home adaptations...welcome .. . 2 innov-age magazine issue nineteen autumn 2017 welcome to issue 19...

contributors:

u-drain: It’s so simple PAGE 8

HOMEADAPTATIONS

The links betweenhealthcare,housing,

research and practice… PAGE 4

cochrane reviewPAGE 18

Older people – Delayed transfer of care and tenancy supportNew Charter Homes has co-created an initiative with Tamesidehospital to pilot cost-effective solutions to the healthchallenges that affect older tenants’.

AUTUMN 2017 ISSUE NINETEEN

Dr Ben Maruthappu Co-founder & CEO

Justine Theaker Msc Clinical Lead Therapist for Trauma andOrthopaedics

Manchester University NHS Foundation Trust

Dr Andrew Kingston Phd Chartered Statistician

Newcastle University’s Institute for Ageing. Cera

Welcome...

innov-age magazine issue nineteen autumn 20172

Welcome to issue 19 of Innov-age, focusing on thetopic of home adaptations.

There are numerous benefitsassociated with adapting a home;it can aid in falls reduction, helpindividuals to perform tasks andreduce hospital and care homeadmission rates. Overall,modifications of the homeenvironment can support olderpeople to live independently forlonger, despite their physicallimitations. According to Care and Repair England, 90 percent of older people live in generalhousing and the suitability,condition and modification of alltypes of accommodation areimperative in an ageing society.

Leading this issue, Sarah Achterofand Emily Somerville, withbackgrounds in occupationaltherapy, introduce the topic ofhome adaptations with themesrevolving around older adultsageing in place and howmodifications increase safety,security and independence.

Katie Thompson of the CochraneCollaboration. The piece discussesthe home adaptations from theperspectives of falls, reduction ininjuries and reduced physicalactivity. Can we also take thisopportunity to congratulate Traceyon her appointment to the Boardof Cochrane.

The Home Adaptations Consortiumidentifies the purpose of anadaptation being to modify thehome environment in order torestore or enable independentliving, confidence and dignity forindividuals and their families; thisfocuses on identifying andimplementing a personalisedsolution to facilitate a person livingwithin a disabling environment touse their home more effectively.

This issue of Innov-age portrays ahandful of work streams coveringthis topic, handpicked from theabundance of informationavailable relating to homeadaptations for the elderly.

Dr Ben Maruthappu, CEO ofhome care start-up Cera, talks usthrough how technology-enabledhomecare can help support theelderly to stay independent.

George McCarthy and GedMurphy discuss the U-draintechnology; aiming to improve thelives of patients who use urinenight drainage bags by simplifyingthe process. Justine Theaker, theclinical lead therapist for traumaand orthopaedics at ManchesterUniversity NHS Foundation Trustdiscusses her recent literaturereview on patient adherence topost-operative restrictionsfollowing total hip replacement.

To add to this issue, Dr AndrewKingston, a chartered statisticianbased at Newcastle University’sInstitute for Ageing, discussesunderstanding pathways ofdisability in older people. Thearticle references age-relatedfunctional decline, characterisingdependency and disability as wellas charting and targetinginterventions.

Tony Powell promotes the workNew Charter Group areundertaking with older tenantsand discusses the delayedtransfer of care and tenancysupport between health and social care.

This issue’s Cochrane Corner isauthored by Professor TraceyHowe, Dr Fiona Kennedy and Dr

Editorial foreword

Jackie Oldham

Honorary Director, Edward Centre for HealthcareManagement Research

autumn 2017 issue nineteen innov-age magazine 3

Edward Centre for HealthcareManagement Research,Citylabs,Nelson Street,Manchester,M13 9NQ

[email protected]

0161 276 4473

If you would like to subscribe forfree, contribute or have any otherenquiries, please contact the teamor visit our website. We lookforward to hearing from you.

Editorial Team Jackie Oldham, Charlotte Haseler,Richard Deed, Peter Bullock.

ContributorsJackie Oldham, Sarah Achterof,Emily Somerville, Ben Maruthappu,Ged Murphy, George McCarthy,Justine Theaker, Andrew Kingston,Tony Powell, Tracey Howe, FionaKennedy, Katie Thomson.

Innov-age® is the official magazine of the EdwardCentre for Healthcare Management Research, part of the Edward Healthcare group of companies.

Published in the UK by Edward Centre for HealthcareManagement Research, part of the Edward Healthcaregroup of companies. Innov-age is produced inassociation with TRUSTECH, MIMIT and MAHSC.

© 2017 Edward Centre for Healthcare ManagementResearch, part of the Edward Healthcare group of companies.

The contents of this publication are protected bycopyright. All rights reserved. No part of thispublication may be reproduced, stored in anyretrieval system or transmitted in any way form or by any means without the written permission of thepublisher. The views expressed in this publication arenot necessarily those of the publisher or editorialteam. While the publisher and editorial team havetaken every care with regard to accuracy of contentthey cannot be held responsible for any errors oromissions contained therein.

Designed and printed by Corner House Design and Print Limited0161 777 6000 www.cornerhousedesign.co.uk

ISSN 2052-5753 (Print)

Contents

page

Editorial Foreword2Insight – The links between healthcare &housing, research & practice4

How technology is transforming social care 7

U-drain: It’s so simple8

News…10Do patients adhere to post-operativerestrictions following Total Hip Replacement?12Understanding pathways of disability inolder people – live longer, die shorter14Older People – Delayed transfer of care andtenancy support16

Cochrane Corner - Review18

Spotlight on…19

Winter Issue – Respiratory 20

Insight


The links between healthcare& housing, research & practice

When faced with the decision of where to live safelyand independently, the majority of older adults chooseto stay at home, or “age-in-place.” Aging-in-place isdefined as “the ability to live in one’s own home andcommunity safely, independently, and comfortably,regardless of age, income, or ability level (CDC2013).” Indeed the older adult population tends tospend the vast majority of their time at home, withthose over 85 years old spending about 90% of theirtime at home (Donald, 2009). The home environmentis closely linked to health outcomes, especially as oneages. Safe and accessible housing has been found todecrease incidence of chronic conditions such as heartdisease, stroke, respiratory conditions, mental illness,and arthritis (The Housing and Ageing Alliance, 2013).

It is within many health care practitioners’ scope ofpractice to address concerns related to healthy aging-in-place and to be knowledgeable about the availableresources and support. As the population of olderadults continues to grow, this is becoming anincreasingly relevant topic that health carepractitioners should be prepared to address.

The most recent edition of the InternationalClassification of Functioning (ICF 10), a frameworkadopted by the World Health Organization fordescribing and organizing information on functioningand disability, endorses the notion that it is notnecessarily the person that needs to adapt to theirenvironment, but rather the environment needs to be

adapted to fit the person and their changingcapabilities (World Health Organization, 2001). Thisidea has been further described by psychologistsLawton and Nahemow in their Ecological Model, as an individual’s performance is maximized when thedemands of the environment match the individual’sabilities (Lawton and Nahemow, 1973). For example, aperson who uses a wheelchair may not be able to fullyparticipate in daily activities if key components of theirenvironment are above wheelchair level. However, ifthe environmental demands are decreased by loweringobjects such as light switches, thermostats, andshelves into reach range, the wheelchair user has thepotential to perform optimally again. These changes tothe environment are known as the home modificationprocess.

Home modifications are defined as changes to a homethat increase usage, safety, security, andindependence. Home modifications include adaptiveequipment, customized or off-the-shelf technology,hardware and controls, as well as completearchitectural modifications (e.g. remodeling abathroom to include a roll-in shower for a wheelchairuser). Occupational therapists (OTs) are trained inrecognizing how the environment affects the ability toperform desired occupations or activities of daily living(American Occupational Therapy Association, 2014).Current evidence supports home modifications toimprove daily activity performance, reduce fall risk,and decrease demands on caregivers.

Sarah Achterhof is an occupational therapy student at University of Wisconsin-Madison. Sarah willgraduate with her Masters of Science in Occupational Therapy in December 2017. Her clinicalinterests include helping rural-dwelling older adults age-in-place with home modifications.

