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Unravelling the role of general self-efficacy in the rehabilitation of acutely hospitalized older adults

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I.W. NEEVEL

University : University of Amsterdam

Student number : 10167196

Supervisor (Intern) : dr. J.A. Bosch (UvA) Supervisor (Extern) : dr. B.M. Buurman (AMC) Co-assessor (Extern) : L.A. Reichardt, MSc (AMC)

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ABSTRACT

Being part of the Hospital-ADL study, the present study investigated the role of General Self-Efficacy (GSE) in the rehabilitation of acutely hospitalized older adults (Reichardt et al., 2016). GSE refers to “one’s estimate of one’s overall ability to perform successfully in a wide variety of challenging achievement situations” (Eden, 1996). A sample of 217 acutely hospitalized patients aged 70 years and above

completed questionnaires at hospital admission, discharge, one and two months post-discharge. The results indicated that GSE was stable between hospital discharge, one and two months post-discharge. Also, GSE predicted independence in Activities of Daily Living (ADL) both at one and two months post-discharge, when controlling for associated socio-demographic variables and premorbid ADL-functioning. Moreover, GSE moderated the positive relationship between depressive symptoms and functional dependence at discharge. The present study showed that GSE is a potentially valuable target for rehabilitation interventions in acutely hospitalized older adults.

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Acute hospitalization occurs frequently among older adults and it often has a prolonged and comprehensive impact on their well-being (Graf, 2006). More than 15% of adults 70 years and older experience at least one acute hospitalization in a time span of one year (Inouye et al., 2008). These patients often develop Hospitalization Associated Disability (HAD), which refers to the loss of independence in at least one activity needed for self-care and to live independently. These activities include bathing, dressing, rising from bed to chair, using the toilet, eating and walking across a room and are collectively denoted as Activities of Daily Living (ADL; Katz, Ford, Moskowitz, Jackson, & Jaffe, 1963). Buurman and colleagues (2011) found that over 30% of acutely hospitalized older patients are discharged with an additional ADL disability.

Not all older patients are equally vulnerable to develop HAD, and depressive symptoms have been proposed as a risk factor that makes older patients prone for ADL decline. Covinsky, Fortinsky, Palmer, Kresevic and Landefeld (1997) studied 572 hospitalized patients aged 70 years and over. Older patients with six or more depressive symptoms were resp. 3.45 and 2.15 times more likely to be dependent in ADL than older patients with two or less depressive symptoms one and three months post-discharge. Covinsky and colleagues (2010) found similar results over a time span of 12 years. In a sample of 7207 community living adults aged 50 - 61, adults with depressive symptoms were at a 2.33 greater risk for persistent difficulty with mobility in ADL than older adults without depressive symptoms (45% vs. 23%).

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ADL-functioning in a systematic review of ten clinical studies in hospitalized patients aged 65 years and older in between 1990 and 2005. Depressive symptoms were among the four most important risk factors that make older patients more prone to develop HAD next to age, premorbid functional independence and cognitive functioning. This risk factor is particularly important because of the high prevalence of depressive symptoms among hospitalized older adults. Several studies found that up to half of all general hospitalized older adults suffered depressive symptoms (Blazer, 2003; Koenig et al., 1999). Ciro and colleagues (2012) found that severe depressive

symptoms (i.e., CES-D ≥ 16) were as high as 37% in a sample of 197 acutely hospitalized older adults at hospital admission. These studies confirm that depressive symptoms are

The high prevalence of HAD and associated risk factors is a major problem, since HAD is indicative of a poor health prognosis for older adults. Hospitalized older adults have a more than 40 times higher chance to develop a persistent decline in ADL-functioning within a month after hospitalization, compared to non-hospitalized older adults (Gill, Allore, Holford, & Guo, 2004). Also, HAD is associated with an increased length of hospitalization and an increased risk for hospital readmission and institutionalising, which is a serious concern for older adults (DePalma et al., 2013; Dramé et al., 2011; Somme, 2003). Moreover, mortality rates among older patients one year after hospital discharge are higher for older patients discharged with reduced ADL-functioning (41.3%), compared to fully recovered older patients (17.8%; Boyd et al., 2008).

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The high prevalence and adverse health outcomes associated with HAD, underline the importance of the prevention of HAD (Reichardt, 2016). Therefore, this study investigates a potentially modifiable factor that

contributes to functional independency (i.e. independency in ADL). One way is to identify a trait that predicts functional independence. Another way is to identify a trait that protects against the negative impact of depressive

symptoms on functional independence. This modifiable, personal factor could be stimulated in preventive interventions in order to maximize rehabilitation outcomes in acutely hospitalised older adults.

General Self-Efficacy (GSE) might be promising in this respect, since it has been identified as a valuable trait in the process of healthy aging

(Moreno et al., 2014; Cooper, Huisman, Kuh, & Deeg, 2011; Singh, Shukla, & Singh, 2010). GSE refers to “one’s estimate of one’s overall ability to perform successfully in a wide variety of challenging achievement situations” (Eden, 1996). GSE should not be confused with Specific Self-Efficacy (SSE), the central concept in Bandura’s Social Cognitive Theory (1977). Whereas GSE captures people’s general tendency to view themselves as capable of dealing with adversities, SSE is the belief in one’s own ability to complete specific tasks and goals.

