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Routinization preferences, anxiety, and depression in an elderly French sample
Journal of Aging Studies 16 (2002) 295 – 302
Routinization preferences, anxiety, and depression in an elderly French sample Jean Bouisson Clinical Psychology Laboratory, University of Bordeaux 2, 3ter Place de la Victoire, 33076 Bordeaux cedex, France Accepted 4 March 2002
Abstract The relationship of routinization preferences to age and clinical variables was examined in a sample of 80 elderly French participants living independently or in residential facilities. Consistent with previous findings, age explained a major portion of the variance in routinization preferences. However, hierarchical multiple regression analyses revealed that the association of anxiety and depression to routinization preferences also remained significant even after controlling for the effects of age and other individual difference variables. These findings are discussed for their implications in understanding inconsistencies in previous research and demonstrating the independent importance of clinical variables in understanding age-related behavioral change. D 2002 Elsevier Science Inc. All rights reserved. Keywords: Elderly; Routinization; Anxiety; Depression
1. Introduction Despite the somewhat negative connotations associated at times with the word ‘routine,’ this concept is of fundamental importance for normal and adaptive functioning across all stages of the life span. Researchers have underscored the necessity of at least a minimal level of stable behavioral patterns or routines in assuring normal family functioning, the successful division of work tasks, coping with adversity, and in the definition of personal roles that constitute important aspects of an individual’s identity and personality (e.g., Agho, 1993; Blegen, 1993; Gallimore, Bernheimer, & Weisner, 1999; Kaufmann, 1992, 1997; Reich, 2000). For the elderly, the presence of routines can also be regarded as adaptive in that it may 0890-4065/02/$ – see front matter D 2002 Elsevier Science Inc. All rights reserved. PII: S 0 8 9 0 - 4 0 6 5 ( 0 2 ) 0 0 0 5 1 - 8
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J. Bouisson / Journal of Aging Studies 16 (2002) 295–302
protect the individual from the dangers or stress associated with novel situations or challenges. However, the presence of inflexible behavioral patterns that resist change or that rigidly follow a particular order (also referred to as ‘routinization’) may represent maladaptive processes that prevent elderly individuals from ameliorating problems or making necessary changes in daily life (Reich & Zautra, 1991). The concept of routinization has most often been examined from a cognitive perspective by assessing the desires or preferences of elderly individuals for particular routines. Although such preferences for behavioral and environmental stability have been shown to become increasingly pronounced with age (see De Beauvoir, 1970; Kastenbaum, 1980–1981, 1984; Reich & Zautra, 1991), they have not been found to be associated with improved well-being or satisfaction (Reich & Zautra, 1991). Moreover, it has been suggested that an increasing preference for routinization as one grows older may reflect more than simply age-related coping and may at times constitute a risk factor for mental health problems such as anxiety or depression (see Bouisson, 1997; De Beauvoir, 1970; Reich & Zautra, 1991). However, despite clear evidence that age is associated with both increases in routinization preferences as well as a high frequency of anxiety and depression (Alexopoulos, 1991; Blazer, George, & Hugues, 1991; Clement, Paulin, & Leger, 1999; Parmalee, Katz, & Lawton, 1993), the relationship among these later variables has received relatively little attention. The examination of routinization preferences and their adaptiveness in the elderly population has been hindered by specific conceptual and methodological barriers. Most importantly, a considerable degree of shared variance exists between the desire for routinization, aging, and clinical variables, and the methodologies employed by previous studies have not used analytic strategies capable of controlling for multicollinearity among these factors. It is therefore unknown if anxiety or depression is directly related to routinization preferences (regardless of age), or if their potential link is best explained through their correlation with age. The examination of this question also requires that the variables included in multivariate analyses each contain sufficient variance to adequately assess its potentially unique role, and therefore examining the role of age in an already elderly population requires that the sample span from the old to the very old. A final issue concerns the role of third variables that are independently related both to routines and to age. Most notably, living in a retirement home or nursing facility is associated not only with age but with a highly regulated daily life schedule (which may explain part of the variance in routinization). Similarly, individuals placed in such facilities are known to experience greater anxiety or depression than independently living older adults (Clement et al., 1999). Such confounding factors should therefore be taken into account in understanding the potentially independent relationship of routinization preferences to age or to clinical variables. The purpose of the present investigation is to examine the association of routinization preferences with both age and negative affective states (anxiety and depression) in light of the above-noted methodological and conceptual issues. Elderly participants were recruited from both retirement homes and private residences across four urban and rural areas of France. Based on previous findings, it is hypothesized that routinization preferences will increase linearly with age. However, the relationship of anxiety and depression to routinization preferences will also be examined independently after controlling for the effects of age or other explanatory factors.
