Built environment and elderly population health: a comprehensive literature review

Global population aging over recent years has been linked to poorer health outcomes and higher healthcare expenditure. Policies focusing on healthy aging are currently being developed but a complete understanding of health determinants is needed to guide these efforts. The built environment and other external factors have been added to the International Classification of Functioning as important determinants of health and disability. Although the relationship between the built environment and health has been widely examined in working age adults, research focusing on elderly people is relatively recent. In this review, we provide a comprehensive synthesis of the evidence on the built environment and health in the elderly.

Systemic lupus erythematosus in the elderly: Clinical and immunological characteristics.

Systemic lupus erythematosus (SLE) predominantly affects young women in their 20s. In 40 out of 250 (16%) patients with SLE seen in our hospital disease onset occurred after the age of 50. The interval between the time of onset and diagnosis was five years in this older group compared with three years in the younger group. Arthritis, as a first symptom, was less common in the older onset group. During the follow up a lower incidence of arthritis, malar rash, photosensitivity, and nephropathy was found in the older onset group. In contrast, this group showed an increased incidence of myositis. High titres of anti-dsDNA tended to occur less often and the incidence of anti-Ro antibodies was lower in the older onset group. These features seem to distinguish patients with older onset SLE as a particular subset.

Improving Quality of Life of Patients With Schizophrenia In Acute Psychiatric Wards

The overall goal of this study was to identify means by which the quality of life (QoL) of patients with schizophrenia could be improved in acute psychiatric wards. First, subjective QoL of patients (n=35) was explored. Second, two different QoL instruments (EuroQoL-5D, EQ-5D; Quality of Life Enjoyment and Satisfaction Questionnaire Short Form, Q-LES-Q SF) were examined. Third, patients’ (n=35) and nurses’ (n=29) perceptions of nursing interventions to support patients’ QoL were examined. Fourth, the effect of three different patient education methods on patients’ QoL (n=311) was compared. The data were collected during the period 2005-2007. Patients named health, family, leisure activities, work or study, and social relationships most frequently as their important QoL areas. It emerged that patients’ QoL was impaired. Examination of two QoL instruments showed that the EQ-5D has moderate and the Q-LES-Q SF good internal consistency. Moreover, both instruments proved to be reasonably valid and feasible for use with patients with schizophrenia. Altogether six nursing interventions which nurses use to support patients’ QoL, and which should be further developed were identified from nurses’ descriptions: interventions related to care planning, empowering interventions, social interventions, activating interventions, security interventions, and interventions to support physical health. Evaluation of different patient education methods showed that patients’ QoL improved significantly during follow-up. No significant differences between groups were found. In light of the findings it is recommended to assess QoL of patients with schizophrenia as a basis for care planning and care evaluation in clinical settings. Valid and feasible instruments should be used in this assessment. Moreover, it is recommend that nursing interventions should be further developed to better improve patients’ QoL.

Customer Driven Service Development – Technology-based Care and Services for the Elderly

The objective of this master’s thesis was to examine technology-based smart home devices and services. Topic was approached through basic theories, transaction cost theory and resource-based view in order to build basis for this thesis. Conceptual framework was discussed by means of networks, value networks and service systems which provide a useful framework for service development. The needs of the elderly living at home were discussed in order to find out which technology-based services could be used to satisfy the needs. Segmentation and need data collected previously during proactive home visits was exploited and additionally a survey targeted to experts and professionals of social and health care sector was done to verify the needs. Finally, the results of the survey were analyzed using quality function deployment method to figure out the most important and suitable service offerings for the elderly. As a conclusion of analysis, social media and monitoring services are the most useful technology-based services. However, traditional home services will still maintain their necessity too.

Patient Seclusion and Restraint Practices in Psychiatric Hospitals - Towards Evidence Based Clinical Nursing

