A randomised controlled trial to prevent hospital readmissions and loss of functional ability in high risk older adults: a study protocol

Background Older people have higher rates of hospital admission than the general population and higher rates of readmission due to complications and falls. During hospitalisation, older people experience significant functional decline which impairs their future independence and quality of life. Acute hospital services comprise the largest section of health expenditure in Australia and prevention or delay of disease is known to produce more effective use of services. Current models of discharge planning and follow-up care, however, do not address the need to prevent deconditioning or functional decline. This paper describes the protocol of a randomised controlled trial which aims to evaluate innovative transitional care strategies to reduce unplanned readmissions and improve functional status, independence, and psycho-social well-being of community-based older people at risk of readmission. Methods/Design The study is a randomised controlled trial. Within 72 hours of hospital admission, a sample of older adults fitting the inclusion/exclusion criteria (aged 65 years and over, admitted with a medical diagnosis, able to walk independently for 3 meters, and at least one risk factor for readmission) are randomised into one of four groups: 1) the usual care control group, 2) the exercise and in-home/telephone follow-up intervention group, 3) the exercise only intervention group, or 4) the in-home/telephone follow-up only intervention group. The usual care control group receive usual discharge planning provided by the health service. In addition to usual care, the exercise and in-home/telephone follow-up intervention group receive an intervention consisting of a tailored exercise program, in-home visit and 24 week telephone follow-up by a gerontic nurse. The exercise only and in-home/telephone follow-up only intervention groups, in addition to usual care receive only the exercise or gerontic nurse components of the intervention respectively. Data collection is undertaken at baseline within 72 hours of hospital admission, 4 weeks following hospital discharge, 12 weeks following hospital discharge, and 24 weeks following hospital discharge. Outcome assessors are blinded to group allocation. Primary outcomes are emergency hospital readmissions and health service use, functional status, psychosocial well-being and cost effectiveness. Discussion The acute hospital sector comprises the largest component of health care system expenditure in developed countries, and older adults are the most frequent consumers. There are few trials to demonstrate effective models of transitional care to prevent emergency readmissions, loss of functional ability and independence in this population following an acute hospital admission. This study aims to address that gap and provide information for future health service planning which meets client needs and lowers the use of acute care services.

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.

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.

Malnutrition and falls risk in community-dwelling older adults

Background and Aims: Falls and fall-related injuries result in reduced functioning, loss of independence, premature nursing home admissions and mortality. Malnutrition is associated with falls in the acute setting, but little is known about malnutrition and falls risk in the community. The aim of this study was to assess the association between malnutrition risk, falls risk and falls over a one-year period in community-dwelling older adults. Methods: Two hundred and fifty four subjects >65 years of age were recruited to participate in a study in order to identify risk factors for falls. Malnutrition risk was determined using the Mini Nutritional Assessment–Short Form. Results: 28.6% had experienced a fall and according to the Mini Nutritional Assessment-Short Form 3.9% (n=10) of subjects were at risk of malnutrition. There were no associations between malnutrition risk, the risk of falls, nor actual falls in healthy older adults in the community setting. Conclusions: There was a low prevalence of malnutrition risk in this sample of community-dwelling older adults and no association between nutritional risk and falls. Screening as part of a falls prevention program should focus on the risk of developing malnutrition as this is associated with falls.

Comparing measures of fat-free mass in overweight older adults using three different bioelectrical impedance devices and three prediction equations

Objectives: To compare measures of fat-free mass (FFM) by three different bioelectrical impedance analysis (BIA) devices and to assess the agreement between three different equations validated in older adult and/or overweight populations. Design: Cross-sectional study. Setting: Orthopaedics ward of Brisbane public hospital, Australia. Participants: Twenty-two overweight, older Australians (72 yr ± 6.4, BMI 34 kg/m2 ± 5.5) with knee osteoarthritis. Measurements: Body composition was measured using three BIA devices: Tanita 300-GS (foot-to-foot), Impedimed DF50 (hand-to-foot) and Impedimed SFB7 (bioelectrical impedance spectroscopy (BIS)). Three equations for predicting FFM were selected based on their ability to be applied to an older adult and/ or overweight population. Impedance values were extracted from the hand-to-foot BIA device and included in the equations to estimate FFM. Results: The mean FFM measured by BIS (57.6 kg ± 9.1) differed significantly from those measured by foot-to-foot (54.6 kg ± 8.7) and hand-to-foot BIA (53.2 kg ± 10.5) (P < 0.001). The mean ± SD FFM predicted by three equations using raw data from hand-to-foot BIA were 54.7 kg ± 8.9, 54.7 kg ± 7.9 and 52.9 kg ± 11.05 respectively. These results did not differ from the FFM predicted by the hand-to-foot device (F = 2.66, P = 0.118). Conclusions: Our results suggest that foot-to-foot and hand-to-foot BIA may be used interchangeably in overweight older adults at the group level but due to the large limits of agreement may lead to unacceptable error in individuals. There was no difference between the three prediction equations however these results should be confirmed within a larger sample and against a reference standard.

