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Background: This thesis explores the concept of frailty, as a latent vulnerability in older people, with the aim of refining its measurement by generating a new measure of frailty - the British Frailty Index (FI). This index was developed and validated in a cohort of community-dwelling older women, the British Women's Heart and Health Study (BWHHS), in 23 towns in Britain. Findings were replicated in another large Medical Research Council (MRC) Assessment of Older People study Methods: A systematic literature review examined the evolution of the concept and definitions of frailty. A meta-analysis on the prognostic value of current frailty measures confirmed extensive heterogeneity in the prediction of all-cause mortality despite consideration of age, sex, type of measure and duration of follow up. A 'General Specific' model of frailty was derived from factor analysis in the BWHHS population and replicated in the MRC cohort. Construct, external criterion and predictive validity of the British FI were assessed and its performance compared to another widely used index - the Canadian Frailty Index - with single indicators of frailty. Results: Frailty was explained by seven factors; physical ability, cardiovascular and respiratory disease and symptoms, visual impairments, other comorbidities, psychological problems and physiological measures. Associations with frailty included increased age, female sex, smoking, living alone, not living in own home, poor social contact and low socioeconomic position. Frailty was an independent predictor of all-cause mortality in both cohorts and predicted hospitalization and institutionalization in the MRC study, performing better than the Canadian Index. Conclusion: This thesis provides better understanding of the multi-dimensional domains of frailty in older people. The British FI demonstrates validity in relation to adverse outcomes, provides a more reliable measurement tool and its application offers further opportunities for the prevention, detection and treatment of frailty at a clinical level.

Sleep is an essential contributor to health, well-being and quality of life. This thesis explores sleep and the night-time in care homes for older people. To date there has been a lack of qualitative research to explore what happens in a care home throughout the night and further our understanding of care home residents' experiences of sleep and the night-time. Forming part of the New Dynamics of Ageing funded Sleep in Ageing project, (www.somnia.surrev.ac.uk) the study aims to explore this previously under-researched area using qualitative methodology including interviews with 38 care home residents and 39 staff, together with observations in each home. The research findings from this study identify aspects of the social and physical environment of a care home which influence the experience of the night-time and the quality of residents' sleep, as perceived by both staff and residents. In particular, residents expressed difficulties exerting control over their sleep environment and lacked strategies and support to do this. Personal control over sleeping routines and bedroom privacy was found to be related to levels of physical and cognitive ability. The dominance in care homes of a risk-averse culture which focuses on the ageing body as the centre of risk, and organisational routines during the night-time, facilitated an environment where disturbed sleep becomes a normal part of the sleep experience and an accepted consequence of night-time care. This thesis concludes that the current model of 'care' within care homes is unable to provide individualised support to care home residents that makes possible choice and control over the night time sleep environment, and which does not contribute to the promotion of good quality sleep.

Objectives. The aim of this study was to explore the application of Weiner's attributional theory of motivation and emotion to care staff working with older adults with challenging behaviour. The research aimed to examine the effect of challenging behaviour type and dependency levels on attributions and the role of optimism and positive affect as mediators for willingness to care for and change patients' behaviour. The study further aims to investigate associations between attributions and management of challenging behaviour by care staff, including abusive and depersonalising actions. Design. A two-factor repeated measures design was used to examine the relative effect of dependency and challenging behaviour upon ratings of attributional dimensions, affect, optimism, and two variables of care staff behaviour. Correlations and path analysis were employed to examine the role of affect and optimism upon the care staff behaviour variables. ANOVAs and correlations were used to examine the effect of challenging behaviour type and dependency upon management strategy use and correlations were used to examine relationships between attributions, affects and management strategies. Method. The participants were 46 unqualified care staff working in specialist NHS mental health residential settings for older adults. Participants rated six vignettes of scenarios of challenging behaviour of older adults for attributions, affects, optimism, and willingness to care for and change the behaviour of the client. Care staff also rated the likelihood that they would use a variety of management strategies in response to the behaviour. Results. Significant differences in attributions were found for different dependency levels and challenging behaviour types. Correlations and path analysis showed that caring for clients was inversely predicted by negative emotion, which was predicted by control. Willingness to change the client's behaviour was best predicted by optimism, which was inversely related to attributions of stability. Abusive strategy use was significantly higher for high dependency clients and was associated with negative affect. Conclusion. The results are consistent with Weiner's attributional theory of motivation and emotion and are discussed in relation to previous research and the wider literature. Clinical implications of the research in the areas of staff training and selection are discussed, as are suggestions for future research.

