INTERGENERATIONAL SUPPORT AND WELL-BEING OF OLDER ADULTS IN CHANGING FAMILY CONTEXTS

This dissertation consists of three papers that examine the complexities in upward intergenerational support and adult children’s influence on older adults’ health in changing family contexts of America and China. The prevalence of “gray divorce/repartnering ” in later life after age 55 is on the rise in the United States, yet little is known about its effect on intergenerational support. The first paper uses the life course perspective to examine whether gray divorce and repartnering affect support from biological and stepchildren differently than early divorce and repartnering, and how patterns differ by parents’ gender. Massive internal migration in China has led to increased geographic distance between adult children and aging parents, which may have consequences for old age support received by parents. This topic has yet to be thoroughly explored in China, as most studies of intergenerational support to older parents have focused on the role of coresident children or have not considered the interdependence of multiple parent-child dyads in the family. The second paper adopts the within-family differences approach to assess the influence of non-coresident children’s relative living proximity to parents compared to that of their siblings on their provision of support to parents in rural and urban Chinese families. The study also examines how patterns of the impact are moderated by parents’ living arrangement, non-coresident children’s gender, and parents’ provision of support to children. Taking a multigenerational network perspective, the third paper questions if and how adult children’s socioeconomic status (SES) influences older parents’ health in China. It further examines whether health benefits brought by adult children’s socioeconomic attainment are larger for older adults with lower SES and whether one of the mechanisms through which adult children’s SES affects older parents’ health is by changing their health behaviors. These questions are highly relevant in contemporary China, where adult children have experienced substantial gains in SES and play a central role in old age support for parents. In sum, these three papers take the life course, the within-family differences, and the multigenerational network perspective to address the complexities in intergenerational support and older adults’ health in diverse family contexts.

Falls and other geriatric syndromes in Blantyre, Malawi: a community survey of older adults

Background The prevalence of geriatric syndromes (falls, immobility, intellectual or memory impairment, and incontinence) is unknown in many resource-poor countries. With an aging population such knowledge is essential to develop national policies on the health and social needs of older people. The aim of this study was to provide a preliminary survey to explore the prevalence of falls and other geriatric syndromes and their association with known risk factors in people aged > 60 years in urban Blantyre, Malawi. Methods This was a cross-sectional, community survey of adults aged > 60 years. Subjects were recruited at home or in the waiting areas of chronic care clinics. They were interviewed to complete a questionnaire on ageassociated syndromes and comorbid problems. The Abbreviated Mental Test (AMT) and Timed Up and Go (TUG) tests were carried out. Results Ninety-eight subjects were studied; 41% reported falling in the past 12 months, 33% of whom (13% of all subjects) were recurrent fallers. Twenty-five percent reported urine incontinence, 66% self-reported memory difficulties, and 11% had an AMT score < 7. A history of falling was significantly associated with urine incontinence (p=0.01), selfreported memory problems (p=0.004) and AMT score < 7 (p=0.02). Conclusions Geriatric syndromes, including falls, appear to be prevalent in older people in Blantyre, Malawi. Falling is associated with cognitive impairment and urinary incontinence. There is an urgent need for more understanding of geriatric problems in this setting to develop national policies on health and social needs of older people. It is likely that many of the contributory factors to falls would be amenable to multifactorial interventions similar to those found to be effective in developed countries.

Beers versus STOPP criteria in polyharmacy community-dwelling older patients

Objective: To assess potentially inappropriate prescribing (PIP) using Beers (2012 version) and STOPP (2008 version) criteria in polypharmacy, community-dwelling, older patients. Methods: From the information collected in the invoicing data of the prescriptions and the electronic medical records, a sample was selected of 223 ≥ 65-year-old patients who were taking simultaneously 10 or more drugs per day. Beers and STOPP criteria were separately applied, and the results obtained with the two methods were compared. Results: A total of 141 (63.2%) patients presented at least one Beers criterion. The two most frequently observed Beers criteria independent of diagnosis were the use of benzodiazepines and the use of non-COX-2-selective non-steroidal anti-inflammatory drugs. With regard to Beers criteria considering diagnosis, the most frequent were the use of anticholinergic drugs in patients with lower urinary tract symptoms or benign prostatic hyperplasia, and the use of benzodiazepines, antipsychotics, Zolpidem or H2-antihistamines, in patients with dementia or cognitive impairment. A total of 165 (73.9%) patients had at least one PIP according to the STOPP criteria. Duplicate drug classes and long-term use of long-acting benzodiazepines were the two most frequent STOPP criteria. Discussion: Our study identified a high frequency of PIP in poly-medicated community-dwelling older patients. Simultaneous application of Beers and STOPP criteria represents a useful tool to improve prescribing in this population group.

