Approaches to long‐term conditions management and care for older people: similarities or differences?

AIM: In the past few years, there has been an increased emphasis both on the care for older people and the management of long-term conditions within the United Kingdom. Currently, the Department of Health and the Scottish Executive identify and manage these two areas as separate entities. The aim of this article is to examine the current approaches to both of these areas of care and identify commonalities and articulate differences. BACKGROUND: The population across the world and particularly within the United Kingdom is ageing at an unprecedented rate. The numbers suffering long-term illness conditions has also risen sharply in recent years. As such, nurses need to be engaged at a strategic level in the design of robust and appropriate services for this increasing population group. EVALUATION: A comprehensive literature review on long-term conditions and the care of older people was undertaken in an attempt to identify commonalities and differences in strategic and organizational approaches. A policy analysis was conducted to support the paper and establish links that may inform local service development. KEY ISSUES: Proposing service development based on identified needs rather than organizational boundaries after the establishment of clear links between health and social care for those with long-term conditions and the ageing population. IMPLICATIONS FOR NURSING MANAGEMENT: Nurse Managers need to be aware of the similarities and differences in political and theoretical approaches to the care for older people and the management of long-term conditions. By adopting this view, creativity in the service redesign and service provision can be fostered and nurtured as well as achieving a renewed focus on partnership working across organizational boundaries. CONCLUSIONS: With the current renewed political focus on health and social care, there is an opportunity in the UK to redefine the structure of care. This paper proposes similarities between caring for older people and for those with long-term conditions, and it is proposed these encapsulate the wider issues that need to be debated to achieve a truly joint approach to care.     

New challenges in ageing: Home care

Most nations are undergoing two fundamental demographic changes: concentration of their population in cities and accelerated pace of population ageing. The fastest-growing population is that 85 years and over. Morbidity increases with advancing age, functional capacities decrease; this results in decreased performance of activities of daily liver and need for services. The challenge is particularly strong in urban areas. Modern societies seek solutions in maintaining the elderly in their homes through home care programmes for those who are functionally impaired, homebound, and need support in home-making and home nursing. Home care is firmly established in programmes for the elderly. In order to become a scientific discipline home care has to define its boundaries, identify clients by careful multidisciplinary assessment, provide answers regarding its cost-effectiveness, evaluate outcomes of home caring, develop indicators of high-quality care and advise appropriate home care technology, which is affordable and accessible. Home care for the elderly population living in remote rural areas is one of the future challenges.     

Older men in contemporary discourses on ageing: absent bodies and invisible lives

Contemporary discourses on ageing are essentially 'feminized', and as such report little on the experiences of older men. Living into late old age has become, and will continue to be, a normal phenomenon in our social worlds for both men and women. As a disadvantaged group, older women have attracted more attention than their older male counterparts. Yet this 'advantaged' older man may well be shackled by his gender role, and male gender socialization does impact upon men in later life. Older single men often have poorly developed social and family networks leaving them at a disadvantage. However, the masculinities of older men are conspicuously absent from most male gender studies. Rather than omitted, it is more that the dominant discourses of younger and middle-aged men are preserved. In turn, disability and disease do accompany old age yet disability has remained in the background and is, consequently, underdeveloped. This is not to say that disability represents the whole experience of health for older people, but it is clearly not an ageist fantasy. The phenomena of ageing, gender (including masculinity), and disability can be connected and consequently interpreted and understood by studying embodiment in old age.     

Older people's views on rural life: a study of three villages

In the context of increasing interest in how rurality affects health services and nursing practice in the UK, this paper reports and discusses data from a survey of older people living in three English villages. The survey found that village populations differed widely, that there were changes in the proportions of older people in the villages over time, and that close social networks existed for some but not all. The paper concludes that health care practitioners should avoid stereotypes of village life. In their increasing emphasis on health promotion and active ageing among older people, nurses may find data collected by the voluntary sector to be a useful resource. Working in partnership with groups to achieve a deep understanding of local contexts may assist nursing practitioners when building up pictures of older patients' health‐related needs and views.     

BRIEF COMMUNICATION: Evaluating changes in life expectancy and survival in the elderly

Introduction: In view of current international interest and research on the elderly, numerous questions present themselves. Examples are: how rapidly are populations ageing? Is physical and functional decline in old age inevitable? Can morbidity be compressed into the final years of life? Are social, medical and other resources available for coping with the increasing numbers of elderly? Not least, how do old people themselves feel about ageing?     

'Going to the bathroom four or five times a night ...': seven men talk about their experiences of benign prostatic hyperplasia and the perioperative period

This study describes ageing men's experiences of benign prostatic hyperplasia and transurethral resection. The experiences of ageing men participating in this study vary in different periods of their treatment. It is evident that experiences are attached to feelings, cognitive thinking and responses.     

