Applying a trauma-informed approach to home visits

The concept of trauma and traumatic stress and its impact on health and mental health has been studied for nearly half a century. Trauma-informed care (TIC) is person-centered care designed and delivered based on knowledge of the ubiquity of trauma. It requires building an understanding of the role that trauma plays in the lives and health outcomes of survivors. In doing so, it helps promote physical, psychological, and emotional safety for both clinicians and patients. Trauma and traumatic events are cumulative over the lifespan, and individuals who have experienced trauma are at higher risk for re-traumatization and poorer health outcomes. TIC approaches have been applied in many healthcare settings successfully; however, to date, there have not been any recommendations made about applying these approaches to care of homebound older adults, even though it may be surmised that this population is at an especially high risk for prior trauma and entering a person's safe space could be especially sensitive for trauma survivors. This paper serves to provide specific recommendations for applying a trauma-informed approach to a home visit and provides recommendations to home-based primary care groups and health systems about implementing universal trauma-informed care to homebound older adults.

Effect of a Telecare Case Management Program for Older Adults Who Are Homebound During the COVID-19 Pandemic: A Pilot Randomized Clinical Trial

IMPORTANCE

Older adults who are homebound can be difficult to reach owing to their functional limitations and social distancing during the COVID-19 pandemic, leaving their health needs unrecognized at an earlier stage.

OBJECTIVE

To determine the effectiveness of a telecare case management program for older adults who are homebound during the COVID-19 pandemic.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial was conducted among 68 older adults in Hong Kong from May 21 to July 20, 2020, with a last follow-up date of October 20, 2020. Inclusion criteria were being 60 years or older, owning a smartphone, and going outside less than once a week in the previous 6 months.

INTERVENTIONS

Participants in the telecare group received weekly case management from a nurse supported by a social service team via telephone call and weekly video messages covering self-care topics delivered via smartphone for 3 months. Participants in the control group received monthly social telephone calls.

MAIN OUTCOMES AND MEASURES

The primary outcome was the change in general self-efficacy from before the intervention to after the intervention at 3 months. Self-efficacy was measured by the Chinese version of the 10-item, 4-point General Self-efficacy Scale, with higher scores representing higher self-efficacy levels. Analysis was performed on an intention-to-treat basis.

RESULTS

A total of 68 participants who fulfilled the criteria were enrolled (34 in the control group and 34 in the intervention group; 56 [82.4%] were women; and mean [SD] age, 71.8 [6.1] years). At 3 months, there was no statistical difference in self-efficacy between the telecare group and the control group. Scores for self-efficacy improved in both groups (β = 1.68; 95% CI, -0.68 to 4.03; P = .16). No significant differences were found in basic and instrumental activities of daily living, depression, and use of health care services. However, the telecare group showed statistically significant interactions of group and time effects on medication adherence (β = -8.30; 95% CI, -13.14 to -3.47; P = .001) and quality of life (physical component score: β = 4.99; 95% CI, 0.29-9.69; P = .04).

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial, participants who received the telecare program were statistically no different from the control group with respect to changes in self-efficacy, although scores in both groups improved. After the intervention, the telecare group had better medication adherence and quality of life than the control group, although the small sample size may limit generalizability. A large-scale study is needed to confirm these results.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04304989.

Effect of Telehealth Treatment by Lay Counselors vs by Clinicians on Depressive Symptoms Among Older Adults Who Are Homebound: A Randomized Clinical Trial

Importance

Older adults who are homebound and have low income have limited access to psychosocial treatments because of their homebound state and geriatric mental health workforce shortages.

Objective

To evaluate clinical effectiveness of a brief, aging service-integrated, videoconferenced behavioral activation (tele-BA) treatment delivered by lay counselors compared with videoconferenced problem-solving therapy (tele-PST) delivered by licensed clinicians and attention control (AC; telephone support calls).

Design, Setting, and Participants

This 3-group randomized clinical trial using a randomization prior to consent approach included individuals aged 50 years or older who were homebound and had 24-item Hamilton Depression Rating Scale (HAMD) scores of 15 or greater between February 15, 2016, and April 15, 2019. Tele-BA and tele-PST participants received 5 weekly treatment sessions. Assessments were performed at baseline and 12, 24, and 36 weeks after baseline. Intention-to-treat statistical analyses were performed from January 1, 2020, to February 15, 2020.

Interventions

Tele-BA participants were taught 5 steps for reinforcing healthy behaviors to improve mood, physical functioning, and social engagement. Tele-PST participants were taught a 7-step approach for problem solving coping skills.

Main Outcomes and Measures

The primary outcome was the 24-item HAMD scores. Response (ie, ≥50% reduction in HAMD) and remission (ie, HAMD <10) rates and effect sizes for clinically meaningful differences were examined. Secondary outcomes were disability, social engagement and activity frequency, and satisfaction with participation in social roles.

Results

A total of 277 participants were enrolled, including 193 (69.7%) women, 83 (30.0%) who were Black, 81 (29.2%) who were Hispanic, and 255 (92.1%) with income of $35 000 or less. The mean (SD) age was 67.5 (8.9) years. Among these, 90 participants were randomized to tele-BA, 93 participants were randomized to tele-PST, and 94 participants were randomized to the AC. Compared with participants in the AC group, participants in the tele-BA and tele-PST groups had significantly higher response and remission rates and medium to large effect sizes (tele-BA: raw growth modeling analysis d = 0.62 [95% CI, 0.35 to 0.89]; P < .001; tele-PST: raw growth modeling analysis d = 1.00 [95% CI, 0.73 to 1.26]; P < .001) for HAMD scores. While tele-PST was significantly more effective than tele-BA for reducing HAMD scores (t258 = -2.79; P = .006), there was no difference between tele-BA and tele-PST on secondary outcomes.

Conclusions and Relevance

In this randomized clinical trial, participants who received tele-BA by lay counselors achieved statistically and clinically meaningful changes in depressive symptoms. Given shortages of licensed mental health clinicians, tele- and lay counselor-delivered services may help improve access to evidence-based depression treatment for large numbers of underserved older adults.

Trial Registration

ClinicalTrials.gov Identifier: NCT02600754.

