Appraisal of the quality of care of older people with cognitive impairment presenting to emergency departments

The medical records of 273 patients 75 years and older were reviewed to evaluate quality of emergency department (ED) care through the use of quality indicators. One hundred fifty records contained evidence of an attempt to carry out a cognitive assessment. Documented evidence of cognitive impairment (CI) was reported in 54 cases. Of these patients, 30 had no documented evidence of an acute change in cognitive function from baseline; of 26 patients discharged home with preexisting CI (i.e., no acute change from baseline), 15 had no documented evidence of previous consideration of this issue by a health care provider; and 12 of 21 discharged patients who screened positive for cognitive issues for the first time were not referred for outpatient evaluation. These findings suggest that the majority of older adults in the ED are not receiving a formal cognitive assessment, and more than half with CI do not receive quality of care according to the quality indicators for geriatric emergency care. Recommendations for improvement are discussed.

Exploring the effect of companion robots on emotional expression in older people with dementia : a pilot randomized controlled trial

This pilot study aimed to compare the effect of companion robots (PARO) to participation in an interactive reading group on emotions in people living with moderate to severe dementia in a residential care setting. A randomized crossover design, with PARO and reading control groups, was used. Eighteen residents with mid- to late-stage dementia from one aged care facility in Queensland, Australia, were recruited. Participants were assessed three times using the Quality of Life in Alzheimer’s Disease, Rating Anxiety in Dementia, Apathy Evaluation, Geriatric Depression, and Revised Algase Wandering Scales. PARO had a moderate to large positive influence on participants’ quality of life compared to the reading group. The PARO intervention group had higher pleasure scores when compared to the reading group. Findings suggest PARO may be useful as a treatment option for people with dementia; however, the need for a larger trial was identified.

The predictors of active ageing of older Australians : the triple a study

The concept of older adults contributing to society in a meaningful way has been termed ‘active ageing’. Active ageing reflects changes in prevailing theories of social and psychological aspects of ageing, with a focus on individuals' strengths as opposed to their deficits or pathology. In order to explore predictors of active ageing, the Australian Active Ageing (Triple A) project group undertook a national postal survey of participants over the age of 50 years recruited randomly through their 2004 membership of a large Australia-wide senior's organisation. The survey comprised 178 items covering paid and voluntary work, learning, social, spiritual, emotional, health and home, life events and demographic items. A 45% response rate (2655 returned surveys) reflected an expected balance of gender, age and geographic representation of participants. The data were analysed using data mining techniques to represent generalizations on individual situations. Data mining identifies the valid, novel, potentially useful and understandable patterns and trends in data. The results based on the clustering mining technique indicate that physical and emotional health combined with the desire to learn were the most significant factors when considering active ageing. The findings suggest that remaining active in later life is not only directly related to the maintenance of emotional and physical health, but may be significantly intertwined with the opportunity to engage in on-going learning activities that are relevant to the individual. The findings of this study suggest that practitioners and policy makers need to incorporate older peoples' learning needs within service and policy framework developments.

Factors influencing caregiver : care receiver communication and its impact on the well-being of older care receivers

Examined communication between frail older people and their caregiving spouses (CGSs), and its relation to well-being in older care receivers. 53 community residing spousal dyads completed questionnaires about their well-being, relational satisfaction, and communication patterns. Conversations between the dyads were also videotaped and analyzed. The type of communication used by the CGSs was influenced by their sex, their earlier relationship with their spouse, and their level of well-being. CGSs who used an overly directive communication tone with their spouse were likely to be wives and CGSs who had a high degree of autonomy in their earlier relationship with their spouse. Low levels of life satisfaction and high affect balance in CGSs were associated with CGSs using a more patronizing tone. The well-being of care receivers was also related to their perceptions of their CGSs' communication. Care receivers who perceived their CGSs' communication as patronizing reported low levels of affect balance and high levels of conflict in the relationship. Findings suggest that certain characteristics of CGSs are related to the type of communication they use when conversing with their partner, although the relations are not always as expected.

Communication predicaments of older health care consumers : what can 'we' do about it?

