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Physical inactivity among older inpatients is associated with worsening physical function and increasing dependence in activities of daily living. Studies have shown that interventions using paid staff to improve physical activity levels may reduce the risk of some of these harmful effects. However, few studies have explored the use of volunteers in this role. The aim of this study was to assess the feasibility and acceptability of using trained volunteers to encourage older inpatients to be physically active. Physical activity levels of inpatients aged ≥ 70 years on three study wards receiving usual care were measured using two accelerometers. An evidence-based training programme for volunteers was developed with therapy colleagues. The volunteer-led activity sessions were implemented on the study wards with repeat measurement of physical activity. Finally, the acceptability of the intervention was assessed through interviews and focus groups among patients, volunteers, nurses and therapists. 42 participants (mean age 87.5 years, SD 4.6) receiving usual care had their physical activity measured. The median daily step count was 636 steps (IQR 298 – 1468), and the mean daily acceleration was 9.1milligravity (mg) (SD 3.3). 17 volunteers were recruited and volunteer retention at the end of the study period was 70% (12 volunteers). 310 activity sessions were offered to 50 participants and 230 sessions (74%) were completed. No adverse event was reported. 25 participants including patients, volunteers, nurses and therapists were interviewed. Findings from the interviews demonstrated that the intervention was well-received among patients, nurses and therapists. Volunteers can be trained and retained to safely encourage older inpatients to be more active. Further research is required on the impact of the volunteer-led intervention on patient outcomes.

Malnutrition is a common problem in older people admitted to hospital, and it is associated with negative healthcare outcomes and considerable healthcare costs. One factor that has been identified as contributory to this is insufficient assistance for patients at mealtimes. A systematic review identified small studies and service improvement projects where volunteers were trained as mealtime assistants and demonstrated that this is feasible and safe, and has a positive impact on satisfaction with mealtime care, although evidence of an effect on dietary intake was unconfirmed. No large-scale studies were identified by this review. This study examined the implementation of volunteer mealtime assistants in four departments of a large university hospital. Volunteers were introduced to Medicine for Older People, the Acute Medical Unit, Trauma & Orthopaedics and General Medicine. Each department was described by characterising 50 patients and measuring dietary intake and nutritional indices on each ward. Implementation was described in terms of adoption (volunteer recruitment, training and characteristics), feasibility (volunteer sessions and activity), sustainability (volunteer retention), acceptability (patients, staff and volunteer interviews and focus groups) and implementation cost. 201 participants were recruited from the four departments. Multimorbidity, polypharmacy and frailty were common, as was risk of malnutrition; dietary intake was often insufficient. 64 volunteers were recruited and adopted across the departments, where they delivered 846 sessions and recorded assisting 1721 patients. The intervention was sustainable, with 52% of volunteers continuing to be active at the end of the study. Patients and staff found the volunteer programme acceptable and volunteers enjoyed their role. The programme released £17,131-£32,359 in staff costs. This study has demonstrated that volunteer mealtime assistants can be successfully trained and implemented in four different hospital departments, and are received positively by both patients and staff. Strategies must be put in place to support volunteers and ongoing training is required to maintain volunteer numbers, but the costs of this are more than offset by staff costs released.

Excessive bed rest and sedentary behaviour in older inpatients are well recognised problems within the NHS which can contribute to a range of negative effects such as infections, thrombosis, pressure damage to skin, urinary incontinence, constipation, mental health issues, loss of muscle and deconditioning. Due to ever increasing time pressures on nursing staff in the NHS, other aspects of care (such as medical treatments, washing and feeding) take priority over frequent daily mobilisation of patients. Volunteers have been used in some hospitals worldwide to assist with mobilisation in older people with promising results. This qualitative study aimed to gain views and perceptions of patients, caregivers, staff and volunteers with regards to volunteer‐led mobilisation of older patients on acute medical wards. The study also investigated perspectives on hospitalisation in general, barriers to mobilisation and suggestions for improvements in the care of older people. 20 patients, 7 family members, 27 staff and 3 mealtime volunteers participated in either individual interviews or focus groups which were audio recorded, transcribed, coded and analysed according to the Framework method. The results of the study were grouped into five main topics: 1. The hospitalised older adult which includes the concept of institutionalisation and disempowerment of the frail patient, advantages and disadvantages of hospitalisation. 2. Mobility of inpatients which includes description of mobilisation practice in hospital, views on importance of keeping active in older age and awareness of bed rest risks. 3. Barriers to mobilisation which were grouped into environmental, patient related, staff related and family related themes. 4. Volunteer‐led walking programme with following areas to consider prior to implementation: patient selection, volunteer selection, environmental issues, staff related issues. 5. Proposed changes which could help improve mobility of older people and care in general. There are many ways in which the hospital environment, staff and even family members can add to the disempowerment in older inpatients which in turn results in increased social care requirements‐ institutional, cultural and organisational factors are all contributive. Early mobilisation could become a good, simple way of empowerment. Close inspection of barriers to mobilisation and searching for ward or hospital specific solutions to overcome them could support the paradigm shift. In this context, training volunteers to assist with mobilisation would provide a strong message not only to patients and caregivers but also to all types and grades of hospital staff. This work provides a multi‐layered insight into the care of older patients in a large NHS hospital. The ideas, reflections and inferences derived from this study mirror the current climate in the NHS and provide evidence that a shift in perception has already happened. My interviewees have created a story that I attempted to unveil and systematise so that at least parts of it can be translated into practical solutions in day‐to‐day clinical practice.

