Vulnerability and narrative in later life

Narrative gerontology considers how people age biographically as well as socially and biologically. Vulnerability as a process category and state of being remains undertheorized in the context of narratives of later life. It is argued that the narrative space for stories from old age privilege backward-looking stories that focus on positive milestones and support cultural narratives of a "life well lived." Sad, emotionally laden or uncertain/unfinished stories that reveal vulnerabilities are rejected and potentially viewed as problematic. Using an illustrative case example of a study of resilience narratives and aging, this paper considers how the study authors position and identify resilience. Some interpretative judgements used in the research regarding who is resilient based on expressions of vulnerability are highlighted. Overall, the tensions between cultural and personal narratives that position older people as vulnerable subjects are considered and it is argued that vulnerability can be a great source of strength and meaning in later life.

Age does matter for hospice care: Health care providers' attitudes toward hospice care in Binzhou, China

Death is still a taboo subject in China. Consequently, hospice remains a relatively new concept in many parts of China. In addition, China is also a rapidly aging country which will likely impact health care delivery, making hospice a potentially effective addition to current healthcare systems. The goal of this study was to better understand health care providers' (physicians and nurses) views about potential hospice implementation, especially with regards to patients' age. Semi-structured, open-ended interviews were conducted with 15 health care providers in Binzhou. Most participants felt that hospice care was only appropriate for older patients and rarely, if ever, for younger ones regardless of disease or prognosis. They also mentioned the links between traditional Chinese medicine (TCM) and many hospice principles. Given deeply held cultural attitudes about dying, hospice implementation would be most successful if directed toward older patients with terminal prognosis and with an emphasis on TCM.

"We Don't Do Any of These Things Because We are a Death-Denying Culture": Sociocultural Perspectives of Black and Latinx Cancer Caregivers

This qualitative study explored the unique challenges and experiences faced by Black and Latinx cancer survivors through the lens of their caregivers, including the specific cultural, social, and systemic factors that influence cancer survivorship experience within these communities in the United States. We conducted six focus group discussions (three Latinx and three Black groups) with a total of 33 caregivers of cancer survivors, (Mean age = 63 years). Data were analyzed using inductive content analysis; The sociocultural stress and coping model was used as a framework to interpret the findings. We identified three main themes: 1) families as (un)stressors in survivorship such as the vitality of social connections and families as unintended burden; 2) responses after diagnosis specifically whether to conceal or accept a diagnosis, and 3) experiencing health care barriers including communication gaps, biased prioritizing of care, and issues of power, trust, and need for stewardship. This study's findings align with previous research, highlighting the complex interplay between cultural, familial, and healthcare factors in cancer survivorship experiences within underserved communities. The study reiterates the need for culturally tailored emotional, physical, financial, and informational support for survivors and their caregivers. Also, the study highlights a need to strengthen mental health and coping strategies, to help address psychological distress and improve resilience among survivors and their caregivers.

The AgeSmart Inventory©: A Multifaceted Tool to Understand Age Bias

Ageism has been recognized as a global problem leading to poorer health, isolation, and workplace discrimination toward people based on their age. Consequently, there are several tools that measure levels and types of ageism with a focus on the quantification of degrees and types of ageism. While such quantification is valuable, this paper describes the development of an inventory, created over four stages, designed to foster introspective and collaborative thinking about age-directed values. In Stage 1, 34 items were identified through a comprehensive literature review. In Stage 2, the items were evaluated and revised via a focus group discussion. In Stage 3, the revised ASI was administered to a representative U.S. sample (N = 513). Based on factor and conceptual analysis, a revised version was tested on a second sample (N = 507) (Stage 4) and again revised. The final ASI consists of 35 age-related statements: 22 psychometrically linked to one of four domains, six related to identity, and seven that, although not aligned with statistical results, are conceptually important. Rather than provide an ageism score, the ASI is a tool for introspection and reflection about individual values and judgements about age which can lead to customized strategies to address potential age biases.

Till Death Do Us Part?: Exploring the Social Convoys of Conjugally Bereaved Women

OBJECTIVES

The hierarchical mapping technique (HMT) is used to study social convoys, peoples' support systems. Recent research integrating the HMT and the continuing bonds framework suggests that deceased persons may be influential convoy members. Extending this idea, the current study aimed to gain insight regarding how older conjugally bereaved women view the role of a deceased romantic partner in their convoy.

METHODS

The study utilized a qualitative descriptive approach. Twenty heterosexual women (mean age = 78 years, range = 65-93 years), recruited via social media and snowball sampling, participated in one 90-min interview. Each discussed their bereavement journey and completed an HMT diagram to comment on how, if at all, their deceased romantic partner was part of their social convoy and their place within it.

RESULTS

Fifteen of the 20 women placed the deceased in the innermost circle of the diagram, with them yet separate from other convoy members. Thematic analysis of transcripts revealed 5 major themes: "We're part of each other," "I think he supports me," "He would want me to be happy," "I just feel so grateful," and "I think about him every day but I don't talk about him every day."

DISCUSSION

Perceptions that deceased romantic partners continue to play a key role in conjugally bereaved older women's lives offer researchers the unique opportunity to examine how loss is carried into old age. Furthermore, this study may assist with the development of interventions that destigmatize continuing bond expressions for conjugally bereaved heterosexual women.

