Divergence and integration of identification methods for geriatric mental health disorders in nonspecialized institutions-a qualitative study of service providers from different departments in Shanghai, China.

OBJECTIVES: Global epidemiological evidence indicates high rates of mental illness but low rates of diagnosis among older people. In China, service providers identify older adults with mental disorders in varied ways. Taking Shanghai as an example, this study revealed how the identification methods of geriatric mental health disorders in nonspecialized institutions diverge, providing a reference for the integration of services. METHODS: A purposive sampling method was adopted to conduct semi-structured interviews with 24 service providers from various nonspecialized geriatric mental health care institutions. Interview audio was recorded with consent and converted into verbatim transcripts. The interview data were analysed thematically. RESULTS: Although service providers from the health care system tended to apply a biomedical-oriented assessment, those from the social care system typically identified mental disorders among older people based on selective attention and interpersonal relationships. Although there are stark differences, the various identification mechanisms implicitly converge-the relationship with clients has become an important consideration. CONCLUSION: Geriatric mental health issues urgently require the integration of formal and informal care resources. Referring to the idea of task transfer, social identification mechanisms are expected to be a useful supplement to traditional biomedical-oriented identification.

Lessons Learned in Implementing an Aging Research Training Program for Underrepresented Minority Students.

This brief report provides an overview of lessons learned through evaluation of the first five years of the NIA-funded South Carolina-Advancing Diversity in Aging Research (SC-ADAR) undergraduate program, whose goal is to increase the number of qualified underrepresented minority (URM) students who pursue scientific graduate studies in programs focusing on medicine, science, technology, engineering, and mathematics and aging. Partnering with five Historically Black Colleges and Universities in South Carolina, we implemented a research training approach that included two consecutive summers of research training in a University of South Carolina faculty laboratory, as part of a comprehensive 24-month research education program. In addition to the mentored research experience in a laboratory, students had coursework in the biology of aging and social gerontology, with additional workshops tailored to emergent student needs including basic academic skills development, work-life management skills, reflective social experiences, and enhanced support in the transition from undergraduate to graduate school. We provide an overview of lessons learned throughout the early program period, and a description of the iterative changes we made in the program in response to this learning, all of which have been incorporated into the existing SC-ADAR program.

Dementia Neuropsychiatric Symptom Frequency, Severity, and Correlates in Community-Dwelling Thai Older Adults.

BACKGROUND: Thailand is experiencing a rapid increase in the number of older people with dementia (PWD). We examined the frequency, severity, and correlates of dementia neuropsychiatric symptoms (NPS) among community-dwelling Thai older adults. METHODS: This study was based on analysis of baseline data from a larger clinical trial comparing two different implementation approaches of an evidence-based exercise intervention for people with dementia. To be eligible, participants needed to be age 60 and above, have probable dementia, have one or more NPS, be ambulatory, and have an adult (age 18+) family caregiver. In the 353 eligible participants, we examined the correlation between NPS severity and caregiver distress (assessed by the Neuropsychiatric Inventory Questionnaire or NPI-Q) and used ordinary least squares (OLS) regression to examine associations between PWD and caregiver characteristics and NPS severity. RESULTS: NPS frequency varied from 18% for appetite and/or eating changes to 42% for delusions. NPS severity was significantly (p <0.05) associated with caregiver stress for all individual NPS. Among PWD characteristics, higher ADL score (less functional impairment) was inversely associated with NPS total severity (b = -0.16, p <0.05). More physical role limitation was significantly associated with higher NPS total severity (b = 0.77, p <0.001). Among caregivers' characteristics, higher burden was significantly associated with higher NPS total severity (b = 0.19, p <0.001). CONCLUSION: Our study found NPS to be common among community-dwelling PWD in Thailand and have adverse impacts on both PWD and family caregivers. These findings highlight the clinical importance of NPS symptoms among Thai older adults.

Long-term care system for older adults in China: policy landscape, challenges, and future prospects.

