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Research article Special Issues

Older adults’ activity on a geriatric hospital unit: A behavioral mapping study

  • Received: 08 October 2018 Accepted: 04 January 2019 Published: 21 January 2019
  • Background: Systematic reviews highlight a preponderance of prolonged sedentary behavior in the hospital setting, with possible consequences for patients’ health and mobility. To date, most of the published literature in this field focus on the hospital experience for older adults with dementia or stroke. Few data describe hospital activity patterns in specialized geriatric units for frail older adults, who are already at risk of spending prolonged periods of time sitting. Yet, promoting older adults’ activity throughout hospitalization, when possible, is an avenue for exploration to identify opportunities to encourage more daily functional activities, and minimize the risk of post-hospital syndrome. Methods: This was a two-part observational study to describe (1) the hospital indoor environment and (2) patients’ activity patterns (using behavioral mapping) within public areas of two hospital units. One combined-trained physiotherapist and occupational therapist recorded information on indoor environmental features for two acute geriatric hospital units, such as potential opportunities for sitting and walking (i.e., handrails, chairs, benches, etc.), and identified obstacles which may impede activity (i.e., food or laundry carts in hallways, etc.). The observer also systematically scanned these units every 15 minutes (8 am to 4 pm) over two days/unit (one weekday and one weekend day) using standard behavioral mapping methods. There were three to four observation stations identified on each unit to count the number of people who were present, distinguish their role (patient, visitor), approximate age, gender, and body position or activity (sitting, standing, walking). We did not enter patients’ rooms. We described units’ indoor environment, and observed activity for each unit. We used Chi square tests to compare differences in observations between units, day of the week, and gender. Results: For both units there were similar indoor environmental features, with the exception of the floorplans, number of beds, minor differences in flooring materials, and an additional destination room (two lounges attached to one unit). Both units had items such as laundry carts against walls in hallways, blocking handrails, when present. We observed between 46–86% (average 60%) of admitted patients in the public areas of hospital units, with variability depending on unit and day: More than half of the observations were of patients sitting. Approximately 20% of patients were observed more than once: This included five women and seven men. There were significant associations for gender and observations on weekdays (men > women; Chi square = 17.01, p < 0.0001), and weekend days (women > men; Chi square = 6.11, p = 0.013). There were more visitor observations on Unit 2. Conclusions: These exploratory findings are an opportunity to, generate hypotheses for future testing, and act as a starting point to collaborate with front line clinicians to highlight the indoor environment’s role in promoting activity, and develop future strategies to safely introduce more activity into the acute care setting for older adults.

    Citation: Patrocinio Ariza-Vega, Hattie Shu, Ruvini Amarasekera, Nicola Y. Edwards, Marta Filipski, Dolores Langford, Kenneth Madden, Maureen C. Ashe. Older adults’ activity on a geriatric hospital unit: A behavioral mapping study[J]. AIMS Medical Science, 2019, 6(1): 33-48. doi: 10.3934/medsci.2019.1.33

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  • Background: Systematic reviews highlight a preponderance of prolonged sedentary behavior in the hospital setting, with possible consequences for patients’ health and mobility. To date, most of the published literature in this field focus on the hospital experience for older adults with dementia or stroke. Few data describe hospital activity patterns in specialized geriatric units for frail older adults, who are already at risk of spending prolonged periods of time sitting. Yet, promoting older adults’ activity throughout hospitalization, when possible, is an avenue for exploration to identify opportunities to encourage more daily functional activities, and minimize the risk of post-hospital syndrome. Methods: This was a two-part observational study to describe (1) the hospital indoor environment and (2) patients’ activity patterns (using behavioral mapping) within public areas of two hospital units. One combined-trained physiotherapist and occupational therapist recorded information on indoor environmental features for two acute geriatric hospital units, such as potential opportunities for sitting and walking (i.e., handrails, chairs, benches, etc.), and identified obstacles which may impede activity (i.e., food or laundry carts in hallways, etc.). The observer also systematically scanned these units every 15 minutes (8 am to 4 pm) over two days/unit (one weekday and one weekend day) using standard behavioral mapping methods. There were three to four observation stations identified on each unit to count the number of people who were present, distinguish their role (patient, visitor), approximate age, gender, and body position or activity (sitting, standing, walking). We did not enter patients’ rooms. We described units’ indoor environment, and observed activity for each unit. We used Chi square tests to compare differences in observations between units, day of the week, and gender. Results: For both units there were similar indoor environmental features, with the exception of the floorplans, number of beds, minor differences in flooring materials, and an additional destination room (two lounges attached to one unit). Both units had items such as laundry carts against walls in hallways, blocking handrails, when present. We observed between 46–86% (average 60%) of admitted patients in the public areas of hospital units, with variability depending on unit and day: More than half of the observations were of patients sitting. Approximately 20% of patients were observed more than once: This included five women and seven men. There were significant associations for gender and observations on weekdays (men > women; Chi square = 17.01, p < 0.0001), and weekend days (women > men; Chi square = 6.11, p = 0.013). There were more visitor observations on Unit 2. Conclusions: These exploratory findings are an opportunity to, generate hypotheses for future testing, and act as a starting point to collaborate with front line clinicians to highlight the indoor environment’s role in promoting activity, and develop future strategies to safely introduce more activity into the acute care setting for older adults.


