Publications by authors named "Susanne Zank"

17 Publications

  • Page 1 of 1

Elder abuse in the oldest old: prevalence, risk factors and consequences.

Z Gerontol Geriatr 2021 Jul 30. Epub 2021 Jul 30.

Lehrstuhl für Rehabilitationswissenschaftliche Gerontologie, Humanwissenschaftliche Fakultät, Universität zu Köln, Köln, Germany.

Background: Experiences of abuse in relationships with an expectation of trust are a common phenomenon among older people and is called elder abuse (EA). This can take various forms, such as physical, verbal, emotional, psychological, financial, sexual abuse or neglect. Due to their high vulnerability and difficulties in receiving support, people aged over 80 years old have been pointed out as a group that needs special focus in research.

Objective: Prevalence, risk factors and consequences of EA for different aspects of quality of life are explored among the oldest old.

Material And Methods: Computer-assisted personal interviews were conducted in a representative sample of the oldest old in North Rhine-Westphalia (Germany). 988 self-report interviews without third persons present of the NRW80+ study are used to assess EA with the help of the elder abuse and emotional consequences scale (EACS). The EACS describes EA in six dimensions that give a broad understanding of EA.

Results: Prevalence of experiences of EA within the last 12 months was 54.1%. In logistic regression, multimorbidity, lower functioning, age below 90 years, smaller social network size, and aggressive behaviorwere significant risk factors for EA. People experiencing EA showed less life satisfaction and autonomy and increased loneliness and depressive symptoms.

Conclusion: EA is prevalent among the oldest old. Serious consequences of EA on life results can be shown with a broad operationalization of EA. Future research should focus on a deeper understanding of reasons for EA and reflect on the relationship between and the perspectives of perpetrators and victims.
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http://dx.doi.org/10.1007/s00391-021-01945-0DOI Listing
July 2021

Multimorbidity in old age and its impact on life results.

Z Gerontol Geriatr 2021 Jun 23. Epub 2021 Jun 23.

Lehrstuhl für Rehabilitationswissenschaftliche Gerontologie, Humanwissenschaftliche Fakultät, Universität zu Köln, Cologne, Germany.

Background: High prevalence diseases, such as high blood pressure, dementia and depression in old age can lead to multimorbidity, which is often defined as the presence of more than one health condition in an individual. Multimorbidity has negative consequences on health-related quality of life and healthcare utilization. As many age-associated diseases are not curable, therapeutic goals like preservation of autonomy, functioning, and life satisfaction become more important in old age patients.

Objective: The prevalence of multimorbidity dementia and depressive symptoms and the consequences of multimorbidity on autonomy, functioning, and life satisfaction among the oldest old were examined.

Material And Methods: In personal computer-assisted interviews, participants of the representative study NRW80+ were asked for which health issues they received medical treatment.

Results: On average, people above the age of 80 years were treated for 3.62 diseases and 31.4% of older people received medical treatment for 5 or more diseases. A connection between multimorbidity and age group could not be shown. Autonomy, functioning, and life satisfaction are reduced in association with multimorbidity.

Conclusion: Multimorbidity is a frequent phenomenon among old people. A lack of diagnostic procedures and medical treatment can be a reason for the missing age trends. The results illustrate the importance of multimorbidity for patient-relevant outcomes and reveal the need to identify patients with multimorbidity.
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http://dx.doi.org/10.1007/s00391-021-01920-9DOI Listing
June 2021

WWII traumatic events, subjective well-being and valuation of life in the very old.

Z Gerontol Geriatr 2021 Jun 11. Epub 2021 Jun 11.

Chair of Rehabilitative Gerontology, Department of Special Education and Rehabilitation Science, Faculty of Human Sciences, University of Cologne, Herbert-Lewin-Str. 2, 50931, Cologne, Germany.

Background: Experiencing war is a major trigger for physical and mental health problems. People in the German population who are currently over 80 years of age experienced the Second World War (WWII) as children or adolescents, at a time when psychological vulnerability is high. Empirical results show that positive subjective well-being (SWB) and valuation of life (VoL) in older cohorts are widespread; however, when confronted with existential age-associated changes, many older adults experience increased burden, sometimes bringing biographical vulnerabilities to the forefront. This study investigated SWB and VoL in the very old and examined the influence of negative WWII experiences on these outcomes.