In China, the population is rapidly ageing and the capacity of the system that cares for older people is increasingly a concern. In this Review, we provide a profile of the long-term care system and policy landscape in China. The long-term care system is characterised by rapid growth of the residential care sector, slow development of home and community-based services, and increasing involvement of the private sector. The long-term care workforce shortage and weak quality assurance are concerning. Public long-term care financing is minimal and largely limited to supporting welfare recipients and subsidising the construction of residential care beds and operating costs. China is piloting social insurance long-term care financing models and, concurrently, programmes for integrating health care and long-term care services in selected settings across the country; the effectiveness and sustainability of these pilots remain to be seen. Informed by international long-term care experiences, we offer policy recommendations to strengthen the evolving care system for older people in China.

Optimization of neutral protease production from Bacillus subtilis: using agroindustrial residues as substrates and response surface methodology.

Statistically based experimental designs were applied to optimize the fermentation medium and cultural conditions for the maximization of neutral protease using three agroindustrial residues (cassava pulp, soybean meal, and wheat bran) and Bacillus subtilis DES-59. The Plackett-Burman design was used to evaluate the effects of variables such as the concentration of substrates, initial pH, shaker's rotating speed, temperature, inoculum size, and incubation time. Among the eight parameters, three significant variables (cassava pulp, soybean meal, and inoculum size) were selected for the optimization study, in which a central composite design was used to optimize the concentrations of cassava pulp and soybean meal and inoculum size and investigate the interactive effects of the three variables. The optimal parameters obtained from response surface methodology are 37.78 g/L of cassava pulp, 15 g/L of soybean meal, and 6.5% (v/v) of inoculum size, respectively, resulting in a maximum neutral protease activity of 4107 ± 122 U/mL.

Studies on the Digital Inclusion Among Older Adults and the Quality of Life-A Nanjing Example in China.

Digital inclusion can bridge the digital divide and reduce the social exclusion of older adults, yet it is understudied in China. This research examined factors influencing the digital inclusion of older adults in China and the relationship between digital inclusion and quality of life. Data collected from 312 older people (M = 69.6 years old) in Nanjing were included in a multinomial logit model to tackle these questions. Their attitudes toward technology were the most significant factor predicting their digital inclusion. Other factors included party affiliation, living situation, personal average monthly income, occupation, and capacity for instrumental activities of daily living (IADLs). This study shows digital inclusion has a direct impact on quality of life. It also serves as an intermediate variable that affects older people's attitudes toward technology and their IADL capacities. Most importantly, digital inclusion promotes social integration of older adults and improves the quality of their lives. Hence, it should not be ignored. Older people's attitudes toward technology are one of the keys to promoting their digital inclusion.

Cultural Adaptation of the Reducing Disability in Alzheimer's Disease (RDAD) Protocol for an Intervention to Reduce Behavioral and Psychological Symptoms of Dementia in Thailand.

BACKGROUND: The Reducing Disability in Alzheimer's Disease (RDAD) program is an evidence-based intervention found to be feasible for implementation in community settings in the United States, and effective in reducing depression, one of the major behavioral and psychological symptoms of dementia (BPSD). OBJECTIVE: The goal of the study is to culturally adapt the RDAD for persons with dementia living in community settings of Thailand. METHODS: Key adaptation steps included: 1) assess the community, 2) understand/select the intervention, 3) consult with experts/stakeholders, 4) decide what needs to be adapted, 5) adapt the original program, 6) train staff, and 7) pilot test the adapted materials. RESULTS: Modifications to the original RDAD protocol included changes in number of sessions, mode of delivery, and the specific pleasant activities targeted. The pilot test demonstrated the feasibility and acceptance of the adapted RDAD intervention protocol. Implementers were able to comprehend and implement the core components of the intervention, while family members demonstrated ability to follow instructions, gain knowledge about dementia, and improve skills for setting up realistic goals. CONCLUSION: Following the key adaptation steps outlined above, we were able to successfully modify the RDAD for the Thai cultural context, maintaining core components of the original protocol. Program implementers demonstrated their ability to supervise family caregivers and help them gain the knowledge and skills needed to provide care for older adults with dementia. Findings from the pilot studies were incorporated into final training and intervention protocols currently being implemented and evaluated in a randomized implementation trial in Thailand.

