Objective and perceived service accessibility and mental health in older adults.

OBJECTIVES: Service accessibility plays a pivotal role in older adults' mental health. However, accessibility measures used in previous studies are either objective or perceived. This study aimed to integrate both objective and perceived measures of service accessibility to explore the relationship between environmental cognition on service accessibility and mental health in older adults and the pathways. METHODS: We used both questionnaire data collected from 2,317 older adults in Hong Kong and geographical data to explore the direct and indirect effect of environmental cognition (i.e. positive, negative, and matching evaluation) relating to service accessibility on mental health and two pathways (i.e. physical activity and sense of belonging) based on a structural equation model. RESULTS: Physical activity mediated the positive relationship between non-negative perceptions toward access to convenience stores, leisure facilities, clinics, community centers, places of worship and mental health. Sense of community can significantly mediate the positive relationships between non-negative perceptions toward all 10 types of services and mental health. CONCLUSION: This study provides an empirical contribution to environmental cognition theory and person-environment fit theory; its findings have implications for urban planning policy.

The findings from this study provide significant evidence that environmental cognition distortion, especially negative perception, can be significantly associated with lower mental health through physical activity and a sense of community. This suggests that policies focused on changing environmental cognitions could be a promising public health strategy. Environmental cognition theory suggests that improving awareness of setting could help improve the precision of cognitive mapping of environmental reality. This can be very important where it is difficult to change the objective environment due to the deep-rooted and long-standing urban structure.

Non-Pharmacological Interventions for Chronic Pain in Older Adults: A Systematic Review and Meta-Analysis.

BACKGROUND AND OBJECTIVES: Gate control theory and fear-avoidance model of chronic pain posit that biopsychosocial factors can modulate pain. Non-pharmacological interventions are recommended in managing chronic pain, but little information is available regarding their efficacy in older adults. We examined and compared the efficacy of different non-pharmacological intervention approaches for chronic pain management among older adults via meta-analysis and subgroup analysis. RESEARCH DESIGN AND METHODS: Following the PRISMA guidelines (PROSPERO number CRD42020222767), a systematic search was undertaken using MEDLINE, Embase, and PsycINFO up to 21 March 2022. Randomized controlled trials were included, and data were pooled using a random-effects meta-analysis model. Risk of bias was assessed using a quality rating scale for psychological interventions. RESULTS: Twenty-five trials (N = 2394 participants) were identified. Six types of non-pharmacological interventions were compared with control conditions (sham/attention control and treatment as usual). Non-pharmacological interventions were associated with significant reductions in pain intensity, pain interference, depressive symptoms and catastrophizing beliefs and improvement in physical performance (standardized mean differences [SMDs] -0.34 to 0.54). Subgroup analyses based on different non-pharmacological approaches revealed the benefits of psychological approaches combined with physical activity. DISCUSSION AND IMPLICATIONS: Non-pharmacological interventions, particularly those adopting psychological approaches and physical activity, have a small but statistically significant effect on chronic pain management in older adults. Reduction in pain interference may be related to reduced catastrophizing beliefs, thus providing support for the fear-avoidance model. Further research with adequate power is needed to establish the efficacy and mechanism of various intervention modalities for older adults.

Projecting the 10-year costs of care and mortality burden of depression until 2032: a Markov modelling study developed from real-world data.

