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  • 00:14

    DR. HEIDI EWEN: Hello.My name is Dr. Heidi Ewen.I'm an Associate Professor of Health and Aging Studiesat the University of Indianapolis.[Dr. Heidi Ewen, Associate Professorof Health and Aging Studies] TodayI'm going to be talking to you about aging,relocation, and biomarkers.Relocation is a major life event thatrequires one to make a decision to plan ahead,sort and box possessions, then make a new residence home,

  • 00:35

    DR. HEIDI EWEN [continued]: acquaint oneself with the home and the neighborhoodand any changes in establishing oneselfwith new physicians, pharmacies, or other community settings.Quantitative data alone cannot capture the full experienceand stresses associated with relocation.The focus of my research is on older womenwho are moving from their own homesinto independent and assisted-living apartments.

  • 00:55

    DR. HEIDI EWEN [continued]: I wanted to understand how they made the decision to relocateand the magnitude and their interpretation of the stressesthat it presented.Lazarus described the transactional modelthat postulates our perception of the stressorin our abilities to manage that stress.And that affects how well we fare.Our appraisal processes can lead to three types of appraisals;

  • 01:16

    DR. HEIDI EWEN [continued]: harm, where there may be psychological damage or a lossmay have already happened; a threat, the anticipationof harm that may be imminent; and challenge,the results from the demands that a person feelsconfident about mastering.For my study, I queried participantsabout their anticipated stresses and coping strategiesone month prior to their move.

  • 01:37

    DR. HEIDI EWEN [continued]: Next, it was imperative to operationalizethe term "stress."We all experience stress and can describewhat that experience was like.But for research, we need to be able to measure it.There are strengths and weaknessesfor all measures of stress, so specifying the definitionand measurement is very important.Researchers often use questionnairesand established reliable and validated survey scales

  • 01:58

    DR. HEIDI EWEN [continued]: which yield a score or sub-scale scores on feelings of stress.Most of these are time limited, such as within the last week,how often, or direct responses to belike, "In general, how often do you feel?", or overall.Biological methods of assessing the stress responseare often used in research as well.

  • 02:19

    DR. HEIDI EWEN [continued]: Such methods include taking blood pressure, heart ratemeasures, and skin conductance to recordthe basic physiological responses to induce stressin experimental studies.Others may use blood samples to capturethe levels of adrenaline and noradrenaline.These are the hormones released during a stressful encounterand serve to mobilize our responses quickly.The fight-or-flight state is moderated

  • 02:40

    DR. HEIDI EWEN [continued]: by those two hormones, which activate our bodiesand then settle us back down to calm.Neither of these approaches were appropriate for my study,so I began investigating the utility of measuring cortisol.Cortisol is a hormone that is produced by the adrenal glands,which lie atop each kidney.Cortisol is released in pulsatile burstsevery 15 minutes and has an established diurnal pattern

  • 03:03

    DR. HEIDI EWEN [continued]: that's closely linked to our sleep-wake cycles.The highest quantity of cortisol releaseoccurs within the first hour after waking in the morning,and it gradually tapers to the trough,or it's also called the nadir, the low point during the nightwhile we sleep.When measured over the course of the day,there's a distinct peak in nadir with a slope corresponding

  • 03:23

    DR. HEIDI EWEN [continued]: to the decreasing levels released.In order to assess the diurnal pattern,saliva samples can be taken at key time points; justafter waking, one hour after waking, early afternoon,late afternoon, evening, and at bedtime.Alternatively, one hour after waking and bedtime

  • 03:44

    DR. HEIDI EWEN [continued]: can also be effective.Stress is determined by the peak cortisol measure--the slope or the area under the curve.Normal values for both the peak in the nadirvary by age and gender.During times of stress, the peak level will rise.And under chronic stress, both the peak and the nadirelevate as our bodies work to sustain energyto manage stress.

  • 04:04

    DR. HEIDI EWEN [continued]: If the stress does not abate, then wesee the curve begin to flatten, whichindicates the body's failure to regulatethe physiological responses.As we age, the curve naturally shifts downward,signaling the slowing of our physical bodies,yet the pattern of the peak in the nadir remain consistent.As a side note, adrenaline provides a burst of energyto help us flee a stressor, whereas cortisol

  • 04:27

    DR. HEIDI EWEN [continued]: helps us sustain it long term.It works to provide constant energy.In order to maintain energy for the long term,our bodies naturally crave carbohydrates,which the body can store and use to sustain us.If you're not hiding from an enemy in a waror running a marathon, these excess carbswill appear around your waist and hips in fat storageand often indicate prolonged stress.