"There is a Place": impacts of managed alcohol programs for people experiencing severe alcohol dependence and homelessness

BACKGROUND

The twin problems of severe alcohol dependence and homelessness are associated with precarious living and multiple acute, social and chronic harms. While much attention has been focused on harm reduction services for illicit drug use, there has been less attention to harm reduction for this group. Managed alcohol programs (MAPs) are harm reduction interventions that aim to reduce the harms of severe alcohol use, poverty and homelessness. MAPs typically provide accommodation, health and social supports alongside regularly administered sources of beverage alcohol to stabilize drinking patterns and replace use of non-beverage alcohol (NBA).

METHODS

We examined impacts of MAPs in reducing harms and risks associated with substance use and homelessness. Using case study methodology, data were collected from five MAPs in five Canadian cities with each program constituting a case. In total, 53 program participants, 4 past participants and 50 program staff were interviewed. We used situational analysis to produce a series of "messy", "ordered" and "social arenas" maps that provide insight into the social worlds of participants and the impact of MAPs.

RESULTS

Prior to entering a MAP, participants were often in a revolving world of cycling through multiple arenas (health, justice, housing and shelters) where abstinence from alcohol is often required in order to receive assistance. Residents described living in a street-based survival world characterized by criminalization, unmet health needs, stigma and unsafe spaces for drinking and a world punctuated by multiple losses and disconnections. MAPs disrupt these patterns by providing a harm reduction world in which obtaining accommodation and supports are not contingent on sobriety. MAPs represent a new arena that focuses on reducing harms through provision of safer spaces and supply of alcohol, with opportunities for reconnection with family and friends and for Indigenous participants, Indigenous traditions and cultures. Thus, MAPs are safer spaces but also potentially spaces for healing.

CONCLUSIONS

In a landscape of limited alcohol harm reduction options, MAPs create a new arena for people experiencing severe alcohol dependence and homelessness. While MAPs reduce precarity for participants, programs themselves remain precarious due to ongoing challenges related to lack of understanding of alcohol harm reduction and insecure program funding.

Home and Community-based Services and Life Satisfaction among Homebound and Poor Older Adults

Little evidence exists regarding the role of Home and Community-Based Services (HCBS) utilization on life satisfaction among older people who are both homebound and low-income. Guided by the personal-environment (P-E) fit perspective, this study aims to: (1) describe characteristics of older people with homebound and low-income status; (2) investigate how the combination of homebound and low-income status is associated with life satisfaction; and (3) examine whether HCBS utilization moderates the association between homebound and low-income status and life satisfaction. Data were drawn from the 2012 Health and Retirement Study, and the sample included respondents who were 51+ years who completed a questionnaire for HCBS utilization (n= 1,662). Results describe sociodemographic, health-related, and environmental characteristics of older adults. Combined homebound and low-income status was a significant predictor of lower life satisfaction (β = -0.15, p< .05), but better life satisfaction when they used HCBS (β = 0.33, p <.10). These findings suggest that promoting HCBS utilization is a promising strategy to enhance well-being among those homebound and poor. Further studies are needed to test the effectiveness of HCBS with longitudinal data and to investigate the details of effective HCBS utilization such as frequency of use and types of services.

Home and community-based services coordination for homebound older adults in home-based primary care

BACKGROUND

Medically complex vulnerable older adults often face social challenges that affect compliance with their medical care plans, and thus require home and community-based services (HCBS). This study describes how non-medical social needs of homebound older adults are assessed and addressed within home-based primary care (HBPC) practices, and to identify barriers to coordinating HCBS for patients.

METHODS

An online survey of members of the American Academy of Home Care Medicine (AAHCM) was conducted between March through November 2016 in the United States. A 56-item survey was developed to assess HBPC practice characteristics and how practices identify social needs and coordinate and evaluate HCBS. Data from 101 of the 150 surveys received were included in the analyses. Forty-four percent of respondents were physicians, 24% were nurse practitioners, and 32% were administrators or other HBPC team members.

RESULTS

Nearly all practices (98%) assessed patient social needs, with 78% conducting an assessment during the intake visit, and 88% providing ongoing periodic assessments. Seventy-four percent indicated 'most' or 'all' of their patients needed HCBS in the past 12 months. The most common needs were personal care (84%) and medication adherence (40%), and caregiver support (38%). Of the 86% of practices reporting they coordinate HCBS, 91% followed-up with patients, 84% assisted with applications, and 83% made service referrals. Fifty-seven percent reported that coordination was 'difficult.' The most common barriers to coordinating HCBS included cost to patient (65%), and eligibility requirements (63%). Four of the five most frequently reported barriers were associated with practices reporting it was 'difficult' or 'very difficult' to coordinate HCBS (OR from 2.49 to 3.94, p-values < .05).

CONCLUSIONS

Despite the barriers to addressing non-medical social needs, most HBPC practices provided some level of coordination of HCBS for their high-need, high-cost homebound patients. More efforts are needed to implement and scale care model partnerships between medical and non-medical service providers within HBPC practices.

Correlates of Depressive Symptoms among Homebound and Semi-Homebound Older Adults

This study aimed to provide a national profile of homebound and semi-homebound older adults with depressive symptoms and to compare risk factors of depressive symptoms by homebound status. A sample of 1,885 homebound and semi-homebound older adults was selected from Round 1 of the National Health and Aging Trends Study (NHATS). The prevalence of depressive symptoms was 43.9% in homebound older adults and 28.1% in semi-homebound older adults, representing over 830,000 and 1.4 million individuals in the population, respectively. Nearly two-thirds of homebound and over half of semi-homebound older adults with clinically significant depressive symptoms also had significant anxiety symptoms. Results from logistic regression showed that younger age, certain medical morbidities, severity of functional limitations, and pain were common risk factors for depressive symptoms among homebound and semi-homebound older adults. Some differences in the risk factor profile emerged between the homebound and the semi-homebound populations. Alleviating the burden of depression in the semi-homebound population may focus on early prevention that considers the diversity of this population. Home-based, integrated programs of health and mental health services that simultaneously address the medical, psychiatric, and neurologic comorbidities and disabilities of homebound older adults are needed to meet the complex needs of this population.

Characterizing the high-risk homebound patients in need of nurse practitioner co-management

By providing more frequent provider visits, prompt responses to acute issues, and care coordination, nurse practitioner (NP) co-management has been beneficial for the care of chronically ill older adults. This paper describes the homebound patients with high symptom burden and healthcare utilization who were referred to an NP co-management intervention and outlines key features of the intervention. We compared demographic, clinical, and healthcare utilization data of patients referred for NP co-management within a large home-based primary care (HBPC) program (n = 87) to patients in the HBPC program not referred for co-management (n = 1027). A physician survey found recurrent hospitalizations to be the top reason for co-management referral and a focus group with nurses and social workers noted that co-management patients are typically those with active medical issues more so than psychosocial needs. Co-management patients are younger than non-co-management patients (72.31 vs. 80.30 years old, P < 0.001), with a higher mean Charlson comorbidity score (3.53 vs. 2.47, P = 0.0001). They have higher baseline annual hospitalization rates (2.27 vs. 0.61, P = 0.0005) and total annual home visit rates (13.1 vs. 6.60, P = 0.0001). NP co-management can be utilized in HBPC to provide intensive medical management to high-risk homebound patients.

