Family members who provide care to their loved ones experience changes in their own health. The caregiver health model (CGHM) is a new model that identifies health holistically and identifies four determinant(s) that contribute to the health status of the family caregiver. The purpose is to introduce the CGHM: Hypothesis 1: the determinants of health in the CGHM contribute to the health of the Caregiver, Hypothesis 2: the determinants of health contribute to changes in the caregivers’ health at 8 and 16 weeks, and Hypothesis 3: a change in health occurs from baseline to 8 and 16 weeks. Methods: A descriptive, longitudinal design used three data collection points and five survey instruments. Community recruitment (N = 90) occurred through word of mouth and newspapers. Inclusion criteria consisted of being a family caregiver, living in a rural residence, and providing care to elders with necessary activities of daily living (ADLs) and/or instrumental ADLs (IADLs). Following a participant generated phone call to provide consent, caregivers received an initial study packet, additional packets were sent upon return of the previous packet. Analysis for the three hypotheses included multiple backwards stepwise linear regression, generalized estimating equations (GEE), and analysis of variance (ANOVA) α = 0.05. Results: A significant decrease in mental (p < 0.01) but not physical health at 8 weeks (p = 0.38) and 16 weeks (p = 0.29) occurred over time. Two determinants displayed significant (p < 0.05 or less) changes in mental and/or physical health at one or more time points. Study limitations include caregiver entry at varying times and self-report of elder nursing needs and medical conditions. Conclusions: Findings support two of the four determinants contributing to caregiver health

Bakgrund: Omvårdnadsepikrisen är den utskrivningsanteckning som sammanfattar viktiga händelser under en patients vårdtid rörande omvårdnadsfaktorer när vårdepisoden tagit slut. Termen omvårdnadsepikris ingår som ett så kallat huvudsökord i den svenska dokumentationsmodellen VIPS. Denna modell har tagits fram för att ge stöd åt de olika delarna av omvårdnadsprocessen. Neuropsykiatriska kliniken, avd 1 (NP) vid Universitetssjukhuset Malmö Allmänna Sjukhus (UMAS) genomför ett fortlöpande utvecklingsarbete gällande utformningen av omvårdnadsepikriser vari denna studie ingår som en del.Syfte: Att undersöka vilken betydelse omvårdnadsepikrisen utfärdad av NP har som underlag i det fortsatta omvårdnadsarbetet för sjuksköterskor verksamma inom hemsjukvård, särskilda boenden samt korttidsboenden. Metod: Kvalitativt och kvantitativt utformad enkätstudie baserad på ett strategiskt urval och presenterat med hjälp av en deskriptiv analysmetod. Totalt deltog 18 respondenter.Resultat: Sjuksköterskorna använder omvårdnadsepikrisen utfärdad av NP som ett underlag i den fortsatta omvårdnadsplaneringen. Detta motiverades bland annat med argumenten att det är viktigt att få bakgrundsinformation om patienten för att lättare kunna möta dess omvårdnadsbehov.Slutsats: De sjuksköterskorna som ingår i studien använder NP:s omvårdnadsepikriser som ett underlag för planering av det dagliga omvårdnadsarbetet. Att dessa sjuksköterskor tycker att NP:s omvårdnadsepikriser är till hjälp vid den fortsatta omvårdnadsplaneringen kan också utläsas. Eftersom studiens svar i princip bara behandlar åsikter om just NP:s omvårdnadsepikriser kan resultatet inte överföras såsom gällande för andra avdelningar inom slutenvården. Viss generalisering för undersökt poulation, det vill säga kommunala vårdboende som tar emot eller potentiellt kan ta emot patienter från NP, bör dock kunna göras. / Background: The note that summarizes important events regarding nursing factors during a patients care episode, after the episodes’ ending, is the nursing discharge note. The term nursing discharge note is a part of the Swedish nursing documentation model VIPS which is a model containg of different headwords, where of the nursing discharge note is one. The model has been developed to support the different parts of the so called nursing process. The Neuropsychiatric clinic, department 1 (NP) at the university hospital Universitetssjukhuset Malmö Allmänna Sjukhus (UMAS) is carrying out continuous work to develop their nursing discharge note where of this study can be seen as one part. Aim: To investigate what importance the nursing discharge note written by NP has as a base in the continuous daily care planning performed by nurses in homecare or at different kinds of livings for patients in municipal geriatric care. Methods: A qualitative and quantitative questionnaire study based on a strategic sample and presented with a descriptive method of analyzes. In total 18 informants participated.Results: The nurses participating in this study use the nursing discharge note written by NP as a base in their continuous daily care planning. The importance of knowing the background information about a person to easier meet his need as a patient was mentioned as one of the reasons.Conclusions: The nurses participating in this study use the nursing discharge note from NP as a base for their daily care planning. It can also be understood that these nurses find that the nursing discharge note from NP is helping them in their care planning. The results from this study cannot be used as a guideline for other departments within hospital care as it only focuses on NP’s nursing discharge note. Though, within the investigated population, a certain generalization could be possible to do.

