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Factors associated with attitudes toward the elderly in a sample of elderly

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Article  in  International Psychogeriatrics · September 2016

DOI: 10.1017/S1041610216001538

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 International Psychogeriatrics (2016), 28:12, 2079–2089 © International Psychogeriatric Association 2016
doi:10.1017/S1041610216001538

Factors associated with attitudes toward the elderly in a

sample of elderly caregivers
...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

Bruna Moretti Luchesi,1,2 Tiago da Silva Alexandre,3 Nathalia Alves de Oliveira,2

Allan Gustavo Brigola,2 Luciana Kusumota,1 Sofia Cristina Iost Pavarini2,3
and Sueli Marques1
1
Ribeirão Preto School of Nursing, University of São Paulo, Ribeirão Preto, Brazil
2
Department of Nursing, Federal University of São Carlos, São Carlos, Brazil
3
Department of Gerontology, Federal University of São Carlos, São Carlos, Brazil

ABSTRACT

Background: The number of elderly caregivers is increasing in the world. It is important to know the attitudes
toward the elderly, because they can influence a range of behaviors. Our aim was to determine factors
associated with attitudes toward the elderly in a sample of older carers.
Methods: Three hundred and thirteen elderly caregivers (75.4% women, mean age 69.7 ± 7.1) who cared
for a dependent older person at home completed a cross-sectional household interview. In addition to the
four domains of the Neri Scale to Assess Attitudes Toward the Elderly, participants were evaluated regarding
the demographics, care recipient (CR) characteristics, functional and cognitive status, general health, life
satisfaction, perceived stress, and depressive symptoms.
Results: Overall, attitudes toward the elderly were neutral in this sample. More negative attitudes in some Neri
Scale domains were associated with being older, living in an urban setting, taking more medications per day,
caring for an elderly dependent in basic Activities of Daily Living (ADLs), being “more or less” satisfied with
life, and having higher levels of perceived stress. There was a negative association between positive attitudes
and educational level.
Conclusions: The results highlight the need for public policies to promote more positive attitudes toward aging
and change negative stereotypes usually used to designate older people. These public policies can try to modify
some predictors of negative attitudes, such as perceived stress, which was associated with all four domains of
Neri Scale.

Key words: carers, aged care, attitudes to aging, psychological well-being

Introduction While people are living longer, there has been

an increase in the prevalence of chronic diseases,
The United Nations describes the elderly as those and disability (United Nations, 2013). In most
aged 60 years or older. The number of people in countries around the world, it is families that are
this population group is growing very fast. This is the most likely to be responsible for the care of an
happening especially in developing countries. It is elderly dependent at home.
hypothesized that the older population will triple Studies show that the caregivers of older people
by 2050, reaching 1.6 billion. By this date, it is are, in most cases, female, a daughter or wife,
expected that 80% of the older population will live middle-aged, and live in the same house as the
in developing countries, which have to be prepared elderly dependent (Pinquart and Sorensen, 2007;
to meet the needs of this group (United Nations, National Alliance for Caregiving, 2015; Lafferty
2013). et al., 2014). However, some studies have stressed
an increase in the number of elderly caregivers
Correspondence should be addressed to: Bruna Moretti Luchesi, PhD,
Universidade de São Paulo - USP, Escola de Enfermagem de Ribeirão Preto,
(Pinquart and Sorensen, 2007; Lafferty et al.,
Av. dos Bandeirantes, 3900, Campus Universitário, Bairro Monte Alegre, 2014; National Alliance for Caregiving, 2015).
Ribeirão Preto-SP-Brazil, ZIP: 14040–902. Phone: +55 16 33150534. Email: This specific group of caregivers requires special
bruna_luchesi@yahoo.com.br. Received 23 Sep 2015; revision requested 15
Dec 2015; revised version received 4 Feb 2016; accepted 30 Aug 2016. First
attention, because in addition to being caregivers,
published online 20 September 2016. they can also be patients, and require care.

