Centre for Gerontology and Rehabilitation - Doctoral Theses

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    Enablement of older people with chronic disease attending an ambulatory care centre
    (University College Cork, 2020-11-15) Foley, Mary J.; Naughton , Corina; Hartigan, Irene; Pawlikowska, Teresa
    Background: Population ageing, and the increasing incidence of chronic disease requires a responsive health service and new enabling models of care (Wren et al. 2017, Bridges et al. 2019, Kennedy 2019). Within the dynamics of healthcare engagement, there is recognition of the positive influence of the enabling skills of the health professional on patient enablement encompassing knowledge, confidence, coping and management of health and illness (Howie et al. 1997, 1998). The clinical consultation is a pivotal exchange between the health professional and patient, so it is vital to optimise its quality (Al Momen et al. 2015, Pawlikowska & Marinowicz, 2015). The Consumer Enablement Model (Batterham et al. 2017) acknowledges the diverse contexts in which people seek care and identifies dynamic determinants and key components (cognitive, affective/motivational, physical, and relational) that impact enablement. Little is known about the factors influencing enablement in an older adult population living with chronic health conditions attending an ambulatory care service. Aim: To examine enablement of older people with chronic disease post consultation with a health professional and identify influencing factors for low enablement. Method: A descriptive quantitative, cross-sectional survey was conducted. Data Collection: Data were collected using a 72-item questionnaire. In addition to demographic questions, it contained the validated instruments Patient Enablement Instrument (PEI) (Howie et al. 1997), Patient Activation Measure (Hibbard et al. 2005) and Clinical Frailty Scale (Rockwood et al. 2005) and modified Physician Enabling Skills Questionnaire (Hudon et al. 2015). Sample: In total, 300 older people with chronic disease were recruited from an ambulatory care centre (attending nurse, doctor, or therapist). Incomplete questionnaires were omitted, leaving a sample of 273 for analysis. Data Analysis: Descriptive and inferential statistical analysis was used. Logistic backward stepwise regression examined the association between the independent variables and the dependent variable low enablement (PEI score ≤ 4). Findings: The study population mean age was 79.7 years (SD 6.8) and 52% were female. Sixty-one per cent of participants had three or more chronic conditions, 35% described their health as fair or poor, and 26% indicated that they were frail (CFS ≥ 5). The population mean PEI score was 4.48 (SD 3.5). In the final multivariate analysis, four variables remained independent predictors of low enablement: female gender (OR 1.96 (CI 1.07- 3.60), clinical frailty (per 1 unit increase) OR 1.26 (95% CI 0.93-1.63), two variables were protective, patient activation OR 0.97 (95% CI 0.95-0.99) and health care professional enabling skills (OR 0.92 (95% CI 0.89-0.94). There were an additional eight variables that were significant in the univariate analysis: older age, living alone, three or more chronic diseases, poor self-reported health, psychological morbidity, receipt of home help, visit from a public health nurse and being seen by a single discipline during the clinic visit. Conclusion: This research affirms that older people have the capacity to become more enabled and are responsive to the enabling skills of the health professional and proactive coordinated multidisciplinary engagement. Enablement post-consultation is multi-faceted, with risk and protective factors that influence individual health gains. Quality measures & expectations of health gains should be viewed within this wider context. Implications for practice: Research findings support a person enablement model that provides for a heterogenous population in a state of transition (health, functional, psychological). Modifiable risk factors associated with low enablement, such as frailty and low patient activation require a comprehensive holistic assessment and bespoke interventions beyond a single consultation. The enabling skills of the health professional are important to optimise patient gains and enhance understanding, management and coping with chronic illness. Healthy ageing strategies reinforced by health professionals committed to making every contact count, supports the political and strategic paradigm shift towards sustaining older people in the community.
