Community integration is vital for older adults with mental health issues, both as a process and as an outcome. The process of deinstitutionalization has made community integration a primary concern for these individuals. Many researchers recognize the significant lack of community resources that have been established in order to accommodate individuals with mental health issues in the community (Davidson, Hoge, Godleski, Rakfeldt, & Griffith, 1996; Pedlar, 1992). Researchers and practitioners alike, however, lack a thorough understanding of the factors that contribute to the successful and lasting community reintegration of older adults with mental health issues. The purpose of this study was to provide an in-depth analysis of the experience of community integration for older adults with mental health issues. The study was guided by the conceptual framework of phenomenology, focusing on the lived experiences of these individuals (Patton, 2002). Utilizing qualitative methods, data collection consisted of semi-structured interviews, oral member checks and the maintenance of a reflexive journal. Participants in the study were five older adults who had been diagnosed with a psychiatric disorder, had received treatment on an inpatient geriatric psychiatry unit, and had returned to their homes in the community upon discharge from the hospital. The findings suggest that being healthy and concomitantly maintaining independence played a key role in the process of community integration for these older adults. Independence, from the perspective of these individuals was quite different from the definitions of independence commonly used in North American society. The older adults in this study did not adhere to the principles of autonomy and individualism in relation to independence. Instead, they accepted a certain degree of dependence in order to prevent or avoid future disability, relapse, and readmission to hospital. A number of factors contributed to their independence, both positively and negatively, including: being healthy; social support; a smooth transition from hospital to community; maintaining feelings of self-worth; solitude; the power of knowledge; feelings of burden; and managing stress. These findings point to an emerging model of community integration that incorporates the concepts of empowerment, recovery, inclusion, and independence. The experience of independence, as described by these individuals, evoked feelings of empowerment and was strongly associated with the concept of recovery. For these older adults, being healthy, and thus, independent, meant being integrated. The findings, as well as the process of conducting this research, have lead to a number of recommendations for future research and suggestions for practitioners and policy makers involved with these older adults.

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.

This study investigated whether lutein and DHA enriched egg consumption can improve electrophysiological retina function for the prevention of age-related macular degeneration in Caucasian older adults. Thirty (male: n=11, female: n=19) healthy Caucasian older adults (64.0 ± 3.4 years) consumed two lutein and DHA enriched eggs (0.87 mg lutein/day, 220 mg DHA/day) daily for six weeks. Retina function, plasma and red blood cell (RBC) DHA, plasma lutein, lipid profiles, and lipoprotein subfractions were assessed at day 0 and 6 wks. The maximum amplitude of scotopic a-wave and photopic b-wave significantly increased along with plasma DHA concentrations No significant alterations in plasma Chol, HDL-Chol, LDL-Chol, triacylglycerides, plasma lutein and RBC DHA were present. A significant increase in large HDL particles and a decrease in intermediate sized HDL particles occurred. This study suggests that consuming two lutein and DHA enriched eggs daily may improve electrophysiological retina function without adversely altering plasma lipids in Caucasian older adults. / May 2017

