Helping understand nutritional gaps in the elderly (HUNGER) : a prospective study of patient factors associated with inadequate nutritional intake in older medical inpatients

BACKGROUND: Malnutrition, and poor intake during hospitalisation, are common in older medical patients. Better understanding of patient-specific factors associated with poor intake may inform nutritional interventions. AIMS: To measure the proportion of older medical patients with inadequate nutritional intake, and identify patient-related factors associated with this outcome. METHODS: Prospective cohort study enrolling consecutive consenting medical inpatients aged 65 years or older. Primary outcome was energy intake less than resting energy expenditure estimated using weight-based equations. Energy intake was calculated for a single day using direct observation of plate waste. Explanatory variables included age, gender, number of co-morbidities, number of medications, diagnosis, usual residence, nutritional status, functional and cognitive impairment, depressive symptoms, poor appetite, poor dentition, and dysphagia. RESULTS: Of 134 participants (mean age 80 years, 51% female), only 41% met estimated resting energy requirements. Mean energy intake was 1220 kcal/day (SD 440), or 18.1 kcal/kg/day. Factors associated with inadequate energy intake in multivariate analysis were poor appetite, higher BMI, diagnosis of infection or cancer, delirium and need for assistance with feeding. CONCLUSIONS: Inadequate nutritional intake is common, and patient factors contributing to poor intake need to be considered in nutritional interventions.

Everyone's problem but nobody's job : staff perceptions and explanations for poor nutritional intake in older medical patients

Aim: Up to 60% of older medical patients are malnourished with further decline during hospital stay. There is limited evidence for effective nutrition intervention. Staff focus groups were conducted to improve understanding of potential contextual and cultural barriers to feeding older adults in hospital. Methods: Three focus groups involved 22 staff working on the acute medical wards of a large tertiary teaching hospital. Staff disciplines were nursing, dietetics, speech pathology, occupational therapy, physiotherapy, pharmacy. A semistructured topic guide was used by the same facilitator to prompt discussions on hospital nutrition care including barriers. Focus groups were tape-recorded, transcribed and analysed thematically. Results: All staff recognised malnutrition to be an important problem in older patients during hospital stay and identified patient-level barriers to nutrition care such as non-compliance to feeding plans and hospital-level barriers including nursing staff shortages. Differences between disciplines revealed a lack of a coordinated approach, including poor knowledge of nutrition care processes, poor interdisciplinary communication, and a lack of a sense of shared responsibility/coordinated approach to nutrition care. All staff talked about competing activities at meal times and felt disempowered to prioritise nutrition in the acute medical setting. Staff agreed education and ‘extra hands’ would address most barriers but did not consider organisational change. Conclusions: Redesigning the model of care to reprioritise meal-time activities and redefine multidisciplinary roles and responsibilities would support coordinated nutrition care. However, effectiveness may also depend on hospitalwide leadership and support to empower staff and increase accountability within a team-led approach.

Effects of enhanced somatosensory information on postural stability in older people and people with Parkinson’s disease

