The lived experience of bathing adaptations in the homes of older adults and their carers (BATH-OUT)

The onset of disability in bathing may be followed by disability in other daily activities for older adults. A bathing adaptation usually involves the removal of a bath or inaccessible shower and replacement with a level, easy access shower. The purpose is to remove the physical environmental barriers and restore older adults’ ability to bathe safely and/or independently. The aim of this study was to explore the views and experiences of older adults and their carers who had received a bathing adaptation in order to examine how the adaptation had affected them and identify mechanisms of impact and outcomes from their perspectives. The study was nested within a feasibility Randomised Controlled Trial (RCT) (BATH-OUT) conducted within one local authority housing adaptations service in England. Semi-structured interviews were completed between 21 December 2016 and 19 August 2017 with 21 older adults and five carer participants of the feasibility RCT. Interview participants were purposively sampled on living arrangement and gender. Interviews were audio-recorded, transcribed verbatim and analysed in seven stages using framework analysis. Findings were presented thematically. Five themes were identified: ease of use; feeling safe; feeling clean; independence, choice and control; and confidence and quality of life. The removal of the physical barriers in the bathroom led to older adults re-mastering the activity of bathing, having an improved sense of physical functioning which gave a sense of ‘freedom’. This appeared to impact a range of areas contributing to a wider sense of increased confidence consistent with constructs underpinning social care-related quality of life. We suggest that future research should examine housing adaptations from a person–environment fit approach, and that timely restoration of bathing ability is especially important as it can affect confidence and perceived competence in other areas of daily living

An audit of dressing practice by occupational therapists in acute stroke settings in England

Introduction Dressing independence is commonly affected after stroke, with clinical guidelines recommending that dressing practice should routinely be provided for those with dressing difficulties. The aim of this study was to update the literature on current practice in the treatment of dressing problems in stroke rehabilitation units. Method A questionnaire survey of occupational therapists experienced in stroke care was sent to 157 stroke units in England. Results Responses were received from 70 stroke units. Frequency and duration of dressing practice varied substantially between units, with respondents typically providing dressing practice for six to 10 patients per week and spending 30 to 45 minutes per treatment session. Only 17 respondents (24.3%) stated that they regularly used standardised assessments of dressing ability. The functional approach was used more widely than the remedial approach. Service priorities, working environment and limitations of time and staffing were reported to influence dressing practice. Conclusion There is widespread variability in dressing practice. There is a lack of use of standardised dressing assessments, and therapists’ rationale for their choice of approach is unclear

Interventions to reduce dependency in bathing in community dwelling older adults: a systematic review

Background The onset of bathing disability for older adults has been found to be an indicator and potential precursor of further disability. Thus interventions targeting bathing may prevent or delay further disability and the use of health and social care services. The aim of this systematic review was to identify interventions targeted at reducing dependency in bathing for community dwelling older adults, and determine their content and effectiveness in maintaining or improving function and quality of life. Methods We conducted a systematic search of electronic databases including: The Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; EMBASE; AMED; CINAHL; PsycINFO and OTSeeker. The search took place on 18 October 2016. We included randomised controlled trials, nonrandomised controlled trials, and controlled before and after studies that evaluated an intervention designed to reduce dependency in bathing. Articles were screened for inclusion by two independent reviewers; risk of bias was assessed using quality assessment tools; and data extracted using pre-prepared forms. Disagreements were resolved by discussion and inclusion of a third reviewer. Results The search process identified one study for inclusion in the review. This study evaluated a bathing intervention delivered by an occupational therapist following discharge from hospital. Overall, the findings suggest modest improvements in functional ability in favour of the intervention group although the results should be interpreted with caution. Conclusion Despite evidence suggesting the importance of addressing bathing difficulties as a means of possible prevention of disability in the ageing process, there is a dearth of evaluative or interventional research studies. Further robust research is warranted, including studies of randomised and controlled design

Bathing adaptations in the homes of older adults and their carers (BATH-OUT): a qualitative extended follow-up study with concurrent nested outcome assessments

