The primary, descriptive aim of this dissertation was to describe the nighttime sleep quality of previously mechanically ventilated older adult patients within 24-48 hours of transfer out of the intensive care unit (ICU) to a medical-surgical floor. The secondary, exploratory aim was to examine the relationships between post-ICU sleep efficiency (SE) and wake after sleep onset (WASO) with grip strength in previously mechanically ventilated older adult patients within 24-48 hours of transfer out of the ICU. The study included 30 adults ages 65 and older (11 women, 19 men; age 71.37 ± 5.35, range 65-86 years), who were functionally independent at home prior to hospitalization, mechanically ventilated during their ICU stay, and were within 24-48 hours of transfer out of ICU to a medical-surgical floor at Tampa General Hospital, a level 1 trauma center. Subjects wore an actigraph monitor on the dominant wrist (Actiwatch Spectrum) to monitor sleep over two consecutive nights. Parameters of post-ICU sleep quality included total sleep time (TST), sleep efficiency (SE), wake after sleep onset (WASO), sleep latency (SL), and number of awakenings (NA). The outcome measure of motor function was dominant hand grip strength, assessed by the National Institutes of Health Toolbox Motor Battery Grip Strength Test. Sleep data collected between nighttime hours (9:00 PM to 9:00 AM) on both nights were analyzed. For the descriptive aim, means for each sleep parameter and clinical characteristics were reported. For the exploratory aims, multiple regression analyses examined the individual associations between mean sleep parameters (SE and WASO) and grip strength. Study subjects had a mean SE of 63.24 ± 3.88% and spent 135.39 ± 9.94 minutes awake after sleep onset. The mean TST among subjects was 7.55 ± 2.52 hours, ranging from 2.02 to 10.84 hours of sleep, out of the 12 hours of total time in bed. A total of 6 (20%) subjects slept less than 5 hours each night, and a total of 6 (20%) subjects slept greater than 10 hours each night. The mean SL among study subjects was 42.57 minutes, and ranged from 0.0 to 237.75 minutes. Overall, subjects’ average NA was 78.28 ± 26.39, ranging from 35 to 136 awakenings. In multiple regression analysis, SE was significantly and negatively associated with grip strength, after adjusting for potential confounding factors. The model predictors explained 80.8% of the variance in grip strength, [R2 = .808, F(10, 15) = 6.324, p = .001]. Higher SE independently predicted worse grip strength (β = -0.326, p = .036). Further, among the tertiles of subjects with moderate or high TST (sleep duration ≥ 6 hours, n = 23), there remained a significant, negative association between SE and grip strength. The predictors explained 73.7% of the variance in grip strength, [R2 = .737, F(5, 15) = 8.416, p = .001]. Higher SE independently predicted worse grip strength among the subset of subjects with moderate or high sleep duration (β = -0.296, p = .046). Among the two quartiles of subjects with moderate-high or high WASO (≥ 120 minutes spent awake after sleep onset, n = 16), there was a significant, negative association between WASO and grip strength, after adjusting for covariates. The model indicated that the predictors explained 91.4% of the variance in grip strength [R2 = .914, F(6, 8) = 14.134, p = .001]. Greater WASO independently predicted worse grip strength (β = -0.276, p = .04). Finally, the effects of sex and preexisting obstructive sleep apnea (OSA) on grip strength were individually examined. Higher SE independently predicted worse grip strength among male subjects (β = -0.353, p = .039), as did preexisting OSA (β = -0.493, p = .033). In summary, objectively measured sleep quality was disturbed among previously mechanically ventilated, hospitalized older adults, even after transfer out of ICU to a medical-surgical floor. Longer TST and greater SE predicted worse grip strength among these frail patients who were previously independent, community dwelling older adults. Among the subjects with more severely fragmented sleep, WASO also independently predicted weaker grip strength. As poor grip strength is an indicator of ICU-acquired weakness, optimal sleep duration and less sleep disturbances may be crucial in prevention of worse functional outcomes and new institutionalization. Additional research is needed to discern the temporality of associations between sleep quality and motor function among older adult survivors of critical illness.

