International responses addressing the under-representation of older people in clinical research.

Older people (aged 65 years +) are under-represented in clinical research across many disease areas. Such exclusions limit the generalisability of trial results and can lead to a gap in critical knowledge regarding the efficacy and safety of interventions in older age groups. International bodies and regulators have addressed this issue to varying degrees. The USA's Food and Drug Administration (FDA) has produced regular non-binding guidance about the inclusion of older trial participants, while the National Institutes of Health's (NIH) binding regulations mean that those seeking research funding must include participants of all ages unless there are scientific or ethical reasons to exclude them. European regulations governing clinical trials of new medications require that participants represent the population groups that are likely to use the product being tested, while Britain highlights the need to improve trial participation of under-served groups, which include older people. Australian clinical trial guidelines point to the potential problem of excluding some groups from research but do not specifically address older participants. While current international approaches may provide some improvements in trial representation, additional strategies are required to promote clinical research that better reflects populations seen in clinical practice. Australia could benefit from clinical trial guidance that highlights the specific issue of the under-representation of older participants and outlines strategies to facilitate greater inclusion. This article provides an overview and critique of the current approaches to the inclusion of older people in clinical research and highlights policy gaps and limitations of current strategies.

A Preliminary Exploration of the Impact of Aged Care Reforms on the Governance of Two Australian Residential Care Facilities.

Objectives: Australia's ongoing aged care reforms have re-focused service provisions from a provider-driven policy approach to a consumer-directed care focus and redirected residential care subsidies. This study aimed (i) to identify the experiences and perceptions of people involved in the governance of residential care facilities about their management of changes due to new accreditation requirements and funding mechanisms, and (ii) to describe their strategic responses to aged care reform changes. Methods: A qualitative description design used interviews exploring perspectives of Board Chairs, Board Directors, and Chief Executive Officers of two NSW-based residential care organizations. Thematic analysis was conducted of interview transcripts. Results: Four key themes emerged from the data: (1) Business strategies and challenges under reform conditions including the need for business diversification and new approaches, (2) costs incurred by the reforms such as compliance with accreditation requirements, (3) workforce demands: for example maintaining staffing levels and training needs, and (4) expectations about maintaining quality of care. Discussion: Changes were necessary in business models for facilities to remain sustainable, meet staffing needs, and continue to provide services in a complex, changing fiscal environment. These included generating revenue streams other than government subsidies, better clarity about government support and establishing partnerships.

From mainstream employment to mainstream retirement: A randomised controlled trial of a transition to retirement intervention for adults with intellectual disability.

BACKGROUND: We evaluated a transition to retirement intervention that adapted strategies used to support employment of people with intellectual disability in mainstream workplaces. The intervention facilitated their independent participation in mainstream community groups and volunteering. METHODS: We randomised 29 older Australians who currently/previously worked in mainstream employment into an intervention group or wait-list control group. Hours of independent participation in target activities were collected before and after the 13-week initial intervention/waiting period, and at 52 weeks for intervention participants. RESULTS: Six of the 12 intervention participants selected an activity and increased hours of independent participation following 13 weeks in the Keeping Active (KA) program and eight were independently accessing their selected activity at 52-week follow-up. None of the 19 wait-list participants increased their independent participation after 13 weeks. CONCLUSIONS: The intervention was effective and highlighted the need to account for factors such as participant choice in evaluation of individualised programs.

'I could no longer cope at home': Experiences of clients and families in residential aged care within the context of Australia's aged care reforms.