The somatosensory system plays an important role in balance control and age-related changes to this system have been implicated in falls. Parkinson’s disease (PD) is a chronic and progressive disease of the brain, characterized by postural instability and gait disturbance. Previous research has shown that deficiencies in somatosensory feedback may contribute to the poorer postural control demonstrated by PD individuals. However, few studies have comprehensively explored differences in somatosensory function and postural control between PD participants and healthy older individuals. The soles of the feet contain many cutaneous mechanoreceptors that provide important somatosensory information sources for postural control. Different types of insole devices have been developed to enhance this somatosensory information and improve postural stability, but these devices are often too complex and expensive to integrate into daily life. Textured insoles provide a more passive intervention that may be an inexpensive and accessible means to enhance the somatosensory input from the plantar surface of the feet. However, to date, there has been little work conducted to test the efficacy of enhanced somatosensory input induced by textured insoles in both healthy and PD populations during standing and walking. Therefore, the aims of this thesis were to determine: 1) whether textured insole surfaces can improve postural stability by enhancing somatosensory information in younger and older adults, 2) the differences between healthy older participants and PD participants for measures of physiological function and postural stability during standing and walking, 3) how changes in somatosensory information affect postural stability in both groups during standing and walking; and 4), whether textured insoles can improve postural stability in both groups during standing and walking. To address these aims, Study 1 recruited seven older individuals and ten healthy young controls to investigate the effects of two textured insole surfaces on postural stability while performing standing balance tests on a force plate. Participants were tested under three insole surface conditions: 1) barefoot; 2) standing on a hard textured insole surface; and 3), standing on a soft textured insole surface. Measurements derived from the centre of pressure displacement included the range of anterior-posterior and medial-lateral displacement, path length and the 90% confidence elliptical area (C90 area). Results of study 1 revealed a significant Group*Surface*Insole interaction for the four measures. Both textured insole surfaces reduced postural sway for the older group, especially in the eyes closed condition on the foam surface. However, participants reported that the soft textured insole surface was more comfortable and, hence, the soft textured insoles were adopted for Studies 2 and 3. For Study 2, 20 healthy older adults (controls) and 20 participants with Parkinson’s disease were recruited. Participants were evaluated using a series of physiological assessments that included touch sensitivity, vibratory perception, and pain and temperature threshold detection. Furthermore, nerve function and somatosensory evoked potentials tests were utilized to provide detailed information regarding peripheral nerve function for these participants. Standing balance and walking were assessed on different surfaces using a force plate and the 3D Vicon motion analysis system, respectively. Data derived from the force plate included the range of anterior-posterior and medial-lateral sway, while measures of stride length, stride period, cadence, double support time, stance phase, velocity and stride timing variability were reported for the walking assessment. The results of this study demonstrated that the PD group had decrements in somatosensory function compared to the healthy older control group. For electrodiagnosis, PD participants had poorer nerve function than controls, as evidenced by slower nerve conduction velocities and longer latencies in sural nerve and prolonged latency in the P37 somatosensory evoked potential. Furthermore, the PD group displayed more postural sway in both the anterior-posterior and medial-lateral directions relative to controls and these differences were increased when standing on a foam surface. With respect to the gait assessment, the PD group took shorter strides and had a reduced stride period compared with the control group. Furthermore, the PD group spent more time in the stance phase and had increased cadence and stride timing variability than the controls. Compared with walking on the firm surface, the two groups demonstrated different gait adaptations while walking on the uneven surface. Controls increased their stride length and stride period and decreased their cadence, which resulted in a consistent walking velocity on both surfaces. Conversely, while the PD patients also increased their stride period and decreased their cadence and stance period on the uneven surface, they did not increase their stride length and, hence walked slower on the uneven surface. In the PD group, there was a strong positive association between decreased somatosensory function and decreased clinical balance, as assessed by the Tinetti test. Poorer somatosensory function was also strongly positively correlated with the temporospatial gait parameters, especially shorter stride length. Study 3 evaluated the effects of manipulating the somatosensory information from the plantar surface of the feet using textured insoles in the same populations assessed in Study 2. For this study, participants performed the standing and walking balance tests under three footwear conditions: 1) barefoot; 2) with smooth insoles; and 3), with textured insoles. Standing balance and walking were evaluated using a force plate and a Vicon motion analysis system and the data were analysed in the same way outlined for Study 2. The findings showed that the smooth and textured insoles caused different effects on postural control during both the standing and walking trials. Both insoles decreased medial-lateral sway to the same level on the firm surface. The greatest benefits were observed in the PD group while wearing the textured insole. When standing under a more challenging condition on the foam surface with eyes closed, only the textured insole decreased medial-lateral sway in the PD group. With respect to the gait trials, both insoles increased walking velocity, stride length and stride time and decreased cadence, but these changes were more pronounced for the textured insoles. The effects of the textured insoles were evident under challenging conditions in the PD group and increased walking velocity and stride length, while decreasing cadence. Textured insoles were also effective in reducing the time spent in the double support and stance phases of the gait cycle and did not increase stride timing variability, as was the case for the smooth insoles for the PD group. The results of this study suggest that textured insoles, such as those evaluated in this research, may provide a low-cost means of improving postural stability in high-risk groups, such as people with PD, which may act as an important intervention to prevent falls.

