Dancing With Dementia: Exploring the Embodied Dimensions of Creativity and Social Engagement

Background and Objectives

Dance is increasingly being implemented in residential long-term care to improve health and function. However, little research has explored the potential of dance to enhance social inclusion by supporting embodied self-expression, creativity, and social engagement of persons living with dementia and their families.

Research Design and Methods

This was a qualitative sequential multiphase study of Sharing Dance Seniors, a dance program that includes a suite of remotely streamed dance sessions that are delivered weekly to participants in long-term care and community settings. Our analysis focused on the participation of 67 persons living with dementia and 15 family carers in residential long-term care homes in Manitoba, Canada. Data included participant observation, video recordings, focus groups, and interviews; all data were analyzed thematically.

Results

We identified 2 themes: playfulness and sociability. Playfulness refers to the ways that the participants let go of what is “real” and became immersed in the narrative of a particular dance, often adding their own style. Sociability captures the ways in which the narrative approach of the Sharing Dance Seniors program encourages connectivity/intersubjectivity between participants and their community; participants co-constructed and collaboratively animated the narrative of the dances.

Discussion and Implications

Our findings highlight the playful and imaginative nature of how persons living with dementia engage with dance and demonstrate how this has the potential to challenge the stigma associated with dementia and support social inclusion. This underscores the urgent need to make dance programs such as Sharing Dance Seniors more widely accessible to persons living with dementia everywhere.

Exploring the sustainability of age-friendly initiatives in a Canadian province

BACKGROUND AND OBJECTIVES

Based on the WHO Age-friendly Cities and Communities (AFCC) framework, the government of Manitoba, Canada, launched a province-wide age-friendly initiative in 2008. The objective of this study was to explore the sustainability of the AFCC initiative more than a decade later. The study was guided by conceptualizations of sustainability as multi-dimensional and dynamic, composed of four aspects (continued capacity; institutionalization; continued benefits; and development/adaptation), and an ecologic perspective that highlights the importance of contextual influences, and their change over time, on AFCC activities.

RESEARCH DESIGN AND METHODS

The study involved a qualitative, multiple case study design. Semi-structured interviews were conducted in 2020 with a key informant from each of 52 AFCC. Interview data were analyzed deductively, guided by the sustainability framework and an ecologic perspective. Census data was used to describe the demographic characteristics of AFCC.

RESULTS

We identified six groups of AFCC initiatives that varied in degree from the most to the least sustainable: active; in hiatus; re-organized; stalled; discontinued; and never got off the ground. Both local, community factors (e.g., lack of capacity), and broader contextual factors, such as demographic changes and provincial legislations influenced initiatives' sustainability.

DISCUSSION AND IMPLICATIONS

AFCC initiatives can range in their degree of sustainability, and can wax or wane over time. On-going external support for AFCC (e.g., from provincial or state government) to promote the vision of age-friendliness, and to addresses lack of capacity (e.g., to assist with community assessments) could help with the long-term sustainability of initiatives.

Exploring University Age-Friendliness Using Collaborative Citizen Science

Background and Objectives

Since the launch of Dublin City University’s Age-Friendly University (AFU) Initiative in 2012, relatively little empirical research has been published on its feasibility or implementation by institutions of higher learning. This article describes how collaborative citizen science—a research method where professional researchers and community members work together across multiple stages of the research process (e.g., data collection, analysis, and/or knowledge mobilization) to investigate an issue—was used to identify barriers and supports to university age-friendliness at the University of Manitoba (UofM) in Canada.

Research Design and Methods

Ten citizen scientists each completed 1 data collection walk around the UofM campus and used a tablet application to document AFU barriers and supports via photographs and accompanying audio commentaries. The citizen scientists and university researchers then worked together in 2 analysis sessions to identify AFU priority areas and brainstorm recommendations for institutional change. These were then presented to a group of interested university stakeholders.

Results

The citizen scientists collected 157 photos documenting AFU barriers and supports on campus. Accessibility, signage, and transportation were identified as being the most pressing issues for the university to address to improve overall age-friendliness.

Discussion and Implications

We suggest that academic institutions looking to complete assessments of their age-friendliness, particularly those exploring physical barriers and supports, could benefit from incorporating older citizen scientists into the process of collecting, analyzing, and mobilizing findings.

Age, Dementia, and Diagnostic Candidacy: Examining the Diagnosis of Young Onset Dementia Using the Candidacy Framework

People living with young onset dementia face significant barriers to diagnosis, resulting in delays, misdiagnoses, and treatment gaps. We examined the process of accessing and delivering a diagnosis of young onset dementia using the candidacy framework as a conceptual lens. Semi-structured interviews were conducted with six people living with dementia, 14 family members, and 16 providers in a western Canadian city. Participants' accounts revealed the diagnosis of young onset dementia as a negotiated process involving patients, family members, and health professionals. Assumptions about age and dementia affected how participants interpreted their symptoms, how they presented to services, and how they, in turn, were perceived by providers. At the organizational level, age-restrictions, fragmentation, and unclear referral pathways further complicated the diagnostic process. Our findings lend support to the growing call for specialist young onset dementia care and point toward several recommendations to develop more age-inclusive diagnostic services.

Design characteristics and inclusion of evidence-based exercise recommendation in fall prevention community exercise programs for older adults in Canada: a national descriptive self-report study

BACKGROUND

Training balance through exercise is an effective strategy to reduce falls in community-dwelling older adults. Evidence-based fall prevention exercise recommendations have been proposed, specifying that exercise programs should: (1) provide a high challenge to balance, (2) be offered for a least three hours per week, (3) be provided on an ongoing basis. Community exercise programs have the potential to deliver effective fall prevention exercise; however, current design characteristics and whether they include the recommendations is not known. This study described design characteristics of fall prevention community exercise programs for older adults (50 years and older) across Canada, and explored whether these programs included the three evidence-based exercise recommendations.

