Environment profiles, social participation patterns, depressive symptoms and quality of life of disabled older adults: a longitudinal investigation

OBJECTIVES

This study used the World Health Organization's healthy ageing framework to explore longitudinal influences of environment profiles and social participation (SP) patterns on depressive symptoms (DSs) and on quality of life (QOL).

METHODS

Data were collected from a sample of community-dwelling older adults in Taiwan in 2018 (T1; N = 1,314) and a follow-up survey in 2020 (T2; N = 831). Latent class analysis was conducted to obtain environment and SP profiles. Multilevel modeling was carried out to explicate the hypothesized associations.

RESULTS

Three unique environment profiles, labeled as Highly- (Highly-FE), Moderately- (Moderately-FE) and Weakly-Facilitative Environment (Weakly-FE), were identified from T1 data. The three SP classes that were obtained from T1 and T2 data denoted High-, Moderate- and Low-SP. Participants in the 'Highly-FE' class were more likely to belong to the 'High-SP' and 'Moderate-SP' subgroups and exhibited significantly fewer DSs and better QOL. The associations were confirmed both cross-sectionally and longitudinally.

CONCLUSION

Interventions should be developed to promote or maintain preferred SP to maximize the current and future mental health and subjective well-being of disabled older adults.

Longitudinal mediation effects of activity meaning on the association between activity performance and quality of life among older adults with disabilities

BACKGROUND

Physical limitations may hinder older adults with physical disabilities' capability to perform various activities, which can affect their quality of life (QOL). Accomplishing meaningful activities may mitigate the impact of limited activity performance on their QOL. This longitudinal study aims to investigate how activity meaning mediates the relationship between activity performance and QOL among older adults with disabilities.

METHODS

Data for this longitudinal study was collected from 813 community-dwelling older adults aged 60 and above who had physical disabilities, over a two year interval. Path analysis was used to examine the cross-sectional and longitudinal mediation effects from activity performance, through activity meaning, to QOL.

RESULTS

At the same wave, high IADL performance or social activity performance, and high QOL was indirectly associated through high IADL meaning or social meaning. As for longitudinal association, high T1 IADL performance was associated with better T2 QOL through high T1 and T2 IADL meaning. Similarly, high T1 social activity performance also contributed to T2 QOL through high T1 and T2 social activity meaning. Additionally, social activity performance exhibited higher influence on QOL than that of IADL.

CONCLUSIONS

Both IADL and social activities have distinct impacts on the QOL of older adults with disabilities. To improve the current and future QOL of older adults with disabilities, professionals must prioritize their involvement in the most meaningful activities while being sensitive to and supportive of their preferences and valued lifestyles.

Effects of types and levels of social capital on emotional well-being for older people in Indonesia: A longitudinal study

OBJECTIVES

The purpose of this study was to examine the effects of different types and levels of social capital and emotional well-being in older adults in Indonesia by a longitudinal data.

METHODS

The fourth and the fifth waves of Indonesian Family Life Survey data were used for this study. The participants aged 60 years or older who participated in both waves were included for analysis (n = 1374). Depressive symptoms and happiness were used to assess emotional well-being. Cognitive social capital (neighborhood trust) and structural social capital (participating in arisan, community meetings, volunteers, village improvement programs, and religious activities) were the main independent variables. The generalized estimating equations model was used for analysis.

RESULTS

Participation in arisan (B = -0.534) and attending religious activities (B = -0.591) were related to lower depressive symptoms, but the effect of religious activities would offset over time. Both a low or high social participation showed protective effects on depressive symptoms at the intercept and the time slope. Having higher neighborhood trust was related to more chance of feeling very happy (OR = 1.518).

CONCLUSION

Structural social capital is protective from depressive symptoms, while cognitive social capital contributes to happiness. Facilitating social participation and improving neighborhood trust through policies and programs is suggested to promote emotional well-being for older people.

LONELINESS AND PSYCHOLOGICAL WELL-BEING OF THE INSTITUTIONAL OLDER ADULTS DURING THE COVID-19 PANDEMIC

Purpose

Institutional residents experienced more restrictions in the lockdown of covid-19. The purpose of this study was to examine the association of loneliness and lonely literacy with mental health wellbeing during covid-19 for older institutional residents.

Methods

The participants living in the 13 long-term care institutions who were aged 65 and more and able to communicate with were invited in the survey (n=143). Mental well-being was measured by depressive symptoms and life satisfaction. Loneliness was measured by the 6-item UCLA loneliness scale. In addition, demographics, health status, active and passive coping strategies, social support from family and friends, social interaction changes after covid-19, loneliness change after covid-19, and worries about covid-19 were investigated. Linear regression and logistic regression models were conducted.

Results

The mean of the loneliness score (6~24) was 9.71 (SD=4.02). Factors related to loneliness increased during covid-19 for the institutionalized residents included having more physical function difficulties (OR=1.179), feeling more lonely (OR=1.146), and having more worries for covid-19 (OR=2.317). The residents having depressive symptoms was related to have more loneliness (OR=1.269), worse self-rate health (OR=0.320), and increased more loneliness during covid-19 (OR=3.233); while having high life satisfaction was related to less loneliness (OR=0.859), less physical difficulties (OR=0.834), higher satisfaction of family support (OR=2.835), and not increasing loneliness during covid-19 (OR=0.255).

Conclusion

Loneliness during covid-19 is related to more depressive symptoms and lower life satisfaction, especially during covid-19. Learning active coping strategy and providing proactive and helpful environment for the long-term care residents is suggested during the pandemics.

