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. Author manuscript; available in PMC: 2022 Jan 1.
Published in final edited form as: J Elder Abuse Negl. 2020 Dec 23;33(1):33–46. doi: 10.1080/08946566.2020.1864697

Implementation of Financial Decision Making Scales into Statewide APS practice: The Michigan Experience

Peter A Lichtenberg 1,**, Maggie Tocco 2, Rebecca Campbell 3, Marie Shipp 4
PMCID: PMC7941736  NIHMSID: NIHMS1657650  PMID: 33357079

Abstract

One of the long recognized challenges in Adult Protective Services and other human services work is the implementation of empirically validated tools into regular practice. One area where this is evident is the assessment of financial decision making abilities in cases investigated for financial exploitation (NAPSA, 2013). Using the Promoting Action in Research Implementation in the Health Services (PARIHS) we examined the core aspects of evidence, facilitation and context. Further, the empirical findings of the scale usage was investigated. Over 400 APS workers were trained and certified using an online narrated training system. Over 500 scales were administered across a 12 month period, with 50% demonstrating financial decision making deficits, and in 88% of the time the APS workers concurred with the risk rating system of the web-based system (https://olderadultnestegg.com)

Keywords: Adult Protective Services, Financial Exploitation, Implementation Science

The assessment of decision-making abilities is often a critical aspect of evaluating financial exploitation cases. It has been designated a core competency of Adult Protective Services (APS) workers, as outlined by the National Adult Protective Services Association (2013). The prevalence of financial exploitation among older adults highlights the need for empirically based assessment measures of decisional abilities. The rate of financial exploitation in this population is between 3.5% and 7.3%, according to several random-sample surveys (Acierno et al., 2010; Anderson, 2013; Laumann et al., 2008). The financial exploitation of elders is estimated to cost about $2.9 billion each year in the United States (MetLife, 2011), which may be a significant underestimate (Anderson, 2013). The current study investigates the implementation in a State Adult Protective Services agency of a financial decision-making screening tool that intersects with financial exploitation. This financial decision-making screening tool is a multiple choice, brief rating scale.

Financial Exploitation and Decision-making

Acierno et al. (2010) reported in their national random sample (N= 5177 , Mean age= 71; SD=8) that 5.2% of all older adults in their sample had experienced financial exploitation during the previous year, and 60% of the instances involved misappropriation of money by a family member. Laumann, Leitsch, and Waite (2008) reported that 3.5% (N=3005; mean age=68; SD=0.2) of their national random sample had been victims of financial exploitation during the previous year; younger older adults (ages 55-65) and African Americans were more likely to report financial exploitation, and participants with a romantic partner were less likely. Beach, Schulz, Castle, and Rosen (2010) collected a random sample of older adults in Allegheny County (N=903; 57% were between ages of 60–74) and found that 3.5% of their sample reported having experienced financial exploitation during the 6 months prior to the interview, and almost 10% had at some point since turning 60. The most common experience was signing documents the participant did not understand.

While the financial exploitation of older adults appears to be skyrocketing overall, one of the most rapidly increasing forms is theft and scams by strangers (Conrad, Iris, Ridings, Langley, & Wilber, 2010). In their review of media-based stories of fraud and financial exploitation of older adults, MetLife researchers found that 51% of fraud cases are perpetrated by strangers (2009, 2011). Burnes et al. (2017) conducted a meta-analysis to measure the prevalence of a specific form of financial exploitation—fraud—and demonstrated that there is great variability in how fraud is measured and how that variability is related to prevalence rates. Overall, a prevalence rate of 5.6% for fraud victimization per year was reported.

Conrad et al. (2010) advanced the conceptual framework of financial exploitation by identifying six clusters: (a) theft and scams, (b) abuse of trust, (c) financial entitlement, (d) coercion, (e) signs of possible financial exploitation, and (f) money-management difficulties. Specifically, they defined financial exploitation of older adults as the illegal or improper use of an older adult’s funds or property for another person’s profit or advantage, and ordered their clusters by severity of the problem. Thefts and scams, which were considered the most severe forms of exploitation, are defined as taking an older adult’s monies without their permission, either by outright stealing or committing fraudulent activities (i.e., perpetrating a scam). Financial exploitation types such as “abuse of trust” and “financial entitlement,” in contrast, imply an ongoing relationship between the parties.

