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Item An exploration into gender and generational differences in mental health literacy in Aotearoa New Zealand and Australia : a thesis presented in partial fulfilment of the requirements for the degree of Doctor of Clinical Psychology at Massey University, Albany, New Zealand(Massey University, 2025-07-25) Dodge, AndrewMental distress touches the lives of many. Society could benefit from enhancing the public’s ability to effectively assist in its identification, management, and prevention. Mental health literacy is a concept that assesses this capacity in the general population. Prior international research indicates that both gender and generational differences for this construct exist, with men and older adults typically exhibiting lower levels of mental health literacy. However, we currently lack an accurate understanding of why such patterns have emerged and an evaluation of whether these differences may be influenced by measurement bias. This study seeks to enhance our understanding of these differences. Using a cross-sectional quantitative study design, a total of 830 participants aged 18 to 76 from Aotearoa New Zealand and Australia completed an online questionnaire measuring their mental health literacy and restrictive emotionality. Men demonstrated lower levels of mental health knowledge and attitudes than women, while partial support was found for a linear pattern of differences across generations for mental health attitudes (with older generations exhibiting lower mental health attitude scores than younger generations). However, given the lack of evidence to support measurement invariance, it is possible that these observed differences were influenced by differences in measurement properties. The results did not support the assertion that younger generations would be more likely to falsely detect the presence of a mental health disorder when presented with a vignette describing normal levels of distress in a difficult situation. Additionally, the study did not find evidence that restrictive emotionality mediates the relationship between gender and mental health attitudes. Overall, this study raises the possibility that gender and generational differences in mental health literacy may be influenced by measurement bias. The findings also suggest that the broad conceptualisation of mental health literacy as a multidimensional construct may fail to adequately capture the nature and strength of the relationships between the variables that it is comprised of. Additionally, these results contrast voices from concept creep literature suggesting an expanding concept of harm concerning mental health terminology among younger generations. Rather, this study suggests that perceived generational differences within this area may be exaggerated.Item Connected older citizens : ageing in place and digitally mediated care in Aotearoa New Zealand : a thesis presented in partial fulfilment of the requirements for the degree of Doctor of Philosophy in Media Studies at Te Kunenga ki Pūrehuroa, Massey University Manawatū, Aotearoa New Zealand(Massey University, 2025-05-07) Vonk, LisaAmidst discussions of Aotearoa New Zealand’s ageing population, how to care for growing numbers of older people is a considered a preeminent social and political issue. Digital technologies are imagined to be a particularly desirable solution in contexts where social values of independence intersect with the neoliberal state’s desire to reduce the amount of money spent on medical and social care. There is a substantial market for gerontechnologies (technologies specifically designed for older people) aiming to capitalise on the ‘silver tsunami’. Yet, digital technologies such as smart phones, exercise watches and laptops are widely accessible in Aotearoa New Zealand. They are increasingly used by older people to maintain social connectedness, coordinate practical support, and manage health. The purpose of this research was to explore how this digitally mediated care functions for community-dwelling older people. Taking an innovative theoretical-methodological approach, I combined actor-network theory with political economy theory. This enabled me to robustly examine sociotechnical care networks, paying attention both to the role of technologies in producing care as well as analysing who benefits from older people’s engagements with technology for care. The research draws on interviews with sixteen community dwelling older people, marketing materials of technologies used by those interviewed, the interface of an exchange platform and a patient portal used by some of those interviewed, as well as government documents. This data was analysed using network mapping, thematic analysis, and interface analysis. I ultimately demonstrate that digitally mediated care practices enact a ‘connected older citizen’. Through digitally mediated care practices, older people adjust (and are adjusted) to a culture of