Experiences of a Community-Based Digital Intervention Among Older People Living in a Low-Income Neighborhood: Qualitative Study

BACKGROUND

Older adults worldwide experienced heightened risks of depression, anxiety, loneliness, and poor mental well-being during the COVID-19 pandemic. During this period, digital technology emerged as a means to mitigate social isolation and enhance social connectedness among older adults. However, older adults' behaviors and attitudes toward the adoption and use of digital technology are heterogeneous and shaped by factors such as age, income, and education. Few empirical studies have examined how older adults experiencing social and economic disadvantages perceive the learning of digital tools.

OBJECTIVE

This study aims to examine the motivations, experiences, and perceptions toward a community-based digital intervention among older adults residing in public rental flats in a low-income neighborhood. Specifically, we explored how their attitudes and behaviors toward learning the use of smartphones are shaped by their experiences related to age and socioeconomic challenges.

METHODS

This study adopted a qualitative methodology. Between December 2020 and March 2021, we conducted semistructured in-depth interviews with 19 participants aged ≥60 years who had completed the community-based digital intervention. We asked participants questions about the challenges encountered amid the pandemic, their perceived benefits of and difficulties with smartphone use, and their experiences with participating in the intervention. All interviews were audio recorded and analyzed using a reflexive thematic approach.

RESULTS

Although older learners stated varying levels of motivation to learn, most expressed ambivalence about the perceived utility and relevance of the smartphone to their current needs and priorities. While participants valued the social interaction with volunteers and the personalized learning model of the digital intervention, they also articulated barriers such as age-related cognitive and physical limitations and language and illiteracy that hindered their sustained use of these digital devices. Most importantly, the internalization of ageist stereotypes of being less worthy learners and the perception of smartphone use as being in the realm of the privileged other further reduced self-efficacy and interest in learning.

CONCLUSIONS

To improve learning and sustained use of smartphones for older adults with low income, it is essential to explore avenues that render digital tools pertinent to their daily lives, such as creating opportunities for social connections and relationship building. Future studies should investigate the relationships between older adults' social, economic, and health marginality and their ability to access digital technologies. We recommend that the design and implementation of digital interventions should prioritize catering to the needs and preferences of various segments of older adults, while working to bridge rather than perpetuate the digital divide.

Occupations and occupational therapy practice with Chinese older adults living with life-limiting illnesses in Singapore: A focus group study

INTRODUCTION

While Singapore is rapidly ageing and the need for palliative care services is projected to rise, there has been limited exploration of the occupations of Chinese older adults with life-limiting conditions. This study is the third in a series of three studies aimed to address this issue. This study also sought to discuss future directions for occupational therapy practice with Chinese older adults living with life-limiting illnesses in Singapore.

METHOD

The study adopted a qualitative exploratory design using focus groups. Participants were recruited using convenience and snowball sampling. Inclusion criteria were occupational therapists who had attained full registration status with the Allied Health Professionals Council in Singapore, had two or more years of practice as an occupational therapist, and had a current or recent palliative care caseload.

FINDINGS

Three focus groups with 16 participants were conducted, and three themes were constructed from the data through reflexive thematic analysis. Reflections on culture and occupations is about the impact of a collectivist culture on occupations, such as tensions new caregivers experience between keeping clients safe and respecting clients' choices. It also highlights that there will always be individual differences within any cultural group. Challenges of occupational therapy practice in palliative care describe the need for therapists to be comfortable with rest and ethical tensions participants faced with billing for sessions that mainly involved time spent conversing with clients and when clients and caregivers' goals differed. Finally, Moving forward is about the importance of having mentors and the learning needs of occupational therapists in palliative care.

CONCLUSION

Occupational therapists experienced in providing services to palliative care clients in Singapore emphasised the collectivist nature of Singaporean Chinese families and contributed more information to its possible impact on occupations and occupational therapy practice and made suggestions for future practice.

Informal Caregiver Social Network Types and Mental Health: The Mediating Role of Psychological Resilience

Little is known about whether and why social networks protect mental health among informal caregivers. This study examined the association between informal caregiver social network types and depressive symptoms and the mediatory mechanism of psychological resilience. Latent class analysis, applied to cross-sectional data on 278 Singaporean caregivers, identified four social network types: restricted (42%), friend (16%), family (21%), and diverse (21%). Path analysis showed that the diverse social network type, compared to the restricted social network type, was associated with a lower level of depressive symptoms, and psychological resilience fully mediated this association. Interventions should help caregivers to maintain social networks with their family and friends.

Feeling Alone Together: Loneliness in Older Adults with Cognitive Impairment and Their Family Caregivers with Low Mastery

INTRODUCTION

Loneliness in older persons with cognitive impairment (PCI) may beget loneliness in their family caregivers, depending on buffering resources caregivers possess. This study examined the association between loneliness in older PCI and loneliness experienced by their family caregivers, and the moderating role of caregiver mastery in this association.

METHODS

Dyadic data from 135 PCI and their family caregivers in Singapore were analyzed using multivariable regression. Loneliness was measured using a three-item UCLA loneliness scale. Mastery was assessed using a seven-item Pearlin instrument.

RESULTS

Multivariable regression showed that PCI loneliness and caregiver loneliness were weakly associated, taking other covariates into account. Notably, a significant interaction between PCI loneliness and caregiver mastery was observed, indicating that PCI loneliness was associated with caregiver loneliness only when caregivers had low mastery.

