The complexities of defining what appears to be the relatively simple concept of resilience are widely recognized. This paper analyses the concept of resilience from a range of disciplinary perspectives and clarifies a definition in order to inform research, policy and practice. The work takes a life course approach to resilience, examining evidence derived from research across the lifespan. It incorporates the methods of systematic review, concept analysis and consultation through face-to-face meetings. The synthesis of methodological approaches enables a clear identification of the antecedents, defining attributes and consequences of resilience, validated with stakeholder partners. Through this process, resilience is defined as the process of effectively negotiating, adapting to, or managing significant sources of stress or trauma. Assets and resources within the individual, their life and environment facilitate this capacity for adaptation and ‘bouncing back’ in the face of adversity. Across the life course, the experience of resilience will vary. A large proportion of resilience research is routed within the discipline of developmental psychology, and has mainly been developed with children and adolescents. A major contribution to resilience research could be made through more multi-disciplinary studies that examine the dynamics of resilience across the lifespan, its role in healthy ageing and in managing loss, such as changes in cognitive functioning.

Introduction

The context for the review of loneliness and social isolation in later life is that of ‘successful aging’ and ‘quality of life’. The term ‘quality of life‘ includes a broad range of areas of life and there is little agreement about the definition of the term. Models of quality of life range from identification of ‘life satisfaction’ or ‘social wellbeing’ to models based upon concepts of independence, control, and social and cognitive competence. However, regardless of how the concept of quality of life is defined, research has consistently demonstrated the importance of social and family relationships in the definition of a ‘good quality of life’.

The term person-centred care has become all-pervasive on the UK dementia care scene. It has been suggested that it has become synonymous with good quality care. It seems that any new approach in dementia care has to claim to be pc (person-centred) in order to be P.C. (politically correct). The term is used frequently in the aims and objectives for dementia care services and provision in the UK and the US, although what lies behind the rhetoric in terms of practice may be questionable.

The well-being of older adults in general, and their loneliness in particular, are important themes in recent discussions in the Western world. The social integration and participation of older adults in society are seen as indicators of productive aging, and the alleviation of loneliness forms part of policies aimed at achieving the goal of ‘successful’ aging. Discussions about loneliness date back to ancient times, when they were led by philosophers. They wrote primarily about ‘positive’ loneliness. This positive type of loneliness - as indicated in the concept of ‘Einsamkeit’ used in German literature until 1945 - is perceived to be related to the voluntary withdrawal from the daily hassles of life and oriented towards higher goals, such as reflection, meditation and communication with God.

The social environment is one of the key factors determining the quality of life of older people. Research has consistently demonstrated a strong and positive relationship between social engagement in all forms but especially participation within kin and wider social networks, and a high quality of life. However, this recognition of the importance of this relationship is not new. In the early 1960s, the ‘activity theorists’ of aging posited that the key to a good old age was the maintenance of high levels of activity, including social participation and the maintenance of kin- and friendship-based relationships. This resonates with the ideas of Rowe and Kahn who suggest that a high level of social engagement is a key factor in achieving the individually and socially desired goal of ‘successful aging’. Furthermore, they argue that, with advanced age, the social context, in combination with the physical environment, exerts a more potent influence upon the experience of later life than either intrinsic genetic or biological factors. Whilst the prescriptive strictures of activity theory and successful aging remain the subject of debate, there seems little doubt that the social environment continues to exert both a powerful influence upon, and provides a context within which people experience old age, both individually and collectively.

Obesity is a worldwide problem with increasing prevalence and incidence in both developed and developing countries. In older adults, excess weight is associated with a higher prevalence of cardiovascular disease, metabolic disease, several important cancers, and numerous other medical conditions. Obesity has also been associated with increased functional limitations, disability, and poorer quality of life. Additionally, obesity has been independently associated with all-cause mortality. The obesity epidemic has important social and economic implications, representing an important source of increased public health care costs. The aim of this review is to report the epidemiology of obesity worldwide, and the implications of obesity on disability and chronic diseases in older adults.