METHODS

Instructors of fall prevention community exercise programs completed electronic self-report questionnaires following a modified Dillman recruitment approach. Questions explored program characteristics, exercise content, target population, and program and instructor demographic information. Using a previously developed coding scheme based on recommendations, exercises were coded for balance challenge.

RESULTS

One hundred fourty completed eligible questionnaires were analyzed (74% response rate). One hundred thirty-three programs (95%) included the challenge recommendation by prescribing mostly moderate or high challenge balance exercises, 16 programs (11%) included at least three hours of exercise a week, and 59 programs (42%) were offered on an ongoing basis. Eight programs (6%) included all three recommendations.

CONCLUSIONS

Most programs included at least one recommendation for effective fall prevention exercise. Future studies should examine organizational barriers and facilitators to incorporating evidence-based exercise recommendations and explore the use of mixed home/in-class strategies to include the recommendations.

Examining social isolation and loneliness in combination in relation to social support and psychological distress using Canadian Longitudinal Study of Aging (CLSA) data

BACKGROUND

Although a large body of research has focused on social isolation and loneliness, few studies have examined social isolation and loneliness together. The objectives of this study were to examine: 1) the relationship between four groups derived from combining social isolation and loneliness (socially isolated and lonely; only socially isolated; only lonely; neither socially isolated nor lonely) and the desire for more social participation, and social support; and 2) the relationship between the four groups and psychological distress.

METHODS

The study was based on the Comprehensive Cohort of the Canadian Longitudinal Study on Aging. Using CLSA baseline data (unweighted N = 30,079), ordinary and logistic regression analysis was used to examine the cross-sectional relationship between the four social isolation/loneliness groups and desire for more social participation and four types of social support (tangible, positive interaction, affection, and emotional support). Prospective logistic regression analysis was possible for psychological distress, which was derived from the Maintaining Contact Questionnaire administered about 18 months after the baseline questionnaire (unweighted N = 28,789).

RESULTS

Findings indicate that being socially isolated and lonely was associated with the most social support gaps; this group also had an increased likelihood of psychological distress, relative to those who were neither socially isolated nor lonely. Participants who were only socially isolated, and those only lonely also perceived some social support gaps. In addition, the only lonely group was more likely to be psychologically distressed than the only socially isolated group and the neither isolated nor lonely group.

CONCLUSION

Examining the four social isolation/loneliness was useful, as it provided more nuanced risk profiles than would have been possible had we examined social isolation and loneliness separately. Findings may suggest avenues for interventions tailored to the unique needs of at-risk individuals.

Examining individual and geographic factors associated with social isolation and loneliness using Canadian Longitudinal Study on Aging (CLSA) data

BACKGROUND

A large body of research shows that social isolation and loneliness have detrimental health consequences. Identifying individuals at risk of social isolation or loneliness is, therefore, important. The objective of this study was to examine personal (e.g., sex, income) and geographic (rural/urban and sociodemographic) factors and their association with social isolation and loneliness in a national sample of Canadians aged 45 to 85 years.

METHODS

The study involved cross-sectional analyses of baseline data from the Canadian Longitudinal Study on Aging that were linked to 2016 census data at the Forward Sortation Area (FSA) level. Multilevel logistic regression analyses were conducted to examine the association between personal factors and geographic factors and social isolation and loneliness for the total sample, and women and men, respectively.

RESULTS

The prevalence of social isolation and loneliness was 5.1% and 10.2%, respectively, but varied substantially across personal characteristics. Personal characteristics (age, sex, education, income, functional impairment, chronic diseases) were significantly related to both social isolation and loneliness, although some differences emerged in the direction of the relationships for the two measures. Associations also differed somewhat for women versus men. Associations between some geographic factors emerged for social isolation, but not loneliness. Living in an urban core was related to increased odds of social isolation, an effect that was no longer significant when FSA-level factors were controlled for. FSAs with a higher percentage of 65+ year old residents with low income were consistently associated with higher odds of social isolation.

CONCLUSION

The findings indicate that socially isolated individuals are, to some extent, clustered into areas with a high proportion of low-income older adults, suggesting that support and resources could be targeted at these areas. For loneliness, the focus may be less on where people live, but rather on personal characteristics that place individuals at risk.

The effect of time perspectives on mental health information processing and help-seeking attitudes and intentions in younger versus older adults

Socioemotional selectivity theory posits that changes in time perspective over the lifespan are associated with distinct goals and motivations. Time perspectives and their associated socioemotional motivations have been shown to influence information processing and memory, such that motivation-consistent information is more likely to be remembered and evaluated more positively.

OBJECTIVE

The aim of this study was to examine the effect of motivation-consistent mental health information on memory for and evaluations of this information, as well as help-seeking attitudes and intentions to seek mental health services.

METHOD

We randomly assigned an Internet-based sample of 160 younger (18-25) and 175 older (60-89) adults to read a mental health information pamphlet that emphasized time perspectives and motivations relevant to either young adulthood (future-focused) or late adulthood (present-focused). Participants completed measures assessing their time perspective, memory for and subjective evaluation of the pamphlet, and help-seeking attitudes and intentions.

RESULTS

The time perspective manipulation had no effect on memory for pamphlet information or help-seeking attitudes and intentions. There was, however, a significant interaction between time perspective and pamphlet version on the rated liking of the pamphlet.

CONCLUSION

Although motivation-consistent information only affected perceptions of that information for present-focused (mostly older) individuals, this finding has important implications for enhancing older adults' mental health literacy.