CONCLUSION

Lonely PCI may share their feelings of loneliness with their caregivers, and this can lead to loneliness among caregivers if they have low mastery. Promoting caregiver mastery may help reduce caregiver loneliness, directly and indirectly as a buffer against PCI loneliness.

Mismatch Between Older Persons' Generative Concern and Internalized Generative Capacities: Leveraging on Generative Ambivalence to Enhance Intergenerational Cohesion

Studies have shown how generativity, the concern for establishing and guiding the next generation and safeguarding its wellbeing, functions as an intergenerational conduit, bridging the developmental stages of older individuals with those younger. Yet, applications of generativity, as a means to bridge generational gaps within rapid social change, remain underexplored in the intergenerational field. Using Singapore as a case study, and through focus group discussions with 103 older persons, this paper examines how older Singaporeans express their generative concern and internalize their generative capacities across different social settings and rapid socioeconomic transformation. Mismatch between older Singaporeans' generative concern and capacity contributes to ambivalence - mixed feelings about guiding younger generations - which emerges out of older Singaporeans' struggles with cultural change prompted by economic progress, as well as concerns about their place and value in a technologically advanced global city-state. The concept of generative ambivalence can add value to policy perspectives on intergenerational cohesion, as it considers people's attempts to forge commonalities and mutual reciprocity despite differences (e.g. gender, age, race, skills), as well as highlights intergenerational complexities beyond superficial binaries. Policies aimed at bringing generations together must be intentional in creating opportunity structures that go beyond categorical differences, where multiple generations can thrive interdependently.

Transiting Back Home: Caregivers' Lived Experiences in Caring for Loved Ones on the Nasogastric Tube in the Home-Setting in Singapore

INTRODUCTION

Little is understood about caregivers' lived experiences when first caring for patients on the nasogastric tube at home in an Asian setting. To enhance understanding, our study aimed to chart these caregivers' psycho-emotional evolutions felt during such caregiving experiences in Singapore.

METHOD

Utilizing purposive sampling, a descriptive phenomenological study was performed, with semi-structured interviews of 10 caregivers of persons on nasogastric tube feeding conducted. Thematic analysis was utilized.

RESULTS

Our findings chart four psycho-emotional transitions of a caregiver's journey in nasogastric tube feeding and the cultural dynamics involved-(a) Disruption of Caregivers' Normality: Attempting to Grasp Reality, (b) Encountering Road-Blocks: Despondency Arises and Frustrations Abound, (c) Adjusting to the New Normal: Reclaiming Confidence and Positivity, (d) Thriving and Integrating into the New Normal, and (e) Cultural Dynamics At Play.

DISCUSSION

Our findings illuminate the understanding of caregivers' varying needs, guiding delivery of culturally-congruent caregiver support targeted at each psycho-emotional evolution.

A scoping review on the factors associated with the lost to follow-up (LTFU) amongst patients with chronic disease in ambulatory care of high-income countries (HIC)

BACKGROUND

Despite the importance of long term follow-up care for patients with chronic disease, many patients fail to adhere to their follow-ups, which increase their risk of further health complications. Therefore, the purpose of this scoping review was to find out the factors associated with lost to follow-up (LTFU) amongst patients with chronic disease in the ambulatory care setting of high-income countries (HICs) to gain insights for better quality of care. Understanding the definition of LTFU is imperative in informing patients, health professionals and researchers for clinical and research purposes. This review also provided an overview of the terms and definitions used to describe LTFU.

METHODS

The following databases: CINAHL, EMBASE, Medline, PsycINFO and Web of Science were searched for studies investigating the factors associated to LTFU from the date of inception until 07 January 2022.

RESULTS

Five thousand one hundred and seven records were obtained across the databases and 3,416 articles were screened after removing the duplicates. 25 articles met the inclusion criteria, of which 17 were cohort studies, five were cross-sectional studies and three were case-control studies. A total of 32 factors were found to be associated with LTFU and they were categorised into patient factors, clinical factors and healthcare provider factors.

CONCLUSION

Overall, the factors associated with LTFU were generally inconsistent across studies. However, some factors such as financial factors (i.e., no insurance coverage) and low accessibility of care were consistently associated with LTFU for both mental and physical chronic conditions. The operational definitions of LTFU also varied greatly across studies. Given the mixed findings, future research using qualitative aproaches would be pivotal in understanding LTFU for specific chronic diseases and the development of targeted interventions. Additionally, there is a need to standardise the operational definition of LTFU for research as well as clinical practice purposes.

Knowledge and Attitudes towards Dementia among the General Public in Singapore: A Comparative Analysis

INTRODUCTION

This paper provides a summary of findings on the public's knowledge and attitudes towards dementia. We aim to investigate if the attitudes of Singaporeans towards dementia have changed over the years by adopting a questionnaire used in a similar study in 2012.

METHODS

A cross-sectional, descriptive study was conducted through the dissemination of an existing, online questionnaire to participants above 16 years of age. Out of 1,500 subjects, results from 1,373 participants were analysed. Descriptive statistics were used to analyse and compare results from the 2012 study while a latent class analysis was performed to understand the categories of study participants based on varying levels of attitudes, knowledge and stigma.

