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Changes over time in emotional status among older adults new to receiving long-term services and supports.

Approximately 70 percent of individuals aged sixty-five or older will need long-term services and supports (LTSS) during their lifetime (Lustig & Olson, 2014). Currently, six million older adults in the United States receive LTSS primarily in one of three settings: at home via home- and community-based services (HCBS), in assisted living facilities, or in nursing homes (Kaye, Harrington, & LaPlante, 2010). Long-term services and supports serves individuals who have limited ability to perform routine daily activities, such as bathing or dressing, and are provided in their own homes, assisted living facilities, and nursing homes. By 2050, the number of older adults in the United States is projected to be 83.7 million, almost double its 2012 population of 43.1 million (Ortman, Velkoff, & Hogan, 2014). The increase is a result of the combination of general growth in the older adult population and advances in medical science and technology that have substantially increased the life span (McLaughlin, Connell, Heeringa, Li, & Roberts, 2010). This projected growth, in combination with the increased life span of older adults with chronic diseases and disabilities, is expected to create a demand for LTSS that the United States is unprepared to meet (Vincent & Velkoff, 2010). To date, LTSS has been characterized by the rapid growth of fragmented and costly health, housing, and social support systems, resulting in substantial and persistent concerns about quality (Institute of Medicine, 2008). For older adults receiving LTSS, maintaining functional abilities and a good quality of life (QoL) is a primary goal; however current LTSS quality measures rarely capture these outcomes (Kaye, 2014).

Emotional Status

A recently expanded health-related quality of life (HRQoL) conceptual model for LTSS addresses the quality gap by providing a framework to measure multiple dimensions of quality that capture outcomes that are important to older adults (Zubritsky et al., 2012). In this new HRQoL model for LTSS, the domain of emotional status has been expanded beyond a single measure of mental status by diagnosis, such as depression, to include a broader view that includes emotional well-being. Emotional status can be characterized by a range of emotional states from positive mental health, evidenced by a sense of well-being and positive affect and stable mental health (Bryant et al., 2005), to unstable, poor mental health evidenced by depression (Fiske, Wetherell, & Gatz, 2009). This broader conceptualization of emotional status captures characteristics such as resiliency and strength--traits that are key characteristics of emotional well-being (Charles, 2010) and are more often found in older adults than in the general adult population. Although the importance of the emotional status of older adults has frequently been cited as a priority for national programs (U.S. Department of Health and Human Services, 2011) few studies have assessed emotional status broadly, capturing both depressive symptoms and emotional well-being and their relationship to HRQoL among older adults transitioning into LTSS.

Emotional Well-being

Emotional well-being is an individual's subjective appraisal that life as a whole is good; key aspects include individual health, freedom from disability, stable life satisfaction, and positive affect and morale (George, 2010). Although emotional well-being tends to be stable over the life course, studies suggest that overall well-being increases with age (Charles, 2010). Happiness is a common outcome measure employed in studies of subjective well-being (Theurer & Wister, 2010). Studies have shown that older American adults are happy and that older men tend to report higher levels of happiness (George, 2010). We use the term emotional well-being in this article as a proxy for individual happiness.

Depression

Depression is experienced by 15 to 20 percent of community-dwelling adults sixty-five and older (Mitchell, Vaze, & Rao, 2009). In spite of these high rates of depression, older adults have traditionally not engaged in mental health treatment (Fiske et al., 2009). Prevalence rates of under-detection of depression among people living in the community ranges between 35 to 50 percent (Baik, Bowers, Oakley, & Susman, 2005). Men between the ages of sixty-five and seventy-four and all individuals eighty-five and older are at the greatest risk for under-detection of depression (Mitchell et al., 2009). The consequences of under-detected and undiagnosed depression are serious and have been associated with increased mortality, suicide, comorbidity, complicating treatment and outcomes, decreased QoL, increased health services utilization, and increased health care costs (Vogeli et al., 2007).

Other Factors Affecting Emotional Status

Functional and cognitive impairments, commonly found in older adult populations, are one of the strongest predictors of a person's entry into LTSS (Gaugler, Duval, Anderson, & Kane, 2007); 50 percent of people receiving LTSS have cognitive impairments (Tilly, Wiener, & O'Keeffe, 2011). These impairments affect physical health and emotional status, can be predictive of the development of major depression, and have been found to be a risk factor for the progression of comorbid conditions (Bruce, 2001). When medical illness causes a new decrement in function, older adults' risk for major depression increases so that depressive symptoms and disability measures change synchronously over time; as depression improves, so do measures of functional impairment (Schillerstrom, Royall, & Palmer, 2008).

This naturalistic observational study was designed to address the existing gap in knowledge of how the emotional status of older adults changes over time following entry into LTSS. We will address the following research questions: (1) How does emotional status, specifically well-being and depression, change over time? and (2) What HRQoL characteristics predict better emotional status over time?

Methods

Design

This study was part of a person-centered longitudinal investigation of changes in multiple domains of HRQoL among older adults new to receiving LTSS. Data for this study were generated during quarterly interviews (baseline through twenty-four months) conducted with newly enrolled older adults receiving LTSS. Institutional review boards reviewed and approved this study for their respective sites.

Participant Eligibility

The study was conducted in Philadelphia and New York. Eligible subjects were age sixty or older, could communicate in either English or Spanish, had a mini-mental state examination (MMSE; Folstein, Folstein, & McHugh, 1975) score of 12 or higher, and had begun to receive LTSS within the sixty days preceding the baseline interview. Volunteer staff members from each participating site identified potential subjects new to their organization upon entry and referred them to the HRQoL study team members via secure methods. Trained research assistants approached potential participants, explained the study, and administered the MMSE. Individuals scoring 23 or higher on the MMSE were eligible for the study, and informed consent was obtained from those willing to participate. For individuals who scored between 12 and 22 on the MMSE and agreed to participate, a legally authorized representative was contacted, the study explained, and written consent obtained.

Persons ineligible for enrollment included individuals with severe cognitive impairment (MMSE < 12), active impairment of perceptions of reality (including hallucinations, delusions, and paranoia as documented in the medical record), planned short-term or prior LTSS experience, or a prognosis of living six months or less (as documented in their medical record or evidenced by active enrollment in hospice services).

