Background: In older adults, respiratory function may be seriously compromised when a marked decrease of respiratory muscle (RM) strength coexists with comorbidity and activity limitation. Respiratory muscle training has been widely studied and recommended as a treatment option for people who are unable to participate in whole-body exercise training (WBET); however, the effects of inspiratory muscle training and yoga breathing exercises on RM function remain unknown, specifi cally in impaired older adults. Purpose: To evaluate the effects of inspiratory threshold training (ITT) and yoga respiratory training (YRT) on RM function in institutionalized frail older adults. Methods: Eighty-one residents (90% women; mean age, 85 years), who were unable to perform WBET (inability to independently walk more than 10 m), were randomly assigned to a control group or one of the 2 experimental groups (ITT or YRT). Experimental groups performed a supervised intervalbased training protocol, either through threshold inspiratory muscle training device or yoga breathing exercises, which lasted 6 weeks (5 days per week). Outcome measures were collected at 4 time points (pretraining, intermediate, posttraining, and follow-up) and included the maximum respiratory pressures (maximum inspiratory pressure [MIP] and maximum expiratory pressure [MEP]) and the maximum voluntary ventilation (MVV). Results: Seventy-one residents completed the study: control (n = 24); ITT (n = 23); YRT (n = 24). The treatment on had a signifi cant effect on MIP YRT (F 6,204 = 6.755, P <.001, η 2 = 0.166), MEP (F 6,204 = 4.257, P <.001, η 2 = 0.111), and MVV (F 6,204 = 5.322, P <.001, η 2 = 0.135). Analyses showed that the YRT group had a greater increase of RM strength (MIP and MEP) and endurance (MVV) than control and/or ITT groups. Conclusion: Yoga respiratory training appears to be an effective and well-tolerated exercise regimen in frail older adults and may therefore be a useful alternative to ITT or no training, to improve RM function in older population, when WBET is not possible.

Background and Purpose: Evidence now links poor oral hygiene to systemic and infectious diseases such as pneumonia. Hospitalized patients, who now retain their teeth into older adulthood, often rely on nurses to provide oral hygiene care. Nurses have the potential to impact oral health outcomes and quality of life by controlling plaque. However, oral hygiene care practices of nurses in post-acute hospital settings are relatively unknown. The purpose of this study was to explore how nurses provide bedtime oral hygiene care, how they decide on interventions provided, and how certain factors influence their ability to provide oral care. Methods: A qualitative, exploratory multiple-case study was conducted with 25 nurses working on five inpatient units at different hospitals. Nurses were accompanied on their evening rounds to observe oral care practices, the physical environment, and workflow. Thematic analysis was used to analyse the case study data base including transcripts of guided conversations, field notes, and documents. Within-case analysis was followed by cross-case analysis. Findings: Findings indicate that: (a) nurses often convey oral hygiene care to their patients as being optional; (b) nurses are inclined to preserve patient autonomy in oral hygiene care; (c) oral hygiene care is often spontaneous and variable, and may not be informed by evidence; and (d) oral hygiene care is not embedded into bedtime care routines. Implications: Oral health history and assessment data are essential to the creation of individualized, feasible oral hygiene care plans that consider patient dignity. Knowledge of the health benefits of oral care, and skills related to assessment and approaches to oral care are required by nurses. Availability of effective products and supplies facilitates provision of oral care. The evidence for oral hygiene care practices, outcomes of nurse-administered oral care, and the role of nurses in influencing the oral health literacy of patients requires further study. / Dissertation / Doctor of Philosophy (PhD) / When in hospital, older people often rely on nurses for help with oral care. Little is known about how nurses provide this type of care, but poor oral care can lead to pneumonia, gum disease, and other diseases of the body. In this study, nurses were accompanied as they provided bedtime oral care to patients. Findings showed that: (a) nurses let patients decide about doing oral care and do not encourage it, (b) nurses let patients do oral care themselves, even if they cannot do a good job, (c) the oral care given depends on the nurse, and (d) bedtime oral care, the most important time of day, is not part of the bedtime routine. Nurses should (a) ask patients about their oral health and inspect their mouths, (b) have the right supplies available so they can more easily provide effective oral care, and (c) teach their patients about the importance of oral hygiene.