J. Bouisson / Journal of Aging Studies 16 (2002) 295–302
297
2. Method 2.1. Participants Eighty elderly individuals (61 women and 19 men) participated in the present study. The sample age range was from 65 to 96 years, with a mean of 79.6 years (S.D.=7.9). Approximately equal numbers of participants were selected from retirement homes (N=41; mean age=82.6, S.D.=7.8) and from independent living accommodations (N=39; mean age=76.3, S.D.=6.6). 2.2. Procedure Participants were contacted in either residential nursing facilities (retirement or nursing homes) or independently through convenience sampling in four geographic areas of France. Following informed consent procedures, participants responded to an anonymous questionnaire packet that assessed demographic information and provided continuous self-report measures of routinization preferences, anxiety, and depression. When requested by participants, research staff blind to the objectives of the present study assisted in reading the questionnaires or in recording responses. 2.3. Materials 2.3.1. State–Trait Anxiety Inventory (STAI) The trait version of the STAI was used in the present study to assess anxiety. The respondent is asked to rate how he or she ‘generally feels’ on a 4-point Likert scale concerning 20 items that assess anxiety-related states. The original STAI measure has been shown to have high internal consistency, good test–retest reliability, and high concurrent validity as a measure of trait anxiety (Spielberger, Gorsuch, & Lushene, 1983). The Frenchlanguage validation of this instrument has produced similar psychometric properties (Bruchon-Schweitzer & Paulhan, 1993). 2.3.2. Center for Epidemiologic Studies of Depression Scale (CESD) The CESD is a 20-item measure of depression symptomatology that asks participants to rate on a 4-point Likert scale the intensity of cognitive, somatic, emotional, and behavior symptoms over the previous week. The original English-language scale is characterized by high internal consistency and test –retest reliability (Radloff, 1977), and the Frenchlanguage translation of the CES-D has conserved these psychometric properties (Fuhrer & Rouillon, 1989). 2.3.3. Routinization preferences Routinization preferences were assessed through a brief French-language scale constructed for this study. Based on direct interviews with elderly individuals, 13 themes were identified relative to commonly cited daily life habits or patterns. These themes are similar
298
J. Bouisson / Journal of Aging Studies 16 (2002) 295–302
to other English-language measures of routinization preferences (e.g., Reich & Zautra, 1991), but differed in that they were limited to specific routines or behavior patterns (concerning meal times, sleep or nap schedules, seating preferences, organization of personal objects, specific recreational activities, and social exchange with friends and family) and intentionally did not include broader questions relative to other personality dimensions such as sensation seeking. A questionnaire was then constructed asking participants to rate on a 5-point Likert scale their level of general agreement with statements about doing tasks in a particular order or their agreement with the desirability of changes to daily life behaviors. Examples of specific items include general activities (e.g., ‘In general, I like to do the same things each day’), leisure (e.g., ‘I like to watch new shows or films on television’) and daily rhythms (‘I like to wake up and go to bed at the same time each day’). A total score of routinization preferences was calculated by summing responses across all items, with higher scores representing greater preferences for routinization. Preliminary analyses of the initial question pool permitted the exclusion of three items having item–total correlations inferior to .40. The 10-item scale had an internal consistency in the present sample of .73, high test–retest reliability over a 2-week period (r=.84), and was appropriately brief for use with very old or infirm participants. Finally, the construct validity of routinization preferences was examined using the Experience Sampling Method (see Swendsen, 1998; Swendsen et al., 2000). A subsample of participants in the present study was assessed several times per day for a period of 4 days to collect a random sample of daily life behaviors and activities (including specific information about where the participants were at the moment of the assessment and what they were doing). Environmental and behavioral assessments were readministered during the same time periods each day, and then were coded for repetition across days. Greater preferences for routinization were highly predictive of the repetition of specific behaviors as well as the environmental contexts in which the behaviors occurred (Bouisson & Swendsen, in preparation). 2.4. Overview of analyses The hypotheses of the present study were tested using hierarchical multiple regression analyses to explain variance in routinization preference scores. All analyses entered sex, residential status (retirement home or independent living), and age as covariates followed by inclusion of the predictor as hypothesized (anxiety or depression scores). Based on the inclusion of three covariates and one predictor, a power analysis demonstrated that the current sample size provides over .80 power for detecting an effect size equivalent to 15% of the total variance in routinization preferences.