Several lines of evidence link Alzheimer's disease (AD) to atherosclerosis (CVD), including that elevated low density lipoprotein (LDL)-cholesterol is a common risk factor. Development of genomic instability could also link the two diseases. Previous fluorescence in situ hybridization (FISH) analyses revealed a clonal expansion of aneuploid smooth muscle cells underlying atherosclerotic plaques. Likewise, cellular and mouse models of AD revealed tau-dependent mitotic defects and subsequent aneuploidy partly resulting from amyloid-beta (A&beta) interference with microtubule (MT) stability, and specific MT motors function. Moreover, AD patients develop aneuploid/hyperploid cells in brain and peripheral tissues, implicating similar mechanism that may lead to apoptosis and neurodegeneration. This dissertation tested the hypothesis that elevated lipoproteins and cholesterol may contribute to genomic instability in AD and CVD and showed that: (1) treatment with oxidized LDL (OX-LDL), LDL and water soluble cholesterol, but not high density lipoprotein (HDL), induced chromosome mis-segregation, including trisomy and tetrasomy 12, 21, and 7 in human epithelial cells (hTERT-HME1), primary aortic smooth muscle cells, fibroblasts, mouse splenocytes and neural precursors; (2) LDL-induced aneuploidy may depend on a functional LDL receptor (LDLR), but not amyloid precursor protein (APP) gene; (3) fibroblasts and brain cells of patient with the mutation in the Niemann-Pick C1 gene (NPC1) characterized by impaired intracellular cholesterol trafficking and changed intracellular cholesterol distribution harbored trisomy 21 cells; (4) young wild-type mice fed high and low cholesterol diets developed aneuploidy in spleen but not in brain cells within 12 weeks; (5) like with the studies on A&beta-induced aneuploidy, calcium chelation reduced OX-LDL and LDL-mediated chromosomal instability; and (6) altering plasma membrane fluidity with ethanol attenuated OX-LDL and LDL-induced aneuploidy. These results suggest a novel biological mechanism by which disrupted cholesterol homeostasis may promote both atherosclerosis and AD by inducing chromosome mis-segregation and development of aneuploid cells. Understanding the cause and consequence of chromosomal instability as a common pathological trait in AD and CVD may be beneficial to designing therapies relevant for both diseases.

Over 43.5 million Americans provide informal care to a fast-growing elderly population in the United States. Informal care allows care-recipients to remain functional members of society. However, research suggests that the demands of informal care can negatively impact the health of caregivers. For example, caregiver burden increases the risk for poor health in caregivers compared to non-caregivers. Caregiving research is on the rise, but the dynamics of informal care in active retirement communities remains widely unexplored. To provide adequate services to lessen caregiver burden and improve the Quality of Life (QoL) of informal caregivers, the various settings in which informal care is delivered must be evaluated. Aiming to understand the needs of informal caregivers and the protective factors against caregiver burden in active retirement communities, data from the USF Health and The Villages study, conducted from October 2011 and March 2013, were analyzed. Data from twenty-nine focus groups (N=144) was used to explore the challenges faced by seniors in a caregiver role and the availability of resources that decrease caregiver burden. The primary focus was informal care and the challenges associated with the caregiver role; findings revealed a great need for caregiver relief and limited information on existing resources is available to informal caregivers. Consistent with existing literature on caregiver burden, having no personal time, financial burden, physical demands, and poor health were commonly identified as the biggest caregiving challenges. However, findings strongly suggest that the unique structure of The Villages community encourages high social support that may be the strongest protective factor against caregiver burden in the community.

Person-centered care is important to the quality of life of nursing home residents with dementia. Preference assessments enable person-centered care by documenting residents’ preferred activities. Residents with severe dementia are less likely to have a role in preference assessment due to communication challenges associated with the disease. External supports (visual and text cues) are effective in improving the communication of residents with dementia, but these cues are often not used in practice. Standard assessment (verbal questioning) places greater demands on short-term memory and attention, which are known deficits in dementia. Applying a within-subjects design, this study evaluated two conditions (standard and supported) for assessing preferences of residents with severe dementia (N=21). This study examined the effect of these conditions on residents’ consistency over time (1-week) and utterance types in response to preference questions. Naïve judges (N=10) listened to the interviews and rated residents’ communication clarity and their confidence with understanding residents’ preferences. Results show that residents with severe dementia can report preferences with similar consistency in both assessment conditions; however, residents may comprehend the assessment better when provided in a supported format. In addition, residents successfully engaged in preference interviews without proxy participation. Anecdotally, many residents demonstrated an accurate understanding of their environment and how they would prefer to spend their days. Future studies will optimize visual stimuli, choice options, staff training components, efficiency measures, and examine acceptability by nursing home staff.

