Trauma-informed patient and public-engaged research: Development and evaluation of an online training programme.

INTRODUCTION: As patients, members of the public, and professional stakeholders engage in co-producing health-related research, an important issue to consider is trauma. Trauma is very common and associated with a wide range of physical and behavioural health conditions. Thus, it may benefit research partnerships to consider its impact on their stakeholders as well as its relevance to the health condition under study. The aims of this article are to describe the development and evaluation of a training programme that applied principles of trauma-informed care (TIC) to patient- and public-engaged research. METHODS: A research partnership focused on addressing trauma in primary care patients ('myPATH') explicitly incorporated TIC into its formation, governance document and collaborative processes, and developed and evaluated a free 3-credit continuing education online training. The training was presented by 11 partners (5 professionals, 6 patients) and included academic content and lived experiences. RESULTS: Training participants (N = 46) positively rated achievement of learning objectives and speakers' performance (ranging from 4.39 to 4.74 on a 5-point scale). The most salient themes from open-ended comments were that training was informative (n = 12) and that lived experiences shared by patient partners were impactful (n = 10). Suggestions were primarily technical or logistical. CONCLUSION: This preliminary evaluation indicates that it is possible to incorporate TIC principles into a research partnership's collaborative processes and training about these topics is well-received. Learning about trauma and TIC may benefit research partnerships that involve patients and public stakeholders studying a wide range of health conditions, potentially improving how stakeholders engage in co-producing research as well as producing research that addresses how trauma relates to their health condition under study. PATIENT OR PUBLIC CONTRIBUTION: The myPATH Partnership includes 22 individuals with professional and lived experiences related to trauma (https://www.usf.edu/cbcs/mhlp/centers/mypath/); nine partners were engaged due to personal experiences with trauma; other partners are community-based providers and researchers. All partners contributed ideas that led to trauma-informed research strategies and training. Eleven partners (5 professionals, 6 patients) presented the training, and 12 partners (8 professionals, 4 patients) contributed to this article and chose to be named as authors.

A Pilot Study of Brief, Stepped Behavioral Activation for Primary Care Patients with Depressive Symptoms.

In a prior pilot study with primary care patients experiencing depressive symptoms, we observed positive outcomes for a behavioral activation protocol involving one visit and three calls. We aimed to pilot test a stepped version with flexible numbers of contacts. Fifteen primary care patients scoring 5-14 on the Patient Health Questionnaire-9 engaged in the three-tiered telephone-based intervention: (1) two calls (15-20 min each); (2) one 30-60 min encounter followed by two calls; and (3) one to six calls. Participants completed assessments at pre-treatment, post-treatment, and three months later. Participants improved from baseline to post-treatment and three months later for depressive symptoms, anxiety symptoms, and disability. Most participants (9 of 15) engaged in the first tier only, averaging less than one hour of contact, and reported benefits and high satisfaction. This intervention showed preliminary evidence of feasibility, acceptability, satisfaction, and benefits, warranting further pilot testing with primary care personnel.

Behavioral activation for live-in migrant home care workers and care recipients in Israel: a pilot study.

In a growing global trend, individuals are migrating to other countries to live with and care for older adults with dementia. Although this trend addresses the geriatric workforce shortage, workers and older adults often experience distress. In a pilot study in Israel, six migrant care workers participated in a six-week group intervention in which they learned to increase valued, enjoyable activities for themselves and the older adult with whom they lived (behavioral activation). After the intervention, workers reported that they increased activities for themselves and the older adult and were satisfied, and quality of life and sense of achievement showed medium and large effect sizes, respectively. Participants suggested adapting the intervention to an online format for greater access. Although findings are tentative, the study points to promising strategies for migrant home care workers: focusing on the worker and older adult and offering online interventions.

Enhancing care transitions intervention with peer support to improve outcomes among older adults with co-occurring clinical depression: a pilot study.

