[Show abstract][Hide abstract] ABSTRACT: OBJECTIVE: This longitudinal study of American veterans investigated the mortality risks of five World War II military experiences (i.e., combat exposure) and their variation among veterans in the post-war years. METHODS: The male subjects (N=854) are members of the Stanford-Terman study, and 38 percent served in World War II. Cox models (proportional hazards regressions) compared the relative mortality risk associated with each military experience. RESULTS: Overseas duty, service in the Pacific and exposure to combat significantly increased the mortality risks of veterans in the study. Individual differences in education, mental health in 1950, and age at entry into the military, as well as personality factors made no difference in these results. CONCLUSIONS: A gradient is observable such that active duty on the home front, followed by overseas duty, service in the Pacific, and combat exposure markedly increased the risk of relatively early mortality. Potential linking mechanisms include heavy drinking.
Full-text · Article · Jul 2009 · Research on Aging
[Show abstract][Hide abstract] ABSTRACT: Chronic hepatitis C (CHC) is the most common blood-borne infection in the United States, but little is known about illness uncertainty in these patients.
The authors examined the constructs of illness uncertainty.
In this cross-sectional study, Mishel's Uncertainty in Illness Scale was used to examine these constructs (ambiguity, complexity, inconsistency, unpredictability) and their relationships with fatigue, pain, depressive symptoms, comorbidity, and quality of life (QOL) in 126 CHC patients undergoing a watchful-waiting protocol.
The Ambiguity subscale had the strongest relationships with depressive symptoms, QOL, and fatigue, and three of the four subscales were significantly correlated with pain.
The results suggest targets for patient self-management interventions.
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND:: With the increase in the number of older adults with dementia, research efforts have focused on increasing community-based support service (CBSS) use to improve older adult and caregiver outcomes. However, the research on factors that may explain CBSS use has been focused on individual characteristics, and how the care recipient and caregiver as a pair influence CBSS use has not been accounted for. OBJECTIVE:: To classify care recipients with dementia and their caregivers who shared similar patterns of CBSS use and to identify predictors of class membership. METHODS:: Participants were 1,813 elders with dementia and their caregivers from the National Longitudinal Caregiver Study, a cross-sectional dataset from 1998. A latent class analysis was used to identify classes of CBSS users by examining use of caregiver support group, home aide, home health, adult day care, and respite care. Multinomial logistic regression analysis was used to examine relationships between predisposing, enabling, and need variables and class membership. RESULTS:: Three classes, that is, Low Users, Adult Day Users, and Home-Based Users, comprised 80%, 10%, and 10% of the sample, respectively. Adult Day Users reported significantly more enabling resources and greater service need. Predictors of home-based use included care recipient age, activities of daily living limitations, number of skilled nursing facilities in the local county, and the extent of caregiver physical limitations from comorbid conditions. DISCUSSION:: Using latent class analysis allows identification of specific subtypes of CBSS users, prevalence of user subtype, and risk factors for underutilization. Determining the long-term outcomes of class membership may identify specific groups at risk, which could inform the design of interventions to improve assessment for and delivery of CBSS.
No preview · Article · Nov 2008 · Nursing research
[Show abstract][Hide abstract] ABSTRACT: PURPOSE: Despite a recent increase in attention toward improved care of the dying, we know surprisingly little about what participants in the process value at the end of life.METHODS: We conducted a national survey of seriously-ill patients, recently bereaved family members, physicians and non-physician providers (nurses, social workers, chaplains and hospice volunteers). Health care providers were recruited from national professional associations (American College of Physicians, American Nurses Association, Association of Professional Chaplains and National Hospice Volunteers). Patients were recruited from national samples of those who had received in-patient care at VA hospitals within the last year; family members were recently (within 1 year) bereaved relatives of former VA patients. 500 surveys were mailed to each of the four groups. Respondents were asked to rate and rank the importance of various attributes of the quality of dying that had been generated previously in focus groups and in-depth interviews.RESULTS: 75% of patients, 70% of family members, 74% of physicians and 87% of non-physician providers returned completed questionnaires (N = 1642). 51% of sample respondents were male; 81% were Caucasian, 7% were African-American; 55% were Protestant, 23% were Roman Catholic and 7% were Jewish. Respondents gave uniformly strong agreement to the importance of pain and symptom control, presence of family, feeling prepared to die, saying goodbye, being treated as a whole person, and trusting one's doctor. In each instance, more than 80% of all groups either agreed or strongly agreed with the importance of the attribute. However, we found broad variation between groups in the importance of use of technology, dying at home, not being a burden, contributing to others, and a range of spirituality issues. For example, 50% of sample respondents agreed or strongly agreed with the importance of dying at home; however, an equal portion of the sample either disagreed or neither agreed nor disagreed with the importance of dying at home. Among ranked items, "freedom from pain" and "coming to peace with God" were most often ranked first or second in importance (on a scale or 1–9). For patients, these two items were considered nearly identical; mean rank scores differed by a value of .02. Physicians made a stronger distinction in importance with mean rank scores differing by 2.46. Dying at home was most often ranked least important.CONCLUSION: Patients, family members and health care providers all construct the quality of the experience at the end of life. To improve care of the dying, we would benefit from an empirically-based understanding of the similarities and differences in what those various participants value.
