Ageing in Place in the United Kingdom

Ageing in Place is a key component of UK policy on older people and housing. Helping older people to ‘age in place’ at home is seen to benefit the quality of life and also provide a cost-effective solution to the problems of an expanding population of very old people. However, the reality is not straightforward and in this paper, some results of qualitative research are presented to illustrate the benefits, problems and challenges that exist in relation to Ageing in Place in the United Kingdom. The research is based on qualitative data collected from 40 people age 80–89 in the north-west of England as part of the ENABLE-AGE Project 2002 to 2004. The research suggests that while Ageing in Place may bring social and psychological benefits, there can also be a significant downside on an everyday level. Home in old age can be a place of negative experiences, such as isolation and loneliness and there are often significant weaknesses in terms of informal support, physical environment of the home and neighbourhood and social network, which undermine the person’s ability to live independently. The paper reviews recent UK initiatives to use “telecare” to address some of these issues.

Recruitment and Retention of Older Adults in Aging Research

Older adults continue to be underrepresented in clinical research despite their burgeoning population in the United States and worldwide. Physicians often propose treatment plans for older adults based on data from studies involving primarily younger, more‐functional, healthier participants. Major barriers to recruitment of older adults in aging research relate to their substantial health problems, social and cultural barriers, and potentially impaired capacity to provide informed consent. Institutionalized older adults offer another layer of complexity that requires cooperation from the institutions to participate in research activities. This paper provides study recruitment and retention techniques and strategies to address concerns and overcome barriers to older adult participation in clinical research. Key approaches include early in‐depth planning; minimizing exclusion criteria; securing cooperation from all interested parties; using advisory boards, timely screening, identification, and approach of eligible patients; carefully reviewing the benefit:risk ratio to be sure it is appropriate; and employing strategies to ensure successful retention across the continuum of care. Targeting specific strategies to the condition, site, and population of interest and anticipating potential problems and promptly employing predeveloped contingency plans are keys to effective recruitment and retention.     

Self-management tasks to improve mobility and reduce fall risk are not leading to lower research participation in older adults

Purpose of studyThe first aim is to evaluate, in a sub-study, the recruitment process of the Senior Step Study, which was an intervention study on the self-management of mobility and fall risk; the second aim is to explore the reasons mentioned by older people, from three different settings, for (not) participating.MethodsSubjects were community-dwelling older persons, residents of homes for the elderly, and older persons regularly visiting community centres. The effectiveness of different recruitment procedures was analysed for each setting separately. We also analysed reasons for accepting and declining participation between the settings.ResultsThe total inclusion rate was 27.9%. A personal initial approach (i.e., first contact was face-to-face or in a group meeting) did not improve the inclusion rate. More subjects consented to participate after an introductory meeting (which was planned after the first face-to-face contact) compared to persons not having one (p < 0.01). At different settings, subjects gave different reasons for participation. No differences were found in the reasons for refusing participation. Especially in homes for the elderly, people refused to participate because the research was too burdensome.ConclusionsThe inclusion rates in this study are comparable to other self-management studies with older people. An introductory meeting during which the study design and benefits of participating are explained and formal interim evaluations of the recruitment process may benefit recruitment. Recruiting older persons for self-management tasks is possible with the appropriate recruitment process, enabling more research on this increasingly important research topic.     

Older people's participation and engagement in falls prevention interventions: Comparing rates and settings

ObjectiveFalls among older people remain a major public health issue. The purpose of this article was to facilitate accurate interpretation of the existing evidence-base and facilitate robust planning of future fall prevention randomised controlled trials (RCTs).MethodTwo systematic reviews were further developed that evaluated older people's participation and engagement in RCTs to prevent falls in both community and institutional settings. It is argued that there is a need to differentiate between: firstly, acceptance rates versus recruitment rates, i.e. respectively the proportion of older people willing to participate in the RCTs versus those willing and included; secondly, rates of recruitment and participation in institutional settings distinguishing between nursing care facilities versus hospitals.ResultsFor community settings (n = 78), the median rates were 41.3% (22.0–63.5%) for recruitment and 70.7% (64.2–81.7%) for acceptance. For institutional settings (n = 25), the median rates were 48.5% (38.9–84.5%) for recruitment and 88.7% (81.2–95.4%) for acceptance. In comparing trials from nursing care facilities and hospitals, recruitment and acceptance rates were remarkably similar, though the remaining data – attrition, adherence, and whether adherence acted as a moderator on the effectiveness of the intervention on trial outcomes – was only available from trials from nursing care facilities.ConclusionResearchers are encouraged to be more inclusive in trials and to conduct more RCTs in hospitals to prevent falls. A consensus on how to define successful engagement with trials and uptake and adherence to trial interventions remains desired.     

