The overall aim of this thesis was to characterize single-channel aEEG/EEG, recorded during the first postnatal days in preterm infants, in relation to brain function and two-year outcome. Study I investigated if aEEG/EEG was associated with neonatal brain injury, inflammation and outcome in 16 very preterm (VPT) infants. The interburst interval (IBI) was prolonged, and aEEG amplitudes were lower in infants with brain injury, and in infants developing handicap. Cord blood TNF-α correlated with IBI. Study II investigated inter-rater agreement of visual burst detection, as compared to automated burst detection based on a non-linear energy operator (NLEO) in an EEG data set from 12 extremely preterm (EPT) and 6 VPT infants. The sensitivity of the NLEO was 64 % and 69 % (EPT and VPT infants, respectively) and the specificity 96 % and 88 %. The algorithm was then modified to further improve the accuracy. Study III investigated if arterial carbon dioxide and plasma glucose is associated with EEG continuity. In 247 sets of samples (PaCO2, plasma glucose, IBI) from 32 EPT infants there was a positive association between PaCO2 and IBI; higher PaCO2 was associated with longer IBI. Corrected for carbon dioxide, plasma glucose had a U-shaped association with IBI in infants with good outcome. Study IV investigated the predictive value of aEEG/EEG in 41 EPT and 8 VPT infants. All VPT infants had good outcome. Predictors of outcome in EPT infants included presence or absence of burst-suppression, continuous activity and cyclicity, median IBI and interburst%. Seizures were associated with neonatal brain damage but not with outcome. Improved preterm brain monitoring may in the future be used for early identification of infants at high risk of brain damage and adverse outcome, which may have implications for direction of care and for early intervention.

Monogenic disorders offer a possibility for studies of genetic disturbances in hearing impairment—a knowledge which could be essential for development of future treatment options. In this thesis, the underlying genetic disturbances in neurofibromatosis 2 (NF2) and familial Meniere’s disease (FMD) were evaluated, and familial X-linked hearing impairment was described from a clinical point of view. In paper I, constitutional DNA from 116 individuals with NF2 of variable severity was studied using the array-CGH method focusing on a 7.6-Mb area surrounding the NF2 gene on chromosome 22q. Deletions were found in 20.7% of samples. In mild NF2, the deletions were small, but variable sizes of deletions were found in cases that were moderately or severely affected. Disease phenotype could not be predicted from the size of the deletions. In papers II and III, a single five-generation family with autosomal dominant FMD was described. Anticipation concerning age of onset was observed. Genome scan revealed five candidate gene regions with a LOD score of > 1. Two additional families with autosomal dominant MD were analyzed for linkage to these five regions. A cumulative Zmax of 3.46 was obtained for a single 463-kb region on chromosome 12p12.3, containing only one known gene: PIK3C2G. This encodes a protein with a proposed role in hair cell regeneration in mammalian ears. No mutations were found in protein-coding sequences or exon-intron borders. In two of the three families, a shared haplotype, suggested common ancestry, was found to extend over 1.7 Mb, which could be a genomic region of importance for FMD. In paper IV, a family in which five males displayed progressive low- and mid-frequency hearing impairment from the first or second decade was described. Female carriers were affected by a high-frequency hearing impairment from the fourth decade. The family could represent a novel X-linked dominant audiophenotype.