connectivity. Digitally mediated care involves new forms of labour. Social connection is framed as a core social value. I argue that digitally mediated self-care redefines independence in terms of the ability to use digital technologies to manage connections to reduce visible dependence on others. Notably, I show the imagined benefits of digitally mediated care are often not realised in practice due to limitations of technologies used in care (such as patient portals). Significantly, the priorities and needs of older people are not often at the forefront of digitally mediated care.Item Higher FORTA (Fit fOR The Aged) scores are associated with poor functional outcomes, dementia, and mortality in older people(Springer Nature Switzerland AG, 2022-11) Pazan F; Breunig H; Weiss C; Röhr S; Luppa M; Pentzek M; Bickel H; Weeg D; Weyerer S; Wiese B; König H-H; Brettschneider C; Heser K; Maier W; Scherer M; Riedel-Heller S; Wagner M; Wehling MPurpose Higher Fit fOR The Aged (FORTA) scores have been shown to be negatively associated with adverse clinical outcomes in older hospitalized patients. This has not been evaluated in other health care settings. The aim of this study was to examine the association of the FORTA score with relevant outcomes in the prospective AgeCoDe–AgeQualiDe cohort of community-dwelling older people. In particular, the longitudinal relation between the FORTA score and mortality and the incidence of dementia was evaluated. Methods Univariate and multivariate correlations between the FORTA score and activities of daily living (ADL) or instrumental activities of daily living (IADL) as well as comparisons between high vs. low FORTA scores were conducted. Results The FORTA score was significantly correlated with ADL/IADL at baseline and at all follow-up visits (p < 0.0001). ADL/IADL results of participants with a low FORTA score were significantly better than in those with high FORTA scores (p < 0.0001). The FORTA score was also significantly (p < 0.0001) correlated with ADL/IADL in the multivariate analysis. Moreover, the mean FORTA scores of participants with dementia were significantly higher (p < 0.0001) than in those without dementia at follow-up visits 6 through 9. The mean FORTA scores of participants who died were significantly higher than those of survivors at follow-up visits 7 (p < 0.05), 8 (p < 0.001), and 9 (p < 0.001). Conclusion In this study, an association between higher FORTA scores and ADL as well as IADL was demonstrated in community-dwelling older adults. Besides, higher FORTA scores appear to be linked to a higher incidence of dementia and even mortality.Item Mild cognitive impairment and quality of life in the oldest old: a closer look(Springer Nature Switzerland AG, 2020-06) Hussenoeder FS; Conrad I; Roehr S; Fuchs A; Pentzek M; Bickel H; Moesch E; Weyerer S; Werle J; Wiese B; Mamone S; Brettschneider C; Heser K; Kleineidam L; Kaduszkiewicz H; Eisele M; Maier W; Wagner M; Scherer M; König H-H; Riedel-Heller SGPurpose Mild cognitive impairment (MCI) is a widespread phenomenon, especially affecting older individuals. We will analyze in how far MCI affects different facets of quality of life (QOL). Methods We used a sample of 903 participants (110 with MCI) from the fifth follow-up of the German Study on Ageing, Cognition, and Dementia in Primary Care Patients (AgeCoDe), a prospective longitudinal study, to analyze the effects of MCI on different facets of the WHOQOL-OLD. We controlled for age, gender, marital status, education, living situation, daily living skills, and the ability to walk, see, and hear. Results Univariate analyses showed that individuals with MCI exhibited lower QOL with regard to the facets autonomy; past, present, and future activities; social participation; and intimacy, but less fears related to death and dying. No significant difference was shown with regard to the facet sensory abilities. In multivariate analyses controlling for age, gender, marital status, education, living situation, daily living skills, and the ability to walk, see and hear, MCI-status was significantly associated with QOL in the facet autonomy. Conclusion Effects of MCI go beyond cognition and significantly impact the lives of those affected. Further research and practice will benefit from utilizing specific facets of QOL rather than a total score.Item Nitrate-rich beetroot juice and its effects on cardiovascular health and cognition in younger and older adults : a thesis presented in partial fulfilment of the requirements for the degree of Doctor of Philosophy in Sport and Exercise Science at Massey University, Auckland, New Zealand(Massey University, 2022) Stanaway, LukeBackground: Evidence suggests supplementation with nitrate-rich beetroot juice (BR) may improve cardiovascular responses and cognition in male and female, younger and older adults. However, there is still limited research in this area, particularly in older adults and with regards to measures of endothelial and cognitive function