Background Palliative care services have widened beyond cancer in recent years, yet frail older adults rarely receive such services. There is a need to understand the dynamic multidimensional end-of-life experiences of this group in order to assess how or if a palliative approach could be beneficial. Physical end-of-life trajectories for frail older people have been described but there remains little person centred research that describes changing experiences across physical, social, psychological and existential dimensions. Aims and objectives To explore the changing multidimensional experiences of frail older people towards the end of life and to reflect on the utility of a qualitative longitudinal multi-perspective design for this population. Methods Thirteen cognitively intact, community dwelling older adults considered to be moderately or severely frail, using a clinical frailty scale, and thirteen nominated informal carers participated in up to three narrative interviews over eighteen months. Eight nominated professionals were also interviewed. The interviews were participant led, audio-recorded and fully transcribed. The ‘voice centred relational’ narrative method, incorporating analyses of multidimensional experience, was used to analyse the data. The data were then analysed longitudinally to compile case studies for each older person. Findings The narratives of these frail older people approaching the end of life illustrate patterns of multidimensional experience that differ from the end-of-life trajectories of other groups. All participants experienced physical decline however three possible patterns of psychological, social and existential experience emerged. These were stable, regressive and tragic according to the capacity to hold on to core values, and maintain a sense of self and of belonging in the world and are illustrated using visual trajectories. When the sense of self was threatened these frail older people lacked valued alternative identities and struggled with the absence of clear causative factors to explain their circumstances. The participants frequently described fears of burdening others, of moving to a nursing home or of developing dementia more than fears of dying. Losses and sustaining factors are described for physical, social, psychological and existential dimensions revealing the importance of social and community networks for supporting frail older people. There were constraints and benefits to using a qualitative longitudinal multi-perspective method, however the method enabled a deep, contextualised and rich understanding of the dynamic experiences of frail older people. Conclusion Frail older people may be supported towards the end of life by considering ways to promote the integration of the self. This may involve promoting valued alternative identities, protecting personhood through social and health care practices and by investigating ways to alleviate or make tolerable greatest fears. Community health and social care structures and social and community networks appear essential for addressing the end-of-life needs of frail older people. A qualitative, longitudinal, multi-perspective design was beneficial for investigating the experiences of frail older people.

The adequate care of older persons is a major global concern and countries are examining ways to respond to these needs, especially the needs of frail older persons in the care environment. Important strides have been made in developed countries but progress has been slow in less developed countries in the Global South and limited information exists on the care needs of frail older persons and lived experiences of formal and informal caregivers. This thesis examines the care needs of frail older persons in Namibia. Namibia has only recently been liberated from colonial rule by Germany and apartheid South Africa. During this time black communities were disenfranchised, resource-scarce and living under poor conditions. For older persons, this meant unequal treatment, social exclusion and denial of access to decent care. The aim of this study was to provide an in-depth understanding of the needs of frail older persons in the care environment in Namibia by examining the lived experiences of caregivers and analysing policy. Using a qualitative methodology, the study collected primary data from formal and informal caregivers based on semi-structured interviews and focus groups. The data analysis relied mainly on coding strategies under Atlas-ti and qualitative content analysis. The secondary data were collected from legislation, government policy documents, journals and other public reports. The finding revealed that Namibia's history has entrenched the current situation of unmet needs of frail older persons, exacerbated by inadequate policy protection. These limitations were highlighted by the Covid-19 pandemic. The study also found that the effective care of frail older persons is only possible through stakeholder engagement and cross-sectoral collaboration. The study therefore recommends that government should undertake a process of social reforms to ensure that the needs of this group are prioritised, that a performance framework should be implemented to ensure delivery and that all stakeholders should be mobilised. The study has contributed to these outcomes by suggesting a model for needs assessment of frail older persons, especially during the Covid-19 pandemic. This model could be used to improve care practices, serve government in evidence-based policy making and provide a useful analytical tool for scholarship.

