Informal carer support needs, facilitators and barriers in transitional care for older adults from hospital to home: A scoping review.

AIM: To synthesise evidence about informal carers' (carers) experience of their support needs, facilitators and barriers regarding transitional care of older adults with multimorbidity. BACKGROUND: Carers provide crucial support for older adults during care transitions. Although health practitioners are well positioned to support carers, system factors including limited healthcare resources can compromise the quality of care transitions. DESIGN: Scoping review. METHODS: Searches were undertaken of the published literature. Five databases were searched including MEDLINE, CINAHL, EMBASE, PsycINFO and the Cochrane Library. Two reviewers independently screened articles to identify relevant studies. Studies were retrieved from January 2000 to July 2022. Data were extracted and tabulated for study characteristics, support needs, facilitators and barriers. Key themes and patterns were synthesised across the studies. RESULTS: Eighteen studies including N = 3174 participants were retrieved. Most studies (n = 13) employed qualitative designs. Five studies used surveys. Carers reported their need to: be involved in coordinated discharge planning; advocate and be involved in decision-making; and receive community-based follow-up. Carers described facilitators and barriers in four themes: (1) relationships with the older adult and health practitioners, (2) being involved in coordinated discharge planning; (3) communication and information strategies; and (4) community-based follow-up. Synthesis of themes across all studies resulted in the identification of five areas of research: carers' health literacy; community-based care; carers' involvement in transitional care planning; inpatient and community health practitioners' communication skills; and culturally diverse carers' experiences. CONCLUSION AND RELEVANCE TO CLINICAL PRACTICE: The review highlights the importance of quality communication and relationships between carers, older adults, health practitioners and health organisations. Although information and education are important there is a need for further research to examine systems that support communication between carers, older adults and health practitioners and health literacy for all carers including culturally diverse carers.

Search and rescue incidents among persons 65 years and older in the USA: Examination of factors associated with death.

OBJECTIVES: Older people are vulnerable to becoming lost from home, especially if alone and in unfamiliar environments. Incidents of older persons becoming lost are frequently reported and often requiring a search and rescue (SAR) response. Becoming lost is distressing to the person concerned, their carer, and family and may result in physical injury and/or death. This study examined what factors are associated with death among older persons reported lost from home. METHODS/DESIGN: A retrospective cross-sectional study. Data were obtained from the International Search and Rescue Incident Database from 1985 to 2013. Participants comprised persons aged 65 years and older living in the United States. Individual, SAR incident, and environmental factors were analysed. The primary outcome of this study was lost person found alive or found dead on arrival. Relationships between categorical variables and outcome were summarised with contingency tables, chi-squared test p-values (or Fisher's-exact-test), and odds ratios (OR) with 95% confidence intervals (CI). Association between continuous variables and outcome were examined using multiple logistic regression. p-value of <0.05 was considered significant. RESULTS: Among the 5242 SAR incidents, 1703 met the inclusion criteria, of which 87.8% (n = 1495) were found alive and 12.2% (n = 208) were found dead. Factors associated with death included: male gender (OR 1.46; CI 1.01-2.13; p = 0.048), cognitively intact (OR 0.32; CI 0.22-0.47; p < 0.001), prolonged SAR duration (OR: 1.028; CI: 1.021-1.035; p < 0.001), found in water/wetlands (OR 7.40; CI 3.37-16.24; p < 0.001), and extreme weather (OR: 2.06; 95% CI: 1.10-3.86; p = 0.024). CONCLUSIONS: Older people have a fundamental human right to protection from preventable deaths. Findings indicate these rights are not being protected with deaths occurring frequently among older people who have become lost from home. To minimise fatalities, knowledge of factors associated with death could inform the development suitable assessment and intervention strategies for SAR teams and caregivers.

Strategies to support older adults' mental health during the transition into residential aged care: a qualitative study of multiple stakeholder perspectives.