All eligible referrals were provided with a brochure in Spanish or English that explained the purpose of the study and recruitment eligibility.

Participant Recruitment and Retention over Twenty-four Months

A total of 1,311 older adults were referred by partnering agencies; 37 percent (480/1,311) were not eligible due to severe cognitive impairment and/or prior LTSS experience. Of the remaining eligible referrals, 37 percent (308/831) declined to participate (lack of interest and/or time to participate), and 6 percent (48/831) did not have a legally authorized representative to cosign the informed consent and therefore could not be enrolled. Between March 2007 and July 2010, 475 older adults were enrolled. Five individuals at one site were dropped post-enrollment for administrative reasons (see Table 1).The final sample comprised 470 older adults (HCBS: n = 156; assisted living facility: n = 156; nursing home: n = 158).

At the end of the two-year time period, 21 percent of the sample (98/470) had died and 7 percent (35/470) withdrew from follow-up interviews; the sample at the completion of data collection was 337. The biggest data collection challenge resulted from individuals missing scheduled interviews for various reasons (e.g., individuals moved to a new location, declined the interview, or had other health appointments); some missed the interview window of thirty days prior to or following the interview date (6%-16%). Approximately 1 percent were hospitalized at the time of their three-month interview. When possible, when a participant interview was missed, additional data were collected through chart review or via proxy if the LTSS recipient scored less than 12 on the MMSE.

Measures

A comprehensive assessment of HRQoL, developed, tested, and refined in a series of earlier pilot studies, included both objective measures of health status and more subjective perceptions of health and quality of life such as cognitive status, symptom status, functional status, social support, general health, well-being, and perceived QoL. Demographic information that was collected included gender, marital status, race (white/non-white), ethnicity (Hispanic/not Hispanic), income level, age (continuous), and education (continuous).

Emotional Status

The dependent variables used to measure emotional status included the Geriatric Depression Scale Short Form (GDS-SF; Brink et al., 1982) and the Medical Outcomes Study (MOS) Short Form (SF-12 version 2) Mental Health Composite Score (SF12 MCS). The GDS-SF assesses the presence and severity of depression and has demonstrated validity and reliability for measuring depression in institutionalized older adults (Burke, Nitcher, Roccaforte, & Wengel, 1992) or older adults with cognitive impairment (Parmelee, Katz, & Lawton, 1989). Scores range from 0 to 15 and scores of 5 or more indicate that depressive symptoms are present, with higher scores signifying greater depressive symptoms. The MOS SF-12 version 2 MCS (SF12 MCS) comprises a subset of items from the SF-36, which measures emotional well-being; higher scores indicate better overall health. The study used the acute version of the MCS, which rated mental health status during the past week. Scores are weighted and summed so that general population scores have a mean of 50 and a standard deviation of 10 (Ware, Kosinski, Turner-Bowker, & Gandek, 2002). The SF-12 has been effectively used to predict mental health status in multiple chronic diseases, such as diabetes (Ciechanowski, Katon, & Russo, 2000), mental illness (Salyers, Bosworth, Swanson, Lamb-Pagone, & Osher, 2000), and cardiovascular disease (Muller-Nordhorn, Roll, & Willich, 2004).

Cognitive Status

The MMSE (Folstein et al., 1975), which was used to measure cognitive function, is widely used to measure orientation to time and place, recall ability, short-term memory, and arithmetic ability in older adults. The MMSE total score ranges from 0 to 30 and reflects the number of correct responses. Lower MMSE scores indicate greater cognitive impairment.

Functional Status

Basic activities of daily living (BADL) were measured on a six-item scale (Katz, 1983); higher scores indicate fewer functional deficits (range 0-6). For older adults with cognitive impairment (MMSE < 23), certified nurse assistants (CNAs) and usual caregivers (family members or home health aides) provided BADL data when necessary. The scores reported are a combination of a self-report for cognitively capable individuals and a proxy report for individuals with cognitive impairment.

Symptom Status

Symptom status was measured using the thirteen-item Symptom Bother Scale (SBS) (Heidrich & Ryff, 1993). Participants were asked if they had any of thirteen symptoms and how bothersome the symptom had been over the past two weeks. A summary score was created for the total number of symptoms (range 0-13).

Social Support

The Social Support Survey was developed to measure social support for the MOS (Stewart, Hays, & Ware, 1988). Four subscales--affection, emotional/ informational, tangible, and positive social interaction--were utilized to capture perceived social support on a five-point Likert scale; higher subscale scores indicated greater feelings of social support.

Physical Health

The MOS SF-12 version 2 Physical Composite Score (PCS), a subset of the SF-36 (Ware, Kosinski, Dewey, & Gandek, 2000), was used to assess overall physical health status. Additional health and utilization data were extracted from medical records and included the total number of: chronic conditions, hospitalizations, and emergency department visits and days of hospice use in the past three months.

Perceived Rating of Quality of Life

The Dementia Quality of Life (D-QoL) scale was used to measure QoL for all individuals, both those who were cognitively capable and those with impairment. The D-QoL is found to be a reliable measure of QoL for individuals with and without impairment (Brod, Stewart, Sands, & Walton, 1999). Results were reported for five D-QoL subscales: self-esteem, positive affect/humor, negative affect, feelings of belonging, and sense of aesthetics. Higher subscale scores indicated greater endorsement. Perceived overall quality of life was measured using a single item in the D-QoL, "How would you rate your overall quality of life at the present time?" Ratings were based on a five-point Likert scale: 1 (poor), 2 (fair), 3 (good), 4 (very good), and 5 (excellent).

Statistical Analysis

Descriptive statistics were used to characterize the sample. Longitudinal mixed-effects modeling was used to identify predictors of emotional status, as measured by the GDS-SF and SF-12 MCS, over time. Time was measured from enrollment. The mixed model is known for its ability to accommodate missing data points often encountered in longitudinal data sets and for its ability to model individual nonlinear characteristics (Laird & Ware, 1982; Long, 1997). Potential covariates (see variables in Table 1) were identified in simple main effects and two-way interaction-with-time models. An initial multivariable mixed-effects model was constructed for emotional well-being (SF12 MCS) and depressive symptoms (GDS-SF), using covariates significantly associated with the outcome on the basis of the interaction terms. Interactions were then sequentially eliminated on the basis of least significance until all interaction effects demonstrating significance at the [less than or equal to] 0.20 level remained. Next, covariates that were not yet included in the interaction model but demonstrated significance in simple main effects models were added to the multivariable interaction model if they were significant at [less than or equal to] 0.20 and assessed sequentially as before (removing variables on the basis of least significance). The final multivariable model included covariates demonstrating significance at p [less than or equal to] 0.05; ethnicity and race were not included in the modeling process because of multicollinearity.