GSE is related to a wide range of positive physical and mental health indicators in non-hospitalized older adults (Luszczynska, Scholz, &

Schwarzer, 2005). Older adults with more optimistic self-efficacy beliefs demonstrate a lower consumption of dietary fat, alcohol, and smoking, and are less likely to be obese than older adults with less optimistic self-efficacy

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beliefs (Grembowski et al., 1993). Also, higher GSE is associated with higher physical activity in older adults, which is one of the pillars of healthy aging (Renner & Schwarzer, 2005; Ainsworth, Sternfeld, Richardson, & Jackson, 2000; Warburton, Nicol & Bredin, 2006). Furthermore, Singh and colleagues (2010) observed that the level of GSE explained 45 – 48% of the variance of general mental health in cross-sectional study of 160 older adults aged 60 years and above, which describes the ability to carry out normal functions and the lack of distressing phenomena. Moreover, Warner and colleagues (2011) observed that optimistic self-beliefs were more important than social support for the feeling of perceived autonomy in longitudinal study of 309 older adults aged 65 years and over with comorbidity. Higher GSE, but not social support, was related to stronger feelings of being capable to organize own live, make own decisions, live by own choices and cope independently with life ten months later. Moreno and colleagues (2014) confirmed the beneficial effects of GSE for healthy aging in a cluster analysis of 154 institutionalized and non-institutionalized older adults aged 65 years and older. Researchers aimed to

identify personal factors that protect or enhance the subjective wellbeing in older adults such as current perceived health, stress, daily functioning, optimism, social support and leisure activity. Apart from physical health indicators, self-efficacy and leisure activity were the most important variables for distinguishing highly successful from moderately successful and highly impaired older adults. Although these studies indicate that GSE is a valuable trait in the process of healthy aging in non-hospitalized older adults, the value of GSE in the rehabilitation of acutely hospitalized older adults is not yet clear.

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The value of GSE for the prevention of HAD dependents both on its

modifiability and its stability. On one hand, GSE should be effectively modifiable by intervention. On the other hand, GSE should be robust to spontaneous change after hospitalisation to produce long-term effects. Research on the modifiability of GSE are rare but promising. De Rooij, Van der Leeden, Roorda, Steultjens, and Dekker (2013) conducted an observational study of 120 patients in the age range of 18–75 years (M =

45.04 years, SD = 10.30 years) with chronic widespread pain following a six-month multidisciplinary treatment programme aimed to improve coping skills and to reduce pain interference. They observed that GSE was unchanged over six months, but improved more gradually over 18 months. However, this study not included a control group and therefore, it is not clear if the enhancement of GSE is due to the

intervention. Bonura and Tenenbaum (2014) found likewise that GSE is modifiable in older adults in a randomized controlled trial of 106 healthy adults aged 65 years and above. GSE was effectively enhanced by both a weekly chair yoga and a chair exercise intervention compared to a control sample, over a period of 6 weeks. Although few, these studies indicate that GSE can be effectively enhanced by intervention.

Research on the stability of GSE in older adults is inconclusive. Eden (1996) argued that GSE is a stable motivational trait, independent of context and situational demands. According to him, GSE would be expected to be stable over time in older adults. However, Singh and colleagues (2010) found contradicting results in a cross-sectional survey of 160 non-hospitalized older adults aged 60 years and over.

Researchers found a main effect of age on GSE and an interaction effect between gender and age on GSE and concluded that GSE decreases with advancement of age

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and this is more so for women than for men. However, this study involved data collection at one specific point in time and therefore the results could be influenced by cohort effects. Mystakidou and colleagues (2013) also found that GSE declined in an observational study of 90 cancer patients in the age range of 18–87 (M = 61.17 years, SD = 5.20 years) between the beginning of radiotherapy and one month post-treatment. However, radiotherapy leaded to an increase of symptom severity and interference and both are negatively associated with GSE. Since rehabilitation after hospitalization is expected to lead to an overall decrease of symptoms, it is not evident that these results also apply for hospitalized older adults. The temporal stability of GSE during the rehabilitation of acutely hospitalized older adults is never addressed and this will be analysed in the present study.

The value of GSE for functional independence is demonstrated in longitudinal observations. These studies controlled for several health related variables to eliminate the confounding effect of baseline health status. Kempen, Ranchor, Van Sonderen, Van Jaarsveld and Sanderman (2006) analyzed three different functional trajectories of a population based sample of 1765 older people aged 57 years and older over a period of eight years. Higher levels of GSE were associated with no change or improvement in ADL-functioning, but lower levels of GSE were not associated with substantially poorer ADL-functioning as compared with somewhat poorer functioning (i.e. the natural pathway of aging). In other words, older adults with higher GSE were protected for the functional decline that can be seen as the natural pathway of aging, whereas older adults with lower GSE were not prone to develop additional functional decline. Hoogendijk and colleagues (2014) observed that GSE also contributed to the maintenance of functional independence over a period of three years of follow-up. In

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a longitudinal cohort of 1665 community-dwelling older adults aged 58 and over, higher levels of GSE (> median) were associated with decreased odds of functional decline. Cooper and colleagues (2011) re-evaluated 1532 older adults from the for mentioned cohort selected under somewhat different inclusion criteria and

additionally investigated gender differences. Researchers observed that GSE

contributed to decreased odds of functional decline in men but not in women, over a period of three years. This gender difference was explained by the finding that women are more likely to receive social support and utilize health care than men (Oksuzyan, Juel, Vaupel, & Christensen, 2008). In men, the use of this protective resources is less common and might require a higher level of GSE in order to increase the likelihood that this resources are used. Above studies indicate that the confidence in one’s own ability to overcome adversities helps to maintain more independence in ADL-functioning over a longer time span. However, little is known about the predictive value of GSE for functional independence in the relatively short process of

rehabilitation after acute hospitalization. This question will be addressed in the present study.