Full-text · Article · Oct 2008 · Journal of General Internal Medicine
[Show abstract][Hide abstract] ABSTRACT: To determine whether elderly people who meet national guidelines have higher physical function (PF) scores than those who do not and the effect on functional trajectory when physical activity (PA) levels change from above to below this threshold, or vice versa.
Two 6-month randomized controlled trials aimed at increasing PA in adults.
Adults aged 65 to 94 (N=357).
PA counseling over the telephone and through mailed materials.
Self-reported PA dichotomized at 150 minutes/week and PF using the Medical Outcomes Study 36-item Short Form Questionnaire PF subscale.
At baseline, individuals reporting 150 minutes or more of moderate PA/week had mean PF scores that were 20.3 points higher than those who did not (P<.001). Change in PA minutes from above threshold to below threshold or from below threshold to above threshold from baseline to 6 months resulted in an average change in PF of -11.18 (P<.001) and +5.10 (P=.05), respectively.
These findings suggest that PA is an important predictor of functional status. Older sedentary adults can improve PF by meeting recommended PA levels. Conversely, dropping below recommended PA levels has a deleterious effect on PF. Given the importance of PF in maintenance of independence and quality of life in older adults, adherence to recommended PA guidelines should be endorsed.
Full-text · Article · Oct 2008 · Journal of the American Geriatrics Society
[Show abstract][Hide abstract] ABSTRACT: The purpose of the present study was to examine the regularity of preventive care for persons with diabetes in the Nord-Trøndelag Health Study to identify associated demographic, lifestyle, and disease-related factors. Among 1,972 persons with diabetes, 1,459 (74%) answered questions related to preventive foot care. The final sample included 1,312 persons with known diabetes, but without a self-reported history of foot ulcer. Almost 85% reported receiving regular clinical diabetes examinations, 31.7% reported regular foot inspection by health care personnel, and 66.3% reported foot self-inspection. Only 58.8% reported regular clinical diabetes examination combined with foot inspection. Males, patients not using insulin, and those with shorter diabetes duration or macrovascular complications were more likely to report less regular preventive care.
No preview · Article · Jun 2008 · Research in Nursing & Health
[Show abstract][Hide abstract] ABSTRACT: To advance the understanding of health-related quality of life among older nursing home residents by assessing their health-related quality of life and comparing this with norms from the general population.
The study used a two-group cross-sectional comparative design. The samples comprised 227 nursing home residents aged 65-102 years with at least six months' residence and a representative population sample of 1137 Norwegian citizens aged 65-102 years. All nursing home residents had a Clinical Dementia Rating Scale score > or =0.5 and were capable of conversing. The respondents provided demographic information and were surveyed using the SF-36 Health Survey. We used univariate and multivariate linear models to identify possible differences in health-related quality of life between the nursing home residents and the general population, controlled for age, sex, marital status and education.
After adjustment for age, group, sex, marital status and education, the nursing home residents scored significantly higher on bodily pain and on physical and emotional role limitation and significantly lower on the other SF-36 subscales, except social functioning, with the largest differences for physical functioning (mean nursing home 23.2 and mean general population 62.9). The general population scores on all subscales generally increased with increasing education but not among the nursing home residents.