Perceived benefits, motivations and preferences for foreign language learning by older adults. Insights from an initiative in Cuenca, Ecuador

El presente estudio analiza las percepciones y actitudes que tienen los adultos mayores de la ciudad de Cuenca, Ecuador hacia el aprendizaje del inglés. Un total de 151 adultos mayores (con edad promedio de 70.3 años) respondió a un cuestionario con 50 ítems. Se llevó a cabo análisis factoriales, de regresión múltiple y cluster con el propósito de definir las dimensiones subyacentes en las percepciones, motivaciones y ambiciones de los adultos mayores para aprender un idioma extranjero, y su relación con las características sociodemográficas de los participantes. Los resultados señalan que el interés por estudiar un idioma extranjero está basado en la percepción de que aquello mejora la interacción social de las personas, su desarrollo personal, el funcionamiento y mantenimiento de la mente y memoria, y que activa y vuelve su vida más dinámica. Los resultados además revelaron que la principal motivación de los participantes para tomar un curso de inglés está relacionada con el potencial de usar este idioma en la vida diaria y el de leer profusamente en esa lengua extranjera. La duración del curso y la obtención de un certificado fueron factores determinantes que permitieron agrupar a los participantes en función de sus preferencias en lo que respecta al diseño práctico de un curso de inglés. Adicionalmente, la edad y el nivel de instrucción fueron variables determinantes de motivación que influyeron en la mayor parte de las respuestas dadas por los participantes.

Older adults and sport and physical activity professionals in spain

Presence of monitors in physical activities and sports practiced by adults older than 64 years of age in Spain is analyzed in this research. The objective of this study is to determine the existence of monitors in relation to the sociodemographic features of older adults, the size of municipalities, the activities practiced, and the organizations where they are performed. The methodology used included a cross-sectional survey applied to a sample of older adults in Spain. The most relevant conclusions are that the presence of monitors in physical activities and sports practiced by older adults is dominant (63.8%), hence, their importance, and that the presence of monitors is higher for women (81.3%) than for men (37.5%). In addition, it is concluded that the bigger the municipality the higher the tendency to have more instructors. Regarding the type of activity, wide diversification is obtained; finally, there is a larger presence of monitors in sports entities (87.5%) and nursing homes (79.5%).

Investigating the outcomes of a physical activity program offered to older adults in South Florida and understanding the correlates of completion

Despite the well-known benefits of physical activity, in 2012, only 37.5% of older adults aged 60 years or older met recommended aerobic physical activity levels and 16.1% met muscle-strengthening guidelines. Effective exercise programs can help combat the problem of inactivity but 50% of those who start participating in an exercise program drop out within first few weeks, preventing them from gaining any health benefits. Since fall 2008, the Healthy Aging Regional Collaborative of South Florida has offered EnhanceFitness (EF), an evidence-based physical activity program to older adults. This dissertation compared EF effectiveness at 4-, 8-, and 12-months and examined the factors that were associated with program completion. A paired sample t-test identified changes at 4-months and repeated measures design was used to identify changes from baseline to 4-, 8-, and 12- months. Logistic regression was used to identify correlates associated with completion.^ Between October 1, 2008 and December 31, 2012, 4,531 older adults (>=60 years) attended one or more EF sessions. Participants showed significant improvement in the number of chair stands performed in 30-seconds with mean change of 1.7, 1.6, and 2.0 respectively at 4-,8-,and 12- months (p<0.001). Results suggest Black, non-Haitian men were less likely to complete the program when compared to white, non-Hispanic men (OR=0.41, p=0.02). Men who self-reported having at least one risk factor were more likely to complete the program (OR=1.81, p= 0.03). In addition, women who lived in Miami-Dade County (OR=2.13, p<0.001) and were 80 years or older (OR=1.46, p<0.05) were more likely to complete the program. When compared with non-Hispanic whites, Black women were less likely to complete the program (OR=0.613, p<0.01). Women who did not report depression were 1.6 times more likely to complete the program (OR=1.62, p<0.05). Absence of risk factors for chronic conditions increased completion rates among women (OR=1.63, p<0.01).^ Effectiveness results revealed that all participants significantly improved on all outcome measures. However, improvement is more than double for those who completed recommended sessions (p<0.01). Study findings reaffirm the successful translation of EF in community-based settings. Our findings suggest that participants should attend the minimum recommended sessions to attain greater health benefits.^

Using a multifactorial approach to determine fall risk profiles in portuguese older adults

The aim of this study was to use a multifactorial approach to characterize episodic and recurrent fallers risk profiles in Portuguese older adults.

An evaluation of a nurse-led rehabilitation programme (the ProBalance Programme) to improve balance and reduce fall risk of community-dwelling older people: a randomised controlled trial

info:eu-repo/semantics/publishedVersion

Using a multifactorial approach to determine fall risk profiles in portuguese older adults

The aim of this study was to use a multifactorial approach to characterize episodic and recurrent fallers risk profiles in Portuguese older adults.