Recent evidence indicates that a deficit in financial decision-making skills intersects with increased vulnerability to financial exploitation. For example, Boyle et al. (2012) found that reduced decision-making is related to increased susceptibility to scams. APS professionals are limited in the tools available to assess decisional capacity. Many require extensive training and more time to administer than is feasible in a fast-paced setting like an APS practice. The Lichtenberg Financial Decision Screening Scale (LFDSS) was created to provide a risk score based on 10 multiple choice financial decision making items (see Lichtenberg et al., 2016, 2017, Campbell, Gross & Lichtenberg 2019 for further details). Development of the LFDSS was guided by two conceptual frameworks: person-centeredness and decisional abilities. These frameworks affirm the importance of assessing the older adult’s understanding of the financial decision in question, with the requirement that the older adult be able to communicate four important elements of his or her decision: choice, understanding, appreciation, and reasoning. The Lichtenberg et al. (2017) study validated the screening scale on 212 cases. In a cross validation study Campbell, Gross & Lichtenberg (2019) reported on 105 APS cases and similar to the validity study found that financial decision making was highly related to whether the case for exploitation was substantiated or not substantiated. In addition, the cutoff score originally derived was supported in the cross validation study.

The LFDSS along with narrated online training and certification became available on https://olderadultnestegg.com website in 2018 and was re-named the Financial Decision Tracker (FDT). The current study examines the transition from the validation phase of the scale to a statewide implementation period.

Implementation Science

Implementation science aims to understand the translation of evidence-based practices into practical, real-world usage. It uses scientific conceptual models and methods to discern processes that are not typically governed by rationality. If the adoption of evidence-based practices were straightforward and rational, they would be adopted via passive methods of dissemination of evidence-based practices. Although the focus of this study is not to conduct a thorough review of all of the variables that impact implementation, we will explore widely known conceptual frameworks and describe our efforts to implement evidence-based risk assessment for cases of suspected financial exploitation of older adults.

Kitson et al. (1998) proposed a conceptual framework for understanding the successes and failures of implementation. Their model, Promoting Action in Research Implementation in the Health Services (PARIHS), has been one of the most popular and well-studied. The core of their model is that implementation of evidence-based practice is a function of three things: (1) Evidence (e.g., quality of the research and widespread acceptability of its utility, as well as the translation to standardized training); (2) Context (e.g., leadership, support, and receptivity to innovation/change within the organization); and (3) Facilitation (e.g., the skills and attributes of an individual who directly supports the process of implementation). Kitson et al. (2008) revisited the model in a study designed to clarify the theory and address the practical challenges of using the PARIHS framework. The authors sought to further define critical concepts while acknowledging the challenges related to implementation. To this end, they detailed the assumptions of the PARIHS framework. Evidence, they assert, includes research, clinical experiences, and patient preferences; implementing evidence entails negotiation, a shared understanding of benefits, and a team effort. The authors acknowledged that some contexts are more conducive to implementation than others. Finally, they amplified the importance of facilitation. Harvey and Kitson (2016) argued that this multidimensional framework highlights the complex nature of implementation. Rarely, they find, does direct implementation occur; the process usually involves experimentation to best fit the organization’s needs.

A review of PARIHS (Harvey and Kitson, 2016), proposed further expanding the framework’s core components. This updated version, titled I-PARIHS, emphasizes not only the translation of evidence into practice, but also the role of individuals in implementation. A core construct, “Recipients,” was added to examine individual behavior and its effect on either fostering or dismissing the adoption of evidence. “Innovation,” which is an expansion of Evidence, examines characteristics of the environment and their influence on adoption, and considers the internal setting’s existing policies. The addition of Innovation encouraged clarity in terms of defining the evidence and its intended use (Malone, 2004). This process entailed investigating issues related to leadership and the feedback systems that evaluate the quality of context, along with identifying both internal and external facilitation. Research on this model emphasizes both its strengths and shortcomings. Helfrich et al. (2010).

Wandersman et al. (2008) introduced an interactive systems framework for dissemination and implementation. The process consisted of three steps: (1) translating knowledge into usable formats, (2) providing training and technical assistance, and (3) working collaboratively with users to render the product more valuable to the end user. Burgio (2001) employed a similar model, in which he identified three necessary components: educational delivery, knowledge gained, and enactment of new behaviors. Educational delivery is particularly enhanced through the use of technology in training, because this approach maximizes fidelity to the educational session (i.e., all individuals receive consistent training).