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 2080 B. M. Luchesi et al.
Attitudes are beliefs related to an object that
have an evaluative component (Neri, 1991; Bryant
et al., 2012). Attitudes to aging are beliefs regarding
elderly individuals in general, and the aging process
(Loi et al., 2015). They are receiving increasing
attention because there is some evidence showing
the impact of attitudes on health outcomes, and
their influence on behaviors (Bryant et al., 2012).
The treatment that older people receive, public
policies, and healthcare can be influenced by the
attitudes toward aging (Ladtika et al., 2004).
An increasing body of research has examined
the relationship between attitudes toward aging in
the older people, and their effect on mental and
physical health. There is some evidence showing
that older people with positive perceptions of aging
live longer, and in better health (Levy et al.,
2002). However, negative attitudes are associated
with chronic conditions, physical impairment, and
health risks (Lai and Tong, 2012; Bryant et al.,
2014; Thorpe et al., 2014).
Many factors can be associated with positive
attitudes, but the psychological variables are
shown to have a greater effect on the attitudes
toward the elderly than physical health, and socio-
demographic characteristics (Chachamovich et al.,
2008; Bryant et al., 2012; Shenkin et al., 2014;
Thorpe et al., 2014). In Taiwan, more negative
attitudes toward the elderly were influenced by
depressive symptoms; and positive attitudes by
happiness (Lu et al., 2010).
Concerning elderly caregivers, few studies have
evaluated the factors that influence their attitudes.
A study conducted with 300 couples aged 50
years or older in Malaysia identified that positive
attitudes toward the elderly affect not only their
own well-being, but also that of the partner
(Momtaz et al., 2013). In Australia, a recent
study conducted with 202 older carers (55 years
and older) who lived with the person for whom
they provided care (60 years and older), aimed
to identify the factors associated with attitudes
toward the elderly. Attitudes were overall positive,
and some carer factors such as depression,
burden, and personality traits contributed to the
variance in attitudes toward the elderly (Loi et al.,
2015).
The factors associated with attitudes toward
aging in the older population have been reported
recently, but there are few studies focused on
understanding these factors in elderly caregivers, a
group with specific needs. Our aim, therefore, was
to determine whether attitudes toward the elderly
are associated with mental and psychical health, as
well as satisfaction with life, subjective well-being,
burden related to care, and level of dependence of
the CR in a sample of elderly caregivers, after taking
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into account some possible confounding factors.
We hypothesized that more positive attitudes to
aging would be associated with lower levels of
burden, stress, depressive symptoms, dependence
of both caregiver and CR and greater satisfaction
with life and well-being; after controlling for socio-
demographic, health, and care factors.
Methods
Participants
This study is part of “The variables associated with
cognition in elderly caregivers” study developed by
Aging and Health research group at the Federal
University of São Carlos, Brazil. It was developed
in São Carlos, Brazil. The city is located in the
Southeast region of Brazil, and has an estimated
population of 221,950 residents, of which 4.0%
lives in rural setting (2010 Brazilian records). It
involved a sample of elderly caregivers (age ≥ 60
years) living in the community who were registered
in all 18 primary healthcare centers in São Carlos.
Of these centers, 16 were located in urban and two
in rural settings.
The elderly caregivers who fulfilled the study’s
inclusion criteria – were 60 years of age and older,
using primary care services in the city, and caring
for a dependent older person (age ≥ 60 years),
the CR, and living in the same household – were
invited to participate in the study. To be considered
dependent, the CR had to be dependent in at
least one of ADLs/IADLs (Instrumental Activities
of Daily Living) assessed by the Katz Index (Katz
et al., 1963) and Lawton and Brody’s Scale (Lawton
and Brody, 1969).
A list containing the total number of households
within the catchment area of these 18 centers,
and which had at least two elderly individuals
living together, were provided by the professionals
employed in these units. Figure 1 shows the
flowchart of sample selection.
The initial number of households was 594, but
in 26 of them, one of the elderly people in the
house had died, in 28 they had moved to a new
address, and in 69 they were not at home after three
visits. The remaining 471 households were visited,
and the objectives of the study were explained to
the elderly individuals living there. Elderly people
living in 84 residences were discarded because they
refused to participate in the study. All the elderly
people living in a total of 387 residences (response
rate 82.2%) were evaluated with regard to ADLs
and IADLs. In 36 residences, all the elderly people
in the household were independent in all ADLs
and IADLs, and excluded. From the remaining
351, it was possible to identify couples comprising
 Attitudes to aging in elderly caregivers 2081

Brazilian Real, continuous), number of people

living in the household (continuous), living
arrangement (living with partner; living with
partner and children; living with partner, children
and grandchildren; other arrangements – groups
divided according to sampling distribution), and
location of the residence (rural or urban setting).
The age and gender variables of the elderly
caregiver were used as control variables.
3. Functional status: evaluated in both the caregiver
and CR. The Katz Index was used which
included the evaluation of six basic ADLs.
Participants were classified in two groups,
dependent (in one to six ADLs) or independent
(without any difficulty) (Katz et al., 1963). The
Scale of IADLs developed by Lawton and Brody
was also used, which evaluated seven IADLs
resulting in a possible score ranging from 7 (total
dependence) to 21 (independent). Participants
were classified into three groups, independence
(21 points), partial dependence (8–20 points),
and total dependence (seven points) (Lawton and
Brody, 1969).
4. Burden related to care: this variable was
Figure 1. Flowchart of sample selection, São Carlos, Brazil, 2014. assessed using the Zarit Burden Inventory (ZBI)
(Scazufca, 2002), which contains 22 items aimed
at evaluating the carer’s burden related to
functional deficits at home. The final score ranges
an elderly caregiver and a dependent CR, and from 0 to 88, with higher scores representing
these couples participated in the study. However, more burden, and it was used as a continuous
38 couples did not complete the questionnaire (37 variable (current study Cronbach’s α = 0.86).
failed to answer the attitudinal scale, and one the 5. Cognitive status: this was evaluated using
perceived stress scale), and these were excluded the Mini-Mental State Examination (MMSE).
from the analyses. There were no differences The cut-off scores were adjusted according to
between the excluded couples and those included educational level (≤13 to illiterate, ≤18 to 1–
with regard to gender, age, and educational 7 years of school and ≤26 to 8 years or over)
level. The excluded participants had a family (Bertolucci et al., 1994) and based on these scores
participants were divided into two groups, with
monthly income higher than that of the participants
or without cognitive impairment (current study
included. Cronbach’s α = 0.70).
The final sample consisted of 313 elderly 6. Care characteristics: the questions focused on
caregivers caring for a dependent CR at home. who was cared for by the caregiver, classified into
five groups (spouse, parent, father or mother in
Data collection law, sibling and other – groups divided according
to sample distribution). Information was also
Before answering the questionnaire, the parti-
collected on how many hours they spent per
cipants gave their written, informed consent. day on caring activities, used as a continuous
Ethical approval for the project was obtained from variable.
the Ethics Committee of the Federal University of 7. Perceived Stress: the Perceived Stress Scale (PSS)
São Carlos. Household interviews were conducted 14 items (Luft et al., 2007) was used to evaluate
by trained professionals in the fields of Gerontology how the caregivers perceived the life situations
and Nursing. as stressful. The final score ranges from 0 to 56,
The variables of interest were investigated using with higher scores representing more stress, and it
the following measures: was used as a continuous variable (current study
Cronbach’s α = 0.81).
1. CR characteristics: the questions included age 8. General health status: self-reported chronic
(60–69; 70–79; 80 or older) and gender. conditions arthritis, cancer, cardiac disease, spine
2. Caregiver characteristics: the questions included problems, diabetes, high blood pressure, or
age (60–69; 70–79; 80 or older), gender, peripheral vascular disease were asked (yes/no).
marital status (with partner and without partner), Use of medication (yes/no) and the number of
literacy (illiterate; 1–7 years schooling; eight medications they took per day were also asked.
years and over), monthly family income (in Self-rated health was evaluated using the question