Abstrakt Bakgrund: Antalet äldre ökar i samhället vilket gör att sköra äldre också blir fler. Flertalet av de patienter som söker sig till hälso- och sjukvården är äldre och sköra som behöver få tillfredställande vård i hela vårdkedjan. Sköra äldre kan vara drabbade av ofrivillig viktnedgång och balanssvårigheter vilket kan öka risken för ytterligare skörhet och försämrad hälsa. Sköra äldres vårdproblematik i kombination med vårdarbete inom ansträngda vårdorganisationer kan skapa en komplexitet för sjuksköterskorna i vårdandet av sköra äldre. Syfte: Syftet med denna studie var att belysa komplexiteten av att vårda sköra äldre ur ett sjuksköterskeperspektiv på en geriatrisk vårdavdelning och inom kommunal hemsjukvård. Metod: Enskilda intervjuer användes som metod för att samla in data. Totalt deltog elva sjuksköterskor, sex sjuksköterskor från geriatrisk vårdavdelning samt fem sjuksköterskor från kommunal hemsjukvård. Data analyserades med hjälp av kvalitativ innehållsanalys. Resultat: Resultatet presenteras i tre kategorier: Hitta balansen att hjälpa i sköra äldres och anhörigas situation, Komplexiteten av att vårda inom ett organisatoriskt ramverk samt Erfarenhet och utveckling i vården skapar möjlighet att kunna bli berikad. Analysen visar att komplexiteten består av flera olika delar tillexempel underlättande och försvårande faktorer som behöver ses utifrån ett helhetsperspektiv. Helhetsperspektivet försvårades för sjuksköterskorna av organisatoriska faktorer så som olika system och behörigheter som hindrade informationsöverföringen samt personal-, tids och kompetensbrist. Det komplexa i vården var även att sköra äldre snabbt skiftade i mående och när anhöriga hade avvikande åsikter från sköra äldre. Underlättande av komplexiteten var när anhöriga fanns som en resurs, då teamet samverkar runt sköra äldre samt då sjuksköterskorna upplevde sig berikande av den kunskap och glädje som vården av sköra äldre tillförde. Slutsats: Komplexiteten av att vårda sköra äldre behöver synliggöras för att sjuksköterskor ska kunna få mer tid till vårdande av sköra äldre, stöd och handledning i sitt arbete, vidareutbildningar och specialistutbildningar från sin arbetsgivare. Detta är viktigt för att sköra äldre ska få en tillfredställande vård som svarar upp till deras behov, i ett samhälle som behöver vara beredd på ökade vårdbehov i framtiden. / Abstract Background: Society in general is facing an ever increasing number of older people, even resulting in a rising number of frail older people. This group of elderly is the main category of patients seeking health care and they can expect to receive satisfactory care throughout the whole professional health care organization. Frail older people may be affected by involuntary weight loss and balance difficulties, which could increase the risk for further frailty and impairment of health. Complex health issues of frail older persons in combination with stressed care organizations contribute to increased complexity in the work of nurses caring for the frail older people. Aim: The aim of this study was to illuminate the complexity of caring for frail older persons as experienced by nurses in a geriatric hospital care unit and in municipal home care. Method: Individual interviews were conducted to collect data. A total of eleven nurses participated, six from the geriatric hospital care unit and five from municipal home nursing. The data was analyzed using qualitative content analysis. Results: The result is presented in three categories: Finding the balance to help the frail elderly and their families, The complexity of providing professional health care within an organizational framework and Experience and development in care enriching for professionals. What makes care for frail elderly complex was described by nurses consisting of several different aspects that needed to be viewed and approached from a holistic perspective. Nurses experienced difficulties in having a holistic perspective because of organizational factors such as different systems for authorisation. This in turn restricted information transfersas well as created shortages of time, staff and competence. The complexity of care was also connected with rapid reduction of frail older persons health and that their relatives had different opinions from the patient. What counteracted complexity was connected to relatives being a resource, a team based approach around the frail elderly and when nurses found joy in their work and were able to learn from working with frail older people. Conclusion: The complexity of caring for the frail older people needs to be acknowledged so that nurses can receive more time for care, support and supervision in their work, and further education and specialist education by their employers. This is crucial for providing frail older people with satisfactory care that meets their needs, in preparing society for the increased needs of frail older people care organisations will face in the future.