OBJECTIVES: Since 2012, Australia has been undertaking major aged care reforms, moving from a previously service provider-focussed approach to a more consumer-oriented policy direction. There is limited research examining consumer perspectives of residential care in the reform environment particularly with respect to both clients and their families. This study explores the lived experiences of clients and families in residential aged care facilities amid the reform implementation process. METHODS: Using a qualitative descriptive research methodology, individual interviews were conducted with clients and family members (n = 10) about their expectations and experiences of residential care. Participants were drawn from two not-for-profit aged care providers. RESULTS: Two broad themes emerged: (i) entering residential aged care and related issues, with subthemes including reasons for entering, decision-making processes, choice of provider/facility and impact of entering care facilities; and (ii) expectations and experiences of care delivery, with subthemes including issues of staffing, service provision, communication and awareness of living in or through the reform environment. The discrepancy between the experiences of care delivered and expectations of initial and changing care needs being met was a major concern. CONCLUSIONS: This study presents a snapshot of the expectations and experiences of both the client and the family cohorts in residential care under the reform conditions. Adequately addressing the relational and interpersonal elements of care delivery is critical in fulfilling the reforms' consumer-oriented objectives.

Perspectives of operational staff working in residential care and aged care reforms.

Australia is undergoing major aged care reforms, changing from the previous service provider-driven approach to consumer-directed care principles. In residential aged care, this has resulted in a significant reduction in government funding in order to support reform initiatives in home and community-based care. There has been limited research on the impact of structural aspects of the reforms such as the effect of changes in funding focus. Using a qualitative descriptive research methodology, this study explores the impact of the reforms on staff at various levels of operational responsibility in residential aged care. Issues identified by participants centered on the capacity to deliver care in three areas, the impact of funding reduction, challenges in meeting increasingly complex needs of residents and their families, and new requirements for care roles within current limitations. This paper provides an insight into how and why operational issues have informed the findings of the current Australian Royal Commission into Aged Care Quality and Safety. It identifies areas of support for the aged care workforce that are crucial in fulfilling consumer-focused care delivery.

Using a smartphone application (App) to assist older adults to navigate their local area during extreme weather events and changing environmental conditions: A qualitative study.

OBJECTIVE: To explore the views of those in later life on the usability of a smartphone application (app) which could assist in negotiating the external environment, particularly during extreme weather and local environmental changes. METHODS: Seven adults aged over 55 years (four women, three men) living in Sydney, Australia, participated in focus groups. Responses were analysed thematically. RESULTS: The findings demonstrate older adults would use a reliable and relevant app to assist in accessing their external environment if it could provide assistance with accurate, up-to-date transport options, road closures, community events and weather. CONCLUSION: If relevant, in real time and locally focussed adults aged over 55 could find value in a mobile app to assist them to navigate their external environment. These results suggest an age-friendly, specifically designed app will have an impact on accessibility to the local environment with the potential to lead to increased walking and social engagement.

Sonographers' level of autonomy in communication in Australian obstetric settings: Does it affect their professional identity?

INTRODUCTION: Unlike the United Kingdom, policies in Australia prevent sonographers from exercising autonomy in their level of communication with pregnant patients in the event of adverse findings. The organisational structure makes the sonographer dependent on the sonologist because sonographers do not have the authority to provide the official report. The emotional labour on sonographers is increased as they struggle to provide patient-centred care, given the limits put on their communication during the ultrasound examination. The aim of this study was to explore Australian sonographers' views on communicating adverse findings, including their level of autonomy in communicating with patients and how this influences their sense of professional identity. METHODS: Following a national survey, seven purposively selected participants, who were qualified to perform obstetric ultrasound examinations, completed follow-up interviews. The interviews were thematically analysed with iterative comparison to the survey results. Three case studies show sonographers differed in their 'communicator type' due to geographical location and workplace setting. RESULTS: The case studies illustrate a sonographer's communication role, and level of autonomy is negotiated/renegotiated depending on the needs and expectations of each workplace. Their communication practices varied due to the sonologist (radiologist/obstetrician) policy on sonographer/patient communication, presence and support in the clinical setting. A strong professional identity and level of autonomy came from the construction of attributes that were built over time based on multiple factors, including previous experience, geographical location, critical incidents, training and supportive work environments. CONCLUSION: The sonography profession demands autonomy and a strong professional identity free of hierarchical barriers within a collaborative model of care.

Retirees' perceptions of goal setting: A qualitative study.

