Systemic lupus erythematosus in the elderly: Clinical and immunological characteristics.

Systemic lupus erythematosus (SLE) predominantly affects young women in their 20s. In 40 out of 250 (16%) patients with SLE seen in our hospital disease onset occurred after the age of 50. The interval between the time of onset and diagnosis was five years in this older group compared with three years in the younger group. Arthritis, as a first symptom, was less common in the older onset group. During the follow up a lower incidence of arthritis, malar rash, photosensitivity, and nephropathy was found in the older onset group. In contrast, this group showed an increased incidence of myositis. High titres of anti-dsDNA tended to occur less often and the incidence of anti-Ro antibodies was lower in the older onset group. These features seem to distinguish patients with older onset SLE as a particular subset.

Inappropriate prescribing to the oldest old patients admitted to hospital: prevalence, most frequently used medicines, and associated factors

Background: Scientific evidence on treatments of chronic diseases in patients 85 years old or older is very limited, as is available information on inappropriate prescription (IP) and its associated factors. The study aimed to describe medicine prescription, potentially inappropriate medicines (PIM) and potentially prescribing omissions (PPO) and their associated factors on this population. Methods: In the context of an observational, prospective and multicentric study carried out in elderly patients admitted to seven Spanish hospitals for a year, a sub-analysis of those aged 85 years and over was performed. To assess PIMs, the Beers and STOPP criteria were used, and to assess PPOs, the START and the ACOVE-3 criteria were used. To assess factors associated with IP, a multivariate logistic regression analysis was performed. Patients were selected randomly every week on consecutive days from the hospitalization lists. Results: A total of 336 patients were included in the sub-analysis with a median (Q1-Q3) age of 88 (8690) years. The median medicines taken during the month prior to admission was 10 (713). Forty-seven point two per cent of patients had at least one Beers-listed PIM, 63.3% at least one STOPP-listed PIM, 53.6% at least one START-listed PPO, and 59.4% at least one ACOVE-3-listed PPO. Use of benzodiazepines in patients who are prone to falls (18.3%) and omission of calcium and vitamin D supplements in patients with osteoporosis (13.3%) were the most common PIM and PPO, respectively. The main factor associated with the Beers-listed and the STOPP-listed PIM was consumption of 10 or more medicines (OR = 5.7, 95% CI 1.8-17.9 and OR = 13.4, 95% CI 4.0-44.0, respectively). The main factors associated with the START-listed PPO was a non-community dwelling origin (OR 2.3, 95% CI 1.0-5.0), and multimorbidity (OR1.8, 95% CI 1.0-3.1). Conclusions: Prescribed medicines and PIM and PPO prevalence were high among patients 85 years and over. Benzodiazepine use in those who are prone to falls and omission of calcium and vitamin D in those with osteoporosis were the most frequent PIM and PPO, respectively. Factors associated with PIM and PPO differed with polypharmacy being the most important factor associated with PIM.

Vanhukset mukaan kuntoutuksen suunnitteluun : lectio praecursoria

Marjo Wallinin väitöskirja Community-dwelling older people in patient rehabilitation : physiotherapists' and clients' accounts of treatments, and observed interaction during group sessions (Jyväskylän yliopisto 2009).

Innovations of ageing and societal transition : Dynamics of change of the socio-technical regime of ageing

