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Psychological Resilience in Older Residents of Long-Term Care Facilities: Occurrence and Associated Factors

  • Milou J. Angevaare
    Correspondence
    Address correspondence to Milou J. Angevaare, MD, MSc, Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Medicine for Older People, Amsterdam Public Health Research Institute, Van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands.
    Affiliations
    Department of Medicine for Older People, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands

    Department of General Practice, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
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  • Karlijn J. Joling
    Affiliations
    Department of Medicine for Older People, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
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  • Martin Smalbrugge
    Affiliations
    Department of Medicine for Older People, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
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  • Hyoungshim Choi
    Affiliations
    Department of Nursing, Hansei University, Gunpo, Gyeonggi, South Korea
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  • Jos W.R. Twisk
    Affiliations
    Department of Epidemiology and Data Science, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
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  • Cees M.P.M. Hertogh
    Affiliations
    Department of Medicine for Older People, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
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  • Hein P.J. van Hout
    Affiliations
    Department of Medicine for Older People, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands

    Department of General Practice, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
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Open AccessPublished:December 30, 2022DOI:https://doi.org/10.1016/j.jamda.2022.12.006

      Abstract

      Objectives

      The researchers aimed to (1) explore the occurrence of psychological resilience in the face of a major life stressor and conflict in older residents of long-term care facilities (LTCFs), and (2) identify factors associated with resilience in this population.

      Design

      Longitudinal cohort study using the Dutch InterRAI-LTCF cohort.

      Setting and participants

      Older residents (≥60 years old) of 21 LTCFs in the Netherlands.

      Methods

      The researchers selected 2 samples of residents who had at least 2 assessments surrounding (1) an incident major life stressor, or (2) incident conflict with other resident or staff. A resilient outcome was operationalized as not having clinically meaningful mood symptoms at the post-stressor assessment and equal or fewer mood symptoms at the post-stressor relative to the pre-stressor assessment. The researchers used 2 resilience outcomes per stressor: 1 based on observer-reported mood symptoms and 1 based on self-reported mood symptoms. The most important factors from among 21 potential resilience factors for each of the 4 operationalizations of resilience were identified using a backward selection procedure with 2-level generalized estimating equations analyses.

      Results

      Forty-eight percent and 50% of residents were resilient in the face of a major life stressor, based on observer-reported (n = 248) and self-reported (n = 211) mood, respectively. In the face of conflict, 26% and 51% of the residents demonstrated resilience, based on the observer-reported (n = 246) and self-reported (n = 183) mood, respectively. Better cognitive functioning, a strong and supportive relationship with family, participation in social activities, and better self-reported health were most strongly associated with resilience in the face of a major life stressor. Better communicative functioning, absence of psychiatric diagnoses, a strong and supportive relationship with family, not being lonely, social engagement, and not reminiscing about life were most strongly associated with resilience in the face of conflict.

      Conclusions and Implications

      Factors with a social aspect appear to be particularly important to psychological resilience in older LTCF residents, and provide a potential target for intervention in the LTCF setting.

      Keywords

      As a result of the continuing increase in life expectancy and the associated increase in the prevalence of chronic morbidities, the population of older adults residing in long-term care facilities (LTCFs) is expected to grow rapidly in the coming years.
      • Spetz J.
      • Trupin L.
      • Bates T.
      • et al.
      Future demand for long-term care workers will be influenced by demographic and utilization changes.
      The likelihood of encountering stressors increases with age,
      • Angevaare M.J.
      • Roberts J.
      • van Hout H.P.J.
      • et al.
      Resilience in older persons: A systematic review of the conceptual literature.
      ,
      • Cosco T.D.
      • Howse K.
      • Brayne C.
      Healthy ageing, resilience and wellbeing.
      and residents of LTCFs specifically are (increasingly) likely to encounter different health, loss, and social stressors. As many of these stressors are unavoidable, it is important to focus on finding strategies to help older residents to deal with these stressors in the best way possible.
      • Manning L.K.
      • Bouchard L.
      Encounters with adversity: a framework for understanding resilience in later life.
      Resilience consists of a positive response (outcome) to some type of stressor and the mechanism (resilience factors) through which that positive response is achieved.
      • Angevaare M.J.
      • Roberts J.
      • van Hout H.P.J.
      • et al.
      Resilience in older persons: A systematic review of the conceptual literature.
      Resilience factors identified through resilience research can inform development of intervention strategies, to help more older adults achieve a positive response in the face of stressors.
      • Angevaare M.J.
      • Roberts J.
      • van Hout H.P.J.
      • et al.
      Resilience in older persons: A systematic review of the conceptual literature.
      ,
      • Cosco T.D.
      • Howse K.
      • Brayne C.
      Healthy ageing, resilience and wellbeing.
      ,
      • Whitson H.E.
      • Duan-Porter W.
      • Schmader K.E.
      • et al.
      Physical resilience in older adults: systematic review and development of an emerging construct.
      Many studies of resilience in older adults applied scales that operationalize resilience as a trait and/or use cross-sectional designs.
      • Angevaare M.J.
      • Roberts J.
      • van Hout H.P.J.
      • et al.
      Resilience in older persons: A systematic review of the conceptual literature.
      ,
      • Gorska S.
      • Singh Roy A.
      • Whitehall L.
      • et al.
      A systematic review and correlational meta-analysis of factors associated with resilience of normally aging, community-living older adults.
      ,
      • Cosco T.D.
      • Kaushal A.
      • Hardy R.
      • et al.
      Operationalising resilience in longitudinal studies: a systematic review of methodological approaches.
      These methods do not do justice to the wide recognition of resilience as a dynamic and contextual process surrounding a stressor.
      • Angevaare M.J.
      • Roberts J.
      • van Hout H.P.J.
      • et al.
      Resilience in older persons: A systematic review of the conceptual literature.
      ,
      • Cosco T.D.
      • Kaushal A.
      • Hardy R.
      • et al.
      Operationalising resilience in longitudinal studies: a systematic review of methodological approaches.
      However, especially recently, several studies have taken longitudinal approaches to studying resilience in community-dwelling older adults, incorporating dynamic measures of resilience surrounding a stressor.
      • Netuveli G.
      • Wiggins R.D.
      • Montgomery S.M.
      • et al.
      Mental health and resilience at older ages: bouncing back after adversity in the British Household Panel Survey.
      • Koivunen K.
      • Portegijs E.
      • Sillanpaa E.
      • et al.
      Maintenance of high quality of life as an indicator of resilience during COVID-19 social distancing among community-dwelling older adults in Finland.
      • Pedone C.
      • Costanzo L.
      • Finamore P.
      • et al.
      Defining resilience in older people: does a subjective definition of stressor work?.
      • van Schoor N.M.
      • Timmermans E.J.
      • Huisman M.
      • et al.
      Predictors of resilience in older adults with lower limb osteoarthritis and persistent severe pain.
      • Wu C.
      • Lin T.Z.
      • Sanders J.L.
      A Simplified approach for classifying physical resilience among community-dwelling older adults: the health, aging, and body composition study.
      Although there is a growing body of work on (psychological) resilience in community-dwelling older adults,
      • Gorska S.
      • Singh Roy A.
      • Whitehall L.
      • et al.
      A systematic review and correlational meta-analysis of factors associated with resilience of normally aging, community-living older adults.
      research on resilience in residents of LTCFs is lacking. Given the relation between mood symptoms and quality of life, investigating resilience in relation to mood symptoms can play an important role in identifying factors that can contribute to the preservation of quality of life in the face of stressors in this population.
      • Huisman M.
      • Klokgieters S.S.
      • Beekman A.T.F.
      Successful ageing, depression and resilience research; a call for a priori approaches to investigations of resilience.
      In previous work, we determined major life stressor and conflict with other residents/care staff to be the most suitable stressors for psychological resilience research in older residents because of their strong association with mood outcomes in this population.
      • Angevaare M.J.
      • van Hout H.P.J.
      • Smalbrugge M.
      • et al.
      The Association Between Possible Stressors and Mood Outcomes in Older Residents of Long-Term Care Facilities.
      ,
      • Windle G.
      What is resilience? A review and concept analysis.
      We aimed to (1) explore the occurrence of psychological resilience in the face of a major life stressor and conflict in older residents of LTCFs, and (2) identify factors associated with resilience in this population.