Factors Associated With Nutritional Risk Among Homebound Older Adults With Depressive Symptoms

OBJECTIVES

This study used the Evans model of public health determinants to identify factors associated with nutritional risk in older adults.

DESIGN

The Evans model domains (physical and mental well-being, social/environmental statuses, individual choice, and economic security) were measured in a sample of homebound older adults. Regularized logistic regression analysis with LASSO penalty function was used to determine the strongest domain of the Evans model. Using traditional logistic regression, individual variables across all domains were compared to identify the significant predictors.

SETTING

Older adults receiving home meal services were referred to the study by community program staff.

PARTICIPANTS

Participants included 164 homebound older adults (age > 60) who endorsed at least one gateway symptom of depression.

MEASUREMENTS

Measurements: Nutritional risk was determined using the Mini Nutritional Assessment. Domains of the Evans model were measured using the MAI Medical Condition Checklist, items from the IADL scale, the Structured Clinical Interview for DSM-IV Axis I Disorders, the Duke Social Support Index, living arrangements, marital status, the Alcohol Use Disorders Identification Test, items from the SCID Screening Module, and a self-report of perceived financial security.

RESULTS

Poor mental well-being, defined by a diagnosis of major depressive disorder, was identified as the strongest Evans model domain in the prediction of nutritional risk. When each variable was independently evaluated across domains, instrumental support (Wald’s Z=-2.24, p=0.03) and a history of drug use (Wald’s Z=-2.40, p=0.02) were significant predictors.

CONCLUSIONS

The Evans model is a useful conceptual framework for understanding nutritional health, with the mental domain found to be the strongest domain predictor of nutritional risk. Among individual variables across domains, having someone to help with shopping and food preparation and a history of drug use were associated with lower nutritional risk. These analyses highlight potential targets of intervention for nutritional risk among older adults.

Six-month postintervention depression and disability outcomes of in-home telehealth problem-solving therapy for depressed, low-income homebound older adults

BACKGROUND

Despite their high rates of depression, homebound older adults have limited access to evidence-based psychotherapy. The purpose of this paper was to report both depression and disability outcomes of telehealth problem-solving therapy (tele-PST via Skype video call) for low-income homebound older adults over 6 months postintervention.

METHODS

A 3-arm randomized controlled trial compared the efficacy of tele-PST to in-person PST and telephone care calls with 158 homebound individuals who were aged 50+ and scored 15+ on the 24-item Hamilton Rating Scale for Depression (HAMD). Treatment effects on depression severity (HAMD score) and disability (score on the WHO Disability Assessment Schedule [WHODAS]) were analyzed using mixed-effects regression with random intercept models. Possible reciprocal relationships between depression and disability were examined with a parallel-process latent growth curve model.

RESULTS

Both tele-PST and in-person PST were efficacious treatments for low-income homebound older adults; however the effects of tele-PST on both depression and disability outcomes were sustained significantly longer than those of in-person PST. Effect sizes (dGMA-raw ) for HAMD score changes at 36 weeks were 0.68 for tele-PST and 0.20 for in-person PST. Effect sizes for WHODAS score changes at 36 weeks were 0.47 for tele-PST and 0.25 for in-person PST. The results also supported reciprocal and indirect effects between depression and disability outcomes.

CONCLUSIONS

The efficacy and potential low cost of tele-delivered psychotherapy show its potential for easy replication and sustainability to reach a large number of underserved older adults and improve their access to mental health services.

Mental health service use among depressed, low-income homebound middle-aged and older adults

OBJECTIVE

This study examined previous mental health service use among low-income homebound middle-aged and older adults who participated in a study testing the feasibility and efficacy of telehealth problem-solving therapy for depression.

METHOD

The sample consisted of 188 homebound adults aged 50 years or older. Data on mental health service use were collected at baseline. We used multivariable logistic regression analysis to examine correlates of different types of outpatient service use within the preceding 12 months.

RESULTS

Of the subjects, 56% reported mental health service use. Of the users, 80% had made at least one primary care mental health visit, 21% had visited a psychiatrist, and 25% had received counseling. Higher depressive symptom severity scores were positively associated with a psychiatrist visit only.

DISCUSSION

The need to improve low-income homebound older adults' access to psychotherapy was clearly evident.

Diogenes syndrome in patients suffering from dementia

Diogenes syndrome (DS) is a behavioral disorder of the elderly. Symptoms include living in extreme squalor, a neglected physical state, and unhygienic conditions. This is accompanied by a self-imposed isolation, the refusal of external help, and a tendency to accumulate unusual objects. To explore the phenomenon of DS in dementia we searched for the terms: "Diogenes syndrome, self-neglect, dementia. " It has long been understood that individuals with dementia often become shut-ins, living in squalor, in the Eastern Baltimore study, dementia was present in 15% of the elderly cases with moderate and severe social breakdown syndrome; twice as many as in the general population of the same age group. Researchers have underlined the frequent presence of DS (36%) in frontotemporal dementia (FTD): different neuropsychological modifications in FTD may contribute to symptoms of DS. The initial treatment should be a behavioral program, but there is not sufficient information regarding pharmacological treatment of the syndrome.

Passive coping response to depressive symptoms among low-income homebound older adults: does it affect depression severity and treatment outcome?

Due to their homebound state, lack of financial resources, and/or other life demands, a significant proportion of depressed, low-income homebound older adults experience depression. Because of their limited access to psychotherapy, most of these older adults self-manage their depressive symptoms. The purposes of this study were to examine (1) the relationship between homebound older adults' coping responses to depressed mood and the severity of their depressive symptoms at baseline (n = 121), and (2) the moderating effect of passive coping responses on the relationship between participation in problem-solving therapy (PST: in-person or telehealth delivery) and depressive symptoms at 12- and 24-week follow-ups. Controlling for the effects of demographic and disability characteristics, cognitive passive coping was significantly associated with baseline depressive symptoms, while behavioral passive coping was not. The main effect of baseline cognitive passive coping response was also significant in mixed-effects regression analysis, but the interaction between coping pattern and group was not significant. The results point to a possibility that cognitive passive copers may have benefited as much from PST as the rest of the PST participants. Further research needs to examine the moderating effect of coping responses to depressive symptoms on treatment efficacy of PST and other psychosocial interventions for late-life depression.

