Holding eternity in an hour: A practical exploration of the arts in the health care of older people with dementia

This project involved creative artists working with older people with dementia and staff from two Belfast Health and Social Care Trust supported housing centres in a mixed programme of dance, painting, music and drama which culminated in an open workshop with relatives and friends of the tenants. The study steered away from traditional medical models of art/music/dance therapy where the participant is perceived as a ‘patient’ in favour of identifying the participant as a ‘student’ who avails of a life-long learning experience. A key premise was that access to the arts is a human right, especially in the context of advancing age and cognitive impairment. . According to one the tenants of Mullan Mews, the project served to ‘awaken - or reawaken - folk with dementia to the endless vista of possibility already in their lives if they will only look for it’. A phenomenographic analysis of video data generated by the project emphasises the importance of the individual experiences of participants in the programme. The evidence from these storylines gained strength from the development of a documentary-style film text that has proved successful in capturing and translating the live experience of the project participants into a supportive text that goes beyond the written word.

Improving appropriate polypharmacy for older people in primary care: selecting components of an evidence-based intervention to target prescribing and dispensing.

Background
The use of multiple medicines (polypharmacy) is increasingly common in older people. Ensuring that patients receive the most appropriate combinations of medications (appropriate polypharmacy) is a significant challenge. The quality of evidence to support the effectiveness of interventions to improve appropriate polypharmacy is low. Systematic identification of mediators of behaviour change, using the Theoretical Domains Framework (TDF), provides a theoretically robust evidence base to inform intervention design. This study aimed to (1) identify key theoretical domains that were perceived to influence the prescribing and dispensing of appropriate polypharmacy to older patients by general practitioners (GPs) and community pharmacists, and (2) map domains to associated behaviour change techniques (BCTs) to include as components of an intervention to improve appropriate polypharmacy in older people in primary care.

Methods
Semi-structured interviews were conducted with members of each healthcare professional (HCP) group using tailored topic guides based on TDF version 1 (12 domains). Questions covering each domain explored HCPs’ perceptions of barriers and facilitators to ensuring the prescribing and dispensing of appropriate polypharmacy to older people. Interviews were audio-recorded and transcribed verbatim. Data analysis involved the framework method and content analysis. Key domains were identified and mapped to BCTs based on established methods and discussion within the research team.

Results
Thirty HCPs were interviewed (15 GPs, 15 pharmacists). Eight key domains were identified, perceived to influence prescribing and dispensing of appropriate polypharmacy: ‘Skills’, ‘Beliefs about capabilities’, ‘Beliefs about consequences’, ‘Environmental context and resources’, ‘Memory, attention and decision processes’, ‘Social/professional role and identity’, ‘Social influences’ and ‘Behavioural regulation’. Following mapping, four BCTs were selected for inclusion in an intervention for GPs or pharmacists: ‘Action planning’, ‘Prompts/cues’, ‘Modelling or demonstrating of behaviour’ and ‘Salience of consequences’. An additional BCT (‘Social support or encouragement’) was selected for inclusion in a community pharmacy-based intervention in order to address barriers relating to interprofessional working that were encountered by pharmacists.

Conclusions
Selected BCTs will be operationalised in a theory-based intervention to improve appropriate polypharmacy for older people, to be delivered in GP practice and community pharmacy settings. Future research will involve development and feasibility testing of this intervention.

Relationships Between Deprivation and the Self-reported Health of Older People in Northern Ireland

Objectives: There are few studies on relationships between deprivation and the self-reported health of people aged over 64 years, and no studies fully representative of Northern Ireland’s older population. This paper addresses this gap. Methods: Deprivation of older people as reported in the 2001 and 2011 Censuses and the relationship with self-reported health are analyzed over a ten-year span using multilevel modeling. The data are from the Northern Ireland Longitudinal Study (NILS) linked to 2001-11 Census returns. Deprivation measures include housing tenure, property-value, access to a car, educational, employment and area-level income-deprivation. Results: Older people suffering deprivation face a significant health disadvantage over a ten-year time span. Discussion: This health disadvantage is stronger in men than in women, likely due to conservative gender roles prevalent among Northern Ireland’s older population, leading to psychological distress among deprived men. The analysis found strongly significant area-level effects, aggravating the health impact of deprivation.