Background: Based on real-world data, we developed a 10-year prediction model to estimate the burden among patients with depression from the public healthcare system payer's perspective to inform early resource planning in Hong Kong. Methods: We developed a Markov cohort model with yearly cycles specifically capturing the pathway of treatment-resistant depression (TRD) and comorbidity development along the disease course. Projected from 2023 to 2032, primary outcomes included costs of all-cause and psychiatric care, and secondary outcomes were all-cause deaths, years of life lived, and quality-adjusted life-years. Using the territory-wide electronic medical records, we identified 25,190 patients aged ≥10 years with newly diagnosed depression from 2014 to 2016 with follow-up until 2020 to observe the real-world time-to-event pattern, based on which costs and time-varying transition inputs were derived using negative binomial modelling and parametric survival analysis. We applied the model as both closed cohort, which studied a fixed cohort of incident patients in 2023, and open cohort, which introduced incident patients by year from 2014 to 2032. Utilities and annual new patients were from published sources. Findings: With 9217 new patients in 2023, our closed cohort model projected the 10-year cumulative costs of all-cause and psychiatric care to reach US$309.0 million and US$58.3 million, respectively, with 899 deaths (case fatality rate: 9.8%) by 2032. In our open cohort model, 55,849-57,896 active prevalent cases would cost more than US$322.3 million and US$60.7 million, respectively, with more than 943 deaths annually from 2023 to 2032. Fewer than 20% of cases would live with TRD or comorbidities but contribute 31-54% of the costs. The greatest collective burden would occur in women aged above 40, but men aged above 65 and below 25 with medical history would have the highest costs per patient-year. The key cost drivers were relevant to the early disease stages. Interpretation: A limited proportion of patients would develop TRD and comorbidities but contribute to a high proportion of costs, which necessitates appropriate attention and resource allocation. Our projection also demonstrates the application of real-world data to model long-term costs and mortality, which aid policymakers anticipate foreseeable burden and undertake budget planning to prepare for the care need in alternative scenarios. Funding: Research Impact Fund from the University Grants Committee, Research Grants Council with matching fund from the Hong Kong Association of Pharmaceutical Industry (R7007-22).

Hybrid-delivered community psychoeducation for people aged 50 and older: A mixed-method evaluation and lesson learned.

Introduction: Hybrid training mode comprising in-person and teleconferencing sessions is effective and sustainable, yet no standardized principles guide its development for older people. This study aimed to develop a set of principles for hybrid-mode psychoeducation for older people from the experiences of middle-aged and older people in two folds: (1) examining the effects of hybrid-mode community psychoeducation and (2) identifying features that could enhance participants' experience. Methods: We delivered 12-hour Older Person Mental Health First Aid and 3-hour late-life depression training to adults aged 50 and older in in-person and hybrid modes. Hybrid group participants received technology-related support, including in-advance training and on-site support. All participants completed assessments on depression literacy, depression stigma, meaning in life, social support, depressive symptoms, and anxiety pre-and post-intervention and evaluated the program in open-ended questions. Results: A total of 471 in-person and 346 hybrid group participants completed the psychoeducation and post-assessment (80.4 % female, mean age = 64.73 years, SD = 7.29). Linear mixed models revealed improvements in depression literacy, depression stigma, meaning in life, social support, and anxiety (B = -1.43 to 0.13, all p < .001), with no significant difference between in-person and hybrid groups. Thematic analysis of open-ended questions identified three themes: (1) informational content with case studies, (2) hardcopy course handouts, and (3) interactive learning environment. Discussion/conclusion: Hybrid-mode and in-person psychoeducation had comparable benefits on middle-aged and older people. The TORCH principles, an acronym for Technology provision, On-site technical support, Rehearsal, Connection with group members, and Hardcopy notes, was derived from practice wisdom and qualitative findings to support older people in online learning.

A core competency framework for mental health peer supporters of older adults in a Chinese community: cross-culturally informed Delphi study.

AIMS AND METHOD: Non-Western literature on the core competencies of mental health peer supporters remains limited. Therefore, we used a three-round Delphi study with peer supporters, service users (i.e. someone using peer support services) and mental health professionals to develop a core competency framework for peer supporters in the Chinese context. RESULTS: The final framework included 35 core competencies, the conceptual origins of which were local (14.3%), Western (20%) and both local and Western (65.7%). They were grouped into five categories in ascending peer supporter role specificity: (1) self-care and self-development, (2) general work ethics, (3) work with others, (4) work with service users and (5) peer support knowledge. CLINICAL IMPLICATIONS: A culturally valid mental health peer support competency framework can minimise role confusion and refine training and practice guidelines. In a Chinese context, peer supporters were valued as generic support companions, whereas functions highlighted in the West, such as role modelling, were perceived as less critical.