Results

Description of sample at baseline

The full sample of LTSS recipients had a mean age of eighty-one years (SD = 8.7, range = 60-98), the majority were female (71%, 334/470) and widowed (52%, 243/470), as shown in Table 1. Twenty percent were Hispanic (93/470) and 16 percent of baseline interviews were conducted in Spanish (77/470). Fifty-one percent were Caucasian (239/470). Most had completed high school (mean = 12 years; SD = 4.4; range = 0-26) and 30 percent had incomes of less than $30,000 annually (144/470).

On average, LTSS recipients were independent in four of six BADLs (mean = 4.3; SD = 1.9; range = 0-6); the mean MMSE score was 24 (SD = 4.3; range = 12-30). Forty-three percent (201/470) had depressive symptoms present (score [greater than or equal to] 5) based on the GDS-SF (mean = 4.6; SD = 3.4; range = 0-15). Eleven percent of LTSS recipients had severe depressive symptoms at baseline (53/470). Data abstracted from chart reviews indicated that individuals were prescribed an average of eleven medications and had an average of nine documented chronic health conditions. General physical health perception (SF-12 PCS) was low (mean = 37; SD = 11.0) and emotional well-being (SF-12 MCS) was average (mean = 49; SD = 10.5) compared to the normed average of 50 for this scale. The overall rating of QoL ranged from poor to excellent, with the average score of 3 indicating good. Sixty-three percent (298/470) rated their overall QoL as good, very good, or excellent (see Table 1).

Emotional Well-being

Bivariate Analysis. Mixed-effects modeling with repeated measures was used to assess predictors of emotional well-being (SF-12 MCS). The results show that emotional well-being increased over time among older adults new to LTSS (p = 0.05; see Table 1). Mixed-effects modeling with repeated measures was also used to assess bivariate associations between emotional well-being and targeted covariates. Bivariate predictors of having higher ratings of emotional well-being (at p < 0.01) include being white, older, having more years of education, and at p < 0.001 greater functional ability, fewer cognitive deficits, and more social support (emotion/information, tangible, affectionate, and positive social interaction). Bivariate predictors of lower emotional well-being include being hospitalized (p < 0.01) and having more depressive and bothersome symptoms and higher ratings of negative affect, all at p < 0.001. Finally, higher ratings of overall QoL, positive affect, sense of aesthetics, feelings of belonging, and self-esteem (all p < 0.001) were predictive of higher ratings of emotional well-being (see Table 1).

Multivariate Analysis. Multivariate generalized estimating equation (GEE) modeling indicates that, as shown in Table 1, independent predictors of greater emotional well-being included being older and having fewer depressive and bothersome symptoms (p < 0.01), better cognition (MMSE), more positive affect, and greater overall QoL ratings (p < 0.001). In addition, predictors of lower emotional well-being included those with higher negative affect and sense of aesthetic scores (D-QoL subscales, p < 0.001). Participants with greater cognitive impairment (lower MMSE scores) had decreasing emotional well-being scores over time (although scores were high overall) whereas participants who were more cognitively capable (higher MMSE scores) had consistent (although overall low) emotional well-being scores over time (all p < 0.001). Finally, participants with less positive affect had increasing emotional well-being scores over time (although scores were low overall), whereas those with more positive affect had consistent (although overall high) emotional well-being over time (p < 0.01).

Depressive Symptoms (GDS-SF)

Bivariate Analysis. Mixed-effects modeling with repeated measures was used to assess predictors of the number of depressive symptoms (GDS-SF). The results show that depressive symptoms decreased over time (p = 0.001; see Table 2). Bivariate predictors of having fewer depressive symptoms at p < 0.01 included being older (p < 0.01) and at p < 0.001 having more education and fewer functional impairments. In addition, older adults with higher SF-12 PCS scores and greater social support (emotional/informational, tangible, affectionate, and positive social interaction) had fewer depressive symptoms (all p < 0.001). As shown in Table 2, higher ratings of overall QoL and dementia QoL subscales were predictive of fewer depressive symptoms (self-esteem, positive affect, sense of aesthetic, and feelings of belonging, all p < 0.001). Finally, having more bothersome symptoms and greater negative affect (both at p < 0.001), as measured by the D-QoL, and not being enrolled in hospice (p < 0.05) were predictive of having more depressive symptoms.

Multivariate Analysis. Multivariate GEE modeling indicates that independent predictors of having greater depressive symptoms included having more bothersome symptoms and higher scores on the D-QoL negative affect scale (p < 0.001). Independent predictors of having fewer depressive symptoms included having better functional status (BADL); higher ratings of physical health (SF-12 PCS), emotional well-being (SF-12 MCS), and overall QoL; greater affectionate social support (MOS); and higher ratings on the following D-QoL subscales: positive affect, self-esteem, and feelings of belonging (see Table 2, all significant at p < 0.001). One interaction was found with depressive symptoms and emotional well-being: Individuals with lower emotional well-being at baseline had decreasing depressive symptoms over time, whereas those with higher well-being at baseline tended to have consistent and fewer depressive symptoms (p < 0.001).

As shown in Table 3, independent predictors of lower emotional well-being include those with higher negative affect and sense of aesthetic scores (D-QoL subscales). Participants with more cognitive impairment had decreasing emotional well-being scores over time (although overall high) whereas participants with better cognition had consistent (although overall low) emotional well-being scores over time. Finally, participants with less positive affect had increasing emotional well-being scores over time (although overall low) whereas those with more positive affect had consistent (although overall high) emotional well-being over time.