The Care Transitions Intervention (CTI) is an evidence-based intervention aimed at supporting the transition from hospital back to the community for patients to ultimately reduce preventable re-hospitalization. In a pilot randomized controlled trial, we examined the preliminary effectiveness of an Enhanced Care Transitions Intervention (ECTI), CTI with the addition of peer support, for a racially/ethnically diverse sample of older adults (age 60+) with co-morbid major depression. We observed a significant decline in health-related quality of life (HRQOL) after being discharged from the hospital among those who received CTI. Additionally, those who received ECTI either maintained HRQOL scores, or, saw improvement in HRQOL scores. Findings suggest the Enhanced Care Transitions Intervention can maintain or improve HRQOL and reduce disparities for older participants from diverse racial/ethnic backgrounds with clinical depression.

Self-perceptions of aging mediate the longitudinal relationship of hopelessness and depressive symptoms.

OBJECTIVES: The purpose of the current study was to examine the hypothesis that the prospective relationship between hopelessness and depressive symptoms is mediated by self-perceptions of aging. METHODS: Data from 3 waves of the US Health and Retirement Study (2008, 2012, and 2014) were used (N = 4606; age M = 65.3, 55.5% female). In mediation analyses, hopelessness in 2008 was the independent variable, self-perceptions of aging in 2012 were the mediator, and depressive symptoms in 2014 were the outcome variable. RESULTS: After controlling for covariates, hopelessness in 2008 was an independent predictor of self-perceptions of aging in 2012 (ß = -.10, P < .001), and self-perceptions of aging in 2012 was an independent predictor of depressive symptoms in 2014 (ß = -.41, P < .001). Hopelessness in 2008 showed both direct (ß = .09, P < .001) and indirect (ß = .03, P < .001) effects on depressive symptoms in 2014, indicating partial mediation by change in self-perceptions of aging. CONCLUSIONS: As hypothesized, change in self-perceptions of aging partially mediated the relationship of hopelessness with depressive symptoms 6 years later. Findings are consistent with a conceptualization of hopelessness as broad negative expectations about the future that may contribute to negative self-perceptions of aging and subsequent changes in depressive symptoms. Reducing hopelessness, increasing hope, and improving self-perceptions of aging have potential to reduce and prevent depressive symptoms for older adults. Future research should examine the mechanisms of these interrelationships and other aging outcomes.

Grip strength and quality of life in the second half of life: hope as a moderator.

OBJECTIVES: The purpose of the current study was to investigate grip strength, hope, and their interaction as predictors of quality of life four years later in a nationally representative sample of older adults. METHOD: Data were derived from the first (2005-2006) and second wave (2009) of the Israeli component of the Survey of Health Ageing and Retirement in Europe (SHARE; N = 344). Hope was measured by three items from the Hope   Scale, and quality of life was measured by the CASP-12 (Control, Autonomy, Self-Realization, and Pleasure). Multiple regression analyses were conducted. RESULTS: Grip strength at T1 predicted QoL in T2, but hope was not a significant predictor. Furthermore, hope moderated the effect of handgrip on QoL, such that the effect was weaker for higher levels of hope. CONCLUSION: As hypothesized, hope acted as a moderator, such that poor grip strength was associated with worse QoL for less hopeful older adults, but grip strength was not associated with QoL for more hopeful older adults. Findings are consistent with a theoretical conceptualization of hope as a buffer between physical challenges and negative outcomes like QoL. Encouraging a hopeful perspective could enhance QoL for older adults with decreased muscle strength.

Longitudinal associations of hopelessness and loneliness in older adults: results from the US health and retirement study.

BACKGROUND: Hopelessness and loneliness are potent risk factors for poor mental and physical health in later life, although the nature of their relationships with each other over time is not clear. The aim of the current study was to examine relationships between hopelessness and loneliness over an eight-year study period. METHODS: Three waves of data from the US Health and Retirement Study (2006, 2010, 2014) were used to test a cross-lagged model of hopelessness and loneliness (N = 7,831), which allows for the simultaneous evaluation of the reciprocal associations of loneliness and hopelessness. Age in 2006, gender, years of education, number of medical conditions, and depressive symptoms were included as covariates. RESULTS: The autoregressive effects of loneliness (B (SE) = 0.63 (0.02), p < 0.001) and hopelessness (B (SE) = 0.63 (0.02), p < 0.001) were substantive and significant across the three waves, pointing to the stability of both constructs over the eight-year study period. The lagged effect of loneliness on hopelessness was non-significant (B (SE) = 0.05 (0.03), p = 0.16), whereas the lagged effect of hopelessness on loneliness was significant (B (SE) = 0.01 (0.01), p = 0.03). These lagged effects were not significantly different from each other, however, χ2 (1) = 2.016, p = 0.156. CONCLUSIONS: Participants who were more hopeless tended to become lonelier four years later, but lonelier participants did not become more hopeless four years later. Findings are tentative given the small magnitude and lack of difference between the cross-lagged effects. Future directions include replicating these findings in different samples and time frames, examining potential mechanisms of relationships between hopelessness and loneliness, and potential intervention strategies that might improve both conditions.

