BACKGROUND: The aging population in the United States will correlate with an increased number of cancer diagnoses as cancer is primarily a disease of the elderly. Providing this ever-growing group of individuals with quality surgical management, while taking into account the unique needs and desires of this cohort, is a great challenge facing both geriatricians and surgeons going forward. The best approach to ensure that oncogeriatric patients receive the best tailored treatment is through the completion of a pre-surgical geriatric assessment. However, only a minority of oncogeriatric patients is undergoing a comprehensive pre-surgical geriatric assessment despite the majority of geriatricians and surgeons acknowledging its importance in order to properly risk stratify their patients. LITERATURE REVIEW FINDINGS: Multiple theories exist as to why geriatric assessments are not being utilized more frequently, but the most probable answer is that these assessments are very time-consuming, making it virtually impossible for incorporation into a healthcare provider’s busy schedule. Comprehensive literature review regarding geriatric assessments amongst the oncogeriatric population found that the most sensitive and specific domains of the geriatric assessments predicting morbidity and mortality include Frailty Index, Social Support Survey, Mini-Nutritional Assessment, and Geriatric Depression Screening. PROPOSED METHODS: A novel educational intervention will be proposed to teach Physician Assistant and Medical Students about the domains of the geriatric assessment most predictive of post-surgical risk during their surgical clerkship. The curriculum will utilize both simulation- and competency-based education training under the guidance of geriatricians and surgeons. Students will first learn the necessary skills in a controlled classroom environment and then proceed to incorporate these skills during their clerkship with patients on their service. CONCLUSIONS: The goal of the proposed method is to instill the confidence and skills necessary to provide an accurate geriatric assessment for oncogeriatric patients in future clinicians. The field of geriatric oncology is going to grow exponentially in the up-coming years and familiarizing future clinicians with the most predictive domains regarding surgical outcome will improve treatment outcomes for oncogeriatric patients in the immediate and foreseeable future.

Introduction Older adults’ sexuality has been linked with a number of factors associated with wellbeing. Despite sexual practices changing across the lifespan, sexuality remains an important part of the identity of older adults. The ageing population of the United Kingdom is placing increasing demands on care homes, yet despite the recognised benefits of older adults’ sexuality best practice guidelines for care homes either fail to comment on residents’ sexuality or provide recommendations which are too minimal or vague to operationalise. Most research exploring older adults’ sexuality in care homes has focussed on the views of health and social care practitioners who report on their lack of willingness to engage with residents about their sexuality needs. Research which attempts to explore older adults’ sexuality in care homes from the perspective of residents favours quantitative research methods, an approach which arguably fails to acknowledge the changes in sexual expression which occur with age. Furthermore, the lack of consensus regarding the conceptualisation of the term ‘sexuality’ across the literature limits the extent to which research findings can be synthesised. This research sought to contribute to understandings of older adults’ sexuality experiences in care homes from a first-person perspective by adopting a prospective planning approach to explore prognostications about how transitioning to a care home might impact upon experiences of sexuality and participants’ hopes and fears regarding care provision. To increase the interpretability of findings and contextualise responses, the definition of sexuality from the perspective of older adults was also considered. Methods Semi-structured interviews were conducted with ten participants to explore three broad questions: (1) How do older adults define ‘sexuality’? (2) What impact might a care home have on sexuality experience? (3) How would individuals like sexuality to be acknowledged by care services? Face-to-face and telephone interviews were audio recorded, transcribed, and analysed using a hybrid inductive/deductive thematic analysis approach at a mixed manifest/latent level. Results Participants defined sexuality as a multifaceted component of self-identity which held individual meaning and changed across the lifespan. Participants’ definitions of sexuality were compared with the World Health Organisation’s (WHO) working definition of sexuality, and areas of difference and similarity were identified. Participants anticipated that becoming a resident of a care home would prompt significant (and often negative) changes with regards to how they could experience sexuality. Participants wanted services to demonstrate attempts to minimise the environmental impact on sexuality and promote positive experiences in a manner that was responsive to individual need. Discussion While used as an ageless term, ‘sexuality’ has different understandings and applications across the lifespan and remains an important part of the identity of older adults. Findings from this study indicated that participants expected to embody the role of the non-sexual resident when transitioning into a care home, changes in identity which were predicated on living in an environment which was predicted to neither acknowledge nor facilitate positive sexuality experiences.

