Risk for Complicated Grief After the COVID-19 Death of a Marital Partner in Late Life

OBJECTIVE

To identify 1) complicated grief symptom clusters among acutely-bereaved older adults who have lost a spouse to COVID-19 and 2) if spousal death due to COVID-19 increased risk of developing probable PGD METHODS: Eighty adults participating in a randomized controlled trial for depression prevention (mean age [± SD] = 70.4 [6.6]) completed the Inventory of Complicated Grief, every 3 months over a maximum of 15 months. Twenty-four percent (n = 19) of participants lost a spouse to COVID-19; 76% (n = 61) lost a spouse to other causes of death. Adjusted linear regression examined the associations between COVID-19 bereavement and six symptom clusters: yearning and preoccupation, anger and bitterness, shock and disbelief, estrangement from others, hallucinations, and behavior change.

RESULTS

Compared to the non-COVID-19 group, the COVID-19 bereaved group reported greater shock and disbelief, hallucinations of the deceased, and estrangement from others. COVID-19 death was also associated with higher risk for probable prolonged grief disorder (PGD) at 12 months (odds ratio = 4.38, p = 0.027).

CONCLUSIONS

Older adults who have lost a spouse to COVID-19 present with specific symptoms of distress and may eventually require clinical care for PGD.

A Multimethod Examination of Medical Students' Experiences With Bereavement and Complicated Grief

Few studies have examined grief in medical students. This study used a multimethod approach to describe how bereavement and CG may impact medical students' educational experience and their perspectives on grief support and training. One hundred three medical students completed an online survey with quantitative and qualitative methods. Seventy-three (71%) students reported experiencing bereavement, of which 12 (18%) screened positive for CG. Medical students who screened positive for CG reported significantly more emotional and behavioral challenges (M = 3.58 [SD = 2.64]) compared to medical students without CG (M = 0.93 [SD = 1.58], p < .001). Qualitative analyses revealed that bereaved and nonbereaved students wanted more grief education and bereavement support from medical institutions. Therefore, it is crucial for medical institutions, to acknowledge that grief and bereavement may impact students' performance due to multifactorial causes.

Incorporating technology in research with older bereaved adults: Lessons learned from conducting an internet-based randomized controlled trial

Objective

Digital health interventions (DHI) involve multiple interactions between the user, technology platform, and study team, posing challenges for implementation. This paper describes the lessons learned while implementing an internet-based randomized controlled trial (RCT) for reducing depression symptom burden in older acutely-bereaved adults.

Methods

The RCT was entitled "Widowed Elders' Lifestyle after Loss" (or WELL), which compared the efficacy of a DHI to an enhanced usual care (EUC) for reducing depression symptoms in adults 60+ years who lost their spouse/life partner within the previous 12 months. Participants randomized to the DHI used their own tablet, smartphone, or pc to record the timing and regularity of sleep, meals, and physical activity twice daily, for 12 weeks. The also received weekly health coaching sessions from a clinician certified in motivational interviewing. Participants randomized to the EUC arm received weekly calls from research staff and were assessed on the same schedule as intervention participants. All study procedures were conducted virtually. Methodological and procedural challenges were discussed weekly with study staff and the primary investigator.

Results

Many challenges can be categorized as follows recruiting virtually, obtaining informed consent, training older adults to use technology, and establishing rapport with older adults. Solutions required researcher and interventionist flexibility in adapting to new strategies. For instance, we redesigned the informed consent process to include a user-friendly brochure that enhanced participants' understanding of the RCT and improved our enrollment rate. We also utilized user-engagement in refining an intervention protocol.

Conclusion

We resolved implementation challenges without compromising internal validity via interdisciplinary collaborations with mobile programmers to ensure our technology met the unique and varied needs of aging users. The solutions from this study may promote the recruitment and retainment of older adults in research studies that use technology-based interventions.

Psychosocial interventions to improve adherence in depressed and anxious older adults prescribed antidepressant pharmacotherapy: a scoping review

Medication nonadherence in depressed and anxious older adults is prevalent and associated with non-response to antidepressant pharmacotherapy. Evidence-based options to improve medication adherence are limited in this population. To review the state of the literature on the types and efficacy of psychosocial interventions for improving antidepressant pharmacotherapy adherence in depressed and anxious older adults. We conducted a scoping review according to PRISMA-ScR guidelines. PubMed/Medline and article references starting in 1980 up to 28 February 2023 were reviewed. Of the 710 records screened, 4 psychosocial interventions were included in the review. All studies included depressed older adults, and none included anxious older adults. Samples included racial and ethnic minorities and were primarily women. The psychosocial interventions consisted mainly of psychoeducation with usual care as the control comparison. Measures of antidepressant adherence included self-reported adherence or pill counting. Three of the four randomized controlled trials improved medication adherence rates and reduced depression symptom burden. Effective interventions exist for improving antidepressant medication adherence in depressed older adults. Improved adherence can reduce depression symptom burden. The lack of interventions for anxious older adults highlights the need to develop and deliver interventions for anxious older adults prescribed antidepressant pharmacotherapy.

Rest-Activity Rhythm Characteristics Associated With Depression Symptoms in Stroke Survivors

OBJECTIVE

To examine which 24-hour rest-activity rhythm (RAR) characteristics are associated with depression symptoms in stroke survivors.

DESIGN

Cross-sectional observational study examining associations of RAR characteristics with the presence of depression symptoms adjusting for age, sex, race, and medical comorbidity.

SETTING

Community setting.

PARTICIPANTS

Stroke survivors: (1) recruited locally (N women=35, N men=28) and (2) a nationally representative probability sample (the National Health and Nutrition Examination Survey [NHANES]; N women=156, N men=124).

INTERVENTIONS

None.

MEASUREMENTS

Objective RAR characteristics derived from accelerometer recordings including activity onset/offset times and non-parametric measures of RAR strength (relative amplitude), stability (interdaily stability), and fragmentation (intradaily variability). The presence of depression symptoms was categorized using Patient Health Questionnaire scores.