Emily Somerville is an occupational therapist at Washington University in St. Louis. Her primaryclinical and research interests include keeping older adults safe and independent at home and inthe community. She has a particular interest in medication management in older adults who liveat home and will complete her doctoral work on this topic in December of 2017.

Emily Somerville ,

Occupational Therapist


Comprehensive home modification interventionsconsist of an assessment of the individual’s personalabilities, assessment of the home environment,occupational goals, an intervention plan to remediatebarriers, implementation of or support for theimplementation of the plan, and training of the clientor caregiver to complete their daily activities usingenvironmental support. These are often more effectivethan less comprehensive interventions (Stark et al,2017).

An example of an assessment designed to evaluatethe older adult’s performance in the homeenvironment is the In-Home OccupationalPerformance Evaluation (I-HOPE). This valid andreliable tool was developed by the ParticipationEnvironment Performance Lab (PEPL) at WashingtonUniversity in St. Louis. The I-HOPE asks the olderadult to prioritize difficult activities, and the OTobserves the individual perform these activities incontext. The OT also identifies and rates the impact ofenvironmental barriers on the individual’s performance(Stark, Somerville, and Morris, 2010) (see Figure 1).This allows the therapist to begin to problem solvehow those barriers can be removed and how to usethe environment to support instead of hinder dailyactivities.

To contribute to the evidence-based homemodification literature, PEPL conducts community-based research to promote the participation of olderadults with functional limitations and reduce falls

through the provision of intensive, tailored homemodification interventions. The evidence shows thathome modifications are effective in promotingparticipation in daily activities and decreasing falls.Therefore, PEPL works to translate these findings intoeveryday clinical practice by identifying and resolvingbarriers to implementation of home modifications.Members of the lab collaborate with colleagues from avariety of disciplines including Engineering, Pharmacy,Nursing, Physical Therapy, and Medicine. The lab hasa strong network of community partners and manycolleagues in the U.S. and internationally thatcollaborate on projects.

Recently members of PEPL have conducted tworesearch studies that have helped to inform bestpractice. The first study, COMPASS, sought todetermine the feasibility of implementing a tailoredhome modification intervention designed to increasecommunity participation of older adult stroke survivorsduring their transition home after in-patientrehabilitation. Participants were assigned to treatmentor control groups randomly. Participants in thetreatment group received four to five 90-minute homevisits with a home modification intervention prior todischarge, as well as training in communityparticipation once they returned home. Participants inthe control group received stroke education over thecourse of four to five 90-minute sessions. Participantsin the treatment group who received homemodifications experienced greater involvement in thecommunity and had fewer environmental barriers intheir home impacting their ability to complete dailyactivities. In addition, the more highly impairedparticipants who received the home modificationintervention experienced meaningful changes inactivity and participation scores on the I-HOPE.

PEPL also conducted a randomized controlled trial ofhome modifications for older adults who hadexperienced a recent fall. Participants in the treatmentgroup received two to three 90-minute visits over thecourse of two to three weeks. The incidence of a firstfall in the home in the first 260 days was increased toover twice the risk for those who did not receive home

Sarah Achterhof ,

Occupational Therapy Student

University of Wisconsin-Madison

continued on next page

Washington University, St Louis

Figure 1 - I-HOPE assessment process

Step 3:Performance-based Ratingof Barriers’Influence onPerformance

Step 2:PrioritizeActivitiesand Rate

Performance

Step 1:Card Sort


Insight

Stark, S. L., Somerville, E. K., & Morris, J. C. (2010). In-Home Occupational PerformanceEvaluation (I-HOPE). American Journal of Occupational Therapy, 64(4), 580–589.Available at: http://dx.doi.org/10.5014/ajot.2010.08065 Stark, S. L., Somerville, E., Keglovits, M., Smason, A., & Bigham, K. (2015). Clinicalreasoning guideline for home modification interventions. American Journal ofOccupational Therapy, 69, 6902290030. Available at:http://dx.doi.org/10.5014/ajot.2015.014266Stark, S., Keglovits, M., Arbesman, M., Lieberman, D. (2017). Effect of homemodification interventions on the participation of community-dwelling adults with healthconditions: A systematic review. American Journal of Occupational Therapy, 71,7102290010. Available at: https://doi.org/10.5014/ajot.2017.018887.World Health Organization (2001). International Classification of Functioning, Disabilityand Health (ICF) Available at: http://www.who.int/classifications/icf/en/

modifications. Performance of a task or activity,satisfaction with performance, and environmentalbarriers to performance were significantly improvedfor the home modification participants compared withcontrols.

Additional evidence produced by PEPL further outlineshow to make home modifications effective. First, homemodifications need to be tailored to the individualneeds and preferences of the individual. Tailoring includes considerations such as preferencefor aesthetics, who else is using the space, whetherthe individual is renting or owns the property, and theclinical course of the individual’s health.

Recommendations for home modifications mustconsider these factors, as well as others, to ensurethat the modification will be acceptable and usable bythe older adult (Stark et al, 2015). For example, someolder adults might be opposed to grab bars becausethey can make a bathroom look institutionalized.

However, if the therapist presents the older adult withoptions that are designed to blend into the existingdécor, the older adult is often more receptive to themand will take steps to implement them. Anotherexample includes an older adult who rents theirapartment and has grab bars that are slippery, butdoes not have permission to permanently alter theexisting structure. Instead of recommending new grabbars or a spray-on adhesive that would alter the grabbars, the OT can recommend removable non-slip grabbar covers (see Figure 2). These eliminate the barrierof slippery grab bars, but are tailored to the client’ssituation. Making sure the home modificationrecommendation is tailored to meet all needs andpreferences will increase effectiveness by ensuring thelasting use of the modification.

Findings from PEPL’s research also indicate that theintervention must be intensive, or about 90 minutes inlength, delivered once a week over the course of amonth. Visits of this length and frequency allow foroptimal comprehension, quick training on newequipment or architectural modifications, andincreased ability to independently identify and solvenew environmental barriers that might arise after theOT is finished with formal treatment. These principlesare to be applied to a home modification interventionto increase ability to complete daily activities in thehome as well as to prevent falls.

As the population continues to age, health careproviders should continue to recognize the need foraccessible housing to allow older adults to age-in-place safely and independently. Familiarizing oneselfwith the available resources and referring to an OTwhen necessary are all appropriate responses to thishealth care need. Making this a priority and providingthese necessary services to older adults in thecommunity has the potential to improve quality of lifeand functional abilities.

References:American Occupational Therapy Association (2014). Occupational Therapy Practice.Framework: Domain & Process, 3rd Edition. The American Journal of OccupationalTherapy, 68(Supplement 1), S1-S48.Centers for Disease Control and Prevention (2013). Healthy Places Terminology.https://www.cdc.gov/healthyplaces/terminology.htm. Donald, I. (2009). Housing and healthcare for older people. Age and Ageing, 38(4), 364–367, Available at: https://doi.org/10.1093/ageing/afp060The Housing and Ageing Alliance (2013). Policy Paper: Health, Housing, and AgeingLawton M.P. & Nahemow, L. (1973). Ecology and the aging process. In C. Eisdorfer &M.P. Lawton (Eds.) Psychology of Adult Development and Aging. 619–674.Stark, S., Landsbaum, A., Palmer, J., Somerville, E., & Morris, J. (2009). Client-centeredhome modifications improve daily activity performance of older adults. Canadian Journalof Occupational Therapy, 76(Spec No), 235-245.

Figure 2 - Before and After Home Modifications – rubberadded to grab bar


Dr Ben Maruthappu

Co-founder & CEO

Cera

How technology is transforming social care Ben Maruthappu is a practising doctor and advisor to the NHS on over £100 billion of health spending, focusingon technology. He built the NHS Accelerator which scaled technology innovations to over 3 million patients in itits first 6 months. Educated at Oxford, Cambridge and Harvard Universities, Ben was the first person from Britishhealthcare included in Forbes’ prestigious 30under30 list. He recently ranked amongst the 100 most influentialleaders in health technology globally.

