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.

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.

There is biochemical evidence that the acute phase protein, a1-antichymotrypsin (ACT), is involved in Alzheimer's disease (AD), the most common form of dementia. Inflammation increases the level of ACT in the plasma, and it has been suggested that AD provokes chronic neuroinflammation. One of the key proteins in AD is beta-amyloid which associates with ACT in the senile plaques characteristic of AD. Studies to demonstrate a genetic association between polymorphisms in the ACT gene and AD have, to date, been inconclusive and contradictory. The discovery, in our laboratory, of a single nucleotide polymorphism in the promoter region of ACT suggested a new marker to test for a genetic association between ACT and AD. To determine if the ACT promoter polymorphism had a functional effect which could modify the risk of AD, the promoter region was cloned into reporter constructs and transfected into mammalian cells in culture. These included hepatocytes, astrocytes, neuronal cells and mixed population neural cells, and these were stimulated with oncostatin M. In astrocytes, the T allele of the promoter allele demonstrates 208% and 146% higher activity than the G allele under basal and stimulated conditions, respectively. In neuronal cells these values are 37% and 46%. Electrophoretic mobility shift assays demonstrated differences in binding affinity of a DNA-binding protein, probably TFIIB, and the two alleles of the ACT promoter polymorphism. However, an analysis of ACT promoter genotypes in AD cases (n= 389) and controls (n= 335) revealed no significant difference in the distribution of genotypes between cases and controls (p= 0.250), nor did any ACT promoter genotype appear to modify the age of onset of AD (p= 0.997). The association between the ACT -51bp polymorphism and early onset AD was not investigated, due to the small number of EOAD cases in the population studied.

UK care home residents are frail, dependent and multimorbid. General practitioners (GPs) provide their healthcare but there is evidence that existing provision fails to meet their needs. Comprehensive Geriatric Assessment (CGA) comprises comprehensive multidisciplinary assessment, goal setting and frequent review. This thesis considers a possible role for CGA in UK care homes through three research projects. The Care Home Literature Review (CHoLiR) was a systematic mapping review of randomized controlled trials (RCTs) in care homes. It found no evidence supporting CGA as a whole but described some CGA components supported by RCTs: advanced care planning; interventions to reduce prescribing; staff education around dementia and end-of-life; calcium/vitamin D and alendronate in preventing fractures and osteoporosis; vaccination/neuraminidase inhibitors in preventing influenza; functional incidental and bladder training for incontinence; and risperidone/olanzapine for agitation. The Care Home Outcome Study (CHOS) was a longitudinal cohort study recording dependency, cognition, behaviour, diagnoses, prescribing, nutrition and healthcare resource use in 227 residents across 11 care homes over six months. It reported high levels of dependency, cognitive impairment, malnutrition, multimorbidity and frequent behavioural disturbance. Polypharmacy and prescribing errors were common. Variability between homes and individuals was significant for most baseline and outcome measures. Staff Interviews in Care Homes (STICH) was a qualitative interview study of 32 staff working with care homes including: GPs; care home managers and nurses; NHS community nurses and specialist practitioners. It described care defined by discontinuity and lack-of-anticipation; driven by communication failure, inadequate training and expertise in frail older patients, and arbitrary boundaries between care homes and the NHS which interfered with care. Using the findings of these studies, the author proposes a model of care which is multidisciplinary, guided by comprehensive assessment, reinforced by frequent review and delivered by experts in the care of frail older patients: CGA has a role in UK care homes.

