Rozprawy doktorskie na temat „Pain in old age”

This thesis is based on narrative interviews with older people who live with pain and explores the meanings they develop. From their stories it emerged that constructions of ageing shape the meaning of pain. Pain is consequently constructed as `ordinary', non-disruptive pain that is a natural consequence of ageing. However, the narrators also developed alternative meanings. They constructed their pain as unique and disruptive, contested age-based definitions of their pain, and resisted medical intervention. The thesis explores the conflicts and contradictions that arise out of these multiple constructions.

The combination of an ageing population in most western societies with an increase in the prevalence of persistent pain with age, has led to a call for more effective pain management for older adults. While there has been a consistent increase in research into the pain experience of older adults in recent years, relatively little of that research has examined specific psychological factors in relation to pain and pain impact. Cognitive-behavioural models hypothesize that the relationship between persistent pain and depression is mediated by cognitive factors, such as catastrophizing, but this relationship has not been confirmed in older adults, with most studies in this area using participants aged less than 65 years. It has also been found that depression is less common in older adults with persistent pain compared to younger adults, but the reason for this difference is unknown. Furthermore, this uncertainty is complicated by methodological shortcomings in the limited existing research on psychological factors in older adults with persistent pain, including: small sample sizes, the lack of use of a well-established method of mediation analysis, the use of measures not validated for use with older adults, and the paucity of patients in the oldest old category (>80 years). As pointed out by the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) group and others, assessment measures should be psychometrically sound, standardized in older adult populations, time efficient, and not an excessive burden on the patient. In order to better understand the pain experience of older adults and hence provide more effective pain management for this population, this thesis examined the mediating role of catastrophizing in the relationship between pain intensity and depressed mood in older adults with persistent pain living in the community. The overall aim of the thesis was to fill a gap in the understanding of the mediating role of cognitive factors in the persistent pain experience of older adults. This thesis consists of a series of four studies. The first three studies evaluated the utility of a number of measures that were used in the evaluation of the mediating role of catastrophizing in the relationship between pain intensity and depressed mood. The third study also evaluated the mediating role of catastrophizing using cross-sectional data from a consecutive sample of older adult patients (age> 60 years) attending a pain management centre for assessment. The fourth study evaluated the mediating role of catastrophizing using longitudinal data from a separate sample of older adults with persistent pain participating in a larger study of an evaluation of a pain self­management program. The first study examined the utility of the Numerical Rating Scale (NRS) as a measure of pain intensity and pain distress in a sample of older adults with persistent pain. A consecutive sample of 800 patients aged over 60 years attending a pain management centre were categorized by age into three groups: 61 to 70 years, 71 to 80 years, and 81 years and over. Patients completed three NRS assessing current pain intensity, and both the usual level of pain and average pain distress in the preceding week at initial assessment. The failure to complete rate was low for all age groups but was significantly higher in the oldest old (2!81 years) group compared to the youngest old (61-70 years) group. The NRS was shown to be a reliable and valid measure of these two constructs across all age groups. However, pain-related distress appeared to be specific to the pain experience and was only weakly related to generalized affective distress. This study provides evidence from a large sample, which included a significant number of patients in the oldest old category (n=126), that pain intensity and pain distress can be reliably and validly measured in community living older adults with persistent pain. The large sample size increases confidence in the psychometric soundness of the NRS with this population. The second study examined the assessment of the negative emotional constructs of depression, anxiety and stress with the short version of the Depression Anxiety Stress Scales (DASS-21) in older adults with pain. The same sample of 800 patients aged over 60 years attending a pain management centre, used in study one, completed the DASS-21 at initial assessment. The results of study two showed that the DASS-21 is a reliable and valid measure of depression, anxiety and stress symptom severity in older adults with persistent pain and overcomes a number of challenges to the assessment of these constructs in this population. Confirmatory factor analysis established a three­ factor structure and is consistent with previous studies. Age differences in depression, anxiety and stress scores were also examined by comparing scores from the older adult sample with DASS-21 scores from a sample of 1,245 younger adults aged 60 years and under also attending the same pain management centre. Younger patients had significantly higher depression and stress scores compared to all patients aged over 60 years. Additionally, younger patients had significantly higher anxiety scores compared to patients aged 61-70 years. These findings help clarify the research on age differences in depression, anxiety and stress in patients with persistent pain. Some studies have found no effect of age on the relationship between pain and depression/anxiety, while other research has found an association between age and mood with symptoms of depression and anxiety decreasing as age increases. The first part of study three examined the reliability and validity of a measure of catastrophizing, the Pain-Related Self Statements scale (PRSS), in a consecutive sample of 669 elderly patients aged over 60 years attending a pain management centre. The PRSS-Catastrophizing was found to be a reliable measure of pain-related catastrophizing in older adults with persistent pain. Exploratory factor analysis on a split-half sample identified a two factor solution (magnification, helplessness), which was replicated with confirmatory factor analysis. Analysis of the mediating role of these two factors in the relationship between pain intensity and depressed mood was then conducted on both the whole sample (n=669) and additionally on a subset of patients aged over 80 years (n=98). The main finding of this study was to show that both magnification and helplessness partially and significantly mediated the relationship between pain intensity and depressed mood in community living older adults with persistent pain. This was also shown to be the case in the subset of patients over 80 years. These findings support a cognitive-behavioural mediation model. The final study used longitudinal data in a two-wave design with the aim of examining whether changes in catastrophizing over 6 months mediated the relationship between changes in pain intensity and depressed mood over the same period. The aim of this study was to strengthen the existing evidence of the mediating role of catastrophizing in the relationship between pain intensity and depressed mood in older adults with persistent pain found in study three. The use of longitudinal data overcomes some of the limitations of a cross-sectional analysis. Participants were from a separate sample than that used in the previous studies (i.e. one, two and three) and included 141 older adults, aged 65 years and over, with persistent non-cancer pain who were part of a larger study evaluating a pain self-management program. This study showed that change over 6 months in the two factors of the catastrophizing subscale of the PRSS (magnification, helplessness) totally mediated the change in the relationship between pain intensity and depressed mood over the same time period. These findings also add support to a cognitive-behavioural mediation model. The studies contained in this thesis are the first to formally evaluate the mediating role of catastrophizing in the relationship between pain intensity and depressed mood in older adults with persistent pain using a well-established mediation analysis method and add to the literature on the role of cognitive factors in the pain experience of this population. Confidence in these findings is enhanced by the methodological rigour of the four studies, which included: the use of a large sample, the inclusion of patients aged over 80 years, and the use of measures that have been validated for use in this population. Additionally, the use of both cross-sectional and longitudinal data from separate samples strengthens the findings. The overall findings suggest that cognitive factors, in this case catastrophizing, play a significant role in the pain experience of older adults with persistent pain. They also highlight the need for further research into the mediating role of other cognitive factors, which may also influence the pain experience in older adults. These findings also highlight age differences in psychological functioning, in this case depression, anxiety and stress, which need to be taken into account when assessing pain ­related mood disturbance in older populations. Finally, the findings support a cognitive-behavioural mediation model, which hypothesizes the mediating role of cognitive factors in the pain-depression relationship and have implications for the role of treatments such as cognitive-behaviour therapy in this population.