In sum, the conceptual frameworks presented here offer valuable guidelines and points of emphasis, even though they have been criticized as overly broad. We chose to examine the original aspects of the PARIHS model: Evidence, Facilitation, and Context. In Table 1, we outline five years of collaborative work between the authors and Michigan’s Adult Protective Services. Although presented chronologically, all aspects,Evidence, Facilitation, and Context were important across all years and will be further described in the results section.

Table 1.

Timeline of Lichtenberg scale validation and implementation work with APS

TASK TIMELINE (YEAR)
Validation of Screening Scale 2015-2017 2015 2016 2017 2018 2019 2020
Connect with APS Supervisors who are interested in piloting
In-person training for staff who will use scales
Feedback from supervisors re: form changes made
300 completed scales collected before website development
Published findings in three major peer-reviewed publications
Implementation Project 2018-2020
Launch of online training and certification
Launch of online risk scoring and interpretation
Supervisors complete online training and certification
APS caseworks complete online training and certification
Reviewed each scale administered-responded to questions
Sought feedback from APS staff champion
Conducted focus group with APS Caseworkers
Developed Decision Tree, User Manual and How to Use Results
Updated APS leadership team
Researchers analyzed surveys to determine appropriate administration
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Purpose of the Study

We set out to evaluate the effectiveness of the implementation of training, certification, and scale use of the ANONYMOUS, an empirically validated 10-item financial decision-making scale. Specifically, we examined how well elements of the PARIHS model (Evidence, Facilitation, and Context) translated into appropriate use of the ANONYMOUS scale, as well as how compatible the risk-scoring system was with the APS caseworker’s conclusions.

Hypotheses for this study were as follows:

  1. Evidence for the ability to train large numbers of staff and have them administer the tool accurately
    • 1a.
      All APS staff members will become certified to administer the ANONYMOUS after completing the online narrated training on the scale’s purpose, administration, and use.
    • 1b.
      Ongoing feedback will lead to a 90% appropriate use and administration rate for the ANONYMOUS.
  2. Evidence for the Scale’s validity and utility in APS cases
    • 2a.
      The expected agreement between the ANONYMOUS risk score and the APS caseworker’s rating will be 85% for completed scales.
    • 2b.
      Financial decision-making risk scores will be significantly different between those whose cases were rated as having decision-making concerns and those whose cases were rated as having intact decision-making.
    • 2c.
      Types of decisions will be identified and differences will emerge between those who were exploited and those who were not exploited.
  3. Facilitation
    • 3a.
      Bidirectional feedback (between APS staff at multiple levels, from directors to field staff, and the authors) will encourage adoption of the ANONYMOUS in practice across APS staff and leadership in Michigan.
    • 3b.
      Bidirectional communication will form the basis for enhanced materials to guide the administration and use of the ANONYMOUS.

Methods

This implementation study received a concurrence of exemption from the Wayne State University IRB.

Timeline of Relationship Building with APS

Evidence: Validity Studies:

Our engagement with Adult Protective Services began in 2015, when the lead author partnered with policy leaders in the State APS office. APS supervisors were also interested in piloting the scales. Between 2015 and 2017, frontline staff responsible for administering the Financial Decision Tracker (FDT) underwent in-person training on appropriate use of the scale. Following a trial period, APS supervisors shared feedback regarding staff use of the FDT in daily practice, as well as recommendations for improving the functionality of the paper-and-pencil version of the FDT. Supervisor feedback improved this version of the FDT by providing concise scoring and direction reminders on the one-page form. A total of 300 scales were collected and analyzed, and our findings were published in three papers (Campbell, Gross & Lichtenberg, 2019; Lichtenberg et al., 2016, 2017).

Implementation Trial:

Launch of the electronic version of the FDT and other Lichtenberg scales occurred in 2018. Concurrently, narrated online training modules and certification also became available. As can be seen in Table 1, APS supervisors were the first to undergo training and obtain certification. APS caseworkers followed in early 2019. Online training was augmented by in-person training and coaching before and after each group was trained. Implementation of the scales began in the spring of 2019, and every supervisor received biweekly updates by email of their team’s use of the FDT. In 2020, an APS liaison became part of the implementation process. Partnering with the research team the liaison also served as a communicator between supervisors and APS leadership. The liaison also organized and led a focus group with caseworkers, and more informal feedback was elicited. The focus group was held in 2020, and consisted of approximately 15 APS caseworkers experienced in administering the FDT. Feedback from the session led to the development of several tools to streamline implementation: a decision tree, user manual, and “How to Use the Results from the Lichtenberg scales” guide. Finally, a comprehensive qualitative and quantitative analysis was conducted to measure appropriate use of APS-administered FDTs. Client records contained no identifying information, and the Wayne State University IRB determined that the research was exempt.