Discussion

Just as all transitions in life create change, older adult transitions to LTSS can provide opportunities for better HRQoL for many individuals. Fundamentally, entrance into any LTSS increases access to and utilization of health services, including access to assessment and treatment for the multiple components of emotional status such as depression and emotional well-being. Our purpose was to describe emotional status through two primary measures, emotional well-being and depression. A unique feature of this study is that individuals with cognitive impairment, who are frequently excluded, were included in data collection efforts, ensuring that we captured the widest range of older adult voices possible (Arlt et al., 2008). Key findings were that individuals with cognitive impairment were able to self-report their level of emotional well-being and that their overall depressive symptoms declined over time. Individuals who entered LTSS with lower emotional status had the greatest gains in the reduction of depression symptoms whereas those entering with higher emotional status had no change in depressive symptoms.

Depression is an important feature to consider in HRQoL because of its importance to emotional and physical health status as well as satisfaction with life (Chachamovich, Fleck, Laidlaw, & Power, 2008). Untreated or undertreated depression in late life is associated with numerous grave consequences, including increased rates of mortality (Cuijpers & Smit, 2002), poorer functional outcomes (Alexopoulos et al., 2005), and diminished HRQoL (Strine, Chapman, Balluz, Moriarty, & Mokdad, 2008). Individuals with depressive symptoms who reported poor/fair QoL and/or lower well-being at baseline may represent a cohort of individuals who had unrecognized, untreated, and/or treatment-resistant depression. Inadequate recognition, diagnosis, and treatment of late life depression continue to represent a serious threat to the QoL, functioning, and mental and physical health of older persons. Despite the availability of efficacious pharmacological and psychosocial treatments for late life depression, only a small minority of older adults with depression receive treatment (Young, Klap, Sherbourne, & Wells, 2001). These issues could be remediated with LTSS because entry into LTSS typically includes psychiatric screening and assessment and a review of medications from which treatment plans can be developed.

Interaction effects seen in this sample among complex health conditions, depression, and health utilization among older adults in LTSS illustrate the importance of diagnosing and treating depression early. Early screening in LTSS could help clinicians identify missed depression cases and initiate appropriate treatment early to ensure accurate diagnosis, effective treatment, and follow-up recommendations (O'Connor, Whitlock, Beil, & Gaynes, 2009). Depression is also a key factor in reducing patient engagement in health treatment, which often results in noncompliance with treatment regimens (Simon, Fleck, Lucas, & Bushnell, 2004). Noncompliance often results in increased symptom severity, progressive development of health conditions, and delays in improvement or cure of comorbid conditions (DiMatteo, Lepper, & Croghan, 2000).

Emotional well-being appeared to provide resiliency to individuals in the transition to LTSS. The authors also found that emotional well-being predicted subsequent functional independence and survival (feelings of happiness, contentment, and hopefulness), a high sense of aesthetics (ability to appreciate beauty, nature, and surroundings), self-esteem, and a sense of belonging. Key well-being constructs of positive affect and sense of aesthetics were found in those individuals who had high emotional well-being scores.

The mechanism and constructs of emotional well-being, which are affected by multiple life stressors such as transitions of care and physical health, often interact with chronic health conditions. Emotional well-being is critical to physical health outcomes; through identification and treatment of the emotional components of health, such as well-being and depression, we increase treatment outcomes in chronic disease (Noel et al., 2004).

Functional and cognitive impairments play important roles in emotional well-being; their measurement varies for individuals with cognitive impairment. Well-being for individuals with cognitive impairment is measured not just by the loss of abilities, but also by feelings of embarrassment, self-consciousness, and not being useful (Brod et al., 1999). A heightened appreciation for and pleasure from sensory awareness such as viewing or creating art, enjoying nature, or listening to music are also measures of well-being for individuals with cognitive impairment (Burgener, Twigg, & Popovich, 2005). Our findings in this emotional status domain offer a direction for the development of LTSS programs that can increase well-being for individuals with cognitive impairment.

Our changes in emotional status findings may be attributable to characteristics at the individual level. Individual resiliency in coping style (Luthar, Cicchetti, & Becker, 2000), through which an individual moderates the negative effects of stress and promotes adaptation, may be a characteristic that predicts successful transitions into LTSS. Individuals vary in their response to life changes and stressors such as entering LTSS; some are able to adjust to major changes and adapt to new stressors with little disruption to their lives, and others have difficulty in the adjustment. Resilience in the face of health limitations, which is a common feature of most LTSS recipients, has been considered a key characteristic of successful aging (Montross et al., 2006). The measurement of HRQoL components includes the common components that also predict resiliency, such as physical functioning, cognitive functioning, well-being, and positive attitude or positive affect (Lamond et al., 2008).

Limitations and Future Directions for Research

To the authors' knowledge, this is the first naturalistic study of individuals' emotional status in LTSS and as such is not without some limitations. Participants had to have a score of 11 or more on the MMSE to be eligible, which limits our ability to generalize to the full population of LTSS recipients. Recruitment was limited to two large urban areas on the East Coast of the United States; therefore, these findings may not be representative of older adults living in rural areas or in other parts of the country. Proxy data were gathered on basic activities of daily living for the individuals with cognitive impairment, a common clinical practice in many assisted living facilities and nursing homes. Finally, race and ethnicity were overrepresented by facility type, with clustering of race/ethnicity by facility type in HCBS.

Conclusions

This study was a first attempt to describe the emotional status of older adults transitioning to LTSS. The authors found that there are both key predisposing and interactive factors that may be predictive of emotional status in LTSS. These factors should be considered in future studies to gain a more comprehensive and predictive picture of the unique relationship between demographic and descriptive factors, individual resiliency, and emotional status. Future research should continue this line of inquiry and solidify and expand upon our findings to determine the ways in which our findings differentially affect well-being, depression, and HRQoL in LTSS. Our findings for QOL self-reports for persons with cognitive impairment are promising because they indicate that proxies do not need to be used when reporting QoL. We also found that emotional status is an important element of HRQoL, regardless of the facility type, because it affects both health and personal outcomes. Early assessment of emotional status upon LTSS entry is paramount to optimize treatment and outcomes. Depression as a mediator in HRQoL should be studied further, as well as multiple components of well-being such as positive affect, aesthetics, self-esteem, and belonging. Resiliency as a key mediating individual characteristic in successful transitioning to LTSS requires further investigation as a potential characteristic for assessment upon entry into LTSS for individualizing treatment planning.