Bakgrund: Sköra äldre definieras som en äldre person med ökad sårbarhet och därmed förhöjd risk att utsättas för vårdskador i hälso- och sjukvården. Det är viktigt att känna till begreppet skörhet och att kunna identifiera skörhet hos äldre personer för att ge den äldre patienten en patientsäker vård samt minska risk för vårdskada. Var tionde äldre patienten får vänta längre än sju timmar innan de kan skrivas in på en avdelning eller lämna en akutmottagning. Sjuksköterskor anser att det är svårt att göra rätt bedömning och anpassa vården efter en skör äldre, samt att prioritera rätt utefter vårdbehov. Syfte: Syftet med denna litteraturöversikt är att studera användbarheten av bedömningsinstrument för att sjuksköterskan ska kunna identifiera sköra äldre som söker vård på en akutmottagning samt sjuksköterskors upplevelse till att använda bedömningsinstrument. Metod: Studien är en litteraturöversikt där resultatet är baserat på 15 vetenskapliga artiklar. Artikelsökningarna genomfördes i databaserna Pubmed och Cinahl. Resultat: Tio bedömningsinstrumenten beskrivs i studiens resultat. Resultaten presenteras i två huvudkategorier; vilka bedömningsinstrument beskrivs och vad är sjuksköterskornas upplevelse till att använda bedömningsinstrumenten. Bedömningsinstrumenten Clinical frailty scale [CFS], och FRail Elderly Support researcH group [FRESH] verkar vara snabba och effektiva för att bedöma skörhet hos de äldre på en akutmottagning. Sjuksköterskorna har en positiv inställning till att använda ett bedömningsinstrument, men upplever att det är tidsbrist och därmed upplever sjuksköterskor svårigheter att använda ett bedömningsinstrument. Slutsats: Ett alternativ för att avlasta sjuksköterskor på en akutmottagning och främja en patientsäkervård kan vara att ha en specialistsjuksköterska inom geriatrik som fokuserar på själva bedömningen av sköra äldre. Sköra äldre patienter bör markeras som sköra i journalsystemet för att lättare och snabbare få en mer anpassad och säkrare vård. Till följd av en snabb bedömning av skörhet kan sjuksköterskorna på en akutmottagning vidta omvårdnadsåtgärder direkt för att förebygga och förhindra att en vårdskada ska uppstå. / Background: Frail elderly are defined as older people with increased vulnerability with a higher possibility of getting injured while receiving healthcare. It is important to know the concept of frailty and to be able to identify frailty in older persons, in order to provide patients with safe care and reduce the risk of injury. One out of ten patients have to wait for 7 hours and 18 minutes before they get offered care or can leave the emergency department. Healthcare personnel admits it is hard to make an assessment, adjust healthcare and prioritize the care towards frail older people. Aim: The aim of this literature review is to study the usefulness of assessment tools for the nurse to be able to identify frailty older who seek care at an emergency department and the nurse's experience of using assessment tools. Method: The study is a literature review and the results are based upon 15 compiled scientific articles. The PubMed and Cinahl databases were used to search for articles. Results: Ten different assessment instruments are described in this study. Two main questions were asked. These were: Which assessment tool are there to help the nurses to identify frail older in an emergency department? What is the nurses experience of using these assessment tools? Clinical frailty scale [CFS], och FRail Elderly Support researcH group [FRESH] seems to be quick and effective in assessing the frailty of the older at an emergency department. The nurses have a positive attitude towards using an assessment instrument, But they feel a shortage of time and therefore nurses experience difficulties in using an assessment instrument. Conclusion: An alternative to relieving nurses at an emergency department and promoting patient care may be to have a specialist nurse in geriatrics that focuses on the assessment of frail older people. Frail older patients should be marked as frail in the medical record system to more easily and more quickly receive a more customized and safer care. As a result of a rapid assessment of fraility, the nurses at an emergency department can take nursing measures directly to prevent and prevent a medical injury from occurring.

