Introduction: Long term care (LTC) residents require complete or extensive support, including 24-hour nursing and personal care. LTC residents contribute a greater number of emergency department (ED) visits when compared to community-dwelling older adults. Little is known about which resident-level characteristics at admission are predictive of LTC resident transfer to the ED. The objective of this thesis was to identify which admission characteristics are associated with ED transfers in Ontario, Canada. Methodology: I conducted a population-level retrospective cohort study using the Resident Assessment Instrument Minimum Data Set Version 2.0 (RAI-MDS). The cohort included 56,433 LTC resident admission assessments from January 1, 2017, to December 31, 2018. Logistic regression and 10-fold cross-validation were used to identify adjusted associations between characteristics routinely collected during LTC admission assessment and ED transfers. Model performance was assessed using the area under the receiver operating characteristics curve (AUC). Outcomes of interest included any ED use, potentially preventable, and low acuity ED transfers. Results: A recent change in medical orders, previous ED visitation, female sex, the presence of an indwelling catheter, and the need for oxygen therapy were informative predictors for any, potentially preventable, and low acuity ED transfers. Deterioration in cognitive status and change in behavior was influential to any ED transfers only. Urinary tract infections, pneumonia, indictors of delirium, and change in mood are unique to potentially preventable ED transfers, and antibiotic resistance is unique to low acuity ED transfers. Similar discrimination was reached for any ED use (AUC = 0.630), potentially preventable transfers (AUC = 0.659), and low acuity transfers (AUC = 0.645). Conclusion: The factors associated with ED transfers may be modifiable, and closer attention to these factors may help reduce ED transfers. Although the discriminability of the models was poor, advanced knowledge of informative characteristics can support upstream decision-making for clinicians. Future studies are required to validate these findings, derive risk scales, and demonstrate the utility of this model in health service planning. / Thesis / Master of Science (MSc) / Long term care (LTC) provides residents with 24-hour nursing and personal care. When the care or clinical needs of the resident cannot be met in the LTC facility, they may be transferred to the Emergency Department (ED). However, the ED’s are poorly situated to manage the distinct needs of older adults, given the sole focus on medical acuity rather than geriatric complexity. Unwarranted ED transfers are burdensome for LTC residents and increase their risk for adverse health events, such as nosocomial infections, delirium, and injuries. Understanding characteristics associated with ED transfers can help identify which residents may be at a risk of an ED transfer. The objective of this thesis was to identify which LTC resident characteristics at admission are associated with ED transfers in Ontario, Canada. A recent change in medical orders, previous ED visitation, female sex, the presence of an indwelling catheter, and the need for oxygen therapy were informative predictors for ED transfers.

Background: Canada has an aging population. With increased life expectancy, older adults become at higher risk of developing chronic disease. Therefore, the need and demand for long-term care (LTC) is expected to continue to increase. LTC homes provide 24-hour nursing care, personal care, and assistance with activities of daily living (Government of Ontario, 2014). Health information technology (IT) presents opportunities to support staff, residents, and their families in LTC environments. This has been particularly emphasized during the latest COVID19 pandemic in light of the challenges that have been observed in LTC homes (e.g., social isolation, limited integration of information, shortage of human resources etc.). Yet, LTC homes still lag significantly behind other areas in healthcare in relation to the adoption of health IT, and little information is available on the factors that affect the decision-making related to health IT solutions in these settings. Objectives and Research Question: This research aims to explore and examine the most relevant and important factors that managers consider when making decisions on the adoption of health IT in LTC homes. Therefore, the research question is: “What are the factors that affect and can inform the decision-making of managers in relation to health IT adoption in LTC homes?” Methods: This research uses an exploratory data-driven Delphi method that consists of a survey of a panel of 19 experts who are decision-makers in their respective LTC homes in Ontario. The Delphi survey is an exploratory approach that elicits the opinion of a panel of experts through iterative feedback consisting of three rounds (brainstorming, narrowing down, and ranking). In this research, the panelists were asked to identify and describe the most important and relevant factors that affect and inform their decision-making regarding health IT solutions in LTC. Then, they were asked to narrow down and rank the list, and a final coefficient of agreement was calculated based on their rankings. Results: The panelists were mostly female, 40-49 years old, and had an average of 9.7 years of experience in their current LTC organization. In addition, participants had an average of 10.5 years of experience in making decisions related to health IT adoption. In the brainstorming round, the panelists provided a total of 102 key factors, which were consolidated into a list of 27 items that varied across 5 general categories: availability of resources, social factors, organizational factors, regulatory requirements, and technical factors of the health IT solution. Fourteen panelists reported key factors related to the cost of technology and ease of use, which were the two key factors that were reported most often by participants. Two items were dropped from the list of key factors in the narrowing down round (i.e., comfort and social environment and vendor reputation) as only items with a rating of 5 out of 7 or greater were retained for the ranking round. In the ranking round, the consensus level was W=0.341. The top 5 factors that were identified and ranked by managers in LTC homes as important in influencing their decisions on the adoption of health IT were (in order of importance): availability of funding, impact on workload and efficiency, value proposition, ease of use, and impact on residents’ outcomes. Contributions: This Delphi survey provides an authoritative list of 25 key factors (and their description) that influence and affect managers’ decisions in LTC homes in relation to the adoption of health IT. This is a first step towards understanding what is happening in the LTC context in relation to health IT decision-making. From a LTC managers’ perspective, the findings provide benchmarking to understand what other LTC homes are doing and the factors that influence their decision-making on health IT solutions. Particular importance should be placed on the highly ranked factors, as they are identified as the factors that are most relevant and most important in facilitating or hindering the decision of LTC managers to adopt health IT solutions. In addition, the results of this thesis may help inform future planning and policies aimed at advancing the use of technology to support the care provided to older adults and the work of health care professionals in LTC. Future studies can use the results of this thesis to develop surveys that assess and monitor the evolution of these factors in broader and more representative samples of LTC managers.