Frailty is a term that is used often, but commonly not defined precisely. As reviewed elsewhere most definitions share several features. Typically, older adults who are frail have a greater rate of dependence on others, so-called ‘loss of physiological reserve’ and multiple diseases. A dynamic component is often included (e.g. ‘loss of reserve’ and such synonyms as ‘unstable disability’ and ‘impaired homeostenosis’) and is manifest when, over time, patients respond less well to stress, or when those with given levels of frailty have higher rates of adverse outcomes. Still, the imprecision of the term frailty has led some to question its merit, and either to develop alternative means of classification or to stay with the concept of function and disability. Alternative methods of classification are either broadly or narrowly focussed.

Loneliness may be regarded as a ‘geriatric giant’, leading to impaired quality of life, greater need for institutional care and increased mortality. For the past 30 years, a growing number of studies have focused on loneliness. However, the majority of these have been descriptive and cross-sectional. Further longitudinal studies are needed to understand the causal relationship between life-events and loneliness, its prognostic significance and, in particular, whether negative consequences may be alleviated.

Chronic obstructive pulmonary disease is a major cause of morbidity, disability and mortality in old age. The disease is characterized by shortness of breath, impaired ventilatory function and easy fatiguability. These are the most distressing and disabling symptoms of COPD, limiting exercise tolerance, interfering with basic activities of daily living and often, in turn, impairing quality of life.

Stroke is particularly prevalent in older people and the effects of stroke can be profound. Not only are the abilities to stand, balance and walk affected, but also the ability to use the upper limb and hand in its diversity of functions in everyday life. Loss of independence of upper limb function contributes enormously to functional disability, affecting quality of life and independence in ‘basic’ (washing, grooming, feeding, dressing, etc.) and ‘instrumental’ activities (shopping, home/financial management, etc.) of daily living. A larger proportion of stroke patients with initial severe upper limb paresis are discharged to institutionalized care (63%) than are discharged home (37%).

Frailty is common in older age, and is associated with important adverse health outcomes, including increased risk of disability and long-term care admission.

This study aims to evaluate whether home-based exercise interventions improve outcomes for frail older people.

We searched systematically for randomized controlled trials (RCTs) and cluster RCTs, with literature searching to February 2010.

All trials that evaluated home-based exercise interventions for frail older people were eligible. Primary outcomes were mobility, quality of life and daily living activities. Secondary outcomes included long-term care admission and hospitalization.

Six RCTs involving 987 participants met the inclusion criteria. Four trials were considered of high quality. One high-quality trial reported improved disability in those with moderate but not severe frailty. Meta-analysis of long-term care admission rates identified a trend towards reduced risk. Inconsistent effects on other primary and secondary outcomes were reported in the other studies.

There is preliminary evidence that home-based exercise interventions may improve disability in older people with moderate, but not severe, frailty. There is considerable uncertainty regarding effects on important outcomes including quality of life and long-term care admission. Home-based exercises are a potentially simple, safe and widely applicable intervention to prevent dependency decline for frail older people.

Research into end of life and dying with dementia in care homes from the family carer's perspective is limited. From the available evidence, it appears that family carers find themselves in an unfamiliar situation about which they lack knowledge and experience. Whilst dementia tends not to be acknowledged as a terminal illness by many family carers, they are expected to make end of life decisions on behalf of their relatives. Family carer decision-making is underpinned by values of quality of life, previously expressed wishes, comfort provision and dignity preservation. This is often approached when family carers are grieving for the anticipated loss of their relative and have their own personal needs that require to be addressed. Within a care home setting, a curative care–palliative care split is unhelpful in resolving these tensions and a model of comprehensive care appears a more appropriate approach. This requires ongoing communication between the person with dementia, family members and professionals from the early stages of the condition.

Young-onset dementia (dementia in people under 65 years of age) remains an under-researched area of dementia care. As populations age in industrialized countries, dementia is set to increase: this includes dementias in younger people. Current estimates suggest there are over 15 000 younger people living with dementia in the UK, whilst dedicated services and research in this area remain limited. Younger people may be affected by rarer forms of dementia that can create various kinds of impairment in the individual. For example, as Boxer and Miller report, although memory can be affected, people with conditions such as frontotemporal dementia can present initially with personality changes as the primary symptom. Younger people may also have more difficulties with visuospatial and semantic tasks when compared with an person, and there are likely to be personal and societal implications for the entire family.

