Denise Cloutier

Geographies of ageing Progress and possibilities after two decades of change

This article examines two-decades of progress toward developing ‘geographies of ageing’ as a distinct field of human geography. Reflecting on the last review in this journal by Harper and Laws (1995), we elucidate the longstanding, emergent, and hidden pathways of scholarship involved in the constitution of the field since the mid-1990s. We consider contemporary developments relating to the empirical gap in understanding the contributions of older people and the potential for relational and nonrepresentational perspectives to expand the breadth of the field. The still nascent profile of ageing within the discipline is contrasted with the interdisciplinary spatial turn underway in gerontology.

The space between: using ‘relational ethics’ and ‘relational space’ to explore relationship-building between care providers and care recipients in the home space

Geographers and other social scientists have a longstanding interest in ‘geographies of aging’ focused on the provision of care to vulnerable older populations and the challenges and experiences of caregivers [Skinner, M. W., Cloutier, D., & Andrews, G. J. (2014). Geographies of ageing: Progress and possibilities after two decades of change. Progress in Human Geography, 1–24]. This qualitative research project explores strategies for relationship-building used by home support workers and older residents according to a ‘relational ethics’ framework, enacted in the ‘relational space’ of the home environment. This framework rests on four principles: engagement, embodiment, mutual respect and environment, and argues that ‘relationships’ between care providers and care recipients must be preserved as the real essence or heart of the health care experience. Two linked conclusions are drawn from the research: that the treatment of the environment can be expanded using a social geographic lens to capture the more active influence of ‘homes’ on relationship-building and second, the relational ethics framework is useful in the home care context to characterize and ground the importance of relationships in the home care domain and the importance of home care to foster aging in place for vulnerable older persons.

Janus at the Crossroads: Perspectives on Long-term Care Trajectories for Older Women With Dementia in a Canadian Context

Purpose of the Study: Janus, the two-faced, Roman god of beginnings and transitions, is used as a metaphor to explore our personal narratives and our quantitative research on the experiences of older women with dementia in long-term care (LTC). Two research questions are addressed: (a) How do our quantitative data map onto our mothers’ experiences? (b) What lessons do our mothers’ experiences offer for the care of older women with dementia? Design and Methods: Informed by a life-course perspective, we triangulate administrative data on 3,717 women with dementia receiving LTC in British Columbia, Canada, with personal narratives—the stories of our mothers who made the transition from home care into residential (nursing home) care. Results: Our quantitative data reveal that the home care to residential care transition is the most common LTC trajectory for women with dementia who are most likely to be widowed and living alone in suburban areas. On entry into residential care, they exhibit greater frailty in terms of activities of daily living, cognition, aggression, and incontinence. Our personal narrative data on our mothers reveals that the relatively straightforward pathways through LTC for women with dementia, are often considerably more complex in a real-world context. Attention is drawn to the public and private services, hospitalization patterns, and substantial communication gaps experienced by our moms and families. Implications: A life-course perspective, and qualitative and quantitative data facilitate understanding the care journeys—health and service trajectories of older women with dementia.

Long-term Care Trajectories in Canadian Context: Patterns and Predictors of Publicly Funded Care

Objectives Drawing on a structural life course perspective (LCP), we examined the most common trajectories experienced by older long-term care (LTC; home and community-based care, assisted living, and nursing home care) recipients. The overall sequencing of care transitions was considered along with the role of social structural location, social and economic resources, and health factors in influencing them. Method Latent class and latent transition analyses were conducted using administrative data obtained over a 4-year period for clients aged 65 and older (n = 2,951) admitted into publicly funded LTC in 1 Canadian health region. Results Four main LTC trajectories were identified within which a wider range of more specific or secondary subtrajectories were embedded. These were shaped by social structural factors (age, gender, rural-urban residence), social and economic resources (marital status, income, payment for services), and health factors (chronic conditions, functional and cognitive impairment and decline, problematic behaviors). Discussion Our findings support the utility of a structural LCP for understanding LTC trajectories in later life. In doing so, they also reveal avenues for enhancing equitable access to care and the need for options that would increase continuity and minimize unnecessary, untimely, or undesirable transitions.

Just the Facts: Changes in Older Driver Attitudes After Exposure to Educational Interventions

Objectives: To examine the change in cognitive processing as measured by consciousness raising and attitudes toward driving following educational interventions for older adults. Methods: Older adults who viewed a research-based applied theater production about older driver safety (n = 110) were compared to those who were exposed to a print-based publication available to all drivers (n = 100). Results: After viewing the play developed with input from older adults and others, older adult viewers’ attitudes toward driving shifted in a manner consistent with an increased openness or willingness to consider changing their driving behavior. Conversely, after reading the print-based materials, the older adults felt more empowered to continue drive. Conclusions: Demonstrating that an intervention that takes into account the views of older drivers can lead to attitudinal outcomes that differ from those achieved with typical “just the facts” programs is an important step in understanding how program content and format affect outcomes. Future interdisciplinary work such as this may enhance our capabilities to understand more about the processes involved in influencing change in attitudes and behaviors.

