Social media use and mental health among older adults with multimorbidity: the role of self-care efficacy.

OBJECTIVES: To describe the prevalence and trends in the use of social media over time and explore whether social media use is related to better self-care efficacy and thus related to better mental health among United States older adults with multimorbidity. MATERIALS AND METHODS: Respondents aged 65 years+ and having 2 or more chronic conditions from the 2017-2020 Health Information National Trends Survey were analyzed (N = 3341) using weighted descriptive and logistic regression analyses. RESULTS: Overall, 48% (n = 1674) of older adults with multimorbidity used social media and there was a linear trend in use over time, increasing from 41.1% in 2017 to 46.5% in 2018, and then further up to 51.7% in 2019, and 54.0% in 2020. Users were often younger, married/partnered, and non-Hispanic White with high education and income. Social media use was associated with better self-care efficacy that was further related to better mental health, indicating a significant mediation effect of self-care efficacy in the relationship between social media use and mental health. DISCUSSION: Although older adults with multimorbidity are a fast-growing population using social media for health, significant demographic disparities exist. While social media use is promising in improving self-care efficacy and thus mental health, relying on social media for the management of multimorbidity might be potentially harmful to those who are not only affected by multimorbidity but also socially disadvantaged (eg, non-White with lower education). CONCLUSION: Great effort is needed to address the demographic disparity and ensure health equity when using social media for patient care.

Agents of Change: Geriatrics Workforce Programs Addressing Systemic Racism and Health Equity.

Many factors affect how individuals and populations age, including race, ethnicity, and diversity, which can contribute to increased disease risk, less access to quality healthcare, and increased morbidity and mortality. Systemic racism-a set of institutional policies and practices within a society or organization that perpetuate racial inequalities and discrimination-contributes to health inequities of vulnerable populations, particularly older adults. The National Association for Geriatrics Education (NAGE) recognizes the need to address and eliminate racial disparities in healthcare access and outcomes for older adults who are marginalized due to the intersection of race and age. In this paper, we discuss an anti-racist framework that can be used to identify where an organization is on a continuum to becoming anti-racist and to address organizational change. Examples of NAGE member Geriatric Workforce Enhancement Programs (GWEPs) and Geriatrics Academic Career Awards (GACAs) activities to become anti-racist are provided to illustrate the framework and to guide other workforce development programs and healthcare institutions as they embark on the continuum to become anti-racist and improve the care and health of vulnerable older adults.

Dying with dementia in nursing homes: A population-based study of decedents and their families.

BACKGROUND: Families play a critical role in end-of-life (EOL) care for nursing home (NH) residents with dementia. Despite the important role of family, little is known about the availability and characteristics of families of persons with dementia who die in NHs. METHODS: This is a retrospective cohort study of 18,339 individuals 65 years and older with dementia who died in a Utah NH between 1998 and 2016, linked to their first-degree family (FDF) members (n = 52,566; spouses = 11.3%; children = 58.3%; siblings = 30.3%). Descriptive statistics, chi-square tests, and t-tests were used to describe the study cohort and their FDF members and to compare sociodemographic and death characteristics of NH decedents with (n = 14,398; 78.5%) and without FDF (n = 3941; 21.5%). RESULTS: Compared with NH decedents with FDF, NH decedents with dementia without FDF members were more likely to be older (mean age 86.5 vs 85.5), female (70.5% vs 59.3%), non-White/Hispanic (9.9% vs 3.2%), divorced/separated/widowed (84.4% vs 61.1%), less educated (<12th grade; 42.2% vs 33.7%), have Medicare and Medicaid (20.8% vs 12.5%), and die in a rural/frontier NH (25.0% vs 23.4%). NH decedents who did not have FDF were also more likely to die from cancer (4.2% vs 3.9%), chronic obstructive pulmonary disease (COPD; 3.9% vs 2.5%), and dementia (40.5% vs 38.4%) and were less likely to have 2+ inpatient hospitalizations at EOL (13.9% vs 16.2%), compared with NH decedents with FDF. CONCLUSIONS: Findings highlight differences in social determinants of health (e.g., sex, race, marital status, education, insurance, rurality) between NH decedents with dementia who do and do not have FDF-factors that may influence equity in EOL care. Understanding the role of family availability and familial characteristics on EOL care outcomes for NH residents with dementia is an important next step to informing NH dementia care interventions and health policies.