This study sought to explore the utilization and perception of best practices by community-based technology training programs when instructing older adults to become technologically literate. The target population included adults age 55 years and older of the Baby Boomer generational cohort who ranged academically from possessing a high school diploma or General Education Diploma (GED) through a college degree and had enrolled in a local technology training program to improve their technological skill level with the goal of obtaining employment and/or to remain functionally independent. This study was conducted at three community technology training centers located in the southeast that offered computer training classes for both civilian and ex-military older adults and employed a mixed methods research design. Data was collected through a series of participant interviews, surveys, and class observations to establish an understanding of current participant computer literacy status, demographic details and experiences, class structure, the computer curriculum, and training execution. It was the intent of this study to help maintain increased focus on the necessity of reducing the present digital divide that exists between younger and older adults by highlighting the importance of designing technology training programs that incorporated both expert recommended best practices for instructing older adults, as well as the expressed benefit and personal needs of the Baby Boomer population being served by local technology training centers.

ABSTRACT Hospice and Dementia Special Care Units (DSCUs) have been shown to be gold standards of care for individuals who are dying and for those with dementia in nursing homes. Using a retrospective administrator and family survey, this study investigated whether the processes of care used in hospice and DSCUs are associated with increased quality of end of life (EOL) care for individuals with dementia. A convenience sample of 17 facilities in four states (FL, PA, MD and MA) was included in the study. Nursing home administrators were surveyed between September 2008 and October 2009. The administrators identified 116 family members of decedents with dementia who were surveyed with the End-of-Life Dementia (EOLD) scale as the outcome. The Donabedian Structure-Process-Outcome theory was used to test the hypothesis that the process characteristics of hospice and DSCU will be associated with higher EOLD scores. Hierarchical regression models were conducted for two of the three subscales of the EOLD. The resident risk characteristics (decedent length of stay and resident immobility), the structure characteristics (profit status, percent Medicaid and presence of other palliation), and the process characteristics (hospice, DSCU, dual, and traditional enrolled, and strength of inter-disciplinary team (IDT)] were entered into the model to determine their association with Satisfaction With Care and Comfort At Death. Strength of the IDT was included as a moderating factor of this association. Only DSCU enrollment was associated with increased Satisfaction With Care (SWC; DSCU: b = .31, p < .01). The moderation analysis showed that strength of IDT did significantly moderate the association between DSCU enrollment and increased SWC (DSCU: b = -.09, p < .05). Study implications include the need for more research into DSCUs and Strength of IDT as best practices in EOL care. This study contributes to an expanding body of research on the extra value of enrollment in a DSCU and the role of IDT in quality of EOL care for individuals with dementia in nursing homes.

<p><strong>Background:</strong> The objective of this mixed methods study is to understand, from the perspectives of seriously ill hospitalized patients, the effect of modifiable physician behaviours on the perceived quality of end-of-life and ACP communication. <strong></strong></p> <p><strong>Methods:</strong> A convergent parallel mixed methods design is used. Participants were recruited from inpatient medical wards at two academic hospitals, and a population with a high risk of mortality at 6-12 months was selected. In the quantitative strand, a questionnaire was administered to measure patients’ self-rated satisfaction with their physician’s ACP communication skills. The primary analysis involved calculation of the strength of correlation between individual QOC items and a global satisfaction score. In the qualitative strand, interpretive description methods were used to explore seriously ill patients’ perceptions of the quality of ACP communication with their physicians. The mixed methods analysis phase involved the creation of a merged analysis table.</p> <p><strong>Results: </strong>From the quantitative strand, three priority behaviours pertained to eye contact, providing full attention, and listening. The three major qualitative themes related to nonverbal behaviours; situating a patient in the context of their background, family and social roles; and assisting patients to make the challenging end-of-life transition. The merged analysis allowed for a fuller, contextualized understanding of why the QOC items with the strongest correlation measures were important from a patient perspective.</p> <p><strong>Conclusions:</strong> This mixed methods study is well-positioned to understand, holistically and from the patient perspective, physician behaviours that influence quality of communication at the end of life.</p> / Master of Science (MSc)

