Dementia care and prevention in community settings: a built environment framework for cognitive health promotion.

PURPOSE OF REVIEW: Most people with dementia live in the community. As lifespan increases, one in three persons aged 85+ are expected to live with dementia. We conduct a systematic search to identify frameworks for dementia care and prevention in community settings. This is important to ensure quality of life for people living with cognitive decline (PLCD). RECENT FINDINGS: 61 frameworks are synthesized into the dementia care and prevention in community (DCPC) framework. It highlights three levels of provision: built environment and policy supports, access and innovation, and inclusion across stages of decline. Domains of intervention include: basic needs; built environment health and accessibility; service access and use; community health infrastructure; community engagement; mental health and wellbeing; technology; end-of-life care; cultural considerations; policy, education, and resources. Personhood is not adequately represented in current built environment frameworks. This is supplemented with 14 articles on lived experiences at home and social practices that contribute to PLCD's social identity and psychological safety. SUMMARY: Policy makers, health and built environment professionals must work together to promote "personhood in community" with PLCD. Clinicians and community staff may focus on inclusion, social identity and a sense of at-homeness as attainable outcomes despite diagnosis.

Neighborhood Makes or Breaks Active Ageing? Findings from Cross-Sectional Path Analysis.

Mental ill-health prolongs and complicates other chronic illnesses, which is a major public health concern because of the potential stress it places on health systems. Prevention via active aging and place-based interventions thus became increasingly important with population aging, e.g., through health promotion and age-friendly neighborhoods. However, how the targeted outcomes of these efforts are related remains unclear. This paper examined whether the relationship between active living and mental health or health-related quality of life is mediated by neighborhood cohesion. Cross-sectional data were drawn from n = 270 community-dwelling adults aged 50 and above in the Gerontology Research Program-Center for Ageing Research in the Environment (GRP-CARE) Survey. Path analysis showed that one can live actively for better mental health (Btotal = 0.24), but it is largely mediated by neighborhood cohesion (37%). Further examination of the factors of neighborhood cohesion showed that this mediation is explained by communal affordance (Bindirect = 0.05) and neighborhood friendship (Bindirect = 0.05). Additional study of the association between these mediators and factors of mental health revealed two psychosocial processes: (1) better community spaces (e.g., greenery and third places) support communal living (B = 0.36) and help older adults obtain emotional support (B = 0.32) for greater autonomy (B = 0.25); (2) spending more time outdoors enhances neighborhood friendship (B = 0.33) and interpersonal skills (B = 0.37), which in turn improves coping (B = 0.39). In short, the effects of active living on health are limited by one's neighborhood environment. Neighborhood cohesion must be considered or it may stifle individual and policy efforts to age actively and healthily in urban environments. Context-sensitive implementations are required.

Environmental Influences on Life Satisfaction and Depressive Symptoms Among Older Adults With Multimorbidity: Path Analysis Through Loneliness in the Canadian Longitudinal Study on Aging.

BACKGROUND AND OBJECTIVES: More older adults with multimorbidity are aging in place than ever before. Knowing how the environment affects their mental well-being could enhance the efficacy of age-friendly interventions for multimorbidity resilience. With reference to the Transdisciplinary Neighborhood Health Framework, we construct and examine a priori models of environmental influences on life satisfaction and depressive symptoms. RESEARCH DESIGN AND METHODS: Baseline and follow-up data (after 3 years) were drawn from the Canadian Longitudinal Study on Aging to identify a subsample (n = 14,301) of participants aged at least 65 years with at least 2 chronic diseases. Path analysis examined sociobehavioral attributes (i.e., social support, social participation, walking) and loneliness as primary and secondary mediators, controlling for age, sex, education, and outcomes during baseline. RESULTS: Good model fit was found (TFI = 1.00; CFI = 1.00; RMSEA < 0.001; SRMR < 0.001). The total effects of housing quality (rtotal = 0.08, -0.07) and neighborhood cohesion (rtotal = 0.03, -0.06) were weak but statistically significant in the expected direction. The mediators explained 21%-31% of the total effects of housing quality and 67%-100% of the total effects of neighborhood cohesion. Loneliness mediated 27%-29% of these environmental influences on mental well-being, whereas walking mediated a mere 0.4%-0.9% of the total effects. Walking did not explain the relationship between housing quality and mental well-being. DISCUSSION AND IMPLICATIONS: Data supported a priori pathways from environment to mental well-being through sociobehavioral attributes and loneliness. If these pathways from neighborhood cohesion to life satisfaction reflect causal effects, community-based age-friendly interventions should focus on enhancing neighborhood cohesion to mitigate loneliness among multimorbid older adults for their mental well-being.

Dementia-Friendly Neighborhood and the Built Environment: A Scoping Review.