3. Results Table 1 presents descriptive information and intercorrelations of routinization preferences, age, and clinical variables. Consistent past findings, stronger preferences for routinization
J. Bouisson / Journal of Aging Studies 16 (2002) 295–302
299
Table 1 Means, standard deviations, and intercorrelations among variables Variables Routinization preferences
Age
STAI anxiety
CESD depression
Means, standard deviations, and ranges Mean 32.2 S.D. 8.0 Range 12 – 50
79.6 7.9 65 – 96
44.3 10.5 24 – 72
21.6 10.6 1 – 44
Intercorrelations among measures Routinization (.73) Age .56* STAI .30* CESD .41*
– .13 .32*
(.86) .75*
(.88)
* P<.01, internal consistencies noted in parentheses.
were strongly correlated with age, and they were also moderately correlated with both anxiety and depression levels. Analyses concerning variance attributable demographic variation revealed that when compared to men, women experienced greater anxiety, t(78)= 2.53, P<.05, depression, t(78)= 2.20, P<.05, and tended to be older, t(78)= 1.71, P<.10. Participants living in retirement homes were older than those living independently, t(78)= 3.91, P<.01, and they also reported greater depression, t(78)= 2.40, P<.05. In order to examine if clinical variables explain variance in routinization preferences independent of other predictors, hierarchical multiple regression analyses were performed. Models were run separately for anxiety and depression, and all analyses entered sex, residential living status, and age as covariates. Concerning the relationship of routinization preferences and anxiety, the overall model was highly significant, F(4,75)=11.08, P<.001, with age explaining the greatest amount of variance as expected, t(1)=5.21, P<.001. As hypothesized, however, anxiety nonetheless remained a significant independent predictor of routinization preferences even after controlling for the effects of the other covariates, t(1)=2.28, P<.05 (Table 2). Parallel results were also found for depression in that the overall
Table 2 Hierarchical multiple regression analyses of routinization preferences by anxiety Variable in order of entry
F
df
Full model Sex Residential status Age Anxiety
11.08**
4, 75 1 1 1 1
* P<.05. ** P<.01.
Beta
S.E.
.75 .21 .54 .17
1.81 1.60 0.10 0.07
R2
t 0.42 0.13 5.21 2.28
0.37 .04 .04 .25** .04*
300
J. Bouisson / Journal of Aging Studies 16 (2002) 295–302
Table 3 Hierarchical multiple regression analyses of routinization preferences by depression Variable in order of entry
F
df
Full model Sex Residential status Age Depression
11.51**
4, 75 1 1 1 1
Beta
S.E.
.90 .89 .51 .19
1.77 1.61 0.11 0.08
R2
t 0.51 0.56 4.81 2.52
.38 .04 .04 .25** .05*
* P<.05. ** P<.01.
model was significant, F(4,75)=11.51, P<.001, and that a significant independent role was found for both age, t(1)=4.81, P<.001, and depression, t(1)=2.52, P<.05 (Table 3).
