Identity cues and dementia in nursing home intervention.

This study examines the identity cues that family caregivers and healthcare personnel use with seniors living with dementia and living in nursing homes. The identity cues represent biographical knowledge used to stimulate the dementia sufferer, trigger signals and incite interaction. Our grounded approach hinges on three objectives: to identify and categorize identity cues; to document their uses; and to gain a better understanding of their effectiveness. We interviewed nine family caregivers and 12 healthcare workers. Qualitative data indicates that the participants use identity cues that evoke seniors' sociological, relational and individual characteristics. These identity cues play a central role in communication and constitute important information that the family caregivers can share with healthcare personnel. They sustain memory, facilitate care and reinforce seniors' self-value. These results help to define identity, foster a greater role for family caregivers, and constitute a sound basis for the implementation of personalized interventions.

Using the Montessori approach for a clientele with cognitive impairments: a quasi-experimental study design.

BACKGROUND: The choice of activities responding to the needs of people with moderate to severe dementia is a growing concern for care providers trying to target the need for a feeling of self-accomplishment by adapting activities to the abilities of elderly patients. The activities created by Maria Montessori seem to be adaptable to this clientele. This study evaluates the short-term effects, as compared to regular activities offered in the milieu. METHODS: This is a quasi-experimental study where each of the 14 participants was observed and filmed in two conditions: during Montessori activities, during regular activities, and one control condition (no activity). RESULTS: The results show that Montessori activities have a significant effect on affect and on participation in the activity. They support the hypothesis that when activities correspond to the needs and abilities of a person with dementia, these positive effects are also observed on behaviours. CONCLUSIONS: This study enabled its authors to corroborate the findings presented in the literature and to contribute additional elements on the positive effects of the use of Montessori activities and philosophy. Used with people with moderate to severe dementia these allow the satisfaction of their basic psychological needs, their well being, and hence, on their quality of life.

Provision of rehabilitation services in Québec following stroke: a comparative survey conducted by postal questionnaire.

We conducted a survey to document the rehabilitation services available to clients aged 65 years and older who had suffered a stroke. In all, respondents - gleaned from 295 resources located in three health regions in the province of Québec - completed a postal questionnaire describing the services that they offer, in terms of type of intervention (related to nine capabilities and seven areas of social participation) and type of services (evaluation, rehabilitation, and support). The results show that most rehabilitation services offered to older people with stroke address motor skills and mobility. Somewhat unexpectedly, for four capability-related interventions and two social-participation-related interventions, there appear to be more active rehabilitation services offered in regions with rural areas than in metropolitan regions.

Responsiveness of mobility, daily living, and instrumental activities of daily living outcome measures for geriatric rehabilitation.

OBJECTIVES: To assess and compare the ability of the Timed Up & Go (TUG) and subscales of the Functional Autonomy Measurement System (SMAF) to detect change in people undergoing geriatric rehabilitation in inpatient geriatric rehabilitation units (GRUs) and day hospitals. DESIGN: Longitudinal design with repeated measures obtained at admission and discharge from rehabilitation and at 2 follow-up interviews. SETTING: Inpatient and outpatient hospital-based settings. PARTICIPANTS: Subjects (N=237, age 80+/-7 y) had data at admission and discharge from rehabilitation (changing time frame), and of these, 160 had data at 2 subsequent follow-ups (stable time frame). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The TUG was used to estimate basic mobility, and subscales of the SMAF were used to estimate general mobility (SMAF-mobility), basic activities of daily living (SMAF-ADL), and instrumental activities of daily living (SMAF-IADL). Professionals' perception of change was used as a criterion. RESULTS: The TUG generated large values for the standardized response mean (SRM) and Guyatt's responsiveness index in GRUs (.98 and 1.12) and day hospitals (.89 and 1.85). Professionals' perception of change in mobility was explained by a perceptible change in the TUG in day hospitals (15%) but not in GRUs. The SMAF-mobility, SMAF-ADL, and SMAF-IADL were associated with large values of SRM and Guyatt's responsiveness index in GRUs (.97-2.17) and with small to moderate values in day hospitals (.29-.54). Moderate to large portions in the professionals' perceptions of change for mobility (20%, 17%), basic ADLs (10% and 14%), and IADLs (23% and 19%) were associated with the respective change scores of the subscales of the SMAF in both GRUs and day hospitals. CONCLUSIONS: Progress of older adults in the areas of mobility, basic ADLs, and IADLs can be captured using the TUG, SMAF-mobility, SMAF-ADL, and SMAF-IADL in both GRUs and day hospitals. The results support their use in settings of high- and low-intensity rehabilitation, thus suggesting their adequacy for use in these 2 settings.

