Project FIND has been providing innovative supportive housing, nutrition, and social support to homeless and low- and moderate-income seniors on New York City’s West Side since 1967. This article profiles this nonprofit, community-based agency, which was established to meet the needs of the frail and isolated elderly, and has continued to grow and evolve in response to changing demographics, neighborhood gentrification, and needs of both the homeless as well as the active “younger old.” The article describes creative programming that has distinguished Project FIND’s response to seniors’ needs beyond basic housing and nutrition. It also explores what it takes to successfully provide senior services using limited resources and examines challenges for the future both nationally and for the agency.

Objective: Share new knowledge about workplace practices related to employer success in hiring, retaining, and promoting people with disabilities, and promote use of findings to employers and service providers.

Design: A transdisciplinary and multifaceted data gathering approach.

Results: Provides an overview of the research approach taken and the strengths regarding this approach.

Conclusions: The significance of findings for rehabilitation researchers and policy makers focused on improving employment outcomes for people with disabilities, for rehabilitation counselor educators preparing future service providers, and for practicing professionals providing services to individuals with disabilities and consultation to employers regarding disability issues, are presented.

In this chapter, we review of the field of gerontological genetics with respect to subjective and objective health, the role of stress on health, and finally frailty and longevity. For most indices of subjective and objective health, frailty, and longevity, genetic influences contribute only modestly to individual differences, wherein heritabilities are typically on the order of 35%–40%. Notable exceptions are the moderate to strong heritabilities for lipid measures and brain structure and function, with a remarkably increasing role of genetic influences for longevity with advancing age. Although candidate gene and genome-wide association studies (GWAS) studies have identified gene variants associated with many subjective and objective health traits, their effect sizes are typically relatively small, as expected for complex traits. There is some evidence for gene–environment interactions, and stress may be an important moderator of genetic variance for health. For example, carrying a risk genotype for cardiovascular disease (CVD) in the angiotensin converting enzyme gene (

In most Western societies, the perception of age and aging is predominantly negative, and this negativity is often integrated into older adults' self-view of age(ing). At the societal level, negative views of aging manifest themselves in the form of age stereotypes, which result in prejudice and discrimination toward older adults. At the personal level, negative views of one's own aging are related, among others, to poor health, lower well-being, and even shorter survival times. Considering these negative effects, interventions that promote positive views of aging seem warranted. This chapter discusses potential routes for changing negative (self-)views of aging and the challenges that are inherent to such efforts, such as determining and reaching the target groups for intervention programs. Strategies such as increasing the knowledge about old age, providing opportunities for children or younger adults to interact with older adults, as well as changing the portrayal of older adults in the media might be used to change societal views of aging. Because it is assumed that for some older adults age stereotypes become self-stereotypes, changing the societal view of aging might eventually also lead to a positive change in older adults' view of their own aging, and it might minimize the burden of belonging to a stigmatized group. Few strategies for changing personal views of aging (e.g., social comparison feedback) have been shown to be successful so far. Overall, more research is necessary to develop interventions which are easy to implement and universally effective.

Regular exercise is a mainstay of preventive health care for individuals of all ages. Research with older adults has shown that exercise reduces risk of chronic illness, maintains mobility and function, enhances mood, and may even improve cognitive function. For individuals with dementia, exercise programs are particularly likely to improve health, mood, and quality of life; the challenge at this time is to make exercise accessible and enjoyable, demonstrate its benefits, and convince family caregivers of its worth for individuals with dementia. Home health providers are uniquely positioned to assist caregivers in developing and implementing a home exercise program for their care recipient with dementia. Results of a controlled critical trial conducted at the University of Washington have demonstrated the feasibility and efficacy of a home health exercise and problem solving intervention (Reducing Disability in Alzheimer’s Disease, or RDAD) for decreasing physical, psychological, and behavioral disabilities associated with dementia. This article describes the RDAD program, discusses the role of home health providers in its delivery, and provides an example of its implementation.

Continued employment of the adult and older adult worker requires resilience in response to growing levels of workplace, demand, and adversity. Four patterns of resilience are considered including dispositional, relational, situational, and philosophical. Life span theory and approaches to developmental change are discussed in the context of resilience and working in later life. Changes in work demands, health, injury and disability, skills and abilities needed, employment and reemployment, organizational culture, as well as worker purpose and fulfillment are included in this overview.

The Commission on Rehabilitation Counselor Certification (CRCC) has taken a proactive stance on perceived test inequities of the Certified Rehabilitation Counselor (CRC) exam as it relates to people who are prelingually deaf and hard of hearing. This article describes the process developed and implemented by the CRCC to help maximize test equity for this target group. Using recommendations from a group of national experts in deafness and rehabilitation, focus groups examined exam items considered linguistically difficult items for people who are deaf or hard of hearing and, from that effort, developed guidelines that could be used to address linguistic complexity concerns for future test items.

This article provides case managers with updated information on intimate partner violence. Case managers provide an important role in the identification, treatment, and prevention of intimate partner violence. Current federal laws provide direction and funding for a complex network of services for survivors. Effective identification involves screening and assessing risk of harm, severity of violence, and the survivor’s readiness for change. Care planning involves working with the survivor and their families to build protective skills, make a safety plan, and build their life independent of violence.