    We consider numerical invariants associated with polynomial identities of algebras over a field of characteristic zero. Given an algebra $ A $, one can construct a sequence of non-negative integers $ \{c_n(A)\}, n = 1,2,\ldots $, called the codimensions of $ A $, which is an important numerical characteristic of identical relations of $ A $. In general, the sequence $ \{c_n(A)\} $ grows faster than $ n! $. However, there is a wide class of algebras with exponentially bounded codimension growth. This class includes all associative PI-algebras [2], all finite-dimensional algebras [2], Kac-Moody algebras [12], infinite-dimensional simple Lie algebras of Cartan type [9], and many others. If the sequence $ \{c_n(A)\} $ is exponentially bounded then the following natural question arises: does the limit

    $ limnncn(A) $ (1.1)

    exist and what are its possible values? In case of existence, the limit (1.1) is called the PI-exponent of $ A $, denoted as $ exp(A) $. At the end of 1980's, Amitsur conjectured that for any associative PI-algebra, the limit (1.1) exists and is a non-negative integer. Amitsur's conjecture was confirmed in [5,6]. Later, Amitsur's conjecture was also confirmed for finite-dimensional Lie and Jordan algebras [4,15]. Existence of $ exp(A) $ was also proved for all finite-dimensional simple algebras [8] and many others.

    Nevertheless, the answer to Amitsur's question in the general case is negative: a counterexample was presented in [14]. Namely, for any real $ \alpha>1 $, an algebra $ R_\alpha $ was constructed such that the lower limit of $ \root n \of{c_n(A)} $ is equal to $ 1 $, whereas the upper limit is equal to $ \alpha $. It now looks natural to describe classes of algebras in which for any algebra $ A $, its PI-exponent $ exp(A) $ exists. One of the candidates is the class of all finite-dimensional algebras. Another one is the class of so-called special Lie algebras. The next interesting class consists of unital algebras, it contains in particular, all algebras with an external unit. Given an algebra $ A $, we denote by $ A^\sharp $ the algebra obtained from $ A $ by adjoining the external unit. There is a number of papers where the existence of $ exp(A^\sharp) $ has been proved, provided that $ exp(A) $ exists [11,16,17]. Moreover, in all these cases, $ exp(A^\sharp) = exp(A)+1 $.

    The main goal of the present paper is to construct a series of unital algebras such that $ exp(A) $ does not exist, although the sequence $ \{c_n(A) $ is exponentially bounded (see Theorem 3.1 and Corollary 3.1 below). All details about polynomial identities and their numerical characteristics can be found in [1,3,7].

    Let $ A $ be an algebra over a field $ F $ and let $ F\{X\} $ be a free $ F $-algebra with an infinite set $ X $ of free generators. The set $ Id(A)\subset F\{X\} $ of all identities of $ A $ forms an ideal of $ F\{X\} $. Denote by $ P_n = P_n(x_1,\ldots,x_n) $ the subspace of $ F\{X\} $ of all multilinear polynomials on $ x_1,\ldots,x_n\in X $. Then $ P_n\cap Id(A) $ is actually the set of all multilinear identities of $ A $ of degree $ n $. An important numerical characteristic of $ Id(A) $ is the sequence of non-negative integers $ \{c_n(A)\},n = 1,2,\ldots\; , $ where

    $ c_n(A) = \dim\frac{P_n}{P_n\cap Id(A)}. $

    If the sequence $ \{c_n(A)\} $ is exponentially bounded, then the lower and the upper PI-exponents of $ A $, defined as follows

    $ \underline{exp}(A) = \liminf\limits_{n\rightarrow\infty} \root n \of{c_n(A)}, \quad \overline{exp}(A)=\limsup\limits_{n\rightarrow\infty} \root n \of{c_n(A)}, $

    are well-defined. An existence of ordinary PI-exponent (1.1) is equivalent to the equality $ \underline{exp}(A) = \overline{exp}(A) $.