Comparing the Overall Health, Stress, and Characteristics of Canadians with Early-Onset and Late-Onset Dementia

Objective: Dementia is increasingly recognized as a public health priority, but little is known about persons with early-onset dementia (EOD). The objectives of this article are (a) to compare the socio-demographic and health characteristics of people with EOD and late-onset dementia (LOD) and (b) to examine the relationships between EOD and overall health and life stress. Method: Data were from the Survey on Living With Neurological Conditions in Canada (SLNCC). Logistic regression models were used to identify the characteristics associated with EOD and LOD, and to assess the impact of EOD on overall health and life stress. Results: Compared with LOD, individuals with EOD were more likely to be male, to have a mood disorder, and to have a longer illness duration. EOD was associated with high life stress, but not with negative overall health. Discussion: This study identified attributes associated with EOD that have important implications for service planning.

Does continuity of care with a family physician reduce hospitalizations among older adults?

Objective: To examine the relation between continuity of primary care and hospitalizations.

Methods: Survey data from a representative sample of older adults aged 67 or over living in the province of Manitoba ( n = 1863) were linked to administrative data, which provide complete records of physician visits and hospitalizations. A visit-based measure of continuity of care was derived using a majority-of-care definition, whereby individuals who made 75% of all their visits to family physicians (FPs) to the same FP were classified as having high continuity of care, and those with less than 75% of their visits to the same FP as having low continuity of care. Whether individuals were hospitalized (for either ambulatory care-sensitive conditions or all conditions) was also determined from administrative records.

Results: High continuity of care was associated with reduced odds of ambulatory care-sensitive hospitalizations (adjusted odds ratio = 0.67, confidence interval 0.51–0.90) controlling for demographic and self-reported, health-related measures. It was not related to hospitalizations for all conditions, however.

Conclusions: The study highlights the importance of continuity of primary care in reducing potentially avoidable hospitalizations.

Rural residence and risk of dementia

INTRODUCTION

We sought to determine whether residence in a rural region is associated with a higher risk of dementia and a higher risk of developing dementia over a 5-year period than residence in an urban region.

METHODS

This was a secondary analysis of a prospective cohort study. In 1991 and 1992, 1751 adults aged 65 years and older and residing in the community were sampled from a representative population-based registry, which included the entire province (time 1). Follow-up occurred 5 years later (time 2). Age, sex and education were selfreported. Rurality was determined by the population of the Census subdivision, with a population greater than 19 999 considered urban. Cognition was assessed using the Modified Mini-Mental State Examination, with those scoring below 78 invited to undergo a clinical examination to determine the presence of dementia. Cross-sectional analyses were conducted for participants with complete data at time 1. Prospective analyses were conducted for participants with normal cognition at time 1, who had complete data and survived until time 2. Logistic regression models were constructed for the outcome of dementia at times 1 and 2.

RESULTS

Residence in a rural region was not associated with dementia in the cross-sectional analyses (adjusted odds ratio [OR] 1.08, 95% confidence interval [CI] 0.61-1.91) and did not predict dementia 5 years later (adjusted OR 1.05, 95% CI 0.66-1.68).

CONCLUSION

We found no difference in the risk of dementia among older adults living in urban and rural regions of Manitoba.

How Important Is Having Amenities Within Walking Distance to Middle-Aged and Older Adults, and Does the Perceived Importance Relate to Walking?

OBJECTIVE

This study examined how important walking to amenities (e.g., food store, park) is to middle-aged and older adults and whether this relates to walking. The relationship between walking to amenities and overall activity level was also explored.

METHOD

The study was based on interviews conducted with 778 individuals aged 45 to 94 years. Overall activity level was measured objectively using pedometers.

RESULTS

A large proportion of participants did not think it was very important to have amenities within walking distance, and the majority of participants drove to get there, even among individuals who reported it was very important to have the amenities within walking distance. Self-reported walking to certain amenities (e.g., park) was associated with overall activity.

DISCUSSION

The study underscores the impact of a car culture where the tendency to drive is paramount. It suggests the need to promote the importance of walking as part of an active, healthy lifestyle.

A Longitudinal Examination of Social Participation, Loneliness, and Use of Physician and Hospital Services

Objective: This study examined whether social participation and loneliness predicted health care service use (physician visits, hospitalizations, length of stay in hospital). Method: Participants’ ( N = 954; 54% female; aged 45+ years) health data were tracked over 2.5 years following in-person interviews. Results: Being lonely was associated with greater number of physician visits, though this relationship was mediated by health. Neither loneliness nor social participation was associated with admission to hospital. However, for those who were hospitalized at least once over 2.5 years, being lonely was associated with a higher odds of being re-hospitalized; furthermore, greater social participation was associated with a lower odds of being in the hospital for an extended duration. These relationships held even when controlling for initial health. Discussion: Results provide evidence, using objective health care data, of the potential importance of social factors in predicting adults’ physician visits, re-hospitalization, and length of stay in hospital.

Assessing Communities’ Age-Friendliness

The notion of age-friendliness is gaining increasing attention from policy makers and researchers. In this study, we examine the congruence between two types of age-friendly surveys: subjective assessments by community residents versus objective assessments by municipal officials. The study was based on data from 39 mostly rural communities in Manitoba, Canada, in which a municipal official and residents ( M = 25 residents per community) completed a survey to assess age-friendly features in a range of domains, such as transportation and housing. Congruence between the two surveys was generally good, although the municipal official survey consistently overestimated communities’ age-friendliness, relative to residents’ ratings. The findings suggest that a survey completed by municipal officials can provide a reasonable assessment of age-friendliness that may be useful for certain purposes, such as cross-community comparisons. However, some caution is warranted when using only these surveys for community development, as they may not adequately reflect residents’ views.

