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Un Older Persons’ Day 2012
Article Type: Guest editorial From: Quality in Ageing and Older Adults, Volume 14, Issue 3.
Promoting Active and Healthy Ageing
Conference and Public Lecture
Thursday 27 September 2012
All Nations Centre, Cardiff
Again, United Nations Older Persons’ Day (1 October) was marked in Cardiff by a conference and Public Lecture. Well over a hundred colleagues, representing health and social care authorities, academics, clinicians, nurses and care workers attended the conference, and were joined by members of the general public for the public lecture in the evening. The first part of this issue of Quality in Ageing in Older Adults (QAOA) offers articles based on the papers delivered at this conference. The second part of the issue offers four further papers, on dying in residential care, on falls, on loneliness and social isolation and, finally, on lasting power of attorney.
A valuable item in these UN Conferences has been poster demonstrations. This year there were a large number, displaying work going on in the area. A poster of particular interest featured “The Eden Alternative Care”, a registered charity dedicated to improving the experience of aging and disability, which focuses on creating person-centred communities, providing people with choice in their daily lives, combating loneliness, helplessness and boredom. Training courses are available and care homes can be registered with the charity. (Indeed QAOA published a paper on Eden Principles in western Australia in the issue before this.)
The Conference was opened by Sarah Stone, Deputy Older People's Commissioner for Wales. The Older People's Commission has a number of functions, the most basic of which is ‘to promote awareness of the rights and interests of older people in Wales’. Sarah welcomed the delegates, and introduced the first speaker.
John Moore, Programme Manager of “My Home Life Cymru”, has been involved in the social care sector for over 25 years as an informal carer, care worker, manager of domiciliary, residential, respite and direct payments services, and has experience within a local authority, a commissioning team and as chair and trustee of several third-sector organisations. John spoke with considerable authority on how care homes can be “de-institutionalised”, and how residents can be encouraged to live, love, laugh, learn, connect with others as a normal part of everyday life – and even, to dream! John's paper raised a number of challenges: to have goals in life, to feel part of things – challenges for all of us, and not just for residents in a care home. John however took issue with the very term “independent” pointing out that none of us can be totally independent, but rather, he stressed the concept of “inter-dependence”, again an ideal state for all of us together with the older people with whom we are involved.
Professor Pradeep Khanna then presented the Gwent Fraility Programme. This ambitious programme aims to shift “frail” people from the acute sector, into “happy independence” in their own homes. Subjects are assessed in a seven-day rapid response and reablement evaluation – the team having immediate access to imaging and pathology services. Following assessment each person is supported within the community in an integrated programme of health and social care. Frail subjects include those with chronic limitations in daily living activities, together with those with health, social and or housing needs. A further group includes subjects defined in a highly flexible way, as “vulnerable – running on empty!” Palliative care, when appropriate, is included in this holistic scheme.
The underlying philosophy of the Gwent scheme is highly ambitious. Community services have not only been divorced from hospitals, but have tended to be process-driven and appropriate for the convenience of the various organisations. Assessments of need have usually followed admission to hospital. In contrast, the Gwent model puts the frail subject at the centre, with assessments made within the community and involving hospital services as appropriate, with continuing care and support from collaborating health and social teams. A long-term commitment is to demonstrate that a third of hospital beds in the area can be closed.
Professor Judith Phillips and Carol Maddock presented the outdoor environment as a key to independent living. Despite changes in legislation in the last 15 years and despite the Equality Act (2010) there is little research on how the environment interacts with older people. In particular, there has been little research on the extent to which falls by older people reduce confidence and restrict independence.
Judith introduced work in the research programmes Inclusive Design for Getting Outdoors (IDGO) and “Going Outdoors, Falls, Ageing and Resilience” (GoFAR). In these, a variety of research methods are being used to increase understanding of the environment through interviews in older people's homes and interviews with people on the street, together with observational studies, watching pedestrians and measuring features on the pavement, including pedestrian crossings and pavement surfaces.
An important feature in the environment relates to the crossing of roads. Their research has shown that older people prefer a plain dropped kerb rather than tactile paving, because balance and comfort are better maintained, and mobility scooters navigate more easily on a dropped kerb. Nevertheless, the use of different surfaces can be confusing for older people and can make difficulties with balance.