The mean SF-36 scale scores differed markedly between the nursing home residents and the general population, with the nursing home residents generally scoring lower. The association with background variables known to be related to health-related quality of life differed between the groups. Healthcare professionals should increase attention to health-related quality of life among nursing home residents, periodically assess health-related quality of life and consider interventions that may improve health-related quality of life in older institutionalised populations.
This study highlights the role of nurses and other health professionals in ensuring that nursing home residents have opportunities to improve their health-related quality of life.
No preview · Article · May 2008 · Journal of Clinical Nursing
[Show abstract][Hide abstract] ABSTRACT: The manuscript examines the influence of contextual factors on whether and for whom a colon polyp diagnosis might be a teachable moment, as indicated by engagement with a proactively delivered intervention. Baseline and 8-month follow-up data were analyzed from a two-site behavioral intervention trial with patients in Massachusetts and North Carolina, USA who had recently undergone polypectomy for pre-cancerous colon polyps and were randomized to a behavior change intervention condition (N=591). Intervention "buy-in" was used as an indicator of response consistent with the polyp identification serving as a teachable moment. Cancer worry, personal risk, health-related self-identity and other sociodemographic factors were tested to predict intervention buy-in. As predicted, those who were most worried about colon cancer were most likely to engage in the intervention. One indicator of personal risk, number of risk behaviors, was significantly and negatively associated with buy-in. Predictors of intervention buy-in and cancer worry were not consistent. We recommend that expanded measures of affect and health-related self-identity should be considered in future research to understand the motivational potential of health events for increasing engagement in effective behavior change interventions.
Preview · Article · Mar 2008 · Social Science & Medicine
[Show abstract][Hide abstract] ABSTRACT: To estimate the proportion of seniors with dementia from three independent data sources and their agreement.
The longitudinal Asset and Health Dynamics among the Oldest Old (AHEAD) study (n=7,974), Medicare claims, and death certificate data.
Estimates of the proportion of individuals with dementia from: (1) self- or proxy-reported cognitive status measures from surveys, (2) Medicare claims, and (3) death certificates. Agreement using Cohen's kappa; multivariate logistic regression.
The proportion varied substantially among the data sources. Agreement was poor (kappa: 0.14-0.46 depending upon comparison assessed); the individuals identified had relatively modest overlap.
Estimates of dementia occurrence based on cognitive status measures from three independent data sources were not interchangeable. Further validation of these sources is needed. Caution should be used if policy is based on only one data source.
Full-text · Article · Mar 2008 · Health Services Research
[Show abstract][Hide abstract] ABSTRACT: To use an innovative statistical method, Latent Class Trajectory Analysis (LCTA), to identify and describe subgroups (called trajectories) of caregiver depressive symptoms in a national sample of wives providing informal care for their husbands with dementia.
Respondents to the National Longitudinal Caregiver Survey were wife caregivers of veterans with dementia who were identified through Veterans Affairs hospitals nationally.
Mean number of depressive symptoms as measured using the Center for Epidemiologic Studies Depression scale (CES-D, 20-item scale).
Overall mean depressive symptoms of wife caregivers were 6.2 of 20, below the cutpoint (8 or 9/20) associated with clinical depression. Four distinct trajectories of caregiver depressive symptoms were identified. The trajectory with the highest number of symptoms (11.9 of 20), contained one-third of the sample. Another third had mean depressive symptoms virtually identical to the overall sample mean. The final third were divided between two trajectories, low depressive symptoms (mean CES-D, 3.0/20, 22% of sample) and very low (mean CES-D, 0.8/20, 14% of sample). Approximately two-thirds of the sample members were in a depressive symptom trajectory, with substantially higher or lower numbers of symptoms than the overall mean. Two subjective measures asked of wife caregivers (desire for more help, life satisfaction) were significantly associated with membership in the highest depressive symptom trajectory.
LCTA identified important depressive symptom subgroups of wife caregivers. A population-averaging method identified a mean effect that was similar to the effect in one-third of the cases but substantially different from that in two-thirds of the cases.
Preview · Article · Mar 2008 · Journal of the American Geriatrics Society
[Show abstract][Hide abstract] ABSTRACT: A large body of evidence suggests that being diagnosed with and treated for cancer adversely affects functioning and quality of life, yet less is known about longer term outcomes. Therefore, this study aims to estimate the prevalence of post-traumatic stress disorder (PTSD) symptoms in survivors of adult non-Hodgkin's lymphoma (NHL) who are at least 2 years postdiagnosis and identify the risk factors associated with PTSD symptoms, with a focus on those that are amenable for screening and modifiable.