RESULTS

The mean age of study participants was 43.8 (SD = 15.7). Majority of the participants were females (76.5%), between 51 and 60 years of age (29.6%) and belonged to the Chinese ethnic group (77.8%). Results demonstrated that there were significant differences in attitudes towards dementia between 2012 and 2021. There was a 70.2% improvement in stigma-associated attitudes and an increase in correct responses to 4 out of 5 questions in the knowledge section.

CONCLUSION

Findings of this study suggest that the general public has a better knowledge and more positive attitude towards dementia. This could have been attributed to higher literacy levels of the current study population and effectiveness of established outreach initiatives in Singapore. However, further research with a more balanced representation of ethnic and cultural groups would offer more comprehensive insights into dementia health literacy.

Derivation, and establishment of the validity and reliability, of the CASP-11-SG quality of life scale among community-dwelling older adults

PURPOSE

The number and proportion of older adults, aged ≥ 60 years, in Singapore is rapidly increasing. A valid and reliable quality of life (QoL) measure will enable assessment of their situation and help evaluate social and clinical interventions, potentially improving care. This study aims to evaluate the validity and reliability of the control, autonomy, self-realization, and pleasure (CASP)-12v.3 QoL scale and establish a scale suitable for use among older adults in Singapore.

METHODS

Data from 3526 community-dwelling older adults from a national survey was used. Measurement properties of the CASP-12v.3 scale were evaluated. Confirmatory factor analysis (CFA; testing single- and two-factor models with residual covariances for negatively worded items and a bifactor model) was performed in half of the sample and exploratory factor analysis (EFA) was performed in the other half. The results led to revised CFA models and the CASP-11-SG scale. The CASP-11-SG scale's measurement properties, convergent, and known-groups validity, and measurement equivalence/invariance (ME/I) across English and Chinese languages were evaluated.

RESULTS

Item 3 'I feel free to plan for the future' of the CASP-12v.3 scale had low correlation with other items of the control/autonomy subscale, low item-total correlation and high item-scale correlation. While CFA and EFA supported the two-factor model, removing item 3 improved model fit. The resulting CASP-11-SG scale (Cronbach's alpha: 0.81) demonstrated convergent and known-groups validity and partial ME/I across English and Chinese languages.

CONCLUSION

The CASP-11-SG scale, with satisfactory psychometric properties, can be used for assessing QoL among older adults in Singapore.

Perspectives on the popularization of smart senior care to meet the demands of older adults living alone in communities of Southwest China: A qualitative study

Background

Older adults who live alone face challenges in daily life and in maintaining their health status quo. Currently, however, their growing demands cannot be satisfied with high quality; therefore, these demands expressed by elders may be settled in the form of smart senior care. Hence, the improvement in smart senior care may produce more positive meanings in promoting the health and sense of happiness among this elderly population. This study aimed to explore the perceptions of demands and satisfaction with regard to the provision of senior care services to the community-dwelling older adults who live alone in Southwest China, thus providing a reference for the popularization of smart senior care.

Methods

This study adopted a qualitative descriptive approach on demands and the popularization of smart senior care. Semi-structured and in-depth individual interviews were conducted with 15 community-dwelling older adults who lived alone in Southwest China between March and May 2021. Thematic analysis was applied to analyze the data.

Results

Through data analysis, three major themes and subcategories were generated: "necessities" (contradiction: more meticulous daily life care and higher psychological needs vs. the current lower satisfaction status quo; conflict: higher demands for medical and emergency care against less access at present), "feasibility" (objectively feasible: the popularization of smart devices and applications; subjectively feasible: interests in obtaining health information), and "existing obstacles" (insufficient publicity; technophobia; patterned living habits; and concerns).

Conclusions

Smart senior care may resolve the contradiction that prevails between the shortage of medical resources and the increasing demands for eldercare. Despite several obstacles that stand in the way of the popularization of smart senior care, the necessities and feasibility lay the preliminary foundation for its development and popularization. Decision-makers, communities, developers, and providers should cooperate to make smart senior care more popular and available to seniors living alone, facilitating independence while realizing aging in place by promoting healthy aging.

Neighborhood Makes or Breaks Active Ageing? Findings from Cross-Sectional Path Analysis

Mental ill-health prolongs and complicates other chronic illnesses, which is a major public health concern because of the potential stress it places on health systems. Prevention via active aging and place-based interventions thus became increasingly important with population aging, e.g., through health promotion and age-friendly neighborhoods. However, how the targeted outcomes of these efforts are related remains unclear. This paper examined whether the relationship between active living and mental health or health-related quality of life is mediated by neighborhood cohesion. Cross-sectional data were drawn from n = 270 community-dwelling adults aged 50 and above in the Gerontology Research Program—Center for Ageing Research in the Environment (GRP-CARE) Survey. Path analysis showed that one can live actively for better mental health (B_total = 0.24), but it is largely mediated by neighborhood cohesion (37%). Further examination of the factors of neighborhood cohesion showed that this mediation is explained by communal affordance (B_indirect = 0.05) and neighborhood friendship (B_indirect = 0.05). Additional study of the association between these mediators and factors of mental health revealed two psychosocial processes: (1) better community spaces (e.g., greenery and third places) support communal living (B = 0.36) and help older adults obtain emotional support (B = 0.32) for greater autonomy (B = 0.25); (2) spending more time outdoors enhances neighborhood friendship (B = 0.33) and interpersonal skills (B = 0.37), which in turn improves coping (B = 0.39). In short, the effects of active living on health are limited by one’s neighborhood environment. Neighborhood cohesion must be considered or it may stifle individual and policy efforts to age actively and healthily in urban environments. Context-sensitive implementations are required.