BACKGROUND: The move from home into residential care is one of the most stressful life experiences for older adults. 'Relocation stress' is a significant risk factor for anxiety and/or depression in aged care residents. Whether long-term or recently diagnosed, these mood disorders are associated with a decline in overall well-being, daily functioning and independence. The mental health needs of older adults are often poorly recognised and supported, including during the transition into residential care. Despite growing interest in how to facilitate this major life transition, few studies have taken the perspective of multiple stakeholders. The aim of this study was to explore resident, relative and staff experiences of the transition into residential aged care, and to identify strategies to support the mental health of older adults at this time. The role of pastoral care practitioners to facilitate transitions and support residents' mental health was also examined. METHODS: This phenomenological study involved individual interviews with 35 aged care residents, relatives and staff, between January and April 2021. Participants were selected using purposive sampling. Audio-recorded interviews were transcribed verbatim and supported by field notes. Data analysis followed Giorgi's steps for qualitative data analysis. RESULTS: Results were distilled into three main categories related to the overall transition experience, recognising and responding to residents' mental health needs, and tailoring support to individual needs. A novel contribution of this study relates to the need to address a broad misunderstanding of the role of pastoral care and subsequent under-utilisation of a potentially valuable resource. CONCLUSIONS: By describing transition experiences and the resources to support residents' mental health, findings of this study provide practical, 'real world' suggestions for reducing relocation stress. New resources developed from the findings include guides, checklists and short question-and-answer films, in which current residents and staff describe strategies to support mental health and overall quality of life. Similar resources could be used to support transitions in other care settings.

End-of-life care in general practice: clinic-based data collection.

BACKGROUND: There are no processes that routinely assess end-of-life care in Australian general practice. This study aimed to develop a data collection process which could collect observational data on end-of-life care from Australian general practitioners (GPs) via a questionnaire and clinical data from general practice software. METHODS: The data collection process was developed based on a modified Delphi study, then pilot tested with GPs through online surveys across three Australian states and data extraction from general practice software, and finally evaluated through participant interviews. RESULTS: The developed data collection process consisted of three questionnaires: Basic Practice Descriptors (32 items), Clinical Data Query (32 items) and GP-completed Questionnaire (21 items). Data extraction from general practice software was performed for 97 decedents of 10 GPs and gathered data on prescriptions, investigations and referral patterns. Reports on care of 272 decedents were provided by 63 GPs. The GP-completed Questionnaire achieved a satisfactory level of validity and reliability. Our interviews with 23 participating GPs demonstrated the feasibility and acceptability of this data collection process in Australian general practice. CONCLUSIONS: The data collection process developed and tested in this study is feasible and acceptable for Australian GPs, and comprehensively covers the major components of end-of-life care. Future studies could develop an automated data extraction tool to reduce the time and recall burden for GPs. These findings will help build a nationwide integrated information network for primary end-of-life care in Australia.

Strategies to optimize aged care volunteer recruitment and retention: A systematic review.

Population aging and resource constraints in aged care indicate an ever increasing need for volunteers in this growing sector. Volunteers in aged care have different expectations and experiences, as they typically form longer and closer relationships with residents, and perform important social support functions that may otherwise not be delivered. Tailored strategies to recruit and retain these volunteers are needed. The aims of this review were to identify the motivations and expectations of aged care volunteers, and to examine strategies that foster their recruitment, retention and role satisfaction. A systematic review of MEDLINE, PsycINFO, CINAHL, Embase and Cochrane Library was conducted. Selection criteria included qualitative and quantitative studies published in English, with no date restrictions. Volunteering roles were restricted to residential aged care services. The 18 studies eligible for review presented consistently strong themes across volunteer motivation, recruitment/retention, and satisfaction/involvement. Implications for policy and practice relate to the importance of setting clear role expectations, matching volunteers' skills with roles, ongoing training and support, and the need for operational frameworks that support volunteers with administrative processes, communication and complaint resolution. Improved volunteer management that enables the consistent provision of social support in this setting stands to improve residents' quality of life.

Resident-to-Resident Elder Mistreatment in Residential Aged Care Services: A Systematic Review of Event Frequency, Type, Resident Characteristics, and History.

