The risk of having a disability increases with advancing age and as the life expectancy is growing worldwide, the number of people living with disability is expected to increase, as well as the number of years lived with disability. Low back pain and sarcopenia are health problems that present a higher prevalence with aging. While low back pain is a symptom, sarcopenia is considered a geriatric syndrome. However, both issues constitute a significant health burden in older adults. Although there are many research studies investigating low back pain, the participation of older adults is often missing from these studies, preventing the generalization of the findings to this population, and leaving some questions unanswered. On the other hand, sarcopenia is a new research field with gaps to fill and flaws to correct. Questions related to low back pain management in older adults, the inclusion of this population in clinical trials, the presence of association between sarcopenia and low back pain and questions pertaining the diagnosis and measurement of sarcopenia have yet to be fully addressed by researchers. The broad aim of this thesis therefore was to contribute to a better understanding concerning low back pain and sarcopenia in older adults by performing studies in these key research areas. Different interventions are presented in clinical practice guidelines for the treatment of low back pain. However, these recommendations are based on clinical trials investigating young and middle-aged adults and as a result, the recommendations do not encompass older adults. Therefore, a systematic review was performed with the objective of assessing the effectiveness of interventions for low back pain in older adults ≥ 60 years (Chapter 3). Eligible studies were identified via searches in Medline, EMBASE, CINAHL, LILACS, PEDro, and Cochrane CENTRAL. A total of 18 randomized controlled trials fulfilled the eligibility criteria and the results from eight trials were pooled in a meta-analysis to test the effectiveness of complementary health approaches (i.e., manual therapy, acupuncture, mindfulness, yoga). Evidence about interventions to manage non-specific low back pain in older adults was found to be weak. Very low to moderate quality evidence showed that complementary health approaches, percutaneous electrical nerve stimulation, education, exercise, or pharmacological agents did not produce a clinically significant reduction in pain and disability at short and intermediate terms compared to sham, usual care, or minimal intervention. Interventions were often not well described and the risk of bias was moderate (average of 6.4 on the 10-point PEDro Scale (SD = 1.44)). Evidence about interventions for non-specific low back pain in older adults is limited and new studies are highly likely to change these results. Participation of older adults in clinical trials pertaining to the management of low back pain has been limited. Usually, the exclusion of older adults from clinical trials is based solely on an arbitrary age limit. Therefore, an investigation concerning the potential increased inclusion of older adults in upcoming clinical trials was conducted (Chapter 4). Chapter four presents an analysis of the International Clinical Trial Registry Platform database from the World Health Organization performed to verify the participation of older adults in registered clinical trials. A total of 167 clinical trial protocols for low back pain with registration dates from January 2015 through November 2018 were planning to recruit participants older than 65 years. However, only five registered trials (2.99%; pooled sample = 169 participants) were designed to target this population specifically. The exclusion of older participants was not formally justified and imposed through an arbitrary upper-age limit in 93.6% of the protocols. Most studies planning to include older adults were interested in pharmacologic interventions, devices/technology, and physical rehabilitation, and were to be carried out in developed regions. However, older adults with low back pain will continue to be under-investigated in clinical trials for low back pain in the near future. Although a slight increase in the participation of older adults in clinical trials was observed, the improvement is small and some questions still need an answer. Therefore, a survey investigating whether researchers recognize the exclusion of older adults from clinical trials, its impact, and justifications to support this exclusion was realized (Chapter 5). All attendees of the 2017 International Back Forum were invited by email to answer an electronic survey about their opinions regarding participation of older adults in clinical trials for low back pain. Approximately 90% of those who answered the questionnaire were engaged with back research, with more than a half having done or doing a clinical trial for low back pain. Most of the respondents believed that older people are excluded from clinical trials for low back pain and that exclusion based solely on age is not justifiable. About two thirds of the respondents reported that the exclusion of older people from clinical trials can impose a barrier in offering evidence-based interventions to this population. More researchers are planning to include older adults in their current/future trials compared to their previous work. An increase in the investigation of older adults in clinical trials is expected in