer cells. This
is an exciting area of research.
Telomerase
No Telomerase
Figure 2. Illustration of telomeres (National Institute on Aging, n.d.).
Moving to another area of genetics research, we address the round worm,
Caenorhabditis elegans. C. elegans is a small (about 1 mm long) soil nematode, or
round worm, with 959 cells all visible by microscope. C. elegans lives from two to three
weeks, and identification of its genome is almost complete. (In fact, many scientists
are spending their entire careers studying C. elegans). Gerontologists are particularly
interested in studying this organism because its short life span allows for the observation
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Faculty Keynote Address
of multiple generations in a single year. Scientists have identified several genes through
their work with C. elegans that are associated with extended life. The graph below
shows the population survival curves for one such gene, age-1, that is associated with
a doubling of the life span.
Figure 3. C. elegans age-1 gene mutation and life span (Friedman & Johnson, 1988).
The application in humans is examined using genetic homologues to the genes
identified in C. elegans, and several such genes have been discovered. For example,
the age-1 gene noted in the figure above has a homologue in humans that is associated
with glucose metabolism. The daf-2 gene, which has a similar impact on life span in
worms, is associated with an insulin-like receptor in humans. In addition, daf-16 in
C. elegans is associated with genetic transcription in humans. Discoveries can also be
applied to C. elegans from humans. For example, the gene for Werner’s Syndrome, a
disease of progeria (premature aging) was first identified in humans, and a homologue
has now been identified in C. elegans.
The other interesting aspect of C. elegans research is that there is actually a
functional scale for measuring the activity of the worms – sort of an “activities of daily
living” (ADL) scale for nematodes. We could call it an AWL for “active worm life.”
This scale measures the activities of worms (i.e., how much they move around), and as
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these worms age and become old, (at 17 to 21 days), they get wrinkled, and they get
slow. You can actually characterize their activity level using the measure of AWL. For
those populations of long-lived worms, their AWL measures indicate that they are very
active until the very end of their lives. So, it’s not just that science is causing worms to
live longer; we are actually increasing their active life expectancy.
Interventions to Increase the Life Span
Animal research on caloric restriction. Studies have shown that, by restricting the
calories in specific animal diets, such as in mice, rats, and several other species, we
can extend life expectancy by about one-third (McCay, Crowell, & Maynard, 1935;
Weindruch & Walford, 1988). The figure below shows the effect of reducing calories
in the diet of rats by about 30%, while providing necessary vitamins and minerals. Not
only did the population of animals have increased life expectancy, as indicated by the
two survival curves, but they were also healthier. For example, the small circles in the
chart represent tumors occurring in each population (solid circles represent tumors in
the animals with their usual diet, and open circles represent tumors in animals with
calorically-restricted diets). There were fewer tumors observed in the caloricallyrestricted group, and the tumors that did occur were observed much later in the animals’
lives.
Figure 4. Effect of caloric restriction on survival rates of rats (National Institute on Aging,
Intramural Program Presentation, 1996, Gerontology Research Center, Baltimore).
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Faculty Keynote Address
These findings have been replicated in a variety of species, and there is now a major
study underway examining the effects of caloric restriction in non-human primates
(Roth, Ingram, Black, & Lane, 2000). Because these animals have such long life-spans,
the survival data are not yet in, but a variety of biological measures indicate that the
calorically-restricted monkeys are in good health and likely to have longer lives (Lane,
Ingram, & Roth, 1999; Kemnitz et al., 1994).
Extending healthy life expectancy in humans. It would be an empty victory if we
were able to extend the unhealthy years of life, as in Jonathan Swift’s Struldbrugs. As has
been pointed out, interventions to extend life expectancy in lower animals have actually
extended healthy life expectancy. Now, let us turn to human populations to see whether
the increase in overall life expectancy is also increasing healthy life expectancy.
Manton and Xiliang (2001) at Duke University first reported exciting new findings
indicating that the functional status of our older population had been improving since
the early 1980s. Although the findings were very controversial initially, they have
since been replicated with other data sets both in the US and in several other developed
countries. Manton and Xiliang used data from the 1982 Long-Term Care survey to
identify gender- and age-adjusted rates of disability among older persons, noting that
there were about 6.4 million elders who had physical disabilities. They then used Bureau
of the Census mid-level projections to predict how many disabled elders there would be
in 1989, 1994, and 1999, if the rates of disability remained the same. They projected that
in 1989 there would be 7.5 million disabled elders; in 1994, there would be 8.3 million
disabled elders; and in 1999, there would be 9.4 million disabled elders. Using actual
data from the next phases of the Long-Term Care Survey, Manton and Xiliang found
that there were actually fewer disabled elders than predicted, indicating that the rates
of disability were decreasing. For example, in 1999, there were 7.0 million disabled
elders, 2.4 million fewer than the 9.4 million projected if the rates of disability had
remained the same as in 1982. In fact, it appears that the rate of decrease in disability
rates is actually accelerating over time. Moreover, the rates are declining most rapidly
amongst the older groups of elders in the population.
While it is now accepted that this finding is robust, we are much less precise in
explaining why this decrease in disability rates is occurring. However, we do know that
there are behaviors we can engage in (or refrain from) that can reduce the likelihood of
disability. For example, we can all wear seatbelts in our cars, avoid or stop smoking,
drink alcohol in moderation, exercise, eat a healthy diet, maintain a healthy weight,
and get flu and pneumococcal vaccines. We can seek appropriate health screenings for
cholesterol, pap smears, mammograms, colonoscopies, and screening for diabetes. We
know what we can do, but we do not know if these interventions are directly contributing
to better functional status among older populations.
Unfortunately, there are some disturbing trends that may threaten this good news
scenario regarding lowering rates of disability. Obesity is currently an epidemic in the
United States, and it is affecting younger and younger age groups, resulting in earlier
onset of Type 2 Diabetes. This is absolutely preventable, and, sadly, we will harvest
terrible illness and disability caused by obesity and diabetes in years to come.
Interventions to improve healthy life expectancy among older adults. We know what
we can do in younger years to improve life expectancy as well as healthy life
Life Extension
Figure 5. Comparison of chronically disabled older Americans, projected rates and
actual rates (Manton & Xiliang, 2001).
expectancy, but can we have an impact on those who are already growing old? One
study, reported by the National Institute on Aging (NIA; n.d.) at its budget hearings,
described men aged 50 and older who participated in a study examining the impact of
being physically fit in later years. Those who were physically fit at the beginning, and
stayed physically fit during the three year observation period, were 80% less likely to
experience cardiovascular mortality than those who were physically unfit for the entire
period. Although this finding was not a surprise to researchers, one very interesting
finding was that the relatively small group of men who began the study unfit, but became
physically fit during the observation period, experienced cardiovascular mortality at
about one-half the rate of those who remained physically unfit. This is exciting news
about the positive impact of becoming fit, even later in life! This finding also leads
to the question of how to motivate people to exercise and become (or stay) physically
fit. This area is a challenge for researchers and clinicians alike, as sedentary behavior
increases with age and generating behavioral change is complex.
In concluding this section, I will offer a few comments about brain health, another
area of functioning that affects healthy life expectancy. We know that the prevalence
of Alzheimer’s disease doubles every five years after the age of 65 (Evans et al.,
1989). Many observational studies have attempted to describe the epidemiology of
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Faculty Keynote Address
Alzheimer’s disease and other cognitive impairments, including identification of risk
and protective factors for these diseases. Although we do not yet have good animal
models for Alzheimer’s disease, there is a strain of transgenic mice that develop the
plaques of Alzheimer’s disease in their brains and also display problems with learning
and memory, much like humans. Schenk and colleagues (1999) reported a beta amyloid
vaccine that reduced the plaques in transgenic mice developed by St. George-Hyslop and
Westaway (1999). Morgan and colleagues (2000) noted that mice receiving the vaccine
had fewer errors in learning a maze. These are exciting findings, and further research is
being done to develop a vaccine that is safe and effective in humans.
In addition to Alzheimer’s disease and other types of abnormal cognitive decline,
we are also concerned with the changes in brain function that occur in normal aging. For
many years, it was believed that, after early childhood, we had as many brain cells as
we would ever have and that new neurons would not be formed later in life. However,
recent science indicates that old dogs can learn new tricks . . . or at least mice can!
Evidence indicates that there is indeed growth of new nerve cells in the brains of both
“adolescent” and “elder” mice. Moreover, by providing these mice with an “enriched”
environment (i.e., new toys and objects to explore), the production of new cells can be
tripled in both young and old mice. In humans, there is evidence of continuing nerve
cell formation among adults (Kempermann, Kuhn, & Gage, 1998).
Social Implications of Life Extension
There is huge private investment in the science of life extension, as well as more
modest public funding. It is very likely that continued gains in life expectancy and healthy
life expectancy will occur as we improve health behaviors, develop new interventions,
and improve access to care. While average life expectancy is likely to continue to
increase in the near future, I think it is unlikely that there will be major increases in
maximum life span in the near term. However, I believe that eventual opportunities for
life extension in the far future are quite likely.
What are the social implications of life extension technology? First, such technologies
are likely to be quite expensive. Therefore, life extension technology may not be available
to all people in the population, and thus is likely to increase health disparities. Second,
these projections raise the question of how we balance the investment in life extension
technologies with other human needs. Currently, we have children in the U.S. who do
not have access to appropriate dental care, children who go hungry, and young people
who are not getting an adequate education.
There are also social and ethical considerations related to what we consider
appropriate activities at each stage of life. Life extension is likely to have a profound
impact on family structure, how one goes about one’s work life, and the very fabric of
society. Generally, we are highly ambivalent about old age, and having major extension
of life expectancy is likely to exacerbate that ambivalence. In addition, substantial
increases in life expectancy would have a huge impact on the structure of our population
(i.e., the age distribution). For example, only 4% of the population was over the age
of 65 in 1900; today, about 13% of the population is over 65 nationwide (in Florida,
20% of the population is over 65). In some European nations, these numbers are even
Life Extension
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higher, approaching a quarter of the population. If this shift in demographics were to
be accelerated, with even larger proportions of old and very old, how might our social
structures respond? What are our life expectations and how might they change with a
substantially increased life span? What are the roles that we would expect to assume
in different periods in our lives? For example, how would an increased life span affect
the meaning and timing of education, the nature and timeline of our work lives, and
the meaning of “retirement?”
In addition, there is likely to be a substantial economic impact. Substantial extension
of life would certainly exacerbate our concerns about Social Security, pensions, and how
we structure health care. Health and service systems are likely to experience increased
demand in the long run, even if increased healthy life expectancy would provide a
counterbalance. Changes in social services might be needed to help individuals adjust
to changing family structures and work force issues.
Figure 6. Annual cost saving of delaying onset of disease by 5 years (The Alliance for
Aging Research, 1995).
On the other hand, delay of disability and increased healthy life expectancy
would have positive benefits as well. For example, the Alliance for Aging Research
developed data to show what the cost savings would be if we were able to delay the
onset of various diseases by just five years (not “preventing” the disease entirely, just
delaying symptom onset). If we achieved a five year delay in the onset of symptoms
of Alzheimer’s disease, we could save $50 billion, 50 times the annual budget of the
National Institute on Aging. If we were able to delay entry into the nursing home by five
13
Faculty Keynote Address
years, we would save $35 billion. If we could delay the onset of stroke or hearing loss
by just five years, we would save $15 billion in each case. Clearly, major cost savings
would result from these relatively modest disease delays, making available substantial
resources to address other important social and health problems.
In sum, life-extending science has, to date, focused primarily on disease prevention
and treatment, rather than on the basic science of life extension. I would argue that we
must consider and prepare for the possible, even if it is not imminently probable. We need
to emphasize the ethical, moral, and social implications of life extension as the science
continues, just as in the human genome investment, where there has been appropriate
emphasis on the ethical and legal implications of genetics research.
Science and research on aging have improved our health and our lives. We should not
fear the future, but as gerontologists, we should prepare ourselves and society for what
is to come. As emerging scientists, you hold the tools, the energy, and the motivation
to continue this important work. You also carry the obligation to assure that science is
used to improve lives and the human condition.
References
Alliance for Aging Research. (1995). Putting aging on hold: Delaying the diseases of old
age. Retrieved June 24, 2005 from http://www.agingresearch.org/bookshelf_details.
cfm?id=34
Evans, D., Funkenstein, H. H., Albert, M. S., Scherr, P. A., Cook, N. R., Chown, M.
J., et al. (1989). Prevalence of Alzheimer’s disease in a community population of
older persons. Higher than previously reported. Journal of the American Medical
Association, 262, 2551-2556.
Friedman, D. B., & Johnson, T. E. (1988). A mutation in the age-1 gene in Caenorhabditis
elegans lengthens life and reduces hermaphrodite fertility. Genetics, 118, 75-86.
Hayflick, L. (1965). The limited in vitro lifetime of human diploid cell strains.
Experimental Cell Research, 25, 614-636.
Kemnitz, J. W. Q., Roecker, E. B., Weindruch, R., Elson, D. F., Baum, S. T., & Bergman,
R. N. (1994). Dietary restriction increases insulin sensitivity and lowers blood
glucose in rhesus monkeys. American Journal of Physiology, 266, 540-547.
Kempermann, G., Kuhn, H. G., & Gage, F. H. (1998). Experience-induced neurogenesis
in the Senescent Dentate Gyrus. Journal of Neuroscience, 18, 3206-3212.
Lane, M. A., Ingram, D. K., & Roth, G. S. (1999). Calorie restriction in nonhuman
primates: Effects on diabetes and cardiovascular disease risk. Toxicology Science,
52, 41-48.
Manton, K. G., & Xiliang, G. (2001). Changes in the prevalence of chronic disability in
the United States black and nonblack population above age 65 from 1982 to 1999.
Proceedings of the National Academy of Sciences, 98, 6354–6359.
McCay, C. M., Crowell, M. F., & Maynard, L. A. (1935). The effect of retarded growth
upon the life span and upon ultimate body size. Journal of Nutrition. 10, 63-79.
Morgan, D., Diamond, D. M., Gottschall, P. E., Ugen, K. E., Dickey, C., Hardy, J., et
al. (2000). A beta peptide vaccination prevents memory loss in an animal model of
Life Extension
14
Alzheimer’s disease. Nature, 408, 982-985.
National Institute on Aging. (1996). Intramural Program Presentation by G. S. Roth.
Presented at the Gerontology Research Center of the National Institute on Aging,
Baltimore, MD.
National Institute on Aging. (n.d). Director’s Statement, FY 2000 President’s Budget
Request. Retrieved April 25, 2005, from http://www.nia.nih.gov/AboutNIA/
BudgetRequests/FY2000/default.htm#rdd
National Institute on Aging. (n.d). Director’s Statement, FY 2000 President’s Budget
Request. Retrieved April 25, 2005, from http://www.nia.nih.gov/AboutNIA/
BudgetRequests/FY2000/default.htm#2
Olshansky, S. J., Carnes, B. A., & Desequelles, A. (2001). Demography, prospects for
human longevity. Science, 291, 1491-1492.
Rose, M.R. (1997). Toward an evolutionary demography. In K. W. Wachter and C. E.
Finch (Eds.), Between Zeus and the salmon: The biodemography of longevity (pp.
96-107). Washington, DC: National Academy Press.
Roth, G. S., Ingram, D. K., Black, A., & Lane, M. A. (2000). Effects of reduced energy
intake on the biology of aging: The primate model. European Journal of Clinical
Nutrition, 54, S15-S20.
Schenk, D., Barbour, R., Dunn, W., Gordon, G., Grajeda, H., Guido, T., et al. (1999).
Immunization with amyloid-b attenuates Alzheimer-disease-like pathology in the
PDAPP mouse. Nature, 400, 173-177.
St. George-Hyslop, P. H., & Westaway, D. A. (1999). Alzheimer’s disease. Antibody
clears senile plaques. Nature, 400, 116-117.
Swift, J. (1938). Gulliver’s Travels. New York: Thomas Nelson and Sons. (Reprinted
from Gulliver’s Travels by J. Swift, 1726, London: Benjamin Mott, Jr.).
Wachter, K. W., & Finch, C. E. (Eds.). (1997). Between Zeus and the salmon: The
biodemography of longevity. Washington, DC: National Academies Press.
Weindruch, R., & Walford, R. L. (1988). The retardation of aging and disease by dietary
restriction. Springfield, IL: Charles C. Thomas.
15
Student Keynote Address I
Student Keynote Address I
Michelle C. Reece (pictured on right) is a predoctoral student at Tennessee State
University, currently working on a Master’s Certificate in Health Care Administration.
She works as a Research Associate for the Center for Health Research. Michelle's research interests include community outreach and health research aimed at improving
health outcomes and health service delivery for low-income, minority, and older populations. She is currently coordinating two community education projects: (1) a diabetes
intervention for older African Americans living in high-rises and (2) a church-based
prostate cancer education program for African American men. Other topics of interests
include race, religion and mental health; self efficacy and locus of control; and the
impact of these constructs on mental health.
Cynthia D. Jackson (pictured on left) is a doctoral student in Counseling Psychology at Tennessee State University where she works on various research projects at
the Center for Health Research. She also works as a research analyst at Vanderbilt University Medical Center in the Division of Adolescent Medicine coordinating several
projects involving adolescents. Her current research interests include chronic diseases
and mental health in the geriatric population; race, self-efficacy and depression with
older adults and locus of control and depression with older adults; depression among
the HIV population, and research looking at teens that suffer from chronic pain.
Chronic Conditions & Comorbidity 16
Chronic Conditions and Comorbid Psychiatric
Disorders Among Tennessee Medicare Older Adults
Michelle C. Reece, M.S.
Cynthia D. Jackson, M.S.
Pamela C. Hull, Ph.D.
Janice Emerson, M.S.
Barbara Kilbourne, Ph.D.
Baqar A. Husaini, Ph.D.
Center for Health Research
Tennessee State University
PURPOSE: Previous studies have suggested that compared to the general population, individuals
with chronic conditions, such as diabetes, cardiovascular disease (CVD), and arthritis, may have
more comorbid psychiatric disorders, while the relationship with cancer is inconsistent. Few studies have tested whether this association is true for older adults, or whether it is consistent across
racial and gender groups. This study examines the co-occurrence of two psychiatric diagnoses
(mood disorder and dementia) with these four chronic conditions among Medicare beneficiaries age
65 and over in Tennessee, by race and gender groups.