OBJECTIVE: To investigate the language and meanings that retirees give to goals, including their perceptions of the benefits and limitations of pursuing goals in retirement. METHODS: In-depth interviews and mini-group discussions were conducted with 60 community-dwelling Australian retirees aged 57 to 88 years. Data were transcribed and analysed thematically. RESULTS: Responses to the term 'goal' varied by age in relation to the meaning and relevance of the term to retirement planning, largely shaped by the perceived formality and flexibility of goal setting which linked to acceptance or fear of failure when goals were not achieved with three profiles emerging: the Acceptors, the Ambivalent and the Rejectors. Language was highly influential in forming perceptions. CONCLUSION: Retirees' perceptions about the meaning and usefulness of goals varied greatly, with the language used a key factor in the perceived relevance of goal setting.

Australians with intellectual disability share their experiences of retirement from mainstream employment.

BACKGROUND: As part of a larger study exploring the transition to retirement for people with intellectual disability from a working life in mainstream employment, this paper reports on retirement from the perspective of those who have already retired. METHOD: Semi-structured interviews were undertaken with five Australian retirees with intellectual disability. Data were analysed using grounded theory methodology. Employment service records provided background information on participants' employment and supports. RESULTS: Retirement occurred as the solution to ongoing problems primarily related to health. Retirement decisions were made in conjunction with family and support staff, with participants reporting varying levels of self-determination in the process, and mixed feelings about their retirement. None of the participants were participating in mainstream community groups in retirement. CONCLUSIONS: There is a need for retirement preparation for this emerging population to support self-determination in retirement-related decisions including individualized training to facilitate independent participation in mainstream social activities in retirement.

Sonographers' communication in obstetrics: Challenges to their professional role and practice in Australia.

INTRODUCTION/PURPOSE: Despite the clinical importance of patient-centred care in the sonographer/patient interaction in obstetric ultrasound, there has been very little current research in Australia on sonographer and sonologist communication practices in the event of an adverse finding. This study sought the views, experiences and practices of Australian sonographers, particularly in relation to adverse findings, with consideration of the implications for their professional role and practice. METHODS: Qualified and trainee sonographers who perform obstetric ultrasound were invited to complete a survey through the Australasian Sonographers Association. Using qualitative methodology, the authors developed themes on a range of issues related to sonographer and sonologist communication practices and roles from responses to three open-ended questions within the survey. RESULT: Analysis of 249 responses revealed three distinct 'Communicator types'. 'Open Communicators' confidently practice open and direct communication; 'Limited Communicators' perceived barriers preventing them from openly communicating; 'Variable Communicators' indicated various challenging 'grey areas' which created inconsistent communication practices. Variables, such as the complexity of an adverse finding and a reporting sonologist's role, attitude and level of control they exercised over sonographer communication, all influenced respondents' communication practices. Respondents believed professional bodies should agree on a standardised policy regarding sonographers' roles. DISCUSSION: This paper highlights the complexity of the sonographer/patient interaction and outlines the difficulty in providing true patient-centred care in obstetric ultrasound. CONCLUSION: The need for a collaborative, patient-focussed policy, which defines and recognises the role of the sonographer in the event of obstetric adverse findings, will improve the current model of care.

Older Adults' Self-Perceptions of Aging and Being Older: A Scoping Review.

BACKGROUND AND OBJECTIVES: Older adults' self-perceptions of aging and being older can influence well-being and quality of life. This systematic scoping review aimed to map out current research on older adults' self-perceptions of aging and being older. RESEARCH DESIGN AND METHODS: The scoping review followed Arksey and O'Malley's methodological framework. A total of 5,037 records were identified (duplicates removed). After screening, a final 148 papers were included. Descriptives, including year of publication, methodology, age, gender, and location of participants, were calculated. Thematic analyses were conducted examining ways in which the topic was conceptualized. RESULTS: The most frequent method used in the research was quantitative. Participants were from 38 different countries. There were more female participants than male. Seven themes representing the main research emphasis emerged: attitudes towards one's own aging (n = 48), aging well (n = 23), aging stereotypes, self-stigma (n = 23), construction of aging identities (n = 22), subjective age (n = 18), the aging body (n = 8), and future self-views (n = 6). DISCUSSION AND IMPLICATIONS: The research within these themes approach self-perceptions of aging using varying points of reference for what participants compare their age to. The methods used to illicit aging perspectives held their own assumptions about aging.