LONGITUDINAL INVESTIGATION OF FACTORS PREDICTING RETIREMENT ADJUSTMENT AMONG RETIREES IN TAIWAN

BackgroundRetirement can substantially affect one's lifestyle and self-identity. However, little research has focused on how pre-retirement conditions are associated with retirement adjustment.MethodThis study utilized data from 1989 to 2015 Taiwan Longitudinal Study on Aging. A total of 1,471 cases who experienced retirement between waves and completed the subsequent four year and eight year follow-up surveys after retirement were included for analyses. High life satisfaction and low depressive symptoms represented good retirement adjustment. Multiple regression analysis was applied to test the hypothesized relationships. ResultsThe findings were as follows: 1. Retirees experienced increased depressive symptoms and worsened family relationships when transiting from pre-retirement to post-retirement.2. High cognition functioning, ideal family relationships and sufficient financial resources before retirement were consistently associated with few depressive symptoms and high life satisfaction, both at four and eight year follow-ups. 3. Of the 10 different leisure activities investigated, physically active leisure activities such as walking and participating group exercise before retirement predicted few depressive symptoms and high life satisfaction four years after retirement, but not eight year follow-up. DiscussionCognitive functioning, financial status, and family relationship before retirement can significantly affect both short-term (four years) and long-term (eight years) retirement adjustment, whereas physically active leisure activities only link to short-term retirement adjustment. At policy level, pre-retirement financial security should be addressed and well-prepared. At practitioner level, maintaining ideal cognition level, positive family relationship, and engaging physically active leisure activities should be the central intervention target when serving employees who are approaching retirement.

Loneliness, loneliness literacy, and change in loneliness during the COVID-19 pandemic among older adults: a cross-sectional study

BACKGROUND

Loneliness has become a significant public health concern for older people. However, little is known about the association of loneliness, loneliness literacy, and changes in loneliness during the COVID-19 pandemic with mental well-being. The purpose of this study was to explore whether loneliness literacy is related to a lower risk of loneliness, increased loneliness during the COVID-19 pandemic, and improved mental well-being for community-based older adults.

METHODS

A telephone survey was conducted to collect data from older adults aged 65 years or older in Taiwan (n = 804). Loneliness, change in loneliness during COVID-19, and loneliness literacy were the main variables. Mental well-being was assessed by depressive symptoms and life satisfaction. Related factors included personal level (demographics, health conditions, health behaviors, and problem-focused/ emotion-focused coping strategies), interpersonal level (marital status, living arrangements, social support, social participation, leisure activities, and social interactions during COVID-19), and societal level (areas and regions) factors.

RESULTS

Four dimensions of loneliness literacy were identified by factor analysis: self-efficacy, social support, socialization, and in-home support. Self-efficacy and in-home support were related to lower loneliness. Lower self-efficacy, higher social support, and higher socialization were related to changes (increases) in loneliness during COVID-19. In-home support may prevent depressive symptoms, while self-efficacy was beneficial for better life satisfaction. In addition, emotion-focused coping may increase loneliness during COVID-19, while satisfaction with family support would be a protective factor against loneliness.

CONCLUSION

Loneliness literacy is related to loneliness and increased loneliness during the COVID-19 pandemic. Building up an age-friendly community with embedded services/information and learning positive coping and mental resilience strategies are suggested.

The impact of HCBS use patterns on older aduts’ physical function among continuous service users

Background Taiwan, one of the fastest aging countries in the world, provides home-and community-based services (HCBS) care recipients through the second 10-Year Long-Term Care Plans (LTC Plans 2.0). The current study aimed to examine the impact of continuous use of HCBS offered by LTC plan 2.0 on older adults’ physical function change overtime. Methods This study used the LTC Plan 2.0 database and the National Health Insurance Plan claim dataset, and included 157,682 clients who had applied for and were evaluated for LTC services for the first time from 2018 through 2020 and continuously used any LTC Plan 2.0 services for six months. Outcome variables were measured by activities ofdaily living (ADLs) and instrumental activities of daily living (IADLs) between baseline assessment and the assessment after the six months of serivce utilization. Latent class analysis and generalized estimating equations were used to investigate the influences of different service use patterns on the changes in physical functions. Results Three subgroups of LTC recipients with different use patterns, including home-based personal care (home-based PC) services (n = 111,976; 71.01%), professional care services (n = 31,584; 20.03%), and community care services (n = 14,122; 8.96%) were identified. When compared to care recipients in the community care group, those in the home-based PC group improved more in IADL scores, and the professional care group improved more ADL scores. Conclusion Those receiving more professional services made more progress in ADL ability, but those in home-based PC made more progress in IADL ability.

Long-Term Care and Wide Effects on Children Caregivers -- New Evidence From Taiwanese Administrative Data

Long-term care (LTC) needs have profound impacts on the care-receivers and their children. Past research has focused on primary caregivers' short-term responses to LTC needs on limited aspects. This study brings new Taiwanese administrative data on health insurance, LTC program usages, and tax records. Rich information allows this study to explore long-term impacts on care-receivers' extended families. Event study combined with various regression analyses is the main framework of this study. Using the longitudinal record of more than 23 million individuals older than 65 over 18 years, the present study examines extended family members' various outcomes along the LTC needs trajectory. Among others, these outcomes include labor market participation and health expenditures. There are several findings in this study. Parents' LTC needs decrease all children's average full-time labor force participation by 2.5 percentage points even 10 years after the needs incurred. These needs do not directly increase children's health expenditure. A precise zero effect is found on children's health expenditure before, during, and after parents' LTC needs. Nevertheless, parents' health status or LTC risks, in general, may still pass on to children through other channels. The inter-generational health association is found to be approximately 0.25, indicating some degree of transmission. The results suggest that the impacts of LTC needs on family members are profound and widespread. Policy needs to address multiple aspects to cater to potential difficulties for care-receivers' family members.

Effectiveness of home- and community-based services in decreasing health care service and expenditure in Taiwan

Background Whether long-term care service use decreases older adults’ health care service use and cost has been a strong interest among aging countries, including Taiwan. The current study examined the impact of continuous use of HCBS offered by Taiwan’s LTC plan 2.0 on older adults’ health service utilization and cost overtime. Methods This study used the LTC Plan 2.0 database and the National Health Insurance Plan claim dataset, and included 151,548 clients who had applied for and were evaluated for LTC services for the first time from 2017 through 2019 and continuously used any LTC Plan 2.0 services for six months. Outcome variables were users’ health service utilization and health care cost 12 months before and after starting to continuously use HCBS. Latent class analysis and generalized estimating equations were used to investigate the influences of different service use patterns on the changes in physical functions. Results Three subgroups of LTC recipients with different use patterns, including home-based personal care (home-based PC) services (n = 107324, 70.8%), professional care services (n = 30466, 20.1%), and community care services (n = 13794, 9.1%) were identified. When compared to care recipients in the community care group, those in the home-based PC group had more emergency room expenditures (1 point/month, p< 0.05) but less hospitalization expenditures (38 points/month, p<0.001), while the professional care group had less emergency room and hospitalization expenditures (3 and 138 points/month, p< 0.001). Conclusion Those receiving professional care and home care services spent less on health care service utilization.