An extended theory of planned behavior intervention for older adults With Type 2 diabetes and cardiovascular disease

A randomized controlled trial evaluated the effectiveness of a 4-wk extended theory of planned behavior (TPB) intervention to promote regular physical activity and healthy eating among older adults diagnosed with Type 2 diabetes or cardiovascular disease (N = 183). Participants completed TPB measures of attitude, subjective norm, perceived behavioral control, and intention, as well as planning and behavior, at preintervention and 1 wk and 6 wk postintervention for each behavior. No significant time-by-condition effects emerged for healthy eating. For physical activity, significant time-by-condition effects were found for behavior, intention, planning, perceived behavioral control, and subjective norm. In particular, compared with control participants, the intervention group showed short-term improvements in physical activity and planning, with further analyses indicating that the effect of the intervention on behavior was mediated by planning. The results indicate that TPB-based interventions including planning strategies may encourage physical activity among older people with diabetes and cardiovascular disease.

Physical activity amongst older adults with musculoskeletal disorders : a descriptive study

"The World Health Organisation has identified physical inactivity as the fourth leading effective cause of death globally. The burden of physical inactivity will increase as the population ages. In addition to increased risk or mortality, prior research has indicated older adults with chronic musculoskeletal conditions are likely to face increased morbidity and poorer prognoses if they are physically inactive. There is currently a scarcity of empirical research describing the physical activity profile of older adults with chronic musculoskeletal disorders. The aim of this investigation was to describe the self-reported physical activity profile and body mass index (BMI) profile of a sample of older adults with chronic musculoskeletal disorders accessing outpatient hospital services."--publisher website

Approaches to designing for older adults' intuitive interaction with complex devices

Many older people have difficulties using modern consumer products due to increased product complexity both in terms of functionality and interface design. Previous research has shown that older people have more difficulty in using complex devices intuitively when compared to the younger. Furthermore, increased life expectancy and a falling birth rate have been catalysts for changes in world demographics over the past two decades. This trend also suggests a proportional increase of older people in the work-force. This realisation has led to research on the effective use of technology by older populations in an effort to engage them more productively and to assist them in leading independent lives. Ironically, not enough attention has been paid to the development of interaction design strategies that would actually enable older users to better exploit new technologies. Previous research suggests that if products are designed to reflect people's prior knowledge, they will appear intuitive to use. Since intuitive interfaces utilise domain-specific prior knowledge of users, they require minimal learning for effective interaction. However, older people are very diverse in their capabilities and domain-specific prior knowledge. In addition, ageing also slows down the process of acquiring new knowledge. Keeping these suggestions and limitations in view, the aim of this study was set to investigate possible approaches to developing interfaces that facilitate their intuitive use by older people. In this quest to develop intuitive interfaces for older people, two experiments were conducted that systematically investigated redundancy (the use of both text and icons) in interface design, complexity of interface structure (nested versus flat), and personal user factors such as cognitive abilities, perceived self-efficacy and technology anxiety. All of these factors could interfere with intuitive use. The results from the first experiment suggest that, contrary to what was hypothesised, older people (65+ years) completed the tasks on the text only based interface design faster than on the redundant interface design. The outcome of the second experiment showed that, as expected, older people took more time on a nested interface. However, they did not make significantly more errors compared with younger age groups. Contrary to what was expected, older age groups also did better under anxious conditions. The findings of this study also suggest that older age groups are more heterogeneous in their capabilities and their intuitive use of contemporary technological devices is mediated more by domain-specific technology prior knowledge and by their cognitive abilities, than chronological age. This makes it extremely difficult to develop product interfaces that are entirely intuitive to use. However, by keeping in view the cognitive limitations of older people when interfaces are developed, and using simple text-based interfaces with flat interface structure, would help them intuitively learn and use complex technological products successfully during early encounter with a product. These findings indicate that it might be more pragmatic if interfaces are designed for intuitive learning rather than for intuitive use. Based on this research and the existing literature, a model for adaptable interface design as a strategy for developing intuitively learnable product interfaces was proposed. An adaptable interface can initially use a simple text only interface to help older users to learn and successfully use the new system. Over time, this can be progressively changed to a symbols-based nested interface for more efficient and intuitive use.