Purpose: To study this locally unexplored scenario and provide a platform of knowledge base and information on physical restraint use, securing relevant information of essence to the older person, care provider and policy makers within care homes. Aims and objectives: This dissertation focuses on care providers’ observations and perceptions concerning (a) the types of restraint devices used in government and privately managed long term care homes for older persons in Malta, (b) their mode and extent of application, (c) older person characteristics which may be conducive to physical restraint use, (d) older persons’ reactions to restraint use (e) care providers’ perceptions to physical restraint use within the context of work, environmental and safety concerns, and (f) how the effects of physical restraint use could influence the older person’s rights, autonomy and integrity. Relevance: The demand for long term care for older persons increases as the population ages. This, coupled with an increasing demand for human resources, aggravates the risk for less humane care for frail and vulnerable older persons. Person centred care is the fulcrum for the quality of service delivery in the care of older persons. It recognises the distinctiveness of each and every person irrespective of mental and functional capabilities, and moves away from the routine-driven, task-oriented and depersonalised services to focus on specific personal needs. Although there is an increasing international body of literature, exploring the concept of physical restraint use in care homes, there is a lack of research-based evidence exploring care providers’ holistic approach to physical restraint use in long term care settings in Malta. More importantly, published papers fail to captivate the human and humane elements of the physically restrained older person. The relevance of physical restraint use is central within care home environments. The knowledge of the framework within which this use operates is necessary for the establishment of a paradigm that places the older person within the hubs of her/his care. Study design: A questionnaire booklet incorporating quantitative and qualitative components was developed, designed and adopted. The questionnaire was anonymous and self-administered by care providers within all Maltese care homes (n=13), managed by the government and private sectors. All care providers within these care homes were eligible for study participation, (medical, allied health, nursing, and nursing support staff). Care providers have direct contact with the older persons, and are therefore in a position to provide first-hand information about the use of physical restraints. Participants were requested to complete and return ‘Physical Restraint Use’ (PRU) questionnaire booklet developed for this study. Four hundred and thirty four questionnaire booklets were distributed and 180 booklets were returned over a 3 month time frame, providing a response rate of 41.5%. Findings: A high observed incidence of physical restraint devices particularly for bed rails and harnesses was registered within both the government and privately managed care homes. Moreover, respondents acknowledged the use of 16 different types of devices, which raised questions as to multiple use of restraining. Privately managed care homes reported a slightly higher incidence of observed devices in use. The observed total duration of restraints in excess of 2 hours by far exceeded durations less than 2 hours in both government and privately managed care homes. Data pertaining to the private care homes points to the existence of potential continual application of restraint. With respect to observations of modalities of physical restraint use (person recommending, explaining, monitoring and deciding, and documentation), within government and privately managed care homes, a consistent statistically higher involvement of management staff in all of the procedures related to the use of restraining was reported. This was however not evident with respect to documenting restraint use within the private sector. Additionally family members/substitute decision makers had a greater influence on recommending restraint use and its removal within privately managed care homes. Nursing support staff offered a greater contribution to monitoring, documenting restraint use in private than in government managed care homes, whilst nurses in government homes contributed more to monitoring restraint use than their professional counterparts within private homes. Care providers’ attitudes on the use of restraining were reported to be the strongest advocators for using physical restraints within care homes, rather than issues related to older persons themselves such as mobility and physical limitations, cognitive problems, continence issues, problems with communication/hearing/vision and activity participation and pharmacological treatment. Respondents also acknowledged observing adverse reactions to restraint use. Care providers reported restlessness to be the most observed reaction from older persons to physical restraint use (87.9%), followed by physical and cognitive consequences (66.7%) and apathy (30.3%). Participants were uncertain that there would be no serious concerns related to work, environment, safety, and caring, should restraints be reduced, scoring between 3.0 and 4.0 on a 5-point Likert scale, with high scores expressing high concerns. Further analysis