While health and social care industries are oftencharacterised separately, their common goal is to fulfil theoverwhelming demand for patient care, both in hospitalsand at home. Inevitably then, attempts have been made to more overtly unify these two sectors in recent years. In April 2016, for example, local authorities in GreaterManchester merged the organisation of health and socialcare through a reform dubbed “Devo Manc’’ after takingcontrol of the area’s £6bn healthcare budget.

Better collaboration between health and social care viacutting-edge technology, specifically in the homecare spacehas also begun to be witnessed. From achieving greatereconomies of scale and efficiency to ensuring greatertransparency and empowerment of care workers,technology is already making great strides to improve howhomecare is delivered up and down the country.

Technology-enabled homecare provides a win-win scenariofor various parties. It enables a faster transfer of patientsfrom hospital beds to the comfort of their own home; italleviates existing strains on hospitals and patients, who arein need of essential provisions like beds and care workers; itfacilitates a wider range of social care service provision andflexibility; and it also supports relatives of patients whomight take on additional caring responsibilities out ofnecessity. Home adaptations serve to alleviate thesepressures.

An acknowledged medical reality is that elderly patients aremore susceptible to multiple conditions that cansubsequently require multiple care visits in a day, quitefeasibly of a varying nature in each instance. At Cera, forexample, an ‘on-demand’ service is provided, where userscan request a care visit as and when required, tailored tothe their specific needs. Through Cera’s technologyplatform, each patient can be matched with the right carer,at the right time, within 24 hours. With hundreds of carehomes closing, it is clear that this model of quick andreliable social care is set to stay.

Social care has long been living in the past, and it is up toinnovative providers to bring cutting-edge technology to thesector, with the view of bringing greater independence tothe elderly, and helping them make the most of their lateryears. This hyperconnectedness – joining the dots betweenhealth and social care – is part of a wider phenomenontaking place around the world called ‘The Internet of Things’(IoT). The principle of IoT is to embrace technology andconnectivity on a universal scale, with the potential topervade every aspect of daily life.

In a social care context, IoT has advocated thesynchronisation of household appliances with predictable

routines. For example, a member of the elderly communitymight wake up every morning and use their kettle. Onemorning, they slip and hurt themselves and don't use thekettle. IoT proposes a system of integration that would notethe failure to adhere to a typical routine and takeprogressive action. Notifications would be sent to nearbyfamily members or carers, prompting them to investigate(Maiden, 2016a).

This is just one hypothetical scenario in which increasedintegration of technology into the typical domestic settingcan benefit consumers. IoT also envisages refrigeratorswhich track stock of fridge contents, as well as expirationdates, and take on the responsibility of orderingreplacement items via the internet – an appliance thatrestocks itself (Mckim, 2017). The scope for this is evenmore feasible considering the delivery capabilities of dronesthat are becoming more commonplace around the world.Again, visions such as self-stocking refrigerators all serveto alleviate excessive errands for the elderly, improving theirlevels of independence (Maiden, 2016b).

When it comes to joining the dots between health andsocial care, the application of this level of interconnectivityis already gaining traction. Artificial Intelligence such asCera’s ‘Martha’ – the UK’s first-ever social care chatbot –helps not only the patients using Cera but also the carers.Very soon, Martha will also be capable of answeringquestions that a care worker may have based on a patient’sdigital care records, and provide crucial advice if somethingcauses concern. For example, if a care worker notes that“Mrs. Taylor seems quite feverish,” Martha might respondwith “Mrs. Taylor had a cough recently, you may want tocheck her temperature and take note of her othersymptoms.”

Of course, technology is not a standalone solution. Manyexisting tech solutions in the health industry are aimed atyoung and healthy smartphone users, ignoring those whoattend A&E most frequently and use the most healthcareresources - the elderly. In order to really experience change,it is time to start focusing on those with multiple healthneeds, who could benefit the greatest from technology, withthe potential to deliver the greatest savings to the healthand care system.

References:Maiden J (2016a), Why we need the Internet of Things and its connected toasters.[online]. Last modified 11 May. https://www.linkedin.com/pulse/why-we-need-internet-things-its-connected-toasters-john-maiden Maiden J (2016b), “The Internet of What?” – How I explain the Internet of Things to myfriends. [online]. Last modified 25 February. https://www.linkedin.com/pulse/internet-what-how-i-explain-things-my-friends-john-maiden?trk=prof-post McKim K (2017), FPS takes flight with first commercial UK drone delivery. [online].http://uk.prweb.com/releases/2015/03/prweb12602535.htm

U-drain: It’s so simple!George McCarthy and Ged Murphy’s friendship began 30 years ago whilst working together at BT.Since that day both have enjoyed successful employment in varying fields. George became ManagingDirector of a European fibre optics company and then a successful property developer. Ged alsoworked in Europe testing fibre optics links until he returned to University and received a first classdegree in Physics and Biology and went on to teach science at a local secondary school. The variousskills accumulated would prove extremely beneficial in the U-drain story.

Twelve years ago George broke the shattering news that hehad colon cancer. He would undertake radiotherapy, followedby surgery leaving him with a colostomy and a urostomy.Whilst recuperating in The Christie Hospital Manchester,George was advised by his stoma nurse that there was notan alternative to night drainage bags (NDB’s). NDB’s aretwo litre plastic bags that collect excess urine from theurostomy pouch throughout the night (Black, 1997). Oncehome, George became “psychologically challenged” withusing the NDB’s, hindering his rehabilitation (Roe, et al1987). He was horrified by the urine spills (Suman et al,2016), the bedroom smelling of urine, the morbid chore ofcarrying, emptying and cleaning them. They became aconstant reminder of his illness. George desperately neededan alternative to NDB’s.

Family and work commitments meant that the invention of anovel urine drainage system was confined to Friday nightmeetings between George and Ged. A simple socket locatedclose to the bed, plumbed into the household waste system,all drained by gravity, was to be the answer. At night patientswould connect their urostomy pouch to the socket, via anextra long connecting tube (now on prescription in the UK).Urine would flow away throughout the night, into thehousehold waste system. In the morning the patient woulduncouple the tubing from the urostomy pouch and flush thesystem with U-drain disinfectant. At last, no more NDB’s!!!!

A patent was applied for in the UK, US, Australia and EU,and granted four years later. Trialists came forward fromacross the world and their testimonials were so positive andhumbling, that U-drain Ltd was born. A local business manGerry Mason, founder of Morson Group, invested in thecompany and the NHS awarded U-drain a framework tosupply the system to patients across the UK. It was not longbefore health and social care professionals and care homedevelopers saw the benefits of U-drain leading to it beinginstalled in to many assisted living and extra caredevelopments across the UK.

As well as the obvious patient benefits, time saving, urinefree smell, discreet and increased patient dignity, maybethere were more benefits to be gained both for patients andthe NHS financially?

Whilst undertaking a literature review for CE markregistration, it was found that NDB’s may be an importantpotential source of Pseudomonas for nosocomial infection(Montgomerie & Morrow, 1980; Nash, 2003). Beetz (2003)and Lin (2013) postulated that patients who increased theirfluid intake had lower rates of urinary bacterial infections.Maybe these were the reasons that all U-drain urologycustomers found the number of UTI’s had significantly fallenonce they started using U-drain. U-drain patients believedtheir incidence of urinary tract infections had decreased dueto them confidently consuming a lot more fluid than theydared to previously, using night drainage bags. A decrease inpatient UTI’s would certainly amount to astronomical HealthCare Provider savings. Data, obtained by a Freedom ofInformation request by the Medical Technology group foundthat “NHS in England spent £434 million in 2013/14 ontreating 184,000 hospital admissions for a urinary tractinfection” equating to £2,359 per patient (MedicalTechnology Group 2015).

