How do older people with sight loss manage their general health? A qualitative study

Purpose: Older people with sight loss experience a number of barriers to managing their health. The purpose of this qualitative study was to explore how older people with sight loss manage their general health and explore the techniques used and strategies employed for health management. Methods: Semi-structured face-to-face interviews were conducted with 30 participants. Interviews were audio-recorded, transcribed verbatim and analysed using thematic analysis. Results: Health management challenges experienced included: managing multiple health conditions; accessing information; engaging in health behaviours and maintaining wellbeing. Positive strategies included: joining support groups, clubs and societies; using low vision aids; seeking support from family and friends and accessing support through health and social care services. Conclusion: Healthcare professionals need to be more aware of the challenges faced by older people with sight loss. Improved promotion of group support and charity services which are best placed to share information, provide fora to learn about coping techniques and strategies, and give older people social support to prevent isolation is needed. Rehabilitation and support services and equipment can only be beneficial if patients know what is available and how to access them. Over-reliance on self-advocacy in current healthcare systems is not conducive to patient-centred care. Implications for Rehabilitation Sight loss in older people can impact on many factors including health management. This study identifies challenges to health management and highlights strategies used by older people with sight loss to manage their health. Access to support often relies on patients seeking information for themselves. However, self-advocacy is challenging due to information accessibility barriers. Informal groups and charities play an important role in educating patients about their condition and advising on available support to facilitate health management.

Diversity and the perceived barriers to participation in volunteer activity by older people

The first chapter introduces the subject from a psychological and sociological perspective emphasising the basic human activity of helping those in need. Governmental prominence for policies that assist this activity is briefly discussed with special mention of the programmes that encourage volunteering. Programmes particularly directed at older people, such as the Age Concern ‘Debate of the Age’ are considered briefly. An extensive review of the extant literature is the subject of the second chapter. The pervious research is explored to discover the formulae used to define a volunteer. A definition relative to this research is created. Volunteering issues aggravated by the demographic situation of older people are explored. Empirical volunteer survey research by mutual organisations is explored to ascertain the extent and nature of the already recorded volunteer population. The penultimate section of this chapter investigates the nature of old age and the strategies that older people adopt to enjoy the benefits and contain the problems. The issue of diversity arises from consideration of the literature suggesting that, although it is an essential voluntary sector strength, it is also a further barrier to recruitment. A model diversity is proposed. Chapter three reviews the theoretical processes, procedures and technologies used to collect and analyse the data required to discover the answer to the research problem. Analysis of the questionnaire survey data received is the subject of chapter four. The discovery of the agency uniqueness of volunteer profiles is the principle finding of this part of the research. The fifth chapter is the qualitative analysis of the oral and written statements received. A content analysis of the scripts and texts provided rich data covering motivational factors. Motivational factors were the same for volunteers in the same organisation, but differed between organisations. Finally, the analysed data is collated and discussed progressively toward a theory of diversity. The individuality of each branch of each agency is progressively described culminating in the creation of a model that infers that diversity is a barrier that aggravates all other barriers. The personal realisations of the researcher are described.

Medication errors in older people with mental health problems:a review

Objective - To review and summarise published data on medication errors in older people with mental health problems. Methods - A systematic review was conducted to identify studies that investigated medication errors in older people with mental health problems. MEDLINE, EMBASE, PHARMLINE, COCHRANE COLLABORATION and PsycINFO were searched electronically. Any studies identified were scrutinized for further references. The title, abstract or full text was systematically reviewed for relevance. Results - Data were extracted from eight studies. In total, information about 728 errors (459 administration, 248 prescribing, 7 dispensing, 12 transcribing, 2 unclassified) was available. The dataset related almost exclusively to inpatients, frequently involved non-psychotropics, and the majority of the errors were not serious. Conclusions - Due to methodology issues it was impossible to calculate overall error rates. Future research should concentrate on serious errors within community settings, and clarify potential risk factors.

Medication -related adverse events in older people with dementia:causes and possible solutions

This submission for a PhD by previously published work is based upon six publications in peer reviewed journals, reflecting a 9-year research programme. My research has shown, in a coherent and original way, the difficulty in treating people with dementia with safe and effective medication whilst providing research-founded guidance to develop mechanisms to optimise medication choice and minimise iatrogenic events. A wide range of methods, including systematic reviews, meta-analysis, randomised controlled trials (RCTs), quantitative research and mixed methods were used to generate the data, which supported the exploration of three themes. The first theme, to understand the incidence and causes of medication errors in dementia services, identified that people with dementia may be more susceptible to medication-related iatrogenic disease partly due to inherent disease-related characteristics. One particular area of concern is the use of anti-psychotics to treat the Behavioural and Psychological Symptoms of Dementia (BPSD). The second and third themes, respectively, investigated a novel pharmacological and health services intervention to limit anti-psychotic usage. The second phase found that whilst the glutamate receptor blocker memantine showed some promise, further research was clearly required. The third phase found that anti-psychotic usage in dementia may be higher than official figures suggest and that medication review linking primary and secondary care can limit such usage. My work has been widely cited, reflecting a substantial contribution to the field, in terms of our understanding of the causes of, and possible solutions to limit, medication-related adverse events in people with dementia. More importantly, this work has already informed clinical practice, patients, carers and policy makers by its demonstrable impact on health policy. In particular my research has identified key lines of enquiry for future work and for the development of my own personal research programme to reduce the risk associated with medication in this vulnerable population.

