Background. The well-cited report from the Institute of Medicine stated that nearly 100,000 deaths in acute care are largely due to miscommunication. Residents in nursing homes are transported for acute care three times higher than those under the age of 65. Approximately 25 percent of these hospital transfers are avoidable. The influence of nurse-to-physician communication upon the decision to hospitalize nursing home residents is not well understood. Objective. The purpose of this study is to explore nurse-to-physician communication in the nursing home setting utilizing the Informatics Research Organizing Model (IROM) and Carrington’s Exploring Nurse-to-Nurse Communication Framework. Methods. The methodology use for this study was a qualitative descriptive (QD) design, with in-depth, one-on-one interviews of nurses and physicians with semi-structured open-ended interview questions. Communication between nurses and physicians regarding clinical events experienced by nursing home residents was digitally recorded and transcribed. Data was analyzed using natural language processing (NLP) methodology and conventional content analysis, as a means of intra-methods data triangulation. A purposive convenience sample of nurses and physicians who provide clinical care to nursing home residents at two sites was recruited. In addition to obtaining recorded communications between nurses and physicians pertaining to clinical events, these same study participants were interviewed to determine their perceptions regarding communication of the clinical events. Outcomes. Findings from this study will increase understanding of nurse-to-physician communication and its contribution to avoidable hospitalizations. Results will inform the development of an electronic interface that supports nurse-to-physician communication in the nursing home setting.

Objectives: This thesis includes two distinct pieces of work. A systematic literature review (SLR) aimed to identify, organise and evaluate constructs and measures of adjustment and adaptation to retirement (AAR), as these are currently used in the literature. A meta-analysis (MA) sought to systematically evaluate the evidence of the relationship between retirement and self-reported symptoms of depression in later life. Methods: For the SLR, a comprehensive list of electronic databases, and additional sources, were searched (March-May 2013). The identified constructs of AAR were evaluated in relation to their content, clarity and frequency of use. The identified measures were evaluated in relation to pre-defined psychometric properties and frequency of use. For the MA, an equally comprehensive search strategy was used (December 2012-March 2013). A metaanalysis and systematic assessment of risk of bias were carried out on the studies eventually included. Results: In the SLR, 27 measures of AAR were put forward for evaluation, and 6 distinct clusters of constructs of AAR were identified. AAR is defined inconsistently in this literature. Most measures that are used to assess these constructs are adapted or imported from other contexts (e.g. mental health, well-being, life-satisfaction). The 7 measures that related specifically to AAR (‘retirement satisfaction and role adjustment’) lacked detailed psychometric information. Eight non-randomised studies were included in the MA, 5 cohort studies and 3 cross-sectional studies. Studies were grouped and analysed according to these two design-type subgroups There was evidence of high dispersion of effect sizes, variable risk of bias and methodological and statistical heterogeneity between studies in both sub-groups – cohort (Q=640.728, df =4, p<0.001), cross-sectional (Q=76.611, df=2, p<0.001). Summary effects were therefore not meaningful. Sensitivity and sub-group analyses did not account for high heterogeneity of effect sizes. Conclusions: The SLR concluded that the variability in outcomes of research on AAR found in this literature may be underpinned, in part, by the different constructs and measures that are used. The 27 measures evaluated did not seem, at face-value, to measure the same construct; their psychometric properties also varied. The interpretation of outcomes, and comparisons between studies, in this area is hindered by this inconsistency. The MA concluded that the relationship between retirement and self-reported depressive symptoms seems to be complex and variable. Effect-sizes of individual studies were small, non-significant and highly dispersed, and heterogeneity of true effects was high. These results may be limited by confounding factors in primary studies. This is discussed and contextualised in relation to the use of non-randomised studies in meta-analysis.