Best care options for older prisoners with dementia: a scoping review.

INTRODUCTION: The prisoner population is ageing, and consideration is needed for how to best support those with age-related health conditions in the system. Existing work practices and organizational structures often fail to meet the needs of prisoners with dementia, and prison staff experience high levels of burden because of the increased needs of these prisoners. Little is known about the best method of responding to the needs of this growing subpopulation of prisoners. METHOD: A scoping review was conducted to answer the question: what are the perceived best care options for prisoners with dementia? To be included, publications had to be publicly available, reported on research findings, or viewed opinions and commentaries on care practices relevant to older prisoners with dementia. Searches were conducted in 11 databases to identify relevant publications. Data from the included publications were extracted and summarized into themes. RESULTS: Eight themes were identified that could support better care practices for prisoners with dementia: (1) early and ongoing screening for older prisoners; (2) specialized services; (3) specialized units; (4) programs or activities; (5) adaptations to current contexts; (6) early release or parole for older prisoners with dementia deemed at low risk of reoffending; and (7) training younger prisoners (8) as well as staff to assist older prisoners with dementia. Besides practical strategies improving care practice, costs, prison-specific resources, and staff skills were highlighted as care barriers across all themes. A lack of empirical evidence supported these findings. CONCLUSION: One of the implications of the international ageing prison population is the higher number of people living with dementia being incarcerated. Suggestions for best care approaches for prisoners with dementia now need to move from opinion to empirical approaches to guide practice.

Developing a falls prevention program for community-dwelling stroke survivors in Singapore: client and caregiver perspectives.

PURPOSE: Drawing on the perspectives of stroke survivors, family members and domestic helpers, this study explores participants' experiences of self-perceived fall risk factors after stroke, common fall prevention strategies used, and challenges to community participation after a fall. METHODS: Semi-structured interviews were conducted in Singapore with community-dwelling stroke survivors with a previous fall (n = 9), family caregivers (n = 4), and domestic helpers (n = 4) who have cared for a stroke survivor with a previous fall. Purposive sampling was used for recruitment; all interviews were audio-recorded with permission and transcribed. Thematic analysis was conducted using NVivo (v10) software. RESULTS: All participants shared their self-perceived intrinsic and extrinsic fall risk factors and main challenges after a fall. For stroke participants and family caregivers, motivational factors in developing safety strategies after a previous fall(s) include social connectedness, independent living and community participation. For family caregivers and domestic helpers, the stroke survivor's safety is their top priority, however this can also lead to over-protective behavior outside of the rehabilitation process. CONCLUSIONS: Reducing the risk of falls in community-dwelling stroke survivors seems to be more important than promoting community participation among caregivers. The study findings highlight that a structured and client-centered fall prevention program targeting stroke survivors and caregivers is needed in Singapore. Implications for rehabilitation Falls after stroke can lead to functional decline in gait and mobility and restricted self-care activities. Community-dwelling stroke survivors develop adaptive safety strategies after a fall and want to be socially connected. However, caregivers see the safety of the stroke survivors as their top priority and demonstrate over-protective behaviors. Fall prevention programs for community-dwelling stroke survivors should target both stroke survivors and their caregivers. A structured and client-centered fall prevention program targeting at multiple risk factors post-stroke is needed for community-living stroke survivors.

Therapists' perspectives on adapting the Stepping On falls prevention programme for community-dwelling stroke survivors in Singapore.