Preventing elder maltreatment: Identification of high risk factors from LTC administrative data

Elder maltreatment is a serious problem endangering physical, emotional, and material well-being of older persons, especially those with physical and cognitive impairment. However, detecting the incident of elder maltreatment is difficult and its prevalence has been seriously underestimated. This study explores how LTC use relates to elder maltreatment report, using government LTC service records in Taiwan. A total of 88,633 reported cases in adult protection system in 2019 were merged with 443,952 valid cases in LTC service system. Descriptive statistics were firstly performed to examine the proportion and characteristics of repeated cases in both systems. Linear probability modeling was then used for analyses. 1. In 2019, 3,413 elder maltreatment clients can be identified in LTC service system, accounting for 27.3% of the elder maltreatment cases. 2. Older persons who used LTC service first and being reported as elder maltreatment cases later had a higher prevalence of being discovered by social workers and care attendants. 3. These group of clients also had higher proportion of being reported as neglected by others, abandonment, and self-neglected. 4. Characteristics in LTC service system, such as being older, low severity of disability, high cognitive impairments, low income status, and with a LTC service use record, were related to high probability of being detected with elder maltreatment problems. Characteristics in LTC service system could be effective indicators in discovering potentially abusive situations of disabled older persons. Training and education are essential for LTC service providers to enhance their literacy and ability of assessing elder maltreatment.

Using Taiwanese Universal Health Insurance Data to Estimate LTC Needs with Machine Learning

One of the core issues in long-term care (LTC) policy is the growing imbalance between demand and supply of LTC services due to aging population. To estimate the imbalance and allocate LTC resources, the government regularly conducts surveys. These surveys are expensive given the sample size requirements and imprecise given their subjective nature. This study links the administrative records of the universal health insurance database with LTC program usage records in Taiwan to explore this issue. Machine learning algorithms are used in projecting LTC needs from administrative records. LTC program usage records provide detailed LTC needs information and the amount of service each individual used. In addition, health insurance claim data provides rich health information. Specific LTC needs are predicted for each individual. By further extrapolating to future demographics, long-term LTC needs could be projected. There are several findings in this study. Prediction of difficulties in activities of daily livings (ADL), measured by Barthel index, works best using the Gradient Boosting algorithm. The mean absolute error is 17.67 out of a 0 to 100 scale. In addition to dementia and stroke, diagnosis of pressure ulcer (ICD 10 code: L89) and pneumonia (ICD 10 code: J18) have high predictive power for LTC needs. Prediction of Instrumental ADL (IADL) also performs well with a mean absolute error 1.31. The prediction model suggests high LTC needs and excess demand as the demographics changing. Our study provides a reliable way of using rich information to estimate future LTC needs without conducting additional costly surveys.

COVID-19-related worries, social disruptions, and depressive symptoms among community-dwelling older adults with disabilities: What makes the difference?

OBJECTIVES

This study explores how home- and community-based services use, COVID-19-related worries and social disruptions are related to the depressive symptoms of community-dwelling older adults with disabilities, and whether the associations differ by month of interview.

METHODS

Data on a sample of 593 older individuals in Taiwan were collected between April and July 2020. Multiple regression analyses were performed to test the hypothesized relationships.

RESULTS

As the number of confirmed cases of COVID-19 in Taiwan continuously declined from April 2020, participants who were interviewed in May, June and July experienced significantly fewer COVID-19-related worries and social disruptions than those interviewed in April. The month interviewed, representing the pandemic development phase of COVID-19, moderated the relationships between home-based service (HBS) use and COVID-19 worries. Month interviewed also moderated the association between COVID-19-related social disruptions and depressive symptoms.

DISCUSSION AND IMPLICATIONS

Differences in the level of COVID-19-related worries between HBS users and non-users were greatest in April, followed by May, and least in June and July, suggesting that the disparities between HBS users and non-users attenuated over time. Perceived high COVID-19-related social disruptions was weakly and negatively correlated with depressive symptoms in April, but the relationship became moderately positive in May, and strongly positive in June and July. These results supported the claim that the associations between COVID-19-related social disruptions and depressive symptoms can vary over time. Professionals who serve disabled older individuals in communities should be aware of their unstated needs and adopt strategies that are appropriate for the current stage of the COVID-19 pandemic to respond better to their needs and emotional state.

Community environment and COVID-19 related stress among older adults with disabilities in Taiwan

The outbreak of the COVID-19 pandemic at the beginning of 2020 forced many countries to implement social distancing policies such as the suspension of activities and gathering. Taiwan is the leading country which took active epidemic prevention measures in local communities, including closing the community centers and programs for older adults. Older adults with chronic health conditions are particularly vulnerable to the COVID-19 pandemic because they have disproportionally been affected by it. This study examined the associations between community environment and COVID-19 related stress of community-dwelling older adults with disabilities. Data were collected from a sample of 547 community-dwelling older adults aged 65 and over with disabilities in Taiwan between April and July, 2020. Multiple Regression Analysis was applied to test the hypothesized relationships. The analytic results suggested that: First, participants who were younger and with better cognitive functioning had higher levels of COVID-19 related stress. Second, as the confirmed case number dropped by month, participants interviewed in the later months expressed lower levels of COVID-19 related stress. Third, older adults who perceived more obstacles in their environment reported higher levels of COVID-19 related stress. In conclusion, although restrictions during the pandemic is inevitable to secure the safety of the public, programs should be designed for older adults with disabilities to remove the obstacles and to make information, policies and services more accessible in the communities to mitigate their COVID-19 related stress.

