A healthy dose of realism: The role of optimistic and pessimistic expectations when facing a downward spiral in health

Downward adjustment of rehabilitation goals may facilitate post-stroke arm motor recovery

Objective: Patients starting with physical rehabilitation often hold unrealistically high expectations for their recovery. Because of a lower-than-expected rate of recovery, such unrealistic goals have been linked to adverse effects on mental health. Additionally, overtraining due to overly ambitious goals can lead to suboptimal recovery. We investigated the effectiveness of adjusting rehabilitation goals to a more realistic level as a strategy to select appropriate exercise intensity and achieve better recovery outcomes. Design: Patients with arm paralysis from recent stroke were recruited and went through 6-8 weeks of telerehabilitation and in-clinic rehabilitation programme conducted at 11 US sites (N = 124). Main Outcome Measures: Adjustment of recovery goal was assessed in two timepoints during the rehabilitation programme and arm motor function was assessed before and after the clinical trial. Results: Greater use of goal adjustment strategies predicted better recovery of arm motor function, independent from therapy compliance. This pattern was observed only when the choice of exercises is patient-regulated rather than directed by a physical therapist. Conclusion: Benefits from goal adjustment were more pronounced among patients who entered the programme with poorer motor functions, suggesting that goal adjustment is the most beneficial when goals of complete recovery are most unrealistic.

The Effect of Physical Limitations on Depressive Symptoms over the Life Course: Is Optimism a Protective Buffer?

OBJECTIVES

We examined the extent to which optimism buffers the effects of physical limitations on depressive symptoms, across four mid- and later-life age groups (ages 40-49, 50-64, 65-74, 75+ at baseline). Analyses are motivated by stress theories, which hold that the protective effects of coping resources are evidenced only at high levels of stress. We further explore whether these purportedly protective effects diminish with age, as health-related stressor(s) intensify and become irreversible.

METHODS

We use data from two waves (2004-06 and 2013-14) of the Health and Retirement Study (HRS, n = 4,515) and Midlife in the United States (MIDUS, n = 2,138). We estimate OLS regression models with three-way interaction terms to examine prospectively the benefits of optimism as a coping resource for persons with physical limitations across four age groups. Physical limitations are assessed with a composite measure encompassing mobility and activity of daily living (ADL) limitations.

RESULTS

In HRS and MIDUS, persons with 3+ limitations reported significantly more depressive symptoms than persons with 0-2 limitations, yet these disparities diminished at higher levels of optimism. Buffering effects of optimism vary by age. For midlife and young-old persons with 3+ limitations, optimism is strongly and inversely related to depressive symptoms at follow-up. Comparable protective effects are not evident among oldest sample members.

DISCUSSION

Stress and coping models should consider more fully factors that limit older adults' capacity to deploy purportedly protective personal resources. Investments in structural or institutional supports may be more effective than interventions to enhance positive thinking.

Effect of Intensivist Communication in a Simulated Setting on Interpretation of Prognosis Among Family Members of Patients at High Risk of Intensive Care Unit Admission: A Randomized Trial

Importance

Discordance about prognosis between a patient's health care decision-making surrogate and the treating intensivist is common in the intensive care unit (ICU). Empowering families, friends, and caregivers of patients who are critically ill to make informed decisions about care is important, but it is unclear how best to communicate prognostic information to surrogates when a patient is expected to die.

Objective

To determine whether family members, who are often health care decision-making surrogates, interpret intensivists as being more optimistic when questions about prognosis in the ICU are answered indirectly.

Design, Setting, and Participants

This web-based randomized trial was conducted between September 27, 2019, and October 17, 2019, among a national sample of adult children, spouses, partners, or siblings of people with chronic obstructive pulmonary disease who were receiving long-term oxygen therapy. Participants were shown video vignettes depicting an intensivist answering a standardized question about the prognosis of a patient at high risk of death on day 3 of ICU admission. Participants were excluded if they had worked as a physician, nurse, or advanced health care practitioner. Data were analyzed from October 18, 2019, to November 12, 2019.

Interventions

Participants were randomized to view 1 of 4 intensivist communication styles in response to the question "What do you think is most likely to happen?": (1) a direct response (control), (2) an indirect response comparing the patient's condition with that of other patients, (3) an indirect response describing the patient's deteriorating physiological condition, or (4) redirection to a discussion of the patient's values and goals.

Main Outcomes and Measures

Participant responses to 2 questions: (1) "If you had to guess, what do you think the doctor thinks is the chance that your loved one will survive this hospitalization?" and (2) "What do you think are the chances that your loved one will survive this hospitalization?" answered using a 0% to 100% probability scale.

Results

Among 302 participants (median [interquartile range] age, 49 [38-59] years; 204 [68%] women) included in the trial, 165 (55%) were adult children of the individual with chronic obstructive pulmonary disease; 77 participants were randomized to view a direct response, 77 participants were randomized to view an indirect response referencing other patients, 68 participants were randomized to view an indirect response referencing physiological condition, and 80 participants were randomized to view a redirection response. Compared with participants who viewed a direct response, participants who viewed an indirect response referencing other patients (β = 10 [95% CI, 1-19]; P = .03), physiological condition (β = 10 [95% CI, 0-19]; P = .04), or redirection to a discussion of the patient's values and goals (β = 19 [95% CI, 10-28]; P < .001) perceived the intensivist to have a significantly more optimistic prognostic estimate.

Conclusions and Relevance

These findings suggest that family members interpret indirect or redirection responses to questions about prognosis in the ICU setting as more optimistic than direct responses.

Trial Registration

ClinicalTrials.gov Identifier: NCT04239209.

Changes in self-esteem and chronic disease across adulthood: A 16-year longitudinal analysis

RATIONALE

Self-esteem is an adaptive personality factor that has been associated with good physical health. While research has observed that self-esteem and physical health typically decline in older adulthood, there is a paucity of research investigating the associations between changes in self-esteem and physical health across the adult lifespan.

OBJECTIVE

The present study examined whether changes in selfesteem and chronic disease exert reciprocal effects on subsequent changes in self-esteem and disease. In addition, it investigated whether individuals' age would moderate these associations.

METHODS

The study analyzed data from 14,117 adult (18+) Canadians who completed surveys over 16 years, from cycles 1 to 9 of the National Population Health Survey (NPHS). Self-esteem, chronic diseases, and demographic information were collected.

RESULTS

Cross-lagged panel analyses indicated reciprocal age-related associations between changes in self-esteem and chronic disease. Initial decline in self-esteem predicted subsequent increases in chronic disease, and initial increases in chronic disease predicted subsequent declines in self-esteem, only among young adults, and not middle-aged or older adults.

CONCLUSION

These results suggest that age may qualify the associations between declines in self-esteem and physical health and that adverse changes in both factors may be particularly problematic for young adults' prospective personality functioning and physical health.