A Community Hub Approach to Older People’s Housing

Purpose. This paper explores the potential of housing with care schemes to act as community hubs. The analysis highlights a range of benefits, barriers and facilitators. Design/methodology/approach. Data is presented from the ASSET project (Adult Social Services Environments and Settings) which used a mixed methods approach including a review of the literature, surveys and in-depth case study interviews. Findings. Most housing with care schemes have a restaurant or café, communal lounge, garden, hairdresser, activity room and laundrette, while many also have a library, gym, computer access and a shop. Many of these facilities are open not just to residents but also to the wider community, reflecting a more integrated approach to community health and adult social care, by sharing access to primary health care and social services between people living in the scheme and those living nearby. Potential benefits of this approach include the integration of older people’s housing, reduced isolation and increased cost effectiveness of local services through economies of scale and by maximising preventative approaches to health and wellbeing. Successful implementation of the model depends on a range of criteria including being located within or close to a residential area and having on-site facilities that are accessible to the public. Originality and Value. This paper is part of a very new literature on community hub models of housing with care in the UK. In the light of new requirements under the Care Act to better coordinate community services, it provides insights into how this approach can work and offers an analysis of the benefits and challenges that will be of interest to commissioners and providers as well as planners. This was a small scale research project based on four case studies. Caution should be taken when considering the findings in different settings.

Enabling older people to stay at home: How adaptable are existing properties?

A multiprofessional research project examined in detail the factors that affect the adaptability of existing housing and explored issues relating to the introduction of assistive technology into the existing homes of older people in order to provide them with the opportunity to 'stay put'. The research reported here investigated the feasibility of adapting the existing stock of social housing and the resulting costs and outcomes of introducing assistive technology. This paper outlines that part of the project that examined in detail the adaptability of 82 properties representing a variety of property types to accommodate the needs of seven notional users, characterising the most common range of impairments of older people. The factors that affect a property's adaptability include property type and specific design and construction features. The implications for housing providers, clients and occupational therapists are discussed. The research identified the unique expertise of occupational therapists, spanning the areas of housing, older people and assistive technology, and it introduced methods and tools that can help to determine best housing outcomes as well as cost implications. It is crucial that the profession is proactive in contributing to the development of housing policies that address the needs of an ageing population effectively.

Enabling older people to stay at home: The costs of substituting and supplementing care with assistive technology

A wide-ranging multiprofessional research project explored issues relating to the introduction of assistive technology into the existing homes of older people in order to provide them with the opportunity to remain at home. The financial relationship between assistive technology and packages of formal care was also explored. The costs of residential care and those of a number of packages containing differing quantities of assistive technology, formal care and informal care were compared. The analyses provide a strong financial case for substituting and/or supplementing formal care with assistive technology, even for individuals with quite disabling conditions. Although needs and hence the cost of provision rise with an increasing level of disability, the savings in care costs accrue quickly. The consideration of a variety of users with different needs and informal care provision, and occupying a very wide range of housing, leads to the conclusion that in comparison with traditional care packages, at worst, incorporating significant amounts of assistive technology into care packages is cost neutral, but that with careful specification of assistive technology major savings are feasible.

Can adapting the homes of older people and providing assistive technology pay its way?

Background: Adaptations and assistive technology (AT) have an important role in enabling older people to remain in their own homes. Objective: To measure the feasibility and cost of adaptations and AT, and the scope for these to substitute and supplement formal care. Design: Detailed design studies to benchmark the adaptability of 82 properties against the needs of seven notional users. Setting: Social rented housing sector. Main outcome measures: Measures of the adaptability of properties, costs of care, adaptations and AT, and relationships between these costs. Results: The adaptability of properties varies according to many design factors and the needs of occupiers. The most adaptable properties were ground floor flats and bungalows; the least were houses, maisonettes and flats in converted houses. Purpose-built sheltered properties were generally more adaptable than corresponding mainstream properties but the opposite was the case for bungalows. Adaptations and AT can substitute for and supplement formal care, and in most cases the initial investment in adaptations and AT is recouped through subsequently lower care costs within the average life expectancy of a user. Conclusion: Appropriately selected adaptations and AT can make a significant contribution to the provision of living environments which facilitate independence. They can both substitute for traditional formal care services and supplement these services in a cost-effective way.

