Number
Age Gender Race & Ethnicity (Hispanic, Latino, or Spanish origin)
1 60 F Prefer not to answer
5 63 F White; No
11 69 M White; No
16 69 F White; No
18 68 M White; No
21 66 F White; No
24 65 F White; No
25 64 F Prefer not to answer
27 70 M Black; No
33 57 F White; No
34 67 F White; No
36 72 F White; No
40 50 M Multi-race; Yes
41 77 M White; No
71 59 F White; No
93 71 F White; No
131 68 F Black; No
149 66 F White; No
150 72 F White; No
189 69 F White; No
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Chapter 4
Examining contextual factors associated with stages of change for readiness to plan for aging and frailty
BACKGROUND
Aging is a multidimensional experience that affects all people and impacts many aspects of society (Kornadt et al., 2020; Rivadeneira et al., 2021). The United States projects a doubling of individuals aged 65 from 43.1 million in 2012 to 83.7 million by 2050 (Ortman, 2014).
Challenges and opportunities lie ahead in preparing for this population trend across all sectors of society including health care, labor, housing, and financial markets (Nations, 2017). Despite the universality of aging, challenges persist surrounding negative connotations about aging and denial of the inevitability of aging and death (Meier, 2015). Recent advances in gerontology literature have focused on educating society and older adults about healthy and successful aging, and current initiatives have emerged on reframing aging by focusing on promotion of positive perceptions of the aging process (DiAntonio, 2020).
Aging is conceptualized as a process involving a series of transitions across the life course (Elder et al., 2003). Life course events earlier in life include the expansion of self, such as obtaining one’s driver license, graduation from school/college, and partnership/family planning, while later life transitions in the aging process include retiring, becoming a grandparent, and a caregiver (Robertson, 2016). Planning for later transitions that focus on the needs of aging individuals requires proactive and supportive environments that facilitate maintenance of independence and health throughout the lifespan (Carmon & Fainstein, 2013). The concept of planning for later life is characterized as the range of activities across multiple domains that people intentionally pursue with the goal of achieving a desired outcome later in life (Preston,
2019). This type of planning is grounded and promoted through successful and productive aging paradigms (Preston, 2019).
Rowe et al., (2016) define successful aging as the avoidance of disease and disability, sustained engagement in social and productive activities, and preservation of high physical and cognitive function as long as possible (Rowe et al., 2016). One’s ability to maintain a sense of well-being throughout life transitions amidst the realities of health or functional difficulties may be an indicator of successful aging (Tovel & Carmel, 2014). More importantly, for an individual to experience successful aging they must be able to reflect on anticipated changes and be willing to accept them as part of the aging process that requires possible future adaptations (Resnick 2015). Such reflection and planning might help individuals choose behaviors to optimize their well-being and quality of life.
In order to maximize well-being and successful aging, it is essential to recognize and overcome the normal challenges of aging, such as age-related difficulties, chronic morbidity and physical impairment that affects social networks and loss of independence (Saad et al., 2021). In light of increasing life expectancy, understanding how people achieve and maintain well-being despite these challenges is critically important. While it is clear that certain behavioral factors contribute to successful aging (i.e. maintaining healthy eating habits [Leveille et al., 1999], physical exercise [(Britton et al., 2008]), we questioned whether preparing and planning for aging and frailty in certain domains of inevitable change might also contribute to successful aging.
Given our desire to evaluate additional processes that might influence successful aging among older adults, the terminology and concept of planning for aging and frailty was
brief report) (DiClemente & Prochaska, 1982). Planning for aging and frailty incorporates the complex nature of aging and inevitable changes across comprehensive domains, including: (1) communication/socialization, (2) environmental (living arrangements and transportation), (3) financial, (4) physical care (dependency and caregiver), and (5) cognitive status. The objective of this study was to evaluate the relationships between contextual factors that influence older adults’ readiness to engage in planning and the TTM stages of change (precontemplation to action/maintenance) to uncover any patterns. The aim of this paper was to report associations between contextual factors and stages of change for readiness to plan for aging and frailty.
METHODS Design and participants
This study used a cross-sectional, descriptive design. Participants were recruited from local community sites in a southeastern U.S. city and through online sources. A single rural senior center and two urban YMCA sites posted recruitment flyers at their respective locations.
Online recruitment occurred through social media platforms associated with the community locations, email listservs, and through ResearchMatch, a national, non-profit volunteer-to- researcher matching platform (Harris et al., 2012). Inclusion criteria were: aged 50-80 years, residing in the community, and having a phone and email address. Exclusion criteria were those who resided in an assisted living facility, long-term care facility, or continuing care retirement community. The principal investigator (PI) verified all online participants with a phone call to verify their willingness to participate in the study.