The purpose of this dissertation is to examine the dynamics of the socio-technical system in the field of ageing. The study stems from the notion that the ageing of the population as a powerful megatrend has wide societal effects, and is not just a matter for the social and health sector. The central topic in the study is change: not only the age structures and structures of society are changing, but also at the same time there is constant development, for instance, in technologies, infrastructures and cultural perceptions. The changing concept of innovation has widened the understanding of innovations related to ageing from medical and assistive technological innovations to service and social innovations, as well as systemic innovations at different levels, which means the intertwined and co-evolutionary change in technologies, structures, services and thinking models. By the same token, the perceptions of older people and old age are becoming more multi-faceted: old age is no longer equated to illnesses and decline, but visions of active ageing and a third age have emerged, which are framed by choices, opportunities, resources and consumption in later life. The research task in this study is to open up the processes and mechanisms of change in the field of ageing, which are studied as a complex, multi-level and interrelated socio-technical system. The question is about co-effective elements consisting of macro-level landscape changes, the existing socio-technical regime (the rule system, practices and structures) and bottom-up niche-innovations. Societal transitions do not account for the things inside the regime alone, or for the long-term changes in the landscape, nor for the radical innovations, but for the interplay between all these levels. The research problem is studied through five research articles, which offer micro-level case studies to macro-level phenomenon. Each of the articles focus on different aspects related to ageing and change, and utilise various datasets. The framework of this study leans on the studies of socio-technical systems and multi-level perspective on transitions mainly developed by Frank Geels. Essential factors in transition from one socio-technological regime to another are the co-evolutionary processes between landscape changes, regime level and experimental niches. Landscape level changes, like the ageing of the population, destabilise the regime in the forms of coming pressures. This destabilization offers windows for opportunity to niche-innovations outside or at fringe of the regime, which, through their breakthrough, accelerate the transition process. However, the change is not easy because of various kinds of lock-ins and inertia, which tend to maintain the stability of the regime. In this dissertation, a constructionist approach of society is applied leaning mainly to the ideas of Anthony Giddens’ theory of structuration, with the dual nature of structures. The change is taking place in the interplay between actors and structures: structures shape people’s practices, but at the same time these practices constitute and reproduce social systems. Technology and other material aspects, as part of socio-technical systems, and the use of them, also take part in the structuration process. The findings of the study point out that co-evolutionary and co-effective relationships between economic, cultural, technological and institutional fields, as well as relationships between landscape changes, changes in the local and regime-level practices and rule systems, are a very complex and multi-level dynamic socio-technical phenomenon. At the landscape level of ageing, which creates the pressures and triggers to the regime change, there are three remarkable megatrends: demographic change, changes in the global economy and the development of technologies. These exert pressures to the socio-technical regime, which as a rule system is experiencing changes in the form of new markets and consumer habits, new ways of perceiving ageing, new models of organising the health care and other services and as new ways of considering innovation and innovativeness. There are also inner dynamics in the relationships between these aspects within the regime. These are interrelated and coconstructed: the prevailing perceptions of ageing and innovation, for instance, reflect the ageing policies, innovation policies, societal structures, organising models, technology and scientific discussion, and vice versa. Technology is part of the inner dynamics of the sociotechnological regime. Physical properties of the artefacts set limitations and opportunities with regard to their functions and uses. The use of and discussion about technology, contributes producing and reproducing the perceptions of old age. For societal transition, micro-level changes are also needed, in form of niche-innovations, for instance new services, organisational models or new technologies, Regimes, as stabilitystriven systems, tend to generate incremental innovations, but radically new innovations are generated in experimental niches protected from ‘normal’ market selection. The windows of opportunity for radical novelties may be opened if the circumstances are favourable for instance by tensions in the socio-technical regime affected by landscape level changes. This dissertation indicates that a change is taking place, firstly, in the dynamic interactionbetween levels, as a result of purposive action and governance to some extent. Breaking the inertia and using the window of opportunity for change and innovation offered by dynamics between levels, presupposes the actors’ special capabilities and actions such as dynamic capabilities and distance management. Secondly, the change is taking place the socio-technological negotiations inside the regime: interaction between technological and social, which is embodied in the use of technology. The use of technology includes small-level contextual scripts that also participate in forming broader societal scripts (for instance defining old age at the society level), which in their turn affect the formation of policies for innovation and ageing. Thirdly, the change is taking place by the means of active formation of the multi-actor innovation networks, where the role of distance management is crucial to facilitate the communication between actors coming from different backgrounds as well as to help the niches born outside the regime to utilise the window of opportunity offered by regime destabilisation. This dissertation has both theoretical and practical contributions. This study participates in the discussion of action-oriented view on transition by opening up of the socio-technological, coevolutionary processes of the multi-faceted phenomenon of ageing, which has lacked systematic analyses. The focus of this study, however, is not on the large-scale coordination and governance, but rather on opening up the incremental elements and structuration processes, which contribute to the transition little by little, and which can be affected to. This increases the practical importance of this dissertation, by highlighting the importance of very tiny, everyday elements in the change processes in the long run.