OBJECTIVES: Resident-to-resident elder mistreatment (R-REM) between residents living in residential aged care (RAC) services is a challenging issue in relation to the care of older people. Evidence suggests that R-REM, such as verbal, physical, and sexual conflict between residents, is a common and pervasive issue. This review examines the frequency with which R-REM occurs in RAC services; identifies the types of R-REM that occur; and provides an overview of the reported characteristics of both the victim and perpetrator involved in the R-REM event. DESIGN: A systematic review was conducted. We searched MEDLINE, EMBASE, CINAHL, PsycINFO, Ageline, and Cochrane Library to identify qualitative and quantitative studies published in the English language. SETTING AND PARTICIPANTS: Residents living in RAC services. MEASURES: Data on frequency and characteristics were collated, and aggregate proportions were calculated where possible. RESULTS: Twenty-six studies were identified; most (n = 20) were published in the United States. The overall proportion of residents engaged in R-REM was provided by 7 quantitative studies with the estimated frequency reported to be 12% to 23%. For qualitative studies, the number of care staff reporting to have observed R-REM ranged from 18.7% to 98.0%. Physical and verbal abuse were the most commonly reported types of mistreatment. Characteristics of the perpetrator of R-REM were reported in 12 (46.2%) studies. Overall, the mean age of perpetrators was 80.93 years, most were men (83.2%), and 64.4% had dementia and/or Alzheimer diagnosis. Characteristics of the victim and the history of R-REM were largely omitted from the published studies. CONCLUSION AND IMPLICATIONS: The findings from the review broaden understanding on the extent of R-REM; the individual and event characteristics and ultimately support care planning, policy, and direction for future research. To improve understanding, quality of care, and RAC residents' well-being, further studies are recommended to address the identified gaps in knowledge.

Recommendations for reducing harm and improving quality of care for older people in residential respite care.

OBJECTIVES: Residential respite care (RRC) is a vital service that supports older people and their informal caregivers to continue to live in the community. Older people in RRC have an increased risk of injury-related harm, such as choking and suicide, compared to permanent nursing home residents. However, the opportunities for the prevention of harm during a RRC admission are largely unknown. This study developed recommendations to reduce harm and improve quality of care for older people in RRC. METHODS: Experts developed, refined and prioritised recommendations through two consultation forums applying the modified nominal group technique and a follow-up online survey. Participants were purposively sampled from an existing network and were selected based on their expertise in aged care practice, nursing, policy, research, caregiver advocacy and quality improvement in the aged and healthcare sectors. Haddon's Matrix, an injury prevention framework, was applied to the recommendations. Final recommendations were released to over 300 organisations for validation and feedback. RESULTS: Five experts were involved in forum one, seven attended forum two, and a further seven completed the survey. Seventeen draft recommendations were developed and refined to 11 final recommendations, four of which were prioritised as most important for implementation. These included the following: (a) a planned preventative care model of RRC; (b) facilities that specialised in RRC; (c) optimising information gathered on RRC residents; and (d) a standardised procedure for admission, handover and discharge from RRC. We received limited feedback from the organisations, which did not alter the recommendations. IMPLICATIONS FOR PRACTICE: The recommendations developed in this study provide a valuable basis for the development of strategies to reduce harm and improve care in RRC and are a valuable first step towards improving practice. The next step is to empirically test the suggested recommendations to determine their effectiveness.

Applying dignity of risk principles to improve quality of life for vulnerable persons.

OBJECTIVES: Freedom of choice impacts quality of life. Expressed through dignity of risk (DoR), nursing home (NH) residents should be afforded the dignity to take risks to enhance well-being. How DoR is understood and implemented in the context of aged care remains largely unknown. This study explored the meaning and the barriers and facilitators to applying DoR to NH residents. METHODS: Qualitative study, comprising semistructured interviews. Senior policy makers and advocate guardians working in the aged care or disability sector were invited to participate. Recruitment continued until data saturation was reached. Two researchers coded interviews, applying inductive and thematic analysis. RESULTS: Fourteen participants took part during 2016-2017. Analysis demonstrated uniformity in participants' description of DoR, comprising four elements: (a) individuals are at the centre of decision making; (b) life involves risk; (c) individuals must have choice; and (d) DoR is a continuum of experiences. Three main barriers for implementing DoR into practice were identified: (a) balancing autonomy with risks; (b) situational nature of DoR; and (c) taking responsibility for risk. CONCLUSION: The novel findings provide an explicit understanding of DoR and the facilitators and barriers to applying the principle in the NH setting. These findings inform those who engage in making and implementing choices in the presence of risk for vulnerable clients. To translate the multifaceted elements of DoR into practice requires the development of unambiguous policies/guidelines about who will be responsibility for potential risks that may arise from residents' choices. Further, education programmes supporting care staff/management to enact resident choices in the presence of real or perceived risk are required.