Hearing impairment is the most common communication disability in older people. The wide-ranging impact of hearing impairment on communication means that not only does the person with hearing impairment experience the consequences but also his or her frequent communication partners. This thesis investigates the impact of hearing impairment on spouses and uses the World Health Organization’s term “third-party disability.” Third-party disability is defined as the impairments, activity limitations, and participation restrictions experienced by the family due to the health condition of their significant other, and was identified by the World Health Organization as an area for future development and application of the International Classification of Functioning, Disability and Health (ICF). Despite a number of studies previously published on the effect of hearing impairment on family members, including younger couples and carers, there remain substantial gaps in knowledge and understanding of the difficulties specifically relating to older people and factors associated with third-party hearing disability. This thesis focuses on the third-party disability experienced by normally hearing spouses (termed the “spouses” in this thesis) of older people with hearing impairment (termed the “partners” in this thesis). To add empirical data to the body of research, this series of studies first explored the lived experience of spouses of older people with hearing impairment in a qualitative study, then identified the ICF domains and categories that described third-party hearing disability, described the extent of third-party hearing disability in this population, modelled the contribution of factors to third-party hearing disability, and developed and psychometrically tested a scale to measure the third-party disability of spouses of older people with hearing impairment. Studies conducted within this thesis were therefore completed in two phases. Ten spouses of older people with hearing impairment participated in the first qualitative phase, consisting of semi-structured in-depth interviews. Results of this study showed that spouses experience a number of effects as a result of their partners’ hearing impairment including: (1) the broad ranging effects of the hearing impairment on the spouses’ everyday lives; (2) the spouses’ need to constantly adapt to their partners’ hearing impairment; (3) the effect of acceptance of the hearing impairment on the spouse; and (4) the impact of ageing and retirement. Findings were then linked to the ICF to identify the most typical and relevant domains and categories of the ICF for spouses of older people with hearing impairment. The majority of themes were able to be linked to the ICF, with most linking to codes in the activities and participation component. A number of contextual factors were also identified that influenced the spouses’ third-party disability. In the second phase, a further 100 older couples affected by hearing impairment participated in a quantitative face-to-face survey to describe the nature and degree of third-party disability in spouses, and to examine factors associated with third-party hearing disability. Concepts identified in the first qualitative study were used to formulate a 36-item tool for measuring spouses’ third-party hearing disability, namely the Significant Other Scale for Hearing Disability (SOS-HEAR). The majority of spouses in this study (98%) reported some degree of third-party hearing disability on at least one item of the SOS-HEAR. Communication difficulties between the couple were the central source of stress reported by spouses, followed by emotional problems in the spouse. Three factors were found to be significantly associated with greater third-party hearing disability: (1) lower relationship satisfaction as described by spouses; (2) a larger spouse-partner age difference; and (3) greater hearing disability in the hearing impaired partner as perceived by the spouse. The scaling properties of the SOS-HEAR were then examined, with a revised 27-item questionnaire found to be a reliable means of measuring older spouses’ third-party hearing disability. Use of the SOS-HEAR is proposed as a means of identifying spouses of older people with hearing impairment in need of intervention. If spouses are identified as experiencing third-party hearing disability, health professionals are then in a position to facilitate discussions with the couple about the impact of the hearing loss on their daily functioning. The inclusion of spouses in rehabilitation takes into account the needs of both members of the couple such that they become partners in rehabilitation. In summary, this research has shown that hearing impairment in older people has an effect on the spouse, as they too experience situations of communication activity limitations and participation restrictions. It is clear that the lives of participants in this study were considerably affected as a result of their partners’ hearing impairment, with spouses reporting a wide variety of stresses involving lifestyle changes, communication difficulties, and emotional consequences. This series of studies has highlighted the potentially important role of family-centred intervention in rehabilitation for older adults with hearing impairment, and strongly suggests the need for increased inclusion of spouses and significant others in the rehabilitation process.