Determinants of emergency department utilisation by older adults in Singapore: A systematic review

INTRODUCTION

Adults aged ≥60 years contribute to disproportionately higher visits to the emergency departments (ED). We performed a systematic review to examine the reasons why older persons visit the ED in Singapore.

METHODS

We searched Medline, Embase and Scopus from January 2000 to December 2021 for studies reporting on ED utilisation by older adults in Singapore, and included studies that investigated determinants of ED utilisation. Statistically significant determinants and their effect sizes were extracted. Determinants of ED utilisation were organised using Andersen and Newman's model. Quality of studies was evaluated using Newcastle Ottawa Scale and Critical Appraisal Skills Programme.

RESULTS

The search yielded 138 articles, of which 7 were used for analysis. Among the significant individual determinants were predisposing (staying in public rental housing, religiosity, loneliness, poorer coping), enabling (caregiver distress from behavioural and psychological symptoms of dementia) and health factors (multimorbidity in patients with dementia, frailty, primary care visit in last 6 months, better treatment adherence). The 7 included studies are of moderate quality and none of them employed conceptual frameworks to organise determinants of ED utilisation.

CONCLUSION

The major determinants of ED utilisation by older adults in Singapore were largely individual factors. Evaluation of societal determinants of ED utilisation was lacking in the included studies. There is a need for a more holistic examination of determinants of ED utilisation locally based on conceptual models of health seeking behaviours.

Cohort profile: Singapore's nationally representative Retirement and Health Study with 5 waves over 10 years

The Retirement and Health Study (RHS) is Singapore's largest nationally representative cohort with over 15,000 participants (aged 45-85 years) followed across five timepoints in 10 years (2014-2024). Accounting for sample weights, the sample represents 1.2 million Singaporeans and permanent residents of a total population of 5.5 million. The RHS sought consent to link survey responses to relevant administrative data, enabling the cross-validation of self-reports with national databases. There are 10 sections in the RHS with over 400 questions, 50% of which are on respondents' physical and mental health, healthcare utilization and insurance; the remaining 50% are about employment history, retirement adequacy, wealth, and household expenditure. The RHS was set up to provide microdata to compliment administrative data for whole-of-government policy making given that Singapore will reach super-aged status by 2026. Sample findings include a need for older adults to balance between immediate financial needs and investments regarding their pension funds. Also, 86% of older adults preferred to transit into partial retirement by reducing workloads. On the health front, existing studies utilising the RHS have revealed latent classes of disabilities, and that intentions to seek employment can mitigate disability developments. Another study reported that physical disability and social isolation was projected to increase, with ethnic disparities in social functioning. Overall, the RHS will be used for evidenced-informed policy agenda setting and evaluation across domains of health, finance, retirement adequacy, social and family development.

Socioeconomic Determinants of Universal Health Coverage in the Asian Region

The World Health Organization (WHO) states that examining medical financial systems is the most important process in evaluating universal health coverage (UHC). This study used the service coverage index (SCI) as a proxy of the progress toward UHC in eleven Asian countries. We employed a fixed-effects regression model to analyze panel data from 2015 to 2017, to explain the interrelationship between the SCI and major socioeconomic indicators. We also conducted a performance analysis (ratio of achieved SCI level to gross domestic product (GDP) or health expenditure displacement) to examine the balance between the degree of achievements related to UHC and a country’s economic level. The results showed that GDP and health expenditure were significantly positively correlated with the SCI (p < 0.01). The panel data analysis results showed that GDP per capita was a factor that greatly influenced the SCI as well as poverty (partial regression coefficient: 0.0017, 95% CI: 0.0013–0.0021). The results of the performance analysis showed that the Philippines had the highest scores (GDP: 1.84 SCI score/USD per capita, health expenditure: 1.04 SCI score/USD per capita) and South Korea the lowest. We conclude that socioeconomic factors, such as GDP, health expenditure, unemployment, poverty, and population influence the progress of UHC, regardless of system maturity or geographic characteristics.

Gender differences in years of remaining life by living arrangement among older Singaporeans

Living arrangements of older adults have often been studied as a measure of the support available to them. Given the rapidly ageing and low fertility context of Singapore where the prevalence of older adults living alone and without children is expected to increase, we construct multistate life tables to estimate the number of years that older persons can expect to live in different living arrangements at a population level (population-based) as well as based on their initial living arrangement (status-based). We focus particularly on whether there are gender differences in the expected years of life in different living arrangement states. We use the Panel on Health and Ageing of Singaporean Elderly, a 2009 nationally representative survey of 4990 Singaporeans aged 60 years and older, with follow-up surveys in 2011 and 2015. In calculating the probabilities of transition between different states, we control for number of children, housing type, and time-varying ADL limitations. We find that at age 60, women can expect to spend more than twice the proportion (18%) of their remaining lives living alone compared to men (7%). Status-based estimates indicate that the proportion of remaining years living with a child is higher for women initially living alone, with a spouse only or already with a child, compared to males. Our results indicate that while older women are more likely to live alone compared to their male counterparts, older women living alone are also more likely to transition to living with children. Our research sheds light on the importance of expanding research on life expectancy beyond health, to consider analysis using other forms of social stratification, particularly gender differences in states of living arrangement.

Supplementary Information

The online version of this article contains supplementary material available at 10.1007/s10433-020-00594-3.