  • 04:50

    DR. HEIDI EWEN [continued]: Combining the survey scale assessmentsand salivary cortisol was the approachthat I chose for my study, and it served well.I interviewed participants one month priorto their move and then three and six months later.The week of each interview, participantsselected one day to collect six samples of saliva, whichwere transported on ice to the lab for processing, analysis,and storage.

  • 05:10

    DR. HEIDI EWEN [continued]: In months where their interviews were not conducted,participants collected their saliva samples four weeksfrom the preceding interview.The last issue to consider was howto document perceived or appraised stress during monthswhen interviews and surveys were not included.Adding a qualitative piece in the form of journalingwas added.Participants kept a log of events experienced,the perceived stressfulness of those, their typical bedtime

  • 05:33

    DR. HEIDI EWEN [continued]: and wake time, the quality of their sleep,and any other information they wanted to note.Thus, a mixed method study was born.It was a six-month longitudinal studythat included psychosocial skills for stress and coping,qualitative information on perceptions of stress,and biological samples to measurephysiological reactivity.Triangulation is the term for using multiple methods.

  • 05:56

    DR. HEIDI EWEN [continued]: It increases the credibility and validity of research findings.Credibility refers to the trustworthinessand how believable a study is.Validity is concerned with the extentto which a study accurately reflects or evaluatesthe concept or ideas being investigated.Triangulation by combining theories, methods, or observersin a research study can help ensure

  • 06:17

    DR. HEIDI EWEN [continued]: that fundamental biases arising from the useof a single method or a single observer are overcome.Triangulation is also an effort to help explore and explaincomplex human behavior using a variety of methodsto offer a more balanced explanation to readers.It's a procedure that enables validation of dataand can be used in both quantitative and qualitative

  • 06:39

    DR. HEIDI EWEN [continued]: studies.The study was reviewed and approvedby the University Medical IRB.Given the size and the scope of the study,participants were offered remunerationfor their participation in the formof $200, paid half after the first interviewand the other half six months after their enrollment.The consent form included statements about their rightsas a research participant in the ways in which their data would

  • 07:01

    DR. HEIDI EWEN [continued]: be used and stored.Two copies of the consent form weresigned at the time of the interview;one was kept for IRB records, and the otherwas kept by the participants.It included the phone numbers for the IRB and for myselfso that they could contact us for information.Enrollment began with contacting and meetingmanagers of senior housing facilities, whichwere limited to housing designed for independent and assisted

  • 07:23

    DR. HEIDI EWEN [continued]: living.The participants needed to be competent enoughnot to require skilled care.Information about the study was providedto prospective residents on housing waitlists,and interested parties would contactme, the principal investigator, to learn more and schedulean interview.The enrollment was ongoing for 18 months with a goalof recruiting 30 participants.

  • 07:44

    DR. HEIDI EWEN [continued]: Complete data were collected for 26 women,with an average age of 78 years, plus or minus 11.The majority of the sample were widowswho had been married an average of 33 years,and the majority had children.8% were married and had been marriedfor an average of 57 years.Approximately 1/4 were divorced, and 2 participants

  • 08:06

    DR. HEIDI EWEN [continued]: have never married.Participants self-rated their health and reported conditionsfor which they were receiving treatment from a physician.The women in the study were in fair health and required carefor comorbid health conditions of disparate severity.The majority of conditions were common among older adultsand included hypertension, arthritis, gastric reflux,heart disease, angina, thyroid dysfunction, and stomach upset.