Adapting the homes of older people: A case study of costs and savings

Meeting the demand for independent living from the increasing number of older people presents a major challenge for society, government and the building industry. Older people's experience of disabling conditions can be affected by the design and layout of their accommodation. Adaptations and assistive technology (AT) are a major way of addressing this gap between functional capacity and the built environment. The degree of adaptability and the differences in the average cost of adaptation of different types of property are large and there is major variation within property type. Based on a series of user profiles, it was found that a comprehensive package of adaptations and AT is likely to result in significant economies arising from a reduction in the need for formal care services. This finding is sensitive to assumptions about how long an individual would use the adaptations and AT, as well as to the input of informal care and the nature of their accommodation. The present study, which focused on social housing, has implications for how practitioners specify ways of meeting individual needs as well as providing a case to support the substantial increase in demand for specialist adaptation work.

The contribution of building research to the independence and quality of life of older people

Many nations are experiencing rapid rises in the life expectancy of their citizens. The implications of this major demographic shift are considerable offering opportunities as well as challenges to reconsider how people should spend their later years. A key task is enhancing the quality of life of older people through enabling them to continue to live independently even though illness, accident or frailty may have severely reduced their physical and sensory abilities and, possibly, mental health. Yet the needs of older people and disabled people have been largely ignored in the design of everyday consumer products, the home, transport systems and the built environment in general. Whilst the need for designers, engineers and technologists to provide products, environments and systems which are inclusive of all members of society is widely accepted, there is little understanding of how this can be achieved. In 1998 the UK Engineering and Physical Sciences Research Council established its EQUAL Initiative. This has encouraged design, engineering and technology researchers in universities to join with their colleagues from the social, medical and health sciences to investigate a wide range of issues experienced by older and disabled people and to propose solutions. Their research, which directly involves older and disabled people and, for example, social housing providers, social services departments, charities, engineering and architectural consultants, and transport firms, has been extremely successful. In a very short time it has influenced government policy on housing, long-term care, and building standards, and findings have been taken up by architects, designers, health-care professionals and bodies which represent older and disabled people.

Introducing assistive technology into the existing homes of older people: Feasibility, acceptability, costs and outcomes

We examined how far, and at what cost, the housing stock could be modified to accommodate the assistive technology (AT) necessary to enable older people to remain in their own homes. A multidisciplinary team devised seven hypothetical user profiles for 10 case study areas, with five local authorities and five housing associations in England and Wales. Each profile was considered at two times, five years apart, with the users' functional abilities deteriorating in between. In addition, in-depth interviews were carried out with a sample of 67 older people in the case study areas about their use and experience of a wide range of AT. The interviews showed the need to listen to older people and that they welcomed AT when it addressed a perceived need. The results showed that the extent of adaptation required of buildings to accommodate a user's needs varied greatly. It was also found that there was confusion about the terminology of AT, including the idea of the 'smart house'. The study shows that the adaptability of the housing depends on a range of factors and costs.

The effect of macro and micro-nutrient fortification of biscuits on their sensory properties and on hedonic liking of older people

BACKGROUND: Under-nutrition in older adults is widespread. Oral nutritional supplement beverages (ONS) are prescribed, yet consumption by older people is often insufficient. A variety of supplement formats may improve nutrient intake. This study developed protein and micro-nutrient fortified biscuits and evaluated their sensory attributes and liking by older people. Two micro-nutrient strategies were taken, to match typical ONS and to customise to the needs of older people. RESULTS: Oat biscuits and gluten-free biscuits developed contained over 12% protein and over 460 kcal 100 g-1 . Two small (40 g) biscuits developed to match ONS provided approximately 40% of an ONS portion of micro-nutrients and 60% of macro-nutrients; however, the portion size was considered realistic whereas the average ONS portion (200 mL) is excessive. Biscuits developed to the needs of older adults provided, on average, 18% of the reference nutrient intake of targeted micro-nutrients. Sensory characteristics were similar between biscuits with and without micro-nutrient fortification, leading to no differences in liking. Fortified oat biscuits were less liked than commercial oat biscuits, partly attributed to flavour imparted by whey protein fortification. CONCLUSION: Macro- and micro-nutrient fortification of biscuits could provide an alternative fortified snack to help alleviate malnutrition in older adults.