This chapter provides an overview of the various strands of my research on community and environmental perspectives on aging and later life. Following an outline of biographical influences and early work in critical gerontology, the chapter provides examples from research (with a variety of colleagues) covering themes relating to family and community life in old age, the impact of social exclusion, and the development of transnational communities. The chapter then reviews subsequent work on the impact of globalization on urban life, and research on the theme of “age-friendly cities.” The chapter concludes with a summary of future research agendas for Environmental Gerontology.

Case management (CM) establishes valuable connections between clients and needed supports. There are, however, mixed results on its prediction of health care use. This quasi-experimental record review (N = 96) of a collaborative CM consortium examined predictors of health care use among older adults (aged older than 60 years) who had received CM for at least 6 months. Descriptive, bivariate, and multivariate models were used to predict differences in outcomes (hospitalization and emergency room [ER] visits) between participants who received CM and those who did not. Hospitalization rates were significantly lower among CM recipients. Living alone, identifying as White/non-Hispanic, and higher numbers of medications were significant copredictors of hospital use. CM was not a significant predictor of ER use. Race/ethnicity, however, remained significant in that White/non-Hispanic participants were 4 times likely to have at least 1 ER visit than persons of color. Implications for future research are discussed to promote better understanding of the effectiveness of CM, particularly within ethnically and racially diverse communities. Further inquiry is needed around the experiences of older adults of color, those who live alone, or who take multiple medications as needed. Further testing of a consortium model is necessary to determine value added through a multiagency approach.

This study focuses on expressions of identity and self among residents at a group home for older persons with dementia in Japan—a study, which started as an explorative study on spirituality—and how residents make meaning of life. Although aware of stages of dementia illness and briefly commenting on these, the analysis does not make any specific point of it. This article views dementia from a sociocultural perspective and is based on participant observations at a group home with 19 residents, combined with interviews with 6 of them. Two central concepts for the study are discussed and drawn on in the analysis: ie, meaning home and family, and dementia and boke, senility. The study examines how the group home is ie and concludes that it is “home enough” in the sense that one’s identity and self are honored here. The old word boke represents a state in which one has “given up” any attempts to keep one’s mental health. This concept was used by some residents to mark the line between those who were “helpless” with boke and those who could manage by themselves without boke. Identities are analyzed in different terms: as profession, as feeling secure, as being physically close, in social interactions, and as being cared for properly also after death. The analysis of self and identity showed that contentment in life was expressed in various ways, as a whole or as a patchwork with light and dark colors, and that it is still in process. Here, the supportive but discreet scaffolding of staff seems to matter. Life is lived until death, and the farewell ceremonies are analyzed as existential closures for many—and for life finalized here at Ie, the group home.

Background: The aim of our study is to quantify the occurrence of suspension of scheduled surgeries in a Brazilian university hospital, trying to identify the causes of suspension of these operations and meet the medical specialties that most contributed to the cancellation.

Methods: This study takes the form of an exploratory, descriptive, and quantitative enquiry carried out by analyzing the database from 2008 to 2011 of the operating theater.

Results: Of the 29,518 scheduled surgeries, 16.1% were cancelled. The patient was the main reason, accounting for more than 40% of all suspensions. When calculating the rate of surgery suspended from a specialty, dividing the number of cancelled surgeries in a specialty by the number of scheduled surgeries in the same, we found that otolaryngology is the specialty with the highest rate of 21.3%.

Conclusions: One of the main reasons in our sample why surgeries were cancelled is nonappearance of the patient. Improving communication between patient and hospital facilitates the client program and also contributes to avoid cancellations.

Purpose: Workplace accommodations are central to improving employment outcomes for people with and without disabilities; this study presents national estimates comparing accommodation requests and receipt as reported by individuals with and without disabilities.

Method: Estimates are developed from the May 2012 Current Population Survey Disability Supplement.

Results: The findings highlight variability in accommodation requests by disability type and status. Accommodation request rates are also presented by occupation and industry groups.

Conclusions: As employers voice concerns about the additional burden of employing individuals with disabilities under new regulatory requirements, our findings highlight that 95% of individuals requesting an accommodation were people without disabilities.

This article describes the contours of the residential care placement experience for social service staff, health care providers, and their client families of patients with Huntington’s disease. The purpose of this study was to determine the factors, conditions, and barriers encountered by outpatient clinical staff and families in the transition to skilled nursing care. A Long-Term Care Contact Survey was developed to (a) gather information about long-term care referral sites; (b) determine the factors considered in choosing a facility; (c) describe the factors that hindered the transition to long-term care; (d) describe conditions prior to institutionalization; and (e) determine research interest. The study found that large cohorts of patients with Huntington’s disease in residential care are scarce. A lack of confidence in the available options suggests the need for increased support for educational and social services to facility staff. Speech/swallowing therapy and physical therapy as placement facilitators reflect salient issues of latter stages of the disease, implicating funding support needs. Families facing this transition require long-term guidance for financial, caregiving, and psychosocial issues.

