Multimodal Observation Method of Digital Accessibility for Elderly People

This article presents a new methodological framework for multimodal observation of digital technologies. It is based on the use of mixed methods developed in the interdisciplinary MAN project founded by CNRS. It focuses on the digital accessibility of older people. The originality of the method lies in the implementation of a method combining qualitative and quantitative measurement to determine relevant indicators. These indicators characterize the person's behavior when using a technology and its usability. We show how these indicators are built, based on the cross-referencing of data. We present the different tools (questionnaire, interviews and technological data recording tools) used in the MAN method in a living laboratory environment controlled with four volunteers. Two use scenarios are proposed to illustrate the method in assessing the accessibility of a tactile application for older people without a digital divide and without disabilities. We present the recorded qualitative and quantitative data and illustrate by an example the unrelatedness of these data through a specific annotation tool.     

What is important, what needs treating? How GPs perceive older patients' multiple health problems: a mixed method research study

ABSTRACT: BACKGROUND: GPs increasingly deal with multiple health problems of their older patients. They have to apply a hierarchical management approach that considers priorities to balance competing needs for treatment. Yet, the practice of setting individual priorities in older patients is largely unexplored. This paper analyses the GPs' perceptions on important and unimportant health problems and how these affect their treatment. METHODS: GPs appraised the importance of health problems for a purposive sample of their older patients in semi-structured interviews. Prior to the interviews, the GPs had received a list of their patients' health problems resulting from a geriatric assessment and were asked to rate the importance of each identified problem. In the interviews the GPs subsequently explained why they considered certain health problems important or not and how this affected treatment. Data was analysed using qualitative content analysis and quantitative methods. RESULTS: The problems GPs perceive as important are those that are medical and require active treatment or monitoring, or that induce empathy or awareness but cannot be assisted further. Unimportant problems are those that are well managed problems and need no further attention as well as age-related conditions or functional disabilities that provoke fatalism, or those considered outside the GPs' responsibility. Statements of professional actions are closely linked to explanations of important problems and relate to physical problems rather than functional and social patient issues. CONCLUSIONS: GPs tend to prioritise treatable clinical conditions. Treatment approaches are, however, vague or missing for complex chronic illnesses and disabilities. Here, patient empowerment strategies are of value and need to be developed and implemented. The professional concepts of ageing and disability should not impede but rather foster treatment and care. To this end, GPs need to be able to delegate care to a functioning primary care team. Trial Registration German Trial Register (DRKS): 00000792.     

森林碳计量方法研究进展

森林是陆地生态系统的主体,不仅是巨大的碳库而且对减缓气候变暖具有积极作用。科学有效的森林碳计量方法,有助于加深对全球碳循环过程的理解。然而,由于森林生态系统结构复杂,对森林碳计量的估算结果普遍存在精度低、不确定性高的问题。近年来,国内外发展了大量对森林碳计量进行估算的方法,主要有基于样地清查的森林植被和土壤碳估算、基于生长收获的经验模型估算、基于定量遥感雷达观测的遥感估测、基于多尺度森林生态系统网络的通量观测和陆地生态系统过程模型模拟等方法。在实际的森林碳计量中,根据不同的森林类型特征和数据获取情况,往往采取不同的碳计量方法,甚至不止一种。以生态过程模型模拟、遥感反演和数据同化技术为主要手段,基于碳通量观测数据、控制实验数据和遥感影像数据,发展多学科、多过程、多尺度的综合联网观测,充分认识森林碳循环过程中碳源/汇的时空分布特征,开展区域、洲际乃至全球尺度碳循环及其对全球变化和人类活动响应的系统性、集成性研究,以便建立高效、可靠的碳计量体系是未来林业碳计量的发展趋势。随着世界各国温室气体排放清单的编制,中国迫切需要科学的方法体系计量森林碳源/汇,提升我国在生态环境问题上的国际发言权和主导权,同时对我国森林可持续经营、生态环境保护以及美丽中国建设提供建议与支持。分析了各类森林碳计量方法的主要特征、优缺点,同时探讨了目前的森林碳计量方法存在的问题和未来的发展趋势,为不同时空尺度下森林碳计量提供参考。     

The environment of ageing.