År 2030 beräknas var fjärde person i Sverige att vara 65 år eller äldre. Akutsjukvården är i dagsläget dåligt anpassad för att tillgodose de sköra äldres specifika behov. För att tillmötesgå de ökande behoven krävs nytänkande i omhändertagandet. Detta ställer stora krav på sjukvårdens kunskap om åldrandet och dess sjukdomar. Sjuksköterskan har en nyckelroll vid omhändertagandet av sköra äldre patienter genom att bedöma vårdbehov, utföra omvårdnadsåtgärder samt bidra till en trygg och säker vårdmiljö. Syftet med denna studie var att identifiera förbättringsområden i omhändertagandet av den sköra äldre patienten på akutmottagningen. Denna studie genomfördes med kvalitativ metod med induktiv ansats och fokusgruppsintervjuer. För att analysera datamaterialet har en kvalitativ innehållsanalys använts. I resultatet framkom en huvudkategori; ”För att tillmötesgå de ökade sköra äldres omvårdnadsbehov krävs av dagens akutvårdspersonal ökad förståelse och kunskap. Detta uppnås lämpligast på välbemannade akutmottagningar med god struktur”. Följande tre kategorier stöttar upp huvudkategorin; ”Tid och prioritering”, ”Förståelse och kunskap” samt ”Struktur”. Slutsatsen är att det finns förbättringsområden på akutmottagningen vid omhändertagandet av de sköra äldre patienterna. Studien visar behov av erfaren och intresserad personal som arbetar på personaltäta och strukturerade akutmottagningar där det finns möjlighet till fortbildning. / In 2030, every fourth person in Sweden is estimated to be 65 or older. Emergency care is currently poorly adapted to meet the specific needs of frail older people. In order to meet the increasing needs, new thinking is needed in the care. This places great demands on the healthcare knowledge about aging and its diseases. The nurse has a key role in the care of frail older patients by assessing care needs, performing nursing and contributing to a safe and secure caring environment. The aim of this study is to identify areas of improvement in the care of the frail older patient at the emergency department. This study was carried out with a qualitative method with inductive approach and focus group interviews. To analyze the data material, a qualitative content analysis has been used. In the result, a main category emerged; “To meet the increased frail older nursing needs, todays emergency care staff require increased understanding and knowledge. This is best achieved on well-manned emergency departments with a good structure”. The following three generic categories support the main category; “Time and priority”, “Understanding and knowledge” and “Structure”. The conclusion is that there are areas of improvement in the emergency department when handling the frail older patients. The study shows needs of experienced and interested staff who work on staff-tight and structured emergency department where there is the possibility of continuing education.