Data to be analyzed:

(1) Proper use of the FDT: Since the FDT measures specific financial decision-making, it is necessary to link the scale with a specific decision. Raters determined whether the scale was used appropriately, based on whether the reported monetary loss centered on a specific financial decision. Two raters were involved in scoring, and inter-rater reliability was 100% on a set of 30 scales. (2) The Olderadultnestegg.com website produces a risk score (No concerns, Some concerns, or Major concerns), as well as recommendations for next steps. In our analysis, we (1) calculated the concurrence between the rater’s score and the Olderadultnestegg.com recommendation; (2) Using t tests and Chi Square analyses we examined the base rate of decision-making deficits and potential demographic differences between those rated as having decisional concerns and those rated as having no decisional concerns; (3) Using t tests and Chi Square analyses we investigated whether the type of financial decision being made differed between those rated as having decision-making deficits (i.e., concerns) and those who did not; and (4) examined successful implementation based on the behavior of site supervisors and state APS leadership.

Results

Hypothesis 1: The web-based system will demonstrate the ability to train large numbers of staff and have them administer the tool accurately.

Context for Implementing the Training: Understanding the context of a situation is critical to understanding why or why not implementation is likely to work. In this case, a recent state audit (circa 2015) found that APS caseworkers lacked risk-assessment tools. Therefore, when we approached APS to collaborate on a validity study for tools that evaluate decision-making in financial exploitation cases, they were receptive. The need for risk-assessment tools remained a primary concern throughout the 5-year validity study and implementation phase. A second context involved our development of electronic tools for training, certification, and scoring. In our validity and cross-validation study, we had not yet developed a web-based system for training. However, by the time we had completed two robust validity studies, we had produced our web-based training and scoring systems. The potential for electronic records and the ability to provide training based on the APS caseworker’s self-determined schedule provided an effective context for increasing the levels of mass training and implementation. Finally, several months into the implementation trial, the administrative section of the website evolved to the extent that the lead author could review every scale and provide feedback/queries to both APS supervisors and staff.

In support of hypothesis 1a four hundred fifty-six APS staff and supervisors were trained and certified on our tools. In general there was enthusiasm about the narrated online training, and the feedback was quite positive overall. Hypothesis 1b was also largely supported. A total of 525 FDT cases were entered into the Olderadultnestegg.com system. Of those, 85% (445) were rated as accurately administered; that is, they centered on a specific financial decision. Inappropriate scale use included (1) theft without any associated financial decision and (2) client cognitive impairment, which usually resulted in all items being marked “I don’t know.” These results provide clear support for hypothesis 1a: the ability to train and certify large numbers of APS staff. Support was also found for hypothesis 1b, although the 85% appropriate administration rate was below the 90% hypothesized.

Hypothesis 2: Evidence for the Scale’s validity and utility in APS cases

For hypothesis 2a we investigated the rate of agreement between the risk score rating and the APS worker’s rating. In support of hypothesis 2a, agreement between the two ratings was nearly 88%, which is slightly better than the predicted 85%. In discordant cases, half involved APS caseworkers who reported being more concerned about decisional abilities than the FDT rating suggested, and half reported being less concerned. Thus, in only 6% of cases were there concerns based on the APS caseworker’s rating and not the FDT risk rating. This finding demonstrates a high level of sensitivity for cases in which decisional incapacity may play a role in the financial exploitation of older clients.

For hypothesis 2b we compared demographic information and FDT risk scores between the two groups —those with decision-making ability concerns and those without. The base rate of concerns about decisional abilities was 49.9%. That is, in half of the cases, APS workers found that the client had financial decision-making deficits related to the complaint; in the other half, the client was found to have no financial decision-making deficits related to the complaint. In support of hypothesis 2b t tests revealed that the FDT risk score was significantly different between those whose cases were rated as having decision-making concerns to those whose cases were considered to have intact decision-making (t= 26.7; p<.01). The only demographic difference between the two groups was that the no-concern group was slightly older (t=2.3; p<.05). There were no group differences regarding race, gender, or education. The mean age of the total sample was 78 years, and nearly 60% were women. Eighty-nine percent of the sample was Non-Hispanic White, 12% were Black, and two-thirds had completed a high school education or more.