    In [14], an algebra $ R = R(\alpha) $ such that $ \underline{exp}(R) = 1,\overline{exp}(R) = \alpha $, was constructed for any real $ \alpha>0 $. Slightly modifying the construction from [14], we want to get for any real $ \alpha>2 $, an algebra $ R_\alpha $ with $ \underline{exp}(R_\alpha)^\sharp = 2 $ and $ \alpha\le \overline{exp}(R^\sharp)\le\alpha+1 $.

    Clearly, polynomial identities of $ A^\sharp $ strongly depend on the identities of $ A $. In particular, we make the following observation. Note that if $ f = f(x_1,\ldots, x_n) $ is a multilinear polynomial from $ F\{X\} $ then $ f(1+x_1,\ldots,1+x_n)\in F\{X\}^\sharp $ is the sum

    $ f=fi1,,ik,{i1,,ik}{1,,n},0kn, $ (2.1)

    where $ f_{i_1,\ldots,i_k} $ is a multilinear polynomial on $ x_{i_1},\ldots,x_{i_k} $ obtained from $ f $ by replacing all $ x_j,j\ne i_1,\ldots,i_k $ with $ 1 $.

    Remark 2.1. A multilinear polynomial $ f = f(x_1,\ldots,x_n) $ is an identity of $ A^\sharp $ if and only if all of its components $ f_{i_1,\ldots,i_k} $ on the left hand side of (2.1) are identities of $ A $.

    The next statement easily follows from Remark 2.1.

    Remark 2.2. Suppose that an algebra $ A $ satisfies all multilinear identities of an algebra $ B $ of degree $ \deg f = k\le n $ for some fixed $ n $. Then $ A^\sharp $ satisfies all identities of $ B^\sharp $ of degree $ k\le n $.

    Using results of [13], we obtain the following inequalities.

    Lemma 2.1. ([13,Theorem 2]) Let $ A $ be an algebra with an exponentally bounded codimension growth. Then $ \overline{exp}(A^\sharp)\le \overline{exp}(A)+1 $.

    Lemma 2.2. ([13,Theorem 3]) Let $ A $ be an algebra with an exponentally bounded codimension growth satisfying the identity (2.2). Then $ \underline{exp}(A^\sharp)\ge \underline{exp}(A)+1 $.

    Given an integer $ T\ge 2 $, we define an infinite-dimensional algebra $ B_T $ by its basis

    $ \{a,b,z_1^i,\ldots,z_T^i\vert\; i = 1,2,\ldots\} $

    and by the multiplication table

    $ z^i_j a = \left\{ zij+1ifjT1,0ifj=T \right. $

    for all $ i\ge 1 $ and

    $ z^i_Tb = z_1^{i+1},\quad i\ge 1. $

    All other products of basis elements are equal to zero. Clearly, algebra $ B_T $ is right nilpotent of class 3, that is

    $ x1(x2x3)0 $ (2.2)

    is an identity of $ B_T $. Due to (2.2), any nonzero product of elements of $ B_T $ must be left-normed. Therefore we omit brackets in the left-normed products and write $ (y_1y_2)y_3 = y_1y_2y_3 $ and $ (y_1\cdots y_k)y_{k+1} = y_1\cdots y_{k+1} $ if $ k\ge 3 $.

    We will use the following properties of algebra $ B_T $.

    Lemma 2.3. ([14,Lema 2.1]) Let $ n\le T $. Then $ c_n(B_T)\le 2n^3 $.

    Lemma 2.4. ([14,Lema 2.2]) Let $ n = kT+1 $. Then

    $ c_n(B_T)\ge k! = \left(\frac{N-1}{T}\right)!. $

    Lemma 2.5. ([14,Lema 2.3]) Any multilinear identity $ f = f(x_1,\ldots,x_n) $ of degree $ n\le T $ of algebra $ B_T $ is an identity of $ B_{T+1} $.