STORIES FROM THE INSIDE OF DEMENTIA: CONSTRUCTING IDENTITIES AND RELATIONSHIPS THROUGH THE DISCOURSE OF EXPERIENCE

Dementia is often characterized as a time of decline and loss. The grand narrative (i.e., the biomedical narrative) of dementia describes it as a time of meaninglessness given the inevitable loss of memory and language, fraught with difficulties recognizing familiar faces, recalling autobiographical events, and orienting to time and place. This unfortunate depiction negatively positions people living with dementia as living a ‘social death’ and overlooks the potential of forming meaningful relationships and experiencing a sense of community. Elements often overlooked can be found in the careful reading and analysis of individual interactions that make up constructions of identity, relationships, and community. In this symposium, we draw data from the “Friendship Study,” a 6-month ethnographic study on the social environments of people living with dementia in long-term care to consider meaning-making in dementia through three perspectives: phenomenological, gerontological, and discursive. The first paper considers the phenomenology of friendship, moving away from linear narratives to look at micro-constructions of identity. The second considers the co-construction of friendship through discursive elements found in conversational interactions. The third challenges staff’s construction of residents, highlighting how negative assumptions about resident capabilities can affect personal relationships and the social environment.

NONE OF THEM ARE REALLY FRIENDS: STAFF PERCEPTIONS OF THE SOCIAL WORLD OF PEOPLE LIVING WITH DEMENTIA IN LONG-TERM CARE

Nursing homes are charged with the care and protection of residents. Consequently, staff exercise tremendous control over residents’ day-to-day lives, including their social worlds. This is especially true for people living with dementia who may have challenges with communication. This paper examined how staff viewed friendships among dementia residents. Eleven staff members were asked to describe the friendship among the 20 residents in their charge to include who was friends with whom and what were the key features of the friendships. Results revealed that nearly all staff viewed residents as incapable of forming friendships among other residents. One exception was that many staff viewed felts that the male residents enjoyed a level of friendship that female residents did not. Overall, the findings point to the need to help staff move beyond a limited view of residents’ capabilities and discover ways to help foster a rich social environment

HOW HAS NARRATIVE BEEN USED IN GERONTOLOGY?: FINDINGS FROM A QUALITATIVE EVIDENCE SYNTHESIS

Narrative gerontology emerged as a concept in the 1990s to describe the ways that people age biographical as well as biologically. Since then, narratives and narrative approaches have gained popularity as methods and ways of knowing. This paper presents findings from a qualitative evidence synthesis (QES) of narrative within the gerontological literature. ). QES describes methods to systematically review qualitative evidence (e.g., extracted text). The purpose is to gain a deeper understanding of a concept rather than evaluate study designs or findings. An initial search returned 1,480 papers. Upon further analysis, the following three large categories with regards to narrative were identified: definitions, accounts, processes, and possibilities. Overall, findings provide an comprehensive overview of uses of narrative within gerontology.

ANOCRITICISM AND THE PERFORMANCE OF MASCULINITY IN OLDER MEN

While anocriticism is a feminist framework often applied in the context of literary gerontology, this paper uses an anocriticism approach to consider how hegemonic masculinities and old age reveal a separation between cultural stereotypes of age and chronological age. Narratives from 5 men aged 65 and over, who participated in a qualitative study on everyday attributions of depression, were analyzed using an anocriticism framework. Results revealed that participants both claimed and contested their chronological age as an identity marker. Of particular note were claims related to the stereotype of loss of vigor in later life, with each man making a clear point to affirm his virility and sexual prowess independent of other interview questions. Overall, findings point to an important way to read interview data through an anocritical lens, paying particular attention to ways that power are questions and performed in relation to age.

Lesbian, Gay, and Bisexual Widows' Experiences of Grief, Identity, and Support: A Qualitative Study of Relationships Following the Loss of a Spouse or Partner

Objective

Research with lesbian, gay, and bisexual (LGB) older widows rarely focuses on familial relationships. Studies on heterosexual spousal bereavement indicate older widows face issues influencing identity but show resilience by maintaining close relationships with adult children and extended family. Though research with older LGB widows suggests similarities around loss and resilience, grief and family engagement are markedly different.

Methods

Guided by Relational Cultural Theory, which illuminates how LGB women cope through connection/disconnection, this qualitative descriptive study employed semi-structured, open-ended interviews with 16 LGB women, 60 to 85 years of age from across the United States who had lost a spouse or partner within the past five years. We conducted interviews regarding the perception of self as bereaved LGB women and sustained or altered relationships with biological and chosen families following the loss of their spouses/partners.

Results

Findings are illustrated in three themes around acceptance, support, and identity. Participants: 1) experienced differing levels of acceptance, tolerance, and inclusion from biological families; 2) experienced family or friends “disappearing” or providing critical support following a spouse/partner death; 3) negotiated challenges by creating or seeking out families of choice, new communities, and a better understanding of themselves.

Discussion

While LGB widows share some grief experiences with heterosexual widows, they also experience varying biological family acceptance and support as well as the need for friends and families of choice as advocates. It is important to recognize the unique consequences of spousal loss for this population and be cognizant of the differences in normative grief.

