Depression is not a normal part of aging; despite this, 15-17% of older adults have symptoms of depression (Lakkis & Mahmassani, 2015). Depression in older adults not only negatively impacts quality of life, but also negatively impacts co-morbid disease progression (Gallagher et al., 2016; Oza, Patel, & Baptist, 2016; Sinnige et al., 2013; Song et al., 2014). Depression treatment improves co-morbid disease outcomes (Bogner et al., 2016; Wood et al., 2015). Arizona has a large population of older adults and the number of older adult is projected to increase 174% by the year 2050 (Arizona Department of Health Services, n.d.). The majority of depressed patients seek treatment in the primary care setting (Lakkis & Mahmassani, 2015; Samuels et al., 2015). Arizona has over five thousand nurse practitioners working in primary care (Arizona Department of Health Services, 2014b). The purpose of this project was to determine the treatment practices of nurse practitioners caring for older adults with depression in southern Arizona. A needs assessment, using a self-administered survey, was conducted to determine how southern Arizona nurse practitioners self-identify their ability to recognize and treat older adult depression. Results revealed that southern Arizona nurse practitioners have barriers to recognition and treatment of depression in older adults. Barriers to the recognition of depression in older adults included the older adult patient’s medical complaint, limited appointment times in the primary care setting, and limited experience as a nurse practitioner. Treatment barriers identified by survey results included the older adult patient’s attitude toward depression, financial status, and ability to participate in depression treatment. The majority of these barriers are consistent with evidence established in previous studies. The ability of the older adult to participate in depression treatment was a barrier identified in the results not found in the synthesis of evidence. This project supports existing evidence regarding barriers to the recognition and treatment of older adult depression in the primary care setting. Further research is indicated to evaluate if removing the identified barriers will increase the nurse practitioners’ ability to recognize and treat depression in the older adult.

The typical cardiac surgery patient is increasing in age and level of frailty. Frailty can be defined as an increased vulnerability to stressors due to decreased physiological reserve. Previous investigations have demonstrated the benefit of cardiac rehabilitation (CR) programming on surgical outcomes. However, the link between pre-operative frailty and post-operative CR completion is unclear. The purpose of this study was to determine if pre-operative frailty status impacts CR completion post-operatively. A total of 114 cardiac surgery patients with an average age of 71 years were included in the analysis. CR completers were significantly less frail than CR non-completers at baseline based on the Clinical Frailty Scale (CFS; p=0.01), Modified Fried Criteria (MFC; p=0.0005), Short Physical Performance Battery (SPPB; p=0.007) and the Functional Frailty Index (FFI; p=<0.0001). The change in frailty status from baseline to 1-year post-operatively was not statistically different between CR completers and non-completers; CFS (p=0.90), MFC (p=0.70), SPPB (p=0.06) and FFI (p=0.07). However, the MFC frailty domains of cognitive impairment (p=0.0005) and low physical activity (p=0.04), in addition to the FFI physical domain of frailty (p=0.009), did significantly improve among CR completers when compared to non-completers. CR attendance measured by swipe card access did not correlate with frailty modifications. Collectively, these data suggest that participants deemed to be frail at the pre-operative time point attend and complete CR less frequently than non-frail participants. Furthermore, CR completion does not appear to modify frailty status overall; although, some frailty domains appear to be more sensitive to change than others. / February 2017

An examination of data from 21 older members of the University community aged 59 and older, including those who do and those who do not use the campus gyms, and six athletic programming staff from the two facilities to attempt to understand how older adults choose to negotiate their physical activity as they age. The study demonstrates that those respondents most comfortable in the gym spaces in the university setting are those who have occupied those spaces over many years, or those who have been habituated to gym culture through their activities outside the university setting. Using the ’mask of ageing theory’ in combination with Bourdieu’s concepts of habitus, capital and field, this study is an attempt to understand the individual and cultural practices that older adults engage in to manage their physical activities at the University, their other activities outside, as well as the performative aspects of their engagement.

An examination of data from 21 older members of the University community aged 59 and older, including those who do and those who do not use the campus gyms, and six athletic programming staff from the two facilities to attempt to understand how older adults choose to negotiate their physical activity as they age. The study demonstrates that those respondents most comfortable in the gym spaces in the university setting are those who have occupied those spaces over many years, or those who have been habituated to gym culture through their activities outside the university setting. Using the ’mask of ageing theory’ in combination with Bourdieu’s concepts of habitus, capital and field, this study is an attempt to understand the individual and cultural practices that older adults engage in to manage their physical activities at the University, their other activities outside, as well as the performative aspects of their engagement.

