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.

Prescribing of Psychoactive Drugs for Older People in Nursing Homes: An Analysis of Treatment Culture

Background There is increasing interest in how culture may affect the quality of healthcare services, and previous research has shown that ‘treatment culture’—of which there are three categories (resident centred, ambiguous and traditional)—in a nursing home may influence prescribing of psychoactive medications. Objective The objective of this study was to explore and understand treatment culture in prescribing of psychoactive medications for older people with dementia in nursing homes. Method Six nursing homes—two from each treatment culture category—participated in this study. Qualitative data were collected through semi-structured interviews with nursing home staff and general practitioners (GPs), which sought to determine participants’ views on prescribing and administration of psychoactive medication, and their understanding of treatment culture and its potential influence on prescribing of psychoactive drugs. Following verbatim transcription, the data were analysed and themes were identified, facilitated by NVivo and discussion within the research team. Results Interviews took place with five managers, seven nurses, 13 care assistants and two GPs. Four themes emerged: the characteristics of the setting, the characteristics of the individual, relationships and decision making. The characteristics of the setting were exemplified by views of the setting, daily routines and staff training. The characteristics of the individual were demonstrated by views on the personhood of residents and staff attitudes. Relationships varied between staff within and outside the home. These relationships appeared to influence decision making about prescribing of medications. The data analysis found that each home exhibited traits that were indicative of its respective assigned treatment culture. Conclusion Nursing home treatment culture appeared to be influenced by four main themes. Modification of these factors may lead to a shift in culture towards a more flexible, resident-centred culture and a reduction in prescribing and use of psychoactive medication. 

‘Potentially inappropriate or specifically appropriate?’ Qualitative evaluation of general practitioners views on prescribing, polypharmacy and potentially inappropriate prescribing in older people

Background: Potentially inappropriate prescribing (PIP) is common in older people in primary care, as evidenced by a significant body of quantitative research. However, relatively few qualitative studies have investigated the phenomenon of PIP and its underlying processes from the perspective of general practitioners (GPs). The aim of this paper is to explore qualitatively, GP perspectives regarding prescribing and PIP in older primary care patients.

Method: Semi-structured qualitative interviews were conducted with GPs participating in a randomised controlled trial (RCT) of an intervention to decrease PIP in older patients (≥70 years) in Ireland. Interviews were conducted with GP participants (both intervention and control) from the OPTI-SCRIPT cluster RCT as part of the trial process evaluation between January and July 2013. Interviews were conducted by one interviewer and audio recorded. Interviews were transcribed verbatim and a thematic analysis was conducted.

Results: Seventeen semi-structured interviews were conducted (13 male; 4 female). Three main, inter-related themes emerged (complex prescribing environment, paternalistic doctor-patient relationship, and relevance of PIP concept). Patient complexity (e.g. polypharmacy, multimorbidity), as well as prescriber complexity (e.g. multiple prescribers, poor communication, restricted autonomy) were all identified as factors contributing to a complex prescribing environment where PIP could occur, as was a paternalistic-doctor patient relationship. The concept of PIP was perceived to be of variable usefulness to GPs and the criteria to measure it may be at odds with the complex processes of prescribing for this patient population.

Conclusions: Several inter-related factors contributing to the occurrence of PIP were identified, some of which may be amenable to intervention. Improvement strategies focused on improved management of polypharmacy and multimorbidity, and communication across primary and secondary care could result in substantial improvements in PIP.

A process evaluation of a cluster randomised trial to reduce potentially inappropriate prescribing in older people in primary care (OPTI-SCRIPT study)

Background
The OPTI-SCRIPT cluster randomised controlled trial (RCT) found that a three-phase multifaceted intervention including academic detailing with a pharmacist, GP-led medicines reviews, supported by web-based pharmaceutical treatment algorithms, and tailored patient information leaflets, was effective in reducing potentially inappropriate prescribing (PIP) in Irish primary care. We report a process evaluation exploring the implementation of the intervention, the experiences of those participating in the study and lessons for future implementation.

Methods
The OPTI-SCRIPT trial included 21 GP practices and 196 patients. The process evaluation used mixed methods. Quantitative data were collected from all GP practices and semi-structured interviews were conducted with GPs from intervention and control groups, and a purposive sample of patients from the intervention group. All interviews were transcribed verbatim and analysed using a thematic analysis.

Results
Despite receiving a standardised academic detailing session, intervention delivery varied among GP practices. Just over 70 % of practices completed medicines review as recommended with the patient present. Only single-handed practices conducted reviews without patients present, highlighting the influence of practice characteristics and resources on variation. Medications were more likely to be completely stopped or switched to another more appropriate medication when reviews were conducted with patients present. The patient information leaflets were not used by any of the intervention practices. Both GP (32 %) and patient (40 %) recruitment rates were modest. For those who did participate, overall, the experience was positively viewed, with GPs and patients referring to the value of medication reviews to improve prescribing and reduce unnecessary medications. Lack of time in busy GP practices and remuneration were identified as organisational barriers to future implementation.

