Substance use disorders among the baby boomer generation are steadily increasing, but knowledge and training satisfaction regarding older adult substance use disorders among behavioral health providers (BHPs) has not been explored. Using the Kirkpatrick evaluation model, this quantitative study involved an examination of the knowledge and training satisfaction of four behavioral provider groups: addiction counselors, licensed professional counselors, marriage and family therapists/social workers, and psychologists. Each participant (N = 154) completed a demographic questionnaire, satisfaction questionnaire, and the Alcohol and Older Adult Questionnaire to measure knowledge level on older adult substance use disorders. The results showed that licensed professional counselors held significantly higher levels of knowledge than any other BHP group. There were no significant differences between BHPs regarding satisfaction with training on older adult substance use disorders. No relationship was found between BHP satisfaction and BHP knowledge scores, even when considering the number of years, a BHP was licensed. Therefore, the findings of this study may encourage more training for BHPs aside from licenses professional counselors as well as future research on BHPs treating older adult substance use disorders.

Over 71 million Americans will be over the age of 65 by the year 2030. With this rise in adults aged 65 years and older also comes an exponential rise in the estimated number of individuals with Alzheimer’s disease (AD); this number is expected to exceed 24 million Americans by the year 2040. The number one risk factor for AD is older age; this factor is also associated with an increased risk in developing a sleep disturbance. Sleep disturbances have been associated with an increased risk of cancer, heart disease, and decline in overall health. Recent research has examined the association between sleep disturbance and risk for AD; however, these results are mixed. This project analyzed existing data from the population-based longitudinal Cache County Study on Memory and Aging (CCSMA), which included permanent residents of Cache County, Utah who were aged 65 years or older in 1995. The CCSMA consisted of 4-triennal waves and ran from 1995 until 2007; the aim of the original study was to examine antecedents of AD and other forms of dementia. In this thesis, the first study examined whether sleep disturbance was associated with increased risk in developing AD. Sleep disturbance was associated with risk of developing AD, but the results differed between males and females. Among females, endorsing sleep disturbance was associated with a 54.5% decrease in the hazards of developing AD (Hazard Ratio [HR]= .455, p = .0001) compared to females without sleep disturbance. Among males, sleep disturbance was not associated with risk of developing AD (p = 0.498). The second study evaluated if use of sleep medications was associated with increased risk of developing AD and if that association differed between males and females: males who reported use of sleep medication, regardless of having a sleep disturbance, were at increased risk of developing AD (for men without a sleep disturbance HR = 3.604; p = 0.0001). By contrast, in females, risk for developing AD varied by the presence of a sleep disturbance. Compared to the reference group (females without a sleep disturbance and no sleep medication use), females who reported a sleep disturbance and use of sleep medication were at a 35.2% reduced risk of developing AD (HR = 0.648; p = 0.011) while, those not reporting a sleep disturbance but were taking sleep medications were at 3.9 times increased risk in the hazards of developing AD (HR = 3.916; p = 0.0001). Although this study is observational in nature and therefore does not prove that the use of sleep medication is harmful, it is recommended that health care providers consider alternative, nonpharmacological approaches to treat sleep disorders in older adults. Further research is needed to examine sex differences and how they may relate to the differences associated with sleep disturbances and risk for AD.

abstract: Approximately 89 million Americans will be age 65 and older by 2050 in the United States. This older adult population is especially vulnerable to loneliness as a result of numerous age-related risk factors including loss of social support and declining health. In addition to these common risk factors, refugee older adults may face increased loneliness as a consequence of war-related trauma, loss, and marginalized cultural values in their host country. Despite their heightened vulnerabilities to loneliness, the experiences of refugee older adults remain understudied. This is the first study aimed at understanding the loneliness experiences of community-dwelling Hmong older adults, an ethnic group resettled in the United States as refugees over 40 years ago. A constructivist grounded theory method guided by an intersectionality framework was used to address three aims: 1) to understand the concept of loneliness among community-dwelling Hmong older adults, 2) to explore the premigration, displacement, and postmigration experiences of loneliness among community-dwelling Hmong older adults, and 3) to examine how community-dwelling Hmong older adults cope with loneliness. Semi-structured individual interviews were conducted with 17 Hmong older adults age 65 and older residing in Sacramento and Fresno, California. Analysis of the data was an iterative process between coding the data, generating focused codes, and connecting the categories to establish a conceptual pattern. Participants conceptualized loneliness as a negative experience represented through physical and emotional expressions and intensity, which were influenced by an intersectional identity. Factors that influenced their experiences of loneliness in the premigration, displacement, and postmigration phase were discussed as trust, loss, aging-related issues, isolation, sense of community, access to cultural community, instability, violence, and cultural adjustments. Their narratives offered several coping mechanisms including religious and spiritual beliefs, social support, wandering, activity engagement, and control and avoidance. These findings informed a conceptual model of loneliness that incorporated an intersectional identity, influencing factors, and coping mechanisms. Overall, the results provide nuanced cultural meanings and insight into the loneliness experiences of Hmong older adults. Implications for social work research, practice, and policy suggests the need for greater culturally- and linguistically-competent services informed by Hmong older adults. / Dissertation/Thesis / Doctoral Dissertation Social Work 2019