Technology Affordance in an Information and Communication Technology Delivered Group Psychotherapy and Exercise Program for Older People With Depressive Symptoms: A Multiple Triangulation Qualitative Study.

Background and Objectives: Health and mental health interventions, such as psychotherapy and exercise programs, delivered via information and communication technology (ICT) may improve service access. However, adjustment among older people and in synchronous group interventions is more challenging. Technology affordance concerns the possibilities engendered by technology for various users and purposes and can help understand challenges in ICT-delivered groups and identify possible solutions. Research Design and Methods: Adopting a multiple triangulation approach, we observed ICT-delivered groups of acceptance and commitment therapy and exercise for older people with depressive symptoms, conducted focus groups with older people who had received group psychotherapy with or without an exercise component, and obtained clinical notes from interventionists. We conducted a thematic analysis of the observation notes, focus group transcriptions, and clinical notes. Results: Four focus groups were conducted with 22 participants (mean age = 72.6 years, standard deviation = 7.2, 86% female). We identified 3 challenges: (1) seeing-be seen dilemma, (2) speaking-hearing dilemma, and (3) blurred therapy-home boundary, and 2 solutions: (1) maneuvering layouts and collaborative tools, and (2) cross-platform mediated strategies. Participants struggled to observe the interventionist while simultaneously demonstrating their posture in front of a camera. Remaining silent and moderated turn-taking allowed for clearer hearing but limited interactions. Interruptions from the background environment and intersections of family living spaces disrupted audio-visual communication and jeopardized the sense of security. As a solution, interventionists maneuvered layouts and collaborative tools on teleconferencing applications to achieve intervention goals and provided support through different media. Discussion and Implications: The identified challenges and potential solutions can be understood from interactivity, portability, temporality, persistence, and multimediality. Technology affordance can guide ICT-delivered group design by matching the affordance of various technologies and communication media with the characteristics of the intervention and users to enhance efficacy and avoid an unnecessary digital divide.

Threats to personhood from within the family? A study of family caregivers of people with dementia in the Chinese context.

BACKGROUND AND OBJECTIVES: Dementia care creates ethical and legal dilemmas due to the struggle to balance the quality of care and personhood. Disagreement and conflict in caregiving relationships are common. However, limited attention has been given to particular stressful circumstances, such as care practice and decision disagreements. Moreover, the cultural context of personhood has been overlooked. This study drew on Hong Kong family caregivers' reports of their cargiving practice and disagreements with care recipients about care-related decisions and their implications for personhood to identify person-centered family care support needs. RESEARCH DESIGN AND METHODS: We conducted 18 semi-structured interviews with family caregivers of people with dementia in Hong Kong, China. Participants were asked to share their family dementia caregiving experience and practice, specifically regarding decisions and practices that elicited disagreement. We used thematic analysis to analyze data generated from interviews. RESULTS: Six caregiver practices were identified: exchange for mutual agreement, a foot-in-the-door approach, acceptance of requests/behaviors contrary to the caregivers' views, infantilization, treachery, and exclusion and imposition. DISCUSSION AND IMPLICATIONS: These findings highlight the importance of providing support and guidelines for person-centered care to promote personhood in the family caregiving context in dementia care.

"Participation Is Fun and Empowering": A Participatory Approach to Co-Design a Cultural Art Program for Older Chinese at Risk of Depression in Hong Kong.