      Methods

      Study Design

      We explored the occurrence of resilience in the face of major life stressor or conflict in older residents of LTCFs and its association with different potential resilience factors using the Dutch interRAI-LTCF cohort.
      • Cosco T.D.
      • Kaushal A.
      • Hardy R.
      • et al.
      Operationalising resilience in longitudinal studies: a systematic review of methodological approaches.

      Data and Population

      Analyses were conducted using routine care assessments of older residents (≥60 years) of LTCFs throughout the Netherlands using the interRAI-LTCF assessment instrument. This assessment is designed to be used by care staff to monitor a LTCF resident’s health and well-being. The assessments consist of ±250 items across 19 domains of health and functioning and are conducted approximately every 6 months by trained nursing staff who are familiar with the resident. These assessments contribute to the early detection of potential problem areas and the design of individualized care plans. All items are scored by the assessors, unless stated otherwise (ie, self-reported).
      LTCFs in the Netherlands provide 24-hour care, are publically funded and subject to governmental inspection, and include both residential care homes (medical care provided by the general practitioner) and nursing homes (treatment by an in-house team, eg, elderly care physicians and psychologists). Data collection has been described in more detail previously.
      • Boorsma M.
      • Joling K.
      • Dussel M.
      • et al.
      The incidence of depression and its risk factors in Dutch nursing homes and residential care homes.
      After de-identification, data were transferred to the interRAI-LTCF database at Amsterdam University Medical Centres – location VU. An opt-out procedure was applied in compliance with the EU General Data Protection Regulation. Residents were informed by facility staff that their data could be used for research purposes and they had the possibility to object to use of their data. The VU ethics committee approved the use of data for research in this way.

      Stressor Selection

      We published the stressor selection procedure previously.
      • Angevaare M.J.
      • van Hout H.P.J.
      • Smalbrugge M.
      • et al.
      The Association Between Possible Stressors and Mood Outcomes in Older Residents of Long-Term Care Facilities.
      Briefly, potential stressors relevant to this population were selected by the research team from the complete LTCF item list. Subsequently, the association between 8 potential stressors and mood outcomes was analyzed. Major life stressor and conflict with staff and/or other resident were the most commonly occurring stressors and were also the most strongly associated with both observer-reported and self-reported mood outcomes. Therefore, these stressors were used to study resilience in the current study. Table 1 provides descriptions of these stressors.
      Table 1Description of Mood Outcomes and Potential Factors
      Variable Type in AnalysisDescription
      Stressors
       1Major life stressorDichotomous stressorThe stressor major life stressor was based on the dichotomous (yes/no) item “major life stressors in the last 90 days,” defined by the interRAI manual as “experiences that either disrupted or threatened to disrupt a person’s daily routine and that imposed some degree of readjustment.” Several examples are provided, such as the death or severe illness of a close family member or friend.
      • Morris JN
      • Belleville-Taylor P
      • Fries BE
      • et al.
       2ConflictDichotomous stressorThe stressor conflict was based on 2 items, namely “conflict with or repeated criticism of staff” and “…other care recipients.” These dichotomous items are described as the presence of “a reasonably consistent pattern of hostility or criticism directed toward 1 or more staff” and “other care recipients,” respectively, over the past 3 days. We created a dichotomous variable indicating conflict with staff and/or other resident.
      Mood outcomes
       1Depression Rating scale (DRS)In observer-reported mood resilience outcomeThe DRS includes 7 observed mood symptoms, such as negativity, anxiety, and crying. The total scores range from 0 to 14, with 14 indicating all mood symptoms present across the past 3 days. Scores of 3 or more indicate clinically meaningful mood symptoms.
      • Burrows A.B.
      • Morris J.N.
      • Simon S.E.
      • et al.
      Development of a minimum data set-based depression rating scale for use in nursing homes.