Chronic disease management and dementia: a qualitative study of knowledge and needs of staff.

Effective self-management is the cornerstone of chronic disease self-management. However, self-management of chronic disease in patients with comorbid dementia is particularly challenging. It is vital that clinicians, patients and carers work collaboratively to tailor self-management programs to each patient with dementia. This study aimed to identify barriers and facilitators of successful self-management in the context of cognitive impairment in order to optimise the capacity for self-management for persons with dementia (PWD). A qualitative study based on semistructured interviews was conducted in Victoria, Australia. Interviews were conducted with 12 people (employed in the ambulatory and dementia care sectors), representing six health services. Participants identified a healthcare system that is complex, not dementia friendly and not accommodating the needs of PWD who have comorbidities. Individual and systemic barriers contributed to ineffective self-management. Chronic disease support programs do not routinely undertake cognitive assessment or have guidelines for modified management approaches for those with cognitive impairment. Support needs to be long-term and requires a specialised skillset that recognises not only chronic disease management, but also the effect of cognition on self-management. Although formal guidelines are needed, care also needs to be tailored to individual cognitive abilities and deficits.

Recommendations for the prevention of deaths among nursing home residents with unexplained absences.

OBJECTIVES: Unexplained absences (UAs) contribute to the mortality and morbidity rates in the nursing home (NH) population. Valuing expert professional knowledge and skills is central to the achievement of improved care in NHs. This study developed and prioritised recommendations to prevent deaths of NH residents (NHRs) with UAs. METHODS: Two expert consultation forums using the modified nominal group technique to develop recommendations were conducted, followed by an online survey to prioritise the most important recommendations for implementation. A framework applying the temporal dimension ("pre-event," "event" and "post-event") of an internationally accepted injury prevention framework, Haddon's Matrix, was applied to the recommendations. Participants were purposively sampled and identified via aged care organisations; and were selected based on their experience in aged care practice, policy, research, elder rights, seniors' law, or missing persons search and rescue (SAR). RESULTS: Forum one comprised six, and forum two comprised nine experts from mixed disciplines. Seven participants completed the online survey. Twenty recommendations to prevent future injury and death were developed, five of which were prioritised for implementation in the aged care sector. In order of priority, these include: universal UA definition; mandated SAR plan, early assessment of NHRs; unmet needs behavioural assessments; and participation in decision-making. CONCLUSIONS: The recommendations cover the broad spectrum of complex issues raised in managing unexplained absences, and are a vital first step towards informing care providers, governments and SAR teams about how to prevent injury and death of NHRs in residents with UAs. Future research should explore how to translate and evaluate the recommendations into practice.

Unexplained absence resulting in deaths of nursing home residents in Australia-A 13-year retrospective study.

OBJECTIVES: To examine deaths of Australian nursing home (NH) residents following an unexplained absence. METHODS: Population based cross-sectional study was conducted using coronial data from the National Coronial Information System. Participants are residents of accredited NHs if death followed an unexplained absence and was reported to the Coroner between July 1, 2000 and June 30, 2013. Individual, organisational, environmental, and unexplained absence event factors were extracted from coronial records. Data were analysed using descriptive statistics. RESULTS: Of 21 672 NH deaths, 24 (0.1%) followed an unexplained absence. This comprised 17 unintentional external (injury-related) causes and 7 natural cause deaths. Drowning was the most frequent external cause of death (59%, n = 10). Deaths occurred more frequently in males (83.3%, n = 20), and in the age group 85-94 years (37.5%, n = 9). The majority of NH residents, for whom data were available (n = 15), had a diagnosis of dementia (86.7%, n = 13). Most residents were found in waterways (41.7%, n = 10). Median distance travelled was 0.5 km (IQR: 0.25-2.4 km), with almost 70% of residents found within 1.0 km of their NH. Most residents left the NH by foot (88.2%, n = 15). Half of the residents were found within 6 hours of time last seen (median: 6 hours, 40 minutes; IQR: 6.0-11.45 hours). CONCLUSION: Unexplained absences in elderly NH residents are a relatively common event. This study provides valuable information for aged care providers, governments, and search and rescue teams, and should contribute to debates about balancing issues of safety with independence.