4. Discussion The most salient finding of the present study is the very strong association between routinization preferences and age, a finding consistent with several previous investigations on elderly samples (Bouisson, 1997; Kastenbaum, 1980–1981, 1984; Reich & Zautra, 1991). However, based on these conservative analyses, a reasonable conclusion is also that the desire for routinization is a complex phenomenon that cannot be universally classified as a normal age-associated adaptation process. Although it may indeed be adaptive in most cases (routines permit the elderly to find stability and control, and therefore become a preferred aspect of daily living), the independent associations found for routinization preferences with anxiety and depression demonstrate potentially undesirable components. In this way, the desire for routinization especially at high levels may be an important index of psychological vulnerability in older adults. The public health implications of such associations are also important in light of the elevated degree of anxiety and depression comorbidity observed in the elderly, and in particular those placed in nursing homes (Alexopoulos, 1991; Blazer et al., 1991; Clement et al., 1999; Parmalee et al., 1993). Concerning the direction of the observed relationship between negative affectivity and routinization (whether examined as preferences for routines or as routines themselves), at least two mechanisms appear tenable. First, the avoidance of change in this population, albeit understandable, may render it difficult to ameliorate difficult life circumstances that in themselves are likely risk factors for anxiety and depression. This possibility is supported by previous findings that routinization preferences in the elderly are associated with an increase in the frequency of undesirable events and a decrease in the frequency of desirable events (Reich & Zautra, 1991). These stressful events may increase anxiety and depression directly or through their impact on self-esteem, sense of personal control, or other consequences confronting the routinized individual in a changing environment. Alternatively, high levels of negative affect may preexist the emergence of routinization (or the expressed desire for such), and, thus, negative affect may serve as an initial motivator to seek security and stability
J. Bouisson / Journal of Aging Studies 16 (2002) 295–302
301
during a vulnerable phase of life. If this is the case, however, the current findings indicate that there is no guarantee that routinization serves an adaptive role nor that it is capable of addressing the fundamental causes of preexisting psychological distress. In interpreting the present finding, several methodological characteristics of this study should be considered. First, a dimensional approach was used to characterize both routinization preferences and clinical variables, and different findings may emerge in applying a categorical or diagnostic approach. Concerning the operationalization of the routinization concept, a basic definition was used that assessed the desirability of changes to specific daily life habits or routines. Although this definition of routinization preferences is highly predictive of actual behavioral routinization in daily life, alternative conceptualizations of routinization or its desirability may find different results (especially if they are broadened to include sensation-seeking, obsessiveness, or other personality traits). Finally, while the present research underscores the complexity routinization preferences in the elderly, several questions merit further attention. Similar to the point raised by Reich and Zautra (1991), it remains unclear as to what differentiates routinization as a resource from routinization as a handicap. It is therefore unknown if a threshold can be determined in support of treatment or prevention efforts aimed at identifying ‘pathological’ routinization. Future research may benefit from considering these issues in exploring the causes and implications routinization preferences and other aspects of enduring behavioral change in the elderly.
References Agho, A. (1993). The moderating effects of dispositional affectivity on relationships between job characteristics and nurses’ job satisfaction. Research in Nursing and Health, 16, 451 – 458. Alexopoulos, G. S. (1991). Anxiety and depression in the elderly. In D. Salzman, & B. D. Lebowitz (Eds.), Anxiety in the elderly ( pp. 63 – 77). New York: Springer. Blazer, D., George, L. K., & Hugues, D. (1991). The epidemiology of anxiety disorders: an age comparison. In D. Salzman, & B. D. Lebowitz (Eds.), Anxiety in the elderly ( pp. 17 – 30). New York: Springer. Blegen, M. A. (1993). Nurses’ job satisfaction: a meta-analysis of related variables. Nursing Research, 42, 36 – 41. Bouisson, J. (1997). La routinisation du sujet aˆge´ (Routinization in the elderly). L’Information Psychiatrique, 3, 239 – 248. Bouisson, J., & Swendsen, J. (2001). Use of the experience sampling method in elderly samples. France: University of Bordeaux (in preparation). Bruchon-Schweitzer, M., & Paulhan, I. (1993). Inventaire d’anxie´te´ e´tat – trait (Forme Y). STAI, Consulting Psychologist Press, Edition franc˛aise: Editions de Centre de Psychologie Applique´e. Clement, J. P., Paulin, S., & Leger, J. M. (1999). Troubles de l’humeur. In J. M. Le´ger, J. P. Cle´ment, & J. Wertheimer (Eds.), Psychiatrie du sujet aˆge´ ( pp. 112 – 132). Paris: Flammarion. De Beauvoir, S. (1970). La vieillesse. Paris: Gallimard. Fuhrer, R., & Rouillon, F. (1989). La version franc˛aise de l’e´chelle CES-D (Center for Epidemiology Studies — De´pression Scale). Description et traduction de l’e´chelle d’autoe´valuation. Psychiatrie et Psychobiologie, 4, 163 – 166. Gallimore, R., Bernheimer, L. P., & Weisner, T. S. (1999). Family life is more than managing crisis: broadening the agenda of research on families adapting to childhood disability. In R. Gallimore, & L. P. Bernheimer (Eds.), Developmental perspectives on children with high-incidence disabilities. The LEA series on special education and disability ( pp. 55 – 80). Mahwah, NJ: Erlbaum.