Functional Status, Meanings of Life Activities, and COVID-19 Related Disruptions among Disabled Older Adults

Participating in meaningful activities has been proven beneficial to the well-being of disabled older adults. However, social distancing policies and restrictions on public activities have been implemented since the outbreak of COVID-19 at the beginning of 2020 in Taiwan. These restrictions not only prevent older individuals from performing meaningful activities but also have actual impacts on their daily life. This study aims to elucidate the intervening role of meanings of life activities on the relationship between functional status and COVID-19 disruptions. Data were collected from a sample of 526 community-dwelling older adults with disabilities in Taiwan between April and July, 2020. Utilizing Multiple Regression Analysis, the research findings were as follows. First, participants with better functional status experienced more COVID-19 related disruptions to their daily routine. In the meantime, they also valued their life activities as more meaningful than those with worse functional status. Second, higher levels of meanings in performing life activities also positively related to COVID-19 disruptions. Third, meanings of life activities fully mediated the relationship between functional status and COVID-19 disruptions. That is, disabled older individuals with better functional status may experience more COVID-19 related disruptions because their accessibility to meaningful activities was limited. Since preventive approaches to control the spread are necessary during COVID-19 epidemic, efforts should be made to sustain meaningful life activities participation among disabled older adults. Based on the findings of this study, this would be especially critical to the well-being of more capable older individuals with disabilities during the pandemic.

Differences in determinants of intention to stay and retention between younger and older nursing assistants in long-term care facilities: A longitudinal perspective

AIMS

This study examines differences in the determinants of intention to stay (Time 1) and actual retention behaviour at follow-up (Time 2) between younger and older nursing assistants in long-term care facilities.

BACKGROUND

The shortage of nursing assistants in long-term care is increasing, and the nursing assistant workforce is also ageing.

METHODS

Data were obtained from a stratified equal probability sample of 595 nursing assistants from 137 institutions over a two-year period in Taiwan. Multilevel modelling was utilized for analyses.

RESULTS

High organisational support and low burnout were associated with high intention to stay at Time 1 for both older and younger nursing assistants. However, the retention of older nursing assistants at Time 2 was more strongly influenced by high work latitude, the use of an optimization strategy and less burnout at Time 1, while the retention of younger nursing assistants at Time 2 was more likely to be affected by personal factors such as gender and marital status at Time 1.

CONCLUSION

Organisational factors, the use of selection, optimization, compensation strategies, and burnout were more strongly associated with retention of older nursing assistants than of younger nursing assistants.

IMPLICATIONS FOR NURSING MANAGEMENT

Nursing assistant managers should recognize the needs of nursing assistants vary by age and stage of life. Retention programs that are designed to account for age differences will be more effective at retaining nursing assistants.

Environment patterns and mental health of older adults in long-term care facilities: the role of activity profiles

Objectives: This study adopts the International Classification of Functioning, Disability and Health (ICF) model to determine extent to which the clustered patterns of long-term care (LTC) environment and activity participation are associated with older residents' mental health. Method: This study enrolled a stratified equal probability sample of 634 older residents in 155 LTC institutions in Taiwan. Latent profile analysis and latent class analysis were conducted to explore the profiles for environment and activity participation. Multilevel modeling was performed to elucidate the hypothesized relationships. Results: Three environment profiles (Low-, Moderate-, and High-Support Environment) based on physical, social, and attitudinal environment domains and two activity profiles (Low- and High-Activity Participation) across seven activity domains were identified. Compared to the Low-Support class, older adults in the Moderate- and High-Support Environment classes had better mental health. Older residents in those two classes were more likely to be in the "High Activity Participation" class, which in turn, exhibited better mental health. Conclusion: Environment and activity participation directly relate to older residents' mental health. Activity participation also mediates the link between environment and mental health. A combination of enhanced physical, social, and attitudinal environments, and continual engagement in various activities may optimize older LTC residents' mental health.

Does geriatric nursing staff burnout predict well-being of LTC residents?

Nursing staff in residential settings are exposed to a large number of stressors. This study examined the relationship between geriatric nursing staff (GNS) burnout and the well-being of residents in long-term care (LTC) facilities. Data were obtained concerning 590 older residents who were served by 315 GNS in 172 LTC facilities in Taiwan, using multilevel modeling. The depersonalization (DP) dimension of burnout in GNS was consistently related to various resident well-being outcomes. Higher DP among GNS was associated with lower residential satisfaction and perceived quality-of-life, as well as more depressive symptoms among older LTC residents. The findings support the claim that DP among GNS has a greater role in determining LTC resident well-being than other dimensions of burnout. Efforts should be made to mitigate the emergence of DP among GNS. Support and education are also needed to enable GNS to foster positive interactions and relationships with LTC residents.

Outdoor activities and depressive symptoms in displaced older adults following natural disaster: community cohesion as mediator and moderator

OBJECTIVES

This investigation examined whether community cohesion mediates or moderates the relationship between outdoor activities and depressive symptoms in older adults displaced by Typhoon Morakot in Taiwan.

METHOD

This cross-sectional study included 292 adults aged 65 years or older who were relocated to permanent houses after Typhoon Morakot damaged their homes on 8th August 2009. Multiple regression analysis was applied to test the role of community cohesion on the association between outdoor activities and depressive symptoms.

RESULTS

The sample of displaced older adults displayed higher prevalence of depressive symptoms than the average for community dwelling older people in Taiwan. Community cohesion fully mediated the relationship between outdoor activities and depressive symptoms. Community cohesion also moderated the relationship between outdoor activities and depressive symptoms.

CONCLUSION

Community cohesion occupies a key role on the link between outdoor activities and depressive symptoms. Participation in outdoor activities was associated positively with community cohesion, while high community cohesion was related negatively to depressive symptoms. Additionally, the benefit of outdoor activities to fewer depressive symptoms only manifested in older adults with high community cohesion. Programs and services should be designed to enhance community cohesion in order to maximize the benefit of outdoor activities to the mental health of displaced older adults after natural disasters.