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 2082 B. M. Luchesi et al.
“How do you evaluate your general health?”
Answers were classified into three groups, “very
good/good,” “average,” or “very poor/poor.”
9. Life satisfaction: the question “Are you satisfied
with your life?” was asked and the possible
responses were “very,” “more or less,” or
“barely.”
10. Depressive symptoms: the Geriatric Depressive
Scale 15 items (Almeida and Almeida, 1999) was
applied. The final score ranges from 0 to 15,
with higher scores representing more depressive
symptoms, and it was used as a continuous
variable (current study Cronbach’s α = 0.73).
11. Attitudes Toward the Elderly: this variable was
assessed using the Neri Scale to Assess Attitudes
Toward the Elderly. This scale was developed
based on Osgood Semantic Differential (Osgood
et al., 1957) and the Aging Semantic Differential
(Rosencranz and McNevin, 1969). The Semantic
Differential comprises a finite group of semantic
alternatives, defined by factor analysis. The
answers show a definition of the concept
that is evaluated, in terms of quality – the
adjectives – and intensity (Osgood et al., 1957).
The first Brazilian version of the scale (Neri,
1991) included 40 pairs of adjectives aimed at
evaluating the concept “The older person is.”
The adjectives selected were chosen based on
Brazilians’ public perceptions of the elderly, and
were then evaluated by a committee of experts
in the field of gerontology who decided which
ones remained in the scale. Each pair of adjectives
was evaluated in seven levels of intensity. The
present study used the revised version of this scale
(Neri, 1997), which included 30 pairs of bipolar
adjectives evaluated in five levels of intensity.
Factor analysis was conducted and items were
divided in four factorial domains: the Cognitive
domain (ten items) referred to the ability to
process information and solve problems, affecting
social adaptation; Agency (six items) referred
to autonomy and instrumentality to perform
actions; Social Relationship (seven items) referred
to affective and emotional aspects, reflecting
the social interaction; and Persona (seven items)
referred to social labels commonly used to
designate or discriminate against the elderly. The
final score in each domain was a mean of the
items, and ranges from 1 to 5, in which one
represents the most positive attitude, and five the
most negative attitude (current study Cronbach’s
α = 0.89).
Data analyses procedure
The Stata 10® program was used for all data
analysis. The dependent variable was the attitude
toward the elderly in each four domains. Since it
did not present normal distribution after Shapiro–
Wilk test, it was categorized into tertiles according
to the sampling distribution:
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1. Cognitive domain: 1.0 < 1st tertile ≤ 2.8 > 2nd
tertile ≤ 3.7 > 3rd tertile < 5.0;
2. Agency domain: 1.0 < 1st tertile ≤ 2.8 > 2nd tertile
≤ 3.4 > 3rd tertile < 5.0;
3. Social Relationship domain: 1.0 < 1st tertile ≤ 2.4
> 2nd tertile ≤ 3.0 > 3rd tertile < 5.0;
4. Persona domain: 1.0 < 1st tertile ≤ 2.6 > 2nd tertile
≤ 3.3 > 3rd tertile < 4.9.
The first tertile represents a more positive
attitude and was considered as the reference in
regression models. The second tertile was the
intermediate one, and the third tertile represents
more negative attitudes.
Multinomial logistic regression analysis was
used to analyze factors associated with each of
the four domains of attitudes toward the elderly.
Associations with p-value ≤ 0.2 in the univariate
analysis were selected for the multiple regression
analysis, in which forward stepwise selection was
used. Associations with p-value ≤ 0.05 in the
multiple analysis remained in the final model, and
the gender variable was used as a confounding
factor.
Results
Sample characteristics
Table 1 summarizes the socio-demographic and
care characteristics, functional status, and results
of the measurements applied in a sample of elderly
caregivers.
In most cases, the elderly caregivers were women
(75.4%), between 60 and 69 years old (56.5%)
and had 1–7 years of schooling (68.0%). Most of
them had a partner (90.1%) and lived only with
this partner (42.8%). The family monthly income
was R$2258.2 ± 1483.2, the houses had a mean of
3.0 ± 1.3 people living together, and most of them
were located in urban settings (80.8%). Regarding
the care context, 85.5% cared for a spouse, for
6.1 ± 4.9 hours/day.
Caregivers were independent in ADLs (87.7%)
and partially dependent in IADLs (57.5%). Mean
scores in ZBI, PSS, and GDS were 17.7 ± 14.1,
18.5 ± 9.7, and 3.6 ± 2.8, respectively, and 85.0%
were classified as without cognitive impairment in
MMSE.
The health status revealed that 62.9% had high
blood pressure, 46.6% spine problems, 35.4%
arthritis, 31.3% peripheral vascular disease, 29.9%
diabetes, 14.4% cardiac disease, and 8.3% cancer.
Regarding the medications, 88.8% reported that
they used at least one per day, and the mean was
3.1(±2.5)/day.
Self-rated health was evaluated as “very
good/good” for 55.9% of the elderly caregivers,
 Attitudes to aging in elderly caregivers 2083

Table 1. Descriptive characteristics of elderly caregivers in São Carlos, Brazil, 2014 (n = 313)
va r i a b l e s c at e g o r i e s ( n) % or mean ± std
............................................................................................................................................................................................................................................................................................................................