      A smallest detectable change of 1.3 was calculated from test-retest DRS data (completion of LTCF twice within 2 days) in 224 European residents.
      • Onder G.
      • Carpenter I.
      • Finne-Soveri H.
      • et al.
      Assessment of nursing home residents in Europe: the Services and Health for Elderly in Long TERm care (SHELTER) study.
      Therefore, an equal post-stressor DRS score was characterized as a score of up to 1 point lower or higher than the pre-stressor score.
       2Self-Reported Mood scale (SRM)In self-reported mood resilience outcomeThe SRM was based on 3 self-reported items: loss of interest, sadness, and anxiety. For these items, the residents were asked by the assessor to report if they have experienced these mood symptoms over the past 3 days.

      A total SRM score was calculated, in a similar fashion as the DRS. Not willing/able to respond was coded as a missing value. The total scores range from 0 to 6, with 6 indicating all 3 symptoms being present across the past 3 days. Approximately 85% of the residents responded to the self-reported mood questions.

      We determined a cutoff for clinically meaningful mood symptoms of 2 based on the distribution of scores on the SRM relative to the DRS. Approximately 30% of residents scored 2 or higher on the SRM, similar to the percentage of residents who scored 3 or higher on the DRS. A smallest detectable change of 0.96 was calculated from test-retest self-reported mood data in 157 European residents.
      • Onder G.
      • Carpenter I.
      • Finne-Soveri H.
      • et al.
      Assessment of nursing home residents in Europe: the Services and Health for Elderly in Long TERm care (SHELTER) study.
      An equal post-stressor SRM score was therefore characterized as a score exactly equal to the pre-stressor score.
      Potential factors
       1Older ageContinuousAge in years
       2Female genderDichotomousGender, reference: male.
       3Significant partnerDichotomousThe presence of a significant partner, reference: no.
       4Better cognitive functioningContinuousBased on the Cognitive Performance Scale: Includes 4 items on short-term memory impairment and executive functioning in the past 3 days. Original score inverted, scores range from 0 (very severe impairment) to 6 (intact). A score of 3 or less indicates moderate to severe impairment.
      • Morris J.N.
      • Howard E.P.
      • Steel K.
      • et al.
      Updating the cognitive performance scale.
       5Better communicative functioningContinuousBased on Communication scale: Includes 1 item of expressive and 1 of receptive communication. Original score inverted, scores range from 0 (very severe impairment) to 8 (intact).
       6Better ADL functioningContinuousBased on ADL hierarchy scale (ADL-HS): Includes 4 ADL items of dependence: personal hygiene, toilet use, locomotion, and eating. Original score inverted, scores range from 0 (total dependence) to 6 (independence). Because of the hierarchical nature of the scale dependence in late-loss ADLs such as eating result in a lower score than early-loss ADLs such as personal hygiene.
      • Morris J.N.
      • Fries B.E.
      • Morris S.A.
      Scaling ADLs within the MDS.
       7Hours of physical activity (physical functioning)ContinuousTotal hours of physical activity in past 3 days.
       8Complete control over move to LTCFDichotomousResident had complete control over the decision to move to the LTCF, reference: no.
       9Social engagementContinuousRevised index for social engagement (RISE): Based on 6 items on an individual’s openness to social contact and group activities. Scores range from 0 (not engaged) to 6 (maximally engaged).
      • Gerritsen D.L.
      • Steverink N.
      • Frijters D.H.
      • et al.
      A revised index for social engagement for long-term care.
       10Finding meaning in day-to-day lifeDichotomousResident finds meaning in day-to-day life, reference: no.
       11Consistent positive outlookDichotomousResident has a consistent positive outlook, reference: no.
       12Not being lonelyDichotomousResident says or indicates that he or she feels lonely in last 3 days, reference: yes.
       13Less painContinuousPain scale: Based on 2 items of pain frequency and pain intensity. Original scores were inverted, scores range from 0 to 4, with a higher score indicating a lower level of pain.
       14Lower number of somatic diagnosesContinuousA count of a total of 15 common somatic (neurological, cardiac/pulmonary, infections, cancer, and diabetes mellitus) diagnoses.
       15Absence of psychiatric diagnosisDichotomousThe presence of a psychiatric diagnosis (anxiety, depression, and/or schizophrenia), reference: yes.
       16Strong and supportive relationship with familyDichotomousResident has a strong and supportive relationship with family, reference: no.
       17Participation in social activities of long-standing interestDichotomousParticipation in social activities of long-standing interest in past 3 days, reference: no.
       18Visit with a long-standing social relation or family memberDichotomousVisit with a long-standing social relation or family member in past 3 days, reference: no.
       19Other interaction with long-standing social relation or family memberDichotomousOther interaction (eg, by telephone or e-mail) with long-standing social relation or family member in past 3 days, reference: no.
       20Reminiscing about lifeDichotomousResident reminisced about life in past 3 days, reference: no.
       21Better self-reported healthContinuousThe resident’s response to the question: In general, how would you rate your health? Original score inverted, scores range from 0 (poor) to 3 (excellent).

      Assessment Selection

      The Dutch interRAI-LTCF data used for this study were collected from 2005 to 2018 and consist of a total of 29,199 assessments involving 7171 residents. The first selection steps led to the creation of a base dataset: (assessments following) discharge assessments were excluded as these are used to register discharge/death, thus are incomplete. In the case of multiple assessments within 1 day, the most complete assessment was included. Subsequently, we selected assessments in residents who were 60 years or older. For those residents with assessments in multiple facilities, we selected the assessments in the facility with the most assessments.
      Subsequently, from within this base dataset we identified the first assessments in which a stressor was reported for a resident (incident stressor) for both of the stressors separately. For those residents with this incident stressor, the assessment preceding (pre-stressor assessment) and following (post-stressor assessment) the incident stressor were included.
      • Netuveli G.
      • Wiggins R.D.
      • Montgomery S.M.
      • et al.
      Mental health and resilience at older ages: bouncing back after adversity in the British Household Panel Survey.
      This resulted in the selection of 2 samples of residents: (1) residents who experienced incident major life stressor, and (2) residents who experienced incident conflict.