This study provides important findings about age-related differences in emotional status among older adults entering LTSS, using the largest nationally representative sample to date. These new opportunities to study LTSS should aggressively promote strategies to increase emotional well-being and recognize and treat depressive symptoms during transitions of care that optimize emotional well-being and promote person-centered care.

References

Alexopoulos, G. S., Kiosses, D. N., Heo, M., Murphy, C. F., Shanmugham, B., & Gunning-Dixon, F. (2005). Executive dysfunction and the course of geriatric depression. Biological Psychiatry, 58, 204-210.

Arlt, S., Hornung, J., Eichenlaub, M., Jahn, H., Bullinger, M., & Petersen, C. (2008). The patient with dementia, the caregiver and the doctor: Cognition, depression and quality of life from three perspectives. International Journal of Geriatric Psychiatry, 23, 604-610.

Baik, S. Y., Bowers, B. J., Oakley, L. D., & Susman, J. L. (2005). The recognition of depression: The primary care clinician's perspective. The Annals of Family Medicine, 3, 31-37.

Brink, T. L., Yesavage, J. A., Lum, O., Heersema, P. H., Adey, M., & Rose, T. L. (1982). Screening tests for geriatric depression. Clinical Gerontologist, 1(1), 37-43.

Brod, M., Stewart, A. L., Sands, L., & Walton, P. (1999). Conceptualization and measurement of quality of life in dementia: The dementia quality of life instrument (DQoL). The Gerontologist, 39, 25-36.

Bruce, M. L. (2001). Depression and disability in late life: Directions for future research. American Journal of Geriatric Psychiatry, 9, 102-112.

Bryant, C., Bei, B., Gilson, K. M., Komiti, A., Jackson, H., & Judd, F. (2005). Antecedents of attitudes to aging: A study of the roles of personality and well-being. The Gerontologist. Advance online publication. doi: 10.1093/ geront/gnu041.

Burgener, S. C., Twigg, P, & Popovich, A. N. N. (2005). Measuring psychologic well-being in cognitively impaired persons. Dementia, 4, 463-485.

Burke, W. J., Nitcher, R. L., Roccaforte, W. H., & Wengel, S. P (1992). A prospective evaluation of the Geriatric Depression Scale in an outpatient geriatric assessment center. Journal of the American Geriatrics Society, 40, 1227-1230.

Chachamovich, E., Fleck, M., Laidlaw, K., & Power, M. (2008). Impact of major depression and subsyndromal symptoms on quality of life and attitudes toward aging in an international sample of older adults. The Gerontologist, 48, 593-602.

Charles, S. T. (2010). Strength and vulnerability integration: A model of emotional well-being across adulthood. Psychological Bulletin, 136, 1068-1091.

Ciechanowski, P. S., Katon, W. J., & Russo, J. E. (2000). Depression and diabetes: impact of depressive symptoms on adherence, function, and costs. Archives of Internal Medicine, 160, 3278-3285.

Cuijpers, P., & Smit, F. (2002). Excess mortality in depression: A meta-analysis of community studies. Journal of Affective Disorders, 72, 227-236.

DiMatteo, M. R., Lepper, H. S., & Croghan, T. W. (2000). Depression is a risk factor for noncompliance with medical treatment: Meta-analysis of the effects of anxiety and depression on patient adherence. Archives of Internal Medicine, 160, 2101-2107.

Fiske, A., Wetherell, J. L., & Gatz, M. (2009). Depression in older adults. Annual Review of Clinical Psychology, 5, 363.

Folstein, M. F., Folstein, S. E., & McHugh, P. R. (1975). "Mini-mental state": A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research, 12, 189-198.

Gaugler, J. E., Duval, S., Anderson, K. A., & Kane, R. L. (2007). Predicting nursing home admission in the U.S.: A meta-analysis. BMC Geriatrics, 7, 13.

George, L. K. (2010). Still happy after all these years: Research frontiers on subjective well-being in later life. Journal of Gerontology: Social Sciences, 65B(3), 331-339. doi: 10.1093/geronb/gbq006.

Heidrich, S. M., & Ryff, C. D. (1993). Physical and mental health in later life: The self-system as mediator. Psychology and Aging, 8, 327.

Institute of Medicine, Committee on Improving Quality in Long-Term Care. (2008). Improving the quality of long-term care. Retrieved from http://www.nap.edu/openbook.php?record_id=9611 doi: 10.1037/ e720082007-001.

Katz, S. (1983). Assessing self-maintenance: Activities of daily living, mobility, and instrumental activities of daily living. Journal of the American Geriatrics Society, 31, 721-727.

Kaye, H. S. (2014). Toward a model long-term services and supports system: State policy elements. The Gerontologist. Advance online publication. doi: 10.1093/geront/gnu013.

Kaye, H. S., Harrington, C., & LaPlante, M. P (2010). Long-term care: Who gets it, who provides it, who pays, and how much? Health Affairs, 29, 11-21.

Laird, N. M., & Ware, J. H. (1982). Random-effects models for longitudinal data. Biometrics, 38, 963-974.

Lamond, A. J., Depp, C. A., Allison, M., Langer, R., Reichstadt, J., Moore, D. J., & Jeste, D. V (2008). Measurement and predictors of resilience among community-dwelling older women. Journal of Psychiatric Research, 43, 148-154.

Long, S, J. (1997). Regression models for categorical and limited dependent variables. In Advanced Quantitative Techniques in the Social Sciences Series: Vol. 7. Thousand Oaks, CA: SAGE.

Lustig, T. A., & Olson, S. (Eds.). (2014). Financing long-term services and supports for individuals with disabilities and older adults: Workshop summary. Washington, DC: National Academies Press.

Luthar, S. S., Cicchetti, D., & Becker, B. (2000). The construct of resilience: A critical evaluation and guidelines for future work. Child Development, 71, 543-562.

McLaughlin, S. J., Connell, C. M., Heeringa, S. G., Li, L. W, & Roberts, J. S. (2010). Successful aging in the United States: Prevalence estimates from a national sample of older adults. The Journals of Gerontology Series B: Psychological Sciences and Social Sciences, 65, 216-226.

Mitchell, A. J., Vaze, A., & Rao, S. (2009). Clinical diagnosis of depression in primary care: A meta-analysis. The Lancet, 374(9690), 609-619.