revealed that both care home sectors tended to favour least restraint use but were reluctant to remove restraint completely. Similarly, private care home respondents disagreed more than government care home respondents with the statement that the majority of physical restraints in use are necessary while nursing and nursing support staff showed a higher agreement with physical restraining being an invasion of a human right than did managers. Training did not impact on the use of restraining within the care homes. . Conclusion: This study highlighted the sensitivity surrounding physical restraint use. It substantiated published data and also offered novel contributions to the body of knowledge pertaining to the physical restraints and their use. Primarily, the study indicated that training had no impact to effecting restraint minimisation approaches within the care homes. Secondly, respondents acknowledged the use of 16 different types of restraining devices. Also, arguments that bed rail use was not considered a restraining device, having become unconditionally and unquestionably the accepted norm within care homes was corroborated through the high reported observed incidence of use. The study also offered a fresh insight into the modalities of physical restraint use, (recommendation to, explaining on, and monitoring/removing restraint device). Few insights into the impact of physical restraining on the human and humane aspects of older person care were captivated in this study, more so as the sensitivity surrounding physical restraining required that the investigation be carried out through care providers’ observations. This situation, within this project, was perhaps the biggest contribution yet, moreover when the study was indicative that care providers’ attitudes towards restraint use were reported to be the strongest advocator for their use. At its most basic level, physical restraining is tantamount to blocking or limiting a person’s free ability to move as she/he pleases, thus infringing on the older person’s human rights. Indeed, physical restraining is the inability of care providers’ to identify and address the needs of the older persons and provide innovative paradigms of care. Restraining implies a failure in people relationships and consequently in the system of care delivery. The message in the bottle must address the urgent provision for personalised services that enable the older person to make full decisions about her/his care through the support of care providers when called for and at later stages through advocates. It is only through these approaches that policies and guidelines could be put in place and managed effectively and efficiently.

Background Falls in older people result in harm for individuals and are a major public health problem, but there is little published data on the recording and incidence of falls seen in primary care, with which to consider the implications of recent policy initiatives. A range of factors contribute to falls risk. Amongst these, the role of some medications is well established, but the evidence base regarding the effects of some of the most commonly prescribed medications remains meagre and inconsistent. Aims The project aims to quantify the overall incidence and distribution of recorded falls among older people in primary care in the UK, and the associated risk of death. The falls risk profile of more recently introduced serotonin noradrenalin reuptake inhibitors (SNRls) is explored to assess whether it is more favourable than that of selective serotonin reuptake inhibitors (SSRls). Similarly, prescribing of subclasses of antihypertensive medication is explored to establish whether any of them modify risk of falling. Finally, other classes or sub-classes of medication prescribed in primary care are identified whose apparent falls risk warrants further investigation. Methods Analysis of falls and prescribing history in the electronic records of patients aged 60 years and over from The Health Improvement Network (THIN) using cohort, survival, case-control and case series study designs. Results Amongst people aged >60 years the overall crude incidence rate of recorded falls was 3.58/100 person-years (3.56-3.61), higher in older age groups, in women and least advantaged social groups, and was constant in the period 2003-2006. Fallers experienced a substantial increase in mortality (two-fold increase for recurrent fallers, and more than five-fold for those aged 60-74 years). This increase is independent of fractures recorded at the time of the fall or subsequently. People who fall have an increased rate of subsequent fracture (approximately three-fold and, for recurrent fallers aged 60-74 years more than eight-fold). There was an increased risk of current prescribing of SNRls (adjusted OR 1.79, 1.42 - 2.25) in first fall cases compared with controls. This was similar in magnitude to that seen with tricyclic antidepressants and SSRls. The increase in risk was apparent within the first 28 days after first prescription. The effects were also apparent in the self-controlled case series analysis: the incidence risk ratio for the period 1-28 days after initiation of treatment compared with unexposed periods was 1.49 (1.15 - 1.93). There was an increased risk of current prescribing of thiazides (adjusted OR 1.28, 1.16-1.42). At 3 weeks after first prescribing the adjusted risk remained 4.28 (1.19-15.42). In the case series analysis the incidence