Next to the predictive value of GSE for functional independency, GSE also moderates the negative relationship between functional independence and depressive symptoms. Paukert and colleagues (2010) analysed 222 adults age 60 or older prior to beginning a treatment for generalized anxiety disorder. GSE moderated the negative relationship between global health status and depressive symptoms. In other words, older adults with poor global health status with higher GSE were less prone to suffer depressive symptoms, than older adults with lower GSE. Pjanic and colleagues (2014) found likewise results in a longitudinal observation of 274 middle-aged workers (age

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M = 43.24 years, SD = 12.40 years) with a minor to moderate injury due to an

accident. Injured workers with more pain and higher GSE were less prone to develop depressive symptoms one year later than injured workers with lower GSE. The relative importance of GSE was underlined by the finding that social support did not buffer, or even worsened, the negatives effects of poor physical conditions on depressive symptoms in above studies. However, no study investigated if acutely hospitalized older patients with depressive symptoms with higher GSE are less prone to suffer functional dependence that patients with lower GSE. This question will be addressed in the present study.

In light of the preceding introduction, the present study investigated the potential value of GSE in the rehabilitation of acutely hospitalized older patients. As illustrated in Figure 2, this study examined the temporal stability of GSE between hospital discharge, one and two month post-discharge. Also, this study investigated the predictive value of GSE for functional independence both at one and two month post-discharge, after adjusting for premorbid functional independence and associated socio-demographic variables. Furthermore, this study investigated if GSE moderates the positive relationship between depressive symptoms and functional dependence at discharge.

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Figure 2. The Role of General Self-Efficacy in the Rehabilitation of Acutely

Hospitalized Older Adults tested in the Present Study.

a

The temporal stability of GSE between hospital-discharge, one and two months post discharge

b

The predictive value of GSE for functional independence both at one and two months post-discharge

c

The moderating role of GSE in the relationship between depressive symptoms and functional independence.

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METHODS Sample characteristics

In total, the present study included 217 acutely hospitalized patients aged 70 years and above who were hospitalized for more than 48 hours. Participants were recruited from departments of Internal Medicine, Cardiology, or Geriatrics of the

Academic Medical Center in Amsterdam (AMC; university teaching hospital), the Isala in Zwolle, the Tergooi in Blaricum, and the BovenIJ Hospital in Amsterdam (all regional teaching hospitals) between October 1st 2015 and May 18st 2016. Written informed consent was obtained from all participants before inclusion. Inclusion criteria were the approval from the attending medical doctor, sufficient knowledge of the Dutch language to understand and complete questionnaires (as judged by the researchers) and sufficient cognitive functioning (Mini Mental State Examination score ≥ 15). In previous self-efficacy research, a score of ≥ 24 is generally handled for inclusion, since this is the cut-off score to indicate cognitive impairment (Rabinowitz, Mausbach, Thompson, & Gallagher-Thompson, 2007). The present study handled a lower score due to the high prevalence of older adults with an indication for cognitive impairment and these older patients are highly prone for the development of HAD (Sands et al., 2003).

Participants were not eligible to participate if their life expectancy was three months or less (estimated by attending medical doctor) and/or if patients were unable to perform any of the Activities of Daily Living independently at admission (Modified Katz Index Scale = 6). Patients did not receive a compensation for their participation and were gratefully thanked by the researchers at the end of the study. The study was approved by the Institutional Review board of the Academic Medical Center (AMC)

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in The Netherlands. The research was performed according to the Dutch Medical Research Involving Human Subjects Act and principles of the Declaration of Helsinki (1964).

Procedure

This study is part of the Hospital-ADL study, a broad, multicenter,

observational and longitudinal prospective cohort study (Reichardt et al., 2016). Only data assessments relevant for the present study are described below. Table 1 shows measurement occasions including the content of the test battery. Assessment during hospitalization (T0, T1, T2) was performed by a geriatric team consisting of a

psychologist, a physiotherapist, and a health scientist, on Mondays, Wednesdays and Fridays. Follow-up assessments (P1, P2) were performed by a team of psychologists

(BSc) and physiotherapists (BSc). The patient was invited within 48 hours of admission for participation and screened for inclusion and exclusion criteria. If eligible for inclusion, the patient was informed about the study objectives and procedures and was informed that he/she is allowed to end their participation at any time. Subsequently, an informed consent was signed by the patient. The participant received a copy of the informed consent and a study description. Functional

independence two weeks pre-admission (T0) was assessed at hospital admission (T1).