the future which may optimize the development of evidence-based interventions for this population. As early evidence suggests an association between sarcopenic markers and low back pain, the association between the diagnosis of sarcopenia and low back pain still needs to be investigated (Chapter 6). Therefore, a study investigating the association between sarcopenia using different diagnosis criteria and low back pain in older adults was performed. Data from 12,646 older adults (50.1% men, 49.9% women) ≥ 65 years of age that participated in the Canadian Longitudinal Study on Aging (CLSA) were analyzed. The prevalence of low back pain in the past 12 months as well the prevalence of sarcopenia assessed through different definitions, and the number of comorbidities and depressive symptoms were included in the analysis. Associations between sarcopenia, comorbidities and lifestyle factors with low back pain were examined using multivariate logistic regressions. Prevalence of low back pain was 16.3% and the prevalence of sarcopenia varied among sarcopenia definitions and the presence of low back pain. Participants with low back pain had higher prevalence of pre-sarcopenia and sarcopenia compared to those without low back pain based on the International Working Group on Sarcopenia (x2 = 20.25, p < 0.001) and the Foundation National Institute of Health definitions (x2 = 13.83, p < 0.001). The odds of having low back pain was higher among those with sarcopenia based on the Foundation National Institute of Health criterion (OR 1.28, 95%CI 1.0-1.64). These results suggest that sarcopenia may influence low back pain in older adults and future studies should consider to test whether the association between sarcopenia and low back pain is causal. Current clinical practice guidelines recommend to divide patients with low back pain in specific subgroups to provide a targeted intervention. However, despite older adults presenting specific age-related characteristics that could classify them as a subgroup, this population has been neglected. Sarcopenia is a muscle disease affecting older adults and is diagnosed with the presence of a reduction in muscle strength and muscle quantity/quality. Although low back pain has been shown to be associated with muscle dysfunction, the role of sarcopenia in relation to low back pain is unknown. An experiment comparing sarcopenic markers (grip strength and gait speed), muscle activity and elasticity between older adults with and without chronic low back pain was conducted (Chapter 7). The anticipatory activity of transversus abdominis muscle during the rapid arm abduction test, transversus abdominis muscle elasticity, grip strength and gait speed were collected from a group of older adults (≥ 60 years) with chronic low back pain (≥ 3 months) and the results compared with a control group of matched older adults without low back pain. Participants with chronic low back pain presented with a reduction in the sarcopenic markers compared with the controls: grip strength (mean difference (MD) = 5.3Kg, 95%CI = 1.5-9.0, p = 0.006), gait speed (MD = 0.21m/s, 95%CI = 0.10-0.31, p<0.001), as well as a delay in activation of transversus abdominis (p = 0.002). A delay in transversus abdominis muscle activation, and a reduction in muscle strength and gait speed were observed in older adults with chronic low back pain compared to subjects without back complaints. These findings show an association between muscle dysfunction and chronic low back pain in older adults. Although the definition of sarcopenia was recently updated establishing muscle strength as the key criteria surpassing the role of muscle mass, there remains confusion regarding its diagnosis and the comparison of estimates is problematic. Therefore, a systematic review assessing how sarcopenia is measured and defined in population-based studies was performed. Chapters 8 and 9 describe the protocol of a systematic review and the full systematic review respectively. The databases Medline, EMBASE, CINAHL, Web of Science (Core Collection), and Google Scholar were searched for observational population-based studies reporting prevalence of sarcopenia in community dwelling older adults. Descriptive statistics were used to present data pertaining to sarcopenia definition and measurement tools, and the quality-effects model for meta-analysis of pooled prevalence. Results found seven different operational definitions of sarcopenia and a variety of measurement tools applied to assess the sarcopenic markers: muscle mass, muscle strength and physical performance. The prevalence of sarcopenia varied between the definitions, with general estimates ranging from 5% based on the European Working Group on Sarcopenia in Older People (EWGSOP1) criterion to 17% with the International Working Group on Sarcopenia criterion. The use of different measurement tools to assess muscle mass, strength and physical performance resulted in variations within definitions ranging from 1 to 7%, 1 to 12% and 0 to 22%, respectively. The criteria used to define sarcopenia, as well as the measurement tools used to assess sarcopenic markers has an influence in the prevalence of sarcopenia. The establishment of a unique definition for sarcopenia, the use of methods that guarantee an accurate evaluation of muscle mass, and the standardization of measurement tools are necessary to allow a proper diagnosis and comparison of sarcopenia prevalence among populations.

