Expert Answer:Grief Depression Oldest-Old in Urban Congregate Ho


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ISW56410.1177/0020872811429954Moon et al.International Social Work
i s w
Risk factors for
depression among the
oldest-old in urban
congregate housing:
of grief
International Social Work
56(4) 516­–533
© The Author(s) 2011
Reprints and permissions:
DOI: 10.1177/0020872811429954
Heehyul Moon
Case Western Reserve University, USA
Kathryn Betts Adams
Case Western Reserve University, USA
Amy Restorick Roberts
Case Western Reserve University, USA
The objective of this study was to research grief and depression in oldestold people living in urban congregate housing by examining the various
types of grief that they experience by using a stress process model for
depression among the oldest old. This study used a convenience sample
of the 128 participants aged 80 and older living in congregate housing.
We found that the two types of grief most significantly associated with
depressive symptoms were grieving about relocating, and loss of health.
Our findings demonstrate the need to explore a variety of grief which
influences mental health among oldest-old.
congregate housing, depressive symptoms, grief, loss, oldest-old
Corresponding author: Heehyul Moon, Mandel School of Applied Social Sciences, Case
Western Reserve University, 10900 Euclid Avenue, Cleveland, OH 44106-7164, USA.
Moon et al.
Although the definition of the oldest-old group varies from study to study,
the oldest-old group (age >75–85 years) is currently the fastest growing
population in many countries, including China, the United States, India,
Japan, Germany, and Russia and expected to increase 151 percent between
2005 and 2030 globally (National Institute on Aging, 2007). Such a population trend implies that there will be an increase in need for formal and informal support by this age group. Accordingly, the number of older adults
living in retirement communities, such as congregate housing ‘a shared living environment designed to enhance older adults’ independent functioning’
including independent living senior apartments or assisted living, will also
increase (Adams and Roberts, 2010: 474). Independent senior apartments
are private apartments that include one or more supportive services such as
meals, housekeeping, transportation, social activities, and laundry (Adams
and Roberts, 2010). Assisted living facilities provide support for older
adults with services that include not only meals, laundry, and housekeeping,
but also medication reminders, and assistance with Activities of Daily
Living (ADLs) and Instrumental Activities of Daily Living (IADLs) and
medical care (Adams and Roberts, 2010; Zimmerman et al., 2006). Older
adults living in congregate housing are more likely to have a smaller social
network, be older, female, live alone, be unmarried, and display higher rates
of depressive symptoms compared to community-dwelling older adults
(Adams and Roberts, 2010). The prevalence of depressive symptoms
increases throughout late adulthood and becomes the highest in the oldestold group (aged > 80) (Glass et al., 1997). Moreover, in old age, people may
experience grief more often compared to other groups in response to negative life events common in old age, such as bereavement, declining health,
and relocation. Previous research has found relationships between these
negative life events and depression (Meller et al., 1997). Great attention has
been paid to understanding stress, coping, and mental health among older
adults, but few studies have focused on those living in congregate housing,
despite the fact that this group is at higher risk of depression. The present
study examines the types of grief experienced by the oldest-old living in
congregate housing and explores the factors associated with depressive
symptoms in this vulnerable group.
Oldest-old and depression
Depression is one of the most common emotional problems among older
adults and is characterized by dysphoric mood, or loss of interest or pleasure
International Social Work 56(4)
in life and free time activities (Bulut, 2009). Depressive symptoms include
poor appetite, insomnia or hypersomnia, loss of energy, fatigue or tiredness,
feelings of excessive guilt, inability to concentrate or think, and suicidal
thoughts (Bulut, 2009; Ryan and Shea, 1996). Depression is not only a risk
factor for mortality (Glass et al., 1997; Kaplan and Reynolds, 1988) but also
for functional impairment (Hybels et al., 2001), decreased quality of life,
and subjective distress among older adults (Lavretsky and Kumar, 2002).
Between 11 percent and 40 percent of community-dwelling older adults
report depressive symptoms, with an average of around 20 percent (Bulut,
2009). Approximately 43 percent of institutionalized older adults have
been diagnosed with depression (Bulut, 2009; Reeker, 1997). Furthermore,
oldest-older adults living in congregate housing tend to be at higher risk of
developing depressive symptoms and major depression than communitydwelling older adults (Adams and Roberts, 2010). Despite the large number
of studies on depression in older adults, relatively little is known about
depression among the oldest-old group and even less about those living in
congregate housing.