The issue of housing and the wider environment for an ageing population is one where there are many unanswered questions. In this paper a number of key issues are discussed and for each of these the focus is on three aspects. These are the current situation, its reasonableness and what research is needed in order to make decisions about policy and practice. The first three issues relate to the profile of older people themselves and the importance of home to them. The changing profile of older people is not just about an ageing population but also about the growing prominence of those with dementia, women, people from black and ethnic minority groups and one person households, yet little is known about the type of housing which should be provided. Of equal concern is the widening gap between those with a high standard of living (including housing) and those with a low standard of living. The importance of home to older people means that research must focus on how people can be enabled to remain there, and also on the costs, financial and otherwise, to carers and to society. The next three issues relate to the type of housing older people live in and moves in later life. The startling change in the tenure pattern with a growth of owner occupation brings problems as does the decline in social housing. The advantages and disadvantages of the different types of housing--mainstream and specialized--for older people are relatively well known. However the balance between the two needs more research as does that on retirement communities. While it is well known that there are peaks of migration in old age and that moves are often made in haste, little is known about the process of decision making. The final two topics concern links between housing and other aspects of older people''s lives. On health more research is needed on temperature, mortality and morbidity, homelessness and accidents and especially on links between services. These topics have implications for planning and design. The emphasis should be on a multidisciplinary approach using a variety of quantitative and qualitative techniques with an emphasis on dissemination.     

Informing the debate on oral health care for older people: a qualitative study of older people’s views on oral health and oral health care

doi: 10.1111/j.1741‐2358.2009.00274.x
Informing the debate on oral health care for older people: a qualitative study of older people’s views on oral health and oral health care Background: Older people represent a growing and diverse section of the population. As age increases, people are more likely to experience health and mobility problems and be at higher risk of developing oral disease. Nevertheless, few older people utilise primary oral healthcare services. It is therefore important to understand the value older people place on oral health and dental services to inform providers and planners of oral health care. This research was conducted as part of a study to identify potential ways of minimising barriers to oral health care in older people. Objectives: To explore perceptions of oral health and oral healthcare services amongst older people living in a socially deprived inner city area and how these are related to service utilisation. Methods: A qualitative approach was utilised to explore the range of issues related to older people’s perceptions of oral health and their views on health care. This involved a combination of focus groups and semi‐structured individual interviews with older people and their carers. Data analysis was conducted using the Framework approach. Results:

• ? Response: Thirty‐nine older people and/or their carers participated in focus groups.
• ? Oral health perception: Oral health was associated with the presence of natural teeth, the absence of pain, practical/social functioning, preferably supported by positive assessment by a dentist.
• ? Oral health life‐course: Older people have a long and complex dental history. Past negative experiences with oral health care, especially in childhood, strongly influenced present attitudes towards dentistry and dental personnel.
• ? Citizenship and right to health care: There was a strong perception that, as ‘British citizens’, older people should have a right to free health care and that the National Health Service (NHS) should support them in this phase of their life.

Conclusions: The oral health life‐course of older people is an important influence on their perceptions of oral health and dental attendance. They consider oral health of importance and place great emphasis on their citizenship and rights of access to state funded oral health care. This raises important issues for the funding and delivery of NHS oral health care for older people.     

Quantifying the impact and relevance of scientific research

Qualitative and quantitative methods are being developed to measure the impacts of research on society, but they suffer from serious drawbacks associated with linking a piece of research to its subsequent impacts. We have developed a method to derive impact scores for individual research publications according to their contribution to answering questions of quantified importance to end users of research. To demonstrate the approach, here we evaluate the impacts of research into means of conserving wild bee populations in the UK. For published papers, there is a weak positive correlation between our impact score and the impact factor of the journal. The process identifies publications that provide high quality evidence relating to issues of strong concern. It can also be used to set future research agendas.     

Lessons learned in the development of process quality indicators for cancer care in Japan

In Japan, attention has increasingly focused on ensuring the quality of care, particularly in the area of cancer care. The 2006 Basic Cancer Control Act reinforced efforts to ensure the quality of cancer care in a number of sectors, including the role of government in ensuring quality. We initiated a government-funded research project to develop quality indicators to measure the quality of care for five major cancers (breast, lung, stomach, colorectal, and liver cancer) in Japan, and palliative care for cancers in general. While we successfully developed a total of 206 quality indicators, a number of issues have been raised regarding the concepts and methodologies used to measure quality. Examples include the choice between measuring the process of care versus the outcome of care; the degree to which the process-outcome link should be confirmed in real-world measurement; handling of exceptional cases; interpretation of measurement results between quality of care versus quality of documentation; creation of summary scores; and the optimal number of quality indicators for measurement considering the trade-off between the measurement validity versus resource limitations. These and other issues must be carefully considered when attempting to measure quality of care, and although many appear to have no correct answer, continuation of the project requires that a decision nevertheless be made. Future activities in this project, which is still ongoing, should focus on the further exploration of these problems.     

