"A Major Issue": The Impact of the COVID-19 Pandemic on How Home Care Leaders Perceive and Promote Aides' Mental Health and Well-Being.

Home care aides play a critical role in the care of older adults, but they do this under difficult working conditions. The COVID-19 pandemic exacerbated aides' stress and worsened their mental health, raising the question of how agencies can better support aides. We explore how home care industry leaders in New York perceived and addressed home care aides' mental health and well-being prior to and during the pandemic through in-depth interviews conducted in 2019 (n = 8 agencies) and 2022 (n = 14 agencies). We found that these topics became more central in leaders' thinking, reflected in a range of new internally and externally funded agency actions, albeit limited by ongoing financial constraints. Maintaining a skilled and reliable aide workforce is critical to societal health but will remain challenging without continued investment in aide support of the kind described in the Surgeon General's Framework for Workplace Mental Health and Well-Being.

Widowhood and bereavement in late life.

Bereavement is a common and often challenging experience in late life. Evidence shows that while many older adults manage to adjust well and demonstrate resilience in response to the death of a close person, bereavement puts a substantial minority at risk of adverse mental and physical health impacts including mortality. Current research further indicates that 1) this is the case across different countries and cultures across the globe; 2) that the COVID-19 pandemic posed unprecedented challenges for coping with late-life bereavement; 3) that loneliness and social isolation among bereaved older adults tend to be prevalent and harmful, particularly under pandemic but also in nonpandemic circumstances; and, recently, 4) that bereavement may be a risk factor for cognitive decline in this population.

Type of Home Care-Informal Versus At Least Some Formal-Matters for Recipients' Perceived Control.

BACKGROUND AND OBJECTIVES: Perceived control is an important psychological resource for middle-aged and older adults. Aging in place may help foster feelings of control, yet many community-dwelling older adults must rely on others-whether family, friends, or professionals-for physical assistance. This study investigated how receiving home care from different sources was associated with two facets of perceived control (mastery and perceived constraints) among adults with varying levels of physical disability. RESEARCH DESIGN AND METHODS: Data were drawn from the 2012 and 2014 waves of the Health and Retirement Study. Community-dwelling adults aged 50 years and older receiving help for at least one activity of daily living (ADL) impairment (N = 884) reported their relationship to each respective caregiver (formal professional and/or informal family or friend), level of ADL impairment, and ratings of perceived control. Ordinary least squares regression was used to examine the association between type of support and perceived control, as well as the moderating effect of physical disability on that relationship. RESULTS: Compared to receipt of informal support alone, receiving a combination of formal and informal support was related to perceptions of greater control over one's life, but only in terms of mastery. The level of one's ADL impairment did not have a moderating effect on the relationship between support type and perceived control. DISCUSSION AND IMPLICATIONS: Findings suggested that the type of instrumental support adults receive in their home has implications for specific facets of perceived control. These findings can help inform home care program development.

Coping Patterns in Advanced Old Age: Findings from the Fordham Centenarian Study.

INTRODUCTION: Research on coping in advanced old age is scarce. In the present study, we explored coping patterns in near-centenarians and centenarians, and characteristics associated to using a specific coping pattern. METHODS: We analyzed the frequency with which participants (N = 87, MAge = 99.05; SDage = 2.6; age range 95-107) reported using specific coping strategies (i.e., coping strategy use) and the relative preference for specific strategies (i.e., relative coping preferences) in data from the Fordham Centenarian Study. Moreover, we applied cluster analysis to detect coping patterns, and we compared cluster characteristics. RESULTS: Very old individuals reported using emotion control and acceptance the most. Cluster analysis further revealed two distinct groups: The high coping group reported significantly higher coping strategy use than the low coping group (p < 0.001). The two groups also favored different strategies (p < 0.001), with the high coping group showing significantly higher relative preferences than the low coping group for active problem-solving, proactive prevention, and strategic planning (all ps < 0.05). The groups furthermore differed significantly in psychological strengths (i.e., personality, self-efficacy, ps < 0.001) and well-being outcomes (i.e., life satisfaction, p = 0.05). DISCUSSION: This study provides evidence for a general preference for acceptance and emotion control in very old individuals, supporting theories of a developmental coping shift in old age, yet our findings also document the existence of groups with different coping patterns. More frequent coping use, and particularly continued use of active problem-solving and proactive prevention, may enable well-being in very old age.

Cognition, function, and prevalent dementia in centenarians and near-centenarians: An individual participant data (IPD) meta-analysis of 18 studies.