Objective We previously completed a nested qualitative interview study, as part of a feasibility randomised controlled trial with 21 older adults and five carers who had an accessible shower installed in their home. The objective of this study was to follow-up the participants approximately 24 months on. Design This was an extended follow-up study comprising semi-structured interviews to explore the longer-term experiences of the older adults. To elaborate and add breadth to the findings these were supplemented with concurrent nested outcome assessment measures. Setting The study was conducted within one local authority City Council housing adaptations service. Participants Thirteen older adults (mean age: 76; SD: 6.87) and three carers from the original study completed the extended follow-up study. Interventions The intervention in the original study was the provision of an accessible showering facility either by immediate provision or routine 4-month wait. Results Findings were presented thematically with three themes identified: environment, autonomy with personal care and wider occupation. Improvements in the physical and social environment combined with greater autonomy in personal care were reported to impact more widely on older adults’ occupations including other self-care activities and leisure. These are consistent with domains underpinning social care related quality of life particularly personal safety, cleanliness and occupation. The results of the outcome assessments support the qualitative themes demonstrating sustained improvements in quality of life, independence in daily living and reduced fear of falling. Conclusion This research suggests the positive lived experiences reported immediately after the installation of the accessible shower are still evident up to 28 months later in this cohort of older adults. Future research should investigate medium to longer-term outcomes with a more diverse sample. Trial Registration ISRCTN14876332; Post-results

Early specialist orthotic interventions for the lower limb in adult stroke patients: a systematic literature review

Background: Stroke is a leading cause of long-term disability worldwide, estimated to affect up to 50% of stroke survivors. Many stroke survivors use orthotic splints and braces to help address difficulties with mobility and gait dysfunction both early after the stroke event and longer-term.Objectives: The aim of this systematic review was to identify, synthesise and appraise the evidence on early orthotic involvement for the lower limb following stroke.Study design: Systematic literature reviewMethods We conducted a systematic search of electronic databases including: AMED (1985 to present; CINAHL (1982 to present); EMBASE (1980 to present); MEDLINE (1949 to present); PsycINFO (1967 to present). The search took place on 18/10/2019. Included studies evaluated an early orthotic intervention designed to either promote mobility or reduce secondary complications after stroke. Articles were screened for inclusion by two independent reviewers.Results: This review included six articles from one research group in the Netherlands. Methodological quality was considered good in each of the included studies. Limitations include small sample size, restricted descriptions of the intervention and short-term follow-ups.Conclusion: This systematic review suggests that earlier lower limb orthotic interventions can result in improved walking speed and balance, and enhanced ability to perform activities of daily living in the early weeks post-stroke. Future research would benefit from considering wider orthotic and orthotist intervention with larger sample sizes and longer-term outcomes

A Biopsychosocial Intervention for Stroke Carers (BISC): development and description of the intervention

Objective: Family members of stroke survivors are often not supported for their caring role, with many reporting adjustment difficulties. This paper describes the development and content of a group-based intervention for informal carers of stroke survivors.Method: The intervention is based on the theoretical foundation of the biopsychosocial model with the aim to understand and address the physical, psychological and social factors of caring for stroke survivors. Findings from a comprehensive literature review and a qualitative study with carers and stroke professionals were synthesized to guide the intervention development. The Template for Intervention Description and Replication (TIDieR) checklist was used as a framework to describe the intervention.Results: The intervention integrates cognitive-behavioural approaches via the identification of the biopsychosocial (physical, emotional, social) factors that can have an impact on the well-being of carers. It includes education on stroke-specific topics and advice on coping strategies. It consists of six two-hour group sessions facilitated in a community setting. It provides information and support on adjusting to the caring role in the first year post-stroke. Intervention materials were designed for addressing carers’ specific needs using psychological techniques, such as problem-solving, goal setting and relaxation exercises.Conclusion: We have underlined the importance for describing and reporting the process of intervention development for complex interventions in the context of stroke rehabilitation. An intervention addressing the needs of informal stroke carers (Biopsychosocial Intervention for Stroke Carers; BISC) has been developed and described. BISC was further evaluated in a single-centre feasibility randomized controlled trial

Biopsychosocial intervention for stroke carers (BISC): results of a feasibility randomised controlled trial and nested qualitative interview study

Objective: To determine the feasibility of recruiting to and delivering a biopsychosocial intervention for carers of stroke survivors. Design: Feasibility randomised controlled study with nested qualitative interview study. Setting: The intervention was delivered in the community in either a group or one-to-one format. Subjects: Carers and stroke survivors within one year of stroke onset. Interventions: A carer targeted intervention delivered by a research psychologist in six structured two-hour sessions or usual care control. The intervention combined education about the biological, psychological and social effects of stroke with strategies and techniques focussing on adjustment to stroke and caregiving. Stroke survivors in both groups received baseline and follow-up assessment but no intervention. Main Outcome: Recruitment rate, study attrition, fidelity of intervention delivery, acceptability and sensitivity of outcome measures used (health related quality of life, anxiety and depression and carer burden six months after randomisation). Results: Of the 257 carers approached, 41 consented. Six withdrew before randomisation. Eighteen participants were randomised to receive the intervention and 17 to usual care. Attendance at sessions was greater when treated one-to-one. Feedback interviews suggested that participants found the intervention acceptable and peer support particularly helpful in normalising their feelings. Thirty participants were assessed at follow-up with improvements from baseline on all health measures for both groups. Conclusions: Our results suggest that a biopsychosocial intervention was acceptable to carers and can be delivered in group and one-to-one formats. Timing of approach and mode of intervention delivery is critical and requires tailoring to the carers individual needs