Bioethics and Gerontology: The Value of Thinking Together

The interdisciplinary field of bioethics focuses on what it means to be a person, flourish as a person, and be respected as a person in different conditions of health, illness, or disability. Bioethics and policy research considers normative questions such as how a good society, through its priorities and investments, should demonstrate its commitments to the lives of different populations. Bioethics and humanities scholarship, often known as "health humanities," shares affinities with age studies and disability studies and with narrative-based approaches to the study of human experience. Gerontology is concerned with the many aspects of life that affect how people age, including social structures and values that influence the experience of growing old. In this article, we briefly explore the evolution of bioethics, from a discourse that emerged in relation to developments in biomedicine, bioscience, and biotechnology; to research ethics; to broader ethical questions emerging from real-world conditions, with attention to how bioethics has considered the experience of aging. Until recently, most age-focused work in bioethics has concerned age-associated illness, particularly end-of-life decision making. Given the reality of population aging and the ethical concerns accompanying the shift in age for most places in the world, the further evolution of bioethics involves greater attention to the support of flourishing in late life and to social justice and health equity in aging societies. We argue that the discourses of bioethics and critical gerontology, in dialogue, can bring a new understanding of privilege and preference, disparity and disadvantage, and reflection and respect for aging individuals.

Inclusion of people living with Alzheimer's disease or related dementias who lack a study partner in social research: Ethical considerations from a qualitative evidence synthesis

BACKGROUND

Because use of a study partner (proxy decision-maker) to give informed consent on behalf of someone living with Alzheimer's disease or related dementias (ADRD) is common in nearly all clinical research, people living with ADRD who lack a study partner are regularly excluded from participation. Social research presents different opportunities and risks than clinical research. We argue that guidelines developed for the latter may be unduly restrictive for social research and, further, that the automatic exclusion of people living with ADRD presents separate ethical challenges by failing to support extant decision-making capacity and by contributing to underrepresentation in research.

PURPOSE

The study objective was to identify key components related to including cognitively vulnerable participants who lack a study partner in social research.

RESEARCH DESIGN/STUDY SAMPLE

We conducted an adaptive qualitative evidence synthesis (QES) and subsequent content analysis on 49 articles addressing capacity and research consent for potentially cognitively compromised individuals, to include people living with ADRD, who lack a study partner.

RESULTS

We identified four major topic areas: defining competency, capacity, and consent; aspects of informed consent; strategies to assess comprehension of risks associated with social research; and risks versus benefits.

CONCLUSIONS

Based on findings, we suggest new and ethically appropriate ways to determine capacity to consent to social research, make consent processes accessible to a population experiencing cognitive challenges, and consider the risks of excluding a growing population from research that could benefit millions.

"By the time she got sick it was just kind of too late": A qualitative study on advanced care planning among bereaved lesbian, gay, and bisexual older women

BACKGROUND

Lesbian, gay, and bisexual (LGB) older women have unmet communication needs around palliative and end-of-life care. Past research has found communication differences for LGB women patients. Consequently, older LGB women may experience healthcare communication barriers around advance care planning.

AIM

To explore experiences of bereaved LGB older women to understand perspectives regarding advance care planning communication between clinicians, patients, and dyads.

DESIGN

Guided by queer gerontology as a theoretical framework, this qualitative descriptive study employed individual interviews with purposively recruited participants. Interviews were conducted in person using a semi structured protocol and analyzed using inductive thematic analysis.

SETTING/PARTICIPANTS

Sixteen LGB women, age 60 years or older from across the United States who had lost a spouse/partner within the past 5 years.

RESULTS

Four main themes emerged from the transcripts, LGB older women: (1) experience unclear advance care planning communication and end-of-life care support from clinicians, (2) often avoid advance care planning discussions with spouse or partners, (3) lack of knowledge about palliative or end-of-life care, and (4) have more positive experiences when there is consistent communication with spouse or partner and clinicians during a spouse/partner's illness and end-of-life.

DISCUSSION

While certain experiences and opinions may reflect those of non-LGB older adults, novel advance care planning barriers exist for LGB older women. Greater understanding among clinicians is needed regarding advance care planning conversations with LGB dyads. We recommend four improvements in training, recognition, acceptance, and dyad-based communication interventions.

Not Wanting to Lose the Dignity of Risk: On Living Alone with Dementia

Of the more than 47 million people living with Alzheimer's disease or other types of dementia, an estimated one-third live alone. This essay explores the idea of the dignity of risk as it presents in the lives of people living alone with dementia, an underrepresented group in research, and considers the tension between safeguarding people with dementia from risks associated with disease progression and denying them the experience of risk as an aspect of everyday life. For individuals, risk is associated with vulnerability, choice, uncertainty, and the pursuit of goals, and may hold positive and negative connotations. This essay considers how myriad choices in the everyday lives of people living alone with dementia present some degree of risk, and how the ability to make these choices may constitute a life of dignity, replete with meaning and richness. The essay concludes with suggestions about how to reframe living alone with dementia as a way of living that can be better socially supported.

