Spatial Associations of Multiple Chronic Conditions Among Older Adults.

Multimorbidity, the presence of two or more chronic conditions in an individual, presents a major challenge for meeting the health care needs of older adults. This study advances understanding of multiple chronic conditions by using local colocation quotients to reveal spatial associations for five chronic conditions (arthritis, diabetes, heart disease, hypertension, and pulmonary disease) in a statewide panel of older adults in New Jersey. Among adults with three or more conditions, large concentrations of Arthritis-Heart Disease-Pulmonary Disease, Arthritis-Hypertension-Pulmonary Disease, and Diabetes-Heart Disease-Hypertension were observed, each triad located in different regions of the state. Individuals with other triads of conditions, in contrast, were distributed among all older adults in the sample as expected with no areas of local concentration. The study provides gerontologists with a new and effective method for uncovering geographical patterns in combinations of chronic conditions among the populations they serve, thereby enabling more effective interventions.

Multiple Chronic Condition Combinations and Depression in Community-Dwelling Older Adults.

BACKGROUND: The U.S. Department of Health and Human Services recently called for a paradigm shift from the study of individual chronic conditions to multiple chronic conditions (MCCs). We identify the most common combinations of chronic diseases experienced by a sample of community-dwelling older people and assess whether depression is differentially associated with combinations of illnesses. METHODS: Self-reports of diagnosed chronic conditions and depressive symptoms were provided by 5,688 people participating in the ORANJ BOWL(SM) research panel. Each respondent was categorized as belonging to one of 32 groups. ANOVA examined the association between depressive symptoms and combinations of illnesses. RESULTS: People with more health conditions experienced higher levels of depression than people with fewer health conditions. People with some illness combinations had higher levels of depressive symptoms than people with other illness combinations. CONCLUSIONS: Findings confirm extensive variability in the combinations of illnesses experienced by older adults and demonstrate the complex associations of specific illness combinations with depressive symptoms. Results highlight the need to expand our conceptualization of research and treatment around MCCs and call for a person-centered approach that addresses the unique needs of individuals with MCCs.

A Longitudinal Examination of the Effects of Early Influences and Midlife Characteristics on Successful Aging.

OBJECTIVES: Previous research revealed that successful aging includes both objective and subjective dimensions. This longitudinal analysis examines how early life influences and midlife characteristics predict stability and change in successful aging over a 4-year period. METHOD: Data from 3,379 people living in New Jersey who completed baseline telephone interviews between 2006 and 2008 and follow-up mail surveys in 2011 were analyzed. Latent profile analysis identified people who aged successfully according to both objective and subjective criteria, neither criteria, and one, but not the other criteria. Multinomial logistic regressions analyses focused on the 2,614 people who were successful according to both objective and subjective criteria at baseline. RESULTS: At follow-up, 18.1% people successful at baseline had transitioned out of that status. Characteristics identifiable early in life (gender, race, education, never marrying, incarceration) as well as midlife status (currently married, working), health behaviors (smoking, drinking, body mass index, exercise), and social support distinguished people who continued to age successfully 4 years later from those who did not. DISCUSSION: Findings suggest that successful aging is a fluid construct and that although some characteristics identifiable early in life predict successful aging, others are dampened by midlife statuses.

Neighborhood characteristics and depressive symptoms of older people: local spatial analyses.

Depressive symptoms in community-dwelling older people significantly increase the risk of developing clinically diagnosable depressive disorders. Knowledge of the spatial distribution of depressive symptoms in the older population can add important information to studies of neighborhood contextual factors and mental health outcomes, but analysis of spatial patterns is rarely undertaken. This study uses spatial statistics to explore patterns of clustering in depressive symptoms using data from a statewide survey of community-dwelling older people in New Jersey from 2006 to 2008. A significant overall pattern of clustering in depressive symptoms was observed at the state level. In a subsequent local clustering analysis, places with high levels of depressive symptoms near to other places with high levels of depressive symptoms were identified. The relationships between the level of depressive symptoms in a place and poverty, residential stability and crime were analyzed using geographically weighted regression. Significant local parameter estimates for the three independent variables were observed. Local parameters for the poverty variable were positive and significant almost everywhere in the state. The significant local parameters for residential stability and crime varied in their association with depressive symptoms in different regions of the state. This study is among the first to examine spatial patterns in depressive symptoms among community-dwelling older people, and it demonstrates the importance of exploring spatial variations in the relationships between neighborhood contextual factors and health outcomes.