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Kastenbaum, R. J. (1980 – 1981). Habituation as a model of aging. International Journal of Aging and Human Development, 12, 159 – 170. Kastenbaum, R. J. (1984). When aging begins. Research on Aging, 6, 105 – 117. Kaufmann, J. C. (1992). La trame conjugale (Analyse du couple par son linge). Paris: Nathan. Kaufmann, J. C. (1997). Le cœur a` l’ouvrage (The´orie de l’action me´nage`re). Paris: Nathan. Parmalee, P. A., Katz, I. R., & Lawton, M. P. (1993). Anxiety and its association with depression among institutionalized elderly. American Journal of Geriatric Psychiatry, 1, 46 – 58. Radloff, L. S. (1977). The CES-D Scale: a self-report depression scale for research in the general population. Applied Psychological Measurement, 3, 385 – 401. Reich, J. W. (2000). Routinization is a factor in the coping and the mental health of women with fibromyalgia. Occupational Therapy Journal of Research, 20, 41s – 51s. Reich, J. W., & Zautra, A. J. (1991). Analysing the trait of routinization in older adult. International Journal of Aging and Human Development, 32(3), 161 – 180. Spielberger, C. D., Gorsuch, R. R., & Lushene, R. E. (1983). Manual for the State – Trait Anxiety Inventory (STAI). Palo Alto: Consulting Psychologists Press. Swendsen, J. (1998). The experience of anxious and depressed moods in daily life: an idiographic and crosssituational test of the Helplessness – Hopelessness Theory. Journal of Personality and Social Psychology, 74, 1398 – 1408. Swendsen, J., Tennen, H., Carney, M., Affleck, G., Willard, A., & Hromi, A. (2000). Mood and alcohol consumption: an experience sampling test of the self-medication hypothesis. Journal of Abnormal Psychology, 109, 198 – 204.
Routinization preferences, anxiety, and depression in an elderly French sample Jean Bouisson Clinical Psychology Laboratory, University of Bordeaux 2, 3ter Place de la Victoire, 33076 Bordeaux cedex, France Accepted 4 March 2002
Abstract The relationship of routinization preferences to age and clinical variables was examined in a sample of 80 elderly French participants living independently or in residential facilities. Consistent with previous findings, age explained a major portion of the variance in routinization preferences. However, hierarchical multiple regression analyses revealed that the association of anxiety and depression to routinization preferences also remained significant even after controlling for the effects of age and other individual difference variables. These findings are discussed for their implications in understanding inconsistencies in previous research and demonstrating the independent importance of clinical variables in understanding age-related behavioral change. D 2002 Elsevier Science Inc. All rights reserved. Keywords: Elderly; Routinization; Anxiety; Depression
1. Introduction Despite the somewhat negative connotations associated at times with the word ‘routine,’ this concept is of fundamental importance for normal and adaptive functioning across all stages of the life span. Researchers have underscored the necessity of at least a minimal level of stable behavioral patterns or routines in assuring normal family functioning, the successful division of work tasks, coping with adversity, and in the definition of personal roles that constitute important aspects of an individual’s identity and personality (e.g., Agho, 1993; Blegen, 1993; Gallimore, Bernheimer, & Weisner, 1999; Kaufmann, 1992, 1997; Reich, 2000). For the elderly, the presence of routines can also be regarded as adaptive in that it may 0890-4065/02/$ – see front matter D 2002 Elsevier Science Inc. All rights reserved. PII: S 0 8 9 0 - 4 0 6 5 ( 0 2 ) 0 0 0 5 1 - 8
296
J. Bouisson / Journal of Aging Studies 16 (2002) 295–302
protect the individual from the dangers or stress associated with novel situations or challenges. However, the presence of inflexible behavioral patterns that resist change or that rigidly follow a particular order (also referred to as ‘routinization’) may represent maladaptive processes that prevent elderly individuals from ameliorating problems or making necessary changes in daily life (Reich & Zautra, 1991). The concept of routinization has most often been examined from a cognitive perspective by assessing the desires or preferences of elderly individuals for particular routines. Although such preferences for behavioral and environmental stability have been shown to become increasingly pronounced with age (see De Beauvoir, 1970; Kastenbaum, 1980–1981, 1984; Reich & Zautra, 1991), they have not been found to be associated with improved well-being or satisfaction (Reich & Zautra, 1991). Moreover, it has been suggested that an increasing preference for routinization as one grows older may reflect more than simply age-related coping and may at times constitute a risk factor for mental health problems such as anxiety or depression (see Bouisson, 1997; De Beauvoir, 1970; Reich & Zautra, 1991). However, despite clear evidence that age is associated with both increases in routinization preferences as well as a