Reflections on Mentorship From Scientists and Mentors in an Alzheimer's Disease Focused Research Training Program.

This paper presents reflections on mentorship from scientists and mentors of the National Institute on Aging (NIA)-funded Carolina Center on Alzheimer's Disease and Minority Research (CCADMR). Using a network approach to mentoring, this program aims to increase the pipeline of underrepresented minority (URM) scientists studying Alzheimer's disease (AD) disparities. Six mentors and five scientists participated in interviews. Thematic analysis identified recurring themes; transcripts of mentors and scientists were compared. Most common thematic categories identified by mentors included experience interacting with scientists, goals as a mentor, recruitment of underrepresented minorities, scientists' challenges, and programmatic qualities. The most mentioned categories by scientists were challenges, seminars, working with mentors, career development, and project experience. The CCADMR will use findings to enhance the experience and training methods for future grant years. Results can benefit other training programs focused on aging and AD.

Implementation Science in Thailand: Design and Methods of a Geriatric Mental Health Cluster-Randomized Trial.

BACKGROUND: Thailand has a rapidly aging population yet lacks evidence for effective and scalable evidence-based psychosocial interventions to support persons living with dementia and their family caregivers. In this study of a culturally adapted and evidence-based clinical program (Reducing Disabilities in Alzheimer's Disease [RDAD]), designed to reduce behavioral and psychological symptoms of dementia in older adults, the authors test the hypothesis that an implementation support strategy, Getting To Outcomes (GTO), would produce better implementation and clinical outcomes compared with usual implementation of RDAD in Thailand. METHODS: The study uses a hybrid type III cluster-randomized design to compare eight geographical districts that receive training on both implementing the RDAD clinical intervention and on GTO implementation support strategies (intervention arm) with eight other districts that receive the same RDAD training but without training in GTO implementation support strategies (control arm). GTO is an evidence-based intervention designed to support implementers to better plan, implement, and evaluate innovative intervention programs in a novel setting. Primary outcomes, including implementation and clinical outcomes, will be assessed at baseline, month 3 (posttreatment), and month 6 (3-month follow-up). RESULTS: The research team anticipates that there will be significantly more improvements in the delivery of the RDAD intervention program in the experimental group than in the control group. NEXT STEPS: If clinical trial findings are positive, the authors plan to replicate and scale up the proposed implementation science approach across Thailand to enhance and expand mental health services for older adults with dementia.

Social Technology: An Interdisciplinary Approach to Improving Care for Older Adults.

Population aging is a defining demographic reality of our era. It is associated with an increase in the societal burden of delivering care to older adults with chronic conditions or frailty. How to integrate global population aging and technology development to help address the growing demands for care facing many aging societies is both a challenge and an opportunity for innovation. We propose a social technology approach that promotes use of technologies to assist individuals, families, and communities to cope more effectively with the disabilities of older adults who can no longer live independently due to dementia, serious mental illness, and multiple chronic health problems. The main contributions of the social technology approach include: (1) fostering multidisciplinary collaboration among social scientists, engineers, and healthcare experts; (2) including ethical and humanistic standards in creating and evaluating innovations; (3) improving social systems through working with those who deliver, manage, and design older adult care services; (4) promoting social justice through social policy research and innovation, particularly for disadvantaged groups; (5) fostering social integration by creating age-friendly and intergenerational programs; and (6) seeking global benefit by identifying and generalizing best practices. As an emergent, experimental approach, social technology requires systematic evaluation in an iterative process to refine its relevance and uses in different local settings. By linking technological interventions to the social and cultural systems of older people, we aim to help technological advances become an organic part of the complex social world that supports and sustains care delivery to older adults in need.