The texture of neighborhoods and disability among older adults.

OBJECTIVES: To present and test an ecological multidimensional model of neighborhood characteristics and examine its relationship to older disability among older adults. METHOD: Indicators of social vulnerability, wealth, violence, storefronts, residential stability, and the presence of physicians, supermarkets, and fast-food establishments for 1,644 of New Jersey's census tracts were derived from sources that include the U.S. Census 2000, Uniform Crime Report for New Jersey, New Jersey Department of Agriculture, Division of Marketing and Development, New Jersey Department of Law and Public Safety Division of Alcohol Beverage Control, and Health Resources and Services Administration Geospatial Data Warehouse. Confirmatory factor analyses were used to develop and test a measurement model of neighborhood texture. Structural equation modeling examined the relationships between neighborhood characteristics and disability of persons aged 65-69 years. RESULTS: Analyses revealed that distinct dimensions of neighborhoods could be modeled with administrative data and that neighborhood contextual (supermarkets, physicians, storefronts, violence) and compositional (social vulnerability, wealth, residential stability) characteristics were related to the prevalence of disability. DISCUSSION: The use of multiple indicators of neighborhood with good psychometric qualities is critical for advancing knowledge about the mechanisms by which neighborhood characteristics are associated with the health of older people.

Balancing Caregiving and Work: Role Conflict and Role Strain Dynamics.

Positing role conflict as a bidirectional construct in which work interferes with caregiving (WIC) and caregiving interferes with work (CIW), this study investigated its antecedents (demands and support of caregiving and work) and consequences (role strain). A national sample of 583 women between the ages of 50 and 64 years identified using random-digit-dial procedures completed a telephone survey. Structural equation modeling revealed that caregiving demands were positively associated with CIW and caregiving burden; instrumental caregiving support reduced CIW and caregiving burden. Work demands were positively associated with WIC, CIW, caregiving burden, and work burden. Emotional workplace support reduced WIC, CIW, and work burden. CIW and WIC were positively associated with caregiving burden; only WIC was positively associated with work burden. Findings suggest that demands and supports related to the caregiving role do not influence work-related role strain; work demands and supports influence role strain experienced from both caregiving and work domains.

A two-factor model of successful aging.

OBJECTIVES: To propose and test a conceptual two-factor model of successful aging that includes objective and subjective components. METHODS: Data were derived from 5,688 persons aged 50-74 years living in New Jersey who participated in the ORANJ BOWL panel. Participants were recruited using random digit dial procedures and interviewed by telephone. A measurement model was developed and tested using data from two independent samples (each n = 1,000); a structural model examining the effects of age and gender was tested using data from another 3,688 people. RESULTS: Confirmatory factor analyses provided support for a multidimensional model incorporating objective criteria and subjective perceptions. Age and gender were associated with objective but not subjective success. DISCUSSION: Results add rigor to the measurement of a construct that has intrigued philosophers and scientists for hundreds of years, providing the empirical foundation on which to build research about successful aging.

Successful aging: early influences and contemporary characteristics.