Quantitative imaging of lymphocyte membrane protein reorganization and signaling

Changes in membrane protein localization are critical to establishing cell polarity and regulating cell signaling. Fluorescence microscopy of labeled proteins allows visualization of these changes, but quantitative analysis is needed to study this aspect of cell signaling in full mechanistic detail. We have developed a novel approach for quantitative assessment of membrane protein redistribution based on four-dimensional video microscopy of fluorescently labeled proteins. Our analytic system provides robust automated methods for cell surface reconstruction, cell shape tracking, cell-surface distance measurement, and cluster formation analysis. These methods permit statistical analyses and testing of mechanistic hypotheses regarding cell signaling. We have used this approach to measure antigen-dependent clustering of signaling molecules in CD4+ T lymphocytes, obtaining clustering velocities consistent with single-particle tracking data. Our system captures quantitative differences in clustering between signaling proteins with distinct biological functions. Our methods can be generalized to a range of cell-signaling phenomena and enable novel applications not feasible with single-particle studies, such as analysis of subcellular protein localization in live organ culture.     

The local‐regional species richness relationship: new perspectives on the null‐hypothesis

Despite considerable criticism in recent years, the use of local (SL) and regional species richness (SR) plots has a long tradition to test for community saturation. The traditional approach has been to compare linear and polynomial regression models of untransformed measures of SL and SR with a statistically significant linear or polynomial model indicating unsaturated and saturated communities, respectively. This approach has been the target of much controversy owing to statistical issues, the confounding effects of the arbitrary choice for the size of the local and regional area, and the difficulty in attributing ecological processes to the underlying SL SR pattern. The statistical issues and effects of scale stem from the lack of statistical independence and induced correlation between SL SR arising from the mathematical constraint, SL<SR. However, by removing this mathematical constraint by means of a logratio transformation, SL SR relationships can be calculated using ordinary linear regression and with a logical and definitive null‐hypothesis based solely on the presence of a statistically significant slope, which provides a quantitative measure of curvature. Simulations of SL SR relationships with varying curvature and SL:SR ratio demonstrate that the logratio model can accurately measure curvature independent of the SL:SR ratio. Therefore, the tendency for studies with high local:regional area ratio to result in linear SL SR trends when analysed by traditional regression methods may be mitigated by reanalysis by the logratio model. By alleviating the effects of scale, the logratio model offers a more statistically sound assessment of the SL SR relationship, which in turn can serve as an effective tool to complement emerging process‐based models.     

Bias, precision and heritability of self-reported and clinically measured height in Australian twins

Many studies of quantitative and disease traits in human genetics rely upon self-reported measures. Such measures are based on questionnaires or interviews and are often cheaper and more readily available than alternatives. However, the precision and potential bias cannot usually be assessed. Here we report a detailed quantitative genetic analysis of stature. We characterise the degree of measurement error by utilising a large sample of Australian twin pairs (857 MZ, 815 DZ) with both clinical and self-reported measures of height. Self-report height measurements are shown to be more variable than clinical measures. This has led to lowered estimates of heritability in many previous studies of stature. In our twin sample the heritability estimate for clinical height exceeded 90%. Repeated measures analysis shows that 2–3 times as many self-report measures are required to recover heritability estimates similar to those obtained from clinical measures. Bivariate genetic repeated measures analysis of self-report and clinical height measures showed an additive genetic correlation >0.98. We show that the accuracy of self-report height is upwardly biased in older individuals and in individuals of short stature. By comparing clinical and self-report measures we also showed that there was a genetic component to females systematically reporting their height incorrectly; this phenomenon appeared to not be present in males. The results from the measurement error analysis were subsequently used to assess the effects of error on the power to detect linkage in a genome scan. Moderate reduction in error (through the use of accurate clinical or multiple self-report measures) increased the effective sample size by 22%; elimination of measurement error led to increases in effective sample size of 41%.     