DESIGN AND METHOD: Physician billing records for 100% of Medicare Part B enrollees in
Tennessee (N = 660,521) for 2002 were analyzed. The presence of diagnoses for chronic medical conditions and psychiatric disorders was determined using ICD-9 diagnostic codes. Logistic
regression analysis was used to estimate adjusted odds ratios for the co-occurrence of a mood
disorder or dementia with each chronic medical condition, while controlling for other factors such
as race, gender, age, and other chronic conditions.
RESULTS: Diabetes, CVD, and arthritis were associated with higher odds of having a diagnosis
for a mood disorder or dementia. CVD had the strongest association with both psychiatric disorders, particularly among black men. For diabetes, the association with mood disorder was strongest
for black men, while the association with dementia was strongest for black women. Arthritis had a
stronger association with mood disorder than with dementia, with white males having the strongest
association for each. Overall, patients with cancer had a small positive association with mood disorder, although cancer had a significant negative association with dementia for whites.
IMPLICATIONS: The positive relationship between certain chronic conditions (i.e., diabetes,
CVD, and arthritis) and comorbid psychiatric diagnoses (i.e., mood disorders and dementia) among
older adults could imply adverse effects on treatment adherence, functional status, health care
costs, and mortality.
_____________________________________________________________________
This research was supported in part by grants from National Institute for Mental Health (R24 MH059748;
Husaini, PI) and Agency for Healthcare Research and Quality (R24 HS014767; Husaini, PI; Levine, Co-PI).
Direct correspondence to: Michelle Reece, M.S., Tennessee State University, Center for Health Research, 3500
John A. Merritt Boulevard, Box 9580, Nashville, TN 37209; 615-320-3005; michellereece@hotmail.com.
17
Student Keynote Address I
Chronic Conditions and Comorbid Psychiatric Disorders
Among Tennessee Medicare Older Adults
Existing research suggests a strong two-way relationship between mental and
physical health. Mental and physical disorders may manifest concurrently for different reasons (National Institute of Mental Health [NIMH], 2002; Rathman, Haastert,
Roseman, & Giani, 1999; Talbot & Nouwen, 2000). For example, physical illness may
create chemical imbalances in the body that lead to mental disorders. Additionally,
stress, pain, and incapacity related to medical illness and its treatment could cause
some people to develop a mental disorder as a psychological reaction. On the other
hand, mental disorders may contribute to physical illness by interfering with the ability to seek and comply with treatment for chronic illnesses (Ciechanowski, Katon, &
Russo, 2000; DiMatteo, Lepper, & Croghan, 2000; Ziegelstein et al., 2000), which in
turn may lead to increased impairment and pain (Koenig, George, Peterson, & Pieper,
1997; Lyness, King, Cox, Yoediono, & Caine, 1999; , Simon, Spertus, & Russo, 2002).
In addition, psychiatric symptoms may impede the likelihood that individuals use certain preventive health services (Husaini et al., 2001). Alternatively, mental disorders
and general physical illnesses may occur simultaneously, but not be directly related to
each other (i.e., the relationship could be spurious).
Regardless of the causal relationship, numerous epidemiological, community, and
clinical studies have suggested that medically ill individuals are more likely to have
psychiatric symptoms than those without illnesses (Harvard Mental Health Letter,
1995). In particular, patients with chronic medical conditions (CMCs) such as diabetes, cardiovascular disease (CVD), and arthritis may be more likely to have psychiatric comorbidities, including but not limited to mood disorders and dementia (Birrer
& Vemuri, 2004; Romanelli, Fauerbach, Bush, & Ziegelstein, 2002). The relationship
with cancer is less consistent, with some evidence suggesting a possible positive association with mood disorders (Lloyd-Williams & Friedman, 2001) and a possible negative association with dementia (Gupta & Lamont, 2004; Roe, Behrens, Xiong, Miller,
& Morris, 2005). Among adults age 65 and older, mood disorders, cognitive impairment, and other forms of dementia are among the most common psychiatric problems.
However, existing research has not clarified whether the possible positive association
between chronic conditions and psychiatric disorders is consistent across conditions
and across race and gender groups in this older population. Medicare claims data offer
the ability to analyze diagnoses on a population (age 65 and over) with near universal
health care coverage.
Mood Disorders
Mood disorders, the most common type of non-organic psychiatric disorders, are
characterized by the disturbance of mood and affect and are identified by a persistent
elevation of mood (mania) or of a sustained feeling of sadness or depression (US Public Health Service, 1999). The American Psychiatric Association’s Diagnostic and
Statistical Manual Fourth Edition – Text Revision (2000) identifies mood disorders as
mood episodes (e.g., manic, mixed or major depressive episode), depressive disorders
Chronic Conditions & Comorbidity 18
(e.g. major depression, dysthymia), bipolar disorders or other mood disorders (e.g.,
substance-induced mood disorder). Among older adults, bipolar disorder accounts for
5 to 19% of mood disorder diagnoses (Sajatovic, Madhusoodanan, & Coconea, 2005).
Major depression and other depressive disorders are the most common type of mood
disorders in the general population (US Public Health Service, 1999).
The lifetime chance for major depression in the general adult population in the
United States ranges from 10 to 25% in women and from 5 to 12% in men (Snow,
Lascher, & Mottur-Pilson, 2000), while 12-month prevalence is around 6.5% overall
(U.S. Public Health Service, 1999). Reports based on the Epidemiologic Catchment
Area study estimate that the 12-month prevalence for any mood disorder for community dwelling adults 55 years and older is 4.4%. Prevalence rates for major depression for this same group are estimated at 3.8%. Other studies have found that the
prevalence of mild to moderate depressive symptoms is 8 to 20% among older community residents (Alexopoulos et al., 2002; Gurland, Cross, & Katz, 1996; Mulsant &
Ganguli, 1999). An even greater prevalence of major depression (11.5%) was found in
a multiethnic sample of older, inner-city adults living in poverty (Arean, Robinson,
& Hicks, 1997). Among older adult patients who live in long-term care facilities, the
rate of major depression is estimated at 12 to 30% (Alexopoulos, Katz, Reynolds,
Carpenter, & Docherty, 2001).
Dementia
Dementia is an organic psychiatric syndrome characterized by a progressive decline in cognitive functions, including thinking, memory, language skills, perception, reasoning, and judgment, and interference with a person’s daily functioning.
Symptoms may include changes in personality, mood, and behavior. Persons diagnosed with dementia also lose their ability to solve problems and maintain emotional
control. There are several different types of dementia diagnoses. Dementia of the
Alzheimer’s type is the most frequently diagnosed form of dementia, followed by vascular dementia (Gupta & Lamont, 2004; Jorm & Jolly, 1998). Some forms of dementia
are irreversible (e.g. vascular, Alzheimer’s, Parkinson’s, and Lewy body dementia),
but there are other forms that may be reversible if caused by drug toxicity, alcohol,
hormone or vitamin imbalances, or depression.
Among community dwelling older adults, 3 to 11% have some form of dementia
(Boustani, Peterson, Hanson, Harris, & Lohr, 2003). It is expected that as the lifespan
of the U.S. population increases in the next 50 years, the incidences of age-related
conditions such as dementia will also increase significantly. It is projected that Alzheimer’s disease (AD) alone will quadruple in this time period (Brookmeyer, Gray,
& Kawas, 1998).
Diabetes Mellitus
A positive association between diabetes mellitus and depression in the general
population has been fairly well established (Eaton, Armenian, Gallo, Pratt, & Ford,
1996; Egede, 2004; Gavard, Lustman, & Clouse, 1993; Lustman, Griffith, Freedland,
19
Student Keynote Address I
& Clouse, 1997; Nichols & Brown, 2003). Studies estimate that, on average, individuals with diabetes are twice as likely to be depressed as those without diabetes
(Anderson, Freedland, Clouse, & Lustman, 2001; Egede, Zheng, & Simpson, 2002).
According to a meta-analysis of existing studies (Anderson et al., 2001), as many as
one in every three individuals with diabetes may have depression at a level that impairs functioning and quality of life (Hanninen, Takala, & Keinanen-Kiukaanniemi,
1999; Jacobson, de Groot, & Samson, 1997). The causal order of this association is
still under debate. For example, in a prospective cohort study of older adults, while a
baseline diagnosis of diabetes was significantly associated with the presence of current depressive symptoms, depressive symptoms were associated with an increased
risk of subsequently developing type-2 diabetes (Palinkas, Lee, & Barrett-Connor,
2004). In a study based on a 5% national sample of Medicare beneficiaries age 65
years and older, Finkelstein and colleagues (2003) found that patients with diabetes
were nearly 60% more likely to have a diagnosis of major depression compared to
their counterparts without diabetes.
Research has more recently begun to examine the link between diabetes and dementia (Allen, Frier, & Strachan, 2004; Coker & Shumaker, 2003; Strachan, Dreary,
Ewing, & Frier, 1997). In the Rush Alzheimer's Disease Center’s Religious Orders
Study, a prospective cohort study designed to examine a possible link between diabetes and cognitive decline, it was shown that diabetes was associated with lower levels
of global cognition, episodic memory, semantic memory, working memory, and visuo-spatial ability, and was linked to a 65% increased risk of developing Alzheimer’s
disease, while appearing to affect certain aspects of cognitive function differently
than others (Arvanitakis, Wilson, Bienias, Evans, & Bennett, 2004). Other studies,
such as the Nurses’ Health Study, indicated that there is an increased risk of developing dementia or other cognitive impairment for persons with diabetes (Yaffe et al.,
2004). Logroscino, Kang and Grodstein (2004) found that women with type-2 diabetes were twice as likely to show significant cognitive impairment or perform worse on
cognitive tests than women without diabetes.
Cardiovascular Disease
Some researchers have cited depression as the most important comorbid psychiatric disorder occurring with cardiovascular disease (Glassman, 2001), although late
onset mania has also been associated with certain vascular disorders (Cassidy & Carroll, 2002). Major depression occurs in approximately 33% of patients with a history
of heart attack (NIMH, 2002). The incidence of major depressive episodes post-myocardial infarction is 15 to 20% (Burg & Abrams, 2001). Recent studies provide evidence that the onset and outcome of both heart attack and stroke are influenced by
depression (Kennedy, 2001). Depressive disorders adversely impact cardiovascular
treatment adherence, rehabilitation, appropriate utilization of services, and general
coping, which could ultimately lead to an increased likelihood for further disability and the hastening of death (Musselman, Evans, & Nemeroff, 1998; Romanelli, et
al., 2002). Major depression has been associated with higher cardiovascular mortality, especially among older adults (Ariyo et al., 2000; Frasure-Smith, Lesperance,
Chronic Conditions & Comorbidity 20
& Talajic, 1993; Giltay, Geleijnse, Zitman, Hoekstra, & Schouten, 2004; Schrader,
Cheok, Hordacre, & Guiver, 2004.).
Cardiovascular risk factors have also been associated with increased risk of dementia and cognitive decline (Whitmer, Sidney, Selby, Johnston, & Yaffe, 2005; Yaffe
et al., 2004). Some evidence indicates that vascular diseases predict the risk of developing some form of dementia (Armstrong, Lantos, & Cairns, 2005). The Cardiovascular Health Study, a population-based, prospective study of the risk factors for cardiac
disease and stroke in older adults, examined rates of dementia in 3,608 participants
(Fried et al., 1991). In this study, the age-adjusted incidence rates of dementia among
older persons with cardiovascular disease were 32.7 per 1000 person-years for whites
and 56.4 per 1000 person-years for blacks, with a slightly higher prevalence among
women (16.0%) than men (14.7%) (Fitzpatrick et al., 2004). Even when patients with
stroke were excluded from this study, older persons with cardiovascular disease still
had a higher likelihood of being diagnosed with Alzheimer’s disease or other dementia than those without (Newman et al., 2005).
Arthritis
The Centers for Disease Control (2003) reports that arthritis affects nearly 60%
of the US population 65 years and older and is one of the most prevalent chronic pain
disorders among this age group. Research shows significant positive associations between chronic pain and mood disorder (McWilliams, Cox, & Enns, 2003). Numerous
studies have found an elevated risk of depression in patients with arthritis (Bartlett,
Piedmont, Bilderback, Matsumoto, & Bathon, 2003; Cunningham, Krishnaswami,
Greco, Kao, & Wasko, 2003; Katz, Lee, & Bahrt, 2003). One study found that older
adults with arthritis have the greatest attributable risk for depression when compared
with other chronic diseases (Dunlop, Lyons, Manheim, Song, & Chang, 2004).
Few empirical studies have examined whether people with arthritis have an increased relative risk of developing dementia or vice versa. A number of studies have
explored whether the use of anti-inflammatory drugs generally prescribed for arthritis
could have possible protective effects against the development of dementia. However,
the findings have been inconclusive. Some studies indicate that these drugs may have
a protective effect against Alzheimer’s disease (McGeer, Schulzer, & McGeer, 1996;
Pasinetti, 2002), but not against vascular dementia (in t’ Veld et al., 2001). More prospective studies are needed to further clarify these associations.
Cancer
Depression is common in older adult patients with cancer (Birrer & Vemuri,
2004). Although depression and anxious moods are frequently present in response
to catastrophic events, nearly 25% of older adult patients who receive a diagnosis
of cancer have depressive symptoms that remain persistent and meet the diagnostic
criteria for clinical depression (Feting, 1997; McDaniel, Musselman, Porter, Reed, &
Nemeroff, 1995). As many as one in five patients with cancer have elevated depressive
symptoms (Bodurka-Bevers et al., 2000; Derogatis et al., 1983; Henriksson, Isometsa,
21
Student Keynote Address I
Hietanen, Aro, & Lonnqvist, 1995; Lloyd-Williams & Friedman, 2001). Honda and
Goodwin (2004) found cancer to be significantly associated with increased rates of
major depression, drug dependence, simple phobia, and agoraphobia, and these associations persisted after adjusting for major socio-demographic factors. Additionally,
Thomas and Weiss (2000) found that emotional distress in cancer patients (especially
depression, anxiety, and beliefs about pain) is predictive of higher patient pain levels,
which can lead to further disability.
While it is known that the incidence of both dementia and cancer increases with
age, there is a dearth of empirical studies examining the relationship between cancer
and dementia. One recent study found that the risk of developing dementia of the
Alzheimer’s type may be lower for participants with a history of cancer and vice versa
(Roe et al., 2005). However more research is needed to clarify whether there is any
association between cancer and dementia among older adults.
Among all of these chronic conditions, very few studies have examined whether
possible associations with psychiatric diagnoses are consistent across race and gender
groups. This study examines race and gender differences in the co-occurrence of a
mood disorder and dementia with diabetes, CVD, arthritis and cancer among Tennessee Medicare Part B beneficiaries.
Method
Data
The data set used in this study consisted of physician (“carrier”) billing records
for 100% of Tennessee Medicare Part B enrollees for the year 2002, who represent
97% of the age 65 and over population in Tennessee. This study limited analysis to
the subset of black and white beneficiaries, since the number of individuals of Asian,
Hispanic and other racial/ethnic descent with psychiatric diagnoses was too small to
make reliable comparisons. Table 1 provides a description of the demographic characteristics of the sample (N = 660,521). The mean age was 74.6 years (SD = 7.2). White
females accounted for 54.0% (N = 356,700) of the sample; white males, 36.1% (N =
238,437); black females, 6.4% (N = 42,302); and black males, 3.5% (N = 23,082).
Table 1
Sample Characteristics
TOTAL N
Race & Gender
Black Male
Black Female
White Male
White Female
Age (Mean ± SD)
660,521
% (N)
3.5% (23,082)
6.4% (42,302)
36.1% (238,437)
54.0% (356,700)
74.6 ± 7.2
Chronic Conditions & Comorbidity 22
Measures
The presence of chronic medical conditions (diabetes, CVD, arthritis and cancer)
and psychiatric diagnoses (mood disorder and dementia) were determined using the
Centers for Medicare and Medicaid Services’ International Classification of Diseases,
9th Revision, Clinical Modification (2004) diagnostic codes. All of the billing records
for the year were aggregated to the level of the individual, and a dummy variable was
created to indicate whether a particular diagnosis appeared at least once in any of the
physician bills in 2002 (1 = yes, 0 = no). The exception was cancer, for which a diagnosis had to appear at least twice to count the diagnosis, in order to minimize the number
of false positives (Nattinger, Laud, Bajorunaite, Sparapani, & Freeman, 2004). Age
was measured in years, and dummy variables for gender (female = 1) and race (black
= 1) were included in models for the total sample.
Statistical Analysis
Multiple logistic regression analysis was used to estimate the odds ratios associated with each chronic physical condition for having a comorbid diagnosis of a mood
disorder or dementia, while adjusting for demographic variables and the other chronic
conditions. Five logistic regression models were estimated for each dependent variable (mood disorder and dementia), one on the total sample and one on each of the four
race-gender split samples (i.e., black males, black females, white males, and white
females), in order to determine whether the effects varied across race and gender
subgroups.
Results
Rates of Diagnoses
The rates of diagnosis for each psychiatric disorder and each chronic condition
by race and gender are presented in Table 2. Fewer men (2.6% black men, 3.4% white
men) were diagnosed with a mood disorder compared to women, with white women
having the highest rate of mood disorder diagnoses overall (4.5% black women, 6.8%
white women). Diagnoses of dementia were highest among black women (3.7%) and
lowest among white males (1.5%), with rates of 2.5% for black men and 2.9% for
white women. Blacks had the highest rates of diabetes (31.2% of black women and
25.0% of black men), compared to 19.9% of white men and 17.2% of white women,
who had the lowest rate. As expected, CVD was the most common chronic condition
examined, with higher rates for women than men, ranging from 64.9% among black
men to 78.6% among black women. Black women also had the highest rate of arthritis
(46.4%), followed by white women (44.9%). Lower rates for arthritis were reported
among black men (28.6%) than white men (31.2%). Cancer diagnoses were higher
among men than women, with white men having the highest rate (15.3%) and black
women with fewest diagnoses (5.0%).