BACKGROUND AND OBJECTIVES: There has been a proliferation of research on dementia-friendly communities in recent years, particularly on interpersonal and social aspects. Nonetheless, the neighborhood built environment remains a co-constituent of the lived experience of people living with dementia (PLWD) that is amenable to interventions for health and well-being in the community. This scoping review presents a narrative synthesis of empirical research on dementia-friendly neighborhoods, with a focus on the built environment and its associated sociobehavioral aspects. Planning and design principles are distilled to identify research and policy implications. RESEARCH DESIGN AND METHODS: We reviewed 29 articles identified through a systematic search of AgeLine, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Global Health, Medical Literature Analysis and Retrieval System Online, and Scopus. Peer-reviewed articles that employed quantitative and/or qualitative methods in community settings were included. RESULTS: An equal number of studies focused on behavioral/psychosocial aspects of the built environment and assessment of specific environmental features. The former often used qualitative methods, whereas statistical methods were common in studies on discrete features of the neighborhood built environment. Few studies focused on rural contexts. Emerging research areas include interactions between dementia risk factors and neighborhood environments to support primary and secondary prevention. DISCUSSION AND IMPLICATIONS: The body of literature needs expansion into planning and design fields to foster community participation of PLWD by optimizing environmental stimuli, minimizing environmental barriers, and engaging PLWD in dementia-friendly community initiatives. While evidence has accumulated on landmarks and social participation at the individual level, research at the community and policy levels is limited. This requires advanced mixed methods.

Walk/Wheelability: An Inclusive Instrument Pair for Participatory Age-Friendly Research and Practice.

BACKGROUND AND OBJECTIVES: Recent critical evaluations of age-friendly efforts have highlighted the need to prioritize the disenfranchised, including people with mobility limitations. This article examines the validity of a 13-item Stakeholders Walkability/Wheelability Audit in Neighborhoods (SWAN13) scale to measure the "walk/wheelability" of street segments from the perspectives of people with mobility limitations. RESEARCH DESIGN AND METHODS: Data were drawn from preliminary studies of the SWANaudit which was conducted in 2 Canadian metropolitan areas. Sixty-one participants who use mobility devices (e.g., walkers, power wheelchairs) and older adults from community organizations audited 195 street segments. We factor analyzed the data from their audits. RESULTS: SWAN13 has a 1-factor structure. 13 items were retained from 85 SWANaudit items. SWAN13 encompassed both physical and social aspects of walk/wheelability. The alpha for the scale was .79. Convergent validity was found with the University of Alabama Life-Space Assessment (ρ = .22, p = .003), especially at the neighborhood level (ρ = .23, p = .002). Significant correlation was also found with subjective assessments of a priori walk/wheelability domains (ρ = .63, p < .001). DISCUSSION AND IMPLICATIONS: Walk/wheelability affects the life space of older adults and people with mobility limitations. It is an important latent variable that should be addressed to promote well-being and social participation. SWAN13 may be used in city-wide surveys to identify neighborhoods that may require age-friendly interventions from mobility perspectives. Detailed audits and interventions may be carried out in tandem using the paired SWANaudit instrument. Walk/wheelability is an inclusive and measurable concept that accounts for the needs of people with various mobility needs.

Prior Social Contact and Mental Health Trajectories during COVID-19: Neighborhood Friendship Protects Vulnerable Older Adults.

Social networking protects mental health during a crisis. Prior contact with social organizations, friends, and non-friend neighbors may be associated with better trajectories of loneliness, depression and subjective memory during COVID-19. Regression analysis was conducted using longitudinal data from a representative sample of n = 3105 US adults aged ≥55 in April-October 2020. Latent profile analysis was also conducted. Prior contact with friends (B = -0.075, p < 0.001), neighbors (B = -0.048, p = 0.007), and social organizations (B = -0.073, p < 0.001) predicted for better mental health during COVID-19. Three profiles were identified: Profile 1 had the best outcomes, with prior contact with social organizations (B = -0.052, p = 0.044) predicting decreasing loneliness. For Profile 2, prior 'meeting' contact with friends predicted decreasing loneliness (B = -0.075, p < 0.001) and better subjective memory (B = -0.130, p = 0.011). Conversely, prior contact with neighbors (B = -0.165, p = 0.010) predicted worsening loneliness among Profile 3. The COVID-19 pandemic has had a differential impact on the mental health trajectories of aging adults with social ties of different strengths. Stronger neighborhood networks are important to mitigate poor mental health outcomes among vulnerable older adults during a crisis. Older adults who are living alone and had relied on non-friend neighbors for social connectedness require additional community supports. Policy interventions are required to mitigate the mental health impact of future pandemics.

Age and sex trends in depressive symptoms across middle and older adulthood: Comparison of the Canadian Longitudinal Study on Aging to American and European cohorts.

