http://gerontologist.oxfordjournals.org The Gerontologist - RSS feed of current issue 1758-5341 December 2009 The Gerontologist 0016-9013 http://gerontologist.oxfordjournals.org/current_cover.gif http://gerontologist.oxfordjournals.org http://gerontologist.oxfordjournals.org/cgi/content/short/49/6/NP?rss=1 Tue, 10 Nov 2009 19:41:05 PST info:doi/10.1093/geront/gnp153 The Gerontological Society of America 6 49 NP 2009-12-01 NP STANDING MATERIAL http://gerontologist.oxfordjournals.org/cgi/content/short/49/6/NP-a?rss=1 Tue, 10 Nov 2009 19:41:05 PST info:doi/10.1093/geront/gnp154 The Gerontological Society of America 6 49 NP 2009-12-01 NP STANDING MATERIAL http://gerontologist.oxfordjournals.org/cgi/content/short/49/6/NP-b?rss=1 Tue, 10 Nov 2009 19:41:05 PST info:doi/10.1093/geront/gnp155 The Gerontological Society of America 6 49 NP 2009-12-01 NP STANDING MATERIAL http://gerontologist.oxfordjournals.org/cgi/content/short/49/6/NP-c?rss=1 Tue, 10 Nov 2009 19:41:05 PST info:doi/10.1093/geront/gnp156 The Gerontological Society of America 6 49 NP 2009-12-01 NP COVER http://gerontologist.oxfordjournals.org/cgi/content/short/49/6/725?rss=1 Tue, 10 Nov 2009 19:41:05 PST info:doi/10.1093/geront/gnp112 The Gerontological Society of America 6 49 726 2009-12-01 725 EDITORIAL http://gerontologist.oxfordjournals.org/cgi/content/short/49/6/727?rss=1 The Minimum Data Set (MDS) is a uniform instrument used in nursing homes to assess residents. In January 2008, the Centers for Medicare and Medicaid Services published a draft of a new MDS—version 3.0. This article traces the instrument's development and the design decisions that shaped it, discusses the MDS's manifest functions—data collection intended to drive quality improvement and the unintended consequences of its use—paper compliance and diminished attention to resident quality of life, and examines the revised version to gauge its success in meeting the instrument's objectives. Although results of the national evaluation of MDS 3.0 are promising, the revisions, especially those pertaining to quality-of-life assessment and the use of resident interviews and standardized assessment procedures, raise questions for future consideration. Additionally, past research suggests that the MDS's impact on quality-of-care improvement will be limited unless efforts are directed toward resolving the industry's persistent struggles with staffing, survey effectiveness, and the development of feasible care processes. MDS 3.0 seems most likely to achieve its potential if it operates within a multifaceted quality improvement framework.

]]> Tue, 10 Nov 2009 19:41:05 PST info:doi/10.1093/geront/gnp066 The Gerontological Society of America 6 49 735 2009-12-01 727 FORUM http://gerontologist.oxfordjournals.org/cgi/content/short/49/6/736?rss=1 Purpose: The purposes of these studies were to develop and initially evaluate the psychometric properties of the Reasons for Living Scale—Older Adult version (RFL-OA), an older adults version of a measure designed to assess reasons for living among individuals at risk for suicide. Design and Methods: Two studies are reported. Study 1 involved instrument development with 106 community-dwelling older adults, and initial psychometric evaluation with a second sample of 119 community-dwelling older adults. Study 2 evaluated the psychometric properties of the RFL-OA in a clinical sample. One hundred eighty-one mental health patients 50 years or older completed the RFL-OA and measures of depression, suicide ideation at the current time and at the worst point in one's life, and current mental status and physical functioning. Results: Strong psychometric properties were demonstrated for the RFL-OA, with high internal consistency (Cronbach's alpha coefficient). Convergent validity was evidenced by negative associations among RFL-OA scores and measures of depression and suicide ideation. RFL-OA scores predicted current and worst-episode suicide ideation above and beyond current depression. Discriminant validity was evidenced with measures of current mental status and physical functioning. Criterion-related validity was also demonstrated with respect to lifetime history of suicidal behavior. Implications: These findings provide preliminary support for the validity and reliability of the RFL-OA. The findings also support the potential value of attending to reasons for living during clinical treatment with depressed older adults and others at risk for suicide.

