Health Disparities in Appalachian and Other Rural Communities.

Rural areas are home to a larger proportion of older adults and populations who age within these locales and suffer disproportionately from health, mental health, and economic disparities compared to their urban counterparts. This article will explore the disparities faced by persons that reside in rural communities across the lifespan. It will briefly discuss what is meant by rural. As a rural region at specific risk, the issues confronting those aging in Appalachia will be examined. Finally, best practices and future directions to combat health disparities among rural residents and elders will be discussed. This includes the Appalachian Gerontology Experiences: Advancing Diversity in Aging Research training program which recruits and trains minority and first-generation undergraduate students in aging and health disparity research.

Anticipated suicidal and death ideation in response to an imagined dementia diagnosis: A qualitative study.

Alzheimer's disease and related dementias are prevalent, highly impactful, and feared diagnoses. A mixed methods study using semi-structured interviews was conducted to clarify causes of dementia-related anxiety. Fifty community-dwelling adults aged 58 to 89 (M = 70.92, SD = 6.08) were recruited from a university participant registry and Memory Clinic; none had dementia diagnoses. Analyses revealed that 42% (n = 21) of participants anticipated suicidal or death ideation if diagnosed with dementia. Among participants endorsing anticipated suicidal or death ideation, responses ranged from active, specific plans, including interest in physician-assisted suicide, to more passive wishes to hasten death rather than continue to live with dementia. Within reports of both anticipated suicidal and death ideation, three subthemes emerged. Participants reported concerns about becoming a burden to others, the devaluation of life/loss of self with dementia, and the desire for (and anticipated thwarting of) personal control as factors contributing to their anticipated responses to a dementia diagnosis. Statements of anticipated suicidal and death ideation were contingent on a dementia diagnosis and may reflect errors in affective forecasting. Nevertheless, given the prevalence of dementias and older adults' elevated rates of suicide, the intersection of these two public health issues warrants greater attention.

Age Moderates the Relation between Sleep Problems and Suicide Risk.

OBJECTIVES: This cross-sectional study examined whether age moderates the relation between sleep problems and suicide risk and investigated whether sleep problems are differentially associated with suicide risk in younger (18-40) and older (60+) adults. METHODS: MTurk workers (N = 733) completed the Pittsburgh Sleep Quality Index, Suicidal Behavior Questionnaire-Revised, Patient Health Questionnaire, and demographic questions. Analysis of variance and linear regressions were utilized. RESULTS: Older adults scored lower on four PSQI components, symptoms of depression, and suicide risk than younger adults. Age significantly moderated the relation between sleep problems and suicide risk after controlling for gender and depressive symptoms, F(5, 635) = 72.38, p < .001. Sleep problems significantly related to suicide risk in younger adults (t = 6.47, p < .001) but not in older adults (t = 0.57, p = .57). Sleep medication use was related to suicide risk in both groups, whereas daytime dysfunction was related to suicide risk in older adults and sleep disturbances were related to suicide risk in younger adults. CONCLUSIONS: The relation between sleep problems and suicide risk differs between younger and older adults. This study adds to the literature suggesting that sleep medications may not be appropriate for older adults. CLINICAL IMPLICATIONS: Sleep problems are significantly related to suicide risk in younger adults but not older adults. Sleep medication use is associated with suicide risk regardless of age.

Relation Between Depression Symptoms and Suicide Risk in Adults and Older Adults: A Brief Report.

Depression symptoms are key risk factors for suicide; however, older adults differ from younger adults in types of depression symptoms experienced and thus their risk factors for suicide. The present brief report investigated relations between different symptoms of depression and suicide risk and whether these relations are moderated by age. Participants were 944 community-dwelling adults (N = 512, M = 39) and older adults (N = 432, M = 66) from the United States recruited through Mechanical Turk. Participants completed self-report measures on depression symptoms and suicide risk. Age was found to moderate the relation between cognitive-affective and somatic symptoms and suicide risk. Younger age exacerbated the negative effects of these symptoms on suicide risk. The study is the first to investigate whether older adults differed from younger adults in the association between types of depression symptoms and suicide risk and found that the risk posed by cognitive-affective and somatic symptoms was greater for younger adults.