Data Collection
Data were collected from May 2021 to July 2021. Participants completed an e-consent and survey through REDCap, a secure web application for building and managing online surveys
(Harris et al., 2009). A $25 gift card was offered to study participants for survey completion. The study was approved by the Vanderbilt University Institutional Review Board (#210232).
Instruments
The study survey included measures of demographic characteristics, functional status, frailty, health status, social support, and stages of change for planning for aging and frailty.
Demographic characteristics included age, sex, race, ethnicity, language spoken at home, education, marital status, living situation, and household income.
Functional status was measured by the Vulnerable Elders Survey (VES-13)
(Saliba et al., 2001). It is comprised of 13 items covering age, self-related health, limitations in physical function and functional disabilities. Scores ≥ 3 represent vulnerability and indicate that individuals are at four times higher risk of death or functional decline when compared to other individuals scoring 3 or less (Saliba et al., 2001).
Frailty status was assessed by the FRAIL questionnaire (Morley et al., 2012), a screening instrument that categories individuals as frail (3+), pre-frail (1-2), and robust (0). FRAIL
includes five-items for assessment of fatigue, resistance, ambulation, illnesses, and loss of weight, and then stratifies individuals to one of three groups. The questionnaire has been found to be predictive of disability and mortality in individuals that are found to be frail or prefrail (Morley et al., 2012).
Health status was operationalized as risk of death from comorbid disease. The Charlson Comorbidity Index (CCI) was used as an indicator of long-term prognosis and survival
(Charlson, 1981). The CCI is comprised of 19 comorbid conditions that are weighted and grouped. A composite index score of ≥ 5 is associated with a 1-year mortality of 85% (Charlson
Social support as measured by The Duke-University of North Carolina Functional Social Support Questionnaire (FSSQ) assessed an individual’s perception of personal social support.
The FSSQ comprises eight items with two scales (confidant support [5 items] and affective support [3 items]), with responses scaled on a 1-5 scale with higher values indicating greater social support (Broadhead et al., 1988; Epino et al., 2012).
Stages of change for planning for aging and frailty is a seven-item survey that measures planning behaviors using the Transtheoretical model (precontemplation [no intention to change], contemplation [thinking about changing behavior in the near future], preparation [commitment to changing behaviors soon], action [recent change], and maintenance [ongoing behavior change] in five domains. The five domains include: (1) communication/socialization, (2) environmental [living arrangements & transportation], (3) financial, (4) physical care [dependency & caregiver], and (5) cognitive status. Individuals selected which stage best described them in each of the domains. Development and testing of this survey is reported in another publication (under review).
Statistical Analysis
Descriptive statistics were used to describe participants’ characteristics and summarize the distributions of stage of change across the planning for aging and frailty domains. Univariate and multivariate logistic regression were performed to evaluate the associations of the assessed contextual factors with each of the aging and frailty domains. Odds ratios (ORs) and 95%
confidence intervals (CIs) were determined for each behavior domain. Analyses were performed using SPSS statistical software version 27.0, and the level for statistical significance was set at p
< .05.
RESULTS Contextual factors (participant characteristics)
Participant demographics and other characteristics are shown in Table 1. Participants had a median age of 68 (IQR 60, 74); 69.9% (n = 160) primarily identified as female; 90.3% (n = 205) white; 59.4% (n = 136) married or in a domestic partnership; with 65.5% (n = 150) reported no co-morbidities on the CCI. Among other characteristics, few identified as vulnerable on the VES-13 (11.4%; n = 26); frail ( 3 FRAIL questionnaire) (9.2%; n = 21); and they report being fairly well supported on the FSSQ median score was 4.75 (range 1-5, IQR 4.0,5.0).
Planning behaviors for aging and frailty
Table 2 presents the distributions of stages of change for each of the domains of planning for aging and frailty. The domain with the highest percentage of participants in the
action/maintenance stage was focused on planning for financial concerns. A total of 153 participants (66.8%) reported that they were either in the action (18.8%, n=43) or maintenance (48.0%, n=110) stages. Conversely, the domain of planning for memory loss had the highest percentage of participants in the beginning planning stages. A total of 166 participants (67.7%) reported that they were either in the precontemplation (51.5%, n=118), contemplation (16.2%, n=37), or preparation (4.8%, n=11) stages. Two other planning behavior domains
(environmental/transportation and physical care/dependence) also demonstrated lower planning stages with over half of participants in precontemplation/contemplation/preparation stages (62.5% and 60.2% respectively, Table 2).
Associations of contextual factors with Activation Stages of Planning
The primary findings from tests of the multivariate associations of the contextual factors
summarized in Table 3. More detailed univariate summaries and findings are presented in the Supplemental Tables 1-7. Each multivariable logistic model included age, income, functional status/vulnerability, frailty, health status, social support, and living situation (living with one or more persons vs living alone). Statistically significant multi-variable effects were observed for each of the domains (p < .05, Table 3).