Kaatumisvaaraa lisäävät lääkkeet; Porissa toteutettu iäkkäiden monitekijäinen kaatumisten ehkäisy

Kaatumiset ovat ikääntyvien yleisimpiä tapaturmia. Niiden seuraukset voivat olla vakavia. Yksilöllisesti toteutetut ehkäisyohjelmat ovat vähentäneet kaatumisvaarassa olevien iäkkäiden kaatumisia. Psyykenlääkkeiden on osoitettu lisäävän kaatumisia ja murtumia. Niiden lopettaminen on vähentänyt kaatumisvaaraa. Monitekijäiset ehkäisyohjelmat kuvaavat harvoin psyykenlääkkeiden vähentämisen menetelmiä ja tuloksia. Satunnaistettuun, kontrolloituun kaatumisten moneen vaaratekijään kohdistettuun ehkäisytutkimukseen osallistui 591 porilaista. Tässä tutkimuksessa selvitettiin kotona asuvien 65 vuotta täyttäneiden, tutkimusta edeltäneiden 12 kuukauden aikana ainakin kerran kaatuneiden henkilöiden psyykenlääkkeiden käyttö, niiden vähentämisen onnistuminen ja vaikutus sekä ehkäisyohjelman merkitys kaatumisten ilmaantumiseen. Lisäksi tutkittiin kaatumisvamman takia hoitoon hakeutuneiden kaatumisvaaratekijöiden tunnistamista ja uusien kaatumisten ja murtumien ehkäisemiseksi suunniteltuja toimenpiteitä perusterveydenhuollossa ja erikoissairaanhoidossa. Joka neljäs osallistuja käytti säännöllisesti psyykenlääkkeitä. Kertaneuvonta niiden vähentämisestä, johon sisältyi kirjalliset ohjeet lääkemuutoksista ja luento lääkkeiden vaikutuksista kaatumisvaaraan, vähensi säännöllisten psyykenlääkkeiden käyttäjien lukumäärää 22 % ja bentsodiatsepiineja tai niiden kaltaisia lääkkeitä käyttävien lukumäärää 35%. Kaatumisen vuoksi terveyskeskukseen ja keskussairaalaan hakeutuneiden iäkkäiden kaatumisvaaratekijöiden selvittelyyn ja uusien kaatumisten tai murtumien ehkäisyyn kiinnitettiin erittäin vähän huomiota. Toimenpiteet keskittyivät syntyneiden vammojen tutkimiseen ja hoitoon. Monitekijäinen ehkäisyinterventio vähensi masentuneiden ja monikaatuilijoiden kaatumisia, mutta ei kaikkien osallistujien kaatumisten määrää 12 kuukauden ehkäisyohjelman aikana. Erityisesti bentsodiatsepiiniryhmän lääkkeitä käyttävät verrokkiryhmän jäsenet joutuivat herkemmin kaatumisen vuoksi lääkärinhoitoon ehkäisyohjelman jälkeisen vuoden aikana kuin nämä lääkkeet lopettaneet koeryhmän jäsenet. Johtopäätöksenä voidaan todeta, että psyykenlääkkeiden tunnistaminen kaatumisten vaaratekijäksi oli puutteellista. Niiden käyttöön tulisi kiinnittää enemmän huomiota, ja niiden käyttö tulisi purkaa aina, kun se on lääketieteellisesti mahdollista. Kaatumisten ehkäisy pitäisi kuulua terveydenhoitoon. Kohdennettuja ehkäisyohjelmia erilaisille kaatumisvaarassa oleville iäkkäille tulee kehittää edelleen.