Supporting the development of inclusive products : the effects of everyday ambient illumination levels and contrast on older adults' near visual acuity

Current older adult capability data-sets fail to account for the effects of everyday environmental conditions on capability. This article details a study that investigates the effects of everyday ambient illumination conditions (overcast, 6000 lx; in-house lighting, 150 lx and street lighting, 7.5 lx) and contrast (90%, 70%, 50% and 30%) on the near visual acuity (VA) of older adults (n= 38, 65-87 years). VA was measured at a 1-m viewing distance using logarithm of minimum angle of resolution (LogMAR) acuity charts. Results from the study showed that for all contrast levels tested, VA decreased by 0.2 log units between the overcast and street lighting conditions. On average, in overcast conditions, participants could detect detail around 1.6 times smaller on the LogMAR charts compared with street lighting. VA also significantly decreased when contrast was reduced from 70% to 50%, and from 50% to 30% in each of the ambient illumination conditions. Practitioner summary: This article presents an experimental study that investigates the impact of everyday ambient illumination levels and contrast on older adults' VA. Results show that both factors have a significant effect on their VA. Findings suggest that environmental conditions need to be accounted for in older adult capability data-sets/designs.

Using GPS and accelerometry to assess older adults' driving behaviours and performance : challenges and future directions

With the projected increase in older adults, the older driver population is estimated to be the fastest growing cohort of drivers among many developed countries. The increased physical fragility associated with the aging process make older adults who drive private automobiles a vulnerable road user group. Much of the current research on older drivers’ behaviours and practices rely on self-report data. This paper explores the utility of in-vehicle devices (Global Positioning Systems and recording accelerometers) in assessing older drivers’ habitual driving behaviours. Seventy-eight older drivers (above 65 years of age), from the Australian Capital Territory, Australia, participated in the current study. The driving behaviours and practices of these participants were prospectively assessed over a two-week period. The use of combined GPS and recording accelerometers to improve understanding of older drivers’ driving behaviours show promise within the current study. The challenges of using multiple in-vehicle devices in assessing driving beahaviours and performances within this cohort will be discussed. Based on the current findings, recommendations for future research regarding the use of in-vehicle devices among the older driver cohort are proposed.

The acute effects of eccentrically-biased versus conventional weight training in older adults : a randomised controlled cross-over study

Background Whilst resistance training has been proven to convey considerable benefits to older people; immediately post-exercise there may be elevated transient risks for cardiac events and falls. Objectives and Measurements We assessed the acute effects of eccentrically-biased (EB) and conventional (CONV) resistance exercise on: platelet number, activation and granule exocytsosis; and mean velocity of centre of pressure displacement (Vm). Design, Setting, Participants and Intervention Ten older adults (7 males, 3 females; 69 ± 4 years) participated in this randomised controlled cross-over study in which they performed EB and CONV training sessions that were matched for total work and a control condition. Results Immediately post-exercise there was a statistically significant difference in platelet count between the control condition, in which it fell (pre 224 ± 35 109/L; post 211 ± 30 109/L: P < 0.05) and CONV in which it increased (pre 236 ± 55 109/L; post 242 ± 51 109/L: P > 0.05). There was no change in platelet activation and granule exocytsosis or Vm following EB and CONV. Conclusions Overall, while minor differences between regimens were observed, no major adverse effect on parameters of platelet function or centre of pressure displacement were observed acutely following either regimen. Eccentrically-biased and conventional resistance exercise training regimens do not appear to present an elevated acute risk in the context of changes to platelet function contributing to a cardiac event or postural stability increasing falls risk for apparently healthy older adults.

The invisible elderly : lesbian, gay, bisexual, and transgender older adults

More than 2 million older adults identify as lesbian, gay, bisexual, or transgender (LGBT). The purpose of this article is to present an overview of the physical and mental health needs of LGBT older adults to sensitize nurses to the specific needs of this group. Nurses are in a prominent position to create health care environments that will meet the needs of this invisible, and often misunderstood, group of people.