Valuation of life: a concept and a scale.

OBJECTIVES: The objective was to derive and test the psychometric characteristics of a scale to measure Valuation of Life (VOL). METHODS: Four samples were used in successive phases of exploratory factor analysis, confirmatory factor analysis, reliability and validity testing, and exploration of response-error effects. Estimates of Years of Desired Life were obtained under a variety of hypothetical quality-of-life (QOL)-compromising conditions of poor health. RESULTS: Confirmed 13-item (Positive VOL) and 6-item (Negative VOL) factors were obtained. A significant relationship between VOL and most Years of Desired Life estimates remained when demographic, health, quality of life, and mental health measures were controlled. Analysis of Negative VOL revealed that some respondents misunderstand the meaning of an agree response to negatively phrased items. DISCUSSION: VOL is a cognitive-affective schema whose function as a mediator and moderator between health and end-of-life decisions deserves further research.

Affect and quality of life: objective and subjective.

OBJECTIVES: The objective of this article is to determine direct and indirect contributions of objective and subjective quality of life (QOL) to positive and negative indicators of mental health. Specifically, the dual-channel hypothesis predicted that objective and subjective social engagement would enhance positive affect (PA) but be unrelated to depression. METHODS: Older people from senior centers and several housing environments volunteered to complete a questionnaire or interview about a number of aspects of their everyday lives (N = 602). Objective and subjective were related to one another. RESULTS: Objective activity participation and subjective time use and friend quality were associated with PA. Only time use was related to depression. DISCUSSION: The importance of assessing both amount of behavior (objective) and its quality (subjective) when measuring QOL was demonstrated. Although external engagement bears a closer relationship to PA than to negative, the dual-channel model relating locus of stimulation differentially to PA and depression requires modification.

Health, valuation of life, and the wish to live.

This research investigated the relationship of an affective-cognitive schema, valuation of life (VOL), to older people's responses to a set of health utility (years of desired life) questions. Six hundred healthy and chronically ill elders aged 70 and older were interviewed to measure quality of life (QOL), mental health, and VOL. Valuation of life was significantly correlated with longer Years of Desired Life under 8 of 10 health conditions when background, health, QOL, and mental health states were controlled. We concluded that VOL is an internal representation of the many positive and negative features of the person and her everyday life that is necessary to comprehend how people may cling to life or welcome its end.

Mortality of the institutionalized old-old hospitalized with congestive heart failure.

BACKGROUND: Congestive heart failure is a major cause of mortality and morbidity in the elderly but the disease impact on the oldest and sickest population has not been defined. OBJECTIVES: To review the mortality and hospital readmission rate of institutionalized elderly persons with congestive heart failure and to examine the relation of baseline characteristics to subsequent clinical outcomes. METHODS: This was a retrospective analysis based on chart review of 231 residents of the Philadelphia (Pa) Geriatric Center (63 congregate housing tenants and 168 nursing home residents) 80 years and older, hospitalized with congestive heart failure from 1989 to 1995. Patients' demographic data and clinical, electrocardiographic, and echocardiographic findings were obtained from their initial (index) hospitalization records. Subsequent outcomes were obtained from their outpatient (nursing home or office) records. RESULTS: Thirteen percent died during the index hospitalization but the total mortality during the follow-up period was 87%. One hundred forty-six patients (63%) died in the first year with a mean +/- SD survival of 4+/-4 months and a readmission rate of 3.9 per patient-year. Eighty-five patients survived the first year with a readmission rate of 1.2 per patient-year and 54 patients subsequently died, with a mean +/- SD survival of 28+/-12 months. The first-year decedents and survivors were comparable in sex, age, medical history, and electrocardiographic findings. However, patients who died in the first year, compared with survivors, were more likely to be nursing home residents (81% vs 59%), have New York Heart Association class IV heart failure (54% vs 32%), have impaired left ventricular function by echocardiogram (53% vs 32%), and have renal insufficiency (32% vs 11%). CONCLUSIONS: Very elderly persons with congestive heart failure had a guarded long-term prognosis. Nursing home residency, class IV heart failure, impaired left ventricular function, and renal insufficiency were associated with higher risk for early death and repetitive hospitalizations.

