INTRODUCTION. La charge mondiale des maladies cardiovasculaires (MCV) ne cesse d’augmenter. Une population particulièrement vulnérable à ces maladies est celle des adultes âgés ayant une maladie neurologique : l’épilepsie. Plusieurs études démontrent que les adultes âgés atteints d’épilepsie ont un risque plus élevé de développer une MCV par rapport à la population générale. Cette association est étonnamment peu étudiée chez cette population. Afin de développer des programmes de soins de santé pour prévenir l’apparition de comorbidité de MCV chez les personnes atteintes d’épilepsie, dresser un portrait précis des adultes âgés atteints d’épilepsie est nécessaire. OBJECTIFS. Afin de combler les lacunes de la littérature scientifique sur les causes du fardeau élevé des MCV chez les adultes âgés atteints d’épilepsie, l’objectif de ce mémoire est d’étudier la répartition des facteurs sociaux, mode de vie et comportements, ainsi que des maladies chroniques connues comme étant des facteurs de risque de MCV chez les adultes âgés atteints d’épilepsie comparée à la population générale. En outre, nous visons à mesurer l’association transversale entre l’épilepsie et les MCV chez les adultes âgés, avec et sans ajustement pour des antécédents d’accidents vasculaires cérébraux (AVC), ainsi qu’à trouver des preuves d’interactions entre l’épilepsie et les facteurs de risque de MCV. MÉTHODES. Nous avons analysé les données de 44 817 participants de l’Étude longitudinale canadienne sur le vieillissement (ÉLCV), une cohorte d’étude longitudinale composée d’individus âgés d’au moins 45 ans et plus dont plus de 700 personnes ont des antécédents d’épilepsie autodéclarés au cours de leur vie. En ajustant pour l’âge, le sexe et le statut d’AVC, nous avons utilisé la régression log-binomiale pour modéliser les associations transversales entre les facteurs de risque de MCV, l’épilepsie et les MCV telles que les maladies cardiaques, les maladies vasculaires périphériques et les infarctus du myocarde. Nous avons comparé le fardeau des MCV attribuable par les AVC dans la population avec et sans épilepsie. Des modèles de régression multivariés ont également été stratifiés en fonction du statut d’épilepsie afin d’observer des différences dans ces associations entre les personnes atteintes d’épilepsie et les personnes non atteintes d’épilepsie. Finalement, nous avons testé l’existence d’interactions entre les facteurs de risque de MCV et l’épilepsie, et leur association avec le statut de MCV. Nous avons utilisé l’imputation multiple pour remplacer les données manquantes. RÉSULTATS. La majorité des caractéristiques sociodémographiques, mode de vie et comportements et maladies chroniques, sélectionnées comme facteurs de risque de MCV dans notre étude, étaient significativement plus prévalentes chez les personnes atteintes d’épilepsie comparée à la population générale non atteinte d’épilepsie. Le fardeau des MCV attribuable par les AVC chez les personnes atteintes d’épilepsie n’était que de 36 %, soit un taux similaire à celui de la population générale qui lui s’élevait à 32 %. Même après l’ajustement du statut d’AVC, ainsi que de l’âge et du sexe, les personnes atteintes d’épilepsie présentaient une prévalence significativement plus élevée de maladies cardiaques [ratio de prévalence (PR) = 1,27 (IC à 95 % : 1,02-1,57)] et de maladies vasculaires périphériques [PR = 1,88 (IC à 95 % : 1,50-2,36)]. Bien qu’elle ne soit plus significative, la tendance vers une augmentation de la prévalence des infarctus du myocarde chez les personnes atteintes d’épilepsie était maintenue [PR = 1,19 (IC à 95 % : 0,89-1,60)]. Finalement, parmi tous les facteurs de risque de MCV, seuls l’âge, l’hypertension et la maladie pulmonaire chronique obstructive ont été associés à une augmentation significative de la prévalence d’une ou plusieurs MCV. CONCLUSION. La grande taille de l’échantillon et l’étendue des informations sur la santé saisies par l’ÉLCV (c’est-à-dire démographiques, sociales, physiques, psychologiques, économiques, physiologiques) nous ont permis de modéliser une analyse approfondie et de présenter un reflet juste d’une population d’adultes âgés. Le mémoire présenté démontre que les facteurs de risque de MCV sont plus fréquemment observés chez les personnes atteintes d’épilepsie et l’association entre l’épilepsie et les MCV est indépendante de l’association entre l’épilepsie et les AVC. Ces résultats constituent une première étape importante pour mieux comprendre les origines des MCV chez les personnes atteintes d’épilepsie. L’analyse de médiation aurait pu être un moyen d’approfondir mes analyses. Cela n’a pas été possible avec l’analyse actuelle étant donné que nous n’avions aucun moyen d’établir la séquence