Examining the relationship between communities' 'age-friendliness' and life satisfaction and self-perceived health in rural Manitoba, Canada

INTRODUCTION

Population aging is a worldwide phenomenon. As a response, the World Health Organization (WHO) introduced the concept of 'age-friendliness' in 2006. Age-friendliness is defined in terms of a range of domains, such as housing, opportunities for participation, and transportation. Communities that accommodate the needs of older adults in these domains will, it is thought, promote healthy, active aging. The purpose of the present study was to examine communities' age-friendliness and its relationship to health-related outcomes in a rural context.

METHODS

The study included 29 communities located in Manitoba, a mid-Western Canadian province, that are part of the Province of Manitoba's Age-Friendly Manitoba Initiative. As part of a needs assessment process in these communities, 593 individuals, including seniors and younger adults, completed an Age-Friendly Survey. The survey was designed to measure a variety of features in seven domains (the physical environment, housing options, the social environment, opportunities for participation, community supports and healthcare services, transportation options, and communication and information), as well as containing measures of life satisfaction and self-perceived health. Community characteristics were derived from census data. Moreover, communities were categorized on a rural-urban continuum.

RESULTS

Multi-level regressions indicated that an overall Age-Friendly Index was positively related to both life satisfaction (b=0.019, p<0.0001) and self-perceived health (b=0.013, p<0.01). When examining more specifically each of the seven age-friendly domains, all but housing was positively related to life satisfaction. Results were not as consistent for self-perceived health, with significant relationships emerging only for the physical environment, social environment, opportunities for participation, and transportation options. A subsequent analysis for seniors versus younger participants, respectively, indicated that significant relationships between age-friendly domains and life satisfaction and self-perceived health were restricted primarily to seniors. None of the community characteristics were related to life satisfaction and self-perceived health, nor was degree of rurality.

CONCLUSIONS

The concept of age-friendliness has been garnering considerable attention from policy-makers as a way to promote healthy aging. For example, in Canada, several provinces have launched age-friendly initiatives. Although causality cannot be inferred from the present, cross-sectional study, the findings are encouraging as they show that age-friendliness is associated with enhanced life satisfaction and self-perceived health in a rural context. The study further supports the notion that a wide range of domains within the community environment are important in older adults' lives and need to be considered. Public policy initiatives, such as the Province of Manitoba's Age-Friendly Initiative, may thus be one approach to enhancing healthy aging in rural settings.

Targeting Socially Isolated Older Adults: A Process Evaluation of the Senior Centre Without Walls Social and Educational Program

The Seniors Centre Without Walls (SCWOW) program provides free social and educational programming for older adults via telephone. The target population for SCWOW is socially isolated older adults, a hard to reach population. The aim of this process evaluation was to examine whether SCWOW was reaching its target population and to gather participant feedback about program implementation and the perceived satisfaction and impact of the program. Telephone interviews were conducted with 26 participants (92% females; aged 57-85 years). Forty-two percent of the sample was socially isolated and more than half reported being lonely. Participants reported having no difficulty using the telephone system. On average, participants were very satisfied with the program and reported that SCWOW had several positive effects (e.g., connecting to the larger community, affecting mental well-being). Importantly, no barriers to participation were identified. The study suggests that telephone-based programs can successfully reach socially isolated older adults.

Understanding bereaved family members' dissatisfaction with end-of-life care in nursing homes

With increasing numbers of older adults identifying a nursing home (NH) as their final place of care, it is important to assess the quality of dying in this setting and understand factors that impact family members' dissatisfaction with end-of-life care. A retrospective bereaved family member survey (N = 208) was conducted in 21 NHs located in urban areas of central Canada. Bereaved family members who were dissatisfied with care identified significantly more concerns in all domains assessed and were more likely to have problems with: (a) receiving confusing information from nursing staff about the resident's care, including medical treatments; (b) receiving inadequate information from nursing staff; and (c) feeling that end-of-life care was different than they had expected. Since the quality of communication between nurses, residents, and family members is the main factor that determines families' dissatisfaction with care, strategies and interventions aimed at reducing unmet information needs will be vital to improving end-of-life care in NHs.

In-region versus out-of-region hospitalizations at the end of life among older rural residents: the relationship between personal and system-related factors

BACKGROUND

Even though a large segment of the population lives in rural areas, relatively little attention has been paid in the literature to date to hospital use at the end of life among rural residents. The objective of this study was to examine factors associated with in- or out-of-region hospitalizations at the end of life among older rural residents.

METHODS

The study included all community-dwelling adults aged 65 or older living in rural regions of a mid-Western Canadian province who had died in fiscal years 2003-04 to 2005-06, as determined from Vital Statistics data (N = 5,550). Complete hospital discharge abstract data were used to identify in- or out-of-region hospitalizations in the last 6 months before death and on the day of death. The type of out-of-region hospitals older adults were admitted to was also examined (urban tertiary hospital, urban community hospital, and rural hospital).

RESULTS

Twenty percent of hospitalizations and 21% of hospital deaths occurred in a hospital that was out of older adults' region of residence. Compared with decedents aged 65-74, those aged 75-84 and even more so those aged 85+ had reduced odds of being hospitalized out of region or dying in an out-of-region hospital. Those 85+ years old also had reduced odds of being hospitalized in a (out-of-region) tertiary hospital. Higher hospital bed rates and physician rates were associated with reduced odds of out-of-region hospitalization and hospital death.

CONCLUSION

Efforts should focus on recruiting physicians to those rural areas with low physician rates, as well as finding mechanisms to retain physicians in those rural regions.

Hospital nurses' perceptions of the geriatric care environment in one Canadian health care region

PURPOSE

To identify and compare perceptions of the geriatric care environment among nurses in three different urban hospital types in one health authority in a Midwestern Canadian province.

DESIGN

The Geriatric Institutional Assessment Profile developed by the Nurses Improving Healthsystem Elders (NICHE) program was administered to staff in eight urban hospitals between 2005 and 2006: two geriatric-chronic care hospitals, four community hospitals, and two tertiary hospitals. The study focused on 1,189 nurses who completed the survey (n= 298 for geriatric-chronic care hospitals; n= 387 for community hospitals, n= 504 for tertiary hospitals).

