Stewart Neufeld

What do we know about older adults and HIV? a review of social and behavioral literature

Abstract The fastest growing segment of the United States HIV population is people aged 50 and older. This heterogeneous group includes people with diverse pathways into HIV positive status in later life, including aging with the disease as well as later life-acquired infections. As people with HIV live into older ages, solving problems of successful secondary prevention and ongoing treatment requires more specific knowledge of the particular aging-related contextual sociocultural, psychosocial, and personal factors salient to the situations of persons living with HIV. Greater knowledge of these factors will help solve challenges to reducing psychological burden and promoting health maintenance for people with HIV. Yet, the current literature on aging and HIV remains nascent. To assess the state of knowledge of the sociocultural and behavioral factors associated with aging with HIV, we conducted a systematic critical content review of peer-reviewed social and behavioral research on aging and HIV to answer the question, “How have older age, and social, cultural, and behavioral aspects of the intersection of HIV and age been addressed in the literature?” We searched First Search, Proquest, Psych Info, Pub Med, Wilson Select Plus, and World Cat and identified 1549 articles. We then reviewed these to select peer-reviewed articles reporting results of research on the social and behavioral aspects of living with HIV at age 50 and older. Fifty-eight publications were identified that met study inclusion criteria. While few publications reported clear age-related differences, there were significant ethnic differences in living with HIV in later life and also differences among older people when groups were defined by mode of transmission. Findings are discussed in light of constructs from gerontology which may contribute to clarifying how later life, life course stage, and psychological development intersect with, influence, and are influenced by HIV disease and long-term anti-retroviral therapy use.

Environmental factors and their role in community integration after spinal cord injury.

Background. The International Classification of Functioning, Disability and Health (ICF) model presents an opportunity to better understand previously neglected longterm social outcomes after traumatic spinal cord injury (SCI), especially the experience of participation. Purpose. The study explored the relationship between perceived environmental barriers and perceived community integration (a participation proxy) in a sample of adults with traumatic SCI. Methods. The study interviewed African American and White women and men (n=136) who had lived with SCI for an average of 11.5 years. Results. Participants reported environmental barriers at twice the level indicated by previous studies; the natural environment and the policies of government were the most problematic. Levels of community integration were also high. Data suggest a significant relationship (p<.01) between perceived environmental barriers and community integration for adults with SCI, providing support for the ICF model. Implications. Improved measures and more sophisticated concepts and theories are needed to explicate the relationship between environmental factors and participation concepts in the ICF. With respect to practice, occupational therapists need to be aware that removal of environmental barriers is only a first step in the more complex effort to facilitate optimal community integration after SCI.

Longitudinal Support for the Relationship Between Vascular Risk Factors and Late-Life Depressive Symptoms

OBJECTIVE The authors examined longitudinal support for the vascular depression hypothesis by assessing the extent to which baseline vascular burden was associated with depressive symptoms 6 and 18 months after discharge from inpatient medical rehabilitation. METHODS One hundred consecutive geriatric rehabilitation patients were assessed during their rehabilitation stay and subsequently screened for depression 6 and 18 months after discharge. Baseline vascular burden was entered into logistic-regression analyses predicting depression at 6 and 18 months after controlling for baseline levels of depression, general medical burden, limitations in activities of daily living, cognitive impairment, and demographic variables including age, education, gender, and race. RESULTS Logistic-regression results demonstrated that, after controlling for the covariates described above, baseline vascular burden was associated with increased odds of positive depression screens at 6- and 18-month follow-up assessments. Furthermore, among patients who were not depressed during their rehabilitation stay, vascular burden was predictive of positive depression screens at 6- and 18-month follow-up assessments. CONCLUSIONS Greater vascular burden was positively associated with depressive symptoms over time. These findings provide further support for the vascular depression hypothesis in late life and highlight the need for careful clinical monitoring of this frail group of elderly patients.