Predictors of daily mobility skills 6 months post-discharge from acute care or rehabilitation in older adults with stroke living at home.

PURPOSE: To determine the evolution of daily mobility skills from the timed up-and-go (TUG) upto 6 months after home return in older adults with stroke discharged from acute care or rehabilitation; and to identify the best predictive factors of the TUG at 6 months post-discharge. METHODS: In this longitudinal prospective study, people with stroke aged 65 years or more and discharged home from an acute care hospital (n = 82) or a rehabilitation service (n = 109) were included. The TUG was measured at discharge (T1), and at 3 and 6 months post-discharge (T2 and T3). Correlations between the TUG at T3 and sociodemographic and clinical variables, as well as physical, cognitive, perceptual and psychological measures at T1, were used in a multiple regression model to identify the best predictors of TUG at T3. RESULTS: TUG did not change between T1, T2 and T3 in the two groups of participants. The best predictors of TUG at T3 in participants from acute care were the use of a walking aid in daily life, age, deficits in oral expression and the presence of depressive symptoms. In participants from rehabilitation, predictors were the stage of motor recovery of the foot, the use of a walking aid in daily life, number of schooling years and memory impairments. CONCLUSION: Daily mobility skills, as assessed with the TUG, did not deteriorate upto 6 months after home return in older adults with stroke. The best predictor of the TUG at T3 is the use of a walking aid during daily life in participants from acute care, and motor recovery of the foot in participants from rehabilitation.

Comparison and correlates of participation in older adults without disabilities.

This study was conducted to compare, by age group and gender, the level of participation of older adults who had no disabilities, and to determine which characteristics are most associated with participation. This study involved 350 randomly recruited community-dwelling older adults. Participation in daily activities and social roles were measured with the Assessment of Life Habits (LIFE-H). Demographic, health-related and environmental data were also collected. A decline with age was observed in four of the six daily activities domains and two of the four social roles domains of participation. However, these lower scores are mainly explained by the 85+ group, which consistently scored lower than the 65-69-year-old group. No differences were found between the 65-69, 70-74 and 75-79 years old groups. Some participation domains differed according to gender. Satisfaction with participation was high and did not differ between age groups. Characteristics most associated with participation vary according to the domains; generally, age and marital status are the best determinants of participation. This study found that most of older adults have an unrestricted level of participation which decreases only late in the aging process. This reduction in participation in very old adults was not accompanied by a decrease in satisfaction, supporting the hypothesis that they can participate satisfactorily in valued activities.

Coping strategies and social participation in older adults.

BACKGROUND: Social participation refers to daily activities, such as personal care and mobility, and social roles, such as interpersonal relationships and leisure. Although restrictions in participation in normal aging have been recognized, little research has been done to study the coping strategies used to alleviate those restrictions. OBJECTIVE: The objective of the present study was to explore the relationships between cognitive and behavioural coping strategies and the social participation of community-dwelling older adults. METHODS: The Assessment of Life Habits (LIFE-H) and the Inventory of Coping Strategies Used by the Elderly (ICSUE) were used to document social participation and coping strategies of 350 randomly recruited older adults living at home independently. Sociodemographic and health-related characteristics were also assessed. Regression analyses were performed to evaluate the relationship between social participation, coping strategies and the other variables. RESULTS: Behavioural coping strategies were the most important factor associated with daily activities, social roles and total participation, followed by the type of living environment and age. These variables explained 33% (p=0.04), 13% (p=0.02), and 28% (p=0.00) of the variance of the models, respectively. The absence of any relationship between the cognitive coping strategies and social participation was a striking result. CONCLUSION: Our study suggests expanding current geriatric approaches to integrate knowledge on useful, safe and appropriate behavioural changes and to help older people acquire such strategies when they are lacking.

Short-term changes in and predictors of participation of older adults after stroke following acute care or rehabilitation.