Objective . To examine the feasibility of family participation in a nurse-supported, multicomponent intervention program for delirium prevention in the older hospitalized adult. Background . Delirium is the leading complication of hospitalization for older adults and is associated with important consequences including increased morbidity and mortality, increased use of health care resources, and increased caregiver burden. The potential role that family caregivers could play in delirium prevention and how nurses could facilitate family participation has been largely unexplored. The Calgary Family Intervention Model (CFIM), operating on the assumptions of a family-centered care philosophy, provided a framework for understanding the feasibility of family participation in delirium prevention efforts. Methods . A descriptive exploratory design using a convenience sample of 15 family caregivers of older hospitalized adults at a large teaching hospital was used to address the research questions. For the Family Participation Delirium Prevention Program (FPDPP), family caregivers implemented five intervention protocols targeted toward four baseline risk factors for delirium and self-tracked daily intervention completion. Feasibility was based on rates of intervention completion, and consideration of the barriers and facilitators for participation based on older adults' and family caregivers' responses on discharge questionnaires and staff nurses' responses on a questionnaire. Results . Intervention completion was highest for the orientation protocol (83.5%), followed by the vision protocol (81.5%), therapeutic activities protocol (76.9%), hearing protocol (73.6%), and early mobilization protocol (55.3%). Three themes emerged on the barriers and facilitators for family participation: therapeutic relationships, partnership, and environment. The barriers and facilitators were generally consistent with the concept of family-centered care as described in the CFIM. Conclusion . Based on the rates of intervention completion, it appears that the FPDPP is feasible for implementation in clinical practice. A remarkable level of agreement was found on the concept of the feasibility of family participation among older adult patients, family caregivers, and staff nurses with the common themes that emerged. Key to its successful implementation will be recognition and attention to the barriers and facilitators for participation. In addition, operating from a framework of family-centered care, nurses can advocate for environments that support family caregivers' participation in a delirium prevention program.

Hearing loss, as a result of old age, has been linked to a decline in speech perception despite the use of additional listening devices. Even though the relationship between hearing loss and decreased speech perception has been well established, research in this area has often focused on the behavioral aspects of language and not on the functionality of the brain itself. In the present study, the mismatch negativity, an event related potential, was examined in order to determine the differences in speech perception between young adult participants, geriatric normal hearing participants, and geriatric hearing-impaired participants. It was hypothesized that a significantly weaker mismatch negativity would occur in the geriatric hearing-impaired participants when compared to the young adult participants and the geriatric normal hearing participants. A passive same/different discrimination task was administered to 10 young adult controls (5 male, 5 female) and eight older adult participants with and without hearing loss (4 male, 4 female). Data from behavioral responses and event related potentials were recorded from 64 electrodes placed across the scalp. Results demonstrated that the mismatch negativity occurred at various amplitudes across all participants tested; however, an increased latency in the presence of the mismatch negativity was noted for the geriatric normal hearing and the geriatric hearing-impaired participants. Dipoles reconstructed from temporal event related potential data were located in the cortical areas known to be instrumental in auditory and language processing for the young adult participants; however, within the geriatric normal hearing and the geriatric hearing-impaired participants, dipoles were seen in multiple locations not directly associated with language and auditory processing. Although not conclusive, it appears that within the geriatric normal hearing and the geriatric hearing-impaired participants there is slower processing of the speech information, as well as some cognitive confusion which leads to fewer available resources for interpretation.