METHODS

Analyses focused on items related to the concept of the geriatric nursing practice environment, including a composite measure of overall perceptions and three subscales (institutional values regarding older adults and staff, resource availability, and capacity for collaboration). Nurses' perceptions of the extent to which facilities supported the provision of aging-sensitive or aging-relevant care to older adults and their families was also examined. Univariate analysis of variance was performed to determine significant group differences among nurses in the three hospital types.

FINDINGS

Perceptions of the geriatric nurse practice environment (both in terms of the composite scale and the three subscales) were least positive among nurses in community hospitals relative to the other two hospital types. Perceptions in tertiary hospitals were significantly more positive than those in community hospitals in terms of institutional values and resource availability, albeit not capacity for collaboration. Perceptions were most positive in the geriatric-chronic care hospitals. Perceptions of aging-sensitive care delivery were also less positive in community and tertiary hospitals, relative to geriatric-chronic care hospitals; perceptions in community and tertiary hospitals did not differ from each other.

CONCLUSIONS

In this Canadian study, nurses' perception of the care environment varied by hospital type, with nurses in community hospitals expressing the most concern and nurses in geriatric-chronic care hospitals being the most positive. This research highlights the importance of the hospital setting in understanding nurses' ability to provide quality geriatric care.

CLINICAL RELEVANCE

Enhancing the quality of care for older patients requires an understanding of the challenges and obstacles experienced by nurses. Assessing their perceptions of the care environment they work in, therefore, becomes a key issue in targeting policy and programs.

Does the Relationship Between Neighborhood Socioeconomic Status and Health Outcomes Persist Into Very Old Age? A Population-Based Study

Objective: The purpose of this article is (a) to extend previous research on the relationship between neighborhood socioeconomic status (SES) and health by considering a wide range of health-related measures derived from administrative health care records and (b) to explore whether this relationship persists into old age. Method: The study involved a complete cohort of community-dwelling residents in Winnipeg, Canada, who were 65 years or older in 2004/2005 ( N = 77,930). Health measures were derived from administrative claims data. Census data were used to derive neighborhood-level SES. Results: Multilevel logistic regressions indicated that, relative to individuals living in the most affluent areas, those in the poorest areas had significantly higher odds of having arthritis, diabetes, hypertension, congestive heart failure, ischemic heart disease, chronic obstructive pulmonary disease, depression, and stroke. Significant neighborhood income effects tended to be evident among individuals age 65 to 75 as well as those age 75+. Discussion: A wide range of health conditions among older adults are disproportionately clustered into the poorest areas. Programs and services should be designed to meet the needs of older adults of any age in such neighborhoods.

Transfers to acute care hospitals at the end of life: do rural/remote regions differ from urban regions?

INTRODUCTION

In population-based studies, transfers into hospitals and hospital deaths are typically considered to be indicators of potentially inappropriate care settings at the end of life. Despite a plethora of research into where people die, few studies have examined whether hospital transfers at the end of life differ in rural versus urban areas. In the present study hospitalizations in the last month before death in one mid-Western Canadian province were examined. The study had three main objectives, to: (1) compare hospitalizations in rural/remote with urban regions; (2) examine the role of healthcare resources in hospitalizations; and (3) explore more specifically whether day-to-day patterns of hospitalization shortly before death differ between rural/remote and urban areas.

METHODS

The source of data was administrative healthcare records, with the study including all adults (aged over 19 years; excluding nursing home residents) who died in the province of Manitoba in 2003-2004 (n = 6523). Whether the decedents were hospitalized in the 30 days before death was determined from hospital files. The number of hospital days incurred was counted. Region of residence was defined along regional health authority boundaries, with 7 regions identified as rural/remote and 2 as urban. Healthcare resources were measured in terms of the number of: physicians, hospital beds, nursing home beds, and home care services per 1000 population. Age, sex and trajectory groups, which categorized decedents according to their cause of death, were included in all analyses.

RESULTS

Residents of 4 of the 7 rural/remote regions had increased odds of being hospitalized relative to the comparison, the larger urban region (adjusted odds ratios [AOR] ranged from 1.25 to 1.70). Hospital days did not differ across regions. Further analyses showed that having more physicians (AOR = .75) and more hospital beds per 1000 population (AOR = .95) both significantly reduced the odds of being hospitalized. Nursing home beds and home care services were not related to hospitalizations. Growth curve models indicated that daily patterns of hospitalizations generally did not differ across rural/remote versus urban regions.

CONCLUSION

The findings suggest that residents of some rural/remote regions were at a disadvantage in terms of access to an appropriate care setting at the end of life. The regional variation in hospitalization can, at least in part, be attributed to the availability of healthcare resources, specifically the number of physicians and hospital beds (per 1000 population). However, the variation that emerged across regions also suggests that conclusions should not be over-generalized to all rural/remote regions; rather, local differences in healthcare resources should be considered when examining healthcare usage at the end of life.

Hospitalizations at the end of life among long-term care residents

BACKGROUND

Concerns have been raised over transfers into acute care hospitals at the end of life. The objective of this study was to examine (a) the extent of and (b) factors related to hospitalization in the last 180 days before death among long-term care (LTC) residents.

METHODS

The study included all LTC residents from 60 facilities in the province of Manitoba, Canada, who died in 2003/04 (N = 2,379), with data derived from administrative health care records. Multilevel regression analyses were conducted to examine the relationship between resident and facility characteristics and the following: location of death (in hospital vs the LTC facility); whether individuals were hospitalized in the last 180 days before death; and number of hospital days in the last 180 days.