      Outcome

      A resilient outcome was operationalized as not having clinically meaningful mood symptoms at the post-stressor assessment and equal or fewer mood symptoms at the post-stressor relative to the pre-stressor assessment (Figure 1). We used 2 resilience outcomes: the Depression Rating Scale (DRS) based on observer-reported mood symptoms, and the Self-reported Mood scale (SRM), based on self-reported mood symptoms (see Table 1). We applied these 2 resilience outcomes to both stressors, leading to 4 dichotomous operationalizations of resilience (resilient/nonresilient), based on: (1) observer-reported mood in the face of a major life stressor, (2) self-reported mood in the face of a major life stressor, (3) observer-reported mood in the face of conflict, and (4) self-reported mood in the face of conflict.
      Figure thumbnail gr1
      Fig. 1Examples of resilient and nonresilient courses are provided. The course of the mood symptom score (either observer-reported or self-reported) was classified as resilient when the score at the post-stressor assessment was below the cutoff for clinically meaningful mood symptoms and equal to or lower than the score at the pre-stressor assessment. The courses of examples Resident 3 (R3), R4, and R5 were classified as resilient. The courses of examples R1, R2, and R6 were classified as nonresilient. For R6, the increase in the score between the pre-stressor and post-stressor assessment was greater than or equal to the SDC, ie the smallest detectable change (2 for observer-reported mood, 1 for self-reported mood).

      Factors

      We were interested in potential resilience factors at 3 levels, namely: the individual, social, and facility levels (Figure 2). Selection of potential resilience factors from the LTCF items was informed by earlier studies on resilience in older adults.
      • Gorska S.
      • Singh Roy A.
      • Whitehall L.
      • et al.
      A systematic review and correlational meta-analysis of factors associated with resilience of normally aging, community-living older adults.
      ,
      • MacLeod S.
      • Musich S.
      • Hawkins K.
      • et al.
      The impact of resilience among older adults.
      We included 17 items as potential individual factors, these included sociodemographics; indicators of cognitive, communicative, activities of daily living (ADLs), physical and psychosocial functioning; and indicators of health. Four items describing participation in social activity and frequency of social contacts were included as potential resilience factors at the social level. All potential resilience factors were determined at the pre-stressor assessment and are described in Table 1. The LTCF items did not include any potential factors at the facility (LTCF) level. Therefore, we took the potential effect of the facility level into account by adding the clustering of residents within the LTCF to the statistical models (see the statistical analysis section).
      Figure thumbnail gr2
      Fig. 2Overview of potential resilience factors. ∗Reminiscing about life and better self-reported health had >5% missing data and were included only in the supplementary analyses.

      Confounders

      In addition to these potential factors, we included 3 confounders, namely: the presence of the stressor (either major life stressor or conflict) at the post-stressor assessment, the number of days between the pre-stressor and stressor assessment, and the number of days between the stressor and post-stressor assessment.

      Statistical Analysis

      We compared the baseline characteristics (as registered during a resident’s first assessment) of the residents in both study samples with the other residents in the base population using Mann-Whitney, T-, and χ2- tests.
      We explored if clustering within facility improved the adjusted model for the association between each factor and resilience operationalization using logistic mixed model analyses. Clustering within facility improved the models for self-reported mood in the face of major life stressor resilience, therefore we perform 2-level models for all outcomes.
      We identified the most important factors for each of the operationalizations of resilience using 2-level generalized estimating equation (GEE) analyses in 3 steps.
      • J.d.V. Twisk W.
      • Apeldoorn A.T.
      • de Boer M.R.
      Should we use logistic mixed model analysis for the effect estimation in a longitudinal RCT with a dichotomous outcome variable?.
      First, we performed an adjusted analysis for each factor. Second, those factors with a P value less than .10 on the adjusted single-factor analyses were included in an adjusted multifactor model for each operationalization. Third, we used a manual backward selection process, leading to a final model in which the P value for each included factor was less than .05. Using the predicted values generated by these final models, a receiver operating characteristic curve was plotted and associated area under the curve (AUC) determined. All confounders described previously were included in all adjusted models.
      As there was a minimal amount of missing data for 19 of the potential factors, we performed complete case analyses. Two factors with more than 5% missing values (reminiscing about life: 18.1%–19.5%; and self-reported health: 5.6%–13.8% missing) were additionally included in a supplementary analysis for each of the operationalizations of resilience.
      Those residents who could not or would not respond to the self-reported mood questions could not be included in the analyses with the self-reported mood outcomes. We performed sensitivity analyses to ascertain if potential differences between the models for observer-reported and self-reported outcomes were a result of this selection effect. In these sensitivity analyses, we repeated the analyses for observer-reported outcomes using the sub-sample with complete self-reported mood data (the same sub-sample as the analyses with self-reported outcomes).
      All data preparation, descriptive statistics, and AUC plotting were performed in IBM SPSS statistics version 26. All GEE analyses were performed in STATA version 14.