Engaging in pleasant events explains the relation between physical disability and mental health outcomes in older adults.

OBJECTIVES: This study expands the body of research examining mediators of the association between physical disability and mental health outcomes. Based on the behavioral model of depression, frequency of pleasant events were examined as a mediator between physical disability and mental health outcomes including depressive symptoms, meaning in life, and positive affect. We predicted that physical disability would have a significant indirect effect on mental health outcomes through the lower frequency of pleasant events. METHODS: Cross-sectional study of 82 community-dwelling adults, Mage = 77.6, SD = 8.0, 64.6% female, was conducted. Self-report instruments measured frequency of pleasant events, physical disability, and mental health outcomes (depression symptoms, positive affect, and meaning in life). RESULTS: Simple mediation analyses demonstrated a significant indirect effect of physical disability on depressive symptoms (unstandardized coefficient = 0.16, 95% bias-corrected CI 0.03, 0.41), positive affect (unstandardized coefficient = -2.65, 95% bias-corrected CI -5.38, -0.88), and meaning in life (unstandardized coefficient = -1.58, 95% bias-corrected CI -3.19, -0.47) through engagement in pleasant events. CONCLUSION: Physical disability was associated with greater depressive symptoms and lower positive affect and meaning in life through reduced frequency of pleasant events. These findings are consistent with the behavioral model of depression and support several applied recommendations for reducing the burden of physical disability on mental health outcomes.

Development and initial validation of the Hopelessness Inventory for Later Life (HILL).

OBJECTIVES: Hopelessness is associated with depression, physical illness, and mortality. It is a key risk factor for suicidality in later life. Limitations have been identified in available hopelessness assessment measures regarding their use with older adults. The current study describes the development and initial psychometric evaluation of a content-valid, self-report scale for late-life hopelessness (i.e. the Hopelessness Inventory for Later Life; HILL). METHODS: A sample of 265 older adults (ages 60-99, M = 71.1, SD = 6.7) was recruited through a combination of in-person, online, and mailed solicitations. Participants completed a survey battery containing the preliminary HILL and measures of related constructs (e.g. depression, anxiety, suicide risk, social support) to examine its psychometric properties. RESULTS: Multiple analytic item selection strategies resulted in two viable versions of the scale: the HILL and the HILL-Shortened (HILL-S). Both exhibited strong item response characteristics and preliminary evidence of unidimensionality (via factor analysis), internal consistency (α = .96 and α = .89, respectively), and construct validity (via correlations with related constructs). CONCLUSION: Findings provide preliminary psychometric support for both the HILL and HILL-S. Advantages for use of the HILL and the HILL-S over existing measures of hopelessness are discussed.

A systematic review of older adults' request for or attitude toward euthanasia or assisted-suicide.

OBJECTIVES: Prevalence rates of death by euthanasia (EUT) and physician-assisted suicide (PAS) have increased among older adults, and public debates on these practices are still taking place. In this context, it seemed important to conduct a systematic review of the predictors (demographic, physical health, psychological, social, quality of life, religious, or existential) associated with attitudes toward, wishes and requests for, as well as death by EUT/PAS among individuals aged 60 years and over. METHOD: The search for quantitative studies in PsycINFO and MEDLINE databases was conducted three times from February 2016 until April 2018. Articles of probable relevance (n = 327) were assessed for eligibility. Studies that only presented descriptive data (n = 306) were excluded. RESULTS: This review identified 21 studies with predictive analyses, but in only 4 did older adults face actual end-of-life decisions. Most studies (17) investigated attitudes toward EUT/PAS (9 through hypothetical scenarios). Younger age, lower religiosity, higher education, and higher socio-economic status were the most consistent predictors of endorsement of EUT/PAS. Findings were heterogeneous with regard to physical health, psychological, and social factors. Findings were difficult to compare across studies because of the variety of sample characteristics and outcomes measures. CONCLUSION: Future studies should adopt common and explicit definitions of EUT/PAS, as well as research designs (e.g. mixed longitudinal) that allow for better consideration of personal, social, and cultural factors, and their interplay, on EUT/PAS decisions.

