PhD Thesis / Background: The home care population is a cohort of medically complex older adults at risk for cardiac arrest and poor post-cardiac arrest health outcomes. Research Question: What is the prognosis of cardiac arrest among patients receiving home care, and what pre-arrest features and geriatric syndromes (e.g., frailty) are prognostic of survival and post-cardiac arrest health? Methods: Following a systematic review and meta-analysis that evaluated the prognostic association between frailty and post-cardiac arrest outcomes, a population-based retrospective cohort was created of adults (≥18 years) who received cardiac arrest care at a hospital in Ontario, Canada, between 2006 and 2018. Patients receiving home care and nursing home residents were identified using the Home Care Dataset and the Continuing Care Reporting System. Arrests were analyzed overall and within distinct sub-groups of in-hospital (IHCA) and out-of-hospital cardiac arrests (OHCA). The primary outcome for this thesis was 30-day survival post-cardiac arrest. Frailty was measured using the Clinical Frailty Scale and a valid frailty index. The odds of survival from cardiac arrest were estimated using multivariable logistic regression. Prognostic models were internally validated using bootstrap resampling (n= 2000). Results: We found high certainty evidence for an association between the Clinical Frailty Scale and death prior to hospital discharge after IHCA (OR = 2.93; 95% CI = 2.43 – 3.53) after adjusting for age as a minimum confounder. Our retrospective cohort contained 86,836 unique adult cardiac arrests, of which 39,610 were OHCA and 47,226 were IHCA. Patients receiving home care represented 10.7% of the cohort and were less likely to survive to hospital discharge (RD = -6.4; 95%CI = -7.4– -5.2) and one-year (RD = -12.8; 95%CI = -14.6 – -10.9) post-cardiac arrest compared to community-dwelling individuals receiving no support in the community. Frail patients receiving home care had worse odds of 30-day survival when measured with the CFS (OR=0.78; 95%CI = 0.61-0.98) and a frailty index (OR=0.89; 95%CI = 0.85-0.95), after adjusting for age, sex, and arrest setting. My prognostic model out-performed the two valid frailty measures and demonstrated fair discriminative accuracy (AUROC = 0.66; 95%CI=0.65-0.65) and good calibration (Slope = 0.95) for group-level prognostication when internally validated among patients receiving home care. Conclusion:Patients receiving home care have a worse absolute risk of death when compared to community-dwelling individuals receiving no community-based support services. Frailty is associated with survival and post-cardiac arrest declines in cognition and function when evaluated in patients receiving home care. The prognostic model developed within my thesis outperformed the ability of frailty to predict 30-day survival and is suitable for group-level prognostication. / Dissertation / Doctor of Philosophy (PhD) / The proportion of older adults receiving home care is growing. The home care population is frail and medically complex, with a greater risk for cardiac arrest. This thesis aims to evaluate the prognosis and prognostic factors influencing survival and other health outcomes, to develop a statistical model that can predict 30-day survival post-cardiac arrest. Findings from my research demonstrate that patients receiving home care have worse survival outcomes post-cardiac arrest compared to well-being older adults living in the community. In my research, frailty was associated with survival and declines in post-cardiac arrest functional independence and cognitive performance among patients receiving home care. Our statistical model performed better than valid frailty measures and had respectable accuracy for group-level prognostication. The home care population is ideally positioned for proactive and shared decision-making about end-of-life care preferences, bearing in mind their receipt of detailed and routine health assessments.

Abstract not available

The importance of spirituality in relation to mental well-being and physical health is currently well regarded in the academic literature. Therefore spiritual care is now considered an important aspect of holistic healing practices. However, research is showing that most health care providers do not feel competent or confident in this area of care. In this thesis I explore how spiritual care is understood and experienced by practitioners in aged and palliative care in a regional area on the coast of New South Wales. The 26 participants, whose insights and experiences are depicted in this thesis, were very happy to be involved in this qualitative research project, because they felt that they now had the opportunity to explore spirituality and spiritual care.The participants in this research describe spiritual care as involving doing in the form of religious practices, such as praying or bible readings and non-religious activities that were seen as spiritual such as talking about dying, touching people or reminiscing. Additionally, they also commented about spiritual care as a special way of being with clients, which involved qualities and attitudes that were clearly felt or recognized by the participants as special. Not necessarily labeled as spiritual care, this special way of being was described as not being separate, but being an integral part of the daily acts of caring such as feeding a patient or preparing them for a bath. Participants found it often difficult to elaborate on what made such an interaction spiritual or how to describe the quality of these interactions as there seemed to be no familiar language to share the experiences of spirituality and spiritual care. Additionally, participants commented quite regularly that, although spiritual care was seen as important, there were many factors that inhibited these practices. In reflecting on these issues I put forward that, although the practitioners in this research are familiar with spiritual care, the most important contribution to encouraging health care providers to feel more confident is to continue conversations about spiritual care to increase competency in a non-denominational spiritual discourse in aged and palliative care.