where equivocal findings have been observed. In addition, it is unclear whether age-related differences impact on the benefits from dietary nitrate supplementation. Older adults tend to have an increase in blood pressure (BP) and decline in cognition with aging, and thus may respond more favourably to BR supplementation compared to younger adults. Additionally, the effects of dose and duration (acute versus chronic) of supplementation with dietary nitrate are still not well known. Overall aims: To 1) investigate the effects of varying doses of nitrate-rich BR on cardiovascular responses and cognition in older adults, and 2) examine the effects of acute and chronic supplementation with BR on cardiovascular responses and cognition in the two age groups. Methods: The “Dose-response study” (Chapter 4) examined the effects of acute supplementation with varying doses of BR (0.15 (placebo; PL), 2.5, 4.9, and 9.8 mmol nitrate) on cardiovascular and cognitive responses in older adults (50-80 years; n=11) in a randomised, double-blind, crossover designed trial. At each visit, resting blood samples for plasma nitrate and nitrite, BP, mean arterial pressure (MAP), systemic vascular resistance (SVR), heart rate (HR), resting metabolic rate, and cognitive function were completed pre- and 2.25 h post-supplementation. The “Acute study” (Chapter 5) was a randomised, double-blind, crossover study. Twenty-four participants, 13 younger (18-30 years) and 11 older (50-70 years), completed resting blood samples, BP, HR, cognitive function, and mood and perceptual measurements pre- and post-supplementation with nitrate-rich BR (10.5 mmol) or placebo (1 mmol). The “Chronic study” (Chapter 6) was a double-blind, randomised control trial investigating acute, acute + chronic, chronic + acute (exercise performance) and chronic supplementation with either nitrate-rich BR (10.5 mmol) or PL (0.15 mmol) over 28 days in 21 younger (18-30 years) and 22 older (50-80 years) adults. On days 0, 14, and 28 resting blood samples, BP, MAP, SVR, HR, and cognitive performance measures were completed pre- and 2.25 h post-supplementation, while oxygen uptake (V̇O₂) and time trial performance were measured 2.5 h post-supplementation. Results: Ingestion of varying doses of dietary nitrate in the Dose-response study increased plasma nitrate and nitrite concentrations in a dose-dependent manner, with a significant difference shown between each treatment for plasma nitrate (p < 0.001). However, plasma nitrite was only significantly increased following consumption of the 9.8 mmol treatment compared to PL (p = 0.004). Systolic blood pressure (SBP), diastolic blood pressure (DBP), and MAP were reduced 2.25 h post-supplementation with the 9.8 mmol treatment compared to the PL, 2.5, and 4.9 mmol treatments (p < 0.05). Following supplementation with the 9.8 mmol dose, Corsi span (cognitive function) was improved during the Corsi block tapering test (CBT) compared to PL (p = 0.013) and 2.5 mmol (p = 0.004) treatments. In the Acute study, supplementation with nitrate-rich BR also significantly increased plasma nitrate (p < 0.001) and nitrite (p = 0.003) concentrations in younger and older adults relative to PL. Systolic BP was reduced in both younger and older adults (p < 0.001) 2.25 h post-supplementation with BR compared to PL, while DBP was only reduced in older adults (p = 0.013). Older adults had a greater increase in plasma nitrite (p = 0.038) and reduction in DBP (p = 0.005) compared to younger adults. Cognitive performance measures were also improved in younger and older adults following acute supplementation with nitrate-rich BR, with a reduction in reaction time observed during the Stroop test (p = 0.045). The Chronic study showed a significant reduction in SBP, DBP, and MAP following acute supplementation with nitrate-rich BR on day 0 in older adults (p < 0.001) and following an acute dose in the context of chronic supplementation (acute + chronic) on day 28 in both older (p < 0.01) and younger (p < 0.05) adults. Fourteen days’ chronic supplementation with nitrate-rich BR, in the absence of an acute dose, also reduced SBP (p = 0.019), DBP (p = 0.004), and MAP (p = 0.005) in older but not younger adults. Older compared to younger adults also had a greater reduction in SBP, DBP, and MAP following acute supplementation with nitrate-rich BR on day 0 (p < 0.05) and following chronic supplementation on day 14 (p < 0.05). Acute + chronic supplementation with nitrate-rich BR reduced SVR in older adults on days 14 (p = 0.032) and 28 (p = 0.016), with a greater reduction in older compared to younger adults observed on day 14 (p = 0.015) and a trend for greater reduction in older adults observed on day 28 (p = 0.056). Acute (on day 0) and acute + chronic (on day 28) consumption of nitrate-rich BR improved reaction time during the Stroop test in older adults (p = 0.042 and 0.006, respectively), while older (relative to younger) adults also showed a greater improvement in