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Presidental Address

"Family Decisions in Dementia Care"

Sara Qualls, Ph.D.

Despite mushrooming research on caregiving to older adults with dementia, there has been a surprisingly small amount of research that examines the family as a multi-person entity, and its role in sharing the experience of dementia or the processes and outcomes of dementia care. However, those of us personally involved in the care of someone with dementia can readily attest to the complexity of the cast of characters who surround us. As caregivers and as clinicians we are often unsure what to do with that cast of characters. I hope to persuade you that clinical practitioners and researchers can and must attend to the family context and that doing so opens fascinating doors.

Families have a reciprocal influence on older adults that is well demonstrated and
profound. When families appear in clinical settings it is often because family stability
has been interrupted by changes in either capacity or context. Dementia is a prime example of a change that disrupts family functioning because it affects biological, psychological, and social functioning, with profound consequences for the surrounding family.

Interpersonal Aspects of Decision Making
Persons with dementia rely increasingly over time on the people around them to meet basic needs. Reciprocally with their growing dependence is the increasing level of responsibility that is assumed by others, typically family. The sequence of changes experienced by families providing care for a person with dementia mirrors the shifts in roles over time experienced during childrearing. The family engages in role changes that alter significantly the types of decisions and the processes by which those decisions are made. Unfortunately, the transitions are ambiguous with no clear markers for their timing, and there are not clear social norms for the process of negotiating the transitions. We know the emotional intensity of participating in those transitions with children (especially adolescents), but do not have as much awareness of them for caregivers.

Consider the case of an elderly widow with dementia whose three adult children all have families of their own. Since her husband's death, she has retained familiar generational boundaries around primary decisions (e.g., finances, health, housing, legal matters). Recently, however, her older daughter has grown concerned about her mother's well-being. Now what? If the daughter honors the generational boundaries, she can do no more than express concern or empathy. If the elderly mother honors those boundaries, she can do no more than ask for assistance with tasks.
Move forward in time a couple of years…everyone in the family acknowledges that mother has dementia. Who decides when a housing change is needed? Dementia demands that family structures change in order to meet the needs of members, but the manual does not exist to tell families how to renegotiate those changes.

Existing theory and research offer some guidelines based on comparisons of families who make the transition well versus those who do not. Boss and colleagues (Boss, Caron, Horbal, & Mortimer, 1990) have documented that members who experience more boundary ambiguity suffer more than those who can figure out a structure. Similarly, Lieberman & Fisher (1999) have demonstrated that clear decision-making roles work better in families dealing with dementia than democratic structures. Williamson (1982) theorizes that adults must claim their personal authority within the family system in order to be able to take on decision-making responsibility in their own lives, let alone that of their parents. Years ago, Blenkner (1965) claimed that a particular kind of filial maturity is needed in individuals in order to take on decision-making and care roles with one's parents. To date, theory and research primarily tells us what does (or should) work, but does not tell us how to accomplish the kinds of renegotiation that is needed.

The process of renegotiation of roles around decision-making likely is quite challenging to families. Several studies document the different values held by different generations regarding end-of-life decisions (e.g., Karel & Gatz, 1996). Roberto (1999) examined interactions between siblings with different values about end-of-life decision making and concluded that their process for reaching consensus did not follow principles of logic, but patterns that appeared to reflect long-term family dynamics.

Families must use several processes in making a transition. Families must perceive change, label the change, claim authority to act on their perception, decide who should act, and choose a specific action. Note that these processes are both intrapersonal and interpersonal processes. Likely, there is meaningful interplay between these levels of social cognition (Meeghan & Berg, 2002). Furthermore, some transitions include the person with impaired ability to understand the issues or processes, albeit often in a different way than other members of the family understand them.

We know very little about any of the intrapersonal processes noted above, and even less about the interpersonal processes through which family members communicate and mutually influence each other's frameworks. I strongly suspect that a complex series of dyadic interchanges occur in telephone calls and side comments or long knowing looks that over time shape the frameworks of family members. Only rarely do I hear of families convening a formal meeting to investigate, let alone address, their concerns over behavior changes.