Testosterone and estradiol assays: current and future trends

Sex steroid measurements for the investigation of endocrine disorders have been fraught with accuracy and imprecision problems since the advent of high throughput, direct assays almost 10 years ago on automated analyzers. Results from testosterone and estradiol measurements at the low end of detectability have suffered the most and there are few automated systems that can accurately measure these steroids in women, children and hypogonadal males on a routine basis. With the advent of mass spectrometry coupled to either gas chromatography or liquid chromatography, an improved approach to the measurement of these steroids has developed that shows promise for accurately and precisely measuring testosterone and estradiol in all patient populations including women and children. These mass spectrometry based methods for the sex steroids have been established as higher order reference method procedures that will resolve the issues of low end sensitivity measurements for these steroids, provide for appropriate standardization and reference materials and align most laboratories in hospital and reference laboratories to generate results that are inter-changeable between laboratories and methods.     

Life Cycle Approach in the Procurement Process: The Case of Defence Materiel (9 pp)

Goal, Scope and Background Procurement in public and non-public organisations has the potential to influence product development towards more environmentally friendly products. This article focuses on public procurement with procurement in Swedish defence as a special case. In 2003, public procurement in Sweden was 28% of the GDP. In the Swedish defence sector the amount was 2% of the GDP. The total emissions from the sector were of the same order of magnitude as from waste treatment (2% of Sweden's emissions). According to an appropriation letter from the Ministry of Defence in 1998, the Swedish Armed Forces (SAF) and the Swedish Defence Materiel Administration (FMV) are required to take environmental issues into consideration during the entire process of acquiring defence materiel. Environmental aspects are considered today, but without a life-cycle perspective. - The aims of this article are to recommend suitable tools for taking environmental concerns into account, considering a product's life-cycle, in the procurement process for defence materiel in Sweden; to make suggestions for how these tools could be used in the acquisition process; and to evaluate these suggestions through interviews with actors in the acquisition process. The procurement process does not include aspects specific to Swedish defence, and it is therefore likely to be comparable to processes in other countries. Methods The method involved a study of current literature and interviews with various actors in the acquisition process. The life cycle methods considered were quantitative Life Cycle Assessments, a simplified LCA-method called the MECO method and Life Cycle Costing (LCC). Results and Discussion Methodology recommendations for quantitative LCA and simplified LCA are presented in the article, as well as suggestions on how to integrate LCA methods in the acquisition process. We identified four areas for use for LCA in the acquisition process: to learn about environmental aspects of the product; to fulfil requirements from customers; to set environmental requirements and to choose between alternatives. Therefore, tools such as LCAs are useful in several steps in the acquisition process. Conclusion From the interviews, it became clear that the actors in the acquisition process think that environmental aspects should be included early in the process. The actors are interested in using LCA methods, but there is a need for an initiative from one or several of them if the method is to be used regularly in the process. Environmental and acquisition issues are handled with very little interaction in the controlling and ordering organisation. An integration of environmental and acquisition parts in these organisations is probably needed in order to integrate environmental aspects in general and life-cycle thinking in particular. Other difficulties identified are costs and time constraints. Recommendation and Perspective In order to include the most significant aspects when procuring materiel, it is important to consider the whole life-cycle of the products. Our major recommendation is that the defence sector should work systematically through different product groups. For each product group, quantitative, traditional LCAs or simplified LCAs (in this case modified MECOs) should be performed for reference products within each product group. The results should be an identification of critical aspects in the life-cycles of the products. The studies will also form a database that can be used when making new LCAs. This knowledge should then be used when writing specifications of what to procure and setting criteria for procurement. The reports should be publicly available to allow reviews and discussions of results. To make the work more cost-effective, international co-operation should be sought. In addition, LCAs can also be performed as an integrated part of the acquisition process in specific cases.     

Interval-based distance function for identifying RNA structure candidates

Many clustering approaches have been developed for biological data analysis, however, the application of traditional clustering algorithms for RNA structure data analysis is still a challenging issue. This arises from the existence of complex secondary structures while clustering. One of the most critical issues of cluster analysis is the development of appropriate distance measures in high dimensional space. The traditional distance measures focus on scale issues, but ignores the correlation between two values. This article develops a novel interval-based distance (Hausdorff) measure for computing the similarity between characterized structures. Three relationships including perfect match, partially overlapped and non-overlapped are considered. Finally, we demonstrate the methods by analyzing a data set of RNA secondary structures from the Rfam database.     

