This qualitative research study addressed the gap in the literature and lack of clinical guidelines and frameworks for health professionals as they assess and manage risk when balancing the safety and autonomy of community-dwelling older adults. Twelve health professionals were asked in individual interviews how they perceive, identify, assess and treat risk and how they negotiate the safety and autonomy of their clients. Informed by grounded theory methodology, the findings revealed what kinds of decisions health professionals made and how they made them within this clinical context. These findings from the perspective of the health professional contributed to the development of a definition of living at risk, a safety continuum and a conceptual/practice framework to help health professionals, including occupational therapists, make sound clinical decisions as they balance the autonomy and safety of their community-dwelling older adult clients.

L’objectif de ce travail était d’étudier l’évolution des symptômes dépressifs (SD) chez 2590 sujets âgés français, issus de la population générale et suivis pendant 20 ans entre 1988 et 2008. Une méthode d’analyse du changement fondée sur l’identification de trajectoires individuelles de développement a été utilisée afin de tenir compte de l’hétérogénéité pressentie dans cette population. Les facteurs et évènements évolutifs associés aux trajectoires de SD ont été étudiés. Nous avons identifié cinq trajectoires d’évolution de SD entre 1988 et 2008 et trois trajectoires entre 65 et 104 ans. La majorité des individus ne présentait pas ou peu de SD au cours des 20 ans de suivi. Cependant, environ une personne sur dix suivait une trajectoire compatible avec un diagnostic de dépression chronique. Les antécédents psychiatriques, la polymédication, les comorbidités somatiques et la perte d’autonomie étaient des facteurs fortement prédictifs de dépression « émergente » ou « persistante ». Le veuvage apparaissait être un facteur protecteur d’appartenance à la trajectoire de dépression « persistante » pour les femmes uniquement. L’entrée en institution et le décès étaient plus fréquents dans les trajectoires les plus défavorables. Les trajectoires de SD étaient significativement associées aux trajectoires de consommation d’antidépresseur. Notre travail confirme l’hétérogénéité de l’évolution des symptômes dépressifs en population âgée. Il alerte sur la prévalence préoccupante de la chronicité et aide à déterminer des sujets à plus haut risque d’évolution défavorable qui pourraient faire l’objet d’actions de prévention. / The aim of this study was to investigate patterns of the course of depressive symptoms (DS) in 2590 community-dwelling older adults followed over a period of 20 years, between 1988 and 2008. Using a group-based trajectory method, we modelled the course of DS and examined associations between trajectory patterns and baseline socio-demographic and health variables, as well as outcomes. We identified five time-related trajectories between 1988 and 2008, and three age-related trajectories between 65 and 104 years old. A majority of participants experienced no or only mild DS. However, about one to ten belonged to high-level trajectories consistent with clinically relevant chronic depression. Psychiatric history, polypharmacy, somatic comorbidities and functional limitation were strongly associated with membership to increasing and persistently high trajectories. Being widowed seemed to be a protective factor for membership of this persistently high trajectory group only in women. Institutionalization and death were more prevalent in worse trajectories. Trajectories of DS and trajectories of antidepressant use were significantly associated. Our study confirmed heterogeneity of the evolution of DS in late-life and highlighted the problematic risk of chronicity. We identified several high-risk groups for later-life depression that can be easily detected and that are amenable to preventive intervention.

This thesis includes three manuscripts with an overarching objective to improve understanding of behavioural risk factors for falling in community-dwelling older adults. The first manuscript presented in Chapter two, presents a protocol for a scoping review. The objective of this scoping review was to highlight the current methods used to identify fall-related risk-taking behaviours in community-dwelling older adults, and to identify factors that might contribute to these behaviours. The second manuscript (Chapter three) presents the results of the scoping review written in the format for publication. The review identified older adults are generally aware of their own falls risk and engage in protective behaviours to reduce their risk of falling. Older adults engaged in risk-taking behaviours based on the potential benefits outweighing perceived risk of the behaviours. An individual’s abilities, self-perception, personal values, and the environment likely influence the perception of risk which contributes to risk-taking behaviours. The third manuscript (Chapter four) includes the analysis of clinical data from a community-based multi-component fall prevention program – the Building Balance Program. Individuals who participated in this six-week fall prevention program improved in balance ability, lower extremity muscle strength, mobility, and reduced fear of falling from baseline. Fear of falling (FoF) was the highest amongst the youngest participants despite having better physical function at the outset of the Program. This suggests that in addition to physical function, other factors, like psychological and social factors may be involved with FoF. / Thesis / Master of Health Sciences (MSc) / Falling is very common for older adults. Falling can lead to injuries and long-term side effects like fear of falling. Community-based exercise programs are a cost-effective way to help large groups of older adults reduce their risk of falling. Exercise programs can reduce older adults’ risk of falling by improving their balance and muscle strength. But exercise might not be enough to prevent falling in older adults. Falls can happen for various reasons, such as the activities or behaviours in which the individual participates. This thesis includes two studies presented in three papers aimed to better understand behavioural components which may be associated with falls. The results of this research suggest there is a psychological and social component involved with falling. The findings from this thesis highlight the importance of a holistic approach to and may help to inform the development of comprehensive interventions for fall prevention.