Another important aspect of the family's involvement in decision-making is their frequently noted experience of resistance from the family member with dementia. Once the family has come to recognize a behavior change as a problem, someone has to communicate the concern to the target person. This task is dreaded precisely because it so often generates resistance to the family member's view: "There's nothing wrong with my driving…I've never had an accident and you get speeding tickets all of the time." "Throughout my career I've balanced $40 million budgets at work and you are telling me I cannot manage my own finances?!"

Unfortunately, there is little research available to guide us in coaching families on how to talk about transitions successfully with the person with cognitive impairment, nor how to get family members to reach consensus in decisions.

A Social Cognition Model of Dementia
A typical referral in our outpatient clinic, the CU Aging Center, is from a daughter who describes her mother as "different", "depressed", and "she just sits a lot." When asked about memory, the daughter denies problems, noting that her mother just forgets things like most older people do. When asked who handles her finances the daughter is emphatic that the family had to take that over a while ago because her mother just quit taking care of things after their father died three years previously. Here is a family that has a vague sense of a problem, but has not labeled it as such, and thus has not sought help from formal providers.

The health psychology literature suggests individuals' frameworks for illnesses need to be understood if we want to understand their behaviors regarding the illness. The basic model suggests that members of a social context (e.g., families) form a conceptual framework for their experience with illness that influences behavior (Leventhal, Leventhal, & Contrada, 1998). Furthermore, the cognitive framework or model needs to be understood as it unfolds over time. The fact that these decisions often involve more than one person means that communication among members describing their concerns and solutions for them emerge from those frameworks and somehow lead to action.
In dementia, the first decision is detection of the disease. Following that, the process of deterioration dictates which decisions must be made. For example, in the early stages when memory and performance deficits are subtle and often hidden, individuals and families make decisions about work responsibilities. Later, when the cognitive impairment is greater, someone typically makes decisions about independence in driving and financial management. Families play important roles at all stages, but may be in a unique position regarding decisions about early detection.

The earliest signs of dementia are available to persons observing daily life, yet we know little about how those signs are processed. Considerable effort has been invested in finding assessment tools to detect dementia in health care settings with the hope that early use of behavioral or pharmaceutical interventions may delay the deterioration in function. However, families are the most likely candidates to detect the very early warning signs, long before a professional would have an opportunity to perform an assessment. Thus, understanding how families detect change, how they label it, and under what conditions they seek help is particularly important.

In our lab we have been using a vignette methodology to examine the information that influences adults' perceptions of problems observed in their hypothetical parent. We are focusing on the factors that influence appraisals of the problem, and how those appraisals influence action alternatives. To date, we have conducted studies that document the influence of various types of cues on the appraisals made about older adults who are showing ambiguous deterioration.

Our research suggests that appraisals of the problem are not influenced by the hypothetical parent's age or gender, but are influenced by the kind of information available about the decline. For example, blatant cues showing objective decline influence appraisals of the problem more than subtler changes in lifestyle that are typical of efforts to compensate for deteriorating cognition. More ambiguous information is rated as less problematic than clearer information if the scenario is depicting very early cognitive impairment (but the opposite is true for physical impairment). Perceptions of danger were primarily influenced by ambiguity level; regardless of type of impairment, more ambiguous situations were rated as less problematic. Preferred responses to concerns about ambiguous deterioration include talking with family and friends, a social information gathering strategy rather than seeking formal health care evaluations. Appraisals appear to predict help-seeking behavior in direct ways (more perceived problem leads to more active intervention) and account for meaningful variance in action preference. Respondent characteristics (e.g., demographics and knowledge of dementia) are only very weakly predictive of appraisals or action.

These studies suggest that adults are likely to see a problem when faced with evidence of deterioration that is ambiguous in cause and nature, and they see themselves as likely to act by involving family and friends, and at times a physician, in their concern. However, the more ambiguous the presentation of cognitive impairment, the less likely it will be considered a problem or lead to help-seeking action (i.e., evaluation). Cues vary as to their salience in shaping the perception of problem with behavior change cues being less influential than objective evidence of trouble handling personal finances or recognizing voices.