The overall goal of this study was to support evidence based clinical nursing regarding patient seclusion and restraint practices. This was done by ensuring professional competence through innovative learning methods. The data were collected in three phases between March 2007 and May 2009 on acute psychiatric wards. Firstly, psychiatric inpatients’ experiences and suggestions for seclusion and restraint practices were explored (n=30). Secondly, nursing and medical personnel’s perceptions of seclusion and restraint practices were explored (n=27). Thirdly, the impacts of a continuing vocational eLearning course on nurses’ professional competence was evaluated (n=158). Patients’ perspectives received insufficient attention during the seclusion and restraint process. Improvements and alternatives to seclusion and restraint as suggested by the patients focused on essential parts of clinical nursing, but were not extensively adopted. Also nursing and medical personnel thought that patients’ subjective perspective received little attention. Personnel proposed a number of alternatives to seclusion and restraint, and they expressed a need for education and support to adopt these in clinical nursing. Evaluation of impacts of eLearning course on nurses’ professional competence showed no statistical differences between an eLearning group and an education-as-usual group. This dissertation provides evidence based knowledge about the realization of seclusion and restraint practices and the impacts of eLearning course on nurses’ professional competence in psychiatric hospitals. In order to improve clinical nursing the patient perspective must be accentuated. To ensure personnel’s professional competence, there is a need for written clinical guidelines, education and support. Continuing vocational education should bring together written clinical guidelines, ethical and legal issues and the support for personnel. To achieve the ambitious goal of such integration, achievable and affordable educational programmes are required. This, in turn, yields a call for innovative learning methods.

Pharmacokinetics of Oxycodone and Paracetamol in the Elderly. Clinical Pharmacokinetic Study on Orthopaedic Surgical Patients and Healthy Volunteers

The proportion of elderly people over 65 years of age in Finland is expected to grow to over 25% by the 2025. It has been estimated that elderly people today consume nearly 40% of all drugs. Age brings about number of physiological changes that may affect the disposition, metabolism and excretion of drugs. The function of heart, lungs, liver and kidneys decreases even in healthy people, as they get older. The proportion of total body water decreases and the relative fat percentage increases. Also several other factors such as concurrent diseases, concomitant medication and nutritional factors have an effect on drug therapy in elderly. Age increases the risk of adverse drug reactions, which most often are dose-dependent. Despite all this there are not enough studies involving the elderly people and the elderly are most often excluded from clinical trials. Oxycodone is a strong opioid analgesic, which is used to treat moderate or severe pain. Paracetamol is a widely used nonopioid analgesic, which has become popular in the treatment of pain in many patient groups. In this series of studies the pharmacokinetics of oral and intravenous oxicodone as well as intravenous paracetamol in the elderly and young adult patients were investigated. Also a study investigating the interaction of oral antibiotic clarityhromycin, a known cytochrome P450 (CYP) 3A4 inhibitor, with oxycodone pharmacokinetics and pharmacodynamics in elderly and young healthy volunteers was carried out. The pharmacokinetics of oxycodone showed a clear age depency. Patients over 70 years had 50-80% higher mean exposure to oral oxycodone and a twofold greater plasma concentration than young adults 12 h after ingestion of the drug. Elderly patients had 40-80% greater exposure to intravenous oxycodone and patients over 80 years had over twofold greater plasma concentrations 8 h post dose than the young adults. The elderly patients had also greater exposure to intra venous paracetamol compared to young adults. Clarithromycin increased the exposure to oral oxycodone in both young and elderly volunteers. The elderly had marked interindividual variation in the pharmacokinetics and pharmacodynamics when clarithromycin was given concomitantly with oxycodone. Because the pharmacokinetics of oxycodone and intravenous paracetamol depend on the age of the subject, it is important to titrate the analgesic dose individually in the elderly.

Adoption of information technology based patient education in psychiatric nursing

The overall goal of the study was to describe adoption of information technology (IT)-based patient education (PE) developed for patients and nurses use in psychiatric nursing. The data were collected in three phases during the period 2000-2006 in a variety of psychiatric settings in Finland. Firstly, the development process of IT-based PE for patients with schizophrenia spectrum psychosis was described. Secondly, nurses’ adoption of IT-based PE and the variables explaining adoption were demonstrated. Moreover, use of daily IT-based PE in clinical practice and factors associated with use were identified and described. And thirdly, nurses’ experiences of the IT-based PE after one year clinical use were evaluated. IT-based PE program was developed in several stages based on users’ needs and it included information and multimedia applications. Altogether, almost 500 IT-based PE sessions were carried out by the nurses on the study wards and revealed nurses’ activity in educating patients using IT to vary and depend on the hospital in which they worked. Almost 80% of all the possible IT-based PE sessions involved 93 patients and 83 nurses. Less than 2% of the IT-based PE sessions were interrupted and less than 10% suffered disturbances due to the patients or external causes. Moreover, the patients whose education took more days had poorer mental status than those whose education was carried out over a shorter period. After a year’s experience, advantages and disadvantages were described by the nurses for both patients and nurses of the IT-based PE. IT-based PE can be used even on closed acute psychiatric wards with patients with serious mental health disorders. However, technology adoption requires time, and therefore, it must fit in with clinical practice. Collaboration between users and developers is needed when developing user-centered methods in the area of mental health services. Moreover, it is important to understand factors that affect IT adoption in healthcare settings. IT-based PE is one option in interactive and co-operative health care practice between patients and nurses. Therefore the staff should begin to refer patients to established, credible and well-maintained Internet sites that provide information on common psychological problems. Even if every nurse should be trained and engaged to carry out IT-based PE, by targeting the training especially for the most active nurses aids them to support the less active ones. Adoption should also be understood from a perspective that includes aspects related to the context where it is implemented and examine how and in what circumstances it works.

