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This study characterized emotional connections between largely female caregivers and female care recipients with dementia living in nursing homes with the research question: How does interpersonal communication between family caregivers and older adults with dementia convey enacted emotional support? Ten dyads (8 with at least one female) of regularly-involved family caregivers (7 female; 3 male) and their relatives with dementia (5 female; 5 male) were videotaped. Qualitatively, three themes emerged: 1) distinct conversational topics, 2) shared physical proximity and silence, and 3) catalysts for natural interaction. These findings may help improve the quality of life of these predominantly female dyads.

Mobility and technology can facilitate in-person and virtual social participation to help reduce social isolation, but issues exist regarding older adults’ access, feasibility, and motivation to use various forms of mobility and technology. This qualitative study explores how a diverse group of low-income, urban-living older adults use mobility and technology for social participation. We conducted six focus groups ( N = 48), two each in English, Spanish, and Korean at a Los Angeles senior center. Three major themes emerged from thematic analysis: using technology for mobility; links between mobility and social participation; and technology-mediated social participation. Cost, perceived safety, (dis)ability, and support from family and friends were related to mobility and technology use. This study demonstrates the range of mobility and technology uses among older adults and associated barriers. The findings can help establish a pre-COVID-19 baseline on how to make mobility and technology more accessible for older adults at risk of isolation.

Major gaps exist in the literature regarding the link between open space and physical activity promotion for older adults. This study conducted a systematic review on older adults, open space, and physical activity to identify their needs and preferences in and near parks. We identified 48 peer-reviewed journal articles. All articles focused on older adults but not necessarily exclusively. Most studies were descriptive and correlational. Findings suggest that older adults have specific open space and physical activity needs in and near parks that partly overlap with younger people. Framed by the biopsychosocial framework, open space and physical activity in and near parks can benefit older adults’ physical health and psychologically well-being to stay socially engaged. Framed within the person–environment and life span perspectives, open space and physical activity in and near parks can facilitate an optimum fit between older adults and their environment as they continue to develop over time.

Respite care is an important service to address caregivers' stress and fatigue when caring for a person with dementia (PWD). YouthCare is a non-medical, at-home, intergenerational respite care program that partners trained student volunteers with PWDs. The Family Caregiver Survey was created and distributed to caregivers of PWDs in Los Angeles to better understand interactions with the community and its caregiver services. The survey assesses caregivers’ demographics, daily activities, mental health, and the type of respite support needed. The survey findings (n=47) show that 53.2% of caregivers are 54 and older and 83% females. 40.4% of the caregivers listened to the radio primarily in the morning while 61.7% watched television in the afternoon to evening time. For transportation of PWDs to and from destinations, 78.3% of caregivers reported using their own vehicles. In regards to their mental health, 61.7% of the caregivers stated that they felt tired and unmotivated to complete daily activities. When asked why they sought respite services, 40% stated that they were overwhelmed by the responsibilities in addition to their own work. The groups that primarily support caregivers are family and professional respite services. Findings indicate that caregivers are most likely to trust resource recommendations from family and friends. Similar surveys should be administered in other cities and in rural locations to improve the generalizability of our findings.

The researchers conducted a communication training intervention for certified nursing assistants (CNAs). The intervention aimed at improving CNAs' therapeutic techniques for relating to agitated residents during care. This study focused on an in-depth evaluation of mealtime interactions using videos. Sixteen CNAs and 16 residents living with dementia from one long-term care facility were videotaped during mealtime interactions before and after a therapeutic communication training program. Mixed-effect Poisson regression revealed no effect of the intervention as a whole on residents' refusals, but the intervention did improve CNAs' communication. Additional analyses using specific CNAs' therapeutic communication behaviors indicated a significant negative association with refusals at post-test but not pretest. The findings suggest some communication mechanisms for how the intervention positively influenced residents' refusals.

Problem, research strategy, and findings: Parks provide important physiological and psychological benefi ts to seniors, improving their quality of life; they are particularly important for low-income, inner-city seniors who lack access to open and green space. However, seniors do not often use parks partly because park design and programming are not responsive to their diverse needs and values. To identify what low-income, inner-city seniors seek and value in neighborhood parks, and to provide guidance to planners on how to better design senior-friendly parks, we conducted a literature review and held focus groups with 39 low-income, ethnically diverse seniors in an inner-city neighborhood in Los Angeles (CA). We asked these seniors about their preferences as well as the challenges and barriers they encounter in using neighborhood parks. Seniors report many impediments to park use; they are not provided appropriate programming that allows opportunities for socializing, safety, and security within the park...