BACKGROUND: Stroke can lead to restrictions in participation in daily activities and social roles. Although considered an important rehabilitation outcome, little is known about participation after stroke and its predictors, and about the differences associated with the types of services provided following stroke. OBJECTIVE: The aims of this study were 1) to follow and compare changes in participation of older adults discharged home after stroke from acute care or postacute rehabilitation, and 2) to identify the best predictors of participation after stroke from physical, cognitive, perceptual, and psychological ability measures taken shortly after discharge. METHODS: Level of participation in daily activities and social roles of 197 older adults who had a stroke was evaluated at 2 to 3 weeks (T1), 3 months (T2), and 6 months (T3) after being discharged home from acute care (n = 86) or rehabilitation (n = 111). Physical, cognitive, perceptual, and psychological abilities were assessed at T1. RESULTS: A significant increase in participation was found over time for both groups, mainly in the first 3 months. The best predictors of participation differed between the groups and between the daily activities and social roles domains. Walking and acceptance of the stroke or fewer depressive symptoms were the best predictors of the level of participation after stroke. CONCLUSIONS: Participation was not optimal at discharge because it continued to increase after the return home. The importance of psychological factors in participation after stroke is undeniable. Many predictors are amenable to interventions.

Selecting process quality indicators for the integrated care of vulnerable older adults affected by cognitive impairment or dementia.

BACKGROUND: This study aimed at evaluating face and content validity, feasibility and reliability of process quality indicators developed previously in the United States or other countries. The indicators can be used to evaluate care and services for vulnerable older adults affected by cognitive impairment or dementia within an integrated service system in Quebec, Canada. METHODS: A total of 33 clinical experts from three major urban centres in Quebec formed a panel representing two medical specialties (family medicine, geriatrics) and seven health or social services specialties (nursing, occupational therapy, psychology, neuropsychology, pharmacy, nutrition, social work), from primary or secondary levels of care, including long-term care. A modified version of the RAND(R)/University of California at Los Angeles (UCLA) appropriateness method, a two-round Delphi panel, was used to assess face and content validity of process quality indicators. The appropriateness of indicators was evaluated according to a) agreement of the panel with three criteria, defined as a median rating of 7-9 on a nine-point rating scale, and b) agreement among panellists, judged by the statistical measure of the interpercentile range adjusted for symmetry. Feasibility of quality assessment and reliability of appropriate indicators were then evaluated within a pilot study on 29 patients affected by cognitive impairment or dementia. For measurable indicators the inter-observer reliability was calculated with the Kappa statistic. RESULTS: Initially, 82 indicators for care of vulnerable older adults with cognitive impairment or dementia were submitted to the panellists. Of those, 72 (88%) were accepted after two rounds. Among 29 patients for whom medical files of the preceding two years were evaluated, 63 (88%) of these indicators were considered applicable at least once, for at least one patient. Only 22 indicators were considered applicable at least once for ten or more out of 29 patients. Four indicators could be measured with the help of a validated questionnaire on patient satisfaction. Inter-observer reliability was moderate (Kappa = 0.57). CONCLUSION: A multidisciplinary panel of experts judged a large majority of the initial indicators valid for use in integrated care systems for vulnerable older adults in Quebec, Canada. Most of these indicators can be measured using patient files or patient or caregiver interviews and reliability of assessment from patient-files is moderate.

Rehabilitation needs for older adults with stroke living at home: perceptions of four populations.

BACKGROUND: Many people who have suffered a stroke require rehabilitation to help them resume their previous activities and roles in their own environment, but only some of them receive inpatient or even outpatient rehabilitation services. Partial and unmet rehabilitation needs may ultimately lead to a loss of functional autonomy, which increases utilization of health services, number of hospitalizations and early institutionalization, leading to a significant psychological and financial burden on the patients, their families and the health care system. The aim of this study was to explore partially met and unmet rehabilitation needs of older adults who had suffered a stroke and who live in the community. The emphasis was put on needs that act as obstacles to social participation in terms of personal factors, environmental factors and life habits, from the point of view of four target populations. METHODS: Using the focus group technique, we met four types of experts living in three geographic areas of the province of Québec (Canada): older people with stroke, caregivers, health professionals and health care managers, for a total of 12 groups and 72 participants. The audio recordings of the meetings were transcribed and NVivo software was used to manage the data. The process of reducing, categorizing and analyzing the data was conducted using themes from the Disability Creation Process model. RESULTS: Rehabilitation needs persist for nine capabilities (e.g. related to behaviour or motor activities), nine factors related to the environment (e.g. type of teaching, adaptation and rehabilitation) and 11 life habits (e.g. nutrition, interpersonal relationships). The caregivers and health professionals identified more unmet needs and insisted on an individualized rehabilitation. Older people with stroke and the health care managers had a more global view of rehabilitation needs and emphasized the availability of resources. CONCLUSION: Better knowledge of partially met or unmet rehabilitation needs expressed by the different types of people involved should lead to increased attention being paid to education for caregivers, orientation of caregivers towards resources in the community, and follow-up of patients' needs in terms of adjustment and rehabilitation, whether for improving their skills or for carrying out their activities of daily living.

