Dementia care and prevention in community settings: a built environment framework for cognitive health promotion

PURPOSE OF REVIEW

Most people with dementia live in the community. As lifespan increases, one in three persons aged 85+ are expected to live with dementia. We conduct a systematic search to identify frameworks for dementia care and prevention in community settings. This is important to ensure quality of life for people living with cognitive decline (PLCD).

RECENT FINDINGS

61 frameworks are synthesized into the dementia care and prevention in community (DCPC) framework. It highlights three levels of provision: built environment and policy supports, access and innovation, and inclusion across stages of decline. Domains of intervention include: basic needs; built environment health and accessibility; service access and use; community health infrastructure; community engagement; mental health and wellbeing; technology; end-of-life care; cultural considerations; policy, education, and resources. Personhood is not adequately represented in current built environment frameworks. This is supplemented with 14 articles on lived experiences at home and social practices that contribute to PLCD's social identity and psychological safety.

SUMMARY

Policy makers, health and built environment professionals must work together to promote "personhood in community" with PLCD. Clinicians and community staff may focus on inclusion, social identity and a sense of at-homeness as attainable outcomes despite diagnosis.

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.

Environmental Influences on Life Satisfaction and Depressive Symptoms Among Older Adults With Multimorbidity: Path Analysis Through Loneliness in the Canadian Longitudinal Study on Aging

BACKGROUND AND OBJECTIVES

More older adults with multimorbidity are aging in place than ever before. Knowing how the environment affects their mental well-being could enhance the efficacy of age-friendly interventions for multimorbidity resilience. With reference to the Transdisciplinary Neighborhood Health Framework, we construct and examine a priori models of environmental influences on life satisfaction and depressive symptoms.

RESEARCH DESIGN AND METHODS

Baseline and follow-up data (after 3 years) were drawn from the Canadian Longitudinal Study on Aging to identify a subsample (n = 14,301) of participants aged at least 65 years with at least 2 chronic diseases. Path analysis examined sociobehavioral attributes (i.e., social support, social participation, walking) and loneliness as primary and secondary mediators, controlling for age, sex, education, and outcomes during baseline.

RESULTS

Good model fit was found (TFI = 1.00; CFI = 1.00; RMSEA < 0.001; SRMR < 0.001). The total effects of housing quality (rtotal = 0.08, -0.07) and neighborhood cohesion (rtotal = 0.03, -0.06) were weak but statistically significant in the expected direction. The mediators explained 21%-31% of the total effects of housing quality and 67%-100% of the total effects of neighborhood cohesion. Loneliness mediated 27%-29% of these environmental influences on mental well-being, whereas walking mediated a mere 0.4%-0.9% of the total effects. Walking did not explain the relationship between housing quality and mental well-being.

DISCUSSION AND IMPLICATIONS

Data supported a priori pathways from environment to mental well-being through sociobehavioral attributes and loneliness. If these pathways from neighborhood cohesion to life satisfaction reflect causal effects, community-based age-friendly interventions should focus on enhancing neighborhood cohesion to mitigate loneliness among multimorbid older adults for their mental well-being.

At-Homeness Influences the Cognition of Multimorbid Older Adults: Longitudinal Path Analysis Through Loneliness

Approximately two-thirds of older adults’ experience multimorbidity in North America. Challenges of symptoms management and reduced mobility often coincide with late-life depression which is associated with a 2 to 5-fold increased dementia risk. Loneliness and depression are connected in the prodromal phases. We examine the effects of physical environment (e.g., housing and neighborhood factors) and social environment (e.g., social support) on loneliness, depression, and cognition using path analysis, controlling for baseline. Data(n=15,087) was drawn from the Canadian Longitudinal Study on Aging. Measures of housing, neighborhood and life satisfaction were used to construct an index of “at-homeness” based on theory. We found good model fit (TLI=.989; CFI=.999; RMSEA=.026; SRMR=.006). At-homeness(B=-.20, p&lt;.001) rivaled the effect of social environment(B=-.19, p&lt;.001) on loneliness. Together, physical environment and loneliness had as much effect on cognition as depression. If causality is supported, modifying older adults’ satisfaction with their home environment may reduce loneliness and cognitive decline.