23
Student Keynote Address I
Table 2
Rates of Psychiatric Diagnoses and Chronic Conditions by Race and Gender
Mood Disorder
Dementia
Diabetes
CVD
Arthritis
Cancer
Black Male
Black Female
White Male
White Female
2.6%
2.5%
25.0%
64.9%
28.6%
12.1%
4.5%
3.7%
31.2%
78.6%
46.4%
5.0%
3.4%
1.5%
19.9%
66.0%
31.2%
15.3%
6.8%
2.9%
17.2%
70.3%
44.9%
8.4%
Mood Disorder Diagnosis
Table 3 presents results of logistic regression models predicting a mood disorder
diagnosis in the total sample and for each race-gender subgroup. The adjusted odds
ratios indicate the ratio of the odds of having a mood disorder diagnosis for persons
with diabetes, CVD, arthritis, or cancer, while controlling for other chronic conditions, age, and (in the total sample) race and gender. In the total sample, patients with
diabetes had 18% higher odds (OR 1.18, p < .05) of having a mood disorder diagnosis
than persons without diabetes, while controlling for demographic variables and other
conditions. Those with CVD were more than two times as likely (136% higher odds)
to have a mood disorder compared to older adults without CVD (OR 2.36, p < .05).
Arthritis was associated with 91% greater odds of a mood disorder diagnosis (OR
1.91, p < .05). Cancer was associated with only a 4% greater odds of a mood disorder
(OR 1.04, p < .05). Therefore, CVD and arthritis had the strongest associations with
mood disorder in the total sample, followed by diabetes, with only a weak association
for cancer.
Table 3
Adjusted Odds Ratios for Mood Disorder Diagnosis
Variables
Total
Black Male
Black Female
White Male
White Female
Diabetes
1.18
2.36
1.91
1.04
1.02
1.76
1.39
4.99
1.81
0.95NS
1.03
--
1.15
2.88
1.93
1.20+
1.01
--
1.17
2.70
1.96
1.05NS
1.03
--
1.17
2.20
1.89
1.01NS
1.01
--
Race
(Black = 1)
.62
--
--
--
--
Constant
.005
.001
.006
.002
CVD
Arthritis
Cancer
Age
Gender
(Female = 1)
.011
Note. All variables significant at p < .05, unless noted: + (p < .10) or NS (not significant).
Chronic Conditions & Comorbidity 24
The split-sample models indicated that the association of each of the chronic conditions with mood disorder varied substantially across race-gender subgroups. The
odds ratios for a mood disorder associated with diabetes ranged from 1.15-1.17 for all
groups except black males, who had a stronger association (OR = 1.39, p < .05). The
association between CVD and mood disorder was also highest for black males. Odds
ratios for CVD for the other groups ranged from 2.20 (p < .05) for white women to
2.88 (p < .05) for black women, with more than double the ratio for black men compared to the total sample (OR 4.99, p < .05). Odds ratios for arthritis were highest for
white men and lowest for black men (1.96 and 1.81, respectively; p < .05), but they did
not vary substantially. Even though in the total sample, persons diagnosed with cancer had a slightly higher odds of having a mood disorder compared to those without
cancer, the odds ratios for cancer in each race-gender subgroup were not significantly
different from zero. The highest odds ratio for cancer was for black females (OR 1.20,
p < .10), but it was only marginally significant due to low statistical power (comprising
only 6.4% of the sample and having the lowest rate of cancer).
Dementia Diagnosis
Table 4 presents results of logistic regression models predicting a dementia diagnosis in the total sample and for each race-gender subgroup. Persons diagnosed
with diabetes were 38% more likely (OR = 1.38, p < .05) to have a diagnosis of dementia than a person without diabetes, after adjusting for the other factors (age and
other chronic conditions). Those with CVD were more than two times as likely (146%
higher odds) to have a dementia diagnosis compared to older adults without CVD (OR
2.46, p < .05). Adults with arthritis had a 34% higher odds of having a dementia diagnosis compared to patients without arthritis (OR = 1.34, p < .05). In contrast, older
adults with cancer had 30% lower odds of having a dementia diagnosis (OR = 0.70,
p < .05) compared to those without cancer. Thus, CVD had the strongest positive association with dementia in the total sample, followed by diabetes and arthritis, while
cancer had a negative association with dementia in the total sample.
The association of each of the chronic conditions with dementia also varied substantially across race-gender subgroups, as seen in the split-sample models. After
adjusting for age and other conditions, the association between diabetes and dementia
was strongest for black females (OR = 1.53 p < .05) and lowest for white men (OR
= 1.24, p < .05). In terms of CVD, men had higher odds of dementia compared to
women; however, the odds ratio for black men was nearly three times that of the total
sample (black men: OR = 7.40, p < .05; white men: OR = 3.21, p < .05). Black women
(OR 2.88. p < .05) also had a higher odds ratio for CVD than white women (OR =
2.09, p < .05). White men had the highest odds ratio (OR = 1.55, p < .05) for dementia
associated with arthritis than any other group, with odds ratios ranging from 1.26-1.31
for the other groups. When the sample was split by race and gender, only whites had
a significant negative association between cancer and dementia (OR = .68, p < .05 for
white males and white females). There was a marginally significant negative association for black females.
25
Student Keynote Address I
Table 4
Adjusted Odds Ratios for Dementia Diagnosis
Variables
Diabetes
CVD
Arthritis
Cancer
Age
Gender
(Female =1)
Race
(Black = 1)
Total
Black Male
Black Female
White Male
White Female
1.38
2.46
1.34
.70
1.12
1.28
1.40
7.40
1.31
.86NS
1.09
--
1.53
2.88
1.26
.80+
1.11
--
1.24
3.21
1.55
.68
1.12
--
1.41
2.09
1.29
.68
1.12
--
1.21
--
--
--
--
.00
.00
.00
.00
.00
Note. All variables significant at p < .05, unless noted: + (p < .10) or NS (not significant).
Constant
Discussion
In this examination of the relationship between chronic medical conditions and
comorbid psychiatric diagnoses, we found that Tennessee Medicare Part B beneficiaries with diabetes, CVD, and arthritis were more likely than those without these
chronic diseases to have a diagnosis of a mood disorder or dementia, when controlling for other factors. These findings confirm previous explorations of the association
between these comorbid conditions, while adding new information on the association
between arthritis and dementia. In addition, this study contributes to the literature by
documenting that these associations vary across race-gender groups. For diabetes, the
association with mood disorder was strongest for black men, while the association
with dementia was strongest for black women. Among the four chronic conditions
examined, CVD had the strongest association with both psychiatric disorders, particularly among black men, for whom respective odds ratios were two to three times as
high as the total sample. Arthritis had a stronger association with mood disorder than
with dementia, with white males having the strongest association for each.
However, cancer had a different relationship with these two psychiatric diagnoses. Cancer had a small positive association with mood disorder in the overall sample
only. On the other hand, cancer had a significant negative association with dementia
for white males, and white females. These findings affirm previous studies examining cancer and mood disorders (Joynt, Wellan, & O’Connor, 2003; Musselman et al.,
1998) and the few studies examining cancer and dementia (Gupta & Lamont, 2004).
Some researchers have noted that the decreased likelihood of a person diagnosed
with cancer also receiving a diagnosis of dementia could possibly be attributed to
under-diagnosis or under-reporting of dementia in cancer patients (Newcomer, Clay,
Luxenberg, & Miller, 1999). For example, Redelmeier, Tan, and Booth (1998) found
that patients with major chronic conditions are less likely to receive a diagnosis for
Chronic Conditions & Comorbidity 26
other unrelated conditions, possibly because the attention and energy of the patient
and health care providers is focused on treatment of the chronic condition.
Limitations
One of the limitations of this study is the cross-sectional design. While this method is useful for examining relationships, it cannot untangle causal order (i.e., which
condition came first) or incidence of new cases. In addition, administrative claims
data are always limited by the possibility of misdiagnosis or coding error and the lack
of information on severity of illness or other individual factors. Nevertheless, this
study contributes new insight into the co-existence of chronic conditions and psychiatric diagnoses among older adults, particularly regarding dementia, and variation in
these relationships across race and gender groups. Future studies should extend this
analysis using prospective studies that untangle the relative risk of being diagnosed
with a psychiatric disorder given each chronic condition and vice versa.
Implications
The positive relationship between certain chronic conditions (i.e., diabetes, CVD,
and arthritis) and comorbid psychiatric diagnoses (i.e., mood disorders and dementia)
among older adults presents a challenge for treatment, medication compliance, and
general mortality rates. For example, depression is positively correlated with both
the perception of greater illness severity and less improvement in physical symptoms
(Grau, Suner, Abuli, & Comas, 2003). Existing evidence suggests that the comorbidity of psychiatric disorders with these chronic conditions may adversely impact treatment adherence, which could ultimately lead to increased likelihood of disability or
death (Joynt et al., 2003; Whyte, Mulsant, Vanderbilt, Dodge, & Ganguli, 2004).
Comorbid chronic conditions and psychiatric diagnoses also have implications
for increased health service utilization and health care costs. For example, Hansen,
Fink, Fydenburg, and Oxhoj (2002) found that high use of primary care and high levels of inpatient admissions were associated with anxiety, depression, and somatoform
disorders, even after adjusting for disease severity. Older primary care patients with
comorbid depression have higher levels of physician visits and emergency room visits, longer hospital stays, and more prescriptions (Callahan, Hui, Nienaber, Musick,
& Tierney 1994; Cooper-Patrick, Crum, & Ford, 1994; Unutzer et al., 1997). A few
recent studies suggest that individuals with diabetes and comorbid depression may
have higher levels of utilization of acute care and other services compared to non-depressed individuals with diabetes (Egede et al., 2002; Finkelstein et al., 2003; Husaini
et al., 2004; Polonsky et al., 2000).
Some evidence suggests that certain combinations of co-occurring mental and
physical disorders may be linked to greater health care costs compared to the physical
disorder only (Druss, Rohrbaugh, & Rosenheck, 1999; Husaini et al., 2000; Husaini
et al., 2002; Husaini, Sherkat, Levine et al., 2003; Husaini, Sherkat, Moonis et al.,
2003; Zhang, Rost, & Fortney, 1999). For example, among patients hospitalized for
heart failure, those who were diagnosed with comorbid depression had 26% higher
27
Student Keynote Address I
costs than those without a depression diagnosis, even after controlling for other factors (Sullivan, Simon, Spertus, & Russo, 2002). At the same time, cardiac rehabilitation among post-myocardial infarction patients with mild to moderate depression or
anxiety was effective in reducing subsequent health care expenditures (Oldridge et
al., 1993). In several studies, the co-occurrence of diabetes and depression has been
linked to higher health care costs compared to diabetes alone (Ciechanowski et al.,
2000; Egede et al., 2002; Nichols et al., 1999). For instance, Medicare claimants with
major depression had 21% higher total annual payments and 7% higher inpatient payments (both non-mental health-related) than those without major depression in 1997,
after adjusting for other factors (Finkelstein et al., 2003). Further research needs to
examine the implications of comorbid chronic conditions and psychiatric diagnoses.
Racial and gender differences in the odds ratios may be attributed to disparities in
care for chronic illnesses, differences in health-seeking behaviors among blacks (e.g.,
delay in seeking early treatment among black men) and issues relating to health locus
of control among blacks. Further research is necessary to tease out these racial and
gender differences among Medicare adults. In addition, since the Medicare claims
data utilized in this study did not include information on severity of chronic illness,
similar analyses using other data (such as hospital discharge data) that would account
for severity of illness may help to clarify the apparent differences in the odds ratios
presented in this study.
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Student Keynote Address I
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Sullivan, M., Simon, G., Spertus, J., & Russo, J. (2002). Depression-related costs in
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Talbot, F., & Nouwen, A. (2000). A review of the relationship between depression and
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Unutzer, J., Patrick, D. L., Simon, G., Grembowski, D., Walker, E., Rutter, C., et al.
(1997). Depressive symptoms and the cost of health services in HMO patients
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Student Keynote Address II
Student Keynote Address II
Katherina (Katie) Nikzad is a doctoral student in the Graduate Center for Gerontology at the University of Kentucky. Katie has had extensive experience as a formal
caregiver for individuals with Alzheimer’s disease and various forms of dementia.
She is currently the secretary of the Emerging Scholar and Professional Organization
of the Gerontological Society of America, Vice President of Sigma Phi Omega (Gamma Mu chapter) honor society for Gerontology, and a member of the Alzheimer’s Association. Katie is the recipient of several national awards and scholarships, and has
publications within academic journals, books, and The Encyclopedia of Aging. Her
current research interests include the onset of family caregiving for dementia patients
and communicating with individuals with Alzheimer’s disease.
Graduate School Trajectory
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The Graduate School Trajectory
Katherina A. Nikzad
Graduate Center for Gerontology
University of Kentucky
The process of obtaining a graduate degree entails an assortment of decisions,
events, and unexpected occurrences. While pursuing a graduate degree involves an
array of positive experiences, the pressures associated with graduate school remain
numerous. There is pressure to stand apart from others as an innovative researcher,
pressure to constantly produce scholarly works and obtain the funding in order to do
so, and amidst all of these expectations is the interminable notion to continue the lifelong process of learning and acquiring knowledge. A graduate professor once referred
to the process of obtaining a graduate degree as follows:
The time spent pursuing a doctorate has historically been the most intense
period of learning in a scholar’s life. I see it as in-depth and careful reading
of advanced and contemporary literatures, refinement of methodologies to a
level of mastery, ongoing critical discourse with a host of faculty and peers,
and the development of confidence in one’s abilities to become capable of
being truly innovative in thought, and eventually in practice. (J. Watkins,
personal communication, August 7, 2004)
This statement thoroughly summarizes what the intent of graduate training should
be for all students. Reaching and fulfilling what this statement articulates, however, is
the challenge that many will face as they strive to complete a graduate program.
When entering graduate school, many students are entering unknown territory. I
believe that hearing about graduate school experiences and getting suggestions from
other graduate students who are encountering similar occurrences is beneficial. When
constructing this address, I strived to transform a variety of information into a useful
and informative address that would benefit the students who hear it. Not only did I
want to communicate findings from my own personal research, entitled The Onset of
Dementia Caregiving: Retrospective and Prospective Approaches, I wanted to incorporate different elements that would be specifically relevant to an audience comprised
primarily of students. The rationale behind having a student mentoring conference
is to provide a conference that is specifically oriented toward students in terms of
research, symposia, and various events. What I aim to do is present what I refer to
as “The Graduate School Trajectory,” in which I will explore different facets of being a graduate student, and provide some helpful approaches that all students should
become familiar with early on in their graduate careers. With this notion in mind,
the following address incorporates elements of research juxtaposed with suggestions
and recommendations regarding various events that students encounter throughout
the course of a graduate career. One of the best ways to begin the graduate school
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Student Keynote Address II
process is to select a mentor who will help you transition through your program more
efficiently.
Setting a Direction
Selecting a Mentor
One of the initial tasks as a new graduate student, other than adjusting to new
surroundings, is to formally choose an advisor. Many new students are automatically
assigned to an advisor who will assist with tasks such as scheduling classes and completing additional paperwork and logistics. However, most students have the opportunity to eventually choose a mentor who will serve as a permanent academic advisor
and most likely, the chair of a dissertation committee. Choosing a mentor is extremely
important for several reasons, especially when beginning graduate school. Mentors
serve not only to make academic decisions regarding classes and scheduling; they
provide guidance and reinforcement in terms of future research endeavors. They are
also there to be honest and realistic in instances when a student may need to rethink
the direction of an idea. It is important for students to familiarize themselves with the
different aspects of choosing a mentor, and ask themselves questions that will guide
in the selection of a mentor. The following questions should be deliberated by students
before finalizing their decision for a mentor:
• Research interests – Do I have an interest in the research that this person
is involved in? Does this person have enough knowledge and experience in the
areas that I am most interested in? Is this person willing to work with me on this
particular area of research that I am interested in?
• Personality – Is this someone who is going to mesh well with my personality
characteristics? Is this person going to intimidate me? Do I feel comfortable going to this person with my ideas, concerns, or questions?
• Similarities in work style – Does this person maintain realistic expectations
that correspond with my ideas and abilities?
• Receptiveness – Is this person receptive of my ideas? Does he or she respect
and encourage my ideas? Will he or she be honest and realistic with me, while still
maintaining my core interests?
• Produces quickly and consistently – How often does this person publish?
Will he or she offer publishing opportunities to me? Will he or she urge me to
meet my deadlines?
• Respects professional goals – Does this person respect my career goals, and
will he or she help me obtain them?
Each of these points is important to consider before formally choosing a mentor.
If the relationship with a mentor is not a good one, then everything else that occurs
within a graduate education will be affected by it, including ideas, research, and per-
Graduate School Trajectory
38
sonal well-being. Keeping in mind these considerations may help the graduate process
to proceed more smoothly.
Choosing and Developing Research
Choosing an area of research is probably one of the most important decisions a
student will make throughout the duration of his or her graduate career, yet it can be
one of the most strenuous and difficult decisions. Prior to entering my doctoral program, I had several preexisting areas of interest that I had developed from previous
work experiences. I have since expanded on these interests, but this process was not
as easy as it sounds. During my first semester I came across many ideas for possible
future research through reading and collaborating with different core faculty. Within
a few months, I was pretty sure that I wanted to do just about everything! I was interested in everything from the epidemiology of Alzheimer’s disease to elder abuse to
nonpharmacological interventions for older adults. Obviously I was not going to be
able to cover every age-related inquiry. I knew early on that I would have to start cultivating more precise ideas so that I could begin transitioning into a more developed
researcher.
So how does one make the transition from wanting to be an expert in everything
to establishing his or her own refined area of expertise? There are several ways to
approach this process. First, students should begin to focus more closely on areas
that are of most interest to them. Ask yourself, “What is it that I am truly passionate about, and what could I see myself involved in for the next several years of my
life?” Secondly, consider what ideas are realistic enough to evolve into a dissertation.
Sure, I would have loved to design and conduct research that led to the development
of the drug that would cure Alzheimer’s disease! Although this plan was just a bit
too ambitious to progress into a path for a dissertation, it did not mean that I had to
give up what I was most passionate about, and that was Alzheimer’s disease. Prior to
entering my doctoral program I came from a background in which I had served as a
formal caregiver for Alzheimer’s patients. This experience exposed to me hundreds
of individuals diagnosed with Alzheimer’s disease and other dementing illnesses, as
well as their families who experienced the many negative impacts of the disease. It
was these experiences that led me to pursue more advanced training in the realm of
aging. While I was not going to be able to discover the drug that provided a cure for
Alzheimer’s disease, I still had the capacity and the knowledge to tailor my research
around the disease.