There is a growing interest in random measurement variability of biological variables. In regression models, such variability of the predictors yields biased estimators of coefficients (regression dilution bias). The objectives of this thesis were to develop an efficient method to correct for such bias, to reveal the relative importance of insulin sensitivity and insulin secretion, corrected for regression dilution bias, on glucose tolerance, and to explore the seasonal nature of the variability of insulin sensitivity. A reliability study is often designed to randomly select subjects from the main study. Our idea was to collect replicates for subjects with extreme values on their first measurement. The extreme selection design, in combination with maximum likelihood estimation, resulted in an efficient estimator of a corrected regression coefficient in a simple linear regression model. Results were presented theoretically and with an application: The relation between insulin sensitivity and fasting insulin in Uppsala Longitudinal Study of Adult Men (ULSAM) where the extreme selection design decreased the standard error of the estimated regression coefficient with 28 per cent compared with the random sampling design. We estimated the partial longitudinal effects of the predictors insulin sensitivity and insulin secretion, corrected for regression dilution bias, on glucose tolerance in ULSAM. The effects of the predictors, when corrected, were similar. Insulin sensitivity in ULSAM increased during summer and decreased during winter and insulin secretion exposed opposite variation keeping glucose homeostasis nearly constant. Insulin sensitivity was related to outdoor temperature. In summary, we developed a cost-efficient reliability design for correction for regression dilution bias. Insulin sensitivity and insulin secretion had similar longitudinal effects on glucose tolerance, which implies that interventions aimed at these targets are equally important. Further, we revealed the seasonal nature of variations of insulin sensitivity and insulin secretion. This result has implications on glycaemic control in diabetic patients.

Soluble oligomeric aggregates of the amyloid-β (Aβ) peptide are suggested to initiate Alzheimer's disease (AD), leading to impaired synapse signalling, widespread neuronal death and loss of cognitive functions. These aggregates seem tightly linked to disease progression, and have therefore gained much attention as potential novel disease markers. In this thesis soluble oligomeric Aβ aggregates in general, and the Aβ protofibril species in particular, have been investigated with the aim to quantify and determine their role in AD pathogenesis. Sandwich-ELISAs specifically measuring Aβ42 peptides are widely used both in AD research and as complements for clinical diagnosis. Here it was demonstrated that presence of soluble Aβ aggregates disturbs such analyses, making it difficult to interpret the results. This discovery was made through analyses of samples from cell- and mouse models carrying the AD causing 'Arctic' APP mutation. When analyzed by ELISA, Aβ42 levels were reduced in Arctic samples, in contrast to levels measured by denaturing SDS-PAGE Western blot. The same divergence in Aβ42-levels between analyses was observed in CSF samples from Down syndrome infants. The discrepancy between methods was hypothesized to be due to presence of soluble Aβ aggregates leading to impaired ELISA detection caused by epitope masking. This was confirmed by developing a protofibril specific ELISA, by which samples from Arctic cell- and mouse models were demonstrated to have enhanced Aβ protofibril levels. AD patients have reduced ELISA-measured Aβ42-levels in CSF compared to healthy controls. To test if this reduction was due to oligomeric Aβ species present in AD CSF, Aβ42-levels were analyzed under both denaturing and non-denaturing conditions. These two measures were combined and an Aβ42 oligomer ratio established. Higher ratios were found in AD patients than healthy controls, implying that Aβ oligomers are present in CSF during Alzheimer pathogenesis. The observations from AD patients and young Down syndrome individuals suggest that Aβ42 oligomer formation is an early mechanism of AD pathogenesis, which potentially could be used as a biomarker to monitor disease development.

This study is intended to explore how physicians can best help their older patients attain a better quality of life through sexual healthcare by eliciting older patients perceptions and experiences regarding their sexual health needs and what role their physician should play in meeting those needs. Participants consisted of individuals and couples over the age of 65 recruited from a continuing care retirement community and from a VA Geriatric Clinic. Twenty in-depth, one-on-one interviews were conducted, and transcripts were analyzed using qualitative methodology. Analysis of transcripts revealed a broad range of findings including seniors perceptions of: the definitions of sexual activity and sexual health, their own sexual status, their own sexual health needs, the barriers to meeting their sexual health needs, and the ageist beliefs of others and themselves. This study exposed older patients self-perceived sexual health needs and the barriers to having those needs met; this knowledge should help physicians improve the quality of life for their senior patients through improved sexual health care.