    Let $ F[\theta] $ be a polynomial ring over $ F $ on one indeterminate $ \theta $ and let $ F[\theta]_0 $ be its subring of all polynomials without free term. Denote by $ Q_N $ the quotient algebra

    $ Q_N = \frac{F[\theta]_0}{(Q^{N+1})}, $

    where $ (Q^{N+1}) $ is an ideal of $ F[\theta] $ generated by $ Q^{N+1} $. Fix an infinite sequence of integers $ T_1<N_1<T_2<N_2\ldots $ and consider the algebra

    $ R=B(T1,N1)B(T2,N2), $ (2.3)

    where $ B(T,N) = B_T\otimes Q_N $.

    Let $ R $ be an algebra of the type (2.3). Then the following lemma holds.

    Lemma 2.6. For any $ i\ge 1 $, the following equalities hold:

    (a) if $ T_i\le n\le N_i $ then

    $ P_n\cap Id(R) = P_n\cap Id(B(T_i,N_i)\oplus B(T_{i+1},N_{i+1})) = P_n\cap Id(B_{T_i}\oplus B_{T_{i+1}}); $

    (b) if $ N_i <n\le T_{i+1} $ then

    $ P_n\cap Id(R) = P_n\cap Id(B(T_{i+1},N_{i+1})) = P_n\cap( Id(B_{T_{i+1}})). $

    Proof. This follows immediately from the equality $ B(T_i,N_i)^{N_i+1} = 0 $ and from Lemma 2.5.

    The folowing remark is obvious.

    Remark 2.3. Ler $ R $ be an algebra of type (2.3). Then

    $ Id(R^\sharp) = Id(B(T_1,N_1)^\sharp\oplus B(T_2,N_2)^\sharp\oplus\cdots ). $

    Theorem 3.1. For any real $ \alpha>1 $, there exists an algebra $ R_\alpha $ with $ \underline{exp}(R_\alpha) = 1, \overline{exp}(R_\alpha) = \alpha $ such that $ \underline{exp}(R_\alpha^\sharp) = 2 $ and $ \alpha\le\overline{exp}(R_\alpha^\sharp)\le\alpha+1 $.

    Proof. Note that

    $ cn(A)ncn1(A) $ (3.1)

    for any algebra $ A $ satisfying (2.2). We will construct $ R_\alpha $ of type (2.3) by a special choice of the sequence $ T_1,N_1,T_2,N_2,\ldots $ depending on $ \alpha $. First, choose $ T_1 $ such that

    $ 2m3<αm $ (3.2)

    for all $ m\ge T_1 $. By Lemma 2.4, algebra $ B_{T_1} $ has an overexponential codimenson growth. Hence there exists $ N_1> T_1 $ such that

    $ c_n(B_{T_1}) < \alpha^n \quad \hbox{for all} \quad n\le N_1-1 \quad \hbox{and} \quad c_{N_1}(B_{T_1}) \ge \alpha^{N_1}. $

    Consider an arbitrary $ n>N_1 $. By Remark 2.1, we have

    $ c_n(R^\sharp)\le \sum\limits_{k = 0}^n {n\choose k}c_k(R) = \Sigma_1'+\Sigma_2', $

    where

    $ \Sigma_1' = \sum\limits_{k = 0}^{N_1} {n\choose k}c_k(R),\quad \Sigma_2' = \sum\limits_{k = N_1+1}^{n} {n\choose k}c_k(R). $

    By Lemma 2.6, we have $ \Sigma_1'+\Sigma_2'\le \Sigma_1+\Sigma_2 $, where

    $ \Sigma_1 = \sum\limits_{k = 0}^{N_1} {n\choose k}c_k(B_{T_1}),\quad \Sigma_2 = \sum\limits_{k = 0}^{n} {n\choose k}c_k(B_{T_2}). $

    Then for any $ T_2>N_1 $, an upper bound for $ \Sigma_2 $ is

    $ Σ2nk=0(nk)2k32n3nk=0(nk)=2n32n, $ (3.3)

    which follows from (3.2), provided that $ n\le T_2 $.

    Let us find an upper bound for $ \Sigma_1 $ assuming that $ n $ is sufficiently large. Clearly,

    $ Σ1N1αN1N1k=0(nk) $ (3.4)

    which follows from the choice of $ N_1 $, relation (3.1), and the equality $ B(T_1,N_1)^n = 0 $ for all $ n\ge N_1+1 $. Since $ N_1\alpha^{N_1} $ is a constant for fixed $ N_1 $, we only need to estimate the sum of binomial coefficients.