The Elderhood Mystique

While elderhood recognizes untapped potential and continued growth and creativity in later life, it also risks becoming a dismissive label that positions older people as different, otherworldly, and mysterious. By analyzing the concept of elderhood and similar movements (e.g., sageing, croning, eldering) in popular and academic literature, paying close attention to how elderhood is defined and framed, I found that elderhood has a role in some religious and cultural practices. However, newer approaches to elderhood have emerged from middle aged writers who imagine an idealized role in later life – the elderhood mystique. Often grounded in introspective passivity and selflessness, elderhood parallels Kathleen Woodward’s depiction of wisdom as a disempowering label that discourages activism and resistance by older people. Subsequently, elderhood and wisdom risk becoming new forms of othering or exclusion. Overall, findings underscore the importance of critical analysis of age-related terms, regardless of how positive they seem.

Unspoiled Identities of People Living Alone With Dementia: Resisting Stigma by Helping Others

Goffman (1963) described stigma as the shift from being viewed as a whole and usual person to one with a spoiled identity. People living with dementia (PLWD) often report feeling stigmatized. Many dementia stereotypes highlight losses (e.g., loss of self) and negatively position the person as a passive, dependent care recipient. Here, we present findings from a qualitative study of people living alone with dementia (N=10) in the community that challenge these stereotypes. Analysis of in-depth interviews revealed that many participants resisted the spoiled identity label through active engagement in the community such as participating in paid employment, providing care for neighbors and family members, and volunteering. Overall, findings underscore the need to rethink and challenge common perceptions of PLWD that are focused solely on care, to recognize their active and valuable role in the lives of others. How PLWD negotiate these identities should inform policies of dementia in community.

We Speak a Different Language: End-of-Life and Bereavement Experiences of Older Lesbian, Gay, and Bisexual Women Who Have Lost a Spouse or Partner

We examine the end-of-life (EOL) experiences, communications, and grief support during and after their loved one's death of older lesbian, gay, and bisexual women (LGB) ages 60 to 85 who have lost a spouse or partner. Queer gerontology was used as a theoretical framework, and descriptive qualitative analytical methods were used to discern themes. Through semi-structured interviews with a purposive sample of 16 participants, we identified two main themes: Gathering the Women and Compassionate Care. Although older LGB women may have some similar support needs as non-LGB adults, other needs are distinct but often unmet. While our participants' interactions with health care professionals were overtly positive, there was often a lack of communication about grief resources, including lesbian and women-specific grief groups. Overall researchers, policymakers, and practitioners should be mindful of the importance of fully integrating and including populations into their care practices to avoid creating systems of superficial tolerance.

"We Are Doing These Things So That People Will Not Laugh at Us": Caregivers' Attitudes About Dementia and Caregiving in Nigeria

Some Nigerians, in their effort to make sense of dementia symptoms, use descriptions that may stigmatize people with dementia and their families. This qualitative descriptive study focused on the everyday understanding of dementia and the impact of stigma on the caregiving experiences of informal female Nigerian dementia caregivers. Semi-structured interviews were conducted with a purposive sample of 12 adult informal female caregivers in Nigeria and analyzed for themes. Afterward, results were presented to focus groups of 21 adult Nigerians residing in the United States for more contextual insight on the findings. The three major themes were misconceptions about dementia symptoms, caregiving protects against stigmatization, and stigma affects caregiving support. Overall, we argue that knowledge deficit, poor awareness, and traditional spiritual beliefs combine to drive dementia-related stigmatization in Nigeria. Strategies such as culturally appropriate dementia awareness campaigns and formal long-term care policies are urgently needed to help strengthen informal dementia caregiving in Nigeria.

Are We Missing the Target When Measuring Quality of Life?

Over the last several decades, many instruments have been created to measure quality of life (QoL) in older adults, particularly for intervention research on individuals living with dementia. However, since definitions of QoL lack standardization across the research literature, the question of how to holistically capture an elusive and expansive concept such as QoL remain. This research uses qualitative content analysis to explore definitions and domains of QoL with an eye toward overlap and gaps. Definitions of QoL were extracted from gerontology encyclopedia entries and other peer-reviewed supplemental resources and analyzed for themes using Dedoose qualitative software. Results revealed three over-arching themes: no standardized or universal definition of QoL, use of subjective and objective factors for measurement, and varying domains of QoL. Additionally, we further distilled theme three to identify eight unique QoL domains: 1) economic/financial, 2) environment, 3) ADL/IADL function, 4) participation in activities, 5) personal resources, 6) physical health, 7) psychological well-being, and 8) social/relational, the total of which were only found in one of 15 definitions of QoL. Overall, findings led to an overarching definition of QoL that cuts across multiple dimensions and factors. We argue that by having all eight domains our understanding and measurement of QoL is enhanced, thereby improving our assessment of existing definitions of QoL, as well as the instruments used to measure QoL.