In the context of health care delivery for senior citizens, this research utilizes three studies that examine the development and implementation of health policy and the factors that can directly or indirectly impact the effective delivery of health services to senior citizens. It utilizes three essays employing mixed methods (qualitative and quantitative) methods including semi structured interviews, multiple regression and partial least squares structural equation modelling to examine the extent to which the implementation of health services delivered attributes of primary and integrated care to seniors. The two essays identified methods, approaches and strategies of integrated care relevant to the development of policy that can be successfully implemented when the contextual issues that older people consider to be important in maintaining their functional capabilities and their motivation to improve health as perceived by them are addressed. Consequent upon the results from these studies, the third essay examines the methodological issues on integrated geriatric care implementation when guidelines for effective policy development identified were not followed. By highlighting the relationship between effective policy and patient satisfaction, these three essays' recommended approach enhances the theory of health design that confirms that theoretical models of primary care must incorporate the system, process and service delivery levels of care to optimize seniors health.

Throughout the last decades, evolving treatment-opportunities provide a better chance of cure and thereby a higher percentage of patients is being treated for chronic disease (Robert Koch Institut, 2016). As treatment-toxicity, side effects and disease-derived symptoms remain high, it has become crucial to assesses parameters reflecting patients’ perspective, instead of solely focusing on illness-centered outcomes such as survival or treatment response. During the last decades, Patient-reported outcomes (PROs) are on the rise throughout research and cancer care as a key component to capture a patient’s perspective. This work illustrates the broad framework that PROs can be conducted in. We gathered experience and pioneered a systematic PRO-assessment in routine outpatient care, which continues to be updated. We identified a suitable PRO-based geriatric screening tool to avoid a time and resource consuming comprehensive geriatric assessment. Furthermore, we explored the beneficial effects of a PRO-based tailored intervention on HRQoL and provided effect-size estimations. Assessing PROs yields many benefits throughout the care pathway (Andreassen et al., 2006; Basch et al., 2016; Kofoed et al., 2012; Velikova et al., 2004; Yang et al., 2018) and was shown to be feasible in different entities and treatment setting (Bennett et al., 2016; M. K. Schuler et al., 2016; Strasser et al., 2016; Warrington et al., 2019). As a strikingly large discordance between patients’ and clinicians’ perception of symptoms exists (Atkinson et al., 2016), PROs can increase the accuracy of detection of adverse events and even predict survival (Efficace et al., 2021). Based on these advantages, the EMA and the FDA advocate the use of PROs as endpoints in cancer research (European Medicines Agency, 2016; U.S. Department of Health and Human Services FDA Center for Drug Evaluation and Research et al., 2006). Throughout previous years, methodological progress has been made resulting in elaborated measurement technics such as computerized adaptive testing being applied to PRO-instruments (Petersen et al., 2018, 2020). Clinical usability was increased with development of summary scores, cut-off values and emerging normative data (Giesinger et al., 2016, 2020). Interventions based on PROs are promising (Ishaque et al., 2019; Kotronoulas et al., 2014). Despite this ever increasing body of literature on PRO, a significant number of questions remain unanswered. Firstly, there was scarce knowledge about the benefits of a PRO-based intervention in sarcoma patients as there was limited PRO-data available in this entity. Sarcomas are rare diseases, still accounting for slightly less than 1% of all malignant neoplasia worldwide. The age adjusted incidence ranged from 7.4 per 100.000 men and 6.6 per women in Germany (Ressing et al., 2018). As sarcoma-treatment is