Conclusions
The OPTI-SCRIPT intervention was positively viewed by both GPs and patients, both of whom valued the study’s objectives. Patient information leaflets were not a successful component of the intervention. Academic detailing and medication reviews are important components in changing PIP, and having patients present during the review process seems to be a more effective approach for decreasing PIP.

Strategies to prevent oral disease in dependent older people (Protocol).

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows:
To assess the effects and costs of primary, secondary and tertiary strategies to prevent oral disease in dependent older people.

Psychometric properties of the Spanish version of the Coping Strategies Inventory (CSI) in older people

The aim of this study was to evaluate the psychometric properties of the Coping Strategies Inventory (CSI) in a sample of 243 people aged 55 to 99 years old. The first order factorial structure was similar to the structure of the original version of the CSI and to the Spanish adaptation with general population. Furthermore, high levels of internal consistency and of convergent validity were observed in the different primary scales. Nevertheless, the problem avoidance scale did not surpass the validity and reliability tests. Due to it we propose to delete two of the items of this scale. On the other hand, in this study we confirmed the secondary and tertiary structure obtained in the original version of the inventory that was neither confirmed in the Spanish adaptation study nor the other studies on the psychometric properties of the Spanish version of the CSI.

The impact of indoor air quality and contaminants on respiratory health of older people living in long-term care residences in Porto

Background: persons who are 65 years or older often spend an important part of their lives indoors thus adverse indoor climate might influence their health status. Objective: to evaluate the influence of indoor air quality and contaminants on older people’s respiratory health. Design: cross-sectional study. Setting: 21 long-term care residences (LTC) in the city of Porto, Portugal. Subjects: older people living in LTC with ≥65 years old. Methods: the Portuguese version of BOLD questionnaire was administered by an interviewer to older residents able to participate (n = 143). Indoor air contaminants (IAC) were measured twice, during winter and summer in 135 areas. Mixed effects logistic regression models were used to study the association between the health questionnaire results and the monitored IAC, adjusted for age, smoking habits, gender and number of years living in the LTC. Results: cough (23%) and sputum (12%) were the major respiratory symptoms, and allergic rhinitis (18%) the main selfreported illness. Overall particulate matter up to 2.5 micrometres in size median concentration was above the reference levels both in winter and summer seasons. Peak values of particulate matter up to 10 micrometres in size (PM10), total volatile organic compounds, carbon dioxide, bacteria and fungi exceeded the reference levels. Older people exposed to PM10 above the reference levels demonstrated higher odds of allergic rhinitis (OR = 2.9, 95% CI: 1.1–7.2). Conclusion: high levels of PM10 were associated with 3-fold odds of allergic rhinitis. No association was found between indoor air chemical and biological contaminants and respiratory symptoms.

Attitudes towards to sexuality among older people: a qualitative research

Sexuality is an important component of human being and contributes to the quality of life. Sexual activity dependa on altitudes toward sexuality. Although this is an important issue, the research on attitudes toward sexuatity among older people hás been a neglected topic. Objectives: To understand altitudes towards sexuality among older people and to assess the relationship between sociodemographic factors and such attitudes.Methods: This cross-sectíonal study was conducted on 35 community-dwelltng older individuais (> 65 years old; 66% were men). Data collectíon was based on a questionnaire whtch includes three components: (1) Questíons on sociodemographic characteristícs; (2) A 13-item scale assessment of attitudes toward to sexualtty (SAATS) scored from O to 52, being highervalues related with positive attítudes; and (3) an open question "in your opinton what is sexuality?". Results: In this sample 40% of participants (n = 14) reported that there is no sexuality among older people. For the whole sample, the mean score of SAATS and respective standard deviatíon (± SD) was 28. 9 (± 6. 63). There were no differences in the mean score of SAATS by gender, but such score was lower among oldest people (p = 0. 006), among individuais reporting less schooling years (p = 0. 001) and among those with no companion (p = 0. 012). In regards to the qualitatíve analysis of the open question, the main answers obtained fali into the affectíve dimension, with the majority of partidpants reporting that sexuality is "lave", "respect" and "tenderness". Conclusions: Oldest people, those with lower educatíon levei and those with no companion presenting more negative attítudes towards to sexuality. Among older people sexuality is manly based on the affective dimension.

Mind the gap! An exploration of the role of lifelong learning in promoting co-production and citizenship within social care for older people

Contemporary themes in public policy have emphasised co-productive approaches within both the access and provision of support services to older people. This paper provides a cross disciplinary exploration from its respective authors perspectives on social work and educational gerontology to examine the potential for lifelong learning and learning interventions from which co-production with those using social care services in later life might be better facilitated. Using an example from the UK, we specifically elicit how co-produced care can enhance the horizon of learning and learning research. The synthesis of ideas across these two disciplines could enrich understanding and provide essential levers for moving towards empowerment and emancipation by engaging with a more co-productive approach in social care for older people. (DIPF/Orig.)