RESULTS

Overall, 19.1% of LTC residents died in hospital; however, 40.7% were hospitalized at least once in the last 6 months before death. Several resident characteristics (age, trajectory group, and level of care) were related to the outcome measures. Living in a not-for-profit LTC facility decreased the odds of dying in hospital (adjusted odds ratio [OR] = 0.589; 95% confidence interval [CI] = 0.402-0.863) or being hospitalized (adjusted OR = 0.647; 95% CI = 0.452-0.926).

CONCLUSIONS

Hospitalization at the end of life is common among LTC residents, and the likelihood of hospital transfers is increased for residents who are younger, have organ failure, lower care level needs, as well as among those who live in for-profit facilities. Particular emphasis should, therefore, be placed on targeting these groups to determine the appropriateness of hospital admission and possible ways of reducing transfers.

Health care use at the end of life among older adults: does it vary by age?

BACKGROUND

Issues around end-of-life health care have attracted increasing attention in the last decade. One question that has arisen is whether very elderly individuals receive overly aggressive treatment at the end of life. The purpose of this study was to address this issue by examining whether health care use at the end life varies by age.

METHODS

The study included all adults 65 years old or older who died in Manitoba, Canada in 2000 (N = 7678). Measures were derived from administrative data files and included location of death, hospitalizations, intensive care unit (ICU) admission, long-term care (LTC) use, physician visits, and prescription drug use in the last 30 days versus 180 days before death, respectively.

RESULTS

Individuals 85 years old or older had increased odds of being in a LTC institution and also dying there than did individuals 65-74 years old. They had, correspondingly, lower odds of being hospitalized and being admitted to an ICU. Although some statistically significant age differences emerged for physician visits, the effects were small. Prescription drug use did not vary by age.

CONCLUSIONS

These findings indicate that very elderly individuals tended to receive care within LTC settings, with care that might be considered aggressive declining with increasing age. However, health care use among all age groups was substantial. A critical issue that needs to be examined in future research is how to ensure quality end-of-life care in a variety of clinical contexts and care settings for individuals of all ages.

Ethnic differences in self-rated health among older adults: a cross-sectional and longitudinal analysis

The objectives of this study were to examine whether self-rated health differs among older adults of different ethnic backgrounds and to explore what factors may account for potential differences. The study was based on the 1983 and 1996 waves of the Aging in Manitoba study. A self-report measure of ethnic background was used to categorize participants into four groups: British/Canadian, Northern/Central European, Eastern European, and Other. In both 1983 and 1996, older Eastern European adults had significantly reduced odds of rating their health as good or excellent relative to British/Canadian adults. Controlling for demographic variables, socioeconomic status, language spoken, and health status attenuated but did not eliminate the difference. Global, subjective ratings of health are frequently used to measure health. The ethnic differences found here suggest, however, that ratings may be influenced by cultural factors, which may warrant some caution in making comparisons across ethnic groups.

Trends in the health status of older Manitobans, 1985 to 1999

Trends in the health status of the entire senior population aged 65 years or older in Manitoba were examined over a 14-year period (1985-1999) using administrative data (about 50,000 individuals). Significant health gains were apparent for a number of important indicators, including acute myocardial infarction, stroke, cancer, and hip fractures, although some of these gains were restricted to urban areas. Improvements in these health indicators are significant, as they can have major implications for individuals' need for health services and ability to live independently. In contrast, chronic diseases were on the rise, with the prevalence of diabetes, hypertension, and dementia increasing substantially over the 14-year period. These trends suggest a need for a policy emphasis on prevention, such as reducing the prevalence of obesity, which is one risk factor for diabetes. Moreover, having sufficient care options in place for the growing number of individuals with dementia is an issue that will have to be addressed.

Exploring reasons for bed pressures in Winnipeg acute care hospitals

Hospital overcrowding has plagued Winnipeg and other Canadian cities for years. This study explored factors related to overcrowding. Hospital files were used to examine patterns of hospital use from fiscal years 1996/1997 to 1999/2000. Chart reviews were conducted to examine appropriateness of admissions and hospital stays during one pressure week. Results indicate that pressure periods in the hospital system were driven by an influx of older adults with influenza-associated respiratory illnesses. Moreover, examination of one specific pressure week showed that at least 100 beds were occupied by patients who likely did not require acute care. The chart review revealed that a substantial proportion of non-acute patient-days were spent awaiting home care, long-term care, or diagnostic testing services. These findings suggest future bed pressures might be prevented through influenza vaccination and an increase in the availability of--and timely transfer to--alternative levels of care.

Does continuity of care matter in a universally insured population?

OBJECTIVE

To examine the relation between continuity of care and preventive health care and emergency department (ED) use in a universal health care system.

DATA SOURCES/STUDY SETTING

Administrative data that capture health care use of the entire population of a midwestern Canadian city.

STUDY DESIGN

A population-based, retrospective study of all individuals who had a least one physician contact in 1998 or 1999 (total N=536,893).

METHODS

Logistic regressions were conducted to examine the relation between continuity of care, defined in terms of the proportion of total visits to family physicians (FPs) made to the same FP, and cervical cancer screening, breast cancer screening, influenza vaccination, pneumococcal vaccination, and ED visits, controlling for demographic variables, socioeconomic status (defined in terms of relative affluence of neighborhood of residence), and health status.

PRINCIPAL FINDINGS

Continuity of care was related to better preventive health care and reduced ED use. A consistent socioeconomic gradient also emerged. For instance, the odds of having a mammogram was double for individuals living in the wealthiest neighborhoods, relative to those in the poorest neighborhoods (adjusted odds ratio=2.31, 99 percent CI 2.13-2.50).

CONCLUSIONS

Having a long-term relationship with a single physician makes a difference even in a universal health care system. Moreover, socioeconomic disparities remain, suggesting the need to target specifically individuals from lower socioeconomic strata for preventive health care.