The rehabilitation process from admission (T1) until discharge (T2) was documented

in the hospital. The follow-up at one month (P1) post-discharge was held at the

participants’ home, whereas the two month’s follow up (P2) was a phone interview.

The total admission time of the test battery ranged from one to two hours per assessment.

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Table 1. Measurement Occasions Including the Content of the Test Battery General Self-Efficacy (ALCOS-12) Cognitive Functioning (MMSE) Functional Independence (KATZ-ADL) Depressive Symptoms (GDS-15) Two Weeks Pre-admission(T0) In the Hospital during T1Hospital Admission (T1) In the Hospital ✓ ✓ ✓ Hospital Discharge (T2) It the Hospital ✓ ✓ ✓ ✓ One month Post-discharge (P1) Home visit ✓ ✓ ✓ ✓ Two months Post-discharge (P2) By Telephone ✓ ✓ ✓ ✓

ALCOS-12 = Algemene Competentie Schaal 12; MMSE = Mini Mental State Examination; KATZ-ADL = Katz Activities of Daily Living; GDS-15 = General Depression Scale 15

Materials

Socio-demographic variables. Socio-demographic variables were assessed in a

face-to-face interview within 48 hours of admission. The documented variables were date of birth, gender, address, data and time of admission, highest level of education,

ethnicity, marital status, and living arrangement (Minimale Data Set Zorgvrager

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Cognitive functioning. Cognitive functioning was examined using the 11-item

Mini Mental State Examination (MMSE; Folstein, Folstein, & McHugh, 1975). The MMSE measures cognition and motor skills and is used extensively in both the clinical and research setting (Pangman, Sloan & Guse, 2000). Participants were requested to answer questions about general orientation (place and data) and perform various tasks, including word memory, backwards counting, writing a full sentence, copying a drawing, closing eyes and folding paper. Possible scores range from 0 to 30, where higher scores indicate better cognitive functioning. The reliability and construct validity of the MMSE are satisfactory (Tombaugh & McIntyre, 1992). Internal consistency ranges from questionable to excellent (Cronbach’s α = .65 – 96) and test-retest reliability is generally rated well through excellent (Cronbach’s α = .80 – .95; Tombaugh & McIntyre, 1992). The criterion validity of the Dutch version is reasonable, shown in the strong positive correlation with another screening instrument for cognitive dysfunction (CAMCOG, Spearman’s r = .66 – .69; Kok & Verhey, 2002).

General Self-Efficacy. Level of GSE was determined using ‘De Algemene Competentieschaal’ (ALCOS-12; Bosscher & Baardman, 1989), the Dutch version of

the original Self-Efficacy Scale (SES; Sherer et al., 1982). A copy of the

questionnaire can be found in Appendix A. The 12-item questionnaire is assessed on a five-point scale ranging from ‘disagree’ (‘mee oneens’, 1) to ‘agree’ (‘mee eens’, 5) (e.g. ‘I can solve most problems if I invest the necessary effort’). These results in a possible score ranging from 12 to 60, where higher scores indicate higher self-efficacy. Reversed items are converted for scoring (3, 4, 6, 8, 9, 11 and, 12). The ALCOS-12 has a good reliability (Cronbach’s α = .86) and an acceptable internal

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consistency in different samples of older adults aged 55 and above (Cronbach's α = .69 – .78, Bosscher, Smit & Kempen, 1997).

Activities of Daily Living (ADL). Functional independence was

measured as the level of independence in Activities of Daily Living (ADL), assessed with the 6-items Modified Katz Index Scale (KATZ-ADL; Katz et al., 1963). Patients were asked if they are able to independently perform the

following activities: walking across a small room, bathing, grooming,

dressing, eating, and getting up from a bed or chair, and toileting (Laan et al.,

2014). Patients were rated as dependent if they either need help of another person or a device. The dichotomous responses ‘Yes’ (‘Ja’) or ‘No’ (‘Nee’) result in a score ranging from 0 to 6 with higher scores indicating more functional dependence. The KATZ-ADL has a high test-retest reliability in a three-week period (Pearson's r = .89, Smith et al., 1990). Reijneveld, Spijker and Dijkshoorn (2007) also found good psychometric characteristics in a large sample (N = 932) of older adults in the Netherlands. The Dutch version shows good internal consistency (Cronbach’s α = .93) and good construct validity, shown by a strong positive correlation with depressive symptoms (Pearson’s r

= .41), limitations in mobility (Pearson’s r = .64), physical functioning

(Pearson’s r = -.60) and role performance (Pearson’s r = -.04).

Depressive symptoms. Level of depressive symptoms was measured

using the Dutch translation of the shortened Geriatric Depression Scale (GDS-15, Yesavage & Sheik, 1986). The GDS-15 is an appropriate screening

instrument to identify depressive symptoms. Participants were asked to reflect about their feelings in the past week including today (e.g. ‘Do you often feel

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helpless’) and answer with ‘Yes’ (‘Ja’) or ‘No’ (‘Nee’). This results in a min-max score of 0 to 15, with higher scores indicating more depressive symptoms. It is a dichotomization instrument that has been tested and used extensively with older adults, with an optimal cut-off point to indicate depression usually set a six or higher (Greenberg, 2012). The GDS-15 has an excellent,

comparative discriminant validity for different age groups of older patients

(aged < 65, 65 –75 and > 75 with respectively AUC = 0.92, 0.91, and 0.95;

Weintraub, Saboe & Stern, 2007).

