The quality of the physical environment and its association with activities and well-being among older people in residential care facilities

The physical environment can influence older people’s health and well-being, and is often mentioned as being an important factor for person-centred care. Due to high levels of frail health, many older people spend a majority of their time within care facilities and depend on the physical environment for support in their daily life. However, the quality of the physical environment is rarely evaluated, and knowledge is sparse in terms of how well the environment meets the needs of older people. This is partly due to the lack of valid and reliable instruments that could provide important information on environmental quality. Aim: The aim of this thesis was to study the quality of the physical environment in Swedish care facilities for older people, and how it relates to residents’ activities and well-being. Methods: The thesis comprises four papers where both qualitative and quantitative methods were used. Study I involved the translation and adaptation of the Sheffield Care Environment Assessment Matrix (SCEAM) into a Swedish version (S-SCEAM). Several methods were used including forward and backward translation, test of validity via expert consultation and reliability tests. In Study II, S-SCEAM was used to assess the quality of the environment, and descriptive data were collected from 20 purposively sampled residential care facilities (RCFs). Study III was a comparative case study conducted at two RCFs using observations, interviews and S-SCEAM to examine how the physical environment relates to older people’s activities and interactions. In study IV, multilevel modeling was used to determine the association between the quality of the physical environment and the psychological and social well-being of older people living in RCFs. The data in the thesis were analysed using qualitative content analysis, and descriptive, bivariate and multilevel statistics. Results: A specific result was the production of the Swedish version of SCEAM. The instrument contains 210 items structured into eight domains reflecting the needs of older people. When using S-SCEAM, the results showed a substantial variation in the quality of the physical environment between and within RCFs. In general, private apartments and dining areas had high quality, whereas overall building layout and outdoor areas had lower quality. Also, older people’s safety was supported in the majority of facilities, whereas cognitive support and privacy had lower quality. Further, the results showed that environmental quality in terms of cognitive support was associated with residents’ social well-being. Specific environmental features, such as building design and space size, were also noted, through observation, as influencing residents’ activities, and several barriers were found that seemed to restrict residents’ full use of the environment. Conclusions: This thesis contributes to the growing evidence-based design field. The S-SCEAM can be used in future research on the association between the environment and people’s health and well-being. The instrument could also serve as a guide in the planning and design process of new RCFs.

Implementación de criterios de Beers en pacientes con atención domiciliaria mayores de 75 años polimedicados y la identificación de las reacciones cruzadas

Introducción: El incremento de la población geriátrica es una realidad a nivel mundial y con esto los modelos de atención domiciliaria toman gran relevancia para dar respuesta a las diferentes patologías que requieran su seguimiento. Se ha evidenciado que en dicho seguimiento, el fenómeno de la polimedicación se presenta con frecuencia, con el riesgo de generar efectos cruzados y reacciones adversas que incrementan el deterioro clínico de los pacientes. Objetivo: Determinar los posibles efectos cruzados de la Polimedicación no pertinente en pacientes mayores de 75 años con hipertensión arterial más enfermedad neurodegenerativa en atención domiciliaria de una EPS del régimen contributivo en Bogotá, con base en los criterios de Beers.

Efeitos de um programa de exercício multimodal em pessoas idosas institucionalizadas