]]> Tue, 10 Nov 2009 19:41:05 PST info:doi/10.1093/geront/gnp052 The Gerontological Society of America 6 49 745 2009-12-01 736 DEATH AND DYING http://gerontologist.oxfordjournals.org/cgi/content/short/49/6/746?rss=1 Purpose Institutionalized veterans in Taiwan are a high-risk group for completing suicide due to their institutionalization and social minority status. The purpose of this study was to understand the suicide experiences, especially the triggers of suicide in this group. Design and Methods Data about suicide experiences were collected from 19 older (≥65 years) residents who had attempted suicide in four veterans’ homes in Taiwan from 2006 to 2007. Transcripts from 26 tape-recorded interviews were analyzed by thematic analysis. Results Five major themes related to suicide triggers were identified: illness and pain, death of close relatives or friends, conflicts with family members, disputes with friends or workers, and difficulty adapting to institutional life. Implications Illness and physical limitation issues were similar to suicidal findings on older people in Western culture. However, the suicidal behavior of these institutionalized, older Taiwanese veterans was influenced by expectations that did not match current social changes, money management issues, death of significant others, and changes in living environment. We suggest that money problems with paraprofessional institutional workers could be minimized among older institutionalized veterans by providing a convenient means for them to withdraw or manage money. Institutional staff should also be educated about communicating with older people and about death and dying; older residents should be educated about current social changes and money management. The study themes may be used to develop a new model for predicting suicide in this population and could be incorporated into current suicide prevention programs in clinical practice.

]]> Tue, 10 Nov 2009 19:41:05 PST info:doi/10.1093/geront/gnp114 The Gerontological Society of America 6 49 754 2009-12-01 746 DEATH AND DYING http://gerontologist.oxfordjournals.org/cgi/content/short/49/6/755?rss=1 Purpose: This study explored the role control plays in the dying process of terminally ill elders by investigating the aspects of the dying process over which they seek to exercise control, the strategies they use, and whether they desire to exercise more control. Design and Methods: In-depth face-to-face interviews were conducted with 84 terminally ill elders receiving hospice care. Directed and conventional content analysis methods were used to identify main themes and patterns. Results: The results revealed that all 84 elders were using at least 1 primary control strategy in their dying process, 83 of whom did so in combination with another primary or compensatory secondary control strategy. Decision making, independence, mental attitude, instrumental activities of daily living, activities of daily living, and relationships were aspects of the dying process over which the respondents sought to exercise control. Over half of the respondents wanted more control; however, they felt their illness prevented it. Implications: The findings highlight the importance of terminally ill elders’ having opportunities to exercise control in their dying process. Practitioners need to ensure that these opportunities exist and to be aware that elders are adaptive and use multiple strategies in exercising control.

]]> Tue, 10 Nov 2009 19:41:05 PST info:doi/10.1093/geront/gnp060 The Gerontological Society of America 6 49 766 2009-12-01 755 DEATH AND DYING http://gerontologist.oxfordjournals.org/cgi/content/short/49/6/767?rss=1 Purpose: Using the Activity Card Sort (ACS), we derived a measure of lifestyle-adjusted function and examined the distribution of this measure and its correlates in a community sample of older adults at risk for disability transitions. Design and Methods: Participants in the Sources of Independence in the Elderly project (n = 375) completed the ACS using a Q-sort (successive pile sort procedure), in which respondents sorted 39 nonbasic activities of daily living (non-BADL) and noninstrumental activities of daily living (non-IADL) tasks into four categories: "never performed," "used to but no longer perform," "hard to do," and "easy to do." Lifestyle-adjusted function was defined as the number reported easy/(number easy + number hard + number no longer performed). Results: Respondents reported that they found it easy to perform about 60% of the activities they ever performed. However, people reporting BADL and IADL disability found it easy to perform only 32% of these activities. Lower extremity performance and depressive symptoms were significant independent correlates of lifestyle-adjusted function in models that controlled for sociodemographic and clinical status. The same 2 correlates were significant in models that excluded people with self-reported BADL or IADL disability. Implications: Because this measure eliminates activities never performed, it can be considered "lifestyle adjusted." Its ability to identify differences in competency among people who do not report BADL or IADL disability suggests that it may be a useful addition to functional assessment.