The Impact of Community Social Capital on the occurrence of Injuries in adolescents and falls in older adults: Population-based Studies Conducted in Canadian samples

The objectives of this thesis were to study specific Canadian populations in order to examine; (1) relationships between the neighbourhood-level social capital and injuries in youth, as well as (2) falls in older adults, and; (3) to address methodological issues relevant to the study of such relationships. The thesis is comprised of four manuscripts. The first addresses methodological issues surrounding the validation of neighbourhood-level variables for the study of adolescent health, and demonstrates the existence of structural confounding in the study of related etiological relationships. Informed by the latter, the second manuscript examines the association between neighbourhood-level social capital and injuries in youth, and demonstrates that lower levels of social capital are protective factors for girls but not for boys. Manuscript 3 uses an international database focused on older adults, and shows that our existing measure of social capital is valid at neighbourhood levels, but also that there is a high possibility for the existence of structural confounding among Canadian older adults. The fourth manuscript then examines the association between neighbourhood-level social capital and the occurrence of falls in older adults and determines that differences between neighbourhoods are important factors in the occurrence of falls, and that higher levels of social capital are a risk factor for falls. Taken together, results from this thesis provide a better understanding of the role of neighbourhood-level social capital on the occurrence of injuries in Canadian youth and on the occurrence of falls in older adults. Our contributions were important both methodologically and etiologically.

Time-limited home-care reablement services for maintaining and improving the functional independence of older adults

Background: Reablement, also known as restorative care, is one possible approach to home-care services for older adults at risk of functional decline. Unlike traditional home-care services, reablement is frequently time-limited (usually six to 12 weeks) and aims to maximise independence by offering an intensive multidisciplinary, person-centred and goal-directed intervention. Objectives: To assess the effects of time-limited home-care reablement services (up to 12 weeks) for maintaining and improving the functional independence of older adults (aged 65 years or more) when compared to usual home-care or wait-list control group. Search methods: We searched the following databases with no language restrictions during April to June 2015: the Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE (OvidSP); Embase (OvidSP); PsycINFO (OvidSP); ERIC; Sociological Abstracts; ProQuest Dissertations and Theses; CINAHL (EBSCOhost); SIGLE (OpenGrey); AgeLine and Social Care Online. We also searched the reference lists of relevant studies and reviews as well as contacting authors in the field. Selection criteria: We included randomised controlled trials (RCTs), cluster randomised or quasi-randomised trials of time-limited reablement services for older adults (aged 65 years or more) delivered in their home; and incorporated a usual home-care or wait-list control group. Data collection and analysis: Two authors independently assessed studies for inclusion, extracted data, assessed the risk of bias of individual studies and considered quality of the evidence using GRADE. We contacted study authors for additional information where needed. Main results: Two studies, comparing reablement with usual home-care services with 811 participants, met our eligibility criteria for inclusion; we also identified three potentially eligible studies, but findings were not yet available. One included study was conducted in Western Australia with 750 participants (mean age 82.29 years). The second study was conducted in Norway (61 participants; mean age 79 years). We are very uncertain as to the effects of reablement compared with usual care as the evidence was of very low quality for all of the outcomes reported. The main findings were as follows. Functional status: very low quality evidence suggested that reablement may be slightly more effective than usual care in improving function at nine to 12 months (lower scores reflect greater independence; standardised mean difference (SMD) -0.30; 95% confidence interval (CI) -0.53 to -0.06; 2 studies with 249 participants). Adverse events: reablement may make little or no difference to mortality at 12 months' follow-up (RR 0.97; 95% CI 0.74 to 1.29; 2 studies with 811 participants) or rates of unplanned hospital admission at 24 months (RR 0.94; 95% CI 0.85 to 1.03; 1 study with 750 participants). The very low quality evidence also means we are uncertain whether reablement may influence quality of life (SMD -0.23; 95% CI -0.48 to 0.02; 2 trials with 249 participants) or living arrangements (RR 0.92, 95% CI 0.62 to 1.34; 1 study with 750 participants) at time points up to 12 months. People receiving reablement may be slightly less likely to have been approved for a higher level of personal care than people receiving usual care over the 24 months' follow-up (RR 0.87; 95% CI 0.77 to 0.98; 1 trial, 750 participants). Similarly, although there may be a small reduction in total aggregated home and healthcare costs over the 24-month follow-up (reablement: AUD 19,888; usual care: AUD 22,757; 1 trial with 750 participants), we are uncertain about the size and importance of these effects as the results were based on very low quality evidence. Neither study reported user satisfaction with the service. Authors' conclusions: There is considerable uncertainty regarding the effects of reablement as the evidence was of very low quality according to our GRADE ratings. Therefore, the effectiveness of reablement services cannot be supported or refuted until more robust evidence becomes available. There is an urgent need for high quality trials across different health and social care systems due to the increasingly high profile of reablement services in policy and practice in several countries.