Bathing Adaptations in the Homes of Older Adults (BATH-OUT-2) : study protocol for a randomised controlled trial, economic evaluation and process evaluation

Background The onset of disability in bathing is particularly important for older adults as it can be rapidly followed by disability in other daily activities; this may represent a judicious time point for intervention in order to improve health, well-being and associated quality of life. An important environmental and preventative intervention is housing adaptation, but there are often lengthy waiting times for statutory provision. In this randomised controlled trial (RCT), we aim to evaluate the effectiveness and cost-effectiveness of bathing adaptations compared to no adaptations and to explore the factors associated with routine and expedited implementation of bathing adaptations. Methods BATH-OUT-2 is a multicentre, two-arm, parallel-group RCT. Adults aged 60 and over who are referred to their local authority for an accessible level access shower will be randomised, using pairwise randomisation, 1:1, to receive either an expedited provision of an accessible shower via the local authority or a usual care control waiting list. Participants will be followed up for a maximum of 12 months and will receive up to four follow-ups in this duration. The primary outcome will be the participant’s physical well-being, assessed by the Physical Component Summary score of the Short Form-36 (SF-36), 4 weeks after the intervention group receives the accessible shower. The secondary outcomes include the Mental Component Summary score of the SF-36, self-reported falls, health and social care resource use, health-related quality of life (EQ-5D-5L), social care-related quality of life (Adult Social Care Outcomes Toolkit (ASCOT)), fear of falling (Short Falls Efficacy Scale), independence in bathing (Barthel Index bathing question), independence in daily activities (Barthel Index) and perceived difficulty in bathing (0–100 scale). A mixed-methods process evaluation will comprise interviews with stakeholders and a survey of local authorities with social care responsibilities in England. Discussion The BATH-OUT-2 trial is designed so that the findings will inform future decisions regarding the provision of bathing adaptations for older adults. This trial has the potential to highlight, and then reduce, health inequalities associated with waiting times for bathing adaptations and to influence policies for older adults. Trial registration ISRCTN Registry ISRCTN48563324. Prospectively registered on 09/04/2021

Bathing adaptations in the homes of older adults (BATH-OUT): results of a feasibility randomised controlled trial (RCT)

Abstract Background Housing adaptations have been identified as an important environmental and prevention intervention for older adults, which may improve health and quality of life. The onset of disability in bathing can act as a warning for further disability in other activities and may therefore be a judicious time-point for intervention. The aim of this study was to determine the feasibility of conducting a Randomised Controlled Trial (RCT) of bathing adaptations, to evaluate whether they improve older adults’ perceived health status and quality of life, prevent further functional deterioration, and reduce the use of other health and social care resources. This study was conducted in preparation for a powered RCT. Method Eligibility criteria were aged > 65 and referred to local authority housing adaptations service for an accessible flush-floor shower. Participants were randomised to either usual adaptations (3–4 month wait) or immediate adaptations (no wait). Outcomes were assessed at 3, 6 and 9 months and included perceived physical and mental health status, health and social care related quality of life, independence in activities of daily living (ADL) and bathing, and falls. Data on costs and the use of health and social care resources were collected during follow-up in order to inform a definitive health economic evaluation. Results Sixty participants were recruited and randomised, 31 to immediate adaptations and 29 to waiting list control. Mean age was 77(SD8), 58% women and 58% living alone. Follow-ups were completed with 90, 85 and 72% at 3, 6 and 9 months respectively. Adaptations were delivered to 65% of participants within the requisite timescales as there were delays with some privately owned properties. There were improvements from baseline in both groups on all outcome measures following the completion of the adaptations. Conclusions This is the first RCT of housing adaptations in the UK. We demonstrated the feasibility of using a waiting list control, subject to minor alterations to the timescales for privately owned properties. A powered trial would evaluate the impact on older adults’ quality of life and investigate the impact of waiting times on functional outcomes and health and care resource use. Trial registration ISRCTN14876332 Registered 12 July 2016