The proportion of older people within the UK population is increasing. This is a diverse group from varying socioeconomic backgrounds and who also exhibit a broad spectrum of dependence. The planning and provision of appropriate oral healthcare should be an important consideration for decision makers for this growing sector of society. This research was carried out in two phrases; the first phase was used to explore the beliefs, values and priorities of older people regarding their oral health and it also examined the barriers faced by older people when accessing dental care services in a rural setting. The second phase investigated low health care professionals involved in providing care for older people viewed local dental services and it looked more closely at how older people use dental services in a rural setting. Using information gathered throughout the study the aim was to develop strategies to improve the oral health of over 65s where necessary. The research highlighted the importance of oral health related quality of life for older people. Barriers such as cost and difficulties with travelling, particularly within a rural setting, were raised, however, older people often found ways of coping with these. Emotional barriers and the impact of the life course were more difficult to overcome and greatly influenced current dental visiting habits. Older people placed importance on trust, professionalism and building up a relationship with their dentist. Local health care service providers also highlighted the close relationships built up with patients in these small communities. However, their work was often constrained by current NHS policy; they are bound by rules and regulations which restricted their practice. Commissioning dental services for older people in a rural setting is challenging. Services should be based on the needs of this group and in order to be effective good linkage between services is necessary.

The decade 1987 to 1997 was one of enormous change for the NHS and for the profession of clinical psychology and older people. This tiJesis is a product of this decade and demonstrates various ways in which the quality of services for older people with dementia can be addressed. Evidence-based assessment, especially when working with clients who present with a bewildering array of complex behaviours, is the cornerstone of providing quality interventions. The development of the BASOLL and its psychometric properties are described. It can differentiate between clients with different levels of dependency and is a useful aid to care-planning. The literature on measuring quality of care in formal care settings is reviewed. Dementia Care Mapping (DCM) was highlighted as a way forward. Its role as an audit of the outcome of the care process in formal dementia care settings was evaluated. The results were generally very positive with improvements in the quality of care practice being demonstrated. Although anxious about the observational nature of DCM, staff viewed it as a positive means of improving quality of care. Measuring levels of patient Engagement over a five-year period is also described. An overview of the general findings is provided. The advantages and disadvantages of DCM and Engagement as tools for improving quality of care are compared. Whilst DCM is seen as more costly in terms of initial investment, the resultant quality of data is superior when the quality of individual care is the main consideration. Engagement levels may suffice if all that is required is an overall indicator of service quality. Structured interviews were conducted with eighty-five staff and seventy-five service users to obtain qualitative feedback and suggestions for improvement in services over a five-year period. An analysis of the percentage of positive and negative comments enabled the general satisfaction of the respective groups to be compared. Generally service users were more positive about the physical environment and standards of professional care than staff, but less positive about issues of privacy, social interaction and empowerment. Both series of interviews led to a number of positive changes in the quality of care. The importance ofthe single case study approach with this client group is discussed. The effects of aromatherapy and massage on disturbed behaviour in four individuals with severe dementia were evaluated using a singl!) case research design. The opinion of the staff providing treatment was that all participants benefited. On close scrutin~ only one of the participants benefited according to the criteria chosen. In two of the cases aromatherapy and massage led to an increase in agitated behaviour. A new computer-assisted tool (CARJE) for the management of continence in people with severe dementia is described. The records it produces can be used in the development of care plans incorporating prompted voiding. Two single case design research studies are described. The length of time that both participants spent wet dramatically decreased when staff had access to the CARJE records and signals. Using the records assisted staff in managing continence through improved careplanning. The results ofthese papers taken together help to provide a way forward in the complex area of quality management for older people with dementia. Their place within the "New Culture of Dementia Care" is discussed.