Cognitive function is not impaired in people with a long history of migraine: a blinded study

Little is known about the long-term consequences of migraine for cognitive functioning. This study compared older migraine patients with matched controls on four measures of cognitive ability, in a blinded design. Migraine patients and case-matched controls were recruited from the database records of a pre-existing study of ageing. Data were available from four tests of cognitive ability: verbal/arithmetic problem solving, spatial problem solving, processing speed, and vocabulary. There were no significant differences between the mean scores of migraine and control groups on any of the four cognitive tests. In addition, there were no significant differences between migraine and control groups in the effect of age on any of the four tests. A long history of migraine does not compromise scores on the four cognitive tests used in this study. These tests are predictive of memory and executive functioning in cognitive ageing, but it remains possible that lower-level cognitive processes, particularly as assessed by visual tasks, may be vulnerable to migraine.     

Psychiatric nurses enhancing consumer and caregiver participation in the state of Victoria: the impact of history and policy

Australian mental health policy now clearly articulates that consumer and carer (informal caregiver) participation in all aspects of service delivery is an expectation. As the largest professional group, nurses clearly play a key role in translating policy into practice. The aim of this article is to briefly overview the history of mental health service development in Victoria, with specific emphasis on the development of psychiatric nursing. Changing perspectives of consumers of mental health services and their informal carers is discussed. Policy development is described in the context of the development of mental health services. It is argued that an appreciation of the history of punishment and confinement is necessary for providing a climate conducive to consumer and carer participation.     

Balancing professional and team boundaries in mental health services: pursuing the holy grail in Somerset

The overcoming of professional boundaries to collaboration in patient care has become one of the goals of mental health service policy in England over the past 25 years, predominantly through the creation of community mental health teams. However, research has shown that these boundaries have been slow to come down, and some commentators have pointed to the benefits of appropriate boundaries. This paper introduces a theoretical framework, which seeks to categorise boundary activity in organisations and then examines the boundary activity of professional groups and community teams during the integration of mental health and social care service provision in one locality in the southwest of England. The paper identifies the ways in which this integration impacted on boundary activity and draws out the messages for mental health policy and practice that emerge.     

Balancing professional and team boundaries in mental health services: pursuing the holy grail in Somerset

The overcoming of professional boundaries to collaboration in patient care has become one of the goals of mental health service policy in England over the past 25 years, predominantly through the creation of community mental health teams. However, research has shown that these boundaries have been slow to come down, and some commentators have pointed to the benefits of appropriate boundaries. This paper introduces a theoretical framework, which seeks to categorise boundary activity in organisations and then examines the boundary activity of professional groups and community teams during the integration of mental health and social care service provision in one locality in the southwest of England. The paper identifies the ways in which this integration impacted on boundary activity and draws out the messages for mental health policy and practice that emerge.     

Personal factors,communication and vision predict social participation in older adults

Social isolation is a predictor of morbidity and mortality in older people. Speech pathologists often consider that communication disabilities associated with normal ageing (sensory loss, language and discourse changes) contribute to social isolation. The aims of this study were to describe the functioning of older people using the International Classification of Functioning, Disability and Health (WHO, ) as a conceptual framework for language and sensory functioning, communicative activity, and social participation, and to explore the relationship between communication (both at an impairment level and an activity level), social participation and personal factors (demographics and emotional health). In a prospective study, 47 women and 28 men aged 62 to 98 years (mean = 74 yrs) completed objective and subjective assessments of functioning and participation, and provided personal information. Assessments were individually conducted in a face-to-face interview situation with the primary researcher, who was a speech pathologist. Assessments revealed the sample had predominantly mild hearing and vision impairments, unimpaired naming ability, frequent involvement in a wide range of communication activities, and variable social network size and social activities participation. Social participation was shown to be associated with vision, communication activities, age, education and emotional health. Naming and hearing impairments were not reliable predictors of social participation. It was concluded that professionals interested in maintaining and improving social participation of older people could well consider these predictors in community-directed interventions. Speech pathologists should therefore promote older people's involvement in everyday communicative activities while also limiting the impact of communication-related impairments, so that social participation is maintained in our ageing population.     

Historical,Cross-cultural,Biological and Psychosocial Perspectives of Ageing and the Aged Person

This paper analyses the concept of ageing and old age from various perspectives. From a historical perspective, people in Antiquity and the Middle Ages explained the ages of man in different schematic terms, related to the physical causes for the processes of human growth and decline, or related to daily, annual or historical time. From a cross-cultural perspective, the predominant view has been that older adults in developing societies were better situated socially and psychologically than their counterparts in developed societies. The process of ageing can be seen from separate biological, psychological and social perspectives. Regarding the individual aged person, these mutually interactive processes, must be considered together, along with the cultural conditions and historical times in which they occur. Increased awareness of the positive contributions to modern society made by the aged as upholders of cultural heritage and traditions may help to counteract the derogatory of references to the elderly as ‘the rising tide’, associating this group of the population with heavy financial burdens on society.     