The Census 2000 Brief (2001) informs us that the American population is aging. The predictions are that by the year 2050 there will be 80 million adults over the age of 65 as compared to 35 million in the year 2000. Since technology is becoming more important in our daily lives, many older adults are interested in learning how to use online technology to communicate and gather information. This study was designed to better understand the process and the experience of older adults as they learn to use online technology with computers. The questions guiding the inquiry were: • What is the experience that older adults have while learning online technologies? • What is the process for older adults of going from non-literate to literate in online technologies? • What are older adults' responses to challenges and successes? Older adults were interviewed, videotaped, and asked to keep a reflection journal while learning and sharing their personal experiences. A qualitative grounded theory methodology was used to explore how online technologies are experienced. These case studies were based on retired adults, sixty-five years of age or older, who had not used (or learned) online technologies. This researcher is not aware of any grounded theory qualitative case studies that used interviews, videotapes, and journaling to detail the process and experiences of how older adults learned online computer technology. This study augments the body of knowledge concerning older adults learning computer technology and informs future studies specifically on how older adults learn online computer technology. The findings in this research showed that the participants in this study applied none of the learning strategies used in a classroom situation (where the instructor controlled the learning process by teaching). A process was depicted illustrating how the participants in this study learned how to use the Internet and e-mail. This process consists of six phases and describes stages within each of the phases. Challenges and successes were also listed and explained in regard to each participant's experience and learning process. / Ph. D.

Objectives: The population, globally and nationally, is ageing and the numbers of those over the age of 65 is increasing. Given this increase in numbers, it is important that the physical and mental health needs of older adults are addressed by service providers. Depression is the most common form of mental ill health in this age group and effective treatments are available. The main aim of the study was to investigate the extent to which general practitioners‘ (GPs) are able to identify depression and offer appropriate treatment strategies to patients over the age of 65 presenting to non-urgent community GP clinics. Method: GPs assessed each participant, attending a general clinic appointment, for depression. Participants (n=31, mean age=75.6 years) completed, with the author, the Abbreviated Mental Test Score (AMTS), and two screening tools: the Structured Clinical Interview for DSM-IV (SCID) and the Geriatric Depression Score – short form, 15 item (GDS-15). A structured interview was conducted and patient records examined to gain demographic information for each patient. Cohen‘s Kappa was used to assess the level of agreement between the GP assessment and the objective measurements for depression. Results: Depression was identified by both the GP and the SCID in three cases. The inter-rater reliability between the SCID and the GP assessment of depression was good (Kappa = 0.61, p <0.001). The inter-rater reliability between the SCID and the GP assessment of dysthymia was poor (Kappa = -0.08, p =ns). Participant numbers prevented further analysis of how the independent variables recorded affected the diagnosis and treatment of depression by GPs. Conclusion: The findings suggest that GPs are able to identify depression but not dysthymia in their older adult patients. The difficulties in engaging GPs in research are explored. The strengths and weaknesses of the study are considered. The clinical implications of the study are discussed.

This exploratory study investigated the strategies that eight older New Zealanders use to enable participation in day-to-day occupations that they need or want to do, in their homes and the community. The types of strategies older people use to overcome barriers to participation and manage limitations are not widely known or reported. Exploring strategies for participation employed by older people is important because the majority of older New Zealanders live in the community and their numbers are growing, and projected to reach 25% of the total population by the year 2051 (Ministry of Health, 2002). New Zealand’s Positive Ageing Strategy (Minister for Senior Citizens, 2001), advocates for a society where people can age positively, where they are highly valued and their participation encouraged. The literature relating to occupation, participation and health was explored, and provided some evidence that older people are developing strategies and, with some education, are able to manage their own health conditions. The assumption underpinning this study is that they are equally able to manage strategies for participation, particularly those devised by older people themselves. A qualitative descriptive methodology was used. The participants were selected following a presentation to a group of older adults and snowball recruitment. They were aged between 73 and 98 years old and were receiving assistance to live in community, which was taken to indicate they had experienced some limitation in, or barrier to their everyday activities, in response to which they might have discovered or developed coping strategies. Interviews were conducted in the participants’ homes, and analysed using a general inductive approach. Four main categories emerged; strategies for keeping me safe, strategies for recruiting and accepting help, strategies for meeting biological needs, and strategies for conserving resources. Overarching themes of managing and getting on with it, sprinkled with a sense of humour by some participants was present in the attitudes of many participants. The study revealed that this group of older people can and do use strategies to enable occupation in their everyday lives, which differ from those recommended by occupational therapists and other health professionals. This finding suggests that health professionals, policy makers and educators have much to learn from older people. The provision of help to older adults should take into consideration the importance of social interactions, not just the physical needs. There is a need for transport to be more readily available and affordable for older people to attend occupations that meet social needs. Health professionals complement the strategies developed by older people, and finding ways to combine the strategies should be developed. Listening to older adults’ current ways of managing and working with them to develop alternate, yet acceptable methods will provide a challenge. Health professionals should take a greater role in advocating for the social and transport needs of older adults. A self-management approach in education for older people, using peers and making use of existing education groups in the community and health system, is suggested. Education of those who engage with older people, such as carers, family, health professionals and community groups should include developing their skills in assisting older people to identify their strategies and developing strategies for the future.