Background: Opioids are often used in nursing homes to manage non-malignant pain, but little is known about their long-term use, initiation, and comparative safety. Methods: We used the Minimum Data Set 3.0 from 2011-2013 merged to Medicare and facility characteristics data to study opioid use and safety among older, long-stay residents. The specific aims were to examine the 1) prevalence of long-term opioid use; 2) geographic variation in the initiation of commonly used opioids (oxycodone, hydrocodone, tramadol); and 3) comparative safety of commonly used opioids and fracture hospitalizations. Results: One in seven long-stay residents were prescribed opioids long-term. There was extensive geographic variation in the initiation of commonly used opioids, with oxycodone (9.4%) initiated less frequently than hydrocodone (56.2%) or tramadol (34.5%) but varying most extensively across the United States, with the majority of variation in prescribing explained by state of residence. Compared to hydrocodone initiators (7.9 fracture hospitalizations per 100-person years), those initiating tramadol had lower rates of fracture hospitalizations (subdistribution hazard ratio [HRSD] = 0.67, 95% Confidence Interval [CI]: 0.56-0.80), whereas oxycodone initiators had similar rates of fracture hospitalizations (HRSD=1.08, 95% CI: 0.79-1.48). Conclusion: The prevalence of long-term opioid use was twice as common in nursing homes as community settings, with initiation patterns varying extensively by region and being strongly driven by state of residence. Although initiating tramadol was associated with lower rates of fractures than hydrocodone, questions on opioid risks and benefits remain and are especially pertinent given the high mortality rates in this population.

Chronic conditions are public health threats. The Chronic Disease Self-Management Program (CDSMP) is an evidence-based disease management program that addresses personal self-management of chronic conditions. The CDSMP involves peer trainers who instruct and assist with chronic disease preventive measures. Although disease management demonstrates promise to improving patient self-maintenance, previous researchers have not evaluated how the program affects program leaders. The purpose of this study was to discover how self-help leaders feel about the CDSM program. The overarching research question asked about perspectives that self-help leaders had toward the program. Through a narrative qualitative approach, the perceptions of peer leaders were examined to determine if the program was personally beneficial. Guided by the social cognitive theory, a purposeful convenience sample of 20 participants completed the study. The participants were practicing peer trainers in the CDSMP program. Data analysis included hand coding using open and axial coding and content analysis. Study findings included themes surrounding how the CDSMP program benefits health in general as well as the management of facilitators' own chronic diseases, health behaviors, and increased quality of life. The ability for chronic disease management leaders to experience positive effects of the program they administer may result in positive social change. This awareness can positively affect social change by enhancing an already established evidence-based community health program with stronger and better-equipped leaders.

Background: Nurses entering the workforce may have limited education in gerontological nursing. Therefore, many nurses are unprepared to provide quality care to older adults. An unprepared nursing workforce could negatively influence older adults’ health outcomes and care experience. Purpose: To determine differences in senior nursing students’ knowledge, attitudes, and perceived competency about older adults based on enrollment in a bachelor of science in nursing degree (BSN), associate’s degree nursing (ADN), and practical nursing (PN) program that offers geriatric content in curricula. Theoretical Framework: Bandura’s social cognitive theory, triadic reciprocal determinism model provided the theoretical framework. Methods: A non-experimental, descriptive survey design with a convenience sample of students enrolled in a BSN, ADN and PN program. A total of 178 students participated in this dissertation study. Palmore Facts on Aging Quiz 2, Kogan’s Attitudes Toward Old People Scale, and the Hartford Geriatric Nurse Competency tool was used to collect data. Results: Students enrolled in BSN, ADN, and PN programs demonstrated limited knowledge about facts on aging. Students’ attitudes toward older adults were positive, and a correlation was found between knowledge and attitudes. Students perceived competency about older adults were high, but purely subjective. Students’ preference to work with older adults post graduation in the PN group were higher compared with students in both the BSN and ADN group. Conclusions: This study underscore the need to systematically design an evidence-based curriculum inclusive of geriatric content across (BSN, ADN, and PN) programs to prepare the future nursing workforce to care for older adults.