Frequency and nature of coroners' recommendations from injury-related deaths among nursing home residents: a retrospective national cross-sectional study.

BACKGROUND: Coroners are tasked with the investigation of unnatural and unexpected deaths. In Australia, the coroner's role also includes making recommendations for promoting interventions to improve public safety. However, the coroners' role in public health and safety in the aged care setting is an underexplored area of research. OBJECTIVES: To describe the frequency and nature of coroners' recommendations for prevention of harm from injury-related deaths among nursing home residents in Australia. SETTING: Accredited nursing homes in Australia. SUBJECTS: Nursing home residents whose deaths resulted from external causes occurring between 1 July 2000 and 31 December 2013 and notified to a coroner. MEASUREMENTS: Coroners' recommendations were identified and extracted from the National Coronial Information System. Descriptive statistical techniques were used to calculate the frequency and proportion of recommendations made. The nature of recommendations was quantified using a method comprising seven elements derived from internationally accepted and applied public health conceptual models of mortality causation and prevention. RESULTS: Coroners made recommendations about the prevention of harm in 53 of the 3289 (1.6%) external cause deaths of nursing home residents. Recommendations were most frequently made for deaths resulting from falls; however, the rate of recommendations per 1000 deaths was highest for thermal mechanisms and complications of clinical care. Most recommendations described the 'countermeasure' element, but rarely specified a timeframe for implementation. CONCLUSION: Coroners' recommendations need to be further enhanced in the age care setting. The development of national and international guidelines on best practice in the formulation of effective recommendations should be undertaken.

Unexplained Absences and Risk of Death and Injury Among Nursing Home Residents: A Systematic Review.

BACKGROUND: Unexplained absence of nursing home (NH) residents is one of the most challenging issues related to the care of older people. The aim of this review was to examine the death and injury outcomes of unexplained absence of NH residents. METHOD: We searched MEDLINE, CINAHL, EMBASE, PsycINFO, AgeLine, and Cochrane Library to identify qualitative and quantitative studies published in the English language. Data on death and injury were collated, and aggregate proportions were calculated where possible. RESULTS: Nine studies were identified; most (n = 6) were conducted in the United States. Persons with dementia formed the study population in all studies. There were 1440 individual unexplained absences reported across the 9 studies. We calculated a rate of 82 deaths and 61 injuries per 1000 incidents of unexplained absence. Extreme temperatures were the most common cause of death. Most individuals left by foot, and were found within a 1-mile radius of place last seen in green vegetation and waterways. CONCLUSION: This review provides valuable insight into death and injury outcomes. Further studies are recommended to improve understanding and prevent adverse outcomes.

Missed Opportunities to Prevent Workplace Injuries and Fatalities.

Prevention efforts, especially in high-income countries, have reduced work-related death and injury. Despite this, the global incidence of workplace fatalities remains unacceptably high with approximately 317 million incidents occurring on the job annually. Of particular concern is the occurrence and re-occurrence of incidents with a similar cause and circumstance, such as fatalities occurring in agriculture and transport industries. Efforts to reduce workplace fatalities include surveillance and reporting, investigation, and regulation. Challenges remain in all three domains, limiting the prevention of work-related injuries and deaths. In this commentary, the nature of these challenges and recommendations on how to overcome them are described. Examples of incidents of workplace injury and death, as well as injury prevention efforts are provided to ensure contextual understanding. Reflecting on the present enhances key stakeholders, policy and decision-makers' understanding of the opportunities to reducing harm and the associated human, and economic and legal costs.