Based on these laboratory analog data, it appears to be fruitful to examine the cognitive frameworks that family members bring to their observations of aging parents. Specifically, we need to know how those frameworks affect cue perception, how the frameworks affect appraisals, and how the frameworks affect actions. Two other areas of investigation add to the complexity of the task: We need to examine how multiple people negotiate the differences in their frameworks and we need to examine how the frameworks evolve over time as new data become available.

Family Interface with Larger Systems in Dementia Care
I want to acknowledge, albeit briefly, that another way in which family roles in decision making warrant the attention of geropsychologists is in examining the interaction between families and formal care systems. The family involved with the older person is engaged in reciprocally influential roles with the larger care systems that provide health care, housing, and social services as well. Within these systems, families play multiple roles. Families provide information, monitor well-being, assist or undermine compliance, co-participate in life style changes, manage affect, provide a safety net for crises, detect problems, and seek help. Any larger social system interacting with the person with dementia needs to be aware that families are intimately linked with their older members in ways that influence the larger system's work.

Implications of the interplay between family systems and larger systems include some very basic changes in how psychologists work. I advocate strongly that we need to engage family in the assessment process routinely (think how often we have been surprised to learn that a person performs differently in our office and at home). We need to engage family in planning for health behavior changes -- we need to anticipate the influence of family dynamics on what we benignly refer to as compliance. We need to expect resistance from the person with dementia when changes are introduced and coach the family on how to proceed. Test reports can and should be written for families as well as other professionals. Families need to be consumers of neuropsychological test findings, and useful reports of those findings need to be made available to them. We need to recognize the patterns of family anxiety when it intrudes on care (e.g., recognize that anxiety is building prior to a decision when the deterioration is ambiguous).

Finally, I want to note an ethical issue that receives remarkably little attention in the literature. We need to attend to the ways our professional care decisions that balance autonomy and beneficence for an older person may impact the autonomy and well-being of other family members. There are almost always trade-offs in what is best for various family members that requires careful analysis and conversation.

Conclusion

As a professional clinician, researcher, trainer, and family member of a cognitively impaired mother and father-in-law, I am increasingly impressed with how well many families manage the amazing quantity and rate of change (especially in decision-making) that runs their lives. However, I find it tragic that our field has generally attended so poorly to the family context of older adults' lives in its research paradigms, clinical services, and training. Emerging paradigms provide us with some exciting avenues for further exploration if we will "think family" in our work in Clinical Geropsychology.

References

Blenkner, M. (1965). Social work and family in later life, with some thoughts on filial maturity. In E. Shanas & G. Streib (Eds.), Social structure and the family: Generational relations (pp. 46-59). Englewood Cliffs, NJ: Prentice-Hall.
Boss, P., Caron, W., Horbal, J., & Mortimer, J. (1990). Predictors of depression in caregivers of dementia patients: boundary ambiguity and mastery. Family Process, 29, 245-254.
Lieberman, M. A & Fisher, L. (1999). The effects of family conflict resolution and decision making on the provision of help for an elder with Alzheimer's Disease. Gerontologist. 39, 159-166.
Karel, M. J. & Gatz, M. (1996). Factors influencing life-sustaining treatment decisions in a community sample of families. Psychology & Aging, 11, 226-234.
Leventhal, H., Leventhal, E. A., & Contrada, R. J. (1998). Self-regulation, health, and behavior: A perceptual-cognitive approach. Psychology & Health. 13, 717-733.
Meegan, S. P, & Berg, C. A. (2002). Contexts, functions, forms, and processes of collaborative everyday problem solving in older adulthood. International Journal of Behavioral Development, 26, 6-15.
Roberto, K. A. (1999). Making critical health care decisions for older adults: consensus among family members. Family Relations, 48, 167-175.
Williamson, D. S. (1982). Personal authority via termination of the intergenerational hierarchical boundary: 2. The consultation process and the therapeutic method. Journal of Marriage and the Family, 8, 23-37.

Section II Award Recipients
Contributed by Greg Hinrichsen, Ph.D.