reaction time during the Stroop test following chronic supplementation on days 14 (p = 0.016) and 28 (p = 0.02) despite no effect of treatment on these days. Older adults also showed a greater reduction in V̇O2 at 20% completion of the cycle time trial following acute supplementation with BR on day 0 (p = 0.044), despite no effect of treatment at this time point. Conclusion: The results from this PhD project showed that acute and daily supplementation with nitrate-rich BR can improve BP and cognitive function in younger and older adults, with greater benefits observed in the older cohort. Furthermore, chronic supplementation with nitrate-rich BR in older adults can improve BP independent of an acute dose. These results suggest that daily supplementation with nitrate-rich BR may have a role in clinical settings for helping maintain healthy cardiovascular and cognitive function. Future research should investigate the use of nitrate-rich BR as a potential preventative therapy for cardiovascular and cognitive diseases such as hypertension and dementia.Item What counts as consent? : sexuality and ethical deliberation in residential aged care : final project report 19 November 2020(Massey University, 2020) Henrickson, Mark; Schouten, Vanessa; Cook, Catherine; McDonald, Sandra; Atefi, Narges (Nilo)This report is intended as a summary of the three-year Royal Society Marsden Fund-funded project “What counts as consent: Sexuality and ethical deliberation in residential aged care” (MAU-1723). The project was funded for the period March 2018 to February 2021. The aim of the project is to interrogate and inform conceptualisations of consent in the domain of sexuality and intimacy in residential aged care. The project completed and exceeded all recruitment and participation goals. While there is a general consensus that sexuality is an intrinsic part of human identity, intimacy and sexuality in aged care remain misunderstood and contested issues. This is particularly so in respect of older persons living with dementia. Gender and sexually diverse communities constitute a significant invisible and invisibilised minority in residential aged care (RAC), and that invisibility means their intimacy needs remain largely unknown and unacknowledged. There are cultural issues in aged care unique to New Zealand: for instance, while 85 percent of residential aged care facility (RACF) residents identify as European and an estimated 5.5 percent are Mäori, 44 percent of staff identify as other than European, including 10 percent who identify as Mäori, and 10 percent Pasifika. The dominant position in the theoretical literature on the ethics of sex and intimacy is that consent is of fundamental importance. Consent has dominated not just the theoretical discourse but also public and legal discourses about the ethics of sex and therefore carers and staff make decisions based on the management of institutional risk rather than the wellbeing of the resident. Vulnerabilisation of older persons in order to protect them, however well-intended, effectively robs them of possibilities to exercise self-governance, depersonalises them, and increases their social isolation. How sexual consent in particular is conceptualised has significant ethical implications for the growing number of elders in Aotearoa New Zealand who are living with degrees of cognitive decline. The specific contribution of this project is to interpret how aged care stakeholders (residents, families, and staff) make sense of consent, to contribute substantively to ethical theory around consent, sexuality, and intimacy, and to inform practice and policy in aged care environments. The project interrogates and intends to inform conceptualisations of consent in the domain of sexuality and intimacy in residential aged care. Our goals were: (1) to analyse how people are making decisions in practice about sex and intimacy in aged care; and (2) to use this information to inform the literature on ethical theory and discourses on consent and wellbeing.Item Muscle strength and muscle mass in older adults : a focus on protein intake, distribution, and sources : a thesis presented in partial fulfilment of the requirements for the degree of Doctor of Philosophy in Nutritional Science at Massey University, Albany, New Zealand(Massey University, 2023) Hiol, Anne NadineBackground: Ageing and obesity, which impair muscle protein synthesis (MPS), are associated with muscle mass and muscle strength loss in older adults. It is recognised that adequate protein intake, distribution and sources contribute to increased MPS and muscle mass in older adults. However, little is known about protein intake, distribution, and sources in New Zealand (NZ) older adults. Furthermore, it is unclear whether dietary protein influences muscle strength. Objectives: This thesis explored muscle strength, muscle mass and dietary protein intake, distribution and sources in community-dwelling older adults living in NZ. To meet this objective, the