Comparison between open and laparoscopic elective cholecystectomy in elderly, in a teaching hospital

Objective: to analyze the differences in mortality rates, length of hospital stay, time of surgery and the conversion rate between elective open cholecystectomies (OC) and laparoscopic ones (LC) in elderly patients. Methods : we evaluated medical records of patients 65 years of age or older undergoing open or laparoscopic cholecystectomy at the Hospital Regional de Mato Grosso do Sul between January 2008 and December 2011. We excluded individuals operated in non-elective scenarios or who underwent intraoperative cholangiography. Results : we studied 113 patients, of whom 38.1% were submitted to the OC and 61.9%, to LC. Women accounted for 69% of patients and men, for 31%. The conversion rate was 2.9%. The mean age and duration of the procudure was 70.1 and 84 minutes, respectively, with no significant difference between OC and LC. Patients undergoing LC had shorter hospital stays (2.01 versus 2.95 days, p=0.0001). We identified operative complications in sixpatients (14%) after OC and in nine (12%) after LC, with no statistical difference. Conclusion : there was no difference in morbidity and mortality when comparing OC with LC. The laparoscopic approach led to shorter hospital stay. Operative time did not differ between the two access routes. The conversion rate was similar to other studies.

Aggression and its Management in Adolescent Forensic Psychiatric Care

The overall goal of this study was to explore and identify good aggression management methods and on that basis to produce recommendations for aggression management in the adolescent forensic setting. The study was conducted in three phases. In Phase I, staff’s (n = 58) perception of adolescent aggressive behaviour and methods to manage it was examined. In Phase II, staff’s (n = 30) perception of treatment settings and treatment interventions available were studied. In Phase III, the effectiveness of an aggression management programme was evaluated. The data were collected during the period 2004-2007. Participants perceived adolescent aggressive behaviour in a similar way and described aggressive behaviour as being a comprehensible phenomenon. Management methods used to control aggressive situations were alike, although the practical solutions varied between the study units, especially regarding coercive methods. Staff members proposed more time and better opportunities to discuss and evaluate the aggression situation in order to improve the methods used. The treatment settings were similar in studied forensic units and interventions were primarily focused on psychological aspects, including management of aggressive behavior. A comprehensive aggression management programme proved to be effective in decreasing incidents of violence. The use of coercive methods in aggression situations decreased and injuries to the staff became less frequent. If staff members intend to apply high quality management methods in aggression situations they have to share a consistent understanding of aggressive behaviour and need to be aware of the various methods available. In addition, they should learn more about assessment methods in order to improve aggression management. International comparison of aggression, methods for managing it and service provision creates a starting point for developing equal care provision and realization within and between European countries.

Containment Measures in Adolescent Psychiatric Care - Focus on Mechanical Restrain