Objetivo: Investigar os efeitos de um programa de exercício multimodal sobre o funcionamento cognitivo e aptidão física funcional em pessoas idosas institucionalizadas. Método: Os participantes foram selecionados por conveniência entre os utentes de duas instituições de apoio a pessoas idosas. O grupo inicial foi constituído por um total de 21 pessoas de ambos os sexos (77-92 anos). Inicialmente, foi garantido um “período de controlo” de 4 semanas, em que os participantes mantiveram as suas atividades de vida quotidianas normais. Posteriormente, todos os idosos integraram um programa de exercício multimodal durante 8 semanas. Para estudar os efeitos da intervenção foram recolhidos dados em 3 momentos distintos: previamente ao período de controlo, após o período de controlo e no final do programa de intervenção. Foram efetuados testes físicos/motores, cognitivos e de dupla-tarefa (motor-cognitivo). Durante as sessões de exercício, alternaram-se períodos constituídos por tarefas motoras com períodos em que as tarefas motoras implicavam uma mobilização simultânea de recursos cognitivos. Resultados: A análise estatística dos dados recolhidos nos três momentos de avaliação, revelou efeitos positivos da intervenção ao nível da atenção, tempo de reação, força muscular, agilidade e capacidade cardiorrespiratória. Nos testes realizados em dupla-tarefa, foram encontradas melhorias no teste timed up and go, mas não se verificaram melhorias no teste de tempo de reação. A análise estatística dos dados recolhidos nos três momentos de avaliação, revelou efeitos positivos (p<0.05). da intervenção ao nível da atenção, tempo de reação, força muscular, agilidade e capacidade cardiorrespiratória. Nos testes realizados em dupla-tarefa, foram encontradas melhorias no teste timed up and go (p<0.05), mas não se verificaram melhorias no teste de tempo de reação. Conclusões: Um programa de exercícios multimodal induz melhorias no funcionamento cognitivo e motor de pessoas idosas institucionalizadas. É aconselhada a divulgação deste tipo de intervenção para pessoas idosas institucionalizadas; Effects of a Multimodal Exercise Program for Elderly Institutionalized Abstract: Objective: To investigate wthe effects of a multimodal exercise program on cognitive functioning and physical fitness of institutionalized elderly. Method: Participants were selected by convenience among two nursing home residents. Twenty-one people (77-92 years old) of both genders participated. During the first 4 weeks (control period), participants were not engaged in the exercise program and continue with their normal daily life activities. After the control period, the group was engaged in a multimodal exercise program for 8 weeks (2 times per week). To study the effects of a multimodal exercise program, data were collected at three different times: prior to the control period, after the control period, and at the end of the intervention. Several motor tests (physical fitness), cognitive tests and dual-tasks (motor-cognitive) were performed. The exercise sessions alternated between periods of motor taks and periods with motor plus cognitive tasks performed simultaneously. Results: The analysis of the data collected in the three moments of evaluation, show positive effects of the exercise program in cognitive dimensions (information processing speed and attention) and functional physical fitness components (muscle resistance, cardiorespiratory fitness and dynamic balance). In tests carried out in dual-task conditions, the exercise program promoted improvements in the timed up and go test (with mental calculations). Statistical analysis of the data collected at the three evaluation moments revealed positive effects (p <0.05). Of attention intervention, reaction time, muscle strength, agility and cardiorespiratory capacity. In the double-task tests, improvements were found in the timed up and go test (p <0.05), but there were no improvements in the reaction time test. Conclusions: The results of this study indicate that a multimodal exercise program can improve cognitive functioning and physical fitness in institutionalized older people. Thus, this type of intervention should be promoted among nursing home residents.

Investigating the links between muscle strength, sun exposure, dietary vitamin D intake and the vitamin D status of ambulatory older adults in South East Queensland

