Dr Chad Han

Caring Futures Institute, Flinders University

Pre-frailty and frailty are clinical syndromes that increase an older adult’s risk to higher dependency and are associated with lower survival rates. [1, 2] This is especially important as many older adults already live with multiple chronic conditions such as metabolic diseases and cancers, that make them vulnerable. Frailty (physical) can be described as a syndrome when three or more of the following conditions are present: low physical activity, slow walking speed, unintentional weight loss, weak grip strength, and self-reported exhaustion. [2] Frailty (inclusive of domains other than just physical) can also be defined as deficits in cognition, general health status, functional independence and performance, social support, medication use, nutrition, mood, continence etc. [3] Pre-frailty, as its name suggests, is a state prior to the spectrum of frailty, though a consensus of its definition is underway. [4]

There is a high prevalence of pre-frailty and frailty in Australia. In a cohort of 329 hospitalised older adults at Flinders Medical Centre in Adelaide, more than half (n=220) were either pre-frail or frail, according to the Edmonton Frail Scale. [5] The acute stress of hospitalisation makes it harder for older adults to ‘bounce back’ as they get discharged [1]. There are ways to alleviate that. Multifaceted interventions combining exercise and nutrition as part of management strategies are recommended by The Australian and New Zealand Society for Sarcopenia and Frailty Research (ANZSSFR) Expert Working Group for pre-frail and frail hospitalised older adults. [6] However, the sustainability of these treatments is questionable, and involving a more collaborative partnership approach with patients may be equivalent as existing models but better reduce burden on healthcare resources.

The INDividualized therapy for Elderly Patients using Exercise and Nutrition to reduce depenDENCE post discharge (INDEPENDENCE) pilot program was developed by a group of researchers at Flinders University involving dietitians (Professor Michelle Miller, Dr Alison Yaxley, Dr Chad Han – as part of his PhD with College of Nursing and Health Sciences, Flinders University), a physiotherapist (Dr Claire Baldwin) and a physician (A/Prof Yogesh Sharma). The novelty of this program was the adaptation for pre-frailty and frailty of a chronic condition self-management model developed by Professor Malcolm Battersby, initially for self-management of conditions such as diabetes. [7] The pilot randomised controlled trial, recently published in Clinical Interventions in Aging, showed promising results on the preliminary effectiveness and acceptability of such a self-management hospital-to-home program. [8]

The trial highlighted that this self-management model was well received by participants, having an average participation in activities/visits of above 90%. [8] There were significant improvements in the Edmonton Frail Scale at 3 months (after the active support ended) and a legacy effect at 6 months (3 months after active support was removed). To understand more about the barriers and facilitators to this program, participants of the intervention group were also interviewed. The barriers and enablers we identified highlight the unique and individualized needs of older adults which can aid or hinder adherence (manuscript under preparation).

Intentions, Social influences, Environmental context/resource, and Emotions served as primary barriers towards adherence to both exercise and nutrition components. For example, a participant shared how depressive mood could prevent her from eating better and moving: ‘Now I hate getting out. I just like staying in my bed. I think the earlier I get up, the longer the day is.’ Common enablers for both components included Knowledge, Social identity, Environmental context/resource, Social influences, and Emotions. For example, the acknowledgement of benefits of exercise encouraged a participant to keep doing her exercises: ‘And I knew it was going to build up stamina and give me strength again. So there was a big incentive.’

Want to know more about the INDEPENDENCE pilot program?

• Watch Chad and Barbara (a participant on the INDEPENDENCE program), as they chat about research and the INDEPENDENCE pilot program: https://www.youtube.com/watch?v=zgVLrwdO5NI
• The idea behind this INDEPENDENCE program was also presented at the Asia Pacific finals of the 3-minute thesis competition: https://vimeo.com/632502129

*The views and opinions expressed in Knowledge Blogs are those of the authors and do not necessarily reflect those of ARIIA, Flinders University and/or the Australian Government Department of Health and Aged Care.

Fiona Telford-Sharp, Innovation Manager

ARIIA

In the bright and breezy grounds of Korongee, older people relax among lush gardens or walk curving pathways, coming and going from their charming small houses, or settling in with a book and cuppa at the local café. Experiencing this life and warmth on a recent visit, I felt like I’d wandered into a friendly village, where we knocked on a door and were welcomed into a home shared by several older people who are living with dementia, as are all of the Korongee residents. With minimal visible markers of an institution, it felt like somewhere one could be at home, and the residents I chatted with assured me it was.

A huge challenge of residential aged care has always been that while grouping people together to provide 24/7 care can achieve economies and efficiencies of scale, and increase affordability for funders, it creates institutions. Most of us would not choose to make our home with strangers unless we felt we had to, nor would we choose to mold our daily life to suit the efficiencies of an institution. We all want to live at home, with the freedoms and joys that affords. ‘Small scale living’ or ‘household models’ of residential aged care, such as Korongee, are now proliferating across the world as an alternative to institutional models, but what are the features that make them work, what does make home, home?

The concept of home is one that has fascinated researchers in fields as diverse as architecture, economics, sociology, geography and anthropology. While my ideal home will be different from yours, there are commonalities. For example, Gram-Hanssen and Darby’s [1] work draws on cross-discipline definitions to define four key aspects of home: security and control, a site of activity, a place for relationships and continuity, and a place of identity and values. Other research by Hatcher, Chang, Schmied and Garrido [2] developed similar categories: enabling freedom, being comfortable, staying in touch, and anchoring self. We all probably know instinctively what it feels like to be at home – in my home I control when, where and how I wake, shower, eat and dress. I can invite or deny guests access, I can come and go as I please, and I am surrounded by my belongings which reflect my identity and values. However, using a framework such as the ones above to conceptualise ‘home’, can help aged care organisations and staff to think broadly about practical changes that will impact on the sense of home. Asking questions such as, ‘will this enable control, activity, relationships, and identity?’, ‘what roles would be part of the older person’s routine at home?’ and ‘should this happen at home?’ can help clarify institutional and medicalised aspects of care which prevent people feeling at home. Would you have a uniformed nurse give you eye drops at the dinner table when you are eating together with friends?

Extending this thinking to smart technologies which have potential to help people live safely at home for longer, or live with fewer restrictions in residential aged care, can also help identify the impact of technology on being and feeling at home. For example, implementing surveillance technology in either residential or home care may increase safety, but may also add to institutionalisation. Among all the many considerations involved in implementing new technology, we should prioritise its potential impact on all the dimensions of home. Ask questions such as ‘how can technology ensure the older person is safe and feels at home.’ The Ethics Centre‘s Principles for good technology [3] provides good food for thought on this topic, with principles such as maximise freedom, and fairness.

The questions above are aimed at staff, but of course we should always involve older people themselves in co-design and get to know each individual to really understand what makes them feel most at home. Sometimes what’s important becomes noticeable through its absence, and asking the older person what they miss about their previous home may help you make positive change. In the end, we all want to live at home, and feel at home, rather than live in an institution. To quote Rose, a participant in one of the studies above, at home ’I can do what I like.‘ [2]

*The views and opinions expressed in Knowledge Blogs are those of the authors and do not necessarily reflect those of ARIIA, Flinders University and/or the Australian Government Department of Health and Aged Care.