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As medical researchers test the feasibility of deprescribing programs to reduce medication burden associated with polypharmacy, limited scholarly consideration has been given to the perspectives of the older adults largely targeted by these programs. This dissertation makes central the voices of older adults experiencing polypharmacy and/or deprescribing. Presented as a collection of three articles, this work explores the perspectives of older adults on their use of medication in the context of both polypharmacy and deprescribing. Data were collected using in-depth semi-structured qualitative interviews with older adults concurrently using 5+ prescription medications. The first article draws on Habermas’ writing on the contribution of communicative action in negotiating trust within complex social relationships. This analysis highlights the social nature of medication work and challenges to communicative action within personal and professional health systems. The second article applies embodiment theory to understand the way older adults’ construct unique forms of expertise regarding their health, resulting from a lifetime of experiences living as and in their bodies. The last article uses social constructionist theories on systems of classification to show the way dichotomies in medical classifications are often paradoxical. This article offers insight into the work older adults do to optimize their use of medicines in the context of these paradoxes. This study, in its entirety, indicates a need for collective efforts to identify and address the problems of polypharmacy while facilitating appropriate polypharmacy for older adults with complex multiple co-morbidities. Doing so encourages a reframing of polypharmacy as a complex phenomenon about which clinical judgments are made through an ongoing collaboration with the patient and family. / Thesis / Doctor of Philosophy (PhD)

Falls are a leading cause of injury and death in older adults. Numerous exercise interventions have been explored for fall prevention with their effectiveness being inconsistent. An alternative intervention based on motor learning concepts has potential to help prevent falls. Two separate studies are reported in this thesis. The purpose of the first study was to investigate if older adults exhibit short-term performance adaptation and long-term motor learning with repeated exposures to a simulated trip. While in a safety harness, participants stood on a treadmill that was quickly accelerated to simulate a trip. Improvements in trip recovery performance due to repeated exposures of a simulated trip included arresting the forward rotation of the trunk more quickly, reacting to the perturbation more quickly, and decreasing agonist/antagonist co-contraction. Overall, the results provide evidence for both short-term performance adaptation and motor learning. The purpose of the second study was to investigate if skills obtained from repeated exposure to a simulated trip transfer to recovery from an actual trip. Participants were randomly assigned to either an experimental or control group performing one trip before and after an intervention. The intervention for the experimental group consisted of trip recovery training on a treadmill while the intervention for the control group was walking on a treadmill. Overall, the results suggested beneficial effects of trip recovery training on actual trip recovery. These beneficial effects included decreasing maximum trunk angle, decreasing the time to reach maximum trunk angle, and raising minimum hip height during the initial recovery step. / Master of Science

As transformações advindas com a modernidade e com a pós-modernidade alteraram de forma significativa a relação entre as gerações mais novas e as mais velhas. Nas sociedades tradicionais, havia uma hierarquia entre o saber adulto, pautado no passado e na tradição, e a aceitação deste saber por parte dos mais novos. A contemporaneidade e seus discursos fornecem um cenário bastante diferente, no qual a adolescência é tida como ideal, a velocidade das transformações são espantosas e o novo, o moderno, têm seu lugar de destaque nos valores do homem contemporâneo. Neste sentido, imagens solidificadas pelo tempo e pela tradição se alteram, trazendo reflexos nas relações entre jovens e adultos. O objetivo deste trabalho foi investigar a imagem de adulto que os adolescentes de hoje carregam, a partir da avaliação que os últimos fazem dos adultos de hoje, do sentido que os jovens atribuem a este lugar e do que valorizam em um adulto. Participaram da pesquisa um total de 520 alunos do Ensino Médio de escolas públicas e particulares e o instrumento utilizado consistiu em um questionário com 24 questões, cada qual contendo quatro opções de respostas, e duas questões abertas. Os resultados demonstraram uma tendência dos jovens a avaliarem negativamente os adultos em relação a suas atuações na esfera pública (política, meio ambiente, educação e mídia) e a desconfiarem da capacidade dos adultos quanto àqueles atributos tradicionalmente referidos a este lugar (confiança, sabedoria, modelo a ser seguido, ética) e, no entanto, 63% dos sujeitos acreditaram dever obediência aos adultos de hoje. O dinheiro, o desemprego e a competição no mundo do trabalho mostraram-se como uma das preocupações mais importantes dos adultos de hoje e dos jovens em relação ao futuro. Aparentemente, a imagem do adulto, lugar de saber e de guia dos mais novos não apresenta a consistência que tinha no passado e poucos parecem ser os modelos passíveis de admiração disponíveis aos jovens hoje. O significado de ser adulto e de ocupar este lugar parece tender a um trabalho e a uma construção exclusivamente pessoal e individual. / The transformations took place during modernity and post-modernity changed in a significant way the relationship between the younger and older generations. In traditional societies, there was a hierarchy between the adult knowledge, based on past and tradition, and the acceptance of this knowledge by the younger people. The contemporary and its discourses provide a different scenario indeed, in which the adolescence is taken as an ideal, the speed of transformations is astonishing and the new, the modern has a predominant place in the values of the contemporary man. In that sense, images solidified by time and tradition change, altering relationships between young people and adults. The aim of this work was to investigate the image of adulthood that todays adolescents have, from the evaluation that they make of todays adults, from the sense that young people have of this place and from what they value in an adult. Participated in the research a total of 520 students from public and private high schools and the tool consisted of a questionnaire with 24 questions, each containing four options, and two open questions. The results reveal a tendency from young people to evaluate negatively the adults concerning their performances in the public sphere (political, environment, education and media) and question the adults capacity on those attributes traditionally attributed to that place (confidence, wisdom, model to be followed, ethical) and, nevertheless, 63% of individuals believed to owe obedience to todays adults. Money, unemployment and competition for jobs in the world were revealed as some of the greatest concerns of todays adults and of young people about their future. Apparently, the image of an adult, place of knowledge and guide for the younger ones doesnt show the consistency that it had in the past and few seem to be the possible models of admiration available for today\'s young people. The meaning of being an adult and occupying that place seems to lean toward a work and a construction exclusively personal and individual.