Predictors of treatment attendance and adherence to treatment recommendations among individuals receiving Cognitive Behavioral Therapy for Insomnia.

Insomnia disorders affect up to 10% of adults and are associated with other health problems and poor quality of life. Cognitive Behavioral Therapy for Insomnia (CBT-I) is an effective treatment; however, its effectiveness is hindered by poor attendance and adherence to treatment recommendations. The present study sought to identify predictors of attendance and adherence in CBT-I. Participants were 108 adults with insomnia disorder. Participants were primarily female (71.3%), middle aged (mean age = 50.5), and Caucasian (92.6%). Demographic variables, physical health problems, Beck Anxiety Inventory, Center for Epidemiologic Studies Depression-Revised scale, and Insomnia Severity Index were used to predict attending three or more sessions and adherence to consistent bedtime and waketime. Higher age was associated with better attendance and less deviation in bed and wake times. Anxiety and depression symptoms were associated with less attendance, and depression was also associated with more deviation in waketimes. To promote better attendance and adherence in treatment, depression or anxiety symptoms should be addressed before or during CBT-I. Identifying and tailoring CBT-I treatments toward the needs of different age groups may also improve attendance and adherence.

Dementia-related anxiety and coping styles associated with suicidal ideation.

Objective: Dementia-related anxiety is associated with general anxiety and depression, which are risk factors for suicidal ideation. Consequently, dementia-related anxiety may be associated with suicidal ideation. When faced with a negative event (e.g. developing dementia), individuals primarily employ monitoring or blunting styles of coping. The present study investigated whether dementia-related anxiety and coping styles were associated with suicidal ideation in adults and whether coping styles moderated the relation between dementia-related anxiety and suicidal ideation.Methods: Online Mturk participants (n = 330) completed the Miller Behavioral Style Scale, Dementia Worry Scale, and Patient Health Questionnaire-9. Suicidal ideation was assessed with the Patient Health Questionnaire.Results: Dementia-related anxiety and monitor/blunter coping styles were independently associated with suicidal ideation in a multiple logistic regression; coping styles did not moderate the relation between dementia-related anxiety and suicidal ideation.Discussion: Greater dementia-related anxiety and less use of monitoring coping style were associated with suicidal ideation. Interventions to decrease suicide risk may benefit from taking into account individual differences in dementia-related anxiety and coping styles.

Giving Support and Suicidal Ideation in Older Adults with Vision-Related Diagnoses.

Objectives: Visual impairment in older adults may increase risk for depression and suicide. Research suggests that giving support to others may be associated with lower depressive symptoms in older adults, but much of the research has been in non-clinical populations. Furthermore, there is limited research on giving support and suicide risk.Methods: Using a sample of older adults with vision-related diagnoses (N = 101), this study investigated the association between informal support giving (unpaid support given to family, friends, or neighbors) and formal support giving (volunteering) on depressive symptoms and suicidal ideation. Linear regressions examined the relation between support giving and depression, and logistic regressions examined the relation between support giving and suicidal ideation.Results: Greater informal support giving was related to lower likelihood of reported suicidal ideation (OR: .82, 95% CI: .68-.99, p = .04), whereas volunteer activity was not significantly related to suicidal ideation. Neither volunteer behavior nor informal support giving was related to depressive symptoms.Conclusions: Providing informal support was associated with lower likelihood of endorsing suicidal ideation in older adults with vision impairment.Clinical Implications: Informal support giving may be a target for decreasing suicidal ideation among older adults with health impairments.

Masculine Traits and Depressive Symptoms in Older and Younger Men and Women.