En vårdvetenskaplig syntes mellan vårdandets ethos och vårdintensitet

This is a study in the field of caring science. The kinds of knowledge expansion and theoretical formation outlined in this thesis have a hypothetic-deductive design. The synthesizer of caring science between caring ethos and nursing intensity evolves through a hermeneutic movement between understanding and interpretation, in the dialectic tension between thesis and antithesis. The study had three main aims with corresponding research questions. The first aim was to deepen the understanding of caring ethos within the care of older people from the perspective of caring science. The second aim was to deepen the understanding of nursing intensity within the care of older people, again from the perspective of caring science. The third aim of the study was to create a theoretical model describing the synthesizer between the caring ethos and nursing intensity. The synthesizer of caring science between caring ethos and nursing intensity took place in a process of creativity, which resulted in six new patterns of interpretation. Good care is in constant movement and tension between the ethical and the unethical. In order to guarantee the older person of the future dignity, a caring community, and integrity in care, there is a need for an awareness of and responsibility for those entities than can become ethical problems and dilemmas. The model that describes the synthesizer between caring ethos and nursing intensity, consist of four cornerstones such as caring ethics, wishes and anticipations, an ethical manner in words and action, and ethical leadership. Good care based on the values dignity, a caring community, safety, and integrity, receive their legitimacy through ethical awareness, and consent among caregivers. Ethical awareness deepens the understanding of wishes and expectations that may arise as special needs. Care thus requires an awareness of the balance between the patient’s care need and optimal level of nursing intensity. An ethical leadership considers the needs of the patient and accepts nothing but a work situation where optimal nursing intensity and optimal resource allocation makes good care possible.

Kjærlighet i forbundethet : en kraft i gamle menneskers åndelighet og verdighet

The thesis is rooted in caring science and the notion that the human being is an indivisible unity of body, soul and spirit. The purpose is to search for new, or expanded knowledge and understanding of the substance of the human’s spiritual space, as well as aspects that may constitute a foundation for the safeguard of human dignity. The clinical research study concerns the importance of spirituality and dignity in the care for older people. The thesis consists of three substudies with four articles, and the methodology is based on Gadamer’s philosophical hermeneutics. Through a metasynthesis of 17 research articles, sub-study I searched for understanding of the concept of spirituality as it may appear in reality (deduction). 17 older people were interviewed in sub-study II. This sub-study sought understanding for spirituality and dignity in the specific reality (induction). Sub-study III searched for theory development regarding spirituality, through a literature review of 20 research articles and a text by Tillich (abduction). The findings imply that spirituality entails human beings’ connectedness with one’s inner space and connectedness beyond oneself. Love in connectedness appears as a force in both spirituality and dignity. Themes portrayed include understanding of the spiritual space, religiousness, dignity, and spiritual care. The relationship between dignity and spirituality can be seen in the confirmation of human worth and care for the whole human being, including the spiritual dimension, and this is understood as a prerequisite for perceived dignity. It seems to be important that older people feel valued, loved, not abandoned, and alive. The theoretical model portrays love as a reunifying and connecting force that may foster confirmation, serving, longing and holiness. The movement towards connectedness may create room for the human being’s perception of dignity and holiness, and as such, it may be a force in the search for wholeness and becoming in health.

Frequency of Werner helicase 1367 polymorphism and age-related morbidity in an elderly Brazilian population

Werner syndrome (WS) is a premature aging disease caused by a mutation in the WRN gene. The gene was identified in 1996 and its product acts as a DNA helicase and exonuclease. Some specific WRN polymorphic variants were associated with increased risk for cardiovascular diseases. The identification of genetic polymorphisms as risk factors for complex diseases affecting older people can improve their prevention, diagnosis and prognosis. We investigated WRN codon 1367 polymorphism in 383 residents in a district of the city of São Paulo, who were enrolled in an Elderly Brazilian Longitudinal Study. Their mean age was 79.70 ± 5.32 years, ranging from 67 to 97. This population was composed of 262 females (68.4%) and 121 males (31.6%) of European (89.2%), Japanese (3.3%), Middle Eastern (1.81%), and mixed and/or other origins (5.7%). There are no studies concerning this polymorphism in Brazilian population. These subjects were evaluated clinically every two years. The major health problems and morbidities affecting this cohort were cardiovascular diseases (21.7%), hypertension (83.7%), diabetes (63.3%), obesity (41.23%), dementia (8.0%), depression (20.0%), and neoplasia (10.8%). Their prevalence is similar to some urban elderly Brazilian samples. DNA was isolated from blood cells, amplified by PCR and digested with PmaCI. Allele frequencies were 0.788 for the cysteine and 0.211 for the arginine. Genotype distributions were within that expected for the Hardy-Weinberg equilibrium. Female gender was associated with hypertension and obesity. Logistic regression analysis did not detect significant association between the polymorphism and morbidity. These findings confirm those from Europeans and differ from Japanese population.