Background: Case management of older people with multiple chronic conditions was being implemented widely across the UK as a method of reducing unplanned hospitalisations. Aim of the study: To determine if a nurse-led case management approach is effective and/or cost-effective in relation to usual care in a community setting. There was a requirement to study care-giving in relation to strain that may be experienced by care-givers as a consequence of the intervention. Methods: Prospective non randomised comparison trial involving control group (n=295) and intervention group (n=295) who received a targeted case management service. Data was collected across a 12 month period. Results Effectiveness Clinically important effect of 10% decrease in mean log bed-days was found when the two groups were analysed. There was an overall reduction in length of hospital stay of 33% in comparison to a higher overall reduction of 59% for the intervention group. Differences were significant in lengths of stay between groups at 6 and 9 months after commencement of the intervention. Significant differences were found over time for EO-50 and EO-50 VAS for the intervention group. Participants in the intervention group reported a significant improvement (significant at p<0.5 df 470.37 Cl: -11.3 to-2.04) at the end point in their level of functionality as a result of the intervention. Cost effectiveness: There were significant differences in costs across groups for each time- point. Combined with significant differences in OAL Ys the cost utility analysis confirmed that the case management service was 100% cost-effective at a willingness to pay of £20,000- £30,000. Impact on caregivers: The participants in the intervention group spent less time in hospital compared with the usual care group and this did not lead to an increase in the burden placed on their care-givers. Conclusion: Targeted nurse-led chronic illness case management approaches are both effective and cost-effective.

This study focused on understanding the meaning and process of social integration in older people who had experienced a stroke. Straussian grounded theory guided the study design. Older people living in their own homes in three counties in southern England were included in the sample. A total of 30 people were purposively selected and semi-structured interviews were conducted with older people (mean age 76) between four and eight years after their stroke. The substantive theory from indecision to volition was generated and conceptualised as the core category and comprised of four related categories: Gaps in identity, internal conflict, negotiating and exploring and renegotiating and reconciling. It was found that people did not feel they had managed to attain social integration; instead they described a more restricted but evolving social world and a process within the context of a personal journey to establish meaningful relationships. After people’s strokes an empty social space unfolded from the loss of social groups. Within this space, feelings of fear emerged and people experienced increasing self-consciousness and an erosion of self-confidence. The journey described was encompassed within a complex framework shrouded in effort and hard work that required many people to make a conscious decision to act in order to forge new relationships outside of their homes and families. This study identified variation in the process with people describing differing social progression. Those people that were able to make progress needed to access and utilise resources, but only at the right time for them, which for some took many years. Only a few people had returned to previous social groups. The majority slowly built new friendships and a new social world began to emerge; one that was often fraught with setbacks or pauses. Targeted and effective interventions that support people’s individual social needs have been suggested. These and opportunities for further research will continue to build a greater understanding, enabling people to move from uncertainty and indecision to an active volitional choice in order to form new and personally meaningful social worlds.

Background: The Emergency Department (ED) is often viewed as an inappropriate environment for terminally ill older patients; however, palliative admissions to the ED continue to occur. Despite an increased focus on end of life and palliative care services, the role of the ED has generally been neglected in the UK. Aim and Methodology: This study used the participatory action research methodology, Experience-based Co-design to identify concerns and solutions to improve experiences of palliative care provision in the ED for older patients (65+), their carers and staff at Guy’s and St Thomas’ Hospital NHS Foundation Trust ED. Methods: Experiential narrative data were gathered using audio and filmed interviews, and analysed using a thematic framework to identify the main challenges. Findings were validated by the staff and patient/carer groups, who selected four improvements priorities (IP) each (eight in total). Findings, in the format of a patient/carer film and a staff presentation were shared at a co-design event which enabled participants to collaboratively select shared IPs and began to redesign applicable elements of the service. The study was enhanced by findings from a data collection field trip to a geriatric-only ED at Mount Sinai Hospital in New York. Using interviews and observation additional background contextual data on palliative care coding and ED impact on the patient journey were identified. Findings: The four staff IPs were: ‘helping them [patients and carers] find their way’, ‘being informed and informing them [patients and carers]’, ‘seeing the person in the patient’, and ‘expectations of the care we can give’. Patient and carer IPs were similar: ‘finding our way’, ‘knowing what’s happening’, ‘seeing the person in the patient’, and ‘expectations of care’. The co-design event explored these issues and the group began to develop plans to improve them. Immediate strategies aimed to: improve self-management and ownership, develop ED-based palliative care pathways and staff training, create dedicated palliative care space in the ED, improve IT and databases, improve patient experience, and share the learning of the study. Impact: Early study impact includes palliative care referral improvements, introducing routine ED visits by the palliative care team, development on palliative care pathway processes in the ED, development of mandatory palliative care training in the ED which includes the patient/carer film. Based on feedback from the co-design event, the film was expanded to include the staff experience as well.