Weight-of-Evidence (WOE): Quantitative Estimation of Probability of Impairment for Individual and Multiple Lines of Evidence

Environmental decision-making is complex and often based on multiple lines of evidence. Integrating the information from these multiple lines of evidence is rarely a simple process. We present a quantitative approach to the combination of multiple lines of evidence through calculation of weight-of-evidence, with reference conditions used to define a not impaired state. The approach is risk-based with measurement of risk computed as the probability of impairment. When data on reference conditions are available, there are a variety of methods for calculating this probability. Statistical theory and the use of odds ratios provide a method for combining the measures of risk from the different lines of evidence. The approach is illustrated using data from the Great Lakes to predict the risk at potentially contaminated sites.     

Highly Sensitive Assay for Measurement of Arenavirus-cell Attachment

Arenaviruses are a family of enveloped RNA viruses that cause severe human disease. The first step in the arenavirus life cycle is attachment of viral particles to host cells. While virus-cell attachment can be measured through the use of virions labeled with biotin, radioactive isotopes, or fluorescent dyes, these approaches typically require high multiplicities of infection (MOI) to enable detection of bound virus. We describe a quantitative (q)RT-PCR-based assay that measures Junin virus strain Candid 1 attachment via quantitation of virion-packaged viral genomic RNA. This assay has several advantages including its extreme sensitivity and ability to measure attachment over a large dynamic range of MOIs without the need to purify or label input virus. Importantly, this approach can be easily tailored for use with other viruses through the use of virus-specific qRT-PCR reagents. Further, this assay can be modified to permit measurement of particle endocytosis and genome uncoating. In conclusion, we describe a simple, yet robust assay for highly sensitive measurement of arenavirus-cell attachment.     

Relative apparent synapomorphy analysis (RASA). I: The statistical measurement of phylogenetic signal

We have developed a new approach to the measurement of phylogenetic signal in character state matrices called relative apparent synapomorphy analysis (RASA). RASA provides a deterministic, statistical measure of natural cladistic hierarchy (phylogenetic signal) in character state matrices. The method works by determining whether a measure of the rate of increase of cladistic similarity among pairs of taxa as a function of phenetic similarity is greater than a null equiprobable rate of increase. Our investigation of the utility and limitations of RASA using simulated and bacteriophage T7 data sets indicates that the method has numerous advantages over existing measures of signal. A first advantage is computational efficiency. A second advantage is that RASA employs known methods of statistical inference, providing measurable sensitivity and power. The performance of RASA is examined under various conditions of branching evolution as the number of characters, character states per character, and mutations per branch length are varied. RASA appears to provide an unbiased and reliable measure of phylogenetic signal, and the general approach promises to be useful in the development of new techniques that should increase the rigor and reliability of phylogenetic estimates.      

The Medical Care of Older Patients

Proper medical care for growing numbers of older people depends upon application of advances in medicine to the special problems of ageing. Despite gaps in understanding of the ageing process, high-quality care can be achieved through routine use of knowledge already available.Older people differ structurally, functionally and psychologically. Health influences every aspect of their lives. Their reactions to stress and disease are altered. In practice, the doctor must assess the biological changes of ageing and their possible influences on symptoms and signs. Modifications in the application of ordinary methods of medicine and surgery are determined by functional impairments and structural defects. While the medical problems of the aged are special, the approach must be general; the practitioner needs experience with disease in all age groups and should be alert to the adverse effects on old people of the universal misunderstandings of ageing and its problems.     

The Problem of Thresholding in Small-World Network Analysis

Graph theory deterministically models networks as sets of vertices, which are linked by connections. Such mathematical representation of networks, called graphs are increasingly used in neuroscience to model functional brain networks. It was shown that many forms of structural and functional brain networks have small-world characteristics, thus, constitute networks of dense local and highly effective distal information processing. Motivated by a previous small-world connectivity analysis of resting EEG-data we explored implications of a commonly used analysis approach. This common course of analysis is to compare small-world characteristics between two groups using classical inferential statistics. This however, becomes problematic when using measures of inter-subject correlations, as it is the case in commonly used brain imaging methods such as structural and diffusion tensor imaging with the exception of fibre tracking. Since for each voxel, or region there is only one data point, a measure of connectivity can only be computed for a group. To empirically determine an adequate small-world network threshold and to generate the necessary distribution of measures for classical inferential statistics, samples are generated by thresholding the networks on the group level over a range of thresholds. We believe that there are mainly two problems with this approach. First, the number of thresholded networks is arbitrary. Second, the obtained thresholded networks are not independent samples. Both issues become problematic when using commonly applied parametric statistical tests. Here, we demonstrate potential consequences of the number of thresholds and non-independency of samples in two examples (using artificial data and EEG data). Consequently alternative approaches are presented, which overcome these methodological issues.     

