The Older, the Happier?: A Cross-Sectional Study on the "Paradox of Aging" in China.

The "paradox of aging" refers to the phenomenon that even though people's physical health and functions may decline when they enter later adulthood, their happiness does not necessarily. Previous studies have shown that older adults' better emotional regulation skills may contribute to the maintenance of their happiness. This study aims to examine the relationship between age, health, and happiness, and the moderating role of emotional stability. We adopted a nationally representative sample (n = 10,968) from the Chinese General Social Survey (CGSS) and performed weight-adjusted regression models with interaction terms. There is generally an S-shaped age-happiness relationship with significant urban-rural differences. Emotional stability buffers the negative association between health and happiness, and this moderating effect was stronger among older than younger adults, especially in rural China. This study calls for special attention paid to the oldest-old population in rural China and older adults' emotional regulation skills.

Accuracy of Caregiver Proxy Reports of Home Care Service Use.

Although much of the research on service use by older adults with dementia relies on proxy reports by informal caregivers, little research assesses the accuracy of these reports, and that which does exist, does not focus on home care services. This brief report compares proxy reports by family caregivers to those with dementia with provincial Ministry of Health records collected for payment and monitoring. The four home care services examined include home nursing care, adult day care, home support, and respite care. Data come from a province-wide study of caregivers in British Columbia, Canada. Caregiver reports are largely consistent with Ministry records, ranging from 81.0% agreement for home support to 96.6% for respite care. Spouses living with the care recipient (the vast majority of the sample) are the most accurate. Others, whether living with the care recipient or not, have only a 50-50 chance of being correct.

Caregiver Experiences Across Three Neurodegenerative Diseases: Alzheimer's, Parkinson's, and Parkinson's With Dementia.

OBJECTIVE: This article asks whether distinct caregiver experiences of Alzheimer's disease (AD), Parkinson's disease (PD), and Parkinson's disease with dementia (PDD) spouses are accounted for by disease diagnosis or by a unique combination of symptoms, demands, support, and quality of life (QOL) cross disease groups. METHOD: One hundred five live-in spouse caregivers (71.4 ± 7 years) were surveyed for persons with AD (39%), PD (41%), and PDD (20%). A hierarchical cluster analysis organized caregivers across disease diagnosis into clusters with similar symptom presentation, care demands, support, and QoL. RESULTS: Four clusters cut across disease diagnosis. "Succeeding" cared for mild symptoms and had emotional support. "Coping" managed moderate stressors and utilized formal supports. "Getting by with support" and "Struggling" had the greatest stressors; available emotional support influenced whether burden/depression was moderate or severe. The results remain the same when diagnostic category is added to the cluster analysis. DISCUSSION: This study supports going beyond disease diagnosis when examining caregiver experiences.

Relationship and stage of dementia differences in caregiver perspectives on the meaning of activity.

Caregivers of persons living with dementia (PWD) taking cholinesterase inhibitors, who care 3 + h over three days/week, were interviewed. This study uses thematic content analysis to compare responses to the open-ended question " What do you believe getting involved in activities outside the home means for someone with dementia?" in spouse ( n = 613) and adult-children ( n = 260) caregivers, and across mild ( n = 314) and moderate-severe stages ( n = 280). For adult-children caregivers, activity participation promotes independence in their parents. Spouses describe activity in the context of their relationship with the PWD, and the experience is framed around their continued social roles as a couple. Mild-stage caregivers report the difficulty and negative outcomes (e.g. frustration, stigma) of engaging in activity, while moderate-severe caregivers discuss activity as preserving abilities in PWD and providing connection to cohort. This may indicate areas for improved activity provision and support for spouse (i.e. emotional) and adult-children (i.e. resources) caregivers across dementia stages.

Family Involvement in Nursing Homes: Are Family Caregivers Getting What They Want?

The provision of person-centered care for nursing home residents with dementia suggests the need for family caregiver involvement. In this article, we argue that optimal family involvement differs by family caregiver and therefore depends on the degree to which family caregivers consider their own involvement to be important. In this Canadian study, we compare the importance that 135 family caregivers of residents with dementia place on 20 kinds of involvement with the degree to which they perceive opportunities for involvement. Family Involvement Congruence Scores are calculated in three ways: those for whom involvement is important, those for whom involvement is not important, and an overall congruence score. Congruence scores varied by involvement type. These scores show promise for use in future research on family caregiver involvement and as tools for use by facilities as they endeavor to meet family caregiver expectations for involvement.

Cholinesterase Inhibitor Utilization: The Impact of Provincial Drug Policy on Discontinuation.