Seasonal patterns of hospital use in Winnipeg: implications for managing winter bed crises

This study examined whether Winnipeg hospitals experience predictable "high-volume periods" in order to determine whether hospital overcrowding might be anticipated and, therefore, avoided. We found that high-volume periods among medical patients occurred during all but one year between 1987 and 1998. Most high-volume periods occurred during influenza seasons. Preventing such recurrent bed pressures requires a multi-faceted approach, involving preventive efforts to reduce hospital admissions (influenza vaccination) and alternatives to managing the hospital system.

The impact of influenza-associated respiratory illnesses on hospitalizations, physician visits, emergency room visits, and mortality

OBJECTIVES

Although the increased risk of hospitalization and mortality during influenza seasons has been documented extensively, there is a relative paucity of research on the impact of influenza-related illnesses on other health care use indicators, such as physician use. The purpose of this study was to examine the impact of influenza-associated respiratory illnesses on the Winnipeg health care system, including hospitalizations, physician visits and emergency room visits. Their impact on mortality was also examined.

METHODS

Administrative data were used to track health care use and mortality over four influenza seasons (1995-96 to 1998-99). Excess health care use and deaths were calculated by subtracting rates during influenza seasons from those during weeks when influenza viruses were not circulating.

RESULTS

Significant excess hospitalization, physician visit, and emergency room visit rates emerged for influenza and pneumonia, acute respiratory diseases, and chronic lung disease, especially among children and adults aged 65 and over. Considerable excess mortality due to influenza and pneumonia and chronic lung disease among individuals aged 65 and over also emerged, particularly among nursing home residents.

DISCUSSION

Influenza-associated respiratory illnesses have a substantial impact on the health care system. Given the burden of illness among children during influenza seasons, the study further suggests that influenza vaccination might be considered for this age group.

The relation between everyday activities and successful aging: a 6-year longitudinal study

OBJECTIVES

Activity has long been thought to be related to successful aging. This study was designed to examine longitudinally the relation between everyday activities and indicators of successful aging, namely well-being, function, and mortality.

METHODS

The study was based on the Aging in Manitoba Study, with activity being measured in 1990 and function, well-being, and mortality assessed in 1996. Well-being was measured in terms of life satisfaction and happiness; function was defined in terms of a composite measure combining physical and cognitive function.

RESULTS

Regression analyses indicated that greater overall activity level was related to greater happiness, better function, and reduced mortality. Different activities were related to different outcome measures; but generally, social and productive activities were positively related to happiness, function, and mortality, whereas more solitary activities (e.g., hand-work hobbies) were related only to happiness.

DISCUSSION

These findings highlight the importance of activity in successful aging. The results also suggest that different types of activities may have different benefits. Whereas social and productive activities may afford physical benefits, as reflected in better function and greater longevity, more solitary activities, such as reading, may have more psychological benefits by providing a sense of engagement with life.

The impact of influenza-associated respiratory illnesses on hospitalizations, physician visits, emergency room visits, and mortality

OBJECTIVES

Although the increased risk of hospitalization and mortality during influenza seasons has been documented extensively, there is a relative paucity of research on the impact of influenza-related illnesses on other health care use indicators, such as physician use. The purpose of this study was to examine the impact of influenza-associated respiratory illnesses on the Winnipeg health care system, including hospitalizations, physician visits and emergency room visits. Their impact on mortality was also examined.

METHODS

Administrative data were used to track health care use and mortality over four influenza seasons (1995-96 to 1998-99). Excess health care use and deaths were calculated by subtracting rates during influenza seasons from those during weeks when influenza viruses were not circulating.

RESULTS

Significant excess hospitalization, physician visit, and emergency room visit rates emerged for influenza and pneumonia, acute respiratory diseases, and chronic lung disease, especially among children and adults aged 65 and over. Considerable excess mortality due to influenza and pneumonia and chronic lung disease among individuals aged 65 and over also emerged, particularly among nursing home residents.

DISCUSSION

Influenza-associated respiratory illnesses have a substantial impact on the health care system. Given the burden of illness among children during influenza seasons, the study further suggests that influenza vaccination might be considered for this age group.

Hospitalizations and Deaths Due to Respiratory Illnesses During Influenza Seasons: A Comparison of Community Residents, Senior Housing Residents, and Nursing Home Residents

BACKGROUND

Although research indicates that influenza is a major cause of morbidity and mortality among older adults, few studies have tried to identify which seniors are particularly at risk of experiencing complications of influenza. The purpose of this study was to compare hospitalizations and deaths due to respiratory illnesses during influenza seasons among seniors (aged 65+) living in the community, senior residences (apartments reserved for seniors), and nursing homes.

METHODS

Using administrative data, all hospital admissions and deaths due to respiratory illnesses (pneumonia and influenza, chronic lung disease, and acute respiratory diseases) were identified for all individuals aged 65 and older living in Winnipeg, Canada (approximately 88,000 individuals) during four influenza seasons (1995-1996 to 1998-1999).

RESULTS

Hospitalization and death rates for respiratory illnesses increased significantly during influenza seasons, compared to fall periods (e.g., 42.7 vs 25.2 hospitalizations per 1000 population aged 80 and older). Moreover, hospitalization rates for pneumonia and influenza, chronic lung disease, and acute respiratory diseases were higher among individuals living in senior residences (42.5 per 1000 for all respiratory illnesses combined) than their counterparts living in the community (22.8 per 1000). Furthermore, deaths due to pneumonia and influenza and chronic lung disease were higher among senior housing residents (4.2 per 1000) than community residents (2.6 per 1000) and were particularly high among nursing home residents (52.1 per 1000).