Montross, L. P., Depp, C., Daly, J., Reichstadt, J., Golshan, S., Moore, D., & Jeste, D. V (2006). Correlates of self-rated successful aging among community-dwelling older adults. American Journal of Geriatric Psychiatry, 14, 43-51.

Muller-Nordhorn, J., Roll, S., & Willich, S. N. (2004). Comparison of the short form (SF)-12 health status instrument with the SF-36 in patients with coronary heart disease. Heart, 90, 523-527.

Noel, P. H., Williams, J. W, Unutzer, J., Worchel, J., Lee, S., Cornell, J., & Hunkeler, E. (2004). Depression and comorbid illness in elderly primary care patients: Impact on multiple domains of health status and well-being. Annals of Family Medicine, 2, 555-562.

O'Connor, E. A., Whitlock, E. P, Beil, T. L., & Gaynes, B. N. (2009). Screening for depression in adult patients in primary care settings: A systematic evidence review. Annals of Internal Medicine, 151, 793-803.

Ortman, J. M., Velkoff, V. A., & Hogan, H. (2014). An aging nation: The older population in the United States. U.S. Census Bureau. Retrieved from: www.census.gov/pvod/2014pubs/p25-1140.pdf.

Parmelee, P A., Katz, I. R., & Lawton, M. P (1989). Depression among institutionalized aged: Assessment and prevalence estimation. Journal of Gerontology, 44, M22-M29.

Salyers, M. P, Bosworth, H. B., Swanson, J. W, Lamb-Pagone, J., & Osher, F. C. (2000). Reliability and validity of the SF-12 health survey among people with severe mental illness. Medical Care, 38, 1141-1150.

Schillerstrom, J. E., Royall, D. R., & Palmer, R. F. (2008). Depression, disability and intermediate pathways: A review of longitudinal studies in elders. Journal of Geriatric Psychiatry and Neurology, 21, 183-197.

Simon, G. E., Fleck, M., Lucas, R., & Bushnell, D. M. (2004). Prevalence and predictors of depression treatment in an international primary care study. American Journal of Psychiatry, 161, 1626-1634.

Stewart, A. L., Hays, R. D., & Ware, J. E. (1988). The MOS short-form general health survey: Reliability and validity in a patient population. Medical Care, 26, 724-735.

Strine, T. W, Chapman, D. P., Balluz, L. S., Moriarty, D. G., & Mokdad, A. H. (2008). The associations between life satisfaction and health-related quality of life, chronic illness, and health behaviors among US community-dwelling adults. Journal of Community Health, 33, 40-50.

Theurer, K., & Wister, A. (2010). Altruistic behaviour and social capital as predictors of wellbeing among older Canadians. Ageing and Society, 30, 157-181. doi: 10.1017/S0144686X09008848.

Tilly, J., Wiener, J. M., & O'Keeffe, J. (2011). Making the long-term services and supports system work for people with dementia and their caregivers. U.S. Administration on Aging. Retrieved from http://www.nasuad.org/ sites/nasuad/files/hcbs/files/211/10519/DementiaCapabilityIssue Brief_12_2_11.pdf.

U.S. Department of Health and Human Services, Administration on Aging. (2011). A profile of older Americans: 2011. Retrieved from http://www.aoa.gov/ Aging_Statistics/Profile/2011/docs/2011profile.pdf.

Vincent, G. K., & Velkoff, V A. (2010). The next four decades: The older population in the United States: 2010 to 2050. Central Population Reports (No. P25-1138). Washington, DC: U.S. Census Bureau. Retrieved from https://www.census.gov/prod/2010pubs/p25-1138.pdf.

Vogeli, C., Shields, A. E., Lee, T. A., Gibson, T. B., Marder, W. D., Weiss, K. B., & Blumenthal, D. (2007). Multiple chronic conditions: Prevalence, health consequences, and implications for quality, care management, and costs. Journal of General Internal Medicine, 22, 391-395.

Ware, J. E., Kosinski, M., Dewey, J. E., & Gandek, B. (2000). SF-36 health survey: Manual and interpretation guide (2nd ed.). Boston: Quality Metric.

Ware, J. E., Kosinski, M., Turner-Bowker, D. M., & Gandek, B. (2002). How to score version 2 of the SF-12 health survey (with a supplement documenting version 1). Boston: QualityMetric.

Young, A. S., Klap, R., Sherbourne, C. D., & Wells, K. B. (2001). The quality of care for depressive and anxiety disorders in the United States. Archives of General Psychiatry, 58, 55-61.

Zubritsky, C., Abbott, K. M., Hirschman, K. B., Bowles, K. H., Foust, J. B., & Naylor, M. D. (2012). Health-related quality of life: Expanding a conceptual framework to include older adults who receive long-term services and supports. The Gerontologist, 53, 205-210.

Cynthia D. Zubritsky, PhD, is director of Policy Research, Center for Mental Health Policy and Services Research, University of Pennsylvania School of Medicine, Philadelphia. Katherine M. Abbott, PhD, is assistant professor of gerontology and Scripps Research Fellow at Miami University in Oxford, OH. Karen B. Hirschman, PhD, MSW, is research associate professor of nursing and New Courtland term chair in Health Transitions Research, and Alexandra Hanlon, PhD, is research associate professor of nursing, New Courtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia. Kathryn H. Bowles, PhD, is director of RN Excellence, Center for Integrative Science in Aging, and Mary D. Naylor, PhD, RN, is FAAN Marian S. Ware professor in gerontology and director, New Courtland Center for Transitions and Health, University of Pennsylvania School of Nursing,

This work was supported by the National Institute for Aging and National Institute for Nursing Research at the National Institutes of Health (R01AG025524) and the Marian S. Ware Alzheimer Program, University of Pennsylvania.