Background: The incidence of falls and severity of fall related injuries steadily increase with age. As well as physical injury, falls can lead to adverse psychological and social consequences, which can further reduce older adults’ quality of life. The most commonly reported cause of falls in older persons is tripping over an obstacle, which may reflect the difficulty many older adults have in making an appropriate stepping response. In order to reduce the number of falls experienced by older adults, individuals at high risk of falling need to be identified so that targeted interventions can be implemented. Aims: This series of studies aimed to develop a new Multiple-Lunge test to distinguish between Fallers and Non-fallers in independent older adults, aged 65 years and over. The studies sought to determine the test-retest reliability of the Multiple-Lunge test; as well its validity to predict faller status in a sample of community-dwelling older adults. Methods: One hundred and thirty community-dwelling older adults, aged 65 – 93 years (mean age 77 ± 7 years) with (n = 40) and without (n = 90) a history of falls were administered the Multiple-Lunge test. For the purpose of this study, a Faller was classified as an older adult with a history of one fall, or a Multiple-faller if there was a history of two or more falls in the previous 12 months. The Multiple-Lunge test required the individual to lunge forward to a step length determined as 60% of their leg length, and return to start position, for a total of five repetitions. Two trials were performed after a familiarisation trial. The number of correct steps and the total time for the five steps were recorded for each trial. The highest number of correct steps and the lowest total time of the two trials were used for data analysis. Test-retest reliability of the Multiple-Lunge test was established across two testing occasions from a sub-sample of the validity study (n = 14, mean age 79 ± 6 years). A cross-sectional design was used to establish the sensitivity and specificity of the Multiple-Lunge test to predict faller status based on retrospective self-reported fall history. Initial analysis using the number of correct steps and total time, was followed by a linear regression analysis to determine the validity of the test to predict falls. Results: The Multiple-Lunge test was found to be reliable across trials (ICC = 0.79 for number of correct steps; ICC = 0.86 for total time). The change in the mean for steps was small and similar across four trials (-0.43 steps, -0.36 steps, -0.50 steps). The change in the mean for time showed a gradual decrease in time scores across trials (-0.69 seconds, -0.73 seconds, -0.93 seconds). Sensitivity and specificity values were calculated as 73% and 63% for predicting Multiple-fallers using the measure of all five steps done correctly. Linear regression analysis did not indicate that the Multiple-Lunge test could be used to predict faller status for either of the step predictor variables (0/5 steps or 5/5 steps). However, a very high sensitivity value (98%) was observed for the variable of both steps and time in predicting Fallers. Also a very high specificity value (99%) was recorded for the variable of time to predict Multiple-fallers. Conclusions: The Multiple-Lunge test is an easily administered test for independent older adults. Due to the challenging nature of the test it may be well suited to detect subtle differences in abilities of higher functioning older adults. The test mimics the movements needed in response to a trip, the most common cause of falls in older adults. This test is a reliable and reasonably valid measure of falls risk. A practitioner can be confident in 7 out of 10 cases that an older adult who cannot complete all five steps of the Multiple-Lunge test is at high risk of falls. The results of this thesis suggest that there is potential for the Multiple-Lunge test to be used in clinical practice and fall prevention research. However, additional research on how to further increase its validity and/or to determine the most appropriate populations with which to administer this test appears warranted.

