Toileting difficulties in older people with and without dementia receiving formal in-home care-A longitudinal study

Availability of family care resources, bathing assistance and toileting assistance among older adults with functional limitations: an evidence-based study from China

BACKGROUND

An aging population has contributed to an increasing prevalence of functional limitations among older adults. Family support plays a crucial role in toileting and bathing assistance. Yet, the relationship between availability of family care resources and such actual assistance remains insufficiently explored. Our study aims to describe availability of family care resources and identify the association between availability of family care resources and toileting assistance or bathing assistance.

METHODS

This study employed a cross-sectional analysis of data from the 2018 National Survey of the China Health and Retirement Longitudinal Study (CHARLS). The availability of family care resources was assessed using measurements of spouse availability, adult child availability, and living arrangement. Bathing assistance and toileting assistance were measured based on self-reported receipt of such assistance. Descriptive statistics were used to depict the overall and subgroup situation of availability of family care resources. Multivariable logistic models were employed to investigate the relationship between availability of family care resources and the receipt of toileting assistance or bathing assistance.

RESULTS

Among the sample of older adults with functional limitations, 69% had a spouse, 63% had at least one adult child, and 80% resided with family members. Among those with bathing disability, 13% reported lacking bathing assistance, and among those with toileting disability, 54% reported lacking toileting assistance. Participants with 1-2 adult children had lower odds of receiving toileting assistance (OR: 0.28, 95% CI: 0.09, 0.91, p= 0.034) compared to those with three or more adult children. Spouse availability and living arrangement did not exhibit statistically significant associations with toileting assistance. Participants without a spouse had lower odds of receiving bathing assistance (OR: 0.27, 95% CI: 0.09-0.78, p= 0.016) in comparison to those with a spouse; however, adult child availability and living arrangement did not display statistically significant associations with bathing assistance.

CONCLUSION

The present findings suggest a gap in family commitment when it comes to assisting older adults with functional limitations in bathing/toileting. To address this, policymakers are encouraged to prioritize the implementation of proactive mechanisms for identifying family caregivers, alongside incentives to enhance their engagement in practical caregiving activities. Furthermore, it is crucial to emphasize the prioritization of affordable and easily accessible formal toileting/bathing assistance options for older adults who lack sufficient family care resources.

Nursing-sensitive quality indicators for quality improvement in Norwegian nursing homes - a modified Delphi study

BACKGROUND

Use of nursing-sensitive quality indicators (QIs) is one way to monitor the quality of care in nursing homes (NHs). The aim of this study was to develop a consensus list of nursing-sensitive QIs for Norwegian NHs.

METHODS

A narrative literature review followed by a non-in-person, two-round, six-step modified Delphi survey was conducted. A five-member project group was established to draw up a list of nursing-sensitive QIs from a preliminary list of 24 QIs selected from Minimum Data Set (2.0) (MDS) and the international Resident Assessment Instrument for Long-Term Care Facilities (interRAI LTCF). We included scientific experts (researchers), clinical experts (healthcare professionals in NHs), and experts of experience (next-of-kin of NH residents). The experts rated nursing-sensitive QIs in two rounds on a seven-point Likert scale. Consensus was based on median value and level of dispersion. Analyses were conducted for four groups: 1) all experts, 2) scientific experts, 3) clinical experts, and 4) experts of experience.

RESULTS

The project group drew up a list of 20 nursing-sensitive QIs. Nineteen QIs were selected from MDS/interRAI LTCF and one ('systematic medication review') from the Norwegian quality assessment system IPLOS ('Statistics linked to individual needs of care'). In the first and second Delphi round, 44 experts (13 researchers, 17 healthcare professionals, 14 next-of-kin) and 28 experts (8 researchers, 10 healthcare professionals, 10 next-of-kin) participated, respectively. The final consensus list consisted of 16 nursing-sensitive QIs, which were ranked in this order by the 'all expert group': 1) systematic medication review, 2) pressure ulcers, 3) behavioral symptoms, 4) pain, 5) dehydration, 6) oral/dental health problems, 7) urinary tract infection, 8) fecal impaction, 9) depression, 10) use of aids that inhibit freedom of movement, 11) participation in activities of interest, 12) participation in social activities, 13) decline in activities of daily living, 14) weight loss, 15) falls, and 16) hearing loss without the use of hearing aids.

