Depressive Symptoms among Older Residents in Assisted Living Facilities

Responding to the dramatic growth in Assisted Living Facilities (ALFs), the present study focused on mental health among older residents in ALFs. We assessed the effects of physical health constraints (chronic conditions, functional disability, and self-rated health) and psychosocial resources (social network, sense of mastery, religiosity, and attitude toward aging) on depressive symptoms. A sample of 150 residents ( Mage = 82.8, SD = 9.41) from 17 facilities in Florida was used for analyses. Higher levels of depressive symptoms were observed among older residents with a greater level of functional disability, poorer self-rated health, lower sense of mastery, less religiosity, and less positive attitude towards aging. In addition, the linkages between physical and mental health were modified by psychosocial resources. For older residents with more positive beliefs and attitudes (a higher sense of mastery, greater religiosity, and more positive attitudes toward aging), the adverse effects of functional disability or poorer self-rated health on depressive symptoms were attenuated. The protective roles of psychosocial resources against physical health constraints yield important implications for designing prevention and intervention strategies for the mental health of older populations in ALF settings.

Preferences For Prolonging Life: A Prospect Theory Approach

Kahneman and Tversky's (1979) Prospect theory was tested as a model of preferences for prolonging life under various hypothetical health statuses. A sample of 384 elderly people living in congregate housing (263 healthy, 131 frail) indicated how long (if at all) they would want to live under each of nine hypothetical health conditions (e.g., limited to bed or chair in a nursing home). Prospect theory, a decision model which takes into account the individual's point of reference, would predict that frail people would view prospective poorer health conditions as more tolerable and express preferences to live longer in worse health than would currently healthy people. In separate analyses of covariance, we evaluated preferences for continued life under four conditions of functional ability, four conditions of cognitive impairment, and three pain conditions—each as a function of participant's current health status (frail vs. healthy). The predicted interaction between frailty and declining prospective health status was obtained. Frail participants expressed preferences for longer life under more compromised health conditions than did healthy participants. The results imply that such preferences are malleable, changing as health deteriorates. They also help explain disparities between proxy decision-makers' and patients' own preferences as expressed in advance directives.

Comparison between passive vision-based system and a wearable inertial-based system for estimating temporal gait parameters related to the GAITRite electronic walkway

Quantitative gait analysis allows clinicians to assess the inherent gait variability over time which is a functional marker to aid in the diagnosis of disabilities or diseases such as frailty, the onset of cognitive decline and neurodegenerative diseases, among others. However, despite the accuracy achieved by the current specialized systems there are constraints that limit quantitative gait analysis, for instance, the cost of the equipment, the limited access for many people and the lack of solutions to consistently monitor gait on a continuous basis. In this paper, two low-cost systems for quantitative gait analysis are presented, a wearable inertial system that relies on two wireless acceleration sensors mounted on the ankles; and a passive vision-based system that externally estimates the measurements through a structured light sensor and 3D point-cloud processing. Both systems are compared with a reference clinical instrument using an experimental protocol focused on the feasibility of estimating temporal gait parameters over two groups of healthy adults (five elders and five young subjects) under controlled conditions. The error of each system regarding the ground truth is computed. Inter-group and intra-group analyses are also conducted to transversely compare the performance between both technologies, and of these technologies with respect to the reference system. The comparison under controlled conditions is required as a previous stage towards the adaptation of both solutions to be incorporated into Ambient Assisted Living environments and to provide continuous in-home gait monitoring as part of the future work.

Women’s Well-Being After Relocation to Independent Living Communities

Late-life relocation to independent living communities is increasing, especially among women. This study described the impact of relocation on the health and well-being of 31 older women who moved from a private residence to an independent living community. Schumacher and Meleis’ (1994) nursing model of transition guided the study. Health status, social activity, self-esteem, depression, and quality of life were measured pre- and postmove. Post-move women reported a significant increase in engagement in social activities and higher quality of life. Participants’ levels of self-esteem, depression, and quality of life were found to correspond with three relocation transition styles: full integration, partial integration, and minimal integration. These preliminary findings suggest that nurses who identify older women with low self-esteem, high depressive symptoms, and low quality of life pre-move may be at risk for poor relocation outcomes. Interventions to ease the transition process and improve relocation adjustment are needed.