One-Visit Behavioral Intervention for Older Primary Care Patients with Mild to Moderate Depressive Symptoms.

OBJECTIVES: We pilot tested a one-visit behavioral intervention with telephone follow-up for older primary care patients with mild to moderate depressive symptoms. METHODS: A total of 16 English-speaking primary care patients aged 60 years and older who scored 5 to 14 on the Patient Health Questionnaire-9 (PHQ-9) engaged in the intervention visit. Outcomes were assessed at baseline and 4 weeks: activity goals, readiness to change (University of Rhode Island Change Assessment), PHQ-9, Generalized Anxiety Disorder-7, World Health Organization Disability Assessment Schedule 2.0, and satisfaction. RESULTS: The 14 participants who completed the study met or exceeded 73% of activity goals on average. They also improved on all outcomes (P < 0.05) with medium (University of Rhode Island Change Assessment, GAD-7) to large effect sizes (PHQ-9, World Health Organization Disability Assessment Schedule 2.0), and they were satisfied. CONCLUSIONS: This pilot study provided preliminary evidence that a one-visit behavioral activation intervention is acceptable and feasible and improves outcomes. If findings are confirmed, then this intervention could be integrated into existing collaborative care programs.

Screening, Brief Intervention, and Referral to Treatment for Older Adults With Substance Misuse.

Objectives. We compared substance use and SBIRT (Screening, Brief Intervention, and Referral to Treatment) services received for older adults screened by the Florida BRITE (BRief Intervention and Treatment of Elders) Project, across 4 categories of service providers. Methods. Staff from 29 agencies screened for substance use risk in 75 sites across 18 Florida counties. Clients at no or low risk received feedback about screening; moderate risk led to brief intervention, moderate or high risk led to brief treatment, and highest severity led to referral to treatment. Six-month follow-ups were conducted with a random sample of clients. Results. Over 5 years (September 15, 2006-September 14, 2011), 85 001 client screenings were recorded. Of these, 8165 clients were at moderate or high risk. Most received brief intervention for alcohol or medication misuse. Differences were observed across 4 categories of agencies. Health educators screening solely within medical sites recorded fewer positive screens than those from mental health, substance abuse, or aging services that screened in a variety of community-based and health care sites. Six-month follow-ups revealed a significant decrease in substance use. Conclusions. The Florida BRITE Project demonstrated that SBIRT can be extended to nonmedical services that serve older adults.

Improving home-based providers' communication to primary care providers to enhance care coordination.

OBJECTIVES: Health care system fragmentation is a pervasive problem. Research has not delineated concrete behavioral strategies to guide providers to communicate with personnel in other organizations to coordinate care. We addressed this gap within a particular context: home-based providers delivering depression care management (DCM) to older adults requiring coordination with primary care personnel. Our objective was to pilot test a communication protocol ('BRIDGE - BRinging Inter-Disciplinary Guidelines to Elders') in conjunction with DCM. METHOD: In an open pilot trial (N = 7), home-based providers delivered DCM to participants. Following the BRIDGE protocol, home-based providers made scripted telephone calls and sent structured progress reports to personnel in participants' primary care practices with concise information and requests for assistance. Home-based providers documented visits with participants, contacts to and responses from primary care personnel. A research interviewer assessed participant outcomes [Symptom Checklist-20 (depressive symptoms), World Health Organization Disability Assessment Schedule-12, satisfaction] at baseline, three months, and six months. RESULTS: Over 12 months, home-based providers made 2.4 telephone calls and sent 6.3 faxes to other personnel, on average per participant. Primary care personnel responded to 18 of 22 requests (81.8%; 2 requests dropped, 2 ongoing), with at least one response per participant. Participants' depressive symptoms and disability improved significantly at both post-tests with large effect sizes (d ranged 0.73-2.3). Participants were satisfied. CONCLUSION: Using BRIDGE, home-based providers expended a small amount of effort to communicate with primary care personnel, who responded to almost all requests. Larger scale research is needed to confirm findings and potentially extend BRIDGE to other client problems, professions, and service sectors.

