Tackling malnutrition among older people in the community

Undernutrition - of both macronutrients and micronutrients - is still a surprisingly common problem among older people in the UK. There is a variety of nutritional supplements that community nurses need to be aware of in managing their patients' nutritional requirements. Different supplements are taken for different disease states. This article looks at the various nutrient and energy requirements that relate directly to clients on the district nurse's caseload. Some of the negative consequences of malnutrition of the older adult are discussed, as are the NICE guidelines for nutrition. Factors affecting dietary intake in older people are considered.     

Frailty as a predictor of disabilities among community-dwelling older people: a systematic review and meta-analysis

Background: Frailty has been shown to be associated with disability in the previous studies. However, it is not clear how consistently or to how much degree frailty is actually associated with the future disability risks.

Methods: A systematic review of the literature was conducted using Embase, MEDLINE, CINAHL, PsycINFO, and the Cochrane Library for any prospective studies published from 2010 to September 2015 examining associations between baseline frailty status and subsequent risk of developing or worsening disabilities among community-dwelling older people. A meta-analysis was performed to synthesize pooled estimates.

Results: Of 7012 studies identified through the systematic review, 20 studies were included in the meta-analysis. Twelve studies examined activities of daily living (ADL) disability risks, two studies examined instrumental activities of daily living (IADL) disability risks, and six studies examined both ADL and IADL disability risks. Overall, frail older people were more likely to develop or worsen disabilities in ADL (12 studies, pooled OR?=?2.76, 95% CI?=?2.23–3.44, p?p?p?p?=?0.08). Prefrailty was also associated with incident or worsening disability risks to a lesser degree in most pooled analyses. High heterogeneity observed among 12 studies with OR of ADL disability risks for frailty was explored using subgroup analyses, which suggested methodological quality and mean age of the cohort were the possible causes.

Conclusion: This systematic review meta-analysis quantitatively showed that frail older people are at higher risks of disabilities. These results are important for all related parties given population aging worldwide. Interventions for frailty are important to prevent disability and preserve physical functions, autonomy, and quality of life.

• Implications for Rehabilitation

• Although frailty has been shown to be associated with disability and considered as a precursor of disability, it is not clear how consistently or to how much degree frailty is actually associated with the future disability risks.

• This systematic review and meta-analysis quantitatively shows frailty is a significant predictor of incident and worsening ADL and IADL disabilities.

• It is a pressing priority to develop interventions for frailty to prevent disability and preserve older people’s physical functions, autonomy, and quality of life.

     

Frailty scales--their potential in interprofessional working with older people: a discussion paper

New models of interprofessional working are continuously being proposed to address the burgeoning health and social care needs of older people with complex and long-term health conditions. Evaluations of the effectiveness of these models tend to focus on process measures rather than outcomes for the older person. This discussion paper argues that the concept of frailty, and measures based on it, may provide a more user-centred tool for the evaluation of interprofessional services - a tool that cuts across unidisciplinary preoccupations and definitions of effectiveness. Numerous frailty scales have been developed for case identification and stratification of risk of adverse outcomes. We suggest that they may also be particularly suitable for evaluating the effectiveness of interprofessional working with community-dwelling older people. Several exemplars of frailty scales that might serve this purpose are identified, and their potential contributions and limitations are discussed. Further work is required to establish which is the most suitable scales for this application. The development of an appropriate frailty scale could provide an opportunity for interprofessional debate about the forms of care and treatment that should be prioritised to improve the health and well-being of this population.     

Suicide among older people

Overall, the number of people who kill themselves across all ages is falling but suicide rates among older people remain comparatively high. This article considers possible risk factors and suggests ways of reducing and containing potential harm. It also explores ways of responding when prevention of suicide fails.     

Promoting a healthy diet for older people in the community

The promotion of a healthy diet for older people is integral to optimum health and effective care. The constituents of a healthy diet are examined and the causes and effects of malnutrition explored. This will help nurses to understand and undertake effective nutritional assessment for patients in the community.     