Types of Caregiving Experience and Their Association With Caregiver Depressive Symptoms and Quality of Life

ObjectiveThis study examines distinct types of caregiving experience, each formed by varied combinations of caregiving burden and benefits, and their association with caregiver depressive symptoms and quality of life. Methods: We apply latent profile analysis and multivariable regression to data on 278 caregivers participating in the Caregiving Transitions among Family Caregivers of Elderly Singaporeans (TraCE) study in 2019-2020. Results: We identify four caregiving experience types: (1) balanced (low burden and moderate benefits, 40% of caregivers), (2) satisfied (low burden and high benefits, 33%), (3) intensive (high burden and high benefits, 17%), and (4) dissatisfied (moderate burden and low benefits, 10%). Caregivers with dissatisfied and intensive caregiving experience tend to report higher depressive symptoms and lower quality of life compared to those with satisfied caregiving experience. Discussion: A person-centered approach helps capture the heterogeneity in caregiving experience. Policymakers should develop tailored interventions by caregiving experience types for promoting caregiver well-being.

Early Implementation of a Patient-Centered Medical Home in Singapore: A Qualitative Study Using Theory on Diffusion of Innovations

Patient-Centered Medical Home (PCMH) has been found to improve care for complex needs patients in some countries but has not yet been widely adopted in Singapore. This study explored the ground-up implementation of a PCMH in Singapore by describing change strategies and unpacking initial experience and perception. In-depth interviews were conducted for twenty-two key informants from three groups: the implementers, their implementation partners, and other providers. “Diffusion of innovations” emerged as an overarching theory to contextualize PCMH in its early implementation. Three core “innovations” differentiated the PCMH from usual primary care: (i) team-based and integrated care; (ii) empanelment; and (iii) shared care with other general practitioners. Change strategies employed to implement these innovations included repurposing pre-existing resources, building a partnership to create supporting infrastructure and pathways in the delivery system, and doing targeted outreach to introduce the PCMH. Initial experience and perception were characterized by processes to “adopt” and “assimilate” the innovations, which were identified as challenging due to less predictable, self-organizing behaviors by multiple players. To work with the inherent complexity and novelty of the innovations, time, leadership, standardized methods, direct communication, and awareness-building efforts are needed. This study was retrospectively registered (Protocol ID: NCT04594967).

Development and Assessment of an Interpretable Machine Learning Triage Tool for Estimating Mortality After Emergency Admissions

IMPORTANCE

Triage in the emergency department (ED) is a complex clinical judgment based on the tacit understanding of the patient's likelihood of survival, availability of medical resources, and local practices. Although a scoring tool could be valuable in risk stratification, currently available scores have demonstrated limitations.

OBJECTIVES

To develop an interpretable machine learning tool based on a parsimonious list of variables available at ED triage; provide a simple, early, and accurate estimate of patients' risk of death; and evaluate the tool's predictive accuracy compared with several established clinical scores.

DESIGN, SETTING, AND PARTICIPANTS

This single-site, retrospective cohort study assessed all ED patients between January 1, 2009, and December 31, 2016, who were subsequently admitted to a tertiary hospital in Singapore. The Score for Emergency Risk Prediction (SERP) tool was derived using a machine learning framework. To estimate mortality outcomes after emergency admissions, SERP was compared with several triage systems, including Patient Acuity Category Scale, Modified Early Warning Score, National Early Warning Score, Cardiac Arrest Risk Triage, Rapid Acute Physiology Score, and Rapid Emergency Medicine Score. The initial analyses were completed in October 2020, and additional analyses were conducted in May 2021.

MAIN OUTCOMES AND MEASURES

Three SERP scores, namely SERP-2d, SERP-7d, and SERP-30d, were developed using the primary outcomes of interest of 2-, 7-, and 30-day mortality, respectively. Secondary outcomes included 3-day mortality and inpatient mortality. The SERP's predictive power was measured using the area under the curve in the receiver operating characteristic analysis.

RESULTS

The study included 224 666 ED episodes in the model training cohort (mean [SD] patient age, 63.60 [16.90] years; 113 426 [50.5%] female), 56 167 episodes in the validation cohort (mean [SD] patient age, 63.58 [16.87] years; 28 427 [50.6%] female), and 42 676 episodes in the testing cohort (mean [SD] patient age, 64.85 [16.80] years; 21 556 [50.5%] female). The mortality rates in the training cohort were 0.8% at 2 days, 2.2% at 7 days, and 5.9% at 30 days. In the testing cohort, the areas under the curve of SERP-30d were 0.821 (95% CI, 0.796-0.847) for 2-day mortality, 0.826 (95% CI, 0.811-0.841) for 7-day mortality, and 0.823 (95% CI, 0.814-0.832) for 30-day mortality and outperformed several benchmark scores.

CONCLUSIONS AND RELEVANCE

In this retrospective cohort study, SERP had better prediction performance than existing triage scores while maintaining easy implementation and ease of ascertainment in the ED. It has the potential to be widely applied and validated in different circumstances and health care settings.