In this chapter, we carry out a narrative review of the longitudinal impact of subjective aging on health and survival. We have a specific focus on the different pathways which can explain the relation of subjective aging to health and survival. We focus on the three most common conceptualizations of subjective age: (a) age identity, (b) self-perceptions of aging, and (c) self-perceptions of age-related growth and decline. For each concept, we present the theoretical background, the empirical studies on the effects on health and survival, and conclude with the pathways which might explain these effects. The chapter ends with a heuristic model that synthesizes the theories and findings in describing how subjective aging is related to different psychological resources, which are in turn related to health and survival. Last, we provide some possible directions for further research in this area.

The majority of older adults do not engage in regular physical activity. In surveys of community dwelling, among older adults age 75 and above, one in three men and one in two women engage in no physical activity. These rates are even lower among those who are hospitalized or institutionalized in nursing homes or assisted living settings. Moreover, those living in institutional settings demonstrate a decline in function that exceeds what would be expected based on disease states. Limited activity and functional decline place older adults at risk for pain associated with contractures, pressure sores, and decreased sense of well-being and overall quality of life. We propose a Function Focused Care approach that encourages caregivers to engage older adults in function and physical activity during all care interactions. This approach can be implemented using a fourstep approach and practical, cost-neutral approaches. This chapter delineates the ways in which to implement Function Focused Care across all settings, describes outcomes associated with this approach, and provides ways in which to overcome the setting-specific challenges.

The special education and rehabilitation literature is replete with articles examining transition planning, services and supports; however, transition models have typically been developed for the school context and not focused on other transition team members. These school-based models are important; however, models developed from the perspectives of other key partners could provide valuable insight and enhance transition team functioning. Vocational Rehabilitation (VR) professionals are often the only link that transition programs have to employment; therefore, VR counselor perceptions of essential competency domains need to be understood by both school and adult agency professionals alike. This study collected data from 291 vocational rehabilitation (VR) counselors from three Midwestern states. Exploratory factor analysis was used to identify an underlying transition domain structure. Seven transition domains areas are presented and conferred. Implications and proposed directions for future research are discussed.

It is critical that cognitively impaired adults be permitted to participate in research in order to develop a greater understanding of the underlying causes of the impairments and strategies to prevent or ameliorate their impact. Significant ethical and legal issues may arise in the recruitment and enrollment of these persons as study participants, due to difficulties in understanding information, uncertainty regarding the existence of sufficient mental capacity to provide informed consent to participate, and the potential for coercion to participate as a function of limited capacity and dependence on others for care. This article explores these issues and suggests mechanisms to maximize the understanding of information and facilitate the cognitively impaired elders’ expression of choice during incapacity.

Sequential mixed methods is a useful research design to inform second-stage methodology when investigating an area of practice in which relatively little is known. This article describes how focus group findings were used to measure advance care planning practice among community-based case managers. The initial qualitative study utilized focus groups to explore aspects of practice in this area. Data revealed themes that embodied ambiguous views of advance care planning, divergent roles in practice, a continuum of practice activities, and multiple facilitators and barriers to practice. In order to further examine case managers’ advance care planning practices, qualitative findings were used to develop the Case Managers Advance Care Planning Practices Instrument. Implications for qualitative to quantitative measurement are discussed.

Views on aging affect development across the life span through different pathways: They create a developmental context for older people by influencing behavior toward them (stereotyping, ageism), and they become incorporated into the self-concept of older people (self-stereotyping, internalization), which influences their attitudes toward their own age and aging, aging-related behaviors, life satisfaction, and even mortality. In this chapter, we argue that views on aging should be conceived as a domain-specific construct. We provide theoretical arguments for such a view that stems from life span research, as well as empirical evidence from studies that investigate the content and activation of views on aging as well as their consequences for developmental outcomes. We argue that a domainspecific perspective provides a fruitful and more comprehensive framework for addressing the role of views on aging in developmental regulation across the life span.

For over a century, western countries have shown continuing declines in mortality at increasingly older ages. The reasons for these mortality declines are poorly understood. For the Netherlands, this study examines to what extent the mortality decline at old age can be explained by improved life course characteristics of subsequent cohorts (life course factors) and/or by improved medical and longterm care (period factors).

The first wave of research on loss and potentially traumatic events (PTEs) was dominated by either a psychopathological approach emphasizing individual dysfunction or an event approach emphasizing average differences between exposed and nonexposed groups. We consider the strengths and limitations of these approaches and then review more recent research that has focused on the heterogeneity of outcomes following aversive events. Using both traditional analytic tools and sophisticated latent trajectory modeling, this research has identifi ed a set of prototypical outcome patterns. Typically, the most common outcome following PTEs is a stable trajectory of healthy functioning or resilience. We review research showing that resilience is not the result of a few dominant factors, but rather that there are multiple independent predictors of resilient outcomes, and then review some of the possible factors that might inform resilient outcomes in older populations. Finally, we close by critically evaluating recent efforts to inculcate resilience and suggest possible ways such efforts might best move forward.