Older adults display concurrent but not delayed associations between life stressors and depressive symptoms: a microlongitudinal study.

OBJECTIVES: The present study investigated the temporal association between life event stressors relevant to older adults and depressive symptoms using a micro-longitudinal design (i.e., monthly increments over a six-month period). Existing research on stress and depressive symptoms has not examined this association over shorter time periods (e.g., monthly), over multiple time increments, or within-persons. DESIGN: An in-person initial interview was followed by six monthly interviews conducted by telephone. SETTING: Community. PARTICIPANTS: Data were drawn from a study of 144 community-dwelling older adults with depressive symptoms. MEASUREMENTS: Stressful life events were measured using the Geriatric Life Events Scale (GALES), and depressive symptoms were assessed with the Short - Geriatric Depression Scale (S-GDS). RESULTS: Using multilevel modeling, 31% of the S-GDS' and 39% of the GALES' overall variance was due to within-person variability. Females and persons with worse health reported more depressive symptoms. Stressful life events predicted concurrent depressive symptoms, but not depressive symptoms one month later. CONCLUSIONS: The lack of a time-lagged relationship suggests that older adults with depressive symptoms may recover more quickly from life stressors than previously thought, although additional research using varying time frames is needed to pinpoint the timing of this recovery as well as to identify older adults at risk of long-term effects of life stressors.

Six-month utilization of psychotherapy by older adults with depressive symptoms.

We explored psychotherapy utilization patterns for community-dwelling older adults with depressive symptoms identified during a statewide initiative designed for identifying risk of substance misuse. Individuals screening negative for substance misuse, but positive for depressive symptoms, agreed to participate in monthly interviews conducted over 6 months (n = 144). Results showed that 39 (27%) received psychotherapy, of which nearly two-thirds reported four or fewer visits. Mental health counselors were the most frequently reported service providers (50-62.5%). Location of service varied considerably. This study documents low rates of psychotherapy use and few visits. Current efforts to increase psychotherapy access are discussed.

Screening and Priority-Setting to Determine Home- and Community-Based Aging Services for Older Floridians.

The National Aging Network serves millions of older Americans seeking home- and community-based services, but places others on waitlists due to limited resources. Little is known about how states determine service delivery and waitlists. We therefore conducted a process evaluation and analyzed data from one five-county Area Agency on Aging in Florida, where an algorithm calculates clients' priority scores for service delivery. From 23,225 screenings over 5.5 years, clients with higher priority scores were older, married, living with caregivers, and had more health problems and needs for assistance. Approximately 51% received services (e.g., meals/nutrition, case management, caregiver support), 11% were eligible/being enrolled, and 38% remained on waitlists. Service status was complex due to multiple service enrollments and terminations, funding priorities, and transfers to third-party providers. More research is needed regarding how other states determine eligibility and deliver services, potentially informing national standards that promote optimal health in older Americans.

The relationships between major lifetime discrimination, everyday discrimination, and mental health in three racial and ethnic groups of older adults.