BACKGROUND: The literature suggests depressive symptoms differ in a non-linear fashion across adulthood and are more commonly reported in women as compared to men. Whether these trends are observed across countries in population-based cohorts is unclear. METHODS: Cross-sectional observational study of approximately 138,000 women and men between the ages of 45 and 95 from three population-based cohorts representing Canadian, European, and American populations. Age, gender, educational attainment and annual income were assessed in each cohort. Depressive symptoms were assessed by the Center for Epidemiological Studies Depression Scale in the US and Canadian cohorts, and by the EURO-D in the European cohort. RESULTS: Across all three cohorts, non-linear age trends and gender differences were observed in the report of depressive symptoms, independent from educational attainment and annual income effects. The non-linear age trends reflected a negative association between depressive symptoms and age during midlife and then a positive association in late life. Females reported greater depressive symptoms than males; however, an interaction between gender and age was also observed in the Canadian and European cohorts. Among Canadians, the gender differences were largest after age 70, whereas among Europeans, gender differences where largest among those approximately aged 60. LIMITATIONS: Limitations include: 1) the cross-sectional nature of the study, resulting in age differences potentially reflecting cohort effects rather than a developmental process; and 2) the use of different depressive symptoms measures across cohorts. CONCLUSIONS: Characterization of depressive symptoms over mid and late adulthood in women and men provides insights into potential focal points for intervention and allocation of resources.

Social connectedness as a mediator for horticultural therapy's biological effect on community-dwelling older adults: Secondary analyses of a randomized controlled trial.

BACKGROUND: Elevated levels of inflammatory marker and a lack of social connectedness are two prominent risk factors for developing dementia and depression. Horticultural therapy (HT) has been shown to improve social connectedness and inflammatory markers. However, the underpinning mechanisms of HT remained unknown. Within this study, we hypothesized that improved social connectedness mediates the effects of HT on IL-6 levels. METHODS: The present study is a secondary analysis of a randomized controlled trial investigating the bio-psycho-social effects of HT. Social connectedness was operationalized as positive relationships with others (PRWO), a sub-scale of the Ryff's scale of psychological well-being. IL-6 was quantified using a commercial ELISA kit. Outcomes were assessed at baseline, 3-month and 6-month post-intervention. Mediation analyses with bootstrapping were run to investigate our primary hypothesis. All analyses were controlled for covariates. RESULTS: We recruited 59 participants (78% women; 67.10 ± 4.31 years). 29 participants partook in HT and 30 participants were included in the waitlist control group. At baseline, social connectedness was significantly correlated with IL-6 levels (ß = -0.12, 95% CI = -0.21 to -0.03, p = 0.008). Furthermore, social connectedness at 3-month significantly mediated the effects of HT on IL-6 levels at 6-month (ß = 0.32, 95% CI = 0.09 to 0.54, p = 0.005; ß = -0.25, 95% CI = -0.45 to -0.05, p = 0.016). CONCLUSIONS: These findings highlight the critical roles of social connectedness as a social determinant of health in eliciting HT's biological effects. When administering HT, interventionalists should consider social connectedness as a modifiable factor for ameliorating increased inflammation in older adults.

Neighborhood atmosphere modifies the eudaimonic impact of cohesion and friendship among older adults: A multilevel mixed-methods study.

A growing body of research on community gerontology suggests that interventions in the neighborhood may promote older adults' wellbeing. Drawing on Costello's community (2014) and phenomenology of atmosphere, we examine contextual moderators of the relationship between neighborhood quality and older adults' mental wellbeing in high-density urban areas. We used mixed methods. Quantitative data were collected from 601 community-dwelling adults over age fifty, using a comprehensive measure of neighborhood perception, which includes neighborhood cohesion, friendship and the physical environment. Positive aspects of participants' mental health were also measured. Regression analysis was conducted. Based on quantitative data, four types of neighborhoods were identified. Interviews and focus groups were conducted to understand their differences using comparative thematic analysis. Better neighborhood experience improves older adults' mental health. This association persists after controlling for a range of covariates including depressive symptoms. At the neighborhood level, neighborhoods of higher quality have significantly better aggregated mental health scores after controlling for depressive symptoms. Three themes were identified from qualitative data, namely sense of self, sense of community, and neighborhood atmosphere. Poor neighborhood atmosphere limited the extent to which the neighborhood improves the mental health of older adults. In neighborhoods where positive neighborly interactions prevailed over individual adversities, older adults exhibited better mental health. Neighborhood atmosphere is an important contextual factor which structures how older adults may benefit from spending time in the neighborhood. Enhancing a sense of community in the neighborhood could improve older adults' mental health. Age-friendly interventions in urban contexts should examine neighborhood atmosphere.