This exploratory study investigated the strategies that eight older New Zealanders use to enable participation in day-to-day occupations that they need or want to do, in their homes and the community. The types of strategies older people use to overcome barriers to participation and manage limitations are not widely known or reported. Exploring strategies for participation employed by older people is important because the majority of older New Zealanders live in the community and their numbers are growing, and projected to reach 25% of the total population by the year 2051 (Ministry of Health, 2002). New Zealand’s Positive Ageing Strategy (Minister for Senior Citizens, 2001), advocates for a society where people can age positively, where they are highly valued and their participation encouraged. The literature relating to occupation, participation and health was explored, and provided some evidence that older people are developing strategies and, with some education, are able to manage their own health conditions. The assumption underpinning this study is that they are equally able to manage strategies for participation, particularly those devised by older people themselves. A qualitative descriptive methodology was used. The participants were selected following a presentation to a group of older adults and snowball recruitment. They were aged between 73 and 98 years old and were receiving assistance to live in community, which was taken to indicate they had experienced some limitation in, or barrier to their everyday activities, in response to which they might have discovered or developed coping strategies. Interviews were conducted in the participants’ homes, and analysed using a general inductive approach. Four main categories emerged; strategies for keeping me safe, strategies for recruiting and accepting help, strategies for meeting biological needs, and strategies for conserving resources. Overarching themes of managing and getting on with it, sprinkled with a sense of humour by some participants was present in the attitudes of many participants. The study revealed that this group of older people can and do use strategies to enable occupation in their everyday lives, which differ from those recommended by occupational therapists and other health professionals. This finding suggests that health professionals, policy makers and educators have much to learn from older people. The provision of help to older adults should take into consideration the importance of social interactions, not just the physical needs. There is a need for transport to be more readily available and affordable for older people to attend occupations that meet social needs. Health professionals complement the strategies developed by older people, and finding ways to combine the strategies should be developed. Listening to older adults’ current ways of managing and working with them to develop alternate, yet acceptable methods will provide a challenge. Health professionals should take a greater role in advocating for the social and transport needs of older adults. A self-management approach in education for older people, using peers and making use of existing education groups in the community and health system, is suggested. Education of those who engage with older people, such as carers, family, health professionals and community groups should include developing their skills in assisting older people to identify their strategies and developing strategies for the future.

Background: The incidence of falls and severity of fall related injuries steadily increase with age. As well as physical injury, falls can lead to adverse psychological and social consequences, which can further reduce older adults’ quality of life. The most commonly reported cause of falls in older persons is tripping over an obstacle, which may reflect the difficulty many older adults have in making an appropriate stepping response. In order to reduce the number of falls experienced by older adults, individuals at high risk of falling need to be identified so that targeted interventions can be implemented. Aims: This series of studies aimed to develop a new Multiple-Lunge test to distinguish between Fallers and Non-fallers in independent older adults, aged 65 years and over. The studies sought to determine the test-retest reliability of the Multiple-Lunge test; as well its validity to predict faller status in a sample of community-dwelling older adults. Methods: One hundred and thirty community-dwelling older adults, aged 65 – 93 years (mean age 77 ± 7 years) with (n = 40) and without (n = 90) a history of falls were administered the Multiple-Lunge test. For the purpose of this study, a Faller was classified as an older adult with a history of one fall, or a Multiple-faller if there was a history of two or more falls in the previous 12 months. The Multiple-Lunge test required the individual to lunge forward to a step length determined as 60% of their leg length, and return to start position, for a total of five repetitions. Two trials were performed after a familiarisation trial. The number of correct steps and the total time for the five steps were recorded for each trial. The highest number of correct steps and the lowest total time of the two trials were used for data analysis. Test-retest reliability of the Multiple-Lunge test was established across two testing occasions from a sub-sample of the validity study (n = 14, mean age 79 ± 6 years). A cross-sectional design was used to establish the sensitivity and specificity of the Multiple-Lunge test to predict faller status based on retrospective self-reported fall history. Initial analysis using the number of correct steps and total time, was followed by a linear regression analysis to determine the validity of the test to predict falls. Results: The Multiple-Lunge test was found to be reliable across trials (ICC = 0.79 for number of correct steps; ICC = 0.86 for total time). The change in the mean for steps was small and similar across four trials (-0.43 steps, -0.36 steps, -0.50 steps). The change in the mean for time showed a gradual decrease in time scores across trials (-0.69 seconds, -0.73 seconds, -0.93 seconds). Sensitivity and specificity values were calculated as 73% and 63% for predicting Multiple-fallers using the measure of all five steps done correctly. Linear regression analysis did not indicate that the Multiple-Lunge test could be used to predict faller status for either of the step predictor variables (0/5 steps or 5/5 steps). However, a very high sensitivity value (98%) was observed for the variable of both steps and time in predicting Fallers. Also a very high specificity value (99%) was recorded for the variable of time to predict Multiple-fallers. Conclusions: The Multiple-Lunge test is an easily administered test for independent older adults. Due to the challenging nature of the test it may be well suited to detect subtle differences in abilities of higher functioning older adults. The test mimics the movements needed in response to a trip, the most common cause of falls in older adults. This test is a reliable and reasonably valid measure of falls risk. A practitioner can be confident in 7 out of 10 cases that an older adult who cannot complete all five steps of the Multiple-Lunge test is at high risk of falls. The results of this thesis suggest that there is potential for the Multiple-Lunge test to be used in clinical practice and fall prevention research. However, additional research on how to further increase its validity and/or to determine the most appropriate populations with which to administer this test appears warranted.