Theses and Dissertations from UMD
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Item UNDERSTANDING THE IMPACT OF LONG-TERM CARE NEED AMONG MEDICARE-ONLY BENEFICIARIES(2024) Albaroudi, Asmaa; Chen, Jie; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)The population of adults 65 years of age and older is growing tremendously, and the majority of this population will have some level of long-term services and supports (LTSS) needs. Most older adults will qualify for Medicare insurance, which does not provide coverage for LTSS. The high costs associated with receiving LTSS, which includes supports for activities of daily living, places a financial burden on Medicare-only beneficiaries with limited resources, increasing their likelihood of becoming eligible for Medicaid coverage (i.e., dual-eligible). Given that Medicaid is the primary payer for LTSS, much of the literature on long-term care (LTC) is focused on a Medicaid eligible population. This dissertation explores the experience of Medicare-only beneficiaries with an LTSS need, who are responsible for the costs of their LTSS and may ultimately qualify for Medicaid. The Health and Retirement Study data are used to explore my dissertation objectives. My dissertation examines three areas: (1) the financial burden of Medicare-only beneficiaries with high functional impairment by assessing out-of-pocket costs; (2) spend down to dual-eligible status for Medicare-only beneficiaries with and without a LTC need; and (3) spend down by race and ethnicity with and without a LTC need.Item THE LONGER-TERM IMPACT OF PERCEIVED DISCRIMINATION ON COUPLE RELATIONSHIP FUNCTIONING: EXAMINING PSYCHOLOGICAL AND PHYSIOLOGICAL PATHWAYS AMONG MIDDLE-AGED AND OLDER-AGED ADULTS IN THE UNITED STATES(2023) Du, Jingshuai; Quinn, Sandra SQ; Mittal, Mona MM; Family Studies; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)The current study aimed to investigate the longer-term impact of everyday discrimination and major lifetime discrimination at Time 1 (T1; 2008 and 2010) on couple relationship functioning at Time 3 (T3; 2016 and 2018) across 8 years. It also aimed to explore if psychological (measured by depressive symptoms) and physiological stress responses (measured by allostatic load) at Time 2 (T2; 2012 and 2014) mediated the longitudinal association between discrimination and couple relationship functioning among middle-aged and older-aged adults in the United States (U.S.). To answer the study aims, I conducted a longitudinal mediation path analysis (N = 2,344) in Mplus Version 8 using data from the Health and Retirement Study, an ongoing national survey of the health and aging experience of U.S. adults aged 51 and older residing in the community. The primary longitudinal mediation model with control variables demonstrated good model fit (χ2[4] = 21.78, p < 0.01, CFI = 0.99, RMSEA = 0.04, SRMR = 0.01). The analysis results suggested that depressive symptoms at T2 significantly mediated the longitudinal association between the two types of discrimination and the two types of couple relationships spanning 8 years while controlling for race, age, gender, education, number of reasons for everyday discrimination and T1 assessments of couple support and couple strain. However, allostatic load was not found to be a significant mediator between the two types of discrimination and the two aspects of couple relationship functioning (couple support and couple strain). The direct relationship between discrimination (everyday and major lifetime discrimination) and couple relationship functioning (couple strain and couple support) was not significant either. The results from the multi-group analysis suggested that several structural paths differed significantly across gender, age groups, and number of reasons for everyday discrimination, but none of the paths differed significantly based on race. Overall, the current study did not find evidence supporting the pathway from perceived discrimination to couple relationship functioning through allostatic load. It provided evidence supporting depressive symptoms as a mediating mechanism between perceived discrimination and couple relationship functioning. Future work should develop innovative methods for assessing and measuring allostatic load to test its possible mediation role between perceived discrimination and couple relationship functioning. Moreover, effective and culturally-responsive interventions and programs are needed to decrease all types of discrimination and depression in order to improve couple relationship functioning among middled-aged and older-aged adults in the U.S.Item Diverse Care Networks and Unmet Care Needs of Older Adults in a Changing America(2020) Lin, Zhiyong; Chen, Feinian; Sociology; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)This dissertation consists of three papers that examine the complexity, dynamics, and stratification in care networks and unmet care needs of older adults in a changing America. For generations, most older Americans have been cared for by loved ones at home in their time of need. However, with sweeping demographic and family changes during the last several decades, care provision by immediate family (typically spouse and adult children) can no longer be assumed. Despite growing public interests in other alternatives beyond the spouse and adult children, limited research attention has been directed toward the provision of care by increasingly diverse care networks. The first paper develops a care network typology that captures the multidimensionality of care networks with a combination of different types of care, including informal care from the spouse, children, extended kin, and nonkin caregivers, formal caregiving from professional services, and self-care with assistive technologies. At the same time, demographic and family transitions are experienced unevenly across racial and ethnic groups, making minority older adults more vulnerable to structurally restricted care networks than older whites. Also, research on racial/ethnic differences in