The National Dementia Strategy in England has performed an essential role in transforming health and social care services and improving the commissioning architecture. However, to date, little attention has been paid to understanding the ways in which the outdoor and built environment impacts and intersects with the lives of people with dementia and their carers. One way of better understanding the outdoor and built environment is through a focus on the ‘neighbourhood’ as this is an area of public policy where attempts are being made across disciplines to unpack its meanings, significance and identity. This paper adopts a realist review method to detail the key findings and messages from the body of work that links the experience of living with dementia to the neighbourhood. Our findings from this review are assimilated and defined/presented under three headings, namely: outdoor spaces, built environment, and everyday technologies. These headings and our definitions are not discrete properties and there is some overlap in content. We found no research that sets out to enquire about how people with dementia might define their neighbourhood or that explores everyday neighbourhood practices for those living with the condition. Emerging concepts such as citizenship and, in the UK, the Coalition Government advancement of the ‘Big Society’, promote a vision of civic responsibilities and networked, dementia-capable communities, but evaluation of such initiatives are virtually absent from the literature. The review did uncover some interesting and innovative research methods that extend neighbourhood working, such as the ‘walking interview’. In order to develop a neighbourhood model for dementia, future research should examine the relationship and interaction between the neighbourhood as a social space and as a physical space alongside the active role of people with dementia as ‘place-makers’.

The use of the term ‘technology’ in relation to dementia care provokes conflicting reactions. For some, ‘technology is a saviour, the way to paradise; others are deeply suspicious of technology and scrutinize its proponents carefully for any tell-tale marks of the Beast’. These conflicting reactions may be attributed to the confusion surrounding the term ‘technology’, the lack of awareness at all levels of the potential of technology to assist people with dementia, and the ethical issues surrounding the use of technology.

Most individuals with dementia live in the community, receiving care from family or lay carers. Carers’ wellbeing, and the quality of the care they provide, depends on their resilience in the face of the challenges associated with caring for someone with dementia. However, factors associated with carers’ resilience are not yet fully understood. The aim of this review is to present a narrative synthesis of factors, materials and resources associated with carers’ resilience. Electronic and hand searches identified relevant published literature, which was narratively synthesized. A framework consisting of three inter-related domains of factors influencing carers’ resilience emerged, encompassing: social and cultural factors; properties of the care relationship; and carers’ psychological factors. Holistic assessment based on this framework can help practitioners to identify vulnerable carers and to target help on factors that help to make them vulnerable but that are amenable to change.

Appropriate social and medical interventions may help maintain independence in older people. Determinants of functional decline, disability and reduced independence are recognized and specific interventions target the treatment of clinical conditions, multiple health problems and geriatric conditions, prevention of falls and fractures, and maintenance of physical and cognitive function and social engagement.

Preventive strategies to identify and treat diverse unmet needs of older people have been researched extensively. We reviewed systematically recent randomized controlled trials evaluating these ‘complex’ interventions and incorporated the findings of 21 studies into an established meta-analysis that included 108,838 people in 110 trials. There was an overall benefit of complex interventions in helping older people to live at home, explained by reduced nursing home admissions rather than death rates. Hospital admissions and falls were also reduced in intervention groups. Benefits were largely restricted to earlier studies, perhaps reflecting general improvements in health and social care for older people. The wealth of high-quality trial evidence endorses the value of preventive strategies to help maintain independence in older people.

There is considerable research on work satisfaction and stress of care staff on the one hand and on quality of care and well-being of older people on the other. However, very little research in continuing-care settings for older people (nursing homes, residential homes and long-stay wards) links perceptions of workers (work satisfaction and stress) with the process of care (quality of care) and outcomes for residents/patients (well-being). This is a notable omission, given the emphasis of government policy on improving quality of health and social care services for vulnerable elderly people in the UK. The White Papers, The New NHS and Modernising Social Services and the National Priority Guidance for Health and Social Services for 2000–2003, all emphasize the importance of services that are responsive to local needs and which maintain and promote independence. The Centre for Policy on Ageing has been commissioned by the Department of Health to develop national standards for nursing and residential home care services for older people. This work will build upon recommendations of the Burgner Report and Achieving a Better Home Life, which identified areas for benchmarking. The national standards proposed under the forthcoming National Service Framework for Older People will underpin new legislation to regulate care services.