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Understanding underlying mechanisms and pathways that lead to chronic homelessness would help develop intervention strategies that could help prevent subsequent episodes of homelessness. Quantitative data for this cross-sectional study was gathered by interviewing individuals who were homeless in the State of Arkansas, using a structured survey between 2007 and 2011. Qualitative data was gathered using semi-structured interviews between 2016 and 2018. Chi-square statistics and a multivariate logistic regression model was used to analyze the quantitative data, while phenomenological methods were used to analyze the qualitative data. Nearly half of the study participants identified themselves as being chronically homeless. Chronically homeless adults in this region were significantly more likely to be older men with no family ties, more likely to be victims of domestic violence, have higher rates of physical health problems, and have alcohol and substance abuse problems. Results from the multivariate nominal regression revealed that individuals who reported themselves as chronically homeless were more likely to be in the 50 years or older age group. In addition, study findings highlighted a dynamic interplay between three biopsychosocial risk factors for homelessness. Fostering development of inclusive sustainable communities, intergenerational relationships, and shared housing practices could help ease such social inequities and prevent problems such as chronic homelessness in older homeless adults.

Background Fewer than one-third of nursing home residents with atrial fibrillation were treated with the only available oral anticoagulant, warfarin, historically. Management of atrial fibrillation has transformed in recent years with the approval of 4 direct-acting oral anticoagulants (DOACs) since 2010. Methods Using the national Minimum Data Set 3.0 linked to Medicare Part A and D claims, we first described contemporary (2011-2016) warfarin and DOAC utilization in the nursing home population (Aim 1). In Aim 2, we linked residents to nursing home and county level data to study associations between resident, facility, county, and state characteristics and anticoagulant treatment. Using a new-user active comparator design, we then compared the incidence of safety (i.e., bleeding), effectiveness (i.e., ischemic stroke), and mortality outcomes between residents initiating DOACs versus warfarin (Aim 3). Results The proportion of residents with atrial fibrillation receiving treatment increased from 42.3% in 2011 to 47.8% as of December 31, 2016, at which time 48.2% of treated residents received DOACs. Demographic and clinical characteristics of residents using DOACs and warfarin were similar in 2016. Half of the 8,734 DOAC users received standard dosages and most were treated with apixaban (54.4%) or rivaroxaban (35.8%) in 2016. Compared with warfarin, bleeding rates were lower and ischemic stroke rates were higher for apixaban users. Ischemic stroke and bleeding rates for dabigatran and rivaroxaban were comparable to warfarin. Mortality rates were lower versus warfarin for each DOAC. Conclusions In nursing homes, DOACs are being used commonly and with equal or greater benefit than warfarin.

The aim of this dissertation was to address several gaps in the existing literature focused on the association between levels and variability in blood pressure (BP) and cognitive functioning. Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), Chapter 1 synthesizes and critically analyzes the outcomes of research reporting the association between BP variability (BPV) and cognition. Fifty-five studies met eligibility criteria, including reports measuring short-term, mid-term, and long-term BPV. Despite substantial between-study heterogeneity in study characteristics, the majority of studies reported that higher systolic BPV is associated with adverse cognitive outcomes. Further, Chapter 1 identified several gaps in the existing literature. For instance, no research has investigated the association between BPV and short-term fluctuations in cognitive functioning, or the association between mid-term BPV and concurrent cognitive functioning. Building on Chapter 1, Chapter 2 used an intensive measurement design to investigate the extent to which mid-term variability in BP, recorded using home-based BP monitoring, is associated with levels and variability in cognitive functioning in a sample of community-living older adults (N=64; Mage=70.58, SD=3.5; 77% female) assessed twice daily over a two-week period. Partial correlation coefficients estimated the association between BPV and variability in several ambulatory cognitive assessments, accounting for the learning effect during the study protocol, while multi-level models (MLMs) estimated the association between BPV and concurrent cognitive functioning. In addition, MLMs examined the extent to which BP and cognitive functioning fluctuate within and between days at the intraindividual and interindividual levels. Findings suggest that more BPV may be associated with slower or more variable reaction time, while higher BP may be associated with worse performance on accuracy tasks. / Graduate / 2022-08-30

