Intergenerational Ambivalence and Dyadic Strain: Understanding Stress in Family Care Partners of Older Adults

Objectives: The present study used Pearlin, Mullan, Semple & Skaff's (1990) caregiving stress process model as a framework to examine the comparative influence of two stressors: (a) intergenerational ambivalence as a unified construct and (b) dyadic strain, which is one isolated component of intergenerational ambivalence.

Methods: Participants were 120 women providing healthcare and medication assistance to an earlier generation family member with physical and/or cognitive impairments.

Results: Hierarchical regression confirmed that intergenerational ambivalence explained perceived stress in family care partners, beyond the variance accounted for by other commonly reported stressors such as length of caregiving experience, memory/cognitive and functional impairments of the care recipient, caregiver overload, family conflict and financial strain. Further analyses revealed that examining dyadic strain apart from intergenerational ambivalence may more accurately explain the influence of ambivalence scores on care partners’ perceived stress.

Conclusions and Clinical Implications: The comparative influence of dyadic strain versus ambivalence suggests that stress-reducing interventions may benefit from a focus on reducing care partners’ experiences of negative strain in the dyadic relationship rather than managing ambivalence.     

Paid Family Leave: An Emerging Benefit for Employed Family Caregivers of Older Adults

As our population ages, the ability to take time off to care for an ill family member or close friend without losing income or a job is a growing social, health, and economic issue for American families. Therefore, the need for paid family leave policies for workers with caregiving responsibilities is an important topic for employers and policymakers, in the clinical care of older adults, and at kitchen tables across the United States. Despite this growing need, paid family leave is not available to most workers, and there is no national paid family leave policy. Health care and social service providers have a role in ensuring that family members of their patients with a serious health condition or disability are aware of the potential availability of paid family leave benefits in the states and businesses that provide them. Building a better system of care for older adults means changes not only in health care settings and in long‐term services and supports, but in workplaces too. This article describes the challenges faced by workers with family caregiving responsibilities, explains why paid family leave matters, indicates which states have adopted these protections, and reviews research on existing paid family leave policies. Finally, actions by clinicians and other stakeholders are offered to advance awareness about paid family leave benefits, including coverage for workers with care responsibilities for older people.     

Adverse Effects of Complementary and Alternative Medicine on Antihypertensive Medication Adherence: Findings from the Cohort Study of Medication Adherence Among Older Adults

OBJECTIVES: To determine the association between complementary and alternative medicine (CAM) use and antihypertensive medication adherence in older black and white adults.
DESIGN: Cross-sectional.
SETTING: Patients enrolled in a managed care organization.
PARTICIPANTS: Two thousand were hundred eighty black and white adults aged 65 and older and prescribed antihypertensive medication.
MEASUREMENTS: Information on CAM use (health food and herbal supplements, relaxation techniques) for blood pressure control and antihypertensive medication adherence were collected in a telephone survey between August 2006 and September 2007. Low medication adherence was defined as a score less than 6 using the eight-item Morisky Medication Adherence Scale.
RESULTS: The mean age of participants was 75.0±5.6, 30.7% were black, 26.5% used CAM, and 14.1% had low antihypertensive medication adherence. In managing blood pressure, 30.5% of black and 24.7% of white participants had used CAM in the last year ( P =.005), and 18.4% of black and 12.3% of white participants reported low adherence to antihypertensive medication (<.001). After multivariable adjustment for sociodemographic information, depressive symptoms, and reduction in antihypertensive medications because of cost, the prevalence ratios of low antihypertensive medication adherence associated with CAM use were 1.56 (95% confidence interval (CI)=1.14–2.15; P =.006) in blacks and 0.95 (95% CI=0.70–1.29; P =.73) in whites ( P value for interaction=.07).
CONCLUSION: In this cohort of older managed care patients, CAM use was associated with low adherence to antihypertensive medication in blacks but not whites.     

Medication review: patient selection and general practitioner's report of drug-related problems and actions taken in elderly Australians

OBJECTIVES: To investigate which patients general practitioners (GPs) selected for medication review based on risk factors for medication problems and patient demographics; to describe drug-related problems and actions taken to solve those problems during medication review consultations based on GPs' self-report. DESIGN: Cross-sectional. SETTING: General practices. PARTICIPANTS: Four hundred fifty-two patients recruited from 11 GPs. MEASUREMENTS: Patients' self-reported risk factors for medication misadventures collected from Medication Risk Assessment Forms; doctors' report of patients' drug-related problems and actions taken to solve those problems collected from Medication Review Checklists. Patients completed a Medication Risk Assessment Form in the waiting room, which they presented to their doctor, who then decided whether the patient needed a medication review. GPs completed a Medication Review Checklist. RESULTS: GPs completed 124 Medication Review Checklists. The group that had a medication review had a lower proportion of individuals aged 65 to 74 than the group that did not (40% vs 56%). The proportion of people with risk factors for medication misadventure was consistently higher for patients who received a medication review. GPs found that 88% (95% confidence interval (CI) =66-97) of patients who had a medication review had at least one problem with use of their medication. GPs reported taking at least one action for 104 (88%) patients (95% CI=65-97) to rectify medication problems. Most common actions taken were monitoring (55%), improving compliance (50%), dose change (37%), cessation of drug (28%), and ordering of a pathology test (26%). CONCLUSION: A Medication Risk Assessment Form completed by patients can be used to select patients for medication review, and medication reviews conducted by GPs can be beneficial in improving the use of medication in older people living in the community.     