PURPOSE: positing that successful aging has independent, yet related, dimensions that are both objective and subjective, we examine how early influences and contemporary characteristics define 4 groups of people. DESIGN AND METHODS: data were gathered from 5,688 persons aged 50-74 years living in New Jersey who participated in telephone interviews. Latent profile analysis defined people who age successfully according to both objective and subjective criteria, neither criteria, and one, but not the other, criteria. Multinomial logistic regression was used to examine the extent to which early influences and contemporary characteristics predict group membership. RESULTS: although characteristics observable early in life predict group membership, their influence is modified by current health behaviors and social support. The roles of education and incarceration feature prominently. Marital, work, and volunteer statuses, as well as moderate alcohol consumption, distinguish those aging successfully according to both criteria from the other 3 groups. IMPLICATIONS: results help to define successful aging as a multidimensional construct having both objective and subjective dimensions, provide greater clarity regarding its correlates, and increase understanding of its modifiable aspects.

Effects of caregiver burden and satisfaction on affect of older end-stage renal disease patients and their spouses.

We examined the extent to which a 2-factor model of affect explains how the burdens and satisfactions experienced by caregivers influence their own well-being and that of the spouses for whom they provide care. Using data from 315 older patients with end-stage renal disease and their spouses, we extended tests of Lawton et al.'s (1991) 2-factor model both longitudinally and dyadically. Multilevel modeling analyses partially support the 2-factor model. Consistent with the model, mean caregiver burden has a stronger effect on both caregiver and patient negative affect than does mean caregiver satisfaction. Contrary to the model, mean caregiver satisfaction has an effect on caregiver positive affect that is similar to that of mean caregiver burden, and it has no effect on patient positive affect. Time-varying effects of caregiver burden are consistent with the 2-factor model for caregiver but not patient negative affect. Time-varying effects of caregiver satisfaction are not consistent with the 2-factor model for either patients or caregivers. Results highlight the powerful role of caregiver burden for both caregivers and patients and suggest important new directions for conducting health-related research with late-life marital dyads.

Effects of marital closeness on the transition from caregiving to widowhood.

OBJECTIVE: To examine the effects of marital closeness on indicators of well-being (depressive symptoms, grief, and relief) as spouses transition from the role of caregiver to that of widowed person. METHODS: 118 spouses of persons with end stage renal disease were interviewed prior to and after the death of the patient. Spouses reported on marital closeness, multiple indicators of pre-death strain as reflected by subjective health, depressive symptoms, caregiving burden, and caregiving satisfaction, as well as post-loss feelings of grief, depression, and relief. RESULTS: Hierarchical regressions indicated that post-loss grief was predicted by gender (b = 0.32, p < 0.001), self-reported health (b = -0.28, p < 0.01), marital closeness (0.22, p < 0.05), and pre-loss depressive symptoms (b = 0.19, p < 0.10). Caregiver burden (b = 0.28, p < 0.05) and marital closeness (b = -0.41, p < 0.001) before the death, predicted relief from the caregiver role post-loss. Subjective health (b = -0.21, p < 0.05) and pre-loss depressive symptoms (b = 0.47, p < 0.001) predicted change in depressive symptoms over time. CONCLUSION: These data highlight differences in the experiences of grief, relief, and depressive symptoms and suggest that marital closeness plays a central role. Results are interpreted in terms of theory regarding marital quality. Implications for interventions to improve the lives of caregivers and newly widowed spouses are discussed.

Quality of life in end-stage renal disease patients: differences in patient and spouse perceptions.

OBJECTIVES: Spouses and other proxies consistently rate patient quality of life (QOL) lower than patients rate it themselves. This pattern has been observed in end-stage renal disease (ESRD), cancer, stroke and other chronic illnesses, but it has not been explained. The purpose of the current paper is to examine similarities and differences in spouse and patient ratings of the QOL of patients with ESRD. METHOD: Patients with ESRD and their spouses participated in baseline and one-year follow-up interviews. Both patients and spouses rated the patient's QOL, mood, functional ability, subjective health, and kidney disease symptoms. Spouses also rated their own QOL. RESULTS: Spouses rated all patient characteristics, including QOL, as worse than did the patient. Change in perceptions of patient's mood and their subjective health predicted both patient and spouse ratings of patient QOL. Change in spouse's perceptions of patient's functional ability predicted spouse ratings of patient QOL, but not the patient's own ratings. Finally, change in the spouse's own QOL explained additional variance in their rating of the patient's QOL. CONCLUSION: Patients and spouses perceive patient QOL and predictors of patient QOL differently. Implications include the need to be aware of negative bias in spouse ratings of patients of QOL and other psychosocial variables, especially when spouse perceptions are considered by health care professionals. Discussing differences in patient and spouse perceptions in clinical settings with both patients and spouses will allow for a more comprehensive understanding of patient status.