Division 12, Section II is proud to announce 2002 award recipients:

M. POWELL LAWTON AWARD FOR DISTINGUISHED
CONTRIBUTIONS TO CLINICAL GEROPSYCHOLOGY:
Martha Storandt, Ph.D., Washington University, St. Louis

DISTINGUISHED MENTORSHIP AWARD:
Barry A. Edelstein, Ph.D., West Virginia University

AWARD FOR EXCELLENCE IN RESEARCH BY A STUDENT MEMBER:
Brian P. Yochim, M.A., Wayne State University, for his work, "Exploring the
Vascular Depression and Activity Limitation Theories of Geriatric Depression"

Member news....
Victor Molinari, Ph.D., President-Elect for Section II, has left the Houston VAMC after 17
years with the geropsychiatry service to take a position as Professor at the University of South Florida. New Address: Louis de la Parte Florida Mental Health Institute; University of South Florida; Department of Aging and Mental Health/MHC 1423; 13301 Bruce B. Downs Blvd.; Tampa, Florida 33612-3899. Work Phone: 813-974-1960. email: vmolinari@fmhi.usf.edu
Congratulations Dr. Molinari!

From the Editor:
Michelle Gagnon, Psy.D.

Please join me in welcoming and congratulating Merla Arnold, Ph.D, who has been selected to assume the role as editor of the Section II newsletter. Dr. Arnold's editorship will begin officially in Fall 2003; however, she and I will be working closely beginning in early 2003 to ensure that the transition is a smooth one. Dr. Arnold was the prior student representative to Section II and I know that she will bring excellence and fresh ideas to the newsletter as well.

My term as editor has been fulfilling both professionally and personally, a wonderful combination. I would like to thank the past and current Boards for allowing me this opportunity to participate in communicating information for Section II. I've met many wonderful people and have learned a lot through this experience.

Society of Clinical Psychology (Division 12) Report

Deborah King, Ph.D., Section II Representative

Aging Issues Off While Deborah King, Ph.D. was transitioning into her new role as Section II Representative Victor Molinari, Ph.D., President-Elect, represented the Section at the Midwest and Spring Division 12 Board meetings. (The Midwinter Report was included previously in the Winter Newsletter).

Spring Board Meeting Summary
Victor Molinari, Ph.D., President-Elect

The Spring Board Meeting of Division 12 was held in Atlanta, June 7th -June 9th. Selected points of interest are summarized below:

1. It was announced that APA's Council of Representatives approved a resolution rejecting ageism in all its forms. The entire resolution is quite lengthy, but available from Deborah King upon request dking005@rochester.rr.com.

2. APA and the Commission for the Recognition of Specialties in Professional Psychology (CRSPP) are debating whether to eliminate proficiencies because they may make it easier for psychologists to be sued for restraint of trade. This issue plus the high cost of developing the proficiency exam weigh against the need to require more training in certain areas to assure competent practice. (Note: Since the Midwinter Meeting, CRSPP revised its defining documents, including a disclaimer about restraint of trade. These documents were discussed at an open forum at the APA Convention in Chicago and we await the outcome of that meeting.)

3. Following remarks in "The Clinical Psychologist" (TCP) likening projective testing to astrology, there was discussion about whether TCP is the official voice of the Division and, therefore, whether TCP articles can take stands contrary to the official position of Division 12. The Board voted to support a plurality of views, but TCP will now print a disclaimer that the opinions expressed in articles are not necessarily the official position of the Division.

4. A task force was assembled to address the advancement of clinical psychology in a manner that facilitates both scientific and professional development.

5. The next meetings will be October 18th - 20th in St. Louis and January 10th -12th in Sante Fe.

~Congratulations to Brian Yochim, M.A.~

2002 Division 12/Section II Student Research Award Winner:

Award for Excellence in Research by a Student Member

Examining the Vascular Depression and Activity Limitation
Theories of Depression in Older Adults
Brian Yochim, M.A., Benjamin Mast, Ph.D., and Peter Lichtenberg, Ph.D.