high frequency of anxiety and depression (Alexopoulos, 1991; Blazer, George, & Hugues, 1991; Clement, Paulin, & Leger, 1999; Parmalee, Katz, & Lawton, 1993), the relationship among these later variables has received relatively little attention. The examination of routinization preferences and their adaptiveness in the elderly population has been hindered by specific conceptual and methodological barriers. Most importantly, a considerable degree of shared variance exists between the desire for routinization, aging, and clinical variables, and the methodologies employed by previous studies have not used analytic strategies capable of controlling for multicollinearity among these factors. It is therefore unknown if anxiety or depression is directly related to routinization preferences (regardless of age), or if their potential link is best explained through their correlation with age. The examination of this question also requires that the variables included in multivariate analyses each contain sufficient variance to adequately assess its potentially unique role, and therefore examining the role of age in an already elderly population requires that the sample span from the old to the very old. A final issue concerns the role of third variables that are independently related both to routines and to age. Most notably, living in a retirement home or nursing facility is associated not only with age but with a highly regulated daily life schedule (which may explain part of the variance in routinization). Similarly, individuals placed in such facilities are known to experience greater anxiety or depression than independently living older adults (Clement et al., 1999). Such confounding factors should therefore be taken into account in understanding the potentially independent relationship of routinization preferences to age or to clinical variables. The purpose of the present investigation is to examine the association of routinization preferences with both age and negative affective states (anxiety and depression) in light of the above-noted methodological and conceptual issues. Elderly participants were recruited from both retirement homes and private residences across four urban and rural areas of France. Based on previous findings, it is hypothesized that routinization preferences will increase linearly with age. However, the relationship of anxiety and depression to routinization preferences will also be examined independently after controlling for the effects of age or other explanatory factors.
J. Bouisson / Journal of Aging Studies 16 (2002) 295–302
297
2. Method 2.1. Participants Eighty elderly individuals (61 women and 19 men) participated in the present study. The sample age range was from 65 to 96 years, with a mean of 79.6 years (S.D.=7.9). Approximately equal numbers of participants were selected from retirement homes (N=41; mean age=82.6, S.D.=7.8) and from independent living accommodations (N=39; mean age=76.3, S.D.=6.6). 2.2. Procedure Participants were contacted in either residential nursing facilities (retirement or nursing homes) or independently through convenience sampling in four geographic areas of France. Following informed consent procedures, participants responded to an anonymous questionnaire packet that assessed demographic information and provided continuous self-report measures of routinization preferences, anxiety, and depression. When requested by participants, research staff blind to the objectives of the present study assisted in reading the questionnaires or in recording responses. 2.3. Materials 2.3.1. State–Trait Anxiety Inventory (STAI) The trait version of the STAI was used in the present study to assess anxiety. The respondent is asked to rate how he or she ‘generally feels’ on a 4-point Likert scale concerning 20 items that assess anxiety-related states. The original STAI measure has been shown to have high internal consistency, good test–retest reliability, and high concurrent validity as a measure of trait anxiety (Spielberger, Gorsuch, & Lushene, 1983). The Frenchlanguage validation of this instrument has produced similar psychometric properties (Bruchon-Schweitzer & Paulhan, 1993). 2.3.2. Center for Epidemiologic Studies of Depression Scale (CESD) The CESD is a 20-item measure of depression symptomatology that asks participants to rate on a 4-point Likert scale the intensity of cognitive, somatic, emotional, and behavior symptoms over the previous week. The original English-language scale is characterized by high internal consistency and test –retest reliability (Radloff, 1977), and the Frenchlanguage translation of the CES-D has conserved these psychometric properties (Fuhrer & Rouillon, 1989). 2.3.3. Routinization preferences Routinization preferences were assessed through a brief French-language scale constructed for this study. Based on direct interviews with elderly individuals, 13 themes were identified relative to commonly cited daily life habits or patterns. These themes are similar
298
J. Bouisson / Journal of Aging Studies 16 (2002) 295–302