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

Indiana University-Purdue University Indianapolis (IUPUI) / Hospital readmission is of growing importance in the healthcare industry because of associated patient and system costs, impact to the quality of patient care, and hospital Medicare payment penalties. The increasing interest in sepsis readmission prevention has highlighted the uniqueness of severe sepsis or septic shock survivors. The results of this study provide insight into the relationship between index hospital length of stay (LOS) and 30-day readmissions for older adults (> 65 years) who discharged home from an index hospital with a principle or secondary discharge diagnosis of severe sepsis or septic shock. The purpose of this study was to investigate the relationship between index hospital LOS and 30-day readmissions in older adults (> 65 years) whose expected primary payer was Medicare and who discharged home with a principle or secondary diagnosis of severe sepsis or septic shock. Data used to answer the proposed research questions consisted of older adult discharge records from the 2014 Nationwide Readmissions Database (NRD), Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality. Differences in 30-day readmissions between older adult age groups, gender, and older adult location were examined. The number of days to readmission since discharge was evaluated for the subset of older adults with a readmission. Approximately 15.6% of older adults were readmitted within 30 days of their discharge. Readmissions were statistically different based on the older adult’s age, gender, and LOS. Location did not have a significant effect on readmissions. Mean LOS among readmitted older adults was 10.1 days. Analysis indicates that an older adult’s LOS had a significant effect on readmissions, although models performed poorly. Findings suggest that there are certain factors that can predict older adults who are at risk for being readmitted after being discharged with a principle or secondary discharge diagnosis of severe sepsis or septic shock.

Indiana University-Purdue University Indianapolis (IUPUI) / Up to 75% of the more than 3.5 million breast cancer survivors (BCS) living in the United States report cognitive dysfunction. However, little is known about cognitive dysfunction among older BCS, who may be at greater risk. Therefore, the purpose of this dissertation was to characterize cognitive dysfunction in older BCS. Specific aims included: (1) synthesize the literature regarding cognitive dysfunction in older BCS; and (2) examine the relationships between a) objective cognitive function (immediate memory, delayed memory, attention, executive function-working memory, verbal fluency) and subjective cognitive function (attention); b) demographic factors, medical factors, treatment factors, and cancer-related symptoms (depressive symptoms, anxiety, fatigue, sleep disturbance) and cognitive function; and c) comorbidity and cognitive function and physical functioning, and quality of life (QoL) in older BCS. In an integrative review, to address aim 1, 12 studies were identified. Up to 41% of older BCS showed objective cognitive dysfunction on neuropsychological assessment, up to 64% reported subjective cognitive dysfunction concerns pre-treatment, and 50% incurred cognitive decline from pre- to post-treatment. Cognitive dysfunction was associated with older age, multiple comorbidities, chemotherapy, sleep disturbance, neuropsychological symptom cluster, frailty, and poorer QoL. To address aim 2, data were leveraged from a large, nationwide, QoL in younger versus older BCS study (PI: Champion), which included 335 older BCS who were ≥60 years of age, had breast cancer (stage I-IIIa), received chemotherapy, and were 3-8 years post-diagnosis without recurrence. Findings included up to 19% of older BCS had mild-moderate objective cognitive dysfunction on at least one neuropsychological assessment, with 26% reporting poor-moderate subjective attention function. BCS, who were older, had less education and more depressive symptoms had greater cognitive dysfunction. Objective attention and executive function-working memory significantly and positively correlated with subjective attention. In turn, subjective cognitive dysfunction and increased number of comorbidities were related to poorer physical functioning. Subjective cognitive dysfunction was also related to poorer QoL. The findings from this study highlights the prevalence and complexity of cognitive dysfunction in older BCS. Further research is needed to better understand the intersection of aging, cancer, comorbidities and cognitive dysfunction and the negative implications in older BCS.

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