]]> Tue, 10 Nov 2009 19:41:06 PST info:doi/10.1093/geront/gnp064 The Gerontological Society of America 6 49 777 2009-12-01 767 FUNCTION AND DISABILITY http://gerontologist.oxfordjournals.org/cgi/content/short/49/6/778?rss=1 Purpose: To report the impact on patient and informal caregiver satisfaction, patient empowerment, and health and disability status of a primary care–affiliated disease self-management–health promotion nurse intervention for Medicare beneficiaries with disabilities and recent significant health services use. Design and Methods: The Medicare Primary and Consumer-Directed Care Demonstration was a 24-month randomized controlled trial that included a nurse intervention. The present study (N = 766) compares the nurse (n = 382) and control (n = 384) groups. Generalized linear models for repeated measures, linear regression, and ordered logit regression were used. Results: The patients whose activities of daily living (ADL) were reported by the same respondent at baseline and 22 months following baseline had significantly fewer dependencies at 22 months than did the control group (p = .038). This constituted the vast majority of respondents. In addition, patient satisfaction significantly improved for 6 of 7 domains, whereas caregiver satisfaction improved for 2 of 8 domains. However, the intervention had no effect on empowerment, self-rated health, the SF-36 physical and mental health summary scores, and the number of dependencies in instrumental ADL. Implication: If confirmed in other studies, this intervention holds the potential to reduce the rate of functional decline and improve satisfaction for Medicare beneficiaries with ADL dependence.

]]> Tue, 10 Nov 2009 19:41:06 PST info:doi/10.1093/geront/gnp090 The Gerontological Society of America 6 49 792 2009-12-01 778 FUNCTION AND DISABILITY http://gerontologist.oxfordjournals.org/cgi/content/short/49/6/793?rss=1 Purpose: A national quality report card for nursing homes, Nursing Home Compare, has been published since 2002. It has been shown to have some, albeit limited, positive impact on quality of care. The objective of this study was to test empirically the hypothesis that nursing homes have responded to the publication of the report by adopting cream skimming admission policies. Design and Methods: The study included all non-Medicare newly admitted patients to all Medicare- and Medicaid-certified nursing homes nationally during the 2001–2005 period. Using the Minimum Data Set data, we calculated for each quarter several admission cohort characteristics: average number of activity of daily living limitations and percent of residents admitted with pain, with pressure ulcers, with urinary incontinence, with diabetes, and with memory limitations. We tested whether residents admitted in the postpublication period were less frail and sick compared with residents admitted in the prepublication period by estimating fixed facility effects longitudinal regression models. Analyses were stratified by nursing home ownership, occupancy, reported quality ranking, chain affiliation, and region. Results: Evidence for cream skimming was found with respect to pain and, to a lesser degree, with respect to memory limitation but not with respect to the 4 other admission cohort characteristics. Implications: Despite the theoretical expectation, empirical evidence suggests only a limited degree of cream skimming. Further studies are required to investigate this phenomenon with respect to other admission cohort characteristics and with respect to post-acute patients.