Introduction: Researchers have postulated two theories of late-life depression. 1) The vascular depression hypothesis states that cerebrovascular risk factors (CVRFs) such as diabetes, hypertension, or heart disease can lead to symptoms of depression. Mast (2001) found that individual CVRFs were not related to depression, but the cumulative burden of more than one CVRF led to significantly higher rates of depression. 2) The activity limitation theory holds that limitations in functional activities account for the relationship between physical illness and depression. No study has investigated the interaction of cumulative vascular burden and activity limitations and their relationship with depression in older adults.
Method: A telephone survey, incorporating the 12-item Short-Form (SF-12) Health Survey, was conducted with 600 randomly selected older adults in Detroit's central city, in which self-report data were collected on medical status, mood, and functional abilities. Participants were predominantly African American with a mean age of 74 years; 75% were women, 48% had less than a high school education, and 66% were living alone.
Results: Those with two or three CVRFs and those who had had strokes had equivalent rates of depressed mood (17% and 20%; 2 [5] = 1.3, p > .90). Both groups had significantly higher rates of depressed mood than did those with no or one CVRF (10%; 2 [5] = 15.0, p < .05; 2 [5] = 11.8, p < .05). The SF-12 Mental Health Summary Score was significantly higher (indicating better mental health) in people with no or one CVRFs than in those with two or three
CVRFs (t [225] = 3.8, p < .001) or with stroke (t [76] = 3.0, p < .01). The latter two groups had equivalent SF-12 mental health scores (t [120] = 0.1, p > .85).
Depression was strongly related to several medical outcome variables. Three 2 x 2 ANOVAs revealed that depressed mood was significantly related to the SF-12 Physical Health Score (interaction term, CVRF x depressed mood: F [1, 465] = 4.1, p < .05), number of days in bed sick (main effect: F [1, 466] = 21.2, p < .001; and interaction: F [1, 466] = 9.9, p < .01), and number of visits to a medical doctor (main effect: F [1, 473] = 8.8, p < .01).
Activity limitations were found to mediate the relationship between vascular burden and depression. Using multiple regression, vascular burden was found to predict restriction of social activities and depressed mood. When both vascular burden and restriction of social activities were used to predict depression, only restriction of social activities emerged as a significant predictor of depressed mood. When similar analyses were completed with limitations in physical activities, this was found to partially mediate the relationship between vascular burden and depression.
Discussion: This study demonstrated that increased vascular burden is related to increased prevalence of depressed mood. Depressed mood had a strong relationship with several medical outcome variables. The relationship between vascular burden and depressed mood was found to be fully mediated by restrictions in social activities and partially mediated by restrictions in physical activities. Results suggest that mood assessment should be encouraged in all elders with significant CVRFs. Therapy for depressed elders should target social and physical activities.

How can I get involved?
This is a question I often ask myself as I join new professional groups or organizations in psychology. When I first joined APA I remember feeling awestruck by the sheer number of professionals who attended the conference. I was unsure about how to connect with other students and how to meet professionals in my area. Joining specialty sections and divisions was my first step toward meeting others and making the conference feel more hospitable.

So, how does a student become involved in APA divisions?
Distribution of a survey querying about career interests and background resulted in several e-mails from student members asking how they can become more involved in the group. Merla and I have been busy this past year brainstorming ideas to increase student involvement and interest in 12/II. Our initial efforts have been quite successful! Here is an update of current opportunities for student members:

1. Student Listserve- A student e-mail list was created recently for the purpose of announcements and discussion among student members. All new student members are added to the listserve and may post geropsychology-related questions and comments.

2. Student Council- There is discussion among members about creation of a student council composed of active student members designated to a particular position, including listserve moderation and membership drives. Stay tuned…

3. Student Social Activities- Every year at the APA convention we have a student breakfast and a student social. This is a great way to meet other students and professionals! Come on out!

4. Student Survey- Your participation in completing the survey helps us to tailor student activities and our focus as a group. Recent accomplishments listed on a survey will be announced in the Student Voice column of the 12/II newsletter.

5. Student Voice- Students with an interest in summarizing their research or in writing an editorial on a thought-provoking topic in geropsychology should contact Sherry (sbeaudreau@hotmail.com) or Merla (ma159@columbia.edu).