Background: Headache is common in the elderly. Cervical degenerative changes are universal with ageing and cervicogenic headache is proposed (albeit without evidence) as a frequent cause of headache in this age group. Previous research identified a pattern of cervical musculoskeletal impairment which differentiated cervicogenic headache from other frequent headaches but this study was undertaken on younger/middle aged individuals. The value of this diagnostic pattern could be questioned for an older population with concomitant age related changes in the musculoskeletal system. The first and foremost aim of this research was to determine if cervical musculoskeletal impairment was specific to headaches classifiable as cervicogenic or was more generic to headache in elders. Participants with headache were sub-grouped on the basis of the pattern of cervical musculoskeletal impairment and the relationship between this grouping and headache classification was investigated. The presence of sensory hypersensitivity and psychological distress are features of headache that can provide information on the underlying mechanisms and provide management directives for headache. There is little knowledge of whether or not these features are influenced by a factor of age. Thus the second and third aims of this research were to investigate sensory features and psychological and quality of life features in the elderly with headache. Methods: One hundred and eighteen subjects, aged 60 to 75 years with recurrent headache and 44 controls were studied. Ninety-three reported a single headache and 25, two or more headache types. All subjects completed the Neck Disability Index (NDI), Geriatric Depression Scale-short form (GDS-S) and SF-36 questionnaires. Subjects with headache also completed a headache questionnaire and the Survey of Pain Attitudes (SOPA-35). Neck function measures included range of motion, manual examination of cervical segments, cranio-cervical flexor muscle function, joint position sense, cervical muscle strength, cross-sectional area of selected cervical extensors and posture. Sensory measures included pressure pain thresholds (PPTs) and thermal pain thresholds (TPTs). PPTs were measured over the forehead, upper neck and at a remote site (tibialis anterior). TPTs were measured over the upper neck. Results: Cluster analysis, based on the three musculoskeletal variables aligned previously with cervicogenic headache, divided headache subjects into two groups; cluster 1 (n = 57), cluster 2 (n = 50). There was significantly reduced cervical extension, axial rotation, rotation in neck flexion and lateral flexion in the headache clusters than the control group, and in the frequency of symptomatic joint dysfunction (C0-1 – C7-T1) (all p < 0.05). Subjects in cluster 1 had significantly reduced range of cervical extension and axial rotation and frequency of symptomatic joint dysfunction (C1-2 and C7-T1) compared to those in cluster 2 and controls (all p < 0.05). More subjects in cluster 1 had headaches ≥ 15 days per month and histories of head/neck trauma (both p < 0.05). Most cervicogenic headaches were grouped in cluster 1, but musculoskeletal dysfunction was also found in headaches classifiable as migraine or tension-type headache. The analysis of subjects with single headaches revealed no significant differences between the headache groups (migraine, tension-type, cervicogenic and unclassifiable headaches) and controls in pressure and cold pain thresholds (all p > 0.05). Heat pain thresholds were significantly lower in the headache groups compared to controls (all p < 0.01) but there were no differences between headache types (all p > 0.05). There were no strong relationships between any headache variable and pain thresholds. Elders with headache scored lower on most SF-36 domains, higher on the GDS-S (p < 0.05) and comparably on the SOPA-35 (p > 0.05) compared to the control group. The GDS score was below the threshold value for depression. Differences in these measures were not dependent on the headache types but rather, headache frequency. Subjects with headaches ≥ 15 days/month scored lowest on SF-36 domains and highest on GDS-S questionnaire compared to those with headache < 15 days/month and controls (all p < 0.05). The mean NDI score in the subjects with headache indicated the presence of mild to moderate neck pain and disability. No strong relationships were found between well-being and headache frequency, intensity and length of headache history. The NDI score had the greatest influence on physical well-being and GDS-S score on mental well-being (p < 0.001). Conclusions: Several aspects of cervical musculoskeletal function, heat thresholds, general well being and quality of life were altered in elders with headache. Neck dysfunction was not uniquely confined to cervicogenic headache but was a generic feature of headache in the elderly. No generalized changes in pain sensitivity were present in elders with headache. Headache had a significant impact on elders’ quality of life but was not associated with depression. Neck pain was an important factor influencing function and well-being. Conservative management such as physiotherapy may be a safe and appropriate option for elders with headache, given its frequent association with cervical musculoskeletal impairment. Further research is required for a better understanding of the neck’s role in elders’ headache.