An Introduction to Geriatrics for First-Year Medical Students

OBJECTIVE: To prepare medical students to better serve their older patients while raising awareness of geriatrics as a career choice. DESIGN: To determine the impact of a new educational program, attitudinal assessments were administered to the group before and after participation in the program and to a comparison group of nonintervention students. SETTING: University of Texas Health Science Center, San Antonio. PARTICIPANTS: Two hundred and three first-year medical students. MEASUREMENTS: Student response on a scale of one to six regarding four constructs: attitudes and beliefs about providing medical care for older people, knowledge and beliefs about aging, interest in pursuing clinical geriatrics, and interest in pursuing aging research. RESULTS: Four factors were consistently formed in the analysis process: beliefs about physical decline; comfort with older people; beliefs about career opportunities; and interest in geriatric research. The intervention group made significant gains in two areas: comfort with older people and understanding of physical decline in aging. Two new factors emerged in post-test data. CONCLUSIONS: The impact of the program was mixed. Although awareness of geriatrics and comfort with older people was increased, there was little change in career aspirations. Students in the program increased their awareness of physical decline in old age, setting the stage for teaching them about the physician's role with regard to function, and learned that geriatrics is a low-status specialty.     

Interdisciplinary Gerontology Education:

Negative attitudes toward older people are thought to impact social policies and service provision, cause adverse medical and mental health treatment of older persons, and diminish self-esteem and feelings of adequacy, usefulness, and security of older people. Research on gerontology education as a change agent of attitudes toward aging has yielded mixed results-predominantly due to the variety of dimensions of attitudes measured by diverse attitude instruments. The present research employed by the Aging Opinion Survey to explore the impact of an introductory interdisciplinary gerontology course on three dimensions of attitudes toward aging. Matched pretest and posttest responses of 115 subjects at a state university were obtained. Analyses of t-tests revealed that subjects experienced significant positive changes in attitudes toward older people in general (t = 3.06, p < .001) and in attitudes toward familiar elders (t = 3.06, p < .003). No significant attitude change occured in personal anxiety about aging. Implications for applied gerontology education and research are discussed.     

Older people and ethics

This article examines the following questions and issues. Is there common agreement about ethical principles or are there variations according to culture, time and place? Are there special issues in policy and research relating to older people compared with other age groups? Why is there interest in ethical issues and older people? It then examines three final questions. Is the medical model for ethical approval (especially for research) suitable for social care and the social sciences? Are there specific ethical issues for different groups ‐ policy makers, practitioners. researchers and older people themselves? How helpful are guidelines?     

Community engagement and the resource centers for minority aging research

The National Institute on Aging created the Resource Centers for Minority Aging Research (RCMARs) to address infrastructure development intended to reduce health disparities among older adults. The overall goals of the RCMARs are to (a) increase the size of the cadre of researchers conducting research on issues related to minority aging; (b) increase the diversity of researchers conducting research on minority aging; (c) create and test reliable measures for use in older diverse populations; and (d) conduct research on recruitment and retention of community-dwelling older adults for research addressing behavioral, social, and medical issues. Along with this latter goal, the RCMARs developed and maintain academic-community partnerships. To accomplish the recruitment and retention goal, the RCMARs established Community Liaison Working Groups using a collaborative approach to scientific inquiry; this special issue will identify research priorities for moving the science of recruitment and retention forward. In addition, sustainable and efficient methods for fostering long-term partnerships will be identified between community and academia. Evidence-based approaches to the recruitment and retention of diverse elders are explored. We expect this supplement to serve as a catalyst for researchers interested in engaging diverse community-dwelling elders in health-related research. In addition, this supplement should serve as a source of the most contemporary evidence-based approaches to the recruitment and retention of diverse older populations for participation in social, behavioral, and clinical research.     

Improving recruitment of older people to research through good practice

There is widespread evidence both of the exclusion of older people from clinical research, and of under-recruitment to clinical trials. This review and opinion piece provides practical advice to assist researchers both to adopt realistic, achievable recruitment rates and to increase the number of older people taking part in research. It analyses 14 consecutive recently published trials, providing the number needed to be screened to recruit one older participant (around 3:1), numbers excluded (up to 49%), drop out rates (5-37%) and whether the planned power was achieved. The value of planning and logistics are outlined, and approaches to optimising recruitment in hospital, primary care and care home settings are discussed, together with the challenges of involving older adults with mental incapacity and those from minority groups in research. The increasingly important task of engaging older members of the public and older patients in research is also discussed. Increasing the participation of older people in research will improve the generalisability of research findings and inform best practice in the clinical management of the growing older population.     