Blood pressure and adiposity in midlife Singaporean women

Hypertension is a major risk factor for cardiac events and stroke. Visceral adipose tissue (VAT) is known to increase the risk of incident hypertension in adults. Although adiposity has been linked to markers of inflammation, few studies have examined these markers as potential mediators of the association between visceral adiposity and elevated blood pressure. We evaluated sociodemographic, reproductive, and lifestyle risk factors for elevated blood pressure among midlife Singaporean women. A total of 1189 women, with a mean age of 56.3 ± 6.2 years, from the Integrated Women's Health Program (IWHP) at National University Hospital, Singapore were studied. Hypothesized risk factors and levels of inflammatory markers were examined in relation to systolic blood pressure (SBP) and diastolic blood pressure (DBP) using multivariable linear regression models. Prehypertension (SBP 120-139 mmHg and/or DBP 80-89 mmHg) and hypertension (SBP ≥140 mmHg and/or DBP ≥90 mmHg) were observed in 518 (43.6%) and 313 (26.3%) women, respectively. Compared to women in the lowest tertiles, women in the middle and upper tertiles of VAT had 7.1 (95% CI, 4.4, 9.8) mmHg and 10.2 (95% CI, 6.7, 13.7) mmHg higher adjusted SBP, respectively. Nulliparous older women with a lower education level and those with no or mild hot flashes also had a significantly higher adjusted SBP. No significant independent risk factors were observed for DBP. Adjustments for IL-6, TNF-α, and hs-CRP did not attenuate the association between VAT and SBP. In summary, we found an independent positive association between VAT and SBP. Elevated levels of inflammatory markers did not mediate the increase in SBP in women with high VAT.

Patterns of family support exchange and personal mastery in later life: a longitudinal study

Objectives: The association between family support exchange and personal mastery among older adults remains unclear. The present study addresses this gap.Methods: We utilized two waves of data from the Panel on Health and Ageing of Singaporean Elderly (N = 1398). Latent class analysis was conducted to identify distinct patterns of family support exchange. Regression analysis was then used to assess whether the identified patterns predicted personal mastery four years later.Results: Four and three prevalent patterns of family support exchange emerged for males and females, respectively. Males who received monetary and material support from their kin developed lower personal mastery than those who only received monetary support. Females who provided and received monetary support developed higher personal mastery than those who lacked support exchange.Conclusion: Our latent class approach has captured the reality of family support exchange and thus provided a valid picture of the implication of such exchange for personal mastery. Our data suggest that support provision may elevate personal mastery. This observation is discussed with reference to the self-enhancement perspective and notion of valence of support provision.

Productive engagement patterns and their association with depressive symptomatology, loneliness, and cognitive function among older adults

OBJECTIVES

Little is known about composite patterns of productive engagement among older people. Related, the implication of these patterns for well-being remains unclear. The present study addresses these gaps.

METHODS

The analytical sample comprised 2037 community-dwelling Singaporeans aged 60 years and above. We included nine productive activities and employed latent class analysis to identify prevalent patterns of productive engagement. Regression analysis was then conducted to investigate the association of these patterns with depressive symptomatology, loneliness, and cognitive function.

RESULTS

Four productive engagement patterns (Low Activity, Family Support, Moderate Working-Volunteering, and Working-Family Support) were identified. Compared with Low Activity, Moderate Working-Volunteering, and Working-Family Support related to lower levels of depressive symptomatology and loneliness, respectively, and both patterns were associated with better cognitive function.

CONCLUSION

Productive engagement patterns are differentially linked with depressive symptomatology, loneliness, and cognitive function. We interpret these findings with reference to the role perspective. We also discuss their policy implications.

The association of human, social, and cultural capital with prevalent volunteering profiles in late midlife

Volunteering can be critical to late middle-aged adults' well-being. Hence, it is essential to understand the antecedents of volunteering in this age group. The present study of Singaporeans aged 50 to 59 (N = 1620) considered 18 volunteering acts and used latent class analysis (LCA) to identify volunteering profiles. The relationships between human, social, and cultural capital and the derived profiles were then examined with reference to resource theory. We observed three prevalent volunteering profiles: low (having a low tendency to engage in any volunteering acts), informal instrumental (primarily offering instrumental help in informal settings), and diverse (exhibiting instrumental and relational acts in formal and informal settings). Using low volunteering as the reference group, we found that informal instrumental volunteering was only predicted by the strength of social networks (social capital). In contrast, diverse volunteering was predicted by several factors including education level, work status, depressive symptoms (human capital), household size, the strength of social networks, attendance at community events (social capital), and religious affiliation (cultural capital). The LCA-derived volunteering profiles reveal population heterogeneity in terms of volunteering acts. The observed relationships between capital and volunteering profiles have implications for policies promoting volunteering in Singapore.

A Fully-Immersive and Automated Virtual Reality System to Assess the Six Domains of Cognition: Protocol for a Feasibility Study

Introduction: Dementia is increasing in prevalence in aging populations. Current questionnaire-based cognitive assessments may not comprehensively assess cognitive function and real-time task-performance. Virtual reality (VR) technology has been used in cognitive assessments but existing systems have limited scope in evaluating all cognitive domains. We have developed a novel, fully-immersive VR system (CAVIRE: Cognitive Assessment by VIrtual REality), which incorporates automated audio-visual instructions. An automated scoring matrix to assess the six cognitive domains—perceptual-motor function, executive function, complex attention, social cognition, learning and memory, and language—is embedded in the CAVIRE system.

Aims: The primary aim is to evaluate the feasibility of using the CAVIRE system to assess cognitive function of participants across different age groups from 35 to 84 years old. The secondary aims are to determine the CAVIRE performance-indices (completion time and scores) of the participants and to assess their acceptability toward the use of CAVIRE as a modality for cognitive assessment.