RESULTS

In both samples, the only RAR characteristic associated with depression symptoms was intradaily variability (fragmentation): local sample, odds ratio=1.96 [95% confidence interval=1.05-3.63]; NHANES sample, odds ratio=1.34, [95% confidence interval=1.01-1.78]). In the NHANES sample, which included both mild and moderate/severe depression, the association between 24-hour sleep-wake fragmentation and depression symptoms was driven by moderate-to-severe cases.

CONCLUSIONS

Stroke survivors with higher levels of RAR fragmentation were more likely to have depression symptoms in both samples. These findings have implications, given prior studies in general samples linking RAR fragmentation with future depression and dementia risk. Research is needed to establish the potential consequences, mechanisms, and modifiability of RAR fragmentation in stroke survivors.

Interpersonal Support Domains Associated With Symptoms of Posttraumatic Stress Among Older Black and White Adults

Objective: Older adults experience numerous changes in their social networks and social environment that may worsen preexisting posttraumatic stress disorder (PTSD) symptoms. This study tested whether tangible support, appraisal support, belonging support, and self-esteem were associated with trauma symptom burden among community-dwelling older Black and White adults at baseline and over 12 months of follow-up.

Methods: This study used data collected from a randomized controlled trial for depression prevention in adults 50 years of age or older who had subsyndromal depression (2006-2011). Two hundred forty-four participants (including 90 older Black adults) were randomly assigned to a problem-solving therapy arm or an active control arm. The Interpersonal Support Evaluation List (ISEL) was administered at baseline and 12 months later. Linear regression analysis was used to examine associations of each of the ISEL dimensions with DSM-IV-defined PTSD symptoms at baseline and over time, with control for well-established correlates of PTSD including depression, anxiety, and sleep quality.

Results: Participants were a mean (SD) of 65.6 (11.0) years of age, and 71% percent were female. Belongingness support was the only dimension of interpersonal support significantly associated with PTSD symptoms at baseline (β = -0.192, t = -3.582, P < .001) and 12 months later (β = -0.183, t = -2.735, P < .01). Regression models accounted for a large proportion of variance in PTSD symptoms. The association between belongingness support and PTSD symptoms did not vary by participant race.

Conclusions: A strong perception of belongingness to family and/or friends was associated with fewer PTSD symptoms at baseline and over 12 months. This observation generates the hypothesis that behavioral interventions which directly target and modify interpersonal support may benefit both older Black and older White adults who have experienced trauma.

Trial Registration: ClinicalTrials.gov identifier: NCT00326677.

Depressive symptoms anticipate behavioral and emotional factors among older adults: A prospective cross-lagged panel design

This study examined the temporal relationship among depression, anxiety, insomnia, perceived stress, and physical activity in adults aged 60+ years with a history of major depressive disorder. We conducted a longitudinal study with 12 weeks of follow-up. Assessments consisted of phone or video interviews and included questionnaires evaluating depression, anxiety, insomnia, perceived stress, and physical activity. Our analytic approach consisted of a depression-focused cross-lagged panel model (CLPM) to examine week-to-week correlations among the five measures. The depression-focused CLPM identified statistically significant week-to-week self-predictive effects for each of the five measures. Higher depressive symptom burden was a strong predictor of increased stress, greater insomnia, and less physical activity the following week. No other cross-measure predictions were statistically significant. Our analytical approach clarifies the directional relationship among variables that typically co-occur with depression showing that higher depression symptom burden predisposes older adults to poor sleep, a reduced level of daytime activity, and a greater sense of stress. These findings support the need for longitudinal assessments and targeted interventions for reducing symptoms of depression in older adults.

A digital health intervention to stabilize the 24-hour rhythm of sleep, meals, and physical activity for reducing depression among older bereaved spouses: Protocol for a randomized controlled trial

BACKGROUND

Despite the high prevalence of depression and disruption to 24-h sleep-wake routines following the death of a spouse in late-life, no bereavement interventions have been developed to re-entrain a regular sleep-wake routine among older widow(er)s. We describe the rationale and methodology of the NIH-funded WELL Study (Widowed Elders' Lifestyle after Loss), a randomized controlled trial (RCT) comparing the efficacy of a digital health intervention (DHI) to enhanced usual care (EUC) arm for reducing depression symptoms in older spousally-bereaved adults.

METHODS

We will randomize approximately 200 recently bereaved (<12 months) adults aged 60+ years to one of two 12-week interventions: digital monitoring of the timing and regularity of sleep, meals, and physical activity plus weekly motivational health coaching; or enhanced usual care consisting of weekly telephone calls and similar assessment schedules. Participants will complete self-report and clinical assessments at baseline, post-intervention, and 3-, 6-, and 12-months post-intervention, and objective actigraphic assessments of their 24-h rest-activity rhythm (RAR) at baseline and 1-, 2-, and 3-months during the intervention. The primary outcome is change in depression symptoms burden (using the Hamilton Rating Scale for Depression) from pre- to post-intervention and over 12 months of follow-up.

DISCUSSION

WELL Study findings will inform the development of widely generalizable and scalable technology-based interventions to support bereaved spouses in community-based settings. Clinical http://Trials.gov Identifier: NCT04016896.

Predicting Medication Nonadherence in Older Adults With Difficult-to-Treat Depression in the IRL-GRey Randomized Controlled Trial

OBJECTIVE

Nonadherence to antidepressants interferes with optimal treatment of late-life depression. This analysis examines clinical and treatment factors predicting medication nonadherence in difficult-to-treat late-life depression.

METHODS

Secondary analysis of data from a clinical trial of antidepressant pharmacotherapy for Major Depressive Disorder in 468 adults aged 60+ years. All participants received venlafaxine XR for 12 weeks. Nonremitters were randomized to augmentation with either aripiprazole or placebo for 12 additional weeks. Medication adherence was assessed 14 times over 24 weeks. The analyses examined sociodemographic, clinical, and treatment factors that may predict antidepressant nonadherence during early (weeks 1-6), late (weeks 7-12), and augmentation (weeks 13--24) treatment.

RESULTS

Poor cognitive function and early response were predictive of early nonadherence. Poor cognitive function and prior nonadherence were predictive of late nonadherence. Living alone was associated with nonadherence both late and during augmentation treatment.