Class of 2017 Abstract / Objectives: To assess older adults’ knowledge of prescription pain and over-the-counter (OTC) medications, to determine if age influences older adults’ choice of OTC pain agents, and to determine if education by a pharmacist about prescription and OTC pain medications impacts the score on a medication knowledge indicator. Methods: This is a descriptive survey study. Participants received a recruitment email with a consent link in order to participate in the secure, online Qualtrics survey. The survey consists of 10 knowledge-based items on pain medications and 12 demographic items. The primary outcome of this study is the knowledge about pain medications of adult 75 years and older. Knowledge scores were analyzed using a Chi square test to compare the proportion of respondents in each age group who score 50% or more. The secondary outcome is the purchase pattern of OTC pain medications based on age. OTC purchasing data was analyzed using a nonparametric regression test. The tertiary outcome is the effect of pharmacist counseling on patients knowledge of prescription and OTC medications. The knowledge indicator scores were compared in patients who reported as either being educated by a pharmacist or not using a one-way ANOVA test. Results: The questionnaire was completed by a total of 50 people, but three were excluded due to not meeting the age requirement of 50 years and older. Forty-seven participants were used in the analysis with mean age of 68.3 years (range 55 to 90) and 72% female. Of 44 participants who completed the entire survey those 75 years and older scored better on the knowledge indicator (71% scored ≥50%) compared with those 74 years and younger (54% scored ≥50%); however, no significant difference was found (p = 0.28). In addition, purchasing pattern based on percentage of both prescription and OTC medications between both groups appeared to be insignificantly different (p = 0.31 and 0.51 respectively). The mean number of OTC medications purchased equaled the mean number of OTC medications purchased for adults less than 75 years of age (Y = 1.2 vs. 1.2 medications per patient, p=0.51). Finally, all patients age 75 and older that reported being educated by a pharmacist scored 50% or greater on the knowledge indicator (100%) while 52% of participants 74 years and younger scored 50% or greater (p = 0.673). Conclusions: Adults ages 75 years and older possess the same basic knowledge of pain medications when compared to adults age 50 to 74. In addition, adults age 75 years and older purchase over-the-counter (OTC) at the same rate as adults age 50 to 74. Finally, adults age 75 years and older benefit most from pharmacist consultation compared to adults age 50 to 74.

Health and well-being of older adults has become a worldwide public health concern and has been attracting increasing attention from scholars across the globe. But little is known about the health of the Chinese elderly. Using data from the China Health and Retirement Longitudinal Study (CHARLS) --Pilot, a pilot survey in 2008 in two provinces of China, Gansu and Zhejiang, this dissertation examines the association between social capital at both the individual- and community- levels and three health outcomes among older adults in China. A series of multi-level models were estimated using SAS 9.2. Statistical results indicate that such individual-level social capital variables as perceived help and support in the future, help from others, and birthplace significantly impacted health among older Chinese adults. When examining the relationship between community-level social capital and health, this study confirms the significant association between community-level social capital and good health independent of individual-level predictors. This study also indicates that the impact of gender and rural-urban Hukou status interacts with the province of residence. The results were discussed in terms of cultural legacy in the Chinese cultural setting, the current social dynamics related to old age support, health-related government reforms, and various disparities across different regions and across different social groups in China.

This thesis is a report of a study of the employment of foster grandparents for the foster grandparent project at the Denton State School in Denton, Texas. There were three specific interests in the study. First, it attempted to ascertain what criteria were used for the hiring of foster grandparents and how they were hired. Included in this area were the necessary steps which an individual had to take to apply for employment. Second, the study was concerned with developing a general description of the social and economic characteristics of those who were hired as foster grandparents, including their performance on certain tests which they took during the employment process. Third, it examined the relationship of selected social and economic characteristics to each other, the inter-relationships of test performance, and the relationships between the selected characteristics and test performance.

The purpose of this study was to explore how stereotypes affect physical performance in older adults. A multigroup pretest post test design was utilized to determine whether implicit activation of positive or negative stereotypes has an effect on physical performance. Ninety six community dwelling older adults 65 years of age or older were included in the sample. Participants were randomly assigned to one of three groups: exposure to positive stereotypes of aging, exposure to negative stereotypes of aging, or a control condition. In order to simulate how older adults are exposed to stereotypes in real world settings, participants were primed with objects representing aging stereotypes. Gait speed, standing balance, and lower extremity muscle performance were tested before and after exposure to stereotypes. Results of MANCOVA analysis, using self-relevance as a covariate, revealed no significant differences between those exposed to positive stereotypes, negative stereotypes, or the neutral condition. Physical performance is not affected by exposure to implicit stereotypes of aging in a more real world setting. In real world settings, there are multiple factors, like motivation and self-focus, competing for the control of behavior which are not present in the lab. These psychosocial factors may lessen the effect of stereotype activation on physical performance