Amnestic mild cognitive impairment (aMCI) has been established as a significant risk factor for Alzheimer‟s disease (AD) and in many cases this state appears to represent an early or incipient stage of AD. Due to difficulties with the diagnosis and prognosis of aMCI and AD, as well as with the projected significant socioeconomic ramifications of AD, there is a need to establish sensitive and reliable biomarkers. The application of event related potentials (ERPs) has been recommended in this context due to their reliability, non-invasive nature, inexpense and relatively widespread availability. This thesis aims to further assess the potential efficacy of ERP markers for such applications. These aims are pursued via investigations of ERPs in healthy ageing, MCI and AD utilising an explicit recognition task that requires the use of key cognitive/memory processes which are often impaired in aMCI and AD. Two ERP effects were analysed: the N400effect which is assumed to index familiarity or trace strength, and the Late Positive Complex (LPC) which appears to index recollection or decision-related factors such as accuracy. Chapter 3 reports ERP and recognition accuracy comparisons between samples of 15 young (mean age = 21.73 years) and 15 older, cognitively healthy adults (mean age = 66.67 years). ERP data were acquired during performance of a word recognition task with high and low memory load conditions (long and short encoding lists, respectively). At test, participants were required to make old/new judgements to visually presented words. There was a trend for young participants to perform more accurately than the older sample, especially on the long list; although these differences only approached significance. However, the N400 old/new effect was found to be significantly reduced in the old compared with the young participants across memory load conditions. LPC old/new effects were generally not observed and this is likely due to the nature of the task which generally places minimal demands on controlled retrieval processes. These results indicate that the N400 effect may be more sensitive to the deleterious effects of ageing on recognition memory-related process(s) than behavioural measures of memory accuracy. Consistent with the view that the N400 indexes familiarity, these results are in accordance with other evidence that familiarity is affected in healthy ageing. The same methodology was used to compare ERPs between aMCI (n = 11) and healthy older adults (n = 11) in Chapter 4. The aMCI participants performed significantly worse than vi healthy elderly participants in discriminating „old‟ from „new‟ words. In the corresponding ERP data, healthy control sample demonstrated significant N400 old/new effects at parietal electrode locations, whereas aMCI participants failed to demonstrate significant N400 old/new effects at any electrode location. Again, LPC effects were not observed in either sample. The absence of significant N400 effects in aMCI participants may reflect a disruption of familiarity-based recognition in aMCI. These results converge with other evidence that the N400 effect may be a sensitive ERP marker useful for detecting, monitoring and/or predicting amnestic related cognitive decline. There are reported variations in underlying causes and sequelae of aMCI (e.g., not all progress to AD). Chapter 5 reports an exploratory investigation aimed at determining whether baseline ERPs differentiate between aMCI participants on the basis of their clinical diagnosis at follow-up. Baseline ERP data were compared in a small sample (n = 7) of aMCI participant who remained cognitively stable at 12-month follow-up (SMCI) with two aMCI participants who progressed to meet an AD diagnosis (PMCI) at the latter time-point. There was a trend for PMCI participants to display smaller old/new effects. However, only one participant displayed significantly smaller N400 old/new effects under low memory load conditions. Interestingly, this participant was also more impaired in baseline cognitive functioning. Chapter 6 examines the relationship between baseline ERPs and performance on neuropsychological assessment at 12-month follow-up in a sample of aMCI and AD participants (n =13) in order to investigate whether ERPs may prove informative for prognoses regarding general trajectories of cognitive decline, irrespective of diagnostic status. Smaller N400 old/new effects (at Fz and CPz) were associated with poorer performance on tasks assessing global cognitive functioning and auditory attention span. Reduced LPC old/new differences were related to poorer performance on tasks assessing global cognitive functioning, verbal learning and memory and better performance on a task assessing working memory at follow-up. In contrast to these results, no relationships were observed between ERP effects and concurrent performance on neuropsychological assessment in this sample, or in 42 elderly participants (including healthy, aMCI and AD), as described in Chapter 7. Taken together these results suggest that ERPs may be more sensitive in predicting future rather than concurrent cognitive functioning and may provide a more objective measure/classification of cognitive impairment vii irrespective of diagnosis. These outcomes are particularly novel as the relationship between baseline ERP data and follow-up neuropsychological measures does not appear to have been systematically reported in the literature to date. Collectively these findings indicate that ERP measure(s), particularly the N400 old/new effect, are sensitive to neurocognitive changes associated with ageing and aMCI, and may prove a useful biomarker for the early detection of AD. This is interesting as the effects of healthy ageing and pathological decline on the N400 from explicit recognition tasks have not been thoroughly explored. Moreover, the N400 (and perhaps, to a lesser degree, LPC) effect(s) appear to have substantial value for informing future prognoses of subsequent cognitive trajectories, at least for persons with amnestic impairment. These results may have significant clinical implications pertaining to the selection and application of efficacious therapeutic interventions in aMCI and AD.