Methods: One hundred and seventy-five participants will be assessed by CAVIRE at a primary care clinic in Singapore. They will be first assessed using questionnaires: Montreal Cognitive Assessment (MoCA), Abbreviated Mental Test (AMT), Mini-Mental State Examination (MMSE), Basic Activities of Daily Living (BADLs), Instrumental Activities of Daily Living (IADLs). Those aged 65–84 years will be grouped into cognitively intact (n = 50, MoCA score ≥ 26) and cognitively impaired (n = 50, MoCA < 26). The CAVIRE performance-indices of cognitively healthy younger participants aged 35–64 years (n = 75) will serve as benchmark references. CAVIRE auto-computes the participant's performance-indices in 13 different segments. The tasks include domestic chores, memory, shopping, and social interactions. The proportion of participants who complete the entire VR assessment in each age group will be evaluated as feasibility indicators. The CAVIRE performance-indices will be compared across the different age groups. Feedback on the acceptability of the CAVIRE system will be collated and compared among the participants across the age groups.

Significance: CAVIRE is designed to assess the six domains of cognitive function using VR. The results of this feasibility study will provide insights for the implementation of the CAVIRE system as an alternative modality of cognitive assessment in the community.

Factors associated with caregiving self-efficacy among primary informal caregivers of persons with dementia in Singapore

Background

Informal caregivers of persons with dementia (PWD) are often associated with negative health outcomes. Self-efficacy in dementia caregiving has been reported to have protective effects on caregiver’s health. This study aims to examine the factors associated with the domains of caregiving self-efficacy among informal caregivers in Singapore, a country with a rapidly aging population and a 10% prevalence of dementia among older adults.

Methods

Two hundred eighty-two informal caregivers were recruited and data including participant’s caregiving self-efficacy, sociodemographic information, perceived social support, positive aspects of caregiving, knowledge of dementia, as well as behavioral and memory problems of care recipients were collected. A confirmatory factor analysis (CFA) was performed for the 3-factor model of the Revised Scale for Caregiving Self-Efficacy (RSCSE), and multiple linear regressions were conducted using the RSCSE subscales as dependent variables.

Results

Our CFA found that the RSCSE 3-factor model proposed by the original scale developer was an acceptable fit among informal caregivers in Singapore. Having established that the 3-factor model of the RSCSE was compatible among our sample, a series of multiple regressions were conducted using each of the factors as a dependent variable. Regressions revealed several factors that were significantly associated with caregiving self-efficacy. Importantly, outlook on life was positively associated to all 3 domains of the RSCSE, while social support was positively associated with self-efficacy in obtaining respite and controlling upsetting thoughts.

Conclusion

The 3-factor model of the RSCSE was found to be an appropriate fit for our sample. Findings from this study elucidated important novel insights into the factors that influences caregiving self-efficacy amongst informal caregivers in Singapore. Crucially, caregivers’ outlook on life and social support should be improved in order to enhance their caregiving self-efficacy.

Cost-effectiveness of FRAX®-based intervention thresholds for management of osteoporosis in Singaporean women

Cost-effectiveness analysis of FRAX® intervention thresholds (ITs) in Singaporean women > 50 years of age showed that generic alendronate was cost-effective at age-dependent major osteoporotic fracture (MOF) IT from the ages of 65 years for both full and real-world adherence whilst hip fracture (HF) ITs were cost-effective from the ages of 60 and 65 years. Alendronate was cost-effective irrespective of age only at fixed MOF IT of 14% and HF IT of 3.5%.

INTRODUCTION

FRAX®-based intervention thresholds (ITs) were recently identified for osteoporosis management in Singapore. This study aimed to assess the cost-effectiveness of ITs in Singaporean women over the age of 50 years.

METHODS

A validated Markov microsimulation model was used to estimate the lifetime healthcare costs (SGD2019) per quality-adjusted life-years (QALY) of generic alendronate compared with no treatment. Cost-effectiveness of age-dependent FRAX® major osteoporotic fracture (MOF) and hip fracture (HF) ITs was explored. In addition, ITs that would lead to cost-effectiveness were computed. Fracture incidence and cost data were obtained from the Ministry of Health and a previously published Singaporean study. A cost-effectiveness threshold of SGD 62,500/QALY gained was used, based conservatively on 0.7 times the Singapore GDP per capita.

RESULTS

Generic alendronate was shown to be cost-effective at MOF ITs from the ages of 65 years, while HF ITs were cost-effective from the ages of 60 and 65 years, assuming full and real-world adherence, respectively. A 14% MOF and a 3.5% HF ITs were required for alendronate to be cost-effective above 50 years.

CONCLUSION

This study suggests that the treatment of Singaporean women with alendronate is cost-effective at age-dependant FRAX® intervention thresholds at 65 years and older. Furthermore, identifying women at any age above 50 years with a 10-year risk of MOF or HF of 14% or 3.5% would lead to efficient use of resources. Cost-effective access to therapy for patients at high fracture probability based on FRAX® could contribute to reduce the growing burden of osteoporotic fractures in Singapore.

Exploring the dimensions of patient experience for community-based care programmes in a multi-ethnic Asian context

Introduction

The aim of this study is to explore patients’ experiences with community-based care programmes (CCPs) and develop dimensions of patient experience salient to community-based care in Singapore. Most countries like Singapore are transforming its healthcare system from a hospital-centric model to a person-centered community-based care model to better manage the increasing chronic disease burden resulting from an ageing population. It is thus critical to understand the impact of hospital to community transitions from the patients’ perspective. The exploration of patient experience will guide the development of an instrument for the evaluation of CCPs for quality improvement purposes.

