Social relationships can have considerable influence on physical and mental well-being. AL research suggests that other residents are among the most available social contacts and that co-resident relationships can affect life satisfaction, quality of life, and well-being. Although functional status influences social relationships, research has yet to provide an in-depth understanding of how cognitive and physical function affects co-resident relationships in AL. In this thesis, I present an analysis of qualitative data collected over a one-year period in two diverse settings. The thesis addressed: 1) How does functional status influence co-resident relationships? ; and 2) What factors shape its influence? Analysis was guided by principles of Grounded Theory Method. Coming together and pulling apart signifies the key finding that functional status is multi-directional, fluid, and operates in different ways in various situations and across time. Facility and resident –level factors further affect the influence of functional status on co-resident relationships.

The overarching theme of this thesis is the prevention of progressive-type disability. Unlike catastrophic disability, progressive disability is gradual and more common in older adults. Because progressive disability can take years to develop, it is often conceptualized as a continuum, from less to more disabled. Disability prevention, by definition, is designed to identify people who are as yet nondisabled but at high risk for future functional decline by identifying an early functional state associated with increased risk of subsequent disability (Fried & Guralnik, 1997). This thesis sought to address two challenges associated with identifying an early functional state of disability. The first challenge relates to instrument calibration. Traditional instruments (based on self-report) used for assessing disability, scales of activities of daily living (ADL) and instrumental activities of daily living (IADL), were originally developed to describe levels of functional status in institutionalized older adults. Thus, these instruments poorly discriminate, as well as underestimate disability in the early stages of development. Poor discrimination refers to tasks or activities (i.e., scale items) that prove unresponsive to changes in a particular person’s ability level. Performance measures on the other hand, such as walk time or grip strength, have proven to be quite responsive to early declines in functional status. Despite the popularity of performance measures used to assess health status in epidemiology or gerontological research, evidence suggests that they measure a somewhat different construct than self-reported activities of daily living. ADLs have a long history of use in the medical community, yet it has been proposed that the relative standing of ADLs, in relation to communitydwelling older adults, could be enhanced by improving construct validities that are at least equivalent to those of physical performance measures. Item response theory (IRT) methodology can be used to improve the structure of ADL scales so that they are more sensitive in detecting the early stages of functional decline within relatively high functioning older adults; a stage that has been shown to be more responsive to clinical interventions aimed at prevention of overt disability or frailty. IRT can improve ADL scales in multiple ways: by confirming an underlying uni-dimensional continuum of disability, establishing interval level measurement or item hierarchies, and increasing scale precision. As part of this thesis I conducted a systematic review of functional status scales, applied to community-dwelling older adults, which employed IRT procedures. The review was useful in that it draws attention to areas of functional assessment that can be improved upon, most notably, the topic of establishing interval level data and construct under-representation. Using data from the Cardiovascular Health Study, I was able to show that a common hierarchy of functional decline was observed for a diverse set of conditions and diseases that are prevalent among community-dwelling older adults. Such an indicator could be used to identify hierarchical declines relating to severity in diverse patient populations. Improvements in validity of functional status scales can also lead to the use of ADL-IADLs as potential determinates of disability, rather than simply acting as outcome measures of disability. Again using data from the Cardiovascular Health Study, I examined the predictive power of IADL (mobility-type) items on later disability. Self reported difficulty in 2 or 3 of the most difficult IADL items increased the odds of being disabled eight years later by a factor of 3.5. The odds of being disabled fell to 1.9 for those reporting difficulty with one item. The second challenge of this thesis relates to defining determinants of functional decline that manifest themselves at the earliest stages of the disablement process. As previously stated physical performance measures have been shown to be sensitive to early stages of functional decline. However, can other measures, potentially spanning multiple domains, be used to identify those at high risk for future disability? In particular I was interested in whether psychosocial and cognitive variables could be used to detect changes in functional status at the preclinical stages of the disablement process. With regard to the Cardiovascular Health Study, I was able to show that, for subjects within the normal range of cognitive functioning, performance in the lowest quartile of the Digit Symbol Substitution Test resulted in a 2.2 increase in the odds of being disabled. Performance on this measure, as well as selfreported mobility noted above, could detect decrements in functional status as much as 8 years prior. With the use of the Lothian Birth Cohort sample I explicitly investigated the psychosocial domain. I found that the level of depressive symptoms increased the odds of being disabled by 56%. Again, these symptoms were assessed as much as eight years prior to self-reported disability. The general findings of this thesis indicate that refinements in ADL-IADL measures can aid in the detection of disability at the pre-clinical level, and that cognitive function and intra-individual factors play a pivotal role in speeding up or slowing down the disablement process.

