Nutraceutics, Frailty and Polypharmacy in the Oldest Old

Malnutrition and nutritional problems are common in older adults. Multiple chronic disease, inflammation, cognitive and functional impairment, geriatric syndromes (including delirium, falls or chronic pain) and drug use (i.e. polypharmacy, adverse drug reactions) may play a role in the onset of malnutrition and nutritional problems.

FOCUS : frailty management optimisation through EIPAHA commitments and utilisation of stakeholders’ input – an innovative European project in elderly care

The goal of FOCUS, which stands for Frailty Management Optimization through EIPAHA Commitments and Utilization of Stakeholders’ Input, is to reduce the burden of frailty in Europe. The partners are working on advancing knowledge of frailty detection, assessment, and management, including biological, clinical, cognitive and psychosocial markers, in order to change the paradigm of frailty care from acute intervention to prevention. FOCUS partners are working on ways to integrate the best available evidence from frailty-related screening tools, epidemiological and interventional studies into the care of frail people and their quality of life. Frail citizens in Italy, Poland and the UK and their caregivers are being called to express their views and their experiences with treatments and interventions aimed at improving quality of life. The FOCUS Consortium is developing pathways to leverage the knowledge available and to put it in the service of frail citizens. In order to reach out to the broadest audience possible, the FOCUS Platform for Knowledge Exchange and the platform for Scaling Up are being developed with the collaboration of stakeholders. The FOCUS project is a development of the work being done by the European Innovation Partnership on Active and Healthy Ageing (EIPAHA), which aims to increase the average healthy lifespan in Europe by 2020 while fostering sustainability of health/social care systems and innovation in Europe. The knowledge and tools developed by the FOCUS project, with input from stakeholders, will be deployed to all EIPAHA participants dealing with frail older citizens to support activities and optimize performance.

What are we waiting for?

The clinical education of Australia’s aged care nurses can no longer be treated as the Cinderella of nursing’s specialities. It is urgent that ways be agreed and measures taken to bring this branch of the profession, and residential aged care nursing in particular, into mainstream health care services. There should be no need to describe again the evolving shape of Australia’s demographic profile between now and the middle of this century; and no need to prove here that the ageing bulge is already placing a severe strain on staffing in the sector. A substantial percentage of the aged care nursing workforce is nearing retirement and the ratio of departures to recruits seems set to worsen at the same time as demand for high quality nursing care escalates. Important indicators – the number of the most highly dependent residents has doubled in the past seven years; compounding co-morbidities are increasingly common and an estimated 60-80% of residents in residential aged care facilities (RACFs) have a dementing illness – reveal the rapidly rising levels of frailty and dependency in the RACF population.

