Nicole Dubuc

Effects of aerobic physical exercise in the elderly with type 2 diabetes mellitus

The objective of this study was to determine the impact of an aerobic physical exercise program in the treatment of a group of elderly patients with type 2 diabetes mellitus (DM) in relation to metabolic control, physical capacity, quality of life (QOL) and attitudes toward diabetes. Patients were randomly assigned to either an experimental (n=19) or a control (n=20) group. The following measurements were conducted at baseline and after week 16: glycosylated hemoglobin (hbA1c), fructosamine, 3 h oral glucose tolerance test, treadmill test (Balke-Naughton), and a questionnaire on QOL and attitudes toward DM. After the intervention, the experimental group showed a significant decrease of glucose excursion during the oral glucose tolerance test (OGTT) (area under the curve) (16.6+/-3.8 vs. 15.3+/-3.1, P<0.05) and an increase in total time on the treadmill (s) (423+/-207 vs. 471+/-230, P<0.05). An improvement in the attitudes toward DM was observed in the experimental group (P=0.01) but not in the control group. Female gender, higher body mass index and hbA1c were factors associated with a response to the intervention. This study suggests that physical exercise has significant effects on glucose excursion during an OGTT and exercise tolerance in elderly patients with type 2 DM.

Resources and Costs Associated with Disabilities of Elderly People Living at Home and in Institutions

This study was carried out on a representative sample of elderly people living at home ( n = 300), in intermediate faculties ( n = 271) and nursing homes ( n = 774) from metropolitan, urban and rural areas in the Province of Quebec (Canada) in order to: 1) determine the level of disabilities and resources involved in the care of elderly people living at home or in institutional settings; 2) estimate the costs (public, private, voluntary) of these resources; 3) compare the costs according to the level of disability; and 4) predict the costs associated with disabilities. Results show that there were significant differences but large overlap in the disability level, cognitive status and nursing care needed and received between participants from the three settings. The disability score explained 85 per cent of the variance in nursing care time and 55 per cent (home), 15 per cent (intermediate facilities) and 68 per cent (nursing homes) of the variance in the cost. Nursing care was responsible for most of the cost in all settings. The total societal cost of home care was greater than the cost of intermediate facilities for elderly participants with a disability score over 7.4 and greater even than the cost of nursing homes for a score over 38.7.

Efficacy of supervised Tai Chi exercises versus conventional physical therapy exercises in fall prevention for frail older adults: a randomized controlled trial

Purpose: To compare the effectiveness of supervised Tai Chi exercises versus the conventional physical therapy exercises in a personalized rehabilitation program in terms of the incidence and severity of falls in a frail older population. Method: The participants were frail older adults living in the community, admitted to the day hospital program in Sherbrooke, Quebec, Canada (n = 152). They were randomized to receive a 15-week intervention, either by supervised Tai Chi exercises (n = 76) or conventional physical therapy (n = 76). Fall incidence and severity were assessed using both the calendar technique and phone interviews once a month during 12 months following the end of the intervention. Other variables were collected at baseline to compare the two groups: age, comorbidity, balance, sensory interaction on balance, and self-rated health. Results: Both interventions demonstrated a protective effect on falls but Tai Chi showed a greater one (RR = 0.74; 95% CI = 0.56–0.98) as compared to conventional physical therapy exercises. Conclusions: Supervised Tai Chi exercises as part of a rehabilitation program seem to be a more effective alternative to the conventional physical therapy exercises for this specific population. Implications for Rehabilitation Seniors who have fallen have a 50% chance of falling again during the following year, leading them to reduce their outings and thus decrease their social activities. Frail older people could benefit more from an individualized intervention than the regular group program generally used in a Tai Chi intervention. Tai Chi exercises seems to be a good alternative to regular physiotherapy exercises as a part of a multidisciplinary intervention in preventing a subsequent fall over a 12-month period.

The effect of supervised Tai Chi intervention compared to a physiotherapy program on fall-related clinical outcomes: A randomized clinical trial

Purpose: To assess some fall-related clinical variables (balance, gait, fear of falling, functional autonomy, self-actualization and self-efficacy) that might explain the fact that supervised Tai Chi has a better impact on preventing falls compared to a conventional physiotherapy program. Methods: The participants (152 older adults over 65 who were admitted to a geriatric day hospital program) were randomly assigned to either a supervised Tai Chi group or the usual physiotherapy. The presence of the clinical variables related to falls was evaluated before the intervention (T1), immediately after (T2), and 12 months after the end of the intervention (T3). Results: Both exercise programs significantly improved fall-related outcomes but only the Tai Chi intervention group decreased the incidence of falls. For both groups, most variables followed the same pattern, i.e. showed significant improvement with the intervention between T1 and T2, and followed by a statistically significant decrease at the T3 evaluation. However, self-efficacy was the only variable that improved solely with the Tai Chi intervention (p = 0.001). Conclusions: The impact of supervised Tai Chi on fall prevention can not be explained by a differential effect on balance, gait and fear of falling. It appeared to be related to an increase of general self-efficacy, a phenomenon which is not seen in the conventional physiotherapy program. Implications for Rehabilitation Each participant received a multidisciplinary intervention with either Tai Chi or physical therapy. Both interventions were associated with improved balance, gait, less fear of falling, improved functional autonomy and greater self actualisation. Only Tai Chi decreased the incidence of falls which appeared to be related to self-efficacy. Tai Chi seems to be a good alternative to physical therapy exercises to prevent falls in frail older people.