Vitamin D deficiency and insufficiency are now seen as a contemporary health problem in Australia with possible widespread health effects not limited to bone health1. Despite this, the Vitamin D status (measured as serum 25-hydroxyvitamin D (25(OH)D)) of ambulatory adults has been overlooked in this country. Serum 25(OH)D status is especially important among this group as studies have shown a link between Vitamin D and fall risk in older adults2. Limited data also exists on the contributions of sun exposure via ultraviolet radiation and dietary intake to serum 25(OH)D status in this population. The aims of this project were to assess the serum 25(OH)D status of a group of older ambulatory adults in South East Queensland, to assess the association between their serum 25(OH)D status and functional measures as possible indicators of fall risk, obtain data on the sources of Vitamin D in this population and assess whether this intake was related to serum 25(OH)D status and describe sun protection and exposure behaviors in this group and investigate whether a relationship existed between these and serum 25(OH)D status. The collection of this data assists in addressing key gaps identified in the literature with regard to this population group and their Vitamin D status in Australia. A representative convenience sample of participants (N=47) over 55 years of age was recruited for this cross-sectional, exploratory study which was undertaken in December 2007 in south-east Queensland (Brisbane and Sunshine coast). Participants were required to complete a sun exposure questionnaire in addition to a Calcium and Vitamin D food frequency questionnaire. Timed up and go and handgrip dynamometry tests were used to examine functional capacity. Serum 25(OH)D status and blood measures of Calcium, Phosphorus and Albumin were determined through blood tests. The Mean and Median serum 25-Hydroxyvitamin D (25(OH)D) for all participants in this study was 85.8nmol/L (Standard Deviation 29.7nmol/L) and 81.0nmol/L (Range 22-158nmol/L), respectively. Analysis at the bivariate level revealed a statistically significant relationship between serum 25(OH)D status and location, with participants living on the Sunshine Coast having a mean serum 25(OH)D status 21.3nmol/L higher than participants living in Brisbane (p=0.014). While at the descriptive level there was an apparent trend towards higher outdoor exposure and increasing levels of serum 25(OH)D, no statistically significant associations between the sun measures of outdoor exposure, sun protection behaviors and phenotypic characteristics and serum 25(OH)D status were observed. Intake of both Calcium and Vitamin D was low in this sample with sixty-eight (68%) of participants not meeting the Estimated Average Requirements (EAR) for Calcium (Median=771.0mg; Range=218.0-2616.0mg), while eighty-seven (87%) did not meet the Adequate Intake for Vitamin D (Median=4.46ug; Range=0.13-30.0ug). This raises the question of how realistic meeting the new Adequate Intakes for Vitamin D is, when there is such a low level of Vitamin D fortification in this country. However, participants meeting the Adequate Intake (AI) for Vitamin D were observed to have a significantly higher serum 25(OH)D status compared to those not meeting the AI for Vitamin D (p=0.036), showing that meeting the AI for Vitamin D may play a significant role in determining Vitamin D status in this population. By stratifying our data by categories of outdoor exposure time, a trend was observed between increased importance of Vitamin D dietary intake as a possible determinant of serum 25(OH)D status in participants with lower outdoor exposures. While a trend towards higher Timed Up and Go scores in participants with higher 25(OH) D status was seen, this was only significant for females (p=0.014). Handgrip strength showed statistically significant association with serum 25(OH)D status. The high serum 25(OH)D status in our sample almost certainly explains the limited relationship between functional measures and serum 25(OH)D. However, the observation of an association between slower Time Up and Go speeds, and lower serum 25(OH)D levels, even with a small sample size, is significant as slower Timed Up and Go speeds have been associated with increased fall risk in older adults3. Multivariable regression analysis revealed Location as the only significant determinant of serum 25(OH)D status at p=0.014, with trends (p=>0.1) for higher serum 25(OH)D being shown for participants that met the AI for Vitamin D and rated themselves as having a higher health status. The results of this exploratory study show that 93.6% of participants had adequate 25(OH)D status-possibly due to measurement being taken in the summer season and the convenience nature of the sample. However, many participants do not meet their dietary Calcium and Vitamin D requirements, which may indicate inadequate intake of these nutrients in older Australians and a higher risk of osteoporosis. The relationship between serum 25(OH)D and functional measures in this population also requires further study, especially in older adults displaying Vitamin D insufficiency or deficiency.

Levels of cardiac knowledge and cardiopulmonary resuscitation training among older people in Queensland

Objectives: The current study was conducted to determine levels of cardiac knowledge and cardiopulmonary resuscitation (CPR) training in older people in Queensland, Australia.---------- Methods: A telephone survey of 4490 Queensland adults examined respondents’ knowledge of coronary heart disease (CHD) risk factors, knowledge of heart attack symptoms, knowledge of the local emergency telephone number, as well as respondents’ rates and recency of training in CPR.---------- Results: Older participants, aged 60 years and over, were approximately one and a half times more likely than the 30–39 year-old reference group to have limited knowledge of heart disease risk factors (OR = 1.53), and low knowledge of heart attack symptoms (OR = 1.60). Knowledge of the local emergency telephone number also decreased with age. Older participants had significantly lower rates of training in CPR, with almost three quarters (71.7%) reporting that they had never been trained. Older people who had completed CPR training were significantly less likely to have done so recently.---------- Conclusions: Cardiac knowledge levels and CPR training rates in older Queensland persons were lower than those found in the younger population.