Statistical Analyses

The data were analyzed using IBM SPSS Version 22 with the significance level α set at 0.05. Descriptive analyses were reported as means (M) and standard

deviations (SD) in case of continuous variables and as frequencies (n) and proportions (%) in case of categorical variables. Data analysis started with the check of several assumptions. Outliers (z > 3) were detected and excluded from analyses, because of the disproportional weight of their large residuals on the mean (Osborne & Overbay, 2004). Also, a visual inspection of the data was performed using a scatterplot to test the continuous data on linearity (the relation between variables is proportional) and homoscedasticity (the variance around the regression line is equal for all values of the independent variables). Next, the independence of the observations (the correlation is non-serial) was tested using the Durbin-Watson statistic (confirmed if ± 2). Last, normality (the data is normally distributed around the mean) was assessed using the Kolmogorov-Smirnov test (confirmed if p > .05). Missing values were excluded pairwise in the analysis.

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The temporal stability of GSE was analyzed using a 2-way Repeated

Measurement ANOVA. The level of GSE was used as dependent variable and time was used as independent variable with three specified levels (T2-P1-P2). The predictive

value of GSE for functional independence was invested using two Hierarchal Linear Regression Analyses. In Step 1, the level of premorbid functional independence was entered. In Step 2, socio-demographic variables (age, gender, highest level of

education, ethnicity, marital status and living arrangement) were entered in the

equation to control for these confounding variables. In Step 3, the level of GSE at one and two months were added to investigate their predictive value for functional

independence. The outcome variables were the scores on ADL-functioning at one and two months post-discharge. Non-significant socio-demographic variables were

excluded and analysis was rerun. The R2 value was used to indicate the amount of variance explained by the model, and the R2 value was used to determine the magnitude of the additionally explained variance by GSE. The moderating role of GSE in the relationship between depressive symptoms and functional dependence at discharge was analyzed using a Hierarchal Linear Regression Analyses. In step 1, socio-demographic variables were entered as control variables. In step 2, the centered GSE at discharge variable, the centered depressive symptoms at discharge variable and the GSE x Depressive Symptoms at discharge interaction were added in the equation. The outcome variable was the scores on ADL-functioning at discharge. Non-significant socio-demographic variables were excluded and analysis was rerun. For the post-hoc analysis, GSE data was divided in groups of low (ALCOS < 40, n = 29.3%), moderate (ALCOS = 40 – 50, n = 37.1%) and high GSE (ALCOS > 50, n = 33.6%; Bosscher & Baardman, 1989). Scatterplots and Spearman’s correlations were

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analyzed for separated groups to interpret the moderation by GSE in the relationship between depressive symptoms and functional dependence.

RESULTS

Descriptive Statistics

Table 2 presents a summary of baseline sample characteristics. In total, 217 older patients were recruited from four Dutch hospitals between October 1st 2015 and May 18th 2016.The participants were in the age range of 70 – 99 years old (M = 79.06,

SD = 6.45). At the moment of analyzing the data, 61 participants (28.1%) fully

completed the study and 101 (46.5%) were still participating in the study. Fifty-five participants (25.3%) did not complete the study due to death (n = 18, 8.3%), retraction of consent (n = 7, 3.2%), loss to follow up (n = 5, 2.3%), or other reasons (n = 25, 11.5%). If study participation was terminated through withdrawal or mortality, participants’ or relatives’ permission was asked to use the current data for analyses. Table 3 shows the levels of GSE, cognitive functioning, ADL-functional and

depressive symptoms at each measurement occasion including number of participants with available data.

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Table 2. Summary of Sample Characteristics

Sample characteristic Total N = 217

Gender n (%) Country of Birth n (%)

Men 103 (47.5%) Netherlands 192 (88.5%)

Women 114 (52.5%) Other 25 (11.5%)

Age Marriage status

< 75 64 (29.5%) Married 113 (52.1%)

75 – 79 56 (25.8%) Divorced 24 (11.1%)

80 – 84 54 (24.9%) Widow 63 (29%)

85 ≥ 43 (19.8%) Unmarried/Single 17 (7.8%)

Education Living condition

< College degree 55 (25.3%) Independent alone 67 (30.9%) College degree 119 (54.9%) Independent together

(i.a. partner, children)

107 (49.3%) > College degree 43 (19.8%) Other (i.a. nursing home,

rehabilitation center) 43 (19.8%) Hospital AMC 107 (49.3%) BovenIJ 18 (8.3%) Isala 13 (6%) Tergooi 79 (36.4%)

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Table 3. Levels of General Self-Efficacy, Cognitive Functioning, Functional Independence and Depressive Symptoms