Background: Thai culture venerates caring for elders, thus care homes are stigmatised as the domain of poor older adults with no family. This impacts negatively on the psychological wellbeing of older residents and the high prevalence of depression reported among them. However, little is understood about the key factors influencing the depressive symptoms and how such stigma is experienced among care home residents. This study explored factors associated with depressive symptoms, internalised stigma, self-esteem, social support and coping strategies among residents from the perspectives of residents and staff. Methods: Mixed methods research (convergent parallel design) was conducted in two care homes in northeast Thailand using a cross-sectional questionnaire, in-depth interview and non-participant observation. A cross-sectional questionnaire study was conducted with 128 older care home residents (with a response rate of 98.46%) using the 15-Item Thai Geriatric Depression Scale, Internalised Stigma of Living in a Care Home Scale, Thai Version of Rosenberg Self-Esteem Scale, Thai Version of Multidimensional Scale of Perceived Social Support and a Coping Strategies Inventory Short Form. Qualitative interviews were conducted with 30 older residents and 20 care home staff purposively sampled from both care homes. Non-participant observation was conducted in various public spaces of the care homes in both care homes for one month. Quantitative data was analysed using the Statistical Package for Social Science (SPSS) IBM PASW Version 22.0 for Windows. Thematic analysis was used to analyse the qualitative data. Results: Depressive symptoms were significantly correlated with internalised stigma, self-esteem and social support (r= 0.563, -0.574, -0.333; p< 0.001), respectively. Perceived internalised stigma of living in a care home was the strongest predictor of care home residents reporting depressive symptoms (odds ratio=9.165). In addition, the qualitative research explained the dynamics of the process of stigma related to three elements: the causes of stigma, the manifestation of stigma and the mitigating factors. Negative beliefs about care homes and people who live in them, coupled with negative attitudes and stereotypes toward older people, are the causes of stigma which are dominated by negative societal attitudes towards care homes. In addition, care home features contributing to stigma and staff issues are negative perceptions and experiences among residents whilst living in care homes. These factors trigger residents exhibiting negative emotions and behaviours (including depressive symptoms). However, the mitigating factors help to diminish or control the manifestation of stigma. These include coping strategies, social support and activities provided in care homes. Conclusion: Older adults who perceived high internalised stigma of LiCH were over nine times as likely to report experiencing depressive symptoms. This was related to the dynamics of the process of stigma with three elements (the causes, the manifestation and the mitigating factors of stigma). The causes of stigma are the factors creating the negative emotions and behaviours among residents living in Thai care homes. In addition, the mitigating factors help to diminish the manifestations of stigma. The most compelling need to improve the physical and mental wellbeing of elderly residents of care homes in Thailand is to combat the societal and cultural stigma associated with this population. This may be achieved through media collaboration, educational interventions in the care home setting and organising social activities for residents and their families.

This dissertation is concerned with the problem of scientific assumptions as it relates to research in gerontology. There are three major areas emphasized in the thesis. First, there is a consideration of the epistemological conditions that give rise to the problem of assumptions and meanings in science. Secondly, a number of different ways of addressing this issue are discussed and an alternative Hermeneutic approach is explicated. This approach constitutes a particular kind of philosophical analysis and is suggested by the insights of Hans Gadamer. Finally, on the basis of the Hermeneutic approach, two major characterizations of research on adult and gerontological intellectual and social competence are identified, namely, a restricted and an expanded picture. In addition, these two characterizations are further clarified by means of a discussion of the contrasting ontological orientations that are presupposed in the restricted and correspondingly, in the expanded picture. The overall purpose of the thesis is to show that a particular kind of philosophical inquiry assists in the integration of disparate forms of research in psychosocial gerontology. In addition, this procedure provides conceptual support for a different understanding of various phenomena associated with human aging that is emerging in the field, namely, the expanded picture. / Graduate and Postdoctoral Studies / Graduate

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This study aimed to explore factors affecting seniors' intention to relocate to a senior living facility. More specifically, the purpose of this study was to examine the influence of push and pull motivational factors and perceived barriers on seniors' intention to relocate to a senior living facility (SLF). In addition, the mediating role of perceived barriers on the relationships between push motivational factors and intention to relocate and pull motivational factors and intention to relocate were explored. The data of the study was collected from 363 seniors. Structural equation modeling (SEM) analysis was conducted to test the study hypotheses. The results indicated that health related, social and family/friend related, housing and property related push motivational factors and facility related pull motivational factor positively influenced seniors' intention to relocate to SLFs. In addition, the study results revealed that family related barriers, economic barriers, socio-psychological barriers, and knowledge and information barriers negatively affected seniors' intention to relocate to SLFs. In terms of the mediation effects, the study results indicated that (1) family related barriers mediated the positive relationship between health related push motivational factor and intention to relocate; (2) economic barriers mediated the positive relationship between facility related pull motivational factor and intention to relocate; (3) socio-psychological barriers mediated the positive relationship between health related push motivational factor and intention to relocate; and (4) socio-psychological barriers mediated the positive relationship between facility related pull motivational factor and intention to relocate. The findings of this study provide valuable theoretical contributions in the context senior living literature and important practical implications for SLF operators, health care facilitators and government agencies.

Book Summary: The 4th Edition of the gold standard of rehabilitation resources is now in full color and thoroughly revised and updated to reflect the art and science of practice today! A compendium of frequently used, but rarely memorized information organized for easy reference, it covers an extraordinary breadth of topics—from the full range of basic scientific information (neuroanatomy and clinical neurology, osteology and clinical orthopedics, general anatomy, cardiac and pulmonary anatomy) to the treatments and methods used in modern rehabilitation practice. With its outcome and evidence-based focus and several expert contributors, this text is a must for PT’s at any stage in their career.

