This thesis combines two research strands: cancer patients’ experiences and care of the older person. Previous cancer research has identified that health care professionals may treat older people with cancer differently, perceiving them as having less power; offering fewer treatment options; and less access to specialist cancer care. This qualitative study seeks to illuminate and compare the experiences of patients and health care professionals in two contrasting hospital wards (specialist and medical). This study considers how cancer patients manage their psychological and social needs. It also explores the challenges for health care professionals. Purposive sampling captures diversity of patient and health care professionals’ perceptions. Semi-structured interviews were conducted with patients and focus groups and semi-structured interviews with professionals. Analysis highlighted commonalities and also different emphasis accorded to issues such as societal perceptions, expectations of care, life stage, relationships, identity, and emotions. The hospital serves as a ‘halfway house’ for patients, allowing them to work through challenges in a ‘protected’ environment. However, health care professionals had difficulties addressing the future and managing some therapeutic opportunities. These are discussed using the thematic codes of ‘professional etiquette’, and types of emotional engagement with patients. Although older people with cancer are often perceived as a homogenous group they may have varying psychosocial needs. Moreover, patients’ understanding is frequently more sophisticated than professionals acknowledge. Finally the thesis will discuss the implications of this research for professional education, assessment and provision of care for the older person with cancer.

No description available.

Background and aim Health literacy is a term used to describe the ability of individuals to access, understand and use health information. Lower health literacy levels are associated with increased mortality and morbidity, and are more prevalent in older adult populations. UK NHS policy advocates meaningful patient engagement in healthcare. Vital health information is often inaccessible and older adults are not always sufficiently supported by healthcare providers to meaningfully engage with healthcare decisions. There is little research in this area. This research aimed to identify facilitators and barriers to meeting older adults’ health literacy needs in clinical practice, from patients’ and healthcare providers’ perspectives. Methods: This research comprised two discrete but interconnecting phases; the findings from the first phase led to the development of the second. The first phase involved conducting semi-structured interviews with nine older adults (aged 65 years and over) attending a falls clinic in the South of England. Participants’ health literacy was measured using the Rapid Estimate of Adult Literacy in Medicine and the Newest Vital Sign-UK. Interviews explored older adults’ views and experiences about access to the service, provider-patient interaction and self-management. Interpretative phenomenological analysis was used to interrogate the data. The second phase involved four focus groups with 22 healthcare providers working with older adults, and explored views about meeting older adults’ health literacy needs. Framework analysis was applied to the focus group data. Findings: Both phases of the research revealed the importance of building relationships and trust, tailoring healthcare information to individuals’ needs and social support when meeting older adults’ health literacy needs. Limitations or concerns about the use of health literacy screening were also identified in both phases. All older adult participants emphasised the importance of clear and simple communication; contrastingly, the healthcare providers expressed strong reservations about using ‘universal precautions’ with all patients. Healthcare providers also had low awareness about health literacy and appeared to shift the responsibility for development of health literacy onto public health and education sectors. Conclusion and implications for clinical practice: The findings corroborate other research emphasising the essential role of face-to-face interactions in meeting older adults’ health literacy needs and recognising health literacy as an interaction between individuals’ personal capabilities and the demands of healthcare systems. This research uniquely identifies issues with the transference of the holistic health literacy concept to a UK healthcare setting, such as healthcare providers viewing health literacy as a static risk and shifting responsibility for development of health literacy onto public health and education sectors. This is the first study to qualitatively compare health literacy screening and universal precautions from healthcare providers’ and older adults’ perspectives, revealing practical and emotional issues with both approaches. The research also reinforces the importance of trust, tailoring interactions to older adults’ unique attributes and goals and preferred learning and communication styles and social support. To engage older adults meaningfully in their healthcare, healthcare providers need support to develop their skills to meet their patients’ health literacy needs. The findings also highlight that further research is needed to develop effective health literacy interventions for older adults and to ascertain the acceptability and utility of using health literacy screening or universal precautions with older adult patients.