Le but général de la thèse consiste à mieux connaître l’influence du milieu d’évaluation (domicile vs clinique) sur la réalisation de tâches liées à la préparation de repas auprès de personnes âgées fragiles. La thèse s'articule autour de trois objectifs spécifiques, dont les résultats sont présentés dans le cadre de cinq articles scientifiques. Le premier objectif vise à faire état des connaissances relatives au concept de fragilité en ergothérapie et à l'influence du milieu d'évaluation auprès des personnes âgées fragiles. Dans un premier temps, une analyse critique d'écrits portant sur la fragilité a été effectuée. Les résultats (article 1) démontrent la pertinence du concept de fragilité en ergothérapie, en suggérant qu'une meilleure compréhension de ce concept puisse aider les ergothérapeutes à offrir aux personnes fragiles des soins et services mieux adaptés à leurs besoins. Dans un deuxième temps, une recension des études ayant comparé la réalisation d'activités de la vie domestique (AVD) entre les milieux d'évaluation a été réalisée. Les résultats (article 2) révèlent que les personnes âgées sans déficit cognitif important tendent à offrir une meilleure performance à domicile, plutôt qu'en milieu clinique, lors de la réalisation d'AVD. Quelques facteurs, tels que la familiarité avec l’environnement, contribueraient à expliquer cette différence entre les milieux d'évaluation. Cette recension critique suggère que des résultats similaires puissent être obtenus auprès de personnes âgées fragiles. Le second objectif cherche à comparer la réalisation de tâches liées à la préparation de repas entre les milieux d’évaluation auprès de personnes âgées fragiles. Pour atteindre cet objectif, trente-sept personnes âgées répondant aux critères de fragilité (Fried et al.,2001) ont été évaluées en milieux clinique et domiciliaire suivant un devis contrebalancé au moyen du Assessment of Motor and Process Skills (AMPS) et du Performance Assessment of Self-Care Skills (PASS). Les résultats (articles 3, 4 et 5) concourent, dans l'ensemble, à démontrer une meilleure performance des personnes fragiles lorsqu’elles sont évaluées à domicile. Le dernier objectif a pour but d'identifier les facteurs sociodémographiques,physiques, cognitifs, psychologiques et environnementaux susceptibles d'expliquer la différence entre les milieux d'évaluation. Les résultats de la thèse (articles 3, 4 et 5) tendent à démontrer que le déclin de certaines fonctions exécutives constitue un facteur prépondérant pour expliquer une meilleure performance à domicile. Nos analyses révèlent que d'autres facteurs cognitifs, sociodémographiques, psychologiques, physiques et environnementaux contribuent également, mais de façon moins importante, à la différence observée entre les milieux d'évaluation. Les résultats de cette thèse peuvent aider les ergothérapeutes à mieux distinguer les personnes âgées fragiles susceptibles de présenter une performance différente selon le milieu dans lequel elles sont évaluées et conséquemment, pour qui une visite à domicile devrait être préconisée. Les connaissances générées par la thèse pourraient ultimement contribuer à offrir aux personnes âgées fragiles des services mieux adaptés à leurs besoins, tout en favorisant une gestion efficiente des ressources en matière de santé. / This thesis aims to advance the state of knowledge about the impact of assessment settings (home versus clinic) on meal preparation task performance in frail older adults. The thesis has three specific objectives and the results are presented in five articles. The first specific objective aims to review current knowledge about the concept of frailty in occupational therapy and the impact of assessment settings in frail older adults. First, a critical review about frailty was conducted. The results (article 1) demonstrate that a better understanding of the concept of frailty may help occupational therapists provide health care and services better tailored to the specific needs of this population. Second, a review of studies comparing performance of instrumental activities of daily living (IADL) between assessment settings was performed. The results (article 2) reveal that older adults without significant cognitive impairments tend to perform better in IADL tasks when assessed at home. Some factors, such as familiarity with the environment, may explain this difference. Based on this review, similar results might be expected with frail elders. The second specific objective aims to compare meal preparation task performance in home and clinical settings in a population of frail older adults. Thirty-seven frail older adults were thus assessed in home and clinical settings with the Assessment of Motor and Process Skills (AMPS) and the Performance Assessment of Self-Care Skills (PASS), using a counterbalanced design. The results (articles 3, 4, 5) globally demonstrate significantly better performance of participants when assessed at home. The third specific objective aims to identify demographic, physical, cognitive, psychological and environmental factors that may explain differences between assessment settings. The results (articles 3, 4, 5) indicate that a better performance in the home setting was mostly related to a decline in certain executive functions. Other cognitive, demographic, psychological, physical and environmental factors also contribute to explain the differences between assessment settings but to a lesser extent. Our findings may help occupational therapists identify frail older adults likely to present a different performance in the clinical setting and thus for whom home assessments would be advisable. Our findings could ultimately mean that frail clients are provided with services adapted to their needs, while ensuring an efficient allocation of health care resources.