To explore how access to transportation and technology/social media influence social connectivity among an ethnically diverse group of vulnerable low-income older adults, six focus groups were conducted (N=48) in English, Spanish, and Korean at a senior services agency. Qualitative thematic analyses revealed overarching themes that fit within the World Health Organization’s Age-Friendly Domains of Livability. The sub-theme “barriers and facilitators to accessibility” ran through each of the overarching themes, demonstrating how specific factors of the built, social, and community health environments intersect to promote or hinder social connection. Although transportation and technology uses were linked to social engagement, challenges with the built environment and limited financial resources hindered older adults’ abilities to remain engaged in their communities, both in-person and electronically. Age-Friendly initiatives must continue to consider the community-specific barriers and facilitators for older adults to remain physically and socially connected to the community.

Older adults living with Alzheimer's disease (AD) experience more of the types of accidents and injuries prevalent among older adults. Relatively few studies specifically on safety risks have included older adults of color and tested interventions. This pilot study tested the feasibility and evaluability of educating Hispanic and African American caregivers of patients living with AD about reducing safety risks in their homes.This outpatient memory clinic-based intervention study included a pre-/post-test survey design with two nonequivalent groups and predominately serves Hispanic and African Americans. Of 60 eligible caregivers, 67% participated in a tailored, safety training class with an optional follow-up call.The results indicate a reduction in some safety risks compared to baseline and/or a no intervention group, respectively, including leaving patients at home alone part-time (p.01 and p.01), getting lost (p.05 and p.05), going outdoors alone less often (p.05 and p.01), and giving themselves medicine (p.05 and p.01). At post-test, 47 clinically significant instances occurred, in which caregivers who participated in the intervention self-reported patients living with AD to be 'completely safe' in one or more of the safety risk items compared to 8 instances among those who did not.This pilot pre/post design with non-equivalent groups study needs refinement in a future randomized control trial. Despite limitations, this pilot study demonstrates the first feasible and evaluable intervention with both statistically and clinically significant results that suggest potential for reducing safety risks among at-risk minority patients living with AD in future research.

In the United States, Alzheimer’s Disease represents the most common type of dementia, accounting for 60 to 80 percent of cases with a prevalence of at least 5 million over the age of 65. Internationally, over 44 million individuals have dementia with predictions that this number will triple by 2050.

Filial piety or China’s tradition of taking care of one’s aging parents continues to evolve as evidenced by a growth in nursing home residents in Shanghai. The reason for this increase in institutional care remains unclear and calls for an exploration on how these elders and their children decided to institutionalize. More specifically, understanding the communication dynamics between generations when they decide to institutionalize would provide insights into whether and how the decision is mutual. Using a phenomenological approach, this study draws on power relations to examine intergenerational communication dynamics during the decision-making process around institutionalization. Twelve matched dyads of elderly residents and their children participated in face-to-face, in-depth interviews in a government-sponsored nursing home in Shanghai (N = 24). Both generations reported how they proposed to institutionalize, initiated intergenerational communication, and finalized the decision, as well as how they reacted to the other generation’s stance during the decision-making process. The findings reveal that more children made the decision for their elderly parents (decision-making power) than did their frail parents for themselves. Adult children’s stronger power evoked their elderly parents’ ambivalent feelings of filial piety. Older adults were simultaneously disappointed about and obliged to their children’s decision to institutionalize. Furthermore, in the power trajectory, one difference may exist that the children’s end matches up with tangible caregiving resources, whereas the elders’ stay at the emotional end. The ongoing aging of Chinese baby boomers requires future research on longitudinal caregiving trajectories between generations. This study also illuminates the needs for comparisons with caregiving expectations between generations to inform the development of long-term care infrastructure in urban China.

Individualizing care in nursing homes can be difficult and complex. The purpose of this study is to characterize the meaning of and experiences with individualized care from the perspectives of both nursing aides and nursing-home residents. Eight focus groups of nursing aides (N =17) and residents (N=15) from two nursing homes generated four dialectical themes related to communication strategies: (a) getting to know versus maintaining a protective distance, (b) mutual respect versus disrespect, (c) avoiding versus addressing conflict, and (d) equity versus perceived favoritism. These findings suggest dialectics in how interpersonal communication affects individualized care from the perspectives of both nursing aides and residents.

Why do some older veterans visit the emergency room (ER) frequently? This study expands an existing decision-making model that describes how ER users recognize symptoms of a health problem, decide to seek medical care for the health problem, and decide to visit the ER specifically for the medical care. The focus of this inquiry is the role of older veterans’ social support networks in decisions to visit the ER. Data were collected through in-depth, semistructured, in-person interviews with 30 community-dwelling, high-functioning veterans aged 65 years and older who had visited the ER frequently (3 or more times) in the previous year. We found that the older veteran study participants, regardless of the availability of social support, preferred to make decisions independently, relied heavily on formal social support network members, and received various types of assistance to visit the ER from informal social support networks.