Because I had been an Alzheimer’s caregiver for so many years, I also had a desire to examine the different aspects of caregiving. So there I had it, my main areas of
interest: Alzheimer’s disease and caregiving. There are only about a thousand articles
published every year pertaining to these two areas! So, that brings me to my next issue: How do you conduct research that has your own personal seal on it? How do you
prevent yourself and your research from being buried within the vast amount of existing literature that has been completed before you? Keep in mind that just because the
subject of interest may not be scarce within the literature does not mean that an individual should not pursue it. Approach the topic in order to find a particular angle of the
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Student Keynote Address II
area or areas of interest that has received little attention or elaboration. Thoroughly
examine the subject matter and ask yourself, “What is it about this topic that still is not
quite understood?” In my case, I knew I wanted to do something with Alzheimer’s
disease and caregiving, but I had to search for an angle that I could expand on and
ultimately design my own research that would be considered relatively innovative.
In order to do this, it required reading great amounts of the existing Alzheimer’s and
caregiving literature, and identifying what areas had not yet been explored or had not
yet received scientific investigation. I also had to critically examine my ideas and ask
myself, how would this contribute to the aging literature? How would this work be
considered useful in the future, and could my research eventually encourage further
research and replications?
After establishing the different components of narrowing down and choosing research topics, how does one actually go about conducting research? I began exploring the Alzheimer’s caregiving literature in order to identify a probable dissertation
topic. For the past year I have been working on refining a particular topic that I am
now in the process of developing into my dissertation: onset of dementia caregiving.
What I now aim to discuss are the different elements of my research, and how they
transpired. I will now transition into exploring the different components of scholarly
research while still maintaining the trajectory theme of this address by demonstrating
the process of conducting research along a continuum.
The Onset of Dementia Caregiving
The first step in conducting research is completing a comprehensive and thorough
literature review. Before delving into an area of research, students must become familiar with extant literature. In the case of caregiving onset, I had to become familiar
with the research that had been completed in the area of family caregiving, and more
specifically in the area of caregiving onset. The following sections demonstrate the
literature review conducted on the onset of dementia caregiving.
Family caregiving for dementia patients is steadily increasing due to the rise in
degenerative illnesses such as Alzheimer’s disease. For those individuals suffering
from dementia in the community, families often provide the bulk of unpaid, or ‘informal,’ care assistance (Volicer & Hurley, 2003). As the extensive research on family
caregiving has noted, the provision of informal long-term care to disabled older adults
has a number of potentially negative consequences, including depression, stress, and
physical impairment (see meta analyses by Pinquart & Sorensen, 2003a, 2003b; Vitaliano, Zhang, & Scanlan, 2003). Emerging research in this area has examined the
long-term ramifications of family caregiving, particularly in instances where family
members assume care responsibilities for loved ones suffering from insidious chronic
diseases such as dementia (e.g., Aneshensel, Pearlin, Mullan, Zarit, & Whitlatch, 1995;
Gaugler, Zarit, & Pearlin, 2003b). The long-term nature of dementia or other chronic
disabilities has led some to characterize dementia family caregiving as a ‘career.’
Implicit in the caregiving career are a number of key transitions (e.g., institutionalization, bereavement) that have potentially important implications for family caregivers
and their cognitively impaired care-recipients (Gaugler, Anderson, Zarit, & Pearlin,
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2004; Schulz et al., 2004; Whitlatch, Shur, Noelker, Ejaz, & Looman, 2001).
Although transitions such as institutionalization and bereavement have received
some attention in the dementia caregiving literature (e.g., see Gaugler, Zarit, &
Pearlin, 2003a; Schulz et al., 2004), less is known about how families assume care
responsibilities. Individuals may transition into the caregiving role through a variety
of circumstances, including the diagnosis of an acute or chronic illness, the occurrence of some sort of health-related crisis, or the early recognition of symptoms. Due
to the potentially unpredictable nature of dementia symptoms, family caregivers of
dementia patients are often faced with unanticipated care situations and responsibilities, particularly in the early stages of dementia care (e.g., Perry, 2002).
Several studies have attempted to understand the process of caregiving onset and
the factors that influence a family member’s decision to intervene and prepare for the
caregiving process. A longitudinal study conducted on dementia caregiving (Aneshensel et al., 1995) aimed to identify the time at which family members were able to indicate they first considered themselves as caregivers. This study utilized three different measures to help determine when the family caregiving process initiated. These
measures included symptom recognition (i.e., when family members first began to
notice changes in cognition and behavior), care provision (i.e., when families began
providing care) and diagnosis (i.e., when families received a formal diagnosis from
a physician). Results of this study indicated that variations in the onset of caregiving
occurred within different families, suggesting that entry into caregiving is a dynamic
and complex procedure.
Other efforts utilized these three indicators of onset to determine how different patterns of entry into the caregiving role impact subsequent outcomes (Gaugler,
Wackerbarth, Mendiondo, Schmitt, & Smith, 2003; Gaugler, Zarit et al., 2003b). These
analyses indicated that caregivers experiencing a more gradual entry into caregiving
roles were less likely to institutionalize their family members, and also experienced
a greater decrease in emotional distress and depression. However, neither of these
studies examined how the sequencing of each indicator of onset is related to caregiver
distress.
Retrospective Analysis
Once a thorough literature review is completed, students should gain a deeper understanding of what is lacking within the current literature, allowing innovative ideas
to transpire and turn into innovative research. For example, while existing caregiving
research emphasizes the effects of caregiving once individuals have already assumed
the caregiver role, less work has examined the potential influence of caregiving onset.
In particular, how the sequencing of various onset events can affect key measures of
caregiver stress and mental health has remained unexplored. In order to comprehend
how individuals enter the caregiving role and how onset influences caregiver distress and other outcomes, multiple indices of caregiving onset should be considered.
These indices can include symptom recognition, care provision, and diagnosis (e.g.,
see Aneshensel et al., 1995; Gaugler, Wackerbarth et al., 2003; and Gaugler, Zarit et
al., 2003b). Using these indices may help explain how the various events surrounding
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Student Keynote Address II
the onset of dementia caregiving can be used as predictors of key caregiving outcomes
following role entry, and would expand our current understanding of onset beyond
when care is first provided (Gaugler, Zarit et al., 2003b).
Because the outcomes associated with dementia care can vary widely among
families, a comprehensive approach is needed to capture the diversity of the caregiving context, care demands, and emotional distress. For this reason, Pearlin and
colleagues’ stress process model (see Pearlin, Mullan, Semple, & Skaff, 1990) was
applied in the current study to account for potential predictors of key caregiving outcomes above and beyond onset. The stress process model offers a dynamic conceptualization of stress and a multifaceted approach for describing how caregiving can
lead to future complications. An important component of the stress process model
is the sociodemographic and historical context in which care is being provided (e.g.,
relationship between caregiver and care-recipient, employment status, caregiver age
and gender). Additionally, different care demands and factors that can exacerbate
emotional distress are proposed in the stress process model, such as primary objective stressors (i.e., behavioral problems, functional dependency, and cognitive impairment). Primary objective stressors are expected to have direct effects on primary
subjective stressors, or the emotional reactions of caregivers to care-recipients’ cognitive and functional impairment. By examining the caregiving experience within this
multidimensional framework, the stress process model provides an ideal conceptual
foundation on which to examine the influence of onset on dementia caregivers’ subjective stress.
It was hypothesized that individuals who began providing care prior to symptom
recognition or formal diagnosis would be less likely to experience subjective stress.
This relationship, however, would be mediated by caregiving demands such as behavioral problems, functional dependency, and cognitive impairment. Although the stress
process model postulates such indirect pathways to caregivers’ emotional reactions to
care demands, few studies have attempted to analyze complex indirect relationships
in favor of direct effects models. Specifically, how individuals assume care responsibilities is likely to be closely associated with the functional and cognitive severity
of dementia and how caregivers approach and treat these problems. As the current
demands of dementia care intensify, it is hypothesized that these factors will have
direct effects on caregivers’ subjective stress, while the onset experience is expected
to have an indirect effect on the emotional ramifications of dementia care. As part of
this model, key aspects of the context of care (e.g., sociodemographic background)
and resources are considered as potential covariates in the process of onset, primary
objective stress, and subjective stress.
Methods
Following the literature review and a refined hypothesis, students must determine
which samples they will use in order to obtain their data. Will the samples come
from within the community, or will they be affiliated with a university? There are
several ways in which students can go about collecting data. However, students must
Graduate School Trajectory
42
also ensure that they are working with an appropriate sample that meets the criteria
consistent with the objectives of their research. For example, my research dealt with
informal dementia caregivers. Therefore, my sample included community caregivers
who were providing care to individuals with dementia. The following section is an
example of a research sample and the measures used to collect the desired data.
Procedure
Individuals and their informal (i.e., unpaid) caregivers who had visited the University of Kentucky (U.S.) Alzheimer’s Disease Research Center (UK-ADRC) for a
memory assessment since 1989 were eligible for inclusion in the subsequent analysis.
Following the diagnostic assessment procedure, UK-ADRC clinical staff recorded
names and addresses of key contacts (family members, friends, or other individuals)
for each patient.
Sample
The current study sample includes those individuals who completed the Community Care Survey (CCS: Gaugler et al., 2003) following UK-ADRC contact identification. Bivariate comparisons (i.e., ANOVAs, chi-squares) were conducted between
those caregivers who did not return a CCS (N = 556) and CCS community respondents (N = 344) on variables included in the UK-ADRC pilot survey. CCS respondents
were less likely to be non-Caucasian (4.8% vs. 15.8%, p < .001) and more likely to be
married (76.1% vs. 64.6%, p < .001). Those who completed the CCS were also more
likely to consider themselves a primary caregiver (75.9% vs. 63.8%, p < .001) and
were spousal caregivers (37.8% vs. 29.1%, p < .01). A greater percentage of care-recipients in the CCS were living in the community (53.2% vs. 41.2%, p < .001). CCS
respondents also indicated higher education (M = 5.28 vs. 5.01, p < .05) and provided
more IADL assistance to their care-recipients (M = 4.41 vs. 3.95, p < .001).
Measures
Onset sequences. Three indicators measured onset of caregiving in the CCS.
Symptom recognition was determined by asking caregivers, “How long ago did you
realize something was wrong with your loved one?” The second indicator, duration
of care, was gauged by asking respondents, “How long ago did you first have to start
helping your loved one do things that (she/he) was no longer able to do for (herself/
himself)?” Diagnosis was discerned from the question, “How long has it been since
your loved one has first been seen by a doctor for memory problems?”
To create measures of onset sequences, the following strategy was implemented.
As it was hypothesized that those caregivers who provided care prior to symptom
recognition or diagnosis would be less likely to experience primary stress (objective
or subjective), two dichotomous variables were created. Caregivers whose duration
of care was greater than time since symptom recognition (duration-symptom) or time
since diagnosis (duration-diagnosis) were coded as 1, respectively, on each of the
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Student Keynote Address II
onset sequence variables; those caregivers who recognized symptoms or received a
dementia diagnosis prior to care provision were coded as 0 on each variable.
Primary subjective stressors. The CCS collected information from three subjective stressors (Aneshensel et al., 1995; Pearlin et al., 1990). The response categories
ranged from not at all (1) to completely (4), and item responses were averaged for
each dimension. A three-item role overload scale was utilized to measure caregivers’
feelings of emotional fatigue (α = .87). A three-item role captivity measure was also
included to assess caregivers’ feelings of being trapped in role responsibilities (α =
.88). Feelings of emotional and physical separation (i.e., loss of intimate exchange) due
to care-recipients’ dementia were measured on a three-item scale (α = .91).
Context of care. Caregivers in the CCS provided information for a wide range of
sociodemographic and background characteristics of care-recipients and caregivers.
Resources. A five-item scale measured socioemotional support provided to the
caregiver by relatives or friends (Pearlin et al., 1990). Responses ranged from strongly
agree (4) to strongly disagree (1) (α = .89). A seven-item subscale from the Given
Caregiver Reaction Inventory (Given et al., 1992) assessed caregivers’ self-esteem/
mastery over the caregiving role. Item responses ranged from strongly agree (1) to
strongly disagree (5) (α = .92). The amount of assistance and help caregivers received
from other family members and friends (i.e., secondary support) during an average
week was included. Caregivers were also asked how many times/days in the past 6
months key community-based and health services were utilized. Similar measures
of self-reported service use have demonstrated that caregivers could correctly indicate whether the service was utilized in 93% of the cases (Miller, Newcomer, & Fox,
1999).
Primary objective stressors. Five measures were included in the CCS to gauge
care-recipients’ functional and cognitive impairments. Caregivers were asked whether the care-recipient needed no help (0), some help (1), or a lot of help (2) to perform
activities of daily living (ADLs; see Katz, Ford, Moskowitz, Jackson, & Jaffee, 1963)
and instrumental activities of daily living (IADLs; Lawton & Brody, 1969) (α = .80;
α = .91, respectively). Caregivers were also asked whether the care-recipient had difficulty climbing one flight of stairs, walking to the end of the room and back, bending
to put on socks/stockings, lifting a 10-pound package and holding it, reaching above
her/his head, combing or brushing hair, washing hair, and using fingers to grasp small
objects (see Manton, Stallard, & Corder, 1998). Response categories for this functional dependence scale ranged from not difficult (0) to can’t do at all (3) (α = .93).
Two additional care demands measured in the work of Pearlin and colleagues were
utilized (Aneshensel et al., 1995; Pearlin et al., 1990). A 16-item behavior problems
scale determined how often care-recipients engaged in disruptive and difficult behaviors in the past week (α = .88). Responses ranged from no days (1) to 5 or more days
(4). A seven-item scale measured the intensity of relatives’ cognitive impairment, or
memory losses, communication deficits, and recognition failures (Pearlin et al., 1990;
α = .93). Responses ranged from not at all difficult (0) to can’t do at all (5).
Graduate School Trajectory
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Results
Analysis
After establishing the procedural methods, one must determine the type of statistical analyses that would be appropriate for analyzing the data. One of my goals
for this presentation was to emphasize how important it is to gain some level of proficiency in statistical analysis while you are in graduate school. Methods cannot be
completed in isolation of your analysis; the two are not separate entities, and should
never be treated that way. The type of analysis has to be intimately linked with the
proposed hypotheses. In the case of my research, it was important to consider the elements of an analysis that would be appropriate based on my proposed hypotheses. For
this reason, I chose a mediational model.
Mediation occurs when an intervening variable is present, and when controlled
for, causes the initial variable to no longer affect the outcome variable (e.g., X → M
→ Y). In simpler terms, the mediating variable, whatever it may be, will reduce the
direct impact of X on Y.
Using a mediational model, a series of regression analyses were conducted incorporating initial variables (symptom recognition and diagnosis), mediating variables
(primary objective stressors), and outcome variables (primary subjective stressors).
The steps required for analyzing the mediational hypotheses presented in this study
were adapted from Baron and Kenny (1986).
Step 1: Primary Subjective Stressors Regressed Onto Indicators of Onset
A series of multiple linear regression models were constructed with each primary
subjective stressor as an outcome (see Figure 1). Indicators of onset (i.e., duration of
care prior to symptom recognition and duration of care prior to diagnosis) were the
independent variables of interest. Results indicated that caregivers in the durationsymptom group reported less role overload (β = -.11, p < .05), while caregivers in both
the duration-symptom and duration-diagnosis groups reported less loss of intimate
exchange (β = -.12, p < .05; β = -.13, p < .05).
Step 2: Primary Objective Stressors Regressed Onto Indicators of Onset
In step two of the mediational analysis, a series of multiple regression models
were constructed with the onset sequence indicators as independent variables and primary objective stressors (the hypothesized mediators between onset and primary subjective stress) as the outcomes. Caregivers in the duration-symptom group reported
less IADL dependency among care-recipients (β = -.14, p < .05). Moreover, caregivers
who were in the duration-symptom group reported fewer memory problems (β = -.18,
p < .01), as well as fewer behavioral problems exhibited by care-recipients (β= -.11, p
< .05).
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Student Keynote Address II
Steps 3 and 4: Primary Subjective Stressors Regressed Onto Primary Objective
Stressors and Indicators of Onset
To complete the mediation analysis and ascertain whether care demands mediated the relationship between caregiving onset and subjective stress, a series of final
regression analyses were conducted with indicators of onset and primary objective
stressors as predictors of primary subjective stressors. Based on our original hypothesis, it was expected that caregiving demands would retain significant empirical associations with primary subjective stressors in each model, with the duration-diagnosis
and duration-symptom as non-significant. The mediation hypothesis was primarily
confirmed across the models; both IADLs and memory impairment predicted loss of
intimate exchange (β = .24, p < .001; β = .26, p < .01), and behavior problems predicted
all three primary subjective stressors (β = .26, p < .001; β = .27, p < .001; β = .20, p <
.001). In the role captivity and role overload models, duration-symptom and durationdiagnosis variables were non-significant. However, duration-diagnosis appeared as an
independent, direct predictor of loss of intimate exchange in the final model (β = -.10,
p < .05). Caregivers not in the duration-diagnosis group were more likely to indicate
greater loss of intimate exchange. Figure 1 depicts the mediational pathways between
onset sequence, primary objective stressors, and primary subjective stressors identified in the regression models.
Note: * = p< .05
** = p < .01
*** = p < .001
Figure 1. Mediational model: Empirical results (standardized regression coefficients
shown).
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Discussion
Following the completion of data analysis, students must become accustomed to
interpreting an array of numerical figures. The discussion section allows researchers
to provide interpretations of the results that were acquired through analysis procedures. In some cases, the results will be consistent with the researcher’s hypotheses.
In other cases, the results may contradict what the researcher proposed. Regardless, it
is important that students learn how to interpret findings, and recognize the implications of each finding.