Extending the Use of the 40-Item HIV-Stigma Scale to Older Adults

Abstract

This paper explores the potential for extending the use of a 40-item stigma scale, developed by Berger and colleagues, to older adults with HIV/AIDS. The increase in the numbers of adults living into older age with HIV, along with new infections in those 50+, makes this issue relevant. A sample of 25 older adults completed the stigma scale, and all answered a semi-structured question about how they felt the scale captured their experiences of stigma. The sample ranged in age from 50 to 72 years (M = 56.1 ± 5.75); 38% were female, and 40% were people of color. The stigma scale and its 4 subscales showed excellent internal consistency ranging from a = .92 to .96. The scale was found to have good convergent validity with the CES-D depression scale. Sixty-four percent of the respondents felt the scale did a good job capturing their experiences of stigma as older persons living with HIV/AIDS or offered no suggestions for improvement. The scale was found to be reliable and valid for measuring HIV-stigma in the original study and appears to maintain its integrity in a sample of older HIV-infected adults.     

Surgical Guidelines for Perioperative Management of Older Adults: What Geriatricians Need to Know

A multidisciplinary panel of experts representing surgery, anesthesia, and geriatrics recently published guidelines for surgeons on the optimal perioperative management of older adults, including recommendations on postoperative recovery and posthospital transitions of care. Geriatricians have an important role in the care for older adults in the preoperative period as older adults consider surgical options and prepare for surgical procedures, during the perioperative period as inpatient consultants, and in the postoperative period as older adults transition to rehabilitation facilities or to home. This article outlines the perioperative surgical guidelines and describes how they apply to the role of the geriatrician in the care of older adults during the perioperative period.     

Effect of Central Nervous System Medication Use on Decline in Cognition in Community-Dwelling Older Adults: Findings from the Health, Aging and Body Composition Study

OBJECTIVES: To evaluate whether combined use of multiple central nervous system (CNS) medications over time is associated with cognitive change.
DESIGN: Longitudinal cohort study.
SETTING: Pittsburgh, Pennsylvania, and Memphis, Tennessee.
PARTICIPANTS: Two thousand seven hundred thirty-seven healthy adults (aged ≥65) enrolled in the Health, Aging and Body Composition study without baseline cognitive impairment (modified Mini-Mental State Examination (3MS) score ≥80).
MEASUREMENTS: CNS medication (benzodiazepine- and opioid-receptor agonists, antipsychotics, antidepressants) use, duration, and dose were determined at baseline (Year 1) and Years 3 and 5. Cognitive function was measured using the 3MS at baseline and Years 3 and 5. The outcome variables were incident cognitive impairment (3MS score <80) and cognitive decline (≥5-point decline on 3MS). Multivariable interval-censored survival analyses were conducted.
RESULTS: By Year 5, 7.7% of subjects had incident cognitive impairment; 25.2% demonstrated cognitive decline. CNS medication use increased from 13.9% at baseline to 15.3% and 17.1% at Years 3 and 5, respectively. It was not associated with incident cognitive impairment (adjusted hazard ratio (adj HR)=1.11, 95% confidence interval (CI)=0.73–1.69) but was associated with cognitive decline (adj HR 1.37, 95% CI=1.11–1.70). Longer duration (adj HR=1.39, CI=1.08–1.79) and higher doses (>3 standardized daily doses) (adj HR=1.87, 95% CI=1.25–2.79) of CNS medications suggested greater risk of cognitive decline than with nonuse.
CONCLUSION: Combined use of CNS medications, especially at higher doses, appears to be associated with cognitive decline in older adults. Future studies must explore the effect of combined CNS medication use on vulnerable older adults.     

Geriatrics‐for‐Specialists Initiative: An Eleven‐Specialty Collaboration to Improve Care of Older Adults

In the early 1990s, visionary leaders at the American Geriatrics Society and The John A. Hartford Foundation recognized that the marked and growing shortage of geriatrics healthcare professionals would lead to a U.S. healthcare system ill prepared to provide optimal care for the ever‐increasing number of older Americans. Led by the late Dennis W. Jahnigen, MD, they set forth a plan to address this shortage by collaborating with surgical and related medical specialists to create a series of programs to foster the highest quality care of older adults. Their unique programmatic vision was that every physician, not just geriatricians, would have basic knowledge and skills in geriatric care, because geriatricians cannot and should not meet the need alone.