Sero-positive African Americans’ Beliefs about Alcohol and Their Impact on Anti-retroviral Adherence

Alcohol consumption has been associated with HIV disease progression; yet, the nature of this association is poorly understood. This study sought to determine the influence of patient beliefs about alcohol on ART adherence, and elucidate clinician beliefs about drinking and taking ART. Most patients (85%) believed alcohol and ART do not mix. The three alcohol consumption groups, light, moderate, and heavy, differed in their beliefs about drinking and ART with 64% of light and 55% of moderate drinkers skipping ART when drinking compared to 29% of heavy drinkers. Beliefs were derived from folk models of alcohol–ART interaction. Patients 50 and older were less likely to skip ART when drinking. Alcohol appears to affect adherence through decisions to forgo ART when drinking not through drunken forgetfulness. Furthermore, over one-half of clinicians believed alcohol and ART should not be taken together. These findings have implications for patient care and physician training.

What is a missed dose? Implications for construct validity and patient adherence

Abstract The construct ‘missed dose’ is central to many assessments of medication adherence. However, few studies have investigated how patients or clinicians conceptualize missed doses or the extent of the concordance or discordance between clinicians and patients. To address this gap we conducted semi-structured interviews with 45 sero-positive African American adults taking HAART and 17 of their clinicians. Results reveal large variability in missed dose conceptions among both patients and physicians and significant differences between the two groups. Overall, patients reported a stricter definition of missed dose than did clinicians. Fifty-five percent of patients thought that a pill-taking delay of six hours beyond the prescribed dosing time constituted a missed dose, by comparison, only one physician agreed with this assessment. More than one-third of patients thought that the proper response to a missed dose would be to skip it altogether, but only about 12% of clinicians agreed. These findings have implications for the construct validity of self-report measures of adherence, for patient adherence behaviours based on missed dose conceptions and for patient-physician relationships and communication within the clinical environment.

Predicting Discharge and Long-Term Outcome Patterns for Frail Elders

Objectives: Using the framework of environmental press theory to examine the predictive value of medical rehabilitation team assessments for both functional abilities and long-term living arrangements of early return home and late return home elders. Participants: One hundred thirty-five older adults (72% women, 84% African American; mean age 73 years) who lived alone prior to hospitalization for medical rehabilitation. Methods: Competency measures were collected during the hospitalization. Living arrangements were determined by phone follow-up at 3, 6, and 18 months after discharge. Multivariate analysis of variance identified early return and late return patient groups. Logistic regression analyses then determined the clinical utility of the prediction model. Chi-square analyses addressed group differences in stability of living arrangements. Results: Medical burden, functional abilities, and cognition were significant predictors of group membership. Among late return patients, 27% continued to live alone at the 18-month follow-up; 59% of the early return patients did so. Conclusions: Interdisciplinary assessments (including psychological measures) completed in the hospital provide valuable data for discharge planning for older medical rehabilitation patients and are clearly related to successful long-term adjustment. A 78-year-old widowed African American woman, who was living alone prior to hospitalization, comes to medical rehabilitation because of problems walking after knee replacement surgery. Her hospital roommate, a 74-year-old never-married African American woman, was also living alone prior to falling and breaking her hip. Both patients are adamant that their primary goal is to return to living alone, despite the fact that the widowed woman’s three children live in the same city and want her to move in with them. The 78-year-old woman scores well on cognitive testing, has no depression, and has few chronic illnesses. Functionally, she is at an independent or modified independence level by discharge. The treatment team, including the patient, all agrees that discharge home is an optimal outcome. By contrast, the 74-year-old woman

Self-care independence after spinal cord injury: Patient and therapist expectations and real life performance

Abstract Purpose: To evaluate changes in self-care performance between rehabilitation discharge and 1 year follow-up and to compare patients’ and therapists’ expectations of self-care independence with actual self-care performance after discharge. Methods: Prospective study of 55 patients with tetraplegia (21 complete and 34 incomplete) after spinal cord injury (SCI) consecutively admitted to a large urban rehabilitation hospital [injury levels: C4 (5), C5 (33), C6 (9), C7 (4), and C8 (4)] . Data were collected using structured patient interviews, occupational therapists’ predictions of patients’ self care, and Functional Independence Measure ratings by rehabilitation staff. Results: Analysis showed that for all skills, expectations of patients (mainly African American men) were higher than therapists’ predictions, and for 3 of these skills, the differences were statistically significant: eating (Z = -4.47, P < .001 ); bathing (Z = -3.67, P < .001 ); and dressing (Z = -3.16, P = .002). Occupational therapists were better predictors of patients’ actual self-care performance at discharge than were patients, although both tended to overestimate patients’ performance. There was no evidence that self-care capability declined between discharge and 12 months follow-up, but routine self-care performance varied widely across patient and personal circumstances. Conclusions: Differential attrition reduced the study sample to 25 SCI patients who were primarily more severely injured African American men. Results showed that these patients maintained their self-care performance 1 year after discharge, but more innovative strategies must be developed to customize self-care retraining to address the unique needs of this patient population. J Spinal Cord Med. 2001 ;24:257–265