An ingenious decision support system for remote health monitoring of pregnant women

Maternal deaths have been a critical issue for women living in rural and remote areas. The need to travel long distances, the shortage of primary care providers such as physicians, specialists and nurses, and the closing of small hospitals have been problems identified in many rural areas. Some research work has been undertaken and a few techniques have been developed to remotely measure the physiological condition of pregnant women through sophisticated ultrasound equipment. There are numerous ways to reduce maternal deaths, and an important step is to select the right approaches to achieving this reduction. One such approach is the provision of decision support systems in rural and remote areas. Decision support systems (DSSs) have already shown a great potential in many health fields. This thesis proposes an ingenious decision support system (iDSS) based on the methodology of survey instruments and identification of significant variables to be used in iDSS using statistical analysis. A survey was undertaken with pregnant women and factorial experimental design was chosen to acquire sample size. Variables with good reliability in any one of the statistical techniques such as Chi-square, Cronbach’s á and Classification Tree were incorporated in the iDSS. The decision support system was developed with significant variables such as: Place of residence, Seeing the same doctor, Education, Tetanus injection, Baby weight, Previous baby born, Place of birth, Assisted delivery, Pregnancy parity, Doctor visits and Occupation. The ingenious decision support system was implemented with Visual Basic as front end and Microsoft SQL server management as backend. Outcomes of the ingenious decision support system include advice on Symptoms, Diet and Exercise to pregnant women. On conditional system was sent and validated by the gynaecologist. Another outcome of ingenious decision support system was to provide better pregnancy health awareness and reduce long distance travel, especially for women in rural areas. The proposed system has qualities such as usefulness, accuracy and accessibility.

Enhancing and promoting Indigenous women's wellness

The term "Social and Emotional Wellbeing" (SEWB) was coined through the noted inability of conventional psychiatric terminology when addressing Indigenous holistic connections and opposes the Anglo-Saxon terminology that often boxes "mental health" as a diagnosis, disease or illness into separate origins from that of other personal holistic existence, which in turn directly objects to Indigenous thinking and perceptions of wellbeing. Purpose: This study's aim was to explore what Indigenous Women's Social and Emotional Wellbeing is, through Indigenous perceptions, beliefs and knowledge of Indigenous women's wellbeing experiences. Methods: Data was derived from semi-structured focus groups incorporating Indigenous specific Yarning, where Aboriginal and Torres Strait Islander women who have experienced or were at risk of developing social and emotional wellness problems came together. Results: The women identified many factors underpinning social and emotional wellness and what it means for Aboriginal and Torres Strait Islander women. The major themes centred around wellness and health, autonomy, Indigenous women being heard, historical factors, support and Indigenous women's group development and continuation. Conclusion: These issues where then explored and compared to the National Aboriginal and Torres Strait Islander Women's Health Strategy Action Areas.

Spelling instruction through Etymology : a method of developing spelling lists for older students

The purpose of this study was to investigate whether an approach to developing word lists centred on etymological roots would improve the spelling performance of older primary school students. Participants were 46 students in the last year of primary school in south-east Queensland (31 girls and 15 boys) across three classes, with two classes being assigned to control conditions. Students were evaluated pre- and post-intervention on three dependent measures: British Spelling Test Series spelling, spelling in writing and writing. The results of this intervention revealed improvements in spelling for girls but not for boys. The implications for improved teaching methods are discussed.

Everyday resilience : narratives of single refugee women with children

This article offers a critical exploration of the concept of resilience, which is largely conceptualized in the literature as an extraordinary atypical personal ability to revert or ‘bounce back’ to a point of equilibrium despite significant adversity. While resilience has been explored in a range of contexts, there is little recognition of resilience as a social process arising from mundane practices of everyday life and situated in person -environment interactions. Based on an ethnographic study among single refugee women with children in Brisbane, Australia, the women’s stories on navigating everyday tensions and opportunities revealed how resilience was a process operating inter-subjectively in the social spaces connecting them to their environment. Far beyond the simplistic binaries of resilience versus non-resilient, we concern ourselves here with the everyday processual, person environment nature of the concept. We argue that more attention should be paid to day-to-day pathways through which resilience outcomes are achieved, and that this has important implications for refugee mental health practice frameworks.

Active ageing among older adults with lifelong intellectual disabilities : the role of familial and nonfamilial social networks

Little research has examined the extent to which active ageing is facilitated by family and nonfamilial support persons of older adults with intellectual disabilities. This study explores the role played by key unpaid carers/support persons of older adults with lifelong intellectual disabilities in facilitating "active ageing." Little research has examined the extent to which active ageing is facilitated by family and nonfamilial support persons of older adults with intellectual disabilities. This study explores the role played by key unpaid carers/support persons of older adults with lifelong intellectual disabilities in facilitating “active ageing.” All key social network members conceived active ageing to mean ongoing activity. Family and extended family members were found to play a crucial role in facilitating independent living and providing opportunities for recreational pursuits for those living in group homes. Members of religious organizations and group home staff provided the same types of opportunities where family support was absent. The findings suggest the need for improvements in resource provision, staff training, and group home policy and building design.