General Self-Efficacy Cognitive Functioning Functional Independence Depressive Symptoms ALCOS-12 M (SD) MMSE M (SD) KATZ-ADL M (SD) GDS-15 M (SD) Two Weeks Pre-admission (T0) 0.76 (1.10) n = 217 Hospital Admission (T1) 26.19 (3.11) n = 202 1.65 (1.75) n = 217 3.95 (2.69) n = 209 Hospital Discharge (T2) 44.96 (8.37) n = 116 26.62 (3.26) n = 166 1.41 (1.62) n = 188 3.74 (2.80) n = 179 One month Post-discharge (P1) 44.49 (8.84) n = 139 27.35 (2.65) n = 133 0.97 (1.32) n = 150 3.54 (2.86) n = 140 Two months Post-discharge (P2) 44.44 (8.42) n = 93 27.30 (2.76) n = 60 0.94 (1.38) n = 109 3.19 (3.21) n = 97

Notes: ALCOS-12 = Algemene Competentie Schaal 12 (range 12-60); MMSE = Mini Mental State Examination (range 0-30) ; KATZ-ADL = Katz Activities of Daily Living (range 0-6); GDS-15 = General Depression Scale 15 (range 0-15)

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The Temporal Stability of GSE

The temporal stability of GSE was analyzed using a two-way Repeated Measurement ANOVA. Mauchly’s test indicated that the assumption of sphericity was violated, χ2(2) = 8.56, p = .014, therefore degrees of freedom were corrected using Huynh-Feldt estimates of sphericity (ε = 0.90). As illustrated in Figure 3, the results suggested that there was no significant effect of Time (T2-P1-P2) on the level of

GSE, F(1.80, 102.76) = 2.41, p = .10. Thus, GSE was stable between hospital discharge, one and two months post-discharge.

Figure 3. Level of General Self-Efficacy in mean(M) and standard error(SE) at

hospital discharge, one and two months post-discharge. M = 45. 84 (SE =.78) M = 44.19 (SE = .75) M = 45.52 (SE = .87) 12 18 24 30 36 42 48 54 60

Hospital Discharge One Month Post

Discharge Two Months PostDischarge

Gen er al S el f-E ffic ac y

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The Predictive Value of GSE for Functional Independence

The predictive value of GSE for functional independence one and two months post-discharge was examined in two Hierarchal Linear Regression Analyses. Outliers (P1= patient 68 and 173, P2= no outliers) were detected and excluded from analyses.

Data on ADL-functioning were not normally distributed for each measurement occasion due to positive skewness (all Kolmogorov-Smirnov test p < .001). However, this does not indicate any major problem, since the sample size was large and the skewness and kurtosis for each measurement occasion were within the critical values (skewness range z = 0.92 – 1.70, kurtosis range z = -0.42 – 2.54; Kim, 2013). The normal P-P plot of standardized residuals showed that the data were distributed close to the line, which indicated that the data contained approximately normally distributed errors. The scatterplot of standardized residuals showed that the data were randomly distributed in the plot, so the assumptions of homogeneity of variance and linearity were met. Also, the assumption of independence of the observations (Durbin-Watson value P1 = 2.20, P2 = 2.00) and collinearity was met for each variable (Tolerance

range = .90 – 1, VIF range = 1.00 – 1.11).

As shown in Table 4, using the enter method it was found that the level of GSE contributed significantly to the level of functional independence one month post-discharge, F(3, 135) = 54.01, p < .001, R 2= .55, ∆R 2= .03. The model was adjusted for premorbid functional independence, β = .79, t(138) = 11.00, p < .001, and the associated socio-demographic variable age, β = .03, t(138) = 2.07, p = .04). The total model explained 55% of the variance, of which 3% additionally explained by GSE.

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Table 4. Hierarchical Regression Analysis for the Predictive Value of GSE for Functional Independence One Month Post-discharge

Variable F (df) B B SE β t ∆R2 Step 1 133.21 (1)*** .50 Pre-morbid Functional Independence .84 .07 .70 11.54*** Step 2 72.78 (2)*** .02 Pre-morbid Functional Independence .79 .074 .66 10.69*** Age .03 .01 .16 2.60** Step 3 54.01 (3)*** .03 Pre-morbid Functional Independence .79 .07 .66 11.00*** Age .03 .01 .13 2.07* GSE -.024 .01 -.17 -2.91** Notes: n = 138; *p < .05, **p < .01, ***p < .001

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As shown in Table 5, using the enter method it was found that the level of GSE contributed significantly to the level of functional independence two month

post-discharge, F(2, 91) = 71.19, p = .01, R2 = .61, ∆R2 = .03. The model was adjusted for

premorbid functional independence, β = .77, t(92) = 11.44, p < .001, and there were

no associated socio-demographic variables (all p > .05). The total model explained 61% of the variance, of which 3% additionally explained by GSE.