Association between participant-identified problems and depression severity in problem-solving therapy for low-income homebound older adults

OBJECTIVES

The purpose of this study was to examine the relationship between the severity of baseline depressive symptoms and the problems that low-income homebound older adults (n = 66) identified in their problem-solving therapy (PST) sessions.

METHODS

Depressive symptoms were measured with the 24-item Hamilton Rating Scale for Depression (HAMD). Participant-identified problems recorded in the therapists' worksheets were coded into seven categories: living arrangement/housing issues, financial/health care expense issues, family or other relationship issues, hygiene/task issues, social isolation issues, physical/functional health issues, and mental/emotional health issues. T-tests and ordinary least squares regression analyses were used to examine differences in HAMD scores between those who identified any problem in each category and those who did not.

RESULTS

Participants who had living arrangement/housing and family or other relationship issues had higher baseline HAMD scores than the rest of the participants. At 2-week posttest, those with living arrangement/housing issues continued to have higher HAMD scores than the others, whereas those with family or other relationship issues did not.

CONCLUSION

The study findings provide insights into the problems that low-income, depressed homebound individuals bring to their PST sessions. It was not clear if family conflict or other relationship issues contributed to their depression or vice versa, but it appears that PST may have contributed to alleviating depressive symptoms associated with these issues. Precarious living/housing situations appeared to have had a serious depressogenic effect and could not be easily resolved within a short time frame of the PST process, as these issues required formal support.

Thought suppression is associated with psychological distress in homebound older adults

BACKGROUND

Engaging in thought suppression as a coping mechanism has been associated with higher rates of anxiety and depressive disorders in younger adults. Homebound older adults are a population of elders experiencing poor health and high levels of depression and anxiety. It is unclear the extent to which psychological factors, such as thought suppression, are associated with distress, given that their health and disability status may be more salient. The aim of this study was to investigate thought suppression in relation to anxiety and depressive symptoms in homebound older adults.

METHODS

Participants (N = 142) were clients of home-based case management services delivered by aging service agencies in Florida. Participants were administered a research interview that included the White Bear Suppression Inventory, Structured Clinical Interview for DSM-IV Diagnosis (SCID), Brief Symptom Inventory-18 (BSI-18), and Modified Mini-Mental Status Examination (3MS). Case managers provided standard assessments containing functional and health status of the participant.

RESULTS

After controlling for physical health and cognitive functioning, thought suppression was significantly associated with higher likelihood of clinically significant somatic, depressive, and anxiety symptoms on the BSI-18. Thought suppression was also associated with meeting criteria for a SCID depressive or adjustment disorder. Engaging in thought suppression was associated with worse mental health in this sample of homebound older adults even after taking into account physical health, disability, and cognitive functioning.

CONCLUSIONS

These findings suggest the need to develop and test interventions that may address thought suppression as a coping mechanism.

[Homebound status and life space among Japanese community-dwelling elderly in an urban area]

OBJECTIVES

To examine the relationship between homebound status and physical, mental, social and life space factors among community-dwelling elderly in an urban area.

METHODS

A cross-sectional survey was conducted using a mail-in self-administered questionnaire between July and September 2009. The target population comprised 149,991 community residents, aged 65 years and over, living in Setagaya Ward, Tokyo, as of April 2009. "Homebound" was defined as going out (leaving the home) only once a week or less. The respondents were further identified as "type 1" or "type 2" homebound; type 1 included those with a low frequency of outings and low mobility level, and type 2 included those with a low frequency of outings despite having a high mobility level. Questionnaire items encompassed frequency of outings and demographic data, as well as physical, mental, social and life space factors.

RESULTS

A total of 103,684 questionnaires were included in the analysis (valid response rate: 69.1%). Among the participants, 3.7% were found to be type 1 homebound and 4.5% were type 2. The older the age group, the higher was the proportion of both types of homebound. Physical and social factors were associated with type 1 homebound, and physical, mental and social factors with type 2. Moreover, regarding the life space factor, poor physical accessibility of the home was associated with type 2 homebound, and less space utilization in daily life was associated with both types.

CONCLUSION

It is important for homebound reduction among the elderly to address the physical, mental and social factors that affect homebound status. In addition, assessing the current home environment and expanding the daily living space could also be strategies to reduce homebound prevalence among the elderly. Collaboration with the housing and public transportation sectors is needed to plan a comprehensive homebound reduction strategy.

Older homebound women: negotiating reliance on a cane or walker

Canes and walkers are commonly characterized as assistive devices that serve the same purpose: as walking aides. These general views were reappraised and tempered in this descriptive phenomenological study with 40 older women (aged 85 to 98 years) who were unable to leave their homes without help. The purpose was to describe the phenomena of negotiating reliance on canes and walkers as walking devices and the lifeworld context underlying each phenomenon. Relative to lifeworld, there were differences between coming to terms with using a cane and coming to terms with using a walker. Data revealed similarities and distinctions between the basic intentions of relying on canes and walkers and the associated purposes served by canes and walkers. Participants did not view either device as consistently assistive. Findings evoke opportunities for dialogue among older persons, scholars, practitioners, and designers of these devices about coming to terms with such devices and relying on them.

Depression and social networks in community dwelling elders: a descriptive study

Social isolation and inadequate social support have been identified as correlates of depression in older adults, although the relationship between depression and social isolation is not entirely understood (Dorfman et al., 1995). This study was conducted to describe the social networks of depressed older adults living in the community and to compare the social networks of depressed and nondepressed individuals, thus adding to the body of knowledge regarding social networks, older adults, and depression. The sample consisted of 91 respondents aged 65 and older who were randomly selected using the voter registry. About 27% (25) respondents reported significant levels of depressive symptomology as measured by the Center for Epidemiological Studies-Depression Scale (CES-D). All respondents completed semistructured interviews that included questions about social contacts with family and others during the prior week. All participants reported social contact with family and friends during this period. In this sample, depressed elders were not socially isolated. They were more likely to report contacts with friends than those who were not depressed, and equally likely to report involvement in volunteer activities. Their likelihood of seeking social support was also comparable. Results emphasize the importance of peer relationships and suggest that, in some groups of older adults, social isolation may not be a hallmark of depressive symptoms.