Hearing impairment is the most common communication disability in older people. The wide-ranging impact of hearing impairment on communication means that not only does the person with hearing impairment experience the consequences but also his or her frequent communication partners. This thesis investigates the impact of hearing impairment on spouses and uses the World Health Organization’s term “third-party disability.” Third-party disability is defined as the impairments, activity limitations, and participation restrictions experienced by the family due to the health condition of their significant other, and was identified by the World Health Organization as an area for future development and application of the International Classification of Functioning, Disability and Health (ICF). Despite a number of studies previously published on the effect of hearing impairment on family members, including younger couples and carers, there remain substantial gaps in knowledge and understanding of the difficulties specifically relating to older people and factors associated with third-party hearing disability. This thesis focuses on the third-party disability experienced by normally hearing spouses (termed the “spouses” in this thesis) of older people with hearing impairment (termed the “partners” in this thesis). To add empirical data to the body of research, this series of studies first explored the lived experience of spouses of older people with hearing impairment in a qualitative study, then identified the ICF domains and categories that described third-party hearing disability, described the extent of third-party hearing disability in this population, modelled the contribution of factors to third-party hearing disability, and developed and psychometrically tested a scale to measure the third-party disability of spouses of older people with hearing impairment. Studies conducted within this thesis were therefore completed in two phases. Ten spouses of older people with hearing impairment participated in the first qualitative phase, consisting of semi-structured in-depth interviews. Results of this study showed that spouses experience a number of effects as a result of their partners’ hearing impairment including: (1) the broad ranging effects of the hearing impairment on the spouses’ everyday lives; (2) the spouses’ need to constantly adapt to their partners’ hearing impairment; (3) the effect of acceptance of the hearing impairment on the spouse; and (4) the impact of ageing and retirement. Findings were then linked to the ICF to identify the most typical and relevant domains and categories of the ICF for spouses of older people with hearing impairment. The majority of themes were able to be linked to the ICF, with most linking to codes in the activities and participation component. A number of contextual factors were also identified that influenced the spouses’ third-party disability. In the second phase, a further 100 older couples affected by hearing impairment participated in a quantitative face-to-face survey to describe the nature and degree of third-party disability in spouses, and to examine factors associated with third-party hearing disability. Concepts identified in the first qualitative study were used to formulate a 36-item tool for measuring spouses’ third-party hearing disability, namely the Significant Other Scale for Hearing Disability (SOS-HEAR). The majority of spouses in this study (98%) reported some degree of third-party hearing disability on at least one item of the SOS-HEAR. Communication difficulties between the couple were the central source of stress reported by spouses, followed by emotional problems in the spouse. Three factors were found to be significantly associated with greater third-party hearing disability: (1) lower relationship satisfaction as described by spouses; (2) a larger spouse-partner age difference; and (3) greater hearing disability in the hearing impaired partner as perceived by the spouse. The scaling properties of the SOS-HEAR were then examined, with a revised 27-item questionnaire found to be a reliable means of measuring older spouses’ third-party hearing disability. Use of the SOS-HEAR is proposed as a means of identifying spouses of older people with hearing impairment in need of intervention. If spouses are identified as experiencing third-party hearing disability, health professionals are then in a position to facilitate discussions with the couple about the impact of the hearing loss on their daily functioning. The inclusion of spouses in rehabilitation takes into account the needs of both members of the couple such that they become partners in rehabilitation. In summary, this research has shown that hearing impairment in older people has an effect on the spouse, as they too experience situations of communication activity limitations and participation restrictions. It is clear that the lives of participants in this study were considerably affected as a result of their partners’ hearing impairment, with spouses reporting a wide variety of stresses involving lifestyle changes, communication difficulties, and emotional consequences. This series of studies has highlighted the potentially important role of family-centred intervention in rehabilitation for older adults with hearing impairment, and strongly suggests the need for increased inclusion of spouses and significant others in the rehabilitation process.