[The tele-surveillance as a tool to favour social participation of elderly at home]. / La télésurveillance comme outil favorisant la participation sociale des personnes âgées à domicile.

Little is known as yet about the impact of telesurveillance services on social participation. To document the interaction between telesurveillance services and social participation of the elderly living at home, a study was conducted in the context of a government call center employing nurses. A focus group study was realized with elders (n = 4), caregivers (n = 6), healthcare system practitioners and industry employees (n = 7). A qualitative analysis was performed using the Disability Creation Process model and generally accepted criteria for evaluating telehealth interventions. The results showed, on the one hand, factors that facilitate the use of telesurveillance services (user's intellectual capabilities, acceptance of clinical settings, relevance of recommendations, cost of service, and accessibility) and, on the other, factors that reinforce such use (user behaviors; level of satisfaction; impact on informal caregiver; system's level of performance; technical features; and life-habit aspects such as personal transportation, sleep, housekeeping, personal care, interpersonal relationships, and recreational activities).

Exploring the impact of a new translation process on the performance of French form writers of the Canadian Certification Exam.

BACKGROUND: In an effort to ensure fairness to French form writers of the Canadian Certification Exam, CAOT instituted a new translation process in 2000. PURPOSE: To determine the impact of this new translation process on the performance of French form writers of the Canadian Certification Exam. METHODS: Average test scores and proportion of unsuccessful candidates were examined between 1986 and 2004 by the language in which the test was administered. FINDINGS: While changes in results for French form writers were observed over the follow-up period, these corresponded to a time before the translation changes were introduced. IMPLICATIONS: The new translation process did not appear to have an impact on the results of French form writers. Further work is recommended to examine and address other potential causes of discrepancies between French and English form writers.

Quality of life indicators in long-term care: opinions of elderly residents and their families.

BACKGROUND: There are very few studies that have integrated the opinions of nursing home residents and their families into the process of developing valid outcome measures for the quality of life in long-term care facilities. PURPOSE: The objective of this study was to identify the interpersonal and environmental characteristics for the best substitute living environment, as perceived by recently (< 6 months) and not as recently (> 6 months of residency) admitted residents and their families. METHODS: A qualitative research approach was used with 27 elderly residents and families from five nursing homes. RESULTS: Of the 11 quality of life indicators identified by the participants, the three most important ones were being treated with respect, sympathetic involvement in relationships, and perceived competency through technical (nursing) acts and attitudes. PRACTICE IMPLICATIONS: As nursing home residents age, substitute homes have to adapt if they are to continue offering opportunities for self-actualization and a continuing sense of identity. Opinions of elderly residents and their families are very helpful for occupational therapists particularly when designing programs in long-term care facilities.

Seniors' views on the use of electronic health records.

In the Mauricie and Centre-du-Québec region of the province of Quebec, Canada, an integrated services network has been implemented for frail seniors. It combines three of the best practices in the field of integrated services, namely: single-entry point, case management and personalized care plan. A shared interdisciplinary electronic health record (EHR) system was set up in 1998. A consensus on the relevance of using EHRs is growing in Quebec, in Canada and around the world. However, technology has out-paced interest in the notions of confidentiality, informed consent and the impact perceived by the clientele. This study specifically examines how frail seniors perceive these issues related to an EHR. The conceptual framework is inspired by the DeLone and McLean model whose main attributes are: system quality, information quality, utilisation modes and the impact on organisations and individuals. This last attribute is the focus of this study, which is a descriptive with quantitative and qualitative component. Thirty seniors were surveyed. Positive information they provided falls under three headings: (i) being better informed; (ii) trust and consideration for professionals; and (iii) appreciation of innovation. The opinions of the seniors are generally favourable regarding the use of computers and the EHR in their presence. Improvements in EHR systems for seniors can be encouraged.

Validity of the Assessment of Life Habits in older adults.