OBJECTIVES: To evaluate the relationships between perceived exposure to major lifetime discrimination, everyday discrimination, and mental health in three racial/ethnic groups of older adults. DESIGN: The Health and Retirement Study is a nationally representative sample of individuals 50 years and older living in the United States. A total of 6455 Whites, 716 Latinos, and 1214 Blacks were eligible to complete a self-report psychosocial questionnaire in the year 2006. RESULTS: Whereas 30% of the general population reported at least one type of major lifetime discrimination, almost 45% of Black older adults reported such discrimination. Relative to the other two racial/ethnic groups (82% Whites, 82.6% Blacks), Latinos were significantly less likely to report any everyday discrimination (64.2%), whereas Blacks reported the greatest frequency of everyday discrimination. Whites reported the highest levels of life satisfaction and the lowest levels of depressive symptoms. Relative to major lifetime discrimination, everyday discrimination had a somewhat stronger correlation with mental health indicators. The relationships between discrimination and mental health outcomes were stronger for White compared to Black older adults, although everyday discrimination was still significantly associated with outcomes for Black older adults. CONCLUSIONS: Black older adults experience the greatest number of discriminative events, but weaker associated mental health outcomes. This could be because they have become accustomed to these experiences, benefit from social or cultural resources that serve as buffers, or selective survival, with the present sample capturing only the most resilient older adults who have learned to cope with the deleterious effects of discrimination.

Behavioral health service utilization and preferences of older adults receiving home-based aging services.

OBJECTIVE: To examine use of behavioral health services, treatment preferences, and facilitators and barriers to service use in older adults receiving home-based services within the aging network. DESIGN: Cross-sectional survey. SETTING: Interviews were conducted in participants' homes. PARTICIPANTS: One hundred forty-two clients receiving home-based aging services. MEASUREMENTS: Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition; Brief Symptom Inventory-18; Discrimination-Devaluation Scale; utilization of behavioral health services; and preferences, facilitators, and barriers for behavioral health services. RESULTS: Use of psychotropic medication was high (54.2%), primarily received in primary care settings (58.8%), with a few visits a year (54.0%). Participants were more likely to be taking psychotropic medication if they were younger and white. Approximately one-third of participants on antidepressant or antianxiety medication still met criteria for an Axis I disorder. Twenty-one participants (14.8%) reported receiving counseling within the past year, with a few visits or less a year for most (57.1%). Almost all were willing to see at least one professional (97.2%) and try prescribed medications or counseling (90.1%). The most common barriers to service use were practical: affordability (71.8%), difficulty traveling (62.7%), and lack of transportation (45.8%). CONCLUSIONS: Aging network clients receiving home-based services have ready access to psychotropic medications but receive very few specialty behavioral health services and medication monitoring visits. They are willing to use a variety of behavioral health services and perceive mainly practical barriers to using services. The aging network has significant potential to enhance access to service utilization; strategies for integrating behavioral health services in the aging network are discussed.

Predictors of preventable nursing home hospitalizations: the role of mental disorders and dementia.

OBJECTIVES: Nursing home (NH) hospitalizations place an enormous economic burden on an already overtaxed American healthcare system. Hospitalizations for "ambulatory care-sensitive" (ACS) conditions are considered preventable, as these are physical health conditions that can potentially be treated safely in a NH. The authors examined risk factors, including mental disorders and dementia, for hospitalization of Medicaid-enrolled NH residents with ACS conditions during fiscal year 2003-2006. METHODS: The authors merged Medicaid claims and enrollment data and Online Survey Certification and Reporting information for 72,251 Medicaid-enrolled NH residents in 647 NHs in Florida. The authors identified at least one ACS hospitalization in 8,382 residents for a total of 10,091 hospital admissions (18.5% of all hospitalizations). The authors used Cox proportional hazard regression to assess time to the first ACS hospitalization. RESULTS: In a fully adjusted model, younger age, non-white race, dementia, and serious mental disorder were associated with greater risk of ACS hospitalization. In addition, residents with a diagnosed mental disorder and no dementia incurred relatively high expenditures for ACS hospitalizations. Among facility characteristics, participants from for-profit facilities, facilities that were not a member of a chain, had more Medicaid recipients, and fewer than 120 beds had greater risk of ACS hospitalizations. CONCLUSIONS: Attention to the identified predictors of hospitalization for ACS conditions, which are potentially preventable, could reduce the risk and cost of these hospitalizations among Medicaid-enrolled NH residents. The need to reduce unnecessary hospitalization will become only more urgent as the population ages and healthcare expenses continue to escalate.

Evaluation of the factor structure and psychometric properties of the Brief Symptom Inventory-18 with homebound older adults.