Effects of geriatric education on the attitudes of medical students

This study investigated the effects of an educational program in geriatrics on the attitudes of a group of third-year medical students. A survey designed to measure attitudes toward geriatric patient care, aging, and older people was administered to all students before and after their participation in a 25-hour geriatrics education component of a Family Practice Clerkship. Results showed the students' attitudes were significantly improved following the geriatrics training program. Prior training in geriatrics and their specialty preference were also found to have an impact on attitude. The implications of the study for medical education and research are discussed.     

Inducting older adults into volunteer work to sustain their psychological well-being

The ways in which social worker induction into volunteer work sustain the older person’s well-being is the focus of this study which surveyed 719 Chinese people aged 60 or above in Hong Kong, China. Results show the significant contribution of social worker induction to the older person’s self-esteem, life satisfaction, and self-assessed health. Moreover, social worker induction magnified the benefit of volunteering. On the other hand, social worker induction was less salutary to older people with higher incomes and more illness. Social worker input is therefore most beneficial to people in a condition compatible with the input. He has recently published articles on services for older people, business ethics, work restructuring, citizenship, and modernization and postmodernization in China. His current research addresses issues of youth development, dancing drug abuse, acceptance of social work services, urban renewal, and new immigrants’ path to success. He is an active researcher in the social gerontology field, and has published journal articles on elderly suicide, elderly abuse, QoL, filial piety, positive aging, caregiver behavior, and comparative studies on aging. Alex is the author of several books (mainly in Chinese) on the social and psychological care of the aged, and has edited several practical work manuals and training manuals on these subjects.     

La thyroïde de la personne âgée (Partie 1)

Aging is associated with changes in thyroid function at several levels of regulation. Thyroid hormones levels are usually within the lower part of normal values reported in the general population. Two changes in aging are of clinical importance: a shift in the distribution of TSH levels, the 97.5th percentile of the TSH distribution being within 6 μUI/ml after 70 years and within 7.5 μUI/ml in subjects older than 80 instead of 4.5 μU/ml in the general population, and an increased prevalence of thyroid nodularity, requiring reliable and non-invasive methods of investigation in older people. Lastly, aging may be associated with comorbidities, high risk of drug interactions and under nutrition, which may make difficult the interpretation of laboratory data and in some cases induce iatrogenic thyroid diseases. Considering the high prevalence of the thyroid diseases in older patients and a better understanding of the physiopathological hormonal variations with the ageing, it seemed useful to propose a review to help the clinician in the care of these situations.     

Transitions in health and social service system at the end of life

This study focuses on the amount and types of transitions in health and social service system during the last 2 years of life and the places of death and among Finnish people aged 70–79, 80–89 and 90 or older. The data set, derived from multiple national registers, consists of 75,578 people who died between 1998 and 2001. The services included university hospitals, general hospitals, health centres and residential care facilities. The most common place of death was the municipal health centre: half of the whole research population died in a health centre. The place of death varied by age and gender: men and people in younger age groups died more often in general or in university hospital or at home, while dying in health centres or in residential care homes was more common among women or the very old. Number of transitions varied from zero to over a hundred transitions during the last 2 years. Number of transitions increased as death approached. Men and younger age groups had more transitions than women and older age groups. Among men and younger age groups transitions between home and general or university hospital were common while transitions between home and health centre or residential care were more common to women and older people. The results indicate that municipal health centres have a major role as care providers as death approaches. Differences between gender and age in numbers and types of transitions were clear. Future research is needed to clarify the causes to these differences.     

Are changes in productive activities of older people associated with changes in their well-being? Results of a longitudinal European study

Using the first two waves from the Survey of Health, Ageing and Retirement in Europe (SHARE) we explore dynamics of participation in two different types of productive activities (voluntary work and care for a person) and test their association with changes in well-being across 11 European countries (N = 10,309) among people aged 50 and older. In order to measure changes in well-being, we use a standardized instrument of quality of life in early old age (CASP-12) and assess relevant decreases and increases between both waves, applying the Edwards–Nunnally method. Main findings demonstrate that older people who maintain or start their productive activity in terms of volunteering between both waves have a lower probability of experiencing a relevant decrease in well-being, while no association with a relevant increase in well-being is observed. In case of caring for a person changes in participation remain unrelated to changes in well-being. These results are maintained after adjusting for important confounders, such as functional limitation, socioeconomic position and living with a partner. These latter conditions were also strongly related to changes in well-being. Our results support a core assumption of the activity theory of ageing claiming that the initiation and maintenance of a productive activity is beneficial for older people’s well-being.     