caregiving often emphasizes the role of cultural values in shaping care networks among specific subgroups of the aging population. Drawing from explanations that focus on both structural and cultural elements, the second paper investigates to what extent, racial/ethnic differences in care networks could be explained by structural and cultural factors separately, and further explores how they jointly shape diverse care networks across different racial and ethnic groups of older adults. The third paper questions whether some compositions of care networks are more effective in serving the needs of older adults, and whether others are more likely to lead to unmet care needs. Moreover, I explore how the perceived association between care networks and unmet care needs is further conditioned by race/ethnicity and gender. In the context of the declining availability of traditional caregivers, this dissertation can contribute to the understanding of which other alternatives are available and provide evidence on whether they can adequately meet the needs of older adults.Item Can Design Evoke Youth? Exploring Paradigms of Intergenerational Interactions(2019) Weber, Emma Isabella; Abrams, Michael C.; Architecture; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)Society lacks a thorough understanding of the concept of aging. By the time Americans reach their senior years, they have little concept of what life will become as an aging adult. Older adults begin to grow isolated from society both physically and mentally. Health limitations, technological or transportation limitations, and spatial discrepancies generate barriers to seniors, perpetuating a cycle of isolation and loneliness. As the senior population rapidly increases with the aging of Baby Boomers, can architecture break this cycle and stimulate the creation of a society of intertwined generations? This thesis challenges the design of senior housing to become a vehicle through which seniors might reconnect with society through intellectual, physical, and social engagement. Designing spaces that foster new paradigms of intergenerational relationships may become the tool through society is exposed to the beauty and importance of aging.Item Community Living and Health Services Utilization among the Aging Services Network Population(2017) Gaeta, Raphael; Simon-Rusinowitz, Lori; Chen, Jie; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)By 2050, the number of older adults will increase from 67 million to 111 million, or roughly 28 percent of the total U.S. population. Age is a principal predictor of physical health status as well as functional and cognitive limitation. As the aging population grows, so too will the demand for long-term services and supports (LTSS) and healthcare services. Despite this intersection, LTSS and healthcare systems are highly disconnected. The Aging Services Network, authorized and partially financed by the Older Americans Act (OAA), may play an important role in an emerging trend toward integrating services. Yet, OAA research is lacking. Existing OAA research faces several obstacles, including handling program variation resulting from a decentralized Aging Services Network, identifying non-user comparison groups for OAA study samples, and limited utility of national datasets. Studies often rely on highly descriptive methods, indirect comparisons to the general population of older adults, or state-restricted analysis. This dissertation addresses several gaps in the research. The first study aims to identify factors associated with community tenure and participation among low-income elderly living in subsidized housing. The research is grounded in conceptual frameworks from the World Health Organization. In-depth interviews and focus groups are used to explore these associations among elderly HUD building residents in Prince George's County, Maryland. The second study aims to identify multilevel predictors of OAA Title III services participation. This study develops a conceptual framework based on the Andersen Behavioral Model of Health Services Use, and uses a merged data set from the nationally representative Health and Retirement Study with geographic data and relevant state policies. The third study further examines the relationship between OAA Title III services participation and patterns of healthcare utilization. This dissertation research provides evidence for the importance of OAA Title III services, including for elderly HUD beneficiaries. Findings from multivariate regression analyses provide evidence for (1) county level targeting criteria used to measure LTSS need and direct OAA Title III funding, (2) substantial influence of Medicaid on access to OAA Title III services, and (3) changes in mix of health care services use among OAA Title III services participants over time.Item Examining Healthcare Expenditures: Mechanical Ventilation & An Evaluation of Long-Term (Acute) Care Hospitals(2013) Frank, Jared; Lee, Sunmin; Epidemiology and Biostatistics; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)This study analyzed demographic and clinical characteristics, actual hospital/facility costs, and Medicare charges/payments among beneficiaries discharged to, and from, long-term (acute) care hospitals (LTCHs), skilled nursing facilities (SNFs), or inpatient rehabilitation facilities (IRFs) following an acute inpatient hospitalization under Medicare-severity diagnosis-related group (MS-DRG) 207, "respiratory system diagnosis with ventilator support for greater than 96 hours." We also examined the likelihood of discharge by provider type to determine criteria informing patient discharge to a LTCH, SNF, or IRF for treatment. Concerning discharges to LTCHs, patients were not significantly older, did not have the highest length of stay, and had comparable diagnoses and diagnosis counts to those discharged elsewhere. Discharges from LTCHs had significantly higher diagnosis counts and lengths of stay. Costs, charges, and payments were significantly higher among discharges to, and from, LTCHs. Multinomial