CONCLUSIONS

Individuals living in seniors residences are at increased risk of being hospitalized for and dying of respiratory illnesses during influenza seasons. Given that influenza vaccination is currently the best method to reduce influenza-associated illnesses among seniors, this suggests that influenza vaccination strategies should be targeted at this population.

Characteristics of patients with a regular source of care

This study was designed to describe patient characteristics associated with having a regular source of care among all patients who received care from large urban clinics in Manitoba over a three-year period (N = 298,222). Using administrative data, patients were classified as having a regular source of care if they made 75% or more of their total ambulatory visits to the same clinic. Overall, 44.2% of patients had a regular source of care. A logistic regression showed that children and adults aged 45 and older were more likely to have a regular source of care than patients aged 18-44. Moreover, patients with a regular source of care tended to live in more affluent neighbourhoods and were healthier than individuals with no regular source of care. Systemic changes might be needed to enhance continuity of care (e.g., mechanisms to enhance access) among vulnerable segments of the population like the poor.

Observers' Reactions to Genetic Testing: The Role of Hindsight Bias and Judgments of Responsibility1

In 3 studies, we examined the effect of birth outcome on observers' reactions to genetic testing. Participants read a scenario in which a woman declined to take a genetic screening test and subsequently gave birth to a child with a genetic disorder (negative outcome) or a healthy child (positive outcome). Retrospective judgments of the likelihood that the child would have a genetic disorder were higher given negative than positive outcome knowledge under conditions of high genetic risk. Moreover, the more likely a negative outcome was perceived to be, the more responsible the mother was held for not taking the genetic screening test. Consistent with Weiner's (1993) theory, responsibility judgments were linked to displeasure and sympathy, with sympathy in turn being related to help judgments.

Primary and secondary control-enhancing strategies: implications for health in later life

OBJECTIVES

The major goal of this article was to assess the link between control-enhancing strategies and health in an older population. In particular, the use of primary-control strategies, which involve modifying the environment (e.g., actively persisting) and compensatory secondary-control strategies, which involve modifying the self (e.g., expecting less of oneself) was studied.

METHODS

Participants (n = 241) in a large-scale longitudinal study were interviewed to assess their use of strategies and their health.

RESULTS

Health (physical and perceived) was found to vary for those using primary- and compensatory secondary-control strategies; however, the nature of this variation depended on age.

DISCUSSION

The findings may indicate that primary-control strategies have positive health implications for the young-old but that these same strategies become detrimental to health in late life. The findings could further suggest that compensatory secondary-control strategies become increasingly more adaptive in late life.

Self-perceptions of health: a prospective analysis of mortality, control, and health

A growing number of studies show that self-perceptions of health are an important predictor of mortality. The present study was designed to extend this research by examining the relation between health perceptions and a range of other outcome measures besides mortality, including control beliefs and morbidity. The results show that older adults who rated their health as "bad/poor" and "fair" were more than twice as likely to die within three to three-and-a-half years following the initial survey than those who perceived their health as "excellent." However, although health perceptions assessed in 1991/92 were related to health perceptions four years later, they did not predict morbidity. Health perceptions also predicted perceived control and use of control-enhancing strategies in dealing with age-related challenges, as assessed in 1995. These findings contribute to our understanding of the benefits of positive health perceptions by showing that they are connected to an adaptive psychological profile including perceptions of control and use of control-enhancing strategies that are linked to health and well-being.

The interactive effect of perceived control and functional status on health and mortality among young-old and old-old adults

The effect of perceived control on health has been examined extensively in the gerontological literature. A question that has received little attention, however, is whether perceived control affords similar benefits to all other adults. In a longitudinal study we examined the effect of perceived control, in combination with functional status and age, on perceived health, morbidity, hospitalization, and mortality. The analyses showed that perceived control interacted with functional status for old-old (80+ years old) adults, but not for young-old (65-79 years old) adults in terms of perceived health, hospitalization, and mortality. For perceived health, feeling in control was of benefit of old-old adults with some functional impairment, but not to those with little impairment. Moreover, a greater sense of control was associated with lower rates of hospitalization and mortality for old-old individuals with little functional impairment. These results highlight the usefulness of examining the buffering effects of perceived control in relation to different age groups.

Remaining active in later life. The role of locus of control in seniors' leisure activity participation, health, and life satisfaction

Although the physical and psychological benefits of feeling in control are well-documented in the research literature, the mechanisms that account for these effects have received less attention. The present study was designed to examine the potential mediating role of exercising and participation in nonphysical leisure activities, such as attending cultural events, involvement in volunteer organizations, and so on, in the relation between perceived control and well-being in seniors. The results indicated that an internal locus of control was positively related to exercising and participation in leisure activities. Exercising and leisure activity participation, in turn, were predictive of better perceived health and greater life satisfaction. These findings point to the potential benefits of increasing seniors' sense of control as a means to promote exercising and to increase leisure activity participation and, consequently, to enhance well-being.

Reactions to stigmas. The effect of targets' age and controllability of stigmas

Reactions toward older adults have been widely researched, but the question of whether such reactions are due to age per se or due to the presence of other stigmas (e.g., physical disabilities) has received little attention. This study was designed to investigate emotional reactions and willingness to help older versus younger adults who exhibited a wide range of stigmas, including AIDS, leg amputation, depression, and so on. Guided by attribution theory, the cause of the stigmas was further ascribed to either uncontrollable or controllable factors. Older adults evoked less anger than younger individuals, particularly in the case of blindness, depression, leg amputation, lung cancer, and unemployment. Subjects were also more willing to help an older than a younger amputee. Moreover, stigmas ascribed to uncontrollable factors generally produced less anger, more pity, and greater willingness to help than stigmas described as due to controllable causes. These results provide little support for the notion of ageism, at least within an age range of up to 65 years, but suggest that responses to older adults with stigmas may be subject to positive stereotyping.