Risk indicators associated with root caries in independently living older adults

Objective: To determine the risk indicators associated with root caries experience in a cohort of independently living older adults in Ireland. Methods: The data reported in the present study were obtained from a prospective longitudinal study conducted in a cohort of independently living older adults (n = 334). Each subject underwent an oral examination, performed by a single calibrated examiner, to determine the root caries index and other clinical variables. Questionnaires were used to collect data on oral hygiene habits, diet, smoking and alcohol habits and education level. A regression analysis with the outcome variable of root caries experience (no/yes) was conducted. Results: A total of 334 older dentate adults with a mean age of 69.1 years were examined. 53.3% had at least one filled or decayed root surface. The median root caries index was 3.13 (IQR 0.00, 13.92). The results from the multivariate regression analysis indicated that individuals with poor plaque control (OR 9.59, 95% CI 3.84–24.00), xerostomia (OR 18.49, 95% CI 2.00–172.80), two or more teeth with coronal decay (OR 4.50, 95% CI 2.02–10.02) and 37 or more exposed root surfaces (OR 5.48, 95% CI 2.49–12.01) were more likely to have been affected by root caries. Conclusions: The prevalence of root caries was high in this cohort. This study suggests a correlation between root caries and the variables poor plaque control, xerostomia, coronal decay (≥2 teeth affected) and exposed root surfaces (≥37). The significance of these risk indicators and the resulting prediction model should be further evaluated in a prospective study of root caries incidence. Clinical significance Identification of risk indicators for root caries in independently living older adults would facilitate dental practitioners to identify those who would benefit most from interventions aimed at prevention.

Mapping and modulating spatial attention asymmetries in young and older adults

Healthy young adults demonstrate a group-level, systematic preference for stimuli presented in the left side of space relative to the right (‘pseudoneglect’) (Bowers & Heilman, 1980). This results in an overestimation of features such as size, brightness, numerosity and spatial frequency in the left hemispace, probably as a result of right cerebral hemisphere dominance for visuospatial attention. This spatial attention asymmetry is reduced in the healthy older population, and can be shifted entirely into right hemispace under certain conditions. Although this rightward shift has been consistently documented in behavioural experiments, there is very little neuroimaging evidence to explain this effect at a neuroanatomical level. In this thesis, I used behavioural methodology and electroencephalography (EEG) to map spatial attention asymmetries in young and older adults. I then use transcranial direct current stimulation (tDCS) to modulate these spatial biases, with the aim of assessing age-related differences in response to tDCS. In the first of three experiments presented in this thesis, I report in Chapter Two that five different spatial attention tasks provide consistent intra-task measures of spatial bias in young adults across two testing days. There were, however, no inter-task correlations between the five tasks, indicating that pseudoneglect is at least partially driven by task-dependent patterns of neural activity. In Chapter Three, anodal tDCS was applied separately to the left (P5) and right (P6) posterior parietal cortex (PPC) in young and older adults, with an aim to improve the detection of stimuli appearing in the contralateral visual field. There were no age differences in response to tDCS, but there were significant differences depending on baseline performance. Relative to a sham tDCS protocol, tDCS applied to the right PPC resulted in maintained visual detection across both visual fields in adults who were good at the task at baseline. In contrast, left PPC tDCS resulted in reduced detection sensitivity across both visual fields in poor performers. Finally, in Chapter Four, I report a right-hemisphere lateralisation of EEG activity in young adults that was present for long (but not short) landmark task lines. In contrast, older adults demonstrated no lateralised activity for either line length, thus providing novel evidence of an age-related reduction of hemispheric asymmetry in older adults. The results of this thesis provide evidence of a highly complex set of factors that underlie spatial attention asymmetries in healthy young and older adults.

An evaluation of a nurse-led rehabilitation programme (the ProBalance Programme) to improve balance and reduce fall risk of community-dwelling older people: a randomised controlled trial

info:eu-repo/semantics/publishedVersion

Coping with stereotype threat: Denial as an impression management strategy

Four experiments tested the hypothesis that people who are concerned with impression management cope with stereotype threat through denial. Consistent with this hypothesis, temporary employees threatened by a stereotype of incompetence (Study 1) and hostel-dwelling older adults (Study 2) were more likely to deny incompetence if they were high in impression management. African Americans (Study 3) showed a similar pattern of denying cognitive incompetence, which emerged primarily when they were interviewed by a White experimenter and had attended a predominantly Black high school. In Study 4, White students who expected to take an IQ test and were threatened by a stereotype of being less intelligent than Asians were more likely to deny that intelligence is important if they were high in impression management.