    From the Stirling formula

    $ m! = \sqrt{2\pi m} (\frac{m}{e})^m e^{\frac{1}{12m+\theta_m}},\quad 0 < \theta_m < 1, $

    it follows that

    $ (nk)nk(nk)nnkk(nk)nk. $ (3.5)

    Now we define the function $ \Phi:[0;1]\to\mathbb R $ by setting

    $ \Phi(x) = \frac{1}{x^x(1-x)^{1-x}}. $

    It is not difficult to show that $ \Phi $ increases on $ [0;1/2] $, $ \Phi(0) = 1 $, and $ \Phi(x)\le 2 $ on $ [0;1] $. In terms of the function $ \Phi $ we rewrite (3.5) as

    $ (nk)Φ(kn)Φ(kn)n<2Φ(kn)n2Φ(N1n)n $ (3.6)

    provided that $ n> 2N_1 $. Now (3.4) and (3.6) together with (3.3) imply

    $ \Sigma_1\le 2N_1\alpha^{N_1}(N_1+1)\Phi\left(\frac{N_1}{n}\right)^n, \quad \Sigma_2\le 2n^3 2^n. $

    Since

    $ \lim\limits_{n\to\infty}\Phi\left(\frac{N_1}{n} \right)^n = 1 $

    and $ \Phi(x) $ increases on $ (0;1/2] $, there exists $ n>2N_1 $ such that

    $ 2N1(N1+1)αN1Φ(N1n)n+2n32n<(2+12)n. $ (3.7)

    Now we take $ T_2 $ to be equal to the minimal $ n>2N_1 $ satisfying (3.7). Note that for such $ T_2 $ we have

    $ c_n(R^\sharp) < (2+\frac{1}{2})^n $

    for $ n = T_2 $.

    As soon as $ T_2 $ is choosen, we can take $ N_2 $ as the minimal $ n $ such that $ c_n(B_{T_2}) \ge \alpha^n $. Then again, $ c_m(R)<m \alpha^m $ if $ m<N_2 $. Repeating this procedure, we can construct an infinite chain $ T_1<N_1<T_2<N_2\cdots\; $ such that

    $ cn(R)<αn+2n3 $ (3.8)

    for all $ n\ne N_1,N_2,\ldots $,

    $ αncn(R)<αn+n(αn1+2n3) $ (3.9)

    for all $ n = N_1,N_2,\ldots $ and

    $ 2Nj(Nj+1)αNjΦ(NjTj+1)Tj+1+2T3j+12Tj+1<(2+12j)Tj+1 $ (3.10)

    for all $ j = 1,2,\ldots\; $.

    Let us denote by $ R_\alpha $ the just constructed algebra $ R $ of type (2.3). Then (3.10) means that

    $ cn(Rα)<(2+12j)n $ (3.11)

    if $ n = T_{j+1}, j = 1,2,\ldots\; $. It follows from inequality (3.11) that

    $ exp_(Rα)2. $ (3.12)

    On the other hand, since $ R_\alpha $ is not nilpotent, it follows that

    $ exp_(Rα)1. $ (3.13)

    Since the PI-exponent of non-nilpotent algebra cannot be strictly less than $ 1 $, relations (3.12), (3.13) and Lemma 2.2 imply

    $ \underline{exp}(R_\alpha) = 1,\; \underline{exp}(R_\alpha^\sharp) = 2. $

    Finally, relations (3.8), (3.9) imply the equality $ \overline{exp}(R_\alpha) = \alpha $. Applying Lemma 2.1, we see that $ \overline{exp}(R_\alpha^\sharp)\le\alpha+1 $. The inequality $ \alpha = \overline{exp}(R_\alpha)\le \overline{exp}(R_\alpha^\sharp) $ is obvious, since $ R_\alpha $ is a subalgebra of $ R_\alpha^\sharp $, Thus we have completed the proof of Theorem 3.1.

    As a consequence of Theorem 3.1 we get an infinite family of unital algebras of exponential codimension growth without ordinary PI-exponent.

    Corollary 1. Let $ \beta>2 $ be an arbitrary real number. Then the ordinary PI-exponent of unital algebra $ R_\beta^\sharp $ from Theorem 3.1 does not exist. Moreover, $ \underline{exp}(R_\beta^\sharp) = 2 $, whereas $ \beta\le\overline{exp}(R_\beta^\sharp)\le\beta+1 $.

    We would like to thank the referee for comments and suggestions.


    Acknowledgments



    A/Prof Ashe gratefully acknowledges the support of the Canada Research Chairs program.

    Conflict of interest



    All authors have no conflict of interest to disclose.

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