Method: Cross-sectional data from the "Survey on quality of life and subjective well-being of the very old in North Rhine-Westphalia (NRW80+)" are presented. Multiple regression models, adjusted for gender, age, physical health, and full inpatient care, were computed to assess the impact of suffering from the effects of WWII traumatic experiences on SWB and VoL.

Results: Over 13% spontaneously reported suffering from the effects of WWII events and an additional 29% reported negative experiences when explicitly asked about them. Multiple regression models showed elevated depression scores for participants suffering from the effects of WWII traumatic events. No association with positive affect was found. Suffering from the effects of WWII traumatic events did not influence VoL engagement with life or VoL optimism.

Discussion: Many very old adults still seem to struggle with the repercussions of WWII traumatic experiences. Future studies could further examine if the missing association with positive affect and VoL is a sign of resilience.
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http://dx.doi.org/10.1007/s00391-021-01906-7DOI Listing
June 2021

WWII trauma impacts physical and mental health in the oldest old: results from a German population-based study.

Aging Ment Health 2021 Feb 8:1-8. Epub 2021 Feb 8.

Department of Special Education and Rehabilitation Sciences, University of Cologne, Cologne, Germany.

Introduction: Epidemiological studies in different traumatised samples indicate an increased risk for numerous physical and mental diseases. It is suspected that this is due to chronic changes in fundamental processes in the immune, nervous, and endocrine systems, which take years to manifest pathologically. Previous studies have considered intervals of a few decades. However, little is known about whether a link between trauma and physical and mental health can be established over very long periods of time and in the oldest old population.

Materials And Methods: A total of 1,299 German citizens aged 80 and above were interviewed about on-going suffering from the effects of traumatic World War II (WWII) events as well as about physical and mental health. Multiple linear and logistic regression models were used to assess the impact of suffering from the effects of traumatic events on general health, several medical conditions, multimorbidity, pain, and depression.

Results: 43.94% of the oldest old were still suffering from the effects of traumatic events in connection with WWII. Participants who were still suffering from the effects of traumatic events were more likely to be treated for heart failure, blood diseases, bladder problems, back pain, respiratory or lung diseases, and sleep disorders. They also had poorer general health, higher multimorbidity, more pain, and higher depression scores.

Discussion: Findings suggest that chronic psychological suffering from the effects of traumatic events in early life is associated with impaired physical and mental health even seven decades after the events.
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http://dx.doi.org/10.1080/13607863.2021.1876637DOI Listing
February 2021

Screening for Depression in Old Age With Very Short Instruments: The DIA-S4 Compared to the GDS5 and GDS4.

Gerontol Geriatr Med 2020 Jan-Dec;6:2333721420981328. Epub 2020 Dec 10.

Chair of Rehabilitative Gerontology, University of Cologne, Cologne, Germany.

This article presents a short form of the Depression in old Age Scale with four items (DIA-S4). The diagnostic accuracy of the DIA-S4 was tested and compared to short forms of the Geriatric Depression Scale (GDS5, GDS4). Using the Montgomery and Asberg Depression Rating Scale (MADRS) as gold standard, the scales were validated with a sample of  = 331 geriatric inpatients. The DIA-S4 had an internal consistency of .70, the GDS5 of .55, and the GDS4 of .58. The test efficiency considering ROC analyses for the DIAS-4 was AUC = .86, for the GDS5 AUC = .78, and for the GDS4 AUC = .74. The best cut-off score for the DIA-S4 was 1.5 with a sensitivity of 87% and a specificity of 68%, for the GDS4 1.5 with a sensitivity of 58% and a specificity of 81%, and for the GDS5 1.5 with a sensitivity of 88% and a specificity of 49%. Based on the data of this study, the DIA-S4 shows better psychometrical qualities than the GDS5 and the GDS4. It can be used as a very short screening scale for depression in old age in research and clinical practice.
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http://dx.doi.org/10.1177/2333721420981328DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7734509PMC
December 2020

Behavioral and emotional quality of life of patients undergoing inpatient geriatric rehabilitation.

Rehabil Psychol 2020 Aug 21;65(3):299-310. Epub 2020 May 21.