logistic regression analyses indicated numerous associations between certain variables and discharge location.Item Old Yankee Women: Life Histories and Cultural Significance(2010) Tydings, Judith Church; Caughey, John L.; American Studies; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)Responding to the notion that old age is like a foreign country, this study explores a small portion of this understudied terrain by examining the lives of eight old New England women (four primary subjects and four supplemental participants). In keeping with current ethnographic and life history practice, this cultural study of these American women in late life uses a journey format with the researcher engaged in exploration along with the other project participants. After a comprehensive review of the various literatures on aging women, this study provides detailed cultural portraits of the project participants who ranged in age from 60 to 92 when their participation in this ten year study began. By a close reading of their writings, by in depth life history conversations, and by participant observation, including living with each participant for a brief period of time, this study illuminates how these women in old age see themselves, the choices they have made or resisted in late life and what gives their lives meaning. This study is intended to illustrate the usefulness of the person centered life history method as a lens through which to examine the complex ways in which women negotiate aging. Old age, as this study shows, is experienced quite differently by each of these individual women; the old are far from a homogenous group. Even within this small group of white New England women of similar class backgrounds, many factors differentiate their experiences. One key factor has to do with their different cultural meaning systems. Using a "cultural traditions" model in conjunction with contemporary life history methods and ethnographic participant observation techniques, and informed by nascent age studies perspectives, this research examines how and to what extent the old age experiences of these women are affected and influenced by the particular cultural orientations of key cultural traditions these New England women bring with them into old age and how the aging process affects the ways they work with these traditions.Item The influence of ECE-1 gene polymorphism and exercise training on plasma and urinary endothelin-1 levels in pre- and stage 1 hypertensives(2007-08-09) Attipoe, Selasi; Hagberg, James; Kinesiology; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)Endothelin-1 (ET-1) is a peptide that mediates blood pressure. ECE-1b-C-338A is a polymorphism in the ECE-1 gene that alters ET-1 synthesis. Thus, the goal of this study was to investigate the influence of the ECE-1b-C-338A polymorphism on plasma and urinary ET-1 levels, as well as on aerobic exercise training (AEX)-induced changes in these variables. Outcome variables were assessed before and after 24 weeks of AEX in hypertensive adults. Separate ANCOVAs were used to compare differences in outcome variables. Only AA homozygote men had higher plasma ET-1 levels. After AEX, there were no significant changes in the main outcome variables. Neither were these changes significantly different between genotype groups. Results suggest that this polymorphism is associated with plasma ET-1 levels in men but not with urinary ET-1 levels. Additionally, this polymorphism does not affect AEX-induced changes in plasma and urinary ET-1 levels.Item Relationship between physical activity and telomere maintenance in peripheral blood mononucleocytes(2007-07-24) Ludlow, Andrew Todd; Roth, Stephen M; Kinesiology; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)The purpose of this study was to examine the relationship between exercise energy expenditure (EEE) and telomere length, telomerase activity, and hTERT genotype. Sixty-nine male (n = 34) and female (n = 35) participants 50-70 yr. were assessed for weekly EEE level using the Yale Physical Activity Survey. Subjects were grouped according to EEE. Telomere length and telomerase activity were measured in peripheral blood mononuclear cells (PBMCs). Relative telomere length was significantly higher in the Middle EEE group compared to both the low and high EEE groups (p<0.05). Telomerase activity was not different among the three EEE groups. The TT hTERT genotype had significantly greater telomerase enzyme activity than both the CT and CC genotypes (P = 0.013). In conclusion, moderate exercise energy expenditure levels may provide a protective effect on PBMC telomere length compared to both low and high EEE levels. hTERT genotype was associated with telomerase activity.Item The Effects of Strength Training on Regional Body Composition in Older Adults: Sex and Race Comparisons(2007-05-22) Walts, Cory; Hurley, Ben F; Kinesiology; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)Purpose: To examine the influence of sex and race on the effects of strength training (ST) on thigh muscle volume (MV), mid-thigh subcutaneous fat (SCF) and intermuscular fat (IMF). Methods: One hundred and eighty-one previously inactive healthy Caucasian (N=117), African-American (N=54), and other (N=10) men (N=82) and women (N=99), aged 50-85 yrs, underwent ~10 weeks of unilateral knee extension ST. Results: Training-induced increases in absolute MV were significantly greater (P < 0.01) in men than in women. There were significant increases in MV within each race (P < 0.001); but no significant differences between races. There were no significant changes in SCF and IMF whether sex and racial groups were separated or combined. In addition, there was no sex by race interaction for changes in MV, SCF, or IMF with ST. Conclusion: Ten weeks of unilateral strength training does not alter subcutaneous or intermuscular fat regardless of sex or racial differences. Although men exhibit a greater muscle hypertrophic response to strength training compared to women, the difference is small. Race does not influence this response.