role of obesity in the relationship between muscle mass and muscle strength was examined. This was followed by an investigation of protein intake, distribution and sources, and their association with muscle strength. Methods: Data were obtained from the Researching Eating Activity and Cognitive Health (REACH) study, a cross-sectional study aimed at investigating dietary patterns and associations with cognitive function and metabolic syndrome in older adults aged 65 to 74 years. Isometric grip strength was measured using a hand grip strength dynamometer (JAMAR HAND). Body fat percentage and appendicular skeletal muscle mass (ASM) (sum of lean mass in the arms and legs) were assessed using dual-energy X-ray absorptiometry (Hologic, QDR Discovery A). The ASM index was calculated by ASM (kilograms, kg) divided by height (meters, m) squared. Dietary intake was collected using a 4-day food record, and the data was entered into FoodWorks 10. Data on absolute daily protein intake (grams, g) were generated. According to the peaks of protein consumption throughout the day, days were divided into three meals: breakfast, mid-day, and the evening meals. Protein sources were classified as meat and fish; plant; or dairy and egg protein sources based on the primary type of protein found in food. The relative protein intakes (g/kg) per day, meal, and source were calculated by dividing the absolute protein intake (g) by each participant's body weight (kg). Statistical analyses: A linear regression analysis was performed to determine the association between muscle mass and muscle strength. This analysis was conducted on males and females based on obesity classifications using body fat percentage (obesity ≥ 30% males, ≥ 40% females). The relative protein intake was compared against a cut-off value of 1.2 g of protein per kg body weight (g/kg BW) per day. The distribution of protein across the three meals was expressed as the coefficient of variance (CV), the average of total protein intake per main meal and the number of meals exceeding 0.4 g/kg BW of protein across the day. Sources of protein intake were assessed at breakfast, mid-day and the evening meals. Results are presented as a percentage of the total protein intake for each meal. Finally, linear regression analyses were conducted separately in males and females to investigate the relationships between BMI- muscle strength and protein intake, distribution and sources, accounting for relevant confounders. Results: Muscle mass was a significant predictor of muscle strength in non-obese participants. However, in participants with obesity, muscle mass was no longer a significant predictor of muscle strength. More than half of the participants had a protein intake of < 1.2 g/kg BW per day (62% females, 57% males). Protein intake was unevenly distributed throughout the day (CV = 0.48 for males and females) and was inadequate for reaching 0.4 g/kg BW at breakfast (for both males and females) and at the mid-day meal for males. The main sources of protein at breakfast were milk (28%), breakfast cereals (22%), and bread (12%); at the mid-day meal, bread (18%), cheese (10%) and milk (9%); and at the evening meal, meat provided over half the protein (56%). In females, relative protein intake was positively associated with muscle strength adjusted BMI (BMI-muscle strength) (r2 = 0.15, ρ < 0.01). Protein derived from either dairy and egg (ρ = 0.03); and plant sources (ρ < 0.01) was related to BMI-muscle strength but not protein from meat and fish (ρ = 0.55). Greater frequency of protein consumption of at least 0.4 g/kg BW per meal was associated with BMI-muscle strength (ρ = 0.01), but the coefficient of variance for protein intake distribution was not related to BMI-muscle strength (ρ = 0.47). There was no relationship between BMI-muscle strength and total daily protein intake, protein from meat and fish; dairy and egg; and plant-based sources, or distribution defined as frequency of protein consumption of at least 0.4 g/kg BW per meal or CV in male older adults. Conclusions: Obesity should be considered when measuring associations between muscle mass and muscle strength in older adults. A higher BMI-adjusted muscle strength was associated with consuming more protein each day and a higher frequency of consumption of a meal containing at least 0.4 g/kg BW; and from dairy and egg; and plant food sources in female older adults. There was no correlation between protein intake, distribution and sources and muscle strength in males. Protein intake was less than 1.2 g/kg BW per day and 0.4 g/kg BW per meal for a large proportion of older adults. At breakfast and the mid-day meals the main sources of protein were from cereals and dairy products, and from meat sources at the evening meal. Further research is needed to investigate how best to optimise protein intake to increase and maintain muscle mass and muscle strength in older adults from the general population.Item Multigenerational caregiving