CONCLUSION

Future studies should consider the role of early response and cognitive function to improve antidepressant adherence, particularly among older adults who live alone.

Pediatric Sleep Disturbances and Symptoms of Depression in Older Adults

We investigated the association between retrospectively reported sleep disturbances during childhood and adolescence and current symptoms of depression and anxiety in older adults. Participants included 116 older adults (M age  =  68 years [SD  =  6.4 years]) who completed a battery of sleep and psychological assessments. We tested two multivariate regression models using age, sex, race, physical illness burden, insomnia status, and pediatric sleep disturbances as correlates of depressive symptoms and anxiety symptoms. Pediatric sleep disturbances were significantly associated with greater depressive symptomatology (β  =  0.247, p  =  .010), independent of current insomnia status. Medium effect sizes were reported. Our results suggest that pediatric sleep disturbances may be a biobehavioral signal for the development of poor emotional health across the lifespan. Future research should identify critical windows of development when sleep disturbances might be most impactful on emotional health trajectories.

Multidimensional Sleep Health and Physical Functioning in Older Adults

Objective: To examine the association between multidimensional sleep health and objective measures of physical functioning in older adults. Method: We conducted a secondary analysis of 158 adults ≥65 years who participated in Midlife in the United States (MIDUS) 2 and MIDUS Refresher studies. Physical functioning was assessed using gait speed during a 50-foot timed walk, lower extremity strength via chair stand test, and grip strength via hand-held dynamometers. Composite multidimensional sleep health scores were derived from 1 week of sleep diaries and wrist actigraphy. Results: Multiple linear regression was used to examine the associations between multidimensional sleep health and physical functioning measures. In adjusted regression analyses, multidimensional sleep health was significantly positively associated with gait speed but not lower extremity strength or grip strength. Discussion: These findings suggest multidimensional sleep health may contribute to physical functioning in older adults. Longitudinal examinations are needed to determine the value of multidimensional sleep health as a therapeutic target to optimize physical functioning.

Cancer Bereavement and Depression Symptoms in Older Spouses: The Possible Modifying Role of the Circadian Rest-Activity Rhythm

OBJECTIVES

This study examines the associations of cancer death and aspects of the 24-h circadian rest-activity rhythm (RAR) on depression symptoms in older spouses.

METHODS

Participants included 46 adults aged 60-94 years (M = 73 years) who experienced the death of a spouse. We tested a multivariate model using cancer death (vs. non-cancer death) and RAR variables as correlates of depression symptoms while controlling for age, sex, physical illness burden, and preparedness for death. We also present a case example to describe the behavioral activity patterns of a participant bereaved by cancer.

RESULTS

Cancer death was associated with elevated levels of depression symptoms. However, the timing of the RAR moderated this association. Cancer bereavement was associated with depression symptoms when participants "settled-down" after 11:00 PM. The case example illustrates how intrusive thoughts about death quality impacts a widower's drive to stay busy with daily activities.

CONCLUSIONS

Settling down earlier in the evening is important for older spouses bereaved by cancer, in terms of fewer symptoms of depression.

CLINICAL IMPLICATIONS

Objectively specifying the activity patterns of older spouses bereaved by cancer is a promising avenue for interventions that aim to reduce depression symptoms.

Subjective Sleep Quality and Trajectories of Interleukin-6 in Older Adults

BACKGROUND

We aimed to identify trajectories of inflammation in older adults at elevated risk for syndromal depression and anxiety and to determine whether baseline physical, cognitive, and psychosocial factors could distinguish 15-month longitudinal trajectories.

METHODS

Older adults (N = 195, mean age (±SD) = 74.4 years (9.0) participating in three depression and anxiety prevention protocols completed a comprehensive battery of psychosocial assessments and provided blood samples for analysis of interleukin-6 (IL-6) every 3 months over a maximum of 15 months. Group-based trajectory modeling identified trajectories. Adjusted logistic regression examined associations between baseline factors and trajectory groups.

RESULTS

Two 15-month trajectories were identified: stable lower IL-6 levels (84%; mean (±SD) = 3.2 (2.1) pg/mL); and consistently higher IL-6 levels (16%; mean = 9.5 (7.4) pg/mL). Poor sleep quality predicted consistently higher levels of IL-6 (OR = 1.9, 95% CI = 1.03-3.55).

CONCLUSION

Poor sleep quality may represent a therapeutic target to reduce inflammation.

The Effects of Gait Speed and Psychomotor Speed on Risk for Depression and Anxiety in Older Adults with Medical Comorbidities

BACKGROUND/OBJECTIVES

Gait speed and psychomotor speed slow with age and may predict neuropsychiatric disease such as depression and anxiety. We explored the relative predictive values of gait speed, psychomotor slowing, and a composite index of these two measures on time to new episode depression or anxiety in older adults at risk for these common psychiatric conditions.

DESIGN

Randomized controlled prevention trial with 15-month follow-up.

SETTING

University-based late-life mental health research clinic.

PARTICIPANTS

Two hundred thirteen individuals, age 60+ years, with subsyndromal symptoms of depression or anxiety and one of the following risk factors for these common conditions: mild cognitive impairment, knee osteoarthritis, or disabilities requiring home-based care.

INTERVENTION

Participants in each of the risk factor groups were randomized to a depression-specific preventive intervention or usual care.

MEASUREMENTS

Gait speed: 4-m walk test from the Short Physical Performance Battery. Psychomotor speed: Coding task of the Repeatable Battery for the Assessment of Neuropsychological Status. We created a composite index of slowing by determining whether participants exceeded established cut-offs for slow performance in both gait speed (≤0.8 m/s) and psychomotor speed (<7 on the coding task). Time to new onset syndromal depression/anxiety was measured using research diagnostic criteria.

RESULTS

Fifty-four participants developed syndromal depression/anxiety (19.5%) over the course of 15 months. Participants with slowing in both areas were over twice as likely to experience new onset depression/anxiety (hazard ratio (HR) = 2.11; 95% confidence interval (CI) = 1.02-4.40, P = .046) compared to participants with no slowing in either area. Slowed gait (HR = 1.88; 95% CI = 0.992-3.55; P = .052) or slowed psychomotor speed (HR = 0.60; 95% CI = 0.14-2.58; P = .488) alone did not increase risk for depression/anxiety.