The Mediating Role of Health Perceptions in the Relation Between Physical and Mental Health

Objective: Responding to the increased need for research on older residents in assisted living facilities (ALFs), this study assessed the connections between physical and mental health among 150 older residents in ALF settings. Method: The major focus of the study was to explore whether individuals' subjective perceptions of their own health mediate the associations between health-related variables (chronic conditions and functional disability) and depressive symptoms. Results: The analyses showed that the adverse effects of chronic conditions and functional disability on depressive symptoms were not only direct but also indirect through negative health perceptions. Discussion: The findings that health perceptions serve as an intervening step between physical and mental health provide important implications for promotion of mental well-being among older residents in ALFs. In addition to disease/disability prevention and health promotion efforts, attention should be paid to ways to enhance older individuals' positive beliefs and attitudes toward their own health and to promote healthful behaviors.

Satisfaction With Care Among Community Residential Care Residents

Measuring satisfaction with community residential care (CRC) is growing in importance but still in its infancy. The authors conducted interviews with 176 CRC residents and their providers. Logistic regression was used to identify resident and physical characteristics, policies and services, and aggregate resident characteristics associated with satisfaction. Residents had high levels of satisfaction, demonstrating most concern with the facility being able to meet their future needs and food quality. Resident demographics and health status were associated with satisfaction. Contrary to hypotheses, facility type (adult family home and assisted living) was the only facility characteristic strongly associated with satisfaction. Possible explanations include that the relationship between satisfaction and facility characteristics is more complex than expected, as well as significant challenges in measuring satisfaction and facility characteristics. The inconsistent results of previous satisfaction studies do not provide direction for imposition of uniform standards for facility characteristics, if the goal is improved satisfaction.

Promoting and Protecting Against Stigma in Assisted Living and Nursing Homes

PURPOSE OF THE STUDY

To determine the extent to which structures and processes of care in multilevel settings (independent living, assisted living, and nursing homes) result in stigma in assisted living and nursing homes.

DESIGN AND METHODS

Ethnographic in-depth interviews were conducted in 5 multilevel settings with 256 residents, families, and staff members. Qualitative analyses identified the themes that resulted when examining text describing either structures of care or processes of care in relation to 7 codes associated with stigma.

RESULTS

Four themes related to structures of care and stigma were identified, including the physical environment, case mix, staff training, and multilevel settings; five themes related to processes of care and stigma, including dining, independence, respect, privacy, and care provision. For each theme, examples were identified illustrating how structures and processes of care can potentially promote or protect against stigma.

IMPLICATIONS

In no instance were examples or themes identified that suggested the staff intentionally promoted stigma; on the other hand, there was indication that some structures and processes were intentionally in place to protect against stigma. Perhaps the most important theme is the stigma related to multilevel settings, as it has the potential to reduce individuals' likelihood to seek and accept necessary care. Results suggest specific recommendations to modify care and reduce stigma.

Depression Training in an Assisted Living Facility: A Pilot Study

Depression in older adults residing in assisted living facilities (ALFs) is often not recognized. ALF staff who work with residents on a daily basis are the most likely individuals to recognize residents' depressive symptoms. The purpose of the current pilot study was to determine feasibility of a 4-week training program for 15 direct care staff to recognize any depression symptoms of 32 residents. Although training significantly improved knowledge, it did not improve staff recognition of residents with positive depressive symptoms. Staff reported the training provided them a better understanding about depression and rated the training as very helpful to be able to recognize depression symptoms. Staff requested more information on ways to respond to someone who is depressed. Additional training should emphasize staff-resident communication skills for staff. Challenges included resident attrition and dwindling staff participation. Strategies to address these challenges are presented. [Journal of Psychosocial Nursing and Mental Health Services, 54(5), 25-31.].