CONCLUSIONS

Multidisciplinary experts were able to reach consensus on 16 nursing-sensitive QIs. The results from this study can be used to implement QIs in Norwegian NHs, which can improve the quality of care.

Association between toileting and falls in older adults admitted to the emergency department and hospitalised: a cross-sectional study

OBJECTIVES

This study aimed to explore the potential risk factors associated with toileting-related falls in community-dwelling older adults who presented to the emergency department and were subsequently hospitalised.

DESIGN

This was a cross-sectional study.

SETTING AND PARTICIPANTS

This study was conducted in two teaching hospitals in Shanghai, China between October 2019 and December 2021 among community-dwelling adults aged ≥60 years.

METHODS

In-person interviews, physical assessment and medical record review were performed to collect data on the characteristics and risk factors of falls. Associations of toileting-related falls with demographic characteristics and geriatric syndromes were examined using logistic regression models.

MAIN OUTCOME MEASURES

Potential risk factors for toileting-related falls.

RESULTS

This study included 419 older patients with a mean age of 73.8±9.7 years. Among 60 (14.3%) patients with toileting-related falls (mean age: 78.8±9.2 years), 63.3% of toileting-related falls, mainly occurred between 00:00 and 05:59 hours, compared with 17.3% of non-toileting-related falls, which primarily occurred during the daytime. The rate of recurrent falls (35%) was significantly higher in the toileting-related falls group than in the non-toileting-related falls group (21.2%) (p=0.02). Logistic regression showed that visual impairment (OR 2.7, 95% CI 1.1 to 7.1), cognitive impairment (OR 3.3, 95% CI 1.3 to 8.4), gait instability (OR 3.1, 95% CI 1.1 to 8.8) and urinary incontinence (OR 3.4, 95% CI 1.2 to 9.9) were strongly associated with toileting-related falls. Twenty-three (38.3%) patients in the toileting-related falls group had moderate and severe injuries, compared with 71.7% in the non-toileting-related falls group (p<0.05).

CONCLUSIONS

This study revealed that patients who reported toileting-related falls were more likely to have cognitive impairment, urinary incontinence, gait instability, visual impairment than patients who fell during other activities. Social and healthcare professionals should prioritise the management of toileting activities in older patients and provide targeted interventions to those in the high-risk group.

Differences by cognitive impairment in detailed processes for basic activities of daily living in older adults with dementia

BACKGROUND

Impairment of activities of daily living in patients with dementia has a fundamental and lasting impact on their quality of life and requires a detailed assessment. This study investigated to clarify characteristic of basic activities of daily living (BADL) processes with the severity of cognitive impairment in community-dwelling older adults with dementia using the Process Analysis of Daily Activity for Dementia (PADA-D).

METHODS

Participants were recruited from outpatient departments of 24 hospitals, daycare centres, and home rehabilitation services in Japan. The severity of cognitive impairment was determined using the Mini-mental State Examination (mild: score ≥ 20; moderate: 10 ≤ score < 20; severe: score < 10). Patient's BADL were assessed according to the PADA-D by observation of the occupational therapist and interviews with family members. Basic information and the scores of BADL items of the PADA-D were compared between the three groups. Subsequently, we compared the percentage of independent or non-independent processes included in the sub-items of BADL in the PADA-D.

RESULTS

A total of 143 patients were included in the analysis. Performance on BADL was shown to decrease significantly with increasing severity of cognitive impairment. The percentage of all BADL processes performed ranged from 58% to 100% in mild, 38% to 97% in moderate, and 0% to 88% in severe. Some of the processes included in BADL of PADA-D showed no significant differences in independence between the three groups.

DISCUSSION/CONCLUSION

Most BADL processes differed with respect to different independence rates depending on the severity of cognitive impairment of the older adults with dementia. However, some BADL processes were not associated with the severity of cognitive impairment. Our findings may suggest that a detailed BADL assessment of patients with dementia is useful in terms of caregiver education to avoid excessive caregiving and in predicting BADL impairment.