      Results

      The selection led to the inclusion of a sample of 248 residents with incident major life stressor and a sample of 246 residents with incident conflict with staff and/or another resident (Supplementary Figure 1). The major life stressor sample significantly differed from the other residents of the base population in the proportion of women (76.6% vs 69.9%), score on cognitive performance scale (mean: 1.3 vs 1.8) and total number of assessments (mean: 9.8 vs 3.6). The age (mean: 82.4 vs 82.9 years) and number of somatic diagnoses (mean: 1.5 vs 1.7) in this sample did not differ from the other residents in the base population. The conflict sample significantly differed from the other residents of the base population in the total number of assessments (mean: 9.0 vs 3.6). The age (mean: 81.7 vs 82.9 years), proportion of women (72.4% vs 70.1%), the score on cognitive performance scale (mean: 1.8 vs 1.7) and number of somatic diagnoses (mean: 1.7 vs 1.7) in this sample did not differ from the other residents in the base population.
      Forty-eight percent and 50% of residents demonstrated resilience in the face of major life stressor, based on observer-reported and self-reported mood, respectively. In the face of conflict, 26% and 51% of the residents demonstrated resilience, based on the observer-reported and self-reported mood, respectively (Table 2).
      Table 2Occurrence of Resilience Across Different Operationalizations
      Major Life StressorConflict
      Observer-reportedSelf-reportedObserver-reportedSelf-reported
      Nonresilient130 (52%)105 (50%)181 (74%)90 (49%)
      Resilient118 (48%)106 (50%)65 (26%)93 (51%)
      Total248211246183
      Agreement
      Indicates percentage of agreement between observer-reported and self-reported operationalization in the sub-sample with SRM data complete.
      69%74%
      Indicates percentage of agreement between observer-reported and self-reported operationalization in the sub-sample with SRM data complete.
      Supplementary Table 1 provides the descriptive statistics of nonresilient and resilient groups, and the results of the adjusted single-factor analyses for the 21 potential factors for each of the 4 operationalizations of resilience.
      Table 3 provides the results of the final main and supplementary models after backward selection. The final model for observer-reported mood in the face of a major life stressor included the factors of better cognitive functioning, and strong and supportive relationship with family and had an AUC of 0.74. The final main model for self-reported mood in the face of a major life stressor included the factor participation in social activities of long-standing interest and had an AUC of 0.66. In the supplementary model, in which we included all 21 factors, the factor better self-reported health was additionally included, raising the AUC to 0.68. The final model for observer-reported mood in the face of conflict included the factors better communicative functioning, absence of psychiatric diagnoses, and strong and supportive relationship with family and had an AUC of 0.73. The final main model for self-reported mood in the face of conflict included the factors of not being lonely, and absence of psychiatric diagnoses and had an AUC of 0.69. The factors social engagement and not reminiscing about life were additionally included in the supplementary model, raising the AUC to 0.75. For both observer-reported mood resilience operationalizations, the results of the supplementary models did not differ from the final main model.
      Table 3Results of the Final Main and Supplementary Models for Each of the Operationalizations of Resilience
      FactorMajor Life StressorConflict
      Observer-reported MoodSelf-reported MoodObserver-reported MoodSelf-reported Mood
      Final Main ModelFinal Main ModelSupplementary ModelFinal Main ModelFinal Main ModelSupplementary Model
      OR (95% CI)
      Two-level GEE analyses corrected for: the presence of the stressor (conflict or major life stressor, respectively) at the post-stressor assessment, the number of days between the pre-stressor and stressor assessment and the number of days between the stressor and post-stressor assessment.
      POR (95% CI)
      Two-level GEE analyses corrected for: the presence of the stressor (conflict or major life stressor, respectively) at the post-stressor assessment, the number of days between the pre-stressor and stressor assessment and the number of days between the stressor and post-stressor assessment.
      POR (95% CI)
      Two-level GEE analyses corrected for: the presence of the stressor (conflict or major life stressor, respectively) at the post-stressor assessment, the number of days between the pre-stressor and stressor assessment and the number of days between the stressor and post-stressor assessment.
      POR (95% CI)
      Two-level GEE analyses corrected for: the presence of the stressor (conflict or major life stressor, respectively) at the post-stressor assessment, the number of days between the pre-stressor and stressor assessment and the number of days between the stressor and post-stressor assessment.
      POR (95% CI)
      Two-level GEE analyses corrected for: the presence of the stressor (conflict or major life stressor, respectively) at the post-stressor assessment, the number of days between the pre-stressor and stressor assessment and the number of days between the stressor and post-stressor assessment.
      POR (95% CI)
      Two-level GEE analyses corrected for: the presence of the stressor (conflict or major life stressor, respectively) at the post-stressor assessment, the number of days between the pre-stressor and stressor assessment and the number of days between the stressor and post-stressor assessment.
      P
      4Better cognitive functioning1.36 (1.09–1.69).006
      5Better communicative functioning1.24 (1.03–1.49).020
      9Social engagement1.22 (1.03–1.44).018
      12Not being lonely3.34 (1.07–10.44).0385.86 (1.57–21.9).009
      15Absence of psychiatric diagnosis3.94 (1.74–8.94).0013.03 (1.39–6.60).0053.41 (1.53–7.61).003
      16Strong and supportive relationship with family4.44 (2.74–7.19).0001.88 (1.06–3.35).032
      17Participation in social activities of long-standing interest1.26 (1.15–1.39).0001.24 (1.10–1.39).000
      20Reminiscing about life
      Reminiscing about life and better self-reported health had >5% missing data and were only included in supplementary analyses.
      0.27 (0.15–0.47).000
      21Better self-reported health
      Reminiscing about life and better self-reported health had >5% missing data and were only included in supplementary analyses.
      1.73 (1.01–2.95).046
      n248211207246183149
      AUC0.740.660.680.730.690.75
      OR, odds ratio.
      Only the supplementary analyses for the 2 operationalizations based on self-reported mood led to the selection of additional factors.
      Two-level GEE analyses corrected for: the presence of the stressor (conflict or major life stressor, respectively) at the post-stressor assessment, the number of days between the pre-stressor and stressor assessment and the number of days between the stressor and post-stressor assessment.
      Reminiscing about life and better self-reported health had >5% missing data and were only included in supplementary analyses.
      Supplementary Table 2 provides the factors included in the final models for the sensitivity analyses for observer-reported mood outcomes in the sub-sample with complete self-reported mood data.