Le but général de la thèse consiste à mieux connaître l’influence du milieu d’évaluation (domicile vs clinique) sur la réalisation de tâches liées à la préparation de repas auprès de personnes âgées fragiles. La thèse s'articule autour de trois objectifs spécifiques, dont les résultats sont présentés dans le cadre de cinq articles scientifiques. Le premier objectif vise à faire état des connaissances relatives au concept de fragilité en ergothérapie et à l'influence du milieu d'évaluation auprès des personnes âgées fragiles. Dans un premier temps, une analyse critique d'écrits portant sur la fragilité a été effectuée. Les résultats (article 1) démontrent la pertinence du concept de fragilité en ergothérapie, en suggérant qu'une meilleure compréhension de ce concept puisse aider les ergothérapeutes à offrir aux personnes fragiles des soins et services mieux adaptés à leurs besoins. Dans un deuxième temps, une recension des études ayant comparé la réalisation d'activités de la vie domestique (AVD) entre les milieux d'évaluation a été réalisée. Les résultats (article 2) révèlent que les personnes âgées sans déficit cognitif important tendent à offrir une meilleure performance à domicile, plutôt qu'en milieu clinique, lors de la réalisation d'AVD. Quelques facteurs, tels que la familiarité avec l’environnement, contribueraient à expliquer cette différence entre les milieux d'évaluation. Cette recension critique suggère que des résultats similaires puissent être obtenus auprès de personnes âgées fragiles. Le second objectif cherche à comparer la réalisation de tâches liées à la préparation de repas entre les milieux d’évaluation auprès de personnes âgées fragiles. Pour atteindre cet objectif, trente-sept personnes âgées répondant aux critères de fragilité (Fried et al.,2001) ont été évaluées en milieux clinique et domiciliaire suivant un devis contrebalancé au moyen du Assessment of Motor and Process Skills (AMPS) et du Performance Assessment of Self-Care Skills (PASS). Les résultats (articles 3, 4 et 5) concourent, dans l'ensemble, à démontrer une meilleure performance des personnes fragiles lorsqu’elles sont évaluées à domicile. Le dernier objectif a pour but d'identifier les facteurs sociodémographiques,physiques, cognitifs, psychologiques et environnementaux susceptibles d'expliquer la différence entre les milieux d'évaluation. Les résultats de la thèse (articles 3, 4 et 5) tendent à démontrer que le déclin de certaines fonctions exécutives constitue un facteur prépondérant pour expliquer une meilleure performance à domicile. Nos analyses révèlent que d'autres facteurs cognitifs, sociodémographiques, psychologiques, physiques et environnementaux contribuent également, mais de façon moins importante, à la différence observée entre les milieux d'évaluation. Les résultats de cette thèse peuvent aider les ergothérapeutes à mieux distinguer les personnes âgées fragiles susceptibles de présenter une performance différente selon le milieu dans lequel elles sont évaluées et conséquemment, pour qui une visite à domicile devrait être préconisée. Les connaissances générées par la thèse pourraient ultimement contribuer à offrir aux personnes âgées fragiles des services mieux adaptés à leurs besoins, tout en favorisant une gestion efficiente des ressources en matière de santé. / This thesis aims to advance the state of knowledge about the impact of assessment settings (home versus clinic) on meal preparation task performance in frail older adults. The thesis has three specific objectives and the results are presented in five articles. The first specific objective aims to review current knowledge about the concept of frailty in occupational therapy and the impact of assessment settings in frail older adults. First, a critical review about frailty was conducted. The results (article 1) demonstrate that a better understanding of the concept of frailty may help occupational therapists provide health care and services better tailored to the specific needs of this population. Second, a review of studies comparing performance of instrumental activities of daily living (IADL) between assessment settings was performed. The results (article 2) reveal that older adults without significant cognitive impairments tend to perform better in IADL tasks when assessed at home. Some factors, such as familiarity with the environment, may explain this difference. Based on this review, similar results might be expected with frail elders. The second specific objective aims to compare meal preparation task performance in home and clinical settings in a population of frail older adults. Thirty-seven frail older adults were thus assessed in home and clinical settings with the Assessment of Motor and Process Skills (AMPS) and the Performance Assessment of Self-Care Skills (PASS), using a counterbalanced design. The results (articles 3, 4, 5) globally demonstrate significantly better performance of participants when assessed at home. The third specific objective aims to identify demographic, physical, cognitive, psychological and environmental factors that may explain differences between assessment settings. The results (articles 3, 4, 5) indicate that a better performance in the home setting was mostly related to a decline in certain executive functions. Other cognitive, demographic, psychological, physical and environmental factors also contribute to explain the differences between assessment settings but to a lesser extent. Our findings may help occupational therapists identify frail older adults likely to present a different performance in the clinical setting and thus for whom home assessments would be advisable. Our findings could ultimately mean that frail clients are provided with services adapted to their needs, while ensuring an efficient allocation of health care resources.