Research demonstrates that mindfulness in younger and middle-aged adults is associated with cognitive and emotional benefits. Mindfulness in older adults is less frequently studied but given the overlap between cognitive and emotional benefits of mindfulness and domains of age-related decline, this may be an important population to investigate. The present set of three studies had three aims: 1) to establish the validity of the Five Faceted Mindfulness Questionnaire (FFMQ) as a measure of mindfulness in an older adult population (Study 1); 2) to examine the cognitive and emotional associations of dispositional mindfulness (as assessed by the FFMQ and breath counting, a behavioral measure of mindfulness) in older adults (Study 2); and 3) to investigate the cognitive and emotional benefits of a brief online mindfulness training for older adults (Study 3). Concurrent goals of these studies were to examine the specificity of the FFMQ facets for predicting behavior (to examine the multifaceted nature of mindfulness) and to address the recent call in the field of mindfulness research for greater methodological rigor. To address the latter, we used objective measures of mindfulness, cognition, and emotional functioning and in our third study, a well-matched, active control condition. Results suggest that the five facets of the FFMQ hold in an older adult population (Study 1), that dispositional mindfulness is modestly associated with some aspects of attention, executive functioning, and emotion regulation (Study 2), and that mindfulness training may improve attention and increase facets of mindfulness (although this was not specific to our mindfulness condition; Study 3). We also found some mixed evidence for the specificity of the facets in predicting cognitive and emotional functioning (Study 2). We did not find that the breath counting task predicted any domains of functioning nor did accuracy on this task improve after training. These preliminary data are interesting but require replication and we are cautious about over-interpreting them given that our samples were small and analyses under-powered.

Class of 2016 Abstract / Objectives: To promote Alzheimer’s disease (AD) awareness in older adults and caregivers by creating and implementing an interactive educational program in several Southern Arizona senior centers, evaluate the helpfulness of the intervention, the confidence and the motivation of the participants. Methods: A 30-minute educational program consisting of a PowerPoint presentation with various interactive learning methods and a 10-minute question and answer session was delivered to those 55 years of age and older at senior centers across Southern Arizona. An anonymous questionnaire was conducted after each educational program to assess the helpfulness of the program, the subject’s familiarity with AD and their motivation to create a personal action plan after participation, and demographic information. Responses from the participants were compared with a priori alpha at 0.05. Results: A majority of participants in the study were female (69.9%) the median age was 75. One hundred (98%) of the participants strongly agreed or agreed that the interactive educational program was helpful in understanding AD, and 95 (96.9%) stated they were more motivated to create a personal care plan. There was no difference between the males or females’ self-reported familiarity with dementia (p = 0.25) or AD (p = 0.75) after program participation, but >50% of overall participants who were not already very familiar with Alzheimer’s disease increased in familiarity. Conclusions: An interactive approach to educating community-dwelling older adults and their caregivers on AD was helpful to the participants, and they were more motivated to create personal care plans.

This thesis investigates computerised cognitive training in older adults, with a focus on training working memory and fluid intelligence. A series of studies is reported, with two broad aims. The first was to develop and validate outcome measures appropriate for use in this population, and the second was to examine whether established gains in cognitive functioning generalised to everyday life. In relation to the first aim, two studies were conducted which concerned the development of a sensitive measure of organisational abilities within a computerised paradigm, the Games Evaluation Task (GET). A further study made use of an existing naturalistic measure, the Multiple Errands Task (MET, Shallice & Burgess, 1991), and investigated whether it was possible to obtain reliable ratings of performance on the basis of video footage taken from the participant’s perspective by means of a body-worn camera. Both the GET and MET were used as outcome measures in the subsequent training studies. In relation to the second aim, three studies of cognitive training are reported. The first is a case study of a man with problems in working memory and time perception following a stroke. He underwent training on an intensive working memory package within a single-case experimental design that incorporated an active control condition. This approach was then extended in a larger sample of healthy older adults, who trained intensively on tasks that focussed either on working memory, or fluid intelligence and problem solving. In the final study participants trained on a combination of both working memory and fluid intelligence tasks. In addition, they watched training videos that focused on teaching various cognitive strategies. The aim of this video supplement was to help participants draw links between the computer training and real-life situations, and hence to foster generalisation of any benefits to everyday life. The thesis concludes with a general discussion which examines the major findings of the studies presented, their clinical applications, the limitations of the research and possible future directions.