Sense of coherence and health among home-dwelling older people

Sense of coherence (SOC) is important for maintaining health. The aim of this study was to investigate if the SOC experience among home-dwelling physically active older people differs from that of hospital patients with the same age and sex. Data were collected with questionnaires and structured interviews containing Antonovsky's SOC scale in an age- and sex-matched study group (n=160). Non-parametric statistical analyses were performed. No differences were found in SOC between home-dwelling individuals and patients. Ninety-five percent of the home-dwelling individuals perceived themselves as being in good health and 42.5% among the patients (p<0.001). SOC and disease were predictors for health in the total study group. Among the home-dwelling individuals, SOC, disease and being single were predictors for health and among the patients solely SOC. When using the components of the SOC concept, comprehensibility and disease predicted health for the home-dwelling individuals and meaningfulness predicted health for the patients.

Being homebound with chronic fatigue syndrome: A multidimensional comparison with outpatients

Many patients with chronic fatigue syndrome (CFS) seem to experience periods in which they are homebound due to their symptomatology. Despite a growing body of research about CFS, little is known about patients who no longer feel able to leave their homes. The purpose of the present study was to examine whether homebound patients differ from other CFS patients on illness-specific characteristics. Besides experiencing more impairment in daily functioning than participants of an outpatient intervention study, homebound patients were characterised by extremely high levels of daily fatigue, predominant somatic attributions, and pervasively passive activity patterns. The course of symptomatology was similarly stable in both groups. Our findings suggest that homebound patients form a distinct subgroup of CFS patients who might profit from a treatment approach that is tailored to their specific needs. The exploratory nature of this first systematic investigation of homebound CFS patients is stressed, and suggestions for future research are made.

Appreciating the Predicament of Housebound Older Adults with Arthritis: Portrait of a Population

This paper draws a socio-demographic, physical, psychosocial, and behavioural profile of housebound older adults with arthritis and compares older adults with rheumatoid arthritis to those with osteoarthritis. Data from 125 housebound older adults with osteoarthritis (65%) or rheumatoid arthritis (35%) were compared to published samples and to population data using appropriate weighting. Respondents were mainly women, living alone, mean age 77 years (SD = 10.50). Symptoms of stiffness, fatigue, and pain intensity were moderate to severe, and a substantial proportion (51.4%) reported depression. Participants reported low levels of health behaviours such as exercise. Overall, older adults with rheumatoid arthritis were significantly younger, reported less pain and limitations, were more optimistic and satisfied with their social life, and had a higher self-efficacy than older adults with osteoarthritis. Home-based pain self-management programs should be constructed considering the unique profiles and needs of this population.

Nurses will always be needed at home

During the last decade, we celebrated the 60th anniversary of the NHS. At the beginning of this new decade – this year – we will mark the 100th anniversary of the death of Florence Nightingale. In celebrating her tremendous contribution to the development of the modern nursing profession, there will no doubt be great emphasis on her work to bring order, cleanliness, infection control, basic patient care and humanity to hospital wards. Much less prominent in most memorials is Florence Nightingale’s seminal contribution to the development of district nursing, about which she advised William Rathbone for many years, and which she admired enormously for its impact on the daily lives of people who received district nurses’ services.

Food choice among homebound older adults: motivations and perceived barriers

OBJECTIVES

The purpose of this paper is to identify: motivations and perceived barriers associated with food choices made by homebound older adults; whether motivations and perceived barriers vary according to social demographic characteristics; and whether motivations and perceived barriers are associated with dietary quality.

DESIGN

This was an observational study using standard interview methods where participants were administered a questionnaire and completed three 24-hour dietary recalls.

SETTING

Participants were interviewed in their homes.

PARTICIPANTS

185 homebound older adults were included.

MEASUREMENT

Motivations were assessed using a modification of The Food Choice Questionnaire and perceived barriers were assessed using the Vailas Food Enjoyment Questionnaire. Participants answered questions regarding social demographic characteristics. Dietary quality measures of adequate intakes of calories, protein, vitamin D, and vitamin B12 were obtained from the three 24-hour dietary recalls.

RESULTS

Mean age was 78.9; 80% were female; and 36% were African American. Key motivations in food choice included sensory appeal, convenience, and price. Key barriers included health, being on a special diet, and being unable to shop. These varied little by social demographics, except for age. Dietary quality varied according to different motivations and barriers.

CONCLUSION

Food choices are based upon a complex interaction between the social and environmental context, the individual, and the food. Efforts to change eating behaviors, especially community-based interventions involving self-management approaches, must carefully take into account individuals' self-perceived motivations and barriers to food selection. Incorporating foods that are tasty, easy to prepare, inexpensive, and that involve caregivers are critical for successful interventions.

Depression is associated with low plasma Abeta42 independently of cardiovascular disease in the homebound elderly

BACKGROUND

Depression often precedes the onset of Alzheimer's disease (AD) before the appearance of cognitive symptoms. Plasma Amyloid-beta peptide 42 (Abeta42) declines before and soon after the onset of AD, yet the relationship between plasma Abeta42 and depression is unclear.

METHODS

We used 515 homebound elders aged 60 and older in a population-based, cross-sectional study to investigate associations between plasma Abeta levels and depression with and without cardiovascular co-morbidities. Depression was evaluated by using the Center for Epidemiological Studies Depression (CES-D) scale. Plasma Abeta40 and Abeta42 were measured.

RESULTS

The elderly with depression had lower plasma Abeta42 (median: 15.3 vs. 18.9, p = 0.008) than those without depression. The CES-D score was inversely associated with plasma Abeta42 (p = 0.001) in subjects with no cardiovascular disease (CVD); however, in the presence of CVD, this association did not exist. Low plasma Abeta42 (OR = 0.41, p = 0.007) and the presence of CVD (OR = 1.84, p = 0.005) were independently associated with depression after adjusting for the confounders of age, stroke and apolipoprotein E4.

CONCLUSIONS

Depressive symptoms are associated with low plasma Abeta42 independently of CVD. Prospective studies are needed to determine whether depression associated with low plasma Abeta42 is a separate depression subtype that could predict the onset of AD.