Thesis (Psy.D.)--Wheaton College, 2006.
The purpose of this study was to evaluate the effectiveness of a cognitive behavioral group therapy intervention for chronic pain with an economically disadvantaged community sample of older adults. Specifically, the study was designed to assess the impact of the intervention on mood, general well-being, and the use of learned coping skills to manage pain. The program was a modified version of Ersek's "Managing Chronic Pain" which incorporated coping skills training in the areas of exercise, relaxation, and cognitive restructuring. The intervention consisted of a six week "class" with a one month follow-up booster session, each session lasting 90 minutes. Twenty-two participants with an average age of 77 living in government subsidized housing completed the program. The program was found to be moderately effective. Participants' pain intensity and interference did not significantly decrease, however scores trended in the predicted direction. Scores in the areas of mood, physical well-being, and coping skills all changed in the predicted directions, however the changes were not statistically significant. Mental health well-being increased significantly following program participation, but returned to initial levels at the one month follow-up booster session assessment. Clinical implications as well as limitations of the study are discussed. Includes bibliographical references (l. 87-96).

Circumstances of an increasing proportion of elderly persons in the population of the United States and the incidence of pain among elderly persons established the need for this research project. Significant to nurses was the lack of information regarding responses to the pain experience and evidence of inadequate pain control. The purpose of this study was to explore the relationship between pain and coping strategies used by a group of elderly persons experiencing pain and living in long-term-care facilities. The population included individuals residing in long-termcare facilities in Indiana. A convenience sample of 36 persons from six facilities in central Indiana participated in the study.Gate Control Theory of pain and Lazarus' theory of stress and coping were the theoretical frameworks of the study. The independent variable, pain, was measured by two Parts of the McGill Pain Questionnaire, pain rating index andpain intensity. Coping, the dependent variable, was measured by the Ways of coping checklist; scoring methods yielded coping, problemfocused coping, emotion-focused coping, and eight subscales. Data was collected by the researcher through use of these two instruments and interviews. Pearson product moment correlations were used for statistical analysis.There were no significant correlations between pain intensity and coping measures. There were no significant correlations between pain rating and coping and emotionfocused coping. Additional findings were based on the data analysis with coping subscales. There was a significant positve correlation between pain rating and the coping subscale escape-avoidance. There was a significant negative correlation between pain rating and the coping subscale distancing.Results of the study indicated elderly individuals experiencing pain used several coping strategies. This finding is consistent with research involving elderly persons living in the community.
School of Nursing

Sitting at a rarely examined intersection between aging, disability, and popular culture, this project explores how the aging body becomes the disabled body in the context of popular music. In what follows, I trouble the distinction between bodies and mediation, between lived-experience and cultural product, and I argue that the voice of the aging artist engages with his lived-experience even as he performs socially-constructed conceptions of aging and disability. I read Johnny Cash’s 2002 cover of Trent Reznor’s “Hurt” on American IV: The Man Comes Around as a performance of the singer’s age and disabled condition. Through pain- saturated lyrics, music filled with unresolved tension, a damaged voice, and a video that puts his aged body on display, Cash performs a disability script that presents his age and personal health as disabling burden. I explore how country music, Cash’s performance past, and strategies pursued by his producer, Rick Rubin, all contribute to a performance that is both successful popular song and a manifestation of the singer’s declining condition. The project invites subsequent explorations of the intersection of age and disability in popular music, and highlights several artists whose voices and performances of old age and disability demand attention. The project aligns with an interactive approach to disability research, breaking down the dialectic between social and individual priorities in disability studies and foregrounding how each influence the overall performance.

Healthy aging influences peripheral and central levels of the neuromotor system. These age-related changes contribute to the decline in dexterous manual behavior. Difficulty in performing activities of daily living increases reliance on external assistance. Understanding specific mechanisms leading to the decline in fine manual performance is crucial for their rehabilitation. In this thesis, we have attempted to increase our awareness of the causes underlying manual disability in old age. The first study investigated how old adults apply forces and moments on a freely-movable object using a precision grip (thumb and index finger) during functionally-relevant tasks. During the grasp-lift task old adults misaligned their thumb and finger contacts and produced greater grip force, greater external moments on the object around its roll axis, and oriented force vectors differently compared with young adults. During a precision-orientation task of inserting a slot on the object over a bar (`key-slot' task), old adults were more variable in digit-tip force directions and performed the key-slot task more slowly. With practice old adults aligned their digits, reduced their grip force, and minimized external moments on the object. We conclude that with old age comes with a reduced ability to control the forces and moments applied to objects during precision grasp and manipulation. This may contribute to the ubiquitous slowing and deteriorating manual dexterity in healthy aging. Another study investigated the effects of transcranial direct current stimulation (tDCS) to the contralateral M1 combined with motor training (MP) on changes in the forces applied to the object during grasp and manipulation. We also measured performances on functional tasks in healthy elderly individuals. Our results indicate that anodal tDCS+MP facilitates retention of learning on a skillful manual task in healthy old adults. Furthermore, improved retention on the pegboard test was associated with reduced force variability on the key-slot task that demanded similar precise control over the forces applied to the object. These findings suggest that the improvement in force steadiness is one of the potential mechanisms through which short-term anodal tDCS during motor training improved performance on a functional task that outlasted the intervention period. Furthermore, anodal tDCS over M1 in combination with motor practice also influenced motor response to tasks that critically depend on sensory signals in healthy old adults. Finally, we found that, in healthy elderly individuals, the memory representations scaling the lift force for the grip and lift task generalized, while the training-based learning on the ballistic task showed an incomplete transfer to the contralateral hand. These differences may indicate task-dependent interhemispheric transfer of learning in old age. Collectively, the work presented in this thesis demonstrates that the performance on dexterous manual tasks in healthy old adults may depend on how they configure their grasp, and control their finger forces (both linear and rotational) applied to the grasped object, specifically how smooth is the applied force.

My thesis explores the realm of middle and old age from a medical point of view as well as from social and literary ones. I first chose to consider two important contributions in this field of study: Simone De Beauvoir’s The Coming of Old Age and Antonio Gramiccia’s La Strage degli Innocenti: Anatomia di un Omicidio Sociale. My work focuses then on Doris Lessing’s representations of aging through her works. Her novel The Diaries of Jane Somers depicts a woman, Jane, who, at the age of fifty, reconsiders herself and her life. The relationship with the ninety-year-old Maudie, moreover, helps her to age more consciously and helps Maudie to find the love of a friend. If The Old Could sees Jane dealing with a new, more mature love and the problems connected with it. Lessing’s stories, An Old Woman and Her Cat, Flight and The Grandmothers give other realistic examples of aging. Her autobiographies, finally, enhance the importance of the role of memory in life. The works of Doris Lessing can fit new literary genres. These give their protagonists the chance to find affirmation and the possibility to progress even in later stages of life. Doris Lessing can also give us a picture of old men and women in society and the chance to change and adapt as life continues. My purpose is to enhance the importance not to forget the past in order to face the present in a society where old age is seen as a condemnation rather than an unavoidable stage of life.