The 'greying' of the United Kingdom nursing workforce: implications for employment policy and practice

One in five nurses on the United Kingdom (UK) professional register is aged 50 years or older. Over the next few years, the profession will lose, through retirement, many of its most experienced practitioners. The significance for policy makers and for employers of this age-shift is two-fold. Firstly it is clear that greater numbers of nurses and midwives are reaching, or soon will reach, potential retirement age. Secondly many more nurses are now reaching their middle years and they are likely to have different requirements and attitudes to nursing work. This paper examines the employment policy and practice of the ageing of the UK nursing population. The paper examines data from official sources, and information from attitudinal surveys and case studies with employing organizations to assess the major effects of the ageing of the nursing workforce. Key findings are that the age profile of those nurses working in the National Health Service appears to be 'younger' than that of the total population, with the age profile of nurses working in nursing homes and as practice nurses being older than that of the NHS nursing workforce. However, the overall age profile of NHS nurses masks considerable variation between specialties and trusts, and the 'pool' of potential nurse returners from which the NHS and other employers attempts to recruit, is declining in numbers, as it too ages. Other major issues requiring policy attention are the provision of appropriate flexible hours to older nurses who have caring responsibilities, improving access to continuing professional development, and reducing pension provision inflexibility.     

Attentional Bias Toward Illness Threat in Individuals with Elevated Health Anxiety

This investigation examined attentional biases for illness-related information in persons varying in their degree of health anxiety (HA). Consistent with cognitive behavioural conceptualizations, it was hypothesized that individuals with high HA would be more likely than those with lower levels to exhibit attentional biases to illness-related information when tested using a modified Stroop colour-naming task. Participants were 26 individuals with each of high, medium, and low HA as assessed using the Illness Attitudes Scale (R. Kellner, P. Abbott, W. W. Winslow, & D. Pathak, 1987). Results indicated that participants with high HA, compared to those with lower levels of HA, selectively attend to illness-related but not other categories of emotionally laden stimuli. These findings, indicative of an attentional bias for illness-related cues in high HA, are discussed in the context of cognitive behavioural conceptualizations of HA. Future research directions are outlined.     

Relationships between nurses and older people within the home: exploring the boundaries of care

mcgarry J. (2009) Relationships between nurses and older people within the home: exploring the boundaries of care. International Journal of Older People Nursing 5 , 265–273
doi: 10.1111/j.1748-3743.2009.00192.x Aim. To explore the nature of relationships between nurses and older people within the home and to illuminate the nature and quality of caring boundaries within this setting. Background. Older people are increasingly receiving nursing care in the home. There has been little exploration of the nature of the nurse–older patient relationship within this setting. Methods. An ethnographic approach using semi-structured interviews with 16 community nurses and 13 older patients (aged 65 years and over), were undertaken to explore the nature of care relationships within the home setting. Findings. The study has highlighted the centrality of the location of care and the concept of ‘the home’ in terms of geographical and metaphorical meanings. Moreover, the study has clearly illuminated the complex nature of relationships and boundary construction from a number of perspectives. Conclusion. As the location of care for older people continues to move closer to home it is crucial that the implicit qualities that are valued within nurse–patient relationships within this context of care, and which contribute to the quality of care, are recognized and made more explicit at the organizational and policy level. Practice implications. For nurses working within the home there is a clear impetus to clearly define and articulate the full breadth of their role, the nature of relationships and issues surrounding professional boundary construction within this environment. There is also a need for the core qualities that underpin the receipt of care within the home and the facets of the nurse–patient relationship valued by older people to be fully recognized and accounted for.     

50 years with Down syndrome: A longitudinal study

Background

A population sample of people with Down syndrome, studied from infancy, has now been followed up at the age of 50 years. From the original sample of 54, there were 27 still in the study at the age of 50, all but four of the losses resulting from deaths.

Methods

Intelligence and language skills were tested and daily living skills assessed. Memory/cognitive deterioration was examined using two test instruments. Other aspects of the people's lives were examined via carers' reports.

Results

Scores on verbal tests showed little change. Those on a non‐verbal test, on self‐help skills and on both memory tests showed some decline, even when the scores of those already suffering from dementia were discounted.

Conclusions

At the age of 50, those not already diagnosed with dementia showed some decline on most tests. While this may include scores of people who subsequently develop dementia, it may also reflect the normal ageing process in this population.     