Objective The purpose of this review is to critique contemporary experimental research and to recommend future directions for research interventions on nursing aides’ therapeutic communication with older adults who have cognitive impairment and/or dementia in institutional long-term care settings. Methods This literature review covers 13 journal articles (1999–2006) and focuses on the strengths and weaknesses of experimental research interventions to improve nursing aides’ therapeutic communication with older adults who have cognitive impairment and/or dementia in long-term care settings. Results Based on this review, recommendations for improved experimental designs include a minimum of two groups with one being a control and randomization of subjects at the care unit level, an average 3–5 h of total training, a minimum of a 6-month total evaluation period, and objective outcomes relevant to both nursing aides and residents. Findings from studies in this review indicate that the following therapeutic communication techniques can be taught and can benefit staffs and older adults’ quality of life: verbal and non-verbal communication behaviors including open-ended questions, positive statements, eye contact, affective touch, and smiling. Conclusions Some evidence exists to support that nursing aides can improve their therapeutic communication during care. Practice Implications Nursing aides need not only more training in therapeutic communication but also ongoing, dedicated supervision in psychosocial aspects of care.

Purpose: The purpose of this article is to explore how kin and nonkin social support networks influence health behaviors among older Samoan women. Method: Using a cross-sectional survey design, 290 Samoan women who were age 50 years and older were interviewed. Using separate logistic regressions, each health behavior was regressed on age and kin and nonkin social support networks after controlling for background characteristics and health status. Results: In multivariate analyses, higher scores on kin increased the likelihood of never salting food, getting screened for diabetes in the past year, and having had a mammogram in the past 2 years, whereas higher scores on nonkin increased the likelihood of exercising at all and ever trying to lose weight. Discussion: Kin networks positively affect mostly chronic disease-related health behaviors, whereas nonkin networks positively affect mostly lifestyle-related health behaviors.

This cross-sectional study assessed undergraduate attitudes toward older adults and attitude endurance 3 to 18 months after aging coursework. Survey respondents included 349 students who took an aging elective and 430 comparison students. Aging-elective students indicated more positive attitudes than comparison students. Attitudes did not vary across 3 groups staggered by time elapsed from completing the course until testing (3 to 18 months). 4 variables accounted for the variance in attitudes toward elders at a statistically significant level: majoring in biology, having frequent or occasional contact with unrelated older adults, taking an aging course, and post-course knowledge of aging.

Purpose The objective of this work was to determine if nursing homes that score differently on prevalence of depression, according to the Minimum Data Set (MDS) quality indicator, also provide different processes of care related to depression. Design and methods A cross-sectional study with 396 long-term residents in 14 skilled nursing facilities was conducted: 10 homes in the lower (25th percentile: low prevalence 0-2%) quartile and 4 homes in the upper (75th percentile: high prevalence 12-14%) quartile on the MDS depression quality indicator. Ten care processes related to depression were defined and operationalized into clinical indicators. Measurement of nursing home staff implementation of each care process and the assessment of depressive symptoms were conducted by trained research staff during 3 consecutive 12-hr days (7 a.m. to 7 p.m.), which included resident interviews (Geriatric Depression Scale), direct observations, and medical record review using standardized protocols. Results The prevalence of depressive symptoms according to independent assessments was significantly higher than prevalence based on the MDS quality indicator and comparable between homes reporting low versus high rates of depression (46% and 41%, respectively). Documentation of depressive symptoms was significantly more common in homes reporting a high prevalence rate; however, documentation of symptoms on the MDS did not result in better treatment or management of depression according to any care-process measure. Psychosocial prevention and intervention efforts, such as resident participation in organized social group activities, were not widely used within either group of homes. Implications The MDS depression quality indicator underestimates the prevalence of depressive symptoms in all homes but, in particular, among those reporting low or nonexistent rates. The indicator may be more reflective of measurement processes related to detection of symptoms than of prevention, intervention, or management of depression outcomes. A depression quality indicator should not be eliminated from MDS reports because of the importance and prevalence of the condition. However, efforts to improve nursing home staff detection of depressive symptoms should be initiated prior to the use of any MDS-based depression indicator for improvement purposes. Homes that report a low prevalence of depression according to the nationally publicized MDS quality indicator should not be regarded as providing better care.

Background: Excessive time in bed has negative effects on both physical conditioning and functioning. There are no data or practice guidelines relevant to how nurses should manage the in-bed times of nursing home residents, although all nursing homes receive a bedfast prevalence quality indicator report generated from the Minimum Data Set. Objectives: To compare nursing homes that score in the upper and lower quartiles on the Minimum Data Set bedfast prevalence quality indicator for proportion of bedfast residents, activity and mobility nursing care, and amount of time all residents spend in bed, and to evaluate whether residents who spend more time in bed are different from those who spend less time in bed according to functional measures. Methods: A cohort design used medical records, resident interviews, and direct observation data to compare 15 nursing homes (n = 451 residents) on the proportion of bedfast residents, the amount of time residents spent in bed, the frequency of activity, and the scores on six activity and mobility care process indicators. Results: Significant differences were found between upper (i.e., higher prevalence of bedfast residents) and lower quartile nursing homes in the proportion of time residents were observed in bed (43% vs. 34%, respectively; p = .007), and in the proportion of residents who spent more than 22 hours in bed per day (18% vs. 8%, respectively; p = .002). All nursing homes underestimated the number of bedfast residents. The residents of upper quartile homes showed more activity episodes and reported receiving more walking assistance than the residents of lower quartile homes. Discussion: Minimum Data Set bedfast quality indicator identified nursing homes in which residents spent more time in bed, but did not reflect differences in activity and mobility care. In fact, upper quartile homes provided more activity and mobility care than lower quartile homes. Across all the nursing homes, most of the residents spent at least 17 hours a day in bed. Further study of activity and mobility care and bedfast outcomes in nursing homes is needed, and nurses need to note the amount of time nursing home residents spend in bed.