CONCLUSION

Evaluating both gait and psychomotor speed in older adults with medical comorbidities and sub-syndromal depression may predict incident mental illness and inform prevention planning. Future research is needed to validate our observations and explore shared neurobiological mechanisms that explain this elevated risk.

Coprescribed Benzodiazepines in Older Adults Receiving Antidepressants for Anxiety and Depressive Disorders: Association With Treatment Outcomes

OBJECTIVE

There is a paucity of data on the effects of coprescribed benzodiazepines on treatment response variability and adherence to antidepressant pharmacotherapy for depression and anxiety in late life. The objective of this transdiagnostic analysis was to examine the effect of benzodiazepines on treatment outcomes in older patients with generalized anxiety disorder (GAD) or major depressive disorder (MDD).

METHODS

Secondary analyses of data from 2 clinical trials of antidepressant pharmacotherapy for GAD (escitalopram vs placebo, 2006-2009) or MDD (open treatment with venlafaxine, 2009-2014) were conducted. Participants included 640 adults aged 60+ years with DSM-IV-defined GAD (n = 177) or MDD (n = 463). Benzodiazepine data were collected at baseline. Adherence and treatment response were assessed over 12 weeks. The analysis addressed whether coprescribed benzodiazepines are associated with treatment response, antidepressant medication adherence, dropout, final dose of antidepressant medication, and report of antidepressant-related adverse effects.

RESULTS

Participants with GAD and coprescribed benzodiazepines were treated with a lower mean dosage of escitalopram and were less likely to complete the trial; there was no difference in adherence or treatment response. Participants with MDD and coprescribed benzodiazepines were less likely to tolerate a therapeutic dose of venlafaxine and reported more medication-related adverse effects; there was no difference in adherence, dropout, or treatment response.

CONCLUSIONS

Coprescription of benzodiazepines was associated with increased dropout in older patients with GAD and more medication-related adverse effects in older patients with MDD. However, with the systematic clinical attention offered in a clinical trial, they do not impede treatment response. Clinicians should be aware that a coprescribed benzodiazepine may be a marker of a more challenging treatment course.

TRIAL REGISTRATION

Data analyzed were from studies with ClinicalTrials.gov identifiers NCT00892047 and NCT00105586.

Timing of Daily Activities over a 24-Hour Period and Affective Status among a National Cohort of Older Dementia Caregivers

Objective: To examine the allocation of daily activities over a 24-hour period in caregivers (CGs) with and without a probable affective disorder. Methods: Participants were 192 older dementia CGs (mean age = 72.9 years, 70% female) who participated in the National Study of Caregiving. Time diary data were used to measure the duration and timing that caregivers were doing hygienic self-care, eating/drinking, household care, physical caregiving, medical caregiving, socializing, and television viewing. Affective status was assessed using the two-item Patient Health Questionnaire and the Generalized Anxiety Disorder screeners. Results: CGs were more likely to screen positive for depression/anxiety symptoms if they started hygienic self-care later (OR = 1.76, 95% CI = 1.10-2.83) and started medical caregiving later (OR = 2.34, 95% CI = 1.24-4.41). Hygienic self-care start times attenuated the effects of medical caregiving on the affective status. Discussion: Later timing of hygienic self-care may be an important behavioral response that contributes to affective disorder risk in dementia CGs.

Resting-State Function Connectivity Associated With Being a "Morning-Type" Dementia Caregiver and Having Lower Depression Symptom Severity

OBJECTIVES

A lack of "morningness" predicts greater depression symptom severity over time, including in a vulnerable group of older adults: family dementia caregivers (dCGs). Evidence regarding the neurobiological basis of these correlations is needed to guide future research towards biomarker-informed detection and prevention approaches. We therefore primarily aimed to identify simple resting-state biomarkers that correlated with a lack of "morningness" in dCGs.

METHOD

We examined 54 dCGs (mean age = 70, range: 61-84; 70% female) of whom 40% were definite "morning types" according to Composite Scale of Morningness (CSM). Using a 7 Tesla resting-state sequence, we compared the functional connectivity of nodes in networks previously implicated in depression (fronto-parietal, default mode, limbic, and salience) between caregivers who were and were not "morning types."

RESULTS

Correcting for voxel-wise comparisons, "morning-type" dCGs had less amygdala-posterior cingulate connectivity (Cohen's d = -1.3), which statistically mediated ~32% of the association between the degree of "morningness" and lower depression severity. Post hoc analyses of CSM items found significant correlations, with both amygdala-posterior cingulate FC and depression severity, for 4/6 items pertaining to difficulty, 2/5 items pertaining to preference, and 0/2 items pertaining to typical patterns.

DISCUSSION

Prior research shows that amygdala-posterior cingulate connectivity increases when allocating attention to peripheral aspects of negative emotional stimuli. As such, difficulty with morning activation may relate to the ongoing direction of focus around distressing content; in contrast, morning activity participation may serve to limit focus on distress. Replication and experimental studies are required to confirm these associations and their modifiability.

Opioid Exposure Negatively Affects Antidepressant Response to Venlafaxine in Older Adults with Chronic Low Back Pain and Depression

OBJECTIVE

Serotonin norepinephrine reuptake inhibitors (SNRIs) are commonly co-prescribed with opioids for chronic pain. The purpose of this study was to describe pain and mood response to venlafaxine among older adults with chronic low back pain (CLBP) and depression relative to opioid exposure.

DESIGN

Secondary analyses were collected from a randomized clinical trial testing a stepped-care approach to comorbid pain and depression in older patients: the Addressing Depression and Pain Together study (ADAPT: 2010-2016).

SETTING

University-based late-life mental health research clinic.

SUBJECTS

Two hundred twenty-seven adults aged 65+ years with CLBP and depression.

METHODS

Participants received six weeks of lower-dose venlafaxine (≤150 mg/d). Pain and depression were measured each week. Response for both pain and depression at the end of six weeks was defined by a ≥30% improvement on a 0-20 numeric rating scale for low back pain and a Patient Health Questionnaire-9 score ≤5. Opioid exposure was analyzed as prescribed (yes or no) and by morphine equivalent dosing (MED).

RESULTS

Patients co-prescribed an opioid were less likely to report a pain response to venlafaxine. MED was negatively correlated with pain response. Depression response was not impacted.

CONCLUSIONS

Opioids are negatively associated with older adults' early analgesic response to lower-dose venlafaxine. These findings suggest that clinicians may wish to consider either nonopioid or alternative antidepressant approaches to pain management in these complex patients. It is reassuring that opioids do not prevent depression response. Future research should examine both longer duration of treatment and a wider range of doses.

Cross-Cultural Experiences of Hospice and Palliative Care Services: A Thematic Analysis

Significant disparity exists among non-Western and minority individuals in hospice and palliative care services. A cross-cultural approach that addresses the needs of these patients would decrease this disparity. This study reviews the literature on the experiences of patients from non-Western and minority cultural backgrounds in hospice and palliative care services to inform clinical practice by Western providers. The PubMed database was searched for qualitative studies on patient and family member experiences of end-of-life services among minority or non-Western cultural groups. Eighteen articles met eligibility criteria. The major themes identified include the following: communication and the flow of information, perceptions of hospice and palliative care, and compatibility with cultural beliefs. This review demonstrates similar themes across many non-Western and minority cultures when interacting with hospice and palliative care services. These findings emphasize the importance of a cross-cultural approach in a palliative care and hospice setting.

Safety Planning to Manage Suicide Risk with Older Adults: Case Examples and Recommendations

Adults age 65 and older have high rates of suicide, despite recent efforts to reduce the suicide rate in this population. One suicide prevention strategy with burgeoning empirical support is safety planning; however, there is a lack of information and resources on safety planning for older adults to support uptake of this evidence-based practice in clinical settings where older adults are commonly seen. Safety plans can address risk factors for suicide in older adults, including social isolation, physical illness, functional limitations, and use of highly lethal means. Safety plans also promote relevant protective factors, including increasing use of coping strategies, social support, and help-seeking. Clinicians may encounter challenges and barriers to safety planning with older adults. This paper describes a collaborative, creative approach to safety planning that is relevant and useful for this vulnerable population. Using two case examples, we illustrate how to engage older adults in safety planning, including ways to minimize barriers associated with the aging process.

Depression Agency-Based Collaborative: Effect of Problem-Solving Therapy on Risk of Common Mental Disorders in Older Adults With Home Care Needs

BACKGROUND

Interventions to prevent depression in older adults have mainly focused on young-old ambulatory adults, not on the old-old with disabilities who receive supportive services in their homes.

OBJECTIVE

The Depression Agency-Based Collaborative (Dep-ABC) is a single-blind pilot randomized controlled trial assessing the effect of an intervention-development strategy using problem-solving therapy (PST) on the risk of common mental health disorders in this vulnerable population.

METHODS

The intervention involved six to eight sessions of PST over 12 weeks. Participants were followed up to 12 months postintervention.

RESULTS

Dep-ABC randomized 104 participants-68.4% of eligible and 17.5% of all older adults screened. The proportion of participants with incident major depressive disorder or generalized anxiety disorder was 11.4% in PST and 14.3% in the enhanced usual care control arm. A test of the interaction between time and intervention for anxiety symptoms favored the PST arm (p = 0.04).

CONCLUSION

PST did not lower the risk of incident common mental illness but did lower anxiety symptom burden. Apart from low power, the effects of PST may have been blunted by referral for medical and aging services in the enhanced usual care group.

Feeling Relieved After the Death of a Family Member With Dementia: Associations With Postbereavement Adjustment

OBJECTIVE

After an extended period of caregiving, the death of a family member with dementia can provide a sense of relief to individuals because caregiving has ended and their loved one is no longer suffering. Little is known about predeath factors associated with feeling relieved after the death of a family member with dementia. This study examined 1) predeath factors associated with caregiver (CG) relief; and 2) whether CG relief is associated with postbereavement adjustment, namely complicated grief and depression symptoms.

METHODS

Participants were bereaved CGs aged 28-90 years old drawn from the Resources for Enhancing Alzheimer's Caregiver Health (REACH) (N = 223) and Family Caregiver Transition Support (FaCTS) (N = 89) studies. In each sample, demographics were assessed at baseline, and CG relief was assessed at the first follow-up assessment after death. Each study administered a similar bereavement battery to CGs following the death of their care recipients (CRs).

RESULTS

CGs of late-stage dementia patients (FaCTS) reported more relief compared with CGs of early- to midstage dementia patients (REACH). CGs were more likely to experience relief if they were prepared for their CR's death and if they perceived their CR's death to be a relief to the CR. A multivariate regression model showed that greater CG relief was associated with less complicated grief postbereavement. CG relief was not significantly associated with depression symptoms.

CONCLUSION

We show prospectively that the caregiving experience impacts feelings of relief, and that feeling relieved facilitates postbereavement adjustment by lessening symptoms of complicated grief.

Restorative activities among bereaved caregivers of nursing home patients

This prospective study examined predictors and correlates of restorative activities in recently bereaved caregivers and their relation to post-bereavement adjustment, namely complicated grief. Participants included 89 caregivers (CGs) age 32-87 (M age - 63 years) whose care recipients recently died in a long-term care facility (M time since loss = 107 days). Our findings show that being prepared prior to death enables CGs the opportunity to engage in restorative activities post death. Restorative activities partially mediated the relationship between preparedness prior to death and complicated grief, but this association was attenuated in multivariable models. It is possible that being prepared prior to death allows CGs to engage in restorative activities post-death, which in turn decreases complicated grief. More research is needed in diverse populations of CGs to determine how restorative activities may impact post-bereavement adjustment.

Living alone and depression: the modifying role of the perceived neighborhood environment

OBJECTIVE

Older adults who live alone are more likely to report feelings of depression than those who live with a spouse or other family members. This study examines the effects of residential status and perceived neighborhood characteristics on depression in middle-aged and older adults.