The constitutional genome, its environment, and a range of stochastic events all interact to produce virtually unique patterns of lifespan and health span. This is certainly the case for genetically heterogeneous organisms living in the wild, but there is growing evidence of considerable variations even among inbred organisms maintained in the laboratory. When one compares different species, it is clear that the dominant variable is the constitutional genome. I shall argue, however, that stochastic events are the dominant variables among members of the same species. Somatic mutations clearly play important roles. Leslie Orgel's protein synthesis error catastrophe remains a potential mechanism because it has been insufficiently tested in vivo. The recent discovery of widespread random clonal monoallelic expression in the laboratory of Andrew Chess provides yet another layer of complexity. Perhaps the most cogent explanation of the growing phenotypic variations among aging cohorts, however, are increasing drifts in gene expression with age, presumably epigenetic in origin, but conceivably also driven by posttranscriptional mechanisms. I shall argue that such drifts evolved because they proved adaptive to groups of organisms in unpredictable environments, but that age-related expansions of such variegated gene expressions will have escaped the force of natural selection and are responsible for a wide range of quasi-stochastic geriatric pathologies, both proliferative and degenerative.

As the world becomes more populated and more medically advanced, more people are starting to live longer. There are growing concerns for the health and well-being of an ever-growing population. Aging is accompanied by a series of changes, cognitive decline being one of them. As health becomes more challenging, physical activity may become more cumbersome. However, in many instances, physical activity has been found to prevent and delay cognitive decline. In fact, exercise may prove to be a powerful preventative measure against cognitive impairment in older adults. The aim of this chapter is to explore the evidence base of the effects of physical activity on cognitive decline prevention as well as to review the recommended guidelines for physical activity in this population based on findings in the field.

130 hospital-discharged elderly patients received our comprehensive assessment by using a Chinese Minimum Data Set-Home Care (MDS-HC). Our case manager developed and implemented care plans with reference to the computer-generated Clients Assessment Protocols. Results showed that the MDS-HC was sensitive to identify elderly persons’ holistic needs, and helpful in formulating all-inclusive care plans.

Many case managers in mental health settings occasionally experience a client’s suicide, and this can be an emotionally devastating event. The symptoms of schizophrenia, including the difficulties those client face in forming trusting relationships with others, brings special challenges to the case manager’s recovery because of the efforts put into developing that relationship. The purposes of this article are to describe a range of possible reactions of case managers following the suicide of a client with schizophrenia and how those persons can be helped to make a positive recovery from such an event. A summary of suicide risk factors for case managers to assess when working with clients who have schizophrenia is included.

The purposes of the study were to explore consumer preferences for a cash option, to inform the ongoing CCDE survey and program design, and to identify the messages that the CCDE and other states should include when informing consumers about a cash option. The preference study consisted of 3 parts: 11 presurvey focus groups, a telephone survey in each of the 4 participating states, and 16 post-survey focus groups. This article highlights unique results from pre- and post-survey focus groups. Focus group discussions were audiotaped and videotaped and transcribed. Transcripts were manually coded and text was clustered according to the moderator’s guide questions and some new and recurrent themes that emerged. Overall, focus group participants, including elders, expressed positive feelings about the CCDE, especially about having a role in hiring workers and determining the workers’ schedules and responsibilities. Focus groups provided important lessons about features to highlight when presenting program information to potential consumers and their families. Program planners must also bear in mind consumer concerns, especially considering that less than 10% of eligible Medicaid consumers volunteered for the cash option. These findings will be useful in guiding other states as they develop new cash and counseling programs, especially those in the current Cash and Counseling replication project.

Little is known about the home care context for lesbian, gay, bisexual, and transgender (LGBT) older adults, most of whom, like the general older adult population, prefer to stay in their home and community for as long as possible. The very limited LGBT-focused home care literature available suggests that there are unique concerns about providing care in the home. In this chapter, access to affi rmative home care services for LGBT older adults is located within the context of the LGBT health services access research literature. A program of research focused on identifying key access and equity indicators and associated prompts to assist organizations to provide high-quality, affi rmative home care for these populations is described.

The interim payment system (IPS) for Medicare home health services, enacted in the Balanced Budget Act of 1997, was intended to slow the growth of home health expenses until HCFA could design a new prospective system. Instead, the IPS has acted like a per-case payment system without case-mix adjustment. Its impact on agencies, along with other policy pressures, has been first to slow and then to reverse the dramatic expansion of the home health sector. In this paper, we identify the impetus for payment changes in the recent history of the Medicare home health benefit. We then present emerging evidence about the effects of IPS and other recent policies on home health. Finally, we draw several lessons from this experience for the impending prospective payment system.

This study documents the development of a new tool to measure the quality of community case management for elderly clients. Information obtained from literature review, client focus groups, and pilot surveys with clients served as the basis for the development of a Case Management Quality Questionnaire (CMQQ). This measure, along with satisfaction, health status, and demographic questions, was administered to 174 home care clients and 78 family members of long term care residents for evaluation of case management services that clients had received in the last 2 to 6 months. Principal components analysis with oblique (Oblimin) rotation identified three subscales of the CMQQ: (1) accessibility, (2) efficiency, and (3) assessment/coordination skill. Study findings suggest that the CMQQ is reliable, valid, and of value in understanding satisfaction with case coordination. Based on client feedback and analysis of the results, some future modifications to the measure are worthy of study. Others interested in measuring and improving case management may similarly benefit from the use of the CMQQ.