Objectives: To examine the effect of staffing level on time observed in bed during the daytime in nursing home (NH) residents. Design: Descriptive, cross-sectional study. Setting: Thirty-four southern California NHs. Participants: A total of 882 NH residents: 837 had hourly observation data, 777 had mealtime observations, 837 completed interviews, and 817 completed a physical performance test. Measurements: Cross-sectional data collected from participants at each NH site included direct observations (hourly and mealtime), resident interviews, medical record review, and physical performance tests. Results: In multivariate analyses, staffing level remained the strongest predictor of time observed in bed after controlling for resident functional measures (odds ratio=4.89; P=.042). Residents observed in bed during the daytime in more than 50% of hourly observations were observed also to experience increased daytime sleeping (P

In 1995, the John A. Hartford Foundation launched an initiative to strengthen geriatric interdisciplinary team training (GITT) for advanced practice nursing and masters-level social work students and residents in internal medicine and family practice. As part of the national evaluation of the initiative, case-study and cross-case designs were employed using quantitative and qualitative data to examine the influence of cultures, regulations, and attitudes of individual disciplines on interdisciplinary training efforts at the first eight GITT programs. This evaluation found that attitudinal and cultural traditions of the different health professions faculty and students (disciplinary split) remain as important obstacles to creating an optimal interdisciplinary team-training experience. In general, physician trainees participated least enthusiastically in GITT. In part, this lower level of enthusiasm may have been the result of inconsistent medicine faculty support of the program. At all but one program, physician trainees also had shorter GITT training experiences than other disciplines. In addition, the disparity in level of training by discipline of GITT participants may have contributed to attitudinal barriers to interdisciplinary training. Discipline-specific regulatory and accreditation barriers also impede interdisciplinary training. Nevertheless, GITT experiences at some clinical sites, especially home visits, appeared to promote interdisciplinary training. Some barriers to creating and implementing GITT programs may be best approached at the level of accrediting agencies and certifying organizations. Others will require local and national efforts of leaders in the different disciplines to model and support good team care.

Objectives: To identify predictors of varying levels of nonadherence to mammography screening in older women. Design: Cross-sectional survey. Setting: Sixty community-based sites where seniors gather. Participants: Consecutive volunteer sample of 499 women aged 60 to 84 who had not received a mammogram within the previous year. Measurements: Three levels of nonadherence (never had a mammogram (never), mammogram more than 2 years before (lapsed), and mammogram in the past 1 to 2 years (due/reference group)). These were based on a Transtheoretical Model and incorporated into the Adherence Model. Bivariate and multivariate multinomial logistic regression analysis was used for variables obtained. Results: Two risk factors, having difficulty getting to a facility and not intending to ask a health provider for a mammogram, were predictive of the never and lapsed levels. Distinct risk factors for being in the never compared with the due level of nonadherence included being concerned about pain, not being enrolled in a health maintenance organization, not getting preventive checkups, and being only somewhat (versus very) likely to ask a physician for mammogram. In contrast, distinct risk factors for the lapsed compared with the due level of nonadherence included perceiving that no friends have routine mammograms and not having a provider referral. Conclusion: Some risk factors for not being up to date with mammography vary by the level of nonadherence. Interventions should be individualized to women's level of nonadherence and include common core strategies that encourage women to ask for a mammogram and to lessen the difficulty of getting to a screening facility.