A total of 886 NHL survivors identified from the cancer registries of two hospitals in North Carolina participated, ranging in age from 25 to 92 years old and ranging from 2 to 44 years postdiagnosis. Survivors were mailed a survey that assessed PTSD symptoms and quality of life.
Participants averaged 10.2 years postdiagnosis, and most (61%) reported no PTSD symptoms. The adjusted prevalence for full PTSD was 7.9%, with an additional 9.1% meeting criteria for partial PTSD. Modifiable risk factors that were independently associated with PTSD in multiple linear regression included less social support, negative appraisals of life threat and treatment intensity, and more employment and insurance issues. Additionally, several demographic characteristics (nonwhite race, less education, and younger age) and clinical or health-related factors (active disease, more recent diagnosis, and more comorbidity) were independently associated with PTSD.
Although only 8% of survivors met PTSD diagnostic criteria, the impact of a cancer diagnosis and treatment persists for many survivors, as evidenced in 39% of this sample. Early identification of those at risk could enable treatment to minimize PTSD symptomatology.
Full-text · Article · Mar 2008 · Journal of Clinical Oncology
[Show abstract][Hide abstract] ABSTRACT: To determine childhood cancer survivors' barriers to increasing exercise and consuming less fat and more fruits and vegetables, whole grains, and calcium-rich foods.
Cases from a comprehensive cancer center.
Convenience sample of 144 childhood cancer survivors aged 13-35 years identified through previous research. Surveys were returned by 118 participants (82% response rate).
Descriptive statistics with chi-square tests were performed between subgroups defined by age (< 18 years and < or = 18 years) and diagnosis (leukemia, lymphoma, and central nervous system cancers).
Barriers to exercise, consuming less fat, and eating more fruits and vegetables, whole grains, and calcium-rich foods.
Proportionately more childhood cancer survivors reported barriers to exercise and following a low-fat diet than to consuming more fruits and vegetables, whole grains, and calcium-rich foods. Primary barriers to exercise included being too tired (57%), being too busy (53%), and not belonging to a gym (48%), whereas barriers for restricting high-fat foods were commercials that make high-fat foods look so appealing (58%) and having friends who eat a lot of high-fat foods (50%). Difficulty associated with ordering healthy foods when dining out also was a leading barrier to following a low-fat diet (50%), as well as eating more whole grains (31%), fruits and vegetables (30%), and calcium-rich foods (15%).
Childhood cancer survivors report several barriers to exercise and consuming a low-fat diet with more fruits and vegetables, whole grains, and calcium-rich foods.
This study's findings may be helpful to nurses, health educators, and allied health professionals in developing effective interventions that promote healthful lifestyle change among childhood cancer survivors.
Full-text · Article · Jan 2008 · Oncology Nursing Forum
[Show abstract][Hide abstract] ABSTRACT: To determine the proportion of people with diabetes mellitus reporting a history of foot ulcer and to investigate factors associated with this adverse outcome.
All inhabitants aged 20 years and older residing in a large geographic region were invited to participate in the Nord-Trøndelag Health Study, 71% (n=65,604) attended. Those reporting diabetes (n=1,972) were invited to take part in an ancillary study on diabetes. Based on 1,494 responses to the question: "Have you had a foot ulcer that required more than three weeks to heal'', the proportion with a history of foot ulcer was estimated.
The overall proportion with a history of foot ulcer was 10.4% (95% CI 8.8-11.9%). In the final multivariate logistic regression model, significant factors for a foot ulcer history included age > or =75 years (OR 1.8, 95% CI 1.2-2.8), height (men>175 cm, women>161 cm) (1.9, 95% CI 1.3-2.8), gender (male) (1.5, 95% CI 1.03-2.2), using insulin (1.6, 95% CI 1.1-2.4), and macrovascular complications (1.8, 95% CI 1.2-2.6).
The proportion of people reporting a history of foot ulcer in this population-based study exceeded the proportion of foot ulcer history reported previously. Height as a correlate has been occasionally reported in previous studies and needs further attention. Associated factors for a foot ulcer history help identify individuals who may be at particular risk of this adverse outcome.