Background: The Portuguese in-home care services have never been adequately studied or identified. This is because of the lack of classification of variables related to the care receiver and to the demographic and organizational context in which it is inserted.

Methods: The 126 organizations in the central region of Portugal were categorized into four groups depending on whether they were located in a rural or urban environment and on whether they were large or small organizations. To obtain information, the In-Home Care Protocol (ProSAD), Elderly Assessment System (EASYcare), and the Center for Epidemiologic Studies–Depression (CES-D) scale were applied to 48 customers (6 randomly chosen customers of in-home care services of each of the 8 randomly selected organizations, 2 per group of variables).

Results: The rural context denoted a lack of diversity of services and the number of organizations available is reduced, which implies less time spent with the customers. The more dependent customers at the time of registration (Kruskal–Wallis test [KW] = 12.79; p < .05) in large organizations (Mann–Whitney [U] = 190.5; p < .05) benefit more from the services. Conclusions: In-home care services are underused and are oriented to treat those that have a family caregiver. Overall, in-home care in Portugal still has much to achieve when compared with other European countries.

This article concerns how globalization and the aging of the world’s population are affecting the already complex issue of intergenerational transnational caregiving. Globalization has caused an increase in workforce mobility with large numbers of individuals seeking employment overseas. This, coupled with increased longevity globally, has resulted in many workers leaving their elderly parents in need of care in their home countries. This has spawned caregiving across national borders, or caring for family relations across nations. Currently in the United States, not enough emphasis is given to family caregiving. Data compiled by AARP and the National Alliance for Caregiving estimate the economic value for this group of family caregivers in 2007 to be $375 billion, accounting for 34–52 million family caregivers per given year. This does not include those families who are transnational caregivers. The seminal work in this emerging field has been done by social anthropologists Loretta Baldassar, Cora Velekoop Baldock, and Raelene Wilding, who have defined the components of transnational caregiving based on an ethnographic study using qualitative data to study nine immigrant communities in Western Australia. Although their research focused on caregiving from a distance, additional work has been added to the discussion by introducing the element of “care drain” and further cultural perspectives. Therefore, this research is an exploratory study on intergenerational transnational caregiving within the context of the changing world and its demographics. Within the context of globalization and global aging, the following questions are addressed: What is the significance of family caregiving? What is a transnational? How has technology changed “transnationalism” today? What are the elements that comprise transnational caregiving? How does culture play a role in transnational caregiving? What are some of the national initiatives undertaken by governments to aid in workforce issues and recognition of caregiving organizations? By exploring these questions, it is hoped that there will be a better understanding of transnational caregiving and its relevance in all societies.

Many older and disabled individuals regularly receive valuable services from home health agencies (HHAs). The unilateral termination or reduction of such services by an HHA may exert a significant impact on the life of a client who has come to depend on those services. The prerogatives of Medicare-certified HHAs to terminate their relationships with clients are constrained today not only by contract and tort law principles, but also by federal statutes and regulations establishing Conditions of Participation, including provisions concerning clients’ rights. A recent important federal judicial decision interpreted and expanded the legal responsibilities of HHAs to provide formal notice to their Medicare clients before terminating or reducing home health care services to those clients, regardless of the reason for ending or altering the relationship. This article critically discusses the background, holding, and practice implications of the 2004 Lutwin v. Thomson decision, which imposes these notice requirements on HHAs.

This chapter discusses the concept of resilience from a life span perspective informed by relational developmental systems theory. Resilience involves mutually beneficial (adaptive) relations between characteristics of individuals (e.g., their self-regulation behaviors) and features of the ecology (e.g., resources promoting healthy development); these links may be represented as individual ←→ context relations, and they involve adjustment in the context of challenges or maintenance of appropriate functioning in the face of variations in the resources needed to achieve health. Resilience, then, is an attribute of positive human development (PHD) achieved through adaptive individual ←→ context relations (termed adaptive “developmental regulations”). We review research across the life span that speaks to the use of this conception of resilience for understanding the contributions individuals make to their own positive development and to the maintenance or perpetuation of PHD-supportive assets of their ecologies. Directions for further research and for applications aimed at promoting PHD are discussed.

Purpose of the study: Using focus group data, this article discusses the use of social marketing principles to enhance enrollment in the Cash and Counseling Demonstration and Evaluation (CCDE). Design and methods: Focus groups were conducted in person and by conference call in two CCDE states, Arkansas and Florida. In Florida, Department of Elder Affairs and Developmental Services Program (DS) staff participated in seven focus groups. In Arkansas, four focus groups were conducted with professionals likely to come into contact with Medicaid consumers who are eligible for Arkansas’ cash option program. Focus group transcripts were coded according to the project research questions. Results: Several important lessons emerged including the importance of (a) conducting process evaluation activities, such as the social marketing focus groups, early during program implementation; (b) using multiple approaches and contacts to inform potential consumers and their families about a new, complex program; (c) carefully selecting and training personnel to conduct outreach and enrollment activities; and (d) developing specific messages to include in marketing the cash option. Implications: Using social marketing principles to examine CCDE enrollment has provided important information to enhance this program.