TP53 codon 72 polymorphism as a risk factor for cardiovascular disease in a Brazilian population

TP53, a tumor suppressor gene, has a critical role in cell cycle, apoptosis and cell senescence and participates in many crucial physiological and pathological processes. Identification of TP53 polymorphism in older people and age-related diseases may provide an understanding of its physiology and pathophysiological role as well as risk factors for complex diseases. TP53 codon 72 (TP53:72) polymorphism was investigated in 383 individuals aged 66 to 97 years in a cohort from a Brazilian Elderly Longitudinal Study. We investigated allele frequency, genotype distribution and allele association with morbidities such as cardiovascular disease, type II diabetes, obesity, neoplasia, low cognitive level (dementia), and depression. We also determined the association of this polymorphism with serum lipid fractions and urea, creatinine, albumin, fasting glucose, and glycated hemoglobin levels. DNA was isolated from blood cells, amplified by PCR using sense 5'-TTGCCGTCCCAAGCAATGGATGA-3' and antisense 5'-TCTGGGAAGGGACAGAAGATGAC-3' primers and digested with the BstUI enzyme. This polymorphism is within exon 4 at nucleotide residue 347. Descriptive statistics, logistic regression analysis and Student t-test using the multiple comparison test were used. Allele frequencies, R (Arg) = 0.69 and P (Pro) = 0.31, were similar to other populations. Genotype distributions were within Hardy-Weinberg equilibrium. This polymorphism did not show significant association with any age-related disease or serum variables. However, R allele carriers showed lower HDL levels and a higher frequency of cardiovascular disease than P allele subjects. These findings may help to elucidate the physiopathological role of TP53:72 polymorphism in Brazilian elderly people.

Läheisen rooli ja tuen tarve iäkkään kotiutuessa arviointi- ja kuntoutusosastolta

Tämän tutkimuksen tarkoituksena oli kuvata läheisen roolia ja tuen tarvetta iäkkään kotiutuessa arviointi- ja kuntoutusosastolta. Tavoitteena oli saada tietoa iäkkäiden kotiutusprosessista läheisen näkökulmasta ja muodostaa käsitteellinen malli, jossa on tyypitelty läheisen erilaiset roolit, niihin vaikuttavat tekijät ja tuen tarpeet iäkkään kotiutuessa arviointi- ja kuntoutusosastolta. Tutkimus oli kuvaileva tutkimus, jossa sovellettiin metodologista triangulaatiota. Kotiutuva iäkäs nimesi läheisen (n=14), jolta kerättiin tutkimusaineistoa teemahaastattelulla ja kyselyllä (COPE -indeksi, Carers of Older People in Europe). Rekrytointi tapahtui viidellä arviointi- ja kuntoutusosastolla Etelä-Suomessa kesällä 2015. Teemahaastattelu analysoitiin induktiivisella sisällönanalyysillä ja kyselyn (COPE -indeksi) vastauksista laskettiin prosenttiosuudet ja kolmella osa-alueella laskettiin lisäksi summapisteiden keskiarvot. Tutkimuksen päätulos tuli teemahaastattelun sisällön analyysistä, jota vahvistettiin kyselystä (COPE -indeksi) saaduilla tuloksilla. Tämän tutkimuksen tuloksena syntyi käsitteellinen malli läheisen roolista ja tuen tarpeista iäkkään kotiutuessa arviointi- ja kuntoutusosastolta. Läheisen rooli jakautui neljään päärooliin, jotka olivat iäkkään arjen auttajan rooli, edunvalvojan rooli, tukijan rooli ja vastuunkantajan rooli. Arjen auttajan rooliin kuului läheisen käytännön järjestäjän rooli ja kodinhoitajan rooli. Edunvalvojan rooliin sisältyi iäkkään terveydellinen edunvalvojan rooli, taloudellinen edunvalvojan rooli ja puolestapuhujan rooli. Tukijan rooli muodostui iäkkään virkistäjän roolista ja muutokseen sopeuttajan roolista. Näissä rooleissa toimimiseen vaikuttavia tekijöitä olivat läheisen ja iäkkään välinen suhde, läheisen oma elämä, rooliin saatu tuki ja roolin mielekkyys. Läheisen roolissa tuen tarpeita olivat arjen tuki, roolissa toimimisen tuki, rohkaiseva ja sosiaalinen tuki. Kyselyn (COPE -indeksi) tulokset täydensivät kuvausta läheisen rooliin vaikuttavista tekijöistä ja tuen tarpeista. Keskeistä tuloksissa oli, että läheisillä oli hyvä suhde iäkkäisiin, avustaminen koettiin vaivan arvoiseksi ja muiden ihmisten koettiin arvostavan heidän toimimistaan iäkkään avustajana. Ajoittain avustaminen koettiin liian vaativana tuoden kielteisiä vaikutuksia omaan tunne-elämään ja fyysiseen terveydentilaan, tunnettiin olevan ansassa. Läheiset tunsivat saavansa hyvin tukea perheeltä, mutta sosiaali- ja terveyspalveluista saatavassa tuessa koettiin parannettavaa. Tämän empiirisen tutkimuksen tuloksena tuotettu käsitteellinen malli todentaa läheisen roolin monimutkaisuuden ja moniulotteisuuden. Läheisen roolissa tarvitaan erityistä tukea tilanteiden muuttuessa, kuten kotiutustilanteissa. Tutkimuksen tuloksia voidaan hyödyntää kehitettäessä iäkkäiden yksilöllistä kotiutumista ja tilanteeseen sopivia läheisen roolia tukevia palveluita.