Purpose: This study investigates the perspectives of rehabilitation therapists on the implementation of fall prevention programmes with community-dwelling stroke survivors in the Singapore context, and elicits recommendations to adapt the Stepping On programme with stroke survivors. Method: Qualitative data were elicited during 4 focus groups with 23 rehabilitation therapists (15 occupational therapists [OTs]; 8 physiotherapists [PTs]) who had received training to deliver the original Stepping On programme, and had experienced delivery of fall-prevention intervention programmes locally. Collected data were analysed using thematic analysis method. Results: Three themes emerged from the focus groups describing: (a) limitations of existing falls prevention intervention for stroke clients; (b) the need to adapt the Stepping On programme to use with stroke clients; and (c) challenges in implementing fall prevention programmes in the stroke context. A series of new components were suggested to be included as part of the Stepping On after stroke (SOAS) programme, including involvement of family members and caregivers, and tailored community reintegration sessions (such as taking public transport and shopping). Conclusions: Rehabilitation therapists describe challenges in addressing fall prevention within a stroke context, and findings highlight the need for a structured, stroke-specific fall prevention programme rather than a more general approach to education and training. Contextual components identified provide valuable inputs towards the development of a culturally relevant fall prevention programme for stroke survivors in Singapore. Implications for Rehabilitation Stroke survivors living in the community are at a high risk of falls. A structured and culturally relevant fall prevention programme for community-living stroke survivors is needed. Falls prevention for community-living stroke survivors should be multi-dimensional and targeting the modifiable risk factors for falls in this group. Both stroke survivors and caregivers should be involved in any fall prevention after stroke programmes.

Climate change and the health of older people in Australia: A scoping review on the role of mobile applications (apps) in ameliorating impact.

OBJECTIVES: Due to the impact of climate change, mobile applications (apps) providing information about the external environment have the potential to improve the health of older people. The purpose of this research was to undertake a scoping review of the evidence on the usability, feasibility and effectiveness of mobile apps to encourage access to activities outside the home in older people. METHODS: A search of databases was undertaken with relevant keywords. Selected manuscripts were judged for relevance to the inclusion criteria and assessed for quality. RESULTS: Very few published studies examined mobile apps specifically designed to prevent, or to treat, chronic disease in ageing populations, and fewer had rigorous designs. No study addressed accessing the external environment in the context of climate change. CONCLUSION: This study demonstrates that there is a gap in the evidence about the mobile apps designed for healthy ageing and, more specifically, to improve access to the external environment.

An Analysis of Factors Associated With Older Workers' Employment Participation and Preferences in Australia.

Australian government and organizational age-management policies continue to target employment participation among older workers in light of an aging population. Typically, efforts to reduce early retirement among older workers have focused on well-established factors, including the promotion of worker health, reducing injury, supporting caregivers, reducing age discrimination and enhancing skill development. This research extends on the former approach by examining established factors along with important emerging factors, namely work-life conflict, work centrality and person-job fit. Additionally, the research analyses the effects of gender and financial pressure on older workers' employment participation and preferences. Logistic regression analysis of cross-sectional survey data involving 1,504 Australians aged 45-65, revealed that two established factors, physical health and caregiving, and all three emerging factors were associated with employment participation and preferences to be employed. However, important variations on the basis of gender and financial pressure were also identified. Caregiving was more strongly associated with the preference to remain employed for men (OR = 0.2.54, p < 0.01) than women (OR = 1.03, ns) and person-job fit was more strongly associated with the preference to remain employed for women (OR = 1.64, p < 0.001) than men (OR = 0.91, ns). Work-life conflict was more strongly associated with the preference to leave employment for those reporting limited financial pressure (OR = 0.60, p < 0.001) compared to those in poorer financial circumstances (OR = 0.87, ns). These findings suggest that organizational age management policies should focus on both established and emerging factors, particularly the provision of flexible working conditions and improving the psychosocial work environment. However, such efforts should carefully consider the different needs of men and women, and those under varying levels of financial stress. With respect to government policy to promote employment participation, the findings support a stronger focus on improving physical and psychosocial work conditions rather than increasing the pension eligibility age. This may require further collaboration between government and employers.

Erognomic education on housework for women with upper limb repetitive strain injury (RSI): a conceptual representation of therapists' clinical reasoning.