BACKGROUND: In October 2007, British Columbia started to cover the cost of cholinesterase inhibitors (ChEIs)-donepezil, galantamine, and rivastigmine-for patients with mild to moderate dementia and prominent Alzheimer's disease. OBJECTIVES: To examine the impact of this policy on persistence with ChEIs. METHODS: A population-based cohort study was conducted using British Columbia administrative health data. We examined 45,537 new ChEI users aged 40 years and older between 2001 and 2012; 20,360 (45%) started the treatment after the coverage policy was launched. Patients were followed until treatment discontinuation, defined as a ChEI-free gap of 90 days, death, or December 2013. Persistence on ChEIs was estimated using survival analysis and competing risk approach. Hazards of discontinuation were compared using competing risk Cox regression with propensity adjustment. RESULTS: Patients who started ChEI therapy after the introduction of the coverage policy had a significantly longer persistence. Median ChEI persistence until discontinuation or death was 9.37 months (95% confidence interval [CI] 9.0-39.7) and 17.6 months (95% CI 16.9-18.3) in patients who started therapy before and after the new policy, respectively. The propensity-adjusted hazard ratio for discontinuing therapy was 0.91 (95% CI 0.88-0.94). Similar patterns were observed for persistence with the first ChEI (propensity-adjusted hazard ratio of 0.94; 95% CI 0.91-0.98). In rivastigmine users, the hazard ratio was insignificant (0.98; 95% CI 0.92-1.02). CONCLUSIONS: The British Columbia ChEI coverage policy was associated with significantly prolonged persistence with donepezil and galantamine, but not rivastigmine.

Relocation and Social Support Among Older Adults in Rural China.

OBJECTIVES: China's economic reforms have led to millions of citizens being relocated to support infrastructure development, reduce poverty, and address ecological, disaster-related and other concerns. This study expands on previous research on the implications of relocation in China by examining the impact of rural elders' relocation on the perceived availability of emotional, instrumental, and financial support. METHODS: Data were drawn from the Ankang Study of Aging and Health conducted with a representative sample of 1,062 rural residents aged 60 and over living in Ankang, China. Two-stage probit and least squares regression models assessed the impact of relocation on familial and nonfamilial emotional, instrumental, and financial support. RESULTS: Relocation was negatively associated with the number of social support resources that older adults perceived as being available. Although this was the case with regard to both familial and nonfamilial support, it was particularly evident with regard to family support and, within families, with regard to instrumental rather than financial or emotional support. DISCUSSION: Relocation has negative implications for the number of social support resources perceived to be available by older adults in rural China. China will need to come to terms with how to provide for the instrumental support needs of an aging society.

A More Nuanced Discussion Required.

Williams and colleagues make a valuable contribution to the home care policy literature, however, their arguments are not always convincing. Missing is a more nuanced discussion of research showing that even when governments provide more supportive services for older adults, families continue to provide care, and a discussion of alternative forms of caring that may arise in the future such as care from siblings and non-married older adults helping one another. Drawing on research pointing to several countries that offer caregivers a range of services would also have been helpful. Furthermore, it is not clear, as the authors argue, that the reason policy makers have moved toward providing for higher needs patients with fewer and fewer services for lower needs patients is a 'wait and see' attitude. Alternative reasoning is just as plausible. The benefits of providing supports to caregivers of children are well articulated but this does not negate the need among caregivers to older adults where some of the issues differ from caring for sick and disabled minors. Finally, action items for government are not offered but could have been helpful. Examples are provided.

Meaningful activity for persons with dementia: family caregiver perspectives.

Dementia threatens the capacity to engage in activity, suggesting meaningful activity may be helpful for persons with dementia (PWDs). This study explores the concept of meaningful activity, as defined by caregivers of PWDs. Family caregivers of PWDs, who provide 3 hours of care over 3 days/week, were interviewed after 6 months of cholinesterase inhibitors (ChEIs) therapy. Caregiver responses (N = 906) to the open-ended question What do you believe getting involved in activities outside the home means for someone with dementia are assessed. The themes are analyzed in terms of content, frequency, co-occurrence, and dementia severity. Caregivers emphasize the benefits of social connectedness, physical health, and mental stimulation. Activity is also viewed as respite, difficult, and has no meaning for care recipient. The implications of activity for self- and social-identity in PWD and caregiver are discussed. The benefits of activity varied by stage of disease. This knowledge indicates areas for improved activity provision and health care support.

Caregiver Well-Being: Intersections of Relationship and Gender.

We know much about caregiving women compared with caregiving men and caregiving spouses compared with caregiving adult children. We know less about the intersections of relationship and gender. This article explores this intersection through the well-being (burden and self-esteem) of caregivers to family members with dementia. Throughout British Columbia, Canada, 873 caregivers were interviewed in person for on average, over 1½ hours. The results reveal that daughters experience the highest burden but also the highest self-esteem, suggesting the role is less salient for their self-identities. Wives emerge as the most vulnerable of the four groups when both burden and self-esteem are considered. The data confirm the usefulness of the intersectionality framework for understanding co-occupancy of more than one status and indicate that positive cognitive well-being and negative affective well-being can be differentially related. Multivariate analyses confirm the importance of caregiver, not patient, characteristics for burden and self-esteem.