Gender Male (77) 24.6

Female (236) 75.4
Age 69.7 ± 7.1
(years old) 60–69 (177) 56.5
70–79 (98) 31.3
≥ 80 (38) 12.2
Marital status With partner (282) 90.1
Without partner (21) 9.9
Literacy (years) 3.9 ± 3.6
Illiterate (57) 18.2
1–7 (213) 68.0
≥ 8 (43) 13.8
Family monthly income (R$) 2258.2 ± 1483.2
Living arrangement With partner (134) 42.8
With partner and children (68) 21.7
With partner, children, and grandchildren (26) 8.3
Others (85) 27.2
Number of people in the house 3.0 ± 1.3
Residence location Urban (253) 80.8
Rural (60) 19.2
Cared for Spouse (266) 85.5
Parent (25) 8.0
Sibling (11) 3.5
Father/Mother – in-law (7) 2.2
Other (4) 1.3
Hours/day in caring activities 6.1 ± 4.9
Katz Index Independent (274) 87.7
Dependent (39) 12.5
Lawton and Brody scale Independent (133) 42.5
Partial dependent (180) 57.5
Total dependent (0) 0.0
ZBI 17.7 ± 14.1
MMSE With cognitive impairment (47) 15.0
Without cognitive impairment (266) 85.0
PSS 18.5 ± 9.7
GDS-15 3.6 ± 2.8
CR gender Male (215) 68.7
Female (98) 31.3
CR age (years old) 74.0 ± 8.7
60–69 (115) 36.7
70–79 (122) 39.0
≥ 80 (79) 24.3
CR Katz index Independent (214) 68.4
Dependent (99) 31.6
CR lawton and brody Scale Independent (0) 0.0
Partial dependent (271) 86.6
Total dependent (42) 13.4

Std = Standard deviation; ZBI = Zarit Burden Inventory; MMSE = Mini-Mental State Examination; PSS-14 = Perceived Stress Scale-14;
GDS-15 = Geriatric Depression Scale-15; CR = care recipient.

“average” for 36.4%, and “very poor/poor” for of cases male (68.7%), between 70 and 79 years
7.7%. The majority of the elderly caregivers were old (39.0%, mean age of CRs 74.0 ± 8.7). CRs
very satisfied with their lives (78.0%), 36.4% were were in most of cases independent in six basic
“more or less” satisfied, and 4.2% barely satisfied. ADLs (68.4%), and 31.6% were dependent in 1–
The elderly caregivers cared for dependent 6 basic ADLs. Concerning the IADLs, 86.6% were
elderly CRs at home who were in the majority partially dependent, and 13.4% totally dependent.

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 2084 B. M. Luchesi et al.
Attitudes toward the elderly
The mean score in Neri Attitudes Toward the
Elderly Scale was 3.0 ± 0.7. In each domain, the
means were: Cognitive (3.1 ± 0.8), Agency (3.2 ±
0.9), Social Relationship (2.7 ± 0.8), and Persona
(2.9 ± 0.9), which signifies that the most negative
domain was Agency and the most positive was Social
Relationship.
Factors influencing attitudes toward the
elderly
Table 2 represents the results of the multiple
regression analysis.
In the Cognitive domain, being 80 years and
older, and having higher scores on PSS were
associated with more negative attitudes toward the
elderly.
In Agency, illiterate caregivers were less likely to
have more negative attitudes. However, being 80
years and older, living in an urban setting, caring
for a dependent CR in basic ADLs, taking more
medications per day, and having higher scores on
PSS were associated with more negative attitudes
in this domain.
More negative attitudes in the Social Relationship
domain were significantly associated with living in
urban settings, and had higher scores on PSS.
There was a negative correlation between positive
attitudes and educational level.
Being “more or less” satisfied with life and
having higher scores on PSS were significantly
associated with more negative attitudes toward the
elderly in the Persona domain.
Discussion
In this sample, attitudes toward the elderly were
considered neutral in the general score. It was more
negative in the Agency domain, and more positive in
the Social Relationship domain. Older age, living in
an urban setting, taking more medications per day,
caring for older people dependent in basic ADLs,
being “more or less” satisfied with life, and having
higher levels of perceived stress were associated
with more negative attitudes toward the elderly.
There was a negative association between positive
attitudes and educational level.
A recent piece of research that evaluated
attitudes toward the elderly and associated factors
is cited to be the first one to describe attitudes
in a sample of elderly carers. Their sample (n =
202) had similar characteristics, 74.3% women,
mean age 70.8 and 85% were spouse caregivers.
But they had higher levels of depression (GDS-
15 median 4.0) and burden (ZBI mean 32.7);
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and found associations between these two variables
and the variance in attitudes, particularly in the
Physical and Loss subscales of the instrument that
they used (Attitudes to Aging Questionnaire) (Loi
et al. 2015).
In our analyses, depressive symptoms were
evaluated too, but when included in the adjusted
model, this variable was not significant.
Other studies showed associations between
depressive symptoms and perceptions related to
aging in older participants, not caregivers. These
studies used different instruments to evaluate
depression: GDS-15 and -30 items (Chachamovich
et al., 2008; Kalfoss et al., 2010; Lai and Tong,
2012; Sindi et al., 2012; Janecková et al., 2013;
Lucas-Carrasco et al., 2013), the Center for
Epidemiological Studies Depression Scale – CES-
D (Lu et al., 2010; Bryant et al., 2012), the
Hospital Anxiety and Depression Scale – HADS
(Shewkin et al., 2014) and the Mini International
Neuropsychiatric Interview – MINI (Thorpe et al.,
2014). All of them considered that the evaluation
of depressive symptoms was an important variable
related to perceptions about aging.
The results presented here showed that per-
ceived stress is another mental health variable that
it is important to evaluate. Perceived stress was
associated with all four domains of attitudes toward
the elderly, which means that higher perceived
stress was linked to more negative attitudes.
Other possible factors related to mental health
included in the present analyses were the burden
and cognitive status of the caregivers, but they
were not significantly associated with the attitude
evaluation.
Our sample had lower levels of depression and
burden when compared to the elderly caregivers
evaluated in the Australian study (Loi et al., 2015).
This may be the reason why in our sample these
variables were not associated with attitudes. These
associations need to be explored in future and
longitudinal studies, in order to understand if
the level of burden and depression can lead to
different results in the analysis. Furthermore, new
investigations should evaluate whether different
instruments used to measure attitudes renders
different associations with burden and depression
given that the aforementioned study applied a
different scale than the current study.
Older age in elderly caregiver’s participants was
associated with two domains of attitudes, Cognitive,
and Agency. The more negative evaluation of these
domains by caregivers aged 80 years and over, may
be a reflection of their own lives. Perhaps, they are
experiencing greater dependence, cognitive losses,
and less autonomy and that is the reason why they
evaluated attitudes more negatively.
 Attitudes to aging in elderly caregivers 2085