Research has demonstrated that chronic pain can compromise identity by becoming enmeshed and centralised with pain. Pain-identity enmeshment and pain-identity centrality are associated with greater affective distress and poorer chronic pain adjustment. However, the literature infers differences between older and younger individuals in terms of pain adjustment, whereby older adults perceive pain as concomitant of aging and experience this as less biographically disruptive and perceive themselves to be younger than their chronological age, which is associated with greater psychological wellbeing. Research has yet to explore the relationship between perceived age and pain-identity enmeshment and adjustment in chronic pain. The purpose of this research was to investigate age in relation to pain-identity enmeshment and centrality and to examine the predictive value of age in pain adjustment. 90 patients with osteoarthritis (OA) and chronic pain were recruited from a musculoskeletal service. Participants completed standardised measures of pain intensity and perceived control (VAS), pain severity and interference (BPI), acceptance (CPAQ), identity (CES, Possible Selves Interviews), affective distress (HADS), and catastrophising (PCS) and provided information regarding their perceived age. Statistical analysis included; correlation, chi square, analysis of variance and linear regression to investigate potential age differences. Chronological age evidenced few significant relationships with variables of pain adjustment and identity. Perceived age evidenced significant relationships with all variables of adjustment and identity, however, did not statistically predict chronic pain adjustment. However, hoped-for proximity and centrality significantly predicted chronic pain adjustment. The CES demonstrated significant relatedness to enmeshment, although effect sizes were small. Therefore, it appears possible that an individual may experience pain becoming central to their identity yet remain un-enmeshed with pain. These findings indicate the necessity to assess hoped-for proximity and centrality in chronic pain populations across all age groups. This research indicates the potential for incorrectly perceiving expectedness and adjustment ease in old age. The implications of these findings are explored, in conjunction with the limitations of this research and potential areas for further research.

Past research suggests that age differences in measures of cognitive speed contribute to differences in intellectual functioning between young and old adults. To investigate whether speed also predicts age-related differences in intellectual performance beyond age 70 years, tests indicating 5 intellectual abilities—speed, reasoning, memory, knowledge, and fluency—were administered to a close-to-representative, age-stratified sample of old and very old adults. Age trends of all 5 abilities were well described by a negative linear function. The speed-mediated effect of age fully explained the relationship between age and both the common and the specific variance of the other 4 abilities. Results offer strong support for the speed hypothesis of old age cognitive decline but need to be qualified by further research on the reasons underlying age differences in measures of speed.

Through the theoretical lens of Foucault's archaeological method, this thesis undertakes a discourse analysis to examine how old age and ageing are strategically positioned as forms of governmentality in New Labour social care policy documents. It is argued that these discourses are not directed purely at the older generation, but at everyone, at all stages of life, encompassing all aspects of everyday living. Old age thus becomes a strategy of governing the population through individual everyday lives. This hints at the way ageing is prefigured, anticipated and lived in advance. An analytical method is developed by weaving together Foucault's notions of archaeology and governmentality; the latter is utilised both as an analytical perspective and to provide an understanding of how people primarily act and interact in contemporary Western societies. This analytical perspective is initially applied to an exploration of how the form and function of social policy enable ordinary practices of life to become targets of political government, making both possible and desirable the government of everyday living: governing how we ought to live in every aspect of life from work and finances to health, to personal relationships and leisure activities. The thesis progresses to explore this in more detail through a practical application of governmentality and focused discourse analysis of eight New Labour social care policy texts. The aim of the analysis is to explore what subjectivities and forms of life are possible within these discourses and therefore what these policies actually do, as distinguished from what they claim to be doing. It is argued that the discourses that emerge in these policies act to limit and subjectify, by attempting to contain and stabilise the multitude of possibilities for practices of living. By ostensibly aiming to create social inclusion the policies make possible vast areas of exclusion that become prime spaces of government. Thus many ways of living, ageing, and being old become untenable due to their inherent contradiction with the social values and rationalities upon which these discourses are based. Whilst governmentality analyses have been brought to many other policy areas, this thesis makes an original contribution by: developing a governmental analysis of social policy as a form of biopolitics; by applying this analysis to the social care field; and by using policy discourses of old age and ageing to draw out significant aspects of a governmental society. In particular it explores the dispersion of many traditional boundaries, leading to the rearrangement of relations, responsibilities and subjectivities.

Includes bibliographical references (leaves 71-74).
This study estimates the mortality of the South African oldest old age population (in five year age groups from age 75 up to the open age interval 100 and above) and in the process re-estimates the numbers of people in the population at these ages at the time of the 1996 and 2001 censuses, and the 2007 Community Survey. In countries where the data on the old age population have been verified, it has been observed that the data are marred by errors in the form of age exaggeration, age digit preference, relative under/over count of the population and under-registration of deaths. These errors have been observed to have the net effect of underestimating mortality of the oldest old age groups. The current research applies the method of extinct generations to estimate indirectly the population numbers at the oldest old age groups (75 up to 100 and above) using data on reported deaths alone. Age heaping and year of birth preference in the reported deaths are assessed using ratios of the probability of death estimated from the data. Age exaggeration in the data on reported deaths is assessed using ratios of deaths compared with same ratios from a standard population. Age heaping and year of birth preference in the census/survey population is assessed using the modified Whipple's Index of age accuracy. The Generalized Growth Balance (GGB) and Synthetic Extinct Generations (SEG+delta) methods are applied to adjust for under reporting of deaths and to assess patterns of age exaggeration in the census/survey population. The difference between the estimates of the completeness of reporting of deaths from the two methods is small (less than 1 per cent) and has been observed to have little impact on the mortality estimates. Final estimates of the completeness of reporting of deaths used are those derived using the SEG+delta method. After re-estimating the population numbers and adjusting for completeness of reporting of deaths, mortality rates were then estimated. Results obtained from the method of extinct generations suggest that there is no systematic difference between the census/ survey population and the population numbers estimated from deaths except at ages 95 and above. Measures of age accuracy show that there are patterns of preferring 1910, 1914, 1918, 1920 and 1930 as the years of birth in the census/survey population and these patterns are also found in the registered deaths. The impact of these errors was investigated and the results show that preference of certain years of birth cause fluctuations in the mortality rates. Patterns observed after applying the SEG+delta method suggest that the completeness of reporting of deaths falls with age at the advanced ages (from age 90 and above) and as a result, the estimated mortality rates above this age are lower than those estimated from the United Nations Population Division (UNPD) and US Census Bureau (USCB) population projections, and Dorrington, Moultrie and Timaeus (2004). Conclusions reached are that the mortality rates for the age groups 75 to 89 derived after re-estimating the population numbers and after allowing for the fall in the completeness of reporting of deaths are lower but not significantly different from those inferred from the UNPD and USCB population projections, and estimates derived by Dorrington, Moultrie and Timaeus (2004). The research recommends mortality estimates from the UNPD since they are the closest to the estimates derived using the published census population numbers for the whole period between the nights of 9-10 October 1996 and 9-10 October 2001. However, the research produced better estimates of the oldest old age population numbers relative to the census/survey numbers.