Older patients request more information : a survey of use of written patient education materials in general practice

Objectives: To determine GPs' reported use of written education materials with older patients and older patients' reported receipt of these materials. To determine GPs' and older patients' perceptions of written materials.---------- Method: Using self-report questionnaires, two populations were surveyed; a randomised sample of 50 GPs (29 males and 21 females) practising in Brisbane's southern suburbs and a convenience sample of 188 older community-dwelling people (aged over 64 years).----------- Results: All GPs reported using written materials with patients, although 28% had not given any to the Last 10 patients. This increased to 46% when patients were older. Twenty percent of patients wanted more written information from their GP, while some GPs believed that older patients preferred verbal information and gave out written information only when they perceived patient interest. All GPs reported giving written materials at the time of consultation and over two thirds discussed the content with patients. Just over 50% of patients reported receiving written information from GPs in the Last six months and only hall of these again discussed it directly with their GP. Overall, patients were more positive than GPs about the value of written education materials.---------- Conclusions: Older patients' desire for written information may be better met if they are more assertive in requesting this of GPs and GPs may better serve their patients' needs if they make written information more readily available to them. Better access to materials and more financial incentives to give them out might also increase GPs' use of written materials.

Poor functional health literacy : the silent disability for older people

In this information age, people are confronted by verbal, visual and written information. This is especially important in the health field, where information is needed to follow directions, understand prescriptions and undertake preventive behaviours. If provided in written form, much of this information may be inaccessible to people who cannot adequately read. Although poor literacy skills affect all groups in the population, older adults with fewer years of education seem to be particularly disadvantaged by an increasing reliance on written communication of health information. With older age comes a higher risk of illness and disability and a greater potential need to access the health system. As a result, poor literacy skills of older individuals may directly impact their health status. This paper explores the link between functional literacy and health, particularly for the older population, provides strategies to practitioners for the management of this problem, and suggests research initiatives in this area.

Investigating Familiarity in Older Adults to Facilitate Intuitive Interaction

This paper discusses how intuitive interaction is a possible way to increase the efficiency and effectiveness of interaction with older adults. It provides insights into existing research on intuitive interaction, and the role of prior experience and familiarity in intuition. An experiment is discussed which investigates differences in familiarity between younger and older adults. A comprehensive coding system has been developed to help analyse the data collected. This research is currently in progress.

Woodturning for older learners : a real 'turn on'

The research reported in this study concerns older adults from Australia who voluntarily chose to learn the craft of woodturning. Semi-structured interviews and a survey questionnaire were distributed to members of a woodturning club to explore their motivations and the processes by which they learned how to woodturn. The findings indicated that participants’ motivation could be construed as both intrinsic and extrinsic. They used seven approaches to learning – structured courses, instruction from convenors, modelling/watching/demonstrations, guided practice and monitoring by convenors, trial and error with practice, advice and help from peers and reading. Finally, the positive climate of the organisation was found to be particularly important to the older learners.

End-of-life decision making for older people

This chapter deals with the increasing issues surrounding end-of-life decision making. As the life trajectory for older people changes, the need for open discussion about their health problems and treatment becomes more critical. Acceptance of the ageing process itself is often not easy so the matter of a good death is even more distressing for some people to consider. The vignette provides an excellent discussion on the need for open dialogue with the older person and their families, whether they are acutely ill or have chronic health problems. How a person wishes to be treated when quality of life is not going to improve, no matter what interventions are put in place, seems essential for person-centred care. The issue of competency is one that must be determined before any decision is made by any person involved in care.