Identifying challenges and recommendations for advancing global mental health implementation research: A key informant study of the National Institute of Mental Health Scale-Up Hubs.

OBJECTIVE: This study explored perspectives of researchers working with the National Institute of Mental Health (NIMH) Scale-Up Hubs, consisting of research partnerships for scaling up mental health interventions in low- and middle-income countries (LMICs), to: 1) identify common barriers to conducting impactful research on the implementation of evidence-based mental health services; and 2) provide recommendations to overcome these implementation challenges. METHODS: A sequential qualitative approach was employed. First, an open-ended survey was distributed to the 10 Scale-Up Hubs and NIMH program staff asking informants to identify challenges in conducting mental health implementation research in LMICs. Second, survey findings guided an in-person workshop to generate implementation recommendations to inform the field. RESULTS: In total, 46 respondents completed surveys, and 101 researchers attended the workshop. The workshop produced implementation recommendations for low-resource settings: 1) identifying impact of research on policy and practice; 2) sustaining careers of early researchers in global mental health; 3) engaging policymakers and donors to value mental health research; 4) supporting the workforce for delivering evidence-based treatments for mental disorders; and 5) promoting sustainability of programs. CONCLUSIONS: These findings can strengthen collaboration between researchers and key stakeholders, and highlight important targets for improving mental health implementation research in LMICs.

A Smartphone App for Self-Management of Heart Failure in Older African Americans: Feasibility and Usability Study.

BACKGROUND: Mobile health (mHealth) apps are dramatically changing how patients and providers manage and monitor chronic health conditions, especially in the area of self-monitoring. African Americans have higher mortality rates from heart failure than other racial groups in the United States. Therefore, self-management of heart failure may improve health outcomes for African American patients. OBJECTIVE: The aim of the present study was to determine the feasibility of using an mHealth app, and explore the outcomes of quality of life, including self-care maintenance, management, and confidence, among African American patients managing their condition after discharge with a diagnosis of heart failure. METHODS: Prior to development of the app, we conducted qualitative interviews with 7 African American patients diagnosed with heart failure, 3 African American patients diagnosed with cardiovascular disease, and 6 health care providers (cardiologists, nurse practitioners, and a geriatrician) who worked with heart failure patients. In addition, we asked 6 hospital chaplains to provide positive spiritual messages for the patients, since spirituality is an important coping method for many African Americans. These formative data were then used for creating a prototype of the app, named Healthy Heart. Specifically, the Healthy Heart app incorporated the following evidence-based features to promote self-management: one-way messages, journaling (ie, weight and symptoms), graphical display of data, and customized feedback (ie, clinical decision support) based on daily or weekly weight. The educational messages about heart failure self-management were derived from the teaching materials provided to the patients diagnosed with heart failure, and included information on diet, sleep, stress, and medication adherence. The information was condensed and simplified to be appropriate for text messages and to meet health literacy standards. Other messages were derived from interviews conducted during the formative stage of app development, including interviews with African American chaplains. Usability testing was conducted over a series of meetings between nurses, social workers, and computer engineers. A pilot one-group pretest-posttest design was employed with participants using the mHealth app for 4 weeks. Descriptive statistics were computed for each of the demographic variables, overall and subscales for Health Related Quality of Life Scale 14 (HQOL14) and subscales for the Self-Care of Heart Failure Index (SCHFI) Version 6 using frequencies for categorical measures and means with standard deviations for continuous measures. Baseline and postintervention comparisons were computed using the Fisher exact test for overall health and paired t tests for HQOL14 and SCHFI questionnaire subscales. RESULTS: A total of 12 African American participants (7 men, 5 women; aged 51-69 years) diagnosed with heart failure were recruited for the study. There was no significant increase in quality of life (P=.15), but clinically relevant changes in self-care maintenance, management, and confidence were observed. CONCLUSIONS: An mHealth app to assist with the self-management of heart failure is feasible in patients with low literacy, low health literacy, and limited smartphone experience. Based on the clinically relevant changes observed in this feasibility study of the Healthy Heart app, further research should explore effectiveness in this vulnerable population.