risk ratio for the period 21 days after first prescription was 2.80 (1.7 - 4.57). We found a reduced risk for current prescribing of beta blockers (adjusted OR 0.90; 0.85- 0.96), but a weakly positive effect in the case series analysis for the corresponding period IRR 1.23 (1.02-1.48). Taken together, the case-control and case series analyses of other subclasses of antihypertensives provided weak or no evidence for an effect on falls. In the hypothesis generating case-control analysis of other medication classes, unadjusted odds ratios of greater than 1.7 were found in a number of classes of medication including: laxatives, antifungals, corticosteroids, insulin, antibiotics for mild to moderate acne, and vaccines for influenza and other infections. Conclusions Older people with a recorded fall represent a group who are at increased risk of death, irrespective of whether they have a subsequent fracture. Nevertheless the incidence of falls recorded in primary care suggests that guidance about asking patients if they have fallen in the last year appears not to have been followed during the study period. The fact that the incidence rate of falls is strongly associated with social disadvantage suggests the need to target the design and delivery of interventions accordingly. The falls risk profile of SNRls, which is similar to that of SSRls and TCAs, suggests that clinicians initiating prescribing of SNRls should be alert to the increased risk of falls. Similarly, clinicians initiating prescribing of thiazides in older people, which has generally been considered a 'safe' option for older patients, should be alert to the possibility of an increased risk of falls in the first three weeks of prescribing. Case series analysis of recurrent periodic exposures can elucidate bias in classis case-control analysis of the same data, and will be useful in assessing the falls risk profile of other medications such as insulin. Given the small size of sources of detailed data about older people who fall and the imprecision in their measurement of exposure to medications and potential confounders, case-control and case series analysis of first falls in THIN represents a valuable source of new evidence about medication risk factors.

Background: Advance care planning (ACP) was originally designed to promote autonomy and is commonly conceptualised as informing treatment and decisions in the event of a person’s loss of capacity. In the UK, healthcare policy has emphasised the potential for ACP to significantly contribute to improvements in experiences of death and dying for patients and their significant others. Older people with progressive frailty are at high risk of mortality, loss of capacity and increasing dependency on carers and care services, yet uptake of ACP in this group is poor. Little is known about whether frail older people regard advance care planning as relevant or what perspectives they have on decision making for the future. Aim: To explore the expectations, experiences and understandings of frail older people and their significant others of planning for future care and to examine the implications of this for the practice of ACP. Methods: The study adopted an exploratory case study design using serial qualitative interviews and the responsive interview technique. Frail older people and their nominated carers were recruited from hospital wards in a large University Hospital NHS Trust prior to discharge. They took part in up to two interviews either in hospital or in their homes. Within and cross-case qualitative analysis was undertaken. Findings: Sixteen frail older people and eight significant others were recruited (Seventeen female, seven male, age range 70-96). The study found that frail older people experience profound uncertainty, associated with rapid changes to their physical and/or mental state and complex challenges in everyday life. Consequently, their attention is focused on day-to-day maintenance of quality of life, rather than on future care or advance decision making. Many had difficulty imagining a future; as dependency grew, so did reliance on care services to support their needs. What once would have been deemed an unacceptable way of living became routine. For many, the care system offers a lifeline without which they would not be able to exist at home. However, it also appeared to offer little individual flexibility, meaning that frail older people struggled to assert the control over day-to-day decisions and choices that others take for granted. This increasing dependency and reliance on care and care services has the potential to undermine the decision-making capacity of frail older people. For many, autonomous choice and decision making gave way to relationships, partnerships and negotiations that are commensurate with a more relational model of autonomy. Conclusion: The end-of-life orientation of current ACP policy and practice is at odds with the dynamic nature of frailty and does not correspond to individuals’ needs to maximise their current quality of life. The liberal ideal of autonomy as self-determination and self-interest presented by the legalistic and ideologically driven policy of ACP is out of step with the lived worlds of frail older people. For those facing increasing dependency on care and care services, frameworks that acknowledge a more relational approach when planning future care will be needed in order to engage this group of frail older people in ACP.