Focuses on the importance of communication to the well-being of older people in Australia. Role of communication for the design, delivery and evaluation of health services for the elderly; Impact of aging on communication; Importance of communication between health care providers and nursing home residents.

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.

Perceived barriers to healthy lifestyle activities in midlife and older Australian women with type 2 diabetes

Purpose: Type 2 diabetes is a leading cause of morbidity and mortality in midlife and older Australian women with known modifiable risk factors for type 2 diabetes including smoking, nutrition, physical activity and obesity. In Australia little research has been done to investigate the perceived barriers to healthy lifestyle activities in midlife and older women with type 2 diabetes. The primary aim of this study was to explore the level and type of perceived barriers to health promotion activities. The secondary aim was to explore the relationship of perceived barriers to smoking behaviour, fruit and vegetable intake, physical activity, and body mass index. Methods: The study was a cross sectional survey of women, aged over 45 with type 2 diabetes, attending metropolitan community health clinics (N = 41). Data was collected from self-report questionnaire and analysed using descriptive and inferential statistics. Results: Women in the study had average total barriers scores similar to those reported in the literature for women with a range of physical disabilities and illnesses. The leading barriers for this group of women were: lack of interest, concern about safety, too tired, lack of money and feeling what they do does not help. There was no association between total barriers scores and body mass index, physical activity, fruit and vegetable intake or socio-demographic variables. Conclusion: This study contributes to understanding the perceptions of midlife and older women with type 2 diabetes about the level and type of barriers to healthy lifestyle activities that they experience. Evidence from this study can be applied to inform health promotion for lifestyle risk factor reduction in women with type 2 diabetes.

Walk@Work : an automated intervention to increase walking in university employees not achieving 10,000 daily steps

This study assessed the workday step counts of lower active (<10,000 daily steps) university employees using an automated, web-based walking intervention (Walk@Work). METHODS: Academic and administrative staff (n=390; 45.6±10.8years; BMI 27.2±5.5kg/m2; 290 women) at five campuses (Australia [x2], Canada, Northern Ireland and the United States), were given a pedometer, access to the website program (2010-11) and tasked with increasing workday walking by 1000 daily steps above baseline, every two weeks, over a six week period. Step count changes at four weeks post intervention were evaluated relative to campus and baseline walking. RESULTS: Across the sample, step counts significantly increased from baseline to post-intervention (1477 daily steps; p=0.001). Variations in increases were evident between campuses (largest difference of 870 daily steps; p=0.04) and for baseline activity status. Those least active at baseline (<5000 daily steps; n=125) increased step counts the most (1837 daily steps; p=0.001), whereas those most active (7500-9999 daily steps; n=79) increased the least (929 daily steps; p=0.001). CONCLUSIONS: Walk@Work increased workday walking by 25% in this sample overall. Increases occurred through an automated program, at campuses in different countries, and were most evident for those most in need of intervention.