What Thinking Like a Bioethicist Can Bring to Dementia Research

Bioethics is an interdisciplinary field that uses critical and empirical tools to explore and make recommendations concerning uncertainty about duties to others, including socially marginalized populations. In the context of social science or biomedical research involving people living alone with dementia, practical challenges in conducting research with capacity-impaired participants have ethical dimensions concerning informed consent and other aspects of research conduct. The underrepresentation in dementia research of the voices and perspectives of people living at home with dementia raises normative questions. Using data from a recent National Institute on Aging bioethics supplemental grant, this paper explores how thinking like a bioethicist can strengthen gerontological research. This paper examines areas such as precarity of housing, poverty and social interactions from a bioethicist’s critical analysis/perspective and provides a framework for others to apply to their own research.

I’m Very Cautious About Who I Let Into My World: Social Vulnerability for People Living Alone With Dementia

Living alone with Alzheimer’s and related dementias (ADRD) can have many risks including social vulnerability that leads to loneliness. This paper reports findings from 9 people living alone with ADRD who completed in-depth, face-to-face interviews as part of a larger, NIA-sponsored study. Narrative data were analyzed using ATLAS. ti. Thematic findings revealed that although participants received supports (e.g., financial, meal preparation) from others, they lacked opportunities to participate in meaningful engagements with people of their choice (e.g., a friend who lives too far away, a son who is busy). In addition to loneliness resulting from lack of control over their social networks, many also reported that personal changes (e.g., difficulties eating) made them hesitant to seek social engagements. Overall, this paper underscores the need for social programs that extend beyond health-related outcomes and instead speak to subjective wellbeing and social connectivity for this population.

Stigmatization and the Experience of Informal Dementia Caregivers in Nigeria

There is no formal word for dementia in Nigeria. Instead, some Nigerians, in their effort to make sense of dementia symptoms, use descriptions that may result in stigmatization of people living with dementia and their families. With Nigeria’s rapid aging, increased risk of dementia, and lack of formal long-term care, this study focused on the impact of stigma on the caregiving experiences of Nigerian women. This exploration is significant as adult females in Nigeria are the pillar of informal caregiving in the country. The study employed a qualitative descriptive method. Semi-structured interviews were conducted with a purposive sample of 12 adult informal female caregivers in Anambra, Nigeria. Data were then transcribed, coded and analyzed for themes. Afterwards, focus groups of 21 adult Nigerians residing in Ohio, US, were conducted to offer more contextual insight on the findings. The three major themes identified were: 1) negative views of dementia symptoms (e.g., witchcraft, madness), 2) caregiving protects against stigmatization (e.g., by keeping family members out of sight), and 3) stigma and caregiving support such as adult children abandoning parents with dementia because of the stigma associated with dementia. Given the overwhelming presence of stigma in all aspects of dementia to include dementia caregiving, results point to the critical need for better strategies to help strengthen informal caregiving in Nigeria. This includes culturally appropriate dementia education for families and caregivers, and formal long-term care policies that include care support in a rapidly aging Nigeria.

Adults With Neurocognitive Disorders Who Reside Alone: Exploration of Nontraditional and Absent Support Systems

Research steadily demonstrates that family functions as the central component in the provision of care for persons with neurocognitive disorders. While it is clear family plays a critical role in the lives of adults with neurocognitive disorders, overlooked is the subpopulation who reside alone, but have no identifiable family to provide care. To address this gap, data were drawn from an interview-based NIA-funded study that focused on community-dwelling live-alone persons with dementia. Subanalyses were conducted on the interviews and field notes of live-alone adults with neurocognitive disorders who had no identifiable family (N=19) and their collaterals (e.g., neighbor, N=20). Using data-derived coding in ATLAS.ti., several themes emerged including transient informal care, consequential peripheral ties, and strained/traumatic nuclear relations. Themes will be discussed in detail. The present study expands the limited information on community-dwelling persons with dementia, providing a lens for understanding the complex intersection of aging and non-traditional/absent support networks.

Exploring cause of death as a factor in social convoy membership: the case of Pauline

Research integrating social convoy and continuing bonds frameworks suggests that deceased individuals can be included in convoys as connections may carry on after death. Building on this, we present a qualitative case study that explores whether such relationships are influenced by the way people die. Pauline, 67, compares the "natural" deaths of relatives to her husband's suicide. Analysis of Pauline's interview revealed that the unexplained death of her husband impacted her identity and contributed to his continued existence within her convoy. Consequently, the cause of death may be an important consideration for researchers integrating the social convoy and continuing bonds frameworks.

CREATIVITY, HOPE, AND EXPECTATION IN A POETRY PROGRAM: RETHINKING WHAT COUNTS AS SUCCESS IN DEMENTIA CARE

Creativity offers liberation from the framework of decline in later life in general, and within the context of dementia specifically. Cohen described the synergy of hope and expectation as ways through which people access their creative potential, especially in the face of loss. This paper explores three case drawn from a qualitative study. Eight residents living in a secure dementia care facility participated in six 30-minute interactive poetry sessions using guidelines from the Alzheimer’s Poetry Project (APP). Observations were conducted at baseline, during the intervention, and one week afterwards. All sessions were audio recorded, transcribed and analysed. Important findings included the positive potential of imagined futures, creative engagement as a tool for building social bonds, and the importance of language play. Overall, these findings point to new ways to consider success in dementia interventions by focusing on the potential to create meaningful and creative engagement opportunities.