Table 2. Multinomial regression analysis for associated factors to attitudes toward elderly caregivers, São
Carlos, Brazil, 2014 (n = 313)
at t i t u d e s t owa r d t h e u n i va r i at e u n i va r i at e
e l d e r ly ( d o m a i n ) model adjusted model model adjusted model
OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI)
............................................................................................................................................................................................................................................................................................................................

Cognitive 2nd tertile 3rd tertile

Age
60–69 years old 1.00 1.00 1.00 1.00
70–79 years old 1.47 (0.79–2.73) 1.54 (0.82–2.89) 1.87 (1.02–3.42) 1.85 (0.99–3.43)
≥ 80 years old 2.95 (1.12–7.74) 3.13 (1.16–8.42)∗ 3.27 (1.25–8.52) 2.66 (0.99–7.18)
Lawton care recipient
Partial dependent 1.00 1.00 1.00 1.00
Total dependent 1.23 (0.61–2.48) 0.40(0.18–0.92) 0.67 (0.32–1.41) 0.97 (0.44–2.13)
PSS (continuous) 1.03 (1.00–1.06) 1.03 (0.99–1.06) 1.06 (1.03–1.09) 1.06 (1.03–1.09)∗
Agency 2nd tertile 3rd tertile
Age
60–69 years old 1.00 1.00 1.00 1.00
70–79 years old 1.15 (0.64–2.04) 1.18 (0.64–2.16) 1.30 (0.70–2.43) 1.31 (0.67–2.57)
≥ 80 years old 2.03 (0.79–5.22) 2.27 (0.82–6.32) 3.79 (1.51–9.53) 3.81 (1.35–10.74)∗
Literacy
≥ 8 years 1.00 1.00 1.00 1.00
1–7 years 0.74 (0.33–1.66) 0.65 (0.28–1.51) 0.56 (0.25–1.27) 0.54 (0.22–1.32)
Illiterate 0.75 (0.28–1.96) 0.44 (0.15–1.25) 0.63 (0.23–1.68) 0.32 (0.10–0.99)∗
Self-rated health
Very good/good 1.00 1.00 1.00 1.00
Average 0.89 (0.52–1.54) 0.69 (0.38–1.25) 0.76 (0.42–1.38) 0.51 (0.26–1.01)
Very poor/poor 1.47 (0.48–4.47) 0.75 (0.21–2.64) 2.24 (0.76–6.59) 0.93 (0.25–3.43)
Residence location
Rural setting 1.00 1.00 1.00 1.00
Urban setting 1.80 (0.84–3.44) 1.71 (0.85–3.44) 2.76 (1.27–5.99) 2.99 (1.27–7.08)∗
Medication/day 1.17 (1.04–1.32) 1.17 (1.03–1.32)∗ 1.14 (1.01–1.29) 1.15 (1.00–1.32)∗
Katz care recipient
Independent 1.00 1.00 1.00 1.00
Dependent in 1–6 activities 1.11 (0.62–2.02) 0.96 (0.51–1.83) 2.61 (1.44–4.71) 1.97 (1.02–3.80)∗
PSS (continuous) 1.04 (1.01–1.07) 1.04 (1.01–1.08)∗ 1.05 (1.02–1.09) 1.05 (1.01–1.09)∗
Social relationship 2nd tertile 3rd tertile
Age
60–69 years old 1.00 1.00 1.00 1.00
70–79 years old 1.46 (0.80–2.66) 1.43 (0.76–2.67) 1.21 (0.66–2.19) 1.14 (0.61–2.12)
≥ 80 years old 1.20 (0.52–2.75) 1.21 (0.49–3.00) 0.85 (0.36–2.02) 0.78 (0.30–1.99)
Literacy
≥ 8 years 1.00 1.00 1.00 1.00
1–7 years 0.48 (0.22–1.05) 0.43 (0.19–0.96)∗ 0.79 (0.34–1.83) 0.72 (0.30–1.71)
Illiterate 0.87 (0.33–2.26) 0.59 (0.21–1.66) 1.30 (0.48–3.52) 0.97 (0.33–2.81)
Residence location
Rural setting 1.00 1.00 1.00 1.00
Urban setting 2.63 (1.28–5.41) 2.28 (1.08–4.81)∗ 2.8 (1.36–5.73) 2.34 (1.11–4.90)∗
PSS (continuous) 1.03 (1.01–1.07) 1.03 (0.99–1.06) 1.04 (1.01–1.07) 1.04 (1.01–1.07)∗
Persona 2nd tertile 3rd tertile
Age
60–69 years old 1.00 1.00 1.00 1.00
70–79 years old 1.05 (0.58–1.88) 1.01 (0.56–1.84) 1.21 (0.65–2.24) 1.14 (0.60–2.18)
≥ 80 years old 0.96 (0.39–2.33) 0.94 (0.38–2.31) 1.72 (0.74–1.00) 1.42 (0.58–3.47)
Satisfaction with life
Very satisfied 1.00 1.00 1.00 1.00
“More or less” satisfied 1.78 (0.82–3.88) 1.83 (0.80–4.19) 3.46 (1.62–7.40) 2.53 (1.00–5.74)∗
Barely satisfied 1.13 (0.15–8.17) 1.20 (0.15–9.67) 7.47 (1.56–35.78) 3.39 (0.60–18.87)
PSS (continuous) 1.00 (0.97–1.03) 0.99 (0.96–1.03) 1.06 (1.03–1.09) 1.04 (1.00–1.08)∗

OR = Odds Ratio. CI=Confidence Interval. PSS-14=Perceived Stress Scale-14. Controlled by gender.

