Falls are a major cause of injury fear of falling and death affecting 24% of older people annually. Falls have a major impact on hospital services, are an important cause of carer strain and admission to long term care. Multifactorial interventions delivered to fallers are effective in reducing falls rates by 25%. However, no UK studies have evaluated the role of screening older people living in the community and offering those at high risk a falls prevention programme. This work describes two studies – the evaluation of a postal falls risk screening tool, and a randomised controlled trial assessing the benefits of offering a falls prevention programme to those identified as being at high risk. 335 older people were recruited into the screening study, using a modified version of the Falls Risk Assessment Tool. The sensitivity was 79%, specificity 58%, positive predictive value 50% and the negative predictive value 83%. In the RCT, 364 community-dwelling older people at high risk of falls were randomised into a pragmatic, multicentre trial evaluating falls prevention programmes. 181 were allocated to the control group and 183 to the intervention. The primary outcome was the rate of falls; the adjusted IRR was 0.73 (0.51-1.03), p=0.071. There were no significant differences between the groups in terms of the proportion of fallers, recurrent fallers, medically verified falls, injurious falls, time to first fall or time to second fall. Nor were there significant differences in terms of institutionalisation, mortality, basic or extended activities of daily living, or fear of falling. Further work on testing falls prevention interventions for acceptability is required, followed by a further adequately powered RCT to determine the clinical effectiveness of a systematic screening programme and intervention. At present, there is insufficient evidence for health care commissioners to recommend screening and intervention for falls.

In rapidly urbanising Sub-Saharan African contexts, not much is known about the economic vulnerability of elderly people and its consequences. Dominant international institutions have indicated that the economic situation of elderly people in developing countries is precarious, especially where high levels of poverty and minimal social safety nets are the norm. As a consequence, the impact of economic vulnerability can be quite punishing on disadvantaged households with an ageing elderly person. Yet, the case of urban elderly Nigerians has thus far remained largely unresearched. This thesis represents a quantitative investigation of economic vulnerability amongst urban elderly Nigerians and its health-related consequences, examined through a consumption allocation welfare measure. It draws on economic, gerontological, and sociological perspectives to undertake this task. The key drivers of economic vulnerability and resulting consequences are likely to be complex and varied. Urban Elderly Nigerians may be economically vulnerable because they possess certain pre-disposing characteristics. This study is concerned with investigating these associated determinants of economic vulnerability amongst urban elderly Nigerians using a recent nationally representative household survey—the Nigerian General Household Panel Survey (NGHPS), which was collected by the National Bureau of Statistics in 2010. The first part of the study examines the determinants of economic vulnerability, through the use of a consumption allocation model. The findings of this study reveal that the age of the household head, household size, household structure, and regional location, are key determinants of economic vulnerability amongst urban elderly households in Nigeria. As a consequence, does economic vulnerability (represented by consumption allocation) influence health status and spending amongst elderly Nigerian households? I extracted useful data from the NGHPS to address this pertinent question. This is the second part of the study. The findings suggest that economic vulnerability is strongly related to health status and health spending. This thesis highlights key methodological challenges in using a secondary data source to study economic vulnerability amongst elderly people in a developing country context. The study also offers some policy options to tackle economic vulnerability among elderly households in urban Nigeria, and its health-related consequences.

This thesis reports on a study of outcome-focused care for older people in one English local authority. The aim of the research was to examine whether altering the delivery of care to an outcome-focused model would improve service delivery and save money for the organisation in the long term. In order for this to be established, a longitudinal study was conducted over 18 months, utilising a mixed-method design. The sample consisted of 40 service users aged 65 years and over who all had critical and substantial care needs. The study also included interviews with and observations from social services staff responsible for the commissioning and delivery of care. The focus of this case study was to examine the impact of two models of home care delivery for older people, and how these two models impact on the older persons’ self-reported well-being. The research established that there was a greater improvement in well-being in the group receiving outcome-focused care, when compared with the comparison group receiving the traditional task-focused model. Managers’ and social workers’ perceptions were also that outcome-focused care improved service users’ sense of well-being, in comparison with those receiving task-focused care. The overall cost (service provision only) of providing the new style of intervention was 17% more than the traditional task-focused model. The main conclusion was that outcome-focused care allowed a meaningful relationship to be established between the home care worker and the service user, whereas the opportunity for such relationship building was limited in the traditional task-orientated model.