Self-rated health among persons with spinal cord injury: What is the role of physical ability?

Abstract Objectives Self-rated health (SRH) is a powerful concept that has greatly advanced our understanding of health and health outcomes. The SRH measure has become increasingly common in health research. Yet, puzzles remain about what shapes SRH ratings. The absence of knowledge is particularly acute in the context of disability. The aim of this study was to examine the relationship between SRH and self-rated physical ability in a sample of individuals with spinal cord injury (SCI). Methods Data from 140 eligible participants drawn from a study of life in the community after SCI were analyzed. The study, cross-sectional in design, was conducted in a large urban city in the mid-western United States. Basic statistics such as ANOVA and chi-square tests were performed as appropriate, and a multiple linear regression analysis modeled the relationship between SRH and physical ability adjusting for potential confounding variables. Results Self-rated physical ability was significantly associated with SRH after controlling for relevant covariates (P < 0.001). An analysis of the interaction between physical ability and level of injury revealed that the relationship was significant for persons with paraplegia but not for persons with tetraplegia. Conclusions This study provides evidence that self-rated physical ability is an important factor associated with SRH for persons with SCI, but that the strength of the relationship depends on level of injury (paraplegia vs. tetraplegia). The challenge for future research is to replicate the study using a more comprehensive measure of physical ability and to ask how beliefs in ones ability to do those activities that are most meaningful and desired shape SRH. Only in this way will our understanding of the physical ability–SRH relationship be clarified.

Elderly Inner City Women Who Return Home to Live Alone

This study examined the status of 107 elderly inner city women who returned to their home after being in a geriatric rehabilitation unit at a large urban medical center. Prior to admission, all women had been living at home alone. After rehabilitation, 50 of the women were discharged directly to their homes, 26 followed within 3 months, 11 were back home alone by 6 months, and 20 additional women were still not home by 6 months. Results showed that, as measured by standardized assessments of physical functioning and cognition, the women who were most functionally independent returned home alone more quickly. Furthermore, those who achieved live-alone status some time after discharge (but not at discharge) did not report the same level of self-care and home maintenance task independence as women who were discharged home alone immediately at discharge. The findings raise questions about the minimum level of functional performance required to return home alone and the interaction of functional ability, assistance from others, and a variety of social and environmental factors on live-alone status.

Falls efficacy and self-rated health in older African American adults

Fear of falling and mobility restrictions have a significant negative impact on the quality of life of older adults. Because older African American adults are at increased risk for various modifiable health problems, understanding potential constraints on their overall health and mobility is critical in this population. The current study investigated this issue by analyzing a dataset of 449 older African American adults (mean age=72.3 years) living in Detroit. We characterized and investigated the relationships among the following falls- and health-related variables: previous falls, falls efficacy, mobility, self-rated health (SRH), and depression and well-being. As a whole, participants reported moderate health and well-being, little depression, few mobility problems (mean=8.4/40), and very high falls efficacy (mean=94.9/100) despite the fact that a quarter of the sample experienced a fall within the past year. Correlation results indicated that previous falls, falls efficacy, mobility, SRH and depression and well-being were all inter-related. Regression analyses revealed that higher falls efficacy was more closely associated with better SRH than was having previously fallen. Findings suggest that improving falls efficacy in older African American adults may be beneficial to their mobility and overall health and well-being. Further, by asking a single-item SRH question, clinicians may be able to quickly identify older African American adults who have low falls efficacy and are at high risk for falling.