Rajoitetoimet, erityisesti sitominen, nuorisopsykiatrisessa hoitotyössä Tutkimuksen tavoitteena oli kuvata ja syventää tietoa rajoitetoimien, erityisesti sitomisen, käytöstä nuorisopsykiatrisessa vastentahtoisessa osastohoidossa. Tutkimuksen tavoitteena oli kuvata hoitajien, lääkäreiden ja potilaiden asenteita eri rajoittamiskeinoja kohtaan nuorisopsykiatrisessa osastohoidossa, kerätä tietoa yhden vuoden aikana tapahtuneiden sitomisten määrästä ja luonteesta sekä kuvata potilaiden kokemuksia sitomisesta nuorisopsykiatrisen osastohoidon aikana. Tutkimus tuottaa arvokasta tietoa korkeatasoisten sitomiskäytäntöjen kehittämiseen nuorisopsykiatrisessa osastohoidossa, sekä sitomisten määrää vähentämällä että sitomistapoja kehittämällä. Tavoitteena on parantaa sidottujen potilaiden kliinistä hoitoa. Tutkimusaineisto kerättiin suomalaisilla, pääkaupunkiseudulle sijoittuvilla, nuorisopsykiatrisilla osastoilla neljässä vaiheessa lokakuun 2009 ja huhtikuun 2012 välisenä aikana. Helsingin ja Uudenmaan sairaanhoitopiirin (HUS) nuorisopsykiatrian erikoisalan seitsemän suljetun osaston hoitohenkilökunta sekä lääkärit suhtautuivat myönteisesti rajoittamistoimenpiteisiin. Nuorisopsykiatriset potilaat suhtautuivat rajoittamistoimenpiteisiin kriittisemmin kuin henkilökunta. Nuoret suhtautuivat myönteisimmin tarvittaessa annettavaan lääkitykseen, ajoittaiseen tarkkailuun ja kulun rajoittamiseen. Vähiten hyväksytty menetelmä oli verkkosänky. Nuoret arvioivat sitomisen kolmen vähiten hyväksytyn menetelmän joukkoon. Sitomisen esiintyvyys ja pitkien sitomisten määrä olivat korkeita tutkimukseen valituissa yksiköissä. Useimmat sidotut nuoret tiesivät syyn sitomiseensa, suhtautuivat siihen ambivalentisti nähden siinä sekä hyötyä että haittaa, pitäen sitä kuitenkin rangaistuksena. Huolimatta tästä, suurin osa haastatelluista nuorista koki, että joissain tilanteissa sitomista tarvitaan nuorisopsykiatrisessa osastohoidossa. Nuorilla oli monia ehdotuksia, kuinka parantaa sitomista käytännön osastohoidossa. Tämä väitöskirja tuottaa uutta tietoa eri rajoittamistoimenpiteiden ja sitomisen toteuttamisesta nuorisopsykiatrisessa osastohoidossa. Käytännön hoitotyön parantamiseksi nuorisopsykiatrisilla osastoilla tarvitaan laaja-alaista ja syvälle luotaavaa koulutusta, jotta rajoittamis-toimenpiteiden määrää voidaan vähentää. Myös kriisitilanteiden hallintaan tarvitaan uusia keinoja. Tietoa, kuvausta toimenpiteistä ja tilanteiden käsittelyä jälkikäteen tulee tarjota ala-ikäiselle potilaalle hänen kehitystasonsa huomioiden. Sitomisten määrää tulee vähentää ja niiden kestoa lyhentää. Nuorten tulee olla aktiivisesti mukana kehittämässä aggression hallintamenetelmiä suomalaisessa nuorisopsykiatrisessa osastohoidossa.

Hearing Impairment and Tinnitus in the Elderly

The purpose of this study was to gather information on hearing impairment and related factors among elderly people. The HHIE-S questionnaire (Hearing Handicap Inventory for Elderly-Screening) and a single hearing question (”Do you feel you have a hearing loss”) were compared to audiometric hearing thresholds (N=164). HHIE-S was reliable for detecting moderate or worse hearing impairment. The single question was equally sensitive and more specific in identifying mild hearing impairment. The prevalence of hearing impairment was evaluated in four age cohorts (70, 75, 80 and 85 years, N=4067) in Turku, Finland. The HHIE-S cut-off score >8 as an indicator of at least mild hearing impairment yielded prevalence values of 37.7% - 54.1%, and a score >18 (moderate or more severe hearing impairment) was 21.1% - 38.9%. The single question test was positive in 25.5% - 46.2%. Hearing aid compliance and problems experienced by hearing aid users were recorded as informed by the participants in a mailed interview (N=249/4067). The hearing aids were used daily by 55.4%, and never by 10.7%. Use sank with advancing age. The disturbance caused by tinnitus among 583 subjects was compared to their level of alexithymia (TAS-20) and depressiveness (BDI). Depressiveness was weakly associated with annoying tinnitus, but not alexithymia. The prevalence of hearing impairment can be measured by enquiry. Hearing aid compliance should be improved by technical means and better counseling. The factors affecting the distress experienced by tinnitus patients need further study.