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This thesis consists of two chapters (1) a systematic review which explores older women's decision-making in relation to medical treatments; (2) an empirical paper which explores the decision-making processes of women aged sixty or above who have been offered Electroconvulsive Therapy (ECT). The empirical paper has been written for a planned publication in the Journal of Geriatric Psychiatry and Neurology and has therefore been written in line with their authors guidelines. These can be found in Appendix A. Also, in the near future the systematic review paper will be prepared for publication in the Journal of Age and Ageing and will be formatted in line with their authors guidelines. Currently the systematic review is formatted in line with APA formatting guidance. Despite being individual papers, the two chapters aim to explore and obtain a greater understanding of older women's decision-making processes and factors which influence an individual's medical treatment decision-making. Such understanding enables clinicians to individualise treatment discussions and enhance educational strategies (Angarita, Elmi, Zhang, & Look Hong, 2018). This in turn increases the likelihood of person-centred care, as clinicians and service-providers alike are better able to develop and tailor interventions, based on their client or patient's goals, values and treatment preferences which positively influences patient satisfaction and clinical outcomes (Angarita et al., 2018; Ciambrone, 2006). Throughout both papers, the researchers acknowledge that there is no consensus on what defines an "older woman" (Angarita et al., 2018). However, for the purpose of both the systematic review and the empirical paper a threshold of sixty years or above was used to classify the population being studied as 'older'. This threshold was chosen as the most recent dataset published by the ECT accreditation service (ECTAS) indicated that 1073 out of 1821 individuals to receive acute courses of ECT between April 2016 and March 2017 were aged sixty or above and the mean age of individuals to receive ECT within the same time frame was sixty-one years, the mode was seventy years and the median was sixty-four years, respectively (Buley, Copland, & Hodge, 2017). The researchers also wished to maintain consistency, where possible, across the two chapters although, they acknowledge that across the papers included within the systematic review authors use thresholds of sixty-five and seventy years to classify the population as 'older' (Husain, Collins, Reed, & Wyld, 2008; Schonberg et al., 2014). Until this point, there has been a lack of synthesised data exploring factors which influence older women's treatment decision-making, when they are faced with a decision around whether to receive or decline a medical treatment. The systematic review therefore identified, appraised and synthesised the existing literature which explores this phenomenon. A systematic search was conducted across six electronic databases and a total of nine papers were identified for review, with all but one paper exploring decision-making within the context of older women's cancer treatment. The findings of this review suggested that the degree to which older women wish to be involved in their medical treatment decision-making varies between individuals. The review also highlighted a range of factors which influence this process. Thus, due to the individual and personal nature of older women's medical treatment decision-making, it was recommended that clinicians take time to work with an individual to explore their concerns, values and personal circumstances to understand how the interplay between such factors influences their treatment decision-making as this is likely to improve collaboration and encourage a more person-centred approach. Several recommendations for future research were also made based on the findings of this review, particularly as throughout the review the researchers were only able to access research relating primarily to older women's cancer treatment decisions and this limits the conclusions that can be made in relation to older women's medical treatment decision-making more generally. The empirical paper explored the personal stories of seven females who had been offered ECT after they had become sixty years of age, in order to gather an increased understanding of their decision-making processes and factors which influenced their decision-making around the treatment. Data collected via seven individual interviews was analysed using Narrative Analysis as this allowed the researchers to explore each participants' own story, as influenced by any personal, ethical, social or political issues that the research may bring (Weatherhead, 2011). The research findings were synthesised into a grand narrative, or coherent story (Howitt, 2016), which is presented across five chapters within the results section of the empirical paper. The grand narrative highlighted a range of factors which influence older women's decision-making around ECT; participants difficulties with depression, feelings of desperation and their desire to "get rid" of distress appeared to be the most influential of these factors. From the research findings, a model highlighting factors which influence older women's decision making around ECT was developed. Several clinical recommendations and recommendations for future research were also made, including, the use of robust and comprehensive consent processes throughout an individual's course of ECT, as feelings of desperation and an individual's perception around their treatment choice are noted to influence an individual's ability to provide informed consent and the voluntariness of their decision (Clarke, Barnes, & Ross, 2018; Swift, 2011), and exploring the perspectives of family members, friends and carers who support individuals offered ECT. The systematic review, empirical paper and their findings highlight the individualised and personal nature of older women's decision-making within the context of medical treatments for both physical and mental health difficulties. Older women's treatment decision-making has largely been neglected within medical and mental health research which in turn is likely to have resulted in clinicians, who work in physical and mental health services, making paternalised assumptions around older women's treatment preferences, their preferred decision-making style and their sense of autonomy and empowerment. Through disseminating the findings, and highlighting the clinical recommendations made it is hoped that clinicians are encouraged to have more open discussions around the physical and mental health treatments available to older women, older women's treatment preferences, their preferred decision-making style and factors which influence their treatment decision-making. This in turn is likely to improve the decision-making process experienced by older women and support more informed decision-making. It is also hoped that by addressing the recommendations for future research, researchers will continue to contribute to the growing evidence base relating to older women's health care decision-making to further increase understanding of factors which influence the decision-making process experienced by individuals when they are faced with a decision around whether to receive a medical treatment for varying physical and mental health concerns.

Urinary stones are a common medical condition affecting over 10% of adults in the developed world. Whilst many different materials are found in kidney stones, the majority are dominated by deposits of calcium oxalate (CaOx). In addition to the mineral phases, urinary calculi also contain macromolecules. It has been shown that many of these, particularly the proteins, can inhibit CaOx crystallisation and are therefore widely assumed to be relevant to stone pathogenesis. More recently, it has been proposed that certain urinary proteins facilitate the prevention of stone formation through their selective inclusion into the growing crystal and subsequent structural disruption through protease activities. Given that the intracrystalline location of proteins would be structurally challenging, their selective occlusion may support a functional role. This thesis explores these concepts. The crystallisation of CaOx in the urine of stone formers and healthy controls was compared. CaOx crystals grown in human urine and inorganic media were examined using a range of complementary techniques, e.g., electron microscopy, X-ray diffraction and thermogravimatric analysis. Proteins associated with the surface of different mineral phases and/or occluded within the crystal structures were isolated and identified using immunoblotting. The recovered proteins were quantified in terms of their crystal volume occupation, and the proportion of proteins taken up from the urine were investigated. Finally, six common methods used to study CaOx/protein interactions in vitro were compared. Significant differences were noted in the crystallisation parameters which define the urine samples from stone-formers and controls. These could not be attributed to electrolyte balance from which it is inferred that the influence of other urinary constituents such as proteins must be significant. Only a small proportion of the urinary proteins associated with the CaOx crystals and they contributed to less than 5% of the total crystal volume, suggesting that arguments for a preventative role in stone formation cannot be supported. Kinetic experiments demonstrated that two proteins, often proposed as inhibitors of stone formation had little effect on CaOx nucleation and growth rates. Different proteins were found to be surface-associated when compared to those that were occluded within the crystal structures. However, the same proteins all associated with both CaO monohydrate and dehydrate, which suggests unique template-mediated interactions are unlikely. The growth of CaOx in urine using six methods showed that the stabilisation of different hydromorphs and induction of some morphological changes in CaOx were protocol dependant and not, as previously suggested, attributable to protein interactions. The method used did not influence the type of protein associating with CaOx. These results indicate that whilst urinary proteins may be capable of modifying CaOx crystal growth they appear to do so through non-specific interactions. There is little evidence that proteins are present in urine as teleological inhibitors of stone formation.