Thesis (M. Phil.)--University of Hong Kong, 2002. / Includes bibliographical references.

Wound-related pain is complex, integrating the experience of noncyclic acute wound pain, cyclic acute wound pain, and chronic wound pain (Krasner 1995). More than 80% of chronic wound patients report pain during wound dressing change. A constellation of physical and psychological factors may be involved in the mediation of pain during wound dressing change. A burgeoning body of evidence suggests the intricate relationship between anxiety and pain. In this study, the attachment framework was examined to determine how personal views of self (attachment anxiety) and others (attachment avoidance) may affect pain during dressing change. Attachment styles are systematic patterns of expectations, emotional reactivity, strategies for distress management and social behaviour that are based on an individual’s belief about the self and others. Internal working models are cognitive-affective schemas that guide the attachment patterns. Purpose: The purpose of this study was to explore the relationship of attachment style and pain during dressing change in an older population. In particular the study focussed on the role that anxiety, anticipatory self reported pain, and behavioural expression of pain play in this relationships. Method: A questionnaire was used in this cross-sectional study to classify 96 older subjects into four different categories of attachment styles. Subjects were asked to rate their levels of anticipatory pain and actual pain levels at different times during wound care using a numerical rating scale. Results: The results indicated that subjects experienced more pain during dressing change than at baseline. Secure subjects reported less pain and anxiety than subjects with other attachment styles. Results of regression analysis indicated that anxiety mediated the relationship between attachment and pain. Conclusion: The results of this study also support the role that attachment plays in the experience of pain in older adults. Clinicians must be cognizant of the impact of personality, anxiety, and anticipation of pain on the actual pain experience.

Wound-related pain is complex, integrating the experience of noncyclic acute wound pain, cyclic acute wound pain, and chronic wound pain (Krasner 1995). More than 80% of chronic wound patients report pain during wound dressing change. A constellation of physical and psychological factors may be involved in the mediation of pain during wound dressing change. A burgeoning body of evidence suggests the intricate relationship between anxiety and pain. In this study, the attachment framework was examined to determine how personal views of self (attachment anxiety) and others (attachment avoidance) may affect pain during dressing change. Attachment styles are systematic patterns of expectations, emotional reactivity, strategies for distress management and social behaviour that are based on an individual’s belief about the self and others. Internal working models are cognitive-affective schemas that guide the attachment patterns. Purpose: The purpose of this study was to explore the relationship of attachment style and pain during dressing change in an older population. In particular the study focussed on the role that anxiety, anticipatory self reported pain, and behavioural expression of pain play in this relationships. Method: A questionnaire was used in this cross-sectional study to classify 96 older subjects into four different categories of attachment styles. Subjects were asked to rate their levels of anticipatory pain and actual pain levels at different times during wound care using a numerical rating scale. Results: The results indicated that subjects experienced more pain during dressing change than at baseline. Secure subjects reported less pain and anxiety than subjects with other attachment styles. Results of regression analysis indicated that anxiety mediated the relationship between attachment and pain. Conclusion: The results of this study also support the role that attachment plays in the experience of pain in older adults. Clinicians must be cognizant of the impact of personality, anxiety, and anticipation of pain on the actual pain experience.

Dementia is characterized as a progressive loss of brain function that results in the deterioration of many cognitive and physical abilities. Alzheimer’s disease (AD) is the most common form of dementia, causing steady declines in memory, functional abilities, and mental functioning. With a projected increase of degenerative illnesses, such as AD, family caregiving for individuals with the disease is also steadily increasing. Caring for an individual with AD has been characterized as a “career,” and within this career are a number of key transitions, including the onset of caregiving. Preexisting caregiving research reveals a number of negative consequences for AD family caregivers, including depression, overload, and physical health complications. The purpose of this study was to examine how different patterns of caregiving onset (gradual and abrupt) and role occupancy (how many roles the caregiver is holding) impact mental health and physical health outcomes for AD caregivers. This study also explored how cognitive decline and behavioral problems found within the care-recipient have the potential to moderate these relationships. Cross-sectional, quantitative data from one hundred participants completing self-administered surveys was used in this study. A series of one-way ANOVAS and multiple regression analyses were conducted to address the study’s aims. Results indicated that care-recipient cognition and behavioral problems moderated the relationship between caregiving onset and mental health outcomes, including depression, role overload, and role captivity for caregivers who experienced a more abrupt entry into the caregiving role. Results suggest the importance of considering moderating factors within the caregiving career, as well as different caregiving onset transitions. Clinical implications of the findings are discussed, as well as directions for future research, including prospective caregiving research.