Methods

A qualitative exploratory study was conducted where face-to-face in-depth interviews were conducted using a purposive sampling method with patients enrolled in CCPs. In total, 64 participants aged between 41 to 94 years were recruited. A deductive framework was developed using the Picker Patient Experience instrument to guide our analysis. Inductive coding was also conducted which resulted in emergence of new themes.

Results

Our findings highlighted eight key themes of patient experience: i) ensuring care continuity, ii) involvement of family, iii) access to emotional support, vi) ensuring physical comfort, v) coordination of services between providers, vi) providing patient education, vii) importance of respect for patients, and viii) healthcare financing.

Conclusion

Our results demonstrated that patient experience is multi-faceted, and dimensions of patient experience vary according to healthcare settings. As most patient experience frameworks were developed based on a single care setting in western populations, our findings can inform the development of a culturally relevant instrument to measure patient experience of community-based care for a multi-ethnic Asian context.

Risk of Psychological Distress Among Community-Dwelling Older Adults Experiencing Spousal Loss in Ghana

BACKGROUND

Spousal loss, common in older age, has been linked to negative mental health outcomes and well-being, yet the mechanisms linking spousal loss and mental health are still unclear.

OBJECTIVE

To investigate whether physical activity, social support, and gender modify the psychological distress effects of marital loss among community-dwelling older persons in Ghana.

METHODS

Data from a 2016/2017 Ageing, Health, Psychological Well-being, and Health-seeking Behavior Study (N = 1,200) were examined. OLS regression models examined associations between spousal loss and psychological distress outcomes and interaction terms.

RESULTS

Spousal loss (widowhood and divorce/separation) was associated with psychological distress (measured by the Kessler Psychological Distress Scale [KPDS-10]) for the full sample (β = .798, p < .001), women (β = .831, p < .001) and for men (β = .533, p < .05). After adjusting for potential confounders, the associations between spousal loss and psychological distress persisted for the full sample (β = .727, p < .001) and females only (β = .730, p < .001). In particular, when experiencing spousal loss, those with meaningful social support (β = -.856, p < .005) and engaged in physical activity (β = -.258, p < .001) were less likely to be psychologically distressed.

CONCLUSIONS

Spousal loss precipitates an independent risk of psychological distress in older age particularly among women, but social support and physical activity engagements moderate the relationship. These findings support the premise that providing opportunities to improve social support and regular physical activity may buffer the effects of psychological distress among older persons experiencing spousal loss. Providing support for older adults in times of divorce and widowhood, and working towards changes in social attitudes towards divorce are important considerations.

Understanding Aging Policies in China: A Bibliometric Analysis of Policy Documents, 1978-2019

Aging poses a big challenge in all aspects of social governance in China. A coherent and focused aging policy response that spans multiple sectors of government has been undertaken to achieve the goal of "Healthy Aging". From an historical perspective, this paper uses a bibliometric analysis method to probe into the evolution of Chinese aging policies from 1978 to 2019, and the roles of core government agencies in policy-making. We obtained 226 Chinese aging policies from the PKULaw Database and the websites of the government departments. Co-word analyses and network analyses were applied in mapping the topics of aging policies and collaboration among the agencies. Gephi software was used to visualize the most frequently used keywords and their network graphs. Findings are as follows. Firstly, the development of the aging policy system in China has undergone two phases, from focusing on basic security to emphasizing the rights and health of the elderly. Secondly, the network structure of aging policy-making departments presents a distinct edge-core layer. More and more government agencies have become involved in the formulation of aging policies. But collaboration among the agencies is insufficient. Thirdly, pilot promotion is the main tool for implementing aging policies.

Novel model for predicting inpatient mortality after emergency admission to hospital in Singapore: retrospective observational study

OBJECTIVES

To identify risk factors for inpatient mortality after patients' emergency admission and to create a novel model predicting inpatient mortality risk.

DESIGN

This was a retrospective observational study using data extracted from electronic health records (EHRs). The data were randomly split into a derivation set and a validation set. The stepwise model selection was employed. We compared our model with one of the current clinical scores, Cardiac Arrest Risk Triage (CART) score.

SETTING

A single tertiary hospital in Singapore.

PARTICIPANTS

All adult hospitalised patients, admitted via emergency department (ED) from 1 January 2008 to 31 October 2017 (n=433 187 by admission episodes).

MAIN OUTCOME MEASURE

The primary outcome of interest was inpatient mortality following this admission episode. The area under the curve (AUC) of the receiver operating characteristic curve of the predictive model with sensitivity and specificity for optimised cut-offs.

RESULTS

15 758 (3.64%) of the episodes were observed inpatient mortality. 19 variables were observed as significant predictors and were included in our final regression model. Our predictive model outperformed the CART score in terms of predictive power. The AUC of CART score and our final model was 0.705 (95% CI 0.697 to 0.714) and 0.817 (95% CI 0.810 to 0.824), respectively.

CONCLUSION

We developed and validated a model for inpatient mortality using EHR data collected in the ED. The performance of our model was more accurate than the CART score. Implementation of our model in the hospital can potentially predict imminent adverse events and institute appropriate clinical management.