Recommendations on Physical Activity and Exercise for Older Adults Living in Long-Term Care Facilities: A Taskforce Report

A taskforce, under the auspices of The International Association of Gerontology and Geriatrics-Global Aging Research Network (IAGG-GARN) and the IAGG European Region Clinical Section, composed of experts from the fields of exercise science and geriatrics, met in Toulouse, in December 2015, with the aim of establishing recommendations of physical activity and exercise for older adults living in long-term care facilities (LTCFs). Due to the high heterogeneity in terms of functional ability and cognitive function that characterizes older adults living in LTCFs, taskforce members established 2 sets of recommendations: recommendations for reducing sedentary behaviors for all LTCF residents and recommendations for defining specific, evidence-based guidelines for exercise training for subgroups of LTCF residents. To promote a successful implementation of recommendations, taskforce experts highlighted the importance of promoting residents' motivation and pleasure, the key factors that can be increased when taking into account residents' desires, preferences, beliefs, and attitudes toward physical activity and exercise. The importance of organizational factors related to LTCFs and health care systems were recognized by the experts. In conclusion, this taskforce report proposes standards for the elaboration of strategies to increase physical activity as well as to prescribe exercise programs for older adults living in LTCFs. This report should be used as a guide for professionals working in LTCF settings.

Developing a system that can automatically detect health changes using transfer times of older adults

BACKGROUND

As gait speed and transfer times are considered to be an important measure of functional ability in older adults, several systems are currently being researched to measure this parameter in the home environment of older adults. The data resulting from these systems, however, still needs to be reviewed by healthcare workers which is a time-consuming process.

METHODS

This paper presents a system that employs statistical process control techniques (SPC) to automatically detect both positive and negative trends in transfer times. Several SPC techniques, Tabular cumulative sum (CUSUM) chart, Standardized CUSUM and Exponentially Weighted Moving Average (EWMA) chart were evaluated. The best performing method was further optimized for the desired application. After this, it was validated on both simulated data and real-life data.

RESULTS

The best performing method was the Exponentially Weighted Moving Average control chart with the use of rational subgroups and a reinitialization after three alarm days. The results from the simulated data showed that positive and negative trends are detected within 14 days after the start of the trend when a trend is 28 days long. When the transition period is shorter, the number of days before an alert is triggered also diminishes. If for instance an abrupt change is present in the transfer time an alert is triggered within two days after this change. On average, only one false alarm is triggered every five weeks. The results from the real-life dataset confirm those of the simulated dataset.

CONCLUSIONS

The system presented in this paper is able to detect both positive and negative trends in the transfer times of older adults, therefore automatically triggering an alarm when changes in transfer times occur. These changes can be gradual as well as abrupt.

Nutrition Screening Practices amongst Australian Residential Aged Care Facilities

OBJECTIVES

To determine the proportion of Residential Aged Care Facilities (RACFs) in Australia who use a nutrition screening tool on residents to identify those at risk of malnutrition, and to review practice following identification of residents as being at high risk of malnutrition.

DESIGN

Multi-center, cross sectional observational study.

SETTING

Residential Aged Care Facilities.

PARTICIPANTS

The Director of Nursing at each site was contacted by telephone and asked questions relating to current nutrition screening practices at their residential aged care facility.

MEASUREMENTS

Data was collected from a stratified sample of 229 residential aged care facilities in each state and territory in Australia.

RESULTS

82% of RACFs (n = 188) use a nutrition screening tool on residents to identify those at risk of malnutrition, however only 52% of RACFs (n = 119) used a screening tool which is validated in the residential aged care setting. There was a significant association between facilities using a nutrition screening tool and the staff members being trained to conduct nutrition screening (p < 0.001). Facilities that employed a dietitian were more likely to use a validated nutrition screening tool (p < 0.005). The most frequently used nutrition screening tool was the 'Mini Nutritional Assessment - Short Form (MNA-SF)', which was used by 32% (n = 60) of the RACFs, followed by the 'Malnutrition Universal Screening Tool (MUST)' (15%, n = 29).

CONCLUSION

We found that the majority of RACFs in Australia use a nutrition screening tool, however many of these RACFs use a tool which has not been validated in the RACF setting. This study highlights the need for greater dietetic advocacy in using validated nutrition screening tools to ensure malnutrition is identified.