Background and Objectives: Internalized ageism and stigma of mental illness may disempower older people and impede help-seeking among those at risk of depression. Arts are deemed enjoyable, stigma-free, and conducive to mental health, and a participatory approach can engage and empower potential service users. This study aimed to co-design a cultural art program and test its feasibility in empowering older Chinese people in Hong Kong and preventing depression. Research Design and Methods: Adopting a participatory approach and guided by the Knowledge-to-Action framework, we co-designed a 9-session group art program using Chinese calligraphy as the channel for gaining emotional awareness and facilitating expression. The iterative participatory co-design process engaged 10 older people, 3 researchers, 3 art therapists, and 2 social workers through multiple workshops and interviews. We tested the program's acceptability and feasibility in 15 community-dwelling older people at risk of depression (mean age = 71.6). Mixed methods were used, including pre- and postintervention questionnaires, observation, and focus groups. Results: Qualitative findings suggest the feasibility of the program, and quantitative findings indicated its effects in increasing empowerment (t(14) = 2.82, p < .05), but not in other mental health-related measurements. Participants reflected that active participation and learning new art skills were fun and empowering, arts enabled them to gain insight into and express deeper feelings, and groups with peers made them feel relatable and accepted. Discussion and Implications: Culturally appropriate participatory arts groups can effectively promote empowerment in older people, and future research should balance eliciting meaningful personal experiences and measurable changes.

Dimensionality and risk factors of the personal stigma of depression in adults aged 50 years and older at risk of depression.

Objectives: Knowledge about the mechanism of the personal stigma of depression may inform strategies to reduce stigma and promote help-seeking. We examined the dimensionality and risk factors of the personal stigma of depression in older adults at risk of depression.Methods: Seven-hundred and one Hong Kong adults aged 50 years and older at risk of depression completed the personal stigma subscale of the depression Stigma Scale (DSS-personal) at two-time points. We used exploratory factor analysis (EFA) to explore the factor structure of DSS personal and confirmatory factor analysis to examine the model fit of the EFA-informed factor structure and structures proposed in previous studies. Regression analyses examined the relationships between risk factors and personal stigma dimensions.Results: Factor analyses identified a 3-factor structure of DSS-personal resembling the social-cognitive model consistent over time and included stereotype, prejudice, and discrimination (CFI = 0.95, TLI = 0.92, RMSEA = 0.05). Regression analyses indicated all stigma dimensions were associated with older age, less education, and no personal history of depression (B = -0.44 to 0.06); discrimination was also associated with more depressive symptoms (B = 0.10 to 0.12).Conclusion: Findings illustrated the potential theoretical underpinning of DSS-personal. Stigma reduction interventions could target and tailor to older adults with risk factors to enhance effectiveness and promote help-seeking.

Depression risk among community-dwelling older people is associated with perceived COVID-19 infection risk: effects of news report latency and focusing on number of infected cases.

Awareness of COVID-19 infection risk and oscillation patterns ('waves') may affect older people's mental health. Empirical data from populations experiencing multiple waves of community outbreaks can inform guidance for maintaining mental health. This study aims to investigate the effects of COVID-19 infection risk and oscillations on depression among community-dwelling older people in Hong Kong.A rolling cross-sectional telephone survey method was used. Screening for depression risk was conducted among 8,163 older people (age ≥ 60) using the Patient Health Questionnaire-2 (PHQ-2) from February to August 2020. The relationships between PHQ-2, COVID-19 infection risk proxies - change in newly infected cases and effective reproductive number (Rt), and oscillations - stage of a 'wave' reported in the media, were analysed using correlation and regression.8.4% of survey respondents screened positive for depression risk. Being female (ß = .08), having a pre-existing mental health issue (ß = .21), change in newly infected cases (ß = .05), and screening during the latency period before the media called out new waves (ß = .03), contributed to higher depression risk (R2 = .06, all p <.01).While depression risk does not appear alarming in this sample, our results highlight that older people are sensitive to reporting of infection, particularly among those with existing mental health needs. Future public health communication should balance awareness of infection risks with mental health protection.

Neighborhood built environments and cognition in later life.

Objectives: Maintaining good cognition is crucial in later life. However, most existing research has focused on individual factors impacting cognition, and few studies have investigated the association between neighborhood built environment and older adults' cognition. This study examined the association between neighborhood built environment and cognition among community-dwelling older adults and identified variations in this association between different age groups in the older population.Methods: Data were derived from a cross-sectional survey of 1873 people aged 65 years and above in Hong Kong. We merged individual data from the survey with neighborhood built environment data based on community auditing and geographical information system. After controlling for individual covariates, we used multivariable linear regression to examine the association between neighborhood built environment and cognition.Results: Residents aged 80 and younger in neighborhoods with a higher land-use mix and more public transport terminals exhibited better cognition. Only the number of community centers in a neighborhood was positively associated with cognition for people older than 80.Conclusion: The built environment creates diverse impacts on different age groups among older adults. Our findings provide useful information for urban planners and policymakers for planning community facilities and built environments that consider the needs of different age groups within the older population.