Stability and change in patient preferences and spouse substituted judgments regarding dialysis continuation.

OBJECTIVES: The objective of this study was to examine whether some treatment preferences are more stable than others, how patient preferences and substituted judgments change over time, and whether some people's decisions are more stable than others'. METHODS: Hypothetical scenarios elicited preferences for dialysis continuation under various health conditions at two points in time. Predictors included initial treatment preference, age, gender, race, education, length of time on dialysis, presence of a living will, and change in patient's health. RESULTS: Some treatment preferences were more stable than others, and the cause of this stability varied across treatment preferences. Similarity between patient preferences and spouse substituted judgments within couples was low and varied as a function of hypothetical condition. The strongest predictor of treatment preferences at follow-up was initial preference. Age, gender, race, education, length of time on dialysis, presence of a living will, and change in patient's health had limited effects on changes to treatment preferences. DISCUSSION: There is a great deal more stability than change in patient preferences and substituted judgments regarding continuation of dialysis over the course of 1 year. This suggests that if patients have previously expressed preferences it is possible for this to maintain their voice in end-of-life decisions when the patients themselves are unable to express their wishes.

Convenience samples and caregiving research: how generalizable are the findings?

PURPOSE: We contrast characteristics of respondents recruited using convenience strategies with those of respondents recruited by random digit dial (RDD) methods. We compare sample variances, means, and interrelationships among variables generated from the convenience and RDD samples. DESIGN AND METHODS: Women aged 50 to 64 who work full time and provide care to a community-dwelling older person were recruited using either RDD (N = 55) or convenience methods (N = 87). Telephone interviews were conducted using reliable, valid measures of demographics, characteristics of the care recipient, help provided to the care recipient, evaluations of caregiver-care recipient relationship, and outcomes common to caregiving research. RESULTS: Convenience and RDD samples had similar variances on 68.4% of the examined variables. We found significant mean differences for 63% of the variables examined. Bivariate correlations suggest that one would reach different conclusions using the convenience and RDD sample data sets. IMPLICATIONS: Researchers should use convenience samples cautiously, as they may have limited generalizability.

Using probability vs. nonprobability sampling to identify hard-to-access participants for health-related research: costs and contrasts.

This article compares the recruitment costs and participant characteristics associated with the use of probability and nonprobability sampling strategies in a longitudinal study of older hemodialysis patients and their spouses. Contrasts were made of people who accrued to the study based on probability and nonprobability sampling strategies. Probability-based sampling was more time-efficient and cost-effective than nonprobability sampling. There were no significant differences between the respondents identified through probability and nonprobability sampling on age, gender, years married, education, work status, and professional job status. Respondents from the probability sample were more likely to be Protestant and less likely to be Catholic than those from the nonprobability sample. Respondents from the probability sample were more likely to be Black, whereas those from the nonprobability sample were more likely to be White. There are strengths and shortcomings associated with both nonprobability and probability sampling. Researchers need to consider representativeness and external validity issues when designing sampling and related recruitment plans for health-related research.

Predictors of patient treatment preferences and spouse substituted judgments: the case of dialysis continuation.