Background The prevalence and incidence of stroke are known to increase with age, which, combined with demographic change, means that very old patients with stroke are a growing patient group. Risk factors for incident stroke among very old people have not been widely investigated. The impact of depression on mortality in very old people who have had a stroke also remains unclear.  The aim of this thesis was to investigate the risk factors for incident stroke, the epidemiology of stroke and depression, and the consequences of having had a stroke regarding the risk of depression and mortality among very old people. Methods A randomly selected half of 85-, all 90-, and all ≥95-year-olds in certain municipalities in Västerbotten County, Sweden, and Pohjanmaa County, Finland were targeted in a population-based cohort study from 2000-2012. The 65-, 70-, 75-, and 80-year-olds in all the rural and random samples from the urban municipalities in the same counties were furthermore targeted in a survey in 2010. In the cohort study patients were assessed in their homes, by means of the 15-item Geriatric Depression Scale (GDS-15) and other assessment scales, as well as blood pressure measurements, several physical tests, and a review of medical diagnoses appearing in the medical charts. Incident stroke data were collected from medical charts guided by hospital registry records, cause of death records, and reassessments after 5 years. Depression was defined as a GDS-15 score ≥5. A clinical definition of all depressive disorders, based on assessment scale scores and review of medical charts was also used. A specialist in geriatric medicine evaluated the diagnoses. The survey included yes/no questions about stroke and depression status, and the 4-item Geriatric Depression Scale. Associations with mortality and incident stroke were tested using Cox proportional-hazard models.  Results In the ≥85-year-olds examined in 2005-2007 (n=601), the stroke prevalence was 21.5%, the prevalence of all depressive disorders was 37.8% and stroke was independently associated with depressive disorders (odds ratio 1.644, p=0.038). The prevalence of depression according to GDS-15 scores was 43.2% in people with stroke compared with 25.0% in people without stroke (p=0.001). However, in ≥85-year-olds examined in Sweden from 2000-2012 (n=955), from all past data collections in the study, depression was not independently associated with incident stroke.  In ≥65-year-olds who responded to a survey in 2010 (n=6098), the stroke prevalence rose with age from 4.7% among the 65- to 11.6% among the 80-year-olds (p<0.001). The prevalence of depression rose from 11.0% among the 65- to 18.1% among the 80-year-olds (p<0.001). In the group with stroke, depression was independently associated with dependence in personal activities of daily living and having a life crisis the preceding year, while in the non-stroke group, depression was independently associated with several additional demographic, social and health factors. In ≥85-year-olds examined in 2005-2007 with valid GDS-15 tests (n=452), having had a stroke was associated with increased 5-year mortality [hazard ratio (HR) 1.53, 95% confidence interval (CI) 1.15-2.03]. Having had a stroke and depression was associated with increased 5-year mortality compared with having only stroke (HR 1.90, 95% CI 1.15-3.13), having only depression (HR 1.59, 95% CI 1.03-2.45), and compared with having neither stroke nor depression (HR 2.50, 95% CI 1.69-3.69). Having only stroke without a depression did not increase mortality compared with having neither stroke nor depression. In ≥85-year-olds examined in Sweden from 2000-2012 (n=955), from all past data collections in the study, the stroke incidence was 33.8/1000 person-years during a mean follow-up period of about three years. In a comprehensive multivariate model, atrial fibrillation (HR 1.85, 95% CI 1.07–3.19) and higher systolic blood pressure (SBP; HR 1.19, 95% CI 1.08–1.30 per 10-mmHg increase) were associated with incident stroke overall. In additional multivariate models, diastolic blood pressure (DBP) ≥90 mmHg (HR 2.45, 95% CI 1.47–4.08) and SBP ≥160 mmHg (v. <140 mmHg; HR 2.80, 95% CI 1.53–5.14) were associated with incident stroke. Conclusion The prevalence of both stroke and depression increased with age, and rates were especially high among very old people. Having had a stroke was independently associated with a higher prevalence of depression among very old people, however, depression was not independently associated with a higher incidence of stroke. Having had a stroke was associated with increased all-cause mortality among very old people, but only among those who were also depressed. High SBP (≥160 mmHg), DBP (≥90 mmHg) and atrial fibrillation were the only consistent independent risk factors for incident stroke among very old people.
I västvärlden inklusive Sverige så ökar gruppen av människor som uppnår åldern 80 år eller äldre. Människorna som uppnår denna mycket höga ålder har en hög förekomst av kardiovaskulära riskfaktorer, har ofta flera samtidiga sjukdomar och ofta funktionsnedsättningar. Medicinska behandlingsåtgärder är ofta mindre effektiva och förknippade med biverkningar i åldersgruppen. Stroke är en sjukdom som beror på skada av hjärnvävnad till följd av minskad blodtillhörsel till delar av hjärnan. Det är känt att såväl förekomsten av och insjuknandet i stroke ökar med stigande ålder. Den som drabbas av stroke löper risk att få en bestående funktionsnedsättning och att dö i förtid. En vanlig komplikation efter att ha drabbats av stroke är nedstämdhet eller depression. Vetenskapliga studier om stroke har tidigare negligerat mycket gamla människor, vilket i takt med den pågående demografiska utvecklingen framstått som allt mer orimligt. Det är ej helt klarlagt vilka riskfaktorer som leder till att insjukna med stroke i mycket hög ålder. Överdödligheten förknippad med att drabbas av depression efter stroke är också oklar i åldersgruppen. Det är också oklart vad som skiljer depression efter stroke från depression bland den övriga befolkningen av åldrade människor. Den populations-baserade kohortstudien GErontologisk Regional DAtabas (GERDA) inleddes år 2000 för att kartlägga faktorer förknippade med gott åldrande bland mycket gamla människor. Hälften av 85-åringarna, alla 90-åringar och alla ≥95-åringar i utvalda kommuner i Västerbotten erbjöds att delta i studien. Därefter har återbesök hos tidigare deltagare i sina nya åldersgrupper och rekrytering av nya deltagare genomförts vart femte år. Studien utvidgades med utvalda kommuner i Österbotten, Finland vid den första femårsuppföljningen. Datainsamlingen i studien bestod av demografiska frågor, skattningsskalor, blodtrycksmätning och kognitiva test genomförda vid ett hembesök i deltagarens hem, samt genomgång av journalhandlingar. År 2010 skickades även en enkät ut till 65-, 70-, 75- och 80-åringar i alla kommuner i Västerbotten och Österbotten. Enkäten innehöll frågor om demografi, hälsa, sjukdomar och intressen. Bland deltagarna i kohortstudien bestämdes förekomsten av tidigare stroke baserat på genomgång av journaluppgifter och uppgifter från hembesöken. Förekomsten av depression bestämdes baserat på poängsättning från en validerad skattningsskala för depression, samt baserat på en sammanvägning av journaluppgifter och skattningsskalor. En specialist i geriatrik fattade det slutliga beslutet om diagnoser. Insjuknande i stroke bestämdes baserat på journalgenomgång av individer med stroke-relaterade diagnoskoder i sjukhusregistret, i dödsorsaksregistret eller uppgift om stroke vid femårsuppföljningen i studien. Bland deltagarna i enkätstudien bestämdes förekomsten av tidigare stroke baserat på självrapportering, och förekomsten av depression bestämdes baserat på en sammanvägning av självrapportering och en skattningsskala för depression.  Förekomsten av stroke i enkätstudien steg med ålder, från 4.7% bland 65-åringar till 11.6% bland 80-åringar. Förekomsten av stroke var omkring 20% bland ≥85-åringar, med minimal variation mellan 85-, 90- och ≥95-åringar. Förekomsten av depression var högre bland dem med stroke jämfört med de övriga deltagarna, både gällande den sammavägda diagnosen och baserat endast på poängsättning. Stroke och sömnproblem var oberoende associerade med depression. Bland ≥65-åringar i enkätstudien var funktionsnedsättning och genomgången livskris associerade med depression hos dem med en tidigare stroke. Bland deltagare utan stroke var ett antal ytterligare externa faktorer, inklusive subjektiv upplevelse av dålig ekonomi och att inte ha någon att anförtro sig till, associerade med depression. Både stroke och depression var associerade med ökad dödlighet bland ≥85-åringar. De med stroke utan depression hade en dödlighet i linje med normalbefolkningen utan stroke eller depression. Förekomsten av samtidig stroke och depression var associerad med högre dödlighet än normalbefolkningen, jämfört med dem med enbart stroke eller enbart depression. Högt systoliskt blodtryck (≥160 mmHg), högt diastoliskt blodtryck (≥90 mmHg) och förmaksflimmer var oberoende riskfaktorer för att insjukna i stroke bland ≥85-åringarna. Sambandet mellan blodtryck och strokerisk försvagades ej hos människor med kognitiv eller funktionell nedsättning. Tidigare stroke, hjärtsvikt, kognitiv nedsättning, näringsbrist, depressiva symtom och låg gånghastighet var också associerade med att insjukna i stroke, men ej oberoende av varandra. Sammanfattningsvis så stiger förekomsten av stroke med åldern och är särskilt hög bland mycket gamla människor. Depression är betydligt vanligare hos mycket gamla människor med stroke, även justerat för störningsfaktorer. Depression är främst associerat med funktions-nedsättning hos människor med stroke, men med ett större antal externa faktorer hos människor utan stroke. Mycket gamla människor med stroke har särskilt hög dödlighet om de samtidigt är deprimerade, men en dödlighet i linje med normalbefolkningen om de inte är deprimerade. Högt systoliskt och diastoliskt blodtryck samt förmaksflimmer är viktiga och behandlingsbara orsaker till att drabbas av stroke i mycket hög ålder.