Accelerometer Assessment of Physical Activity and Its Association with Physical Function in Older Adults Residing at Assisted Care Facilities

OBJECTIVES

To describe levels of physical activity among older adults residing at assisted care facilities and their association with physical function.

DESIGN

Cross-sectional analysis.

SETTING

Assisted care facilities within the greater Boston, MA area.

PARTICIPANTS

Older adults aged 65 years and older (N = 65).

MEASUREMENTS

Physical Activity Level (PAL) as defined by quartiles from accelerometry (counts and steps), Short Physical Performance Battery (SPPB) Score, gait speed, and handgrip strength.

RESULTS

Participants in the most active accelerometry quartile engaged in 25 minutes/week of moderate to vigorous physical activity (MVPA) and walked 2,150 steps/day. These individuals had an SPPB score, 400 meter walk speed, and handgrip strength that was 3.7-3.9 points, 0.3-0.4 meters/second, and 4.5-5.1 kg greater respectively, than individuals in the lowest activity quartile, who engaged in less than 5 min/wk of MVPA or took fewer than 460 steps/day.

CONCLUSION

Despite engaging in physical activity levels far below current recommendations (150 min/week of MVPA or > 7000 steps/day), the most active older adults in this study exhibited clinically significant differences in physical function relative to their less active peers. While the direction of causality cannot be determined from this cross-sectional study, these findings suggest a strong association between PAL and physical function among older adults residing in an assisted care facility.

Facilitating Inter-Domain Synergies in Ambient Assisted Living Environments

Current Ambient Assisted Living (AAL) environments lack integration of sensors and actuators of other sub-domains. Creating technical and organizational integration is addressed by the BASIS project (Build Automation by a Scalable and Intelligent System), which aims to build a cross-domain home bus system. The main objective of this paper is to present an overview of design, architecture and state of realization of BASIS by describing the requirements development process, underlying hardware design and software architecture. We built a distributed system of one independent building manager with several redundantly meshed segment controllers, each controlling a bus segment with any number of bus nodes. The software system layer is divided into logical partitions representing each sub-domain. Structured data storage is possible with a special FHIR based home centered data warehouse. The system has been implemented in six apartments running under daily living conditions. BASIS integrates a broad range of sub-domains, which poses challenges to all project partners in terms of a common terminology, and project management methods, but enables development of inter-domain synergies like using the same sensor and actuator hardware for a broad range of services and use cases.

A middleware for intelligent environments in ambient assisted living

The increasing elderly population is changing the demography of many countries, becoming a major issue for society. As a direct consequence of this demographic phenomenon, allied to technological developments and pressure to reduce healthcare costs, new healthcare technologies for proactive health and elder care is needed. However, interoperability issues among different levels of available technologies restricts a wider deployment among intermediate and end-users. This work presents a service-oriented middleware that was developed to provide access to the functionality offered by virtually any existing device, or application, in a residential setting, in a transparent and intuitive form. The proposed middleware abstracts the communication technologies involved, allowing to seemingly integrate different communication protocols, making possible the distributed cooperation of devices that were built as stand-alone products. As a test case, an application was built with the middleware to monitor blood pressure and electromyography signal using typical health devices.

Knowledge-Based Query Construction Using the CDSS Knowledge Base for Efficient Evidence Retrieval

Finding appropriate evidence to support clinical practices is always challenging, and the construction of a query to retrieve such evidence is a fundamental step. Typically, evidence is found using manual or semi-automatic methods, which are time-consuming and sometimes make it difficult to construct knowledge-based complex queries. To overcome the difficulty in constructing knowledge-based complex queries, we utilized the knowledge base (KB) of the clinical decision support system (CDSS), which has the potential to provide sufficient contextual information. To automatically construct knowledge-based complex queries, we designed methods to parse rule structure in KB of CDSS in order to determine an executable path and extract the terms by parsing the control structures and logic connectives used in the logic. The automatically constructed knowledge-based complex queries were executed on the PubMed search service to evaluate the results on the reduction of retrieved citations with high relevance. The average number of citations was reduced from 56,249 citations to 330 citations with the knowledge-based query construction approach, and relevance increased from 1 term to 6 terms on average. The ability to automatically retrieve relevant evidence maximizes efficiency for clinicians in terms of time, based on feedback collected from clinicians. This approach is generally useful in evidence-based medicine, especially in ambient assisted living environments where automation is highly important.