Functional status, postural stability and falls among older adults with glaucoma

Visual impairment is an important contributing factor in falls among older adults, which is one of the leading causes of injury and injury-related death in this population. Visual impairment is also associated with greater disability among older adults, including poorer health-related quality of life, increased frailty and reduced postural stability. The majority of this evidence, however, is based on measures of central visual function, rather than peripheral visual function. As such, there is comparatively limited research on the associations between peripheral visual function, disability and falls, and even fewer studies involving older adults with specific diseases which affect peripheral visual function, the most common of which is glaucoma. Glaucoma is one of the leading causes of irreversible vision loss among older adults, affecting around 3 per cent of adults aged over 60 years. The condition is characterised by retinal nerve fibre loss, primarily affecting peripheral visual function. Importantly, the number of older adults with glaucomatous visual impairment is projected to increase as the ageing population grows. The first component of the thesis examined the cross-sectional association between glaucomatous visual impairment and health-related quality of life (Study 1a), functional status (Study 1b) and postural stability (Study 1c) among older adults. A cohort of 74 community-dwelling adults with glaucoma (mean age 74.2 ± 5.9 years) was recruited and completed a baseline assessment. A number of visual function measures was assessed, including central visual function (visual acuity and contrast sensitivity), motion sensitivity, retinal nerve fibre analysis and monocular and binocular visual field measures (monocular 24-2 and binocular integrated visual fields (IVF): IVF-60 and IVF-120). The analyses focused on the associations between the outcomes measures and severity and location of visual field loss, as this is the primary visual function affected by glaucoma. In Study 1a, we examined the association between visual field loss and health-related quality of life, measured by the Short Form 36-item Health Survey (SF-36). Greater binocular visual field loss, on both IVF measures, was associated with lower SF-36 physical component scores, adjusted for age and gender (Pearson's r =|0.32| to |0.36|, p<0.001). Furthermore, inferior visual field loss was more strongly associated with the SF-36 physical component than superior field loss. No association was found between visual field loss and SF-36 mental component scores. The association between visual field loss and functional status was examined in Study 1b. Functional status outcomes measures included a physical activity questionnaire (Physical Activity Scale for the Elderly, PASE), performance tests (six-minute walk test, timed up and go test and lower leg strength) and an overall functional status score. Significant, but weak, correlations were found between binocular visual field loss and PASE and overall functional status scores, adjusted for age and gender (Pearson's r =|0.24| to |0.33|, p<0.05). Greater inferior visual field loss, independent of superior visual field loss, was significantly associated with poorer physical performance results and lower overall functional status scores. In Study 1c, we examined the association between visual field loss and postural stability, using a swaymeter device which recorded body movement during four conditions: eyes open and closed, on a firm and foam surface. Greater binocular visual field loss was associated with increased postural sway, both on firm and foam surfaces, independent of age and gender (Pearson’s r =|0.44| to |0.46|, p <0.001). Furthermore, inferior visual field was a stronger contributor to postural stability, more so than the superior visual field, particularly on the foam condition with the eyes open. Greater visual field loss was associated with a reduction in the visual contribution to postural sway, which underlies the observed association with postural sway. The second component of the thesis examined the association between severity and location of visual field loss and falls during a 12-month longitudinal follow-up. The number of falls was assessed prospectively using monthly fall calendars. Of the 71 participants who successfully completed the follow up (mean age 73.9 ± 5.7 years), 44% reported one or more falls, and around 20% reported two or more falls. After adjusting for age and gender, every 10 points missed on the IVF-120 increased the rate of falls by 25% (rate ratio 1.25, 95% confidence interval 1.08 - 1.44) or every 5dB reduction in IVF-60 increased the rate of falls by 47% (rate ratio 1.47, 95% confidence interval 1.16 - 1.87). Inferior visual field loss was a significant predictor of falls, more so than superior field loss, highlighting the importance of the inferior visual field area in safe and efficient navigation. Further analyses indicated that postural stability, more so than functional status, may be a potential mediating factor in the relationship between visual field loss and falls. Future research is required to confirm this causal pathway. In addition, the use of topical beta-blocker medications was not associated with an increased rate of falls in this cohort, compared with the use of other topical anti-glaucoma medications. In summary, greater binocular visual field loss among older adults with glaucoma was associated with poorer health-related quality of life in the physical domain, reduced functional status, greater postural instability and higher rates of falling. When the location of visual field loss was examined, inferior visual field loss was consistently more strongly associated with these outcomes than superior visual field loss. Insights gained from this research improve our understanding of the association between glaucomatous visual field loss and disability, and its link with falls among older adults. The clinical implications of this research include the need to include visual field screening in falls risk assessments among older adults and to raise awareness of these findings to eye care practitioners and adults with glaucoma. The findings also assist in developing further research to examine strategies to reduce disability and prevent falls among older adults with glaucoma to promote healthy ageing and independence for these individuals.

Inferior visual field reductions are associated with poorer functional status among older adults with glaucoma

Purpose: To examine the relationship between visual impairment and functional status in a community-dwelling sample of older adults with glaucoma. Methods: This study included 74 community-dwelling older adults with open-angle glaucoma (aged 74 ± 6 years). Assessment of central vision included high-contrast visual acuity and Pelli-Robson contrast sensitivity. Binocular integrated visual fields were derived from merged monocular Humphrey Field Analyser visual field plots. Functional status outcome measures included physical performance tests (6-min walk test, timed up and go test and lower limb strength), a physical activity questionnaire (Physical Activity Scale for the Elderly) and an overall functional status score. Correlation and linear regression analyses, adjusting for age and gender, examined the association between visual impairment and functional status outcomes. Results: Greater levels of visual impairment were significantly associated with lower levels of functional status among community-dwelling older adults with glaucoma, independent of age and gender. Specifically, lower levels of visual function were associated with slower timed up and go performance, weaker lower limb strength, lower self-reported physical activity, and lower overall functional status scores. Of the components of vision examined, the inferior visual field and contrast factors were the strongest predictors of these functional outcomes, whereas the superior visual field factor was not related to functional status. Conclusions: Greater visual impairment, particularly in the inferior visual field and loss of contrast sensitivity, was associated with poorer functional status among older adults with glaucoma. The findings of this study highlight the potential links between visual impairment and the onset of functional decline. Interventions which promote physical activity among older adults with glaucoma may assist in preventing functional decline, frailty and falls, and improve overall health and well-being.