METHODS

This study is based on a probability sample of 1049 adults aged 55-98 years (M = 69 years) residing in Allegheny County, Pittsburgh, PA, USA in 2014. Thirty percent of participants reported living alone. We tested a multivariate model using living alone (vs. living with a family member or others) and perceived neighborhood physical and social quality as predictors of depressive symptomatology while controlling for age, sex, race, education, and disability.

RESULTS

Living alone (compared to living with a family member) was associated with elevated levels of depressive symptomatology. However, perceptions of neighborhood social quality moderated this association. Living alone was more highly associated with depression when the perceived social quality of the neighborhood was low. Neighborhood social quality was not associated with depression among older adults who lived with a family member. Perceptions of neighborhood physical quality were not significantly associated with depression.

CONCLUSIONS

Perceptions of good neighborhood social quality is important for adults who live alone, in terms of fewer symptoms of depression.

Design and Rationale for a Technology-based Healthy Lifestyle Intervention in Older Adults Grieving the Loss of a Spouse

Introduction

Experiencing the death of a spouse during late life is associated with an increased risk of developing debilitating mental health problems. Healthy lifestyle practices, such as regular exercise, healthy eating, and good sleep hygiene are promising strategies to influence the mental health and associated physical symptoms of late-life spousal bereavement.

Objective

This paper describes the design and rationale of an intervention development study addressing selective and indicated prevention of depression, anxiety, and/or complicated grief disorder(s) among adults 60 years and older who are grieving the recent loss (within 8 months) of a spouse or partner.

Methods

In Phase I, now complete, we developed and standardized behavioral self-monitoring of daily lifestyle choices via an electronic diary (BSM) and the combined BSM + motivational interviewing-based lifestyle coaching (BSM+MI) to be administered to participants grieving the loss of loved one. In Phase II, we have been implementing the interventions in a randomized controlled trial and addressing challenges related to recruitment. Randomization is to one of three cells: BSM, BSM+MI, or an enhanced usual care condition.

Discussion

Several challenges in implementing our lifestyle interventions to older widow(er)s who are at risk for common mental disorders have been identified. Direct outreach to hospice organizations is an effective way to identify older adults in the early months following spousal death. Results from study may advance the field of grief support and promote a healthy adaptation to widowhood.

Measuring Participant Effort in a Depression Prevention Trial: Who Engages in Problem-Solving Therapy?

OBJECTIVE

To determine the acceptability of clinical interventions for depression prevention, identification of clinical characteristics associated with intervention engagement is needed. The purpose of this study is to describe levels and correlates of participant engagement in Problem Solving Therapy (PST) in adults 60 and older with subthreshold depression.

METHODS

As part of a clinical trial to prevent depression among older adults with subthreshold depression, participants who were randomized to receive PST completed 6-8 sessions in which they learned skills to solve self-selected problems that were contributing to stress and reduced quality of life. To measure participants' engagement with PST, interventionists completed 3 scales that rated participants' level of participation in problem solving activities, understanding of the multistep process of PST, and between-session homework effort. Using logistic regression, we examined whether physical health, level of cognitive function, gait speed, and disability served as correlates of engagement in the PST intervention.

RESULTS

Gait speed, a measure of physical and cognitive health, was significantly associated with engagement in PST. Participants who walked faster were more likely to engage with PST compared to participants who walked more slowly. No other baseline variables were significant correlates.

CONCLUSIONS

Older adults who walk more slowly may need alternative delivery methods to fully engage in PST. Gait speed reflects physical and cognitive health, and predicts frailty, disability, and psychomotor speed slowing. For these reasons, gait speed may be a marker for factors that will serve to predict poorer engagement in psychosocial interventions like PST.

Treatment Considerations for Depression Research in Older Married Couples: A Dyadic Case Study

OBJECTIVE

Critical gaps remain in understanding optimal approaches to intervening with older couples. The focus of this report is to describe the pros and cons of incorporating spousal dyads into depression-prevention research.

METHODS

In an intervention development study, the authors administered problem-solving therapy (PST) dyadically to participants with mild cognitive impairment (MCI) and their caregivers. Dyads worked with the same interventionist in the same therapy session. The dyadic PST (highlighted in a case example of a husband with MCI and his wife/support person) and the potential feasibility of the program are described.

RESULTS

The authors found that the wife of the individual with MCI could be trained as a PST coach to help her husband learn and use problem-solving skills. A decrease in depressive symptom severity was observed for the individual with MCI, which was sustained over 12 months of follow-up. Neither the husband nor wife experienced an incident episode of major depression over the course of the study.

CONCLUSION

Dyadic interventions need to be further developed in geriatric psychiatry; proven methods such as PST can be modified to include patients' support persons. Recommendations are offered for developing randomized controlled trials that aim to recruit dyads and prevent depression in at-risk older married couples.

Psychiatric Diagnoses Among Older Recipients of Publicly Funded Mental Health Services

OBJECTIVES

To compare the prevalence of psychiatric diagnoses among older recipients of publicly funded mental health services (county safety-net base services and Medicaid) to psychiatric diagnoses in an insured population of older adults from the same county.

DESIGN

Secondary analysis of county human services claims data and claims from an insured population in the same county.

SETTING

Inpatient and outpatient clinics in Allegheny County, PA.

PARTICIPANTS

Adults aged 65 and older in the county who received treatment for a psychiatric diagnosis in 2012 (county base services, n = 1,457; Medicaid, n = 641; Health plan insurance, n = 5,595).

MEASUREMENTS

Psychiatric diagnoses were classified using the International Classification of Diseases, 9th revision (ICD-9).

RESULTS

Episodic mood disorders and schizophrenia were more common among county-funded and Medicaid recipients (50-54% vs 34%). Neurotic conditions were more common among older adults with health plan insurance (18% vs 8%). Nearly a quarter of older adults receiving county base services were classified as having "ill-defined and unknown causes of morbidity and mortality," compared <1% among insured and 6% among Medicaid recipients.