The effect of a weighted-vest strength and balance training program on obstructed walking in postmenopausal women

SUMMARY Background: Age related declines in lower extremity strength have been associated with impaired mobility and changes in gait patterns, which increase the likelihood of falls. Since community dwelling adults encounter a wide range of locomotor challenges including uneven and obstmcted walking surfaces, we examined the effect of a strength 11 and balance exercise program on obstructed walking in postmenopausal women. Objectives: This study examined the effect of a weighted-vest strength and balance exercise program on adaptations of the stance leg during obstacle walking in postmenopausal women. Methods: Eighteen women aged 44-62 years who had not engaged in regular resistance training for the past year were recruited from the St. Catharines community to participate in this study. Eleven women volunteered for an aerobic (walking), strength, and balance training program 3 times per week for 12 weeks while 7 women volunteered as controls. Measurements included: force platform dynamic balance measure of the center of pressure (COP) and ground reaction forces (GRFs) in the stance leg while going over obstacles of different heights (0,5, 10,25 and 30 cm); and isokinetic strength measures of knee and ankle extension and flexion. Results: Of the 18 women, who began the trial, 16 completed it. The EX group showed a significant increase of 40% in ankle plantar flexion strength (P < 0.05). However, no improvements in measures of COP or GRFs were observed for either group. Failure to detect any changes in measures of dynamic balance may be due to small sample size. Conclusions: Postmenopausal women experience significant improvements in ankle strength with 12 weeks of a weighted-vest balance and strength training program, however, these changes do not seem to be associated with any improvement in measures of dynamic balance.

Our future in geriatrics : an examination of the knowledge, attitudes and career choices of physical therapy students in Ontario : a pretest-posttest study /