The relationships between health beliefs and utilization of free health examinations in older people living in a community setting in Taiwan

OBJECTIVE: To examine the influence of demographics and the health beliefs of older people on uptake of a free annual health examination administered by the Twu-Tyan Bureau of Sanitation (TTBS), Pingtung, Taiwan. BACKGROUND: The free health examination is a preventive intervention with potential to detect illness. This programme for older people aged 65 years and over, has been available free in some areas since 1980. METHOD: A stratified random systematic sample of 200 men and women over 65 years was selected and consisted of 100 individuals who had undertaken the free health examination and 100 who had not. A 17-item Health Belief Scale (HBS) was used to glean information on their health beliefs and uptake of a free health examination. FINDINGS: It was found that those with higher education and higher economic status had a greater uptake. Family support was also found to influence take-up. A statistically significant difference was found between the health beliefs of users and nonusers. Users perceived a higher level of seriousness and susceptibility to ill health than nonusers. CONCLUSIONS: A number of practical pointers are given that might help clinicians increase uptake rates in such health promotion programmes. These encompass understanding the influence of key demographical and social factors, perceived susceptibility, severity and benefits of the intervention, barriers to attendance and self-efficacy.     

Outcomes among older people in a post-acute inpatient rehabilitation unit

Purpose: Designated multidisciplinary rehabilitation units have been shown to provide several benefits for the frail older population. The aim of this research was to evaluate changes in strength, mobility, balance, endurance, frailty and quality of life (QoL) following a 6-week multidisciplinary inpatient rehabilitation programme. Method: This was a prospective, observational study performed in a post-acute multidisciplinary geriatric inpatient rehabilitation service. A consecutive sample of heterogenous frail older adults (n?=?32) participated. Subjects were assessed on admission to the rehabilitation service (T1) and following 6 weeks of rehabilitation (T2). A range of outcome measures were used to assess function and QoL: Berg Balance Scale (BBS), Timed Up and Go (TUG), 6-Minute Walk Test (6MWT), Barthel Index (BI), EuroQol-Visual Analogue Scale (EQ-VAS), Clinical Frailty Scale (CFS), lower limb and grip dynamometry. Results: The majority were female (n?=?25), the mean age was 82.9 years (SD 6.35). The median length of stay was 49 days. Patients improved significantly between T1 and T2 assessments in the BBS (p?≤?0.0001); TUG (p?≤?0.0001); 6MWT (p?≤?0.0001); BI (p?≤?0.0001); EQ-VAS (p?=?0.002); CFS (p?≤?0.0001); and in some aspects of grip and lower limb strength. Conclusion: This study has demonstrated that positive outcomes occurred in a range of measures in an older, frail inpatient rehabilitation population.

Implications for Rehabilitation

• Elderly inpatients undergoing rehabilitation programmes improve across a range of measures looking at impairment, activity, participation and quality of life.

• However, gains were modest and patients did not attain their baseline level of performance after a 6-week programme of inpatient rehabilitation.

• Using outcome measures in clinical rehabilitation practice can facilitate comparison between units and can form the basis for future research in this population.

     

Reducing falls among older people in hospital

Thousands of patients fall on hospital wards each year, leading to potentially devastating consequences for them and their families. Falls among inpatients usually arise from a complex combination of risk factors, including dementia, delirium, incontinence and medication. This article discusses the FallSafe project that aimed to reduce falls in inpatient settings. The results suggested a 25 per cent reduction in falls on average across the wards involved. The project also had a positive effect on patients and staff. A case study of a staff nurse involved in leading the project on her ward and the care bundle that comprised the project intervention are explored.     

Cross-boundary working: a generic worker for older people in the community

The care of older people often crosses the boundaries of health and social care. The new role of a health and social care trained generic worker was developed to provide comprehensive care for older people living at home. The role is a cross between a nursing auxiliary, health care assistant and a community support worker. The evaluation of the one-year pilot project demonstrated that clients were very satisfied with the care they received, particularly the emotional aspects of care. A high proportion of the generic workers time was spent listening and responding to their clients' mental health needs, and providing comfort and emotional support. Having been trained by local health professionals, the generic workers felt valued and respected, better able to communicate with their health colleagues, and therefore able to provide holistic care to their clients.     