As a result of U-drain’s urology success many cliniciansadvised U-drain to go into the field of Automated PeritonealDialysis (APD). APD is a form of peritoneal dialysis (PD)used to treat patients with End Stage Renal Disease (ESRD)another being Haemodialysis (HD). Clinicians believed U-drain would be even more advantageous in this field.Patients currently have to carry and dispose of around 15 Kgof waste fluid each morning as well as large volume of wasteplastic and use a substantial amount of water. Patients would

Article


Figure 1 - Patient usingU-drain system

Figure 2 - U-drainfitted to property

References:Beetz R (2003) Mild dehydration: a risk factor of urinary tract infection? Eur J ClinNutr.57 Suppl 2:S52-8.Black, P (1997). Practical stoma care: Nursing Standard, Volume 11, Issue 47 Brown, E.A. (2005). Peritoneal dialysis in elderly patients: clinical experience.Peritoneal Dialysis International. Feb;25 Suppl 3:S88-91.Burch, J. (2005). The pre- and postoperative nursing care for patients with a stoma.British Journal of Nursing . 3/24/2005, Vol. 14 Issue 6, p310-318. Dimkovic N and Oreopoulos DG, (2008), Assisted peritoneal dialysis as a method ofchoice for elderly with end-stage renal disease, International Urology and Nephrology,December 2008, 40:1143Forsythe, I (2017) Carbon Life Cycle Assessment Report for U-Drain PermanentlyInstalled Urine/Waste Dialysate Drainage System. [Preprint] available at: http://u-drain.co.uk/userfiles/downloads/2017_05%20lca%20assessment%20report%20u-drain%20limited%20v1.2.pdf. Lewis, D. (2017). Preliminary analysis of U-Drain experience in peritoneal dialysispopulation at Salford Royal. [Preprint]. Available at: http://u-drain.co.uk/userfiles/downloads/salford%20preliminary%20analysis%20of%20u%20drain%20ver%202.pdf Lin SY. (2013). A pilot study: fluid intake and bacteriuria in nursing home residents insouthern Taiwan. Nurse Researcher. Jan-Feb;62(1):66-72. Montgomerie,J.Z. Morrow, J.W. (1980). Long term Pseudomonas colonisation inspinal cord injury patients. American Journal of Epidemiology 112 (4): 508-517. Nash, M.A. (2003). Best practice for patient self-cleaning of urinary drainage bags.Urologic Nursing. 2003 Oct;23 (5):334, 339. Oliver, M.J. Quinn R.R. Richardson, E.P. Kiss, A.J. Lamping, D.L. Manns, B.J. (2007).Home care assistance and the utilization of peritoneal dialysis. Kidney International,Volume 71, Issue 7, 1 April 2007, 673-678 SDU case study (2017).http://www.sduhealth.org.uk/documents/case_study/North_Cumbria_Acute_Hospitals_NHS_Trust_Udrain_DESIGNED.pdfTait, S (2017)http://www.sduhealth.org.uk/documents/case_study/North_Cumbria_Acute_Hospitals_NHS_Trust_Udrain_DESIGNED.pdf


simply plug the APD machine’s waste line into the U-drainsocket and the 15 litres of waste APD fluid would drain awaythroughout the night.

Following a successful APD trial; U-drain demonstrated thesystem to multiple renal units throughout the UK. NorthCumbria University Hospital NHS Trust purchased U-drainand recently produced a case study highlighting its benefitsand cost savings (SDU Case Study 2017).

U-drain also secured a Greater Manchester Academic HealthScience Network Innovation Nexus Momentum grant to funda trial at Salford Royal’s Peritoneal Dialysis Unit. The systemwas installed into the homes of 15 automated peritonealdialysis patients and data collected was evaluated by DrDavid Lewis senior PD Consultant.

U-drain was successful in an application to the NHSSustainable Development Unit and Carbon Footprint Ltd

was commissioned and found the emissions footprint of theU-Drain system to be 99.1% lower than current APD practicewith cost benefits realising approximately £1000 per patientper year (Forsyth, 2017). Scaling this up over five yearswould equate to NHS savings of: l £16.6 million l 23 million KgCO2e l 6,500 tonnes waste plasticl 87 million litres water

Although cheaper, Oliver et al (2007) and Dimkovic &Oreopoulos DG (2008) found uptake of PD to be declining in many countries, particularly among the elderly. Brown(2005) agreed but adds despite the fact that older patientscope as well as, if not better than, younger patients on PD.There are many barriers preventing the uptake of PD. One inparticular documented by Oliver et al (2007) showed 43% ofpatients were unable to undertake PD as they had decreasedstrength and were therefore unable to lift PD bags. Tait(2017) reports that without U-Drain, “the patient would havehad to return to hospital Haemodialysis, due to being too frailto carry drain bags”. Lewis (2017) also concluded that“nurses noted a time saving in their role from 5-20 minutesper home visit” when U-drain was installed, considerablyreducing healthcare provider costs.

This simple device borne out of necessity has so much tooffer including increased patient quality of life, possibility oflowering UTI’s, huge financial savings, decrease staffing time and astronomical environmental savings. Adoption ofinnovations by the NHS is notoriously difficult. Help frompartners including GM AHSN, TRUSTECH, NHS SustainableDevelopment Unit and renal units, such as North Cumbria and Salford Royal, will help to secure U-drain’s future as thefirst line urine/APD drainage system across the globe.

Contact U-drain at: +44 (0)161 941 [email protected]

Dr Lewis reported that 100% of patients wouldrecommend U-Drain to another person ondialysis: “makes life a lot easier”, “much moreconvenient than using large drain bags”, “itsaved a lot of time and you don’t struggle withheavy drain bags”. He also revealed that 100%of clinicians found benefit in not carrying the fulldrainage bags around a patient’s house and allwould recommend the system to other patients.

Ged Murphy ,

Operations ManagerGeorge McCarthy ,

Managing Director

U-drain Ltd U-drain Ltd

Figure 3 -Waste bags fordialysis patients

Figure 4 - U-drain adaptor


News

Public Health and Social CareDisabled people face delays in home adaptations from councils

Disabled people risk being left in unsuitableaccommodation because of delays with grants from councils meant to help individuals adapt theirhomes, a report from the Local GovernmentOmbudsman warns. Research from LeonardCheshire Disability found that 62% of councils arenot funding agreed adaptations with disabledfacility grants within set timescales.Research from the home improvement agency,Foundations, shows that adaptations funded by agrant can help elderly people stay living in their own homes for an average of four years longer.

To find out more visit…http://www.publicsectorexecutive.com/Public-Sector-News/disabled-people-face-delays-in-home-adaptations-from-councils

Keeping people out of care homesThe push in recent years has been to keep people out of care homes byproviding support in their own homes

It is an unlikely setting for a revolution in care, but the former disused warehouse on the New Dock industrialestate close to the centre of Leeds is being seen as the future of support for the elderly. The warehouse hasundergone a £2.1m refurbishment to make it into Leeds City Council’s assisted-living hub, acting as a one-stopshop for care needs. It houses all necessary home adaptation equipment as well as being the application centrefor blue badge holders.

For more information visit… http://www.bbc.co.uk/news/health-30922483

Only 1 in 10 MPs in England believe the socialcare system is fit for purpose for the UK’sageing population 10% of MPs in England believe the current social care system is suitable for the UKs ageing population and 86%of MPs in England believe a cross-party consensus is needed for lasting settlement on health and social care.That’s according to a new poll of 101 MPs of all parties representing constituencies in England commissioned byIndependent Age, the older people’s charity. The new poll by ComRes finds there are strong majorities acrossboth major parties who believe funding for social care is inadequate.