Psychometric characteristics of the minimum data set I: confirmatory factor analysis.

OBJECTIVE: To determine the structure and statistical reliability of the federally mandated Minimum Data Set (MDS). DESIGN: Confirmatory, hypothesis-testing factor analysis was performed on MDS protocols of 733 nursing home residents. SETTING: All participants were residents of the Philadelphia Geriatric Center. PARTICIPANTS: Participants represented consecutively admitted skilled and intermediate care residents and another pool of residents with probable dementia. MEASUREMENTS: MDS protocols were completed by nurse care coordinators. Item composites hypothesized represented the domains of cognition, activities of daily living, time use, social quality, depression, and problem behaviors. RESULTS: For higher functioning residents (n = 336) and for all residents together, all domain clusters except social quality were confirmed. None of the domain clusters were confirmed within the more impaired (n = 391) group. CONCLUSIONS: The MDS does provide usable indicators of five areas of basic competence of nursing home residents. Lack of reliability in rating many aspects of the behavior and states of cognitively impaired residents is evident, however. Improvement of such measures and rating procedures constitutes a major research priority.

Psychometric characteristics of the minimum data set II: validity.

OBJECTIVE: To determine the validity of the Minimum Data Set (MDS). DESIGN: MDS domain scores were correlated with a variety of independently obtained measures of basic behavioral and mental health functions of 513 nursing home residents. SETTING: All participants were residents of the Philadelphia Geriatric Center. PARTICIPANTS: One group of residents (n = 260) represented consecutive admissions who were able to respond to formal testing. The other group of residents (n = 253) represented presumably cognitively impaired residents whose data did not depend on self-report. MEASUREMENTS: MDS item-composite scores based on a confirmatory factor analysis were derived for the domains of cognition, activities of daily living (ADL), time use, depression, and problem behaviors. Hypotheses stating how these MDS domains should be related to standard measures of cognitive function, ADL, depression, agitation, social behavior, and irritability were tested. CONCLUSIONS: The majority of the hypotheses were upheld, thus suggesting that the MDS is usable as a source of research data. The sizes of the validity coefficients were modest, however. Depression and problem behavior were less well affirmed than cognition, ADL, and Time Use. There is a clear need for improvement in training and probably in the form of MDS measurement in some areas.

A stimulation-retreat special care unit for elders with dementing illness.

Two equivalent special care nursing home units for elders with dementing illness were randomly designated as experimental and control units for an intervention called the "stimulation-retreat" model. This model introduced a set of staffing and program changes whose purpose was to diagnose, prescribe, and apply a package of care according to individual needs for additional stimulation or relief from stimulation ("retreat"). A total of 49 experimental and 48 control unit residents completed 12 months of care and were evaluated at baseline, 6 months, and 12 months. It was hypothesized that the intervention would not affect the basic disability (cognitive and activities of daily living functions), would improve negative behaviors and observed affects, and would have maximum impact in increasing positive behaviors and affects. Over time, most functions worsened, including negative attributes and affects. Lesser decline in positive affect and increases in external engagement, however, led to the conclusion that the intervention showed a marginally significant and selective effect on positive behaviors and affect.

Methodological aspects of the study of streams of behavior in elders with dementing illness.