Not all older adults have insight into their driving abilities : evidence from an on-road assessment and implications for policy

Purpose To compare self-reported driving ability with objective measures of on-road driving performance in a large cohort of older drivers. Methods 270 community-living adults aged 70 – 88 years recruited via the electoral roll completed a standardized assessment of on-road driving performance and questionnaires determining perceptions of their own driving ability, confidence and driving difficulties. Retrospective self-reported crash data over the previous five years were recorded. Results Participants reported difficulty with only selected driving situations, including driving into the sun, in unfamiliar areas, in wet conditions, and at night or dusk. The majority of participants rated their own driving as good to excellent. Of the 47 (17%) of drivers who were rated as potentially unsafe to drive, 66% rated their own driving as good to excellent. Drivers who made critical errors, where the driving instructor had to take control of the vehicle, had no lower self-rating of driving ability then the rest of the group. The discrepancy in self-perceptions of driving and participants’ safety rating on the on-road assessment was significantly associated with self-reported retrospective crash rates, where those drivers who displayed greater overconfidence in their own driving were significantly more likely to report a crash. Conclusions This study demonstrates that older drivers with the greatest mismatch between actual and self-rated driving ability pose the greatest risk to road safety. Therefore licensing authorities should not assume that when older individuals’ driving abilities begin to decline they will necessarily be aware of these changes and adopt appropriate compensatory driving behaviours; rather, it is essential that evidence-based assessments are adopted.

Women, alcohol and pregnancy

This paper examines a history of knowledge from Greek times regarding the possible teratogenic effect of alcohol. Literature on the topic up to the early 1980s is included and some recommendations are suggested.

Identifying familiarity to facilitate intuitive interaction for older adults

Almost every nation on the planet is experiencing increases in both the number and proportion of older adults. Research has shown that older adults use technology less intuitively than younger adults, and have more difficulty with using products effectively. With an ever-increasing population of older adults, it is necessary to understand why they often struggle to use technology, which is becoming more and more important in day to day living. Intuitive use of products is grounded in familiarity and prior experience. The aims of this research were twofold: (i) to examine the differences in familiarity between younger and older adults, to see if this could explain the difficulties faced by some older adults; (ii) to develop investigational methods to assist designers in identifying familiarity in prospective users. Two empirical studies were conducted. The first experiment was conducted in the field with 32 participants, divided across four age groups (18 – 44, 45 – 59, 60 – 74, and 75+). This experiment was conducted in the participants’ homes, with a product they were familiar with. Familiarity was measured through the analysis of data collected through interviews, observation and retrospective protocol. The results of this study show that the youngest group demonstrated significantly higher levels of familiarity with products they own than the 60 – 74 and the 75+ age groups. There were no significant differences between the 18 – 44 age group and the 45 – 59 age group and there were also no significant differences between the three oldest age groups. The second experiment was conducted with 32 participants, across the same four age groups. Four everyday products were used in this experiment. The results of Experiment 2 show that, with previously unused products, younger adults demonstrate significantly higher levels of familiarity than the three older age groups. The three oldest age groups had no significant differences between them. The results of these two studies show that younger adults are more familiar with contemporary products than older adults. They also demonstrate that in terms of familiarity, older adults do not differ significantly as they get older. The results also show that the 45 – 59 age group demonstrate higher levels of familiarity with products they have owned, in comparison with those they have not. The two older age groups did not demonstrate such differences. This suggests that interacting with products over time increases familiarity more for middle-aged adults than for older adults. As a result of this research, a method that can be used by designers to identify potential users’ product familiarity has been identified. This method is easy to use, quick, low cost, highly mobile, flexible, and allows for easy data collection and analysis. A tool has been designed that assists designers and researchers to use the method. Designers can use the knowledge gained from this tool, and integrate it into the design process, resulting in more intuitive products. Such products may lead to improvements in the quality of life of older adults, as a result of improved societal integration, better health management, and more widespread use of communications technology.