The Seattle Care Pathway: Defining Dental Care for Older Adults

It is well-recognized that the demographic shift in the population will result in a larger proportion of older adults and those adults will live longer than ever before. There is, therefore, a need to ensure dental services recognize this transition and plan for the management of older adults in primary care dental practices. This article describes the evidence for, and the details of, the Seattle Care Pathway to ensure older adults receive optimum dental care.

Evaluation of Three State-of-the-Art Classifiers for Recognition of Activities of Daily Living from Smart Home Ambient Data

Smart homes for the aging population have recently started attracting the attention of the research community. The “health state” of smart homes is comprised of many different levels; starting with the physical health of citizens, it also includes longer-term health norms and outcomes, as well as the arena of positive behavior changes. One of the problems of interest is to monitor the activities of daily living (ADL) of the elderly, aiming at their protection and well-being. For this purpose, we installed passive infrared (PIR) sensors to detect motion in a specific area inside a smart apartment and used them to collect a set of ADL. In a novel approach, we describe a technology that allows the ground truth collected in one smart home to train activity recognition systems for other smart homes. We asked the users to label all instances of all ADL only once and subsequently applied data mining techniques to cluster in-home sensor firings. Each cluster would therefore represent the instances of the same activity. Once the clusters were associated to their corresponding activities, our system was able to recognize future activities. To improve the activity recognition accuracy, our system preprocessed raw sensor data by identifying overlapping activities. To evaluate the recognition performance from a 200-day dataset, we implemented three different active learning classification algorithms and compared their performance: naive Bayesian (NB), support vector machine (SVM) and random forest (RF). Based on our results, the RF classifier recognized activities with an average specificity of 96.53%, a sensitivity of 68.49%, a precision of 74.41% and an F-measure of 71.33%, outperforming both the NB and SVM classifiers. Further clustering markedly improved the results of the RF classifier. An activity recognition system based on PIR sensors in conjunction with a clustering classification approach was able to detect ADL from datasets collected from different homes. Thus, our PIR-based smart home technology could improve care and provide valuable information to better understand the functioning of our societies, as well as to inform both individual and collective action in a smart city scenario.

A Comparison of Accelerometer Accuracy in Older Adults

Older adults' gait disorders present challenges for accurate activity monitoring. The current study compared the accuracy of accelerometer-detected to hand-tallied steps in 50 residential care/assisted living residents. Participants completed two walking trials wearing a Fitbit® Tracker and waist-, wrist-, and ankle-mounted Actigraph GT1M. Agreement between accelerometer and observed counts was calculated using concordance correlation coefficients (CCC), accelerometer to observed count ratios, accelerometer and observed count differences, and Bland-Altman plots. Classification and Regression Tree analysis identified minimum gait speed thresholds to achieve accelerometer accuracy ≥0.80. Participants' mean age was 84.2 and gait speed was 0.64 m/s. All accelerometers underestimated true steps. Only the ankle-mounted GT1M demonstrated positive agreement with observed counts (CCC = 0.205). Thresholds for 0.80 accuracy were gait speeds ≥0.56 m/s for the Fitbit and gait speeds ≥0.71 m/s for the ankle-mounted GT1M. Gait speed and accelerometer placement affected activity monitor accuracy in older adults.

Evaluation of a pet-assisted living intervention for improving functional status in assisted living residents with mild to moderate cognitive impairment: a pilot study

BACKGROUND

In older adults with cognitive impairment (CI), decreased functional status and increased behavioral symptoms require relocation from assisted living (AL) to nursing homes. Studies support positive effects of pets on health/function.

PURPOSE

Evaluate the effectiveness of the Pet AL (PAL) intervention to support physical, behavioral, and emotional function in AL residents with CI.