Oldest-old and grief
Negative stressful life events including bereavement, onset of significant
health problem, and relocation are significant risk factors of depressive
symptoms among older adults (De Beurs et al., 2001; Glass et al., 1997).
However, the specific effects of negative life events on depression are
inconsistent among the oldest-old group. For example, Jeon and Dunkle’s
(2009) longitudinal study of 193 oldest-old people (aged >85) living independently found that trajectories of negative life events were not significantly associated with depression among the oldest-old group. However, in
a longitudinal study by Meller and colleagues (1997) with 402 people older
than 85 years living in a community, negative life events (i.e. death of partners, illness of others, and moving) were risk factors for depression. Since
there have been so few studies of the influences of life events in the oldestold group, these different findings have yet to be reconciled.
Other risk factors for depression and oldest-old
Although the findings on the relationship between age and the prevalence of
depression are inconsistent, several studies have revealed the highest prevalence of depression was found in the oldest-old group in some studies
Moon et al.
(Blazer et al., 1991; Jeon and Dunkle, 2009; Pàlsson et al., 2001; Valvanne
et al., 1996). For example, in the longitudinal study by Jeon and Dunkle
(2009), the oldest-old (aged >85) group was likely to report increased
depressive symptoms with age. However, other studies have found a decline
in the propensity for depression with increasing age (aged >65 years)
(Mojtabai and Olfson, 2004) or no significant relationship with increasing
age (aged >65 to >85 years) (Meller et al., 1997; Minicuci et al., 2002).
Education level is also associated with depression. In a review of 122 studies of the prevalence and predictors of depression in populations of older
adults, Djernes (2006) suggested that older adults (aged >65) with lower
education tended to report more depressive disorders and depressive symptoms (Gostynski et al., 2002; McCall et al., 2002). This has also been found
in the oldest-old group (Beekman et al., 1995).
Physical and cognitive function
Both physical and cognitive impairment are risk factors in older adults for
the onset or persistence of depressive symptoms and depressive disorders
(Djernes, 2006). This also holds true for the oldest-old group (aged >75–
90), for which several studies have found that physical (Forsell et al., 1998;
Meller et al., 1997; Païvarintä et al., 1999) and cognitive functional impairment (Forsell et al., 1998) predict depression.
Recent studies have supported the significance of loneliness in later life
(Adams et al., 2004a; Kwag et al., 2011; Pinquart and Sorensen, 2001). For
instance, Kwag and colleagues (2011) reported that perceived stress had
direct and indirect effects on loneliness among community-dwelling older
adults (aged >65). Adams and colleagues (2004a) demonstrated that loneliness is a potential risk factor for depressive symptoms among older adults
in congregate housing (aged 60–90). In particular, loneliness is more prevalent in the oldest-old group (aged >80) than the middle-aged group (Pinquart
and Sorenson, 2001), and is among risk factors for the onset of depressive
symptoms among the oldest-old (Meller et al., 1997; Roberts et al., 1997).
Conceptual model and research questions
Few studies have specifically focused on the relationships between
stressor and outcome in this age group (Jeon and Dunkle, 2009). Therefore,
in this study, one of the most widely used stress process models in
International Social Work 56(4)
sociology, psychology, gerontology, nursing and public health was applied
to conceptualize the process that occurs for oldest-old individuals in congregate housing (Thoits, 2006). The stress process model proposed by
Pearlin and colleagues (1981) includes four domains: stressors, resources,
outcomes and the contextual or background information. This process
model focuses on direct effects of various types of stressors, and resources
for coping on outcome. Also the model proposes the indirect effects (e.g.
mediating effect) in the stress process by illustrating how individuals may
reduce the potential negative outcomes (e.g. depression) to stressful situations by controlling stress in their lives through mechanisms such as
social support. This study included stressors such as physical and cognitive impairment and grief from various recent losses; resources such as
social support, here represented negatively through emotional and social
loneliness; with depressive symptoms as an outcome.
Given the gaps in our knowledge of the risk factors for depression in the
oldest-old group, particularly the role of grief from common stressful life
events, this study aims to address the following research questions:
Research question 1: What kinds of grief do the oldest-old living in urban
congregate housing experience?