The intersectionality of life course socioeconomic status, race, and cognitive decline: An 18-year follow-up.

OBJECTIVES: Studies have documented the impact of childhood socioeconomic status (SES) on cognition. However, research that simultaneously considers SES in varied life stages, the multidimensional mechanisms, and racial differences is relatively understudied. This study examines the intersectionality across age, SES, and race and its impact on cognitive trajectories. METHODS: Using 8376 respondents aged 65+ from the 1998-2016 Health and Retirement Study, we used latent growth curve modeling to examine the effects of four life course models (latency, pathway, accumulation, and mobility) on 18-year trajectories of mental status and episodic memory. We further tested for differences in the links between SES and cognitive trajectories between black and white respondents. RESULTS: Cognitive function declines with age and is interrelated with SES and race. Adulthood has a stronger effect on cognitive performance than childhood. However, linked positive childhood and adulthood SES contributes to positive cognition. Accumulated SES disadvantages were associated with lower cognition. Older adults with downward mobility and low SES throughout their lifespans had the lowest cognition scores. Life course models operated differently on trajectories of cognitive decline, yet the effects were particularly evident among older black respondents. Overall, those with socioeconomic advantages tended to have a slower decline in cognition, while a faster decline occurred for those with accrued disadvantages. CONCLUSIONS: Cognitive performance is a complex, longitudinal process intertwined with socioeconomic conditions and population heterogeneity shaped by life course contexts. Policies that facilitate healthy cognitive performance and address SES inequality could equalize health opportunities and address racial cognitive disparities later in life.

Spatial uncertainty and environment-health association: An empirical study of osteoporosis among "old residents" in public housing estates across a hilly environment.

BACKGROUND: Built environment can influence physical conditions of older adults (e.g. osteoporosis). However, traditional methods using 2-dimensional circular buffer as a spatial structure to measure neighbourhood effect may create bias in health estimation, especially for the hilly and compact environment across low-income neighbourhoods (e.g. public housing estates). METHODS: We evaluated the environmental influences on self-reported osteoporosis among "old residents" (age≥65) in Hong Kong (n = 2077). Twelve public housing estates across hilly neighbourhoods in Hong Kong were selected as study sites. A cross-validated approach was developed to evaluate four spatial structures (2D circular, 2D service area, 3D circular, 3D service area). To determine problems of spatial uncertainty, we compared odds ratios (OR) and differences in effect sizes from models using different spatial structures. When all adjusted models achieve significant results based on 95% confidence intervals (CI) and with all positive/negative ORs, this study reported to have reached "a result with consistency". Results from the 3D service area were then used to explain the environment-health relationship. RESULTS: Different spatial structures can yield different results. Particularly, circular buffers overestimated environmental effects on self-reported osteoporosis. Overestimated measures were related to walkability and accessibility but not greenery. Specifically, results from the 3D service area showed that more public space and health facilities within a walkable distance (500 m) from a location of subject's residence were negatively associated with self-reported osteoporosis (adjusted ORs: 0.44 [0.29, 0.66]; 0.94 [0.90, 0.99]). However, more major transport facilities at the immediate distance from residence (200 m) was positively associated with self-reported osteoporosis (adjusted OR: 1.11 [1.01, 1.23]). CONCLUSIONS: Physical conditions (e.g. osteoporosis) of older adults living in a hilly neighbourhood could be driven by walking behaviours. It is necessary to include local terrain and road network to define a walkable neighbourhood for environment-health estimations to minimize spatial bias.

Collaborative community mental health and aged care services with peer support to prevent late-life depression: study protocol for a non-randomised controlled trial.