A software system (The Observer) was used in combination with a hand-held event recorder to study the ecology of older people with dementing illness who were residents of special care units in a nursing home. Methods and problems in the use of this behavior stream technology are discussed. Directly observed behaviors, positions, locations, and contexts were observed in real time on 154 residents over 16 10-minute periods each. The resulting observations were downloaded directly into a personal computer for analysis. Reliability and programming processes for the production of individual subject analytic files are reported. Descriptive data displayed characteristics of the ecology of these residents: concentration of time in a single spatial area (lounge, 73% of all behavior), alone (83%), inactive gaze (40%), and totally passive behaviors (24%). Social interaction (13%) and positively engaged activities (4%) were infrequent. Concurrent validity was tested through correlations between behavior stream aggregate time and core measures of function. Although the sizes of the correlations were modest, their pattern generally confirmed the expected relationships. Advantages and disadvantages of the method are discussed.

Marital status of caregiving daughters and co-residence with dependent parents.

The role of caregiving daughters' marital status is examined as it relates to their sharing households with disabled elderly parents. Married daughters fared best in well-being, income, and social support. Never-married women were the most likely to have never moved out of the parental home. Separated/divorced caregivers, more than the married and widowed, had moved into the parent's home rather than the reverse and widowed daughters had lived in re-formed joint households longest. The main reason for re-forming shared households was disability of the parent. Among other reasons were death or withdrawal of previous caregiver and financial problems, with separated/divorced daughters the most likely to mention finances.

Attachment among adult children and their institutionalized parents.

Structural equation analysis using data from 424 adult children with parents living in long-term care facilities indicated that the attachment experienced by adult children for their institutionalized parents was predicted from child's report of parent's mood and child's sense of guilt regarding his/her parent. Parent's mood was predicted by parent's health, and child's sense of guilt was predicted by the amount of help provided to the parent by the adult child. Results are interpreted in the context of theories of attachment.

Affect and age: cross-sectional comparisons of Structure and prevalence.

The self-reports of 207 young-adult (ages 18-30), 231 middle-aged (ages 31-59), and 828 older-adult (age 60 and over) Ss were used to study the structure of affect. Affects were represented by terms included in various circumplex arrays of emotions as presented by previous investigators. A set of 46 affects was subjected to exploratory analysis, and a final set of 38 affects was subjected to confirmatory factor analysis. The goodness of fit of each group's factor loadings to the hypothesized factors of positive affect, depression, anxiety-guilt, contentment, hostility, and shyness was not up to the desired .90 level, and some significant differences in factor structure were observed for each age-group comparison. There were few age differences in levels of positive affect. Depression was most frequent among younger Ss and least frequent among older Ss. Younger Ss were most often anxious and shy. Older Ss were most often content and least often hostile.

Time use of caregivers of impaired elders before and after institutionalization.

Time use was examined by means of time budgets obtained from 165 caregivers of older persons recruited from nursing home waiting lists and state nursing home assessment programs. "Yesterday interviews" were done at baseline (T1) and, again, an average of 5 months later when the elder had either entered a nursing home (n = 77) or was still awaiting entry (n = 88). Caregivers who provided more help (particularly instrumental assistance) to their elder were more likely to see that person placed in a nursing home at follow-up. More caregiving time was reported by those living with the elderly person and by nonworking and lower income caregivers; the elders being cared for by these groups were also more impaired. Less caregiving time (a total gain of 1 hour 47 minutes) was reported by caregivers following admission of the older person to the nursing home. The gained time was allocated to a significant degree to family interaction, recreation, and time outside the home.

Caring for an institutionalized parent: the role of coping strategies.

This study extends knowledge about the stresses of caregiving by considering relationships between adult children and their institutionalized parents. Although previous studies have indicated that emotional strains experienced by adult children with institutionalized parents are of similar magnitude to those experienced by caregivers in the community, little attention has been paid to effects that may mediate the stressor-mental health relationship. Coping strategies were hypothesized as mediators of the stressor-mental health relationship. Data from 424 adult children with a parent living in a nursing home revealed that emotion-focused coping strategies mediate the relationship between stressors and mental health, whereas problem-focused coping strategies do not mediate this relationship. Findings emphasize the importance of examining coping strategies as multidimensional entities having differential effects on mental health.