      Discussion

      The occurrence of resilience in this study was approximately 50% for 3 of the 4 operationalizations. For the fourth operationalization, observer-reported mood in the face of conflict, the occurrence of resilience was clearly lower, namely 26%. The clearly lower occurrence of resilience based on observer-reported mood in the face of conflict relative to the other operationalizations is in line with our earlier finding that conflict was particularly highly associated with a higher DRS score.
      • Angevaare M.J.
      • van Hout H.P.J.
      • Smalbrugge M.
      • et al.
      The Association Between Possible Stressors and Mood Outcomes in Older Residents of Long-Term Care Facilities.
      Sensitivity analyses, in which we explored the association with an adapted DRS without the 2 items most closely related to conflict (“persistent anger with self or others” and “made negative statements”) showed this association was most likely not a result of a potential theoretical overlap in the items of the DRS and conflict. Possibly, conflict influences the way an observer perceives mood symptoms in a resident who is involved in a conflict. However, the strong association between conflict and DRS was similar for both conflict with a staff member and conflict with another resident.
      • Angevaare M.J.
      • van Hout H.P.J.
      • Smalbrugge M.
      • et al.
      The Association Between Possible Stressors and Mood Outcomes in Older Residents of Long-Term Care Facilities.
      Many of the individual and social-level factors found to be important to resilience based on the different operationalizations had a social aspect, namely, a strong and supportive relationship with family (both observer-reported mood operationalizations), better communicative functioning (observer-reported mood in the face of conflict), participation in social activities (self-reported mood in the face of major life stressor), and not being lonely and social engagement (self-reported mood in the face of conflict). The importance of social factors to (psychological) resilience has been repeatedly described previously in community-dwelling older adults.
      • Gorska S.
      • Singh Roy A.
      • Whitehall L.
      • et al.
      A systematic review and correlational meta-analysis of factors associated with resilience of normally aging, community-living older adults.
      ,
      • Tay P.K.C.
      • Lim K.K.
      Psychological resilience as an emergent characteristic for well-being: a Pragmatic View.
      Psychological resilience (using a dynamic measure of resilience) has not been described in LTCF residents previously; however, a recent scoping review of studies showed that 28 of 35 studies reporting on social connection and depression found a significant positive impact of social connection on depression in residents of LTCFs.
      • Bethell J.
      • Aelick K.
      • Babineau J.
      • et al.
      Social connection in long-term care Homes: a scoping review of published research on the mental health impacts and potential strategies during COVID-19.
      This association was found for different aspects of social connection, some of which, like loneliness, social engagement, and social support, were similar to the resilience factors found here.
      • Bethell J.
      • Aelick K.
      • Babineau J.
      • et al.
      Social connection in long-term care Homes: a scoping review of published research on the mental health impacts and potential strategies during COVID-19.
      • Davison T.E.
      • McCabe M.P.
      • Busija L.
      • et al.
      Trajectory and predictors of mental health symptoms and wellbeing in newly admitted nursing home residents.
      • Hsu Y.C.
      • Wright C.L.
      The association between participation in social activity and depressive symptoms in institutionalized elders in Taiwan.
      These factors with a social aspect form a potential basis for intervention, especially in the LTCF setting: relationships with family can be encouraged/facilitated, social activities can be offered and encouraged, and social contact among residents and between residents and staff can be facilitated. The AUCs of the final models of this exploratory study suggest that the models have a reasonable discriminative ability. However, further research in the LTCF setting is necessary to explore the external validity of the models and identify the most robust resilience factors, which also may be the most promising targets for intervention.
      Although we found that, overall, factors with a social aspect were important to resilience, the importance of specific factors differed across these operationalizations. There was significant overlap in the single factors (single-factor analyses), which played a role in achieving resilience based on the 4 different operationalizations. The most important factors for each operationalization of psychological resilience, as based on backward selection in multifactor models, differed, however, across both the different stressors and perspectives (observer-report and self-report). Sensitivity analyses showed that the factors in the final models for the 2 observer-reported mood operationalizations in the sub-sample with complete self-reported mood data differed somewhat from the final models for observer-reported mood resilience in the complete samples. However, the factors included in the models of observer-reported resilience in the self-reported mood sub-sample differed completely from those included in the final models of self-reported mood resilience. Therefore, we conclude that the difference between the 2 perspectives cannot be (completely) explained by a selection effect of the self-reported mood items. The difference between resilience operationalizations underscores the fact that resilience in older adults is highly context-specific,
      • Angevaare M.J.
      • Roberts J.
      • van Hout H.P.J.
      • et al.
      Resilience in older persons: A systematic review of the conceptual literature.
      ,
      • Windle G.
      What is resilience? A review and concept analysis.
      ,
      • Smith G.C.
      • Hayslip B.
      resilience factors that are found to be important in one context are not necessarily of importance in another one, even if the contexts are very similar. This is important to take into account when designing resilience interventions.
      Reminiscing about life was negatively associated with self-reported mood in the face of conflict. The inclusion of reminiscing about life as a potential resilience factor was based on a qualitative study of resilience in older women that concluded that reminiscing about life and its struggles and survival could act as reassurance of the capacity of older women to deal with stressors.
      • Gattuso S.
      Becoming a wise old woman: resilience and wellness in later life.
      The negative relationship found here is difficult to interpret, as the interRAI item does not specify if the reminiscing is resident-initiated or staff-initiated and does not specify the type of experiences that are reminisced on.

      Strengths and Limitations

      This study uses a comprehensive approach to study resilience in a growing, but understudied, population of older adults who are likely to encounter stressors. To our knowledge, this is the first study to study resilience in the LTCF setting using a dynamic measure of resilience. A recent editorial has stressed the importance of studying resilience dynamically in this population.
      • Guion V.
      • Rolland Y.
      Editorial: resilience in nursing home residents.
      The interRAI-LTCF database allowed us to study a resident’s response to a stressor over time in a natural LTCF setting, incorporate both observer-reported and self-reported mood outcomes, and study the association of resilience with a great amount of potential resilience factors.
      There are also some limitations to consider. The information on the stressors and potential factors are limited by the information available within the interRAI assessment. For example, the descriptions of the potential resilience factor reminiscing about life and major life stressor are quite broad, resulting in limited knowledge on the background and nature of this factor and stressor. In addition, we were interested in potential resilience factors at the facility level, such as staffing ratios and the presence of an outdoor space, but these factors were not available within the Dutch interRAI-LTCF dataset.
      To get a sense of important resilience factors, we studied resilience surrounding a single stressor. However, in reality, stressors do not occur in isolation. Especially in an older population, it is important to realize persons may be dealing with multiple stressors simultaneously. In the previous study in which we identified the relevant stressors, we showed that multiple stressors had a greater impact on mood outcomes than a single stressor.
      • Angevaare M.J.
      • van Hout H.P.J.
      • Smalbrugge M.
      • et al.
      The Association Between Possible Stressors and Mood Outcomes in Older Residents of Long-Term Care Facilities.