Purpose: This study investigated whether the use of restraining devices and related measures of care quality are different in nursing homes that score in the upper and lower quartiles on the Minimum Data Set (MDS) ‘‘prevalence of restraint’’ quality indicator, which assesses daily use of restraining devices when residents are out of bed. Design and Methods: The study was a cross-sectional study, with 413 residents in 14 nursing facilities. Eight homes scored in the lower quartile (25th percentile; low prevalence, 0– 5%) on the MDS restraint prevalence quality indicator, and six homes scored in the upper quartile (75th percentile; high prevalence, 28–48%). Eight care processes related to the management of restraints and gait and balance problems were defined and operationalized into clinical indicators. Research staff conducted direct observations during three 12-hr days (7 a.m.–7 p.m.) to determine the prevalence of restraining devices and identify resident and staff behaviors that may be affected by restraint use. Results: Residents in high-restraint homes were in bed during the day on more observations than residents in low-restraint homes (44% vs. 33%; p , .001), were more frequently observed with bed rails in use (74% of residents vs. 64% of residents; p , .03), and received less feeding assistance during meals (2.7 min vs. 4.1 min; p , .001). There were no differences between homes in the use of out-of-bed restraints, nor were there any differences on any care process measure related to the management of restraints, gait and balance problems, or measures of physical or social activity. Implications: A home’s score on the MDSgenerated prevalence of restraint quality indicator was not associated with differences in the use of restraints, physical activity, or any care process measure when residents were out of bed. However, there were differences in the use of in-bed restraining devices, and residents in high-restraint homes were in bed more often during the day. These differences were associated with poor feeding assistance and reflect important differences in quality of care between homes, even though these differences are not what the restraint prevalence quality indicator purports to measure. Methods to monitor and improve the quality of care related to exercise, in-bed times, and resident freedom of movement are discussed.

Objectives: To determine whether nursing homes (NHs) that score differently on prevalence of weight loss, according to a Minimum Data Set (MDS) quality indicator, also provide different processes of care related to weight loss. Design: Cross-sectional. Setting: Sixteen skilled nursing facilities: 11 NHs in the lower (25th percentile—low prevalence) quartile and five NHs in the upper (75th percentile—high prevalence) quartile on the MDS weight-loss quality indicator. Participants: Four hundred long-term residents. Measurements: Sixteen care processes related to weight loss were defined and operationalized into clinical indicators. Trained research staff conducted measurement of NH staff implementation of each care process during assessments on three consecutive 12-hour days (7 a.m. to 7 p.m.), which included direct observations during meals, resident interviews, and medical record abstraction using standardized protocols. Results: The prevalence of weight loss was significantly higher in the participants in the upper quartile NHs than in participants in the lower quartile NHs based on MDS and monthly weight data documented in the medical record. NHs with a higher prevalence of weight loss had a sig-nificantly larger proportion of residents with risk factors for weight loss, namely low oral food and fluid intake. There were few significant differences on care process measures between low- and high-weight-loss NHs. Staff in low-weight-loss NHs consistently provided verbal prompting and social interaction during meals to a greater proportion of residents, including those most at risk for weight loss. Conclusion: The MDS weight-loss quality indicator reflects differences in the prevalence of weight loss between NHs. NHs with a lower prevalence of weight loss have fewer residents at risk for weight loss and staff who provide verbal prompting and social interaction to more residents during meals, but the adequacy and quality of feeding assistance care needs improvement in all NHs.

Objectives: To determine whether nursing homes (NHs) that score in the extreme quartiles of pressure ulcer (PU) prevalence as reported on the Minimum Data Set (MDS) PU quality indicator provide different PU care. Design: Descriptive, cohort. Setting: Sixteen NHs. Participants: Three hundred twenty-nine NH residents at risk for PU development as determined by the PU Resident Assessment Protocol of the MDS. Measurements: Sixteen care process quality indicators (10 specific to PU care processes, five related to nutrition, and one related to incontinence management) were scored using medical record data, direct human observation, interviews, and data from wireless thigh movement monitors. Results: There were no differences between homes with low- and high-PU prevalence rates reported on the MDS PU quality indicator on most care processes. NHs with high PU prevalence rates used pressure-reduction surfaces more frequently and were better at documentation of four wound characteristics when PUs were present. No measure of PU care processes was better in low-PU NHs. Neither low- nor high-PU prevalence NHs routinely repositioned residents every 2 hours, even though 2-hour repositioning was documented in the medical record for nearly all residents. Conclusion: The assumption that homes with fewer PUs and thus low PU prevalence according to the MDS PU quality indicator are providing better PU care was not supported in this sample. NHs that scored low on the MDS PU quality indicator did not provide significantly better care than NHs that scored high. All NHs could improve PU prevention, as evidenced by the poor performance on prevention care processes by low- and high-PU NHs. The MDS PU quality indicator is not a useful measure of the quality of PU care in NHs and can be misleading if not presented with an explanation of the meaning of the indicator.