BACKGROUND: Late-life depression is common, modifiable, yet under-treated. Service silos and human resources shortage contribute to insufficient prevention and intervention. We describe an implementation research protocol of collaborative stepped care and peer support model that integrates community mental health and aged care services to address service fragmentation, using productive ageing and recovery principles to involve older people as peer supporters to address human resource issue. METHODS/DESIGN: This is a non-randomised controlled trial examining the effectiveness and cost-effectiveness of the "Jockey Club Holistic Support Project for Elderly Mental Wellness" (JC JoyAge) model versus care as usual (CAU) in community aged care and community mental health service units in 12 months. Older people aged 60 years and over with mild to moderate depressive symptoms or risk factors for developing depression will be included. JoyAge service users will receive group-based activities and psychoeducation, low-intensity psychotherapy, or high-intensity psychotherapy according to the stepped care protocol in addition to usual community mental health or aged care, with support from an older peer supporter. The primary clinical outcome, depressive symptoms, and secondary outcomes, self-harm risk, anxiety symptoms, and loneliness, will be measured with the Patient Health Questionnaire-9 (PHQ-9), Self-Harm Inventory, Generalized Anxiety Disorder 7-item scale (GAD-7), and UCLA Loneliness 3-item scale (UCLA-3) respectively. Cost-effectiveness analysis will assess health-related quality of life using the EQ-5D-5L and service utilisation using the Client Service Receipt Inventory (CSRI). We use multilevel linear mixed models to compare outcomes change between groups and calculate the incremental cost-effectiveness ratio in terms of quality-adjusted life years. DISCUSSION: This study will provide evidence about outcomes for older persons with mental health needs receiving collaborative stepped care service without silos and with trained young-old volunteers to support engagement, treatment, and transitions. Cost-effectiveness findings from this study will inform resource allocation in this under-treated population. TRIAL REGISTRATION: ClinicalTrials.gov NCT03593889. Registered on 20 July 2018.

The Moderating Role of Community Capacity for Age-friendly Communication in Mitigating Anxiety of Older Adults During the COVID-19 Infodemic: Cross-sectional Survey.

Background: Older adults were perceived as a vulnerable group during the COVID-19 pandemic due to the health and mental health challenges they faced. The pandemic was accompanied by an "infodemic" of overabundant and questionable information that has affected older adults' mental health. As the infodemic and ageist narratives were prevalent online, more anxiety symptoms have been induced among older adults who used social media. Age-friendly communication, advocated by the World Health Organization's Age-friendly City (AFC) guide, could be an antidote by providing tailored information via appropriate channels for older adults. Objective: This study investigated the role of community capacity for age-friendly communication in mitigating anxiety during the pandemic. We hypothesized that age-friendly communication would moderate the effects of infection risks and social media use on anxiety. A double-moderating effect was hypothesized in the context of diminished trust in traditional media. Methods: Data were collected from a cross-sectional telephone survey conducted in Hong Kong in 2020. Older adults (N=3421, age≥60 years) were interviewed about their well-being and daily lives. Community capacity for age-friendly communication was measured in a living district-based evaluation. It had 2 components: the reach of appropriate information to older adults (AFC-Information) and the age-friendliness of communication technologies (AFC-Communication Technology) in the community. We tested the hypothesized moderation and double-moderation effects with ordinary least squares regressions. Results: Perceived COVID-19 infection risk (b=0.002, P=.02) and use of social media for COVID-19 information (b=0.08, P=.04) were associated with more anxiety symptoms. The effect of using social media was moderated by AFC-Information (b=-0.39, P=.002) and AFC-Communication Technology (b=-1.06, P<.001), and the effect of perceived COVID-19 infection risk was moderated by AFC-Information (b=-0.03, P=.002) and AFC-Communication Technology (b=-0.05, P<.001). Lower trust in traditional media exacerbated anxiety symptoms associated with social media use (b=-0.08, P=.02). Higher AFC-Information alleviated this moderation effect (AFC-Information × media trust b=-0.65, P<.001; AFC-Information × social media use b=-2.18, P<.001; 3-way interaction b=0.40, P=.003). Conclusions: Our findings highlight the role of community age-friendly communication in mitigating anxiety related to the infodemic. Although using social media may have exacerbated the impact of the infodemic on older adults, it has the potential to deliver timely information for an adequate health response. Although the amplifying effects of low media trust was associated with social media use, age-friendly communication determined its strength. Instead of discouraging the use of digital technologies for COVID-19 information, efforts should be made in tailoring information and communication technologies in local communities for older adults.