Despite the limited time most older people spend outside, falls are more common out of doors than within the home. Men are more likely to fall outdoors than women and elderly people are more likely to experience a fall at home. In a recent study 15 per cent of 972 older persons reported having stumbled or fallen outside within the last 12 months, and the real figure likely to be higher. Other research has shown that many of the environmental risk factors associated with outdoor falls appear to be preventable through better design and maintenance of pavements. In conclusion, Judith urged that everything possible should be done to make the outdoor environment conducive for older people to leave the house and continue as active members of their communities.
Although Judith's paper has not been published in this issue, a paper here by Andrew Sixsmith and colleagues does offer further insight into this problem They stress the huge impact falls can have on the health and well-being of older people, and their consequent burden on hospital and care services. Video recordings were used to enable the study of the complex interactions between the sensory and motor impairment of older people together with their inappropriate behaviour on occasions, their inappropriate footwear and improper use of walking aides on occasions, together with extrinsic factors such as environmental hazards and inadequate lighting, and social and psychological issues such as a noisy and active environment, in contrast to calm and peaceful surroundings. They conclude that the risks of a fall cannot be removed entirely without limiting freedom and independence.
We all know how difficult it is to change behaviour – our own, every much as that of a patient! A talk on “motivational interviewing” by Professor Chris Butler was therefore of wide application. Motivational interviewing has been defined as “a client-centred, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence”. Sounds simple, but it contrasts sharply with the more usual dictatorial behaviour of the health professional, by stressing the establishment of rapport with the patient or subject, the setting of an agenda agreed by both and the negotiating of attainable goals set by the health professional according to his/her perception of the needs of the patient/subject.
While models of motivational interviewing have been developed and evaluated most fully within selected situations such as smoking and excessive drinking by heart disease patients; users of illegal drugs seen in emergency clinics, etc. yet the approach clearly has an almost unlimited utility – given interviewing time!
The evidence of benefit from motivational interviewing, over that from straight brief advice, is considerable and is growing, and in fact, it has been found that dictatorial advice can even on occasions be harmful. In one trial, five out of seven outcomes, including smoking prevalence, showed increased reductions six months after the original interviews. Other randomised trials of motivational interviewing have shown increased effects in the reduction of alcohol consumption and in reducing cannabis, cocaine and heroin use.
It is important that services are evaluated, and how better could services to older people be evaluated than by the older people themselves? Mark Llewellyn presented the findings of an enquiry in which just over one thousand older people (27 per cent of those approached) had completed a questionnaire. On the whole, the responses give a lot of encouragement to care workers. Thus 45 per cent of the residents who responded stated that they were “always” listened to; had as much time with their carers as they thought necessary; and received good quality care, while only 5 per cent said that they “rarely”, or “never” (also 5 per cent) received good care from care workers. Overall 84 per cent of the older people questioned said they were “satisfied” or “very satisfied” with the care they received, and 27 per cent said they believed that the care they received had “got a little better” or “a lot better” during the previous 12 months.
While the work of Llewellyn and colleagues, together with the Office of the Older People's Commissioner, gives considerable reassurance, uncaring and unsafe events do of course occur. The paper by Kelly and Jones on “whistleblowing” and its potential in the promotion of best standards, is therefore of very great interest.
Kelly and Jones highlighted the dilemma faced by those with honest concerns about an incident or a practice, and the fear that they will be treated as malcontents, and will suffer and perhaps face dismissal if they speak out. Yet, while whistleblowing attracts overwhelming negative reactions – even by some of the authorities – and the very term “whistleblower” acts as a deterrent to speaking out, it is a most important – perhaps an essential activity, if a complex and diverse system such as healthcare is to be trustworthy and accountable. Another aspect which is discussed in the paper, is the all too frequent lack of response by the authorities when an issue has been brought to their attention. The bottom line in Kelly and Jones’ paper is that more attention should be paid to ways in which fairness and openness can be promoted within organisations like the NHS, and within the whole area of health and social care, rather than the opposite. While there is a focus upon health it is evident that some more thought could be given to the context and place of social care with regard to these issues and some further exploration of public/private sector differences would be of interest.