As humans age, the brain undergoes many changes. This includes loss of the neurotransmitter dopamine, which forms a bridging link between age and the ensuing changes in cognition. However many questions about the precise nature of this relationship with regards to brain structure and function remain unanswered. These questions are important given our expanding aging population, and the answers may help the discovery of new therapeutic interventions for age-related impairments as well as identify mechanisms to promote successful aging. Old age also provides a model for understanding the role of dopamine in many fundamental human behaviours. The aim of my research was to use a multimodal approach to explore the contribution of dopamine to learning and memory in healthy older age. In this thesis I present four studies in which I used a combination of behavioural testing, pharmacological manipulation, structural and functional magnetic resonance imaging in older adults. I show that dopamine boosts delayed episodic memory in a non-linear dose-dependent manner. Using functional MRI, I show this effect is mediated through consolidation rather than encoding by the hippocampus. In two further imaging studies conducted to explore the role of dopamine in reward-based learning, I show that the flexibility of learning depends on the structural integrity of the substantia nigra/ventral tegmental area (the origin of dopamine projections) and that pharmacological enhancement of dopamine levels can remediate abnormal reward processing in the ventral striatum. Individual differences in neural activity associated with reward prediction also relate to anatomical nigro-striatal connectivity, identified using diffusion tensor imaging. Finally, I show that in old age, valence influences decision-making in relation to ones own beliefs about the future, mediated by volume of the anterior cingulate cortex. I conclude this thesis with a brief discussion of the implications of these findings, study limitations and potential future studies.

Why is independence a central theme for proponents of assisted living facilities? How do assisted living providers respond to this theme? These questions are pursued in an ethnographic study centered on Oregon's assisted living program. Assisted living facilities (ALF), defined and monitored by Oregon's Senior and Disabled Services Division (SDSD), are a type of housing for disabled, primarily elderly, persons. Oregon Administrative Rules (OAR-411-56) define independence, requiring ALF providers to support resident independence. Using social worlds theory as a sensitizing concept, assisted living is treated as a distinct social world. The activities of key groups, including SDSD staff, an ALF professional group, and assisted living managers, are described. These members commit to a “social model” approach to long-term care for which independence is the unifying construct. This approach offers a value-practice “package” that explains how to implement the value of independence (Fujimura, 1997). Three arenas where this package is apparent are described: marketing, manager training, and daily operations. Content analysis of marketing brochures from 63 assisted living facilities shows that independence is a dominant theme, promoted like any other product. These materials indicate that assisted living operators promote resident independence by providing a barrier-free environment, helping residents with daily tasks, and allowing residents control over their decisions. Manager training programs are another arena where the policy value of independence is evident. Here, new managers learn “who we are” and “what we do” in this social world. They learn a new vocabulary and are introduced to tools for daily practice. They learn the boundaries of this social world, and above all, how to behave differently from nursing facilities that they associate with the “medical model.” In daily practice, managers use institutional conventions, including the “negotiated service agreement” and "managed risk agreement." These tools are designed to respond to the tension between supporting independence and providing care to chronically ill, disabled individuals. Observations of marketing, management training, and resident assessments indicate that the social world of assisted living is in a formative stage, as members attempt to define and legitimate who they are and what they do.

The study of old age in the humanities has developed significantly in the last few decades, but there is still much scope for progress. This thesis, therefore, seeks to contribute to the growing academic discourse in this area by considering ageing as it is represented in ancient Greek theatre. At the same time, it seeks to take its place within Classical Studies by developing new readings of the plays. To develop a context for its analysis, this study begins with consideration of the contemporary demographics, social position, and stage portrayal of old age, and following this dedicates a chapter to each of the four surviving fifth century dramatists. In Aiskhylos’ Agamemnon, old age emerges as a crucial element in choral self-identity, and an important component of the authority that they display. Following this, the thesis considers the chorus of Euripides’ Herakles, in particular its use of metadramatic language, and the impact this has on plot-development and the representation of their age. The next chapter, on Oidipous Koloneus, shifts to consideration of the protagonist. The old age of Oidipous emerges as a powerful driver of his mental and spiritual power, and forms a striking background to the exploration of his character. The final chapter of the thesis examines how mechanisms of renewal that old men undergo in Aristophanes’ comedies (Knights, Akharnians, Peace, Wasps, Birds) differ across the dramas, and the impact this difference has on their interpretations. Such reassessments of ancient dramatic texts through the lens of old age can provide significant insight into the complexity of old men’s characterisations and of their involvement in the dramas. At the same time (from a gerontological perspective), this thesis’ analysis contributes to the developing discussion of the history of ageing, and highlights the differences between the ancient and modern worlds in this respect.

Since the late 1980s, representations of Japanese national identity and Japanese old age have been deconstructed. Images of the resilience of traditional cultural and social institutions are shown to have over-emphasized social and cultural homogeneity, elided social differentiation and inequality and minimized the significance of historical transformation. Key institutions of the postwar modernization project, including the patriarchal seniority system and household structure, are being transformed through globalization and feminization. This thesis focuses on the problem of representing individual and collective ageing in Japan in the context of modernization. Research is focussed on the contradictions, within essentialist representations of Japanese collective and individual identity, between socially constructed policy forms of old age and collective identities. Contemporary trends towards individualization and diversification of identities, and discourses on the ageing/information society, indicate cultural distance between an instrumentally rational administration and the life world of old people. Research explores the concept of embodiment through its significance in debates on postmodernization of the lifecourse in accordance with the structural shifts towards a postindustrial structure. This study examines representations of old age in broader social and cultural processes. Images of the social and cultural trajectory of the lifecourse draw attention to the embodiment of individual identities and ultimately generational cultures in contemporary social and cultural spaces. This research is the result of analyses of old age, which have been informed by postmodern theory. It in turn informs sociological theorizations of cultural representations of old age in contemporary societies.