∗ p ≤ 0.05.

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 2086 B. M. Luchesi et al.
Literature shows that the relationship between
attitudes toward aging and the respondent’s age
is divergent. Some studies conducted with elderly
adults found that there is no relation between the
age of the respondent and attitudes and perceptions
about aging in South Korea (Jang et al., 2004),
China (Chow and Bai, 2011a; Lai and Tong, 2012),
Czech Republic (Janecková et al., 2013), and UK
(Shewkin et al., 2014). In the USA, three groups
of a college community (20–34, 35–59, and >60
years old) had their attitudes evaluated using a
semantic differential scale with 24 bipolar adjectives
and seven points of intensity. They found that
the older groups had more positive attitudes than
the younger ones (Laditka et al., 2004). However,
the evaluation of the attitudes, perceptions, and
expectations with regard to aging in older adults
living in the USA (Sarkisian et al., 2002), Australia
(Bryant et al., 2012; Bryant et al., 2014), and
Canada (Sindi et al., 2012) found that the higher
the age of the participant, the worse the results
of the evaluations. In a sample of elderly carers
in Australia, older age was associated with more
negative attitudes in terms of Growth, and more
positive in terms of Loss (Loi et al., 2015). A
literature review observed that some studies show
that the attitudes are more negative in young
people and become positive during the course of
life, others that negative perceptions and attitudes
appear in old age, and the authors suggested the
need for more research focused on understanding
this relation (National Centre for the Protection of
Older People, 2009). These differences could exist
because of the instrument used to evaluate attitudes
or because of the context in which the evaluations
occurred.
An intriguing data was the relationship between
literacy and the attitudes toward the elderly. In the
Social Relationship domain, elderly caregivers who
received schooling for 1–7 years had more positive
attitudes. The same happened in the Agency
domain, in which being illiterate was associated
with positive attitudes. We did not find a study
to corroborate our findings. The one developed
with 202 elderly carers found no association
between literacy and attitudes, but their sample was
relatively well-educated, 54.4% had achieved the
tertiary level of education (Loi et al., 2015). As the
association occurred only in two domains in the
present study, we cannot generally attribute this to
the degree of literacy. This led to the need for new
investigations.
Living in urban settings was associated with
more negative attitudes toward aging in two
domains, Social Relationship, and Agency. Living
in rural communities was identified as a factor
related to better images of aging in previous studies
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conducted in China with 445 elderly individuals
(Chow and Bai, 2011a) and in Australia with 421
elderly adults (Bryant et al., 2012). Urban settings
are in a continuous process of modernization,
which has two important consequences. On the
one hand, it provides a better standard of life and
benefits that result from the society progress. On
the other hand, this can have a negative impact
on the social status of the elderly and stereotypes
placed on them by society (Chow and Bai, 2011b).
In addition to this, a Brazilian study evaluated
the quality of life of elderly people living in rural
and urban settings. They found that the elderly in
rural areas had a better quality of life in most of
domains and facets, including social relations and
autonomy (Tavares et al., 2014). In the present
study, the more positive attitudes toward the elderly
in Social Relationship and Agency domains that rural
caregivers had compared to the urban ones, could
have been partially due to their higher quality of
life. Public policies should be developed to improve
the image people have about the elderly and the
quality of life of elderly individuals, especially in
urban areas.
In our sample, care for a dependent older
person at home did not appear to influence
the development of negative attitudes toward the
elderly, except for the Agency domain, in which
the care provided to the CR dependent in ADLs
was associated with more negative evaluations.
The Agency domain reflects the evaluation of
autonomy and instrumentality to perform actions.
More negative attitudes to aging in this domain
may be related to the household living with a more
dependent older people. The study conducted
with elderly caregivers did not evaluate that
characteristic of the CR, and it is not possible to
compare this data (Loi et al., 2015). Future studies
can explore the relation between the CR factors and
their influence on caregivers’ attitudes.
The only variables related to the health aspects
of elderly caregivers that showed some association
with attitudes was the number of medications
used per day and Agency domain. Each unit of
medication used per day increases the chance of
having more negative attitudes in this domain,
which reflects the evaluation of autonomy and
instrumentality of older people. The high number
of medications taken per day by elderly individuals
is worrying, particularly considering that these
individuals are responsible for others and perform
care activities daily. In the present study, this
variable influenced the way that they evaluate older
people. The more negative attitude showed by the
caregivers in Agency domain may be related their
own limitations and conditions that require them to
take more medications. Indeed, a literature review