To find out more visit… https://www.independentage.org/news-media/press-releases/only-1-10-mps-england-believe-social-care-system-fit-for-purpose-for-uks


Occupational Therapy Show 22nd November 2017 – 23rd November 2017 The Occupational Therapy Show is the UK’s largest dedicated CPD education and trade event forOccupational Therapists. The conference programme covers clinical areas such as physical, mental health,children and families, innovation in practice and shaping the future and research in practice. The exhibitionwill feature leading suppliers displaying practical new equipment, products and services.http://www.theotshow.com/

British Geriatrics Society (BGS) Autumn Meeting 22nd November 2017 – 24th November 2017 The BGS Autumn meeting will cover the latest scientific research and the best clinical practice in the careof the older people. Our ageing population is stimulating extensive NHS service redesign to deal with thechallenge of caring for larger numbers of older people both in and out of hospitals. The conference willcover core areas of interest to all specialists responsible for the health care of older people in theUnited Kingdom.http://www.careengland.org.uk/british-geriatrics-society-autumn-meeting

The Future of Ageing 2017: Transforming Tomorrow Today29th November 2017 The conference will aim to reinvigorate those of us already convinced of the importance of ageing. Theyneed businesses, entrepreneurs, people managers, and marketing professionals to work with the charitysector and policy makers and politicians to deliver change. The event aims for everyone to come awayhaving learnt something new and with a plan to act on it.http://www.futureofageing.org.uk/

Occupational Therapy Adaptation Conference13th December 2017 This is an opportunity to gain valuable knowledge around adaptations and equipment not only for personaldevelopment and reflection but to also to enable you to showcase the value an Occupational Therapist orindividual specialising in adaptations for the disabled can bring within housing adaptations regardless ofyour working environment.https://www.otac.org.uk/events/edinburgh/

Upcoming Events…

Cohousing: ‘It makes sense for people withthings in common to live together’

Cohousing is a pioneering housing scheme where members would move together into a custom-built housingdevelopment, in which each would have their own self-contained apartment and front door, but where they wouldshare communal facilities, commit to eating together regularly and in the words of one of its members, “sign up tobe neighbourly”. Their homes would be ‘future-proofed’, allowing them to make mobility adaptations in later years ifthey needed to and thus to live independently for as long as possible. However crucially, unlike standard shelteredhousing, the development would be designed and managed by the community itself, and the residents would chooseeach other.

Housing scheme offering older people the chance to live independently but in ashared community

News

To learn more about this innovative scheme visithttps://www.theguardian.com/society/2015/feb/16/co-housing-people-things-common-live-together-older-people

Research


Hip replacements are now one of the most commonoperations in the UK with the National Joint Registry ofEngland and Wales reporting 76,274 primary Total HipReplacements (THR) in 2013 compared with 14,413 in 2003(Hunt et al., 2013). THR is reported make a significantcontribution to improving the quality of life of individuals(Quintana et al., 2006).

Before surgery extensive patient education and preparationof the home environment with appropriate aids andadaptations is required. Patients are also advised to followrigid post-operative restrictions that support their normaldaily function after surgery. These are now commonpractice to reduce the risk of hip dislocation (see table 1)(eg Smith et al., 2016; van der Weegen et al., 2016).

In order for patients to adhere to these restrictions aids andadaptations are required to support activities of daily living.These include the provision of mobility aids, high seatchairs, perching stools, toilet frames, grab rails, secondstair rails, devices to raise the bed and armchairs, kitchentrolleys and small dressing aids. Equipment however isreported as burdensome and unsightly with patientspreferring not to use them for the recommended periods oftime. This has a direct impact on adherence to restrictionsfollowing THR, with some patients complaining they werenot able to return to driving, return to work, resume sexualactivities and exercise until at least 6 weeks after surgery(Hippychic, 2014; DePuy, 2016b).

Emerging evidence now casts doubt on the impact of post-operative restrictions on incidence of dislocation, which is reported as the main driver for their imposition low

dislocation rates are now reported to be a result ofcombined factors such as improved surgical techniques,large femoral head sizes, and hip joint capsule repairalongside restriction of patient activities following surgery(eg Mikkelsen et al., 2014; Smith et al., 2016). The impactof patient adherence to the restrictions following surgery on dislocation incidence is therefore unknown. A review of evidence exploring adherence to the restrictions wasundertaken therefore to allow contextualisation of theimpact this may have on dislocation rates.

ResultsAssessment of studiesOnly five selected studies were relevant to THR patients.

Driving Kelly et al., (2013) studied adherence of time to resumedriving. Although this would indicate a return to independence,it is a restricted activity for a minimum of 6 weeks due to therisk of inability to perform an emergency stop safely andeffectively and the subsequent risk of hip dislocation (Patakyet al., 2009). Using telephone interviews 18 months followingTHR they found that 19% of patients resumed driving less than6 weeks post THR.

Elbow crutch useKelly et al., (2013) explored adherence to use of elbowcrutches following THR. A telephone interview wasconducted 18 months after surgery. Of the patients able to recall their adherence, 26% reported they had stoppedusing elbow crutches before 6 weeks, despite being advisedto continue with their use until then.

Supine sleeping (sleeping on the back) Only one study (Modi et al., 2012) investigated whetherpatients adhered to the post-operative sleeping restriction.98% of patients recalled being advised to sleep supine for12 weeks following their THR. Despite this advice the meanperiod of supine sleeping was only 9.6 weeks with 53%patients reporting sleeping supine for the full 12 weeks.

Partial weight bearingThree studies explored training for partial weight-bearingafter THR using a combination of physiotherapist training

Do patients adhere to post-operative restrictions followingTotal Hip Replacement?Justine Theaker is the Clinical Lead Therapist for Trauma and Orthopaedics at ManchesterUniversity NHS Foundation Trust. Justine has 13 years’ experience working in orthopaedic andfracture clinics as an Extended Scope and Advanced Practitioner. She is currently studying for a PhDexploring the impact of prescriptive post-operative restrictions following total hip replacement.

Hip restrictions/precautions for upto 12 weeks

Partial weight bearing

Use of elbow crutches

Use of assistive devices

Supine Sleeping

No driving

Table 1. Common practice to reduce the risk of hip dislocation.


ReferencesBowling, A. (2005). Mode of questionnaire administration can have serious effectson data quality. Journal of Public Health, 27(3), 281-291.Brooks, P. J. (2013). Dislocation following total hip replacement. causes and cures,95-B(11 Supple A), 67-69.Dargel, J., Oppermann, J., Bruggemann, G. P. & Eysel, P. (2014). DislocationFollowing Total Hip Replacement. Deutsches Arzteblatt International, 111(51-52),884-890.DePuy. (2016a). Bone smart; Knee Replacement & Hip Replacement PatientAdvocacy & Online Community [Online]. Available:http://bonesmart.org/forum/view/hip-replacement-recovery-area [Accessed18/09 2015].Fox, R., Halliday, B., Barnfield, S., Roxburgh, J., Dunford, J. & Chesser, T. J. S.(2011). Hip precautions after hemiarthroplasty: what is happening in the UK and atwhat cost? Annals of the Royal College of Surgeons of England, 93(5), 396-397.Higgins, J. P. T., Altman, D. G., Gotzsche, P. C., Juni, P., Moher, D., Oxman, A. D.,Savovic, J., Schulz, K. F., Weeks, L., Sterne, J. A. C., Cochrane Bias Methods, G.& Cochrane Stat Methods, G. (2011). The Cochrane Collaboration's tool forassessing risk of bias in randomised trials. BMJ-British Medical Journal, 343.Hippychic, T. 2014. The Hippychic blog. Available from:https://njrhippychickblog.wordpress.com [Accessed 18/09 2016].Hunt, L. P., Ben-Shlomo, Y., Clark, E. M., Dieppe, P., Judge, A., MacGregor, A. J.,Tobias, J. H., Vernon, K. & Blom, A. W. (2013). 90-day mortality after 409 096 totalhip replacements for osteoarthritis, from the National Joint Registry for Englandand Wales: a retrospective analysis. The Lancet, 382(9898), 1097-1104.Hurkmans, H. L., Bussmann, J. B., Selles, R. W., Benda, E., Stam, H. J. & Verhaar,J. A. (2007). The difference between actual and prescribed weight bearing of totalhip patients with a trochanteric osteotomy: Long-term vertical force measurementsinside and outside the hospital. Archives of Physical Medicine and Rehabilitation,88(2), 200-206.Kelly, E., Campbell, J. & Murray, P. (2013). Total hip replacement: patientsatisfaction and early outcomes. International journal of health care qualityassurance, 26(3), 262-268.Khan, R. J. K., Fick, D., Khoo, P., Yao, F., Nivbrant, B. & Wood, D. (2006). Lessinvasive total hip arthroplasty - Description of a new technique. Journal ofArthroplasty, 21(7), 1038-1046.Margulis, A. V., Pladevall, M., Riera-Guardia, N., Varas-Lorenzo, C., Hazell, L.,Berkman, N. D., Viswanathan, M. & Perez-Gutthann, S. (2014). Qualityassessment of observational studies in a drug-safety systematic review,comparison of two tools: the Newcastle-Ottawa Scale and the RTI item bank.Clinical Epidemiology, 6, 359-368.Mayer, A. B., Lefebvre, R. C., McDermott, R. J., Bryant, C. A., Courtney, A. H.,Lindenberger, J. H., Swanson, M. A., Panzera, A. D., Khaliq, M., Biroscak, B. J. &Wright, A. P. (2014). Case study: a social marketing approach for increasingcommunity coalitions' adoption of evidence-based policy. Social Marketing andBehaviour Change: Models, Theory and Applications. Cheltenham: Edward ElgarPublishing Ltd.Mikkelsen, L. R., Petersen, M. K., Soballe, K., Mikkelsen, S. & Mechlenburg, I.(2014). Does reduced movement restrictions and use of assistive devices affectrehabilitation outcome after total hip replacement? A non-randomized, controlledstudy. European Journal of Physical and Rehabilitation Medicine, 50(4), 383-393.Modi, C. S., Gudipati, S., Poole, C. & Brooks, S. (2012). Compliance with SleepInstructions After Total Hip Arthroplasty.Oxman, A. D., Sackett, D. L. & Guyatt, G. H. (1993). Users Guides To The MedicalLiterature .1. How To Get Started. Jama-Journal of the American MedicalAssociation, 270(17), 2093-2095.Pataky, Z., Rodriguez, D. D., Golay, A., Assal, M., Assal, J. P. & Hauert, C. A.(2009). Biofeedback Training for Partial Weight Bearing in Patients After Total HipArthroplasty. Archives of Physical Medicine and Rehabilitation, 90(8), 1435-1438.Quintana, J. M., Escobar, A., Arostegui, I. & et al. (2006). Health-related quality oflife and appropriateness of knee or hip joint replacement. Archives of InternalMedicine, 166(2), 220-226.Schaefer, A., Hotfiel, T., Pauser, J., Swoboda, B. & Carl, H. D. (2015). Incomplianceof total hip arthroplasty (THA) patients to limited weight bearing. Archives ofOrthopaedic and Trauma Surgery, 135(2), 265-269.Smith, T. O., Jepson, P., Beswick, A., Sands, G., Drummond, A., Davis, E. T. &Sackley, C. M. (2016). Assistive devices, hip precautions, environmentalmodifications and training to prevent dislocation and improve function after hiparthroplasty. Cochrane Database of Systematic Reviews, (7).van der Weegen, W., Kornuijt, A. & Das, D. (2016). Do lifestyle restrictions andprecautions prevent dislocation after total hip arthroplasty? A systematic reviewand meta-analysis of the literature. Clinical Rehabilitation, 30(4), 329-339.Walsh, J. C., Mandalia, S. & Gazzard, B. G. (2002). Responses to a 1 month self-report on adherence to antiretroviral therapy are consistent with electronic dataand virological treatment outcome. Aids, 16(2), 269-277.