Social Contact Prior to COVID-19 and Longitudinal Mental Health Trajectories During COVID-19 Among Adults Ages ≥55

Social support protects mental health during a crisis. We examined whether prior contact with social organizations and friends/neighbors was associated with better trajectories of loneliness, depression and self-rated memory during the COVID-19 pandemic. We conducted latent class analysis and regression analysis on longitudinal data from the COVID-19 Coping Study of US adults aged ≥55 from April-October 2020 (n=3105). Overall, prior contact with friends(B=-.075,p<.001), neighbors(B=-.048,p=.007), and social organizations(B=-.073,p<.001) predicted better mental health amid COVID-19. Three classes were identified: Class1 had the best outcomes, whereas Class3 had the worst outcomes and were most likely to live alone(B=.149,p<.001). For Class1, prior contact with social organizations(B=-.052,p=.044) predicted decreasing loneliness. For Class2, prior contact with friends(B=-.075,p<.001) predicted decreasing loneliness and better memory(B=-.130,p=.011). Conversely, prior contact with neighbors(B=-.165,p=.010) predicted worsening loneliness among Class3. Our findings pose new questions on the role of neighborhood networks to mitigate poor mental health outcomes among older adults during a crisis.

Neighborhood Cohesion and the Mental Health of Multimorbid Older Adults: CLSA Path Analysis Through Loneliness

More older adults with multimorbidity are aging in place than ever before. Their mental health may be affected by housing and neighborhood factors. In this paper, we use structural equation modelling (SEM) to examine how the physical environment influences life satisfaction and depressive symptoms in two separate models. We included social environment (i.e., social support, social participation, walking) and loneliness as intermediate variables. Data were drawn from baseline and the first follow-up (after 3-4 years) of the Canadian Longitudinal Study on Aging (CLSA). Participants were N=14,301 adults aged □65 with □2 chronic illnesses. Good model fit were found after controlling for age, sex, education and baseline values (TFI=1.00; CFI=1.00; RMSEA<0.001; SRMR<0.001). The total effects of housing quality (Btotal=0.08,-0.07) and neighborhood cohesion (Btotal=0.03,-0.06) were weak but statistically significant in the expected direction. Together, the intermediate variables explained 21-31% of the total effects of housing quality and 67-100% of the total effects of neighborhood cohesion. Loneliness explains 27-29% of the total effects of physical environment on mental health, whereas walking explained a mere 0.4-0.9% of their total effects. Walking did not mediate between housing quality and mental health outcomes. Overall, the results support our path analysis framework: physical environment -> social environment -> loneliness -> mental health. Our model provided excellent explanations of the effects of neighborhood cohesion, especially on life satisfaction. If these associations reflect causal effects, community-based age-friendly interventions should focus on neighborhood cohesion and loneliness to promote the well-being of older adults who are aging in place with multimorbidity.

At-Homeness: Rethinking Personhood-in-Community Through the Lens of Social Identity

Since Chaudhury’s seminal work (2008), spatial ethnographies of the everyday lives of people living with dementia(PLWD) have proliferated. From an experiential perspective, geographies of home (Blunt & Varley, 2004) and geographies of dementia may overlap significantly. We conducted a meta-ethnographic synthesis of n=28 articles to identify points of convergence and divergence in these literatures using comparative thematic analysis with NVivo 12. Whereas geographies of home highlight at-homeness (e.g., ontological safety and daily activities), geographies of dementia underscore communal and civic participation (e.g., social relationships). These themes converge around “social identity” which may be an important construct that helps PLWD feel at home. The quality of life of PLWD in the community may be influenced by prior (and present) experiences of at-homeness. These become more pertinent as older adults shelter in place. We discuss the implications of these findings in relation to relational models of personhood-in-community (Swinton, 2020) and community gerontology.