showed that there is a relation between medication
use and worse functional status (Peron et al., 2011).
On the other hand, a more recent study showed
no significance in multivariate regression analyses
testing for associations between the number of
medications prescribed and attitudes toward the
elderly in older carers (Loi et al., 2015). Given
this discrepancy, further studies should explore the
relation between medications taken by caregivers
and their attitudes toward the elderly.
Being “more or less” satisfied with life was
associated with more negative attitudes toward
the elderly in the Persona domain. The fact that
this association, in our study, occurred in the
Persona domain, which reflects the social labels
used to designate and discriminate against the
elderly, may show that elderly people who are more
satisfied with life tend to suffer less discrimination
and to discriminate less against the elderly. In
Australia, a study conducted with 421 older adults
evaluated the satisfaction with life using a scale
with five questions seven Likert points and found
an association between greater satisfaction with life
and attitudes toward the elderly (Bryant et al.,
2012; 2014).
The data shown in this paper are supported
by the literature review, confirming the fact that
attitudes to aging are complex and influenced by
different factors (National Centre for the Protec-
tion of Older People, 2009). A previous literature
review made some recommendations and our
results corroborate to them. The recommendations
were: development of new research to identify the
variables associated with attitudes toward aging;
the need for new educational programs related
to aging in different groups in society, including
the school curriculum; focus on training health
and education professionals to deal with older
people; and encouraging older people to engage
in community activities (National Centre for the
Protection of Older People, 2009).
Some limitations can be cited. First, the
study was cross-sectional and did not allow us
to establish temporal relationships between the
variables. Second, the data refers only to elderly
caregivers living in one city in Brazil and cannot
be applied to older adults in general. Finally,
we were not able to evaluate some aspects that
may be associated with attitudes toward aging,
for example, personality. According to previous
reports, personality has greater influence on the
attitudes (Jang et al., 2004; Shewkin et al., 2014;
Loi et al., 2015) and these factors can be explored
in future researches.
The results extend the knowledge about
attitudes to aging in a sample of elderly caregivers
and the factors associated with it. In this sample,
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Attitudes to aging in elderly caregivers 2087
attitudes to older people were considered neutral.
There is a clear relationship between the attitudes
and the mental health of the elderly caregivers.
Perceived stress, more than other mental health
variable, contributes to the development of negative
attitudes. The location of the residence also
contributes to the variance in attitudes. Future
analyses can focus on understanding what different
characteristics can promote more positive attitudes
in rural settings. Being older was associated
with more negative attitudes. The influence of
educational level was not clear in our study,
and it requires more research to analyze these
associations. Our data shows that there is a need
for public policies that promote more positive
attitudes to aging and changing negative stereotypes
usually used to designate older people. These
public policies can be developed within all groups
of society, including the elderly caregivers, trying to
modify some predictors of negative attitudes, such
as perceived stress.
Conflict of interest
None.
Description of author’s role
Bruna Moretti Luchesi, Luciana Kusutmota,
Sueli Marques, and Sofia Cristina Iost Pavarini
planned the study. Bruna Moretti Luchesi, Allan
Gustavo Brigola, and Nathalia Alves de Oliveira
carried out data collection. Bruna Moretti Luchesi
prepared draft paper. Tiago da Silva Alexandre was
responsible for the statistical analyses. All authors
contributed to the final revision.
Acknowledgments
We thank to all the elderly people who participated
in the study. Thanks to Coordenação de Aper-
feiçoamento de Pessoal de Nível Superior (CAPES)
for funding the project.
References
Almeida, O. P. and Almeida, S. A. (1999). Short versions
of the geriatric depression scale: a study of their validity for
the diagnosis of major depressive episode according to
ICD-10 and DSM-IV. International Journal of Geriatric
Psychiatry, 14, 858–865.
Bertolucci, P. H. F., Brucki, S. M. D., Campacci, S. R.
and Juliano, Y. (1994). O Mini-exame do Estado Mental
em uma população geral. Impacto da escolaridade.
Arquivos Neuropsiquiatria, 52, 1–7.
 2088 B. M. Luchesi et al.
Bryant, C. et al. (2014). Antecedents of attitudes to aging: a
study of the roles of personality and well-being. The
Gerontologist. doi: 10.1093/geront/gnu041.
Bryant, C., Bei, B., Gilson, K., Komiti, A., Jackson, H.
and Judd, F. (2012). The relationship between attitudes to
aging and physical and mental health in older adults.
International Psychogeriatrics, 24, 1674–1683. doi:
10.1017/S1041610212000774.
Chachamovich, E., Fleck, M., Laidlaw, K. and Power,
M. (2008). Impact of major depression and subsyndromal
symptoms on quality of life and attitudes toward aging in
an international sample of older adults. The Gerontologist,
48, 593–602. doi: 10.1093/geront/48.5.593.
Chow, N. and Bai, X. (2011). Modernization and its impact
on Chinese older peopleś perception of their own image
and status. International Social Work, 54, 800–815.
Chow, N. and Bai, X. (2011). The effects of
sociodemographic characteristics on Chinese elders’
perception of the image of ageing. International Journal od
Population Research, 11 pages. doi:10.1155/2011/642874.
Janecková, H., Dragomirecká, E., Holmerová, I. and
Vanková, H. (2013). The attitudes of older adults living in
institutions and their caregivers to ageing. Central European
Journal of Public Health, 21, 63–71.
Jang, Y., Poon, L. W., Kim, S. Y. and Shin, B. K. (2004).
Self-perception of aging and health among older adults in
Korea. Journal of Aging Studies, 18, 485–496. doi:
10.1016/j.jaging.2004.06.001.
Kalfoss, M. H., Low, G. and Molzahn, A. E. (2010).
Reliability and validity of the attitudes to ageing
questionnaire for Canadian and Norwegian older adults.
Scandinavian Journal of Caring Sciences, 24, 75–85. doi:
10.1111/j.1471-6712.2010.00786.x.
Katz, S., Ford, A., Moskowitz, R., Jackson, B. and Jaffe,
M. (1963). Studies of Illness in the aged. Journal of the
American Medical Association, 185, 94–99.
Laditka, S. B., Fisher, M., Laditka, J. N. and Segal,
D. R. (2004). Attitudes about aging and gender among
young, middle age, and older college-based students.
Educational Gerontology, 30, 403–421. doi:
10.1080/03601270490433602.
Lafferty, A., Fealy, G., Downes, C. and Drennan, J.
(2014) Family Carers of Older People: Results of a
National Survey of Stress, Conflict and Coping. NCPOP,
University College Dublin.
Lai, D. W. L. and Tong, H. (2012). Effects of social
exclusion on attitude toward ageing in older adults living
alone in Shanghai. Asian Journal of Gerontology and
Geriatrics, 7, 88–94.
Lawton, M. P. and Brody, E. M. (1969). Assessment of
older people: self-maintaining and instrumental activities of
daily living. The Gerontologist, 9, 179–186.
Levy, B. R., Slade, M. D. and Kasl, S. V. (2002).
Longitudinal benefit of positive self-perceptions of aging on
functional health. The Journals of Gerontology Series B:
Psychological Sciences and Social Sciences, 57B, 409–417.
Loi, S. M. et al. (2015). Attitudes to aging in older carers –
do they have a role in their well-being?. International
Psychogeriatrics, 1–9. doi: 10.1017/S1041610215000873.
Lu, L., Kao, S. H. and Hsieh, Y. H. (2010). Positive
attitudes toward older people and well-being among
Chinese community older adults. Journal of Applied
Downloaded from http:/www.cambridge.org/core. UFSCAR - Universidade Federal de Sao Carlos, on 04 Dec 2016 at 20:56:05, subject to the Cambridge Core terms of use, available at
http:/www.cambridge.org/core/terms. http://dx.doi.org/10.1017/S1041610216001538
Gerontology, 29, 622–639. doi:
10.1177/0733464809343289.
Lucas-Carrasco, R., Laidlaw, K., Gómez-Benito, J. and
Power, M. J. (2013). Reliability and validity of the
Attitudes to Ageing Questionnaire (AAQ) in older people
in Spain. International Psychogeriatrics, 25, 490–499. doi:
10.1017/S1041610212001809.
Luft, C. D. B., Sanches, S. O., Mazo, G. Z. and
Andrade, A. (2007). Versão brasileira da Escala de
Estresse Percebido: tradução e validação para idosos.
Revista de Saúde Pública, 41, 606–615.
Momtaz, Y. A., Hamid, T. A., Masud, J., Haron, S. A.
and Ibrahim, R. (2013). Dyadic effects of attitude toward
aging on psychological well-being of older Malaysian
couples: an actor-partner interdependence model. Clinical
Interventions in Aging, 8, 1413–1420. doi:
10.2147/CIA.S51877.
National Alliance for Caregiving (2015). Research report:
caregiving in the U.S. 2015 – focused look at caregivers of
adults age 50+. Available at:
http://www.caregiving.org/wp-content/uploads/2015/05/
2015_CaregivingintheUS_Care-Recipients-Over-50_WEB.
pdf; last accessed 30 July 2015.
National Centre for the Protection of Older People
(2009). Public Perceptions of Older People and Aging: a
Literature Review. Available at:
http://www.ncpop.ie/Year%201%20Reports/Microsoft%
20Word%20-%20NCPOP%20Lit%20Rev%201%20IL%
2001_12_09Cover%20inc22_01_10.pdf; last accessed 30
January 2015.
Neri, A. L. (1991). Envelhecer Num País de Jovens: Significados
De Velho e Velhice Segundo Brasileiros Não Idosos. Campinas,
SP: Editora UNICAMP.
Neri, A. L. (1997). Atitudes em relação à velhice: evidências
de pesquisa no Brasil. Gerontologia, 5, 130–139.
Osgood, C. E., Suci, G. J. and Tannenbaum, P. H.
(1957). The Measurement of Meaning. Urbana, IL:
University of Illinois Press.
Peron, E. P., Gray, S. L. and Hanlon, J. T. (2011).
Medication use and functional status decline in older
adults: a narrative review. The American Journal of Geriatric
Pharmacotherapy, 9, 378–391. doi:
10.1016/j.amjopharm.2011.10.002.
Pinquart, M. and Sörensen, S. (2007). Correlates of
physical health of informal caregivers: a meta-analysis.
Journals of Gerontology: Psychological Sciences, 62B,
126–137.
Rosencrantz, H. A. and McNevin, T. E. (1969). A factor
analysis of attitudes toward the aged. The Gerontologist, 9,
55–59.
Sarkisian, C. A., Hays, R. D. and Mangione, C. M.
(2002). Do older adults expect to age successfully? the
association between expectations regarding aging and
beliefs regarding healthcare seeking among older adults.
Journal of the American Geriatrics Society, 50, 1837–1843.
Scazufca, M. (2002). Brazilian version of the burden
interview scale for the assessment of burden of care in
carers of people with mental illnesses. Revista Brasileira de
Psiquiatria, 24, 12–17.
Shenkin, S. D., Laidlaw, K., Allerhand, M., Mead, G. E.,
Starr, J. M. and Deary, I. J. (2014). Life course
influences of physical and cognitive function and