METHODS

Cognitively impaired AL residents randomized to 60-90 minute sessions [PAL (n = 22) or reminiscing (n = 18)] twice/week for 12 weeks. PAL interventionist encourages residents to perform skills with the visiting dog; reminiscing interventionist encourages residents to reminisce. Monthly assessment of physical (energy expenditure, activities of daily living), emotional (depression, apathy), and behavioral (agitation) function.

RESULTS

In linear mixed models, physical activity depressive symptoms improved more with PAL.

CONCLUSION

Evidence supports that the PAL program helps preserve/enhance function of AL residents with CI. Additional study is required to evaluate the duration and predictors of effectiveness of the PAL intervention.

Policies to protect persons with dementia in assisted living: déjà vu all over again?

Continued growth in the number of individuals with dementia residing in assisted living (AL) raises concerns about their safety and protection. In this Forum, we review current AL practices relevant to residents with dementia and present a rationale for examining the government role in protecting these individuals within this context. Since public oversight of AL is currently a state prerogative, we assess states' regulatory activity across 3 domains closely related to safety and protection of persons with dementia: environmental features, staffing, and use of chemical restraints. We then step back to consider the state policymaking environment and assess the feasibility of developing a minimum standard of regulations from one state to the next. This Forum concludes with a historical comparison between the contemporary AL market and the nursing home care market prior to the Nursing Home Reform Act of 1987, and we discuss how an increased amount of federal interest could improve existing state efforts to protect persons with dementia residing in AL.

Client safety in assisted living: perspectives from clients, personal support workers and administrative staff in Toronto, Canada

As the population ages, the demand for long-term care settings is expected to increase. Assisted living is a suitable and favourable residence for older individuals to receive care services specific to their needs while maintaining their independence and privacy. With the growing transition of older individuals into assisted living, facilities need to ensure that safe care is continually maintained. The purpose of this study was to determine the gaps and strengths in care related to safety in assisted living facilities (ALFs). A qualitative descriptive research design was used to provide a comprehensive understanding of client safety from the perspectives of clients, administrative staff and personal support workers. Interviews were conducted with 22 key informants from three ALFs in Toronto, Ontario throughout July 2012. All interviews were semi-structured, audio-recorded and transcribed verbatim. Initial deductive analysis used directed coding based on a prior literature review, followed by inductive analysis to determine themes. Three themes emerged relating to the safety of clients in ALFs: meaning of safety, a multi-faceted approach to providing safe care and perceived areas of improvement. Sub-themes also emerged including physical safety, multiple factors, working as a team, respecting clients' independence, communication and increased education and available resources. The study findings can contribute to the improvement and development of new processes to maintain and continually ensure safe care in ALFs.

Admission for osteoporotic pelvic fractures and predictors of length of hospital stay, mortality and loss of independence

OBJECTIVE

To study the implications of osteoporotic pelvic fractures in older patients in terms of mortality, length of hospital stay and independent living.

METHODS

The study included 110 consecutive patients, aged over 60 years, with osteoporotic pelvic fractures admitted to the Queen Elizabeth Hospital, Gateshead, between July 2009 and March 2011. Demographic and routine clinical data were collected prospectively until date of discharge, and vital status data were collected up to 3 months post-fracture. These data were analysed to assess associations with outcomes such as length of hospital stay, mortality and loss of independence (according to changes in residential housing status).

RESULTS

Fourteen patients died either in hospital, or within 3 months of fracture. Length of hospital stay was associated with age (b=0.77 days per year, 95% CI 0.001, 1.54, P=0.05) and was significantly longer in those with acute medical problems on admission (b=21.2 days, 95% CI 8.72, 33.73, P=0.001). The odds of changing from independent to institutionalised accommodation were significantly associated with age (OR 1.08 per year, 95% CI 1.01, 1.04, P=0.007) and length of hospital stay (OR 1.12 per day, 95% CI 1.01, 1.04, P=0.007).

CONCLUSION

In-hospital mortality rates in this patient group are similar to those seen for hip fractures, yet pelvic fractures in older people receive relatively little in the way of attention or funding. Guidelines to improve the management of such fractures in older people are important to improve care while in hospital, reduce time spent in hospital and reduce the impact on independent living.