Comparison of depressive symptoms between homebound older adults and ambulatory older adults

Due to the social isolation imposed by chronic illness and functional limitations, homebound older adults are more vulnerable to depression than their mobility-unimpaired peers. In this study, we compared 81 low-income homebound older adults, aged 60 and older, with their 130 ambulatory peers who attended senior centers, with respect to their depressive symptoms, depression risk and protective factors, and self-reported coping strategies. Even controlling for sociodemographics, health problems, and other life stressors, being homebound, as opposed to participating in senior centers, was significantly associated with higher depressive symptoms. However, when the coping resources-social support and engagement in frequent physical exercise, in particular-were added to the regression model, the homebound state was no longer a significant factor, showing that the coping resources buffered the effect of the homebound state on depressive symptoms. In terms of self-reported coping strategies, even among the depressed respondents, only a small proportion sought professional help, and that was largely limited to consulting their regular physician and social workers, who may not have had professional training in mental health interventions.

Community nurses and self-management of blood glucose

Self-monitoring of blood glucose (SMBG) is commonly recommended to patients with diabetes, although the rationale for this is unclear. This small research project was designed to explore the reasons why nurses working in the community recommend SMBG. Seven interviews were carried out with community nurses caring primarily for housebound patients. Those interviewed believed that a sound evidence-base supported the recommendation that patients test their blood, but not urine, for glucose levels. Though nurses believed in the importance of patient choice and empowerment, the scope for these was limited among housebound patients. There was no evidence that patients understood how to respond to test results, or that comprehensive care planning was normal practice. Although small, this study suggests that nurses working in community settings may need to update their knowledge. It also suggests that a national debate is necessary to disseminate better the evidence about SMBG, and its implications for nursing practice.

Participant Characteristics Predicting Voluntary Early Withdrawal from a Multidisciplinary Program Providing Home-Delivered Meals and Dietitian/Social Work Case Management to Homebound Elders

We examine whether baseline characteristics of participants enrolled in a multidisciplinary program providing home-delivered meals and dietitian/social work case management to homebound seniors predicted voluntary early withdrawal. Sixty-nine participants voluntarily withdrew early and 111 completed the project. Six hypotheses were based on a conceptual framework incorporating (1) agreement between project elements and needs/preferences of individuals and (2) whether participants would improve and no longer require or desire the intervention. Three of the hypotheses were supported by means of logistic regression analysis. Voluntary early withdrawers at baseline: (1) were more mobile, (2) ate less often, and (3) responded that food tastes good less often. The results suggest that carefully considering the interaction of potential participant characteristics and project interventions will improve nutrition project retention.

Psychological responses of pregnant women to an infectious outbreak: a case-control study of the 2003 SARS outbreak in Hong Kong

OBJECTIVE

The aim of the present study was to examine the behavioral and psychological responses of pregnant women during the 2003 severe acute respiratory syndrome (SARS) outbreak in Hong Kong.

METHODS

Ethnographic interviews were first conducted to identify the common psychological and behavioral responses to the outbreak. This was followed by a case-control study of 235 consecutive pregnant women recruited during the SARS epidemic, and a historical cohort of 939 pregnant women recruited a year before the outbreak. Both cohorts completed standardized rating scales on depression, anxiety, and social support.

RESULTS

Women in the SARS cohort adopted behavioral strategies to mitigate their risk of contracting infection. However, pregnant women tended to overestimate the risk of contracting SARS and nearly a third of the women were homebound. The anxiety level of the SARS cohort was slightly higher than that of the pre-SARS control. No statistical difference was found between the depression levels of the two cohorts.

CONCLUSION

The improved social support experienced by pregnant women during SARS might have buffered the stress associated with an outbreak. However, clinicians should monitor for overestimation of infectious risk among pregnant women.

Understanding and tackling fear of crime among older people

In this article, brought to you in association with Help the Aged, Alan Burnett examines the causes of fear of crime among older people, and proposes ways to reduce it.

An exploration of nurse practitioner care to homebound frail elders

PURPOSE

To identify and classify care activities of nurse practitioners (NPs) providing primary care for frail homebound elders and to describe NPs' perceptions of the outcomes of their care activities.

DATA SOURCES

Three focus groups were held with 24 NPs with at least 1-year experience in caring for frail homebound elders to elicit NPs' descriptions of their practice. In addition, individual interviews with 10 NPs and participant observation of 2 NPs visiting elders in their homes validated the data. The total sample size was 36 NPs. Field notes and audiotapes were transcribed for analysis and coded using Brykczynski's existing domains and competencies of NP practice.

CONCLUSIONS

Most of the care activities of NPs providing primary care to frail elders in their home involve management of patient health and illness, case management, and the teaching-coaching function. The NP informants believe that they prevent medication errors, falls, emergency room visits, hospitalizations, and even death. They reported that they improve their patients' quality of life and help to provide a peaceful death when death is imminent.

IMPLICATIONS FOR RESEARCH

Further refinement of the proposed model is needed in order to examine the effectiveness of NP care on clinically relevant patient outcomes.

Mental health services for homebound elders from home health nursing agencies and home care agencies

OBJECTIVE

This study examined the practices of home care agencies and home health nursing agencies in the management and treatment of homebound clients with behavioral problems, dementia, and undiagnosed mental illnesses.

METHODS

A survey was mailed to all 54 directors of agencies in Rhode Island in 2003; 53 responded, either by mail or telephone.

RESULTS

Data indicated a lack of psychiatric services, a reluctance to address behavioral problems, and a failure to identify undiagnosed disorders. There was also a bias against accepting individuals with primary psychiatric disorders.

CONCLUSIONS

Although the population of homebound elders with mental illness is increasing, their needs are not being met by these agencies.

The health status and health promotion behavior of low-income elderly in the Taipei area

The purpose of this study was to understand health promotion behaviors and their correlated factors among low-income elderly in the Taipei area. This study used a cross-sectional design with a descriptive correlation approach. A total of 89 low-income elderly from Peitou District of Taipei participated in the study. Structured questionnaires, the primary sources of measurement, were read to study subjects by a trained research assistant. The mean age of low-income elderly in the study was 76.85 year-old. A plurality were single (41.6%) and 31.5% lived alone. Subject IADLs (instrumental activities of daily living) were not as good as their ADLs (activities of daily living). Their psychosocial health status was worse than their physical health status. Among health promotion behaviors, regular exercise appears to be the most prevalent. The most significant factor among subjects for failing to follow health-promoting behaviors was their IADLs. Homebound elderly who lived alone and had poor IADL were less likely to have health promoting behaviors. A proposal to encourage health promotion behaviors for low-income elderly derived from study results is the initiation of formal personal assistance programs to remedy the inability of many elderly, especially those living alone, to leave the home due to ADL-related or other limitations.