improving, side-effects and toxicity remain to occur frequently (Gough et al., 2011; McDonough et al., 2019; Reichardt et al., 2012; Storey et al., 2019; Winnette et al., 2017). Until recently, there was quite limited knowledge about the patient-reported burden in terms of HRQoL, symptoms and psychological distress in patients with STS (Tang et al., 2012). PRO-based interventions yield beneficial effects in different cancer entities. Nevertheless, the effects of a PRO-based intervention in STS-patients was scarcely explored. The YonLife-Study (Publication B, Hentschel et al., 2020) contributes new evidence that a PRO-based intervention yields beneficial effects on HRQoL and suggests a positive, yet non-significant effect on survival. Concerning symptoms, the results of the YonLife-intervention remain far from being encouraging. As effects sizes are available now, RCTs which are powered to a confirmatory purpose could be performed in this population. Secondly, the importance of PROs are emphasized by authorities such as EMA or FDA that emphasize the need to incorporate PRO in scientific studies. Yet during the early 2010s, the actual incorporation of PROs in clinical routine was limited in Germany. We therefore designed and established a routine assessment of PROs (Publication C, (Trautmann, Hentschel et al., 2016) incorporating the automatized calculation, comparison with normative or threshold data and implemented it to our hospital information system. As until recently, feasibility data such for such an intervention is scarce, we collect measures of adherence, required time and barriers reported by staff. For the clinical benefit, the established PRO-assessment is being developed further and expanded to other departments and clinics of our institution. Thirdly, as numbers of geriatric cancer patients rise (Le Saux et al., 2019), older patients continue to be underrepresented in clinical trials (Singh et al., 2017), therefore an immense lack of knowledge on treatment-toxicities and side effects in this population exists. Treatment needs to be adapted to older patients frailty-level, which can be conducted applying a time- and resource consuming Comprehensive Geriatric Assessment (Le Saux et al., 2019). Still, there is no consensus on which domains to include and how to measure them (Hamaker, Jonker, et al., 2012). A geriatric screening can alleviate burden of conducting a whole CGA. Several screening instruments exists, yet there is inconsistent data (Kotzerke et al., 2019; Mohile et al., 2018; Soubeyran et al., 2014) which tool yields the best predictive performance. Our project aimed to compare three of the available screening tools (VES-13, G8, POT/CARG). Being far from having a perfect predictive performance, the POT/CARG occurs to be the screening instrument with a high sensitivity and sufficient negative predictive value. Furthermore, our research supports the increasing evidence that ultra-short-screeners such as ECOG state or age bear only insufficient predictive performance.:1. Introduction 1.1 What are Patient-reported outcomes (PROs)? 1.2 Assessment of PROs 1.2.1 Feasible in clinical routine, improving relevant outcomes 1.2.2 Improving diagnostic accuracy 1.2.3 Supporting drug development 1.2.4 Evolving measurement techniques and standardization 1.3 PRO-based feedback interventions 1.4 PRO-based geriatric screening 1.5 Research needs 1.5.1 Identifying a suitable geriatric screener 1.5.2 Limited PRO-data on Soft-Tissue Sarcoma (STS) patients 1.5.3 Feasibility-research in routine care 1.6 study aims 2. Methods 2.1 Design and Sample of Publication A 2.2 Design and Sample of Publication B 2.3 Design and Sample of Publication C 2.4 Instruments 2.5 Non-PRO-Outcomes 2.5.1 Predictive performance 2.5.2 Survival analysis 2.5.3 Feasibility analysis 2.6 Statistical Analysis 2.6.1 Sample Size Estimation 2.6.2 Non-participation and drop-out analysis 2.6.3 Regression Analyses 2.6.4 Statistical software 2.6.5 Statistical analysis plans 3. Outline of Publications Publication A Publication B Publication C 4. Discussion 4.1 Main findings, integration in existing research and research implications 4.1.1 Geriatric screening tools 4.1.2 PROs in soft tissue sarcoma (STS) 4.1.3 Implementation of PROs into routine care 4.2 Strengths and Limitations 4.2.1 Strengths 4.2.2 Limitations 5. Conclusions 6. Summary 7. References 8. Appendix 8.1 Darstellung des eigenen Beitrags 8.1.1 Darstellung des eigenen Beitrags zur Publikation A 8.1.2 Darstellung des eigenen Beitrags zur Publikation B 8.1.3 Darstellung des eigenen Beitrags zur Publikation C 8.2 Erklärung über die eigenständige Abfassung der Arbeit 8.3 Curriculum Vitae 8.4 Publikationsverzeichnis 8.5 Danksagung