to other English-language measures of routinization preferences (e.g., Reich & Zautra, 1991), but differed in that they were limited to specific routines or behavior patterns (concerning meal times, sleep or nap schedules, seating preferences, organization of personal objects, specific recreational activities, and social exchange with friends and family) and intentionally did not include broader questions relative to other personality dimensions such as sensation seeking. A questionnaire was then constructed asking participants to rate on a 5-point Likert scale their level of general agreement with statements about doing tasks in a particular order or their agreement with the desirability of changes to daily life behaviors. Examples of specific items include general activities (e.g., ‘In general, I like to do the same things each day’), leisure (e.g., ‘I like to watch new shows or films on television’) and daily rhythms (‘I like to wake up and go to bed at the same time each day’). A total score of routinization preferences was calculated by summing responses across all items, with higher scores representing greater preferences for routinization. Preliminary analyses of the initial question pool permitted the exclusion of three items having item–total correlations inferior to .40. The 10-item scale had an internal consistency in the present sample of .73, high test–retest reliability over a 2-week period (r=.84), and was appropriately brief for use with very old or infirm participants. Finally, the construct validity of routinization preferences was examined using the Experience Sampling Method (see Swendsen, 1998; Swendsen et al., 2000). A subsample of participants in the present study was assessed several times per day for a period of 4 days to collect a random sample of daily life behaviors and activities (including specific information about where the participants were at the moment of the assessment and what they were doing). Environmental and behavioral assessments were readministered during the same time periods each day, and then were coded for repetition across days. Greater preferences for routinization were highly predictive of the repetition of specific behaviors as well as the environmental contexts in which the behaviors occurred (Bouisson & Swendsen, in preparation). 2.4. Overview of analyses The hypotheses of the present study were tested using hierarchical multiple regression analyses to explain variance in routinization preference scores. All analyses entered sex, residential status (retirement home or independent living), and age as covariates followed by inclusion of the predictor as hypothesized (anxiety or depression scores). Based on the inclusion of three covariates and one predictor, a power analysis demonstrated that the current sample size provides over .80 power for detecting an effect size equivalent to 15% of the total variance in routinization preferences.
3. Results Table 1 presents descriptive information and intercorrelations of routinization preferences, age, and clinical variables. Consistent past findings, stronger preferences for routinization
J. Bouisson / Journal of Aging Studies 16 (2002) 295–302
299
Table 1 Means, standard deviations, and intercorrelations among variables Variables Routinization preferences
Age
STAI anxiety
CESD depression
Means, standard deviations, and ranges Mean 32.2 S.D. 8.0 Range 12 – 50
79.6 7.9 65 – 96
44.3 10.5 24 – 72
21.6 10.6 1 – 44
Intercorrelations among measures Routinization (.73) Age .56* STAI .30* CESD .41*
– .13 .32*
(.86) .75*
(.88)
* P<.01, internal consistencies noted in parentheses.
were strongly correlated with age, and they were also moderately correlated with both anxiety and depression levels. Analyses concerning variance attributable demographic variation revealed that when compared to men, women experienced greater anxiety, t(78)= 2.53, P<.05, depression, t(78)= 2.20, P<.05, and tended to be older, t(78)= 1.71, P<.10. Participants living in retirement homes were older than those living independently, t(78)= 3.91, P<.01, and they also reported greater depression, t(78)= 2.40, P<.05. In order to examine if clinical variables explain variance in routinization preferences independent of other predictors, hierarchical multiple regression analyses were performed. Models were run separately for anxiety and depression, and all analyses entered sex, residential living status, and age as covariates. Concerning the relationship of routinization preferences and anxiety, the overall model was highly significant, F(4,75)=11.08, P<.001, with age explaining the greatest amount of variance as expected, t(1)=5.21, P<.001. As hypothesized, however, anxiety nonetheless remained a significant independent predictor of routinization preferences even after controlling for the effects of the other covariates, t(1)=2.28, P<.05 (Table 2). Parallel results were also found for depression in that the overall
Table 2 Hierarchical multiple regression analyses of routinization preferences by anxiety Variable in order of entry
F
df
Full model Sex Residential status Age Anxiety
11.08**
4, 75 1 1 1 1
* P<.05. ** P<.01.
