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The aims of this thesis were to investigate the changes in muscle strength that occur in older adults during unplanned hospital admissions, and to investigate the feasibility and efficacy of in-hospital exercise interventions in improving muscle strength and functional outcomes. To investigate changes in muscle strength during hospitalisation, I conducted a systematic review and meta-analysis, and a repeated measures cohort study. The review concluded that adult patients who undergo an unplanned hospital admission may, regardless of age, experience a reduction of around 10% in knee-extension strength. To corroborate these findings in an older general medical population, I conducted a cohort study, which included 70 participants aged ≥75 recruited within 24 hours of acute hospital admission. Knee-extension strength declined during hospitalisation by 11% (p <0.001) but did not change by follow-up four to six weeks after hospitalisation (p = 0.458). General functional ability as measured by the Barthel Index deteriorated by 9 points (10%) between two weeks before admission and follow-up (p < 0.001). Functional mobility as measured by the de Morton Mobility Index improved by 6.5 points (15%) during hospitalisation (p < 0.001) but had not changed at follow-up (p = 0.508). A repeated measures mixed model showed that greater loss in knee-extension strength during hospitalisation was associated with increased sedentary time, frailty, baseline strength and lower baseline inflammatory levels. To investigate the feasibility and efficacy of in-hospital exercise interventions, I conducted a feasibility study and a meta-analysis. The feasibility study found that it is possible to conduct a randomised control trial of a twice-daily exercise programme for older adults during an acute hospital admission in an NHS hospital. The exercise intervention was well received, with most participants describing health benefits in terms of both physical improvement and increased confidence. The meta-analysis concluded that there is low certainty of evidence that exercise interventions, and more specifically progressive resistance training, when compared to usual care or sham interventions, results in improved independence with activities of daily living and functional mobility at discharge from hospital, without increasing the risk of adverse events. The thesis has several limitations including: that the primary research studies were all single-centre studies using convenience samples thereby limiting generalisability; that causality between sedentary activity and loss of knee-extension strength could not be confirmed in an observational design; and that recruitment to the feasibility study achieved only half of the initial target. Nevertheless, the objectives of the thesis were met, and provide a solid foundation to continue the development of interventions to prevent hospital-associated deconditioning. In line with the MRC guidance on the development of complex interventions, next steps will include refinement of the intervention, including identifying or developing an appropriate behavioural change theory, before further feasibility work and evaluation of the intervention.

Long Term Conditions (LTCs) with co-morbid common mental health conditions of anxiety and depression present a significant challenge for UK health and social care services. Depression and anxiety are common in heart failure (HF) patient populations and research suggests depression has a detrimental effect on a range of health outcomes, including Health related Quality of Life (HRQoL). The impact of anxiety is relatively under-researched in this patient group. In this doctoral study a systematic review was conducted to consolidate the evidence base for the prevalence and variance of rates of anxiety in HF patients. Importantly, the relative contribution of anxiety symptoms, measured using the Hospital Anxiety and Depression Scale (HADS), to reported HRQoL , measured using the Kansas City Cardiomyopathy Questionnarie (KCCQ) was examined in a cross-sectional survey of 158 HF patients attending specialist HF outpatient clinics. The systematic review identified 72 studies, with reported rates of anxiety varying dramatically, ranging from 6.2% to 72.3%. The random effects pooled prevalence estimate for anxiety disorders was 13.01% (95% CI 9.3% - 16.9%), for probable clinically significant anxiety was 28.8% (95% CI 23.3% - 34.3%) and the random effects pooled prevalence estimate for elevated symptoms of anxiety was 55.5% (95% CI 48.1% - 62.8%). Not all tools used to assess anxiety were population appropriate. In the survey multivariate analysis found that anxiety symptoms, did not account for a significant proportion of unique variance in HRQoL scores. Higher levels of physical symptom burden, depression and an increased number of physical co-morbidities predominantly account for 69% of the variance in HRQoL (F13,125 = p <0.0005). The findings highlight the need for accurate and valid measurement of anxiety and depression within the context of a physical LTC. Anxiety and depression are common in HF patients and the evidence suggests depression in particular predicts reported HRQoL. Further research is required to understand more about the role of anxiety in influencing patient’s health outcomes.

Introduction: Following ST-elevation myocardial infarction (STEMI) and treatment with Primary Percutaneous Coronary Intervention (PPCI), some patients re-present with potential ischaemic heart disease (IHD) symptoms. Symptoms may be related to cardiac ischaemia, reduced psychological health or a comorbid condition, which share similar symptoms and may lead patients to seek help via acute services. The purpose of the study was to investigate the proportion of PPCI patients who re-presented to acute services due to potential IHD symptoms within 6 months of STEMI, and to explore associated factors. Methods: An explanatory mixed methods study was conducted. Quantitative data were collected at baseline and 6 months from consecutive patients attending two centres in Manchester. Variables were carefully considered based on a conceptual model for re-presentation. These included potential IHD symptom and psychological health assessments using self-report measures: the Seattle Angina Questionnaire (SAQ) and the Hospital and Anxiety and Depression Scale (HADS). Physiological health was measured using the Global Registry of Acute Coronary Events (GRACE) and the Charleson Comorbidity Index (CCI) at baseline. At 6 months re-presentation data were collected using patient records, a telephone interview and a self-report diary card. The experiences of some who re-presented (purposeful sampling) were explored through semi-structured interviews conducted at least 6 months following PPCI. Framework analysis was adopted to analyse data. Results: 202 PPCI patients returned baseline questionnaires [mean age 59.7 years (SD 13.9), 75.7% male]; 38 (18.8%; 95% CI 14.0% to 24.8%) participants re-presented due to potential IHD symptoms at 6 months; 16 (42.1%) re-presented due to a cardiac event and 22 (57.9%) did not receive a diagnosis. At both baseline and 6 months, mean HADS anxiety scores were higher for the re-presentation group compared to the non-representation group (baseline 9.5 vs 7.1, p=0.006; 6 months 9.4 vs 6.0, p<0.001). Angina symptoms were stable and infrequent at both time points for the groups. Multivariate regression modelling with the inclusion of predictors HADS anxiety, SAQ angina stability, SAQ angina frequency, GRACE and CCI, determined HADS anxiety as a predictor of re-presentation with an adjusted odds ratio of 1.12 (95% CI 1.03 to 1.22, p=0.008). The qualitative interviews with re-presenters included 25 participants (14 men, 27-79 years). Four themes were identified: fear of experiencing a further heart attack, uncertainty and inability to determine cause of symptoms, insufficient opportunity to validate self-construction of illness and difficulty adapting to life after a heart attack. Conclusion: Elevated levels of anxiety at baseline were predictive of re-presentation with potential IHD symptoms at 6 months. Factors such as shock at experiencing a heart attack, hypervigilance of symptoms and difficulty with symptom attribution appeared to play a role in raised anxiety levels for the re-presentation group. Findings suggested that changes are needed to cardiac rehabilitation and post-STEMI follow-up to address educational needs and psychological issues and changes in STEMI treatment.