Introduction to the Special Issue: Toward a Lifespan Prevention Science - A Focus on Middle and Late Adulthood.

The interdisciplinary field of prevention science was founded on the premise of a lifespan developmental model. Prevention scientists have developed a strong set of tools and intervention technologies for understanding and potentially modifying risk and protective factors through early adulthood. However, there is a demographic imperative to apply prevention science principles to health issues in middle and late adulthood. The articles in this special issue utilize a variety of methods to investigate important scientific questions about how theories, methodologies, and interventions applied in the science of prevention can be usefully integrated into the study of health and wellness in middle and late adulthood. More specifically, contributions (1) highlight current empirical research that draws on lifespan developmental science to address the unique prevention and intervention needs in middle and late adulthood, (2) illustrate the opportunities and challenges of a lifespan approach to prevention science with special attention to middle and late adulthood, and (3) identify additional areas that prevention science can contribute to advancements in middle and late adulthood. These articles provide a glimpse into the challenges and opportunities at the intersection of prevention science and gerontology. As a field, we have much room to grow in leveraging innovative tools, approaches, and efforts to best support older adults' physical, mental, and social health, particularly for diverse and under-served populations.

The Context of Elder Maltreatment: an Opportunity for Prevention Science.

Elder maltreatment (EM) has been understood as a worldwide major public health threat for decades, yet it remains a form of victimization receiving limited attention, resources, and research. EM, which includes caregiver neglect and self-neglect, has far-reaching and long-lasting impacts on older adults, their families, and communities. Rigorous prevention and intervention research has significantly lagged in proportion to the magnitude of this problem. With rapidly growing population aging, the coming decade will be transformative: by 2030, one in six people worldwide will be aged 60 or older, and approximately 16% will experience at least one form of maltreatment (World Health Organization, 2021). The goal of this paper is to raise awareness of the context and complexities of EM, provide an overview of current intervention strategies based on a scoping review, and discuss opportunities for further prevention research, practice, and policy within an ecological model applicable to EM.

Feasibility of Hair Cortisol as a Biomarker of Chronic Stress in People With Dementia.

Hair cortisol concentrations (HCC) are an innovative way to measure chronic stress relying on a small sample of hair. To date, there are no studies that have studied HCC as a biomarker of chronic stress in individuals with dementia. Given the vulnerability to chronic stress in people with dementia, using HCC as an objective measure of physiological stress in those with dementia has potential to enhance our understanding of this population. The goal of this exploratory, multidisciplinary, pilot study was to establish feasibility of HCC testing in people with dementia as a biomarker of chronic stress. HCC was examined over a 6-month period to assess physiological stress response during a transition to memory care. Newly admitted memory care residents (n = 13, mean age = 82) were followed over 6 months. Residents' hair samples and health information were collected at 3-month intervals. HCC levels significantly changed during the transition to memory care, which may reflect chronic physiological stress. Participants with frequent behavioral and psychological symptoms of dementia (BPSD) had significantly lower HCC at baseline and exhibited a blunted cortisol reactivity at follow-up. Based on detected changes in HCC, participants likely experienced stress reactions during the transition to memory care, providing preliminary evidence that HCC may be a useful, non-invasive measure of physiological stress in this population. This approach may also be applied to understanding the significance of person-centered care environments on minimizing chronic stress for people with dementia.

Attitudes toward aging as a psychological resource among caregivers of persons living with dementia.

Although there are a number of existing interventions to support caregivers in managing the behaviors and functioning of care recipients with dementia, less attention has focused on caring for caregivers and understanding how their characteristics may contribute to distress or wellbeing Positive psychological resources can promote health and well-being among caregivers and may also serve as protective factors that buffer negative caregiving experiences and minimize burden and stress. Informal dementia caregivers (N = 99, mean age = 54) answered survey questionnaires related to psychological resources (e.g., Brief Aging Perceptions Questionnaire, Caregiver Self-efficacy for Managing Dementia, Positive Affect and Negative Affect Scale) to explore the connection to their emotional health. After controlling for caregiver factors and care recipient factors, caregivers' aging attitudes and caregiving self-efficacy were predictive of both caregivers' positive and negative affect. Caregivers' aging attitudes also directly affected their emotional health and indirectly influenced emotional health through self-efficacy for caregiving. Future caregiver outreach and education should highlight positive aspects of caregiving, provide accurate dementia information, and improve psychoeducation regarding typical/atypical aging experiences while dispelling negative age stereotypes, which may foster better adaptation and resilience to a dementia caregiver role and strengthen positive mental representations of dementia caregiving.