Hearing impairment is the most common communication disability in older people. The wide-ranging impact of hearing impairment on communication means that not only does the person with hearing impairment experience the consequences but also his or her frequent communication partners. This thesis investigates the impact of hearing impairment on spouses and uses the World Health Organization’s term “third-party disability.” Third-party disability is defined as the impairments, activity limitations, and participation restrictions experienced by the family due to the health condition of their significant other, and was identified by the World Health Organization as an area for future development and application of the International Classification of Functioning, Disability and Health (ICF). Despite a number of studies previously published on the effect of hearing impairment on family members, including younger couples and carers, there remain substantial gaps in knowledge and understanding of the difficulties specifically relating to older people and factors associated with third-party hearing disability. This thesis focuses on the third-party disability experienced by normally hearing spouses (termed the “spouses” in this thesis) of older people with hearing impairment (termed the “partners” in this thesis). To add empirical data to the body of research, this series of studies first explored the lived experience of spouses of older people with hearing impairment in a qualitative study, then identified the ICF domains and categories that described third-party hearing disability, described the extent of third-party hearing disability in this population, modelled the contribution of factors to third-party hearing disability, and developed and psychometrically tested a scale to measure the third-party disability of spouses of older people with hearing impairment. Studies conducted within this thesis were therefore completed in two phases. Ten spouses of older people with hearing impairment participated in the first qualitative phase, consisting of semi-structured in-depth interviews. Results of this study showed that spouses experience a number of effects as a result of their partners’ hearing impairment including: (1) the broad ranging effects of the hearing impairment on the spouses’ everyday lives; (2) the spouses’ need to constantly adapt to their partners’ hearing impairment; (3) the effect of acceptance of the hearing impairment on the spouse; and (4) the impact of ageing and retirement. Findings were then linked to the ICF to identify the most typical and relevant domains and categories of the ICF for spouses of older people with hearing impairment. The majority of themes were able to be linked to the ICF, with most linking to codes in the activities and participation component. A number of contextual factors were also identified that influenced the spouses’ third-party disability. In the second phase, a further 100 older couples affected by hearing impairment participated in a quantitative face-to-face survey to describe the nature and degree of third-party disability in spouses, and to examine factors associated with third-party hearing disability. Concepts identified in the first qualitative study were used to formulate a 36-item tool for measuring spouses’ third-party hearing disability, namely the Significant Other Scale for Hearing Disability (SOS-HEAR). The majority of spouses in this study (98%) reported some degree of third-party hearing disability on at least one item of the SOS-HEAR. Communication difficulties between the couple were the central source of stress reported by spouses, followed by emotional problems in the spouse. Three factors were found to be significantly associated with greater third-party hearing disability: (1) lower relationship satisfaction as described by spouses; (2) a larger spouse-partner age difference; and (3) greater hearing disability in the hearing impaired partner as perceived by the spouse. The scaling properties of the SOS-HEAR were then examined, with a revised 27-item questionnaire found to be a reliable means of measuring older spouses’ third-party hearing disability. Use of the SOS-HEAR is proposed as a means of identifying spouses of older people with hearing impairment in need of intervention. If spouses are identified as experiencing third-party hearing disability, health professionals are then in a position to facilitate discussions with the couple about the impact of the hearing loss on their daily functioning. The inclusion of spouses in rehabilitation takes into account the needs of both members of the couple such that they become partners in rehabilitation. In summary, this research has shown that hearing impairment in older people has an effect on the spouse, as they too experience situations of communication activity limitations and participation restrictions. It is clear that the lives of participants in this study were considerably affected as a result of their partners’ hearing impairment, with spouses reporting a wide variety of stresses involving lifestyle changes, communication difficulties, and emotional consequences. This series of studies has highlighted the potentially important role of family-centred intervention in rehabilitation for older adults with hearing impairment, and strongly suggests the need for increased inclusion of spouses and significant others in the rehabilitation process.