Background: Statins have questionable benefits among older adults with life-limiting illness. Statin use is widespread among U.S. older adults, but little is known about use in nursing homes. This dissertation was designed to identify the prevalence and predictors of statin pharmacotherapy use and discontinuation in U.S. nursing homes. Methods: Data sources (2011-2016) included: Minimum Data Set 3.0, Medicare administrative claims data, Provider of Service files, and Dartmouth Atlas files. Analyses included: descriptive statistics, multilevel modeling, and proportional change in cluster variations with adjustments to reduce confounding and model misspecification. Results: Approximately 36% of older adults admitted to U.S. nursing homes between 2015 – 2016 were actively using statins at the time of admission. Among long-stay residents with life-limiting illness, 34% were on statins at one time (2016; aged 65-75 years: 44%, >75 years: 31%). Statin use varied significantly by hospital referral regions, with most variation in the >75 age group. Limiting the sample to statin users, 20% discontinued statins within 30 days of nursing home admission. While discontinuation was positively associated with severity of life-limiting condition, the majority of residents remained on statins 30 days post-admission, including those with a < 6-month prognosis. Conclusion: Statin use is pervasive across US nursing homes and persists with life-limiting illness. Geographic variation appeared to coincide with clinical uncertainty, especially among adults >75 with few national guidelines. More needs to be done to prioritize statin deprescribing in nursing homes with research that identifies ways to facilitate improved patient-provider awareness and engagement in the discontinuation process.

Mental health is an intrinsic capability that constitute an essential component of healthy aging. Mental health is constituted by positive constructs such as happiness and negative constructs (mental disorders) such as depression. As people grow older, they become more prone to developing mental disorders which are linked to poorer quality of life, increased disability, increased utilization and cost of health services, and higher rates of suicide. This dissertation involved three studies that focused on factors that predict change in mental disorders and happiness of older Americans over a period of five years. Two waves of publicly available national representative data from the National Social Life Health and Aging Project (NSHAP) collected in 2010 and 2015 were used. A total of 2210 older adults within the ages 62-90 years were used in the analyses. Mental health measures were CES-Depression scale, HADS anxiety scale, and self-rated happiness. Essay 1 aimed to identify the important aspects of older adults' interaction with their neighborhood that predict the presence of mental disorder and happiness. Essay 2 evaluated the psychosocial factors that predict change in mental disorder and happiness of older adults, whereas essay 3 investigated the multifactorial determinants of change in mental disorder and happiness of older adults. These three essays provide insight into the impact of mental health in old age and the role of environmental, social, and demographic factors in successful aging. It also provides gaps for future research in the field of mental health and aging.