A team approach to bladder retraining: a pilot study

Research has shown that bladder retraining can reverse or reduce symptoms of urge or stress/urge incontinence. An analysis of the A+ Links bladder-retraining program showed improved urinary symptoms and improved quality of life. There were statistically significant reductions in nocturia and episodes of urinary incontinence. There was also a significant increase in the mean amount of urine voided in milliliters. This pilot study appeared to validate and provide evidence that a bladder retraining program is a valuable strategy to reduce the impact of this most debilitating problem.

Improvements in nutritional intake and quality of life among frail homebound older adults receiving home-delivered breakfast and lunch

OBJECTIVE

This study evaluated the influence that expanding a home-delivered meals service to include breakfast and lunch would have on the nutritional status and quality of life of at-risk older adults.

DESIGN

This cross-sectional field study compared two groups. The breakfast group (n=167) received a home-delivered breakfast and lunch, 5 days per week. The comparison group (n=214) received a home-delivered lunch 5 days per week. Participants' 24-hour food recall, demographics, malnutrition risk, functional status, and surveys of quality of life as health, loneliness, food enjoyment, food security, and depression were obtained.

PARTICIPANTS

Study participants were recruited from five Elderly Nutrition Programs involved in the Morning Meals on Wheels breakfast service demonstration project. They formed a geographically and racially/ethnically diverse sample. Participants ranged in age from 60 to 100 years, were functionally limited, and at high nutritional risk. Most were low income, lived alone, and had difficulty shopping or preparing food.

STATISTICAL ANALYSIS

Descriptive statistics were used to assess group comparability. Independent sample t tests were used to examine group differences, with Bonferroni's method used to control for familywise Type I error.

RESULTS

Breakfast group participants had greater energy/nutrient intakes (P<.05), greater levels of food security (P<.05), and fewer depressive symptoms (P<.05) than comparison group participants.

CONCLUSIONS

The addition of a breakfast service to traditional home-delivered meals services can improve the lives of frail, homebound older adults. Agencies should be encouraged to expand meals programs to include a breakfast service to a targeted population.

[Effect of a life review process to improve quality of life for the homebound elderly in Japan]

OBJECTIVE

This study examined the therapeutic effects of Life Review processes on physical and psychological functions of homebound elderly in Japan.

METHODS

From 1998, a cohort of people aged 65 and over living in two cities in Yamagata Prefecture has been followed. Sixty-three subjects (24 men, 39 women) were classified as rank A (homebound). Fifty-two persons completed the baseline survey in 1999 and 46 eligible persons (18 men and 28 women) were allocated to intervention and control groups whose age and sex distribution were matched. Intervention entailed giving some health information and Life Review processing for four months, twice a month on average. Each session started with provision of health information followed by the Life Review process which took an hour to finish. All subjects of both groups were assessed for dependent variables at the beginning and the end of the intervention period (pretest and post-test). Dependent variables were physical (Activities of Daily Living, Visual deficit, and others), psychological (subjective health, life satisfaction, self-efficacy scale, and others), and social (functional ability and frequency of getting out of the house). The control group received only the pretest and the post-test.

RESULTS

Pretest scores for all physical, psychological, and social variables did not significantly differ between the two groups. The rate for improvement/no change were higher with regard to hearing deficit, ADL (eating, dressing), cognition, subjective health, ikigai and frequency of getting out of house in the intervention group than in the control group, but there were no significant differences.

CONCLUSION

The developed intervention program featuring delivery of health information and structured Life Review Process had no negative influence on physical and psycho-social functions. Practicability of the intervention was suggested. But the study highlights problems such as selection of subjects, duration and method of intervention.

Patterns of complementary therapy use by homebound cancer patients in Taiwan

This study explores the use of complementary therapy and factors associated with the use of such therapies by cancer patients in Taiwan who were receiving surgery, chemotherapy, or radiotherapy and lived at home. Data were collected by purposive sampling and analyzed by chi-square testing. Subjects (N = 137) from two Taipei area hospital-based oncology centers were interviewed by using a structured questionnaire. Sixty percent of the total sample used complementary therapies. Variables, such as gender, duration of illness, diagnostic stages, chemotherapy, and symptoms distress, were significantly (p <.05) related to the use of complementary therapies. Western health professionals need to know what complementary therapies their clients are using so that they can respond appropriately to questions raised by their clients, as well as help them to acknowledge diverse kinds of treatment in their therapeutic plans.

[Strategies to reduce bed-ridden or house-bound elderly people in Japan]

Preventive medicine is supposed to be important for reducing bed-ridden ('netakiri', in Japanese) or frail elderly people. Previous studies showed that only about 30% of the bed-ridden elderly had decreased their ADL levels directly due to diseases, such as cerebrovascular disease or hip fracture. One of the other important causes of 'Netakiri' is disused syndrome. A few weeks after staying in bed, not only muscle power but also bone mineral density and intellectual interest often decrease in the elderly. Rehabilitation in daily life is expected to prevent disused syndrome. House-bound ('tojikomori', in Japanese) is supposed to be another cause of reduction of ADL. There are miscellaneous causes of tojikomori. Aging is one of the most important factors, but cannot be modified. Physical, mental, social or environmental factors are also important. Participation in social activity, improvement of intellectual interest and habitual physical excise, as well as prevention of diseases, is expected to be useful for preventing 'tojikomori' and 'netakiri' in the elderly.

[Life with fear of falling after hip fracture]

Elderly people who experienced hip fracture often experience complicated psychological reaction as well as decline in physical functions. In order to avoid falls and re-fractures, they limit various activities resulting to worsening physical performance. This article reports perception among the community dwelling elders who experienced hip fracture, it includes quotation from the interviews conducted with focus clients. Elders were always worried about falling and some avoid the activities that were major cause of hip fracture. Also, they complained of feeling a foreign substance coming dull pain resulting from the bipolar hip prosthesis. They were also worried about being bed-ridden so that they tried to expand their level of mobility, which tend to increase their risk of falling.

Use of psychotropics among home-dwelling nondemented and demented elderly

OBJECTIVE

To describe the use of psychotropics in the nondemented and demented elderly.

PARTICIPANTS

The home-dwelling elderly (n=523) among the random sample of 700 subjects from the total population of individuals aged 75 years or more in 1998 and living in the city of Kuopio, Finland.