Neighbourhood physical environment, intrinsic capacity, and 4-year late-life functional ability trajectories of low-income Chinese older population: A longitudinal study with the parallel process of latent growth curve modelling.

BACKGROUND: Knowledge of how intrinsic capacity (IC) and neighbourhood physical environment shape functional ability (FA) trajectories in later life remains understudied. We investigated four-year trajectories of IC and their impact on FA trajectories and the association between neighbourhood physical environment and FA trajectories among community-dwelling older adults in Hong Kong, China. METHODS: We conducted a four-wave longitudinal study from 2014 to 2017 in Hong Kong with 2,081 adults aged 65 and above. FA was assessed by The Chinese Lawton Instrumental Activities of Daily Living Scale. We used cognition, affect, locomotion, sensory capacity, and vitality to capture the multiple domains of IC. Neighbourhood physical environment attributes included green space, land use diversity, and availability of facilities, assessed within 200- and 500-meter buffers of respondents' homes. We used the parallel process of latent growth curve model. FINDINGS: IC (Unstandardized coefficient, ß = -0.02, p<0.001) and FA (ß = -0.20, p<0.001) each decreased significantly over time. Individuals with declines in IC experienced a faster decline in FA over time. Green space within a 200-meter buffer (ß = 1.15, p = 0.023), the number of leisure (ß = 0.03, p = .0.043) and public transport (ß = 0.08, p = .0.003) facilities within a 500-meter buffer slowed the rate of FA decline. INTERPRETATION: The level of FA decreased over time in later life. Changes in IC shaped FA trajectories. Increased residential green space and the number of leisure and public transport facilities in the neighbourhood may help slow FA decline over time. FUNDING: The Hong Kong Housing Society.

The relationship between insomnia symptoms and frailty in community-dwelling older persons: a path analysis.

BACKGROUND: The relationship between sleep and frailty in older age is complex. Most previous studies focused on sleep duration, while insomnia, a common sleep problem in older adults, has not been adequately examined and the factors implicated in its association with frailty were under-explored. METHODS: A community-based sample of 345 prefrail and frail older adults were recruited and completed the measures on insomnia symptoms (Pittsburgh Sleep Quality Index) and frailty status (FRAIL Scale). The relationship between insomnia symptoms and frailty, with potential mediators including physical performance (Short Physical Performance Battery), depression (Patient Health Questionnaire-9), and level of physical activity (Physical Activity Scale for the Elderly), were tested in path analysis adjusting for age, gender, body mass index and sleep medications. RESULTS: The prevalence of sleep-onset insomnia was higher in frail participants than their prefrail counterparts (48% vs. 34%, aOR = 1.73; 95% CI 1.09, 2.76; p = 0.02), but there was no significant difference in the prevalence of sleep-maintenance insomnia (61% vs. 54%). The association between sleep-onset insomnia and frailty was explained by reduced physical performance (standardized coefficient = 0.11; 95% BCa CI [0.002, 0.233]), but not depression and level of physical activity. Sleep-maintenance insomnia was not associated with frailty. CONCLUSIONS: Insomnia symptoms are prevalent in frail and prefrail older adults. Sleep-onset insomnia is associated with poorer physical performance, which is further linked to a higher risk for frailty in older persons. The findings highlight the importance of timely assessing and managing insomnia among older adults at risk of frailty.

Effectiveness of a Two-Tier Family-Oriented Intervention in Enhancing the Family Functioning and Care Capacity of the Family Caregivers of Stroke Survivors: Protocol for a Randomized Controlled Trial.