While population ageing is attracting ever more attention of international scientific community and social policy, its cultural and communicative aspects remain underinvestigated. The goal of the dissertation is to investigate the old age (ageing) identity in Lithuania, applying the sociological concept of stigma. In the pursuit of this goal, the research areas of stigma and ageism are connected, highlighting their common denominator - discrimination. The following questions are raised: whether/to what extent old age is stigma in contemporary Lithuania? When and why old age did become stigma? What are manifestations of the old age stigma? How is it reproduced? Searching for answers the historical changes of attitudes towards ageing are reviewed, dominant theories of ageing identity are examined and the concepts of A.Gidden‘s reflexive self and E.Goffman‘s stigma are applied. Scientifically new theses presented for defense are grounded in the findings of three empirical investigations: media texts analysis, interviews with older people and data analysis of the European Social Survey Round 4. The results lead to conclusion that old age in Lithuania is an „open secret" type stigma: verbally favourable view of older people conceals discrimination. The constructed and internalized stigma is detected both in media and in everyday interactions. The level of discrimination experienced by Lithuanian population over 60 is close to other post-communist and Mediterranean countries.
Tarptautinei mokslo bendruomenei bei socialinei politikai vis daugiau dėmesio skiriant gyventojų senėjimui, kultūriniai ir komunikaciniai jo aspektai lieka mažai tyrinėti. Šios disertacijos tikslas yra ištirti senatvės (senėjimo) tapatumą Lietuvoje, remiantis sociologine stigmos koncepcija. Šio tikslo siekiama, sujungiant priešiškumo vyresniam amžiui (ageism) ir stigmos tyrinėjimų sritis bei išryškinant jų bendrą vardiklį – diskriminaciją. Joje keliami klausimai: ar/kokiu mastu senatvė šiuolaikinėje Lietuvoje yra stigma? Kada ir kaip ja tapo? Kuo pasireiškia? Kaip senatvės stigma palaikoma? Atsakymų ieškoma, apžvelgiant istorinę nuostatų į senėjimą kaitą, tikrinant vyraujančias senėjimo tapatumo teorijas ir taikant Anthony Giddenso reflektyvaus Aš bei Ervingo Goffmano stigmos koncepcijas. Gynybai teikiami moksliškai nauji disertacijos teiginiai yra pagrįsti trijų empirinių tyrimų rezultatais: medijų tekstų analize, interviu su vyresnio amžiaus žmonėmis ir Europos socialinio tyrimo 4 bangos duomenų analize. Rezultatai leidžia daryti išvadą, kad senatvė Lietuvoje yra stigma: už verbaliai deklaruojamo palankaus požiūrio į senus žmones slypi priešiškumas. Masinėse medijose ir kasdienėse sąveikose aptinkama konstruojama ir internalizuota senatvės stigma. 60 m. ir vyresni Lietuvos gyventojai dažniau nei pažengusių Vakarų šalių vyresnio amžiaus žmonės patiria diskriminavimą - Lietuvos rezultatai panašūs į kitų pokomunistinių ir Viduržemio jūros šalių rezultatus.

Objectives: The context of the increase in life expectancy and the demographic shift towards a more elderly population in the UK presents a number of challenges to society‟s perception of old age and to the likelihood of increasing demands upon health professionals and psychologists who work with the elderly. Existing studies have focused on the effectiveness of therapeutic endeavours with older people, yet have failed to discretely examine the constructs of old age among psychologists who work in the field. Given the prominence of the ageing population and the likelihood of an increase in demands for therapeutic interventions, the aim of the present study was to explore how psychologists discussed and constructed old age within the context of their therapeutic work with older people. The research questions focused on the way in which psychologist who have experienced working with older people talk about old age, the way they construct ideas of therapy with old people and how those constructs of age relate to wider cultural and social constructs of old age. Method: Individual in-depth interviews were conducted with eight psychologists, who were aged between mid thirties to late fifties, all of whom had a minimum of two years experience working therapeutically with older people. The interview transcripts were analysed using the discursive analysis methods of Discursive Psychology and Foucauldian Discourse Analysis. The analysis focused on the way the psychologists used discursive resources when discussing old age and the implications of their subject positions in their therapeutic work with older people. Results: The results identified a number of discourses of old age; old age as heterogeneous, old age as dichotomous, that the therapeutic intervention with older people can be seen as complex and challenging as well as a rewarding pursuit for the therapist, that the choice of the therapeutic model has implications itself and that old age can be seen as an internal attribute. Discussion: The study demonstrated how constructions of old age influenced psychologists in terms of their expectations, their therapeutic delivery, their willingness to integrate a number of therapeutic models, and in their ability to set goals with their elderly clients. The clinical implications of the present study are discussed and the study concludes with recommendations suggesting additional training aiming at furthering psychological knowledge of old age and current theories of ageing.

This study describes the situation for community living older people, 65 years of age and older in Iceland, analyzing their needs for care and services and how these needs are met. The study analyzes the relationship between the main providers of help and care, the formal caregivers and the informal carers. The study further depicts what kinds of care and support older informal caregivers provide and receive themselves and analyze what factors are related to providing care alone or in combination with other caregivers, informal and formal. The study also analyzes the relationship and mutual support between grandparents and grandchildren and whether there are gender differences in intergenerational relations and support. As little research has been conducted on informal care in Iceland, it is important to show the importance of the informal carers in the care paradigm. Two Icelandic studies were used for the descriptions and analysis. The main data source is the ICEOLD survey (Icelandic older people), based on a random representative national sample of 700 non-institutionalized persons in ages 65 – 79 years and 700 persons aged 80+. The final sample consists of 1,189 older persons to which an introduction letter was sent. They were contacted by phone a few days later and 782 persons, 341 men and 441 women, agreed to participate, giving a response rate of 66%. A study carried out among college students in Iceland, The Grammar School study, was also used to retrieve information on intergenerational relations between grandparents and grandchildren. The study indicates that older people in Iceland are receiving help and care from both informal and formal carers but informal help provided by family members seems to play a major role in supporting older people in their home. The great majority of the respondents with Instrumental Activities of Daily Living (IADL) limitations and Personal Activities of Daily Living (PADL) limitations received either informal or formal help but not both. The care and help provided is more often help with domestic tasks than with personal care. However, when the need increases the formal system steps in. It is not clear whether the informal care is a substitute for the formal one. As the formal help provided is rather sparse, it is suggested that when the need for personal care increases, the older person moves into a nursing home instead of increasing the formal care in the home. Women more often than men are the sole carers, and daughters are more important carers for older people than sons are. Older informal caregivers were alone in their caregiving in almost half of the cases and women more often than men. One third provided help with several tasks, such as help with errands and surveillance or keeping company in addition to ADL help. Older caregivers provide care even when they need help themselves. The results indicate that grandparents and grandchildren exchange more emotional than practical support. The emotional support provided and received by the generations is of great value. Gender influences the contact frequency between the generations, as women more often cultivate ties between grandparents and grandchildren.

Falls and gait impairment in older populations present a major challenge to healthcare systems and reduce quality of later life. There is evidence that cognitive decline contributes to falls and gait impairment in older adults and may, therefore, serve as a marker for persons at risk. Intraindividual variability (IIV; trial-to-trial fluctuations in response time across a neurocognitive task) may have screening potential in this respect as this measure is thought to capture unique information about cognitive function not captured by other neuropsychological metrics. The present research, therefore, examined relationships between IIV, gait and falls in cognitively intact older adults. The extent to which relationships varied according to age and the demands placed on the individual when assessing IIV and gait, was also investigated. Finally, a mediational approach identified potential mechanisms underpinning these relationships. Systematic reviews of published research were followed by cross-sectional experimental studies and a longitudinal investigation. The findings provided mixed evidence of a link between IIV and falls. There was strong cross-sectional evidence that greater IIV was associated with poorer gait performance, and that this relationship strengthened with increasing age. Variability better predicted gait outcomes when gait was assessed under more demanding dual-task conditions, and when IIV measures were derived from tasks with higher executive demands. Tests of mediation suggested that processing speed underpinned relationships between IIV and less demanding single-task gait, whereas executive function played a greater role in more demanding gait conditions. Together, the outcomes suggest that IIV measures have potential as an early screening tool for gait impairment, and also falls. Importantly, general slowing accounts of cognitive ageing explained findings when IIV and gait were assessed under lower demand conditions, whereas frontal lobe/executive control perspectives provided a better account when demands were greater.