"Being careful": How much caution is enough? The relational context of fear of older adult falling in older adult-family caregiver dyads.

Family caregivers play an important role in coping with older adult falls; however, their perspectives on fear of older adult falling are lacking from the falls prevention literature. A mixed-method design (N=25 dyads) with interview and survey data examined linguistic characteristics and coping strategies used by older adult and family caregiver dyads to manage fear of older adult falling. Fear of older adult falling consisted of both affective (e.g., worry) and cognitive (e.g., cautious) properties. Family caregivers more frequently used affective words and first-person plural pronouns ("we" language) when talking about fear of older adult falling, while older adults more frequently used cognitive and first-and-second person singular pronouns ("I", "you"). The concept of "being careful" was shared within dyads. However, dyad partners differed in their perspectives of what constituted "being careful" and the possibilities of future falling. Findings suggest that the need for family-centered interventions to prevent falls are needed.

Preparing for the Future While Living in the Present: Older Adults' Experiences Creating a Legacy of Values.

BACKGROUND AND OBJECTIVES: A legacy of values (e.g., legacy letter) is a nonlegal way to intentionally communicate intangible assets (e.g., values, life lessons, and emotional and supportive instruction) with others. There is scant research on legacy creation outside of a palliative care context, and no studies have explored the experiences of community-dwelling older adults creating a legacy of values. RESEARCH DESIGN AND METHODS: As part of an exploratory sequential mixed methods study, we conducted semistructured interviews with older adults (N = 16) who had previously created a legacy of values. We analyzed transcribed interviews using an interpretive descriptive approach. We iteratively coded interviews deductively with sensitizing concepts identified in the literature (existential well-being, end-of-life preparation and completion, generativity, and resilience), and inductively, based on participants' descriptions. Codes were categorized by patterns of motivations, content, outcomes, and meaning, and thematically summarized. RESULTS: We conceptualized the overall experience of creating a legacy of values as Preparing for the Future While Living in the Present and identified 4 themes: Preserving the Intangible for You and for Me, Sharing What I Want You to Know, Obtaining Peace through Reflection and Preparation, and Living into a Continuing Legacy. Participants attained peace, realized their life was not complete, and were challenged to live intentionally through legacy creation. DISCUSSION AND IMPLICATIONS: Creating a legacy of values may concurrently prepare older adults for the end of life and the remainder of life. These findings offer insight into a generative act that can promote intentional living among older adults.

What is the relationship between falls, functional limitations, and depressive symptoms among Chinese older adults? The role of living alone.

OBJECTIVES: Although the association between falls and depressive symptoms is well documented, the mechanisms underlying this association remain largely unexplored. We investigated the mediation role of functional limitations in the association between falls and depressive symptoms among Chinese older adults and determined whether the living arrangement (living alone or not) is a significant moderator of the above-mentioned mediation pathway. STUDY DESIGN: Cross-sectional study. MAIN OUTCOME MEASURES: Depressive symptoms were measured using the 10-item Center for Epidemiologic Studies Depression Scale short form (CESD-10), on which higher scores indicate higher levels of depressive symptoms. RESULTS: We used the harmonized China Health and Retirement Longitudinal Study national baseline data (2011-2012 year) involving 7410 participants aged 60 years and over. After adjusting for covariates (e.g., age and sex), the effects of falls on depressive symptoms were seen to be mediated by functional limitations among Chinese older adults (ß = 0.82, p < .001). The moderated mediation analysis, which assesses whether an indirect effect is conditional on values of a moderating variable, found that the mediation effect was contingent upon the living arrangement (ß = -0.60, p = .029). Specifically, the levels of functional limitations and depressive symptoms were higher for people with falls who were living with others relative to those living alone. CONCLUSIONS: These results suggest that functional limitations are an important intervening variable that links falls to depressive symptoms among Chinese older adults. Interventions to promote older adults' physical function and prevent falls are recommended to decrease the risk of depressive symptoms. These interventions can particularly benefit those who live with others.