Social support, coping strategies and their correlations with older adults' relocation adjustments after natural disaster

AIM

The present study examines the associations among social support, coping strategies and relocation adjustment outcomes, including community cohesion, residential satisfaction and depressive symptoms, for older persons in Taiwan displaced by Typhoon Morakot.

METHODS

This study enrolled 372 adults aged 60 years or older who were relocated to permanent houses after Typhoon Morakot destroyed their homes on 8 August 2009. A path analysis simultaneously examined the hypothesized links among social support, coping strategies and relocation adjustment outcomes.

RESULTS

The relationships between coping strategies and relocation outcomes varied. Problem-focused and support-seeking coping were positively related to perceived community cohesion, whereas emotion-focused coping was associated with a high number of depressive symptoms. Social support was positively related to residential satisfaction. Additionally, social support was also indirectly related to increased community cohesion and residential satisfaction through its positive relationship with support-seeking and problem-focused coping.

CONCLUSIONS

More interventions should be implemented to enhance support within informal networks and a sense of belonging to the new resident community, thereby promoting more active coping strategies, enhancing the effectiveness of coping efforts and maximizing positive adjustment outcomes. Geriatr Gerontol Int 2017; 17: 1006-1014.

Functional disability and depressive symptoms: longitudinal effects of activity restriction, perceived stress, and social support

OBJECTIVES

This longitudinal study investigates how activity restriction, perceived stress, and social support affect the relationship between functional disability and depressive symptoms.

METHOD

This longitudinal study of a Taiwan population analyzed a nationally representative sample of 1268 subjects aged 60 years and over. Path analysis was used to assess interrelations among functional disability, activity restriction, perceived stress, social support, and depressive symptoms over time.

RESULTS

The analytical results supported the following relationships: (a) high functional disability were associated with high activity restriction, low social support, and high perceived stress over time, (b) high functional disability, high activity restriction, low social support, and high perceived stress were associated with high levels of depressive symptoms over time, (c) among the four factors, perceived stress exerted the strongest cross-sectional and longitudinal effect on depressive symptoms, and (d) the significant effect of prior functional disability on subsequent depressive symptoms substantially contributed to indirect changes in activity restriction, perceived stress, and social support between waves.

CONCLUSION

The findings indicate that functional disability may contribute to subsequent depressive symptoms by reducing activities and social support. Decreased activities and social support increased perceptions of stress, which then increased depressive symptoms during the 8-year follow-up study.

Functional disability and psychological well-being in later life: does source of support matter?

OBJECTIVES

This study explored the buffering effects of instrumental and emotional support from different sources against the impact of increasing functional disability on depression and life satisfaction.

METHODS

Random effects modeling was utilized with data from a nationwide longitudinal study in Taiwan. A total of 6722 observations from 2856 elders over a seven-year period served as subjects of this study.

RESULTS

The results suggested that instrumental support from family members and formal organizations as well as emotional support from families, friends and formal organizations was significantly associated with better psychological well-being among the elderly in Taiwan. In addition, receiving instrumental support from family members and formal organizations can moderate the linkage between increasing functional disability and depression.

CONCLUSION

The results emphasize the importance of encouraging a partnership between natural helpers and health care professionals. A good integration between formal and informal networks could more effectively meet the needs of the frail older adults and their families. This study also calls for more attention to the cultural competence of health care policy and service delivery.

Assessing social support and depressive symptoms in older Chinese adults: a longitudinal perspective

OBJECTIVES

This study examined the relationship between social support and depression in a national longitudinal sample in Taiwan. This study integrates previous literature and develops a predictive model involving seven components of social support - social network size, network composition, frequency of social contact, proximity, types of support received, helping others, and satisfaction with social support.

METHOD

A total of 4049 elders who were interviewed up to five times over a 14-year period from the 'Surveys of Health and Living Status of Elderly' (SHLSE) in Taiwan served as the subjects of this study. Random effects modeling was used to analyze the data.

RESULTS

Greater network size, broader networks, more frequency of contact, living with a married son, receiving instrumental, emotional and financial support, providing financial and short-term instrumental support to others, and higher satisfaction with support were all associated with fewer depressive symptoms. Providing physical care was related to higher levels of depression. Of the social support measures, satisfaction with support emerged as the most powerful predictor of elders' depression.

CONCLUSION

This investigation provides evidence that each aspect of social support accounts for a certain portion of the concept and emphasizes the importance of distinguishing different dimensions of social support. Also, the inconsistent findings between the current study and the Chinese literature reminds future investigators that the effect of social support on depression may differ among Chinese elderly in different communities, even through they share the same cultural origin.

Factorial validity and consistency of the Maslach Burnout Inventory among staff working with persons with intellectual disability and dementia

BACKGROUND

Burnout has been considered important to understanding the well-being of workers in the intellectual disabilities (ID) field and the quality of services delivered to clients/consumers. However, little research has examined the psychometric properties and applicability to staff in ID services of one of the most widely used burnout measurements - the Human Services Survey version of the Maslach Burnout Inventory (MBI-HSS).

METHODS

Data were gathered using a mailed questionnaire comprising the MBI-HSS and demographic information. The sample consisted of 435 staff delivering direct care and working in out-of-home community placements for persons with ID in New York state. The factorial structure of the scale was examined using confirmatory and exploratory factor analysis. Internal consistency estimates of reliability of the MBI-HSS were determined using Cronbach's alpha.

RESULTS

Confirmatory factor analysis supported the MBI-HSS as an acceptable measure to evaluate burnout in ID services staff. However, the reliability statistics obtained for the Depersonalization (DP) sub-scale was much lower than what has been reported in studies with other staff populations. An exploratory factor analysis suggested that a four-factor solution, dividing the DP sub-scale into two factors, provided a somewhat better fit for the sample.

CONCLUSIONS

The use of the MBI-HHS as an instrument for measuring burnout among ID workers has its attraction but also its limitations. In particular, the DP sub-scale should be used with caution because there appear to be wording issues for staff in ID settings that may lead to inconsistent responses.