BACKGROUND: Stroke has profound impacts on families. Often, family members, including stroke survivors and the person who takes up the role of the primary caregiver, would encounter demands on finances, rehabilitation arrangement, and even conflicts. Hence, a family-oriented intervention is expected to enable families to rebuild internal and external resources to achieve optimal rehabilitation and community reintegration. OBJECTIVE: This study aims to describe a design of a two-tier family-oriented care management intervention for enhancing the family functioning and care capacity of the caregivers of stroke survivors. METHODS: The two-tier care management intervention was guided by a standardized protocol conducted by trained professional care managers (first tier) with the support of trained volunteers (second tier), which lasted for 8-12 weeks. Participants were recruited through collaborating hospitals according to inclusion and exclusion criteria. In order to examine the effectiveness and cost-effectiveness of the two-tier care management intervention, a two-arm randomization multicenter study was designed, including an active comparison group, which was guided by a standardized protocol conducted by trained volunteers. Dyadic participants, including both stroke survivors and their primary caregivers for both groups, were invited to participate in a questionnaire survey using standardized and purposefully developed measures 3 times: before the intervention, immediately after the intervention, and 2 months after the intervention. The primary outcome was family functioning measured by the Family Role Performance Scale and Family Assessment Device-General Functioning Scale. The secondary outcomes included caregiving burden, depressive symptoms, care management strategies, and the incremental cost-effectiveness ratio. RESULTS: Recruitment began in January 2017 and was completed at the end of April 2019. Data collection was completed at the end of March 2020. As of March 2020, enrollment has been completed (n=264 stroke caregivers). A total of 200 participants completed the baseline questionnaires. We aim to publish the results by mid-2021. CONCLUSIONS: This study successfully developed a two-tier care management protocol that aims to enhance the family functioning of the caregivers of stroke survivors. Guided by a standardized protocol, this family-oriented two-tier intervention protocol was found to be feasible among Chinese families. TRIAL REGISTRATION: ClinicalTrials.gov NCT03034330; https://ichgcp.net/clinical-trials-registry/NCT03034330. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR1-10.2196/16703.

Longitudinal associations between neighbourhood physical environments and depressive symptoms of older adults in Hong Kong: The moderating effects of terrain slope and declining functional abilities.

Little is known about the accumulative impacts of neighbourhood physical environments on older adults' depressive symptoms over time. Based on a cohort study of 2081 older adults in Hong Kong, this study examined longitudinal relationships between neighbourhood physical environments and depressive symptoms among older adults, with a particular focus on the moderating effects of terrain slope and individual functional ability using latent growth curve modelling. Results indicated that the availability of community centres and passive leisure facilities reduced depressive symptoms over time. The protective effects of residential surrounding greenness on depressive symptoms among older adults differed by the terrain slope types. Longitudinal associations between neighbourhood physical environments and depressive symptoms varied between older adults with and without functional limitations. This study has implications for the Ecological Theory of Ageing by identifying the dynamic interplay of environment demands and individual functional ability. Planning policies for building age-friendly neighbourhoods are discussed.

Associations between Volunteering and Mental Health during COVID-19 among Chinese Older Adults.

Evidence about the association between volunteering and the mental health of older adults during COVID-19 remains underexplored. This study investigated (1) patterns of volunteering among older adults in Hong Kong during COVID-19; (2) associations between volunteering and mental health of older adults during COVID-19; and (3) associations between key psychological resources (e.g., self-efficacy and self-esteem) and volunteering among older adults during COVID-19. This study applied a cross-sectional design with data collected from 128 older adults in June 2020, who were trained as volunteers in a volunteer program that began before COVID-19. The study found that older adults continued to actively contribute to their communities by engaging in volunteering during COVID-19. The specific type of volunteering activities was linked to few depressive and anxiety symptoms. Older adults with increased self-esteem prior to COVID-19 were more likely to participate in volunteering activities related to COVID-19. Our study suggested that encouraging older adults to volunteer during the pandemic is a key pathway to maintain mental health. Social workers are encouraged to engage older adults in volunteerism regularly to offset the risk of depression and anxiety symptoms in times of crisis.