In terms of the current study, several interpretations exist regarding the indirect
pathways between duration-symptom recognition, primary objective stressors, and
primary subjective stressors. First, providing care prior to symptom recognition may
have allowed caregivers the opportunity to become entrenched in their roles, and better manage the frequency of care demands, such as behavior problems. Caregivers
who began providing informal assistance may have already acquired the skills necessary for better managing difficult behaviors associated with dementia once symptoms were recognized. This pattern of acclimation to care demands may have offered
the opportunity to utilize personal strategies effective for managing these potentially
challenging situations. In contrast, those who provided care soon after recognizing
symptoms may have experienced a more ‘abrupt’ transition into care provision and
experienced greater challenges in dealing with care demands. For example, an unexpected health care crisis may have occurred (i.e., a fall), leading to a more rapid decline in the functional abilities for the care-recipient. For those family members who
assumed immediate care responsibilities, this transition may have been overwhelming and unexpected, causing these caregivers to experience more negative emotional
outcomes. These findings are important contributions to the caregiving literature, as
they contradict prior research, which implies that the longer caregiving procedures
endure, the greater the number of negative outcomes that will occur. Our findings
suggest that the length of time as caregiver may not be as important as how caregivers
actually acquire their roles. Alternative explanations may also exist for the observed
findings. It is possible that those in the duration-symptom category simply cared for
loved ones with fewer memory, behavioral, and IADL impairments at the time of the
CCS or throughout the caregiving career.
It can also be inferred from these findings that behavior problems played a key
role in mediating the relationship between onset and primary subjective stress, since
behavior problems served as the fulcrum in the manifestation of negative emotional
well-being in caregiving (e.g., Pinquart & Sorensen, 2003a). Behavior problems, in
particular, emerged as the key care demand linked to onset, as well as the symptom
most likely to cause negative emotional reactions among caregivers, depending on
how onset was experienced. Behavior problems pose many challenges for caregivers because of the difficulty in managing physical and verbal behavioral symptoms.
Research has shown that increased behavior problems can be detrimental to the emotional well-being of caregivers, and are often more upsetting for dementia caregivers
47
Student Keynote Address II
than the losses in cognitive and functional abilities experienced by the care-recipient
(Gaugler, Davey, Pearlin, & Zarit, 2000; Volicer & Hurley, 2003). Probable explanations for the emotional impact of behavior problems include the disruptive nature of
behavioral disturbances (i.e., keeping the caregiver up at night, emotional outbursts,
inappropriate social interaction). The unpredictable nature of behavioral disturbances
can also be problematic for family caregivers, and may exacerbate the challenges
caregivers face in managing behavior problems. In relation to onset, caregivers who
had already established daily routines for managing care demands may have been
more likely to have intimate experience identifying and possibly assuaging behavior problems as they occurred. For caregivers not classified in the duration-symptom
group, the sudden exposure to behavioral disturbances may have put them at greater
risk for experiencing subjective stress throughout the caregiving career.
While care demands largely mediated the relationships between the durationsymptom onset sequence and subjective stressors, the duration-diagnosis variable
exerted a direct effect on loss of intimate exchange. A probable explanation for this
finding may be that diagnosis, in and of itself, is an event that leads to upheaval and
significantly influences the nature of the caregiver-care-recipient relationship. More
specifically, those who were engaged in care activities prior to a formal diagnosis
may have been better equipped to deal with further chronic illness and the distressing
symptoms that may have resulted. Receiving a formal dementia diagnosis can lead
to several psychosocial impacts for family members, including uncertainty in where
to seek additional help, disagreements among other family members, and feeling inadequately prepared for future events (Connell, Boise, Stuckey, Holmes, & Hudson,
2004). Moreover, family caregivers may not be given sufficient assistance or referrals
when preparing for future incidences associated with dementia (i.e., managing care
demands). Family members who had little or no experience in providing care prior to
a formal diagnosis may have been less able to maintain the psychosocial quality of
the caregiver-care-recipient relationship due to these potentially overwhelming and
unexpected responsibilities. On the contrary, for family members who began performing care prior to a formal diagnosis, the ability to maintain and preserve intimate
relationships with care-recipients in the context of care provision may have been more
easily achieved.
Results from this study potentially contribute to our understanding of onset within dementia caregiving, and the ramifications that this transition entails. The findings
strongly emphasize the importance of considering timing when examining adaptation in informal long-term care, and offer several implications for the development
and administration of interventions as well. Focusing more attention to the timing of
service delivery and the onset experience may help practitioners identify individuals
who experience immediate difficulty. This, in turn, may lead to the development of
more refined psychosocial interventions that target family caregivers who experience
more abrupt transitions into the caregiving role, and that help address and alleviate
negative outcomes experienced by community-based caregivers early in the caregiving career.
Graduate School Trajectory
48
Transitioning from Graduate School to Career
Prospective Analysis
Once a student completes an area of research and obtains data, he or she should
begin focusing on new ideas that arise as a result of their previous research. For example, after completing the retrospective portion of this study, I decided to construct
new elements of research dealing with the onset of dementia caregiving. This new
portion of the study was designed to examine how the potential onset of dementia affects an individual and his/her spouse psychosocially.
This study will gather information collected from a group of healthy controls
who may develop dementia over time. Consenting participants will be given a protocol to complete containing questions regarding a variety of domains, including
background characteristics, anticipation of care, memory and behavior issues, health
status, marital satisfaction, overall well-being, current and past care responsibilities,
and the NEO-Five Factor Inventory (Costa & McCrae, 1992). The spousal participants will be sent protocols annually, and have agreed to notify the researchers in the
event that either they or their spouse develop dementia at any time during the course
of this study. If a participant indicates the onset of dementia, a new protocol will be
sent to the participants to complete. This second protocol is designed to capture how
individuals respond to a diagnosis of dementia, and how this diagnosis impacts their
lives psychosocially. This project is still an ongoing process, and final results will be
available pending the completion of this study.
Publishing as a Graduate Student
In the midst of formulating research into something that is constructive and
unique, it is essential to begin concentrating on ways in which to disseminate research
findings. This includes presenting at conferences, both on the local and national level.
Most importantly, however, it includes preparing elements of research for submission
for publication, and becoming familiar with the publishing process.
Over the past decade there has been increasing pressure applied to graduate students to produce publications from their scholarly endeavors. Because publishing
is something that many typically do not encounter as undergraduates, it becomes a
new process once a student enters a graduate school. So, if publishing is so vital at
the graduate level, what is an adequate number of publications to have listed on an
academic vita at the completion of a graduate education? Some say one or two is
sufficient, while others say at least five. Others will contest that you need to have at
least seven to ten in order to even be considered for a position within a competitive
research-oriented university. So what is the actual answer? While it may not be appropriate to provide a subjective answer to the proposed question, it is just as important to
focus on the actual process of publishing in conjunction with the quantitative aspects
of publishing.
49
Student Keynote Address II
In addition to being concerned about the amount of publications one should obtain over the course of a graduate education, perhaps it would be wise to focus on
the elements that help make the process of publishing more successful. For example,
consider publishing within the domains in which you hold a true passion and scholarly
interest. Many students may begin to publish in a variety of topical areas. While this
is not necessarily a bad thing, it may end up prohibiting students from establishing
a level of expertise in selected areas. Remain focused by maintaining a consistent
theme with your publishing that will ultimately contribute to the completion of a dissertation. Furthermore, consider publishing within different types of academic literary contexts. Aside from publishing within academic journals, also consider book
chapters, encyclopedias, and even different types of aging newsletters. Finally, plan
ahead: The publishing process is long and tedious. It can take months to receive a
response from an academic journal, so in order to remain continually productive, it is
crucial to understand the details of publishing before beginning the process. It is also
important to have a backup plan! There is nothing wrong with wanting to aim for the
top; in fact, students should be encouraged to consider submitting their research to a
top tier journal. However, being realistic and having a secondary plan should always
be a priority within the publishing process. While the amount of publications that one
obtains is important, it is just as important to familiarize oneself with the details that
are rooted within publishing procedures, which will ultimately turn out to be very
beneficial at the conclusion of a graduate education.
The Post-Graduate Life – What Now?
Several challenges along the graduate school continuum have been addressed
thus far: choosing the right mentor, selecting research that is innovative and feasible,
the process of conducting different elements of research, and publishing research so
that others are aware of ongoing work. Among each of these challenges, perhaps one
of the biggest challenges that graduate students encounter is discerning what it is
they want to do upon completion of their degree. It is never too early to begin thinking about where you will end up and what type of work you will be doing once your
degree is completed. There are new and emerging careers available for those wishing
to pursue a career in aging, but how do students adequately prepare themselves for
what they really want to do? First, students must determine what type of setting they
envision themselves in. If the academia route is desired, it must be discerned whether
or not the student prefers a heavily research-oriented university, or a more teaching-oriented atmosphere. If one would prefer to work at a university that is heavily
research-oriented, then he or she needs to adequately prepare while still in graduate
school by becoming involved in various research projects, and by demonstrating a
sufficient amount of publications. If a teaching-oriented setting is preferred, then the
student must obtain an adequate amount of teaching experience and create an impressive teaching portfolio. Many programs offer teaching certificates for students who
wish to go on to teach, and it would be wise for students to consider this option as well.
What about non-academia related careers? The aging field has expanded well beyond
the boundaries of academia as societies around the world are preparing to adjust to the
Graduate School Trajectory
50
widespread number of aging adults. The following are different options for students
wishing to enter into a non-academic environment:
•
•
•
•
•
•
•
•
Long-term care and health care facilities
Retirement communities
Government agencies (federal, state, and local)
Professional organizations
Business and industry
Religious organizations
Community and human services
Advocacy groups
The ability to obtain a sufficient amount of academic and clinical experience during a graduate career will be key as students embark on a formal career that integrates
academic and scholarly potential with the provision of direct services to older adults.
Whether this means obtaining a teaching certificate or producing numerous publications, these procedures need to begin early on in the graduate career so that individuals may walk away with the necessary qualifications to acquire their desired career.
Conclusion
As graduate students, we share many similar occurrences, and hearing about
them and coming to the realization that we are all more similar than we once believed
is comforting. Graduate curricula are competitive and demanding, and students are
expected to exhibit steady progress throughout their course of study. Viewing the
graduate school process in terms of a trajectory may assist students in making wise
and constructive decisions. It was my intent to offer suggestions regarding the various
aspects of a graduate curriculum, and propose to students ways in which they can approach different situations while completing a graduate degree. As graduate students,
we are at an advantage to be able to further our education and utilize our skills for
numerous endeavors. Make the most of your graduate education so that you can look
back and say, “I wouldn’t change a thing!”
References
Aneshensel, C., Pearlin, L., Mullan, J., Zarit, S., & Whitlatch, C. (1995). Profiles in
caregiving: The unexpected career. San Diego: Academic Press.
Baron, R., & Kenny, D. (1986). The moderator-mediator variable distinction in social psychological research: Conceptual, strategic, and statistical considerations.
Journal of Personality and Social Psychology, 51, 1173-1182.
Connell, C., Boise, L., Stuckey, J., Holmes, S., & Hudson, M. (2004). Attitudes toward
the diagnosis and disclosure of dementia among family caregivers and primary
care physicians. The Gerontologist, 44, 500-507.
51
Student Keynote Address II
Costa, P. T., Jr., & McCrae, R. R. (1992). Revised NEO Personality Inventory (NEO
PI-R) and NEO Five Factor Inventory (NEO-FFI) professional manual. Odessa,
FL: Psychological Assessment Resources.
Gaugler, J. E., Anderson, K. A., Zarit, S. H., & Pearlin, L. I. (2004). Family involvement in the nursing home: Effects on stress and well-being. Aging & Mental
Health, 8, 65-75.
Gaugler, J. E., Davey, A., Pearlin, L. I., & Zarit, S. H. (2000). Modeling caregiver
adaptation over time: The longitudinal impact of behavior problems. Psychology
and Aging, 15, 437-450.
Gaugler, J. E., Wackerbarth, S., Mendiondo, M., Schmitt, F., & Smith, C. (2003). The
characteristics of dementia caregiving onset. American Journal of Alzheimer’s
Disease and Other Dementias, 18, 97-104.
Gaugler, J. E., Zarit, S. H., & Pearlin, L. I. (2003a). Family involvement in nursing
homes: Modeling nursing home visits over time. International Journal of Aging
and Human Development, 57, 91-117.
Gaugler, J. E., Zarit, S. H., & Pearlin, L. I. (2003b). The onset of dementia caregiving
and its longitudinal implications. Psychology and Aging, 18, 171-180.
Given, C. W., Given, B., Stommel, M., Collins, C., King, S., & Franklin, S. (1992).
The Caregiver Reaction Assessment (CRA) for caregivers to persons with chronic
physical and mental impairments. Research in Nursing & Health, 15, 271-283.
Katz, S., Ford, A. B., Moskowitz, R. W., Jackson, B. A., & Jaffee, M. W. (1963). Studies of illness in the aged. The index of ADL: A standardized measure of biological
and psychosocial function. Journal of the American Medical Association, 185,
914-919.
Lawton, M. P., & Brody, E. M. (1969). Assessment of older people: Self-maintaining
and instrumental activities of daily living. The Gerontologist, 9, 179-186.
Manton, K. G., Stallard, E., & Corder, L. S. (1998). The dynamics of dimensions of
age-related disability 1982 to 1994 in the U. S. elderly population. The Journals
of Gerontology: Social Sciences, 53, B59-B70.
Miller, R., Newcomer, R., & Fox, P. (1999). Effects of the Medicare Alzheimer’s Disease Demonstration Evaluation on nursing home entry. Health Services Research,
34, 691-714.
Pearlin, L., Mullan, J., Semple, S., & Skaff, M. (1990). Caregiving and the stress
process: An overview of concepts and their measures. The Gerontologist, 30,
583-594.
Perry, J. (2002). Wives giving care to husbands with Alzheimer’s disease: A process
of interpretive caring. Research in Nursing and Health, 25, 307-316.
Pinquart, M., & Sorensen, S. (2003a). Associations of stressors and uplifts of caregiving with caregiver burden and depressive mood: A meta-analysis. The Journals of
Gerontology Series B: Psychological Sciences, 58, 112-128.
Pinquart, M., & Sorensen, S. (2003b). Differences between caregivers and noncaregivers in psychological health and physical health: A meta-analysis. Psychology
and Aging, 18, 250-267.
Schulz, R., Belle, S. H., Czaja, S. J., McGinnis, K. A., Stevens, A., & Zhang, S. (2004).
Graduate School Trajectory
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Long-term care placement of dementia patients and caregiver health and well-being. Journal of the American Medical Association, 292, 961-967.
Vitaliano, P., Zhang, J., & Scanlan J. (2003). Is caregiving hazardous to one’s physical
health? A meta-analysis. Psychological Bulletin, 129, 946-972.
Volicer, L., & Hurley, A. C. (2003). Management of behavioral symptoms in progressive degenerative dementias. The Journals of Gerontology: Biological Sciences
and Medical Sciences, 58, 837-845.
Whitlatch, C. J., Schur, D., Noelker, L. S., Ejaz, F. K., & Looman, W. J. (2001). The
stress process of family caregiving in institutional settings. The Gerontologist,
41, 462-473.
53
Lee Awards
Lee Awards
The Anne and Everett Lee
Scholarship Awards
The Student Mentoring Conference on Gerontology and Geriatrics traditionally
gives awards to students who have outstanding posters and presentations. From 1984
to 2004, awards were given in the names of Dr. James P. and Geneva Montgomery.
Dr. James Montgomery was the Director of the UGA Gerontology Center (now the
Institute of Gerontology) until his retirement in 1984. Unrestricted funds contributed
by James and Geneva Montgomery funded the awards for several years.
Effective 2005, the awards were given in the name of Drs. Everett S. and Anne
Lee. Dr. Everett Lee is a Professor Emeritus of Sociology and has served as Assistant
Director of the Institute of Gerontology. Dr. Everett Lee is interested in the demographics of aging, and both of the Lees have research interests in migration. Funding
for the awards is now provided by Drs. Lee.
Awards of $200, $100, and $50 were presented at the close of the conference for
the top three presented posters as judged by a committee of faculty. Posters were
evaluated on importance, timeliness, relevance of the topic, soundness of approach,
and clarity of presentation.
First Prize
A Case Study of Culture Change in Long Term Care: Evergreen Retirement
Community
Meldrena Chapin
Architecture, University of Wisconsin - Milwaukee
The nursing home/long-term care facility as a place has continually and slowly been
undergoing a design and organizational evolution since its conception. Particularly
during the past few decades, a small number of long-term care facilities have been
experiencing a new phase of cultural, organizational, and physical evolution. This
new phase of evolution is related to the Culture Change movement. Culture Change
recognizes the need to create a place where older adults can live comfortably and
receive needed care, rather than simply creating a building where medical and/or limited social services are provided. Culture Change is the process of transforming a
long-term care facility from operating under a medical model of care to operating in
a more holistic resident-centered care manner. This case study investigates the orga-
Lee Awards
54
nizational and architectural alterations undertaken by Evergreen Retirement Community, a long-term care facility leading the way in the Culture Change movement.
This case study highlights a) the philosophies and operations which support culture
change at Evergreen, b) the process used for creating culture change at Evergreen,
and c) the level of congruence between the physical environment at Evergreen and the
goals of culture change. This poster briefly illustrates one of the in-depth case studies
undertaken during the dissertation research. Data was collected through interviews
and archival research during 2004 and early 2005. Although the dissertation research
is much more thorough, this poster aims to illustrate the timeline of culture change
at Evergreen Retirement Community, highlighting significant changes in philosophy,
operations, and environment and demonstrating how the alterations in these three
arenas are inter-related. In particular, the facility’s decision to pursue person-centered
care and how that decision required extensive operational and environmental changes
will be illustrated.
Second Prize
How Senior Multipurpose Centers Affect the Quality of Life of AfricanAmerican Older Adults
DaVette Taylor-Harris
Gerontology Institute, Georgia State University
There have been several studies examining how informal social networks impact the
quality of life of African-American older adults, but few studies have examined how
social networks within formal settings affect the African-American aged. This research examined how senior multipurpose centers impact the quality of life of African-American older adults. A survey was distributed at the Adell Senior Multipurpose Facility, an African-American facility in Fulton County, Georgia, December
6-10, 2004. Since the survey was distributed during the monthly Participants’ Forum and holiday festivities, response to the survey was high (n = 227). The findings
showed several trends. The mean age of participants was 73, but the data also revealed
that the baby boom generation is beginning to retire and seek activities provided at
multipurpose centers. Women accounted for 80.4% of the facility’s population. Furthermore, the data revealed that 62% of participants attended the facility four to five
times a week. Ninety-nine percent indicated that the facility is important to their life
satisfaction. Positive effects included improved self-esteem and increased cognitive
and physical functioning. Although participants’ experiences were mostly positive,
some expressed a need for improvement in areas such as longer operating hours and
more activities geared toward the baby boom generation. Based on these findings,
several recommendations are made for improving senior center programs for African-Americans, including more senior centers in predominantly African-American
neighborhoods and better programming for baby boomers.