The E1 helicase of human papillomavirus type 11 binds to the origin of replication with low sequence specificity

Expression of the human papillomavirus type 11 E1 and E2 genes is necessary and sufficient to support viral DNA replication. The full-length E2 protein is a transcriptional modulator that also interacts with the E1 helicase to form an E1/E2 complex at the viral origin of replication. Previous studies indicated that efficient binding of this complex to the replication origin is site-specific and that the E2 homodimer was required for efficient E1 binding. Human papillomavirus type 11 E2 and E1 proteins have been purified and their cooperative binding to the HPV type 11 viral replication origin has been characterized. Low-affinity E1 binding to the HPV type 11 replication origin was demonstrated and found to be largely nonspecific. DNA binding by E1 does not require complex formation with E2 and appears to be independent of ATP binding or hydrolysis. E1 binding quantitatively increased with the addition of increasing amounts of E2 and mutations in the E2 binding site demonstrated that the E2BS site is required for E1 and E2 to specifically bind as a high-affinity complex at the replication origin. Analysis of the A/T-rich E1 binding site via mutation showed that it was nonessential for high-affinity E1/E2 complex formation. Thus, although the replication functions between the animal and the human papillomaviruses are well conserved, there are subtle differences in the DNA binding requirements for E1, which may portend mechanistic differences among the DNA replication systems of various papillomavirus types.

Maturation of the hepatitis A virus capsid protein VP1 is not dependent on processing by the 3Cpro proteinase

Most details of the processing of the hepatitis A virus (HAV) polyprotein are known. Unique among members of the family Picornaviridae, the primary cleavage of the HAV polyprotein is mediated by 3Cpro, the only proteinase known to be encoded by the virus, at the 2A/2B junction. All other cleavages of the polyprotein have been considered to be due to 3Cpro, although the precise location and mechanism responsible for the VP1/2A cleavage have been controversial. Here we present data that argue strongly against the involvement of the HAV 3Cpro proteinase in the maturation of VP1 from its VP1-2A precursor. Using a heterologous expression system based on recombinant vaccinia viruses directing the expression of full-length or truncated capsid protein precursors, we show that the C terminus of the mature VP1 capsid protein is located near residue 764 of the polyprotein. However, a proteolytically active HAV 3Cpro that was capable of directing both VP0/VP3 and VP3/VP1 cleavages in vaccinia virus-infected cells failed to process the VP1-2A precursor. Using site-directed mutagenesis of an infectious molecular clone of HAV, we modified potential VP1/2A cleavage sites that fit known 3Cpro recognition criteria and found that a substitution that ablates the presumed 3Cpro dipeptide recognition sequence at Glu764-Ser765 abolished neither infectivity nor normal VP1 maturation. Altered electrophoretic mobility of VP1 from a viable mutant virus with an Arg764 substitution indicated that this residue is present in VP1 and that the VP1/2A cleavage occurs downstream of this residue. These data indicate that maturation of the HAV VP1 capsid protein is not dependent on 3Cpro processing and may thus be uniquely dependent on a cellular proteinase.

Subunit affinities and stoichiometries of the human papillomavirus type 11 E1:E2:DNA complex

The association between the papillomavirus E1 and E2 proteins is an important regulatory interaction, imparting coordinated control of viral transcription and replication. Using fluorescence polarization, we have characterized the interactions between HPV-11 E1, HPV-11 E2, and DNA in solution at equilibrium. For these studies, two double-stranded fluorescein-labeled oligonucleotides were prepared. The first fluorescent oligonucleotide, designated Fl-E2BS and containing a single E2 binding-site palindrome (ACCGN6CGGT), was used to determine the affinity of E2 for its DNA binding site. HPV-11 E2 bound Fl-E2BS with an apparent Kd of 0.84 nM. Binding was saturable and consistent with a single class of noninteracting sites. The second oligonucleotide, designated Fl-E1E2BS, contained both E1 and E2 sites in sequence derived directly from the HPV-11 origin of replication. Under titration conditions identical to those used for Fl-E2BS, the E2 protein exhibited reduced affinity for Fl-E1E2BS (Kd > 100 nM). E1 binding to Fl-E1E2BS was of very low affinity. Addition of excess HPV-11 E1 to Fl-E1E2BS lowered the dissociation constant for the E2:Fl-E1E2BS interaction to 2 nM. This effect was not dependent upon ATP or magnesium ion. Fluorescence polarization and other data suggest formation of a complex containing six E1 molecules and a single dimer of E2 bound to a single Fl-E1E2BS oligonucleotide; E2 dissociation from the final complex did not occur. In summary, physical interaction between E1 and E2 increases the DNA binding affinity of each. The role of this energy coupling may be to promote origin-specific binding of both E1 and E2 to DNA.

A genetic approach for identifying critical residues in the fingers and palm subdomains of HIV-1 reverse transcriptase

By using oligonucleotide-directed saturation mutagenesis, we collected 366 different single amino acid substitutions in a 109-aa segment (residues 95-203) in the fingers and palm subdomains of the HIV-1 reverse transcriptase (RT), the enzyme that replicates the viral genome. After expression in Escherichia coli, two phenotypic assays were performed. The first assay tested for RNA-dependent DNA polymerase activity. The other assay used Western blot analysis to estimate the stability of each mutant protein by measuring the processing of the RT into its mature heterodimeric form, consisting of a 66-kDa subunit and a 51-kDa subunit. The resulting phenotypic data provided a "genetic" means to identify amino acid side chains that are important for protein function or stability, as well as side chains located on the protein surface. Several HIV-1 RT crystal structures were used to evaluate the mutational analysis. Our genetic map correlates well with the crystal structures. Combining our phenotype data with crystallographic data allowed us to study the genetically defined critical residues. The important functional residues are found near the enzyme active site. Many residues important for the stability of the RT participate in potential hydrogen bonding or hydrophobic interactions in the protein interior. In addition to providing a better understanding of the HIV-1 RT, this work demonstrates the utility of saturation mutagenesis to study the function, structure, and stability of proteins in general. This strategy should be useful for studying proteins for which no crystallographic data are available.