OBJECTIVE: To study the construct validity of a participation scale, the Assessment of Life Habits, with older adults having functional limitations. More specifically, the study aimed to verify the ability of the Assessment of Life Habits to discriminate between clienteles in 3 living environments, and to compare participation scores to functional independence scores obtained with the Functional Autonomy Measurement System (Système de mesure de l'autonomie fonctionnelle). DESIGN: Participants were evaluated once with the Assessment of Life Habits and the Functional Autonomy Measurement System. SUBJECTS: Eighty-seven older adults (mean age 78.0 years (8.2)) living in 3 types of environment: own home, private nursing home or long-term care centre. RESULTS: Results suggest that the Assessment of Life Habits scores discriminate between different levels of participation according to the living environments of the participants. The Assessment of Life Habits measures some similar aspects to the Functional Autonomy Measurement System scale but also additional concepts not included in the Functional Autonomy Measurement System. CONCLUSION: This study supports the validity of the Assessment of Life Habits as a participation measure. It suggests the importance of going beyond disability measures to evaluate the overall functioning of older adults correctly.

Identification of rehabilitation needs after a stroke: an exploratory study.

BACKGROUND: Services to meet adequate rehabilitation needs of elderly stroke survivors are not always provided. Indeed, since 1995, in the wake of the Quebec shift to ambulatory care, home care services, mainly those related to rehabilitation of the elderly, are either unavailable or incomplete. The aim of this study was to examine the rehabilitation needs of this clientele from their hospitalization to their reintegration into the community. METHODS: The "Handicap Production Process" conceptual approach was chosen to help identify the rehabilitation needs of persons affected by physical or cognitive disabilities due to the interactions between personal and environmental factors, and (activities of daily living, social roles). This qualitative exploratory study was performed in 2003. Data were collected among four groups of experts: patients, caregivers, health care providers and administrators. Data triangulation was used to ensure a rigorous analysis and validity of the results. RESULTS: Unfulfilled needs could be found in the categories of pertaining to residence, community living, psychological and emotional needs. Indeed, it appears that a psychological follow-up to discuss acceptance and consequences of non-acceptance would facilitate mid-to long-term rehabilitation. CONCLUSION: Improving accessibility to healthcare services, respecting priority parking spaces for the disabled as well as promoting public awareness would enable a better social reintegration and recovery of social roles, thus limiting the onset of handicap situations.

Measuring social participation: reliability of the LIFE-H in older adults with disabilities.

PURPOSE: Much more attention should be paid to instruments documenting social participation as this area is increasingly considered a pivotal outcome of a successful rehabilitation. The purpose of this study was to document the reliability of a participation measure, the Assessment of Life Habits (LIFE-H), in older adults with functional limitations. METHODS: Eighty-four individuals with physical disabilities living in three different environments were assessed twice with the LIFE-H, an instrument that documents the quality of social participation by assessing a person's performance in daily activities and social roles (life habits). RESULTS: The intraclass correlation coefficients (ICC) computed for intrarater reliability exceeded 0.75 for seven out of the 10 life habits categories. For interrater reliability, the total score and daily activities subscore are highly reliable (ICC

Developing an instrument for identifying coping strategies used by the elderly to remain autonomous.

OBJECTIVES: Behavioral or cognitive coping strategies may be defined as attitudes developed via life experience to minimize the functional impacts of an impairment or disability that thereby enable the elderly to continue participating in their social environment. The objective of this study was to develop an instrument that was capable of identifying the ways and methods used by the elderly whenever obstacles arise and to assess four psychometric qualities. DESIGN: The Inventory of Coping Strategies Used by the Elderly is a questionnaire that includes a list of almost 100 behavioral and cognitive strategies. It is based on two Likert scales: the frequency of use of a given strategy and the satisfaction felt by the person whenever he or she used the strategy in an everyday situation. RESULTS: Reliability analysis showed intraclass correlation coefficients of 0.80-0.89. Discriminant analysis showed that the inventory differentiated the seniors' club subjects from the other three groups. This first survey involved a sample of 64 subjects aged > or =65 yr, classified among four subgroups of different levels of autonomy. Content validation was performed with the assistance of four experts in gerontology and measurement and evaluation. Internal consistency analysis made it possible to select the items in relation to which items correlated most with the overall score from among the initial list of 114 items. CONCLUSIONS: This instrument will enable health professionals to familiarize themselves with the coping strategies of both normal seniors and those who are involved in the adaptation and rehabilitation process. When such strategies are lacking, action should be taken to develop or reinforce them to prevent the loss of autonomy.