6. Student Research Award- Each year 12/II offers an award for excellent research by a student member. This year Brian P. Yochim, M.A., of Wayne State University is our winner! Congratulations to Brian!

Student Announcements:
Merla's tenure as student representative ends this summer. I'd like to send out a special thanks to Merla for passing on her wisdom as student representative. I also wanted to announce that Merla recently passed her licensure exam. Congratulations Merla!
Laura Phillips, M.A. from the University of Alabama was selected to join me as student representative. A hearty welcome to Laura!

Profile on: Deborah W. Frazer, Ph.D.

Director of Behvioral Health, Genesis ElderCare

In 1996, I left the Philadelphia Geriatric Center to work for Genesis ElderCare, where I am the Director of Behavioral Health. I used to joke that out of 40,000 employees, I was the only mental health professional, but actually there are a few others now. Genesis owns or manages about 300 nursing centers, and about 50 assisted living facilities, primarily on the East Coast. In addition, the company provides respiratory, pharmacy, rehab, hospitality, and other services for long term care. I work in a 20-person group called the "Clinical Practice Division," that is based in the corporate headquarters in Kennett Square, PA. My work group consists of clinical specialists in different areas of long-term care; we work as internal consultants to the company to improve the quality of care in our area. A second work group does all the clinical outcomes measurement for the company.

As a mental health professional, I work on policies and procedures, educational programs, and research related to behavioral/mental health issues, including substance use/abuse. I am charged with working to develop and to standardize our company's approach to dementia and special care units, including everything from standards of care to interior design. I facilitate a group of dementia specialists (3 MSWs and 1 Psy.D.) who implement this work in their geographic regions. In addition, I trouble-shoot when a particular nursing center is having extraordinary difficulties related to mental health or behavioral issues. I have been assigned a few times to work with pharmaceutical companies related to their psychotropic products. Occasionally I help a region or center with their mental health professional contracting.

More recently, I have added Assisted Living to my job duties, helping the company to: define an appropriate model of care; define the role of nursing; comply with the myriad and evolving state regulations; and develop policies and procedures that mandate staff to provide assistance while maintaining the choice and autonomy that are hallmarks of assisted living care. As with dementia, I facilitate a group of regional specialists (these are all RNs) who do the implementation in the field. I also track and participate in the national debate on defining and monitoring quality in Assisted Living.
And then there are always the unexpected things that "land on my desk." One very challenging issue was developing a policy on residents who come to our nursing centers on methadone - an area about which I originally knew very little. Many months of research and consensus-building later, I think we're close to getting all the physician and nurse leadership to agree on a "package" consisting of policies, procedures, staff education, and sample contracts with Opioid Treatment Programs. A similarly complex issue has been building consensus on a company-wide approach to resident sexual expression.

It seems like a long way from my original training to my current work. I graduated from Swarthmore College in 1969, with a major in psychology. After 5 years off, primarily working on issues of peace and justice, I returned to my original focus on the individual. In 1979, I completed my Ph.D. in Clinical Psychology at Temple University. Through my internship and dissertation, I became fascinated with the work of M. Powell Lawton, who combined broad interests in aging, assessment, and the person-environment interaction.

Unfortunately, the clinical job market required a rather narrow and payer-oriented focus, whether I was in a community mental health, state hospital, or private, non-profit setting. I was interested in the "environment" side of the p-e equation; and my peace/justice/political side enjoyed understanding the large forces at work in determining individual well-being. In the mid-80s, Powell recruited me to Philadelphia Geriatric Center (PGC) to head the psychology department. I enjoyed enormously building a geropsychology postdoctoral program at PGC during the late 80s through the mid-90s . I also got to work directly with Powell and his associates in the PGC research department - a real lifetime gift. Research was a way to relate the "big picture" to a single individual's well-being.
In 1995, and then again in 1996, I was recruited for my current position. I was ready to try something new, and at mid-life, realized that opportunities for change might become more limited. After initially turning down the position (could I really work for a corporation??), I succumbed in 1996. Although I think Powell never entirely approved of my job decision, I often feel that I am potentially able to affect an enormous "real world" population with many of his groundbreaking concepts. Both my dementia unit work and my assisted living work are directly informed by his person-environment and quality of life research.