RECRUITING COMMUNITY-DWELLING LIVE-ALONE PERSONS WITH DEMENTIA: AN EXPLORATION OF FIVE GATEKEEPER DOMAINS

Although recruiting persons with dementia into research is challenging enough, finding those who live-alone in the community is even more difficult. Consequently, live-alone persons with dementia are often overlooked and/or deliberately excluded from inquiry despite calls for more inclusive approaches to dementia research. Based on enrollment strategies from an interview-based protocol recruiting 120 live-alone persons with dementia, our National Institute on Aging- funded study identified five domains of gatekeepers imperative to gaining access to community-dwelling, live-alone persons with dementia: 1) housing (e.g., service coordinators), 2) data proprietors (e.g., regulatory specialists), 3) institutional (e.g., review boards), 4) kin (including fictive kin), 5) clinical (e.g., medical providers, clinician practices). In addition, gatekeeper domains are multilayered and serve distinct roles in both facilitating and hindering access to and enrollment of this under-researched vulnerable population. Analysis of our recruitment efforts contribute significant insights into how the dementia research community may engage the various domains of community gatekeepers, providing direction for current and future social science research.

What Can Thinking Like a Gerontologist Bring to Bioethics?

I am a social gerontologist, broadly defined as a social scientist who studies how later life is experienced, structured, and controlled in a society and in social settings. Although gerontology is often confused with geriatrics (a medical specialty), gerontologists are typically not clinicians but may study issues related to old age and health care such as the societal conditions that shape how medical care is provided and financed and how early exposure to education relates to later life health. In this essay, I argue that thinking like a gerontologist is important when considering what makes a good life in late life. To think like a gerontologist is to consider the cultural and societal values-past and present-that shape the experience of aging, to recognize people as complex beings whose individual lives do not follow predictable patterns or easily identified trajectories, and to recognize our own habits of regarding older persons as "other" and the consequences of "othering" for older persons and social systems. After a brief history of gerontology, highlighting a few core concepts that gerontologists share, I propose three important questions to consider regarding a good life in late life.

Chronic Illness and Generativity in Late Life: A Case Study

Purpose of the Study

This article presents a narrative-based case study about chronic illness and genetic uncertainty and their relationship to generativity throughout the life course. Our focus is a woman who experienced vision loss early in life and interpreted its impact on her generativity through present-day biographical rescripting.

Design and Methods

The case we present was chosen from the study "Generativity and Lifestyles of Older Women," which explored life history, social relations, and forms of generativity in an ethnographic interview format with 200 older women.

Results

In constructing a present-day identity, the informant used shifting and conflicted self-constructions to produce a self-image as generative. Three critical themes emerged in understanding her life course: (a) retrospective interpretations of autonomy; (b) renegotiating control in the present, and (c) generativity across the life course.

Implications

This article contributes an understanding of childlessness as observed through the lenses of chronic illness, autonomy, and generativity. We conclude that a history of chronic illness, as it is co-occurring with internal debates about the meaning of key life events, may influence older adults' present-day identity. Implications for later life care needs are discussed.

Participatory arts programs in residential dementia care: Playing with language differences

This article examines connections between language, identity, and cultural difference in the context of participatory arts in residential dementia care. Specifically, it looks at how language differences become instruments for the language play that characterizes the participatory arts programs, TimeSlips and the Alzheimer’s Poetry Project. These are two approaches that are predominantly spoken-word driven. Although people living with dementia experience cognitive decline that affects language, they are linguistic agents capable of participating in ongoing negotiation processes of connection, belonging, and in- and exclusion through language use. The analysis of two ethnographic vignettes, based on extensive fieldwork in the closed wards of two Dutch nursing homes, illustrates how TimeSlips and the Alzheimer’s Poetry Project support them in this agency. The theoretical framework of the analysis consists of literature on the linguistic agency of people living with dementia, the notions of the homo ludens (or man the player) and ludic language, as well as linguistic strategies of belonging in relation to place.

"Calm . . . Satisfied . . . Comforting": The Experience and Meaning of Rabbit-Assisted Activities for Older Adults

Animal-assisted activity programs are commonly used in long-term care facilities to enhance the well-being of older residents. Although research suggests that older adults benefit from these programs, little is known about the experience from the perspective of older adults themselves. In this qualitative study, we used direct observation and in-depth interviews to gain an understanding of the experience of participating in a unique rabbit-assisted activity program delivered in a Midwestern residential facility. Several benefits were identified, with no negative experiences articulated by the participants. In addition to finding the rabbits soothing, the rabbits served as a source of social support for some participants and encouraged social interaction. Participants generally felt that rabbits are good animals to use for this type of activity, but expressed a desire for more frequent, longer, and more interactive visits. Facilities considering animal-assisted activities (AAA) programs should consider these factors when designing their programs.

Caregiver report versus clinician impression: disagreements in rating neuropsychiatric symptoms in Alzheimer's disease patients

BACKGROUND

The measurement of neuropsychiatric symptoms (NPS) in dementia is often based on caregiver report. Challenges associated with providing care may bias the caregiver's recognition and reporting of symptoms. Given potential problems associated with caregiver report, clinicians may improve measurement by drawing from a wider array of available data and by applying clinical judgment.