METHODS

A trained nurse interviewed the participants about their health and current use of medicines. A geriatrician performed clinical examinations and diagnosed diseases. Dementia and depression were diagnosed according to the DSM-IV criteria.

RESULTS

The demented subjects used more medicines of all kinds (p<0.01), and especially more psychotropics than the nondemented (p<0.001). One in four demented subjects, compared to one in ten nondemented ones used at least two psychotropics (p<0.01). The demented subjects used antipsychotics six times more often than the nondemented ones (p<0.001). Among the nondemented subjects, one out of two antipsychotics users was suffering from depression according to DSM-IV criteria. Three out of four persons who had dementia with Lewy bodies were using psychotropics. Persons with moderate dementia were more commonly using all kinds of psychotropic preparations especially, antipsychotics three times more commonly than persons with mild or severe dementia.

CONCLUSION

Psychotropics, especially antipsychotics, are commonly used in the treatment of both nondemented and demented elderly, even without proper indication. Physicians need more training about the appropriate use of psychotropics to minimize their adverse effects.

Telephone use among noninstitutionalized persons with dementia living alone: mapping out difficulties and response strategies

The aim of this study was to map out and describe difficulties and response strategies in telephone use among elderly, noninstitutionalized persons with dementia living alone. To obtain explorative data, interviews and observations in the homes were undertaken with 10 participants diagnosed with dementia. The participants were observed when showing their telephones, calling a well-known number, responding to a request previously sent by letter to make a telephone call, and finding a number in the telephone directories. The data were analysed using a comparative approach, and resulted in descriptive categories. The participants' difficulties were categorized as difficulty in 'knowing what', 'knowing where', 'knowing how' and overcoming motor, perceptual, verbal and environmental obstacles. In responding to these, they used a variety of environmentally related strategies such as using perception or habits and habitual places, verbalizing aloud, seeking help from others, and adjusting the physical environment. They also used a few cognitively related strategies such as repeating and stopping and reflecting. Overall, difficulties were frequent and common, and the effectiveness of the strategies was questionable. The results indicate that it might be unrealistic to assume that elderly persons with symptoms of dementia who live alone are able to satisfactorily use the telephone for safety, communication and participation in society.

Planning for death but not serious future illness: qualitative study of housebound elderly patients

OBJECTIVE

To understand how elderly patients think about and approach future illness and the end of life.

DESIGN

Qualitative study conducted 1997-9.

SETTING

Physician housecall programme affiliated to US university.

PARTICIPANTS

20 chronically ill housebound patients aged over 75 years who could participate in an interview. Participants identified through purposive and random sampling.

MAIN OUTCOME MEASURES

In-depth semistructured interviews lasting one to two hours.

RESULTS

Sixteen people said that they did not think about the future or did not in general plan for the future. Nineteen were particularly reluctant to think about, discuss, or plan for serious future illness. Instead they described a "one day at a time," "what is to be will be" approach to life, preferring to "cross that bridge" when they got to it. Participants considered end of life matters to be in the hands of God, though 13 participants had made wills and 19 had funeral plans. Although some had completed advance directives, these were not well understood and were intended for use only when death was near and certain.

CONCLUSIONS

The elderly people interviewed for this study were resistant to planning in advance for the hypothetical future, particularly for serious illness when death is possible but not certain.

Treatment of homebound mentally ill elderly patients: the multidisciplinary psychiatric mobile team

Authors evaluated the general feasibility of using a multidisciplinary psychiatric mobile team model for homebound elderly patients. Information was collected with a semistructured interview on 235 homebound elderly patient referrals over a 2.5-year period. Ninety-three subjects were accepted into the program; 12.9% of those accepted required psychiatric hospitalization during the follow-up. Maintaining individuals in the community was achieved with intense case management and significant increases in home-care hours. The multidisciplinary team approach appeared to lessen psychiatric disability in homebound mentally ill elderly patients.

Prevalence and recognition of depressive symptoms among homebound older adults with urinary incontinence

Within a group of homebound elders with urinary incontinence, the objectives of this study were to (1) examine the prevalence of depressive symptoms, (2) examine the extent to which depression had previously been recognized by health care providers, (3) describe the type and intensity of antidepressant treatment prescribed for subjects, and (4) identify the demographic and functional characteristics associated with depressive symptomatology. A descriptive correlational design was used. The 15-item Geriatric Depression Scale (GDS-15) was administered to 345 homebound adults age 60 years and over referred to a study examining the effectiveness of behavioral therapy for urinary incontinence. Individuals were referred to the study by home care nurses from two large Medicare-approved home health agencies in a large metropolitan county in Pennsylvania. Data were collected during in-home assessments and by chart review. Measures included the GDS-15, structured medical history, in-home review of medications, Older Americans Research and Service Center Physical and Instrumental Activities of Daily Living scales, Mini-Mental State Examination (MMSE), Clock Drawing Test, Performance-Based Toileting Assessment, and bladder diaries. One half of the participants (n = 173; 50.1%) had significant depressive symptomatology, with 35.7% having scores suggesting mild depression and 14.5% severe depression. Only 26.4% and 34.7% of those with mild and severe depressive symptoms, respectively, had a previous diagnosis of depression and only 21.7% and 34.0%, respectively, had been prescribed an antidepressant. The most commonly prescribed class of antidepressants was tricyclic antidepressants, being taken by 9.0% (n = 31) of the total sample, 14 (11.4%) of those with mild symptoms and 4 (8.0%) of those with severe depressive symptomatology. A little over half (60.0%) of subjects being treated with antidepressants continued to exhibit significant depressive symptomatology. Greater dependence in physical activities of daily living, the need for assistance during ambulation, higher MMSE scores, and higher levels of comorbidity were associated (P < .05) with a GDS-15 score of 5 or higher. Depression symptoms are common in homebound older adults with urinary incontinence, but clinical recognition and treatment are limited.

Homebound older adults' experiences with the Internet and e-mail

The purpose of this study was to explore homebound older adults' experiences with the Internet and e-mail employing the Dutch phenomenological approach. A sample of 5 homebound older adults was included. All participants were interviewed twice. Data were analyzed employing the technique recommended by Dutch phenomenologists. The analysis resulted in a total of 10 shared themes and a thick description of the homebound older adults' experiences with the Internet and e-mail. The findings indicated that all participants were faced with various challenges in learning the Internet and e-mail. Those difficulties, however, were overcome by continuous practice and support from various sources. Ultimately they found that the Internet and e-mail were excellent sources of support and enjoyment, resulting in an improved quality of life.