A paper from John Woolham and colleagues in this issue deals with loneliness. This work was based on a city-wide questionnaire survey of people aged over 55 years and managed to achieve a response rate of nearly 40 per cent. The paper reviews policy issues with a relevance to loneliness in older people and then attempts to identify relevant factors within their own data. The findings resonate with the findings of others and are largely in line with what could be reasonably expected. Thus, half the people who responded admitted loneliness on occasions, and people who took part in social activities, who lived alone, who made no use of a mobile phone, etc. had a higher prevalence of loneliness. There remains a major problem of selection bias in studies of loneliness, so it is difficult to extrapolate results with any confidence. Lonely people are less likely to participate in any collective activities – including responding to surveys – hence the need to develop innovative techniques for exploring the problem. And this is even more the case with lonely older people.
The penultimate paper in this issue on “Death and dying in residential care” is a most valuable addition to the papers from the UN Day Conference. This paper challenges the negative image of terminal care in care homes frequently portrayed in the media and in the press. The authors also point out that despite the issue of many publications and regulations on the care of older people, little attention is given specifically to “a good death” or “good end of life care”. Nevertheless, the paper argues that not only can, and do many care homes facilitate “a good death” preceded by “good end of life care”, but good practice in terminal care can stimulate changes in overall practice within care homes. In summary, this challenging and moving paper urges “caring about” residents in care homes, rather than just “caring for” them, and suggests that more attention should be given to palliation rather than to attempted rehabilitation.
The final paper from Roberto Martins offers valuable instruction and guidance on power of attorney – a problem that needs to be confronted sooner rather than later in the care of ageing relatives. This paper offers practical advice and information that, if followed, can help ease the more “formal” problems we confront while allowing more valuable time for the more “informal” concerns of caring.
The Public Lecture following the conference was given by Dame June Clark DBE, PhD, FRCN. June commenced her lecture by saying that she is passionate about nursing, and seeks opportunity to explain to people what makes it special. She lamented the bad press that nurses and carers were getting at that time in the media, and yet, she had been reassured by a feature in The Times which had reported a survey in which nurses had been rated above doctors and teachers, and were the professional group most trusted by the public.
June clearly regards nurses as different and “special”! Not everyone, she said, who looks like a nurse, wears a nursing kind of uniform and calls her/him self a “nurse”, is truly a nurse. No surprise therefore that research has shown that if the proportion of qualified nurses in the workforce is reduced, the quality and outcomes of care go down too. The true nurse has a multidisciplinary approach to care, encompassing highly intricate assessment and detection of needs, ongoing monitoring and evaluation of each intervention, together with communication to patients with understanding, with empathy and with encouragement. This all combines into a care performance, focused upon each individual client. The introduction of time-based care plans, with expectations of completion of each task within a set time, operates against compassionate concern, and against effective outcomes.
June then stressed that 90 per cent of healthcare takes place outside hospitals. Furthermore, she challenged the myth that “medical” care differs from “social” care. Such a distinction has led to the present chaotic system of eligibility and funding, and leads to the assessments of the needs of older people being made by people who have little or no experience of the full potential of nursing and medical interventions.
There are two ways of looking at nursing. The first is to see nursing simply as a set of activities. On this model anyone can be a nurse, and June believes that this is the dominant way in which nursing is perceived. The second sees nursing as the building up of knowledge and experience of the problems of individual clients, together with an integration of the various possible ways of addressing each problem. In fact, the core in any adequate definition of nursing is: “The use of clinical judgement in the provision of care”.
June then reviewed various developments in nursing, and in particular those proposed for Wales. As she reviewed some of the 45(!) proposals in the forthcoming Social Services Bill for Wales, she lamented that many of the proposals do not go far enough!
In concluding her talk, June stressed that the nurse makes a unique contribution to the handling, and the solving of healthcare and social situations and problems. “She contributes knowledge, she contributes skills and she contributes experience – with compassion and with understanding!” (And I know exactly what she means by this final phrase – I have a daughter trained in terminal care nursing!).
Based at Cochrane Institute of Primary Care and Public Health, Cardiff University, Cardiff, UK.