OBJECTIVE

The objective of this study is to evaluate potential disagreements between caregiver report and clinician impression when rating psychopathological manifestations from the same patient with dementia.

METHODS

Three hundred twelve participants (156 patients with Alzheimer's disease [AD] and 156 caregivers) were studied using the Neuropsychiatric Inventory-Clinician Rating Scale. We considered disagreement to be present when caregiver ratings were significantly higher or lower (p < 0.05) than NPS ratings by clinicians of the same patient. To evaluate whether disagreements were related to dementia severity, we repeated comparisons across levels defined by the clinical dementia rating.

RESULTS

The most common disagreements involved ratings of agitation, depression, anxiety, apathy, irritability, and aberrant motor behavior especially in patients with mild dementia. There were fewer discrepancies in moderate or severe dementia. The most consistent disagreements involved global ratings of depression where caregiver scores ranged from +22.5 higher to -4.5 lower than clinician rating.

CONCLUSIONS

Caregivers may have incomplete perception of patient NPS mainly in mild dementia. NPS ratings might be confounded by cultural beliefs, sometimes leading caregiver to interpret symptoms as part of "normal" aging.

"Successful aging," gerontological theory and neoliberalism: a qualitative critique

This article is a critique of the successful aging (SA) paradigm as described in the Rowe and Kahn book, Successful Aging (1998). The major point of this article is that two key ideas in the book may be understood as consonant with neoliberalism, a social perspective that came into international prominence at the same time the SA paradigm was initially promoted. These two key ideas are (a) the emphasis on individual social action applied to the nature of the aging experience and (b) the failure to provide a detailed policy agenda for the social and cultural change being promoted and, particularly, for older adults who may be left behind by the approach to change the book suggests. The article provides no evidence for a direct connection between SA and neoliberalism, but rather shows how similarities in their approaches to social change characterize both of them. In sum, the article shows (a) how the implicit social theory developed in the book, in a manner similar to neoliberalism, elevates the individual as the main source of any changes that must accompany the SA paradigm and (b) the focus on SA as individual action does not provide for those older adults who do not or will not age "successfully." This, we conclude, implicitly sets up a two-class system of older adults, which may not be an optimal means of addressing the needs of all older adults. The article also reviews a number of studies about SA and shows how these, too, may emphasize its similarities to neoliberalism and other issues that the SA paradigm does not adequately address.

Generativity in Elderly Oblate Sisters of Providence

PURPOSE OF THE STUDY

We explored how generativity and well-being merged in a group of childless older women: African and Hispanic Roman Catholic Religious Sisters, linking two minority identity characteristics.

DESIGN AND METHODS

We qualitatively interviewed 8 Oblate Sisters of Providence (OSP), by providing a framework for examining the range of the women's generativity-cultural spheres in which generativity is rooted and outlets for generativity.

RESULTS

Early negative experiences, such as fleeing despotism in Haiti and Cuba and racism within the Catholic Church, occurred alongside positive experiences-families who stressed education, and Caucasian Religious who taught children of color. This became a foundation for the Sister's generative commitment.

IMPLICATIONS

Findings highlight that research gains from a phenomenological understanding of how religious faith promotes generative cognitions and emotions. Findings also reveal that the experiences of a subculture in society-African-American elderly women religious-add to theories and definitions of generativity.

Extending the Framework of Generativity Theory Through Research: A Qualitative Study

PURPOSE OF THE STUDY

Based on ethnographic interviews, we discuss three ideas we believe will expand knowledge of older informants' thoughts about and representations of generativity. We adapt the notion of "dividuality" as developed in cultural anthropology to reframe ideas on generativity. The term dividuality refers to a condition of interpersonal or intergenerational connectedness, as distinct from individuality. We also extend previous definitions of generativity by identifying both objects of generative action and temporal and relational frameworks for generative action.

DESIGN

We define 4 foci of generativity (people, groups, things, and activities) and 4 spheres of generativity (historical, familial, individual, and relational) based in American culture and with which older informants could easily identify. The approach outlined here also discusses a form of generativity oriented to the past in which relationships with persons in senior generations form a kind of generative action since they are involved in caring for the origins of the self and hence of future generative acts. These 3 elements of a new framework will allow researchers to pose critical questions about generativity among older adults. Such questions include (a) How is the self, as culturally constituted, involved in generative action? and (b) What are the types of generativity within the context of American culture and how are they spoken about? Each of the above points is directly addressed in the data we present below.

METHODS

We defined these domains through extended ethnographic interviews with 200 older women.

RESULTS AND IMPLICATIONS

The article addresses some new ways of thinking about generativity as a construct, which may be useful in understanding the cultural personhood of older Americans.

The Role of Relevancy and Social Suffering in "Generativity" Among Older Post-Soviet Women Immigrants

PURPOSE OF THE STUDY

This paper examines generativity, social suffering, and culture change in a sample of 16 women aged 65 years or older who emigrated from the former Soviet Union. Key concerns with generativity are identity, which can be strongly rooted in one's original cultural formation, and a stable life course, which is what ideally enables generative impulses to be cultivated in later life.