The role of transport and mobility in the health of older people

The world's population is ageing. Older people are healthier and more active than previous generations. Living in a hypermobile world, people want to stay connected to dispersed communities as they age. Staying connected to communities and social networks enables older people to contribute and connect with society and is associated with positive mental and physical health, facilitating independence and physical activity while reducing social isolation. Changes in physiology and cognition associated with later life mean longer journeys may have to be curtailed. A shift in focus is needed to fully explore older people, transport and health; a need to be multidisciplinary in approach and to embrace social sciences and arts and humanities. A need to embrace different types of mobilities is needed for a full understanding of ageing, transport and health, moving from literal or corporeal through virtual and potential to imaginative mobility, taking into account aspirations and emotions. Mobility in later life is more than a means of getting to destinations and includes more affective or emotive associations. Cycling and walking are facilitated not just by improving safety but through social and cultural norms. Car driving can be continued safely in later life if people make appropriate and informed decisions about when and how to stop driving; stringent testing of driver ability and skill has as yet had little effect on safety. Bus use facilitates physical activity and keeps people connected but there are concerns for the future viability of buses. The future of transport may be more community led and involve more sharing of transport modes.

Examining factors associated with excess mortality in older people (age ≥ 70 years) with diabetes - a 10-year cohort study of older people with and without diabetes

Aims: To compare all-cause mortality in older people with or without diabetes and consider the associated risk of comorbidity and polypharmacy. Methods: A 10-year cohort study using data from the Health Innovation Network database (2003-2013) comparing mortality in people aged ≥ 70 years with diabetes (DM cohort) (n = 35 717) and without diabetes (No DM cohort) (n = 307 918). Results: The mean age of the DM cohort was 78.1 ± 5.8 years vs. 79.0 ± 6.3 years in the No DM cohort. Mean diabetes duration was 8.2 ± 8.1 years, and 30% had diabetes for > 10 years. The DM cohort had a greater comorbidity load and people in this cohort were prescribed more therapies than the No DM cohort. The 5- and 10-year survival rates were lower in the DM cohort at 64% and 39%, respectively, compared with 72% and 50% in the No DM cohort. The excess mortality in the DM cohort was greatest in those aged <75 years with longer duration diabetes, the relative hazard for mortality was higher in females. Although comorbidity and polypharmacy were associated with increased mortality risk in the DM cohort, this risk was lower compared with the No DM cohort. The hazard ratios (95% confidence interval) for comorbidities > 4 and medicines ≥ 7 were 1.29 (1.19 to 1.41) and 1.34 (1.25 to 1.43) in the DM cohort and 1.63 (1.57 to 1.70) and 1.48 (1.40 to 1.56) in the No DM cohort, respectively. Conclusions: There is significant excess mortality in older people with diabetes, which is unexplained by comorbidity or polypharmacy. This excess is greatest in the younger old with longer disease duration, suggesting that it may be related to the effect of diabetes exposure.

The knowledge and promotion of exercise to older adults with type 2 diabetes by dietitian diabetes educators

The extent to which Registered Dietitians (RD) promote exercise as part of diabetes self-management education to older diabetic adults has not been established. This study explored the exercise-related knowledge, design, and content of educational programs among RDs who were Certified Diabetes Educators (CDEs) and non-CDEs. The Exercise Teaching Questionnaire was completed by 94 CDEs and 73 non-CDEs in Florida, California, and Texas. ^ CDEs had significantly (p < 0.001) higher mean Knowledge, Design, and Content scores (11.8 ± 1.1, 33.5 ± 9.4, 26.9 ± 4.8, respectively) than non-CDEs (11.1 ± 1.6, 29.2 ± 11.1, 22.4 ± 7.4, respectively). However, Knowledge means for both CDEs and non-CDEs were above the 85 percentile. Design and content scale responses showed that while dietitians provided basic information about safety and benefits related to exercise, they frequently reported “never” or only “sometimes” making exercise recommendations. ^ Although these results suggest that RDs are knowledgeable about exercise for older adults with Type 2 diabetes, greater importance should be made on training RDs to promote exercise, perhaps with an emphasis on a comprehensive team approach. ^

Association of anticholinergic burden with adverse effects in older people with intellectual disabilities:an observational cross-sectional study