Meeting the home-care needs of disabled older persons living in the community: does integrated services delivery make a difference?

BackgroundThe PRISMA Model is an innovative coordination-type integrated-service-delivery (ISD) network designed to manage and better match resources to the complex and evolving needs of elders. The goal of this study was to examine the impact of this ISD network on unmet needs among disabled older persons living in the community.MethodsUsing data from the PRISMA study, we compared unmet needs of elders living in the community in areas with or without an ISD network. Disabilities and unmet needs were assessed with the Functional Autonomy Measurement System (SMAF). We used growth-curve analysis to examine changes in unmet needs over time and the variables associated with initial status and change. Sociodemographic characteristics, level of disability, self-perceived health status, cognitive functioning, level of empowerment, and the hours of care received were investigated as covariates. Lastly, we report the prevalence of needs and unmet needs for 29 activities in both areas at the end of the study.ResultsOn average, participants were 83 years old; 62% were women. They had a moderate level of disability and mild cognitive problems. On average, they received 2.07 hours/day (SD = 1.08) of disability-related care, mostly provided by family. The findings from growth-curve analysis suggest that elders living in the area where ISD was implemented and those with higher levels of disability experience better fulfillment of their needs over time. Besides the area, being a woman, living alone, having a higher level of disability, more cognitive impairments, and a lower level of empowerment were linked to initial unmet needs (r2 = 0.25; p < 0.001). At the end of the study, 35% (95% CI: 31% to 40%) of elders with needs living in the ISD area had at least one unmet need, compared to 67% (95% CI: 62% to 71%) in the other area. In general, unmet needs were highest for bathing, grooming, urinary incontinence, walking outside, seeing, hearing, preparing meals, and taking medications.ConclusionsIn spite of more than 30 years of home-care services in the province of Quebec, disabled older adults living in the community still have unmet needs. ISD networks such as the PRISMA Model, however, appear to offer an effective response to the long-term-care needs of the elderly.

Yearly transitions of disability profiles in older people living at home.

PURPOSE Planning home services for older people requires extensive knowledge about the progression of disabilities. Disability-based case-mix classifications identify meaningful groups of older people; yet transitions between profiles are mostly unknown. METHODS Disability was assessed annually over four years with the Functional Autonomy Measurement System (SMAF) in 1410 older people at risk of functional decline aged 75 and over and living at home. The SMAF generates a case-mix classification of 14 Iso-SMAF profiles with progressive mean disability levels. Transitions made by older people were analyzed using a continuous-time, multi-state Markov model to estimate the probabilities of annual transitions into and out of each profile as well as the mean sojourn time in each profile. RESULTS The probability of staying in a profile tended to decrease as profile severity increased. For profiles 5 and above, recovery to mild profiles 1, 2 and 3 was low, while annual probabilities of death and institutionalization were high (>0.10). The lower disability profiles (1 and 2) evidenced a mean profile sojourn time of over two years, contrary to sojourn times of 18 months or less with the other profiles. CONCLUSIONS The probabilities are identifiable, indicating that a disability-based classification can characterize progression in older people. Since the required resources and costs are known for each profile, these probabilities are very helpful in planning home services for elderly populations.

Identifying Characteristics of Residential Care Facilities Relevant to the Placement Process of Seniors

OBJECTIVE To identify which characteristics of the physical and organizational environments of residential care facilities (RCFs) need to be known to support the placement process of seniors with cognitive and physical disabilities. DESIGN We used a 2-round postal Delphi survey based on the RAND/UCLA Appropriateness Method with 2 groups of experts. PARTICIPANTS Participants are representatives of concerned stakeholder groups from various sectors (public, private, and community) and geographical regions within the province of Quebec, Canada. RESULTS Of the 58 persons who were interested in participating, 48 (82.8%) returned their questionnaires. The first group identified 171 items essential to consider when a cognitively impaired senior needs to move into an RCF. Of these, 88 were related to the physical environment of the RCF and 83 to its organizational environment. The second group identified 146 items to be relevant to consider when a senior with physical impairments needs to choose an RCF; 75 for the physical and 71 for the organizational environment. 85% of the items selected by both groups (cognitive versus physical group) were identical. CONCLUSION This study provided a list of important items that described residential care facilities in regard to their physical and organizational environments to support the placement process of seniors. It also provides the possibility to develop a self-administered tool that will supply valuable information to seniors and their relatives, to health care professionals, and to administrators and decisions-makers.