Leaving a lasting legacy: A scoping review of ethical wills.

OBJECTIVES: Palliative care guidelines recommend an interdisciplinary approach to address patients' awareness of mortality and need for end-of-life preparation. An ethical will is a nonlegal way to address mortality by communicating a lasting and intangible legacy of values to others. The aim of this scoping review is to clarify the operationalization of ethical wills across disciplines and map the purposes and outcomes of creating an ethical will. METHODS: We followed the Joanna Briggs Institute methodology for scoping reviews. We searched 14 databases in November 2019 and January 2021 without filtering publication date or type. Two reviewers independently screened 1,948 publications. We extracted frequently used terms describing content, audience, format, purpose, and outcomes identified in ethical will creation. RESULTS: Fifty-one publications met inclusion criteria. Six (11.7%) were research articles. Twenty-four (47.1%) were lay literature published within law, estate, and financial planning. Collectively, our included studies defined an ethical will as a nonlegal way to express values, beliefs, life lessons and experiences, wisdom, love, history, hope for the future, blessings, apology, or forgiveness using any format (e.g., text, audio, video) that is meant to be shared with family, friends, or community. The most common purposes were to be remembered, address mortality, clarify life's meaning, and communicate what matters most. Creation provided opportunity to learn about self, served as a gift to both writer and recipient, and fostered generativity and sense of symbolic immortality. SIGNIFICANCE OF RESULTS: Our findings highlight interdisciplinary utilization and a lack of research of ethical wills. This review provides supportive evidence for ethical wills as a way for patients to address mortality, renew intergenerational connections, solidify self, and promote transcendence before their final days. Ethical wills have potential to be incorporated into interdisciplinary palliative care in the future to address psychological symptoms for patients anticipating the end of life.

Communication Disparities between Nursing Home Team Members.

Optimal care in nursing home (NH) settings requires effective team communication. Certified nursing assistants (CNAs) interact with nursing home residents frequently, but the extent to which CNAs feel their input is valued by other team members is not known. We conducted a cross-sectional study in which we administered a communication survey within 20 Utah nursing home facilities to 650 team members, including 124 nurses and 264 CNAs. Respondents used a 4-point scale to indicate the extent to which their input is valued by other team members when reporting their concerns about nursing home residents. We used a one-way ANOVA with a Bonferroni correction. When compared to nurses, CNAs felt less valued (CNA mean = 2.14, nurse mean = 3.24; p < 0.001) when reporting to physicians, and less valued (CNA mean = 1.66, nurse mean = 2.71; p < 0.001) when reporting to pharmacists. CNAs did not feel less valued than nurses (CNA mean = 3.43, nurse mean = 3.37; p = 0.25) when reporting to other nurses. Our findings demonstrate that CNAs feel their input is not valued outside of nursing, which could impact resident care. Additional research is needed to understand the reasons for this perception and to design educational interventions to improve the culture of communication in nursing home settings.

Working Dynamics of Licensed Nurses and Nurse Aides in Nursing Homes: A Scoping Review.

Collaboration between licensed nurses (LNs) and nurse aides (NAs) is critical in the provision of quality care for residents living in nursing homes (NHs). The current scoping review explores how working dynamics between LNs and NAs in the NH setting are researched and described in the literature. Thirty-five articles were identified and reviewed that address the LN/NA relationship in the context of (a) the LN role as a supervisor and leader; (b) variation in structure; (c) expanding, understanding, and supporting staff roles; and (d) communication. We found that the LN/NA relationship has been primarily explored through the LN lens and often studied in the context of role expansion and revision associated with new models of care. Our contribution to the literature includes the following main points: efforts to improve LN/NA collaboration may be hindered without substantial structural change; collaboration may be limited within the hierarchal LN/NA relationship; LNs and NAs in NHs need greater support, recognition, and empowerment; and NAs require a representative voice. [Journal of Gerontological Nursing, 48(5), 27-34.].