Introduction: Grip strength across the life course is associated with disability, morbidity and mortality, and forms a key component of the sarcopenia and frailty phenotypes in older people. However it is unclear how individual measurements of grip strength should be interpreted. My objectives were to produce centile values for grip strength across the life course in Great Britain (GB), and then to compare with those in international settings. Methods: I combined data from 12 general population studies in GB to produce centile curves using the Box-Cox Cole and Green distribution. I estimated the prevalence of weak grip, defined as at least 2.5 SDs below the gender-specific peak mean. I then did a systematic literature search and expressed the resulting international normative data as Z-scores relative to my British centiles. I used metaregression to pool these by world region. Results: I combined 60,803 grip strength observations from GB at ages 4 to 90. I saw an increase to a peak median in early adulthood of 51kg in males and 31kg in females, maintenance to midlife and then decline. The prevalence of weak grip increased with age, reaching 23% in males and 27% in females by age 80. My systematic literature search returned 60 papers containing 730 international normative data items. Those from developed regions were similar to my GB centiles, pooled Z-score 0.12 (95% CI: 0.07, 0.17), whereas those from developing regions were clearly lower, pooled Z-score -0.86 (95% CI: -0.95, -0.77). Conclusion: My GB centiles are the first to cover the entire life course. Published normative data showed a similar pattern, but with clear differences in magnitude between developing and developed regions. The findings have the potential to inform the clinical assessment of grip strength, recognised as an important part of the identification of people with sarcopenia and frailty.

Studies assessing the grip strength of older people have typically recruited community dwelling participants, or those in acute hospital settings. There are few studies of grip strength of older people in rehabilitation or long term care. The aim of this thesis was therefore to investigate the epidemiology of grip strength in these healthcare settings. The specific objectives were to study in each setting a) the feasibility and acceptability of grip measurement; b) the grip strength values recorded in comparison with published reference ranges; c) the clinical correlates of grip strength; and d) the association of grip strength with discharge outcomes for the rehabilitation inpatients. Participants were recruited prospectively between 2007 and 2010 from four healthcare settings within the same geographical area. Data on age, anthropometry, current comorbidities and medication, physical, cognitive and nutritional status, and subsequent - discharge were recorded, and grip strength was measured. The feasibility of grip strength measurement was evaluated and its acceptability was assessed by questionnaire and by semistructured interviews with a purposive sample of participants from each setting. 305 participants were recruited. Almost all could complete the grip strength assessment and would repeat the test. Qualitative data confirmed the high level of acceptability of grip strength measurement. There were significant differences in grip strength of both men and women between settings, and the grip strength of the in-patients and the nursing home residents was far below published reference values. Age, gender, body size and Barthel Score were the characteristics most consistently associated with grip strength in these settings. Among the 101 rehabilitation in-patients higher grip strength was associated with a reduced length of stay but this was only statistically significant among the men. This thesis has demonstrated that grip strength measurement of older people in these healthcare settings is both feasible and acceptable, and has described its values as well as its clinical correlates. It has shown the need for reference ranges specific to each healthcare setting since grip strength appears to be associated with length of stay even amongst those with low grip strength.

The population of the United Kingdom (UK) is ageing; the already substantial burden of musculoskeletal disorders on health and social care systems will increase over time as the population ages. Social inequalities in health are well documented for the UK in general but little is known about social inequalities in musculoskeletal ageing. Using data from the 3,225 ‘young-old’ (age 59 to 73 years) community dwelling men and women who participated in the Hertfordshire Cohort Study, this thesis has explored social inequalities in musculoskeletal ageing: specifically, loss of muscle strength and physical function (PF); falls; Fried frailty; and osteoporosis. Socioeconomic position was characterised by age left full-time education, parental social class at birth and own social class in adulthood, and current material deprivation by housing tenure and car availability. Not owning one’s home was associated with lower grip strength and increased frailty prevalence among men and women and with poorer self-reported short-form 36 (SF-36) PF among men. Reduced car availability was associated with lower grip strength and poorer SF-36 PF among men and women and with increased falls and frailty prevalence among men. There was no convincing evidence for social inequalities in fracture, dual-energy x-ray absorptiometry (DXA) total femoral bone mineral density (BMD) and bone loss rate, or peripheral quantitative computed tomography (pQCT) strength strain indices for the radius or tibia. This thesis has argued that social variations in height, fat mass, diet and physical activity are likely to have mediated these results. Moreover, evidence for a social gradient in grip strength but not BMD is consistent with ageing skeletal muscle remaining highly responsive to physical activity in later life in a way that ageing bone does not; the impact of lifecourse customary and occupational physical activity on social inequalities in musculoskeletal ageing merits further research. The results presented in this thesis suggest that any clinical interventions designed to reduce the loss of muscle mass and function with age should be targeted proportionately across the social gradient; strategies to reduce fracture and osteoporosis should continue to have a universal population focus. Finally, this thesis suggests that there exists a subgroup of older men and women in the UK who face the multiple jeopardy of increased levels of material deprivation combined with greater loss of muscle strength and physical function; these men and women urgently need the government to commit to reform of the funding system for adult care and support.