A review and discussion of Death, Dying and the Ending of Life, edited by Margaret P. Battin, Leslie P. Francis, and Bruce M. Landesman. Ashgate Publishing, 2007. The many philosophical, ethical, legal, and social aspects of death and the dying process remain deeply controversial despite substantial and continuous public discussion and debate about them. Springing from an in-depth review of a newly-published compilation of some of the most seminal writings in this area, the author in this essay reflects on and systematically analyzes how the classical literature of the past millennium has set the intellectual stage and in many respects established the rules of engagement for modern discourse on end-of-life decisions and decision-making.

This article explores the intersection between discourses with multiple meanings that relate to the cultural construction of elder identities in South Korea. The authors explore the experiences of elder patients at a free clinic to consider how government policy, attitudes among biomedical professionals, and elders themselves come into contact and influence the experiences of older Koreans within the national health care system. The study is ethnographic, using interview data to examine how the identities of elder Koreans are being shifted from “weak and in need of care” to “potentially problematic consumer” and how governmental policies both stimulate and respond to that shift. By focusing on the situational status of the elderly, this article is intended to represent the voices of some elderly, voices that can be submerged within the process of decision making related to public policy.

This article proposes that social role theory (SRT) and social role valorization (SRV) be established as organizing theories for care managers. SRT is a recognized sociological theory that has a distinctive place in care management practice. SRV is an adjunct for SRT that focuses on people who are devalued by being in a negative social position and supports behavior change and movement to a valued social position.

The operating environment in the health care industry is turbulent—organizations are expected to adapt or die. This paper addresses the structure of a strategic planning process for long-term-care organizations. Nursing homes, assisted living (personal care) facilities, continuing care retirement communities, adult day services centers, hospice programs and home-and community-based agencies face both opportunities and threats. The authors recommend an eight-step process for strategy making: plan to plan; external analysis; internal analysis; vision; matching current and future strategies; strategy choice; action and linkage to operations and budget. A case example illustrates the concepts. Long-term-care leaders are encouraged to plan for their future or face a future planned by competitors and regulators.

Even after 30 years of experience, two questions persist about case management practice. Who needs it and does it work? Answers to these questions are neither direct nor simple. This article examines the significance of various contexts (policy, system, community, and organization) to efforts attempting to provide responses to these basic questions. Beyond the question of who needs case management, two additional questions are addressed. Who needs it and who gets it? Clients’ qualitative perspectives on case management effectiveness, beyond attempts to measure satisfaction and quality of life, are usually absent. The article concludes with a discussion of whether these are the right questions.

Filial piety provides an important ideological basis for family-based support in China. Evidence indicates that in recent years the support of the aged within the Chinese extended family has decreased. This article examines filial piety, residence, and support arrangements in three rural Chinese villages. Anthropologists independently conducted research in these villages in the 1990s: Hong Zhang in Zhongshan Village in Hubei Province, Yunxiang Yan in Xiajia Village in Heilongjiang Province, and myself in Lijia Village in Shandong Province. This article examines the strategies used by the young and old in negotiating intergenerational support and residential arrangements within the context of local village circumstances and policies. In each village, the aged are increasingly likely to live apart from children, and to express a preference for living independently. Although these facts appear to contradict filial piety, filial piety continues to be valued. Filial respect of elders, however, is seen less as an inherent right and more as a reciprocal relationship that can be built, maintained, and lost. Housing policies and the economic status of the aged both appear to play an important role in explaining the common trends in these villages as well as explaining the differences between them. To varying degrees in each village, power has shifted to the younger generation.

Unaffiliated workers are directly hired personal assistance workers who are not employed through an agency and are not family members or close friends. This article examines the working conditions of unaffiliated workers in a consumer-directed setting in comparison to agency workers and to other consumer-directed workers. Unaffiliated workers earned higher wages than their peers but were less satisfied with these wages and benefits than other directly hired workers. Findings for consumer-directed programs are discussed in terms of the recruitment and retention of unaffiliated workers, implications for consumers and workers, and future research recommendations.

There are several population-based studies of aging, memory, and dementia being conducted worldwide. Of these, the Cache County Study on Memory, Health and Aging is noteworthy for its large number of “oldest-old” members. This study, which has been following an initial cohort of 5,092 seniors since 1995, has reported among its major findings the role of the Apolipoprotein E gene on modifying the risk for Alzheimer’s disease (AD) in males and females and identifying pharmacologic compounds that may act to reduce AD risk. This article summarizes the major findings of the Cache County study to date, describes ongoing investigations, and reports preliminary analyses on the outcome of the oldest-old in this population, the subgroup of participants who were over age 84 at the study’s inception.