Purpose: To explore how older people with complex problems experience and make sense of frailty in their daily lives. Relevance: Frail older people have complex care and support needs that are currently challenging the health and social care system. There is a need for more appropriate models of service provision that can deliver personalised care for frail older people. Although there is an increasing body of literature that has explored the concept of frailty from a biomedical and functional perspective, there is a lack of research-based evidence exploring the personal experience of frailty from an older person’s perspective. Study design: A prospective, longitudinal, ethnographic case study design was adopted. Ten cases were studied over a period of two and a half years. Each case comprised an older person, a community matron and a significant other, such as a daughter. Cases were followed up monthly for a minimum of six months or until death. In total, 56 care visits between an older participant and their community matron were observed and 54 interviews were conducted with older people. Medical and nursing documents were reviewed for each case. A narrative approach to data analysis was undertaken, with identification of common themes within and across cases. Findings: Three themes illuminated the experience of living with frailty. ‘Transitions in health and illness’ details how the older people in this study experienced transitions in health and illness in later life. ‘Dimensions of frailty’ reports perceptions of frailty in later life and accounts of how feeling frail relate to episodes of uncertainty. ‘The provision of health and social care – rhetoric and reality’ explores the inter-relationship between the older person’s world of declining health and the episodic interactions with health professionals. Conclusions: This study offers a number of original contributions to the body of knowledge pertaining to the personal experience of frailty. First, new insights into the interrelationship between frailty and transitions in health and illness have been revealed, particularly how transitions in health and illness contribute to and shape the experience of frailty. Second, frail older people experience temporary moments of ‘liminality’ which are expressed as uncertainty and/or feeling frail. It is in these situations where there is real therapeutic potential in exploring the emotional experiences linked to a frail older person’s interpretation of events. Third, there are challenges to engaging in partnership working with frail older people. In some circumstances frail older people can exercise autonomy and make decisions that are relevant to their own situation. However, often community matrons’ work is framed by a policy of clinical assessment and therefore at times assumptions underpinning the label of frailty can challenge partnership working. These competing demands need to be considered by policy makers, commissioners and providers of community services and practitioners alike. Only then can effective supportive care services be delivered to frail older people.

There are concerns about cognitively impaired older patients’ experiences of general hospital care. Nottingham University Hospital developed a medical and mental health unit (MMHU) as a demonstration model of best practice dementia care. This thesis describes a controlled clinical trial comparing patients’ experiences of care on the MMHU to standard care wards. Patient experience was measured using the structured non-participant observational tool Dementia Care Mapping. Observations lasted 6 hours during which a score was recorded every five minutes for the patient’s mood and engagement and activity, together with incidents of enhancing and detracting staff behaviours. Noise (alarms, background noise and co-patients calling out) was recorded. 90 (46 MMHU, 44 Standard care) patients were observed between March and December 2011. At admission, most characteristics of patients on MMHU and standard care were similar. However, patients observed on MMHU had more behaviour disturbance, more often were care home residents and were less disabled than those observed on standard care. Patients on MMHU experienced a median 11% (95% Confidence Interval (CI) 2%, 20%) improvement in the proportion of time in positive mood and engagement (79% versus 68%); a median 3 (95%CI 1, 5) more enhancers (4 versus 1); a median 13% (95%CI -17%, -7%) less time noise could be heard (79% versus 92%) but a median 15% (95%CI 1, 23%) increase in proportion of time co-patients called out (21% versus 6%). Patients on MMHU had a better experience of care than those on standard care wards in terms of their mood and engagement, number of enhancers and improved noise levels, but experienced more co-patients calling out. This is the first study measuring an intervention to improve cognitively impaired older patients’ experiences in the general hospital and the first study to use the Dementia Care Mapping tool to evaluate an intervention in this setting.

Falls are a major cause of injury fear of falling and death affecting 24% of older people annually. Falls have a major impact on hospital services, are an important cause of carer strain and admission to long term care. Multifactorial interventions delivered to fallers are effective in reducing falls rates by 25%. However, no UK studies have evaluated the role of screening older people living in the community and offering those at high risk a falls prevention programme. This work describes two studies – the evaluation of a postal falls risk screening tool, and a randomised controlled trial assessing the benefits of offering a falls prevention programme to those identified as being at high risk. 335 older people were recruited into the screening study, using a modified version of the Falls Risk Assessment Tool. The sensitivity was 79%, specificity 58%, positive predictive value 50% and the negative predictive value 83%. In the RCT, 364 community-dwelling older people at high risk of falls were randomised into a pragmatic, multicentre trial evaluating falls prevention programmes. 181 were allocated to the control group and 183 to the intervention. The primary outcome was the rate of falls; the adjusted IRR was 0.73 (0.51-1.03), p=0.071. There were no significant differences between the groups in terms of the proportion of fallers, recurrent fallers, medically verified falls, injurious falls, time to first fall or time to second fall. Nor were there significant differences in terms of institutionalisation, mortality, basic or extended activities of daily living, or fear of falling. Further work on testing falls prevention interventions for acceptability is required, followed by a further adequately powered RCT to determine the clinical effectiveness of a systematic screening programme and intervention. At present, there is insufficient evidence for health care commissioners to recommend screening and intervention for falls.