Home care has been the fastest growing sector in the U.S. healthcare system for over three decades. In 2012, there were over 4.7 million home care patients in the United States. Most of these patients were elders (4 million); and this number is expected to increase as the U.S. population continues to age. One major health concern in this elderly home care population is mental health disorders (MHDs), which have been noted with increasing rates and substantial consequences in local data. However, much of our knowledge on this topic was generated from local studies that had a number of methodological limitations. These include over reliance on local and outdated data, a lack of theoretical foundation, and a lack of statistical justification, which may well account for the high variability across findings. To date, no national investigation has been conducted on this topic, supporting the need for a large-scale study which employs recent data to better understand the prevalence, risk factors and impact of MHDs among home care elders in the U.S. This dissertation study addressed these gaps by using the de-identified national home care dataset, Outcome and Assessment Information Set (OASIS), to: 1) examine the national prevalence of MHDs and MHD-caused medical events in the U.S. elderly home care population, and 2) identify factors associated with MHDs and MHD-caused medical events in this population. The 5% random sample used in this study was consisted of 28,475 elderly home care patients: their average age was 79.41; patients were mostly female, white, Medicare beneficiaries, referred from short-stay acute hospitals, and living with others at home. Approximately 38% of this sample had MHDs, mostly depression (28.0%) and anxiety (18.9%). Compared with other patients, those with MHDs were younger, more likely to be female, smokers, frail, living alone, referred from psychiatric hospitals, cognitively or sensually impaired, in poorer general health, had a recent history of falls or multiple hospitalizations, and evidenced insufficient social support. Among patients identified with MHDs, less than one third (31.8%) received mental health services, including psychiatric nursing services (n=317) and depression interventions (n=4,459). During the 60-day home care episode, 16.95% of the sample had subsequent hospitalizations and 12.72% had subsequent emergent care events; 0.45% of these medical events were directly caused by MHDs. In addition, depression intervention was the strongest risk factor for these subsequent medical events, associated with an approximate two-fold risk for all-cause hospitalizations (HR: 1.943) and emergent care events (HR: 1.974). However, 61.61% (n=2,747) of these high-risk depression intervention recipients did not screen positive for depression at admission. Findings in this dissertation study revealed the high national prevalence of MHDs in the elderly U.S. home care population, and the strong association between these disorders and subsequent all-cause medical events. However, these MHDs were largely under-detected and under-managed in this population, highlighting the need for closer monitoring and targeted intervention through enhanced psychiatric training among front-line home care nurses. Recommendations for further work are made, including the development of an electronic algorithm of identified MHD correlates and risk factors as useful in the development of a nationwide monitoring system for geriatric MHDs in the home care setting.

Self neglect among older people refers to situations in which older individuals fail to adequately maintain their environment and to perform essential self care tasks. This concept has been variably addressed in the fields of biomedicine, adult protection, and suicide prevention, yet minimal research has been conducted on this topic in Australia. While the existing literature acknowledges that these situations can pose considerable challenges for professionals, no research has explored the actual experience of these dilemmas in professional practice. This thesis aims to address these gaps by critically exploring how self neglect among older people is understood in the Australian context, investigating the content of ethical dilemmas that arise in these situations, and examining how professionals resolve these ethical dilemmas. A two-part, qualitative methodology was used to address the research aims. In Part One, a five-month period of participant observation was conducted at a community-based organisation that had obtained funding to provide case management to people living in squalor. In Part Two, 18 semi-structured interviews were conducted with professionals who worked with situations of squalor and self neglect in the community. The results from both parts of the research were analysed using NVivo, a software program specifically designed to assist in the analysis of qualitative data. This research uncovered that, unlike the definition of self neglect used in the wider literature on this topic, participants clearly differentiated between personal neglect (self neglect) and environmental neglect (squalor and hoarding). Ethical dilemmas were common in these situations and fully understanding how professionals resolved these dilemmas required that both objective and relational approaches to ethics be used to analyse participant responses. In this way, a pluralistic approach to ethics emerged as the theory best suited to fully explore ethical decision-making in situations where older people were self neglecting or living in squalor. Decisions that resulted in good outcomes were found to be increasingly constrained by changes to services driven by neoliberalism and managerialism. Individual reflection and peer support emerged as important elements that helped professionals to cope with the ethical dilemmas and the practical constraints that were encountered in these situations.

published_or_final_version / Public Health / Master / Master of Public Health

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Moving into an institutional environment may cause feelings of anxiety, depression, grief or loss in the increasing number of elderly residents in long term care facilities. The lived experience of pet visitation was explored as a possible remedy. This study is significant because findings provide information about intervention strategies to assist residents in comfort and adjustment.Five themes, identified in ten interviews of residents in three midwest long term care facilities, illustrated that pet interaction: (a) contributed a sense of responsibility, environmental control, (b) afforded unconditional caring, companionship, (c) provided a connection with family and home. (d) furnished a sense of identity in the facility community, and (e) provided a sense of being protected within the facility. Evidence supports that pet visitation is a beneficial experience to the residents in long term care facilities. Study results are available for facility administrators as encouragement and justification to establish pet visitation programs. / School of Nursing