CONCLUSIONS

The prevalence of psychiatric conditions among older adults varies by insurance coverage, suggesting a role for social and economic factors associated with safety net coverage as well as system-level differences in delivery of mental health services. Comparing the prevalence of psychiatric diagnoses across insurance types offers insight on social determinants of risk for mental disorders in late life.

Self-reported obstructive sleep apnea is associated with nonresponse to antidepressant pharmacotherapy in late-life depression

BACKGROUND

Obstructive sleep apnea (OSA) is frequently comorbid with late-life depression. The purpose of this project was to determine, using a sample of older adults with major depressive disorder, whether patient-reported diagnosis of OSA was associated with rate of response to venlafaxine.

METHODS

Participants from this multisite study were adults ≥60 years old (n = 468) with major depressive disorder and a Montgomery Asberg Depression Rating Scale (MADRS) score of ≥15. Depression response was the outcome variable, defined as a MADRS score of ≤10 for two consecutive assessments at the end of 12 weeks of open-label treatment with venlafaxine 300 mg/day. To assess OSA, participants were asked if they had been diagnosed with OSA using polysomnography.

RESULTS

Eighty participants (17.1%) reported a diagnosis of OSA prior to baseline. Participants with OSA were more likely to be male, report greater impairment on measures of health, experience a longer duration of the index episode, and receive an adequate antidepressant trial prior to entering the study. During the 12 weeks of treatment, 40.8% responded to treatment with venlafaxine (43.6%, n = 169/388 of the no OSA group, and 27.5%, n = 22/80 of the OSA group). Participants without OSA were 1.79 times more likely to respond to treatment (HR: 1.79 [95%CI: 1.13-2.86], P < .05) compared to those with OSA.

CONCLUSIONS

OSA may impair response to antidepressant pharmacotherapy in depressed older adults. Future studies of antidepressant response rates among depressed older adults with OSA should both prospectively diagnose OSA and monitor adherence to treatments such as continuous positive airway pressure.

Systematic review of dyadic and family-oriented interventions for late-life depression

OBJECTIVE

Supportive behaviors (both instrumental and emotional) from spouses and close family members can impact the trajectory of older adults' depressive symptoms. Interventions that target both the patient and support person may be more effective than interventions that target the patient only, in terms of alleviating mood symptoms in the identified patient. The purpose of this paper was to review the characteristics and findings of dyadic and family-oriented interventions for late-life mood disorders to determine if they are effective and beneficial.

METHODS

Following PRISMA guidelines, we conducted a systematic review of reports in the literature on dyadic or family-oriented interventions for late-life mood disorders. We searched PubMed, OVID PsycINFO, and EMBASE for peer-reviewed journal articles in English through October 2014.

RESULTS

We identified 13 articles, representing a total of 10 independent investigations. Identified studies focused on spouses and close family members as support persons. Effect sizes for dyadic interventions that treated major depressive disorder were, on average, moderately strong, while effect sizes for dyadic interventions that reduced depressive symptoms were generally small. We did not identify any dyadic studies that treated bipolar disorder.

CONCLUSIONS

This review showed that dyadic interventions are feasible and that these interventions can decrease symptomatology in individuals who have major depressive disorder. Research is needed to understand the relative efficacy of a dyadic approach over a single-target approach in treating depression. Copyright © 2016 John Wiley & Sons, Ltd.

Dyadic Associations Between Physical Activity and Depressive Symptoms in Older Adults with Musculoskeletal Conditions and Their Spouses

This study examined the association between physical activity of older individuals with musculoskeletal conditions (IMCs) and their spouses' physical activity, how physical activity related to one's own and one's partner's depressive symptoms, and whether the similarity of partners' physical activity related to each partner's depressive symptoms using the actor-partner interdependence model. Seventy-seven dyads completed self-report measures of physical activity, depressive symptoms and potential covariates (socio-demographics, physical health conditions and marital satisfaction; IMCs' functional impairment and pain; and spouses' support-related stress). As hypothesized, we found a positive association between the IMC's and the spouse's physical activity. Also, spouses had more depressive symptoms when IMCs engaged in less physical activity. However, for both partners, one's own physical activity was not significantly associated with one's own depressive symptoms. The spouse's physical activity was also not significantly associated with the IMC's depressive symptoms, and the similarity between partners' physical activity did not significantly relate to either partner's depressive symptoms. Our findings suggest that interventions that help increase the physical activity of both partners, but particularly IMCs, may benefit spouses' well-being. Copyright © 2014 John Wiley & Sons, Ltd.

Husbands' and Wives' Physical Activity and Depressive Symptoms: Longitudinal Findings from the Cardiovascular Health Study

BACKGROUND

When examining older adults' health behaviors and psychological health, it is important to consider the social context.

PURPOSE

The purpose of this study was to examine in older adult marriages whether each spouse's physical activity predicted changes in their own (actor effects) and their partner's (partner effects) depressive symptoms. Gender differences were also examined.

METHOD

Each spouse within 1260 married couples (at baseline) in the Cardiovascular Health Study completed self-report measures at wave 1 (1989-1990), wave 3 (1992-1993), and wave 7 (1996-1997). Dyadic path analyses were performed.

RESULTS

Husbands' physical activity significantly predicted own decreased depressive symptoms (actor effect). For both spouses, own physical activity did not significantly predict the spouse's depressive symptoms (partner effects). However, husbands' physical activity and depressive symptoms predicted wives' physical activity and depressive symptoms (partner effects), respectively. Depressive symptoms did not predict physical activity.

CONCLUSION

Findings suggest that husbands' physical activity is particularly influential for older married couples' psychological health.

Gender differences in physical activity patterns among older adults who fall

OBJECTIVE

This study describes gender differences in the level and pattern of physical activity in groups of older adults who were frequent fallers, intermittent fallers, or non-fallers.

METHODS

Interviews were conducted with adults aged 50 years and older (N=1834) at senior centers across Pennsylvania from 2010 to 2011. Self-reported falls and validated measures of physical activity were collected at baseline and at 6- and 12-month follow-up assessments.