and, or biofeedback to train patients. In the initial partialweight bearing training phase following THR, patients wereable to reduce weight bearing across all studies by varyingamounts.

Schaefer et al., (2015) used bathroom scales andbiofeedback to evaluate the patient’s ability to partialweight-bear and evidenced a significant reduction to 70%weight-bearing, from pre-operative baseline whenmeasured on an even floor. This reduced further to 53%when patients ascended stairs.

Pataky et al., (2009) used biofeedback and bathroom scalestraining by a physiotherapist and was able to establishsignificant improvements in the ability of patient to weightbearing following training with a physiotherapist. Howeverpatients were not able to maintain this level after repeatedtesting and weight bearing increased 2 days after initialtesting.

Hurkmans (2007) illustrated the limited effect of ongoingsupervision of patients following the initial partial weight-bearing training period after THR. By the time patientsreach 2 weeks after discharge there were 0% of patientsbeing able to achieve the ≤10% body weight restriction and37.5% of patients achieving ≤ 50%.

DiscussionThere is limited evidence of patients’ adherence to post-operative restrictions and use of assistive devices followingTHR. However all studies alluded to the possibility thatpatients following THR did not comply with recommendedrestrictions.

The findings of the review concur with clinicians’observations in current practice. Firstly some patients do not have the physical ability to adhere to medicalrecommendations following THR, even with assistivedevices (Hippychic, 2014; DePuy, 2016a) and secondly thatof the proportion of patients that are able to adhere to therecommendations many choose not to do so.

Despite the lack of adherence to post-operative instructionsand restrictions, the incidence of dislocation following THRremains unchanged for the last 30 years at 2 - 2.5% (Khanet al., 2006, Dargel et al., 2014). If dislocation risk was theprimary reason for enforcement, this could call into questionthe value, necessity and benefit to patients of burdensomeassistive equipment and restrictions. The study doeshowever call into question the quality of data to challengethis question.

ConclusionHistorical practice has shaped post-operativerecommendations and restricted functional activities ofpatients following THR. However, it is becoming apparentthat the benefits of current practice to reduce the risk ofpost-operative dislocation lack a robust evidence base.Enforcement of restrictions may be unnecessarilycausing discomfort and inconvenience for thosepatients that adhere to them with potentially noinfluence on risk of dislocation.

Justine Theaker Msc Advanced practice Clinical LeadTherapist for Trauma and Orthopaedics

Manchester University NHS Foundation Trust

The available evidence confirms that patients are unable toadhere to some post-operative restrictions following THR,although the proportion is unknown. Further research is needed to better define patient adherence to therecommendations and the impact of adherence on overallquality of life and on the risk of post-operative THRdislocation.


Research

Age-related functional declineFrom the perspective of individuals who are currentlyexperiencing (and those who will at some point moveinto) older age, uncertainty about what their remaininglifetimes have in store can be a daunting prospect.One of the greatest fears (notwithstanding concernsabout ill-health) is a loss of independence. A study bythe Disability Living Foundation in December 2009indicated that 68% of older adults feared adependence on others more than death itself (29%)and 44% had concerns about moving into a care home(Disability Living Foundation, 2009). In addition, theloss of independence is linked with, and oftenexacerbates age-related diseases and drivesincreased health service use (Jagger et al., 2011;Kingston et al., 2014).

This is coupled with the potential demand for anadditional 71,000 care home places over the nexteight years due to dependency (Kingston et al., 2017).Therefore, efforts must be channelled to understandhow a person’s functional ability unfolds with age, howit is shaped by lifestyle factors and disease and,moreover, how it can be altered such that age-relatedfunctional decline is compressed into the shortestpossible window before death.

Characterising dependency and disabilityFifty-four years ago, Sidney Katz developed an indexof ageing containing items that have become knownas basic activities of daily living (BADL) or sometimessimply ADL (Katz et al., 1963). His five activities:feeding, dressing/undressing, bathing or showering,

using toilets, and transferring from bed to chair, werethose which, when not performed, indicated a highdependence on others. Although the Katz index wasuseful, it could not detect milder, yet still important,levels of disability.

So, in 1969 Powell Lawton and Elaine Brodydeveloped an additional scale, Instrumental ADL(IADL), focused on the ability to perform householdcare activities and functioning in the wider society(Lawton and Brody, 1969). This IADL index consistedof eight items: cooking, shopping, laundry, housework,using public transport, using the telephone, takingmedications and managing money, though subsequentresearch has found the two latter items have acognitive component, tapping a different construct tothe other ADL items.

Disability, often defined in terms of theability to carry out activities related to dailytasks, is a forerunner of numerous importantoutcomes such as health service use,institutionalisation and mortality and it hasbeen used to assess levels of dependency(Isaacs and Neville, 1976). When combined tomeasure disability, ADL and IADL are good predictorsof outcomes indicating older people’s vulnerability.

IADL/ADL items are usually self-reported but studieshave clearly shown a gap between what older peoplethink they can do and what they do. Disability orvulnerability information may be required onperformance (do you...) rather than self-reported

Understanding pathways ofdisability in older people –live longer, die shorterAndrew Kingston is a Chartered Statistician with a PhD in the epidemiology of health in veryold people (85+) and is based at Newcastle University's Institute for Ageing. Andrew's mainresearch interest is understanding pathways to disability in older people. His vision is tounderstand how age-related functional decline can be compressed into the shortestduration possible, leading to better quality of life for older people.