Faculty of Human Sciences.

Purpose: In the context of geriatric rehabilitation, 2 quality of life (QoL) facets are of particular importance: a behavioral, more objective facet, and an emotional, more subjective facet. This study looked at changes in these 2 QoL facets during rehabilitation, their relationship to each other and potential mediating processes.

Design: Ninety-two geriatric patients were assessed by the geriatric assessment and a structured face-to-face interview at admission to and discharge from an inpatient geriatric rehabilitation ward. Behavioral QoL was measured in terms of independence in the activities of daily living and mobile abilities, while positive and negative affect represented emotional QoL. As potential mediators, self-perceptions of health (self-rated health, subjective pain, temporal health comparison) were assessed. Statistical analysis comprised repeated-measures (multivariate) analyses of variance as well as regression and mediation analyses based upon a fixed effects-panel model.

Results: All behavioral and emotional QoL indicators showed significant prepost improvements. During rehabilitation, changes in behavioral QoL were significantly related to changes in emotional QoL. Multiple regression of changes in emotional QoL on changes in behavioral QoL and in self-perceptions of health revealed, however, that only health perceptions significantly predicted emotional QoL. Mediation analysis showed that self-perceptions of health fully mediated the relationship between behavioral and emotional QoL outcomes.

Conclusions: During geriatric rehabilitation, significant progress can be made regarding QoL. The results indicate that the influence of physical progress on affective improvements is conveyed through self-perceptions of health, showing the importance of self-perceptions of health for emotional QoL in geriatric rehabilitation. (PsycInfo Database Record (c) 2020 APA, all rights reserved).
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http://dx.doi.org/10.1037/rep0000332DOI Listing
August 2020

Assistive Technology and Mobile ICT Usage Among Oldest-Old Cohorts: Comparison of the Oldest-Old in Private Homes and in Long-Term Care Facilities.

Res Aging 2020 Jun-Jul;42(5-6):163-173. Epub 2020 Mar 13.

Mixed Methods Research, Heidelberg University of Education, Germany.

This study examines technology adoption among oldest-old cohorts (80+) in private homes and long-term care facilities and analyzes relationships between individual characteristics, the living environment, and different kinds of assistive technologies (AT) and information and communication technologies (ICT). The data analysis is based on a representative survey of the oldest-old group's quality of life and well-being in North Rhine-Westphalia, Germany ( = 1,863; age range: 80-103; 12.7% long-term care). Descriptive and multiple binary logistic regression analyses were conducted. Fewer than 3% of people in long-term care used internet-connected ICT devices. AT and ICT device adoption is associated with the living environment and individual characteristics (e.g., functional health, chronological age, education, and technology interest), and different patterns of ICT and AT use can be observed. These results indicate that individual characteristics and the living environment are both decisive in the use of technology among the oldest-old group.
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http://dx.doi.org/10.1177/0164027520911286DOI Listing
August 2021

Berlin Inventory of Caregiver Stress-Dementia (BICS-D).

Gerontologist 2021 07;61(5):e173-e184

Department of Special Education and Rehabilitation Science, Faculty of Human Sciences, University of Cologne, Cologne, Germany.

Background And Objectives: Dementia is becoming increasingly prevalent and family caregivers have been providing most of the care for persons with dementia. This caregiving is a mentally and physically demanding task. "The Berlin Inventory of Caregiver Stress-Dementia" (BICS-D) is a theory driven, multidimensional assessment which was developed as part of the Longitudinal Dementia Caregiver Stress Study (LEANDER).

Research Design And Methods: The inventory consists of 25 subscales with a total of 121 items. Analyses of the psychometric properties of the inventory were based on responses from 594 caregivers.

Results: Factor analyses confirm the multidimensionality of the inventory. The reliabilities of the subscales (Cronbach's α) are between .72 and .95. Validity and sensitivity of the inventory were also confirmed. Differing patterns of burden could be demonstrated for different relatives (partners, children, and daughters-in-law) as well as for different degrees of severity of dementia.

Discussion And Implications: The scores derived for the instrument have support for reliability and validity, and sensitivity to change. It is suitable for the differential measurement of burden experienced by different subgroups of caregivers as well as for the evaluation of interventions. The different subscales of the battery can also be used separately, depending on the study's objectives.
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http://dx.doi.org/10.1093/geront/gnz195DOI Listing
July 2021

Use of Information and Communication Technology (ICT) Devices Among the Oldest-Old: Loneliness, Anomie, and Autonomy.