Objectives. The purpose of this study was to examine long-term trajectories of visits to nursing homes by family caregivers to persons suffering from dementia. Methods. The data were obtained from a 5-year longitudinal study of family caregiving. This analysis used a subsample of caregivers who moved their relatives from home to a nursing home ( n 5 210). The frequency (times per week) and length (hours per week) of visits for up to 5 years after placement were examined in relation to select caregiver and care-recipient characteristics. A semiparametric, group-based method using a latent class mixture model was used to identify distinctive trajectories over time. Results. The majority of caregivers maintained the frequency and length of their visits for extended periods of time. Five distinct patterns for frequency and three patterns for length were identified. Being a spouse, lower education, a close past relationship, a strong sentiment against placement, and living close to the facility predicted membership in groups visiting frequently and for longer times. Caregiver characteristics were more strongly associated with frequency, whereas care-recipient characteristics were related to length. Discussion. To a large extent, family visits to nursing home residents with dementia become established in the period immediately after relocation, which means that efforts to enhance continued family involvement should commence at the time of admission. HE contemporary increase in the number of elderly persons has been accompanied by an increase in the number of persons afflicted by Alzheimer’s disease (AD) or other forms of dementia, a segment of the population with substantial need for long-term care. In 1997, an estimated 2.3 million persons in the United States were afflicted with AD, and this figure is projected to almost quadruple in the next 50 years, largely because of the demographic increase of the “old-old” population (Brookmeyer, Gray, & Kawas, 1998). The total cost in the United States for Alzheimer care was estimated at $67.3 billion in 1991 (Ernst & Hay, 1994). The care of elderly persons with dementia has become an important social issue in terms of health care costs and the well-being of older persons and their family members. Family members play a significant role in caring for elderly persons, including those who suffer from dementia. Family constitutes 72% of paid and unpaid caregivers for elderly persons with activity limitations, with adult children accounting for the largest segment (National Academy on an Aging Society, 2000). The recognition that this care is not a “cost-free” alternative to institutional care has generated a substantial accumulation of research, but most studies focus on caregiving in the home, limiting our knowledge about caregiving to those living in institutions. This oversight has far-reaching consequences because many elderly people are eventually institutionalized because of their progressive degenerative illness. In particular, those who suffer from dementia have a relatively high rate of institutionalization and having dementia increases the risk of institutional

Objective This article addresses the question of biological pathways through which social integration and support may affect morbidity and mortality risks. A new concept of cumulative biological risk, allostatic load, is used to test the hypothesis that social experiences affect a range of biological systems. Data from two community-based cohorts are examined to evaluate the consistency of findings across two different age groups. Methods One cohort included older adults aged 70 to 79 years (N = 765); the other cohort included persons aged 58 to 59 years (N = 106). Allostatic load was assessed using identical protocols in the two cohorts. Measures of social experience were similar but not identical, reflecting levels of social integration and support for the older cohort vs. childhood and adult experiences of loving/caring relationships with parents and spouse for the younger cohort. Gender-specific analyses were examined to evaluate possible gender differences in patterns of association. Results In the younger cohort, positive cumulative relationship experiences were associated with lower allostatic load for men and women. In the older cohort, men who were more socially integrated and those reporting more frequent emotional support from others had lower allostatic load scores; similar but nonsignificant associations were seen for women. Conclusions Evidence from two cohorts provides support for the hypothesis that positive social experiences are associated with lower allostatic load. These findings are consistent with the hypothesis that social experiences affect a range of biological systems, resulting in cumulative differences in risks that in turn may affect a range of health outcomes.

Long-term care policy has evolved with little attention to racial differences in the need for and use of services. Using 1987 National Medical Expenditure Survey data on nursing home care, formal in-home personal care, and informal-only help, a model was created to show how different races would use each type of care if: (1) a universal home-care benefit was established, (2) existing Medicaid home-care benefits were ended, or (3) the income level for Medicaid eligibility was substantially reduced. Expanded community care benefits would primarily serve severely disabled older whites. Reductions in long-term care benefits or eligibility would disproportionately impede access to long-term care for severely disabled older African-Americans. These differences indicate that race must be taken into account in long-term care policy initiatives.

Older adults in long-term care facilities have few opportunities for emotionally meaningful social interactions with noninstitutional social ties; yet having such relationships is a basic human need that affects well-being. Among institutional social ties, affective communication can enhance relationships between residents and nurse aides, who provide most of their care. This naturalistic study identifies types and examples of nurse aide-initiated communication with long-term care residents during mealtime assistance in the context of residents' responses. Verbal and nonverbal communication from videos of nurse aides and residents in two skilled nursing facilities (n = 17) and an assisted living facility (n = 6) were transcribed. The transcripts were coded and the data were organized into categories using grounded theory methods. Although substantial content emphasized instrumental communication (i.e., prompts to eat and/or drink), 4 types of affective communication initiated by nurse aides emerged: "personal conversation," "addressing the resident," "checking in," and "emotional support/praise." These results suggest that affective verbal communication needs further development in terms of scope and depth to optimize residents' well-being. The specific examples of nurse aides' affective verbal communication with residents from these findings can be incorporated and expanded on in nurse aide training programs to improve the way nurse aides relate to residents during care provision.