Aim: To recognise and understand how to prevent water-loss dehydration occurring in older people living in care homes. Background: Water-loss dehydration is common and linked to poor drinking, but prevention is likely to be multi-faceted. Methods: Three independent studies investigating hydration care in older care home residents were conducted and the findings integrated (mixed methods, convergent parallel design): • Diagnostic accuracy of clinical signs and symptoms of dehydration. • Systematic review investigating effectiveness of interventions and associations of modifiable environmental factors on improving fluid intake and/or hydration status. • Qualitative study involving residents, families and care-staff in focus groups, exploring challenges and facilitators in hydration care. Results: In the diagnostic accuracy study, 188 residents (mean age 85 years, 66% women) were recruited from 56 care homes. Clinical signs and symptoms were ineffective in identifying older people with dehydration. The 23 included studies in the systematic review addressed a range of strategies at carer, institutional and societal (‘macro’) levels to improve fluid intake and hydration status, but high risk of bias in many studies meant findings were inconclusive. Three themes emerged from the qualitative study: ‘meanings and experiences of drinking’, ‘caring roles’, and ‘tensions and barriers to successful drinking’. Integrated findings identified residents’ and families’ contributions to residents’ hydration care and preventing dehydration requires a multi-faceted approach. The researcher-led quantitative studies of the systematic review indicated how macro factors may impact on hydration care (along with institutional and carer-led factors). Findings from the diagnostic accuracy should inform national guidelines at the macro level. The qualitative study provided experiential perspectives and insights into relational care between each care level and how these have positive and negative impacts on residents’ drinking. Conclusion: Fluid intake is a physiological necessity to prevent dehydration. Supporting care home residents to drink involves multi-levels of care and is a social experience. (300 words) Medline medical subject headings (MeSH): aged; beverages; dehydration; diagnostic tests, routine; drinking; geriatrics; long-term care; osmolar concentration; qualitative research; residential facilities; review, systematic.

This thesis explores how older people in residential accommodation experience home and everyday life through their interactions with material culture. Taking an ethnographic approach, it looks in detail at how residents’ feelings about living in and being at home are revealed through their practices with the things that surround them. It also shows how residents’ attitudes towards home are shaped by new and ongoing social relationships, as reflected in and constituted through the gifting and circulation of objects. By focusing on the everyday, this thesis emphasises hitherto neglected aspects of residential home culture. Where previous research on residents and their possessions has concentrated on ‘cherished’ or ‘treasured’ belongings, for instance, this study widens the scope to all things, however mundane. In doing so, it argues that homes are continually shaped by materially-mediated social practices, and that ‘becoming at home’ is an ongoing process, where meanings are made through the interactions between residents and objects. Conceptualising home and the nature of the relationship between people and things in this way diverges from studies which suggest that possessions can ‘transfer’ a sense of home or identity when residents move into older people’s homes, essentially rendering them passive repositories of meaning ascribed to them by residents. While residents’ feelings of home are shaped by institutional features such as the built environment and care culture, those able to exert agency do not just rely on existing belongings to recreate a sense of home, but also turn the spaces of their rooms into places of home through interacting with objects in the present and making plans to buy new things. This thesis therefore argues that becoming at home in residential homes for older people need not be so different from becoming at home in other situations and stages of the life course.

The narrative literature review presented in Chapter One explores the concept of independence referred to within western ageing policies, and argues that this concept is often poorly defined. It is argued that negative perceptions of ageing and dependency have influenced the western ideals of promoting independence among older people. The potential negative impact of striving for independence is explored, including the possibility of older adults denying increasing support needs due to fear of appearing dependent on others. The implications of continuing to promote an unrealistic and marginalising goal of independence are discussed. The research paper presented in Chapter Two provides a narrative exploration of older people's experiences of moving into residential care. This transition has often been considered to be a major, and potentially stressful life event requiring substantial adjustment, however little research has been conducted exploring the lived experience of this move, and how it is incorporated into residents' lives. Eight residents participated in individual interviews, and discussed this transition in relation to their lives. Narrative analysis exploring convergent and divergent themes across participant's stories revealed major plots of control, uncertainty and identity. These plots occurred throughout all eight narratives, and appeared to be important in influencing older people's perceptions of residential care; more so than their duration of residence. This suggests that considering the transition into residential care as a phase and time based event does not encapsulate older people's experiences; the clinical implications of this are discussed.