<p><strong>Background:</strong> Postnatal growth of preterm infants does not match recommended intrauterine growth, due to the initial weight loss that accompanies healthy body composition rearrangements after birth. Thus, optimal postnatal growth for preterm infants is currently unknown.</p> <p><strong>Objectives: </strong>(1)<strong> </strong>Collect longitudinal postnatal growth data of 30–36 week GA preterm infants with unimpaired postnatal adaptation; (2) Develop regressions that predict the growth trajectory such an infant will adjust to by days of life 7/14/21; (3) Extrapolate and validate the regressions downwards to 25 weeks.</p> <p><strong>Methods:</strong> Infants of 30–36 week GA, born/admitted to 1/5 participating centres between 2008–2012, who met pre-specified criteria for unimpaired postnatal adaptation and who had at minimum 14 days of data were included. Day-specific anthropometric data from birth to discharge were abstracted retrospectively. Z-score regressions for days 7/14/21 were developed. Regressions were then extrapolated to 25 weeks and validated using an independent study population.</p> <p><strong>Results:</strong> Of 6203 infants, 665 met the screening criteria. By day 14, infants adjusted to stable growth trajectories that were 84±13% of the recommended weight-for-age. Using the following predictors: GA, z-score at birth and hospital-centre, regressions accurately predicted z-scores at days 7, 14 (n=665; R²=0.939, 0.889) and 21 (n=333; R²=0.841). Validation using 25-29 week GA infants (n=173) suggested models were also accurate within this age-range.</p> <p><strong>Conclusion: </strong>These results provide robust estimates of a hypothesis of healthy postnatal growth for preterm infants. Future steps include assessing long-term outcomes in a randomized control trial and assessing the quality of growth using body composition analyses.</p> / Master of Science in Medical Sciences (MSMS)

Background: Disruptive technology describes technology that is significantly more advanced than previous iterations, such as: 3D printing, genetic manipulation, stem cell research, innovative surgical procedures, and computer-based charting software. These technologies often require extensive overhauls to implement into older systems and must overcome many difficult financial and societal complications before they can be widely used. In a field like healthcare that makes frequent advancements, these difficulties can mean that the technology will not be utilized to its full potential or implemented at all. Objective: To determine the inhibiting factors that prevent disruptive technology from being implemented in conventional healthcare. Methods: Peer reviewed articles were gathered from Cumulative Index to Nursing and Allied Health Literature (CINAHL), Educational Resources Information Center (ERIC), Elton B. Stephens Co. Host (Ebsco Host), Medical Literature On-line (Medline), and Psychological Information Database (PsychINFO). Articles were included if written in English and focusing on technology that was or is difficult to implement. Results: Research suggests that the primary reason disruptive technology is not implemented sooner is the cost versus benefit ratio. Those technologies with extremely high benefits that greatly improve efficiency, safety, or expense are integrated relatively quickly, especially if their cost is reasonable. Secondary reasons for difficulty with integration include ethical dilemmas, extreme complexity, technical limitations, maintenance, security, and fallibility. Conclusion: Research indicates that a decrease in production cost and selling price along with removing any issues that may depreciate the technology will provide better incentives for healthcare systems to integrate disruptive technologies on a wider scale.

<p>All images in this document may not be produced without the expressed written consent of the author.</p> / <p>The innovative research method of “body mapping” was used in this study with geriatric inpatients receiving daily hæmodialysis therapy for end-stage renal disease at Toronto Rehabilitation Institute.</p> <p>Five people took part in this study; three participants completed all study phases. They created three body maps each and took part in one follow up, semi-structured interview to share their experiences of body mapping. Two themes were drawn from the data: (1) body mapping gives patients a voice to communicate their experiences in the dialysis unit; and (2) body mapping makes visible participants’ illness adjustment patterns, and levels of connection, or disconnection in the dialysis unit.</p> <p>Based on the ways body mapping benefitted participants in this study, it is reasonable to suggest that this visual communication tool could be useful in other research settings, and as a clinical tool to support patients’ attention to their bodies and their interactions with healthcare providers.</p> / Master of Arts (MA)