Young adults' experiences with loss and grief during COVID-19.

In the wake of the COVID-19 pandemic, people are experiencing unprecedented cumulative loss and grief. Guided by life course theory, we used inductive qualitative analysis and explored young adults' (N = 86) written accounts of their earliest and most significant losses associated with COVID-19, as well as their coping mechanisms. Overall, participants experienced substantial loss, especially losses related to their education and social life/events. We discuss five subthemes related to approaches to coping and five subthemes related to barriers to coping. Our findings are relevant to informing strategies that support adapting to significant loss in early adulthood, beyond the pandemic.

High death anxiety and ambiguous loss: Lessons learned from teaching through the COVID-19 pandemic.

For gerontological educators, topics such as mortality, loss, and end-of-life issues often emerge or are central in their courses. However, teaching in the era, and aftermath, of the COVID-19 pandemic has heightened the salience of death and loss, raising questions about best practices and teaching pedagogies to support student learning amidst a global crisis. This qualitative study utilized written narratives collected during the pandemic from students enrolled in an undergraduate thanatology course. Content analysis of written narratives (n = 44) revealed three themes that can help inform strategies to best support student learning during challenging times. Participants desired more flexibility; compassion and understanding; and more targeted resources and socioemotional support. Results have immediate implications for educators teaching during the pandemic and for years to come. We provide recommendations for teaching and learning support, as well as advocate for more university and community-based thanatology and gerontology education offerings.

The Role of Caregivers in Physical Activity for Older Adults With Alzheimer's Disease.

This study examined the determinants of physical activity (PA) for older adults with Alzheimer's disease (AD) to learn more about how to promote PA in this population. Caregivers of older adults with AD (N = 99) provided information related to care recipient's PA, as well as addressed sociodemographics and perceptions about their care recipient's PA. Gender of care recipient was a significant predictor of PA (ß = .80, P < .05); men with AD participated in more PA than women with AD. Also, caregiver's outcome expectation for care recipient's PA also predicted more PA (ß = .82, P < .05). Caregiver's perceived benefits of PA (outcome expectation) for their care recipient partially mediated the relationship between self-efficacy for care recipient's PA and the reported levels of PA for the care recipient. This study demonstrated the importance of caregiver perceptions about care recipient's PA.

Addressing the needs of Nicaraguan older adults living on the edge: A university-community partnership in international service-learning.

Nicaragua is a very low-income country entering a period of rapid aging with limited geriatric training for health care professionals. To help build capacity and to enhance student learning, a short-term international service-learning program was implemented in 2004 in partnership with the Jessie F. Richardson Foundation and Nicaraguan community stakeholders. Graduate and undergraduate students at Portland State University complete coursework for one term in the United States then travel to Nicaragua for about two weeks to participate in educational, research, and service activities, primarily in group homes for older Nicaraguans. Students learn about global aging, gerontology, community development, service learning, and Nicaraguan history and culture, then apply their gerontology-related knowledge by training direct care staff, older adults and their family members, and students. The authors describe the impetus for and evolution of the program, students' evaluation of the program, faculty observations on program benefits and challenges, lessons learned, and future plans.

Women Veterans with Depression in Veterans Health Administration Primary Care: An Assessment of Needs and Preferences.

OBJECTIVE: Depression is the most prevalent mental health condition in primary care (PC). Yet as the Veterans Health Administration increases resources for PC/mental health integration, including integrated care for women, there is little detailed information about depression care needs, preferences, comorbidity, and access patterns among women veterans with depression followed in PC. METHODS: We sampled patients regularly engaged with Veterans Health Administration PC. We screened 10,929 (10,580 men, 349 women) with the two-item Patient Health Questionnaire. Of the 2,186 patients who screened positive (2,092 men, 94 women), 2,017 men and 93 women completed the full Patient Health Questionnaire-9 depression screening tool. Ultimately, 46 women and 715 men with probable major depression were enrolled and completed a baseline telephone survey. We conducted descriptive statistics to provide information about the depression care experiences of women veterans and to examine potential gender differences at baseline and at seven month follow-up across study variables. RESULTS: Among those patients who agreed to screening, 20% of women (70 of 348) had probable major depression, versus only 12% of men (1,243 of 10,505). Of the women, 48% had concurrent probable posttraumatic stress disorder and 65% reported general anxiety. Women were more likely to receive adequate depression care than men (57% vs. 39%, respectively; p < .05); 46% of women and 39% of men reported depression symptom improvement at the 7-month follow-up. Women veterans were less likely than men to prefer care from a PC physician (p < .01) at baseline and were more likely than men to report mental health specialist care (p < .01) in the 6 months before baseline. CONCLUSION AND IMPLICATIONS FOR PRACTICE: PC/mental health integration planners should consider methods for accommodating women veterans unique care needs and preferences for mental health care delivered by health care professionals other than physicians.