The authors wish to thank the older adults participating in this study as well as the administrators and staff from the LTSS organizations who provided guidance throughout the study period.
Table 1 Demographic and clinical characteristics of older adults
receiving LTSS, N = 470

                                                    N (%) or
Variable                                    mean [+ or -] SD (range)

Individual Characteristics

Gender: female, n (%)                              334 (71.06)
Marital status, n (%)
  Married                                          93 (19.78)
  Widowed                                          243 (51.70)
  Separated or divorced                            82 (17.45)
  Single (never married)                            51(10.85)
  Unknown/not reported                              1 (<1.0)
Race, n (%)
  White                                            239 (50.85)
  African American                                 162 (34.47)
  More than one race                               57 (12.13)
  Other (Asian/Native Hawaiian or Pacific           9 (1.91)
    Islander/
  American Indian or Alaskan Native)
  Not reported                                      3 (<1.0)
Ethnicity, Hispanic, n (%)                         93 (19.79)
Age (yr), mean [+ or -] SD (range)             80.89 [+ or -] 8.71
                                                     (60-98)
Education (yr), mean [+ or -] SD (range)       11.88 [+ or -] 4.42
                                                     (0-26)
Missing, n (%)                                      1 (<1.0)
Overall quality of life, n = 463            3.59 [+ or -] 7.79 (1-5)
Dementia-quality of life (D-QoL)
  Self-esteem, n = 462                      3.28 [+ or -] 0.82 (1-5)
  Sense of aesthetics, n = 463              3.46 [+ or -] 0.78 (1-5)
  Positive affect, n = 463                  3.40 [+ or -] 0.75 (1-5)
  Negative affect, n = 463                  2.47 [+ or -] 0.74 (1-5)
  Feelings of belonging, n = 462            3.28 [+ or -] 0.82 (1-5)
Total number of chronic conditions          8.63 [+ or -] 3.94 (1-27)
Symptom status
  Number of bothersome symptoms, mean        6.1 [+ or -] 3.2 (0-13)
    [+ or -] SD (range)
Functional status
  Cognitive: MMSE                              23.96 [+ or -] 4.29
                                                     (12-30)
  Missing or unable to complete, n (%)              17 (3.62)
  Basic activities of daily living,          4.3 [+ or -] 1.9 (0-6)
    mean [+ or -] SD (range)
  Missing or unable to complete, n (%)              18 (3.83)
  SF-12 physical composite score,             37.27 [+ or -] 10.95
    mean [+ or -] SD (range)                      (12.60-61.31)
  Missing or unable to complete, n (%)              17 (3.62)
Social support, mean [+ or -] SD (range)
  Emotional or informational                2.72 [+ or -] 1.02 (0-4)
  Tangible                                  2.97 [+ or -] 0.95 (0-4)
  Affection                                 2.79 [+ or -] 1.18 (0-4)
  Positive social interaction               2.46 [+ or -] 1.14 (0-4)
LTSS type, n (%)
  Assisted living                                  156 (33.19)
  Nursing home                                     158 (33.62)
  Home and community based                         156 (33.19)
Resource use prior to the start of LTSS
  Number previously enrolled in hospice             3 (<1.0)
    services, n (%)
  Missing, n (%)                                    10 (2.13)
  Number of emergency room visits in                30 (6.38)
    prior 3 months, n (%)
  Missing, n (%)                                    26 (5.54)
  Number of hospitalizations in prior 3            101 (21.49)
      months, n (%)
  Missing, n (%)                                    2 (<1.0)
Emotional status
  Emotional well-being (SF-12 MCS), mean      49.01 [+ or -] 10.52
    [+ or -] SD (range)                           (13.89-76.18)
  Missing or unable to complete, n (%)              17 (3.62)
  Depressive symptoms (Geriatric               4.55 [+ or -] 3.39
    Depression Scale Short Form)                     (0-15)

Table 2 Bivariate and multivariate associations between independent
variables and depressive symptoms

                                                   Unadjusted

                                                               95%
                                                           confidence
                                                            interval

Variable                               [beta]      SE    Lower   Upper

Time (months)                         -0.01 ***   0.00    0.02   -0.00
Gender
  Female (reference)
  Male                                -0.10       0.28   -0.66    0.45
Race
  Non-white (reference)
  White                               -0.47       0.25   -0.97    0.03
Age (yr)                              -0.04 **    0.01   -0.07   -0.01
Education (yr)                        -0.10 ***   0.03   -0.15   -0.04
Facility type
  Assisted living                     -1.27 ***   0.30   -1.87   -0.67
  Nursing home                        -0.12       0.31   -0.72    0.48
  Home & community (reference)
Overall QoL                           -0.81 ***   0.05   -0.90   -0.71
Dementia quality of life (D-QoL)
  Self-esteem                         -1.17 ***   0.07   -1.30   -1.03
  Sense of aesthetic                  -0.40 ***   0.05   -0.51   -0.30
  Positive affect                     -1.31 ***   0.07   -1.45   -1.18
  Negative affect                      1.69 ***   0.08   -1.55   -1.84
  Feelings of belonging               -0.09 ***   0.06   -1.05   -0.80
Total no. of chronic conditions        0.03       0.03    0.03    0.10
Symptom status
  Total no. of bothersome symptoms     0.29 ***   0.02    0.26    0.33
Functional status
  Cognitive (MMSE)                    -0.04       0.01   -0.07   -0.02
  BADL (self + proxy)                 -0.23 ***   0.03   -0.29   -0.17
  Physical health (SF12 PCS)          -0.06 ***   0.00   -0.07   -0.05
Social support
  MOS social support                  -0.70 ***   0.06   -0.81   -0.59
  Emotional informational
    MOS social support tangible       -0.76 ***   0.06   -0.88   -0.64
    MOS social support affectionate   -0.62 ***   0.05   -0.72   -0.52
    MOS social support positive       -0.65 ***   0.05   -0.75   -0.55
Resource use prior to start of LTSS
  Hospice
    Yes (reference)
    No                                -1.07 *     0.44   -1.98   -0.15
  No. of emergency dept visits in
    prior 3 months                     0.08       0.12   -0.15    0.32
  No. of hospitalizations in prior
    3 months                           0.10       0.08   -0.05    0.26
Emotional status
  Emotional well-being (SF12 MCS)     -0.09 ***   0.00   -0.10   -0.08
Interaction
  Emotional well-being (SF12 MCS) x
    time (a)

                                                   Adjusted

                                                               95%
                                                           confidence
                                                            interval