GoFundMe as a Medical Plan: Ecological Study of Crowdfunding Insulin Success.

BACKGROUND: Individuals in need of medical care turn to crowdfunding websites to engage a "crowd" or group for financial support. In the last decade, access to insulin has decreased considerably for several reasons, including the rising cost of insulin, increasing popularity of high-deductible insurance plans, and increasing insurance premiums. Many people with diabetes are forced to ration or go without insulin, and they turn to crowdfunding websites to seek financial donations to purchase insulin needed to reduce health risks and mortality, and sustain quality of life. OBJECTIVE: This study aimed to explore crowdfunding campaign requests to purchase insulin in the United States. METHODS: In this retrospective, quantitative, and qualitative study, we coded the text of GoFundMe online crowdfunding campaigns and viral measures (shares, hearts, and comments) from February 25 to April 15, 2019. We described campaigns (N=205) and explored the factors associated with campaign success using correlations and qualitative thematic analysis. RESULTS: The majority of campaigns were initiated by middle-aged adults (age 26-64 years; 77/205, 37.6%), those with type 1 diabetes (94/205, 45.9%), and those needing funds owing to insurance coverage issues (125/205, 61.0%). The factors associated with campaign success included requests for ≤US $500 (P=.007) and higher viral measures (shares, P=.007; hearts, P<.001; comments, P=.002). The following 4 themes emerged from the campaign text: (1) desire for self-management and survival, (2) diabetes management untenable given insulin access, (3) aftermath of insulin unaffordability, and (4) privacy issues with crowdfunding. Campaign comments were both supportive (tangible, informational, and emotional) and unsupportive (questioned the need for the campaign and deemed crowdfunding inappropriate). CONCLUSIONS: Despite crowdfunding websites being used to support the purchase of insulin, campaigns raised only a fraction of the money requested. Therefore, GoFundMe campaigns are not a reliable solution to obtain funds for insulin in the United States. Applying quantitative and qualitative methods is adequate to analyze online crowdfunding for costs of medications such as insulin. However, it is critical for people with diabetes to use resources other than online crowdfunding to access and obtain insulin owing to low success rates. Clinicians should routinely assess difficulty accessing or affording insulin, and federal health care policies should support lowering the cost of insulin.

The Development and Validation of a Communication Survey Instrument for Long-term Care Staff.

Information transfers in long-term care (LTC) settings between and among providers, staff, residents, and family caregivers are often fragmented. In order to identify training needs to improve communication, a survey instrument was developed and refined to assess the self-efficacy of LTC staff in communicating with staff, providers, residents, and caregivers. This 11-item survey instrument, based on a literature review, covered four key concepts (mutual respect, recognizing and responding to sensory deficits, limited health literacy, and changes in condition) relevant to communicating health information in LTC settings. Ten content experts evaluated each survey item using a 4-point scale. The content validity of the survey was established by using the content validity index to assess results at the item and scale levels. All items scored 0.90 or greater and were retained. Future work should entail broad-scale validation and testing of this survey across the United States. By assessing the self-efficacy of LTC staff in communicating with the interprofessional team, leadership teams can design personalized interprofessional continuing education activities aimed at improving communication skills. [J Contin Educ Nurs. 2022;53(3):123-130.].

Collaboration Between Licensed Nurses and Certified Nurse Aides in the Nursing Home: A Mixed Methods Study.