INTRODUCTION: There are limited data on prevalence of dementia in centenarians and near-centenarians (C/NC), its determinants, and whether the risk of dementia continues to rise beyond 100. METHODS: Participant-level data were obtained from 18 community-based studies (N = 4427) in 11 countries that included individuals ≥95 years. A harmonization protocol was applied to cognitive and functional impairments, and a meta-analysis was performed. RESULTS: The mean age was 98.3 years (SD = 2.67); 79% were women. After adjusting for age, sex, and education, dementia prevalence was 53.2% in women and 45.5% in men, with risk continuing to increase with age. Education (OR 0.95;0.92-0.98) was protective, as was hypertension (odds ratio [OR] 0.51;0.35-0.74) in five studies. Dementia was not associated with diabetes, vision and hearing impairments, smoking, and body mass index (BMI). DISCUSSION: Among the exceptional old, dementia prevalence remains higher in the older participants. Education was protective against dementia, but other factors for dementia-free survival in C/NC remain to be understood.

Focusing on the Positive: Home Health Aides' Desire for Autonomy and Control.

Home Health Aides (HHAs) are one of the fastest growing workforces in the country, yet the industry struggles to recruit and retain workers. This study explored HHAs' experiences with the level of control, autonomy, and decision-making authority in their work. Six focus groups with 37 HHAs were conducted in Massachusetts. Findings showed that HHAs viewed control as a positive job characteristic, which attracted them to and led them to remain in the position. Positive benefits included having control over client selection, location, hours, and the ability to determine their day-to-day tasks and schedules. The study results highlight the value that HHAs place on autonomy and control and the potential benefit that these job qualities have for greater recruitment and retention of these workers. Amplifying control by bolstering training and expanding scope of practice may entice new individuals to pursue a HHA career and help maintain those currently in the position.

The Role of Contextual Factors in the Health Care Utilization of Aging LGBT Adults.

BACKGROUND AND OBJECTIVES: Research suggests lesbian, gay, bisexual, and transgender (LGBT) populations have unique health care challenges. The purpose of this study was to understand contextual factors, including minority stress and social resources, associated with the health care utilization of LGBT middle-aged and older adults. RESEARCH DESIGN AND METHODS: Using data from the Caring and Aging With Pride: National Health, Aging, and Sexuality/Gender Study (N = 2,560), multiple logistic regression investigated associations between minority stress (i.e., internalized stigma and LGBT identity disclosure) and health care utilization (i.e., health screenings, emergency room use, routine checkups, and regular provider). We also examined the moderating effect of social resources (i.e., social network size, social support, and LGBT community belonging) in these associations. RESULTS: Internalized stigma was negatively associated with having a routine checkup in the previous year. LGBT identity disclosure was positively associated with having a health screening within the past 3 years. Social support moderated the association between LGBT identity disclosure and health screenings. DISCUSSION AND IMPLICATIONS: Health and human service professionals and their clients should be educated about the ways that LGBT identity disclosure can affect health care utilization. Providers should consistently assess the social support of their aging LGBT clients and inform them about the potential risk of low social support in health care utilization.

From dementia mindsets to emotions and behaviors: Predicting person-centered care in care professionals.

BACKGROUND AND OBJECTIVE: High-quality care standards for dementia care are increasingly based on person-centered care principles. To better understand facilitating factors of person-centered care this research focuses on individual characteristics of care professionals. Applying mindset theory to dementia care, we examined dementia mindsets (viewing dementia symptoms as either malleable or fixed) in care professionals. We tested whether there is a positive relationship between a malleable dementia mindset and person-centered care as well as a negative relationship between a fixed dementia mindset and person-centered care. Moreover, we examined whether care professionals' emotional responses in care situations help explain associations between dementia mindsets and person-centered care. RESEARCH DESIGN AND METHOD: In two cross-sectional studies, care professionals of long-term care facilities (total N = 370) completed a measure of dementia mindsets and reported their emotional and behavioral responses to five care scenarios. Regression and mediation analyses were performed. FINDINGS: The tested hypotheses were partially supported. A fixed dementia mindset predicted reported person-centered care negatively, while a malleable dementia mindset did not. Mediation analyses suggest that reduced negative emotions may underlie the association between a malleable mindset and reported person-centered care, while reduced positive emotions in care situations may underlie the association of a fixed mindset and reported person-centered care. Study 2 partially replicated these findings. A fixed mindset and positive emotional responses were the most robust predictors of reported person-centered care. DISCUSSION AND IMPLICATIONS: This study extends knowledge on facilitators (positive emotional responses to care situations) and barriers (fixed dementia mindset) to person-centered care in care professionals working with persons with dementia. We discuss how dementia mindsets and emotional responses to care situations may be a fruitful target for trainings for care professionals.