Older drivers' crashes in Queensland, Australia

Background: The growing proportion of older adults in Australia is predicted to comprise 23% of the population by 2030. Accordingly, an increasing number of older drivers and fatal crashes of these drivers could also be expected. While the cognitive and physiological limitations of ageing and their road safety implications have been widely documented, research has generally considered older drivers as a homogeneous group. Knowledge of age-related crash trends within the older driver group itself is currently limited. Objective: The aim of this research was to identify age-related differences in serious road crashes of older drivers. This was achieved by comparing crash characteristics between older and younger drivers and between sub-groups of older drivers. Particular attention was paid to serious crashes (crashes resulting in hospitalisation and fatalities) as they place the greatest burden on the Australian health system. Method: Using Queensland Crash data, a total of 191,709 crashes of all-aged drivers (17–80+) over a 9-year period were analysed. Crash patterns of drivers’ aged 17–24, 25–39, 40–49, 50–59, 60–69, 70–79 and 80+ were compared in terms of crash severity (e.g., fatal), at fault levels, traffic control measures (e.g., stop signs) and road features (e.g., intersections). Crashes of older driver sub-groups (60–69, 70–79, 80+) were also compared to those of middle-aged drivers (40–49 and 50–59 combined, who were identified as the safest driving cohort) with respect to crash-related traffic control features and other factors (e.g., speed). Confounding factors including speed and crash nature (e.g., sideswipe) were controlled for. Results and discussion: Results indicated that patterns of serious crashes, as a function of crash severity, at-fault levels, road conditions and traffic control measures, differed significantly between age groups. As a group, older drivers (60+) represented the greatest proportion of crashes resulting in fatalities and hospitalisation, as well as those involving uncontrolled intersections and failure to give way. The opposite was found for middle-aged drivers, although they had the highest proportion of alcohol and speed-related crashes when compared to older drivers. Among all older drivers, those aged 60–69 were least likely to be involved in or the cause of crashes, but most likely to crash at interchanges and as a result of driving while fatigued or after consuming alcohol. Drivers aged 70–79 represented a mid-range level of crash involvement and culpability, and were most likely to crash at stop and give way signs. Drivers aged 80 years and beyond were most likely to be seriously injured or killed in, and at-fault for, crashes, and had the greatest number of crashes at both conventional and circular intersections. Overall, our findings highlight the heterogeneity of older drivers’ crash patterns and suggest that age-related differences must be considered in measures designed to improve older driver safety.

Predicting vitamin D deficiency in older Australian adults

OBJECTIVE There has been a dramatic increase in vitamin D testing in Australia in recent years, prompting calls for targeted testing. We sought to develop a model to identify people most at risk of vitamin D deficiency. DESIGN AND PARTICIPANTS This is a cross-sectional study of 644 60- to 84-year-old participants, 95% of whom were Caucasian, who took part in a pilot randomized controlled trial of vitamin D supplementation. MEASUREMENTS Baseline 25(OH)D was measured using the Diasorin Liaison platform. Vitamin D insufficiency and deficiency were defined using 50 and 25 nmol/l as cut-points, respectively. A questionnaire was used to obtain information on demographic characteristics and lifestyle factors. We used multivariate logistic regression to predict low vitamin D and calculated the net benefit of using the model compared with 'test-all' and 'test-none' strategies. RESULTS The mean serum 25(OH)D was 42 (SD 14) nmol/1. Seventy-five per cent of participants were vitamin D insufficient and 10% deficient. Serum 25(OH)D was positively correlated with time outdoors, physical activity, vitamin D intake and ambient UVR, and inversely correlated with age, BMI and poor self-reported health status. These predictors explained approximately 21% of the variance in serum 25(OH)D. The area under the ROC curve predicting vitamin D deficiency was 0·82. Net benefit for the prediction model was higher than that for the 'test-all' strategy at all probability thresholds and higher than the 'test-none' strategy for probabilities up to 60%. CONCLUSION Our model could predict vitamin D deficiency with reasonable accuracy, but it needs to be validated in other populations before being implemented.

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.

Nutrition screening and risk factors prior to chemotherapy in cancer patients 65 years and older

Background The largest proportion of cancer patients are aged 65 years and over. Increasing age is also associated with nutritional risk and multi-morbidities—factors which complicate the cancer treatment decision-making process in older patients. Objectives To determine whether malnutrition risk and Body Mass Index (BMI) are associated with key oncogeriatric variables as potential predictors of chemotherapy outcomes in geriatric oncology patients with solid tumours. Methods In this longitudinal study, geriatric oncology patients (aged ≥65 years) received a Comprehensive Geriatric Assessment (CGA) for baseline data collection prior to the commencement of chemotherapy treatment. Malnutrition risk was assessed using the Malnutrition Screening Tool (MST) and BMI was calculated using anthropometric data. Nutritional risk was compared with other variables collected as part of standard CGA. Associations were determined by chi-square tests and correlations. Results Over half of the 175 geriatric oncology patients were at risk of malnutrition (53.1%) according to MST. BMI ranged from 15.5–50.9kg/m2, with 35.4% of the cohort overweight when compared to geriatric cutoffs. Malnutrition risk was more prevalent in those who were underweight (70%) although many overweight participants presented as at risk (34%). Malnutrition risk was associated with a diagnosis of colorectal or lung cancer (p=0.001), dependence in activities of daily living (p=0.015) and impaired cognition (p=0.049). Malnutrition risk was positively associated with vulnerability to intensive cancer therapy (rho=0.16, p=0.038). Larger BMI was associated with a greater number of multi-morbidities (rho =.27, p=0.001. Conclusions Malnutrition risk is prevalent among geriatric patients undergoing chemotherapy, is more common in colorectal and lung cancer diagnoses, is associated with impaired functionality and cognition and negatively influences ability to complete planned intensive chemotherapy.