Stigma Predicts Treatment Preferences and Care Engagement Among Veterans Affairs Primary Care Patients with Depression.

BACKGROUND: Whereas stigma regarding mental health concerns exists, the evidence for stigma as a depression treatment barrier among patients in Veterans Affairs (VA) primary care (PC) is mixed. PURPOSE: This study tests whether stigma, defined as depression label avoidance, predicted patients' preferences for depression treatment providers, patients' prospective engagement in depression care, and care quality. METHODS: We conducted cross-sectional and prospective analyses of existing data from 761 VA PC patients with probable major depression. RESULTS: Relative to low-stigma patients, those with high stigma were less likely to prefer treatment from mental health specialists. In prospective controlled analyses, high stigma predicted lower likelihood of the following: taking medications for mood, treatment by mental health specialists, treatment for emotional concerns in PC, and appropriate depression care. CONCLUSIONS: High stigma is associated with lower preferences for care from mental health specialists and confers risk for minimal depression treatment engagement.

Possible selves and depressive symptoms in later life.

The pursuit of personal goals has been linked to general psychological well-being; however, less is known about the association with depression in later adulthood when individuals are contending with age-related changes in health and social relationships. We explored the connection between both health- and social related goals (as measured by possible selves) and depressive symptoms in a sample of 85 community-dwelling older adults who ranged in age from 60 to 92 (M = 74, standard deviation = 7.5). Participants took part in face-to-face, semistructured interviews in which they responded to measures of possible selves (future images of oneself), health, and depressive symptoms. We found that the presence of health-related, but not social-related, possible selves was significantly associated with fewer reported depressive symptoms. Additionally, the presence of health-related fears was specifically linked to fewer reported depressive symptoms. These findings suggested that the promotion of and investment in health-related personal goals may be useful in off-setting depressive symptoms in older adults, as well as indicated a potential benefit of a disease prevention focus regarding health in later life. Finally, the results may have implications for potential clinical interventions in addressing late-life depression.

Learning through loss: implementing lossography narratives in death education.

Students may have a greater willingness to discuss issues of death and loss through written assignments; however, there is little guidance for instructors regarding how to manage these sensitive assignments, nor how students benefit from them. The authors implemented and evaluated a "lossography" assignment in an undergraduate thanatology course in which students wrote about their losses and anonymously shared these narratives with their classmates. Although many themes of loss emerged, the most frequently reported significant loss was death of a grandparent. Additionally, most significant losses occurred in childhood/adolescence. Prominent themes related to student learning included gaining self-awareness, knowledge about grief responses, and compassion for others. Students (N = 64) also completed a survey reflecting on their course learning. Of all aspects of course delivery, 44% identified the lossography as the most beneficial, whereas 97% recommended this assignment for future students. The implications of the assignment for death education are also discussed.

Veterans with depression in primary care: provider preferences, matching, and care satisfaction.

Primary care is often the first point of care for individuals with depression. Depressed patients often have comorbid alcohol use disorder (AUD) and posttraumatic stress disorder (PTSD). Understanding variations in treatment preferences and care satisfaction in this population can improve care planning and outcomes. The design involved a cross-sectional comparison of veterans screening positive for depression. Veterans receiving primary care during the previous year were contacted (n = 10, 929) and were screened for depression using the PHQ-2/PHQ-9. Those with probable depression (n = 761) underwent a comprehensive assessment including screens for AUD and PTSD, treatment provider preferences, treatments received, and satisfaction with care. Treatment provider preferences differed based on specific mental health comorbidities, and satisfaction with care was associated with receipt of preferred care. Depressed veterans with comorbid PTSD were more likely to prefer care from more than one provider type (e.g., a psychiatrist and a primary care provider) and were more likely to receive treatment that matched their preferences than veterans without comorbid PTSD. Veterans receiving full or partial treatment matches affirmed satisfaction with care at higher rates, and veterans with comorbid PTSD were least satisfied when care did not match their preferences. Patient satisfaction with care is an increasingly important focus for health care systems. This study found significant variations in depressed patients' satisfaction with care in terms of treatment matching, particularly among those with comorbid PTSD. Delivery of care that matches patient treatment preferences is likely to improve depressed patient's satisfaction with the care provided. (PsycINFO Database Record (c) 2014 APA, all rights reserved).