Awareness, Acceptance, Avoidance: Home Care Aides' Approaches to Death and End-of-Life Care.

Death and dying are woven throughout the work of home care aides, and yet the care they provide at the end of life (EOL) remains poorly understood. This is due in part to the multiple circumstances under which aides provide EOL care. In this paper, we elucidate the EOL care experiences of aides working in home care agencies in New York City. We conducted in-depth interviews with 29 home care aides, and we analyzed these data using inductive, team-based methods. Our findings show that aides may not be aware of or accept a client's EOL status, and they may avoid EOL care. These conditions shape EOL care, and we detail the committed forms of care aides provide when they are aware and accepting. We recommend improved training, support systems, and policy change to enhance aides' contributions to EOL care, while protecting aides' health and well-being.

Social Resource Variations Among LGBT Middle-Aged and Older Adults: The Intersections of Sociodemographic Characteristics.

BACKGROUND AND OBJECTIVES: Understanding the influence of social resources on health is crucial in gerontological research. However, access to social resources may differ by one's particular lesbian, gay, bisexual, and transgender (LGBT) identity and the intersection of LGBT identity with other sociodemographic characteristics, including age. RESEARCH DESIGN AND METHODS: Using 2010 data from Caring and Aging With Pride (N = 2,536), this study examined how access to social resources varied by LGBT identity and whether the effect of LGBT identity was modified by additional sociodemographic characteristics among LGBT adults aged 50-95 years. RESULTS: Lesbian respondents had larger social networks than gay male respondents, and gay male respondents had smaller networks than transgender respondents. Lesbian respondents reported more social support and community belonging than other identity groups. Bisexual male respondents and transgender respondents had less support than gay male respondents, and bisexual male respondents reported less community belonging than gay male respondents. Age and education moderated the association between LGBT identity and social support. DISCUSSION AND IMPLICATIONS: This study demonstrated differences in access to social resources according to environmental circumstances that can intersect and govern access to social resources. Findings highlight the importance of considering social support separately from social network size; thus, large social networks do not necessarily provide ample social support. LGBT older adults had different perceptions of social support than their middle-aged counterparts. Health and human service professionals should not only consider the sexual and gender identity of their LGBT clients, but also education and age when assessing access to social resources.

Understanding the Role of Virtual Outreach and Programming for LGBT Individuals in Later Life.

Due to health disparities LGBT older adults may have more health care needs, but they are likely to have less informal sources of support. While efforts have been made to serve LGBT older adults, traditional forms of in person outreach and service may still be inaccessible to those living in rural areas, with restricted mobility, due to lack of transportation, during inclement weather, or in public health situations as the Covid-19 pandemic. We conducted focus group discussions to understand the role of virtual outreach in serving LGBT individuals' needs in their later years of life. Study participants expressed a desire for dating, community, aging in place, and affirming health care. However, their experience of internalized and institutional homophobia and ageism may act as barriers in fulfilling those needs. A dedicated virtual space has the potential to overcome these barriers by facilitating online get-togethers, support groups, dating events, having coming out resources, and exchanging information on LGBT friendly health services. Having a space to express their generativity may make such virtual services more empowering. Lack of technological access and privacy concerns may hinder the use of virtual services but can be overcome with training and education.

Psychological and Physical Health in Widowhood: Does Marital Quality Make a Difference?

We investigate how preloss marital quality is associated with changes in psychological distress and physical health among older widow(er)s. Using prospective data with a 2-year follow-up from the Health and Retirement Study, we selected 546 respondents who transitioned into widowhood. Respondents were classified as supportive, ambivalent, aversive, or neutral groups. The supportive and ambivalent group experienced greater increase in depressive symptoms compared to the aversive group, in widowhood. The aversive group showed greater increase in chronic conditions compared to the supportive group. Findings indicated that spousal loss may result in more psychological distress for those with supportive and ambivalent marital relationship. Yet, those with mostly negative accounts of their marriage may experience worsened physical health, albeit no increase in psychological distress. Understanding different benefits and challenges facing older individuals after a positive or negative marriage may help direct support and interventions efforts toward older couples during marriage and in widowhood.

Interventions to Reduce the Impact of Client Death on Home Care Aides: Employers' Perspectives.