With the increasing number of elderly people and higher expectations of a good life within society, this study recognised the need to provide an environment for enhancing Quality of Life for elderly people. At the heart of the research agenda was the need to provide a decision-support framework to assist decision-makers to take into account the requirements of elderly people in everyday pursuits in the context of the external residential environment. The results of the study revealed a difference in responses between the built environment professional and elderly respondents. This mismatch and the built environment professionals’ views being more aligned with those of the care providers, could be construed to mean that built environment professionals rely more on providers of care services in making decisions that affect elderly people than elderly people themselves, creating a situation whereby the actual views of elderly people are missed out. These findings provided the platform upon which to develop a holistic decision-support framework for the built environment professionals to take into account the requirements of elderly people in the planning and design of the external residential environment. It was recognised that the framework needed to utilise the experience of the built environment professionals whilst making the requirements of elderly people the focus of the decision-making process. The principle of Quality Function Deployment formed the foundation of the BEDSEQoL-QFD framework, which ensures that each step of the design process is linked to fulfilling a specific client requirement and that the voice of the client is always central to the planning and design process. The BEDSEQoL-QFD framework also enabled the research to claim an important contribution to the body of knowledge. The validation exercise that followed the development of the framework confirmed its practical utility within the planning and design decision-making processes of the built environment in general, and elderly people’s external residential environment in particular.

Background Kidney function reduces with age, increasing the risk of harm and hospital admission from medicines. This project aimed to investigate the extent to which recommendations for prescribing drugs are applied for older people with reduced kidney function in primary care, and what needs to change to improve patient safety. Research design and methods A pragmatic sequential mixed methods design was used: 1. Cross-sectional case-note review. 2. Scoping literature review. 3. Primary Care Trust (PCT) wide cross-sectional survey of prescribing data. 4. GP interview study using the Theoretical Domains Framework. 5. Expert and stakeholder consensus group study. Results For 8 study drugs across a large PCT, a kidney function too low for recommended use was found for 3.5-39.6% in ≥65 year olds, and 24.2-79.5% in ≥85 years. The Cockcroft Gault equation provides a more accurate estimate of kidney function when prescribing for older people; 68.9-95.3% of patient drug events where kidney function was too low would have been missed if an estimated glomerular filtration rate had been used. GPs expressed a lack of awareness and knowledge about prescribing when kidney function is reduced. Although they monitored kidney function, it was not thought of when prescribing. Not having warnings and prompts at medication review was a particular barrier identified by GPs, and that the British National Formulary information on prescribing in renal impairment information needs to be clarified. The priorities for intervention and research agreed were to increase awareness of the need to assess kidney function in the prescribing process for older people, and to provide patient and drug specific warnings and prompts at medication review as well as initiation. Conclusion Many older people were taking medication that needed altering, or stopping, because of their reduced kidney function. This research has mapped the prevalence of inappropriate prescribing, and explored the behaviour determinants of GP prescribing, in reduced kidney function in primary care, identified what needs to change in practice, policy, and further research required, to improve patient safety.

Changes in memory and concerns regarding memory performance are common in older people, with many fearing developing dementia. Older people both with and without objective memory impairment may engage in compensatory strategies to reduce feelings of uncertainty, including checking or a reliance on memory aids. However, a number of studies have demonstrated that checking may paradoxically lead to reductions in metamemory (memory confidence, vividness and detail) as well as potential reductions in memory accuracy. The present study aimed to build upon previous research by adapting a stove paradigm developed by Radomsky, Gilchrist & Dussault (2006) to investigate the effects of repeated ‘relevant’ and ‘irrelevant’ checking on memory accuracy and metamemory in 20 community dwelling older people without memory problems, as well as a smaller sample of 14 individuals with mild cognitive impairment (MCI). The study employed 2 x 2 mixed factorial experimental designs for both samples. The independent variable was checking type (relevant checking and irrelevant checking). Participants were randomly assigned to either a ‘relevant checking’ or an ‘irrelevant checking’ condition. Participants in the ‘relevant checking’ condition completed 15 ‘checks’ of a non-functional replica stove while those in the ‘irrelevant checking’ condition completed 15 ‘checks’ of a dosette box, before completing a final checking trial of the stove. The dependent variables were measures of memory accuracy and metamemory (confidence, vividness and detail) assessed at two time points (pre-checking and post-checking). Consistent with earlier findings, repeated relevant checking led to significant decline in memory confidence, vividness and detail compared to the irrelevant checking condition for the older adult sample. The MCI sample showed significant decline in memory confidence following repeated checking although declines in vividness and detail did not reach significance. No change was observed in memory accuracy in either sample. The clinical and theoretical implications of this finding are discussed.