Research question 2: What are the relationships among presence of grief/various
types of grief and depressive symptoms in the oldest-old living in urban congregate
Research question 3: What are the relationships among stressors (physical and
cognitive function, grief), resources (social and emotional loneliness), and
depressive symptoms in the oldest-old living in urban congregate housing?
This study used a convenience sample of the 128 participants who were
aged 80 and older living in one of six Continuing Care Retirement Facilities
in northeast Ohio, out of a total population of approximately 1500 residents.
Data were collected through a self-administered survey form and follow-up
phone interview with the participants’ permission. To recruit participants,
signs were posted in prominent locations, flyers were distributed in residents’ open mailboxes, and labeled boxes of blank survey packets were
placed near the residents’ mailbox area. Self-addressed stamped return
envelopes were included in the survey packets so that participants could
Moon et al.
return them by mail. During the follow-up interviews participants were
asked additional screening questions and two open-ended questions about
any concerns they had and how they cope with aging in a congregate living
setting. Trained research assistants with experience in gerontological social
work or psychology conducted the phone interviews. The participants who
completed both the survey and the follow-up telephone interview were provided with a $20 gift card.
Depression. Depressive symptoms were measured using the Geriatric Depression Scale (GDS; Brink et al., 1982) which has demonstrated adequate reliability and validity in over 300 studies (Adams and Roberts, 2010). This
scale consists of 30 items with yes/no responses. The original scale was constructed by adding 30 items on depressive symptoms (Yesavage et al., 1983).
Although there is no clear consensus on cut-off scores, the original developers of the scale recommend that 11 points and above indicates moderate to
severe depression with a sensitivity of 84 percent and a specificity of 95
percent (Yesavage et al., 1983). Others recommend a cut-off of 14 points
(Lyons et al., 1989), a 12-point cut-off (Lavretsky and Kumar, 2002), and a
nine-point cut-off for the oldest-old residents (aged >85) of retirement communities (Watson et al., 2004). Adams et al. (2004b) proposed a six factor
structure for the GDS including a nine-item Dysphoric Mood (i.e. downhearted and blue), six-item Withdrawal-Apathy-Vigor (WAV, i.e. prefer to
day home), four-item Worry (i.e. afraid something bad may happen), fouritem Cognitive Impairment (i.e. more problem with memory than most),
four-item Hopelessness (i.e. feel situation is hopeless), and three-item Agitation (i.e. restless and fidgety). Cronbach’s alpha of the GDS scale in the current study was 0.852 and of each subscale was 0.756 (Dysphoric Mood),
0.587 (WAV), 0.620 (Worry), 0.598 (Cognitive Impairment), 0.515 (Hopelessness), and 0.349 (Agitation). The Agitation subscale was excluded
because of the low level of reliability (Cronbach’s alpha), and in the current
study both a summed score and the five reliable subscales were used.
Physical and cognitive function. The levels of physical function in everyday
tasks were measured by the Katz Index of Activities of Daily Living (ADLs;
Katz et al., 1963) and the Older Americans Resources Scale for Instrumental Activities of Daily Living (IADLs; Duke University Center for the Study
of Aging and Human Development, 1978). The six-item ADL scale used a
three-anchor response (0 = unable, 1 = some help, 2 = able) with the total
range from 0 to 12. Higher scores indicate better functioning. Cronbach’s
International Social Work 56(4)
alpha was 0.930. The seven-item IADL scale was rated on a three-point
scale based on responses about capability to perform a task (0 = unable, 1 =
some help, 2 = without help). The total score ranges from 0 to 14 with a
higher score indicating greater functionality. Cronbach’s alpha was 0.808.
The level of cognitive function was assessed by using the Telephone Interview for the Cognitive Screening – Modified (TICS-M; Welsh et al., 1993),
a cognitive screening measure modeled after the Mini-Mental State Exam
(MMSE; Folstein et al., 1975). This scale was designed for use in a telephone interview to test functioning in several domains such as concentration, orientation, memory, naming, comprehension, and abstraction. It
consists of 21 items with a maximum score of 50 points, with lower scores
reflecting higher cognitive impairment. Cronbach’s alpha was 0.647.