In support of hypothesis 2c five basic types of decisions were being made in the sample. The most common decisions were allowing someone to take over managing the person’s money or allowing them access to the person’s money (45% when combined). Other decision types included giving a gift (27%), participating in a scam (16%), and making a purchase (9%). Only two cases were classified as an “Other” type decision that did not fit one of the other categories. Thus, about half of the cases involved someone having access to the client’s funds and the other half involved client spending.

Hypothesis 3: Facilitation was examined through the process of creating bi-directional communication and enhanced support from APS professionals at all levels. In support of hypothesis 3a Facilitation through bi-directional communication at all levels was also a vital part of the implementation trial. Given that APS leadership includes multiple levels (senior management supervisors, policy leaders, staff supervisors, and APS staff), we decided to communicate with each level. Our first facilitation opportunity came in August of 2018, when we met with the APS State Director and four regional directors. One of the regional directors had volunteered to assist with the cross-validation study in 2016. As a result, he and the State Director were familiar with our progress and enthusiastic about going forward, and the group voted unanimously to begin an implementation trial of training and certification in the use of our tools. Facilitation continued for several months through direct contact with each supervisor and their APS teams. The lead author made face-to-face presentations in various locations across the state for three of the four regional teams and a webinar for the fourth. Between the training period for supervisors and staff and use of the tools in practice, a secondary set of face-to-face presentations took place in the three regions, with a follow-up webinar for the fourth.

In support of hypothesis 3b eight months into the implementation, a former APS supervisor was designated as a liaison between APS senior leadership, supervisors, and staff and the project team. This liaison was instrumental in the early 2020 feedback sessions with both users and non-users on the APS staff. The APS liaison was responsible for focus groups with APS staff.

Feedback received during the focus group described above was overwhelmingly positive. After administering the scale three or four times, APS workers reported that it took 5–10 minutes per administration. It then took 2–3 minutes to enter the results into the web-based system if they used the printed version of the scale. APS workers described how they used the scale with law enforcement, health providers, and prosecutors to support their cases and that the use of an empirically validated tool was well received by all professionals, including judges. The group requested additional guidance on how to improve the precision of administration. As a result, we worked with APS staff to create a decision tree for the ANONYMOUS (and its sister scale, the Family and Friends Interview). This tool was well received by caseworkers as the area supervisors and APS staff in the field approved it unanimously during one of their semi-annual meetings (see Figure 1).

Figure 1.

Figure 1.

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Use of the Financial Decision Tracker Older Adult Decision Tree for Adult Protective Services Staff

Our partnerships across levels of APS and our developing relationship with the APS liaison led to the scale’s heightened visibility and credibility. When the APS liaison described the tool’s positive reception and related specific case examples, APS leadership and staff became more invested in the tool’s integration into APS. At this time, the tool is in the final stages of review for approval as a best practice instrument that would be used according to the decision tree.

Discussion

This study is one of very few that prospectively investigate the implementation of an evidence-based tool by Adult Protective Services. Overall, the implementation trial was successful. The context for the implementation trial was supported throughout by senior APS leadership, because the State was interested in remediating weaknesses in the formal assessment of risk that were revealed during an audit. This need, conveniently, had been acknowledged before the research team contacted APS about partnering on validity studies. Facilitation occurred at multiple levels. First, the lead author was involved in both training and ongoing coaching, especially with area supervisors. This process was greeted with enthusiasm by supervisors, since the tool was new to them, and learning how best to use it and explain its use to their staff was continually evolving. The ongoing coaching involved not only supervisors but APS staff as well. The lead author communicated directly with staff about specific cases, both when it was not clear why the scale was being used and when cases produced exciting results. The staff also responded enthusiastically to this facilitation.

The second form of facilitation involved the APS liaison and coauthor, who was able to independently gather feedback through informal conversations and a formal focus group. Focus group conversations resulted in ancillary documents (e.g., the decision tree) that improved staff members’ understanding of how and when to use the FDT. The liaison also sought guidance from the State’s legal department on how the tools and ancillary documents fit with APS’s legal requirements. The third form of facilitation involved senior APS supervisors and the director. Updates on progress were provided in periodic face-to-face and virtual meetings, and unanimous support for use of the tools was an essential form of facilitation.