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    The effect of simultaneous implementation of an advance care planning program and a palliative care initiative on end of life care in long term care
    (University College Cork, 2018) McGlade, Ciara; Molloy, D. William; Timmons, Suzanne; Irish Hospice Foundation; Atlantic Philantrophies
    Introduction: International research suggests care at the end of life in long term care is suboptimal, but quality improvement initiatives incorporating advance care planning have shown promising results. Little is known about the care given at this time of life, in this environment, in Ireland, where advance care directives are not yet part of the Irish culture. The objectives of this thesis were to examine the effect of implementation of as advance care planning program combined with a palliative care educational initiative on end of life care in the long term care setting in Ireland. Methods: A study was carried out to examine healthcare professionals’ attitudes and knowledge of advance care directive, end of life care and decision making for older adults with diminished decision making capacity in Ireland, Canada and the United Kingdom. The baseline educational needs of Irish nursing home staff was explored and the data used to create a palliative care educational initiative tailored to the needs of staff. An existing advance care planning program (Let Me Decide) was modified for use in an Irish long term care setting. The effect of systematically implementing both these programs simultaneously on end of life care was examined through a before and after feasibility study. Results: Attitudes to and knowledge of advance care directives was good amongst healthcare professionals in Ireland compared with the UK and Canada, but knowledge of the legal situation for medical decision making for a person with diminished capacity was lacking, as was knowledge of the successful outcome for cardiopulmonary resuscitation. End of life care education was suboptimal but improved subsequent to the study program initiation. The challenges faced in advance care planning and implementing an associated educational program found lack of time and staff pressures to be key factors. The program resulted in a substantial rise in the proportion of decedents with a plan for end of life care and a marked shift in the timing of care conversations from the last weeks and days of life, to a median time almost 6 months before death. The proportion of long term care residents included in care planning decisions improved from 5.5% to 27%. Bereaved relatives commended the end of life care received by their loved ones, they rated the quality of their loved ones dying experience highly and highlights practices of good end of life care that could be disseminated elsewhere. In addition the prescribing practices in the last 3 months of life were examined. Though there was evidence of deprescribing in over half of decedents this tended to only happen close to death, when anticipatory prescribing for end of life symptoms also took place, albeit to a greater extent in the after period of the study. The study findings were sustained when re-examined in 2017. Conclusions: Advance care planning with residents (or their family) was not part of the culture of end of life care in Ireland, and decisions on resuscitation or hospitalisation tended to occur with family when imminent death of nursing home residents was recognised. The advance care planning program introduced in this project was acceptable, feasibility and its impact sustainable in the longer term. Palliative care training was suboptimal in long term care in Ireland but staff were keen to engage with education and the study initiative improved the prevalence of trained staff in the study sites. Additionally, the end of life care provided in nursing homes in Ireland is rated highly by bereaved relatives.
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    Rationalising antipsychotic prescribing in dementia: a mixed-methods investigation
    (University College Cork, 2019) Walsh, Kieran A.; Timmons, Suzanne; Byrne, Stephen; Browne, John P.; McSharry, Jenny; Health Research Board; Atlantic Philanthropies
    Introduction: Antipsychotics are commonly prescribed to people with dementia, especially in nursing homes, despite limited benefits and significant harms. There have been calls to better understand the reasons why antipsychotics continue to be inappropriately prescribed to people with dementia, and to develop sustainable interventions. Hence the overarching aim of this thesis was to develop and assess the feasibility of a theoretically-informed, evidence-based and sustainable intervention to rationalise (or optimise) antipsychotic prescribing in nursing home residents with dementia. Methods: The overarching Medical Research Council (MRC) framework for developing and evaluating complex interventions guided our approach to this mixed-methods research. Firstly, a systematic review was undertaken to determine the effectiveness of pharmacists’ intervention in improving the appropriateness of prescribing in hospitalised older adults, with a particular focus on people with dementia. Secondly, a retrospective cross-sectional study was conducted examining prescribing differences between older adults with and without dementia, on admission to hospital. Next, a systematic review of qualitative evidence was undertaken to explore the influences on decision-making regarding antipsychotic prescribing in nursing home residents with dementia, which subsequently informed a semi-structured interview study exploring antipsychotic prescribing behaviours. The Behaviour Change Wheel (BCW) was then used to develop a complex intervention with Patient and Public Involvement (PPI) throughout. Finally, a feasibility study of the novel intervention was conducted in a nursing home setting. Results: Despite the fact that our cross-sectional study showed that hospitalised adults with dementia were prescribed significantly more antipsychotics, our systematic review found no pharmacist intervention existed which aimed to improve the quality of prescribing in this population. Our qualitative synthesis highlighted the complexity of decision-making with regards antipsychotic prescribing to nursing home residents with dementia. The interview study identified determinants influencing prescribing behaviours. Based on these findings, we developed the ‘Rationalising Antipsychotic Prescribing in Dementia’ (RAPID) complex intervention which consisted of academic detailing with general practitioners, education and training with nursing home staff, and an assessment tool. This intervention was found to be both feasible and acceptable, however limited uptake of the assessment tool compromised intervention implementation. Conclusion: This thesis has made a significant original contribution to knowledge, generating a much needed conceptual understanding of this complex issue and contributing towards intervention development. Further research is required to evaluate the effectiveness and sustainability of our novel intervention through larger scale evaluations.