      Conclusions and Implications

      Approximately half of residents displayed resilience in the face of relevant psychological stressors according to 3 of the 4 resilience operationalizations in this study. Factors with a social aspect seem to be particularly important to psychological resilience in older LTCF residents, and provide a potential target for intervention in the LTCF setting.

      Supplementary Data

      Supplementary Table 1Single Factor Analyses
      a. Major Life Stressor
      FactorObserver-reported MoodSelf-reported Mood
      nNon Resilient
      Mean (SD) or %.
      Resilient
      Mean (SD) or %.
      Adjusted OR
      Two-level GEE analyses corrected for the following: the presence of the stressor (major life stressor or conflict, respectively) at the post-stressor assessment, the number of days between the pre-stressor and stressor assessment and the number of days between the stressor and post-stressor assessment.
      PnNon Resilient
      Mean (SD) or %.
      Resilient
      Mean (SD) or %.
      Adjusted OR
      Two-level GEE analyses corrected for the following: the presence of the stressor (major life stressor or conflict, respectively) at the post-stressor assessment, the number of days between the pre-stressor and stressor assessment and the number of days between the stressor and post-stressor assessment.
      P
      130118105106
      1Older age24883.1 (7.5)83.3 (7.4)0.99 (0.96-1.02).38721184.2 (7.1)82.8 (7.7)0.96 (0.92-1.02).164
      2Female gender24878%75%0.78 (0.49-1.25).30121175%78%1.12 (0.66-1.89).669
      3Significant partner24125%18%0.71 (0.35-1.45).34620422%21%1.13 (0.71-1.81).609
      4Better cognitive functioning (0–6)
      Original scores inversed in this table and for analyses: Higher score signifies better functioning.
      2484.2 (1.6)4.9 (1.2)1.47 (1.24-1.73).0002114.6 (1.5)4.9 (1.2)1.15 (0.93-1.44).199
      5Better communicative functioning (0–8)
      Original scores inversed in this table and for analyses: Higher score signifies better functioning.
      2486.2 (2.2)7.2 (1.3)1.36 (1.15-1.61).0002116.9 (1.6)7.1 (1.3)1.11 (0.92-1.34).284
      6Better ADL functioning (0–6)
      Original scores inversed in this table and for analyses: Higher score signifies better functioning.
      2483.7 (1.8)4.5 (1.8)1.29 (1.09-1.54).0032114.1 (1.8)4.4 (1.8)1.10 (0.98-1.23).122
      7Hours of physical activity (physical functioning)2481.5 (1.2)1.6 (1.2)1.12 (1.00-1.27).0602111.5 (1.1)1.7 (1.2)1.11 (0.89-1.39).335
      8Complete control over move to LTCF23767%74%1.46 (0.90-2.35).12321078%74%0.94 (0.47-1.86).853
      9Social engagement2483.6 (2.3)4.3 (1.9)1.15 (1.01-1.31).0302113.9 (2.1)4.4 (1.9)1.11 (0.92-1.34).285
      10Finding meaning in day-to-day life24883%88%1.46 (0.65-3.26).36221186%89%1.12 (0.41-3.08).828
      11Consistent positive outlook24866%86%3.44 (1.85-6.40).00021171%90%2.78 (1.19-6.49).018
      12Not lonely24872%89%2.87 (1.14-7.25).02521174%93%3.28 (1.12-9.59).030
      13Less pain (0–4)
      Original scores inversed in this table and for analyses: Higher score signifies less pain.
      2482.3 (0.86)2.3 (0.93)1.00 (0.81-1.23).9702112.4 (0.84)2.3 (0.91)0.95 (0.68-1.32).751
      14Lower number of somatic diagnoses (0–15)
      Absolute scores (count of diagnoses) as represented in this table were inversed for analyses.
      2482.1 (1.4)1.8 (1.3)1.18 (0.99-1.42).0692111.9 (1.3)1.8 (1.3)0.96 (0.78-1.19).726
      15Absence of psychiatric diagnosis24868%78%1.60 (1.03-2.47).03521165%83%2.28 (0.83-6.21).108
      16Strong and supportive relationship with family24862%89%5.42 (3.40-8.65).00021170%84%1.96 (1.01-3.82).048
      17Participation in social activities of long-standing interest24848%66%1.80 (0.98-3.32).05721152%67%1.80 (0.97-3.34).063
      18Visit with a long-standing social relation or family24859%71%1.60 (0.89-2.87).11621163%73%1.57 (0.91-2.72).102
      19Other interaction with long-standing social relation or family member24838%61%2.61 (1.38-4.94).00321152%57%1.00 (0.54-1.84)1.000
      20Reminiscing about life20332%38%0.77 (0.44-1.33).34717528%44%1.33 (0.67-2.64).414
      21Better self-reported health
      Original scores inversed in this table and for analyses: Higher score signifies better health.
      2340.97 (0.59)1.2 (0.57)2.10 (1.31-3.36).0022070.98 (0.61)1.3 (0.56)2.08 (1.30-3.33).002
      b. Conflict
      FactorObserver-reported MoodSelf-reported Mood
      nNon- resilient
      Mean (SD) or %.
      Resilient
      Mean (SD) or %.
      Adjusted OR
      Two-level GEE analyses corrected for the following: the presence of the stressor (major life stressor or conflict, respectively) at the post-stressor assessment, the number of days between the pre-stressor and stressor assessment and the number of days between the stressor and post-stressor assessment.
      PnNot resilient
      Mean (SD) or %.
      Resilient
      Mean (SD) or %.
      Adjusted OR
      Two-level GEE analyses corrected for the following: the presence of the stressor (major life stressor or conflict, respectively) at the post-stressor assessment, the number of days between the pre-stressor and stressor assessment and the number of days between the stressor and post-stressor assessment.