There continues to be a shortage of health professionals interested in providing care for the older adult. Part of the problem seems to stem from the negative perceptions of geriatrics as a clinical speciality. This study examines the knowledge, attitudes and career decisions of physical therapy students in Ontario before and after an educational intervention. Surveys were conducted with 144 physical therapy students from five universities before and after their geriatrics course in order to measure their knowledge, attitudes and interest in working with older adults. The incoming class of physical therapy students (n = 1 86) acted as control subjects for the study. The Revised Palmore Facts On Aging Quiz measured the students' knowledge of aging (Miller & Dodder, 1980). The Revised Tuckman-Lorge (Axelrod & Eisdorfer, 1961) and the Kogan Old People Scales (Kogan, 1961) were used to examine attitude. An environmental scale was developed based on the work of Snape (1986) to measure the impact of the working conditions on the students' career choices. A 10-point Likert-type scale based on the work of Michlelutte & Diseker (1985) was modified and used to measure career interest in working with the elderly. On independent sample t-tests, positive attitudes were related to the demographic characteristic of gender; ethnicity was negatively related; and marital status was found to be unrelated to attitude (fi<.05). Having a relationship with an older adult and taking courses in gerontology were also found to be positively related to attitude (fi<.05). Results on a betweensubjects design which compared students before and after the course found that knowledge scores improved from pretest to posttest (fi<.05). In general, attitude scores improved from T1 to T2 on both measurement tools (b<.05). The environmental and vocational interest scales yielded statistically significant differences between the control and experimental groups during the intervention period (p<.05). The results of this research indicated that knowledge and attitudes improve after an educational intervention; however, there was little impact on the students' overall career decisions. Further research is indicated to examine the complex relationship between attitude and behaviour and its impact on students' career choices. In addition, the impact of geriatric clinical environment on students' attitudes and career decisions needs to be further explored.

Improving the oral health status of functionally independent and dependent seniors residing in long-term care facilities through dental hygiene education /

The purpose of this study was to evaluate the oral health status of residents residing in 2 long-term care facilities and determine if dental hygiene education was required in order to improve their current oral health. The oral health status of 6 independent and 4 dependent individuals residing in 2 long-term care facilities was evaluated. In addition, the current oral health and disease prevention practices employed by 4 caregivers who were responsible for providing oral care to dependent residents in the long-term care facilities were evaluated. Furthermore, an evaluation of the oral care practices of independent residents who were responsible for providing their own care was conducted. Finally, the challenges that caregivers and independent residents faced when performing oral care were determined, and methodological changes were proposed. Using a generic qualitative research methodology, data collection was comprised of semi structured interviews, field observations, and documentation. The oral health status of the residents was reevaluated 3 months later. The findings of this study demonstrated an increase in plaque accumulation, gingival inflammation, and unhealthy gingival tissue colour changes among the residents over the 3-month period. The study revealed that poor oral health among the residents was a result of inadequate oral hygiene care techniques, difficulties accessing oral health care, financial limitations, insufficient care staff, insufficient time for personal care duties, lack of professional development, minimal interprofessional collaboration of health disciplines, and lack of perseverance on the part of the caregivers and residents. Overall, oral health is essential, and maintaining optimal oral health requires increased collaboration and communication between health care providers.

Aging policy: a case study of co-ordination in Canadian governments

ABSTRACT Canada is an aging society. The number of people aged sixty-five and over is rising, while the number of people under twenty is declining. These two concurrent changes in the age structure have produced a sh~ft in the demographic composition of Canada which is commonly referred to as the aging phenomenon. Regardless of whether or not the number of people under twenty continues to decline, the number of elderly in Canada will almost double over the next twenty years. This rapidly growing elderly clientele will doubtless have an impact on Canadian governments. Federal, provincial and municipal governments are presently providing a variety of programs that have a special bearing on the aged and most senior citizens are beneficiaries of one or more of these programs. The ramifications of a rapidly growing elderly clientele are obvious. In order to cope with the impact of a significant increase in the number of elderly persons, the development and implementation of aging policy must be co-ordinated at each level of government and between and among levels of government. If aging policy is not co-ordinated, the results are likely to be: inappropriate policy decisions; duplication and overlap; and, ineffective and irresponsive services. No one benefits from these results. The need for co-ordination is apparent. The purpose of this thesis is to examine existing governmental efforts to co-ordinate policy in the field of aging. These efforts are examined by focusing on interactions directed at co-ordination between and among major actors in aging policy. A framework is used to structure the description and analysis of these interactions. The variables of formalisation and intensity and the concept of power are instrumental in analysing interactions for co-ordination. The underlying intent of this thesis is to discover some of the main gaps in existing governmental efforts to co~ordinate aging policy. Gaps are, in fact, discovered. Several explanations for the existence of gaps in interactions for co-ordination are discussed. A major hypothesis involving a relationship between a bureaucratic form of organisation and interactions for coordination is suggested. Finally, three recommendations for improving co-ordination in aging policy are offered.