The older generation and the housing market

This paper identifies and analyses the influence of older households upon the detached housing market in Brisbane.

Nutrition screening of older people in a community general practice, using the MNA-SF

Background: Objective The study aimed to determine the prevalence of malnutrition risk in a population of older people (aged 75 years and over) attending a community general practice and identify characteristics of those classified as malnourished or at risk of malnutrition.

Design Cross-sectional study of nutritional risk screen conducted over a six month period.

Participants and setting Patients attending a general practice clinic in Victoria, Australia, who attended for the “75 plus” health assessment check.

Measurements The Mini Nutritional Assessment Short Form (MNA®-SF) was included as part of the health assessment. Information was collected on living situation, co-morbidities, independence with meal preparation and eating, number of medications. Height and weight was measured and MNA®-SF score recorded.

Results Two hundred and twenty five patients attending a general practice for a health assessment with a mean age of 81.3(4.3)(SD) years, 52% female and 34% living alone. Only one patient was categorised by the MNA®-SF as malnourished, with an additional 16% classified as at risk of malnutrition. The mean Body Mass Index (BMI) of the at-risk group was significantly lower than the well-nourished group (23.6 ± 0.8 (SEM) vs 27.4 ± 0.3; p=0.0001). However, 34% of the at-risk group had a BMI of 25 or more with only 13% in the underweight category.

Conclusion In this population of older adults attending their general practitioner for an annual health assessment, one in six were identified as being at nutritional risk which is an additional risk factor for a severe health issue. Importantly, one third of the at-risk group had a BMI in the overweight or obese category, highlighting that older people can be at nutritional risk although they may be overweight or obese.

Quality care outcomes following transitional care interventions for older people from hospital to home: a systematic review

 Background
Provision of high quality transitional care is a challenge for health care providers in many western countries. This systematic review was conducted to (1) identify and synthesise research, using randomised control trial designs, on the quality of transitional care interventions compared with standard hospital discharge for older people with chronic illnesses, and (2) make recommendations for research and practice.

Methods
Eight databases were searched; CINAHL, Psychinfo, Medline, Proquest, Academic Search Complete, Masterfile Premier, SocIndex, Humanities and Social Sciences Collection, in addition to the Cochrane Collaboration, Joanna Briggs Institute and Google Scholar. Results were screened to identify peer reviewed journal articles reporting analysis of quality indicator outcomes in relation to a transitional care intervention involving discharge care in hospital and follow-up support in the home. Studies were limited to those published between January 1990 and May 2013. Study participants included people 60 years of age or older living in their own homes who were undergoing care transitions from hospital to home. Data relating to study characteristics and research findings were extracted from the included articles. Two reviewers independently assessed studies for risk of bias.

Results
Twelve articles met the inclusion criteria. Transitional care interventions reported in most studies reduced re-hospitalizations, with the exception of general practitioner and primary care nurse models. All 12 studies included outcome measures of re-hospitalization and length of stay indicating a quality focus on effectiveness, efficiency, and safety/risk. Patient satisfaction was assessed in six of the 12 studies and was mostly found to be high. Other outcomes reflecting person and family centred care were limited including those pertaining to the patient and carer experience, carer burden and support, and emotional support for older people and their carers. Limited outcome measures were reported reflecting timeliness, equity, efficiencies for community providers, and symptom management.

Conclusions
Gaps in the evidence base were apparent in the quality domains of timeliness, equity, efficiencies for community providers, effectiveness/symptom management, and domains of person and family centred care. Further research that involves the person and their family/caregiver in transitional care interventions is needed.

Another minority group: use of aged care day programs and community leisure services by older people with lifelong disability

Objective: This study examined the extent to which programs available to the general aged community are accessible to older people with lifelong disability. Method: Forty Victorian generic aged day activity and community leisure programs used by older people responded to a survey that sought information on the extent to which such services are used by older people with a lifelong disability. Results: More than half of these services are accessed by a small number of people with lifelong disability and overall there was a willingness to include this group in generic services. Barriers and solutions to successful generic service use were reported. Conclusions: The findings indicate that the issues for people with lifelong disability differ little from those of other minority groups. It is proposed that disability services have a role in brokering services for their older clients, and continued planning and collaboration between disability and aged services will benefit all older people.