Earning Their Keep: The Productivity of Older Women and Men in Rural Bangladesh

In Bangladesh, being active and able to participate in productive activities is often essential to ensure ongoing health and survival. This study aims to describe and explore the patterns of participation in productive activities by older people in Matlab, a rural area of Bangladesh. Data from a cross sectional survey of people over 60 years of age was utilised. Six hundred and twenty five men and women participated in home based interviews providing information about their participation in productive activities including work, domestic activities and community groups. Overall, 94.4% of subjects reported participation in at least one productive activity. Men were the main participants in paid work and community groups, with 62% reporting engagement in paid work and 44% contributing to community groups. Both men (95.4%) and women (91.9%) reported performing at least one domestic activity. Performance of higher numbers of domestic tasks was associated with being younger, female, not requiring any assistance with self care, not married, not living with any children and earning between 100–999 Bangladesh Taka in the past month. Participation in community groups was low with only 26% of the sample reporting any involvement. This study indicates a high level of productivity in the older population in Matlab which benefits the individual, the family and the wider community. The safety and suitability of typical productive activities needs further investigation, in order to inform strategies protecting the older population from the effects of over work and harmful activities.     

Multimorbidity and functional status in community-dwelling older adults

BackgroundMultimorbidity is common in older people and may contribute to many adverse health events, such as disability. The aim of the study was to investigate how chronic health conditions (single, paired, and grouped) affect functional independence.MethodWe used two samples (a one-time, convenience sample and a nationally representative cross-sectional survey) of community-dwelling people of 65 years old or over, with a total of 2818 subjects in Spain. To assess functional independence, we used the Barthel index, administered as an interview. Information about the presence of 11 chronic health problems was collected by interview or review of their medical chart. Explanatory factor analysis was performed to assess associations between chronic health conditions.ResultsDiabetes mellitus and hypertension emerged as the pair of chronic health conditions that most affected functional status [OR 1.98; 95% CI (1.51–2.60)], followed by visual and hearing impairment. A synergistic effect was found (p < 0.05) for the cardiovascular disease and hypertension pair. Four multimorbidity groups emerged from the factor analysis: sensory and bone; cancer, lung and gastrointestinal; cardiovascular and metabolic; neuropsychiatric disorders. The neuropsychiatric disorders group was the most strongly associated with physical impairment [OR 4.94; 95% CI (2.71–8.99)], followed by the sensory and bones group [OR 1.90; 95% CI (1.56–2.31)].ConclusionDespite its low prevalence, the neuropsychiatric disorders group was most strongly associated with lower functional status. Analysis of the relationship between chronic medical conditions and functional status could be useful to develop primary health care strategies to improve functional independence in older people with comorbidities.     

Reasons given by older people for limitation or avoidance of leisure time physical activity

OBJECTIVES: This study investigates reasons given by older people for limitation or avoidance of physical exercise. DESIGN: Community-based longitudinal study of free-living persons age 55 years or older in Sonoma, California. METHODS: Baseline standardized interviews were conducted (n = 2046) as part of a longitudinal study of aging and physical performance. Seventeen reasons for limitation or avoidance of physical activities were evaluated, with responses grouped as: no limitations, medical, non-medical, and combined medical and non-medical reasons. Patterns of physical activity and medical conditions and direct measures of physical function were evaluated in relation to reasons for activity limitation by multinomial logistic regression. RESULTS: Women reported more limitations/avoidance of physical activity than men (81.0% vs 73.5%). Medical reasons increased with age. Reduced walking speed and depressive symptomatology were associated with a combination of medical and non-medical reasons in both sexes. Living arrangements were associated with non-medical reasons for women but were not for men. Non-medical reasons were associated with a 20 to 30% reduction in the number of subjects who reported physical activity at recommended levels. DISCUSSION: Non-medical factors are important determinants of activity limitation and should serve as targets for patient care providers and future interventions to improve participation in physical activity by older people.     

Update in Geriatric Medicine

INTRODUCTION  

With an aging population, internists will provide care to a growing number of older adults, a population at risk of developing multiple chronic medical conditions and geriatric syndromes. For this update in geriatric medicine, we highlight recent key articles focused on preventive strategies and lifestyle changes that reduce the burden of disease and functional decline in older adults.