Loneliness. Loneliness was measured by the De Jong-Gierveld Loneliness
Scale (De Jong-Gierveld and Van Tilberg, 1999), which consists of 11
dichotomous items. The authors identified two subscales of Social (five
items, i.e. someone to talk to about problems) and Emotional Loneliness
(six items, i.e. sense of emptiness). The scores for Social Loneliness range
from 0 to 5 and for Emotional Loneliness from 0 to 6, and higher scores on
both subscales indicate more loneliness. Cronbach’s alpha for Emotional
Loneliness was 0.797 and Social Loneliness was 0.823.
Grief. We also included a yes/no item written for this study: ‘I am grieving
over an important loss’. If they answered yes, participants were asked to
indicate the source of their grief from a list of specific types of losses including death of their spouse, death of a family member or friend, death or loss
of a pet, moving house, and loss of health. Respondents could check all
types of grief that applied to them.
Demographic variables. Demographic variables included age in years, and
education was measured with the following three categories: high school,
beyond high school and beyond college.
Statistical analysis plan
To address the research questions, descriptive analyses of demographic
and study variables were conducted. Bi-variate association was used to
examine correlations among possible predictors to test for multicollinearity.
Experiencing grief was included as a dichotomous variable as a predictor in
six hierarchical multiple regression analyses on depression symptoms after
controlling for demographic variables. And finally, various types of grief
Moon et al.
were included in six hierarchical multiple regression analyses on depressive
symptoms (one total score and five subscales of depression) after controlling for demographic variables.
Description of the sample population
As shown in Table 1, the average age of the participants was 86.56 years.
The majority of participants were female (79.7%) and White (90.6%). Over
two-thirds of the participants were widowed. The participants predominantly lived alone in an apartment, or in a unit within the congregate facility.
More than three-quarters of the participants had some college education or
more advanced education. Most participants (84%) in this study were
strongly and moderately satisfied with their income adequacy. Of the 113
respondents who reported religion, 40.6 percent were Protestant and 30.5
percent were Jewish.
One-fourth of the sample reported moderate to severe depression based on
Watson and colleagues’ nine-point cut-off for the oldest-old residents (aged
>85) of retirement communities. The mean depression score for the sample
was 6.52 (SD = 4.92), with a range from 0 to 23: the means of subscales of
depressive symptoms were − 0.57 (SD = .93) (Worry), .55 (SD = .85)
(Hopelessness), 1.11 (SD = 1.21) (Cognitive Impairment), 1.13 (SD = 1.72)
(Dysphoric Mood). In terms of IADL, the most needed instrumental help was
housework (63%). Respondents also needed some help with going to places
outside of walking distance (40%), grocery shopping (35.9%), meal preparation (32.8%), handling finances (15.6%), taking medications (6%), and telephone use (3.1%). The ADL measure revealed that most participants did not
need help with activities of daily living, with only 5.5 percent needing assistance in bathing, 2.3 percent in control of bladder or bowels, and 1.6 percent
each in dressing, using the bathroom, transferring from chair to bed or vice
versa, and eating. The TICS-M score ranged from 14 to 44, and 28 individuals
(21.9%) were identified as having mild cognitive impairment. On average the
participants reported low levels of emotional and social loneliness.
In order to examine what kinds of grief the oldest-old living in urban
congregate housing experience, a descriptive analysis was performed. In
this study, the majority of the sample was not currently grieving a recent
loss. In this study, 40 (31.1%) participants reported grieving a recent loss,
approximately three-quarters of which reported one type of grief, 3 percent
reported two types, 0.8 percent reported three types, and 4.7 percent reported
four types of grief. Of those who were grieving, 85 percent reported a loss
International Social Work 56(4)
Table 1. Descriptive statistics of socio-demographic and key variables.
% or M (SD)
Male = 20.3%
Female = 79.7%
African American = 7.8%
White = 90.6%
Single = 7.8%
Widowed = 16.4%
Living with a partner = .8%
Separated/divorced = 5.5%
Widowed = 69.5%
Can’t make ends meet = .8%
Just managed to get by = 14.1%
Have enough money with a little extra = 45.3%
Money is not a problem = 39.1%
Catholic = 10.2%
Protestant = 40.6%
Jewish = 30.5%
No religious preference = 1.6%
86.56 (4.12)
8th grade or less = 4.7%
Som …
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