Variable                               [beta]      SE    Lower   Upper

Time (months)                         -0.08 ***   0.02   -0.13   -0.04
Gender
  Female (reference)
  Male
Race
  Non-white (reference)
  White
Age (yr)
Education (yr)
Facility type
  Assisted living
  Nursing home
  Home & community (reference)
Overall QoL                           -0.32 ***   0.05   -0.42   -0.22
Dementia quality of life (D-QoL)
  Self-esteem                         -0.31 ***   0.08   -0.47   -0.15
  Sense of aesthetic
  Positive affect                     -0.39 ***   0.08   -0.55   -0.22
  Negative affect                      0.72 ***   0.08    0.56    0.88
  Feelings of belonging               -0.28 ***   0.07   -0.42   -0.15
Total no. of chronic conditions
Symptom status
  Total no. of bothersome symptoms     0.07 ***   0.02    0.03    0.11
Functional status
  Cognitive (MMSE)
  BADL (self + proxy)                 -0.09 ***   0.03   -0.15   -0.04
  Physical health (SF12 PCS)          -0.05 ***   0.01   -0.06   -0.04
Social support
  MOS social support
  Emotional informational
    MOS social support tangible
    MOS social support affectionate   -0.20 ***   0.05   -0.29   -0.10
    MOS social support positive
Resource use prior to start of LTSS
  Hospice
    Yes (reference)
    No
  No. of emergency dept visits in
    prior 3 months
  No. of hospitalizations in prior
    3 months
Emotional status
  Emotional well-being (SF12 MCS)     -0.09 ***   0.01   -0.10   -0.07
Interaction
  Emotional well-being (SF12 MCS) x
    time (a)

(a) Covariate x [10.sup.-2]

* p < 0.05; ** p < 0.01; *** p < 0.001

Table 3 Bivariate and multivariate associations between
independent variables and mental health (SF-MCS)

                                                 Unadjusted

                                                               95%
                                                           confidence
                                                            interval
                                                  Std
Variable                              [beta]     error   Lower   Upper

Time (months)                         0.05 *     0.02     0.01    0.09
Gender
  Female (reference)
  Male                               -0.09       0.84    -1.74    1.56
Race
  Non-white (reference)
  White                               2.23 **    0.76     0.75    3.72
Age, yr                               0.16 **    0.04     0.07    0.24
Education, yr                         0.21 **    0.08     0.04    0.37
Facility type
  Assisted living                     2.59 **    0.91     0.08    4.37
  Nursing home                       -1.18       0.92    -2.99    0.62
  Home & community (reference)
Overall quality of life               2.82 ***   0.20     2.43    3.22
Dementia quality of life (D-QoL)
  Self-esteem                         3.65 ***   0.28     3.10    4.21
  Sense of aesthetics                 0.79 ***   0.23     0.34    1.24
  Positive affect                     4.84 ***   0.29     4.27    5.41
  Negative affect                    -6.74 ***   0.30    -7.32   -6.16
  Feelings of belonging               2.62 ***   0.26     2.10    3.14
Total no. of chronic conditions       0.05       0.09    -0.14    0.25
Symptom status
  Total no. of bothersome symptoms   -0.91 ***   0.08    -1.06   -0.76
Functional status
  Cognitive (MMSE)                    0.20 ***   0.05     0.10    0.30
  BADLs (self + proxy)                0.73 ***   0.13     0.48    0.97
Social support
  MOS social support emotional/
    informational                     2.33 ***   0.23     1.89    2.78
  MOS social support tangible         2.53 ***   0.25     2.04    3.03
  MOS social support affectionate     1.74 ***   0.21     1.34    2.14
  MOS social support positive         1.91 ***   0.20     1.51    2.31
Resource use prior to start of
    LTSS
  Hospice
    Yes (reference)
    No                                3.59       1.84    -0.25    7.44
  No. of emergency dept visits in
    prior 3 months                   -0.73       0.51    -1.74    0.27
  No. of hospitalizations in prior
    3 months                         -0.83 **    0.34    -1.49   -0.16
Emotional status
  Depressive symptoms (GDS-SF)       -1.68 ***   0.07    -1.81   -1.55
Interactions
  Cognition (MMSE) x time            -0.02 *     0.00    -0.02   -0.00
  D-QoL, positive affect x time       0.06       0.03     0.00    0.12

                                                 Adjusted

                                                         95%
                                                         confidence
                                                         level
                                                  Std
Variable                              [beta]     error   Lower   Upper

Time (months)                         0.12       0.14    -0.16    0.39
Gender
  Female (reference)
  Male
Race
  Non-white (reference)
  White
Age, yr                               0.08 *     0.03     0.02    0.14
Education, yr
Facility type
  Assisted living                    -2.06 **    0.64    -3.31   -0.80
  Nursing home                       -1.37 *     0.63    -2.61   -0.14
  Home & community (reference)
Overall quality of life               0.82 ***   0.21     0.42    1.23
Dementia quality of life (D-QoL)
  Self-esteem
  Sense of aesthetics                -0.83 ***   0.21    -1.23   -0.42
  Positive affect                     1.29 **    0.41     0.49    2.10
  Negative affect                    -3.84 ***   0.33    -4.49   -3.18
  Feelings of belonging
Total no. of chronic conditions
Symptom status
  Total no. of bothersome symptoms   -0.23 **    0.07    -0.37   -0.08
Functional status
  Cognitive (MMSE)                    0.36 ***   0.07     0.23    0.49
  BADLs (self + proxy)
Social support
  MOS social support emotional/
    informational
  MOS social support tangible
  MOS social support affectionate
  MOS social support positive
Resource use prior to start of
    LTSS
  Hospice
    Yes (reference)
    No
  No. of emergency dept visits in
    prior 3 months
  No. of hospitalizations in prior
    3 months
Emotional status
  Depressive symptoms (GDS-SF)       -0.94 ***   0.08    -1.10   -0.78
Interactions
  Cognition (MMSE) x time            -0.02 ***   0.00    -0.02   -0.01
  D-QoL, positive affect x time       0.08 **    0.03     0.02    0.14

* p < 0.05; ** p < 0.01; *** p < 0.001
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Author:Zubritsky, Cynthia D.; Abbott, Katherine M.; Hirschman, Karen B.; Hanlon, Alexandra; Bowles, Kathryn
Publication:Best Practices in Mental Health
Article Type:Author abstract
Date:Sep 22, 2016
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