Objectives. This study’s objective was to refine a method for coding nursing home (NH) residents’ comments about their perceptions of care into unmet needs specific to the manner and frequency of care delivery. Methods. NH residents (N ¼ 69) were interviewed with both closed-ended (i.e., forced-choice) and open-ended (i.e., residents’ own words) questions about their perceptions of care across eight care domains. Unmet needs included comments indicating that residents desired a change in staff- and non-staff-related care. Staff-related unmet needs were further coded into unmet emotional support (i.e., emotional support or manner of care delivery) and instrumental (i.e., instrumental support or frequency of care) needs. Results. Of 66 residents who commented, 66% expressed at least one unmet need across eight care domains. Among these 44 residents, 52% and 84% had unmet emotional support and instrumental support needs, respectively (j ¼ .68 and .92). An additional 18% expressed both unmet emotional support and instrumental support needs. Discussion. The refined method offers a systematic way to code residents’ comments about their care into unmet needs related to the manner and frequency of care delivery. The findings have direct implications for the identification of care areas in need of improvement from the resident’s perspective and the evaluation of improvement efforts.

To examine the effect of staffing level on time observed in bed during the daytime in nursing home (NH) residents.Descriptive, cross-sectional study.Thirty-four southern California NHs.A total of 882 NH residents: 837 had hourly observation data, 777 had mealtime observations, 837 completed interviews, and 817 completed a physical performance test.Cross-sectional data collected from participants at each NH site included direct observations (hourly and mealtime), resident interviews, medical record review, and physical performance tests.In multivariate analyses, staffing level remained the strongest predictor of time observed in bed after controlling for resident functional measures (odds ratio=4.89; P=.042). Residents observed in bed during the daytime in more than 50% of hourly observations were observed also to experience increased daytime sleeping (P.001) and less social engagement (P=.026) and consumed less food and fluids during mealtimes than those observed in bed in less than 50% of observations, after adjusting for resident function (P.001).In this sample of NHs, resident functional measures and NH staffing level predicted observed time in bed according to hourly observations, with staffing level the most powerful predictor. Neither of these predictors justifies the excessive in-bed times observed in this study. Staff care practices relevant to encouraging residents to be out of bed and resident preferences for being in bed should be examined and improved. Practice recommendations regarding in-bed time should be considered, and further research should seek to inform the development of such recommendations.

In 1995, the John A. Hartford Foundation launched an initiative to strengthen geriatric interdisciplinary team training (GITT) for advanced practice nursing and masters-level social work students and residents in internal medicine and family practice. As part of the national evaluation of the initiative, case-study and cross-case designs were employed using quantitative and qualitative data to examine the influence of cultures, regulations, and attitudes of individual disciplines on interdisciplinary training efforts at the first eight GITT programs. This evaluation found that attitudinal and cultural traditions of the different health professions faculty and students (disciplinary split) remain as important obstacles to creating an optimal interdisciplinary team-training experience. In general, physician trainees participated least enthusiastically in GITT. In part, this lower level of enthusiasm may have been the result of inconsistent medicine faculty support of the program. At all but one program, physician trainees also had shorter GITT training experiences than other disciplines. In addition, the disparity in level of training by discipline of GITT participants may have contributed to attitudinal barriers to interdisciplinary training. Discipline-specific regulatory and accreditation barriers also impede interdisciplinary training. Nevertheless, GITT experiences at some clinical sites, especially home visits, appeared to promote interdisciplinary training. Some barriers to creating and implementing GITT programs may be best approached at the level of accrediting agencies and certifying organizations. Others will require local and national efforts of leaders in the different disciplines to model and support good team care.

Minority migrant populations, such as older Samoan women, are likely to underuse preventive health services, including mammography screening. The purpose of this paper is to explore how informal (lay peers from churches) and formal (health care providers) health communication networks influence mammography screening use among older Samoan women. To do so, we apply diffusion of innovation theory and network analysis to understand how interpersonal networks may affect mammography use in this urban-dwelling, migrant population. The data come from a survey of 260 Samoan women, aged 50 years or older, who attended 39 randomly sampled Samoan churches in Los Angeles County (USA) between 1996 and 1997. Retrospective data, based over a 20-year period from this sample's year of first use of mammography screening, suggest that interpersonal networks may have accounted for the dramatic increase in the rate of adoption within the past 5 years of the survey. Using this information, we categorized women into mutually exclusive stages of mammography use and regressed these stages of mammography use on formal (had a provider referral) and informal (level of connectedness with peers in churches) health communication networks. The results indicated that being well-connected within women's informal, church-based health communication networks increased the likelihood of being in the decision (planned to have) and implementation and confirmation (had a recent mammogram) stages, but having a provider referral for a mammogram (formal networks) only increased the likelihood of being in the latter stages compared to women in the knowledge and persuasion stages. Formal and informal health communication networks influence recent use of mammography screening, but informal networks, in and of themselves, are also influential on future intention to use mammography screening.