The factorial generality of brief positive and negative affect measures.

Confirmatory factor analysis was used to test the structure of 5-item affect rating scales designed to measure positive affect and negative affect. A proposed circumplex affect structure was the source of scales constructed to represent a cluster of positive terms, including pleasantness and activation; the negative terms represented anxiety, depression, and hostility. The hypothesized simple-structured positive and negative trait affect factors, with a moderate correlation between them, were found in all cases. Equivalent structure was confirmed for younger adults, middle-aged, and older adults of good health and above-average education. Although the hypothesized simple-structured positive and negative factors emerged for all other groups, three other tests of factor equivalence failed to be confirmed: trait and state factors in the older adult group were not identical. Factors derived from healthy and frail elders were structurally different. Variability among frail elders and variability over 30 days within the same person, when factored, also showed nonequivalence. Although the scales are extremely useful in assessing affect, comparisons across some subject groups should be made with caution.

The dynamics of caregiving for a demented elder among black and white families.

Caregiving dynamics were studied in a sample of 157 Black caregivers of elders suffering from Alzheimer's disease and other dementias. By comparison with White caregivers (N = 472), there were fewer spouses and more nonspouse-nonchild caregivers among Blacks. With control exercised on background and socioeconomic variables, race differences in caregiving appraisal were found. Blacks showed more favorable scores on indices of traditional caregiving ideology, caregiving as intrusion, caregiving satisfaction, and caregiving burden. Interactions between race and background factors increased explained variance in caregiving appraisal only slightly. A cultural explanation of the more favorable appraisals of Blacks was sought in the caregiving ideology factor, but this dimension was not associated with caregiving outcomes. The overall hypothesized two-factor model was generally consistent with the observed covariance structures of both Black and White caregivers. Within both White and Black groups, caregivers who provided more care showed simultaneously more satisfaction and more burden.

Dimensions of affective experience in three age groups.

The dimensions by which adults of differing ages experience emotion were studied by self-administering questionnaires administered to older adults (n = 828) recruited from Elderhostel programs, middle-aged (ages 30-59) children of Elderhostel attenders (n = 231), and young adult (ages 18-29) subjects recruited from college classes or through Elderhostel participants (n = 207). Elders were higher in emotional control, mood stability, and emotional maturity through moderation and leveling of positive affect and lower in surgency, psychophysiological responsiveness, and sensation seeking. These findings are consistent with the hypothesized increase in self-regulatory capacity with age. These cross-sectional differences cannot, however, be distinguished from cohort-related explanations; they require considerable replication across different types of subjects and further characterization of the dimensions in terms of their functions for self-regulation.

The structure of variation in affect among depressed and nondepressed elders.

The intraindividual variability of self-ratings of 10 affects was studied in 69 older residents of a long-term care facility. Each person rated his or her affective state over 30 days. P-technique factor analysis was applied to each subject's ratings. In general, the expected two-factor structure showing one positive and one negative factor emerged from both traditional R-analysis and from "chain P-analysis" (all subjects' ratings pooled after standardizing within subjects). Because many subjects gave invariant ratings on one or more affect terms, only 28 P-analyses could be performed, of which 12 yielded one-factor solutions, 16 yielded two-factor solutions (10 the expected two factors), and 5 failed to converge. Possible reasons for the only partial intraindividual replication of the interindividual factors are discussed.

Differential effects of daughters' marital status on their parent care experiences.

This study compared the parent care experiences of five groups of daughters (N = 492) (married, remarried, separated/divorced, widowed, and never married). Data include demographic characteristics and measures of depression, positive affect, personality strength, health, social support, relationship quality, caregiving burden, caregiving mastery, and caregiving satisfaction. Women with husbands had more socio-emotional and instrumental support, much higher incomes, less financial strain from caregiving, and less depression. They felt their own particular marital status made caregiving easier than did the three groups of not-married women.