Table 5. Hierarchical Regression Analysis for the Predictive Value of GSE for Functional Independence Two Months Post-discharge

Variable F (df) B B SE β t ∆R2 Step 1 127.31 (1)** Pre-morbid Functional Independence .78 .07 .76 11.28*** .58 Step 2 71.19 (2)** .03 Pre-morbid Functional Independence .77 .07 .75 11.44*** GSE -.02 .01 -.17 -.262** Notes: n = 93; *p < .05, **p < .01, ***p < .001

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The Moderating Role of GSE in the Relationship between Depressive Symptoms and Functional Dependence at Discharge

The moderating role of GSE in the relationship between depressive symptoms and functional dependence at hospital discharge was examined in a Hierarchal Linear Regression. In step 1, the associated socio-demographic variables age, β = .09, t(112)

= 4.07, p < .001, and marital status, β = .34, t(112) = 2.61, p = .01, were entered as

control variables. As shown in Table 6, the results showed that the interaction variable GSE x Depressive Symptoms was significant, β = -.01, t(112) = -2.62, p = .01, which indicated that GSE moderates the relationship between depressive symptoms and functional dependence. As shown in Figure 4, post-hoc analyses showed that depressive symptoms and functional dependence are only significantly positively correlated for patients with low GSE (Spearman’s r = .41, p = .02, ALCOS < 40), but not for patients with moderate (ALCOS = 40 – 50) or high GSE (ALCOS > 50). This results suggest that acutely hospitalized older patients with depressive symptoms with higher GSE are less prone to suffer functional dependence that patients with lower GSE.

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Table 6. Hierarchical Regression Analysis for the Moderating Role of GSE in the Relationship between Depressive Symptoms and Functional Dependence at Hospital Discharge Variable F (df) B B SE β t ∆R2 Step 1 15.75 (2)*** .23 Age .09 .02 .36 4.07*** Marital Status .34 .13 .23 2.61** Step 2 8.45 (5)*** .06 Age .09 .022 .35 4.00*** Marital Status .32 .13 .22 2.49* GSEa .01 .02 .06 .60 Depressive Symptomsa .07 .05 .13 1.43 GSE by Depressive Symptoms Interaction -.01 <.01 -.22 -2.62* n = 110; *p < .05, ** p < .01, *** p < .001 a Centered variable

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Figure 4. Relationship between depressive symptoms and functional

dependence for high, moderate and low GSE, n = 110; *= p < .05; Y = 0.51 + 0.21X. Y = 0.67+0.18X Y = 0.51+0.21X* Y = 1.46-0.06X 0 0,5 1 1,5 2 2,5 3 3,5 4 0 5 10 15 20 F unc ti o na l D epe nde nc e Depressive Symptoms

Moderate General Self-Efficacy

Low General Self-Efficacy*

High General Self-Efficacy

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DISCUSSION

This study aimed to investigate the role of GSE in the rehabilitation of acutely hospitalized older adults. The current data showed that GSE was stable between hospital discharge, one and two months post-discharge. Also, GSE predicted to functional independence both at one and two months post-discharge when controlling for premorbid functional independence and associated socio-demographic variables. Moreover, GSE moderated the positive relationship between depressive symptoms and functional dependence at hospital discharge, indicating that acutely hospitalized older patients with depressive symptoms with higher GSE are less prone to suffer functional dependence that patients with lower GSE.

Surprisingly, among older adults with high GSE, patients suffered less from depressive symptoms when they were more functional dependent. Although not statistically significant, the generally positive relationship between depressive symptoms and functional dependence was reversed for older adults with high GSE (Spearman’s r = -.12, p > .05; see also Figure 4). This finding is consistent with previous research by Paukert and colleagues (2010). This was explained by the finding that older adults with high GSE use active coping mechanisms in response to stressors (Cassidy & Burnside, 1996). Researchers argued that mood may actually be better in presence of problems due to this active coping and positive mentality (Ben-Zur, 2002). Another explanation might be that this finding reflects a degree of unrealistic positivism, which is “the objective mismatch between the expectations of dispositional optimism and actual evidence about probability of life events occurring” (Weinstein & Klein, 1996). Unrealistic positivism is a strong force in decision-making and may negatively affects rehabilitation, because it tends to prevent individuals from

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taking on preventative measures for good health (Bränström & Brandberg, 2010). As a result, this can hinder the appropriate implementation of assistive devices for older adults such as shower seats, walk in tubs, or wheelchairs, which are important to prevent hospitalization and functional decline (Chiu & Man, 2004). The potential negative consequences of unrealistic positive self-efficacy beliefs would be an interesting topic for further research.

The remaining question is how to evaluate the clinical relevance of

GSE in the rehabilitation of acutely hospitalized older adults. Although statistically significant, current data suggested that the additionally explained variance of General Self-Efficacy to functional independence both at one and two month post-discharge was small (resp. 3%). This might be explained by the fact that GSE is a general trait and, in contrast to SSE, it is not specified to the research aim (e.g. walking self-efficacy to indicate positive self-beliefs about one’s ability to walk; Pajares, 1997). SSE has the advantages that correlations with outcome measurements are generally higher and

enhancement by intervention arises more rapidly (Jones, Mandy, & Partridge, 2009; Mc Auley, 2006). However, SSE is less stable compared to GSE and enhancement by intervention is also found to decline fast (Hellstrom, Lindmark, Wahlberg, & Fugl-Meyer, 2003;McAuley, Elavsky, Motl, Konopack, Hu, & Marquez, 2005). One hypothesis is that both types of self-efficacy are relevant for the prevention of HAD in distinct ways. During rehabilitation, SSE might be more suitable as a specific target for intervention programs with short-term and concrete goals. Previous to hospitalization, GSE might be more valuable for intervention programs aimed to stimulate general

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healthy aging and thereby contributing to the prevention of HAD. A more fine-grained literature research on this topic can be read in the additional chapter.