for older people in Bali : combining macro and micro perspectives to understand ageing, family, and caregiving : a thesis presented in partial fulfilment of the requirements for the degree of Doctor in Philosophy in Psychology at Massey University, Manawatū, New Zealand(Massey University, 2022) Lestari, Made DiahMost of the existing research on family caregiving focuses on the nuclear family, consisting only of parents and children as the research population and women as the primary caregivers. Research on family caregiving needs to take into account demographic and social-cultural contexts. Thus, I sought to explore caregiving and ageing in multigenerational households. As populations continue to age, older people’s needs for special care has become a critical issue that affects families as the primary support of older people and sometimes presents a burden for families in terms of caregiving. While we are witnessing the development of public provisions to support our ageing population, at the same time, the cultural obligation to care for older generations may be reinforced by policies, effectively shifting state responsibilities to the private sphere. The study was framed by a critical gerontology approach to ageing issues from two perspectives: political-moral economy and humanistic gerontology. Critical gerontology provides space for a dialogue between macro and micro perspectives in understanding ageing and family caregiving. The research was conducted in Bali, where most older people live in multigenerational households. At the macro level of caregiving, this study aimed to critically review the regional ageing policies in Indonesia. Using critical discourse analysis, this study explored constructions of older people’s identities in regional ageing policies and found two identity constructions, namely “material ageing” and “cultural ageing”. Such positioning has macro and micro effects on ageing and caregiving practices. At the intersection between macro and micro levels of caregiving, individual narrative interviews were conducted from January until May 2020 with 49 members of 11 multigenerational households to explore the social construction of ageing and family caregiving specific to Balinese culture. Thematic analysis, narrative analysis, and discursive positioning analysis were used to analyse the interview data, exploring: (a) important aspects of local knowledge about multigenerational caregiving reported by participants; (b) the role played by the local narratives in shaping family members’ stories of multigenerational caregiving; and (c) how two dominant ageing discourses in regional ageing policies, “decline” and “successful ageing”, were taken up by older people and their family members in constructing their stories on ageing and family caregiving. I discussed the collective implications of these findings for the micro experiences of ageing and policy and developed a theoretical model of multigenerational caregiving, including its opportunities and challenges by synthesising the findings into a socioecological model. This model provided the basis for an analysis of the intersection between private and public domains of multigenerational caregiving and suggestions for initiatives at the family, community, society, and cultural levels to ensure the sustainability of family caregiving in Bali as well as providing support for the family caregivers.Item Dietary patterns in the older New Zealand adult and their associations with cognitive function and metabolic syndrome : the Researching Eating, Activity, and Cognitive Health (REACH) study : a thesis presented in partial fulfilment of the requirements for the degree of Doctor of Philosophy in Nutritional Science at Massey University, Albany, New Zealand(Massey University, 2021) Mumme, KarenBackground: The global population is ageing. Ageing and poor diet are common risk factors for cognitive decline and metabolic syndrome which reduce functionality in later years. A dietary pattern approach considers the full complexity of the diet. Dietary patterns in an older New Zealand context have not been identified nor their associations with cognitive function or metabolic syndrome. Aims and objectives: This thesis, referred to as the REACH (Researching, Eating, Activity, and Cognitive Health) study, explored associations between dietary patterns and cognitive function and metabolic syndrome in older New Zealand adults. To achieve the aim a food frequency questionnaire (FFQ) was assessed for reproducibility, relative validity, and its suitability to derive robust dietary patterns. Further, associations between these dietary patterns and their nutrient and energy intake; the socio-demographic and lifestyle factors of the participants; and cognitive function and metabolic syndrome outcomes were examined. Method: Community-dwelling adults from Auckland, New Zealand were recruited (aged 65-74 years, 36% male, n 371). Dietary patterns were derived from a 109-item FFQ using 57 food groups and principal component analysis. Nutrient, energy, and alcohol intake were calculated using FOODfiles, the New Zealand Food composition database. The REACH FFQ and its derived dietary patterns were assessed for reproducibility and relative validity in a sub-set of the REACH participants (n 294). Reproducibility was assessed using an identical FFQ (FFQ2) administered one month after the initial REACH FFQ. A 4-day food record (4-DFR), collected between FFQ administrations, assessed relative validity. Cognitive function, covering six domains (global cognition, attention and vigilance, executive function, episodic memory, working memory and spatial memory), was assessed using COMPASS (Computerised Mental Performance Assessment System). Self-administered questionnaires collected health (medication and supplement intake), demographic and lifestyle [including sex, education levels, living status (alone or with someone), smoking status, physical activity levels, address (for Index of Multiple Deprivation)], and physical activity (International Physical Activity Questionnaire) data. A fasted blood sample was collected for measuring genetic [Apolipoprotein E -ε4 (APOE -ε4)] and biochemical markers (triglycerides, high- and low-density lipoprotein cholesterol). Blood pressure and anthropometric measures [weight, height, waist circumference, and body fat % (using dual X-ray absorptiometry)] were collected. Metabolic syndrome was defined by the National Cholesterol Education Program Adult Treatment Panel III. Abstract ii Statistical analyses performed: Reproducibility and relative validity of the REACH FFQ (food group intakes) and its derived dietary patterns (scores) were assessed using Spearman correlation coefficients (acceptable correlation rho=0.20-0.49), weighted kappa statistic (κw) (acceptable statistic κw=0.20-0.60), and Bland-Altman analysis including mean difference, limits of agreement, plots, and slope of bias. The similarity between dietary pattern loadings were assessed using Tucker’s congruence coefficient. Linear or logistic regression were used to examine associations between dietary patterns and their nutrients; socio-demographic and lifestyle factors; and health outcomes. Confounding adjustments included age, sex, education, index of multiple deprivation, energy intake, APOE -ε4, and physical activity. Results: In the validation study, the FFQ food groups showed good reproducibility (mean correlation coefficient = 0.69, mean κw = 0.62) and acceptable relative validity (mean correlation coefficient = 0.45, mean κw = 0.38) though Bland Altman plots showed bias and mean differences significantly different to zero in some food groups. Three similar dietary patterns were identified from each dietary assessment tool: ‘Mediterranean style’, ‘Western’, and ‘prudent’. Congruence coefficients between factor loadings ranged from 0.54 to 0.80. Correlations of dietary pattern scores ranged from 0.47 to 0.59 (reproducibility) and 0.33 to 0.43 (validity) (all P<0.001); weighted kappa scores from 0.40 to 0.48 (reproducibility) and 0.27 to 0.37 (validity); limits of agreement from ± 1.79 to ± 2.09 (reproducibility) and ± 2.09 to ± 2.27 (validity); a slope of bias was seen in the ‘prudent’ pattern for reproducibility and validity (P<0.001). From the full REACH dietary data set, three valid dietary patterns were derived explaining 18% of the variation in the diet. The ‘Mediterranean style’ pattern (salad vegetables; leafy cruciferous vegetables; other vegetables; avocados and olives; alliums; nuts and seeds; white fish and shellfish; oily fish; berries; water; salad dressings; cruciferous vegetables; eggs; cheese; tomatoes; and all other fruit) was associated with higher levels of beta-carotene equivalents, vitamin E, and folate intake (all P<0.001, all R2 ≥ 0.26), along with being female, having a higher physical activity level, and higher education (P<0.001, R2 = 0.07). The ‘Western’ pattern (processed meat; sauces and condiments; cakes, biscuits and puddings; meat pies and chips; processed fish; confectionery; vegetable oils; beer; chocolate; salad dressings; cheese; and sweetened cereal) was associated with higher daily energy intake (P<0.001, R2 = 0.43), along with being male, having a higher alcohol intake, living with others, and a secondary education (males only) (P<0.001, R2 = 0.16). The ‘prudent’ pattern (dried legumes; soy-based foods; fresh and frozen legumes; whole grains; carrots; and Abstract iii spices) was associated with a higher fibre and carbohydrate intake (both P<0.001, both R2 ≥ 0.25), along with higher physical activity and lower alcohol intake (P<0.001, R2 = 0.15). Neither the ‘Mediterranean style’ nor ‘prudent’ patterns were associated with either cognitive function or metabolic syndrome. The ‘Western’ pattern was not associated with cognitive function, but was positively associated with metabolic syndrome [odds ratio = 1 .67 (95% CI 1.08, 2.63)] (P=0.02). Being younger (P<0.05), female (P<0.001), having a higher education (P<0.01) or no APOE -ε4 allele (P<0.05) were associated with better cognitive function. Higher deprivation (P<0.001) was associated with metabolic syndrome. Conclusion: A novel and robust study with valid tools did not find any associations between dietary patterns and cognitive function in older adults living in New Zealand. Age, sex, education, and the APOE -ε4 allele were more predictive of cognitive function than the dietary patterns. A ‘Western’ dietary pattern and higher deprivation were predictive of metabolic syndrome. To reduce the odds of metabolic syndrome, actions should aim to improve deprivation, and shift people’s dietary intake away from the ‘Western’ dietary pattern.Item Concomitant alcohol and alcohol-interactive medication use by older New Zealanders : investigating the prevalence, and potential associations with health, healthcare utilization, and depression : a thesis presented in partial fulfillment of the requirements for the degree of Doctor of Clinical Psychology at Massey University, Manawatū, New Zealand(Massey University, 2021) Barnard, EddieBackground: Older adults are more vulnerable to the adverse effects of alcohol-medication interactions (AMIs) than younger populations, and are more likely to use medications capable of causing an AMI when used with alcohol (alcohol-interactive (AI) medications). Survey findings from the United States (US) and Europe indicate many older adults use alcohol and AI-medications concomitantly. However, the prevalence of this issue in New Zealand is currently unknown, and few observational studies have explored the impact of concomitant alcohol and AI-medication use (concomitant alcohol/AI-medication use) on health outcomes in community samples. Research exploring motivating factors underlying alcohol use by AI-medication users indicates having awareness of AMI risks often motivates reduced alcohol consumption. There is also evidence that depression may increase the likelihood of concomitant alcohol/AI-medication use, particularly when alcohol is used to ‘self-medicate’ depressive symptoms. However, the moderating effects of depression on alcohol use by AI-medication users have not been directly assessed in a large community sample. Design and Methods: Two studies were conducted, both involved secondary analysis of existing survey data and national pharmaceutical claims data. Samples were drawn from a representative sampling frame of older adults living in New Zealand. The first study (study 1) analysed data from a survey of adults aged 54-70 years, and the second study (study 2) analysed data from an augmented sample aged 49-83 years. The prevalence of concomitant alcohol/AI-medication use was explored in both study samples overall, and in subsamples of participants aged ≥65 years. Study 1 investigated the potential impact of concomitant alcohol/AI-medication use on general physical health and healthcare utilization. Study 2 assessed the potential relationships between alcohol use, AI-medication use, and depression. An evidence-based protocol was developed to inform methods of classifying AI-medications and measuring AI-medication use among survey participants using pharmaceutical dispensing records. Relationships between variables of interest were assessed using a series of hierarchical regression models and Chi-squared tests. Results: Alcohol and AI-medications were used concomitantly by approximately one-in-four participants aged 54-70 years, one-in-three participants aged 49-83 years, and two-in-five participants aged 65-83 years. Concomitant alcohol/AI-medication use was not significantly associated with physical health or healthcare utilization, although these non-significant findings may reflect limitations of the outcome measures used in the present research. Alcohol use was negatively associated with AI-medication use, with stronger associations being observed for medications associated with more severe AMIs. These findings are consistent with research and theory indicating AMI awareness may lead to reduced alcohol consumption by AI-medication users. Depression did not influence the relationship between AI-medication use and alcohol use. Conclusions: The present research findings indicate many New Zealand older adults are at risk of AMI. Providing relevant health warnings may help reduce the potential for AMI-related harm, although additional intervention may be needed for many older adults. Future research in this area should include longitudinal health outcome measures that are specific to the effects of AMI, and measures that assess drinking motives directly. The two studies presented in the present thesis were the first to explore the prevalence of concomitant alcohol/AI-medication use by older adults in New Zealand, which is a major contribution of this project overall. Another important contribution was the development of an evidence-based framework for measuring AI-medication use among survey participants.