Identification and site-directed mutagenesis of the primary (2A/2B) cleavage site of the hepatitis A virus polyprotein: functional impact on the infectivity of HAV RNA transcripts

The junction between 2A and 2B proteins of the hepatitis A virus (HAV) polyprotein is processed by the virus-encoded 3C protease to liberate the precursor for capsid proteins, but details of this cleavage remain poorly defined. We identified the location of this primary cleavage by a novel approach involving expression of HAV polypeptides in eukaryotic cells via recombinant vaccinia viruses. A substrate polyprotein spanning the putative HAV 2A/2B site was fused at its C-terminus to a poliovirus VP1 reporter sequence. This substrate was cleaved efficiently in trans by protease 3C derived from another recombinant vaccinia virus expressing a 3C precursor protein. N-terminal sequencing of the 2B-poliovirus VP1 fusion product identified the site of cleavage as the Gln836/Ala837 dipeptide, 144 residues upstream of the originally predicted site. Two mutations were introduced at the P1 position of the 2A/2B site. Gln836-->Asn, and Gln836-->Arg. Asn substitution at the P1 residue reduced the efficiency of cleavage in the vaccinia expression system and resulted in a small replication focus phenotype of virus rescued from infectious HAV RNA transcripts. Arg substitution abolished cleavage and was lethal to HAV replication. In addition to identifying the site of the primary HAV polyprotein cleavage, these results shed light on the in vivo specificities of the HAV 3C protease.

An infectious cDNA clone of a cytopathic hepatitis A virus: genomic regions associated with rapid replication and cytopathic effect

Rapidly replicating, cytopathic (rr/cpe+) variants of hepatitis A virus (HAV) isolated from persistently infected BS-C-1 cells have numerous mutations from cell culture-adapted rr/cpe- HAV. To determine which mutations in one rr/cpe+ virus, HM175/18f, determine enhanced replication in BS-C-1 cells, a series of chimeric viruses was rescued from infectious cDNAs in which HM175/18f genomic segments were placed within the background of a related rr/cpe- virus, HAV/7. Chimeric viruses containing the P2 region of HM175/18f produced replication foci in BS-C-1 cells that were larger than HAV/7, but not as large as HM175/18f virus. Enhanced viral replication required mutations in both 2B and 2C proteins, suggesting that these proteins remain closely associated during replication. Mutations in 5' nontranslated RNA (5'NTR) or P3 proteins had no independent effect, but acted cooperatively with mutations in P2 proteins to enhance replication and render the virus capable of conventional plaque formation. Cytopathic effects correlated with viral replication capacity and were not the result of any single mutation. Full expression of the rr/cpe+ phenotype required mutations within the 5'NTR, P2, and P3 segments. These results suggest novel interactions between the 5'NTR and P2 proteins during HAV replication and provide useful new infectious cDNA clones.

Mutational sensitivity patterns define critical residues in the palm subdomain of the reverse transcriptase of human immunodeficiency virus type 1

We have analyzed 154 single amino acid replacement mutants within a 40 amino acid region (residues 164-203) of the reverse transcriptase (RT) from human immunodeficiency virus type 1 (HIV-1). This region consists of two antiparallel beta-strands (strands 9 and 10) flanked by two alpha helices (E and F). The structure of this region of the 'palm' subdomain is conserved in a variety of DNA and RNA polymerases, indicating a critical role in enzyme structure and function. Functional assays were performed by screening RT activity of mutants expressed in E. coli. A functionally important region corresponding closely to beta-strands 9 and 10 and the loop joining them was revealed by its mutational sensitivity. Structural analysis of mutants was performed by using Western blots to assay correct folding, which is required for processing to produce the mature p66 and p51 RT species. This analysis indicates that beta-strand 10 is a structurally important region. Combined analysis of these two assays revealed diagnostic patterns of mutational sensitivity which identify key positions in the RT sequence at which a specific amino acid side chain is critical, either for structure or function, as well as residues which are external to the RT structure. This work illustrates the utility of large-scale mutagenesis in relating primary sequence to significant features of protein structure and function.

Alcohol and aldehyde dehydrogenases in human esophagus: comparison with the stomach enzyme activities

Alcohol dehydrogenase (ADH) and aldehyde dehydrogenase (ALDH) isoenzymes from surgical esophageal and gastric mucosa were compared by agarose isoelectric focusing. Two prominent ADH forms, designated mu 1 (equivalent to the recently reported mu-form) and mu 2, were expressed in all the 15 esophagus specimens studied, whereas only four of seven examined gastric specimens exhibited a weak to moderately strong mu 1-ADH activity band on the isoelectric focusing gels. pI values of the esophageal mu 1-ADH and mu 2-ADH, and the liver pi-ADH were determined to be 8.61, 8.13, and 8.90, respectively. mu-ADHs exhibited high Km for ethanol (12 mM) and low sensitivity to 4-methylpyrazole inhibition. ALDH3 (BB form) and ALDH1 were the major high- and low-Km aldehyde dehydrogenase in the esophagus, respectively. The ADH and ALDH activities were determined at pH 7.5 to be 751 +/- 78 and 29.9 +/- 3.0 nmol/min/g tissue, respectively (measured at 500 mM ethanol or at 200 microM acetaldehyde; mean +/- SEM; N = 15). The esophageal ADH activity was approximately 4-fold and the ALDH activity 20% that of the stomach enzyme. Because the presence of high activity and high Km mu-ADHs as well as low-activity ALDH1 were found in human esophageal mucosa, it is suggested that there may exist an accumulation of intracellular acetaldehyde during alcohol ingestion. This reactive and toxic metabolite may be involved in the pathogenesis of alcohol-induced esophageal disorders.