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Introduction: More than half a million Canadians are living with dementia and 260,000 of these individuals live at home. As dementia progresses, persons with dementia require more assistance from caregivers to meet their daily needs including stimulation and emotional support. However, caregivers receive little training in this role. Namaste Care is a program originally developed for use in long-term care homes promoting a structured routine, a slow pace of care, and multisensorial activities for persons with advanced dementia. The program has not yet been adapted or evaluated for use by caregivers of community-dwelling older adults with moderate to advanced dementia. The objective of this study is to explore the feasibility, acceptability and preliminary effectiveness of a version of Namaste Care adapted by caregivers. Methods: A multiphase mixed methods design was used. In the adaptation phase, six caregivers participated in workshop sessions to adapt Namaste Care for home use. In the evaluation phase, 12 caregivers received training to use the adapted program. Surveys were used to collect data on caregiver quality of life, perceptions of caregiving, self-efficacy, and burden at baseline and 3-month follow-up. Qualitative interviews at 3-month follow-up were also completed to assess the acceptability of the program and implementation facilitators and barriers. Findings: All caregivers used the program for a minimum of twice a week as planned and used a variety of program activities. The retention rate was 83%. Caregivers perceived that the program improved their relationships with persons with dementia. Implementation facilitators were receiving a Namaste Care Toolbox and written resources about Namaste Care. No statistically significant effects were found with regards to the outcome measures listed above. Conclusions: The adapted Namaste Care program was feasible and acceptable for use by caregivers. There is a need to conduct a larger trial to determine the extent of its effects. / Thesis / Doctor of Philosophy (PhD) / With the growing numbers of family and friend caregivers across Canada supporting people living with dementia at home, there is a need to better prepare caregivers for their role. The aim of this study is to adapt, implement and evaluate a sense-based, skill-building program called Namaste Care delivered by caregivers of older adults living with moderate to advanced dementia. First, workshops for caregivers were held to adapt the Namaste Care program for home use. Afterwards, 12 caregivers received training in using the adapted program and delivered the program for three months. Caregivers used the program at least twice a week as intended and delivered a variety of activities. The program improved relationships with persons with dementia. No significant changes for caregiver quality of life, positive beliefs of caregiving, burden, and confidence were found. Next steps are to further test the effects of the program in a larger trial.

Home and community based services (HCBS) are designed to provide services that meet the increasing and diverse needs of the older adult population who wish to age-in-place for as long as possible in their homes and community. Yet, little is known about the choices people make when selecting services. The purpose of this study was to assess HCBS use among vulnerable older adults. Andersen’s (1995) behavioral model of health services use provided theoretical guidance for selecting and explaining predisposing, enabling, and need-based variables associated with service use within the Community Living Program (CLP) federal initiative. Through consumer direction of services, 18 routine or one-time services were offered to 76 participants enrolled in the Virginia CLP. Two-step cluster analysis identified four distinct profiles of service users, ranging in size from 7 to 34 members. Services used within the groups ranged from 11 to 16 services. Use of personal care services (p=.033) and respite (p=.010) were significantly associated with group membership differentiation. Within each cluster, the percentage of participants using each service varied greatly. The most important variables that differentiated service user membership were caregiver relationship to participant, participant living arrangement, participant disability type, and length of time caregiver provided care. Between-cluster membership was significantly different with regard to average service cost per day for services used (p=.002) and the likelihood of moving to a nursing home if services were not provided (p=.034). Findings inform future research and have implications for practitioners assisting vulnerable older adults in selecting services to meet different care needs. / Master of Science

京都大学 / 新制・課程博士 / 博士(医学) / 甲第25170号 / 医博第5056号 / 新制||医||1071(附属図書館) / 京都大学大学院医学研究科医学専攻 / (主査)教授 山本 洋介, 教授 近藤 尚己, 教授 西浦 博 / 学位規則第4条第1項該当 / Doctor of Agricultural Science / Kyoto University / DFAM

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