Evidence suggests that men who strongly endorse masculine traits display an atypical presentation of depression, including more externalizing symptoms (e.g., anger or substance use), but fewer typical, internalizing symptoms (e.g., depressed mood or crying). This phenomenon has not been adequately explored in older adults or women. The current study used the externalizing subscale of the Masculine Depression Scale in older and younger men and women to detect atypical symptoms. It was predicted that individuals who more strongly endorsed masculine traits would have higher scores on the measure of externalizing symptoms relative to a measure of typical depressive symptoms Center for Epidemiologic Studies-Depression Scale. It was anticipated that results would differ by age-group but not by gender. Multigroup path analysis was used to test the hypothesis. The hypothesized path model, in which endorsement of masculine traits was associated with lower scores on the Center for Epidemiologic Studies-Depression Scale and with scores on the externalizing, but not internalizing, factor of the Masculine Depression Scale, fit the data well. Results differed significantly by age-group and gender. Masculine individuals reported lower levels of typical depressive symptoms relative to externalizing symptoms, but further research is needed within age- and gender groups. Results are consistent with the gendered responding framework and suggest that current assessment tools, which tend to focus on internalizing symptoms of depression, may not detect depression in individuals who endorse masculine traits.

Sleep Disturbance, Activities of Daily Living, and Depressive Symptoms among Older Adults.

OBJECTIVE: Research suggests sleep disturbance plays a role in depression and risk for suicidal behavior (i.e., ideation, attempts, death by suicide). How sleep disturbance affects suicide risk is unclear and one's ability to perform activities of daily living (ADLs) may help explain this relation. This study examined associations between sleep problems, ADLs, and either depressive symptoms or suicide risk among older adults. We hypothesized that ADLs would mediate relations between sleep problems and depressive symptoms and suicide risk. METHOD: Participants (N = 134; age ≥65) were recruited through Amazon's Mechanical Turk. Participants completed questionnaires that assessed insomnia symptoms, nightmares, ADLs, depressive symptoms, and suicidal behaviors. RESULTS: Nightmares were associated with depressive symptoms and suicide risk but not independently associated with ADLs. Insomnia symptoms were associated with depressive symptoms, suicide risk, and ADLs. ADLs mediated the relation between insomnia symptoms and depressive symptoms. The insomnia symptom-suicidal behavior relation and the nightmare-suicidal behavior relation were significantly mediated by a pathway containing ADLs and depressive symptoms. DISCUSSION: ADLs help explain how insomnia symptoms and nightmares confer suicide risk among older adults, either independently or in association with depressive symptoms. CLINICAL IMPLICATIONS: Practitioners should attend to ADL performance when treating older adults with insomnia and depression.

Functional disability and suicidal behavior in middle-aged and older adults: A systematic critical review.

BACKGROUND: Middle-aged and older adults have elevated rates of suicide around the globe, but there is a paucity of knowledge about risk factors for suicide in these age groups. One possible risk factor may be functional disability, which is more common at later ages. METHODS: The current systematic critical review examined findings regarding the associations between functional disability and suicidal behavior (suicidal ideation, suicide attempts, and death by suicide) in middle-aged and older adults (i.e. age 50 and older). RESULTS: Forty-five studies were found that examined these associations. The majority of studies supported a significant association between functional disability and suicidal ideation. In addition, findings to date strongly suggest that depression serves as a mediator of the association between functional disability and suicidal ideation, though most studies did not directly test for mediation. LIMITATIONS: Firm conclusions regarding suicide attempts and death by suicide, as well as mediation, cannot be drawn due to a relative lack of research in these areas. CONCLUSIONS: The association between functional disability and suicidal behavior suggests an important area for prevention and intervention among middle-aged and older adults, but additional research is necessary to clarify the specifics of these associations and examine appropriate intervention strategies. Important future directions for research in this area include the direct comparison of associations of risk factors with different types of suicidal behavior, greater use of longitudinal data with multiple time points, and further examination of potential mediators and moderators of the association between functional disability and suicidal behavior.

Perceived Burdensomeness in Older and Younger Adults: Evaluation of the Psychometric Properties of the Interpersonal Needs Questionnaire.