Objective: To evaluate the level of agreement between two self-reported medication adherence scales and prescription refill records in older adults. Design: Cross-sectional study Setting: Imperial Plaza; a retirement community located in Richmond, Virginia. Participants: 32 independent-living older adults, taking anti-hypertensive medications and filling their prescriptions at on-site Plaza Professional Pharmacy were recruited in the study. Methods: Participants’ 6 months refill records were obtained and Medication Possession Ration (MPR) was calculated. Participants were interviewed using Morisky Medication Adherence Scale (MMAS) & Brief Medication Questionnaire (BMQ). Kappa statistics was used to evaluate the level of agreement. Results: Poor level of agreement was found between refill records and MMAS (k=-0.004), refill records and BMQ belief screen (k=-0.09), regimen screen (k=-0.09), and recall screen (k =-0.004). Strong agreement was found between MMAS and BMQ regimen screen (k=0.79) and recall screen (k=0.87) respectively. Conclusion: Self-reported measure of adherence exhibited poor agreement with prescription refill records.

Although research has shown that the complex constructs of intelligence and personality are necessarily intertwined, studies exploring this issue in elderly individuals are rare. The importance attached to this interface in older adults becomes particularly clear in light of the debate over the cause and extent of age-related decrements in cognitive performance as well as whether such losses can be ameliorated or not, especially given societal shifts toward increased life expectancies. The present study explored the basis for shifts in personality-ability relationships in adulthood by comparing two samples of older adults, one of which was assessed in 1975 (N = 102, M age = 68.4), and the second of which was assessed in 1995 (N = 100, M age = 72.0), and a sample of younger adults (N = 100, M age = 21.8), also assessed in 1995. Each participant was administered the Holtzman Inkblot Technique and the Gf-Gc Sampler, a measure of crystallized (Gc) and fluid (Gf) abilities. LISREL analyses of both age-related and historical shifts in personality-ability relationships suggested that not only were such shifts associated with cohort differences as reflected in factor loading (lambda) differences between the older samples and the younger sample, as well as between each of the older samples, but also that such connections were weaker among younger adults. These findings are important in revealing that sociocultural shifts in opportunities for continued cognitive growth influence the impact of noncognitive (personality) factors on intellectual functioning in later life. Limitations of the current study, implications of the results, and suggestions for future research are discussed.

Frailty in older adults is characterised as a vulnerable state, which predicts a range of health outcomes (e.g., injurious falls, institutionalisation, and mortality). The physiological and practical outcomes of frailty are recognised, but the psychosocial processes are largely unexplored so they were the focus the thesis. The overall aim of the thesis was to advance the understanding of frailty in older adults and its relationship with ageing perceptions. Three studies were conducted to achieve this aim. The first piece of work was a systematic review that investigated the association between older adults’ perceptions of ageing, broadly defined, and their health and functioning. The review showed that negative ageing perceptions were associated with poor health and functioning across a variety of health domains relevant to understanding frailty including: self-rated health; comorbidities; disability; memory; quality of life; mortality. However, conclusions from the review were limited by the quality and cross-sectional nature of the studies. Consequently, the second piece of work analysed data from a large longitudinal sample to test the relationship between older adults’ ageing perceptions and frailty explicitly. Older adults with more negative perceptions of ageing were more likely to be frail after adjusting for age, sex, depression symptoms, and socioeconomic status. However, ageing perceptions were found to be a weak predictor of frailty six years later. To investigate the mechanisms of the relationship between ageing perceptions and frailty, a qualitative exploration of older adults’ understanding of frailty and their beliefs concerning its progression and consequences was conducted as the third piece of work. Twenty-nine participants participated in semi-structured interviews, which were analysed using a Grounded Theory approach. An understanding of frailty as a negative identity and the strategies by which self-identification “as frail” occurs and is resisted were developed. Participants believed that the consequences of self-identifying as frail were poor health and functioning, disengagement from physical and social activities, depressive thoughts, negative affect, stigmatisation, and discrimination. Most participants actively resisted the identity, and they used a variety of resistance strategies. Collectively, the findings from this project indicate that older adults’ ageing perceptions are related to the development and progression of frailty. Ageing perceptions are associated with older adults’ health and how they view themselves – whether they identify as frail and the different strategies they may use to resist identification. Whilst additional research is needed, the results of this research suggest an influential psychosocial aspect to frailty. Accordingly, a new model of frailty and its relationship with older adults’ ageing perceptions is offered. The model has implications for the way frailty is identified, supported and treated.