personality on attitudes to aging in the Lothian birth
cohort 1936. International Psychogeriatrics, 26, 1417–1430.
doi: 10.1017/S1041610214000301.
Sindi, S., Juster, R. P., Wan, N., Nair, N. P. V., Kin, N. Y.
and Lupien, S. J. (2012). Depressive symptoms, cortisol,
and cognition during human aging: the role of negative
aging perceptions. Stress, 15, 130–137. doi:
10.3109/10253890.2011.599047.
Tavares, D. M. S., Bolina, A. F., Dias, F. A., Ferreira,
P. C. S. and Haas, V. J. (2014). Quality of life of elderly.
Downloaded from http:/www.cambridge.org/core. UFSCAR - Universidade Federal de Sao Carlos, on 04 Dec 2016 at 20:56:05, subject to the Cambridge Core terms of use, available at
http:/www.cambridge.org/core/terms. http://dx.doi.org/10.1017/S1041610216001538
View publication stats
Attitudes to aging in elderly caregivers 2089
Comparison between urban and rural areas. Investigación y
Educación en Enfermería, 32, 401–413.
Thorpe, A. M., Pearson, J. F., Schluter, P. J.,
Spittlehouse, J. K. and Joyce, P. R. (2014). Attitudes to
aging in midlife are related to health conditions and mood.
International Psychogeriatrics, 26, 2061–2071. doi:
10.1017/S1041610214001550.
United Nations (2013). World Population Ageing 2013. New
York, NY: United Nations: Department of Economic and
Social Affairs, Population Division.