Practitioners' identification of informal caregivers' difficulties with activities of daily living interventions for older people with dementia in Japan

BACKGROUND

Older people with dementia who cannot perform daily activities independently due to cognitive impairment need support at home and in the community. This study identified aspects of activities of daily living (ADL) interventions that advanced dementia care practitioners recognise as challenging for informal caregivers to perform.

METHODS

We conducted a self-administered cross-sectional survey on advanced dementia care practitioners, including certified nurses, specialising in gerontological, community health, home care, and visiting nursing, nurses specialising in dementia certified by the Japanese Nursing Association, and dementia care leaders certified by prefectural governors. The participants rated a caregivers' extent of difficulty in aspects of ADL interventions on a four-point Likert scale. Factor analysis was performed to determine ADL intervention aspects that are recognised by advanced dementia care practitioners as challenging for informal caregivers.

RESULTS

The highest loaded factors for mild, moderate, and severe cognitive impairment stages were 'right time to draw attention,' 'opportunities to perform ADL,' and 'communicating how to perform ADL without giving up,' respectively. Therefore, it is imperative to educate informal caregivers about the effects of cognitive impairment on ADL performance in people with dementia and enable them to provide concrete ADL interventions and tips to support the persons' autonomy and independence. The Cronbach's alpha values of the highest loaded factors for mild, moderate, and severe cognitive impairment stages were 0.851, 0.925, and 0.946, respectively. Moreover, the cumulative contribution ratios of each stage were 46.04%, 50.52%, and 47.36%, respectively.

CONCLUSION

This study dealt with identifying informal caregivers' difficulties with ADL interventions across the stages of dementia. Informal caregivers should be supported on aspects of ADL interventions that are potentially difficult for them to perform. Useful educational content and approaches in training programs for informal caregivers should be developed to enable them to help people with Alzheimer's disease maintain ADL performance toward 'ageing in place' even as the disease progresses.

Toileting Disability Among Older Adults in China and Role of Environmental Factors

Objectives: We investigated the risk factors associated with toileting disability among older adults in China, focusing on environmental factors (physical, social, and external supports). Methods: Data were drawn from the WHO's SAGE wave 1. We proposed a conceptual framework to guide the selection of risk factors, and implemented logistic regressions separately for urban and rural subpopulations. Results: In both subsamples, older adults who relied on assistive devices were about three times more likely to be toileting-disabled. Rural residents using non-flush toilets were 1.94 more likely to have difficulty toileting than those using flush system toilets. Sharing toilets and did not feel safe in homes were also positively associated with toileting disability. For urban residents, low neighborhood trust was weakly predictive of higher odds of toileting disability. Discussion: This study highlights the importance of environmental factors in explaining toileting disability, and the potential for related policy interventions in developing countries.

Functional difficulties and toileting among older adults in Ghana: evidence from the World Health Organization Study on global AGEing and adult health (SAGE) Ghana Wave 1

Ghana's older population is projected to increase in coming decades and as a result will see increasing care needs. Understanding the functional difficulties older adults experience, and the associated factors, will help identify relevant intervention to assist older adults in meeting their care needs. This study aimed to analyse the prevalence of functional difficulties among older adults in Ghana, and examine how the World Health Organization International Classification of Functioning, Disability and Health (WHO-ICF) conceptual framework can relate to toileting difficulty to understand the factors that increase older adults’ care needs. Data were for 5,096 adults aged ⩾50 years from the WHO Study on global AGEing and adult health (SAGE) Ghana Wave 1. Difficulties were assessed using self-reported difficulty on 22 functional items, including toileting. Multivariate logistic regression tested associations between toileting and other factors as related to the WHO-ICF conceptual framework. Older adults reported climbing one flight of stairs without resting as a common functional difficulty. Difficulty eating was the item least identified. Toileting difficulty was ranked second among five total activities of daily living difficulties. Age, marital status, self-reported health, memory, bodily pain, short- and far-distance vision, obesity, stroke, chronic lung disease, trust at individual and neighbourhood level, toilet facility type, socialising with co-workers, and public and religious meeting attendance were statistically significantly associated with toileting difficulty in the final parsimonious model. Post-hoc analysis testing interaction revealed that interaction existed between female sex and never married marital status (p = 0.04), and obesity and widowed marital status (p = 0.01), with toileting as the outcome. A significant level of functional difficulty existed among Ghanaian older adults in this sample. Toileting difficulty was associated with factors across different components in the WHO-ICF, emphasising functional, social and environmental factors related to this fundamental human activity.