The current mixed methods study explored how nursing team collaboration is perceived and experienced in four nursing homes (NHs) in the western United States. Licensed nurses (LNs) and certified nurse aides (CNAs) completed two survey tools to assess their perception of collaboration and team-work in their current work environment. LNs and CNAs were paired and interviewed individually and as a caregiving pair to explore the lived experience of collaboration in NH residents' care. Quantitative survey results were analyzed, and participants reported a collaborative working environment with equally strong ratings in the following categories: partnership, cooperation, and coordination; they agreed with statements reflective of teamwork, including team structure, leadership, situation monitoring, mutual support, and communication. No significant differences were found between LN and CNA responses or between team members in any of the four participating facilities. Qualitative survey data were analyzed using a thematic analysis approach. Findings revealed five primary themes, including essential elements in successful team collaboration-perspective, coworker connection, communication, mutual support, and "it makes a difference"-and ways teamwork and collaboration impact resident care. These findings provide rich insights into successful LN/CNA collaboration for academic and clinical LN and CNA educators. [Research in Gerontological Nursing, 15(1), 16-26.].

"I worry about this patient EVERY day": Geriatrics Clinicians' Challenges in Caring for Unrepresented Older Adults.

Unrepresented older adults are at risk for adverse outcomes, and clinicians who care for them may face ethical dilemmas and unique challenges when making person-centered care recommendations. However, little is known about their perspectives on clinical challenges in caring for this population. An online survey was used to assess issues around providing care for unrepresented patients. Ninety-two American Geriatrics Society members working with older adults in inpatient and/or outpatient settings completed the survey. Descriptive qualitative analysis of narrative survey responses identified five broad themes: (a) health risk characteristics of patients, (b) care decisions facing the team, (c) psychosocial considerations by the team, (d) patient outcomes, and (e) burden of the provider and/or health system. These findings demonstrate that geriatrics clinicians face challenges in working with unrepresented adults in both inpatient and outpatient settings. We interpret these results in light of existing literature and propose collaborative approaches that may improve outcomes.

Development of a Long-Term Care Nurse Residency Program.

Nurses working in the long-term care (LTC) setting provide increasingly complex patient care, often without formal training on the specific needs of LTC patients, which can lead to burnout and high turnover rates. Nurse residency programs (NRPs) have been used effectively to orient novice RNs to their work setting, address transition-to-practice challenges, and promote retention, yet few LTC NRPs have been developed. The University of Utah Geriatric Education Consortium Geriatric Workforce Enhancement Program created an online LTC NRP to provide LTC nurses with the knowledge and skills to succeed in the LTC environment. RNs with <1 year of LTC experience were paired with experienced nurse mentors working within the same LTC facility. Synchronous and asynchronous curricular modules addressed leadership and communication, caring for older adult patients, quality improvement, and the LTC regulatory environment. A distance-based LTC NRP allows nurses flexibility in gaining gerontological nursing and leadership expertise that supports their professional goals. [Journal of Gerontological Nursing, 47(2), 37-43.].

Fear of older adult falling questionnaire for caregivers (FOAFQ-CG): Evidence from content validity and item-response theory graded-response modelling.

AIMS: (1) Determine the content validity of the Fear of Older Adult Falling Questionnaire-Caregivers using a panel of gerontological experts and a target sample of family caregivers (Stage 1) and (2) Examine the response patterns of the Fear of Older Adult Falling Questionnaire-Caregivers and compare it with older adult version of Fear of Falling Questionnaire Revised using graded-response modelling (Stage 2). DESIGN: Cross-sectional mixed-method design. METHODS: Five content experts and 10 family caregivers were involved in the Stage 1 study and 53 family caregiver-older adult dyads (N = 106) were included in the Stage 2 study. The content-validity index and graded-response modelling were used to analyse data. RESULTS: Among experts, the Fear of Older Adult Falling Questionnaire-Caregivers content-validity index for relevancy, importance, and clarity of individual items and total scale ranged from 0.60-1.00 and from 0.77-0.87, respectively. Among family caregivers, the ratings of the item and scale level content-validity index for relevancy, importance, and clarity ranged from 0.90-1.00 and from 0.95-0.97, respectively. Combining feedback from both groups, we revised one item. Subsequently, the graded-response modelling revealed that a 1-factor, 3-item version of the Fear of Older Adult Falling Questionnaire-Caregivers had acceptable psychometric properties. CONCLUSIONS: The brief 3-item version of the Fear of Older Adult Falling Questionnaire-Caregivers is promising for assessing caregivers' fear of their older adult care recipient falling. IMPACT: A significant concern for family caregivers is fearing that older adult care recipients will fall, but a lack of validated measures limits the study of this phenomena. A 3-item version of the Fear of Older Adult Falling Questionnaire-Caregivers has the potential to identify family caregivers with high fear of older adult falling so that fall risk can be appropriately assessed and addressed.