Balancing the polarized notions of quality and quantity of service and care is a challenge for the 21st century health and social service system. The expectation of transparent decision making at both the policy and the practice level of case management has forced practitioners to seek guidance in ethical decision making. Case management, as a system, has potential to lead this new practice approach by incorporating the principles of ethical decision making in planning and coordinating care. A recent case study of ethical decision making within the bureaucratic context offers some insight and learning and may help inform future practice.

The administration of artificial nutrition by means of a percutaneous endoscopic gastrostomy (PEG) tube in older persons in the advanced stages of dementia is commonplace, yet the treatment is associated with significant treatment burdens and unclear benefits in this population. In addition, there is wide and unexplained geographic variability in the use of PEG in advanced dementia, which may stem partly from physicians’ lack of understanding about its indications, risks, benefits, and effect on quality of life in advanced dementia. This study was a mail survey undertaken to assess physician knowledge regarding tube feeding in advanced dementia and explore whether certification in geriatrics or other physician characteristics are associated with physician knowledge. To assess knowledge about tube feeding, we asked participants to rate the importance of commonly cited, but non–evidence based, indications for tube feeding in advanced dementia, including recurrent aspiration pneumonia, abnormal swallowing evaluations, abnormal nutritional parameters, preventing an uncomfortable death, and others. Discrepancies between physician knowledge and current evidence regarding tube feeding in advanced dementia were found, indicating a need for improved education of primary care physicians in order to ultimately provide better end-of-life care for patients with advanced dementia.

Healthy life expectancy is the length of expected life lived in a healthy state; remaining life would be unhealthy life. When health is defined by ability and disability, the measure is usually referred to as active and inactive life. Those with higher socioeconomic status can expect to live more healthy years and fewer unhealthy years; as a consequence of this, socioeconomic differences in healthy life expectancy tend to be greater than differences in total life expectancy. At age 70, there is a 1 year difference in total life expectancy for men with a high school degree versus those with less education; however, there is a 1.5 year difference in years lived without disability. For women, the difference is 2.2 years of expected life with some disability versus 1.5 years difference in total life expectancy.

In quite a short amount of time, Sweden has gone from being a relatively homogeneous society to a multicultural one, with a rapid expansion of immigrants having culturally and linguistically diverse (CALD) backgrounds growing old in Sweden. This is particularly interesting in relation to studying age-related dementia diseases. Research shows that not only do CALD persons with dementia diseases tend to mix languages, have difficulties with separation of languages, or revert to speaking only their native tongue as the disease progresses, but they also show tendencies to experience that they live in the cultural environment in which they were brought up, rather than in the current Swedish one. In this article, we explore findings in relation to one such CALD group in Sweden, Iranians. The article is empirically driven and based on data gathered in 2 separate settings with specific ethnocultural profiles, offering dementia care with Middle Eastern, Arab, and/or Persian profile. Observations were carried out in combination with semistructured in-depth interviews (n = 66). By using a combination of content and ethnographic analysis, 4 main findings related to ethnocultural dementia care were elucidated. These include (a) a wider recognition of people from different CALD backgrounds possibly having different perceptions of what dementia is, (b) a possibility that such ascribed meaning of dementia has a bearing on health maintenance and health-seeking behavior as well as the inclination to use formal services or not, (c) choosing to use formal service in the forms of ethnoculturally profiled dementia care facility seems to relate to being able to “live up to ideals of Iranian culture,” and (d) “culture,” however ambiguous and hotly debated a concept it is, appears to be a relevant aspect of people’s lives, an aspect that is both acquired as well as ascribed to oneself and to others. As such, we argue that culture needs to be further addressed in relation to dementia care in multicultural societies because ascribing culture boxes people in as well as out. In addition, ethnocultural contextualization of dementia care needs to be understood in relation to this because it affects the care provided.

Caregivers of patients with mental illness play a vital role caring for their loved ones, yet they may not always be fully included in the process of assessment and treatment. A patient-centered approach to treating persons with mental illness views caregivers as partners in providing care for the patient. This study sought to explore perceptions of caregivers of persons with mental illness regarding the care their loved ones receive and to illicit specific issues caregivers wish to communicate with professionals that could improve patient care. A modified nominal group technique exercise was conducted as part of a suicide prevention workshop. Participants completed a four-item questionnaire. Five main themes emerged: the caregivers’ perception that they need to be included in the mental health care of their loved one; concerns about the diagnosing process; communication with professionals; a desire for individualized, holistic treatment; and the need for information about services and resources for the caregiver and the patient. Findings are similar to studies that also sought to understand the perspectives of caregivers. Caregivers provide an invaluable resource for the patient with mental illness. Efforts to include caregivers would enhance the overall care provided to patients with mental illness.

Families and social support systems have been found to be instrumental for the physical and psychological well-being of older adults. However, the majority of research on families has assumed that all members within a family are hetero sexual. This chapter discusses families and social support systems for lesbian, gay, bisexual, and transgender (LGBT) older adults. The chapter initially provides an overview of the research on social networks and social support systems of the general older adult population. The discussion on LGBT older adults' families and social support systems highlights families of choice, LGBT communities, and the impact of disclosing one's sexual orientation on social network relationships. The chapter concludes with recommendations for future research and best practices that focus on addressing the unique needs and concerns of LGBT elders.