Innov Aging 2020 1;4(2):igz050. Epub 2020 Jan 1.

Mixed Methods Research, Faculty of Educational and Social Sciences, Heidelberg University of Education, Germany.

Background And Objectives: A good person-environment-fit has positive effects on well-being in old age. As digital technologies are an integral part of older adults' environments, we predicted that the use of information and communication technologies (ICT) is associated with subjective well-being among the oldest-old. Specifically, we compared different user groups of ICT devices (nonusers, users of nonweb-connected ICT, users of web-connected ICT) and analyzed the relations among ICT use and three domains of subjective well-being (loneliness, anomie, autonomy).

Research Design And Methods: We performed a quantitative data analysis using data from the first representative state-wide survey study in North-Rhine Westphalia, Germany on quality of life and well-being of the oldest-old ( = 1,698; age range: 80-103; 9% long-term care). Multiple regression analyses were applied.

Results: The findings revealed that 25.9% of all individuals aged 80 years and older reported using web-connected ICT, in contrast to 38.5% who do not use ICT at all. Individuals who used web-connected ICT reported lower levels of loneliness and anomie, and higher levels of autonomy. These differences remain significant when controlling for indicators of social inclusion and individual characteristics.

Discussion And Implications: This study investigated an underexplored group in terms of ICT use, shedding light on the relationship between ICT use and subjective well-being. The oldest-old generally use ICT in their everyday life but an age-related digital divide still exists. To avoid negative consequences of nonuse digital infrastructures and technology training for older adults need to be established.
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http://dx.doi.org/10.1093/geroni/igz050DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6938466PMC
January 2020

Organizational factors of fall injuries among residents within German nursing homes: secondary analyses of cross-sectional data.

Eur J Ageing 2019 Dec 11;16(4):503-512. Epub 2019 Apr 11.

3Rehabilitative Gerontology, Faculty of Human Sciences, University of Cologne, Cologne, Germany.

The present study explored risk factors for fall injuries among nursing home residents, with a specific focus on the influence of organizational structure within facilities and their environment, which have been insufficiently investigated in the European context. For the analyses, secondary data collected in 2016 from 220 nursing homes across Germany were used. As a risk adjustment, two separate models were calculated for fall injuries among residents without ( = 7320) and with cognitive impairment ( = 8633). Results showed that residents without cognitive impairment had a decreased risk of fall injuries by 40.1% ( < 0.01), while those with cognitive impairment were at an increased risk of 23.8% ( < 0.05) when living in facilities that had dementia care units. However, disparities were found between federal states for both groups of residents ( < 0.05 vs.  < 0.01, respectively). Similarly, a higher proportion of registered nurses were associated with decreased risk of fall injuries among cognitively impaired residents (45.6%), which differed between federal states ( < 0.01). Facilities with homelike environments had a 16.7% ( < 0.05) lower risk of fall injuries among cognitively impaired residents than did traditionally organized facilities. Further research is needed to explain the disparities between German federal states using representative samples.
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http://dx.doi.org/10.1007/s10433-019-00511-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6857205PMC
December 2019

Online activities among elder informal caregivers: Results from a cross-sectional study.

Digit Health 2018 Jan-Dec;4:2055207618779715. Epub 2018 Jun 5.

Rehabilitative Gerontology, Faculty of Human Sciences, University of Cologne, Germany.

Objectives: The internet can be used as a source to gain information or support during highly demanding circumstances, e.g. providing informal care. While internet use has been studied among older people, less is known about informal caregivers' online behaviour. This study aims to explore differences in internet use regarding online activities between informal caregivers and non-caregivers.

Methods: We used data of the Dutch Longitudinal Internet Studies for the Social Sciences panel (2014), including people aged 65 and older ( = 1413). To test differences with regard to 15 common internet activities; descriptive statistics and tests were conducted.