Correlates of the perceived need for institutionalisation among older adults without cognitive impairment.

Background: While many studies investigate the factors that influence the institutionalisation of older persons, only a few consider one of its most important predictors, namely, the perceived need for institutionalisation. Also referred to as ‘desire for institutionalisation’, it has mainly been investigated for informal caregivers of older adults suffering from dementia. Not many studies target caregivers of people without dementia; even fewer have been interested in the older adult’s own perceived need. Objective: To measure the prevalence and identify the correlates of the perceived need for institutionalisation among community-dwelling older adults without cognitive impairment. Methods: During the fourth wave of the longitudinal PRISMA study, cognitive-impairment-free participants (78 years or older and at risk of functional decline) were presented with three questions assessing their perceived need for institutionalisation. Correlates were identified through multivariable logistic regression analyses. Analyses were conducted separately for two types of home living arrangements: individual and collective dwellings. Results: 27% of the older adults at least thought about institutionalisation, irrespective of their current living arrangements. For homeowners/tenants, age ranging from 80 to 85, transfer and vision problems, the absence or advanced age of the informal caregiver, and the use of the ER or help for home maintenance during the past year led them to think about institutionalisation. Seniors living in collective dwellings think about institutionalisation after experiencing a recent highly significant functional decline, when feeling that their current environment fails to meet needs, and after requiring the use of voluntary services during the past year. Conclusions: The percentage of community-dwelling older adults considering institutionalisation is the same for people currently in individual or collective settings. Factors related to physical disabilities and insufficiencies of resources are important correlates, with specific factors differing between the two types of current living arrangements.

Is there agreement between Canadian older adults and their primary informal caregivers on behaviour towards institutionalisation

We aimed to compare behaviour towards institutionalisation between frail older adults and their informal caregivers, and identify correlates of differential behaviour. In 2004, during the fourth wave of the longitudinal Program of Research to Integrate Services for the Maintenance of Autonomy (PRISMA) study (province of Québec, Canada), 86.7% of eligible dyads, that is 593 participants and their primary informal caregivers, were asked separately if they thought about placement, discussed it with someone or visited an institution during the previous year. An ordinal measure of behaviour towards institutional placement was derived and agreement between dyad members was assessed with the weighted kappa. Although identical behaviour was relatively high (65.4%), it represented almost exclusively no thoughts by either member and the weighted kappa was low (0.16). Differential behaviour was then analysed as a three-level dependent variable (thoughts only by the care-receiver, thoughts only by the caregiver, no thoughts by either dyad member) in a multiple multinomial logistic regression analysis. Compared with neither person thinking about it, the care-receiver alone thinking about placement was associated with using voluntary services, receiving help for home maintenance and visits to the emergency room during the previous year, along with the caregiver being aged 70 years or over. Compared with neither person thinking about it, the caregiver alone thinking about placement was associated with being male, not residing with the care-receiver, sensing a higher subjective burden, along with the care-receiver being 85 years or older, not being able to feed him/herself independently and visits to the emergency room during the previous year. Identified correlates can be useful in targeting dyads likely to behave differently. Communication within these dyads needs to be enhanced, as it is crucial to ensure that both parties are comfortable with possible future institutionalisation. In this regard, health professionals could play a role in bringing the issue to discussion.

DOES REGULATING PRIVATE LONG-TERM CARE FACILITIES LEAD TO BETTER CARE? A STUDY FROM QUEBEC, CANADA

OBJECTIVE In the province of Quebec, Canada, long-term residential care is provided by two types of facilities: publicly funded accredited facilities and privately owned facilities in which care is privately financed and delivered. Following evidence that private facilities were delivering inadequate care, the provincial government decided to regulate this industry. We assessed the impact of regulation on care quality by comparing quality assessments made before and after regulation. In both periods, public facilities served as a comparison group. DESIGN A cross-sectional study conducted in 2010-12 that incorporates data collected in 1995-2000. SETTINGS Random samples of private and public facilities from two regions of Quebec. PARTICIPANTS Random samples of disabled residents aged 65 years and over. In total, 451 residents from 145 care settings assessed in 1995-2000 were compared with 329 residents from 102 care settings assessed in 2010-12. INTERVENTION Regulation introduced by the province in 2005, effective February 2007. MAIN OUTCOME MEASURE Quality of care measured with the QUALCARE Scale. RESULTS After regulation, fewer small-size facilities were in operation in the private market. Between the two study periods, the proportion of residents with severe disabilities decreased in private facilities whereas it remained >80% in their public counterparts. Meanwhile, quality of care improved significantly in private facilities, while worsening in their public counterparts, even after controlling for confounding. CONCLUSIONS The private industry now provides better care to its residents. Improvement in care quality likely results in part from the closure of small homes and change in resident case-mix.