Older adults face many age-related changes affecting functional ability. Function is defined as the interaction between a person and their real-world environment. Currently, no objective measures of function exist assessing the environmental component. A newly-developed measure of functional-living, the Movement and Activity in Physical Space (MAPS) score, combines accelerometer and geospatial data providing quantitative measurement of real-world function. Because MAPS is a new measure of functional-living, the purpose of the current study was to provide further construct validity for MAPS as a functional-living measure in older adults and to determine what combination of 3 days, using weekend and week days, are needed to obtain reliable MAPS scores in older adults. While there are many factors known to impact function, cognitive function has a well-known relationship with physical activity. MAPS assesses physical activity. Therefore, a relationship between cognitive function and functional-living was expected. Physical activity and physical function were also expected to be related to functional-living. Thirty community-dwelling older adults aged 72.6 (± 7.0) completed the study. Five measures of cognitive function were used, each assessing a different cognitive domain (i.e., executive function, working memory, processing speed, reaction time, and spatial visualization). A physical function test and a measure of physical activity were also administered. Pearson r correlations were conducted among all measures to assess the correlations between MAPS scores and the measures of cognitive function, physical activity questionnaire, and physical function test. If a correlation was found to be significant between MAPSI and MAPSV scores with any of the cognitive function measures, physical activity questionnaire, or physical function test, then further construct validity would be provided for MAPS as a functional-living measure in older adults. MAPSI and MAPSV scores were significantly correlated with the measure of processing speed and spatial visualization. The physical function score was also significantly correlated with MAPSI scores. The remaining measures of cognitive function and the physical activity questionnaire were not found to be associated with functional-living, as measured by MAPS, due to several limitations in the measures used. Wearing the activity monitors during any 3-day combination of days provided reliable MAPS data. Results of the study provided evidence of construct validity for MAPS as a functional-living measure.

Anxiety is a mental illness that can have significant deleterious impacts on an individual’s functioning. Although anxiety has been studied in older adults, there is conflicting evidence on differences in anxiety as a function of age. Anxiety sensitivity is a construct that is positively related to anxiety but has limited research in older adults. Extant literature suggests that older adults experience less anxiety sensitivity than do younger adults. According to Socioemotional Selectivity Theory, this may be due to older adults letting go of the things that make them anxious. The current study proposed that age impacts self-rated anxiety such that it is lower in older adults than it is in middle-aged adults and posits that anxiety sensitivity may mediate the relationship between anxiety and age. The results suggested a significant indirect effect but no direct effect, precluding the presence of mediation. There was a significant relationship between age and anxiety sensitivity. Further examination revealed that the relationship between age and anxiety sensitivity was not significant for people under 60 years old, but it remained significant for participants 60 years and older.

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Book Review of B. Fast and R. Chapin. 2000. Strengths-Based Care Management for Older Adults. Baltimore: Health Professions Press.

While picture books are often viewed as educational resources for young readers, it is crucial to not overlook the images and content this literary medium contains. Research suggests that repetitive messages encompassing a stereotypical nature cultivate lasting impressions on young audiences. One portrayal often associated with negative implications is the depictions of older characters in children's first literature. This investigation analyzed a selection of picture books from the New York Times best sellers list, the Book Sense best sellers list, and the Caldecott award winners for the years 2000–2010. In an attempt to provide a time spectrum communicating the levels of ageism that remain prevalent within the last decade, over 700 illustrated literary works were included in this exploration. Although conclusions supported a continuation of the under-representation of senior adults that is congruent to similar studies, findings suggested a significant improvement in the overall portrayal of older characters in illustrated books. This result communicates an optimistic outlook in continuing the promotion of positive attitudes for children regarding the aging process.

Background -- Cardiovascular disease (CVD) is a primary premature killer of adults and risk of CVD has been linked to modifiable risk factors including dietary intake. Many diet assessment tools are costly, time consuming, and complicated. This study investigated the relationship between diet quality and cardiovascular disease risk as indicated by carotid intima-media thickness (cIMT) using a validated, simple, self-administered rapid food screener. Methods -- Participants were 51 male and 33 female older adults with an average age of 67 years. Carotid intima-media thickness was assessed using B-mode high resolution diagnostic ultrasound. Unhealthy and healthy diet intake was assessed using a validated 22-item rapid food screener. Data on other potentially confounding variables were also collected and included blood lipid profile, BMI, and resting blood pressure. Results -- Pearson correlation analysis showed a significant relationship for the unhealthy diet pattern and cIMT for both average and maximum region cIMT (r = 0.218, p = .023; r = 0.197, p = .037 respectively). There were no significant correlations related to the healthy diet pattern. ANOVA results did indicate significant differences in cIMT means (average cIMT and maximum region cIMT) when highest intakes of fruits and vegetables were compared with lowest intakes (average cIMT, (F (1,30) 4.54, p = .041; maximum region cIMT, (F (1,30) 5.41, p = .027). Average cIMT was 0.729mm vs 0.853mm respectively for highest vs lowest fruit and vegetable intake. Maximum region cIMT was 0.864mm vs 1.023mm when comparing highest vs lowest fruit and vegetable consumers. Conclusion -- Results of this study are similar to other studies that have indicated a relationship between diet and CVD/cIMT. Dietary intakes in the present study were assessed with an easy to use, self-administered rapid food screener. This is an important aspect of the study considering previous studies have used lengthier, complicated, time intensive tools. Because the rapid food screener can be self-administered and is inexpensive it may be used as an indicator of CVD /cIMT risk by health promotion professionals and even individuals themselves.

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