Influence of home care on life satisfaction, loneliness, and perceived life stress.

Strong evidence has established the medical and health services utilization benefits of home care services for older adults. However, sparse research has been conducted on potential psychosocial benefits. Older adults (65 and over) receiving home care with their needs met are compared with persons who have unmet needs (whether they received home care or not) on three key indicators of quality of life ­ life satisfaction, loneliness, and perceived life stress. Data are drawn from the 2008-2009 Canadian Community Health Survey respondents who met the study criteria (n = 3,244). Regression analyses showed that older adults who had their home care needs met reported higher levels of life satisfaction, and lower levels of loneliness and perceived life stress, than those with unmet needs, net of co-variates. The results suggest that filling this home care gap would significantly raise quality of life by increasing social and environmental resilience to age in place.

Spouse and adult child differences in caregiving burden.

This study compared the correlates of burden for spouse and adult child caregivers at two points in time and assessed whether correlates at T(1) predicted burden at T(2). The sample consisted of 878 caregivers to older adults throughout British Columbia who were prescribed cholinesterase inhibitors. Burden was measured six months after the older adult was prescribed the medication and one year later (n = 759). Findings suggest that adult children experience more burden than spouses at both T(1) and T(2) with adult children but not spouses decreasing their burden over time. Correlates of T(1) burden explained significant amounts of variance, revealing differential correlates for the two groups and the importance of caregiver characteristics over patient characteristics. Burden at T(2) is explained mostly by T(2) factors, plus T(1) burden, suggesting the importance of relatively immediate factors for direct effects on caregiver burden. Indirect effects operated through T(1) burden.

Change and predictors of change in social skills of nursing home residents with dementia.

BACKGROUND: Social skills are of primary importance for those with dementia and their care providers, yet we know little about the extent to which basic social skills can be maintained over time and the predictors of change. METHODS: A total of 18 nursing homes with 149 newly admitted residents with moderate to severe dementia, 195 direct care staff, and 135 family members, in British Columbia, Canada, contributed data on change in social skills from admission to 6 months and 1 year later. RESULTS: Three-quarters of residents maintained or improved their basic social skills during both the time periods. Decline was explained primarily by cognitive status at the time of admission, notably present orientation. However, staff-to-resident communication becomes more important over time. CONCLUSIONS: Social skills appear to present an opportunity to maintain interaction with these residents. The findings also suggest that a focus on the present orientation before and following admission and on staff-to-resident communication may be beneficial.

The conceptualization and measurement of individualized care.

Individualized nursing care, a form of person-centered care delivery, is accepted as best practice, yet its implementation into actual care is far from complete. Appropriate measures of this elusive concept are needed to better understand barriers to implementation. This study explored and tested the convergent validity and the reliability of 2 individualized nursing care measures. A cross-sectional survey design was used to collect data using the Individualized Care Scale and the Individualized Care Instrument (ICI) from a sample of nurses (n = 263, response rate 71%) working in older peoples' care settings in Finland, and the data were analyzed statistically. Cronbach's alpha coefficients for the ICI scales (.63-.80) and ICS-A and B subscales (both α = .91) demonstrated only moderate correlation between the 2 instruments (r = -.39 to .50) and possibly the complexity of measuring "individualized care." The study acknowledges the latent influence of culture and care approach to the conceptualization of individuality. It concludes that the concept may best be measured at this point with the use of other factors in addition to instruments to capture its multiple domains.

Aging and late-life depression.

OBJECTIVES: The objective of this study is to examine the relationship between age and depression among people aged 65 and older. METHOD: The study uses three waves of longitudinal data (1991, 1996, 2001) from a community and institutional sample of Canadians aged 65 and older. The study uses generalized linear mixed-model techniques to estimate the trajectories of depressive symptoms and major depression in late life. RESULTS: There is a linear increase in depressive symptoms after age 65, but this occurs in the context of medical comorbidity and is not an independent effect of aging. There is a significant u-shaped relationship between age and major depression, after adjusting for selected covariates. DISCUSSION: The relationship between age and late-life depression is complex, and it depends on how the dependent variable is measured. Late-life depression develops through a different set of risk factors than it does in earlier stages of the life course. The "fourth age" appears to be a period of psychiatric morbidity.

Filial caregivers; diasporic Chinese compared with homeland and hostland caregivers.