For home care agencies and aides, the death of clients has important, yet often unrecognized, workforce implications. While research demonstrates that client death can cause grief and job insecurity for aides, we currently lack home care agencies' perspectives on this issue and approaches to addressing it. This study uses key informant interviews with leaders from a diverse sample of eight New York City home care agencies to explore facilitators and barriers to agency action. We found that agencies engaged primarily in a range of informal, reactive practices related to client death, and relatively few targeted and proactive efforts to support aides around client death. While leaders generally acknowledged a need for greater aide support, they pointed to a lack of sustainable home care financing and policy resources to fund this. We recommend increased funding to support wages, paid time off, and supportive services, and discuss implications for future research.

"I'm Getting Older Too": Challenges and Benefits Experienced by Very Old Parents and Their Children.

Very old parents and their "old" children are a growing group in industrialized countries worldwide. However, virtually nothing is known about the nature and implications of this relationship constellation. To fill this gap, this study explored the challenges and rewards of the very old parent-child relationship. In-depth interviews were conducted with 114 parent-child dyads (parent age ≥90; child age ≥65). While both challenges and rewards were present, the balance of challenges and rewards was notably less favorable for children with more challenges experienced overall. Challenges reported by children were often characterized by references to children's own advanced age and health problems, and the prolonged caregiving involvement due to their parents' longevity. Health care professionals, policymakers, and families should be made aware of this increasingly common phenomenon, and specific services and policies will be needed to adequately support very old adults and their families.

Diagnoses of Chronic Health Conditions and Change in Subjective Age: The Moderating Role of Chronological Age.

BACKGROUND AND OBJECTIVES: Health is a predictor of subjective age, and although inconclusive, the strength of this association is not uniform across different age groups. This study investigates if new diagnoses of chronic health conditions are associated with a change in subjective age and if chronological age moderates this relationship. RESEARCH DESIGN AND METHODS: Using data from the Health and Retirement Study, residualized change regression analysis was performed for a sample of 5,158 respondents older than 50 years to examine their subjective age in 2014 relative to that reported in 2010. The main predictor was the number of chronic health conditions newly diagnosed between 2010 and 2014. Chronological age in 2010 was the moderator. RESULTS: Results showed that each new diagnosis of a chronic health condition was significantly associated with a 0.68-year increase in subjective age reported in 2014, compared to subjective age reported in 2010. However, this increase in subjective age was attenuated by 0.05 years for each additional year in 2010 chronological age. DISCUSSION AND IMPLICATIONS: According to Social and Temporal Comparison theories, people compare themselves to their age peers and earlier selves. Given expectations for better health at younger chronological ages, being diagnosed with chronic health conditions may have a stronger association with subjective age among middle-aged persons when compared with older persons. The findings suggest that subjective age may be used as a screening tool to predict how chronic disease diagnosis may influence peoples' sense of self, which in turn shapes future health.

Support Exchanges Among Very Old Parents and Their Children: Findings From the Boston Aging Together Study.

BACKGROUND AND OBJECTIVES: Very old parents and their "old" children are a growing group in industrialized countries worldwide. Care needs of very old parents can be substantial, while children may also face their own age-related issues. Continued mutual support represents an important pathway to addressing emerging care needs. This study aimed to identify patterns of support exchanges occurring in very old parent-child dyads and to ascertain associated individual and relationship factors. RESEARCH DESIGN AND METHODS: Participants were 114 very old parents (aged ≥90) and their children (aged ≥65) from the Boston Aging Together Study. Data were collected using comprehensive, semistructured in-person interviews with both dyad members, including standardized assessments of support exchanges, relationship quality, health, and perceptions of family norms. Actor-Partner Interdependence Models were used to predict upward and downward support reported by children and parents. RESULTS: Both dyad members not only reported substantial upward support (child to parent) in all domains but also notable amounts of downward (parent to child) in the domains of emotional support, listening, and socializing. Findings showed significant associations of parent functional impairment, parent and child relationship quality, and child perceptions of family obligation with upward support and of relationship quality with downward support. DISCUSSION AND IMPLICATIONS: Continued support exchanges among very old parents and their children indicated that intergenerational theories still hold up in very late-life relationships. Health care professionals should be aware that attention to relationship quality and family norms might be vital to ensure that support needs are met.

Use of Home Care Services Reduces Care-Related Strain in Long-Distance Caregivers.