Reconstruction of right ventricular outflow tract by autologous pericardial tri-semilunar valve with sinus of Valsalva: report of a case with absent pulmonary valve

The choice of a valved conduit or a valve in the right ventricular outflow tract remains a problem. We propose to reconstruct the pulmonary valve inside the patient's own pulmonary trunk by autologous pericardium in tri-semilunar fashion with concomitant formation of the sinus of Valsalva and commissure. This operation was carried out on a 7-year-old girl suffering from Fallot's tetralogy with an absent pulmonary valve. The ventricular septal defect was repaired and the pulmonary valve reconstructed as above. The postoperative cross-sectional echocardiogram, color Doppler echocardiogram and angiogram showed a pliable tri-semilunar valve across the pulmonary outflow tract without regurgitation. It is concluded that firstly, the sinus of Valsalva is indispensable for a stentless semilunar valve to be competent; secondly, reconstruction of the semilunar valve inside the pulmonary trunk by autologous pericardium is recommended for the absent pulmonary valve syndrome, but the long-term fate of this pericardial valve awaits further evaluation.

Growth of the aortic anastomosis in pigs. Comparison of continuous absorbable suture with nonabsorbable suture

Growth at the anastomotic site after continuous vascular anastomosis in the pediatric patient remains a problem. Primary end-to-end anastomosis of the infrarenal aorta was performed with absorbable Maxon suture or nonabsorbable Prolene suture in 20 piglets. Ten of the Maxon suture group and nine of the Prolene suture group survived; one pig died of infection. The animals were put to death 6 months after the operation. Each abdominal aorta was removed and a roentgenogram was obtained. The aorta was then burst-tested to 300 mm Hg, measured, and examined both grossly and histologically. All anastomoses were patent and no burst failures were observed in either group. However, Prolene sutures protruded into lumen and were partially embedded in the aortic wall in all animals in the Prolene suture group. Thrombus adhered to the intraluminal Prolene suture in six of nine animals. The growth of the anastomotic area was wider in the Maxon suture group (446.4% +/- 131.8% versus 317.6% +/- 121.5%, p less than 0.05). Stenosis was more common in the Prolene suture group (7/9) than in the Maxon suture group (1/10) (p less than 0.01), but the distal segment was widely patent in both groups. Dilatation at the anastomotic site was present in eight of 10 pigs in the Maxon suture group and in two of nine in the Prolene suture group. Histologic study showed that the area of tissue reaction was more prominent in the Prolene suture group. No sutures were observed in the Maxon suture group. We therefore recommend the use of absorbable Maxon sutures for anastomoses in which the suture line must be able to grow.

Determination of a functional ancestral sequence and definition of the 5' end of A-type mouse L1 elements

The complete nucleotide sequence of L1Md-A13, a 6372 base-pair (bp) member of the L1Md repetitive family isolated from a BALB/c mouse genomic DNA library, is reported. The nucleotide sequence of 4331 bp from the 5' end of L1Md-9, which is located in the beta-globin complex of the C57BL/10 mouse, is also reported. Parsimony analysis of these sequences plus two previously reported L1Md sequences allows the determination of an ancestral L1Md sequence. Analysis of the L1Md population indicates that this ancestral sequence is likely to represent a functional L1 sequence. This ancestral sequence confirms that the length (1137 bp and 3900 bp) and relationship (14 bp overlap) of the two large open reading frames previously reported are conserved features of the L1Md family. It also allows the determination of an ancestral amino acid sequence for these two open reading frames. Full-length L1Md elements have one of two sequences tandemly repeated at the 5' end. These two monomers are called A-type and F-type. Our data define the 5' end of A-type full-length L1Md elements. L1Md elements of the A-type have varying numbers of tandemly repeated 208 bp monomers, but each element ends about 78 bp from the 5' end of the terminal 208 bp monomer.

Genomic heterogeneity among human and nonhuman strains of hepatitis A virus

Cloned cDNA probes derived from the P1 and P2 regions of the genome of HM175 virus, a reference strain of human hepatitis A virus (HAV), failed to hybridize under standard stringency criteria with RNA from PA21 and PA33 viruses, two epizootiologically related HAV strains recovered from naturally infected New World owl monkeys. Hybridization of these probes to PA21 RNA was only evident under reduced stringency conditions. However, cDNA representing the 5' nontranslated region of the HM175 genome hybridized equally to HM175 and PA21 RNA under standard stringency conditions, while a probe derived from the 3' 1,400 bases of the genome yielded a reduced hybridization signal with PA21 RNA. In contrast, no differences could be discerned between HM175 virus and three other HAV strains of human origin (GR8, LV374, and MS1) in any region of the genome, unless increased stringency conditions were used. These results suggest that PA21 and PA33 are unique among HAV isolates and may represent a virus native to the owl monkey. Despite extremely poor homology within the P1 region, which encodes capsid polypeptides, monoclonal antibody analysis confirmed that the immunodominant neutralization epitopes of HAV were highly conserved between HM175 and PA21 viruses. Furthermore, experimental challenge of the owl monkey with successive PA33 and HM175 inocula confirmed a high but incomplete degree of cross-protection. Only one of six monkeys previously infected with PA33 developed recurrent hepatitis 28 days after intravenous HM175 challenge, while none of six monkeys previously infected with HM175 had demonstrable hepatitis following PA33 challenge. These data provide molecular evidence for the existence of HAV strains unique to nonhuman primate species and indicate that strict conservation of antigenic function may accompany substantial genetic divergence in HAV.

Transposition of a long member of the L1 major interspersed DNA family into the mouse beta globin gene locus

A long member of the highly repeated long interspersed DNA family L1Md (for L1 in Mus domesticus) has integrated by transposition into a target site which lies between the two adult beta globin genes of mouse. DNA hybridization and nucleotide sequence analysis show that this target site, which is part of the single copy DNA flanking the globin genes, is interrupted by the L1 element in one chromosome but is uninterrupted in both allelic and ancestral chromosomes. Other large DNA rearrangements of the region between the two adult beta globin genes are also associated with these allelic chromosomes, and include insertions or deletions of both single copy DNA and simple and complex repetitive DNA. This has caused extensive reorganization of this intergenic region. However, the distance between the two genes flanking this region remains conserved, suggesting that the spacing of the globin genes may be subject to conservative selection.