Sedentary behaviour (SB) is prevalent across all ages, but particularly in older adults aged 50 years and above. Given that older adults spend more than 60% of waking hours sedentary, enhancing our understanding of the correlates of SB will be important to inform the development of interventions to reduce SB in mid-age and older adults. This thesis provides five studies focusing on the correlates of SB in mid-age and older adults. Firstly, Chapter 2 presents a literature review using behaviour epidemiology framework to examine the existing evidence on sedentary behaviour in general adults in order to identify the gap of current knowledge in sedentary behaviour. Chapter 3 presents a systematic review which included the existing evidence on correlates of SB in mid-age and older adults and provides evidence-based conclusions on the topic. Chapter 4 presents a study examining the association of demographics and physical activity (PA) with daily sitting time in mid-age and older adults, and found behavioural correlates of SB and PA in mid-age and older adults. Chapter 5 presents a secondary data analysis using the data of the older office worker from the Stormont study. This chapter uses the results from the cross-sectional and longitudinal data to examine the association of demographics and behaviours with domain-specific sitting time among the older office workers. In this study, differences were found in demographic and behavioural correlates according to the studied domain of sitting. Chapter 6 presents a 6-month longitudinal study, which was designed to fill the gaps of our understanding of the associations between demographics, health and PA with SB in older adults aged 65 years and above. This chapter also looked into the changes of sitting time and its correlates. Together, these four studies provide adequate evidence on the demographics and behavioural correlates of SB and also identified the determinants of SB in mid-age and older adults. This thesis found that demographics had limited associations with SB, and sociodemographics were associated with work-related sitting time. Health behaviour was generally inversely associated with SB. These findings provide information to the correlates and determinants of mid-age and older adults SB and will inform further research on behaviour change strategies.

This investigation, comprising two studies, examined the number of barriers to physical activity (Study 1) and barrier strength (Study 2) reported by middle-aged and older adults using a social ecological framework (McLeroy et al., 1988). Researchers were interested in assessing age group (45-54; 55-64; 65-74 yrs) by physical activity group (active, less active) effects for barrier responses using analyses of variance. In Study 1, 180 participants completed a physical activity level survey (Godin & Shephard, 1985) and answered open-ended questions about barriers. Results indicated that 45-54 yr-olds reported more barriers overall, and more intrapersonal barriers than older groups. Less active 45-54 yr-olds reported more organizational-interpersonal barriers than the other groups. Descriptive analyses of coded themes demonstrated that common intrapersonal barrier sub-themes cited by younger adults related to family commitments, while sub-themes reported by middle-aged and older adults related to having a health problem or an injury. In the organizational-interpersonal category, the most common barrier sub-theme related to the workplace. In Study 2, 116 participants completed a survey assessing weekly physical activity and barrier strength for items pertaining to ecological categories and barrier sub-factors. Results showed that less active adults reported each of intrapersonal, interpersonal, and physical environment barriers more strongly than active adults, irrespective of age; the intrapersonal category was relatively the most constraining for our participants. In terms of barrier sub-factors, results showed that significantly higher barrier strength scores are most often associated with physical activity level (i.e., less active), and only occasionally associated with age group. The overall investigation can provide valuable information for improving physical activity interventions for middle-aged and older adults.

Muscular stabilisation strategies during activities of daily living alter in the presence of knee osteoarthritis (OA). By examining neuromuscular adaptations using our weight-bearing target match protocol, the main objective of this research is to establish sex differences in adaptations of neuromuscular control that are associated with older males and females with and without OA. 66 participants completed the protocol while EMG, ground reaction forces (GRF), and kinematics were recorded. Muscle activation patterns were presented in polar plots with an EMG vector representing normalised muscle activation in twelve directions, each representing a GRF vector scaled to 30% maximal effort. Asymmetry about the polar plot (activation occurring in one direction more than another) was determined and specificity index (SI) and mean direction of activation were calculated when appropriate. Healthy females demonstrated greater rectus femoris (RF) mean muscle magnitude (XEMG) (p=0.067) and less biceps femoris (BF) XEMG than healthy males (p=0.084) and females with OA (p=0.041), and males and females with OA demonstrated greater RF XEMG than healthy controls of the same sex (p=0.016, 0.072, respectively). Females with OA had significantly greater medial gastrocnemius XEMG than healthy females (p=0.031) and males with OA (p=0.020). Females with OA have less specificity in all muscles compared to males with OA and OA participants generally had less specificity compared to healthy controls of the same sex. Healthy males had the largest SI for lateral gastrocnemius with an asymmetrical activation pattern contrasting the more symmetrical activation pattern of all other groups. In conclusion, we suggest OA-affected adults and healthy females use a quadriceps dominant strategy to stabilise the joint, and that this strategy may be a compensatory mechanism for reduced quadriceps function. We suggest RF, BF, MG, and LG should be targeted for prophylactic intervention as they displayed altered activation strategies in participants with OA and healthy females.