Within the communication/socialization domain, increased age (OR=1.06; 95%
CI=1.01-1.10) and social support (OR=1.49; 95% CI=1.04-2.12) were associated with an increased likelihood of being in activation stages of planning for aging and frailty. Relative to those living alone, individuals living with others were less likely to be in the action/maintenance stage of communication/socialization (live with one: OR=0.36; 95% CI=0.17-0.73; live with multiple: OR=0.32; 95% CI=0.11-0.87).
Findings for the associations of contextual factors with being in action/maintenance in the domains of environmental/living arrangements and financial/health resources were similar.
Only increased age and social support were associated with being in the active/maintenance stage (environmental/living arrangements (age: OR=1.07; 95% CI=1.03-1.11, p<.001; social support: OR=1.80; 95% CI=1.21-2.67, p=.003); financial/health resources (age: OR=1.11; 95%
CI=1.06-1.16, p<.001; social support: OR=1.48; 95% CI=1.03-2.13, p=.031).
Within the domain of environmental/transportation, increased planning was associated with variables of age, functional status/vulnerability, and social support. As with the prior
domains, increased age and social support increased the likelihood of an individual being in the action/maintenance stages of planning (age: OR=1.06; 95% CI=1.02-1.11, p=.002; social support: OR=1.60; 95% CI=1.08-2.37, p=.019). In addition, increased functional decline
(vulnerability), was also significantly associated with a higher likelihood of having taken action
in this domain (OR=1.24; 95% CI=1.02-1.49). Similarly, the domains of physical
care/dependence and cognitive status/memory issues also demonstrated increased planning associated with increased vulnerability and increased social support (physical care/dependence [vulnerability: (OR=1.29; 95% CI=1.06-1.56); social support: (OR=1.78; 95% CI=1.19-2.65)];
cognitive status/memory issues [vulnerability: (OR=1.25; 95% CI=1.02-1.52); social support:
(OR=1.98; 95% CI=1.20-3.25)].
Finally, within the domain of physical care/caregiver, contextual factors associated with increased planning for aging and frailty were the same as those within the domain of
communication/socialization. Increased age and living with other people (compared to living alone) both increased the likelihood of having taken action ([age: OR=1.05; 95% CI=1.01-1.10];
[live with one: OR=2.54; 95% CI=1.25-5.16; live with multiple: OR=2.85; 95% CI=1.03-7.85]).
In summary, increased social support was found to be associated with an increased likelihood in all of the domains except for physical care/caregiver, and age with all except for physical care/dependence. Increased functional decline (vulnerability) was associated with increased likelihood of action within the domains of environmental/transportation, physical care/dependence, and cognitive status/memory issues. Compared to living alone, living with others increased the likelihood of planning in physical care/caregiver and decreased it in communication/socialization. Income level and health status (as assessed by the CCI) were not significantly associated with planning action in any of the domains (p>.05, Table 3),
DISCUSSION
The purpose of this study was to examine the relationships between contextual factors that influence older adults’ readiness to engage in planning for aging and frailty and the TTM
likely influence active planning for older age, such as increasing vulnerability and increased social support. Although our study is cross-sectional, our findings advance understanding of circumstances that prompt individuals to move from early planning stages (pre-contemplation to preparation) to activation stages (action, maintenance). These results suggest implications for policy-making and future research.
First, social support is strongly associated with activation of planning for aging and frailty across all domains except physical care/need for caregiver. Perhaps, when strong support from family/friends is present, individuals assume that the need for a caregiver is already in place, thus, negating the need to plan. This finding implies that social support networks play a vital role in the promotion of successful aging. Compared with prior studies examining future planning, our results are similar, demonstrating increased planning with support systems (Lindquist et al., 2017; Prenda & Lachman, 2001). Increased levels of social support also
predicated fewer negative beliefs about the usefulness of planning (Sorensen & Pinquart, 2000a).
Second, older age and increasing vulnerability influenced planning behaviors in the domains of environmental/transportation, physical care/dependence, and cognitive
status/memory issues. We know from past studies that vulnerability, such as loss of activities of daily living (ADLs) and age, are consistent predictors of preparation for care (Sorensen &
Pinquart, 2000b). Our study aligns with previous work reporting that increased personal vulnerability increases odds of planning for one’s ability to get around through transportation and to care for themselves in light of increased dependency (Sorensen & Pinquart, 2000a). Both domains require a significant level of autonomy which becomes compromised in the presence of functional deficits and frailty. Regarding the domain of cognitive status/memory loss, increased vulnerability heightened planning behaviors which corresponds with other research that found