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A Sustainable Approach to Healthy and Independent Ageing
Leef: Reversing how people feel about ageing
Functional Decline (FD)
While common among older people it is important to note that FD is not an inevitable consequence of ageing (AIHW, 2014). It can be prevented or managed, with early detection and appropriate intervention (Grimmer et at., 2015).
There is evidence to suggest the pattern of FD can be predicted (Avlund, Pedersen, & Schroll,2003; Grimmer, Beaton, & Hendry, 2013; Grimmer, Luker, et al., 2013; Kingston et al., 2012; Kingston et al., 2015; Vermeulen, Neyens, van Rossum, Spreeuwenberg, & de Witte, 2011), making prevention, management, and early detection possible. Regarding the order of decline, it appears the order in which people loose functional ability is converse to the order in which they acquired them (Eager & Owen, 2002). For example, results from one national field trial targeting the HACC and aged care population in Australia suggest domestic functions such as housework, transport, handling money are typically gained last, but lost first, whereas self-care functions such as dressing, toileting, feeding, and bed mobility are typically gained first, but lost last (Table 1) (Eager & Owen, 2002).
Furthermore, Levy and colleagues analysed ADLs of 296,051 residents in Veteran Affairs nursing homes between 2000 and 2012. The longitudinal data were used to identify the sequence of occurrence of 9 ADL deficits. Similar to Kingston et al. findings, data showed that the majority of residents (57%) followed 4 pathways in loss of function. The most typical sequence in order of occurrence, was bathing, grooming, walking, dressing, toilet, bowel continence, urinary continence, transferring, and feeding (Levy et al., 2016). Outcomes from Levy et al. however allude to the importance of accounting for individual variation in functional decline. Thus, while typical sequence of functional decline has been identified, from domestic functions to self-care, individual variations (e.g. age, comorbidities, access to treatment, socioeconomic status, family support, resilience) can influence decline.
In addition to distinct tasks that progressively decline, numerous factors have been identified as early signals of FD. For example, a prospective study of 226 75 year old men showed sustained tiredness to be an early sign of FD (Avlund et al., 2003). Outcomes from another study suggest older adults aged 85 years who experienced early life socio-economic status (education) disadvantage are more likely to experience severe disability than those with more education (Kingston et al., 2015). Furthermore, a systematic review by Vermeulen and colleagues identified physical frailty such as unintended weight loss, lower grip strength, reduced physical activity and exercise, poor balance, or reduced lower extremity function, to be predictors of future ADL disability in community-dwelling older people (Vermeulen et al., 2011). Knowledge of early FD signals such as the aforementioned can assist with predicting, and ideally preventing FD in older adults. It is important to note however that trajectories of FD are quite variable between one person to another (Lunney, Lynn, Foley, Lipson, & Guralnik, 2003) .Thus, tailored and patient-centred approaches are needed to prevent FD and promote healthy ageing. Despite available evidence, there remains a lack of awareness and knowledge about early FD in all health care sectors, resulting in FD not being detected until a health crisis occurs and older people are hospitalized.
Interventions to reduce functional decline
Early and targeted interventions can prevent or reduce FD in community-dwelling older people. A range of effective interventions exist, including physical activity (Gudlaugsson et al., 2012; Liu, Shiroy, Jones, & Clark, 2014), provision of assistive equipment and technology (Agree, 2014; Khosravi & Ghapanchi, 2015; Muncert et al., 2011;Ocepek, Roberts, & Vidmar, 2013); education (Avlund, Vass, Kvist, Hendriksen, & Keiding, 2007; Vass, Avlund, Siersma, & Hendriksen, 2009); and appropriate assistance from health care professionals to re-establish functional ability after a period of illness (Shearer & Guthrie, 2013). For example, a randomised control trial (RCT) showed that older adults (aged 71 to 90 years) who took part in a 6 months multimodal training intervention on functional fitness, had notable significant improvements in functional performance, strength, and endurance (Gudlaugsson et al., 2012). These findings underline the importance of an active lifestyle for ageing well.
A variety of assistive equipment and technologies have been found beneficial for accelerating improvements in health and quality of life (WHOQOL SRPB Group), promoting independence in the ageing population, and reducing costs to the healthcare system. For example, a recent systematic review evaluating the literature on assistive technologies and their effectiveness identified six categories of technological interventions used to assist older adults with reducing FD and improving the quality of life (Khosravi & Ghapanchi, 2015). These include general information and communication technologies (e.g. using computer and internet to communicate with loved ones or cope with lifestyle changes); Robotics (a rapidly growing area of technology to assist with daily tasks, mobility, and social connectedness); Telemedicine (e.g. provision of specialist consultations by distance); Sensor technology (e.g. alerting caregivers and patients of critical events such as falls); Medication management applications; and Video games (e.g. a therapy tool for relaxation and entertainment). With rapid advancements in technologies, the benefits of technology for older adults is a growing and exciting field of research.
Education or assistance from health professionals, may also be beneficial in reducing FD in communitydwelling older adults. For example, Avlund and colleagues investigated whether immediate effects of a 3-year brief educational intervention on functional ability, were sustained 18 months after intervention cessation. Participants were 4,060 older adults living in Denmark municipalities, and the intervention involved health professionals providing regular education at home visits, and implementing falls prevention strategies. Results showed participants who completed the intervention had better functional ability, which was sustained 1.5 years after the intervention (Avlund et al., 2007). Additionally, there is evidence to suggest older adults who receive tailored ADL retraining (e.g. 3 x 1hr sessions per week for 6 months) with trained Occupational Therapist (OT) during acute hospital stay, may reduce the level of care they require on discharge (Shearer & Guthrie, 2013).
A critical translational gap currently exists between best practice evidence, and the availability of holistic/ comprehensive services and supports for older people wanting to age - well, and - in place.
Authors: Melissa Moore, PhD (John Richards Initiative, La Trobe University), Irene Blackberry, PhD (John Richards Initiative, La Trobe University), John Pollaers (Leef Interactive Health), Catherine Lindholm (Leef Interactive Health) - February 2016
What is Leef and how can Leef bridge this gap?
Leef delivers an innovative and holistic approach to maintain health and independent living among older adults. Based on best practice evidence, Leef provides an all-inclusive portal of information, selfassessment, and access to cutting edge services and products to older Australians. Leef aims to prevent functional decline, and support healthy ageing and independence.
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