Despite a widely accepted view of the importance of understanding experience from the point of view of the individual using services in modern western society, there are relatively few studies that have explored day-to-day living in a care home from the older person's perspective. This study aimed to present the voice of the untold stories of care home residents through an interpretative study that was informed by a biographical approach and narrative method. Eight older people who lived in four different care homes in England participated in a sequence of up to eight narrative interviews over a six month period. Through the process of listening to, retelling and interpreting the residents' stories the resident world was explored. There were three stages to the interpretative process that focused on:- developing a naïve or surface understanding to acquire a sense of the whole sequence of a participant's interviews; a structural analysis that examined the interviews to investigate what the text said and how it was said; and a critical in-depth examination of the interpretation within the wider social context. The interpretation revealed the unique way that each participant lived in a care home. These older people worked hard to reconstruct their life following the move to a care home and as they lived there. Though the residents were limited by physical, functional and cognitive problems, they developed strategies with the aim of influencing the life that they lived within a care home. Where they were able to implement those strategies they reconstructed their life in ways whereby they 'lived with care.' In this sense they were active biographical agents shaping this phase of their life. This is an alternative biography, to that of older people 'existing in care' as an outcome of care received. This thesis provides new insights into the residents' world. The overriding conclusion that can be drawn from these stories is that these older people were trying to live as active biographical agents who were instrumental in shaping their own life. They were able to do this to a greater or lesser extent and the conceptual model of biographical living that has been developed from the resident stories provides a framework to depict the complex interactions that shape an individual's experience in this environment. An inherent feature of this model is recognition that residents can be active agents throughout their lives in care homes. In summary, residents' desire to 'live with care' and this is not only possible, it is achievable.

The structure of the United Kingdom population is changing with the percentage of people aged 65 and over increasing from 15% in 1985 to 17% in 2010 (Office of National Statistics 2012). During this time older people have been encouraged to remain living in their own homes (National Consultative Ethics Committee for Health and Life Sciences 1998). There is a growing body of evidence regarding older people and their homes concentrated primarily on the interpretative paradigm. In view of the existing evidence base the question posed was: ‘How do the discursive practices of older people living in their own homes reflect societal discourses?’ The aim of the research was to investigate the meaning of the home space and how older peoples’ discursive practices reflect societal discourses. In order to meet this aim the paradigm of post-modernism was selected along with the methodology of discourse analysis using Michel Foucault’s ideas. Narrative accounts were generated from a sample of 12 older people on two separate occasions on a one-to-one basis. The data was transcribed verbatim and a thematic analysis was used to condense the data and to allow for a Foucauldian discourse analysis of the topics identified by the participants. Five dominant discourses were identified as follows: Discourse of Risk – this was related to danger and trauma such as falls but the underlying risk was that of losing the home; Discourse of the Failing Body - explained how the participants were managing the physical demands of home-keeping with bodily changes threatening self-sufficiency; Discourse of Cognition – ageing as cognitively ‘challenged’ and again could be a threat to self-sufficiency; Discourse of Connections – the importance of contact and socialisation with others, animals and artefacts; Discourse of Consumption – highlighted the acquisition of equipment, adaptations and services to look after the self and the home and demonstrate ability. The meta-discourse of ageing as inevitable decline that circulates in society was being adhered to. However, one of the main findings was that the older people managed ageing in the home via managing risk. There was a constant underlying fear of losing their home and the participants consequently adopted the subject position of vulnerability. Foucault discusses the pervasiveness of power but stresses that where there is power there is resistance. In order to resist power, however, individuals need to gain critical consciousness. Challenging the status quo is essential if the dominant discourses regarding ageing are to be changed. Discursive trends towards ageing do appear to be emerging, but these are being heavily influenced by neoliberal policies and challenges from other modes of thinking are limited. Older people themselves can and do resist these dominant discourses and this requires continued encouragement and facilitation by professionals, voluntary organisations and the media.