Dr Andrew Kingston Phd Chartered Statistician

Newcastle University’s Institute for Ageing.

ability (can you...). There may be an argument forcollecting both performance and capacity data asdiscrepancies may represent compensations or reflectgender-specific tasks such as cooking. The originalindex had response categories: without aids or help(independent); with aids; only with the help of anotherperson. Later an extra category of independent withdifficulty was added. Difficulty is more a characteristicof the person and less affected by social support andtherefore more appropriately indicates disability.

The order of age-related functional declineRecent research has also illuminated that items thatmake up the IADL indices tend to unfold in an order.Research conducted at Newcastle University, usingdata from the Newcastle 85+ Study, has shown thatthe order in which people encounter difficulty withIADL is largely consistent for both sexes (Kingston etal., 2012). For both men and women, cutting toenailsis the first activity with which people have difficulty,and feeding the last. The order of loss of ability toperform activities can be classified in terms of fourdomains, with each domain containing multipleactivities that are similar in terms of their need forspecific functional integrity combinations of dexterity,balance, strength and upper or lower extremityinvolvement. For example, the first abilities lostrequire complex manual dexterity and balance and thelast upper rather than lower limb control.

The hierarchy of tasks that underpin age-related functional decline can predictpatterns of loss in capability in IADL and thesubsequent need for short and long-termcare.

Moreover, an ordered scale that can accuratelyforecast functional decline has important predictivevalue in terms of identifying people at high risk ofdisability and progression from early to advancedstages. This opens potential for significant and novelways to prevent/decelerate and compress theprogression of disability, therefore maximising theindependence of individuals. It could also aid therecovery from more severe stages through targeteduse of care/support/rehabilitative services,depending on a person’s location in the hierarchy.Additionally, an ordered scale provides a commonmetric that health professionals and patientsunderstand thereby providing potential for asynergistic health professional/patient partnership inthe management of age-related functional decline.

Charting and targeting interventionsUsing the hierarchical property, a system of managingdisability has potential to be developed. At anindividual level, it would allow for targetedinterventions dependent upon where a personcurrently is within the hierarchy on their disability

Figure 1Hierarchy of disability starting with first ability lost (cutting

toenails) to last ability lost (feeding) continued on next page


Research

References:Disability Living Foundation (2009) Losing independence is a bigger ageing worrythan dying. Available at: http://www.dlf.org.uk/blog/losing-independence-bigger-ageing-worry-dying (Accessed: 20th July, 2017).Isaacs, B. and Neville, Y. (1976) 'The needs of old people. The ‘interval’ as amethod of measurement’, Br J Prev Soc Med, 30(2), 79-85.Jagger, C., Collerton, J., Davies, K., Kingston, A., Robinson, L., Eccles, M., vonZglinicki, T., Martin-Ruiz, C., James, O., Kirkwood, T. and Bond, J. (2011)'Capability and dependency in the Newcastle 85+ cohort study. Projections offuture care needs’, BMC Geriatrics, 11(1), 21.Katz, S., Ford, A., Moskowitz, R., Jackson, B. and Jaffe, M. (1963) ‘Studies ofillness in the aged: the index of ADL, a standardised measure of biological andpsychosocial function’, JAMA, (185), 914-919.

Kingston, A., Collerton, J., Davies, K., Bond, J., Robinson, L. and Jagger, C.(2012) ‘Losing the ability in activities of daily living in the oldest old: a hierarchicdisability scale from the Newcastle 85+ study’, PLoS ONE, 7(2), p. e31665.Kingston, A., Davies, K., Collerton, J., Robinson, L., Duncan, R., Bond, J.,Kirkwood, T.B. and Jagger, C. (2014) ‘The contribution of diseases to the male-female disability-survival paradox in the very old: results from the Newcastle 85+study’, PLoS ONE, 9(2), p. e88016.Kingston, A., Wohland, P., Wittenberg, R., Robinson, L., Brayne, C., Matthews, F.E.and Jagger, C. (2017) ‘Is late-life dependency increasing or not? A comparison ofthe Cognitive Function and Ageing Studies (CFAS)’, The Lancet.Lawton, M. and Brody, E. (1969) ‘Assessment of Older People: self maintainingand instrumental activities of daily living’, Gerontologist, 9, 179-186.

‘journey’. Those at the beginning, and those at risk ofjoining the hierarchy of disability, are targets fortherapies that focus attention of strengthening bodystructures that maintain balance and complex manualdexterity; thereby decelerating decline, or bringing itto a standstill, or even re-enabling abilities that wereonce lost. People mid-journey are those for whominterventions would target long-distance mobility,upper limb control and balance and it is at thisjuncture that assistive technologies and environmentalmodifications could play a part to help maintainfunction. Later stages of the process (where peopleare likely to have difficulty with ADL specifically),would be the likely point at which the use of formalcare is used to aid people in their day-to-day lives. It isan important caveat, that use of technologies orinterventions that assist a person rather than allowingautonomous completion of tasks, are a last resort, asovercompensation is likely to accelerate age-relatedfunctional decline.

Conclusion

The hierarchy of decline has utmostpotential in its capacity to provide ametric with which we can targetinterventions tailored to individualsusing their location in the hierarchyof disability.

It is beyond the scope of this article to discuss suchinterventions and their type, but it provides a solidbasis upon which their efficacy can be evaluated.Furthermore, this process is readily understood byhealth care practitioners and older people alike,thereby nurturing a partnership in health care planningand delivery.


In every locality, commissioners of health and social careservices for older people increasingly need to invest inintegrated, collaborative ways of working that enablethem to balance the twin pressures of decreasingresources against an ageing population where researchsuggests rates of multi-morbidity increase with age.

In Greater Manchester, New Charter Homes (a housingassociation) has co-created an initiative with TamesideHospital, a local GP practice and Tameside Public Healthto pilot cost-effective solutions to the health challengesthat affect older tenants’ quality of life while reducing the demand their poor healthplaces on hospitals and primary health care services.

In the first phase of this pilot, New Charter Homes hasrecruited a Tenancy Support Officer who works withclinicians and health professionals to developpersonalised, solution oriented programmes of supportthat address the housing and support needs of up to 10older people at any one time. The subjects in the pilotare drawn from two groups:

Older tenants who are clinically fit to be dischargedfrom hospital, but where assessment has identifiedthem as being likely to experience difficulties livingindependently and managing their tenancy on theirreturn to the community.

Older tenants where GPs at the participatingpractice have identified them as being at risk ofadmission to hospital because a chronic healthdifficulty is associated with day-to-day difficulties inliving independently and managing their tenancy.

It’s intended for this way of working to provide the basisfor a self-financing, sustainable service by April 2018.The business model is based on attaching a time limited‘Intensive Housing Management Charge’ against NewCharter tenants who are eligible for Housing Benefit -

for the duration of the intervention by the TenancySupport Officer.

In the medium/long term, future development of thispilot initiative will be based on a formative evaluation,which is intended to enable New Charter Homes to moreaccurately calculate the scale of charge that will benecessary to ensure full-cost recovery.

The formative evaluation will include:l Analysis of estimated levels of demand for thisway of working

l The throughput of cases which is viable with olderpeople with chronic health difficulties

l The impact – the difference - made by this way ofworking with older people

l Ratification by Tameside Council’s Housing Benefitteam of an agreement in principle to accept theaddition of eligible Intensive Housing Managementcharge; and, agreeing to pay Housing Benefit foreligible customers referred to the service

A long-term goal, should this way of working prove to beeffective in reducing ‘Delayed Transfer of Care’ and non-elective admissions to hospital, is for New CharterHomes, Tameside Hospital and Tameside Council toengage local health and social care commissioners inidentifying funding that would enable older people inTameside who aren’t New Charter tenants to benefit fromany improvement in their capability to live independentlyand quality of life provided by this way of working.