The purpose of this study was to compare two groups of nurses's attitudes towards the elderly and the knowledge base of the nurses as to signs, symptoms and interventions with depression and dementia in the elderly. The theoretical framework for this study was Oren's (1985) self-care deficit theory. Attitude was measured using the Koan Attitude Toward Old People Scale (Koan, 1961) and knowledge was measured using a scale developed by (Myton, Allen, and Baldwin, 1991).The population studied was registered nurses working at these state hospitals in a midwestern state and agency nurses from four agencies that provide staff coverage at these hospitals. The convenience sample consisted of state nurses (n=65) and agency nurses (n=38). A cover letter explaining confidentiality and voluntary participation was attached to each survey. Completion of the survey constituted consent to participate in the study. There were no identified risks related to participation in the study.The study did not identify significant differences between groups in any of the variables involving attitude toward the elderly, ability to differentiate signs, symptoms, and interventions for dementia and depression in the elderly. Both groups were able to correctly identify signs, symptoms and interventions for dementia and depression about one-half the time. The treatment modalities are different for dementia and depression. The problem is significant because if signs, symptoms and interventions are not identified correctly the patient will not be assisted toward recovery and self-care may decrease. The recommendation for increased inservice education on gerontological nursing are applicable to both groups. / School of Nursing

This study was designed to measure differences between elderly and young adults in terms of their expression of positive and negative emotion. It was hypothesized that that there would be a difference between young and aged subjects in intensity of positive and negative emotional experience as measured by response to cartoons and the Survey of the Quality of Life of Adult Men and Women (SQLAMW, Malatesta & Kalnok, 1984). Sex differences as well as the effect of the sequence of cartoons were also tested.Emotions have been widely studied, yet researchers have rarely focused on the elderly population and those studies that do exist have methodological problems. Early research suggests a drift towards negative emotion with age, whereas more recent studies challenge this position.Volunteer subjects were 61 noninstitutionalized adults (24 males, 37 females) age 60 and over and 93 college undergraduates (36 males, 57 females) age 18-25. They met in groups of 2 to 10 to complete the research instruments.Positive and negative emotional reactions were obtained from ten point Likert scale ratings of 38 cartoons for funniness, pain, and hostility. Cartoons were presented in two sequences. Additional measurements of emotion were obtained from the SQLAMW.Four mean scores were calculated for each subject and served as dependent variables. Positive and negative affect on the SQLAMW generated two mean scores. A mean score for positive emotion on cartoons was calculated from ratings of funniness and for negative affect by combining ratings of pain and hostility. A 2 X 2 X 2 (Age x Sex x Cartoon Sequence) multivariate analysis of variance was conducted.Analysis for negative emotion resulted in a significant main effect for age on the SQLAMW and an age by sex interaction on cartoons. The young reported higher levels of negative emotion on the SQLAMW. However, cartoon ratings showed aged males higher than young males on negative emotion. For positive emotion, males scored higher than females on cartoons. All other effects were nonsignificant.

Self neglect among older people refers to situations in which older individuals fail to adequately maintain their environment and to perform essential self care tasks. This concept has been variably addressed in the fields of biomedicine, adult protection, and suicide prevention, yet minimal research has been conducted on this topic in Australia. While the existing literature acknowledges that these situations can pose considerable challenges for professionals, no research has explored the actual experience of these dilemmas in professional practice. This thesis aims to address these gaps by critically exploring how self neglect among older people is understood in the Australian context, investigating the content of ethical dilemmas that arise in these situations, and examining how professionals resolve these ethical dilemmas. A two-part, qualitative methodology was used to address the research aims. In Part One, a five-month period of participant observation was conducted at a community-based organisation that had obtained funding to provide case management to people living in squalor. In Part Two, 18 semi-structured interviews were conducted with professionals who worked with situations of squalor and self neglect in the community. The results from both parts of the research were analysed using NVivo, a software program specifically designed to assist in the analysis of qualitative data. This research uncovered that, unlike the definition of self neglect used in the wider literature on this topic, participants clearly differentiated between personal neglect (self neglect) and environmental neglect (squalor and hoarding). Ethical dilemmas were common in these situations and fully understanding how professionals resolved these dilemmas required that both objective and relational approaches to ethics be used to analyse participant responses. In this way, a pluralistic approach to ethics emerged as the theory best suited to fully explore ethical decision-making in situations where older people were self neglecting or living in squalor. Decisions that resulted in good outcomes were found to be increasingly constrained by changes to services driven by neoliberalism and managerialism. Individual reflection and peer support emerged as important elements that helped professionals to cope with the ethical dilemmas and the practical constraints that were encountered in these situations.

This study investigated older persons' perception of the negative impact of ill health, retirement, and widowhood in relation to the mobilization of relevant coping mechanisms. In addition, the relationship of coping mechanisms and dissatisfaction with current gender-role identity to seeking counseling was studied. A distributed questionnaire package provided demographic data as well as information pertaining to satisfaction in various areas of life, impact of live events, and coping style. Subjects were 54 males and 67 females aged 50 to 92. Safeguards were taken to ensure complete confidentiality and anonymity of response. Stepwise multiple regression (listwise deletion of data), multivariate and univariate analysis of variance and bivariate correlational analyses of the data were performed, suggesting that perception of negative impact of the events measured (ill health, widowhood, retirement) was related a) to employing numerous useful coping strategies, b) to low dyadic satisfaction, and c) to low life satisfaction. Analyses also suggested that variables which distinguished those in the sample who sought counseling were a) identity discrepancy (wherein Ideal exceeded Real) on the Masculine and Androgynous dimensions, b) employing fewer Coping with Health strategies, and c) employing more Coping with Retirement strategies. These variables also distinguished males who sought counseling, but only the variable Age, distinguished females, who sought counseling from those who do not.