Thesis (M.S.)--University of Michigan, 1989.

Thesis (Ph. D.)--University of Texas at Austin, 2009. / Title from PDF title page (University of Texas Digital Repository, viewed on Sept. 9, 2009). Vita. Includes bibliographical references.

Thesis (M.S.)--University of Michigan, 1996. / Includes bibliographical references.

Thesis (doctoral)--Lund University, 1995. / Added t.p. with thesis statement inserted.

Thesis (M.S.)--University of Michigan, 1993.

Background: Improving care for people living with dementia when they are admitted to hospital is a national priority. Interventions have been designed and implemented to support staff to improve how they provide care to patients with dementia. However, there is limited understanding of how these interventions work in practice and what the outcomes are for patients and their family carers. Objective: To develop, test, and refine a theory-driven explanation of what supports hospital staff to provide dementia-friendly care and with what outcomes for people living with dementia and their carers. Method: A two-phase study design employing realist methodology. Phase one was a realist review which combined evidence from stakeholder interviews and literature searches. Phase two used realist evaluation to analyse data collected from two NHS Hospital Trusts in the East of England to test the theory developed in phase one. Findings: Initial scoping in the realist review identified three candidate theories which structured the literature searches and analysis. Six related context-mechanism-outcome configurations were identified and collectively made the initial programme theory. The review found that single strategies, such as dementia awareness training, would not on their own change how staff provide care for patients with dementia. An important context was for staff to understand behaviour as a form of communication. Organisational endorsement for dementia care and clarity in staff roles was important for staff to recognise dementia care as a legitimate part of their work. The realist evaluation refined the programme theory. While the study sites had applied resources for patients with dementia differently, there were crosscutting themes which demonstrated how key mechanisms and contexts influenced staff actions and patient outcomes. When staff were allocated time to spend with patients and drew on their knowledge of the patient with dementia and dementia care skills, staff could provide care in ways that reassured patients and recognised their personhood. However, accepted organisational and social norms for care practices influenced whether staff considered providing skilled dementia care was an important contribution to the work on the ward. This impacted on how staff prioritised their work, which influenced whether they recognised and addressed patient needs such as pain or hunger, made attempts to reduce distress, and if patients and carers considered they were listened to. Organisational focuses, such as risk management, influenced how patient need was defined and how staffing resources were allocated. Staff commitment to continuing in dementia care was influenced by whether or not they valued dementia care as skilled work. Discussion: Single strategies, such as the use of dementia awareness training, will not on their own improve the outcomes for patients with dementia when they are admitted to hospitals. In addition, attention needs to be paid to the role of senior managers and their knowledge of dementia to support staff to provide care in ways that recognise the needs of the person. The way dementia care is valued within an organisation has implications for how resources are organised and how staff consider their role in providing dementia care. Evidence from observations demonstrated that when staff are supported to provide good dementia care, patients experienced positive outcomes in terms of their needs being addressed and reducing distress. Dementia care needs to be recognised as skilled work by the staff and the organisation.

Dementia is a devastating disorder that commonly affects people over the age of 65. Alzheimer's disease and vascular dementia are the most common forms of dementias. A number of studies have implicated cardiovascular risks as important factors in the development of dementia. These risks include high-risk behaviors such as smoking and risks related at least partially to health behaviors such as diet and exercise. This study examines a group of cardiovascular risk factors, as defined by the Framingham study, to ascertain if they are predictors of dementia. A retrospective chart review of 481consecutive patients seen in a geriatric medicine clinic produced a sample of 177 individuals diagnosed with dementia and 304 individuals without a dementia diagnosis. Relative risk ratio (RRR) results indicate that a history of hypertension (RRR= 1.80, p = .009) and a history of hypercholesterolemia (RRR = 1.85, p = .016) are significant predictors of Alzheimer's disease. A history of tobacco use (RRR = 2.18, p = .01) is a significant predictor of vascular dementia. Stepwise regression analyses indicate that hypercholesterolemia is an independent predictor of dementia (b = -.113, p = .009) and hypercholesterolemia (b = -.104, p = .018) and hypertension (b = -.094, p = .031) clustered together have an additive risk factor effect. These results are discussed in terms of the importance of specific health behaviors in the development and possible prevention of dementia.

This study examined differences in scoring patterns among those diagnosed with Alzheimer's dementia and vascular dementia on the clock-drawing test. Archival clock drawing data was retrieved on 279 patients presenting at a county hospital-based memory clinic. Analysis of drawings was based on frequency of qualitative errors, as well as an overall quantitative score. Mean comparisons found those patients with Alzheimer's dementia to perform worse on both quantitative and qualitative scoring measures. However, Pearson's chi-squared test revealed a significantly higher rate of spacing errors among subjects with vascular dementia. Such lends support to my hypothesis that impaired executive functioning in vascular dementia patients would lead to poor qualitative performance. Logistic regression found significant predictive ability for the qualitative criteria in diagnosis (χ2 = 25.49, p < .001), particularly the rate of omission (z = 8.96, p = .003) and addition errors (z = 7.58, p = .006). Such findings hold important implications for the use of qualitative criteria in cognitive screening assessments.

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