Social isolation and loneliness are consistently associated with worse health and well-being outcomes among older adults. However, many studies have not examined their concurrent impact on health and well-being, and even fewer studies examine their influence among Black older adults. The 2014 and 2016 waves of the Health and Retirement Study were used to examine the influence of social isolation and loneliness among a nationally representative sample of Black older adults. Social isolation was measured using a social network index based on marital and household status, contact with family members and friends, and participation in social and religious activities. Loneliness was measured by the 3-item loneliness scale. Health outcomes were self-rated physical health and number of chronic health conditions, depressive symptoms, and lifetime occurrence of a psychiatric disorder. Each health outcome was examined using: (a) social isolation, (b) loneliness, and (c) social isolation and loneliness, controlling for sociodemographic covariates. Social isolation was associated with self-rated health and depressive symptoms, while loneliness was associated with all health outcomes. When examined jointly, social isolation was associated with self-rated health, while loneliness was associated with all health outcomes. Study findings suggest that due to its association with multiple physical and mental health measures, loneliness may be a more significant factor for health that should be routinely assessed in working with Black older adults.

This article explains various mechanisms that are available to plan for the future prior to the development of incapacity. These include powers of attorney, revocable living trusts, advance medical directives such as powers of attorney for health care and living wills, psychiatric advance directives, and guardianships and conservatorships. Case examples are utilized to illustrate the consequences of a failure to plan and what can be accomplished through advance planning. The suitability of each such mechanism is dependent on the situation of each individual. Additionally, the specific details of each mechanism may vary across states.

Steady growth in human life expectancy has been a key feature of the last century, with projected further increases likely to have enormous impacts on societies worldwide. Despite the significance of these changes, our understanding of the factors shaping this trend is incomplete. During most of the historical increase, by far, the major influence was progressive decline in early and midlife death rates because of the reduction in premature deaths, caused chiefly by infection. Recent decades have seen the emergence of a new driver of increasing longevity—declining mortality among those who are old already, pointing to greater malleability in human aging than had been foreseen. There is still debate, however, as to how much of this decrease in old age mortality is caused by a better early-life environment and how much is caused by improved conditions in late life. A unique resource exists in the case of Japan, where material circumstances for the general population were consistently adverse through the early decades of the 20th century but improved rapidly after 1950. Here, we compare the Japanese birth cohorts of 1900, 1910, and 1920 and follow their period and cohort mortality trends. The results show that cohorts with similar environments early in life have very different mortality trajectories in old age. This strengthens the expectation that preventive measures in later life can deliver great benefit, while not contradicting the importance of life course approaches, to improving health and well-being.

The implications of economic inequality for American families are profound, giving rise to widening race and socioeconomic disparities in key family transitions including marriage, divorce, cohabitation, childrearing, and family bereavement. However, little scholarly attention focuses on how these divergences in family structure shape the health and well-being of older adults, and especially older women. In this chapter, I propose that family relationships are an important although overlooked mechanism linking economic inequality to persistent race, socioeconomic, and gender disparities in late-life well-being. I provide a statistical snapshot of older adults’ families, showing how rates of marriage, divorce, widowhood, and remarriage differ markedly on the basis of gender, socioeconomic status, and race, with these disparities widening against the backdrop of rising economic inequality in the late 20th and early 21th centuries. I then describe how these patterns perpetuate disparities in late-life economic well-being, due in part to the structure of Social Security benefits which advantage those whose family lives conformed to the mid-20th century White middle-class “ideal” of a lifelong marriage between a male breadwinner and female homemaker. I further show how three stressful aspects of family lives—family bereavement, custodial grandparenting, and caregiving—disproportionately befall women, and especially low-income and women of color. As such, these family-related stressors exacerbate race, class, and gender-based disparities in health and well-being. I conclude by highlighting social policies that may help to mitigate against these disparities, and provide resources so that Americans of all backgrounds have an opportunity to grow old with dignity.

In this essay, I assume the stance of a “reflective practitioner,” critically examining my research practices and trajectory to gain insight as to how I have engaged in and possibly impacted Environmental Gerontology. I first examine the “what” (description of what has been done), then examine the “so what” (factors contributing to success [or not] and key achievements), and finally, the “now what” (logical next steps or vision for future endeavors). I characterize my stance towards Environmental Gerontology as a consumer or “user” of its concepts and principles. My research focus is on employing key environmental constructs to develop and evaluate biopsychosocial environmental interventions to improve the “good life” or quality of life of older adults and family caregivers. I have considered the socio-physical environment from varied roles: as cause of behavioral or psychological outcomes; as moderator of outcomes, as mediator of outcomes, as an outcome itself, or as the context in which behavioral, cognitive, and affective processes unfold. I suggest that modifying physical and social environments results in clinically meaningful benefits to older adults and caregivers; and that understandings from Environmental Gerontology may advance the science of implementing interventions in real-world community, clinical, and service settings.