Input data quality control for NDNQI national comparative statistics and quarterly reports: A contrast of three robust scale estimators for multiple outlier detection

ABSTRACT: BACKGROUND: To evaluate institutional nursing care performance in the context of national comparative statistics (benchmarks), approximately one in every three major healthcare institutions (over 1,800 hospitals) across the United States, have joined the National Database for Nursing Quality Indicators[REGISTERED SIGN] (NDNQI[REGISTERED SIGN]). With over 18,000 hospital units contributing data for nearly 200 quantitative measures at present, a reliable and efficient input data screening for all quantitative measures for data quality control is critical to the integrity, validity, and on-time delivery of NDNQI reports. METHODS: With Monte Carlo simulation and quantitative NDNQI indicator examples, we compared two ad-hoc methods using robust scale estimators, Inter Quartile Range (IQR) and Median Absolute Deviation from the Median (MAD), to the classic, theoretically-based Minimum Covariance Determinant (FAST-MCD) approach, for initial univariate outlier detection. RESULTS: While the theoretically based FAST-MCD used in one dimension can be sensitive and is better suited for identifying groups of outliers because of its high breakdown point, the ad-hoc IQR and MAD approaches are fast, easy to implement, and could be more robust and efficient, depending on the distributional property of the underlying measure of interest. CONCLUSION: With highly skewed distributions for most NDNQI indicators within a short data screen window, the FAST-MCD approach, when used in one dimensional raw data setting, could overestimate the false alarm rates for potential outliers than the IQR and MAD with the same pre-set of critical value, thus, overburden data quality control at both the data entry and administrative ends in our setting.     

Who is too old for shift work? Developing better criteria

Demographic and social trends in industrialized countries are expected to lead to increasing numbers of older shift workers, raising concerns about possible health and safety risks. For older night workers, the International Labour Organization has recommended options for transferring to day work or early retirement, but few States have adopted these measures. For commercial air transport pilots, the International Civil Aviation Organization has implemented a series of regulatory measures that could manage the risks associated with aging, including a mandatory retirement age, regular medical assessments for fitness to fly, and limits on the duration of duty and rest. Each of these approaches has strengths and weaknesses. The mandatory retirement age is effectively arbitrary, has been controversial, and was recently increased from 60 to 65 yrs for one member of a two-person cockpit crew. Medical assessments offer a more individualized approach, but to improve safety, they must address aspects of health and physical or mental function that affect work performance and safety outcomes. The traditional focus has been on cardiovascular risk factors, although cardiac incapacitation is not a cause of accidents in a two-person cockpit aircraft. On the other hand, while pilot fatigue is an acknowledged cause of accidents, there is currently no requirement to consider issues associated with fatigue or sleep problems in fitness-to-fly medical assessments. Older long-haul pilots show greater sleep fragmentation than their younger colleagues and those in the general population. Sleep becomes more fragmented with increasing age, but the functional significance of this remains unclear. Among younger adults, experimental sleep fragmentation leads to increased sleepiness and degradation of performance and mood. Greater sleep loss is reported by older long-haul pilots, as well as other older shift workers, compared to younger people working similar duty patterns. Experimental sleep restriction causes a degradation of performance and mood that is cumulative and dose-dependent. In addition, a recent large-scale flight simulation study indicates that the duration of sleep obtained by individual pilots is an independent predictor of crew performance in a two-person cockpit. Based on these considerations, we propose that fatigue and sleep-related issues should become a standard part of fitness-for-work medical assessments, particularly for older shift workers. A multi-layered approach is proposed, with a routine structured sleep history leading to referral to specialist sleep services where appropriate. Criteria for specialist referral and medical retirement should be related to the workplace risk represented by an older worker. Additional research is needed to develop and validate sleep-related criteria for assessing fitness for work. For example, a better understanding of the effects of sleep fragmentation on the waking function of older workers might lead to a fragmentation threshold for fitness for work. The potential negative effects of unemployment and early retirement also need to be taken into account when considering the options for managing the occupational health and safety needs of older shift workers.