55
Lee Awards
Third Prize
Subjective and Objective Measures of Income: Which is the Better Predictor of
Caregiver Outcomes?
Daniel W. Durkin, Fei Sun, Michelle Hilgeman, Lucinda Roff
Center for Mental Health and Aging, The University of Alabama
Symbolic interactionism posits that the meanings we attribute to things are more important than the things themselves. Subjective measures of health have been shown to
be better predictors of caregiver outcomes than objective measures. However, similar
trends have rarely been explored in income measures. We examined the differential
impact of objective income and subjective income adequacy to determine the better predictor of three outcome variables: depression, anxiety, and positive aspects of
caregiving (PAC). Secondary data of 1,215 caregivers of individuals with Alzheimer’s
disease was drawn from the NIH Resources for Enhancing Alzheimer’s Caregiver
Health (REACH) study. Using symbolic interactionism, we hypothesized that subjective measures of income would be a better predictor of caregiver outcomes than
objective measures. We found the objective and subjective measures of income to be
modestly correlated (r = 0.432). We then entered the objective and subjective measures
of income into a regression equation with controls for household size and caregiver
health to predict caregiver depression, anxiety, and PAC. In the case of depression and
anxiety we found that the subjective measure of income was statistically significantly
related to the outcome measure and the objective measure was not. In the case of PAC,
the objective measure remained significant but the subjective measure explained more
of the variance. Subjective income adequacy was found to be a better predictor of the
three outcome variables than objective income. Our results suggest that subjective
income measures may portray a more accurate depiction of financial stress on caregiving outcomes than objective measures.
Poster Presentations
56
Poster Presentations
Students prepared research posters and presented them to their peers and faculty during formal 10-minute sessions. Each presentation was followed by a brief questionand-answer period. The top three poster presentations, winners of the Lee Awards,
are listed in the previous section. This section provides the abstracts from the rest of
the poster presentations.
Note: “*” indicates that the research summarized in the poster was supported by a Seed
Grant awarded by The University of Georgia Institute of Gerontology.
Mental Health Among Older Residents in Assisted Living Facilities
Elizabeth Bergman
School of Aging Studies, University of South Florida
Yuri Jang, Lawrence Schonfeld, Victor Molinari
Department of Aging and Mental Health, University of South Florida
This study was undertaken in response to the pressing need for research regarding the
mental health status of older adults living in assisted living facility (ALF) settings. In
this cross-sectional study of 150 ALF residents (M age = 82.8, SD = 9.41), we assessed
the predictability of potential risk factors (physical and health constraints and stressful life events) and psychosocial attributes (social network, sense of mastery, religiosity, and attitude toward aging) to depressive symptoms. We tested both for direct and
moderating effects of the predictive variables on depressive symptoms. The results
showed that older participants with a higher level of functional disability, poorer selfrated health, lower sense of mastery, less religiosity, and less positive attitude towards
aging exhibited higher levels of depressive symptoms. Further, the relationship between physical and mental health was moderated by subjective beliefs and attitudes.
These findings have important implications for mental health promotion efforts and
for the development of prevention and intervention strategies for the mental health of
older adults living in ALF settings.
57
Poster Presentations
Effects of Medications with Anticholinergic Properties on Cognition in Older
Adults with Alzheimer’s Disease
Kara Bottiggi
Gerontology, University of Kentucky
Objectives: Medications with anticholinergic (AC) properties are commonly prescribed for older adults. Patients with Alzheimer’s disease (AD) who are taking both
cholinesterase inhibitors and ACs are at increased risk for medication-induced cognitive impairment. The objective of this study is to examine the effect of ACs and cholinesterase inhibitors on cognition in older adults with AD. Methods: This was a retrospective analysis of data from a normal aging study at the University of Kentucky.
Participants were divided into two groups; those taking cholinesterase inhibitors and
one or more ACs and those taking cholinesterase inhibitors and no ACs. The cognitive
effects of these medications were assessed using the participants’ annual test scores
on cognitive status exams. Results: The statistical analyses showed a main effect of
drug and a main effect of time on some of the cognitive measures. However, results
did not show any significant interaction effect between drug and time. Conclusions: In
this study, results showed a difference between the two groups based on drug status,
showing that older adults taking both cholinesterase inhibitors and ACs performed
less well on cognitive status exams than those taking cholinesterase inhibitors and no
ACs. Results also showed a difference in mental status exam scores over time for both
groups. However, the main finding of the study was that older adults with AD taking
both cholinesterase inhibitors and ACs did not show an accelerated rate of change in
cognition.
The Question Is How Do You View Aging: The Relations Between Belief in
Stereotypes, Self-Stereotyping, Locus of Control and Self-Perceptions of Aging
Karly A. Branch*
Life-Span Developmental Psychology, The University of Georgia
Self-perceptions of aging have been found to be more powerful predictors of mortality than other variables traditionally thought to play a large role in mortality, such as
social ties and functional health. Given the significant influence of self-perceptions
of aging on mortality, the goals of the current study are to better understand (1) how
stereotypes of aging are related to self-perceptions of aging, and (2) how individuals
with more positive self-perceptions of aging differ from those with less positive selfperceptions. To answer these questions, this study investigated belief in stereotypes
Poster Presentations
58
of aging, self-stereotyping, and locus of control (LOC) as possible correlates of selfperceptions. Seventy community-residing adults over 55 years of age completed a
questionnaire designed to assess the variables of interest. The results are expected to
show that belief in stereotypes of aging is positively correlated with self-stereotyping,
which is related to self-perceptions, and that LOC is a central personality variable that
moderates both relations in the model. Determining what factors contribute to and
influence self-perceptions of aging will enable the design of interventions that would
give people the best opportunity to have more positive self-perceptions of aging, a
psychological variable related to such favorable outcomes as better functional health.
Osteoporosis and Medication: What’s Routine Got To Do With It?
Allison Brown, Katherine Eckler, Melissa Varnes
Department of Occupational Therapy, Brenau University
It is estimated that as many as 44 million Americans have low bone mass, ten million of which have been diagnosed with osteoporosis (Hellekson, 2002). Preventative,
rehabilitative, and pharmacological treatments for this silent disease are available;
however, these measures are most effective when adhered to properly. This study is
designed to gather information regarding the performance patterns of older women
taking the bone-forming drug Forteo for the treatment of osteoporosis. The purpose
of the study is to investigate the part performance patterns (habits, roles, and routines)
play in an individual’s ability to take on and adhere to a rigid medication regimen.
Participants will be identified by a physician specializing in the treatment of individuals with osteoporosis. Researchers will interview approximately 12 women over
the age of 65 who have been taking Forteo for three to twelve months, using a semistructured, open-ended interview guide. Interviews will be transcribed and coded to
establish themes and categories regarding medication compliance and performance
patterns. The side effects of osteoporosis and medication non-compliance impact the
occupational performance of older adults. This directly affects the successfulness of
treatment with this population. Ludwig (1998) stated that health care practitioners
should use or advocate for routine in individuals’ lives to enhance well-being and to
increase compliance with rehabilitation and medication regimens. It is hoped that the
findings from this study will add to the limited sources of literature that explore the
possible connection between performance patterns and an individual’s ability to take
on a new medication regimen.
59
Poster Presentations
The Age of Anti-Aging
Jessica Bunch
Department of Sociology and Anthropology, Georgia Southern University
Americans have stereotypes about older adults and aging individuals that are mostly
unflattering and undesirable. The mass media plays an important role in not only
revealing but also constructing those ideas when portraying various aspects of aging to the public and influencing people’s opinions and perspectives about them. The
purpose of this study was to examine how Americans’ perceptions about aging and
older individuals are represented and shaped by the mass media. More specifically,
the study addressed how popular magazines represent and shape ideas about aging
and the aged regarding health and appearance, in particular. I conducted content analysis of articles and advertisements concerning aging and older individuals from 100
People magazines. I found that articles and advertisements about aging and the aged
frequently promote the maintenance of youth or beauty and that people in the United
States appear to be preoccupied with resisting old age. There is also evidence for the
rapid growth of the anti-aging industry that involves providing any treatment, product,
or therapy designed to reverse or impede the signs of aging. An alternative approach
to anti-aging campaigns, which describes a lifestyle of positive aging, is discussed.
Senescence of a Gene Network
Joep M. S. Burger*
Daniel E. L. Promislow
Department of Genetics, The University of Georgia
Molecular genetic studies of aging currently focus on identifying the molecular pathways of known and novel genes associated with aging. The target of a mutation that
reduces the rate of aging is typically a single gene. However, recent studies have shown
that the effect of genes affecting longevity depends on the genetic background. One
of the current challenges in the evolutionary biology of aging is to analyze genes associated with aging in the context of a gene network. The ultimate aim of this project
is to determine how age-related changes in a gene network influence the physiological
basis of senescence. A network of interacting olfactory genes in Drosophila melanogaster has been identified and provides an ideal system to address this question.
Odor-guided behavior is quantified using a simple bioassay to identify smell-impaired
loci. The assay measures the ability of flies to avoid a diluted repellent odorant, benzaldehyde. Before we identify if and how gene interactions change with age, we first
need to quantify dose-response curves of different age classes of flies, to measure agerelated declines in odor-guided behavior and to determine if smell-impaired mutants
and their controls differ in the rate of age-specific decline in olfaction. Results from
these pilot studies will be presented at the conference.
Poster Presentations
60
Research Participation
Diane Byrd*
Department of Psychology, The University of Georgia
Although older adults are, in general, less likely to participate in research than are
younger adults, older African Americans are even more difficult to recruit and less
likely to be retained in research. A growing interest about the well being of an increasingly aging population has resulted in efforts to determine the factors responsible
for the under-representation of older ethnic minority adults in research. The African
American participation model proposes that the decision to participate in research for
older African Americans is connected to their relationship with society. The model
includes a substantial developmental component (age and the developmental environment). In a two-part study, the developmental predictors of expressed willingness to
participate and continued research participation among older individuals (i.e., African
Americans and White Americans) will be examined. Participants will be recruited
from the middle Georgia area and complete six self-report surveys. The proposed
study will expand current information on research participation by: (a) including measures of developmental predictors (i.e., mistrust, discriminatory experiences, ethnic
identity development, perceived social control, and attitudes toward aging), and (b)
test multivariate models of age and developmental predictors with continued participation. In sum, the purpose of the study is to explore barriers relating to research
participation to enhance research participation among African Americans and older
adults in general.
Connecting Roots: Community Elders and Medicinal Plants in Gullah-Geechee
Communities
Lisa Shanti, Noack Chaudhari *
Department of Anthropology, The University of Georgia
This project evaluates the perception of communities in regard to older adults within these communities. The emphasis is on medicinal plant knowledge held by older
adults, which has been passed down from generation to generation to varying degrees,
impacting the (self-) valuation of these members of the community. This study identifies the social networks older adults create within their community in two GullahGeechee communities off the Southeast coast of the United States. The focus on medicinal plant knowledge as knowledge systems represents a valued cultural dimension
(at least historically), a link that can tie generations closer together as these relatively
isolated communities are being diluted and becoming more scarce, and an alternative
history of these communities’ contributions. The focus on knowledge among older
adults promotes dignity in their aging process, as the environment around them has
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Poster Presentations
been greatly altered (though this dimension is not measured). The indirect value of describing and documenting this knowledge mainly held by older adults in oral form is
a patrimony that cannot be discounted. I am also looking at the activities older adults
are engaged in surrounding medicinal plants - wild collection, gardening, preparations, and the proven therapeutic nature of these activities. The principal methods
used are interviews, cognitive mapping, surveys and multidimensional scaling, plant
identification as well as a literature review. This study highlights the importance of
older adults and their knowledge in these communities that have historically highly
valued older members of the community.
Validation of the Balance Domain of the Bone Safety Evaluation: A Tool for
Measuring Physical Functional Performance in People with Osteoporosis
Jamie Empert, Francine Bride, Mary Shotwell, Barbara Schell, Stephanie Grant
Department of Nursing, Brenau University
It is estimated that 10 million Americans have osteoporosis and 34 million are at risk
to develop osteoporosis because they have low bone density. The impact of osteoporosis on an individual’s life can be far-reaching, and research has shown that individuals with osteoporosis report more difficulties performing activities of daily living,
decreased physical function, emotional problems, and a reduction in leisure activities
than do individuals without osteoporosis. Despite the fact that many of the sequelae of
osteoporosis can be prevented or ameliorated with activity, strengthening, and education, many individuals with osteoporosis do not receive rehabilitative therapy. In order
to demonstrate effectiveness of rehabilitation and educational interventions, a new
tool, the Bone Safety Evaluation (BSE) was developed. This tool assesses functional
performance while doing tasks that are based on typical everyday life activities and
identifies individuals who may be at risk for falls or fractures based upon their quality
of movement. This evaluation is comprised of three domains that measure balance,
spinal compression forces, and strength and flexibility. The purpose of this study was
to validate the balance domain of the Bone Safety Evaluation. In order to accomplish this purpose, the results of the BSE Balance domain were compared against
two well-established assessment tools, including the modified Clinical Test of Sensory Interaction and Balance (mCTSIB) and the Sensory Organization portion of the
Computerized Dynamic Posturography (CDP) in 40 adults ages 50+ with and without
osteoporosis. Findings: It is anticipated that the BSE will correlate with the CTSIB
and the CDP with an R value of .80 or better. Implications: If this instrument is found
to have good correlations with the other assessment tools, it may have more significance for therapy practice and for older adults, because older adults strive to preserve
functional independence as they age. It will identify individuals whose functional
movements put them at risks for falls and fractures, thereby allowing early intervention to prevent the sequelae of osteoporosis. This assessment tool would also provide
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therapists and clients with baseline data about functional performance to measure the
impact of changes in bone density on daily life activities.
Auditory Information Processing Speed in Older Adults
Yuan Gao, Megan Boyd, Brett A. Clementz*
Department of Psychology, The University of Georgia
Leonard Poon
Institute of Gerontology, The University of Georgia
Studies indicate that auditory information processing becomes less efficient with increasing age. The present investigation used 143-channel Magneto-encephalography
(MEG), a sensitive measure of neural activity, to address possible reasons for this
reduced efficiency among older adults. Data were collected from 12 younger (18-25
years) and 12 older (65-75 years) participants while they listened to sounds containing
different densities of auditory information. Results indicated that older individuals
had a compromised ability to rapidly integrate auditory information within the first 50
msec of stimulation at even modest information densities, suggesting reduced neuronal processing speed. This effect was most dramatic in the right auditory cortex.
The Lived Experience of Rural, 65-Year and Older, Home-Bound Diabetics
Sharon R. George
College of Nursing, University of Tennessee
Persons aged 65 years and older are disproportionately affected by diabetes and are
more likely to have comorbid illness, diabetic complications, and disabilities than
younger adults. These complications place an extraordinary burden on the body and
produce additional stress on the diabetic individual. Supported by abundant empirical
evidence are the findings that effective self-management reduces the occurrence of
long-term complications. The literature proposes why it is difficult for older adults to
manage their diabetes but does not cite specific studies. Even the gerontology literature
provides no insight into rural, home-bound older adults with diabetes, and how they
live with their condition on a day-to-day basis. Guidelines for diabetes management
and treatment developed by the American Diabetes Association are not specifically
targeted to older adults. Understanding the experience of diabetes for rural, homebound older adults may provide a foundation for development of diabetic protocols
that focus on this growing and vulnerable population. The purpose of this phenomenological study is two-fold. The first is to explore the meaning of the lived experiences
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of rural, home-bound older adults with diabetes who are insulin dependent. The second is to examine what is unique about this population compared to other adults with
diabetes. Method: A purposive sample of participants will be recruited from senior
center referrals in North Alabama following University of Tennessee Institutional
Review Board approval. Participants will be 65 years of age or older, male or female,
insulin dependent, home-bound, live alone, lucid, English speaking, and willing to
participate. Unstructured, audiotaped, face-to-face interviews will be conducted individually. These will last approximately 1½ hours and take place in the participant’s
home. Each participant will describe his/her experiences with diabetes. The audiotaped interviews will be transcribed and analyzed using the Thomas and Pollio’s phenomenological method, which begins with bracketing. Data Analysis: Data analysis
will begin with data collection. Audiotaped interviews will be transcribed verbatim
and read while listening to the audiotape. All transcripts will be analyzed, and selected transcripts will be read aloud to members of an interdisciplinary phenomenology
research group to determine emerging themes described by the participants.
Advocating for Georgia’s Elderly
Abby Griffis
School of Social Work, The University of Georgia
In working with the Georgia Council on Aging, I have learned about the importance
of advocacy. As the population of older adults in Georgia continues to grow, politicians can no longer turn a blind eye to the demands made by this population. Though
the thought of becoming an advocate might initially seem overwhelming to some
individuals, it is important to note that advocacy can be done on several levels. Issues such as Social Security, Medicare, and prescription drugs have dominated the
national news. On a local level, issues such as nursing home reform, abuse of older
adults, and tort reform have received considerable attention. These are just a few of
the many issues that will affect older adults today and in the future. Whether an individual is involved on a small or large basis, it is important to get involved. Legislators
want to hear from their constituents and, with advanced technology, this communication has become increasingly easier. My presentation will examine the different levels
of advocacy, as well as suggestions as to how one can become involved. I will also
describe one advocacy organization that is working hard to represent the interests of
older Georgians: the Coalition of Advocates for Georgia’s Elderly (CO-AGE). I will
highlight the budgetary and legislative issues that CO-AGE will be following during
this 2005 session at the Capitol. If given the opportunity, advocacy can be empowering and rewarding.