Family involvement, medication adherence, and depression outcomes among patients in veterans affairs primary care.

OBJECTIVE Family involvement and social support are associated with recovery from mental disorders. This project explored how family involvement in health care and social support among depressed veterans in primary care related to medication adherence and depression outcomes. METHODS During a longitudinal telephone survey, 761 Veterans Affairs (VA) primary care patients (mean age=60 years) with probable major depression were asked about depression symptoms, self-reported health, medication adherence, social support, family involvement with care, and satisfaction with clinicians' efforts to involve the patients' families in their care. Follow-up interviews at seven and 18 months assessed depression severity and medication adherence. RESULTS Most participants lived with others (71%) and reported moderately high social support. Most participants (62%) reported being very likely to discuss treatment of a major medical condition with family, but 64% reported that VA providers had not involved the participants' family in their care within the prior six months. In multivariate regression analyses, lower depression severity and better medication adherence over time were significantly linked to higher satisfaction with limited efforts by clinicians to involve families in care. Neither social support nor the extent of family involvement by itself was associated with outcomes. CONCLUSIONS The results suggested a link between patient satisfaction with family involvement by clinicians and clinical outcomes among depressed veterans. In addition, clinician responsiveness to patient wishes may be more important than the amount of family involvement per se. Further research is needed to clarify when and how clinicians should involve a patient's family in depression treatment in primary care.

Help-seeking from clergy and spiritual counselors among veterans with depression and PTSD in primary care.

Little is known about the prevalence or predictors of seeking help for depression and PTSD from spiritual counselors and clergy. We describe openness to and actual help-seeking from spiritual counselors among primary care patients with depression. We screened consecutive VA primary care patients for depression; 761 Veterans with probable major depression participated in telephone surveys (at baseline, 7 months, and 18 months). Participants were asked about (1) openness to seeking help for emotional problems from spiritual counselors/clergy and (2) actual contact with spiritual counselors/clergy in the past 6 months. At baseline, almost half of the participants, 359 (47.2%), endorsed being "very" or "somewhat likely" to seek help for emotional problems from spiritual counselors; 498 (65.4%) were open to a primary care provider, 486 (63.9%) to a psychiatrist, and 409 (66.5%) to another type of mental health provider. Ninety-one participants (12%) reported actual spiritual counselor/clergy consultation. Ninety-five (10.3%) participants reported that their VA providers had recently asked them about spiritual support; the majority of these found this discussion helpful. Participants with current PTSD symptoms, and those with a mental health visit in the past 6 months, were more likely to report openness to and actual help-seeking from clergy. Veterans with depression and PTSD are amenable to receiving help from spiritual counselors/clergy and other providers. Integration of spiritual counselors/clergy into care teams may be helpful to Veterans with PTSD. Training of such providers to address PTSD specifically may also be desirable.

Relationships between mood and employment over time among depressed VA primary care patients.

OBJECTIVE: Associations between depression, productivity and work loss have been reported, yet few studies have examined relationships between longitudinal depression status and employment continuity. We assessed these relationships among Veterans of conventional working ages. METHODS: We used longitudinal survey data from Veterans receiving primary care in 1 of 10 Veterans Health Administration primary care practices in five states. Our sample included 516 participants with nine-item Patient Health Questionnaire (PHQ-9) scores indicating probable major depression (PHQ-9≥10) at baseline and who completed either the 7-month follow-up survey or follow-up surveys at both 7 and 18 months postbaseline. We examined relationships between depression persistence and employment status using multinomial logistic regression models. RESULTS: Although general employment rates remained stable (21%-23%), improved depression status was associated with an increased likelihood of becoming employed over 7 months among those who were both depressed and nonemployed at baseline. Improvements in depression status starting at 7 months and continuing through 18 months were associated with remaining employed over the 18-month period, relative to those who were depressed throughout the same time frame. CONCLUSIONS: Given the pressing need to prevent socioeconomic deterioration in the increasing population of conventional working-aged Operation Enduring Freedom and Operation Iraqi Freedom Veterans, further attention to the depression/employment relationship is urgently needed.

Implementing collaborative care for depression treatment in primary care: a cluster randomized evaluation of a quality improvement practice redesign.