      P
      181659093
      1Older age24682.1 (7.6)83.0 (8.6)1.00 (0.97-1.04).80118381.6 (7.7)83.0 (8.8)1.02 (0.97-1.06).469
      2Female gender24674%68%0.78 (0.37-1.64).51618370%75%1.29 (0.70-2.39).407
      3Significant partner23921%19%0.91 (0.50-1.67).76717618%21%1.24 (0.58-2.67).581
      4Better cognitive functioning (0-6)
      Original scores inversed in this table and for analyses: Higher score signifies better functioning.
      2463.9 (1.3)4.4 (1.4)1.35 (1.10-1.66).0041834.2 (1.2)4.4 (1.2)1.18 (0.89-1.56).249
      5Better communicative functioning (0-8)
      Original scores inversed in this table and for analyses: Higher score signifies better functioning.
      2466.0 (1.9)6.8 (1.7)1.32 (1.11-1.57).0021836.3 (1.6)6.8 (1.5)1.23 (1.02-1.48).032
      6Better ADL functioning (0-6)
      Original scores inversed in this table and for analyses: Higher score signifies better functioning.
      2464.2 (1.5)4.2 (1.7)0.96 (0.78-1.19).7161834.3 (1.5)4.4 (1.5)1.04 (0.87-1.24).668
      7Hours of physical activity (physical functioning)2461.7 (1.2)1.6 (1.1)0.91 (0.71-1.17).4691831.7 (1.2)1.7 (1.1)0.97 (0.76-1.24).787
      8Complete control over move to LTCF23452%63%1.75 (1.12-2.73).01418160%61%0.99 (0.55-1.81).998
      9Social engagement2463.9 (2.1)4.3 (1.5)1.09 (0.95-1.24).2101833.9 (2.1)4.4 (1.9)1.12 (1.02-1.24).020
      10Finding meaning in day-to-day life24685%88%1.29 (0.71-2.34).39518387%91%1.85 (1.16-2.96).010
      11Consistent positive outlook24676%88%2.30 (1.39-3.81).00118378%83%2.41 (0.87-6.68).091
      12Not lonely24680%94%3.77 (1.31-10.89).01418379%94%3.79 (1.15-12.47).029
      13Less pain (0–4)
      Original scores inversed in this table and for analyses: Higher score signifies less pain.
      2462.5 (0.76)2.6 (0.65)1.41 (0.91-2.16).1201832.48 (0.78)2.6 (0.70)1.22 (0.85-1.76).273
      14Lower number of somatic diagnoses (0–15)
      Absolute scores (count of diagnoses) as represented in this table were inversed for analyses.
      2462.4 (1.5)2.1 (1.4)1.06 (0.77-1.46).7121832.7 (1.6)2.0 (1.2)1.24 (0.83-1.84).300
      15Absence of psychiatric diagnosis24665%89%4.81 (2.35-9.89).00018359%82%3.24 (1.55-6.73).002
      16Strong and supportive relationship with family24669%86%2.69 (1.46-4.96).00218369%85%2.35 (0.99-5.57).052
      17Participation in social activities of long-standing interest24647%45%0.89 (0.53-1.48).64118349%53%1.26 (0.76-2.07).376
      18Visit with a long-standing social relation or family24657%63%1.14 (0.65- 2.02).64418362%63%0.98 (0.47- 2.06).966
      19Other interaction with long- standing social relation or family member24634%35%0.96 (0.54- 1.69).88118346%37%0.69 (0.34–1.40).297
      20Reminiscing about life19831%46%1.32 (0.66–2.65).42714941%31%0.44 (0.25- 0.77).004
      21Better self-reported health
      Original scores inversed in this table and for analyses: Higher score signifies better health.
      2121.3 (0.58)1.4 (0.52)1.34 (0.89–199).1581741.2 (0.57)1.4 (0.53)1.88 (1.00–3.58).052
      Adjusted coefficients with a P < .10 were included in the multifactor analysis and are bolded.
      Two-level GEE analyses corrected for the following: the presence of the stressor (major life stressor or conflict, respectively) at the post-stressor assessment, the number of days between the pre-stressor and stressor assessment and the number of days between the stressor and post-stressor assessment.
      Original scores inversed in this table and for analyses: Higher score signifies better functioning.
      Original scores inversed in this table and for analyses: Higher score signifies less pain.
      § Absolute scores (count of diagnoses) as represented in this table were inversed for analyses.
      Mean (SD) or %.
      ∗∗ Original scores inversed in this table and for analyses: Higher score signifies better health.
      Supplementary Table 2Factors Included in the Final Sensitivity Models for Observer-Reported Mood Outcomes in the Subsample for Whom the SRM Data Were Complete, as Compared With the Final Models for the Observer-Reported Mood and Self-Reported Mood Resilience Outcomes
      Observer-Reported MoodObserver-Reported Mood in Population With SRM CompleteSelf-Reported Mood (Supp. Analyses)
      Major Life StressorBetter cognitive functioning, Strong and supportive relationship with familyBetter ADL functioning, Strong and supportive relationship with familyParticipation in social activities of long-standing interest (and Better self-reported health)
      ConflictBetter communicative functioning, Absence of psychiatric diagnoses, Strong and supportive relationship with familyAbsence of psychiatric diagnoses, Strong and supportive relationship with familyAbsence of loneliness, Absence of psychiatric diagnoses (and Social engagement, Not reminiscing about life)
      The factors which were included in both the model for the Observer-Reported Mood and the model for the Observer-Reported Mood in Population With SRM Complete (overlap) are bolded.
      Figure thumbnail fx1
      Supplementary Fig. 1Flowchart of assessment selection.

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