Changing Roles of Care Team Members within New Models of Care Delivery in Residential Care Facilities: Implications for the Delivery of Quality of Care

Providing quality of care (QoC) to older adults in residential care settings is an ongoing challenge given the increasingly complex needs of this population and the escalating economic constraints within which health authorities operate. While the implementation of the residential care delivery model in a Western Canadian health authority has contributed to some improvements in QoC, it has also highlighted key challenges that are both interpersonal and organizational in nature; specifically, gaps in leadership, teamwork, mentorship, and communication, as well as staffing mix, staffing consistency, resident complexity, and competing policy and program initiatives and directives. The implementation of a major change in care delivery impacts residents, families, and staff and may, in turn, impact their perceptions of change in QoC. When evaluating a model, therefore, it is important to examine both qualitative and quantitative outcomes: stories from those most affected in their everyday lives and trends in QoC indicator data.

Long-Term Care Service Trajectories and Their Predictors for Persons Living With Dementia: Results From a Canadian Study:

Objective: We used latent transition analysis to explore common long-term care (LTC) service trajectories and their predictors for older adults with dementia. Method: Using linked administrative data collected over a 4-year interval (2008-2011), the study sample included 3,541 older persons with dementia who were clients of publicly funded LTC in British Columbia, Canada. Results: Our results revealed relatively equal reliance on home care (HC) and facility-based residential care (RC) as starting points. HC service users were further differentiated into “intermittent HC” and “continuous HC” groups. Mortality was highest for the RC group. Age, changes in cognitive performance, and activities of daily living were important predictors of transitions into HC or RC. Discussion: Reliance on HC and RC by persons with dementia raises critical questions about ensuring that an adequate range of services is available in local communities to support aging in place and to ensure appropriate timing for entry into institutions.

“When I Said I Wanted to Die at Home I Didn’t Mean a Nursing Home”: Care Trajectories at the End of Life

Abstract Background and Objectives Little is known regarding the care trajectories older adults experience at the end of life (EOL). We drew on a structural/institutional life course perspective to examine the trajectories evident among older adults transitioning through the Canadian formal long-term care system. The sequence of care transitions as well as the impact of social location, social and economic resources, and health-related factors on these trajectories were examined. Research Design and Methods To identify EOL care trajectories, we used administrative data collected on older adults (aged 65+) who received publicly subsidized long-term care services (e.g., nursing home and home and community-based care) in one health region in British Columbia, Canada from January 1, 2008 through December 31, 2011 and who died by March 31, 2012 (n = 11,816). Multinomial logistic regression analyses assessed the impact of selected covariates on these trajectories. Results The majority of those studied (65.4%) died outside of acute hospital settings. The most common trajectories involved transitions from home care to nursing home/residential care to non-hospital death (39.5%) and transitions from in-home care to hospital death (22.4%). These and other trajectories were shaped by social structural factors, access to social and economic resources, as well as health status and prior hospitalizations. Discussion and Implications Despite calls for minimizing hospital-based deaths and maximizing home-based deaths, older LTC recipients often experience EOL care trajectories that end in death in a nursing home care setting. Our findings point to the value of a structural/institutional life course perspective in informing an understanding of who experiences this and other major EOL care trajectories. In doing so, they also provide direction for policy and practice designed to address inequalities and enhance the quality of EOL care.

Social Engagement and Antipsychotic Use in Addressing the Behavioral and Psychological Symptoms of Dementia in Long-Term Care Facilities

Objectives The use of antipsychotics, mainly to address the behavioral and psychological symptoms of dementia (BPSD), remains a common and frequent practice in long-term care facilities (LTCFs) despite their associated risks. The objective of this study was to explore the association between social engagement (SE) and the use of antipsychotics in addressing the BPSD in newly admitted residents to LTCFs. Methods A cross-sectional study was undertaken using administrative data, primarily the Resident Assessment Instrument Minimum Data Set (Version 2.0) that collected between 2008 and 2011 (Fraser Health region, British Columbia, Canada). The data analysis conducted on a sample of 2,639 newly admitted residents aged 65 or older with a diagnosis of Alzheimer’s disease or other dementias as of their first full or first quarterly assessment. Multivariate logistic regression analyses were undertaken to predict antipsychotic use based on SE. Results SE was found to be a statistically significant predictor of antipsychotic use when controlling for sociodemographic variables (odds ratio (OR) = .86, p < .0001, confidence interval (CI) [0.82, 0.90]). However, the association disappeared when controlling for health variables (OR = .97, p = .21, CI [0.97, 1.0]). Conclusion The prediction of antipsychotic use in newly admitted residents to LTCFs by SE is complex. Further research is warranted for further examination of the association of antipsychotic use in newly admitted residents to LTCFs.

A Tale of Two Sites: Lessons on Leadership from the Implementation of a Long-term Care Delivery Model (CDM) in Western Canada

Residential, long-term care serves vulnerable older adults in a facility-based environment. A new care delivery model (CDM) designed to promote more equitable care for residents was implemented in a health region in Western Canada. Leaders and managers faced challenges in implementing this model alongside other concurrent changes. This paper explores the question: How did leadership style influence team functioning with the implementation of the CDM? Qualitative data from interviews with leadership personnel (directors and managers, residential care coordinators and clinical nurse educators), and direct care staff (registered nurses, licensed practical nurses, health care aides, and allied health therapists), working in two different facilities comprise the main sources of data for this study. The findings reveal that leaders with a servant leadership style were better able to create and sustain the conditions to support successful model implementation and higher team functioning, compared to a facility in which the leadership style was less inclusive and proactive, and more resistant to the change. Consequently, staff at the second facility experienced a greater sense of overload with the implementation of the CDM. This study concludes that strong leadership is key to facilitating team work and job satisfaction in a context of change.