Beta
S.E.
.75 .21 .54 .17
1.81 1.60 0.10 0.07
R2
t 0.42 0.13 5.21 2.28
0.37 .04 .04 .25** .04*
300
J. Bouisson / Journal of Aging Studies 16 (2002) 295–302
Table 3 Hierarchical multiple regression analyses of routinization preferences by depression Variable in order of entry
F
df
Full model Sex Residential status Age Depression
11.51**
4, 75 1 1 1 1
Beta
S.E.
.90 .89 .51 .19
1.77 1.61 0.11 0.08
R2
t 0.51 0.56 4.81 2.52
.38 .04 .04 .25** .05*
* P<.05. ** P<.01.
model was significant, F(4,75)=11.51, P<.001, and that a significant independent role was found for both age, t(1)=4.81, P<.001, and depression, t(1)=2.52, P<.05 (Table 3).
4. Discussion The most salient finding of the present study is the very strong association between routinization preferences and age, a finding consistent with several previous investigations on elderly samples (Bouisson, 1997; Kastenbaum, 1980–1981, 1984; Reich & Zautra, 1991). However, based on these conservative analyses, a reasonable conclusion is also that the desire for routinization is a complex phenomenon that cannot be universally classified as a normal age-associated adaptation process. Although it may indeed be adaptive in most cases (routines permit the elderly to find stability and control, and therefore become a preferred aspect of daily living), the independent associations found for routinization preferences with anxiety and depression demonstrate potentially undesirable components. In this way, the desire for routinization especially at high levels may be an important index of psychological vulnerability in older adults. The public health implications of such associations are also important in light of the elevated degree of anxiety and depression comorbidity observed in the elderly, and in particular those placed in nursing homes (Alexopoulos, 1991; Blazer et al., 1991; Clement et al., 1999; Parmalee et al., 1993). Concerning the direction of the observed relationship between negative affectivity and routinization (whether examined as preferences for routines or as routines themselves), at least two mechanisms appear tenable. First, the avoidance of change in this population, albeit understandable, may render it difficult to ameliorate difficult life circumstances that in themselves are likely risk factors for anxiety and depression. This possibility is supported by previous findings that routinization preferences in the elderly are associated with an increase in the frequency of undesirable events and a decrease in the frequency of desirable events (Reich & Zautra, 1991). These stressful events may increase anxiety and depression directly or through their impact on self-esteem, sense of personal control, or other consequences confronting the routinized individual in a changing environment. Alternatively, high levels of negative affect may preexist the emergence of routinization (or the expressed desire for such), and, thus, negative affect may serve as an initial motivator to seek security and stability
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during a vulnerable phase of life. If this is the case, however, the current findings indicate that there is no guarantee that routinization serves an adaptive role nor that it is capable of addressing the fundamental causes of preexisting psychological distress. In interpreting the present finding, several methodological characteristics of this study should be considered. First, a dimensional approach was used to characterize both routinization preferences and clinical variables, and different findings may emerge in applying a categorical or diagnostic approach. Concerning the operationalization of the routinization concept, a basic definition was used that assessed the desirability of changes to specific daily life habits or routines. Although this definition of routinization preferences is highly predictive of actual behavioral routinization in daily life, alternative conceptualizations of routinization or its desirability may find different results (especially if they are broadened to include sensation-seeking, obsessiveness, or other personality traits). Finally, while the present research underscores the complexity routinization preferences in the elderly, several questions merit further attention. Similar to the point raised by Reich and Zautra (1991), it remains unclear as to what differentiates routinization as a resource from routinization as a handicap. It is therefore unknown if a threshold can be determined in support of treatment or prevention efforts aimed at identifying ‘pathological’ routinization. Future research may benefit from considering these issues in exploring the causes and implications routinization preferences and other aspects of enduring behavioral change in the elderly.
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