  • 08:31

    DR. HEIDI EWEN [continued]: They reported sleeping an average about 6.8 hoursper night, regularly awakened about three timesand considered their sleep quality to be somewhat restful.When asked about their reasons for relocating,they could mention more than one reason,and these were clustered into themesusing qualitative methods.The themes included; they were encouragedto do so by their children, they wanted

  • 08:53

    DR. HEIDI EWEN [continued]: to be free from home maintenance,they needed to be closer to a relative who needed care,or they were experiencing health issues.The women experienced an average of six major lifeevents in the year prior to relocation.These included death of a spouse,deaths of friends, health changesas well as changes in diet, sleep, and activity

  • 09:14

    DR. HEIDI EWEN [continued]: participation, all of which are stressful.The stresses influencing relocationwere analyzed through qualitative methods,and themes emerged from the cluster of meaningson the most stressful events.These included health issues, moving and selling a residenceat the same time, the declining health of a family member

  • 09:34

    DR. HEIDI EWEN [continued]: and caregiving responsibilities, death of loved ones,and finance.The details of moving, such as sorting items, packing,organizing the move-in helpers, and the accompanyingphysical exertion was one emergent theme.A second theme of divestment emerged.Divestment is a process of downsizing and partingwith personal possessions.Disruptions in place attachment was a third theme

  • 09:56

    DR. HEIDI EWEN [continued]: and included details such as leaving former communitiesand churches and adjusting to livingnear so many other people.Transitional stresses included complicating factors,such as selling a house while settling into the new home.Health issues, either for oneself or for a relative,were common.Some of the initial quantitative resultsyielded support for hypotheses, including;

  • 10:20

    DR. HEIDI EWEN [continued]: women who had experienced multiple life eventsand had influence of others to make the choice to movewould report higher levels of stress.This hypothesis was fully supported.The second hypothesis was that women who made the decisionto relocate would have higher scores on proactive coping,well-being, and health both at the time of the move and three

  • 10:41

    DR. HEIDI EWEN [continued]: months afterward.Results yielded partial support for this hypotheses,with significant differences and positive and negative affectbut not in proactive coping or health.We also hypothesized that women making the decision alonewould have higher scores on positive affect and lowerscores on negative affect at the time of the move.Three months post-move, there was no difference in affect

  • 11:03

    DR. HEIDI EWEN [continued]: or self-rated health between the two groups,yet positive affect did increase from the time of moveto three months in the new residence.The salivary cortisol samples were analyzed in the lab.The samples were centrifuged for 15 minutesand analyzed in duplicate throughenzyme-linked immunosorbent assay techniques,also known as ELISA assays.

  • 11:26

    DR. HEIDI EWEN [continued]: The inter-assay coefficient of variation resultsranged from 3.5 to 4.7, and the inter-assay CVsranged from 3.3 to 5.4, indicating acceptable precisionin results.Analyses began by looking at datafrom women who had indicated that relocation was a stressor.It was expected that these cases would show elevationsin peak cortisol values and that physiological trends over time

  • 11:50

    DR. HEIDI EWEN [continued]: would follow their psychosocial reports of stress.Analysis of the cortisol assays beganby looking at data from women who had indicatedthat relocation was a stressor.It was expected that these cases would show elevationsin the peak cortisol levels and that physiological trendsover time would follow psychosocial self-reportsof stress.This figure illustrates the four profile types

  • 12:12

    DR. HEIDI EWEN [continued]: that emerged from the study.The top left graph shows a normal diurnal profile.You can see that there are error bars, indicatedby dashed lines, and a sun and then a moon.The sun indicates the normal average peakfor women aged 60 and over as well as

  • 12:33

    DR. HEIDI EWEN [continued]: the moon indicating the typical nadir of a woman whois over the age of 60.And you'll see that, by and large,most of these peak and nadir responsesare within the normal limits.However, looking at the second graph on the top right,these are cases where there was an experience of stress.You can see that the peaks are elevated

  • 12:54

    DR. HEIDI EWEN [continued]: above the normal range, and half of thoseare above average for the nadir as well.This state is called allostasis, whichmeans the body is attempting to manage the stress.And you can see that the cortisolis increased in order to sustain the bodythrough that moderation.

  • 13:15

    DR. HEIDI EWEN [continued]: The bottom left graph illustrates an absolute rhythm.This is a rhythm that is not consistent with either normalcortisol release or stress.You can see from this one that the peaks areall over the place, and it's highly likelythat these women were either overwhelmed,had irregular sleeping patterns, or had collected their salivasamples in the wrong vials.

  • 13:37

    DR. HEIDI EWEN [continued]: The bottom right graph illustrates allostatic load.This is a term that indicates the body has failedto adapt to the stressor.The natural homeostatic mechanismthat returns the body back to a normal statehas been exhausted, and it can no longer respond to stress.