Support networks of older people living in the community

Aim. The aim of the study was to identify the social support networks of older people living in the community in Ireland using Wenger’s (1994) network typology. Background. The population of older people in the community is increasing. With increasing age and changes in family circumstances a substantial proportion of older people will require social, psychological and instrumental support. However a lack of adequate social support networks for vulnerable older people can result in poor health, loneliness and isolation. Method. A national, cross‐sectional telephone survey of 683 people aged between 65 and 99 years was undertaken using the Practitioner Assessment of Network Type as the basis for identifying social support networks. Results. The results demonstrated that the majority of older people were living in stable and supportive social networks and reported high levels of contact with family, friends and neighbours. However, a significant minority of older people were living in vulnerable networks. Older people in these networks are susceptible to loneliness, isolation and poor emotional and physical health. Conclusion. Through the identification of people in vulnerable networks, nurses working both in the hospital and community setting can ensure that formal support is aimed at providing care to older people who do not have access to informal care networks. Furthermore, the predictive utility of the Practitioner Assessment Network Type (PANT) can enable nurses to identify people at risk of poor social support.     

Enhancing the care of older people in the community

This article describes a pilot project that aimed to enhance the care of older people who dialled 999 but did not require hospital admission. The project demonstrated how intermediate care teams and the ambulance service worked in partnership to avoid unnecessary hospital admission and to improve health and social care services for this patient group.     

Frailty is associated with pain and cognitive function in older people in post-acute care settings

BackgroundTo describe pain, cognitive function, and frailty of older people in post-acute care settings and examine the association between the three elements.MethodsThis cross-sectional study involved 142 participants from a rehabilitation ward and a geriatric day centre. Pain, cognitive function and frailty were assessed using Brief Pain Inventory, Abbreviated Mental Test, and 5-item Frail Scale respectively.ResultsParticipants were mostly women (51.7%) with a mean age of 76.5 (SD 7.8). Mean scores for pain, cognition, and frailty were 9.0 ± 1.0, 4.0 ± 2.8, and 2.2 ± 1.2, respectively. Cognition had a significant inverse association with frailty (β = −0.160, p = 0.047), and pain had a significant positive association with frailty (β = 5.122, p < 0.001). This linear regression model explained a variance of 0.269.ConclusionsThe study demonstrated the association between pain, cognitive function, and frailty. In predicting frailty, however, more studies are required to determine the predictive value and cut-off points for pain and cognitive measures.     

Care of people with multiple sclerosis in the community setting

Approximately 85,000 people live with Multiple Sclerosis (MS) in the UK. The majority are self-caring, with or without some specialist in-put. A minority, approximately 10-15%, have severe disability and are in receipt of more extensive care from health and social services. This article providesan overview of MS and discusses its management in the community.     

Detecting and managing undernutrition of older people in the community

Undernutrition is an important public health issue which is frequently undetected and untreated. Disease and illness are the major causes of undernutrition in this country, and older people are a particularly vulnerable group. Effective screening is needed to reduce the prevalence of malnutrition in older people and when this is established, action can then be taken to address the problem. Community nurses and the primary care team have a key role to play in making this happen. The recently developed Malnutrition Advisory Group (MAG) nutrition screening tool, for adults will help community staff and primary care staff to identify those older patients most at risk of malnutrition in the community. Routine nutrition screening of vulnerable individuals is the first stage in raising standards of nutrition care. Further improvements can be made through the development of appropriate nutritional guidelines, clinical risk management strategies provides opportunities to highlight the importance of nutrition care of older people.     

Reablement in a community setting

Abstract

Purpose: When older adults experience a decrease in functional independence including decreased ability to perform activities of daily living (ADL) tasks, rehabilitation services are required. The aim of this pilot study was to evaluate if a home-based reablement program influenced the ADL ability of older adults. Methods: Ninety-one older adults (80?±?9 years) were allocated to a 12-weeks home-based reablement program consisting of ADL task performance training by a home carer supervised by an occupational therapist. ADL ability was measured at baseline, at 12 weeks and at follow-up (range: 310–592?d) using the ADL-Interview (ADL-I). Results: Overall, ADL ability improved significantly over time (p?=?0.041). Post-hoc t-tests indicated that the improvements occurred between baseline and end of intervention (p?=?0.042) and were maintained at follow-up 10 months after intervention (p?=?0.674). There were no effects related to age (p?=?0.787) or to whether the older adult had received help previously (p?=?0.120). Conclusion: A 12-weeks home-based reablement program was found to improve ADL ability among older adults regardless of whether they previously received help. This implies that receiving home care services should not be considered a barrier to participation in a reablement program.

• Implications for Rehabilitation

• Older adults, motivated for obtaining independence within performance of ADL tasks, will potentially benefit from participation in the reablement program.

• Older adults, already receiving home care services, will also have the potential to benefit from participation in the reablement program.