temporelle de nos données. Les adultes âgés constituent une population vulnérable à laquelle les prestataires de soins de santé doivent accorder une attention particulière. Mener des études longitudinales sur les personnes dont les crises d'épilepsie viennent d'être diagnostiquées et qui présentent une maladie chronique, des caractéristiques sociodémographiques et un mode de vie entièrement caractérisé (avant et après le diagnostic d'épilepsie) sont nécessaires. / INTRODUCTION. The global burden of cardiovascular disease (CVD) is steadily increasing. A population particularly vulnerable to these diseases are the older adults with a neurological condition: epilepsy. Several studies show that older adults with epilepsy have a higher risk of developing CVD when compared to the general population. This association is surprisingly poorly studied among people with epilepsy. In order to develop health care programs to prevent the onset of CVD comorbidity in people with epilepsy, creating an accurate portrait of older adults with epilepsy is required. OBJECTIVES. In order to fill the gaps in the scientific literature on the causes of the high burden of CVD in older adults with epilepsy, the purpose of this thesis is to investigate the distribution of social factors, lifestyle and behaviors, as well as chronic disease CVD risk factors, in people with epilepsy as compared to the general population. In addition, we aim to measure the cross-sectional association between epilepsy and CVD in older adults, with and without adjustments for a history of stroke as well as looking for evidence of interactions between epilepsy and CVD risk factors. METHODS. We analysed data for 44,817 participants in the Canadian Longitudinal Study on Aging (CLSA), a longitudinal study cohort of individuals aged at least 45 years and where more than 700 individuals have a lifetime self-reported history of epilepsy. Adjusting for age, sex and stroke, we used log-binomial regression to model the cross-sectional associations between CVD risk factors, epilepsy, and CVD such as heart disease, peripheral vascular disease, and myocardial infarction. We compared the CVD burden attributable to stroke in the population with and without epilepsy. Multivariable regression models were also stratified across levels of epilepsy status to observe for differences in these associations between epilepsy and people without epilepsy. Finally, we tested the existence of interactions between CVD risk factors and epilepsy and their association with CVD status. We used multiple imputation to replace missing data. RESULTS. The majority of the sociodemographic characteristics, lifestyle and behavior and chronic diseases, selected as CVD risk factors in our study, were significantly more prevalent in people with epilepsy as compared to the general population without epilepsy. The CVD burden attributable to stroke in people with epilepsy was only 36%, similar to the general population which reached 32%. Even after adjusting for a history of stroke, as well as age and sex, people with epilepsy had a significantly higher prevalence of heart disease [prevalence ratio (PR) = 1.27 (95% CI: 1.02, 1.57)] and peripheral vascular disease [PR = 1.88 (95% CI: 1.50, 2.36)]. Although no longer significant, the trend towards an increase in the prevalence of myocardial infarction in people with epilepsy was maintained [PR = 1.19 (95% CI: 0.89, 1.60)]. Finally, among all the CVD risks factors, only age, hypertension, and chronic obstructive pulmonary disease were associated with significant increases in the prevalence of one or more of the CVD. CONCLUSION. The large sample size and breadth of health information captured by the CLSA (i.e. demographic, social, physical, psychological, economic, physiological) allowed us to model in-depth analysis and present a fair reflection of an older adult population. The presented thesis demonstrates that CVD risk factors are more frequently seen in people with epilepsy and that the association between epilepsy and CVD is independent of the association between epilepsy and stroke. These findings are important first steps in more comprehensively understanding the origins of CVD in people with epilepsy. Mediation analysis could have been a way of further examining my analysis. This was not possible with the current analysis given that we had no way to establish the temporal sequence of our data. Older adults are a vulnerable population in which health care providers should pay particular attention. Conducting longitudinal studies of individuals with newly diagnosed epilepsy seizures and fully characterized chronic disease, sociodemographic characteristics and lifestyle (prior to and post a epilepsy diagnosis) are needed.