The objectives for this study were to develop a continuity of care scale, to assess the mean level of continuity of care, to assess association between demographic variables and clinical variables with continuity of care, and to assess association between continuity of care and medication adherence among Medicare beneficiaries. A retrospective cohort study was conducted to achieve the objectives using data from the 2015 to 2017 Medicare Current Beneficiaries Survey (MCBS). To be included in the sample, beneficiaries had to have a hyperlipidemia diagnosis, be continuously enrolled in Medicare Part D for six months from start of medication adherence, be continuously enrolled in Medicare Part A and Part B in the preceding year, and had to have at least two prescription claims for hyperlipidemia medications. Beneficiaries were excluded if they had a proxy responder, had an Alzheimer’s disease or dementia diagnosis, were enrolled in Medicare due to end-stage renal disease or disability, or were residing in a long-term care facility. Among 2,120 beneficiaries that met sample selection criteria, 57 percent were aged 75 years or older, 57 percent were female, and 87 percent were White. An overall continuity of care scale was developed using MCBS items that asked respondents about their care experience. Exploratory factor analysis was used to determine subscales of continuity of care using a randomly selected 60 percent of the sample, which yielded three subscales of continuity of care: relational continuity (Factor 1), informational continuity (Factor 2), and management continuity (Factor 3). Confirmatory factor analysis conducted using the remaining 40 percent of the sample validated factor structure of the continuity of care scale. The mean level of overall continuity of care among Medicare beneficiaries was 3.26 out of 4. Medication adherence was assessed using proportion of days (PDC) covered for anti-hyperlipidemia medications. Beneficiaries with a PDC of 80 percent or more were considered medication adherent. Approximately, 81 percent of beneficiaries were adherent to prescribed hyperlipidemia medications. Association between demographic variables and clinical variables with overall continuity of care was assessed using multivariable logistic regression based on purposeful selection of variables method. Older age, low perceived health status, and lower number of prescribed medications were associated with low overall continuity of care. Race and marital status were found to have interaction effect on overall continuity of care. Among non-white beneficiaries, married beneficiaries reported higher overall continuity of care than not-married beneficiaries. Among married beneficiaries, whites reported lower overall 12 continuity of care than non-whites. Association between overall continuity of care and medication adherence was assessed using multivariable logistic regression with purposeful selection of variables method. There was no association found between overall continuity of care and medication adherence.

Introduktion: I takt med samhällets tekniska utveckling ökar även implementering av tekniska lösningar i vård och omsorg. Den ökade teknikanvändningen påverkar både vård- och omsorgspersonal och den äldre. Syfte: Syftet var att beskriva vad som påverkar vård- och omsorgspersonalens attityder till tekniska lösningar och upplevelse av hur teknikanvändning påverkar den äldres dagliga liv. Metod: En intervjustudie med induktiv ansats genomfördes med n = 12 vård- och omsorgspersonal i en mellanstor kommun i Mellansverige. Kvalitativ innehållsanalys resulterade i åtta huvudkategorier: arbetssituation, kompetens, delaktighet, självständighet, trygghet, frihet, social kontakt och hälsa. Resultat: Vård- och omsorgspersonalens attityder till tekniska lösningar var både positiva och negativa och påverkades utifrån deras arbetssituation, känsla av kompetens och delaktighet. Vård- och omsorgspersonalen upplevde att teknikanvändningen påverkade den äldres dagliga liv genom att deras självständighet, trygghet, frihet och hälsa ökade. Samtidigt upplevde vård-och omsorgspersonalen att teknikanvändning kunde leda till ökad känsla av ensamhet hos den äldre. Konklusion: Studiens slutsats är att vård- och omsorgspersonalen överlag hade positiva attityder till tekniska lösningar och de upplevde att teknikanvändningen påverkade den äldre både positivt och negativt i det dagliga livet. Med anledning av det ansåg vård- och omsorgspersonalen att det är viktigt att teknikanvändningen individanpassas. / Introduction: In step with society´s technical development, the implementation of technical solutions in health and care also increases. The increased use of technology affects both the health and care staff and the older adult. Aim: To describe what affects health and care staff´s attitudes to technical solutions and howthe use of technology affects the older adult´s daily life. Method: An interview study with an inductive approach was conducted with n = 12 health andcare staff in a mid-sized municipality in the middle of Sweden. The qualitative content analysis resulted in eight main categories: work situation, competence, participation, independence, sense of security, freedom, social interaction and health. Result: The attitudes of health and care staff towards technical solutions were both positive and negative. Their attitudes were affected by their work situation, competence and participation. The health and care staff´s experience was that the use of technical solutions affected daily life of the older adult by increasing their independence, sense of security, freedom and health. At the same time health and care staff experienced an increased sense of loneliness of the older adult. Conclusion: The conclusion of the study is that the health and care staff had positive attitudes towards technical solutions and they experienced that the use of technic usage affected the daily life of the older adults, both in a positive and negative way. Because of this it was important to individually adapt the solutions. / DigitalWell