This paper examines the distinctiveness and similarities of diasporic Chinese Canadian caregivers to older adults compared with Hong Kong Chinese and Caucasian Canadian caregivers. Particular interest lies in whether filial responsibility, actual caregiving behaviours, health and a variety of structural characteristics cluster in ways that suggest these three groups of filial caregivers are distinctive. Data were collected using face-to-face interviews. The findings suggest that the caregivers participating in this study cluster into types that roughly approximate their original cultural groupings. Interestingly, however, the diasporic or immigrant Chinese appear more similar to homeland (Hong Kong) than hostland (in this instance Caucasian) Canadian caregivers - all diasporic Chinese were originally, or their ancestors were, from Hong Kong. Chinese Canadians are not necessarily in the middle in terms of caregiving behaviours, but rather show variability depending on the behaviour examined. In addition, these findings confirm past research that Western culture does not have clear and explicit norms of filial responsibility to the same extent as does Chinese culture.

Social support, caregiving, and aging.

This article reviews the international English-language literature on social support and caregiving in gerontology since the early 1990s. The literature has grown, but consensus on the terms' meaning and measurement is lacking. Interest is ongoing in practical help, in benefits of social support, and in demands and negative outcomes for caregivers, with growing but less emphasis on more theoretical questions, on negative outcomes from the receipt of support, and on positive consequences of providing care. Nevertheless, social support is duly recognized as a social determinant of health and receiving attention at policy levels - both are significant shifts from two decades ago and add to the interest this area will receive from researchers in coming decades. There remain many unanswered questions regarding the changing societal context, but it is clear that the social support of others - throughout our lives including old age - will continue in the future, albeit in ever-changing forms.

An evidence-based policy prescription for an aging population.

In this paper, the authors provide a policy prescription for Canada's aging population. They question the appropriateness of predictions about the lack of sustainability of our healthcare system. The authors note that aging per se will only have a modest impact on future healthcare costs, and that other factors such as increased medical interventions, changes in technology and increases in overall service use will be the main cost drivers. They argue that, to increase value for money, government should validate, as a priority, integrated systems of care delivery for older adults and recognize such systems as a major component of Canada's healthcare system, along with hospitals, primary care and public/population health. They also note a range of mechanisms to enhance such systems going forward. The authors present data and policy commentary on the following topics: ageism, healthy communities, prevention, unpaid caregivers and integrated systems of care delivery.

Measurement and analysis of individualized care inventory responses comparing long-term care nurses and care aides.

PURPOSE: Motivating and enabling formal caregivers to provide individualized resident care has become an increasingly important objective in long-term care (LTC) facilities. The current study set out to examine the structure of responses to the individualized care inventory (ICI). DESIGN AND METHODS: Samples of 242 registered nurses (RNs)/licensed practical nurses (LPNs) and 326 care aides were recruited from 54 LTC facilities in 3 of 5 British Columbia health authorities. Baseline confirmatory factor analytic (CFA) models were computed separately for RNs/LPNs and care aides; invariance analyses were next undertaken to compare these CFA models. RESULTS: For both RNs/LPNs and care aides, support was found for a 4-factor model of ICI responses mapping onto a higher order individualized care (IC) construct. This model was largely equivalent between formal caregiver groups, although the relative contribution of certain first-order factors differed between the two. Of further note, both groups appear to interpret and respond to 31 of 35 ICI items in a similar manner. IMPLICATIONS: The results of this study provide further support for the psychometric properties of ICI responses. Although further research is required, the ICI appears to be an appropriate self-report measure. This instrument may be used by researchers, policymakers, administrators, and practitioners alike to assess strengths as well as areas for improving the delivery of IC to LTC residents by formal caregivers.

Who cares and how much? The imputed economic contribution to the Canadian healthcare system of middle-aged and older unpaid caregivers providing care to the elderly.

Canadians provide significant amounts of unpaid care to elderly family members and friends with long-term health problems. While some information is available on the nature of the tasks unpaid caregivers perform, and the amounts of time they spend on these tasks, the contribution of unpaid caregivers is often hidden. (It is recognized that some caregiving may be for short periods of time or may entail matters better described as "help" or "assistance," such as providing transportation. However, we use caregiving to cover the full range of unpaid care provided from some basic help to personal care.) Aggregate estimates of the market costs to replace the unpaid care provided are important to governments for policy development as they provide a means to situate the contributions of unpaid caregivers within Canada's healthcare system. The purpose of this study was to obtain an assessment of the imputed costs of replacing the unpaid care provided by Canadians to the elderly. (Imputed costs is used to refer to costs that would be incurred if the care provided by an unpaid caregiver was, instead, provided by a paid caregiver, on a direct hour-for-hour substitution basis.) The economic value of unpaid care as understood in this study is defined as the cost to replace the services provided by unpaid caregivers at rates for paid care providers.