Age-related bone fractures are usually painful and have highly negative effects on a geriatric patient's functional status, quality of life, and survival. Currently, there are few analgesic therapies that fully control bone fracture pain in the elderly without significant unwanted side effects. However, another way of controlling age-related fracture pain would be to preemptively administer an osteo-anabolic agent to geriatric patients with high risk of fracture, so as to build new cortical bone and prevent the fracture from occurring. A major question, however, is whether an osteo-anabolic agent can stimulate the proliferation of osteogenic cells and build significant amounts of new cortical bone in light of the decreased number and responsiveness of osteogenic cells in aging bone. To explore this question, geriatric and young mice, 20 and 4 months old, respectively, received either vehicle or a monoclonal antibody that sequesters sclerostin (anti-sclerostin) for 28 days. From days 21 to 28, animals also received sustained administration of the thymidine analog, bromodeoxyuridine (BrdU), which labels the DNA of dividing cells. Animals were then euthanized at day 28 and the femurs were examined for cortical bone formation, bone mineral density, and newly borne BrdU+ cells in the periosteum which is a tissue that is pivotally involved in the formation of new cortical bone. In both the geriatric and young mice, anti-sclerostin induced a significant increase in the thickness of the cortical bone, bone mineral density, and the proliferation of newly borne BrdU+ cells in the periosteum. These results suggest that even in geriatric animals, anti-sclerostin therapy can build new cortical bone and increase the proliferation of osteogenic cells and thus reduce the likelihood of painful age-related bone fractures.

Abstract HEART FAILURE SYMPTOM CLUSTERS AND FUNCTIONAL STATUS Janet Kay Herr Ph.D A dissertation submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy at Virginia Commonwealth University Virginia Commonwealth University 2012 Major Director: Dr. Jeanne Salyer, Ph.D., R.N., F.N.A.P Associate Professor, Adult Health & Nursing Systems Clinical assessment of heart failure includes symptom identification and the evaluation of the relationship of symptoms to functional status. Symptom clusters are groups of at least 2 or 3 co-occurring symptoms that are related but are independent of other groups of symptoms. The objectives of this study are to: (1) examine relationships among symptoms commonly experienced by individuals with heart failure, (2) identify symptoms that form clusters, and (3) evaluate the impact of heart failure symptom clusters on attributes of functional status: limitations and mobility The Theory of Unpleasant Symptoms guided the conduct of this study. Heart failure symptoms and the outcome variables functional limitations and mobility were evaluated in a convenience sample of individuals (n = 117) with a confirmed diagnosis of heart failure recruited viii from an academic medical center. Principle components analysis was used to extract symptom clusters and regression analysis was used to evaluate the relationship between the symptom clusters, their interaction terms, the demographic variables, age and co-morbidity, and functional status. Three symptom clusters, sickness behavior, discomforts of illness, and GI distress were extracted. Predictors of functional limitations (F = 35.96, p = 0.0005, R2 = 0.578) included sickness behavior (β = -.681, p 0.0005), discomforts of illness (β = - .765, p = 0.0005) and the interaction term between these two symptom clusters (β = .649, p = 0.014). This model predicted 59% of the variance in functional limitations. Predictors of limited mobility (F 20.68, p = 0.0005, R2 = 0.275) included sickness behavior (β = -0.441, p 0.0005) and co-morbidity (β = -.200, p = 0.019). This model predicted 28% of the variance in mobility. Relationship between clusters of heart failure symptoms and functional limitations or mobility was observed. The interaction between discomforts of illness and sickness behaviors implies that not only do functional limitations increase as discomforts of illness increase, but increases at a faster rate when sickness behaviors are increased. Changes in sickness behaviors has the potential to improve mobility from being bed or chair bound everyday or most days to being bed or chair bound only some days.