Rising up from a chair (sit-to-stand; STS) and stair climbing are both activities of daily living (ADLs) done throughout our lives. The ability to complete ADLs is crucial for independent living. The goal of this thesis was to research how two ADLs interact with each other and affect postural control. It was hypothesized that an increased number of flights of stairs climbed would lead to a decline in postural control during/after a STS in older more than younger adults. Fourteen older adults and fourteen young adults were tested by completing three STSs before and after climbing 1, 3 and 5 flights of stairs, chosen at random. Movements of the center of pressure (COP) for each STS were obtained from a force platform. Only an age effect was found for COP velocity (left-right and anterior-posterior directions) during the momentum transfer phase, during stabilization and after stabilization. Therefore, contrary to our hypothesis, stair climbing did not lead to significant changes in COP movements during and following a STS.

It is well known that physical activity can bring many benefits to people as they become older. In addition, a great deal is known about the personal and environmental motivators and barriers for older adults engaging in physical activity, yet policy imperatives have failed to deliver the change in activity levels required to even relatively modest levels of activity. This study has sought to ascertain the effect of involving older adults in the design, delivery, implementation and promotion of interventions to promote physical activity amongst their age group. Through a two phase design the study has sought to find out what the essential ingredients of a successful intervention to promote physical activity would be, before applying some of these findings to the promotion of interventions and considering their effect. The first phase of the study consisted of a qualitative study to identify older adults’ views and experiences. Some 61 older adults, aged between 49 and 87 years, were involved in 11 focus groups and 12 individual semi-structured interviews. Participants were asked why they engaged in physical activities, or what might encourage them to do so. The study was designed to identify the essential elements of a successful physical activity intervention. The second phase of the study, an action research project evolving from the qualitative study, involved older adults who were running community groups and physical activity sessions in their local areas and were keen to increase membership numbers. The Action Research Group, consisting of six older adults, two community development workers and the researcher, identified a number of problems to address as part of the study. New promotional literature for the community groups was developed, using the findings from the first study. Easy access, enjoyment, fun and affordability were highlighted on posters and leaflets that were distributed in the local communities. The studies established that there are various factors that make engaging in physical activities accessible and appealing to older adults. Participants reported that activities must be flexible; affordable; accessible; sociable; enjoyable and that engagement is seasonal. Factors relating to personality and lifestyle were also important. Not feeling the need to be active, and being unmotivated to do so, cannot be easily influenced by external promotion of physical activity. However, ensuring that activities are as easy as possible to engage in could help to encourage older adults to try activities that they might otherwise rule out. The health benefits of physical activity were far less important to the participants than the social benefits. Involving older adults in the promotion of activities, focussing on the characteristics of activities that appeal to them, had some success. Difficulties in appealing to older adults across a broad age range emerged, as many participants in both studies were put off attending any activity labelled as for ‘over 50s’. They did not identify themselves as ‘over 50’. Both studies highlighted the additional difficulty of attracting men to existing activity groups and sessions. A multilevel, social ecological model is presented, which highlights the influences on engagement in physical activity at individual and environmental levels. The future promotion of physical activity should focus on the social benefits and enjoyment that can be gained through participation, rather than on potential health benefits. How activities are labelled and promoted requires careful consideration and local older adults should be involved in local interventions. Community groups delivering interventions must receive tangible support.