We use 32 age measurements of passively evolving galaxies as a function of redshift to test and compare the standard model ($\Lambda$CDM) with the $R_{\rm h}=ct$ Universe. We show that the latter fits the data with a reduced $\chi^2_{\rm dof}=0.435$ for a Hubble constant $H_{0}= 67.2_{-4.0}^{+4.5}$ km $\rm s^{-1}$ $\rm Mpc^{-1}$. By comparison, the optimal flat $\Lambda$CDM model, with two free parameters (including $\Omega_{\rm m}=0.12_{-0.11}^{+0.54}$ and $H_{0}=94.3_{-35.8}^{+32.7}$ km $\rm s^{-1}$ $\rm Mpc^{-1}$), fits the age-\emph{z} data with a reduced $\chi^2_{\rm dof}=0.428$. Based solely on their $\chi^2_{\rm dof}$ values, both models appear to account for the data very well, though the optimized $\Lambda$CDM parameters are only marginally consistent with those of the concordance model ($\Omega_{\rm m}=0.27$ and $H_{0}= 70$ km $\rm s^{-1}$ $\rm Mpc^{-1}$). Fitting the age-$z$ data with the latter results in a reduced $\chi^2_{\rm dof}=0.523$. However, because of the different number of free parameters in these models, selection tools, such as the Akaike, Kullback and Bayes Information Criteria, favour $R_{\rm h}=ct$ over $\Lambda$CDM with a likelihood of $\sim 66.5\%-80.5\%$ versus $\sim 19.5\%-33.5\%$. These results are suggestive, though not yet compelling, given the current limited galaxy age-$z$ sample. We carry out Monte Carlo simulations based on these current age measurements to estimate how large the sample would have to be in order to rule out either model at a $\sim 99.7\%$ confidence level. We find that if the real cosmology is $\Lambda$CDM, a sample of $\sim 45$ galaxy ages would be sufficient to rule out $R_{\rm h}=ct$ at this level of accuracy, while $\sim 350$ galaxy ages would be required to rule out $\Lambda$CDM if the real Universe were instead $R_{\rm h}=ct$. This difference in required sample size reflects the greater number of free parameters available to fit the data with $\Lambda$CDM.

Spatial navigation is essential for everyday function. It is successfully achieved by combining internally generated information – such vestibular and self-motion cues (known as path integration) – with external sources of information such as visual landmarks. These multiple sources and sensory domains are often associated with uncertainty and can provide conflicting information. The key to successful navigation is therefore how to integrate information from these internal and external sources in the best way. Healthy younger adults do this in a statistically optimal fashion by considering the perceived reliability of a cue during integration, consistent with the rules of Bayesian integration. However, the precise impact of ageing on the component senses of path integration and integration of such self-motion with external information is currently unclear. Given that impaired spatial ability is a common problem associated with ageing and is often a primary indicator of Alzheimer’s disease, this thesis asks whether age-related navigational impairments are related to fundamental deficits in the components of path integration and/or inadequate integration of spatial cues. Part 1 focussed on how ageing impacts the vestibular, kinaesthetic and visual components of path integration during linear navigation in the real world. Using path reproduction, distance estimation and depth perception tasks, I found that older adults showed no performance deficits in conditions that replicated those of everyday walking when visual and self-motion cues were present. However, they were impaired when relying on vestibular information alone. My results suggest that older adults are especially vulnerable to sensory deprivation but that weaker sensory domains can be compensated for by other sensory information, potentially by integrating different spatial cues in a Bayesian fashion: where the impact of unreliable/diminished senses can be minimised. Part 2 developed the conclusions of Part 1 by testing younger and older adults’ integration of visual landmarks and self-motion information during a simple homing task. I investigated the hypothesis that the integration of spatial information from multiple sensory domains is driven by Bayesian principles and that old age may affect the efficiency and elasticity of reliability-driven integration. Younger and older participants navigated to a previously visited location using self-motion and/or visual information. In some trials there was a conflict of information, which revealed the relative influence of self-motion and visual landmarks on behaviour. Findings revealed that both younger and older adults integrated visual and self-motion information to improve accuracy and precision, but older adults did not place as much influence on visual information as would have been optimal. This may have been the result of increased noise in the underlying spatial representations of older adults. Furthermore, older adults did not effectively re-weight visual and self-motion cues in line with the changing reliability of visual information, suggesting diminished plasticity in the underlying spatial representations. However, further development of the testing paradigm would strengthen support for these findings. Together, the findings of Part 2 suggest that increased neural noise and the suboptimal weighting of spatial cues might contribute to the common problems with navigation experienced by many older adults. This thesis provides original evidence for age-related changes to multisensory integration of spatial cues. Path integration abilities are relatively preserved when older adults navigate linear paths in the real world, despite loss of vestibular function. However, navigation is affected by old age when the task becomes more complex. Multisensory integration of spatial cues is partially preserved but it is not fully efficient. I offer evidence that the navigational impairments common to old age are related to fundamental deficits in the components of path integration, task complexity, and suboptimal integration of spatial cues. Crucially however, path integration is preserved sufficiently in older adults that they are able to navigate in small scale with relative success.

Estimating the level and trend in population mortality rates at advanced ages in South Africa is complicated by problems with both the population and death data. Population and death data, particularly in developing countries, often suffer from age misreporting - age exaggeration and digit preference. Also, censuses may under- or overestimate the population and registration of deaths is usually incomplete in developing countries (Dorrington, Moultrie and Timæus 2004). To avoid these problems, the research in this dissertation relies on the method of extinct generations and its extensions (Thatcher, Kannisto and Andreev 2002) to re-estimate the population using only the death data, which is often recorded more accurately than the population data. Since deaths are not reported completely in South Africa, the death data must be corrected before use. Death Distribution Methods (Moultrie, Dorrington, Hill et al. 2013) are used to correct the death data for incomplete registration of deaths. After correction, Near Extinct Generation methods (NEG) are used to re-estimate the population by projecting future deaths of nearly extinct cohorts. After showing that mortality rates produced using the original NEG methods are biased because of age and year of birth heaping present in the South African death data, the NEG methods are adapted to the South African context. The adapted NEG model smooths the age and year of birth heaping in the death data and produces mortality rates that are less biased than the original NEG methods. This model - referred to as the NEG-GAM model in this research - is used to re-estimate the population at each age from 70 and above and to calculate mortality rates since 1985. The population estimates aged 70+ produced using the NEG-GAM model match those from the 2011 census well. It is found that both the population and death data suffer from the same pattern of heaping, that the population and death data are affected by age exaggeration and that the death data are less affected by age exaggeration than the population data. The level and trend in mortality rates calculated using the NEG-GAM model are discussed and compared to the mortality rates in the Human Mortality Database and other studies of South African mortality. The mortality rates produced for the African and Coloured population groups appear too low at the older ages due to age exaggeration in the death data, while those for the Indian and White population groups appear to be reasonable over the entire age range. Mortality appears to be improving in the age range 70-79 for the Coloured, Indian and White population groups and deteriorating slowly for the African population group.