>Magister Scientiae - MSc / Persons with lower limb amputations (LLA) experience different challenges in the community. These challenges include the physical, psychological and social function of an individual. Little is known in Malawi on what persons with lower limb amputations go through in the communities where they live. Therefore, the study aimed at exploring and determining community experiences of persons with LLA in Malawi. The study sought to address the following objectives: 1) To determine the functional and psychological status of persons with LLA in the community; 2) To explore and describe experiences on social participation of persons with LLA in the community; 3). To explore experiences on community re-integration following LLA. A mixed method approach was applied where quantitative and qualitative data were collected simultaneously to provide a more holistic overview of the experiences of persons with LLA at one point in time. The study setting was Queen Elizabeth Central Hospital (QECH) and Kamuzu Central Hospitals (KCH) (500 miles), located in Malawi. A sample of 180 participants was recruited to participate in the study. Three self-administered questionnaires (socio-demographic questionnaire, OPUS module of lower extremity functional status, and a Beck’s depression inventory scale) and a semi-structured interview guide were used for data collection. Thematic data analysis was used to analyze qualitative data, while quantitative data was analyzed using descriptive and inferential statistics. Ethical clearance was obtained from the University of the Western Cape Biomedical Research Ethics Committee (BMREC) and College of Medicine Research Ethics Committee (COMREC). Permission to conduct the study was obtained from KCH (500 miles) and QECH. Privacy andconfidentiality was strictly observed such that data obtained was anonymous. It was kept in a secure place, and electronic data was secured using a password.

Many older adults residing in long term care (LTC) homes have underlying health conditions and limited functionality. The objective of this research was to address the issues which might affect the health status and functionality of older adults (age ≥ 60y) living in LTC homes. To achieve this objective, the research was carried out as four studies. In the first study, supplement and medication use was examined, specifically exploring the impact of dementia, and to assess pill burden in older adults residing in LTC home. In the second study, menu served in this LTC was assessed for recommendations of Canada’s Food Guide servings, macro, micro nutrients, and diet quality score. This menu analysis was compared to a similar analysis conducted a decade ago to find out what changes had occurred over time. In the third study, LTC residents were assessed for blood inflammatory markers, 25-hydroxyvitamin D (25(OH)D), metabolic syndrome, physical functioning, cognition, pain, and associations between inflammation and markers of functionality. Similar analyses on healthy community dwelling older and younger adults was conducted to draw differences amongst all three groups, i.e., older frail (LTC residents), older healthy, and younger healthy (community dwelling). In the fourth study the option of adding an anti-inflammatory diet was explored to address the issues of inflammation and compromised menus in LTC. Major findings suggested that there was inappropriate overuse of supplements, yet vitamin D supplements were consumed by only one-third residents of the LTC home. The LTC menu did not meet the recommendations for Canada’s Food Guide servings except for Fruits & Vegetables. Diet quality of the LTC menu was low and indicated the need of improvement, however, the comparison of current menu to a decade old menu showed some improvements. Inflammatory markers in LTC older adults were high, and the majority of subjects had insufficient 25(OH)D. Metabolic syndrome was seen in about more than one-third of subjects. Significant correlations between C-reactive protein, cognition and activities of daily living were detected. The anti-inflammatory diet was validated from research, and strategies of incorporating it into the diets of LTC residents were addressed.

Background: During the early postpartum period, new mothers commonly experience fatigue and depressive symptoms which may affect their ability to function and care for themselves and their newborn. Given the demonstrated positive effects of physical activity on mood and fatigue, the purpose of this study was to describe physical activity levels across late pregnancy and the first three months postpartum, and to determine the associations between physical activity and postpartum functional status, mood, and fatigue at 6- and 12-weeks postpartum. Design: We employed a longitudinal, descriptive study design. Prenatal classes were used to recruit women. Questionnaires containing validated measures of functional status, physical activity, mood, and fatigue were administered at baseline (pregnancy), 6- and 12-weeks postpartum. Results: The sample consisted of 73 primiparous women with a mean age of 30 (+3.7) years. The majority were married (83%), Caucasian (98%), educated (70%) and middle to upper-middle class. Women in this study were physically active, with the majority being moderately active (52%). Few women had low physical activity levels (n = 4-8) throughout the study. Household activities and walking accounted for the majority of physical activity. Women in this study reported moderate levels of fatigue, with fatigue levels decreasing over time. For most postpartum women, mood and fatigue scores improved from six to 12 weeks; however, for 26% of women, scores did not. Self-care and social/community activity subcategories of functional status were the slowest to improve. Women who were low/moderately physically active at six weeks postpartum were three times as likely to have low functional status in comparison to highly physically active women (OR 3.22, 95% CI: 1.07, 9.73). At 12-weeks women with higher mental (OR 1.33, 95% CI: 1.00, 1.79) and physical fatigue (OR 1.23, 95% CI: 1.07, 1.40) were more likely to be in the lower functional status group at 12-weeks postpartum. Conclusion: Our findings indicate that high levels of self-reported mental and physical fatigue relate to lower functional status for primiparous women at six and twelve weeks postpartum. Women who are highly physically active at six and twelve weeks postpartum are more likely to have higher functional status, but this effect is influenced by perception of both mental and physical fatigue. / Thesis (Master, Nursing) -- Queen's University, 2011-09-29 15:57:25.901