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A Six-Month Follow-Up Assessment of Physical Function in an Older Adult
Population Living in Public Housing
Dawn M. Hayes*
M. Elaine Cress
Department of Exercise Science, Aging & Physical Performance Lab
The University of Georgia
Geraldine Clarke
Athens Housing Authority, Resident Services
Background: Older adults residing in public housing tend to be at risk for nursing
home placement or loss of independence. Identification and annual evaluation of
modifiable risk factors and functional change are recommended solutions to facilitate
independence maintenance. Specific aims include determining factors contributing
to loss of independence specific to older adults living in public housing, monitoring
change over time, and providing training to public housing staff on proper administration of an assessment tool. Methods: Six-month follow-up study of self-report
and physical functional performance (Short Physical Performance Battery (SPPB) and
the Physical Functional Performance 10 (PFP-10)) of residents residing in Denney
Tower public housing. The initial study included 30 residents. Analyses: Statistical
analyses include: 1) correlation for SPPB and PFP-10; 2) multivariate analysis using
SPPB risk levels (no risk 10-12, low risk 7-9, high risk 4-6) as independent variable
and self-report function, PFP-10, and use of support services as dependent variables;
3) inter-rater reliability of SPPB using intra-class correlation. Prediction of Results:
PFP-10 total scores will be positively related to SPPB, indicating similar risks of loss
of independence in older adults living in public housing. Inter-rater reliability of SPPB
will be >.9 following staff training on administration. Implications: Potential benefits
to older residents in public housing include determining a need for social services and
physical activity programming, and assisting the public housing authority with identification of physical functional limitations. Objective tools can potentially be used for
annual assessment of older residents conducted by public housing authority staff.
Quality of Life and Pleasant Events in Nursing Homes
Amber Heuerman, Douglas Welsh, Suzanne Meeks
Department of Psychological and Brain Studies, University of Louisville
Purpose: Along with the aging of the baby boomer generation comes an inevitable increase in institutionalized older adults. Unfortunately, for many, the idea of institutionalization is unattractive, with problems such as depression - an important component
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of quality of life - rated as one of the top concerns of nursing home residents. In this
honors' thesis, we are looking at correlations between quality of life and activity participation, as well as which types of activities - passive-active versus social-nonsocial
- are most highly correlated with quality of life. We hypothesized that higher scores
on the Quality of Life-Alzheimer’s Disease (QoL-AD) scale would be correlated with
higher activity and pleasantness ratings for activities, and more frequent participation
in activities. Methods: The instruments used were the QoL-AD, the Geriatric Depression Scale, mood ratings, and the Pleasant Events Scale (PES). Participants were
chosen from nursing homes in the greater Louisville area based on recommendations
from activity coordinators (anticipated N = 40). Questionnaires were completed by
face-to-face interview and participants were given $5 for their participation. Results:
Preliminary correlational analyses (N = 12) are in the hypothesized direction although
they do not yet reach significance. Correlations with QoL-AD scores were .39 (p =
.22) for the sum of pleasant activities, and .42 (p = .17) for participation frequency in
the past month. Pleasant activities were positively correlated with positive affect (r =
.65, p = .02), a component of quality of life. Type of activity analyses will be completed when all the data are collected, and updated analyses will be presented.
The Relationship Between Cigarette Smoking and Late-life Depression in
Nursing Home Residents
Bethanie Hilkey
Psychology and Brain Studies, University of Louisville
A significant relationship between cigarette smoking and depression has been found
in numerous studies. However, past research associated with the relationship has been
primarily restricted to adolescents and middle-aged adults. In the present study, the
relationship between cigarette smoking and depression was examined in older adults
in a nursing home setting. The hypothesis is that if smoking influences depression in
late-life, there will be a significant difference in the rate of depression between smokers and nonsmokers. Data was collected from 88 nursing home residents. A review
of medical files determined whether a resident is a smoker or nonsmoker. Additional
data included the results from the 30-item Geriatric Depression Scale (GDS) and Mini
Mental Status Exam (MMSE) scores, also available from the medical record. The
participants were divided into two groups: smokers and nonsmokers, and rates of
depression were compared to determine whether or not there was significant difference in rates of depression between the two groups. The chi-square test was used to
determine whether smokers were more likely to be depressed. In this sample (N = 88),
cigarette smokers were more likely to be depressed than non-smokers. A chart diagnosis of depression was present for 14.9% of smokers as compared to 2.5% of nonsmokers. These findings suggest a significant correlation between cigarette smoking
and depression in nursing home residents.
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Risky Behaviors in Assisted Living Facilities: Autonomy vs. Safety
and Liability
Andrew Horne
Department of Gerontology, University of Kentucky
Assisted Living Facilities (ALFs) represent the fastest growing residential option for
older adults because they are a viable and less restrictive alternative to traditional
nursing homes. Many older adults participate in behaviors that make themselves and
other residents susceptible to health risks (e.g., smoking, excessive alcohol consumption, illicit drug use, sexual promiscuity). Other behaviors that may seem innocuous
but also pose hazards include older adults with diabetes eating sweets, frail older
adults bathing without assistance, or forgetful older adults self-administering medication or cooking unsupervised. In most cases, facility policy errs on the side of least
restriction and respect of personal autonomy, provided that this does not infringe on
the rights or safety of other residents and staff. In practice, however, autonomy is often
superseded by overzealous concerns regarding resident safety and fears of litigation.
To diffuse these situations, facilities have adopted a myriad of approaches to negotiate
and manage risky behaviors. Data for the present study was obtained from interviews
of administrators of several ALFs in Kentucky. Transcripts of these interviews were
analyzed for emergent themes. Results include the delineation of common risky behaviors encountered in ALFs and procedures currently employed to balance resident
autonomy with safety and liability. Suggestions are provided for policies to further
enhance resident autonomy.
Predicting Differences in the Leisure Behavior of Older Adults
Megan C. Janke*
Department of Child & Family Development, The University of Georgia
Adam Davey
Polisher Research Institute, North Wales, PA
The potential importance of leisure for health promotion and well-being in older
adults is increasingly gaining recognition as this segment of the population grows.
Data from individuals ages 60 and above from two waves of the Consumption and
Activities Mail Survey of the Health and Retirement Study (N = 3,102) will be used to
examine categories and predictors of leisure behavior. The national sample consists
of 64% women and 12% African-American respondents, with a mean age of 71.4
years old at the initial wave of the questionnaire in 2001. Research has suggested that
there are significant individual differences in patterns of leisure engagement based on
factors such as age, race, gender, educational attainment, and retirement status. The
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life span developmental perspective suggests that individuals’ experiences throughout
their life course contribute to their development, and that development has elements
of multidimensionality and multidirectionality. Determining predictors of leisure behavior has implications for older adults. Participation in leisure activities has been
associated with improved physical and psychological health, and understanding the
variability that occurs in leisure behavior patterns will help practitioners in both aging
and leisure services to meet the growing needs of their constituents.
Attitudes and Pain Management
Misti Johnson
Center for Mental Health and Aging, The University of Alabama
A large body of literature demonstrates the high prevalence of pain in older nursing
home (NH) residents and indicates that it is often undetected and untreated. Resident
and staff beliefs about pain may play a role in the poor detection and treatment of
pain among this population. The present study examines NH resident and certified
nursing assistant (CNA) attitudes toward resident pain using surveys developed by
Weiner and Rudy (2002). There are separate versions of the survey for residents and
CNAs, measuring ten beliefs about pain: 1) lack of time to assess pain; 2) emphasis
on function; 3) pain as part of old age; 4) chronic pain doesn’t change; 5) belief in
pathology; 6) fear of addiction; 7) fear of dependence; 8) desensitization; 9) ageism;
and 10) pain complaints unheard. This study will show which beliefs are commonly
endorsed by residents and CNAs. It will also expand prior research in this area by exploring how attitudes relate to pain assessment and management. Specifically, we will
examine correlations among resident attitudes, levels of depression, and the amount
of analgesic medication received and correlations between CNA attitudes and ratings
of resident pain.
Dementia Caregivers in South Korea: Risk Indicators of Elder Abuse
Minhong Lee*
School of Social Work, The University of Georgia
The purpose of this study is to identify characteristics that would increase the likelihood that a Korean older adult with dementia being cared for by a family caregiver is
at risk of being abused. This analysis was based on a sample of 490 primary family
caregivers from the Comprehensive Study for the Elderly Welfare Policy in Seoul. A
multiple regression method was employed to identify significant predictors among the
demographic characteristics of caregivers and care recipients, the severity of cognitive
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impairment, functional ability, caregiver burden, and social support for the degree of
abuse. Analysis of the important determinants of symptoms of abuse indicated that
the degree of abuse was significantly associated with caregiver burden (b = .094, p <
.01), mental impairment (b = .239, p < .001), and dependency of daily living (b = -.126,
p < .01) of care recipient. Consistent with previous research, as the level of caregiver
burden and the severity of cognitive impairment increased, the caregivers were more
likely to abuse older family members in the domestic setting. However, contrary to
the researchers’ expectations, as functional ability of the care recipient with dementia
weakened, caregivers were less likely to abuse their care recipients. Findings implied
that in order to prevent possible abuse of older adults in Korea, researchers, social
workers, and policy makers should focus more on primary caregivers who care for the
older adults with severe cognitive impairment.
I Survived WWII - Can I Survive This?
Aloise McNichols
Department of Psychology, Brenau University
Over the next twenty years those ages 65+ will represent 20% of the population. As
longevity and the rate of divorce increase, the resources for caring for older adults
substantially decrease. Additionally, 76 million baby boomers are poised to retire in
the next five years. The implications for these demographic shifts are obvious and
discomforting. This current research reflects the inevitable decline in the physical and
emotional well being of seniors moving from independent living to assisted living.
As they age in place, their unique rearing, during pre-war America, may hinder their
development of coping mechanisms necessary to deal with vast transitions. Instead it
may encourage a dependence upon superficial lifestyles achieved more through strict
role adherence than through experiential based reality. This study examined a 43-person sample of residents in a retirement community. The roles among these individuals
reflect the time in which they were socialized and have less to do with where than
when. Succumbing to narrow role definitions proscribed early and followed rigorously may render either gender incapable of adequately coping when spousal death
occurs. Utilizing a narrative and detailed timeline, this research chronicles significant
events in a journey of just one of these individuals, a widower, as he struggles over
three years with the emotional and physical changes the loss of complete independence brings. Further research can focus on identifying and leveraging the skills once
used successfully by such seniors.
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Attitudes Toward Older Adults with Arthritis: The Impact of Race and
Diagnostic Label on Emotions, Beliefs, and Willingness to Help Family
Members
Chivon A. Mingo, Jessica M. McIlvane, William E. Haley
School of Aging Studies, University of South Florida
This study examines attitudes toward older persons with osteoarthritis (OA), the most
common chronic illness in old age. A common misconception is that OA is simply
part of old age rather than a disease. It is unknown if the diagnostic label of OA affects young adults’ attitudes toward older adults, and whether reactions vary by race.
For this study, 105 African American and 308 White undergraduates were randomly
assigned to read vignettes describing an older mother suffering from chronic pain,
either with the label of osteoarthritis or without a diagnostic label. A series of 2 x 2
(race x diagnostic label) ANOVAs were examined. The label of OA led to higher attribution of problems to illness (F(1,409) = 6.12, p = .01), and decreased ratings that
better health care would improve the mother’s condition (F(1,409) = 10.46, p = .001)
than those without a diagnostic label. African Americans were more favorable about
the mother and positive about providing care than Whites across nearly all measures.
No significant interactions were found between diagnostic label and race. Results
indicate that the label of OA does affect perceptions of older adults, but the negative
effect of the label on perceptions that better health care could be useful suggests that
public education on the effectiveness of arthritis care should be considered. Findings
suggesting that race significantly affected perception of the parent and willingness to
provide care are consistent with the previous literature on race and family caregiving, and indicate that cultural values regarding family caregiving may be important
in arthritis care.
Executive Functioning and Functional Ability in Older Adults
Meghan Mitchell*
L. Stephen Miller
Department of Psychology, The University of Georgia
The present study will characterize deficits in executive functioning in older adults,
and will determine how strongly these deficits predict functional ability. This will be
done by examining the predictive abilities of a comprehensive set of specific cognitive processes, including inhibition, sequencing, and planning, on measures of both
observed and self-reported functional ability. There are three specific aims: 1) to assess overall levels of executive functioning in a community-based sample of older
adults; 2) to examine the relationship between executive processes and observed
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functional ability and to determine which executive tasks are most predictive of decreased functional ability; and 3) to compare a direct assessment measure of functional ability to a self-report measure to determine which measure is most strongly
correlated with performance on measures of executive process. It is hypothesized that
executive processes will be variably distributed across a community sample of older
adults. Second, it is hypothesized that there will be a negative correlation between
scores on measures of executive process and levels of functional ability, with greater
impairment on executive measures predicting decreased performance on functional
measures. Third, it is hypothesized that, consistent with earlier work from our laboratory, direct observation of functional abilities will be more strongly correlated with
performance on measures of executive process than either a self-report or collateral
measures of functional ability.
Interventions To Abate Functional Dependency
Trudy L. Moore*
Department of Exercise Science, The University of Georgia
Mary Ann Johnson
Department of Foods and Nutrition
The University of Georgia
M. Elaine Cress
Department of Exercise Science and Institute of Gerontology,
The University of Georgia
Background: Older adults with low income, low education, and low physical reserves
are at disproportional higher risk for disability from chronic disease. Exercise has
proven beneficial effects; however, these populations are under-represented in exercise intervention literature. Purpose: To evaluate the effect of walking or nutrition
education on functional performance with a randomized controlled trial of low socioeconomic older adults. Methods: Thirty older adults will be screened for eligibility and randomized into a sixteen-week walking group or into a nutrition education
control group. The primary outcomes will be aerobic capacity, Physical Functional
Performance 10, and the Short Physical Performance Battery. The Medical Outcomes
Short Form 36 will be used to evaluate self-reported health status. Measures to evaluate strength will include the leg press and leg extensor power. Statistical Analysis:
ANOVA will be used to determine whether the treatment group significantly changes
more than the control group over time. Prediction of Results: Aerobic capacity and
functional performance will both increase more in the walking group as compared
to those randomly assigned to the nutrition education group. Functional performance
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will demonstrate a disproportional increase as compared to the aerobic capacity. Results will be reported as means ± standard deviations. Significance will be set at alpha
level ≤ 0.05. Implications: This study will add to the understanding of exercise, aerobic capacity and physical function in low socioeconomic older adults.
Arch Support Use for Improving Balance and Comfort in Older Adults
Deborah L. Mulford
Department of Nursing, Armstong Atlantic State University
Falls are a serious health problem among older adults in the United States and are the
most frequent cause of injury-related morbidity, mortality, and health care spending
among the older population. Sixty-seven participants ages 60 to 87 (mean = 69.9)
completed the study. At the first measurement, each participant completed tests for
balance (Berg Balance Scale, BBS), functional mobility (Timed up and go test, TUG),
and pain intensity scale assessment. They were fitted for arch supports, and while
wearing the arch supports, the participants repeated the balance and functional mobility tests. Participants were instructed and given printed instructions on how to wear
arch supports. After 6 weeks the participants returned and repeated the balance and
functional mobility tests (with arch supports), and completed a six-week post-intervention pain intensity scale assessment and post survey. The purpose of this study
was to evaluate (a) change in balance (BBS) and functional mobility (TUG) measures
in pre-intervention to immediate post-intervention (arch support use) to six-week
post-intervention (arch support use), (b) change in the report of feet, ankle, knee, hip,
and back pain from immediate post-intervention to six-week post-intervention; and
(c) self-reported benefits using arch supports for six weeks. One-way repeated measures ANOVA and paired-samples t test were used for analysis. The results indicated
statistically significant changes in scores for balance, functional mobility, pain, and
self-reported benefits with use of arch supports (p < .05). There was no statistically
significant change in ankle pain (p > .05).
African American Family Relationships and Diabetes: A Multigenerational
Perspective
Nancy L. Murray, Sharon King, Margaret Counts-Spriggs
Gerontology Institute, Georgia State University
Research confirms that African American older adults with chronic illnesses, such
as diabetes, rely on family members for caregiving support. Less is known about the
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role of family relationships in caregiving. This “collective case study” examines the
impact of diabetes caregiving on families who reside in multigenerational African
American households. The data, taken from a larger NIA-funded pilot study, were
collected with individual interviews and focus groups with four 3-generational, African American co-residential families, in metropolitan Atlanta. Interviews were audiotaped and transcribed verbatim. Data analysis utilized the grounded theory approach.
Findings suggest that family relationships were most affected by medication management, dietary adjustments, and changes in family routines. Both G2s (Generation 2;
the middle or 2nd generation) and G3s (Generation 3; the youngest generation) participated in caregiving. They provided mobility assistance, medication management,
and meal preparation, and monitored G1s’ (Generation 1; the first or eldest generation)
daily activities. Factors that influenced G2s’ and G3s’ support included their level
of knowledge of diabetes, the amount of available caregiving time, the caregivers’
age, and the G1s’ level of self-care. Scheduling conflicts, G1s’ dietary restrictions and
problematic relationships were barriers to support. G2s’ and G3s’ caregiving attitudes
ranged from judgmental, uncooperative, and inconsiderate, to supportive, helpful, and
empathetic. Supportive attitudes for G1s were enhanced in families where G2s or
G3s also had diabetes. This study suggests the need for a family-systems approach
to diabetes management for older adults and for more family level health disparities
research.
The New Age of Hormone Replacement Therapy
Gretchen Olds
Department of Nursing, Brenau University
Statement of problem: In the United States, an estimated 40 million women are over
the age of 50. Menopause, its process and treatment, is of great concern to patient and
provider. The issue of hormone replacement therapy (HRT) in these women is at the
forefront of medical controversy. Used since the 1930s, HRT has been commonly prescribed as a treatment for symptoms of menopause and a preventative method against
osteoporosis and cardiovascular disease. In 2002, a landmark study, the Women’s
Health Initiative, provided evidence that estrogen and progestin use can contribute
to the development of cardiovascular disease and greatly increase the risk of breast
cancer. Current research has also identified benefit in decreasing the risk of hip fracture and colorectal cancers. Fear and confusion generated by these new findings for
provider and patient has resulted in dramatic decreases in HRT use in any woman for
any reason. Literature supports that some menopausal women still demonstrate the
need for HRT for relief of vasomotor symptoms related to declining hormone levels.
The question at hand is how to provide accurate, clear information regarding risks and
benefits of HRT to providers and patients. In practice, providing accurate information
to providers will contribute to their ability to appropriately counsel and treat meno-
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pausal women regarding HRT. Providing clear information to patients empowers them
to make an informed decision in collaboration with the provider regarding HRT.