BACKGROUND: No studies to date have investigated cumulative anticholinergic exposure and its effects in adults with intellectual disabilities. AIMS: To determine the cumulative exposure to anticholinergics and the factors associated with high exposure. METHOD: A modified Anticholinergic Cognitive Burden (ACB) scale score was calculated for a representative cohort of 736 people over 40 years old with intellectual disabilities, and associations with demographic and clinical factors assessed. RESULTS: Age over 65 years was associated with higher exposure (ACB 1-4 odds ratio (OR) = 3.28, 95% CI 1.49-7.28, ACB 5+ OR = 3.08, 95% CI 1.20-7.63), as was a mental health condition (ACB 1-4 OR = 9.79, 95% CI 5.63-17.02, ACB 5+ OR = 23.74, 95% CI 12.29-45.83). Daytime drowsiness was associated with higher ACB (P<0.001) and chronic constipation reported more frequently (26.6% ACB 5+ v. 7.5% ACB 0, P<0.001). CONCLUSIONS: Older people with intellectual disabilities and with mental health conditions were exposed to high anticholinergic burden. This was associated with daytime dozing and constipation.

Making it real of sustaining a fantasy? Personal budgets for older people

The restructuring of English social care services in the last three decades, as services are provided through a shifting collage of state, for-profit and non-profit organisations, exemplifies many of the themes of governance (Bevir, 2013). As well as institutional changes, there have been a new set of elite narratives about citizen behaviours and contributions, undergirded by modernist social science insights into the wellbeing benefits of ‘self-management’ (Mol, 2008). In this article, we particularly focus on the ways in which a narrative of personalisation has been deployed in older people’s social care services. Personalisation is based on an espoused aspiration of empowerment and autonomy through universal implementation to all users of social care (encapsulated in the Making it Real campaign [Think Local, Act Personal (TLAP), no date)], which leaves unproblematised the ever increasing residualisation of older adult social care and the abjection of the frail (Higgs and Gilleard, 2015). In this narrative of universal personalisation, older people are paradoxically positioned as ‘the unexceptional exception’; ‘unexceptional’ in the sense that, as the majority user group, they are rhetorically included in this promised transformation of adult social care; but ‘the exception’ in the sense that frail older adults are persistently placed beyond its reach. It is this paradoxical positioning of older adult social care users as the unexceptional exception and its ideological function that we seek to explain in this article.

Complexity as key to designing cognitive-friendly environments for older people

The lived environment is the arena where our cognitive skills, preferences, and attitudes come together to determine our ability to interact with the world. The mechanisms through which lived environments can benefit cognitive health in older age are yet to be fully understood. The existing literature suggests that environments which are perceived as stimulating, usable and aesthetically appealing can improve or facilitate cognitive performance both in young and older age. Importantly, optimal stimulation for cognition seems to depend on experiencing sufficiently stimulating environments while not too challenging. Environmental complexity is an important contributor to determining whether an environment provides such an optimal stimulation. The present paper reviews a selection of studies which have explored complexity in relation to perceptual load, environmental preference and perceived usability to propose a framework which explores direct and indirect environmental influences on cognition, and to understand these influences in relation to aging processes. We identify ways to define complexity at different environmental scales, going from micro low-level perceptual features of scenes, to design qualities of proximal environments (e.g., streets, neighborhoods), to broad geographical areas (i.e., natural vs. urban environments). We propose that studying complexity at these different scales will provide new insight into the design of cognitive-friendly environments.

Withdrawal of Antidementia Drugs in Older People: Who, When and How?

The evidence base to guide withdrawal of antidementia medications in older people with dementia is limited; while some randomised controlled studies have considered discontinuation of cholinesterase inhibitors, no such studies examining discontinuation of the N-Methyl-D-aspartate receptor antagonist memantine have been conducted to date. The purpose of this opinion article was to summarise the existing evidence on withdrawal of cholinesterase inhibitors and memantine, to highlight the key considerations for clinicians when making these prescribing decisions and to offer guidance as to when and how treatment might be discontinued. Until the evidence-base is enhanced by the findings of large scale randomised controlled discontinuation trials of ChEIs and memantine which use multiple, clinically relevant cognitive, functional and behavioural outcome measures, clinicians’ prescribing decisions involve balancing the risks of discontinuation with side-effects and costs of continued treatment. Such decisions must be highly individualised and patient-centred.

Pharmaceutical strategies towards optimising polypharmacy in older people

This paper focuses on the issue of polypharmacy in older people and potential pharmaceutical strategies to optimize the use of multiple medicines. Although polypharmacy has long been viewed negatively, increasing emphasis is being placed on the difference between appropriate and inappropriate polypharmacy. This is largely being driven by the increasing prevalence of multimorbidity and the use of evidence-based guidelines. In this paper, we outline a number of key considerations that are pertinent to optimizing polypharmacy, notably prescribing appropriate polypharmacy, pharmaceutical formulations, the involvement of older people in clinical trials and patient adherence.