Increasing numbers of older patients with cognitive impairment and disturbed behaviour are likely to present to acute care hospitals in the future. Nurses are not well disposed towards care due to safety and morale issues caused by knowledge deficits, job stress, oppressed group behaviours and ageist attitudes. Patient outcomes are often poor with multiple adverse events, long lengths of stay and levels of mortality. Disturbed behaviour may be caused by delirium, depression or other mental disorders and dementia or all. The research question addressed was “Can the instigation of a person-centred approach to care of patients with cognitive impairment and disturbed behaviour result in decreased nursing stress, improved patient care practices, outcomes and relatives’ satisfaction?” A conceptual framework incorporating the constructs of Person-Centred Care, the Integrated Structural Model of Human Behaviour and Practice Development informed the action research methods utilised. The processes of facilitation were used to undertake four action research cycles incorporating plans, actions, observations and reflections in one 25-bed acute aged care ward in a large tertiary referral hospital The first cycle involved setting up the study, recruitment of nurses and patients, gathering of baseline data and application of nonparticipant observational studies of the quality of nurse-patient interactions which served to inform the plan for interventions. The following three cycles demonstrated efforts to undertake those interventions through strategies to increase nursing empowerment and knowledge in the context of constant staff turnover and diversions that compromised support and participation. During the study there were few apparent adverse patient outcomes with significant improvements in patient analgesic administration, relatives’ satisfaction with care, nursing care practices involving the completion of a Communication and Care Cues form and nurses’ interactions with the patients. New care planning tools were developed that will enable ongoing activities for practice improvement. Conversely, there was a significant increase in the nurses’ stress levels when caring for hypoactive delirious patients, a trend towards more emotional exhaustion, high nursing turnover and increased sick leave rates. Nursing care practices were unchanged and the new care planning tools were not well utilised. Reflection on the implications and limitations of action research methods supported by practice development strategies in the dynamic, often chaotic environment experienced during the study, suggested that if there is an absence of hierarchical managerial sponsorship for such activities, then sustainable change is difficult. Therefore, it was shown that a person-centred approach to care of patients with cognitive impairment and disturbed behaviour using action research methods in this environment, can result in some enhanced nurse-patient interactions, patient care practices, outcomes and relatives’ satisfaction. However, progress is likely to be slow and time consuming. Further improvements require attention to the well-being status of the nurses through actions that generate feelings of empowerment through individual recognition, knowledge enhancement, adequate access to patient information and sufficient time to undertake their duties as equal members of the multidisciplinary team.

Obstructive Sleep Apnoea (OSA) is a disease characterised by repetitive upper airway obstructions which are manifest by desaturation and arousal from sleep. It has been known for many years that this interruption to the normal architecture of sleep may present to the clinician as excessive daytime somnolence often with a complaint of difficulties with concentration and short term memory. Previous work had demonstrated a relationship between variables of cognitive dysfunction in patients with obstructive sleep apnoea, however, little was known about which components of the syndrome contributed to this outcome and whether specific clinical thresholds of sleep disordered breathing could be defined for the development of cognitive dysfunction. In the context of this body of work cognitive dysfunction is defined as: a level of cognitive performance below normal derived values for a given cognitive test, when the subjects performance is controlled for age, sex and level of education.

No description available.