Methods: A thorough literature search was performed regarding HRT in postmenopausal women. National guidelines and current research were reviewed. The information was then synthesized, resulting in the development of two HRT guidelines:
a provider checklist and patient information sheet. Conclusion: Two guidelines were
developed to assist both providers and patients in understanding the myriad of issues
surrounding HRT. In climacteric and post-menopausal women, HRT may be safely
administered to manage symptoms associated with ovarian failure and subsequent
cessation of estrogen and progesterone. Through client education and counseling and
Nurse Practitioner following guidelines, HRT can be utilized to treat adverse symptoms of menopause and increase quality of life without significant risk of morbidity.
Vitamin D and Calcium Deficiency Accelerate Age-Related Auditory
Dysfunction in Mice with Genetic Defects in Hearing
Sohyun Park, Mary Ann Johnson
Department of Foods and Nutrition, The University of Georgia
Albert R. De Chicchis, Houssam Marseli
Department of Communication Sciences and Disorders, The University of Georgia
James F. Willott
Department of Psychology, University of South Florida
We investigated the relationship of dietary vitamin D and calcium (Ca) deficiency
with age-related hearing loss measured by auditory brainstem responses. We examined the effect of vitamin D and Ca deficiency initiated in pregnancy in BALB/c mice.
The BALB/c strain has a genetic defect causing age-related hearing loss. Beginning
at 14 days of pregnancy, mice were fed one of these purified diets during pregnancy,
lactation, and weaning: adequate in vitamin D and Ca (0.5% Ca); deficient in vitamin
D and Ca (0.2% Ca); or deficient in vitamin D and Ca (0.1% Ca). Hearing thresholds
were not different in the offspring after weaning except at 32 kHz. The rate of change
in hearing thresholds corresponded to the severity of diet. That is, the more severe the
diet the greater the rate of change in thresholds. At one week post-weaning, differences
in hearing sensitivity began to emerge at 4, 8, 24, and 32 kHz. Four weeks following
weaning, the mice receiving the adequate diet had better hearing thresholds than the
deficient in vitamin D and 0.1% Ca group at 4, 24, & 32 kHz (p < 0.05). These results
indicate that vitamin D and Ca deficiency initiated in pregnancy and maintained after
weaning may cause age-related hearing impairment in offspring and may have effects
throughout their life. Funding: USDA-NRICGP #2001-35200-10677.
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Cognitive Predictors of Independent Functional Abilities in High-Risk Older
Adults
Amie A. Peloquin*
Department of Psychology, The University of Georgia
The present study will explore the relationship between multiple domains of cognitive
processes and functional independence in community-based older adults at high risk
for loss of independence. The older adults examined for this study are each independently functioning but at high risk for nursing-home placement. These older adults
are currently participating with the Community Care Services Program (CCSP), a
Medicaid-funded program that works to meet the needs of older adults and families.
In conjunction with data collected by CCSP, this investigation proposes to use an
efficient, relatively brief 30-minute standardized neurocognitive assessment to investigate individual cognitive abilities. The Repeatable Battery for the Assessment of
Neuropsychological Status (RBANS), the Trail Making Test, and the Frontal Assessment Battery (FAB) will be administered to community-based older adults and will
assess the cognitive domains of immediate memory, language, visuospatial/constructional abilities, attention, delayed memory, and executive functioning. Participant demographics and information of basic and independent activities of daily living, emotional well being, physical health, social support, and potential caregiver information
gathered from the CCSP database, and the cognitive data gathered through this study,
will be analyzed via a multiple regression model to determine correlated predictive
variables of functional independence. The results are expected to enhance our current
understanding of critical aging variables and offer support for services that emphasize
prevention and early intervention to enable older adults to remain in their homes and
communities.
Growing Old Behind Bars: A Qualitative Review of the Aging Male Prisoner
Laura Phillips, Rebecca Allen, Daniel W. Durkin, Lucinda Roff
Center for Mental Health and Aging, The University of Alabama
Currently, there are more than 132,000 state and federal prisoners that are at least 50
years old, and the numbers are growing by 10,000 a year. Seventy older prisoners at
Alabama’s Hamilton Prison for the Aged and Infirmed were asked seven qualitative
questions using a phenomenological approach. Based on these interviews, the majority of prisoners do not experience a significant change in religious views, often stating
their views have remained the same while their attendance at services has decreased.
The relationships between prison staff and prisoners were reported by many prisoners to be “okay,” recognizing the importance of following the rules to function well
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in prison. With respect to other prisoners, most prisoners were able to identify at
least one other prisoner in whom they confide. When asked what changes prisoners
have noted in themselves, many recognized the physical changes that have occurred,
while others commented on changes in their ability to control their temper or failure
to appreciate what they had outside of prison. In closing, prisoners were asked what
they would tell younger prisoners and what they would tell their families. These two
questions elicited responses regarding staying out of trouble/not using substances,
messages seeking forgiveness, and declarations of love/a desire to be with their family again.
A Comparison of Nursing Homes’ Effectiveness in Providing Clients Activities
that Reflect Residents’ View of Pleasant Events as Expressed in the PES-NH
Sarah Ramsey, Douglas Welsh, Suzanne Meeks
Department of Psychological & Brain Sciences, University of Louisville
Depression in nursing homes has been recognized as a serious, widespread problem
that often gets overlooked because of the focus on physical healthcare. Research suggests that engaging in pleasant activities is associated with less depression or more
positive feelings, and behavioral treatments for depression focus on increasing pleasant activities. As a part of a larger study on activity and affect in nursing homes, the
purpose of this honor’s project was to evaluate the quality of activities offered in nursing homes. We hypothesized that if residents express more satisfaction with facility
activity programming, and have a higher percentage of preferred activities available,
they will be happier and less depressed. Measures include a cognitive screen, the
Pleasant Events Schedule - Nursing Home version, ratings of the each facility’s activities, the Geriatric Depression Scale, the Quality of Life Scale – AD, mood ratings,
and the Physical Self-Maintenance Scale. The goal is to include 35-40 residents. Preliminary correlations on the first 12 participants all approached significance. Activity
preference ratings, and activity participation, were correlated with both depression
(r = .66, p = .05; r = .58, p = .10), and positive affect (r = .58, p = .06; r = .58, p = .05),
providing initial support for the hypothesis. Further analyses with the complete data
set, including comparisons of activities across facilities, will also be presented. Results may be used to guide selection of activities for nursing homes.
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Elder Law: What You Need to Know
Sarah Rasalam
Institute of Gerontology, The University of Georgia
The field of elder law, dealing with issues that affect older adults, such as guardianship
and elder abuse, arose as a necessity due to the rapidly growing population of older
adults, and this cohort’s shortage of representation in legal matters. However, due to
its nature as a relatively new field, the effective practices of elder law are not widely
known. This exploratory pilot study sought to observe the extant elder law practices in
north Georgia and to evaluate them according to the guidelines provided by Assessing
Clients with Diminished Capacity and Assessment of Older Adults with Diminished
Capacity: A Handbook for Lawyers, an upcoming collaborative publication of the
American Psychological Association and the American Bar Association. A sample of
ten elder law practitioners was interviewed for this qualitative study. They discussed
difficulties associated with representing clients having diminished capacity and their
solutions to these problems. They also proffered advice to enhance their relationship
with an individual having diminished capacity. An analysis of these findings revealed
that most professionals take some, but not all, of the necessary measures when dealing
with people who have diminished capacity. This presentation will offer insight into
the field of elder law, demonstrating the duties of the attorney and the rights of the
client. Furthermore, the challenging issue of representing a client who has diminished
capacity, a condition that could compromise the attorney-client relationship, will also
be addressed. Methods to combat these issues and to improve the elder law system as
a whole will be discussed.
Is It Home Anymore? Post-discharge Adjustment and Outcomes Among Older
Rehabilitation Patients
A. M. Redwine, J. F. Watkins
Graduate Center for Gerontology, University of Kentucky
Broadly conceptualized, home is the nexus of life that embraces physical and mental
representations of control, belonging, familiarity, and satisfaction. Changes in either
the residential structure and its characteristics (i.e., the environment) or the person
in terms of physical and cognitive ability, may disrupt the sense of home and, consequently, diminish life quality. Furthermore, we argue that a diminished sense of
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home may pose a barrier to effective and timely recovery following serious injury
or disability. Our research considers the change in person-environment fit, and the
extension to a sense of home, with an examination of older rehabilitation patients
following discharge from a skilled nursing facility. This study evaluated 16 participants, ages 65 to 86, with varying disabilities, within four days of release from a
facility’s rehabilitation program, and about four weeks after returning home. Pre-test
and post-test instruments included the Philadelphia Geriatric Institute Center Moral
Scale and the Mini-Mental State Examination. A qualitative interview using a Likerttype scale assessed relocation problems and concerns. Results demonstrate that life
satisfaction and morale decline after discharge, and qualitative supplements suggest
a host of causative factors, most of which are based on differences between perceived
home, as known prior to institutionalization, and the actual lived experience following discharge.
Custody and Visitation
Kellie Rogers
Department of Nursing, North Georgia College & State University
In an age of population growth with lengthening life expectancy and the aging of the
“baby boomers,” the population of older adults is growing, and will continue to grow
at a rate greater than the other segments of the population. While society is preparing
for this older population to be in need of care, these individuals are more frequently
finding themselves as caregivers to their grandchildren. Many issues that were previously ignored or of lesser significance now take on new importance and impact in
society. Older adults now face multiple legal issues beyond traditional estate planning
and preparation of wills. Critically important issues these individuals may face relate
to their custody and visitation rights with grandchildren. These are impacted by divorce, premature death of one or both of the grandchild’s parents, or by questions of
who has custody if the parents are deemed unfit. Legal issues include: whether grandparents have a legal right to gain custody, and whether grandparents have legal rights
to visitation with their grandchildren. This poster discussion will demonstrate how
the law and the courts have dealt with these issues in the past and the direction the law
is likely to take in the future. Examples of both past and current trends of decisions in
these matters will be provided.
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Widowhood: Variability and Predictors of Resilience in Bereaving Older
Adults
Jyoti Savla*
Institute of Gerontology, The University of Georgia
Adam Davey
Polisher Research Institute, Philadelphia
Spousal death is considered to be the most catastrophic and stressful event experienced by an older adult. Although several researchers have noted that the transition
to widowhood brings about several physical, social and psychological distresses, in
the present study, we argue that the bereaved display tremendous variation in their
social and psychological adjustment to loss. We use prospective data on widowed
persons (N = 276) from the Changing Lives of Older Couples dataset who participated
at the initial interview and at least one of the three follow-up interviews that were six
months apart. Variations in the adjustment process to the transition to widowhood are
examined using growth curve analysis. Individual level (i.e., gender, age, ADLs, personality, self-esteem), dyadic level (i.e., marital quality, division of labor) and social
level (i.e., social participation, perceived social support) factors that predict the initial
adjustment to bereavement and adjustment over time are discussed. Suggestions for
bereavement intervention researchers and implications on health care policy and legislations regarding end-of-life care are made.
Poor Physical Function and Nutrition-Related Disorders Coexist in Older Adults
in Northeast Georgia Senior Centers
Tiffany Sellers, Mary Ann Johnson, Joan G. Fischer
Department of Foods and Nutrition, The University of Georgia
We examined the relationship of poor physical function with nutrition and health
complications in a random sample of congregate meal recipients in 12 senior centers
in 11 northeast Georgia counties (N = 137, mean age = 78, 75% female, 61% Caucasian, and 39% African American). Trained staff conducted the nutrition and health
assessments. Physical fitness was assessed with the Short Physical Performance Battery. There was a wide range of physical function: 18% were very low (0 to 3), 27%
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ranged from 4 to 6, 37% ranged from 7 to 9, and 18% were in the highest range (10
to 12). Low SPPB scores have been associated with future disability, nursing home
admission, and death. The lowest category of physical function (0 to 3) was associated with several nutrition problems. Compared to those with SPPB of 4 or more,
those with 3 or less were more likely to be obese (BMI > 30kg/m2: 29% vs. 55%, p <
0.05), unable to shop, cook or feed themselves (15% vs. 38%, p < 0.01), and unable to
prepare necessary healthy meals (10% vs. 33%, p < 0.01). Participants with poor physical function were three to five times more likely to have health problems that usually
require extensive and complex nutritional interventions (e.g. congestive heart failure,
renal disease, and stroke, p = 0.01 to 0.06). These findings suggest that poor physical
function may limit the ability to prepare healthy meals that are needed to manage
nutrition-related health conditions.
Cerebrovascular Risk Factors
Avani Shah
Department of Psychology, The University of Alabama
The relation between cerebrovascular risk factors (CVRFs), depressive symptoms,
and activity restriction was explored using baseline data gathered from an ongoing
study investigating the efficacy of home-delivered cognitive-behavioral therapy for
medically frail rural older adults. The Symptom Checklist-90-Revised, Health &
Health Behaviors Checklist, Fast Assessment of Physical Functioning, and the Activity Restriction Scale assessed depressive symptoms, presence of CVRFs, functional
impairment, and activity restriction, respectively. Though CVRFs were correlated
with depressive symptoms (r = .16, n = 137, p < .05), functional impairment (r = .25,
p < .05), and activity restriction (r = .29, n = 61, p < .05), analyses did not indicate
that activity restriction mediated depression. These findings differ from the results of
a previous study.
Religion and Spirituality: Do Private Beliefs of Geropsychologists Influence
Their Practice?
Michael T. E. Sliter, Aimee Harr, Karya Ottey, Natalie Staats Reiss
Department of Psychology, Hiram College
Previous research suggests that clinical psychologists report lower levels of religiosity and spirituality than the general population. This seems to indicate a mismatch
between therapists and their clients who have a strong religious/spiritual base. In particular, older adults are a group that often is associated with a religious lifestyle. The
Poster Presentations
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current study was designed to assess levels of religiosity/spirituality among clinical
geropsychologists and to determine whether these clinicians routinely assess and address religiosity/spirituality in older adults. Clinical geropsychologists completed a
demographics sheet, the NIA scale of religiosity/spirituality, and questions about assessment and treatment of religious/spiritual issues in clients. Preliminary respondents (N = 18) (age M = 35, SD = 5.92) were Caucasian. Among current participants,
8.3% considered themselves “very religious,” while 50% were “not at all religious.” In
contrast, 33% rated themselves as “very spiritual” and 25% were “not at all spiritual.”
Only 41% reported having training in spirituality, and this training was typically limited. Most (67%) asked clients about their religious beliefs, practices, and spirituality during the assessment process. Preliminary results failed to show an association
between clinician’s private religious-spiritual beliefs and whether they brought these
issues into their practice. Current results suggest that, despite low-level of self-identified religiosity and spirituality, the majority of clinical geropsychologists ask about
clients’ religious and spiritual background during assessment. Religion is a cornerstone in the lives of many older adults, and many psychotherapists recognize this,
even if religion is not important in their personal lives.
The Effects of Social Support and Religiosity on Depressive Symptoms of Older
Adults
Melissa Snarski
Department of Psychology, The University of Alabama
The current study measures intrinsic and extrinsic religiosity and social support in
relation to depression levels of older adults. Both social support that the individual received and the social support that the individual gave were measured. This study aims
to clarify inconsistencies in the literature and separates social support and religiosity
into two distinguishable constructs. Qualified participants completed questionnaires.
Results from multiple regression analyses showed that frequency of attending religious services (F = 3.22, p < .10), and giving support (F = 7.85, p < .10), accounted for
a significant amount of the variability in depressive symptoms when controlling for
health status and pleasant events.
Caregiving Among Chinese Families With An Elderly Relative
Maggie Tang
School of Social Work, The University of Alabama
Despite the large body of literature on caregivers for older relatives, few studies have
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included minority caregivers. Chinese Americans are one of the most rapidly growing
ethnic minority groups in the United States. It is important to investigate the experience of caregiving for this population. The majority of the older Chinese population
is foreign-born and most of them still maintain traditional values that emphasize the
family’s role in caring for older relatives. Of interest to many professionals is how the
unique traditional values and social support system of Chinese American caregivers
affect their perceptions of caregiving and influence their use of social and health services. This poster will review research studies on caregiving among Chinese families
with an older relative. The purpose of this review is to describe these studies and their
outcomes as a basis from which to recommend new directions for research and practice. Extant studies of Chinese American caregivers indicate that the moral imperative
of filial obligations to take care for one’s aging parents may mediate the caregiving
burden. There is a need to identify concepts and measures which are valid and reliable
for Chinese American caregivers of older relatives. It is important that social work
practitioners and policy makers understand the unique needs of Chinese American
families and provide culturally competent services to enhance the physical and mental
well being of Chinese caregivers and their families.
Influence of Gender and Income on Perceptions of Financial Planning for Health
Costs
Alicia Webb
Department of Gerontology, University of Kentucky
Compared to men, women are more likely to live in poverty in old age, which can
reduce their access to healthcare. Several studies have examined gender differences
in financial planning in old age, but few have concentrated on planning for future
health costs. The goals of the present study were to examine the influence of gender
and income on individuals’ perceptions of the importance of being prepared for future health cost and their attitudes toward purchasing health insurance. Participants
included 249 men (n = 117) and women (n = 132) ages 55-71 years (M = 63.1721; SD =
4.61112) who completed a survey on healthcare planning and provided demographic
information. Data were analyzed using a 2 (gender) x 2 (income) factorial ANOVA.
Findings indicated that compared to men, women expressed more concern about future healthcare costs. They also placed more importance on (a) being prepared for
healthcare expenses, and (b) the benefits of health insurance over the costs. It would
seem that because women are more concerned about future health costs, that they
would be willing to pay more for insurance than men; however, this was not the case.
Income was associated with the amount individuals were willing to pay for health
insurance. This study indicates that gender may be a key factor in individuals’ level of
preparation for future healthcare costs. Future studies should continue to expand on
these findings so that we will have a broader understanding of how men and women
make decisions regarding healthcare insurance.
Institute of Gerontology
College of Public Health
The University of Georgia
255 E. Hancock Ave.
Athens, GA 30602-5775
Phone: (706) 425-3222
Fax: (706) 425-3221
http://www.geron.uga.edu
Technical Report# UGAIG-05-002