OBJECTIVE: Homebound older adults are at high risk for depression and anxiety. Systematic screening may increase identification of these difficulties and facilitate service usage. The purpose of this study was to investigate the factor structure, internal consistency, and concurrent validity of the Brief Symptom Inventory-18 (BSI-18) for use as a screening instrument for depression and anxiety with homebound older adults and to examine if the BSI-18 could be shortened further and exhibit comparable psychometric properties. METHODS: A sample of 142 older adults receiving in-home aging services completed interviews that included the BSI-18 and the depression and anxiety modules of the structured clinical interview for DSM-IV. RESULTS: Confirmatory factor analysis showed that the theorized three-factor, second-order model of the BSI-18 fit the data well (S-B X(2) = 136.17; p = 0.36). The depression and anxiety subscales exhibited high internal consistency (alpha > 0.81), whereas the somatic subscale exhibited lower internal consistency (alpha = 0.69). Receiver operator curve (ROC) analyses suggest that the BSI-18 depression and anxiety subscales were able to predict those with DSM-IV diagnoses (Depression AUC = 0.89 p < 0.001; Anxiety AUC = 0.80, p < 0.001). The ROC results suggested adapting a cut score of T = 50 to achieve optimal sensitivity and specificity. The short three-item depression scale exhibited comparable psychometric properties to the full scale, while the three-item somatic and anxiety scales exhibited lower internal consistency and sensitivity. CONCLUSIONS: These findings provide initial evidence that the BSI-18 is valid for use with homebound older adults.

Moving to a Continuing Care Retirement Community or Staying in the Community? A Comparison Between American and Israeli Older Adults.

Using the theory of diffusion of innovations, this study examined differences between American and Israeli older adults who decided to move to continuing care retirement communities (CCRC) and American and Israeli older adults who decided to stay at home. A total of 101 American participants (52 residents, 49 nonresidents) and 154 Israeli participants (104 residents, 50 nonresidents) completed measures of attitudes toward CCRCs, well-being, limitations in daily living, health status, proximity to services, and collectivism. Americans were more likely to relocate to CCRCs compared with staying at home when they reported positive attitudes toward CCRCs, higher well-being, and poorer subjective health. Among Israelis, positive attitudes toward CCRCs, better subjective health, and higher collectivism were associated with moving to CCRCs compared with staying at home. This study has implications for facilitating older adults' decision-making and CCRC policies, as findings point to potential sources of influence on older adults' decision to relocate.

Longitudinal Analysis of Mortality for Older Adults Receiving or Waiting for Aging Network Services.

OBJECTIVES: For older adults screened by an Area Agency on Aging (AAA) in the National Aging Network, we aimed to examine the 12-month mortality rate for wait-listed callers compared with those who received services within 12 months, and to assess whether the mortality rate differed according to how quickly they received services. DESIGN: The design was a longitudinal analysis of 3 years of AAA administrative data, using survival analysis. SETTING: The data source was administrative data from an AAA spanning a five-county region in west central Florida. PARTICIPANTS: All older adults (age 60 y and older) screened for service eligibility from July 15, 2013, to August 15, 2015, who completed initial screening during the study period were included (N = 6288). MEASUREMENTS: The outcome was mortality within 12 months of the initial screening. Covariates included demographics, caregiver status, health status, access to healthcare, and AAA service status. RESULTS: In the first survival analysis, the strongest predictor was waiting for services compared with receiving services; waiting increased the odds to die vs not to die by 141%, after controlling for health status and other covariates. In the second survival analysis, those who received services within 0 to 3 months had a higher mortality risk compared with those who received services within 6 to 9 months or 9 to 12 months. CONCLUSION: Older adults placed on aging service waiting lists may be at a greater risk of mortality within 12 months than those receiving services. Given that rapid receipt of services was less protective than receiving services later, those prioritized to receive services quickly may be at very high risk of adverse outcomes. Findings raise the possibility that aging services may lower mortality, although additional services may benefit those waiting long periods for services, as well as those eligible for services rapidly. Research is needed to replicate and extend these findings. J Am Geriatr Soc 68:519-525, 2020.