Age and sex trends in depressive symptoms across middle and older adulthood: Comparison of the Canadian Longitudinal Study on Aging to American and European cohorts

BACKGROUND

The literature suggests depressive symptoms differ in a non-linear fashion across adulthood and are more commonly reported in women as compared to men. Whether these trends are observed across countries in population-based cohorts is unclear.

METHODS

Cross-sectional observational study of approximately 138,000 women and men between the ages of 45 and 95 from three population-based cohorts representing Canadian, European, and American populations. Age, gender, educational attainment and annual income were assessed in each cohort. Depressive symptoms were assessed by the Center for Epidemiological Studies Depression Scale in the US and Canadian cohorts, and by the EURO-D in the European cohort.

RESULTS

Across all three cohorts, non-linear age trends and gender differences were observed in the report of depressive symptoms, independent from educational attainment and annual income effects. The non-linear age trends reflected a negative association between depressive symptoms and age during midlife and then a positive association in late life. Females reported greater depressive symptoms than males; however, an interaction between gender and age was also observed in the Canadian and European cohorts. Among Canadians, the gender differences were largest after age 70, whereas among Europeans, gender differences where largest among those approximately aged 60.

LIMITATIONS

Limitations include: 1) the cross-sectional nature of the study, resulting in age differences potentially reflecting cohort effects rather than a developmental process; and 2) the use of different depressive symptoms measures across cohorts.

CONCLUSIONS

Characterization of depressive symptoms over mid and late adulthood in women and men provides insights into potential focal points for intervention and allocation of resources.

Prior Social Contact and Mental Health Trajectories during COVID-19: Neighborhood Friendship Protects Vulnerable Older Adults

Social networking protects mental health during a crisis. Prior contact with social organizations, friends, and non-friend neighbors may be associated with better trajectories of loneliness, depression and subjective memory during COVID-19. Regression analysis was conducted using longitudinal data from a representative sample of n = 3105 US adults aged ≥55 in April-October 2020. Latent profile analysis was also conducted. Prior contact with friends (B = -0.075, p < 0.001), neighbors (B = -0.048, p = 0.007), and social organizations (B = -0.073, p < 0.001) predicted for better mental health during COVID-19. Three profiles were identified: Profile 1 had the best outcomes, with prior contact with social organizations (B = -0.052, p = 0.044) predicting decreasing loneliness. For Profile 2, prior 'meeting' contact with friends predicted decreasing loneliness (B = -0.075, p < 0.001) and better subjective memory (B = -0.130, p = 0.011). Conversely, prior contact with neighbors (B = -0.165, p = 0.010) predicted worsening loneliness among Profile 3. The COVID-19 pandemic has had a differential impact on the mental health trajectories of aging adults with social ties of different strengths. Stronger neighborhood networks are important to mitigate poor mental health outcomes among vulnerable older adults during a crisis. Older adults who are living alone and had relied on non-friend neighbors for social connectedness require additional community supports. Policy interventions are required to mitigate the mental health impact of future pandemics.

Social connectedness as a mediator for horticultural therapy's biological effect on community-dwelling older adults: Secondary analyses of a randomized controlled trial

BACKGROUND

Elevated levels of inflammatory marker and a lack of social connectedness are two prominent risk factors for developing dementia and depression. Horticultural therapy (HT) has been shown to improve social connectedness and inflammatory markers. However, the underpinning mechanisms of HT remained unknown. Within this study, we hypothesized that improved social connectedness mediates the effects of HT on IL-6 levels.

METHODS

The present study is a secondary analysis of a randomized controlled trial investigating the bio-psycho-social effects of HT. Social connectedness was operationalized as positive relationships with others (PRWO), a sub-scale of the Ryff's scale of psychological well-being. IL-6 was quantified using a commercial ELISA kit. Outcomes were assessed at baseline, 3-month and 6-month post-intervention. Mediation analyses with bootstrapping were run to investigate our primary hypothesis. All analyses were controlled for covariates.