How much do residential aged care staff members know about the nutritional needs of residents?

Background Undernutrition, weight loss and dehydration are major clinical issues for people with dementia in residential care, with excessive weight loss contributing to increased risk of frailty, immobility, illness and premature morbidity. This paper discusses a nutritional knowledge and attitudes survey conducted as part of a larger project focused on improving nutritional intake of people with dementia within a residential care facility in Brisbane, Australia. Aims The specific aims of the survey were to identify (i) knowledge of the nutritional needs of aged care facility residents; (ii) mealtime practices; and (iii) attitudes towards mealtime practices and organisation. Methods A survey based on those used in other healthcare settings was completed by 76 staff members. The survey included questions about nutritional knowledge, opinions of the food service, frequency of feeding assistance provided and feeding assessment practices. Results Nutritional knowledge scores ranged from 1 to 9 of a possible 10, with a mean score of 4.67. While 76% of respondents correctly identified risk factors associated with malnutrition in nursing home residents, only 38% of participants correctly identified the need for increased protein and energy in residents with pressure ulcers, and just 15% exhibited correct knowledge of fluid requirements. Further, while nutritional assessment was considered an important part of practice by 83% of respondents, just 53% indicated that they actually carried out such assessments. Identified barriers to promoting optimal nutrition included insufficient time to observe residents (56%); being unaware of residents' feeding issues (46%); poor knowledge of nutritional assessments (44%); and unappetising appearance of food served (57%). Conclusion An important step towards improving health and quality of life for residents of aged care facilities would be to enhance staff nutritional awareness and assessment skills. This should be carried out through increased attention to both preservice curricula and on-the-job training. Implications for practice The residential facility staff surveyed demonstrated low levels of nutrition knowledge, which reflects findings from the international literature. This has implications for the provision of responsive care to residents of these facilities and should be explored further.

A nurse-led model of oncogeriatric assessment

Background There is growing consensus that a multidisciplinary, comprehensive and standardised process for assessing the fitness of older patients for chemotherapy should be undertaken to determine appropriate cancer treatment. Aim This study tested a model of cancer care for the older patient incorporating Comprehensive Geriatric Assessment (CGA), which aimed to ensure that 'fit' individuals amenable to active treatment were accurately identified; 'vulnerable' patients more suitable for modified or supportive regimens were determined; and 'frail 'individuals who would benefit most from palliative regimens were also identified and offered the appropriate level of care. Methods A consecutive-series n=178 sample of patients >65 years was recruited from a major Australian cancer centre. The following instruments were administered by an oncogeriatric nurse prior to treatment: Vulnerable Elders Survey-13; Cumulative Illness Rating Scale (Geriatric); Malnutrition Screening Tool; Mini-mental State Examination; Geriatric Depression Scale; Barthel Index; and Lawton Instrumental Activities of Daily Living Scale. Scores from these instruments were aggregated to predict patient fitness, vulnerability or frailty for chemotherapy. Physicians provided a concurrent (blinded) prediction of patient fitness, vulnerability or frailty based on their clinical assessment. Data were also collected on actual patient outcomes (eg treatment completed as predicted, treatment reduced) during monthly audits of patient trajectories. Data analysis Data analysis is underway. A sample of 178 is adequate to detect, with 90% power, kappa coefficients of agreement between CGA and physician assessments of K>0.90 ("almost perfect agreement"). Primary endpoints comprise a) whether the nurse-led CGA determination of fit, vulnerable or frail agrees with the oncologist's assessments of fit, vulnerable or frail and b) whether the CGA and physician assessments accurately predict actual patient outcomes. Conclusion An oncogeriatric nurse-led model of care is currently being developed from the results. We conclude with a discussion of the pivotal role of nurses in CGA-based models of care.