OBJECTIVES: We evaluated measurement invariance of the Interpersonal Needs Questionnaire (INQ-15) Perceived Burdensomeness subscale across younger and older adult age groups as well as the construct validity of the Perceived Burdensomeness subscale by comparing nomological networks across age groups. METHOD: We used nested multigroup confirmatory factor analyses to address measurement invariance and Fisher's r-to-z transformations to compare correlations between perceived burdensomeness and other constructs in younger and older samples. RESULTS: Results generally supported measurement invariance, but signals of differences in fit in older adults were present. The INQ-15 Perceived Burdensomeness subscale exhibited a significantly lower correlation with depressive symptoms in older adults compared to younger adults. Correlations between perceived burdensomeness and all other constructs were similar across age groups. CONCLUSION: This study provides marginal support for measurement invariance of the INQ-15 Perceived Burdensomeness subscale across younger and older adults, but results also suggest age differences in the perceived burdensomeness construct.

Health Conditions and Passive Suicidal Ideation in the Survey of Health, Ageing, and Retirement in Europe.

OBJECTIVES: To examine the associations between health conditions and passive suicidal ideation in middle-aged and older adults. METHOD: Multivariate logistic regression analyses were conducted on data from 35,664 middle-aged and older adults from the Survey of Health, Ageing, and Retirement in Europe. Mediation analyses were also conducted to test the roles of disability and depression in risk of ideation. RESULTS: After including demographic variables, disability, depression, and other health conditions as covariates, heart attack, diabetes/high blood sugar, chronic lung disease, arthritis, ulcer, and hip/femoral fractures were associated with increased odds of passive suicidal ideation. When grouped by organ systems, conditions affecting the endocrine, respiratory, and musculoskeletal systems were associated with increased odds of passive suicidal ideation, as was the total number of conditions. Individuals with greater numbers of health conditions exhibited greater levels of disability and depression, which partially explained the increased risk of passive suicidal ideation among those with more health conditions. DISCUSSION: Certain specific health conditions, as well as total number of conditions, are associated with passive suicidal ideation in middle age and older adulthood. Health is a critical risk factor for suicidal ideation in late life and should be further studied in this particularly at-risk population.

Toward an understanding of late life suicidal behavior: the role of lifespan developmental theory.

OBJECTIVES: Suicidal behavior in late life differs in important ways from suicidal behavior that occurs earlier in the lifespan, suggesting the possibility of developmental differences in the etiology of suicidal behavior. This paper examines late life suicidal behavior within the context of lifespan developmental theory. METHODS: This paper presents a conceptual framework for using lifespan developmental theory to better understand late life suicidal behavior. RESULTS: We argue that the motivational theory of lifespan development, which focuses on control, is particularly relevant to late life suicide. This theory posits that opportunities to exert control over important aspects of one's life diminish in late life as a result of declines in physical functioning and other factors, and that successful aging is associated with adaptive regulation of this developmental change. Although continued striving to meet goals is normative throughout the lifespan, most individuals also increase the use of compensatory strategies in old age or when faced with a decline in functioning. We propose that individuals who do not adapt to developmental changes by altering their strategies for exerting control will be at risk for suicidal behavior in late life. This paper reviews evidence that supports the importance of control with respect to suicidal outcomes in older adults, as well as findings regarding specific types of control strategies that may be related to suicide risk in older adults with health-related limitations. CONCLUSION: Although suicidal behavior is not a normal part of aging, the application of lifespan developmental theory may be useful in understanding and potentially preventing suicide among older adults.

The Brief Cognitive Status Examination (BCSE): Comparing Diagnostic Utility and Equating Scores to the Mini-Mental State Examination (MMSE).

The study purpose was to compare the diagnostic utility of the Brief Cognitive Status Exam (BCSE) to that of the Mini-Mental State Examination (MMSE) and to develop equated scores to facilitate comparisons. One hundred and eighty-two patients underwent cognitive evaluation and were placed into three groups: dementia (DEM), cognitive impairment, no dementia (CIND), and no cognitive impairment (NCI). One hundred and eighty-two healthy controls from the BCSE standardization sample served as a comparison group. On both measures, the DEM group obtained significantly lower scores than the other two groups, and the CIND group scored significantly lower than the NCI group. The BCSE was more sensitive in all clinical groups, although at extremely low scores, the two tests displayed similar sensitivity. Results indicate the BCSE has diagnostic utility as a cognitive screening measure in a mixed clinical sample and is more sensitive at detecting cognitive impairment, particularly milder levels, than the MMSE.