The rapid increase in the number of ageing population brings major issues to health care including a rise in care cost, high demand in long- term care, burden to caregivers, and insufficient and ineffective care. Activity recognition can be used as the key part of the intelligent sys- tems to allow elderly people to live independently at homes, reduce care cost and burden to the caregivers, provide assurance for the fam- ilies, and promote better care. However, current activity recognition systems mainly focus on the technical aspect i.e. systems accuracy and neglects the practical aspects such as acceptance, usability, cost and privacy. The practicality of the system is the vital indication whether the system will be adopted. This research aims to develop the activity recognition system which considers both practical and technical aspects using multiple wrist-worn sensors. An extensive literature review in wearable sensor based activity recog- nition and its applications in healthcare have been carried out. Novel multi-sensor activity recognition utilising multiple low-cost, non-intrusive, non-visual wearable sensors is proposed. The sensor fusion is per- formed at feature and classi er levels using the proposed feature se- lection and classi er combination techniques. The multi-sensor ac- tivity recognition data sets have been collected. The rst data set contains data from accelerometer collected from seven young adults. The second data set contains data from accelerometer, altimeter, and temperature sensor collected from 12 elderly people in home environ- ment performing 10 activities. The third data set contains sensor data from accelerometer, gyroscope, temperature sensor, altimeter, barometer, and light sensor worn on the users wrist and a heart rate monitor worn over the users chest. The data set is collected from 12 elderly persons in a real home environment performing 13 activities. This research proposes two feature selection methods, Feature Com- bination (FC) and Maximal Relevancy and Maximal Complementary (MRMC), based on the relationship between feature and classes as well as the relationship between a group of features and classes. The experimental studies show that the proposed techniques can select an optimum set of features from irrelevant, overlapped, and partly over- lapped features. The studies also show that FC and MRMC obtain higher classi cation performances than popular techniques including MRMR, NMIFS, and Clamping. Two classi er combination tech- niques based on Genetic Algorithm (GA) are proposed. The rst technique called GA based Fusion Weight (GAFW), uses GA nd the optimum fusion weights. The results indicate that 99% of classi er fusion using GAFW achieves equal or higher accuracy than using only the best classi er. While other fusion weight techniques cannot guar- antee accuracy improvement, GAFW is a more suitable method for determining fusion weight regardless which fusion techniques are used. Another algorithm called GA based Combination Model (GACM) is proposed to nd the optimal combination between classi er, weight function, and classi er combiners. The algorithm does not only nd the model which has the minimum classi cation error but also select the one that is simpler. Other criteria e.g. select the classi er with low computation can also be easily added to the algorithm. The re- sults show that in general GACM can nd the optimum combinations automatically. The comparison against manually selection revealed that there is no statistical signi cant in the performances. Applications of the proposed work in home care and decision support system are discussed The results of this research will have a signi cant impact on the future health care where people can be health monitored from their homes to promote healthy living, detect any changes in behaviour, and improve quality of care.

Background: Frailty is common and is associated with important adverse health outcomes. There is evidence that exercise may influence the biological mechanisms of frailty and improve adverse outcomes. This thesis describes the development and evaluation of the Home-Based Older People's Exercise (HOPE) programme - a home-based exercise intervention for frail older people. Methods: The MRC framework for the development and evaluation of complex interventions was used to develop and evaluate the HOPE programme. The development process synthesised information from four key domains: a systematic literature review; a process of intervention modelling work incorporating multiperspective focus group meetings; a review of behaviour change techniques and a review of international exercise guidelines. Following development, the HOPE programme was evaluated in a pilot randomised controlled trial. The primary outcome was mobility, measured using the Timed-Up-and-Go test (TUGT). Secondary outcomes included activities of daily living (ADL), quality of life and depression. Results: The systematic review identified preliminary evidence that exercise may improve outcomes for frail older people. A grounded theory analysis of the multiperspective focus group meetings identified the important challenges faced by frail older people, along with motivators and barriers to exercise. The results were synthesised into the HOPE programme, which is a 12 week home-based exercise intervention. 60 participants were recruited to the HOPE trial. Mean age was 78 years. Baseline characteristics were similar in the two groups. There was a nonsignificant trend towards an improved outcome in the intervention group (mean adjusted between group difference in TUGT 16.7s, 95% CI -33.3, 66.6s). There were no differences in any of the secondary outcomes. Discussion: The HOPE trial has provided valuable process, resource, management and scientific data to guide the development of a future definitive RCT and has provided important information to help inform future research involving frail older people.