Older people are the world’s fastest growing population group. By 2050 eighty per cent of older persons will live in what are now developing countries. There is established and growing evidence of the difficulties families in developing countries are experiencing in providing adequate support for their older members. This thesis explores how international development is responding to the interests of older people. The research examines how older people are represented in international development discourse and illustrates the impact of this on practice. This is informed by a comparative analysis with the progress of women in development. A critical discourse analysis of a corpus of texts from intergovernmental agencies illustrates the degree of visibility of older people in the development discourse. A case study of the work of inter-government organisations in West Bengal, India, shows how this can impact on grassroots activity. An original conceptual framework is introduced which aligns the dominant development paradigms with the dominant perspectives on older people emerging from this research. To the best of my knowledge this is the first research study to consider the (in)visibility of older people in international development discourse and to look at its implications on policy and practice. It highlights that a concentration of development resources at one end of the age spectrum to increase life expectancy is being met with an absence of planned support to meet the consequences when people successfully reach old age. The research further shows that when visible, older people are generally viewed as a homogeneous group in need of support and care, and not as citizens able to contribute and participate in development. The research illustrates a connection between global discourse and local practice in relation to older people and indicates a need for further studies to assess the extent of the links and to examine how local practice could inform the international development discourse.

No description available.

Rural areas are particularly affected by demographic ageing. In later life, the likelihood of living with chronic, manageable, physical conditions increases, affecting the ability to get out and about and be involved with the community. New digital technologies offer novel opportunities for overcoming physical barriers associated with engagement with others, which, amongst other benefits, can enhance wellbeing. These technologies may benefit all age groups in all types of community but could be of particular value in rural areas, which are characterised with dispersed settlement structures, accessibility restrictions and out-migration of family members and in-migration of new residents. The aim of this PhD project was to explore the potential benefits of digital technology, specifically designed for largely housebound older adults in rural North East Scotland, to enhance the sense of involvement they have with the local community. In this multi-methods project, sixteen interviews were conducted with largely housebound older adults living across North East Scotland, the majority in remote and accessible rural areas, to investigate how technology could enhance the sense of involvement older adults could have with their local community. These interviews, along with findings from two focus groups carried out with older adults, were used iteratively to inform the overall concept of the technology, followed by the design and development of a technology prototype. The prototype, entitled Window to the Outside World, was then evaluated with ten interviewees to explore whether live-streaming of local events could potentially enhance the sense of involvement one had with their local community, for those who were largely housebound in rural areas. The findings indicated that digital technologies, such as Window to the Outside World, carry much potential to provide supplementary avenues for increasing one's sense of involvement in the community for largely housebound older adults. There is scope to investigate whether use of such a technology could bring both individual and community-wide benefits for wellbeing, through increased opportunities for identity continuity, imaginative mobility as well as those gained from adopting a purely spectator role, and potential therapeutic benefits from the content of the footage. There is potential to develop the technology further to make it fit to their needs even more effectively.

This thesis explores doctors’ and medical students’ attitudes toward older patients in UK hospital settings. There have been regular and strong assertions in the grey literature and the news media that negative attitudes toward older patients may contribute to the inequality of healthcare service provision and treatment for older patients, compared to younger patients (those aged under 65 years), in UK hospital settings. However, much of the evidence does not investigate or explore these attitudes using a theoretical framework of attitudes outlined in the scientific research literature. This thesis comprises three studies. Firstly, a systematic search and review (Study 1) was undertaken in order to determine how attitudes toward older patients had been explored to date in the English-language, scientific research literature. Results demonstrated that previous studies had focused on attitude measurement rather than exploring the content of attitudes toward older patients. In fact, there was little evidence that previous research had ever explored these attitudes, despite the number of studies attempting to measure them. Furthermore, the review indicated the lack of research emanating from UK settings. In Study 2, attitudes toward older patients and their care were explored in twenty-five in-depth interviews with medical students and doctors in a UK NHS Hospital trust. Data were thematically analysed and findings indicated that attitudes toward older patients and their care could be conceptualised as: (1) attitudes toward older patients and their healthcare needs, and (2) attitudes toward providing care for older patients (e.g. the social and organisational barriers and facilitators). Within these two domains, the themes, subthemes and nodes, which represent attitude content with increasing levels of specificity, are presented. The findings from Study 2 mark one of the first attempts in this research area to explore and describe the content of attitudes in line with a theoretical framework of attitudes. The final study, Study 3, explored the devaluation and unpopularity of the specialty of geriatric medicine as a future career choice in a sample of junior doctors. Having identified, in Study 2, that geriatric medicine was not highly regarded in a range of doctors and medical students, Study 3 aimed to ascertain whether this was due to the organisational and working environment or due to older patient-related factors in a recently-qualified sample of doctors. The findings indicated that organisational and work-related factors serve to discourage junior doctors from pursuing geriatric medicine, rather than factors related to the older patients treated on geriatric wards. This thesis contributes to the research literature in two main ways. Firstly, this thesis outlines the research gaps in the worldwide English-language scientific research. Secondly, this thesis presents a conceptualisation of doctors’ and medical students’ attitudes toward older patients in a UK hospital setting. Importantly, this conceptualisation provides research that is relevant to UK settings and is in line with a theoretical framework of attitudes that has been identified from the scientific research literature. The strengths and limitations of this work are discussed.