This study has several limitations. First, this study only used a subjective measurement to indicate the rehabilitation of acutely hospitalized older adults. This may negatively influences the accuracy of the data, since the subjective ADL-measurement is prone to misinterpretation as well as over- or underestimation(Graf, 2006; Zisberg, Shadmi, Gur‐Yaish, Tonkikh, & Sinoff, 2015). To illustrate, patients

with higher GSE might overestimate their ability to perform the Activities of Daily Living independently compared to patients with lower GSE (Eden, 1996; Schwarzer, 1994). This limitation could be overcome by the use of objective health indicators to measure rehabilitation without bias or prejudice, such as hand-grip strength. Hand-grip strength is identified as a fast, easy to perform and reliable instrument with a strong predictive value for long term health indicators (Innes, 1999). To illustrate, hand grip strength is consistently shown to be an accurate predictor of the permanent disability development in ADL, the risk of complications or prolonged length of stay after hospitalization or surgery and even the likelihood of premature mortality (Bohannon, 2008; Al Snih, Ottenbacher, & Raji, 2004). Moreover, Goldman, Glei, Rosero-Bixby, Chiou, and Weinstein (2014) showed that objective measurements of physical functions (e.g. walking speed and grip strength) were a better predictor of mortality in older adults than the subjective ADL-measurement over a time-span of five years. In further research, it would be interesting to investigate the predictive role of GSE for objective health indicators describing the rehabilitation of older patients.

Second, this study only included acutely hospitalized older adults and the results might not be applicable to hospitalized older adults from other departments.

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The rehabilitation processes of different groups of older patients might be

incomparable, since their medical conditions differ urgency and diagnosis (Latham & Ackroyd-Stolarz, 2014). To illustrate, the average length of hospital stay in Europe is shorter for acute care (6.43 days) than for general care (8.16 days; World Health Organization, 2014). This indicates that acutely hospitalized adults suffer less from the direct hazards of hospitalization that encourage HAD, such as poor nutrition, poly pharmacy, damaging effects of medical treatment or immobility weakness (Covinsky et al., 1999; Steinman, & Hanlon, 2010; Saint, Lipsky & Goold, 2002; Kortebein et al., 2008). As a result, the amount and persistency of ADL loss might be higher in general hospitalized adults, which may lead to robustness for the beneficial effects of individual factors such as GSE. In further research, it would be interesting to include hospitalized older adults from other departments to facilitate generalization.

This study also has several strengths. First, this study is a prospective cohort study. As a results, the study analyzed rehabilitation process over time and controlled for premorbid functional independence. Moreover, a prospective design is less influenced by selection and information biases than retrospective design and case-control studies (Euser, Zoccali, Jager, & Dekker, 2009; Schlesselman, 1982). Second, the study was based on a large sample of older adults recruited from four hospitals, resulting in a demographically diverse medical sample (see Table 2) . The large sample also provided the required power to perform multivariable analyses (Faul, Erdfelder, Lang & Buchner, 2007).

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In summary, this study added to previous knowledge about the rehabilitation of acutely hospitalized adults. This was the first study to test the temporal stability of GSE and the value of GSE for functional independence in the relatively short period of rehabilitation after acute hospitalization in older adults. These findings are

important in the light of preventing HAD, because GSE could be a potentially valuable target for preventive intervention. Further research could investigate if the enhancement of GSE by intervention is valuable for the prevention of HAD in acutely hospitalized older adults.

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APPENDIX A – ‘De Algemene Competentieschaal’ (ALCOS-12; Bosscher & Baardman, 1989)

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TOTAAL ALCOS-12

__________+

LIST OF ABBREVATIONS

ADL Activities of Daily Living

Mee

oneens

(1)

Enigszin

s mee

oneens

(2)

Noch

mee

eens,

noch mee

oneens

(3)

Enigszin

s mee

eens (4)

Mee

eens(5)

1.

Wanneer ik plannen maak, ben ik er ook

van overtuigd dat ik ze met succes zal

uitvoeren.

2.

Wanneer iets mij de eerste keer mislukt,

bijt ik mij er in vast totdat het beter gaat.

3.

Wanneer ik iets beslist wil, gaat het

meestal fout.

4.

Wanneer ik de indruk heb dat iets

ingewikkeld is, begin ik er niet aan.

5.

Ook bij onplezierige taken houd ik vol

totdat ik klaar ben.

6.

Ik heb er moeite mee problemen in mijn

leven goed op te lossen.

7.

Wanneer ik heb besloten iets te doen,

dan doe ik het ook.

8.

Wanneer ik aan iets nieuws begin, moet

ik snel het idee hebben dat ik op de

goede weg ben, want anders houd ik er

mee op.

9.

Onverwachte problemen brengen mij

snel uit mijn evenwicht.

10. Wanneer ik een fout maak, ga ik juist

extra mijn best doen.

11. Ik begin niet aan het leren van nieuwe

dingen wanneer zij mij te moeilijk lijken.

12. Ik twijfel aan mezelf.

(47)

AUC Area under ROC curve

CES-D Center for Epidemiologic Studies Depression scale

GDS-15 Geriatric Depression Scale

GSE General Self Efficacy

MMSE Mini Mental State Examination

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