DESIGN AND METHODS

To better understand how early social suffering may affect later life generativity, we conducted two 90-min interviews with each of our participants on their past experiences and current views of generativity.

RESULTS

The trauma of World War II, poor quality of life in the Soviet Union, scarcity of shelter and supplies, and fear of arrest emerged as common components in social suffering, which affected their identity.

IMPLICATIONS

Overall, the theme of broken links to the future--the sense that their current lives were irrelevant to future generations--was strong among informants in their interviews, pointing to the importance of life course stability in relation to certain forms of generativity.

Generative acts of people with dementia in a long-term care setting

Although generativity is used as a central cultural construct within life course theory to illustrate how older persons create interpersonal ties, it is also tied to key concepts in social exchange theory since generative acts can provide a way for achieving more equity in intergenerational power relationships. Without opportunities for older adults to invest themselves in younger generations, they may no longer feel needed within their family or community. In this article, we discuss the relationship of generativity and dementia through the generative activities of older persons with cognitive decline. Field notes from 8 months of research in a dementia-care setting as well as interviews with 20 residents were thematically analyzed to identify: (a) generative acts among people with dementia; (b) residents' expressions regarding giving to others; and (c) barriers to generativity. Examining generativity among people with dementia requires that one considers the subjective experience of the condition and understands that many social behaviors remain intact irrespective of any quantified cognitive loss (captured here through the use of case examples).

"Shall I compare thee to a dose of donepezil?": cultural arts interventions in dementia care research

The cultural arts have gained attention for their potential to generate social and behavioral changes in people with dementia. Although individual cultural arts intervention studies have reported positive outcomes, most are excluded from systematic reviews because of methodological weakness. We reviewed findings from 27 systematic and integrative reviews of pharmacologic, psychosocial, and cultural arts interventions to identify promising outcomes as well as limitations in current approaches. Although results point to the potential success of interventions tailored to individual interests, most focused on limited measurements of individual change. In moving forward, cultural arts intervention research must not be limited to the tools of the clinical trial model. Instead, researchers should carefully rethink what constitutes rigorous and effective research for interventions aimed at creating a meaningful personal experience for the participant rather than measurable change.

Childless Elders in Assisted Living: Findings from the Maryland Assisted Living Study

We compared data drawn from a random sample of 399 current assisted living (AL) residents and a subsample of 222 newly admitted residents for two groups: childless AL residents and AL residents with children. The percentage of childless AL residents (26%) in our study was slightly higher than US population estimates of childless persons age 65 and over (20%). In the overall sample, the two groups differed significantly by age, race and women's years of education. The childless group was slightly younger, had a higher percentage of African American residents, and had more years of education than the group with children. In the subsample, we looked at demographic, functional, financial and social characteristics and found that compared to residents with children, fewer childless residents had a dementia diagnosis, received visits from a relative while more paid less money per month for AL and reported having private insurance. As childlessness among older adults continues to increase, it will become increasingly important to understand how child status affects the need for and experience of long-term care.

The discourse of friendship: Mediators of communication among dementia residents in long-term care

One the most difficult challenges experienced by people with dementia and their caregivers is their communication. The ability to communicate is essential to creating and maintaining social relationships. Many individuals who suffer from dementia experience increased agitation and diminished social interaction in the long-term care living setting. This paper demonstrates how, through language, they construct social relationships. As part of The Friendship Study, which is an ethnographic observation of persons with dementia living in a long-term care setting, we analyzed transcripts from video- and audio-taped data and performed a discourse analysis of conversations to show how persons with dementia who live in a long-term care setting use language to create friendships. These analyses show that friendships are constructed using concepts such as conversational objects, discourse deixis, indexicality, and alignment among speakers.

Nested social groups within the social environment of a dementia care assisted living setting

The social environments of people with dementia are complex and still not fully understood. Investigating how residents in a dementia care setting navigate and participate within social groups is critical as the therapeutic benefits of social engagement are unequivocal. An ethnographic study of social environments within a dementia care residence revealed that there is active socialization and even strong and lasting friendships formed between people with dementia. Many of these relationships were observed to be a part of groups, ‘nested’ within the larger social environment. These ‘nested social groups’ had unique dynamics and their structuring was often influenced by outside factors (e.g. physical environment and staff preferences). The existence of these groups has implications for the experiences and quality of life of the residents in long-term care. Nested social groups will be defined and their function within the social environment will be discussed.

Friendships among people with dementia in long-term care

Despite the growing literature on social interactions in dementia settings, few studies have investigated ‘friendships’ in people with dementia living in long-term care. ‘Social interactions’ describe communicating, verbally and/or non-verbally, at least once with another person while ‘friendship’ suggests a deeper, more meaningful connection that may include reciprocity, intimacy, and shared trust. During a 6-month, mixed-methods study, we investigated friendships among 31 assisted living residents with moderate to advanced dementia. Results revealed no correlation between test scores or demographic characteristics (except gender) and friendship dyads identified by staff. Staffs’ perceptions of residents’ friendships were not supported through our observations. We did observe friendships among residents characterized by voluntary participation and accommodation in conversation, and recognition of the uniqueness of the other. Findings suggest staff perceptions of residents’ friendships are not sufficient and that more research on this topic is needed.