Background: By the year 2030 the prognosis is that one fourth of the Swedish population will be 65 years or older. An age group that today stands for 40 percent of all the daily visits in the Swedish emergency departments. Nearly half of them are 80 years or older. The frail older adults are often low prioritized due to their diffuse symptoms whereby long waiting times and healthcare-related injuries may occur. As a complement to the standard prioritizing procedure, that triage stands for, some emergency departments have introduced screening tools for detecting those individuals that are older adults and frail. Unfortunately, the introduction of new guidelines, do not always imply that the implementation comes easy because there are factors that facilitate and inhibit their intended use. Aim: To illustrate factors that affect the nurses use of the screening tool Clinical Frailty Scale (CFS) which identifies frailty in elders during triage in the emergency department. Method: A descriptive quantitative cross-sectional study where data was collected through a web-based questionnaire. The data of the study was analyzed through descriptive and analytical statistics. Results: When it came to influencing factors regarding the use of CFS in the selected emergency department, CFS as a method with its practicalities constituted as facilitators, whilst the organizational and working cultural aspects constituted as barriers. The differences in the nurses' experience and education effected the perception of CFS in different ways. Conclusion: There is a need of a working culture where responsibility is shared between stakeholders to facilitate a guideline. Advanced nurse practitioners can have a crucial role in educating, motivating and creating space for discussion relating to organizational, theoretical and practical components of the process in identifying the frail older adults. / Bakgrund: Prognosen är att år 2030 kommer en fjärdedel av den svenska populationen vara 65 år eller äldre. Åldersgruppen utgör idag cirka 40 procent av alla besök på Sveriges akutmottagningar där nästan hälften av dem är 80 år eller äldre. De sköra äldre erhåller ofta låg prioritering på grund av sina diffusa symtom, där långa väntetider och vårdrelaterade skador kan uppstå som följd. Som komplement i den vanliga prioriteringsrutinen som triagering innebär har akutmottagningar infört screeningverktyg för att upptäcka de individer som är sköra äldre. Dessvärre innebär införandet av nya rutiner att de inte alltid lätt implementeras i verksamheten eftersom det finns faktorer som främjar och hindrar dess avsedda användning. Syfte: Att belysa faktorer som påverkar sjuksköterskors användning av screeningverktyget Clinical Frailty Scale (CFS) för att identifiera sköra äldre vid triagering på akutmottagningen. Metod: En kvantitativ tvärsnittsstudie där data samlades in genom en webbenkät. Studiens data analyserades deskriptivt samt med analytisk statistisk. Resultat: När det kom till faktorer som påverkade användningen av CFS på den valda akutmottagningen utgjorde CFS som metod med dess praktiska delar en främjande faktor, medan organisatoriska och arbetskulturella aspekter utgjorde hindrande faktorer. Skillnaderna i erfarenhet och utbildning hos sjuksköterskorna påverkade uppfattningen om CFS på olika sätt. Slutsats: Det behövs en arbetskultur med ett delat ansvar mellan organisation och medarbetare för att främja följsamheten till en rutin. Specialistsjuksköterskor kan ha en betydande roll i att utbilda, motivera och skapa forum för diskussion gällande organisatoriska, teoretiska och praktiska delar i processen av att identifiera sköra äldre.