In 1990, annual health checks for people aged 75 years and over were introduced into general practice. This was seen as a potential vehicle for systematic screening, with subsequent referral to specialist community services, for older people with depression. Previous research had identified a number of obstacles to the recognition and treatment of late life depression. This thesis consists of two studies to evaluate the effectiveness of a structured approach by primary care and community services to the identification and management of depression among older people. Phase One was a validation study of the short Geriatric Depression Scale (GDS15) as part of an annual over-75 health check by the practice nurse. A stratified random sample of patients who completed the GDS15 was followed up with a diagnostic interview. At a cut-point of <3/3+ the GDS15 was 100% sensitive and 72% specific in detecting cases of depression. Phase Two was a randomised controlled trial of follow-up assessment by the local Community Mental Health Team (CMHT) for older people identified as depressed at the practice nurse health check. A total of 93 older people with GDS15 scores of 5 or more were randomised to either CMHT assessment (N=47) or routine GHP care (N=46). Uptake of the intervention was 72% (N=34). At the follow-up health check, 18 months after the initial health check, a greater proportion of the control group had improved GDS15 scores (p=0.08). Requests by the CMHT to continue to be involved with some of the patients in the intervention group were often rejected by patients' general practitioners. Although the GDS15 appears to be a useful instrument in the context of an over-75 health check, further mental health assessment should only be considered where there is a commitment by all service provides to implement recommendations.

This review explores current research on reactivated posttraumatic stress disorder (PTSD) among older adults. Diagnostic system classifications of PTSD and possible trauma-based presentations among the elderly are considered before work concerning prevalence, symptomatology and course, triggers, theoretical explanations of reactivated trauma and treatments is examined. Conceptual and methodological strengths and weaknesses of existing work are highlighted and we conclude that the next phase in research efforts should continue to explore the relative contributions of cognitive/neuropsychological and developmental/social factors in understanding this phenomenon.

Background The United Kingdom's elderly population and incidence of hip fracture are rising, yet outcome evidence to support optimum surgical intervention is lacking. Functional outcome is described by independence in activities of daily living (ADL), however the ideal measure to assess these activities following hip fracture is not known. The role of occupational therapy (OT) in regaining independence for patients with a hip fracture in the Leicestershire trauma unit was unclear. Therefore, the aim of this research was threefold:;To determine the optimum standardised ADL and Instrumental ADL (IADL) measures to assess outcome post hip fracture. To observe the role of OT within the orthopaedic trauma unit in regaining independence following hip fracture. To measure the pattern of independence and determine the effect of type of surgery on functional outcome, contributing to an evidence base. Methods Three studies were conducted to determine the best ADL outcome measure. Firstly a study using content analysis aimed to identify a suitable IADL index. The second compared a new individualised assessment, the Canadian Occupational Performance Measure (COPM), with a traditional OT approach and the third study compared the Barthel index with a new community assessment, the Community Dependency Index (CDI). An observational study of OT intervention was completed. The impact on functional outcome of three types of surgery in two age groups was examined in the context of a randomised controlled trial. 902 functional assessments performed in patients' homes were analysed. Main Results and Conclusion No suitable IADL measure was identified therefore a new index was developed. The Barthel Index was considered insensitive, the CDI being preferred for use whilst the COPM highlighted areas of occupational performance not included in the other assessments. The main analysis of the 902 assessments found these elderly people more dependant in IADL than ADL, but type of surgery did not significantly affect their functional outcomes. This has several implications for patients, purchasers and providers including the justification of choice of surgical intervention by orthopaedic surgeons.

Total populations aged 75 years an over, drawn from the age-sex register of the General Practice for Melton Mowbray in 1981 and 1988, were surveyed on health and sociodemographics by trained fieldworkers. For this study, participants were subdivided into seven year birth cohorts, born 1885-1891, 1892-1898, 1899-1905 and 1906-1912. Age-cohort and age-period logistic regression models were fitted to quantify trends in dependency (defined by human or technological help in at least one of: mobility about the home getting in and out of bed getting in and out of a chair dressing and eating), in self-perceived health defined by response to the question "For your age, in general, would you say that your health was good, fair or poor", and in self-reported GP contact in the home or surgery in the past month. Five-year survival and predictors of GP contact were also modelled. With more than 90% response, numbers interviewed at home were 1124 in 1981 and 1500 in 1988. Prevalence of dependency in the newer cohorts was slightly reduced compared to earlier cohorts surveyed at comparable age, but perceptions of health were less favourable in the newer cohorts, this difference being statistically significant for women. Less than good self-perceived health was confirmed as a predictor of five-year mortality in people aged 75-81 years, and an independent predictor of GP contact. For men, each succeeding cohort had higher rates of GP contact, whilst rates were stable for women. Associations of self-perceived health with GP contact were strongest for men aged 75-81 years in 1988, these men also having higher risk of contact and worse 5-year survival compared to men aged 75-81 years in 1981.