  • 13:57

    DR. HEIDI EWEN [continued]: This type of profile is commonly associatedwith concurrent health declines and often is followed by death.When looking at the relationship between stress and cortisol,I found that peak cortisol values were relatedto perceived stress, and the evening cortisolvalues as well, which is consistent with the theory.

  • 14:18

    DR. HEIDI EWEN [continued]: Neither peak nor even cortisol valueswere related to self-reported sleep quality, sleep quantity,or the number of awakenings during the night.Use of hormone replacement therapy or medicationsfor depression, anxiety, or pain was notrelated to perceived stress or the cortisol measures.However, the use of anxiolytics was related to sleep quality.

  • 14:39

    DR. HEIDI EWEN [continued]: The saliva collection could have benefitedfrom repeated measures.In particular, collecting four time points instead of sixon two successive days may have provided greater insightto the typical diurnal rhythm.Such a procedure may have been mostbeneficial for those whose rhythmsappeared to be aberrant.Two of the aberrant rhythms may possiblybe elevated normal rhythms, with collection times deviant

  • 14:60

    DR. HEIDI EWEN [continued]: from those that were requested.Had the data been collected on two successive days,the graphs may have provided better indicationof cortisol release or determinationof whether the vials had been used out of sequence.One recommendation for use of this method in future researchincludes the hiring of a project manager.A manager or a director would oversee

  • 15:21

    DR. HEIDI EWEN [continued]: all aspects of the study and coordinate team members.The director would work with a clinical research organizationand their participant outreach coordinator for advertisingand recruitment, screening of volunteers,and managing contacts with outside agencies,like the senior housing managers.A qualitative research specialistwould be needed to provide guidance on question

  • 15:41

    DR. HEIDI EWEN [continued]: development and analytic strategiesfor open-ended experiential questions.A quantitative specialist would needto contribute perspectives for empirical and valid assessmentskills, scoring protocols, data coding, and scoring.Scholars with expertise in psychophysiology,endocrinology, and laboratory methodswould provide input on the collection, processing,

  • 16:04

    DR. HEIDI EWEN [continued]: storage, analysis, and interpretationof the biological data.Another lesson learned was boundaries.Boundaries are essential for the protectionof both the researchers and the participants,but those boundaries are fluid dependingon the type of scientific approach or method used.Qualitative research has more fluid boundariesdue to the nature of exploration inherent with the methods.

  • 16:26

    DR. HEIDI EWEN [continued]: Quantitative research approaches emphasize objectivityand requires more firm boundaries.Therefore, a mixed method study like this can be challenging.It can be complicated when repeated measures arerequired since relationships begin to develop.Preparing in advance, determiningwhere those boundaries should be set,and how to broach any problematic issues

  • 16:46

    DR. HEIDI EWEN [continued]: is advisable in advance of collecting data.The Belmont Report is a key foundation pieceon research ethics.Best practices for qualitative and mixed method studiescan be found in the literature.Recommendations for future research.Research on relocation outcomes wouldbenefit from using the methods we described here.A longitudinal design involving the triangulationof self-report, psychosocial, and physiological measures.

  • 17:09

    DR. HEIDI EWEN [continued]: Optimally, data collection beginningwith potential participants on the housing waitlistwould provide a better method for ascertainingthe baseline physiological measuresas well as for identifying the social and lifestyle changesthat naturally occur when moving into congregate housing.This one also afforded opportunityfor developing a control group of peers who are consideringa move yet are currently aging in place

  • 17:31

    DR. HEIDI EWEN [continued]: within their own homes in the community.Thank you for the opportunity to present my research on mixedmethods, including biomarkers.My next video will include informationon age, period, and cohort effects in research on aging.


Dr. Heidi Ewen, Associate Professor of Health and Aging Studies, University of Indianapolis, discusses mixed methods research on aging, relocation, and biomarkers, including research design, recruitment, data analysis, and lessons learned.

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Aging, Location and Biomarkers

Dr. Heidi Ewen, Associate Professor of Health and Aging Studies, University of Indianapolis, discusses mixed methods research on aging, relocation, and biomarkers, including research design, recruitment, data analysis, and lessons learned.

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