Background: Information communication technology (ICT) such as the Internet, mobile phones, computers and tablets, has become a central part of daily life. However a large number of older people do not use ICT, putting them at risk of exclusion from the digital society. Aims: To investigate level to which older people or are “e-included” (or engage with ICT) across various contexts, the factors which influence their e-inclusion and their access to ICT-based care, and the effects of ICT-use on their quality of life. Methods: Using a mixed method approach, I collected both secondary and primary data from numerous different sources including national datasets, the MonAMI project, the relevant literature, and interviews with older adults and technical experts. Analysis: Quantitative and qualitative analyses were performed according to the dimensions of the 6C framework for e-inclusion. The effects of ICT use was assessed against the domains of the ASCOT and WHOQOL models of quality of life. Results: Older people’s e-inclusion and access to ICT-based care were affected by a number of person-centred and environmental factors. There were marked variances in level of e-inclusion with the older population, which was partly attributed to a cohort effect. The evidence showed that access to ICT-based care was affected by local eligibility policies and care practitioner endorsement. Analyses revealed that ICT use positively affected older people’s quality of life in terms of maintaining independence and social networks, and improving psychological wellbeing. However, ICT-use had negative effects on older people’s sense of privacy. Moreover, ICT-based care services proved to be obtrusive and stigmatising for many older people. Conclusion: The findings highlighted a paucity in targeted policies which consider older people’s specific digital interests. There is also a need for a better understanding of the effects of ICT-based care on older people’s quality of life.

Background: With life expectancies continuing to rise and more people living beyond the age of 65, health services are under increasing pressure to provide effective care for an ageing population. Increased life expectancy increases the risk of long-term conditions like Type 2 Diabetes and cardiovascular disease that require self-management – something that poses a challenge for many people, and for older adults there may be additional barriers. Identifying modifiable factors that impede self-management is an ongoing focus in the literature; and in recent years increasing attention has been paid to the impact of individuals’ attitudes to their own ageing. Aims: The first part of this thesis portfolio is a systematic review of the literature that aims to answer the question “Are lower expectations regarding ageing associated with lower levels of physical activity in older adults?” The second is an empirical study that aims to explore the relationships between attitudes to ageing, executive function, glycaemic control and selfmanagement adherence in older adults with Type 2 Diabetes. Method: A systematic literature search was undertaken to identify studies reporting quantitative analyses of the relationship between expectations regarding ageing and physical activity. Methodological quality of the studies was appraised and synthesized, and clinical and research implications discussed. In the empirical study; 77 older adults completed self-report measures of attitudes to ageing and self-management adherence, and two brief measures of executive function. HbA1c; a biological measure of glycaemic control was also recorded for each participant. Correlations and multiple linear regressions tested the relationships between attitudes to ageing, EF, self-management and glycaemic control. Results: 8 studies (derived from 9 papers) were eligible for the systematic review, and were in consensus in their support of lower expectations regarding ageing being associated with lower levels of physical activity. The findings of the empirical study indicated that more negative attitudes to ageing in relation to physical changes predicted poorer self-management; and more negative attitudes to ageing in relation to psychosocial loss predicted poorer glycaemic control. Conclusion: The current findings are in line with an emerging evidence base supporting a relationship between attitudes to ageing, and physical health outcomes and behaviours; with more negative attitudes and perceptions of old age acting as a barrier to health promoting behaviours. Therefore, interventions targeting those cognitions could help to promote better health outcomes for older populations, as well as promoting healthy ageing and valuing older people – a current focus in policy and strategy.

This study is concerned with the issue of substitution between formal and informal care in Britain between 1985 and 2000. This period provides the conditions for a ‘natural experiment’ in social policy. During the late 1980s/early 1990s, there was a rapid increase in long-stay residential care for older people, which came to an end around the mid-1990s. The key issues examined here are whether this increase in formal services led to a decline in provision of informal care, and whether this was subsequently reversed. For reasons identified in the literature review, the focus is on provision of intense informal care by adult children to their older parents, trends in which are identified using General Household Survey data. The study shows that there was a significant decline in provision of intense and very intense co-resident care for older parents between 1985 and 1995, which came to an end in the mid-1990s. A number of potential explanations for these trends are explored, including supply-side explanations in terms of changes in socio-demographic factors and employment rates, and an alternative demand-side explanation in terms of changes in ‘spouse care’. The study finds that, under certain circumstances, key trends in intergenerational care were negatively related to changes in long-stay residential care. In particular, the study finds evidence of substitution effects between nursing home/hospital care and very intense co-resident care for older parents provided by adult children for 50 hours a week or more. A key policy implication is that an expansion of very intense formal services for older people could bring about a decline in some of the most intense forms of intergenerational care for older people. The study relates these conclusions to options around reform of the long-term care system currently under consultation in England following the recent Green Paper on social care.