Things that fall over : Women's playwriting, poetics and the (anti-)musical

Abstract: This study explores the contradictions and ambivalences experienced by a working artist at a time when her age, her gender, and broader cultural shifts are all potential obstacles or liabilities to creative flourishing. It is the product of practice-led research into the creative process from the perspective of the female "late bloomer". In this phrase, I have in mind the mature-aged woman who is, in mid-life, suddenly seized with inspiration and fired with creative energy. At its heart is the question: If an Elizabeth Jolley were in our midst today, would we hear from her? The result is a full-length libretto and accompanying exegetical binoculars in the form of a Preface and an Afterword. The creative work, Things That Fall Over (TTFO) is conceived in two parts: a libretto and oratorio for performance. It begins as a play, but over three acts and into a coda, the work becomes something entirely other - an (anti-) musical. The work grew from a personal interest in the nexus between women, ageing and creative practice, via investigation into the oeuvre of two Australian artists, Elizabeth Jolley, author, first published at age 53, and Rosalie Gascoigne, sculptor, first exhibited at 58. A second strand of the research grew from a fascination for the stage musical, especially in its more alternative modes as in the hands of Stephen Sondheim, or in more provocative manifestations as witnessed in recent Tony Award winners Avenue Q and The Book of Mormon. Contextually, this research is conducted at a time when anecdotal evidence suggests that women’s work in the performing arts and in literature is being pushed to the margins after a late twentieth century Golden Age on page and stage. Using hybrid practice-led methodologies - bricolage, log-keeping - and working within queer and feminist paradigms, this study seeks to counter that push with a new work that is all-female, part-pantomime, part monstrous allegory. In illuminating the creative process of a mature-aged playwright it concludes that hybrid and interstitial forms still offer an inclusive and democratic space in which voices that may otherwise be muted will continue to be heard.

Intuitive interaction and older people

Older people often struggle with using contemporary products and interfaces. They show slower, less intuitive interaction with more errors. This paper reports on a large project designed to investigate why older people have these difficulties and what strategies could be used to mitigate them. The project team found that older people are less familiar with products that they own than younger ones, while both older and middle aged people are less familiar with products that they do not own than younger ones. Age related cognitive decline is also related to slower and less intuitive performance with contemporary products and interfaces. Therefore, the reasons behind the problems that older people demonstrate with contemporary technologies involve a mix of familiarity and capability. Redundancy applied to an interface in the form of symbols and words is helpful for middle aged and younger old people but the oldest age group performed better with a words only interface. Also, older people showed faster and more intuitive use with a flat interface than a nested one, although there was no difference in errors. Further work is ongoing in order to establish ways in which these findings can be usefully applied in the design process.

The use of amenities in high density neighbourhoods by older urban Australians residents

Like other major cities, Brisbane (Australia) has adopted policies to increase residential densities to meet the liveability goal of decreasing car dependence. This objective hinges on urban neighbourhoods being amenity-rich spaces, reducing the need for residents to leave their neighbourhood for everyday living. While older people are attracted to urban settings, there has been little empirical evidence linking liveability satisfaction with older people's use of urban neighbourhoods. Using a case study approach employing qualitative (diaries, in-depth interviews) and quantitative (Global Positioning Systems and Geographical Information Systems mapping) methods,this paper explores the effect of the neighbourhood environment and its influence on liveability for older urban people. Reliance on motor vehicles and issues with availability and access to local amenities inhibit local participation for older people. Highlighting these issues furthers our understanding of the landscape planning and design factors that make urban neighbourhoods more liveable for older residents.

The lived world of older urban Australians: relating everyday living to GPS tracking data

Neighbourhood like the concept of liveability is usually measured by either subjective indicators using surveys of residents’ perceptions or by objective means using secondary data or relative weights for objective indicators of the urban environment. Rarely, have objective and subjective indicators been related to one another in order to understand what constitutes a liveable urban neighbourhood both spatially and behaviourally. This paper explores the use of qualitative (diaries, in-depth interviews) and quantitative (Global Positioning Systems, Geographical Information Systems mapping) liveability research data to examine the perceptions and behaviour of 12 older residents living in six high density urban areas of Brisbane. Older urban Australians are one of the two principal groups highly attracted to high density urban living. The strength of the relationship between the qualitative and quantitative measures was examined. Results of the research indicate a weak relationship between subjective and objective indicators. Linking the two methods (quantitative and qualitative) is important in obtaining a greater understanding of human behaviour and the lived world of older urban Australians and in providing a wider picture of the urban neighbourhood.