Integrated specialty mental health care among older minorities improves access but not outcomes: results of the PRISMe study.

OBJECTIVE: In this secondary data analysis of Primary Care Research in Substance Abuse and Mental Health for the Elderly (PRIMSe) study, we hypothesized that older minorities who receive mental health services integrated in primary care settings would have greater service use and better mental health outcomes than older minorities referred to community services. METHOD: We identified 2,022 (48% minorities) primary care patients 65 years and older, who met study inclusion criteria and had either alcohol misuse, depression, and/or anxiety. They were randomized to receive treatment for these disorders in the primary care clinic or to a brokerage case management model that linked patients to community-based services. Service use and clinical outcomes were collected at baseline, three months and six months post randomization on all participants. RESULTS: Access to and participation in mental health /substance abuse services was greater in the integrated model than in referral; there were no treatment by ethnicity effects. There were no treatment effects for any of the clinical outcomes; Whites and older minorities in both integrated and referral groups failed to show clinically significant improvement in symptoms and physical functioning at 6 months. CONCLUSIONS: While providing services in primary care results in better access to and use of these services, accessing these services is not enough for assuring adequate clinical outcomes.

Stigma of depression is more severe in Chinese Americans than Caucasian Americans.

Stigma of mental illness is a major obstacle to its diagnosis and treatment and may be worse among Asians than Caucasians. This study compared the stigma of depression in 50 Chinese Americans (CA) and 50 Caucasian Americans (WA). Subjects were asked to read 5 case vignettes in the following order: diabetes mellitus (DB), major depressive disorder (MDD), somatoform depression (SD), psychotic depression (PD), and fever of unknown origin (HA). Diagnosis of each case was not revealed. Subjects then rated their response to each case, on a Likert scale from "strongly disagree" to "strongly agree," to 25 statements that contained 6 stigma factors: fear, shame, cognitive distortion, social consensus, discrimination, and sanction. Composite scores constructed from ratings of each factor were used to calculate the severity of stigma. Stigma of all 5 cases was worse in CA than WA. Both groups ranked DB and HA to be least and PD to be most stigmatizing. CA rated SD to be less stigmatizing than MDD but not WA. We concluded that stigma formation and severity were determined by fear, shame, cognitive distortion, social communication, consensus, and sanction. Mental symptoms, particularly psychotic symptoms, were more stigmatizing than physical symptoms, especially for CA. Belief that depression was like a physical illness did not diminish its stigma.

The role of cognitive functioning and distress in suicidal ideation in older adults.

OBJECTIVES: To evaluate the role of cognitive functioning and other clinical and demographic characteristics as potential predictors of suicidal ideation in older primary care patients. DESIGN: Cross-sectional. SETTING: Primary care clinics at three Department of Veterans Affairs Medical Centers, three community health centers, and two hospital networks. PARTICIPANTS: Fifteen thousand five hundred ninety older adults without dementia who were receiving primary care (mean age+/-standard deviation 74.0+/-6.4; 62.8% men). MEASUREMENTS: Hierarchical logistic regressions were conducted with passive (e.g., thoughts of being better off dead) and active (e.g., thoughts of hurting one self) suicidal ideation as outcome variables. All demographic variables (age, sex, marital status, and ethnicity) were entered in the first block. All clinical variables (distress, cognitive functioning, alcohol consumption, and perceived health) were entered in the second block. RESULTS: In addition to the typical demographic predictors of late-life suicide (age, martial status, and ethnicity), having poorer cognitive functioning, poorer health, and greater mental distress were associated with passive suicidal ideation (chi-square (chi2) (14, n=14,618)=1,192.12, P<.001). Younger age, female sex, poorer cognitive functioning, and greater mental distress were associated with active suicidal ideation (chi2(14, n=14,605)=205.35, P<.001). CONCLUSION: Distress and cognitive impairment are the only two variables that consistently predicted passive and active suicidal ideation. Primary care providers who work with older adults need to take both into consideration when evaluating suicidal ideation.