RESULTS

We recruited 59 participants (78% women; 67.10 ± 4.31 years). 29 participants partook in HT and 30 participants were included in the waitlist control group. At baseline, social connectedness was significantly correlated with IL-6 levels (β = -0.12, 95% CI = -0.21 to -0.03, p = 0.008). Furthermore, social connectedness at 3-month significantly mediated the effects of HT on IL-6 levels at 6-month (β = 0.32, 95% CI = 0.09 to 0.54, p = 0.005; β = -0.25, 95% CI = -0.45 to -0.05, p = 0.016).

CONCLUSIONS

These findings highlight the critical roles of social connectedness as a social determinant of health in eliciting HT's biological effects. When administering HT, interventionalists should consider social connectedness as a modifiable factor for ameliorating increased inflammation in older adults.

Walk/wheelability: An inclusive instrument-pair for participatory aging-friendly research and practice

BACKGROUND AND OBJECTIVES

Recent critical evaluations of age-friendly efforts have highlighted the need to prioritize the disenfranchised, including people with mobility limitations. This article examines the validity of a 13-item scale (SWAN13) to measure the "walk/wheelability" of street segments from the perspectives of people with mobility limitations.

RESEARCH DESIGN AND METHODS

Data were drawn from preliminary studies of the Stakeholders' Walkability/Wheelability Audit in Neighborhoods (SWANaudit) which was conducted in two Canadian metropolitan areas. Sixty-one participants who use mobility devices (e.g., walkers, power wheelchairs) and older adults from community organizations audited 195 street segments. We factor analyzed the data from their audits.

RESULTS

SWAN13 has a one-factor structure. Thirteen items were retained from 85 SWANaudit items. SWAN13 encompassed both physical and social aspects of walk/wheelability. The alpha for the scale was .79. Convergent validity was found with the University of Alabama (UAB) Life-Space Assessment (rho=.22, p=.003), especially at the neighborhood level (rho=.23, p=.002). Significant correlation was also found with subjective assessments of a priori walk/wheelability domains (rho=.63, p<.001).

DISCUSSION AND IMPLICATIONS

Walk/wheelability affects the life space of older adults and people with mobility limitations. It is an important latent variable that should be addressed to promote well-being and social participation. SWAN13 may be used in city-wide surveys to identify neighborhoods that may require age-friendly interventions from mobility perspectives. Detailed audits and interventions may be carried out in tandem using the paired SWANaudit instrument. Walk/wheelability is an inclusive and measurable concept that accounts for the needs of people with various mobility needs.

The Effect of Neighborhood Experiences on Positive Mental Health Among Community-Dwelling Older Adults

Given reduced life spaces, the neighborhood often functions as a social venue for older adults. Yet how these everyday social spaces affect older adults’ psychosocial wellbeing remains largely unknown. Drawing on the GRP-CARE Survey data, this paper examined the relation between neighborhood experiences and positive mental health. Participants were 601 community-dwelling Singaporeans aged 50+ who lived in public housing neighborhoods. Neighborhood experiences were measured using the four-factorial, 16-item OpenX scale (Gan, Fung, Cho, 2019); positive mental health was measured using a six-factorial, 19-item scale (Vaingankar et al., 2011). Both scales have good psychometric properties and had been validated. Path analysis between relevant factors of both scales was conducted using Stata, within a theorized model of causation from neighborhood environment to social factors to psychosocial health. Age, education, ethnicity and sex were controlled for. Multiple linear regression analysis showed a strong, positive association between neighborhood experiences and mental health (p=0.000) even after controlling for personal traits (operationalized as depressive symptoms, GDS) in addition to sociodemographic variables. Path analysis showed that two distinct neighborhood health processes mediated this association. These were (1) the potential for a sense of community in the neighborhood improved emotional support, and (2) having better neighborly friendships improved interpersonal skills. These neighborhood health processes provide us with new lenses to understand older adults’ everyday experiences of their neighborhoods. Community-based interventions to improve older adults’ psychosocial wellbeing may be developed to facilitate these processes. Spatial and programmatic implications will be discussed in relation to age-friendly cities and communities (AFCC).