Alzheimer’s disease (AD) affects over 5 million individuals in the United States annually. By the year 2050, the number of individuals living with AD is projected to triple (Latest Alzheimer’s Facts and Figures, 2016). Although there is no cure for AD, there are many prescriptive pharmacologic agents used to help manage the clinical manifestations of the disease. Complementary and alternative medicines (CAM) and herbal supplements are also used in the treatment of AD, however indications for their use and effectiveness during the progression of AD have not been examined. The purpose of this study was to examine the use of herbal supplements in managing the clinical manifestations of AD. The secondary purpose was to compare a variety of herbal supplements used to treat the clinical manifestations of AD and to evaluate the most widely used and most beneficial for clinical practice. A literature review examining herbal supplements and their risks, benefits, and uses in AD was conducted from multiple online databases. Peer reviewed articles published in the English language from 1998-2016 that focused on herbal supplements used to control the clinical manifestations of mild to severe AD were included for synthesis. Results from 14 studies that used herbal supplements as a treatment for the clinical manifestations of AD were compared for effectiveness in the management of symptoms. The findings suggest Ginkgo Biloba is the most effective and widely used herbal supplement in the treatment for cognitive decline in AD. Other supplements including Saffron, Curcumin, Cistanches Herba, and Sage were found to improve memory function and activities of daily living in individuals with AD. Herbal supplements can be cost effective and easier to retrieve for many individuals in comparison with prescriptive drug therapy. Although the research demonstrated beneficial results with the use of herbal supplements, the limitations of these studies make the application of the results problematic. Therefore, further research in this area is required.

Background: Fear of falling has significant adverse physical and psychological effects for the community-dwelling older adult. Objective: The purpose of this study was to assess fear of falling in community-dwelling older adults and explore participant perceptions of fear of falling assessments and interventions. Methods: A mixed methods case study was utilized to gain an in-depth understanding of older adults' perceptions. It consisted of quantitative data collection by objective measures and qualitative data collection by four individual in-depth interviews. A sample of four community-dwelling adults aged 65 years and older and living in Orlando, Florida, completed the study in their home environment. To combine quantitative and qualitative data for each participant, a case-specific analysis was used, resulting in narratives with a storytelling approach aiming to explore each participant independently. This was followed by a cross-case analysis to gain a more comprehensive understanding of the participants in relation to one another. Results: Four themes emerged: 1) Feedback from an objective measure is valuable; 2) Family experiences with fear of falling drive personal interventions; 3) Fundamental assessments for fear of falling are missing, and 4) Fluctuating definitions of "fear" contribute to difficulty in assessments and interventions. Conclusion: Clear perceptual themes developed to provide a comprehensive understanding of community-dwelling older adults' perceptions of fear of falling assessments and interventions. Future research is needed to determine how to best combine feedback-oriented assessments with established interventions, such as exercise. Standardization of a subjective measure for fear of falling to use in combination with objective measures is also needed. Keywords: assessment, intervention, fear of falling, older adults, community-dwelling, mixed methods

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