Bathing and toileting difficulties of older adults in rural China: the role of environment

BACKGROUND

For older adults, difficulties in bathing and toileting are often the most prevalent in the index of Activities of daily living (ADL). This study aims to examine how environmental factors are associated with difficulty of bathing and toileting among older adults in rural China.

METHOD

The data are from the 2014 Thousand-Village Survey (TVS), a national survey of Chinese rural residents of old age. The sample consists of 10,689 subjects, 55 years or older, from 536 villages across all provinces of China. Logistic regressions were applied to examine how difficulty of bathing and toileting was related to environmental factors such as geographic location, neighbourhood amenity, and related facilities of bathing and toileting.

RESULTS

Older adults living in the Southern regions of China had lesser difficulty in bathing and toileting than those living in Northern China, controlling for other confounders. Better neighbourhood conditions also reduced the likelihood of having such disabilities. Persons who bathed indoors without showering facilities, in public facilities, and outdoors were significantly more likely to have bathing disability than those who showered indoors with facility. Rural older adults who used pedestal pans and indoor buckets for toileting were more likely to have toileting disability than those who used indoor squatting facilities.

CONCLUSION

Environmental barriers were associated with functional disability among older adults in rural China, but the disabled individuals may change their environments to adapt to their functional capabilities. Our findings suggest that it is imperative to promote the use of showering facilities and pedestal pans for toileting in rural China.

Content of Home-Based Dementia Care: Adverse Consequences of Unmet Toileting Needs

Despite high-intensity caregiving support, those with dementia may experience adverse consequences because the care they receive does not match their care needs. This study evaluates the relationship between content of care (i.e., specific assistance with toileting) and adverse consequences (i.e., toileting accidents because no one was there to help) in a population of community-dwelling Medicare beneficiaries with dementia and impairment in toileting enrolled in the National Health and Aging Trends Study (NHATS). Only two thirds of individuals received specific assistance with toileting, which was associated with a reduced risk of adverse consequences related to toileting in a multivariable model adjusted for key variables including high-intensity caregiving (odds ratio [OR] = 0.36, 95% confidence interval [CI] = [0.23, 0.58]). To ensure care meets the needs of those with dementia living in the community, it is important to consider not only the quantity but also the content of care received.

Working status of caregivers for people with dementia: Analysis data from a Japanese Nationwide Survey

BACKGROUND

The prevalence of dementia has increased rapidly in Japan, while the proportion of the population accounted for by working-age individuals is facing a sharp decline. Optimizing the balance between work and caregiving for persons with dementia is a major public health issue.

AIMS

Using a nationally representative sample, this study investigated the working status of caregivers (CGs) for elderly people (care recipients) with dementia (CRDs) and assessed the effects of sociodemographic factors on this status.

METHODS

Data were obtained from the 2013 Comprehensive Survey of the Living Conditions for CRDs and CGs (the latter aged 65 years or less). Individual data of CRDs and CGs were linked, and 452 pairs were extracted. The Japanese version of the Kessler 6 (K6) with a cut-off point of 13 was used to assess general psychological distress among CGs. Multivariable logistic regression analysis with the forward selection method was used to identify the predictors of their working status.

RESULTS

Overall, the mean age of CGs was 57.1 ± 6.8 years, with 57.5% (260/452) performing paid work. Male sex, higher educational attainment, and having their own house were associated with having paid work for CGs, while higher age, spending almost all day performing nursing care, and participation in helping with toilet activities and laundry were associated with not performing paid work.

CONCLUSIONS

Several sociodemographic factors, including nursing care-related factors, are associated with the employment status of CGs. Further research should examine detailed information on CRDs' activities of daily living, behavioral and psychological symptoms, medical service use, and social support to strengthen the system of supportive services for both CRDs and their CGs.