No description available.

Partnership working between Health and Social Care is the Scottish Government’s strategy to affect major policy and practice level changes within public services in order to meet the fiscal challenges arising from the ageing demographic profile within our society. The Joint Future Group Report, published by the Scottish Government in 2002, specifically identified the profession of occupational therapy as central to the strategy for public service reform and inspired an inter-organisational occupational therapy service redesign within Lanarkshire. The practice and system service redesign transcended Acute, Primary Care and Local Authority care of the elderly occupational therapy services, introducing measures to promote patient continuity of care at an informational, management and relational level. The aim was to promote longitudinal models of patient care that minimised the incidence of patients being transitioned between occupational therapy services. This PhD adopted a critical realism research approach with a mixed method sequential explanatory research design. The aim was to develop a theoretical understanding of the structural and agential influences at the macro meso and micro levels that gave rise to the service redesign outcomes. The results provided illuminating insights as to the agential and structural barriers to partnership working. Service specific patterns emerged that suggested structural and cultural influences on occupational therapy practice resulted in service specific variation in the ability to deliver on the continuity of care service redesign intentions. The agency of the occupational therapists was explored through mechanism based theorising in order to identify morphogenetic influences (facilitators to change) and morphostatic influences (barriers to change) in engaging in the service redesign measures in practice. The results reflect that the occupational therapists within all three service sectors enacted their agency to preserve their respective pre-existing organisational service structures. These results suggest that the learning strategies and associated behaviours of the participating occupational therapists were not conducive to transformational change. The practical insights of the conditioning power of structure vis a vis the discrete reflexive power of agency outlined within this thesis offers the profession of occupational therapy within public services the means of exploring and conceptualising the complex implications of partnership working.

Public health still needs to better understand how older people’s life circumstances influence key risk factors for chronic disease, and also how women and men differ in their exposures and outcomes. This dissertation aimed to examine, separately for women and men, the role and inter-relationships of factors describing the economic and social contexts in relation to healthful eating and adiposity. A systematic review of economic determinants of diet in the elderly indicated that longitudinal evidence remains limited and focused on employment-related changes affecting diet. Thus, novel economic variables concerning financial hardship (FH) were examined in over-50s from the population-based EPIC-Norfolk cohort for associations with quantity and variety of fruit and vegetable intake, as proxies for healthful eating. FH was inversely associated with variety, more than quantity, independent of socioeconomic status (SES). Given the importance of social contexts for diet, it was notable that three aspects of structural social relationships were each associated with variety differently for women and men and, when combined, differed across categories of a second social tie. The next study of EPIC data investigated inter-relations between multiple economic variables, including FH, and social ties, demonstrating a magnification of unit differences in variety when economic and social disadvantage occurred simultaneously. Obesity is another chronic disease risk factor with known social gradients; thus a fourth study in EPIC examined associations of FH and SES with objectively measured obesity. All three FH measures were independently associated with general and central obesity, with the strongest relationships between greatest level of difficulty paying bills and central obesity in women, and general obesity in men. Finally, a longitudinal study of civil servants (Whitehall II) showed a strong association of persistent FH with 11-year adjusted mean weight change, and excess gain, in women only, which was not explained by any of the six potential mechanisms examined in mediation analyses. In sum, everyday financial troubles constituted a unique economic influence on diet quality and obesity in older adults, and the influence of a given economic or social factor on diet quality was modified when another social factor was also considered. Unique aspects of economic or social circumstances, and their different combinations, must be considered separately in future public health research and practice as each reflects a distinct process of social differentiation and hence adds to our understanding of contextual influences on chronic disease risk factors.