Full-text · Article · Jan 2008 · Scandinavian Journal of Public Health
[Show abstract][Hide abstract] ABSTRACT: The objective of the study was to determine whether spousal caregiving and bereavement increases caregiver depressive symptoms. We followed 1,967 community-dwelling elderly couples from the 1993 Health and Retirement Study (HRS) until 2002 (five bi-annual surveys) or death. Depressive symptoms were measured by the Center for Epidemiological Studies-Depression (CESD) scale. Adjusted depressive symptoms were higher for females for three of the four caregiving arrangements tested (as were unadjusted baseline levels). Depressive symptoms were lowest when neither spouse received caregiving (adjusted CESD of 2.97 for males; 3.44 for females, p<0.001). They were highest when females provided care to their husband with assistance from another caregiver, (4.01) compared to (3.37; p<0.001) when males so cared for their wife. A gender by caregiving arrangements interaction was not significant (p=0.13), showing no differential effect of caregiving on CESD by gender. Depressive symptoms peaked for bereaved spouses within three months of spousal death (4.67; p<0.001) but declined steadily to 2.75 (p<0.001) more than 15 months after death. Depressive symptoms initially increased for the community spouse after institutionalization of the care recipient, but later declined. We conclude that caregiving increases depressive symptoms in the caregiver, but does not have a differential effect by gender. Increases in depressive symptoms following bereavement are short-term.
Full-text · Article · Jan 2008 · Aging and Mental Health
[Show abstract][Hide abstract] ABSTRACT: To utilize the Diet Quality Index-Revised (DQI-R) as a framework for delivering and evaluating an intervention to improve overall diet quality among older cancer survivors.
As part of a randomized controlled trial to improve lifestyle behaviors among older cancer survivors, we sought a dietary measure that could serve as both an intervention framework and a means to evaluate global dietary quality. The DQI-R measures overall diet quality by summing 10 subscales that relate to national guidelines. At baseline, DQI-R scores were generated from three multi-pass 24-hour dietary recalls. The 6-month intervention delivered tailored feedback on individual DQI-R subscales. Dietary recalls were repeated at 6 and 12 months.
Elderly (aged >or=65 years) individuals within 18 months of diagnosis of breast or prostate cancer (n=182) were randomized postbaseline measures to intervention vs attention control arms.
Significant differences in overall diet quality were observed between arms at 6 months, with the intervention arm improving (67.6+/-12.2 to 69.8+/-13.9), and controls declining (67.5+/-12.5 to 64.6+/-14.7) (P=0.003). Significant differences were observed between arms over time in dietary diversity subscale scores: baseline and 6-month follow-up means among intervention and control arms were 4.8+/-1.3 to 4.8+/-1.4, and 4.7+/-1.2 to 4.1+/-1.1, respectively (P=0.001).
The DQI-R served as an effective guide and evaluation tool for this diet-related randomized controlled trial. Like many interventions, our effect diminished after the intervention was complete. Future research should consider testing interventions that use the DQI-R, or other global diet-related indexes, as guides and evaluation tools over longer study periods, as well as in other populations.
No preview · Article · Oct 2007 · Journal of the American Dietetic Association
[Show abstract][Hide abstract] ABSTRACT: To describe two versions of a new measure, The Quality of Dying in Long-Term Care, for postdeath administration to surrogate respondents (staff and family caregivers) of all decedents (QOD-LTC) and of cognitively intact decedents (QOD-LTC-C) who die in nursing homes (NHs) and residential care or assisted living (RC/AL) facilities.
Using two levels of exploratory factor analysis, 15 candidate items for the QOD-LTC and 36 candidate items for the QOD-LTC-C were tested using multiple criteria to determine factor structure and interpretability of the quality of dying in long-term care (LTC).
One hundred seventeen RC/AL facilities and 31 NHs in FL, MD, NC, and NJ.
Family (n=439) and staff (n=332) caregivers of 633 decedents from a stratified random sample from RC/AL facilities and NHs in four states.
Trained interviewers asked respondents to rate statements describing potentially important aspects of the quality of dying using a 5-point Likert scale. The scale items were analyzed using exploratory factor analysis with communalities set to unity using a Promax rotation.