Purpose of study: To examine change in balance-related fall risk and daily functional abilities in the first 2 postoperative weeks and up to 6 weeks after gynecologic surgery. Materials and methods: Prospective cohort study in gynecologic surgery patients age 65 and older. Balance confidence (Activities-specific Balance Confidence Scale) and functional status (basic and instrumental activities of daily living) were recorded pre-and post-operatively daily for 1 week and twice the second week. Physical performance balance and functional mobility were measured pre-and 1 week post-operatively using the Tinetti Fall Risk Scale, Timed Up and Go, and 6-Minute Walk test. Measures were repeated 6 weeks after surgery. Nonparametric tests for paired data were used comparing scores baseline to post-operative (POD) 7 and to POD 42. Results: Median age was 72 years (range 65-88). Fall risk was elevated during the first 2 post-operative weeks, greatest on the median discharge day, POD 2 (p < 0.01). Balance performance and functional mobility at 1 week were significantly lower than baseline (p < 0.01). Functional abilities declined, including new dependence in medication management at home in 22% of these independent and cognitively intact women. Conclusions: After gynecologic surgery, older women's fall risk is highest on POD 2 and remains elevated from baseline for 2 weeks. Functional limitations in the early home recovery period include the anticipated (bathing, cooking, etc.) and some unanticipated (medication management) ones. This information may help with postoperative discharge planning.

Indiana University-Purdue University Indianapolis (IUPUI) / Chronic obstructive pulmonary disease (COPD) is a significant worldwide cause of chronic illness and mortality and one of the most common admitting diagnoses in the United States. Persons with COPD are at increased risk for deconditioning during hospitalization, which can lead to decreased functional status at discharge. Disease-related factors and elements of the hospital environment make older adults with COPD vulnerable to hospital-associated functional status decline. The purpose of this dissertation was to identify activity factors that contribute to hospital-associated functional status decline in older adults with COPD by promoting functioning during hospitalization. This predictive correlational study is a secondary analysis of a pre-existing dataset. Patients with COPD were pulled from the larger parent study sample for comparison with patients without COPD. The convenience sample consisted of 111 patients with COPD and 190 patients without COPD. Subjects were 46.5% male, 53.5% female, and a mean age of 66 years. All subjects were patients admitted to a pulmonary unit and received an intervention protocol designed to address mobility barriers related to COPD and hospitalization. Statistical analysis explored the number, type, and timing of activity events in relation to the selected functional status outcomes of discharge disposition, length of hospital stay, and 30-day readmission rates for hospitalized older adults with COPD. Multivariate and bivariate analyses results indicated ambulation to the bathroom, ambulation outside the patient room, and number of days to first out-of-bed activity were significant predictors (p < 0.05) of patient discharge to home; days to first activity and ambulation were significant predictors (p < 0.05) of reduced length of stay; none of the variables were predictive of 30-day readmission. Patients with COPD experienced longer lengths of stay and more non-weight bearing activity than patients without COPD in this sample. These findings provide a foundation for future research to explore hospital environmental factors influencing mobility, determine optimal modes of activity during hospitalization, and examine potential cost savings associated with promotion of early mobility. Findings help explain the effects of physical activity during hospitalization and may aid development of nursing interventions to prevent or alleviate functional status decline in this vulnerable population. / 2 years

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