Problem statement: As a result of the aging population, the number of people living with chronic disease has increased to almost 50% (CDC, 2004). Two of the main goals in treating patients with chronic diseases are to provide seamless care from setting to setting and prevent disability in the older adult. Many have proposed the use of electronic personal health record systems (PHRs) in the self-management process, but adoption remains low. The purpose of this research was to validate and test an explanatory model of the barriers and facilitators to older adults' adoption of personal health records for self-managing chronic illnesses. The long range goal of the research is to use the explanatory model to develop interventions that will maximize the facilitators and minimize the barriers to adoption. Methods: A preliminary attempt to capture the essential barriers and facilitators that predict adoption of PHRs among older adults with chronic illness was synthesized from the literature. In Phase One of the study, the model was integrated from existing literature and validated using a Delphi method. In Phase Two of the study, the model was pilot tested and refined for future investigations. Findings: The results of this study validated the Personal Health Records Adoption Model (PHRAM) and a preliminary instrument that measured barriers and facilitators to the adoption of PHRs in older adults who are self managing chronic illness. Additional findings indicate that while seniors are seeking options to manage their health and have expressed an interest in using Internet-based PHRs, they may require assistance to gain access to PHRs. Implications: The potential for PHRs to increase patient autonomy and reduce for disability and the resulting negative health consequences needs further investigation as we move into the next era of healthcare delivery. The results of this study provided the foundation for continued theoretically-based research in this area.

There has been a growing interest among policymakers in the potential role of physical activity (PA) as a strategy to mitigate the challenges associated with an aging population, specifically the potential pressures on the health care system presented by an increasing need and demand for long term management of chronic health conditions. In this dissertation, the relationship between PA and health service utilization among older adults and the role of PA in reducing health services utilization in this population is examined via two studies. Study 1: The purpose of Study 1 was to examine relationships between LTPA and health services utilization in a nationally representative sample of community-dwelling adults aged 50 years and older. Methods: This study involved a secondary analysis of data from the Cycle 3.1 of the Canadian Community Health Survey. The analysis was restricted to individuals aged 50 years and older, resulting in an unweighted sample of 56,652 adults (48%M; 52%F; mean age 63.5±10.2 years), stratified a priori into three age groups (50 – 64 years, 65 – 79 years, 80 years and older). Self-reported use of general physician (GP) services, specialist physician services and hospital services for the 12-month period prior to the survey were the outcomes of interest. The main independent variable of interest was self-reported LTPA for a 3-month period prior to the survey. A comprehensive set of predisposing, enabling, and health need factors associated with health services utilization were included as control variables in all analyses. Separate multiple logistic and negative binomial regression models were used to assess the association between LTPA and each dichotomous and count-based dependent variable, respectively. Bootstrap re-sampling procedures were applied in all regression analyses. Results In the 50-64 year age group, active individuals were 27% less likely to report any contact with a GP (OR=0.73; p<.001) and had 8% fewer GP consultations (IRR=0.92; p<.01) than their inactive counterparts. Among 65 to 79 year olds, active respondents were 18% less likely than their inactive counterparts to have had an overnight hospitalization in the previous 12 months (OR=0.82, p<.05). Across all age groups, higher levels of non-leisure physical activity was associated with lower health services utilization. Study 2: The purpose of Study 2 was to investigate the effects of a randomized community-based PA intervention (50+ in motion) on participants’ health service utilization and healthcare costs over a 5-year period. Methods: 50+ in motion was a randomized clinical trial comparing the effectiveness of a class-based (CB) and home-based (HB) exercise program for older adults with select chronic health conditions (hypertension, dyslipidemia, type 2 diabetes mellitus, osteoarthritis, overweight or obesity). Of the 172 participants randomized, 59 CB and 69 HB participants granted access to their administrative health data. Data pertaining to GP and specialist physician services utilization and costs as well as hospital services utilization and costs were obtained for all consenting participants from the Saskatchewan Ministry of Health for the year prior to enrolment in the 50+ in motion study through to 48-months post-randomization, for a total of 5-years of data. Independent variables including demographic characteristics, physical activity, sedentary behaviour, cardiovascular endurance, functional fitness, body composition, blood pressure, and self-reported physical and mental health status were collected directly from participants prior to randomization and then annually for 4 years. Longitudinal effects of the 50+ in motion intervention on health services utilization and healthcare costs were assessed using the generalized estimating equation (GEE) approach with covariates selected for inclusion based on methods of purposeful selection. Results: There were no significant differences in health services utilization or health care costs between the CB and HB interventions until the final year of the study when the HB group had 60% more GP visits than the CB group and were 89% less likely than the CB group to be frequent users of specialist services. There were no significant differences between the randomization groups in healthcare costs. Measures of functional fitness emphasizing lower body strength, endurance and power were more consistently associated with lower health services utilization than CV endurance, body composition or physical activity. Sedentary behavior was associated with higher hospital costs, independent of physical activity, functional fitness and health status. Overall Conclusion: Taken together, the two studies in this thesis address a significant gap in the Canadian literature and provide novel insights into the relationships between PA, health and health services utilization in older adults. While further research is needed to improve our understanding of the relationships between physical activity and sedentary behaviour, physical fitness, and health services utilization, the findings presented in this thesis suggest reducing sedentary behaviour and improving functional fitness in older adults may be as important as physical activity, if not more so, in terms of potential impact on health services utilization and health care costs. For health care professionals and policymakers at all levels, the findings highlight the advantages of a multi-pronged, interdisciplinary approach to the development of public health initiatives and interventions focused on increasing PA participation and functional fitness among older adults.

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.