The 11-item QOD-LTC (alpha=0.66), appropriate for surrogate respondents for all decedents, consists of three domains (personhood, closure, preparatory tasks). The 23-item instrument for surrogate respondents of cognitively intact decedents, the QOD-LTC-C (alpha=0.85), consists of five domains (sense of purpose, closure, control, social connection, preparatory tasks).
The QOD-LTC and QOD-LTC-C are psychometrically acceptable measures of the quality of the dying experience, developed for and tested in LTC settings. Use of these measures can increase understanding of the dying experience in LTC.
No preview · Article · Oct 2007 · Journal of the American Geriatrics Society
[Show abstract][Hide abstract] ABSTRACT: Cancer survivors are at increased risk for cardiovascular disease, diabetes, osteoporosis, and second primary tumors. Healthful lifestyle practices may improve the health and well-being of survivors. The FRESH START trial tested the efficacy of sequentially tailored versus standardized mailed materials on improving cancer survivors' diet and exercise behaviors.
Five hundred forty-three individuals with newly diagnosed locoregional breast or prostate cancer were recruited from 39 states and two provinces within North America. Participants were randomly assigned either to a 10-month program of tailored mailed print materials promoting fruit and vegetable (F&V) consumption, reducing total/saturated fat intake, and/or increasing exercise or to a 10-month program of nontailored mailed materials on diet and exercise available in the public domain. Telephone surveys conducted at baseline and 1 year assessed body mass index (BMI), dietary consumption, physical activity, and other psychosocial/behavioral indices. Clinical assessments were conducted on a 23% subsample; information was used to validate self-reports.
Five hundred nineteen participants completed the 1-year follow-up (4.4% attrition; sample characteristics: 57 +/- 10.8 years old, 83% white, 56% female, 64% overweight/obese, and 0% underweight). Although both arms significantly improved their lifestyle behaviors (P < .05), significantly greater gains occurred in the FRESH START intervention versus the control arm (practice of two or more goal behaviors: +34% v +18%, P < .0001; exercise minutes per week: +59.3 v +39.2 minutes, P = .02; F&V per day: +1.1 v +0.6 servings, P = .01; total fat: -4.4% v -2.1%, P < .0001; saturated fat: -1.3% v -0.3%, P < .0001; and BMI: -0.3 v +0.1 kg/m2, respectively, P = .004).
Mailed material interventions, especially those that are tailored, are effective in promoting healthful lifestyle changes among cancer survivors. Further study is needed to determine sustainability, cost to benefit, and generalizability to other cancer populations.
[Show abstract][Hide abstract] ABSTRACT: This study examines extent of agreement between oncologists' and cancer patients' reports of current cancer status. Participants with history of cancer were given a comprehensive geriatric assessment in which they were asked whether they had cancer at the present time. This was compared to cancer status concurrently recorded by their physicians in the chart. 75.5% of patients whose physicians reported 'no evidence of disease' (NED) reported that they currently had cancer. 30% of them were anxious and 27% were depressed. Among patients for whom both the patient and physician reported no cancer, only 12.5% were anxious and 7% depressed. Compared to patients with concordant responses, those who discrepantly reported they had cancer had significantly more comorbid illnesses, medications, and pain, and lower levels of social, emotional, and physical functioning. Moreover, equal levels of distress and dysfunction were found between those who reported cancer but had NED and those who reported cancer and did have active disease by physician notation. Although conclusions about cause and effect are limited due to study design, findings suggest that some patients might suffer unnecessarily from lack of understanding about current disease status. These findings also suggest the need for improved physician-patient communication and symptom recognition/management.
[Show abstract][Hide abstract] ABSTRACT: Although providing informal care can negatively affect caregiver emotional health and lead to depression, the association
between caregiver depression and missed work is unknown. We use data from the National Longitudinal Caregiver Survey to examine
the relationship between caregiver depression and missed work among informal caregivers for older veterans with Alzheimer’s
disease or vascular dementia. Two-part models are used to estimate the expected hours of work missed among working caregivers.
Caregiver depression is statistically significantly associated with the likelihood and amount of time missed at work, resulting
in an average of an extra half-day of work missed per month. While the effect of caregiver depression on work missed is modest,
it represents another possible benefit from interventions to support caregivers.
No preview · Article · Feb 2007 · Journal of Family and Economic Issues