Purpose: This paper compares three interview methodologies to assess nursing home (NH) residents’ unmet needs with regard to activity of daily living (ADL) care. Design and Methods: The study was a survey of 70 residents across seven ADL care domains. The three types of interview methods included: (a) direct satisfaction questions about ADL care, (b) questions that compared residents’ preferences about ADL care frequency or occurrence to perceptions of the ADL care delivered (discrepancy measure), and (c) open-ended questions that asked what residents wanted changed about ADL care. Results: Estimates of the proportion of residents with unmet needs were significantly higher with the discrepancy and openended measures as compared to the direct satisfaction measures across most ADL care domains (McNemar’s Test; p � .05‐ p � .01). Implications: The analysis of residents’ responses to open-ended questions produced the most useful information for individualizing aspects of technical care and assessing the interpersonal quality of care, whereas the discrepancy questions elicited specific information useful for changing the frequency or occurrence of ADL care. Interview methodologies that directly ask residents questions about satisfaction with ADL care are the least useful for designing improvement interventions.

We examine the use of nursing homes, formal personal care, informal Activities of Daily Living (ADL) assistance, and no care to identify racial differences in their use. Using the 1987 National Medical Expenditure Survey of both nursing homes and the community, multinominal logistic regressions controlled for predisposing, enabling, and need variables as well as other types of service use. Additional state-level variables make few changes in race/ethnicity parameters, indicating that race/ethnicity are not simply proxies for state-level variables. Older African Americans are less likely to use nursing homes than similar whites, with the lower institutionalization replaced by a higher use of paid home care, informal-only care, and no care. This suggests that formal in-home community care is not fully compensating for the racial differences in nursing home use. Persistent effects of race/ethnicity could be the result of culture, class, and/or discrimination that may impair equitable access to services.

OBJECTIVES. The purpose of this study was to compare the national prevalences and predictors of paid in-home functional assistance among disabled Latino and non-Latino elderly people who receive such assistance. METHODS. Data were derived from the 1988 wave of the National Center for Health Statistics Longitudinal Study on Aging and the 1988 Commonwealth Fund Commission Survey of Elderly Hispanics. Logistic regression was used to model paid care use and to calculate estimated probabilities of such use. RESULTS. Among Latino and non-Latino Whites 74 years of age and older who received functional assistance, similar proportions used paid assistance. Predictors of paid care coincided with established models for non-Latino Whites only. Disabled Latinos had a lower estimated probability of using paid assistance when they were highly disabled and socially isolated but had a higher estimated probability when their children lived nearby. CONCLUSIONS. The effects of disability and social support differ among non-Latino White and Latino elderly people. Latino elderly people with high anticipated needs obtain less paid assistance than similar non-Latino Whites. In addition to a reduction in financial barriers, improving access to long-term care services requires addressing this diversity in service use patterns.

Objectives. This article examines the impact of nursing home admission on mortality among persons with dementia, comparing social selection and social causation explanations of excess deaths occurring immediately after relocation. Methods. Data from a multiwave panel survey of caregivers to persons with Alzheimer’s Disease ( N 5 555) are analyzed with proportional hazard models of time from illness onset to death of the care recipient and, for those admitted to a nursing home ( N 5 272), time from admission until death ( N 5 272). Results. Relocation is associated with a two-fold increase in mortality risk net of health status. Social selection effects were found for poor health, advanced age, being male, and being White. Patients admitted for reasons other than poor health also experienced elevated mortality immediately following admission, which is inconsistent with a social selection interpretation. However, none of the specific indicators of stressful admission or unsatisfactory nursing home conditions are significantly related to mortality. Discussion. These data demonstrate selection processes for postadmission mortality, but indicate that the admission of patients in poor health may not fully account for the elevation in mortality that occurs immediately following admission. ESIDENTIAL family care for frail elders is typically considered far more desirable than care provided within the confines of a formal organization. This conviction reflects cultural values supporting family ties, social norms mandating the obligations of family members for one another, and economic constraints impinging on individual families and society. Indeed, support from kin enables many elderly persons who would otherwise be placed in longterm care facilities to continue living in their communities

This study estimated the effects of gender and ethnic differences on the risk of first intercourse (FI) among a population-based sample of Los Angeles County youths aged 12-17 years. Longitudinal surveys were conducted during 1992-94 and 1994-95. The sample was of the multistage stratified probability type. The sample included 877 interviewed adolescents in the 1st round and 675 in the 2nd. Almost 50% of respondents were Hispanic. 58% lived with both parents. The median age of intercourse was 16.9 years; 16.6 years for males and 17.2 years for females. Blacks reported the youngest age of FI at 15.8 years. Asian adolescents had the oldest age of FI at 17.6 years. The same pattern occurred for median age at FI. Age at FI did not vary as much by ethnicity for females. White and Black females had younger ages of FI than Asian females. Black males had significantly higher rates of FI than White females. Asian males were less likely than White females to be sexually experienced. Hispanic and Asian females had significantly lower rates of sexual activity than White females. Family structure was significantly associated with risk of sexual activity. With controls for differences in family background rates of FI differed significantly by ethnicity among males but not females. Teenagers living with a single parent or step family had significantly higher rates of transition to first sex than those living with both parents. Family structure may measure the effects of family disruption rather than parenting behaviors. Findings demonstrate that ethnicity and gender are key factors that predict adolescents risk of becoming sexually active.