Background: In 1946, a proposal was made for a law on national pensions with the aim of reforming the pension system and giving pensioners better finances, which later was implemented at 1948. The theory of the social determinants of health suggests that income is an important factor that has an impact on health. The study aim was therefore to investigate whether the general pension reform implemented in 1948 could account for any differences in death rates for those aged 67 and older, and the research question was to examine if there was change in death rates for those aged 67 and older after 1948 that could be explained by an increase in income from the pension reform  Method: The study design was a quantitative inductive method. Data used in the study was death rates for those aged 67-90 years in Sweden between 1933-1962, as well as statistics from the Statistical Yearbook for Sweden to obtain data on income from the pension system. To investigate whether the pension reform has had any significant effects on the health of people of old ages, an interrupted time series analysis was used to measure changes in death rates for those aged 67-90 years between 1933 and 1962 in Sweden.  Results and conclusion: The results showed that there was an increase in the average pension by 461% for men and 442% for women between the years of 1947 and 1948. The study suggests that for women there was a significant change in death rates since the reform started, but that the reform of 1948 might not have had a significant effect on men’s death rates. Overall my study indicates that the changes in death rates for women in the pension age in 1948 and after could be explained by an increase in income from the pension reform, and that the pension reform seems to be a sustained policy effect that have accumulated over time.

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The SARS-CoV-2 pandemic disrupted health professions education on a number of different levels. Many health professions and pre-health professions students lost access to real-world clinical experience which has lead to disruptions in the healthcare workforce pipeline. At the University of Montana a diverse group of health professions educators designed an innovative experiential learning program, called Griz Health, that would allow UM students to engage in healthcare experiences while helping the campus with COVID-19 response. Because of the overwhelmingly positive response from students and community members that participated in this program, the Griz Health program was shifted from a volunteer response program to a year-long course. Students in the Griz Health course will work in small, interprofessional teams to engage in the innovation process to tackle local healthcare issues in underserved communities.

<p>  </p> <p>Polypharmacy in older adults presents several challenges, such as suboptimal therapeutic outcomes and increased adverse effects. Deprescribing, a clinically supervised process of decreasing dosage or stopping the medication when risks outweigh benefits, has emerged as one possible solution to these problems. However, the literature describing deprescribing intervention frameworks is heterogenous regarding targeted medications to deprescribe, population characteristics, clinical settings, and measured outcomes. This dissertation utilizes Linsky et al.'s deprescribing conceptual model, which details factors influencing decisions regarding initiating deprescribing interventions and their direct impact on the process. </p> <p>This dissertation utilizes a multimethod approach to investigate factors that facilitate and improve the deprescribing of anticholinergic medications for older adults, addressing gaps in this population's anticholinergic medication use. The three studies included in this dissertation provide a comprehensive understanding of deprescribing anticholinergic medications for this population, each contributing unique insights and results. </p> <p>The first study explores the feasibility of in-person and remote Home Medication Inventory Method (HMIM) approaches to evaluate over-the-counter (OTC) and prescription medication possession and use, including anticholinergics. Results demonstrate that both methods can accurately assess anticholinergic medication usage patterns, providing healthcare providers with reproducible methods and detailed medication profiles to make informed deprescribing decisions based on complete medication lists.</p> <p>The second study examined the intertwined roles of social determinants of health and health beliefs in predicting older adults' self-reported deprescribing behaviors, proposing the Deprescribing Health Belief Model (DeRx-HBM) framework that can be utilized for these efforts. These results emphasize the importance of considering these elements when creating a patient-centric and culturally sensitive intervention since they significantly shape deprescribing behaviors.</p> <p>In the third study, we explored the use of a symptom-specific scale for measuring the symptom burden in older adults during the deprescribing of anticholinergic medications prescribed for urinary incontinence, depression, and pain management. This research introduces a validated scale for assessing anticholinergic symptom burden prior to, throughout, and following the deprescribing attempt. The implementation of this scale has the potential to enhance the reproducibility and standardization of deprescribing decisions. Furthermore, it can improve communication between healthcare professionals and patients, as well as monitor the effectiveness of interventions during and after the deprescribing process.</p> <p>Collectively, these studies provide invaluable insights into factors influencing deprescribing decisions, obstacles to implementing deprescribing practices, and potential strategies to optimize medication management in older adults. The major takeaway from these studies is that addressing these factors leads to more informed decisions among healthcare professionals and patients - potentially leading to improved patient outcomes, ensure the ongoing effectiveness of deprescribing initiatives among older adults, and the promotion of health equity throughout the deprescribing process.</p>