Despite parks have been widely recognized as key environmental sites by building free and accessible physical activity (PA) resources in nature, evidence suggests that less than one third of surveyed or observed elderly park visitors use parks for PA. Additionally, little is known about older adults’ PA patterns in parks and the potential attributes of their park-based PA. Based on social ecological approach, the attributes of park-based physical activity can be explained in terms of types of PA areas, and the psychosocial and perceived park environmental factors (Sallis et al., 2006). Comprehensively understanding park-based PA among older adults and the relevant attributes could contribute to developing a conceptual framework of park-based PA, as well as guiding the evidence-based policies aimed at creating user-friendly environments for elderly park users. The overall purpose of the dissertation is to get a picture of older adults’ PA in parks and the underlying mechanism of their park-based PA. Based on the overall research question and the limitations in previous studies, there are three specific research questions with several sub-questions, including: Q1: How about older adults’ PA observed in PA areas in Leipzig and Hong Kong parks? Q2: Is there association between types of PA areas and park-based PA (i.e., number of active elderly visitors) for elderly park visitors in Leipzig and Hong Kong? and Q3: Is there association between the psychosocial and perceived park environmental factors and park-based PA for elderly park visitors in Leipzig and Hong Kong?

Background: Functional Assessment (FA) in older adults is an important measure of their health status. FA using Activities of Daily Living (ADL) is a strong predictor of health outcomes, especially as we age. With the development of increasingly-connected health, we have a new opportunity for more robust and improved FA. Objective: The objective of this thesis is to collate and discuss published evidence on FA predictors and how the FA predictors can be collected using the paradigm of Connected Health (CH) architectures through an industrial case study in CHAPTER 5: INDUSTRIAL CASE STUDY. Methods: The method is to do two Systematic Literature Reviews (SLRs). The two SLRs were undertaken with Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement (PRISMA) and Parsifal, an online tool for SLR. This thesis catalogs various FA and state-of-the-art Software Engineering Architectural Tactics and Styles (SEATS) used within Connected Health (CH) that focus on ADL. The results of the cataloged information were used in the industrial case study where some of the FA predictors were automated. Articles obtained from the data source during the SLRs were filtered based on the titles, abstracts, full-text provision, English language literature, including age, which must be sixty-five years and above. Another reviewer was also included in this study, while all the defined inclusion and exclusion criteria detailed in this thesis were applied. Information about FA via ADL were extracted from the articles with further extraction on the SEATS used for computer-supported FA during the industrial case study. Data Source: During the SLRs processes, database searched included PubMed, EBSCOhost, Engineering Village, IEEE Xplore Digital Library, and ScienceDirect. The conducted search contains both controlled terms called Medical Subject Headings(MeSH) such as activities of daily living and search strings such as functional assessment, older adults, geriatrics, seniors, elderly care, and aging. Results: From four hundred and ninety-five initial abstracts and titles, nineteen full-text journal articles were included in the final review for the SLR on FA predictors. Six full-text journal articles were obtained from the SLR on CH architectures after reading its 449 titles and abstracts. In the SLR on FA predictors, predictor metrics for FA via ADL were extracted from each of the articles. Gait speed, sleep quality, and movement activities were assessed as ADL predictor metrics for FA in older adults. Other FA predictors published involved self-reported metric scale measurement using Barthel-20 scale and performance-based scale through Timed-UP and Go test. This thesis reviewed each metric for sleep quality and movement activities. In the SLR on CH architectures, quick response of ADL and resource efficiency such as sensors were some of the major tactics related to performance in Software Engineering (SE) quality in CH, while confidentiality and integrity of FA measures related to security in SE quality in CH was another major concern. Conclusion: Having conducted the two SLRs, a wide range of measures were used for FA in older adults, including consideration on the SEATS used for computer-supported FA. Overall, these FA measures and SEATS provide inexpensive and easy-to-implement FA. The diversity of the FA measures and SEATS contributes towards the development of computer-supported FA. However, future work is needed to consider the result of this study as an open-source computer-supported FA tool, and such tool should also be evaluated and verified through direct examination with older adults. / Graduate