]]> Tue, 10 Nov 2009 19:41:06 PST info:doi/10.1093/geront/gnp062 The Gerontological Society of America 6 49 802 2009-12-01 793 NURSING HOMES http://gerontologist.oxfordjournals.org/cgi/content/short/49/6/803?rss=1 Purpose: The objectives of this study were to develop measures of end-of-life (EOL) care processes in nursing homes and to validate the instrument for measuring them. Design and Methods: A survey of directors of nursing was conducted in 608 eligible nursing homes in New York State. Responses were obtained from 313 (51.5% response rate) facilities. Secondary data on structural characteristics of the nursing homes were obtained from the Online Survey Certification and Reporting System. Exploratory factor analyses and internal consistency reliability analyses were performed. Multivariate regression models with fixed and random effects were estimated. Results: Four EOL process domains were identified—assessment, delivery, communication and coordination of care among providers, and communication with residents and families. The scales measuring these EOL process domains demonstrated acceptable to high internal consistency reliability and face, content, and construct validity. Facilities with more EOL quality assurance or monitoring mechanisms in place and greater emphasis on EOL staff education had better scores on EOL care processes of assessment, communication and coordination among providers, and care delivery. Facilities with better registered nurse and certified nurse aide staffing ratios and those with religious affiliation also scored higher on selected care process measures. Implications: This study offers a new validated tool for measuring EOL care processes in nursing homes. Our findings suggest wide variations in care processes across facilities, which in part may stem from lack of gold standards for EOL practice in nursing homes.

]]> Tue, 10 Nov 2009 19:41:06 PST info:doi/10.1093/geront/gnp092 The Gerontological Society of America 6 49 815 2009-12-01 803 NURSING HOMES http://gerontologist.oxfordjournals.org/cgi/content/short/49/6/816?rss=1 Purpose: This article challenges popular conceptions of the nature of ethnicity and religiousness in the gerontological literature. Using the example of older Jewish Americans, the authors argue for more nuanced definitions and usage of terms such as "religion" and "ethnicity" in order to begin to understand the complex interweaving of these two dimensions in the lives of older persons. Design and Methods: The analyses used data from the 2000–2001 National Jewish Population Survey (NJPS) as well as comparisons with the 1990 NJPS. There were 1,099 respondents aged 65 years and older in the 2000–2001 NJPS who reported themselves to be Jewish. This sample was then split into three groups: those who reported observing only Judaism and were affiliated with a denomination within Judaism (n = 776) or were not affiliated (n = 277) and those who reported observing another faith in addition to Judaism (n = 46). Results: Respondents to the 2000–2001 NJPS were older, wealthier, and less likely to be members of a religious denomination than those in the 1990 NJPS. Denominational affiliates were more likely than the other two groups to have a strong ethnic identity but less likely to indicate that religion was important in their lives. Denomination members were also more likely to be children or grandchildren of immigrants. Implications: Several key assumptions in the study of ethnicity and religiousness in much of current gerontological research need reassessment especially assumptions about the links between religious identification, beliefs, practices, and communal solidarity.

]]> Tue, 10 Nov 2009 19:41:06 PST info:doi/10.1093/geront/gnp070 The Gerontological Society of America 6 49 827 2009-12-01 816 RELIGION AND ETHNICITY http://gerontologist.oxfordjournals.org/cgi/content/short/49/6/828?rss=1 Purpose: The Medicare Prescription Drug Benefit (Part D) program debuted in January 2006. We ascertained the sociodemographic and health characteristics of Blacks and Whites who enrolled in the early stages of the program. Design and Methods: Data were collected between April 2006 and October 2007 from an ongoing population-based biracial study of older adults. Results: We interviewed 2,694 subjects, 1,784 Blacks and 910 Whites, of whom 40% and 35% reported to have enrolled in Medicare Part D, respectively. Among Blacks, those who enrolled were more likely to be female, unmarried, have less education and income, more medical conditions, greater physical disability, and poorer physical function than Blacks who did not enroll. Among Whites, enrollees were older, female, and had less education compared with White nonenrollees. In the multivariate analyses, older age, female, being married, lower income, worse physical function, and better cognitive function were associated with program enrollment. Implications: These results indicate that the profiles of adults who initially enrolled in Medicare Part D differed somewhat by race. Program enrollment among Blacks was largely driven by financial need and poor health; however, among Whites, there was no such discernible pattern of enrollment. In addition, we observed a knowledge gap among Black nonenrollees who reported that they were unaware of and confused by the program and plans. The findings suggest that Medicare Part D may serve different needs in different subpopulations. The long-term impact of these differential program profiles on Black–White health disparities remains uncertain and requires continued monitoring.