BACKGROUND: Ergonomic education in housework that aims to facilitate behavior change is important for women with upper limb repetitive strain injury. Therapists usually conduct such programs based on implicit reasoning. Making this reasoning explicit is important in contributing to the profession's knowledge. AIM: To construct a conceptual representation of how occupational therapists make clinical decisions for such program. METHOD: Based on a constructivist-grounded theory methodology, data were collected through in-depth interviewing with 14 occupational therapists from a major hospital in Singapore. Interviews were audiotaped and transcribed. Data was analyzed with line by line, focused and axial coding with constant data comparison throughout data collection. RESULTS: Therapists made clinical decisions based on their perceptions of their clients' behavior change in three stages: (i) listen; (ii) try; and (iii) persevere, bearing significant similarities to the transtheoretical theory of change. The study also showed that therapists may not have considered the full range of meanings that their clients attach to housework when interacting with them, a gap that needs to be addressed. CONCLUSIONS: The present study indicates the importance of therapists' understanding of the meanings that their clients attach to housework. Further research needs to address how to achieve this in a time-pressured clinical environment. Implications for Rehabilitation This study used qualitative research to demonstrate the process of translating therapists' tacit knowledge into an explicit form. It elucidates the following major implications for practice when therapists conduct ergonomic education to facilitate behavior change in housework for female homemakers with upper limb RSI:The conceptual framework of clinical reasoning constructed from the results can be used to increase therapists' awareness of how they make clinical decisions during an intervention. This framework can also be used for training new therapists. It is important for therapists to actively listen to their clients. Active listening will enable the therapists to understand and consider the personal meanings that these women attach to housework in order to facilitate a behavior change. Client-therapist interactions to facilitate clients' willingness to change should become a major focus in such a program. Similar research should be conducted in other clinical areas to develop explicit clinical reasoning frameworks to facilitate learning of novice therapists and reflection of experienced therapists to address any gap in their clinical reasoning.

Risk Factors for Falls in Community Stroke Survivors: A Systematic Review and Meta-Analysis.

OBJECTIVE: To identify the risk factors for falls in community stroke survivors. DATA SOURCES: A comprehensive search for articles indexed in MEDLINE, Embase, CINAHL, PsycINFO, Cochrane Library, and Web of Science databases was conducted. STUDY SELECTION: Prospective studies investigating fall risk factors in community stroke survivors were included. Reviewers in pair independently screened the articles and determined inclusion through consensus. Studies meeting acceptable quality rating using the Q-Coh tool were included in the meta-analysis. DATA EXTRACTION: Data extraction was done in duplicate by 4 reviewers using a standardized data extraction sheet and confirmed by another independent reviewer for completeness and accuracy. DATA SYNTHESIS: Twenty-one articles met the minimum criteria for inclusion; risk factors investigated by ≥3 studies (n=16) were included in the meta-analysis. The following risk factors had a strong association with all fallers: impaired mobility (odds ratio [OR], 4.36; 95% confidence interval [CI], 2.68-7.10); reduced balance (OR, 3.87; 95% CI, 2.39-6.26); use of sedative or psychotropic medications (OR, 3.19; 95% CI, 1.36-7.48); disability in self-care (OR, 2.30; 95% CI, 1.51-3.49); depression (OR, 2.11; 95% CI, 1.18-3.75); cognitive impairment (OR, 1.75; 95% CI, 1.02-2.99); and history of fall (OR, 1.67; 95% CI, 1.03-2.72). A history of fall (OR, 4.19; 95% CI, 2.05-7.01) had a stronger association with recurrent fallers. CONCLUSIONS: This study confirms that balance and mobility problems, assisted self-care, taking sedative or psychotropic medications, cognitive impairment, depression, and history of falling are associated with falls in community stroke survivors. We recommend that any future research into fall prevention programs should consider addressing these modifiable risk factors. Because the risk factors for falls in community stroke survivors are multifactorial, interventions should be multidimensional.