The purpose of this dissertation research was to understand the decision-making process that well older adults use when deciding whether to make a home modification. The researcher also sought to understand the views of well older adults concerning the use of home modification to prevent injury and declines in occupational performance. The researcher used the Person-Environment-Occupation (PEO) model (Law et al., 1996) from occupational therapy and occupational science as the orienting framework. A qualitative grounded theory approach based on that proposed by Strauss and Corbin (1998) was used to structure data collection and analysis. Participants were obtained using purposive and theoretical sampling and were interviewed by the researcher. The 19 participants in this study ranged in age from 65 to 89. Findings from this study include a model of the decision-making process that well older adults used to plan for their futures related to home setting and modification and also a substantive grounded theory. The Theory of Home Modification Decision-Making: Well Older Adults is proposed and explained. Central to the theory are two decision-making processes, including the conditions that influence the decisions. These findings and the theory are discussed relative to the PEO model and existing occupational therapy and gerontology literature. The information gained from this study is beneficial to occupational therapists and Certified Aging-in-Place Specialists to improve and expand their services to the well older adult population.

Bakgrund: Konfusion är ett övergående akut förvirringstillstånd som många patienter med höftfraktur drabbas av varje år efter att de genomgått en operation. De främsta orsakerna är det kirurgiska traumat, anestesin, smärta, sömnbrist, läkemedel och stress. Kvinnor är mest drabbade av konfusion men det kan vara en skrämmande upplevelse oavsett vem som drabbas. Syfte: Syftet med studien var att studera hur patienter som genomgått höftoperation kan undgå att drabbas av konfusion, genom att studera vad sjuksköterskor behöver för att uppnå god beredskap att förebygga eller lindra konfusion. Metod: Detta arbete är en litteraturöversikt som grundar sig på 11 kvantitativa vetenskapliga originalartiklar. Litteratursökningen genomfördes på databaserna PubMed, PsycInfo samt CINAHL. Samtliga studier kvalitetsgranskades med Fribergs (2017) granskningsmall för kvantitativa studier. Resultat: Artiklarnas resultat sammanställdes i två tabeller, en för vardera av de frågeställningar som kompletterade litteraturöversiktens syfte. I resultatet framkom det att sjuksköterskor saknade kompetensen att i kliniken identifiera tecken på konfusion hos patienterna. Sjuksköterskor utbildade i konfusion hade lägre konfusionsincidenter bland sina patienter. Hade patienten haft konfusion tidigare var detta viktig information för personal som sköter vården postoperativt. Det var också en fördel om kompletterande kompetenser, till exempel i form av geriatriksjuksköterskor, fysioterapeuter och arbetsterapeuter, kunde finnas tillgängliga vid behov. Patienter som fick lyssna på lugn klassisk musik fick en bättre utveckling på den kognitiva funktionen. Slutsats: Studiens resultat visar att det behövs mer kunskap, instrument och verktyg för sjuksköterskor för att förebygga, identifiera och behandla konfusion tidigt. En god kompetens, snabb identifiering och information till patientens andra vårdgivare kan leda till bättre vård för patienten och en bättre arbetsmiljö för sjuksköterskan. / Background: Delirium is a transient acute state of confusion that thousands of hip fracture patients suffer from each year after undergoing surgery. The main causes are surgical trauma, anesthesia, pain, lack of sleep, medication and stress. Women are most affected by delirium but it can be a scary experience no matter who is affected. Aim: The aim of the study was to study how patients who have undergone hip surgery can avoid being affected by delirium, by studying what nurses need to achieve good readiness to prevent or alleviate delirium. Method: This work is a literature review based on 11 quantitative scientific original articles. The literature search was performed on the databases PubMed, PsycInfo and CINAHL. All studies were quality reviewed with Friberg’s (2017) review template for quantitative studies. Result: The results of the articles were compiled in two tables, one for each of the questions that complemented the purpose of the literature review. The results showed that nurses lacked the competence to identify signs of delirium in the patients in the clinic. Nurses trained in delirium had lower delirium incidents among their patients. If the patient had had delirium before, this was important information for staff who provide care postoperatively. It was also an advantage if complementary competencies, for example in the form of geriatric nurses, physiotherapists and occupational therapists, could be available if needed. Patients who were allowed to listen to calm classical music had a better development of cognitive function. Conclusion: The results of the study show that more knowledge, instruments and tools are needed for nurses to prevent, identify and treat delirium early. Good competence, quick identification and information to the patient's other care providers can lead to better care for the patient and a better working environment for the nurse.

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