Although the global population is older than ever before, older persons' health is not necessarily included in policy planning. This study aimed to study how older people were included, excluded, and framed in Agenda 2030. Through qualitative content analysis, the sub-targets and indicators of Agenda 2030 were categorised and analysed. Seven categories were located; Poverty relates to age, Violence relates to age, Political inclusion relates to age, Elderly as a vulnerable group, Health of children and fertile women prioritised, Sexual health, and Youth seen as an investment. By analysing the manifest and latent material, this study showed that older persons are not prioritised in the SDGs and that when they are included, they are framed as vulnerable. While older persons are explicitly included in some ways (such as in political inclusion), they are also excluded from many sub-targets and indicators of Agenda 2030. This study argues that in order to not “leave the elderly behind”, more needs to be done to include older persons and to age disaggregate the data. / <p>Betyg i Ladok 220617.</p>

Den demografiska förändringen över ålderstrukturen står inför en förändring, där antalet äldre förväntas öka markant. För att äldreomsorgen ska ges möjlighet att tillhanda hålla en god omvårdnad, bör behovet av kompetent personal och en god arbetsmiljö tillgodoses. Syftet med denna undersökning var att skaffa kunskap om vilka möjligheter samt vilka resurser arbetsledare inom äldreomsorgen har för att implementera en god arbetsmiljö. Metoden som använts för denna kvalitativa undersökning var hermeneutisk metod, för att erfara och tolka arbetsledarnas arbetsmiljöarbete. I resultatet av undersökningen framkom att en majoritet av arbetsledarna ansåg att de hade en god arbetsmiljö och resurserna var adekvata, men utifrån intervjuerna kunde det tolkas att arbetsledningen och medarbetarna arbetade mot olika mål. En möjlighet för att implementera en god arbetsmiljö enligt studien, var att skapa en värdegrund som utgår ifrån hälsans bestämningsfaktorer. Ytterligare något som framkom ur undersökningen var att kompetensen borde ökas inom äldreomsorgen för att möt den framtida förändringen. / The demographic over the age structure stand before a change, when the elderly people expect to increase considerably. For making it possible for care of the elderly and to provide a good form of health care should the need for competent staff and work environment be satisfactory. The purpose of this study was to examine which possibility and which facilities work leaders have to implement a healthy work environment. The method that was used in this qualitative research was hermeneutic method, to examine and interpret work leaders work environments work. In the results of this study it emerged that a majority of the work leaders meant that they had a good work environment and adequate facilities, but from the interviews could it be interpreted that the management and coworkers worked towards different goals. In the study it emerged that the foundation of values should be from the determinants of health, and these values can be a possibility to implement a healthy work environment within the care of the elderly. Another finding in the study was that the competence within care of elderly should increase, to encounter the future changed demands on care of elderly.

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Pregnant and parenting young women rarely access community-based smoking cessation interventions. Targeted cessation interventions have been laden with challenges and have produced suboptimal outcomes. There is a paucity of qualitative research specific to young women that explores the context of their tobacco use, as well as their attitudes towards and experiences with smoking cessation supports in pregnancy and postpartum. To bridge this gap, an interpretive descriptive design was used to explore the personal and contextual factors influencing young women’s smoking behaviour during and after pregnancy. Factors were identified by analyzing influences at the multiple levels of McLeroy’s social ecological model of health promotion. Data were collected via in-depth, semi-structured interviews with young women aged 16-24 years (n=13) who smoked regularly preconception and were pregnant or parenting. Transcripts were analyzed using qualitative content analysis. Findings highlighted the complexity and chronicity of issues young women faced and emphasized the interplay of social determinants that influenced their smoking. Smoking was a crutch that helped them to relieve psychological distress stemming from exposure to adverse or traumatic experiences; and persistent stress in the context of socioeconomic hardship, neighborhood disadvantage and limited social support. Smoking also was influenced by young women’s understanding of the harms related to smoking during pregnancy and their reconceptualization of risk for smoking-related consequences postpartum. Young women described having limited discussions regarding smoking with maternity care providers and found their passive approach to cessation counselling unhelpful. They desired more comprehensive cessation support from providers. They expressed interest in a tailored group cessation program and offered suggestions for improving cessation supports for young women in pregnancy and postpartum. Study findings bridge gaps in the literature and identify appropriate next steps in addressing the issue of smoking in pregnancy and postpartum amongst young women by suggesting a multi-level approach to cessation. / Thesis / Master of Science (MSc)