Quality of life for older people in residential care is related to connectedness, willingness to enter care, and co-residents

Aim: To establish associations with quality of life (QOL) of older people in long-term residential care facilities in two New Zealand cities. Methods: The outcome measure of QOL was the Life Satisfaction Index. We used multiple linear regression to explore how broad categories of factors might contribute to QOL. Results: A total of 599 people (median age of 85 years; 74% women) participated. Response rates were 85% for facilities and 83% for residents. A resident's QOL was significantly related to the QOL of co-residents. QOL was higher for people who were more positive about entry to residential care, more physically able, and not depressed, and for those with more family and emotional support. Conclusion: Attending to the circumstances around entry to residential care may enhance QOL, as may promoting physical activity, treating depression and ensuring older people remain emotionally connected to their families. In choosing a facility, noting the QOL of co-residents is important.

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 baby boomers and beyond report : physical activity levels of older Western Australians 2006

Participation in sufficient levels of physical activity provides significant health benefits, particularly in older adults. The monitoring of physical activity levels in the Western Australian population is therefore necessary for developing and implementing strategies and programs for increasing participation. The Premier’s Physical Activity Taskforce (PATF) conducted a survey in 2006 to measure physical activity levels among Western Australian adults to follow-up the 1999 and 2002 state physical activity surveys. There is now widespread agreement that many health problems of older life – including the onset of frailty and disability – can be postponed or delayed by adopting health-enhancing habits such as physical activity. Adults over 65 years are the most rapidly growing age group and will continue to rise as more persons turn 65. If older adults could be encouraged to be more active as they age, frailty and disability associated with falls would be reduced, and function and physical and mental health in older people would be improved thereby reducing the burden of disease and injury. Given that physical inactivity is one of the most important and modifiable risk factors contributing to ill health, particularly for people as they age, the overall aim of this study was to examine patterns of physical activity in those aged 45 years and over – referred to hereafter as baby boomers+ – in more detail.

Never too old : engaging retired people inventing the future with MaKey MaKey

Within HCI, aging is often viewed in terms of designing assistive technologies to improve the lives of older people, such as those who are suffering from frailty or memory loss. Our research adopts a very different approach, reframing the relationship in terms of wisdom, creativity and invention. We ran a series of workshops where groups of retirees, aged between early 60s and late 80s, used the MaKey MaKey inventor's toolkit. We asked them to think about inventing the future and suggest ideas for new technologies. Our findings showed that they not only rose to the challenge but also mastered the technology, collaborated intensely together while using it and freely and at length discussed their own, their family's and others' relationship with technology. We discuss the value of empowering people in this way and consider what else could be invented to enable more people to be involved in the design and use of creative technologies.

Young People and Crime in Rural Communities

Because childhood and adolescence are crucial phases in psycho-social development and the formation of responsible citizens, an unusual degree of attention and supervision is directed at the young (Bittner, 1976; Rose, 1989). Such is the moral frailty of youth that mere presence or 11 doing nothing" (Corrigan, 1979) can, under certain circumstances, excite adult anxieties as a harbinger of immediate or later danger. Delinquency and adolescent antisocial behaviour are not, therefore, a matter of objective, positivistic measurement and control, but are bound up with larger patterns of intergenerational relationships. These relationships are also conditioned by social and spatial environments.

A systematic review of prescribing criteria to evaluate appropriateness of medications in frail older people

This study systematically reviews the published literature regarding inappropriate prescribing in frail individuals aged at least 65 years. Twenty-five of 466 identified studies met the inclusion criteria. All papers measured some surrogate indicators of frailty, such as performance-based tests, cognitive function and functional dependency. Beers criteria were used in 20 studies (74%) to evaluate inappropriate medication use and 36% (9/25) studies used more than one criterion. The prevalence of inappropriate medications ranged widely from 11 to 92%. Only a few studies reported the relationship between potentially inappropriate medication use and surrogate measures of frailty. These diverse findings indicate the need for a standardized measure for assessing appropriateness of medication in frail older individuals. Prescribing tools should address both medication and patient-related factors such as life expectancy and functional status to minimize inappropriate prescribing in frail individuals.