BACKGROUND: Meta-analyses show collaborative care models (CCMs) with nurse care management are effective for improving primary care for depression. This study aimed to develop CCM approaches that could be sustained and spread within Veterans Affairs (VA). Evidence-based quality improvement (EBQI) uses QI approaches within a research/clinical partnership to redesign care. The study used EBQI methods for CCM redesign, tested the effectiveness of the locally adapted model as implemented, and assessed the contextual factors shaping intervention effectiveness. METHODS: The study intervention is EBQI as applied to CCM implementation. The study uses a cluster randomized design as a formative evaluation tool to test and improve the effectiveness of the redesign process, with seven intervention and three non-intervention VA primary care practices in five different states. The primary study outcome is patient antidepressant use. The context evaluation is descriptive and uses subgroup analysis. The primary context evaluation measure is naturalistic primary care clinician (PCC) predilection to adopt CCM.For the randomized evaluation, trained telephone research interviewers enrolled consecutive primary care patients with major depression in the evaluation, referred enrolled patients in intervention practices to the implemented CCM, and re-surveyed at seven months. RESULTS: Interviewers enrolled 288 CCM site and 258 non-CCM site patients. Enrolled intervention site patients were more likely to receive appropriate antidepressant care (66% versus 43%, p = 0.01), but showed no significant difference in symptom improvement compared to usual care. In terms of context, only 40% of enrolled patients received complete care management per protocol. PCC predilection to adopt CCM had substantial effects on patient participation, with patients belonging to early adopter clinicians completing adequate care manager follow-up significantly more often than patients of clinicians with low predilection to adopt CCM (74% versus 48%%, p = 0.003). CONCLUSIONS: Depression CCM designed and implemented by primary care practices using EBQI improved antidepressant initiation. Combining QI methods with a randomized evaluation proved challenging, but enabled new insights into the process of translating research-based CCM into practice. Future research on the effects of PCC attitudes and skills on CCM results, as well as on enhancing the link between improved antidepressant use and symptom outcomes, is needed. TRIAL REGISTRATION: ClinicalTrials.gov: NCT00105820.

Suicide risk management: development and analysis of a telephone-based approach to patient safety.

Research-based queries about patients' experiences often uncover suicidal thoughts. Human subjects review requires suicide risk management (SRM) protocols to protect patients, yet minimal information exists to guide researchers' protocol development and implementation efforts. The purpose of this study was to examine the development and implementation of an SRM protocol employed during telephone-based screening and data collection interviews of depressed primary care patients. We describe an SRM protocol development process and employ qualitative analysis of de-identified documentation to characterize protocol-driven interactions between research clinicians and patients. Protocol development required advance planning, training, and team building. Three percent of screened patients evidenced suicidal ideation; 12% of these met protocol standards for study clinician assessment/intervention. Risk reduction activities required teamwork and extensive collaboration. Research-based SRM protocols can facilitate patient safety by (1) identifying and verifying local clinical site approaches and resources and (2) integrating these features into prevention protocols and training for research teams.

Dual use of VA and non-VA services among primary care patients with depression.

BACKGROUND: Depression treatment requires close monitoring to achieve optimal, long-term control. Use of multiple sources of health care can affect coordination and continuity of treatment for depression. OBJECTIVES: To assess levels of non-Veterans Health Administration (VA) use among depressed primary care patients by service type and examine patient factors associated with non-VA use. DESIGN: Cross-sectional comparison of dual and VA-only users among depressed primary care patients. Depression was defined as PHQ-9 >or=10. SUBJECTS: Five hundred fifty depressed patients from the baseline sample of a group-randomized trial of collaborative care for depression in ten VA primary care practices. MEASUREMENTS: VA and non-VA outpatient utilization for physical and emotional health problems in the prior 6 months, patient demographics, and co-morbid conditions. All measures were self-reported and obtained at the baseline interview. RESULTS: Overall, 46.8% of VA depressed primary care patients utilized non-VA care. Dual users were more likely to use acute care services (emergency room or inpatient), especially for physical health problems. Dual users of physical health services had more total visits, but fewer VA visits than VA-only users, while dual users of emotional health services had fewer total and VA visits. Factors associated with dual use were urban clinic location, having other insurance coverage, and dissatisfaction with physical health care in general. CONCLUSIONS: Almost half of depressed primary care patients used non-VA care, with most of their non-VA use for physical rather than emotional health problems. Care management strategies for depressed patients should include communication and coordination with non-VA providers.