Engineering the fitness of older patients for chemotherapy : an exploration of Comprehensive Geriatric Assessment in practice

Clinicians often report that currently available methods to assess older patients, including standard clinical consultations, do not elicit the information necessary to make an appropriate cancer treatment recommendation for older cancer patients. An increasingly popular way of assessing the potential of older patients to cope with chemotherapy is a Comprehensive Geriatric Assessment. What constitutes Comprehensive Geriatric Assessment, however, is open to interpretation and varies from one setting to another. Furthermore, Comprehensive Geriatric Assessment’s usefulness as a predictor of fitness for chemotherapy and as a determinant of actual treatment is not well understood. In this article, we analyse how Comprehensive Geriatric Assessment was developed for use in a large cancer service in an Australian capital city. Drawing upon Actor–Network Theory, our findings reveal how, during its development, Comprehensive Geriatric Assessment was made both a tool and a science. Furthermore, we briefly explore the tensions that we experienced as scholars who analyse medico-scientific practices and as practitioner–designers charged with improving the very tools we critique. Our study contributes towards geriatric oncology by scrutinising the medicalisation of ageing, unravelling the practices of standardisation and illuminating the multiplicity of ‘fitness for chemotherapy’.

Predicting fitness for chemotherapy in older cancer patients

Background: The Vulnerable Elders Survey-13 (VES-13) is increasingly used to screen for older patients who can proceed to intensive chemotherapy without further comprehensive assessment. This study compared the VES-13 determination of fitness for treatment with the oncologist's assessments of fitness. Method: Sample: Consecutive series of solid tumour patients ≥65 years (n=175; M=72; range=65-86) from an Australian cancer centre. Patients were screened with the VES-13 before proceeding to usual treatment. Blinded to screening, oncologists concurrently predicted patient fitness for chemotherapy. A sample of 175 can detect, with 90% power, kappa coefficients of agreement between VES-13 and oncologists’ assessments >0.90 ("almost perfect agreement"). Separate backward stepwise logistic regression analyses assessed potential predictors of VES-13 and oncologists’ ratings of fitness. Results: Kappa coefficient for agreement between VES-13 and oncologists’ ratings of fitness was 0.41 (p<0.001). VES-13 and oncologists’ assessments agreed in 71% of ratings. VES-13 sensitivity = 83.3%; specificity = 57%; positive predictive value = 69%; negative predictive value = 75%. Logistic regression modelling indicated that the odds of being vulnerable to chemotherapy (VES-13) increased with increasing depression (OR=1.42; 95% CI: 1.18, 1.71) and decreased with increased functional independence assessed on the Bartel Index (OR=0.82; CI: 0.74, 0.92) and Lawton instrumental activities of daily living (OR=0.44; CI: 0.30, 0.65); RSquare=.65. Similarly, the odds of a patient being vulnerable to chemotherapy, when assessed by physicians, increased with increasing age (OR=1.15; CI: 1.07, 1.23) and depression (OR=1.23; CI: 1.06, 1.43), and decreased with increasing functional independence (OR=0.91; CI: 0.85, 0.98); RSquare=.32. Conclusions: Our data indicate moderate agreement between VES-13 and clinician assessments of patients’ fitness for chemotherapy. Current ‘one-step’ screening processes to determine fitness have limits. Nonetheless, screening tools do have the potential for modification and enhanced predictive properties in cancer care by adding relevant items, thus enabling fit patients to be immediately referred for chemotherapy.