Thesis (Ph. D.)--University of Washington, 2001. / Vita. Includes bibliographical references (leaves 94-104).

Thesis (Psy. D.)--Wheaton College Graduate School, Wheaton, Ill., 2002. / Abstract. Includes bibliographical references (leaves 48-53).

This thesis uses an evaluation of a course based on a Rogerian approach to education to challenge the efficacy of the normative/behaviourist approach, which has been used to train adults labelled as having learning difficulties. Unlike behaviourist approaches, Rogers' work seeks to empower students to become self-directed learners and claims to teach them how to become their own behaviour change agents. The research questions focused fIrstly on whether it was possible to use genumess, acceptance and empathic understanding to build the 'climate of trust' that Rogers claimed facilitates student learning (Rogers, 1983: 18) and secondly on the learning that took place in such a 'climate.' Primary data were gathered usmg participant-observation, written records and tape recordings throughout the two-year action-research programme. The evaluation took place post hoc. The evidence demonstrates that the adoption of Rogerian principles to develop the skills of communication, decision-making and self-evaluation generated a 'climate of trust' in which student learning and 'trust' became mutually reinforcing. Evidence from the second year, in the form of case studies, showed how different each individual student was, how their talents and needs varied and how they developed increased self-esteem and self-confidence. However, the Rogerian approach was not implemented without problems. His beliefs about genuineness, acceptance and empathic understanding do not recognise that the source of genuineness is the tutor's subjective values, whilst empathy requires an imaginative leap to grasp the students' subjective meaning. The tutor may well have to face dilemmas where her personal values are in conflict with her empathic understanding of her students' perspectives. Conflicts also arose between the needs of individual students and the needs of the group as a whole. Furthermore, Rogers' work largely ignores the pedagogic skills required of the tutor. In advocating breaking down the 'us and them' divide between tutor and taught, he ignores the problem of establishing a structure of legitimate authority. This was resolved by establishing a form of democratic decision making as a radical alternative to the praise/blame culture of the traditional classroom. Rogers' ideas may be utilised by tutors in ways that help students labelled as having learning difficulties drop the 'defensive strategies' (Goffinan, 1968:44) and 'facades' (Rogers, 1983:24) associated with stigma and 'spoiled identity.' The importance of 'critical events' (Woods, 1993:3) as turning points for learning following the building of trust, is highlighted. Several incidents highlighted the problems that arise for tutors who lack background knowledge of students' involvement with other professionals. This has led to unresolved issues and hence to a recommendation for more research into the potential for greater team-work. The Rogerian approach is not a formula. It engenders a climate of mutual respect where trust can grow. It is recommended to tutors working with adults labelled as having learning difficulties as it empowers them to direct their own learning and to become their own behaviour change agents.

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