BACKGROUND AND OBJECTIVES: Prior work examining the role of older adult home care service use in alleviating strain in family caregivers has resulted in contradictory findings. However, prior research has been entirely limited to caregivers who live within close geographical proximity to their care recipients. Long-distance caregivers are a unique caregiving subgroup that has remained understudied. Guided by the stress process model, this study examined if the association between primary caregiving stressors (the care recipient's functional and cognitive status) and secondary stressors (perceived role strains related to work and to other family responsibilities) in long-distance caregivers was mediated by the care recipient's utilization of home care services. RESEARCH DESIGN AND METHODS: The sample included 166 long-distance caregivers in the United States who provide and manage care to a community-dwelling care recipient living 2 or more hours away. Participants reported on their care recipient's cognitive and functional status, perceived interference of caregiving with work and other family responsibilities, and the care recipient's use of home care services. RESULTS: Path analyses show that home care use by the care recipient fully mediated the association between care recipients' functional impairment and caregiver strains (work and family). Furthermore, home care use partially mediated the effects of care recipients' cognitive impairment on caregiver strains. DISCUSSION AND IMPLICATIONS: Results indicate that the care recipient's home care service utilization may serve as a protective factor against care-related strain in long-distance caregivers. These findings can be used to inform intervention efforts focused on a family-centered care approach that can be specifically tailored to long-distance caregivers.

A systematic review of loneliness in bereavement: Current research and future directions.

Bereaved people suffer from loneliness and loneliness is associated with poor mental health. In this study, this topic is reviewed. An agenda is suggested for future research. Research that is theory-driven, addresses measurement consistency, correlates of loneliness in bereaved and non-bereaved, and treatment is necessary for prevention and intervention.

Loneliness in Bereavement: Measurement Matters.

The role of loneliness in the bereavement experience has been reported as substantial, with the death of a close person leaving a considerable void in the life of the bereaved. Yet, there is lack of agreement about its precise role and, notably, whether loneliness should be included as a core symptom for diagnosis of grief complications. The ongoing threat of heightened social isolation due to the COVID-19 pandemic underlines the need to understand the impact of loneliness, and to accurately chart its prevalence, intensity, duration, and associated difficulties in the context of bereavement. Assessment issues are central to this endeavor. In this article, we review the scientific literature to examine how loneliness after bereavement has been operationalized and measured. Sixty-three articles analyzing 51 independent datasets were reviewed. Results show major disparities: approximately half of the projects assessed loneliness by means of one of two validated scales (spanning different versions); the remainder included only single- or few-item measures. Diverse instructions, content and answer categories were used. While one size does not fit all, awareness of assessment options and dis/advantages may aid selection of the most appropriate measure, to suit the goals of a particular study and the specific groups under investigation. Our conclusion is that, in selecting a loneliness measure, health care professionals should come to their own well-informed decision, aided by the information provided in our review.

Evaluation of the Caring Ahead: Preparing for End-of-Life With Dementia Questionnaire.

OBJECTIVES: Family caregivers of persons with dementia rarely feel prepared for end of life although preparedness predicts outcomes in bereavement. The Caring Ahead: Preparing for End-of-Life With Dementia questionnaire was developed to measure family caregiver death preparedness. The aim of this study was to evaluate questionnaire psychometrics and refine the Caring Ahead questionnaire. DESIGN: A quantitative cross-sectional reliability study design was used to evaluate the questionnaire. SETTING/PARTICIPANTS: Data were collected by mail from 134 English-speaking family caregivers of persons with dementia recruited from more than 50 congregate living facilities in Canada. Thirty-two participants completed a test-retest. METHODS: Analysis of psychometrics included exploratory factor analysis, calculation of correlation with a single-global preparedness item, Cronbach alpha, intraclass correlation coefficient (ICC) over time. RESULTS: A 4-factor model with 20 items emerged through exploratory factor analysis with principal factors extraction and promax rotation. The revised questionnaire includes 4 factor subscales: Actions (7 items), Dementia Knowledge (5 items), Communication (4 items), and Emotions and Support Needs (4 items). Evidence was demonstrated for concurrent validity (0.44-0.55, P < .001), internal consistency (alpha > 0.7), and reliability (ICCs > 0.7). Lower levels of preparedness were reported for "knowing what the dying process with dementia may be like" and "discussing end-of-life care and preferences with health care providers." CONCLUSIONS AND IMPLICATIONS: Preliminary evidence for validity and reliability of the refined 20-item Caring Ahead questionnaire suggests the questionnaire may be useful to clinicians and researchers seeking to assess caregivers' feelings of preparedness, identify specific areas for intervention, and evaluate the effectiveness of caregiver interventions. Additional testing is needed to evaluate predictive validity.