]]> Tue, 10 Nov 2009 19:41:06 PST info:doi/10.1093/geront/gnp055 The Gerontological Society of America 6 49 838 2009-12-01 828 MEDICARE http://gerontologist.oxfordjournals.org/cgi/content/short/49/6/839?rss=1 Purpose: Motivating and enabling formal caregivers to provide individualized resident care has become an increasingly important objective in long-term care (LTC) facilities. The current study set out to examine the structure of responses to the individualized care inventory (ICI). Design and Methods: Samples of 242 registered nurses (RNs)/licensed practical nurses (LPNs) and 326 care aides were recruited from 54 LTC facilities in 3 of 5 British Columbia health authorities. Baseline confirmatory factor analytic (CFA) models were computed separately for RNs/LPNs and care aides; invariance analyses were next undertaken to compare these CFA models. Results: For both RNs/LPNs and care aides, support was found for a 4-factor model of ICI responses mapping onto a higher order individualized care (IC) construct. This model was largely equivalent between formal caregiver groups, although the relative contribution of certain first-order factors differed between the two. Of further note, both groups appear to interpret and respond to 31 of 35 ICI items in a similar manner. Implications: The results of this study provide further support for the psychometric properties of ICI responses. Although further research is required, the ICI appears to be an appropriate self-report measure. This instrument may be used by researchers, policymakers, administrators, and practitioners alike to assess strengths as well as areas for improving the delivery of IC to LTC residents by formal caregivers.

]]> Tue, 10 Nov 2009 19:41:06 PST info:doi/10.1093/geront/gnp053 The Gerontological Society of America 6 49 846 2009-12-01 839 BRIEF REPORT http://gerontologist.oxfordjournals.org/cgi/content/short/49/6/847?rss=1 Purpose: This study assessed the effectiveness of Active Start, a community-based behavior change and fitness program, designed to promote physical activity among sedentary community-dwelling older adults. Design and Methods: A quasi-experimental design was used. Data were analyzed using a within-group pretest–post-test design to calculate changes in the intervention group and changes in the waitlist comparison group. Further analyses were conducted after the comparison group completed the intervention. Paired t tests were employed to analyze unadjusted mean changes in physical performance measures from pretest to post-test. Repeated measures analysis of covariance (using SAS Proc Mixed) was then conducted to calculate the adjusted mean change for the intervention group. Results: Significant improvement was found on all performance measures (strength, flexibility, and balance) for the intervention group as a whole. Similar improvements were found among subgroups (Whites, African Americans, and Hispanics). No significant changes were found in the comparison group when they were in the control condition; however, they significantly improved on all measures after completing the intervention. Implications: This study suggests that a community-based physical activity program benefits sedentary, racially, and ethnically diverse older adults by coupling a behavioral change support group and fitness classes.

]]> Tue, 10 Nov 2009 19:41:07 PST info:doi/10.1093/geront/gnp113 The Gerontological Society of America 6 49 855 2009-12-01 847 PRACTICE CONCEPTS http://gerontologist.oxfordjournals.org/cgi/content/short/49/6/856?rss=1 Tue, 10 Nov 2009 19:41:07 PST info:doi/10.1093/geront/gnp146 The Gerontological Society of America 6 49 859 2009-12-01 856 BOOK REVIEWS http://gerontologist.oxfordjournals.org/cgi/content/short/49/6/859?rss=1 Tue, 10 Nov 2009 19:41:07 PST info:doi/10.1093/geront/gnp145 The Gerontological Society of America 6 49 863 2009-12-01 859 BOOK REVIEWS http://gerontologist.oxfordjournals.org/cgi/content/short/49/6/863?rss=1 Tue, 10 Nov 2009 19:41:07 PST info:doi/10.1093/geront/gnp144 The Gerontological Society of America 6 49 864 2009-12-01 863 BOOKS RECEIVED http://gerontologist.oxfordjournals.org/cgi/content/short/49/6/865?rss=1 Tue, 10 Nov 2009 19:41:07 PST info:doi/10.1093/geront/gnp136 The Gerontological Society of America 6 49 865 2009-12-01 865 Erratum