Use,non-use and perceived unmet needs of assistive technology among Swedish people in the third age

Purpose: To describe the most prominent use of or perceived unmet need of assistive technology (AT) and to compare the characteristics of users, non-users and those expressing perceived unmet need with respect to overall health, independence in everyday life, environmental barriers and socio-demographic features. Method: The study is based on data collected in the “Home and Health in the Third Age Project”. In all, 371 individuals participated and data were collected during home visits in southern Sweden by interviewers trained specifically for this project. The data collection comprised well-proven self-report scales and observational formats on the home environment and health indicators as well as questions about basic demographics and socio-structural data. Results: The proportion of users constituted almost half of the total sample. The most common types of AT used were for furnishing/adaptation (35%) and the highest perceived unmet need concerned AT for communication, in total 8%. Those cohabiting were to a higher extent users of AT for furnishing/adaptation, compared to those who lived alone. A higher perceived unmet need was seen among those who lived alone compared with cohabiting people. Conclusions: These findings are of importance for future planning and development of policy to improve health services for the new generation of elderly.

• Implications for Rehabilitation

• In order to support the ageing process, the need for assistive technology has to be monitored in the third age.

• Assistive technology for furnishings and adaptation are frequently used by individuals in their third age and are important to support ageing in the home.

• Not only do health aspects impact the use of assistive technology, but gender, living conditions and social situation also matter – older men especially need to be monitored thoroughly according to their perceived unmet needs as well as do older persons living alone.

     

Integrative review of the social determinants of health in older adults with multimorbidity

Aim

To examine how the social determinants of health have been considered in conceptualizations of multimorbidity in older adults in the literature and to identify implications for nursing practice, research and healthcare planning and policy.

Background

The common conceptualization of multimorbidity is the presence of multiple chronic conditions where one is not more central than others.

Design

The integrative review methodology of Whittemore and Knafl was employed. The World Health Organization Social Determinants of Health framework was used to determine how the social determinants of health have been considered in conceptualizations of multimorbidity.

Data sources

A search of electronic databases (2000–2015) generated 22 relevant articles, including quantitative and qualitative studies and grey literature reports.

Review methods

A systematic process was used to appraise the quality of the documents, conduct qualitative data analysis procedures of data extraction, coding and theme development, and synthesize conclusions.

Results

Current conceptualizations of multimorbidity provide limited consideration of the complex interplay of multimorbidity with the broader social determinants of health. Gender, education, behaviours and the health system were the most commonly cited determinants. Ethnicity, socioeconomic status/social class and material circumstances received little attention. Most of the dimensions of socioeconomic political context were not discussed.

Conclusion

The predominant conceptualization of multimorbidity focuses on the biomedical dimensions of multimorbidity. Consequently, nursing practice, research and policy informed by this literature could inadvertently sustain the mismatch between the needs of older adults with multimorbidity and the services they receive. Future research to inform a new conceptualization is necessary.     

Blurring boundaries: professional perspectives of the emergency nurse practitioner role in a major accident and emergency department

The role of the emergency nurse practitioner (ENP) has increasingly become part of mainstream healthcare delivery in major accident and emergency departments in the United Kingdom. Although some research data are available in this field, there has been little attempt to evaluate the impact of the implementation of the ENP role from the perspective of those healthcare professionals most closely involved at local level. This paper describes one part of a case study evaluation of the role in an accident and emergency department in the South Thames English region. Nine face-to-face semi-structured interviews were carried out with the key multidisciplinary stakeholders in the organization. Five major themes emerged from the data analysis: blurring role boundaries; managing uncertainty; individual variation; quality vs. quantity; and the organizational context. Whilst some professional consensus was evident regarding the benefits of the role, such as improved waiting times and patient satisfaction, there appeared also to be a degree of ambivalence, particularly regarding current role configuration, value for money, and the extent to which the role should be expanded in the future. These issues are discussed in terms of professional identity, changing role boundaries, and professional personhood. It is argued that the benefits and pitfalls of the ENP role need to be considered within the context of local service provision. The growing emphasis on clinical governance reinforces the need for ongoing audit of role effectiveness in order to meet the challenges and uncertainties of increasingly blurred professional boundaries.     

Applying to a nursing home is a way to maintain control of life—Experiences from Swedish nursing home applicants

Background

Swedish social policy enables ageing in place with support from home-based care services despite high age and/or declining health.

Aim

This study aims to describe the daily life experiences behind the decision to apply for a nursing home placement in older adults ageing in place.

Materials and Methods

A qualitative design was chosen, and 11 semi-structured interviews were conducted and analysed using inductive qualitative content analysis.

Results

The participants described a feeling of dependence in which they had to ignore their personal privacy when receiving home-based care. They reached a turning point when ageing in place was, for several reasons, no longer considered an acceptable option. This influenced their choice to apply to a nursing home where they expected that they could maintain control over their lives.

Discussion and Conclusion

The results indicate that when enhancing ageing in place it is important to enable older adults to receive support to maintain autonomy in daily activities and to have the opportunity to age in the right place.