Alcohol consumption among older adults in primary care.

BACKGROUND: Alcohol misuse is a growing public health concern for older adults, particularly among primary care patients. OBJECTIVES: To determine alcohol consumption patterns and the characteristics associated with at-risk drinking in a large sample of elderly primary care patients. DESIGN: Cross-sectional analysis of multisite screening data from 6 VA Medical Centers, 2 hospital-based health care networks, and 3 Community Health Centers. PARTICIPANTS: Patients, 43,606, aged 65 to 103 years, with scheduled primary care appointments were approached for screening; 27,714 (63.6%) consented to be screened. The final sample of persons with completed screens comprised 24,863 patients. MEASUREMENTS: Quantity and frequency of alcohol use, demographics, social support measures, and measures of depression/anxiety. RESULTS: Of the 24,863 older adults screened, 70.0% reported no consumption of alcohol in the past year, 21.5% were moderate drinkers (1-7 drinks/week), 4.1% were at-risk drinkers (8-14 drinks/week), and 4.5% were heavy (>14 drinks/week) or binge drinkers. Heavy drinking showed significant positive association with depressive/anxiety symptoms [Odds ratio (OR) (95% CI): 1.79 (1.30, 2.45)] and less social support [OR (95% CI): 2.01 (1.14, 2.56)]. Heavy drinking combined with binging was similarly positively associated with depressive/anxiety symptoms [OR (95%): 1.70 (1.33, 2.17)] and perceived poor health [OR (95% CI): 1.27 (1.03, 1.57)], while at-risk drinking was not associated with any of these variables. CONCLUSIONS: The majority of participants were nondrinkers; among alcohol users, at-risk drinkers did not differ significantly from moderate drinkers in their characteristics or for the 3 health parameters evaluated. In contrast, heavy drinking was associated with depression and anxiety and less social support, and heavy drinking combined with binge drinking was associated with depressive/anxiety symptoms and perceived poor health.

Assessing Needs among Elders in Urban China: Interview and Limitations.

Accurately assessing the needs of elders and their families is critical to developing an effective elderly service program or successful aging policy. In China and other Asian countries, such as Japan and South Korea, where the aging population is rapidly growing, this need is particularly apparent. Using case examples collected from a pilot study in urban China, we explore challenges in using the interview method for conducting needs assessments among elders and their family caregivers, including socio-cultural, cognitive, and conceptual limitations. To address these limitations, strategies are discussed to improve the use of interview methods for accurate assessments of needs among elders and their family caregivers, especially among those in developing countries, like China.

PRISM-E: comparison of integrated care and enhanced specialty referral models in depression outcomes.

OBJECTIVE: This study, entitled Primary Care Research in Substance Abuse and Mental Health for the Elderly, examined six-month outcomes for older primary care patients with depression who received different models of treatment. METHODS: Clinical outcomes were compared for patients who were randomly assigned to integrated care or enhanced specialty referral. Integrated care consisted of mental health services co-located in primary care in collaboration with primary care physicians. Enhanced specialty referral consisted of referral to physically separate, clearly identified mental health or substance abuse clinics. RESULTS: A total of 1,531 patients were included; their mean age was 73.9 years. Remission rates and symptom reduction for all depressive disorders were similar for the two models at the three- and six-month follow-ups. For the subgroup with major depression, the enhanced specialty referral model was associated with a greater reduction in depression severity than integrated care, but rates of remission and change in function did not differ across models of care for major depression. CONCLUSIONS: Six-month outcomes were comparable for the two models. For the subgroup with major depression, reduction in symptom severity was superior for those randomly assigned to the enhanced specialty referral group.