Mitigating the Effects of a Pandemic: Facilitating Improved Nursing Home Care Delivery Through Technology.

The coronavirus disease (COVID-19) pandemic has been particularly challenging for nursing home staff and residents. Centers for Medicare & Medicaid Services regulation waivers are burdening staff and affecting how care is delivered. Residents are experiencing social isolation, which can result in physical and behavioral health issues, particularly for persons with dementia. These challenges can be addressed in part through technology adaptations. Full integration of electronic health record systems can improve workflow and care quality. Telehealth can improve access to outside providers, provide remote monitoring, and improve social connectedness. Electronic and audiovisual programs can be used for end-of-life planning and information sharing between nursing home staff and families. Online learning systems and other online resources provide flexible options for staff education and training. Investing in and adapting technology can help mitigate workforce stress and improve the quality of nursing home care during and after the COVID-19 crisis.

Loneliness as a mediator of the impact of social isolation on cognitive functioning of Chinese older adults.

BACKGROUND AND OBJECTIVE: older adults have increased risk of social isolation, loneliness and cognitive functioning impairment, but the relationships among these factors are not conclusive. We investigated the potential mediation mechanism of loneliness on the association between social isolation and cognitive functioning among Chinese older adults within their cultural context. DESIGN: secondary analysis of the baseline wave (2011-12) of the harmonised China Health and Retirement Longitudinal Study. SETTING AND SUBJECTS: community-dwelling older adults in China (N = 7,410 participants aged 60-101 years). METHODS: we applied a multiple indicator multiple cause approach to determine whether the construct of social isolation is well defined by four indicators (social activity engagement, weekly adult children contact, caregiving for grandchildren and living alone) and used structural equation modelling to examine the direct and indirect effects among variables of interest. RESULTS: the results demonstrated that social activity engagement, weekly adult children contact and caregiving for grandchildren were significantly related to social isolation (ß = -0.26 to -0.28) (Living alone was fixed to 1 for model identification.) The indirect effect of social isolation on cognitive functioning through loneliness was significant (ß = -0.15), indicating loneliness was an important mediator. However, the direct effect of social isolation on cognitive functioning also remained significant (ß = -0.83), suggesting a partial mediation effect. CONCLUSIONS: our study highlights the mediation role of loneliness in the relationship between social isolation and cognitive functioning among Chinese older adults. The findings support the beneficial effects of maintaining social relations and coping with feelings of loneliness on older adults' cognitive functioning.

Pivoting to stay the course: How women entrepreneurs take advantage of opportunities created by the COVID-19 pandemic.

COVID-19 is unique in the severity of its impact as it is a humanitarian disaster that has caused both a supply and a demand shock to the global economic system. It has disproportionately affected women entrepreneurs as their firms are younger and smaller. In this commentary, we contend that while all businesses must pivot their business models in times of tumultuous change, simultaneously reducing risk and seizing new opportunities, this is particularly difficult for women entrepreneurs, whose businesses are concentrated in the industry sectors most severely affected by the economic shutdown. We draw on recent survey data from the Diana International Research Institute (DIRI) to identify business model pivots in women-owned businesses, and conclude by offering a set of gendered future research questions.