Old-age hippocampal sclerosis (HS), characterised by severe neuron loss in hippocampal CA1, is a poorly understood cause of dementia. At present no objective pathological HS criteria exist. In life HS is commonly diagnosed as Alzheimer's disease. HS aetiology is unclear, although it has been associated with both ischaemia and TAR-DNA-binding protein-43 (TDP-43)-related neurodegeneration. Variations in genes GRN, TMEM106B and ABCC9 are proposed as HS risk factors. The aim of this thesis was to investigate epidemiological, clinical, pathological and genetic characteristics of HS in older European populations. 976 brains donated for the Cambridge City over-75s Cohort, the Cognitive Function and Ageing Study and the Finnish Vantaa 85+ study were available for evaluation -including bilateral hippocampi from 302 individuals. A protocol capturing the extent and severity of hippocampal neuron loss was developed, establishing objective HS diagnosis criteria and allowing observation of distinct neuron loss patterns associated with ischaemia and neurodegeneration. 71 HS cases (overall prevalence: 7.3%) were identified. HS was significantly associated with an advanced age at death as well as dementia at the end of life. Neuropsychological and cardiovascular characteristics were similar between HS and AD, except for a longer duration of dementia and more disability in HS. HS was not associated with neurofibrillary tangles, amyloid plaques, or vascular pathologies, but all HS cases evaluated for TDP-43 showed neuronal inclusions in the hippocampal dentate and a high frequency of other glial, neuronal and neurite TDP-43 pathologies. GRN and TMEM106B but not ABCC9 variations were linked to HS. A moderating effect of TDP-43 on this association was detected. HS presented pathologically similarly to frontotemporal dementia cases with TDP-43 (FTLD-TDP) caused by mutations in GRN, but differed from other FTLD-TDP subtypes. Results of this thesis reveal the importance of HS in the oldest old in the population, the key role of TDP-43, as well as providing robust methods to capture HS characteristics for an area that has been under-researched but is clearly vital to understanding dementia in the oldest old.

Background: Old-old age (80+ years) is associated with substantial cognitive decline. In this population, training-induced cognitive plasticity has rarely been studied. While earlier findings on strategy trainings suggested reduced training gains in old-old age, recent results of an extensive process-based working memory (WM) training have been more positive. Objective: Following up on previous research, the present study aimed at examining the effects of a short WM training in old-old adults and the influence of baseline WM capacity on training gains. Methods: A training group (mean age: 86.8 years) and a matched control group (mean age: 87.1 years) participated in the study. The WM training consisted of five tasks that were trained in each of 10 sessions. To evaluate possible transfer effects, executive functions were assessed with two tests before and after training. The training group was divided via median split in high- and low-capacity individuals to determine the influence of baseline WM capacity on training gains. Results: The training group improved in four of the trained tasks (medium-to-large effects). Training gains were significantly larger in the training group than in the control group in only two of those tasks. The training effects were mainly driven by the low-capacity individuals who improved in all trained tasks. No transfer effects were observed. Conclusions: These positive effects of a short WM training, particularly for low-capacity individuals, emphasize the potential for cognitive plasticity in old-old age. The absence of transfer effects may also point to its limits
Dieser Beitrag ist mit Zustimmung des Rechteinhabers aufgrund einer (DFG-geförderten) Allianz- bzw. Nationallizenz frei zugänglich

Background: Old-old age (80+ years) is associated with substantial cognitive decline. In this population, training-induced cognitive plasticity has rarely been studied. While earlier findings on strategy trainings suggested reduced training gains in old-old age, recent results of an extensive process-based working memory (WM) training have been more positive. Objective: Following up on previous research, the present study aimed at examining the effects of a short WM training in old-old adults and the influence of baseline WM capacity on training gains. Methods: A training group (mean age: 86.8 years) and a matched control group (mean age: 87.1 years) participated in the study. The WM training consisted of five tasks that were trained in each of 10 sessions. To evaluate possible transfer effects, executive functions were assessed with two tests before and after training. The training group was divided via median split in high- and low-capacity individuals to determine the influence of baseline WM capacity on training gains. Results: The training group improved in four of the trained tasks (medium-to-large effects). Training gains were significantly larger in the training group than in the control group in only two of those tasks. The training effects were mainly driven by the low-capacity individuals who improved in all trained tasks. No transfer effects were observed. Conclusions: These positive effects of a short WM training, particularly for low-capacity individuals, emphasize the potential for cognitive plasticity in old-old age. The absence of transfer effects may also point to its limits.
Dieser Beitrag ist mit Zustimmung des Rechteinhabers aufgrund einer (DFG-geförderten) Allianz- bzw. Nationallizenz frei zugänglich.

This thesis heeds W. Andrew Achenbaum’s call for historians of ageing to analyse the inner lives of their subjects. Building on and problematizing existing studies of health and welfare policies for the old, it explores the ways that mid-century public and private life shaped how individuals felt about old age. Both public discussions and private narratives of ageing are used to consider how older people understood and expressed their emotional experiences during a challenging period of the life cycle. I argue that old age in general, and its emotional dimensions in particular, are missing from British historiography. Yet both were vital to social life in the mid-century, when the ageing population was an important political issue and a large number of experts hoped to manage the emotional and psychological aspects of this ‘problem’. This thesis begins by setting out this national context for old age, showing that heightened interest in ageing and emotion were significant influences over the expansion of the welfare state. However, contrary to the expectations of mid-century researchers and policy-makers, my subsequent chapters show that older people frequently maintained their social roles and relationships through informal means. This thesis explores how ageing men and women engaged with work, retirement, ill health, marriage, bereavement, fashion, beauty culture, and autobiography as opportunities to find meaning in late life. Together, these varied perspectives on old age make a series of interventions in its history. I argue that historians could do much more to detail the significance of the life cycle for their subjects, whether they write political, social, or cultural history. As this thesis shows, such studies should approach ageing as a lifelong and personal process, which has been shaped by reminiscence and story-telling. I suggest that historians of emotion are best-equipped to write scholarship that is sensitive to the passing of time and personal biography in this way.

Physical activity is associated with greater independence in old age. While most research has focused on the frequency, intensity and time spent in activity, inconsistent findings have emerged, possibly due to differences across different types of physical activity. Physical activities differ in terms of their non-metabolic, mental, physical and social demands, however, to date, the effects of these demands on functional independence are unexplored. The present thesis aimed to investigate the effect of different types of physical activity on functional independence in old age. A systematic review of randomised controlled trials (RCTs) found a significant, beneficial effect of physical activity on functional performance, with the largest effects found for moderate physical activity levels, and activity types with high levels of mental (e.g. memory, attention), physical (e.g. coordination, balance) and social (e.g. social interaction) demands. These findings generated the hypothesis that physical activities high in mental, physical and social demands are associated with greater functional independence. Thus, a novel typology of physical activities was generated by systematically coding the mental (i.e. attention/concentration, memory, decision-making and strategy), physical (i.e. flexibility, balance, coordination, speeded reactions) and social (i.e. social interaction) demands of 59 physical activities. The typology was then used to recode data from the Understanding Society survey. Findings revealed that as the non-metabolic, physical activity demands increased, functional independence improved. Associations remained significant after controlling for demographics. Key findings included differences across gender, in that the mental and physical demands of activity predicted muscular strength in males, whereas social demands predicted muscular strength in females. In conclusion, physical activities with higher mental, physical and social demands (e.g. dancing) are associated with greater functional independence in old age, compared with simpler types (e.g. walking). Future research is required to test whether these novel findings are replicated elsewhere, ideally using longitudinal or RCT designs.