RESULTS

Complete follow-up data were available for 1487 participants. Men who fell frequently decreased in recreational/leisure activity and household/yard work compared to the intermittent fallers and non-fallers. This association remained even when controlling for baseline health status. All women-regardless of fall group-engaged in similar levels of recreational/leisure activity and household/yard work over time. For both men and women, frequent fallers also showed a greater decrease in walking activities compared to intermittent fallers and non-fallers.

DISCUSSION

Frequent falling among older adults is associated with declines in common leisure, household, and walking activities. The effect of falling frequency on physical activity appears to affect men and women differently, generating the hypothesis that interventions to promote physical activity among fallers need to be gender specific.

Changes in routine health behaviors following late-life bereavement: a systematic review

This systematic review examines the relationship between late-life spousal bereavement and changes in routine health behaviors. We review six behavioral domains/modifiable risk factors that are important for maintaining health among elderly populations: physical activity, nutrition, sleep quality, alcohol consumption, tobacco use, and body weight status. Thirty-four articles were identified, derived from 32 studies. We found strong evidence for a relationship between bereavement and nutritional risk and involuntary weight loss, and moderate evidence for impaired sleep quality and increased alcohol consumption. There was mixed evidence for a relationship between bereavement and physical activity. We identify several methodological shortcomings, and describe the clinical implications of this review for the development of preventive intervention strategies.

Coaching in healthy dietary practices in at-risk older adults: a case of indicated depression prevention

Prevention of major depressive disorder is important because current treatments are only partially adequate in reducing symptom burden and promoting health-related quality of life. Lifestyle interventions may be a desirable prevention strategy for reasons of patient preference, particularly among older patients from minority groups. Using evidence from a randomized depression prevention trial for older adults, the authors found that coaching in healthy dietary practices was potentially effective in protecting at-risk older adults from developing incident episodes of major depression. The authors describe the dietary coaching program (highlighted in a case example) as well as the feasibility and potential efficacy of the program within the context of evidence-based interventions for preventing episodes of major depression and mitigating symptoms of depression. Older adults receiving dietary coaching experienced a low incidence of major depressive episodes and exhibited a 40%-50% decrease in depressive symptoms, as well as enhanced well-being, during the initial 6-week intervention; these gains were sustained over 2 years. The authors also describe why lifestyle interventions like coaching in healthy dietary practices may hold promise as effective, practical, nonstigmatizing interventions for preventing episodes of major depressive disorder in older adults with subsyndromal depressive symptoms.

The effect of widowhood on husbands' and wives' physical activity: the Cardiovascular Health Study

This prospective study examined the effect of widowhood on physical activity by comparing widowed elders to health status-, age-, and sex-matched married controls. Participants included 396 married controls and 396 widows/widowers age 64-91 (M age = 72.7 years) who experienced the death of their spouse while participating in the Cardiovascular Health Study. Compared to married controls, widowed men, but not women, were more likely to increase their physical activity following the death of their spouse. However, this increased level of activity was not sustained and declines as time since spousal death passes. Moreover, during the year before spousal death, soon-to-be widowed men, but not women, increase their physical activity. Our results suggest that widowed men experience significant changes in physical activity and that the transition to widowhood contribute to these changes.

Caloric expenditure assessment among older adults: criterion validity of a novel accelerometry device

Criterion validity of a novel accelerometry device that measures caloric expenditure (Fitbit) was evaluated against a self-report estimation of caloric expenditure (Community Healthy Activities Model Program for Seniors) in older adults. Community Health Activities Model Program for Seniors and Fitbit estimates of total caloric expenditure per day were significantly correlated (r = .61, p < .05). Bland-Altman plots indicated that 70 percent of participants' data were within 1 standard deviation of the mean difference between measures. These preliminary findings suggest that the Fitbit may be considered a viable instrument for measuring daily caloric expenditure among older adults. However, further work is required to determine the optimal measurement technique for caloric expenditure among older adults.

College students' ageist behavior: the role of aging knowledge and perceived vulnerability to disease

This cross-sectional study examined the associations among perceived vulnerability to disease, aging knowledge, and ageism (positive and negative) in a sample of undergraduate students enrolled in a human development course (N = 649; M age = 19.94 years, SD = 2.84 years). Perceived vulnerability to disease and aging knowledge were associated with self-reported ageist behaviors. Undergraduates who viewed themselves as more susceptible to disease and knew less about the aging process tended to report more negative ageist behavior. Sex moderated the association between aging knowledge and ageist behavior, indicating the association was stronger for males. Discussion focuses on implications for gerontology educators.

Disordered Eating and Psychological Distress among Adults

The majority of our knowledge about eating disorders derives from adolescent and young adult samples; knowledge regarding disordered eating in middle and later adulthood is limited. We examined the associations among known predictors of eating disorders for younger adults in an age-diverse sample and within the context of psychological distress. Using data from 567 adults (ages 18 to 88 years), we tested a path model in which age, gender, eating-related cognitions, and satisfaction with appearance predicted eating disorders which, in turn, predicted psychological distress. The model fit the data well (χ2 (DF= 11, N = 567) = 30.58, p < .001; GFI = .987, NFI = .963; RMSEA = .056), explaining 20.1% of the variance in psychological distress.

Adults' future time perspective predicts engagement in physical activity

OBJECTIVE

Our aim was to examine how the relations among known predictors of physical activity, such as age, sex, and body mass index, interact with future time perspective (FTP) and perceived functional limitation to explain adults' engagement in physical activity.

METHOD

Self-report data from 226 adults (range 20-88 years) were collected to examine the hypothesis that a more expansive FTP is associated with engagement in physical activity.

RESULTS

Results indicated a good fit of the data to the model χ(2) (4, N = 226) = 7.457, p = .14 and accounted for a moderate amount of variance in adults' physical activity (R(2) = 15.7). Specifically, results indicated that perceived functional limitation (β = -.140) and FTP (β = .162) were directly associated with physical activity. Age was indirectly associated with physical activity through its association with perceived functional limitation (β = -.264) and FTP (β = .541).

DISCUSSION

Results indicate that FTP may play an important role in explaining engagement in health promoting behaviors across the life span. Researchers should consider additional constructs and perhaps adopt socioemotional selectivity theory when explaining adults' engagement in physical activity.