In some ways I have come full circle back to my peace and social justice work. Conceiving of grand programs is exciting and fun, but the successful implementation, including changing the daily interactions between tens of thousands of nursing assistants and residents, is as challenging as creating world peace! In either case, I guess you have to simultaneously sustain your belief in the ultimate vision, while managing the day-to-day "baby steps" required to get us all a little further down the road.

Division 12, Section II Student Participant Research Award Abstracts

Contributed by Greg Hinrichsen, Ph.D.

Never Too Old to Learn: The Impact of an HIV/AIDS Education Program
on Older Adults' Knowledge
Nicole Falvo, Psy.D. and Suzanne Norman, Ph.D., Xavier University

This study assessed changes in AIDS-related knowledge as a result of a sex education workshop created specifically for older adults and the subsequent retention of this information. Our findings support the acquisition of knowledge by older adults as a result of the sex education workshop. In addition, AIDS-related knowledge was retained for at least 3 months. Thus, older adults are likely to acquire new information regarding AIDS-related information when it is presented to them. Difficulties in collecting information regarding risk-related behaviors to examine the relationship between knowledge and behavior change were also discussed.

The Relationship Between Cognitive Flexibility, Anxiety, and Depression in Older Adults
Lisa Delano-Wood , M.A., Michigan State University

The relationship between cognitive flexibility (one aspect of executive functioning), anxiety, and depression in older adults was explored. A sample of 283 older adults (aged 55-86) was analyzed using structural equation modeling to assess whether age, anxiety, and/or depression would significantly predict cognitive flexibility as measured by the Stroop, Trailmaking (B), Wisconsin Card Sorting, and Word and Category Fluency. In addition, analysis of cognitive flexibility as a one- and two-factor model was completed. Results demonstrated that a two-factor model better fit the data; in addition, depression and age significantly predicted cognitive inflexibility. This result is striking given that average levels of depression for the sample were mild to moderate.

Diabetes and Health Status: The SF-36 among Older Mexican Americans
Diane G. Stoebner-May, Ph.D.1, M. Kristen Peek, Ph.D.1,3, Steven V. Owen, Ph.D.3,4, Ha Nyguyen, Ph.D.1, Kenneth J. Ottenbacher, Ph.D.1,2,3

1Sealy Center on Aging, University of Texas Medical Branch at Galveston
2Division of Rehabilitation Sciences, School of Allied Health Sciences, University of Texas Medical Branch at Galveston
3Department of Preventive Medicine and Community Health, University of Texas Medical Branch at Galveston
4School of Nursing, University of Texas Medical Branch at Galveston

Little is known about the health status of older Mexican Americans with diabetes, a group that is disproportionately affected by this disease. The objective of this study was to examine the association of diabetes with health status. Data were taken from the Hispanic Established Population for the Epidemiologic Study of the Elderly, a longitudinal study of Mexican American adults. Individuals with diabetes had lower scores on the physical functioning, role-physical, general health, bodily pain, social functioning, and vitality subscales of the SF-36 when controlling for sociodemographic variables and chronic illness. Further study of health status and interventions aimed to improve health status are recommended for this population.

Positive Psychosocial Functioning Despite Poor Health in Later Life: Use of Meaning-Based Coping Strategies by Nursing Home Residents
Suzanne C. Danhauer, Ph.D., Postdoctoral Fellow, Center for Research in Disease Prevention, Stanford University School of Medicine

This study examined factors associated with positive psychosocial functioning (PPF: positive affect, psychological well-being) in 94 non-cognitively impaired nursing home residents (86% female, mean age = 83 yrs). It was hypothesized that meaning-based coping (MBC) would be positively associated with PPF. Participants responded to measures of coping, affect, psychological well-being, depression, activities of daily living, self-rated health, and recent uplifts. Results revealed that MBC (positive reappraisal, uplifts) accounted for significant variance in PPF but not distress while physical health variables accounted for significant variance in distress but not PPF, suggesting a distinction between positive and negative psychosocial outcomes.