The empirical findings related to implementation were largely positive. First, almost every APS worker in the state received training on and was certified in use of the tool. Second, the administration of 500 scales and their input into the system demonstrates its widespread use. Third, the accuracy of administration was good, but feedback from focus groups led to improvements that clarified when to use the tool. Finally, concurrence between the tool’s risk rating on the Olderadultnestegg.com website and APS caseworkers’ final ratings was excellent: Sensitivity and specificity rates were 94% with respect to whether the client had decision-making deficits.

Financial exploitation risk tools are not as straightforward as one might expect. For instance, a self-report tool such as Conrad et al.’s (2010) Older Adult Financial Exploitation Measure asks about many types of perceived exploitation, but has no items related to financial decision-making. In all APS cases, the professional is faced with the dilemma of whether the older adult needs support for their autonomy or further protection. It is particularly vital that this determination be made thoughtfully when the decision is whether an older adult should make a significant gift or allow someone else to assume control of their finances. Financial decision-making capacity, with a focus on the older adult’s unique decision, is often central to the APS caseworker’s determination of whether the case is substantiated. This common situation is one in which the Financial Decision Tracker is uniquely valuable, because the 10-item, multiple-choice rating scale provides a way to quickly assess decision-making capacity. Ideally, the determination would be based on both the FDT and the 14-item self-report Family and Friends Interview, so that informants’ observations could be included in analysis of the case.

The study has several limitations. It was conducted in only one state. It may be that the unique context and organizational structure in this state made it particularly receptive to a series of validity and then implementation steps. It will be necessary to examine how well the scale can be implemented in states without such a hierarchical structure. Second, the implementation trial occurred after a relationship had been established with APS leadership and supervisors. How well implementation can occur in states where there is little or no relationships with the scale’s developer should be examined. This is a major issue in implementation—training and follow up coaching may be a necessary part of the facilitation process. A third limitation is the lack of an ability to follow up on the cases and determine what some of the final outcomes were in terms of steps taken to protect vulnerable older adults. Nevertheless, this case study demonstrates successful implementation by using the PARIHS theoretical model of implementation. Further, by the end of the study, the state had designated the FDT a best practice tool for APS staff statewide.

Table 2.

Comparison of financial decision making capacity groups on demographic and FDT risk scores

Demographics & FDT scores Overall Sample
(n = 445)		 Interviewer Score Statistical Test
Concerns (n = 222) No Concerns (n= 223) t-test or Chi-square
Age
   Years M (SD) 		78.3 (9.2) 77.3 (8.8) 79.3 (9.6) t(443) = −2.26 p<.05
Gender
   Female N (%) 		262 (58.9%) 128 (57.7%) 134 (60.1%) Χ2 (1)=.27, p = .60
Race
    Black N (%) 		53 (11.9%) 32 (14.4%) 21 (9.4%) Χ2 (1) = 2.66, p=.10
Education High school & beyond
      N (%) 		291 (65.4%) 141 (63.5%) 150 (67.3%) Χ2 (1) = .69, p=.41
FDT
  Risk Score M (SD) 		5.4 (3.9) 8.4 (2.8) 2.3 (2.0) t(443) = 26.69 p<.01
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Funding

Funding for this project was provided in part by the following grants: the National Institute of Justice MU-CX-0001 the opinions, findings, and conclusions or recommendations expressed in this publication are those of the authors and do not necessarily reflect those of the Department of Justice. National Institutes of Health P30 AG015281, Michigan Center for Urban African American Aging Research, American House Foundation, Retirement Research Foundation, Michigan Alzheimer’s Center Core grant #P30AG053760.

State of Michigan Department of Health and Human Services and the Michigan Health Endowment Fund

Contributor Information

Peter A. Lichtenberg, Director, Institute of Gerontology and Merrill Palmer Skillman Institute, Distinguished University Service Professor of Psychology, Institute of Gerontology, 87 E. Ferry Street, Wayne State University, Detroit, MI 48202.

Maggie Tocco, Research Staff, Institute of Gerontology, 87 E. Ferry Street, Wayne State University, Detroit, MI 48202.

Rebecca Campbell, Graduate Research Assistant, Institute of Gerontology and Department of Psychology, Wayne State University, 87 E. Ferry Street, Detroit, MI 48202.

Marie Shipp, Adult Services Program Administrator, State of Michigan, Department of Health and Human Services.

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