Results: The sample included 1197 participants aged 65 and older, and 325 (27.2%) were identified as informal caregivers. It was found that informal caregivers played more online games ( (1, 1198) = 6.20,  = 0.01), while non-caregivers more often read online news ( (1, 1198) = 4.44,  = 0.04) and were more active on social network websites ( (1, 1198) = 5.07,  = 0.02) compared to their counterparts.

Conclusion: Based on a representative sample, the results show that informal caregivers do not use the internet more for information seeking, but more often for playing online games, which may indicate that the internet is used to compensate for stress. Further research is needed to identify how informal caregivers can be supported by online services.
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http://dx.doi.org/10.1177/2055207618779715DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6034351PMC
June 2018

Falls in hospitalized geriatric psychiatry patients: high incidence, but only a few fractures.

Int Psychogeriatr 2018 01 18;30(1):161-165. Epub 2017 Sep 18.

Department of Geriatric Psychiatry and -psychotherapy,LVR-Klinik Köln,Germany.

Fall rates from 3.2 to 17.1 falls per 1,000 hospital days in geriatric psychiatry facilities have been reported to date. Up to 5% of the falls result in severe injuries, but data concerning medical consequences are scare. This brief report presents a retrospective analysis of one year fall protocols from a geriatric psychiatry department focusing on consequences of falls. Fall-induced injuries were rated in four categories: no injuries, mild injuries (contusions, hematomas, abrasions), moderate injuries (lacerations, dislocations), and severe injuries (fractures, cerebral hemorrhages). In total, 510 falls were registered during the study period, indicating a fall rate of 17.7 falls per 1,000 hospital days. Overall, 375 falls (73.5%) resulted in no injuries, 67 (13.1%) resulted in mild injuries, 59 (11.6%) resulted in moderate injuries, and only 9 (1.8%) falls led to severe injuries (fractures and cerebral hemorrhages). These results indicate a quite high fall rate in our sample of hospitalized geriatric psychiatry patients with only a relatively small number of severe injuries resulting from the falls. These results raise the question about the use of physical restraints and the use of bedrails in geriatric patients to prevent falls as the medical implications of falls may be less problematic than previously thought.
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http://dx.doi.org/10.1017/S1041610217001831DOI Listing
January 2018

[Developing a framework for a public health monitoring of the population aged 65 years and older : Results of the IMOA workshop on concepts and indicators].

Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2017 Aug;60(8):879-882

Abteilung für Epidemiologie und Gesundheitsmonitoring, Robert Koch-Institut, General-Pape-Str. 62-66, 12101, Berlin, Deutschland.

Main goal of the Improving Health Monitoring in Older Age (IMOA) project is to provide a framework for an indicator-based public health monitoring of the population aged 65 years and older. The workshop served as a forum to discuss and agree upon relevant concepts with gerontologists, nursing care and public health scientists.
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http://dx.doi.org/10.1007/s00103-017-2573-2DOI Listing
August 2017

Quality of life of the very old : Survey on quality of life and subjective well-being of the very old in North Rhine-Westphalia (NRW80+).

Z Gerontol Geriatr 2018 Feb 22;51(2):193-199. Epub 2017 Mar 22.

Faculty of Humanities, Rehabilitative Gerontology, University of Cologne, Cologne, Germany.

Background: In Germany, the very old are the most rapidly growing proportion of the population. A comprehensive investigation of the conditions for a good quality of life in this group is relevant for both society and politics.

Objective: The project "Quality of life and subjective well-being of the very old in North Rhine-Westphalia" (NRW80+) at the University of Cologne surveys quality of life of the very old. Taking into account many specific methodological and theoretical challenges, it aims at setting up a specific theoretical framework and methodological approach.

Methods: Existing studies on quality of life in old age in Germany and abroad as well as models on quality of life are reviewed with respect to their relevance for the very old and their specific living conditions, needs and interests. A theoretical framework of quality of life in very old age is developed. The NRW80+ study combines three levels: the empirical level of description of life situations and conditions, the explanative level of evaluating models of quality of life and the normative level of societal and ethical standards and norms.

Results: Considering results of recently conducted studies with the very old, an integrative conceptual model for studying quality of life of very old persons is introduced. In the model of challenges and potentials (CHAPO), environmental and individual factors as well as life chances and life results are thereby taken into consideration from a subjective as well as an objective point of view, supplemented by the concept of successful life conduct.