OBJECTIVES: To examine the factors predicting preferences for continued hemodialysis treatment among patients with endstage renal disease (ESRD) and to compare these factors to those predicting their spouses' predictions of patients' preferences (substituted judgments). DESIGN: Descriptive, cross-sectional. PARTICIPANTS: Total of 291 hemodialysis patients, aged 55 years and older, and their spouses. MEASUREMENT: Hypothetical scenarios were designed to elicit preferences for dialysis continuation under various health conditions. Other measures included the Philadelphia Geriatric Center Negative Affect Scale, Kidney Disease Symptoms Scale, Brief Multidimensional Measure of Religiousness, single-item global subjective health and quality-of-life measures, 2-item fear of end-of-life suffering measure, and selected demographics. RESULTS: Patients' preferences and spouses' judgments were only moderately correlated (r = 0.33). Multiple regression analyses revealed that patients' preferences to continue dialysis were positively related to education, subjective quality of life, and religious participation and negatively related to months of ESRD treatment and fear of end-of-life suffering (R(2) = 0.15). Spouses' substituted judgments regarding patients' dialysis continuation preferences were positively related to African American race and spouses' perceptions of patients' quality of life and negatively related to months of ESRD treatment, spouses' perception of patients' negative affect, and spouses' own fear of end-of-life suffering. CONCLUSION: Patients and surrogates used different criteria in formulating judgments about continuation of life-sustaining treatment and had different perceptions about the patients' condition. Furthermore, the substituted judgments of spouses were influenced by their own characteristics. These processes may explain inaccurate substituted judgments.

Spouse as health care proxy for dialysis patients: whose preferences matter?

PURPOSE: We examined the extent to which the substituted judgments made by spouses of patients with end-stage renal disease actually reflect patient preferences. DESIGN AND METHODS: We used data from 291 couples to compare dialysis patients' preferences for continuing hemodialysis under a variety of hypothetical situations with both substituted judgment data from spouses and information about spouses' own preferences. RESULTS: Substituted judgments were more highly related to spouses' preferences than to patients' preferences. IMPLICATIONS: Findings raise questions about the extent to which the moral principle of patient autonomy should guide decision making at the end of life.

Health-related stress, affect, and depressive symptoms experienced by caregiving mothers of adults with a developmental disability.

The interrelationships among health-related stress, positive and negative affect, and depressive symptoms patterned in the dynamic model of affect (J. Reich, A. Zautra, & M. Davis, 2003) were examined using data from 932 women having an adult child with a developmental disability. Results indicate that women experience a moderate inverse correlation between positive and negative affect under conditions of low levels of health-related stress, whereas at high levels of stress, positive and negative affect become more strongly inversely correlated. Under high-stress conditions, both negative affect and positive affect have a stronger relationship to depressive symptoms than they do under low-stress conditions.

Patterns of service utilization by adults with a developmental disability: type of service makes a difference.

Patterns and correlates of service utilization by adults with a developmental disability were examined using data from 831 mothers of an adult child with a developmental disability. A modified Andersen model of health services was used to examine service utilization in seven domains. Multinomial logistic regression revealed that predictors of services received as well as predictors of unmet need for services varied by service. Findings emphasize the importance of considering predisposing characteristics, enabling resources, and need as well as service in order to understand patterns of service utilization.

Enmeshed lives: adult children with developmental disabilities and their aging mothers.

This article uses equity theory to examine the ways in which aging mothers and their adult children with developmental disabilities support each other and the effects that this exchange has on the caregiving satisfaction and burden of the mothers. Data from 305 mothers revealed that exchange flows both from mother to child and from child to mother. Results indicate that caregiving satisfaction increased when affection from child to mother was greater. Caregiving burden was not affected by either functional support or affection from child to mother.

Psychological well-being of Black and White grandmothers raising grandchildren: examination of a two-factor model.

A theoretical model predicting the positive and negative affect of caregiving grandmothers was tested with a sample of 867 grandmothers caring for a grandchild in households that did not include either of the grandchild's parents. Results confirm that the principles guiding a two-factor model of psychological well-being operate at the level of subjective role appraisals. Unique predictors of positive and negative affect as well as unique predictors of caregiving satisfaction and burden were identified. The stability of the model for Black and White grandmothers highlights the similarity of the experience across race.