Tony Powell ,

Deputy Chief Executive

New Charter Group

Older people – Delayed Transferof Care and tenancy supportTony Powell is Deputy Chief Executive at New Charter Group – a medium size housing association, whichoperates in Tameside, Greater Manchester and Nottinghamshire. Tony has over 40 years’ experience in LocalAuthorities and Social Housing. He brings extensive experience of housing management, housing advice,supported housing, and community regeneration to the Greater Wellbeing Board, and has developed closeworking partnerships with health organisations including Tameside Hospital and local GPs. Tony is a Director ofthe Great Academy Education Trust and a Chair of Governors at a local primary school.


Research

Household adaptations

Injury in the home environment is an extremely commonevent, accounting for around a third of injuries in all agegroups. The majority of injuries in people aged 75 and overoccur in the home. In particular falling in and around thehome is a significant concern for an ageing population, andas such is of interest to a wide audience including healthand social care practitioners and researchers.

Household adaptations to try and prevent injury or falls caninclude improvement of lighting in halls and stairways,installation of grab rails or ramps and the removal of triphazards. Reviews have looked at the effectiveness ofhousehold adaptations to determine whether modificationof the home environment reduces injuries and falls in thehome.

Reduction of injuries - physical hazards, poor designand layout may contribute to events leading to injuries inthe home. However there is little high-level scientificevidence to suggest that home modifications do actuallyreduce the number of injuries. This may be due to the factthat many injuries are a result of a number of factors andmodifying the home is tackling just one of these factors.

Falls - assessing and modifying the home environment has been identified as having a positive impact on theeffectiveness of falls preventions. Evidence from 13 studies(incorporating over 8200 participants) suggests that boththe risk of falling, and the actual number of falls wasreduced through interventions where the household isassessed and adapted.

Household adaptation is a core concern for OccupationalTherapists, and research has shown that the most effectivehome environment interventions have been led by anOccupational Therapist.

Reduced physical activity - those who have visualimpairment may be fearful of engaging with physical activityaround the home due to a fear of falling. Home adaptationsare frequently used as an intervention to address this fearof falling, and health and social care professionals such asOccupational Therapists routinely implement modificationssuch as introducing contrasting visual cues on stairs, orremoving rugs.

However, the effectiveness of these modifications has notbeen robustly concluded. There is currently a notable gap inresearch focused on the physical activity limitations ofpeople who have visual impairments.

Given that household adaptations are a keyintervention, researchers and clinicians are urgedto consider this gap, and to conduct trials thatcan be used to inform and underpin this specificarea of practice.

Cochrane CornerThe Cochrane Collaboration is an international network of more than 28,000dedicated people from over 100 countries. They work together to help healthcareproviders, policy-makers, patients, their advocates and carers, and the generalpublic make well-informed decisions about health care, by preparing, updating,and promoting the accessibility of Cochrane Reviews.

References:Gillespie, LD, Robertson MC, Gillespie WJ, Sherrington C, Gates, S, Clemson LM,Lamb, SE. Interventions for preventing falls in older people in the community.Cochrane Database of Systematic Reviews 2012, Issue 9. Art. No.: CD007146.DOI: 10.1002/14651858.CD007146.pub3.

Skelton, DA, Howe, TE, Ballinger C, Neil F, Palmer S, Gray, L. Environmental andbehavioural interventions for reducing physical activity limitation in community-dwelling visually impaired older people. Cochrane Database of Systematic Reviews2013, Issue 6. Art. No.: CD009233. DOI: 10.1002/14651858.CD009233.pub3.

Turner S, Arthur G, Lyons RA, Weightman AL, Mann MK, Jones SJ, John A,Lannon, S. Modification of the home environment for the reduction of injuries.Cochrane Database of Systematic Reviews 2011, Issue 2. Art. No.: CD003600.DOI: 10.1002/14651858.CD003600.pub3.

Tracey HoweProfessor of Rehabilitation Sciences at GlasgowCaledonian University, Director Cochrane GlobalAgeing and Editor for the CochraneMusculoskeletal Review Group.

Dr Fiona KennedyAssistant Head of Learning Teaching and Qualityfor the School of Health and Life Sciences,Professional member of the Royal College ofOccupational Therapist registered with theHealth and Care Professions Council.

Dr Katie ThomsonOccupational Therapy Lecturer at GlasgowCaledonian University. Katie’s research interestsinclude use of assistive technology and strokerehabilitation.


Justine Theaker

What is your current positionand what was your career paththat took you there?I was always interested in health andfitness which led me to Physiotherapy.I currently have two roles as ClinicalLead Therapist for Trauma andOrthopaedics at ManchesterUniversity NHS Foundation Trust(MFT). My second role is as a ClinicalAcademic Fellow at the University ofManchester where I am just startingthe third year of my PhD.

What challenges do you face inyour current position and whichhas been the greatest one?Both my positions have the capacityto become full time jobs. This createsmy greatest challenge, knowing whento stop to make room for ‘life’.

In your opinion, what are the topthree issues affecting the careof older people?• One issue that concerns meis as the older population grows, thefield of specialists in medicine forolder people appears to beshrinking. If this issue is notaddressed, the demand will faroutweigh capacity in future years.

• A further issue I see at thecoal face of healthcare is the impactof Major Trauma Centres (MTCs)on the care of older people. Theredesign of services presentchallenges for clinical teams interms of prioritisation of care.

• Another key issue in myopinion is engagement andempowerment of older people. Thisis essential to ensure access to thebenefits of devolved health andsocial care budgets which areincreasing across the UK.

Where do you go for adviceand information? I choose my advisors carefully. Noteveryone will tell you what you needto hear but rather what you want to hear.

Who would you most like to work with?Professor Henrik Kehlet developedthe Enhanced Recovery Programme(ERP). This improved the entirepathway for patients undergoingelective colorectal surgery. A chancemeeting with him at a conference inLondon in 2010 led to my return to my‘day job’ armed with the ERP. 4 yearslater we had implemented this in allsurgical specialities at MFT, makingsignificant changes to direct patientcare.

What do you enjoy doing when youare not working?I love being outdoors socialising withfamily and friends. That could meananything from walking to the localwatering hole or up a high peak for abetter peek.

What do you do in a typical working day?Last week was a pretty average week;I presented at a national conference, I worked in Orthopaedic clinics, wrotea research proposal and a businesscase, presented a new spinal fracturepathway for hospital ratification,attended a planning meeting for auniversity visit, and met with theresearch design service aboutmethodology for a study proposal.

If you were stranded on adesert island what would beyour one luxury?A memory foam mattress.

What changes in elderly care doyou anticipate in the next fewyears?Healthier Together work is shapingSingle Site Hospitals across the UK.The proposed benefits of thepartnerships include reducinghealthcare inequalities and servicegaps, standardising care pathways,recruitment of more specialist stafffor future healthcare improvements.Although this will have a positiveimpact on specialist care it will haveimplications for patients which mayneed to travel further to access care.

If you hadn't become aEpidemiologist what might youhave done?I would have loved to be a pilot.I have had an enduring love ofanything resembling flying, fuelled by10 years in the Air Training Corps asa Cadet and also as a staff member.

What experience has influencedyour career the most?When I returned to education as amature student, I did not hold highaspirations, I was just curious to seewhat I could achieve. At the bottom ofmy first assignment the concludingread; ‘Justine, you can, and will achieveyour dream. Just believe.’I’m still going and I still believe.

What advice would you give tosomeone contemplating followingin your footsteps?1. Learn how to make friends andinfluence people. 2. Do favours but expect nothing inreturn, they will be returned but whenyou least expect it. 3. My mantra of ‘make peace withimperfection’ is not easy to adopt,however it has served thisperfectionist well.

Integrated Clinical Academic andAdvanced Practitioner

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In our next quarterly issue ofInnov-age we will be looking at respiratory issues.

It is noted that the effects of ageing onthe respiratory system are similar tothose that occur in other organs, i.e.maximum function gradually declines.As a result of changes in the body due toage, older people are at increased risk oflung infections such as pneumonia andbronchitis, shortness of breath, andabnormal breathing patterns which canresult in problems such as sleep apnoea.

home adaptations...welcome .. . 2 innov-age magazine issue nineteen autumn 2017 welcome to issue 19...

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