Conclusion: Starting from the CHAPO model of quality of life, the representative study NRW80+ aims at challenging methodological standards for the inclusion of the very old in social research thus providing the basis for further research as well as for sustainable social politics especially for the very old.
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http://dx.doi.org/10.1007/s00391-017-1217-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5801376PMC
February 2018

[Caregiving relatives of people with dementia: which factors influence the transfer from home-care to nursing home?].

Psychother Psychosom Med Psychol 2012 Sep-Oct;62(9-10):367-74. Epub 2012 Oct 1.

Heilpädagogik und Rehabilitation, Lehrstuhl für Rehabilitationswissenschaftliche Gerontologie, Universität Köln.

Recent research on institutionalization of family members with dementia has shown caregiving-need, caregiver's burden and role conflicts as important influence factors. However, current knowledge is still superficial because most studies used highly aggregated indicators. Logistic regression was used to explore whether differentiated measures of caregiving-needs, caregiver-burden and role conflicts were risk factors for institutionalization of demented elderly people (N=373). A greater distance between households, increased need in housekeeping, a higher income, increased caregiver-burden and low self-evaluation of caregiving-quality are related to an increase in chance for institutionalization. A constant need for supervision and lack of social appreciation are associated with a smaller chance. The results illustrate the dilemma of many caregiving relatives. A future enhancement of the given regression model by including prior decline in caregiving-burden is discussed.
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http://dx.doi.org/10.1055/s-0032-1323708DOI Listing
March 2013

Personal growth and cognitive complexity in caregivers of patients with dementia.

Eur J Ageing 2008 Sep 26;5(3):203-214. Epub 2008 Aug 26.

Fachbereich Erziehungswissenschaften und Psychologie, Lehrstuhl für Klinische Psychologie, Universität Siegen, Adolf-Reichwein-Str. 2, 57076 Siegen, Germany.

According to several theoretical models, crises or demands can result in enhanced cognitive maturity. Two studies examined whether demands on caregivers provide an opportunity to experience increased cognitive maturity (e.g., cognitive complexity, personal growth through caregiving). In Study 1 (126 relatives of dementia patients; cross-sectional design), personal growth through caregiving was associated with two specific caregiving demands: duration of caregiving and lack of social acknowledgment. Cognitive complexity correlated with duration of caregiving and crystallized intelligence. The caregivers in the second study ( = 321) were participants in LEANDER, The Longitudinal Dementia Caregiver Stress Study. Caregivers were examined in four waves over 27 months. The results indicated an increase in personal growth over time. Using latent growth models, we found that increases in personal growth through caregiving were predicted by increases in the objective caregiving tasks. Cognitive processes (e.g., ruminative thoughts, life reflection) provide a possible explanation for an increase in cognitive maturity.
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http://dx.doi.org/10.1007/s10433-008-0090-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5546334PMC
September 2008

Evaluation of geriatric day care units: effects on patients and caregivers.

J Gerontol B Psychol Sci Soc Sci 2002 Jul;57(4):P348-57

Freie Universitaet Berlin, Germany.

The aim of this study was to evaluate the effects of geriatric day care on patients and caregivers. Day care patients (n = 43) were compared with an untreated matched control group (n = 40). Matching criteria were age, gender, physical and mental health status, and socioeconomic status. The mean age of both groups was 79.5 years. Data were collected at three measurement points: T1 took place during the first 10 days of service use, T2 was conducted 6 months later, and T3 took place 9 months after service use began. In addition, a short follow-up was conducted 6 months after T3. Well-being, dementia symptoms, health indicators, and activities of daily living were investigated. Individual growth curves of these patient variables were computed and analyzed with multivariate analyses of variance. The results show significant positive effects of day care on well-being and dementia symptoms. Patients in day care stabilized or improved on various measures, whereas the untreated control participants worsened. Follow-up data showed a significant decline in health in the control group in comparison with the day care users. Results concerning effects on caregivers were not that clear. Individual change parameters in subjective well-being and burden did not differ between the two groups of caregivers in the longitudinal follow-up. In a semistructured interview, however, caregivers of patients in the treatment group reported substantial positive change due to use of day care.
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http://dx.doi.org/10.1093/geronb/57.4.p348DOI Listing
July 2002
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