Interventions to prevent disability in frail community-dwelling elderly: a systematic review

Definitions and markers of frailty: a systematic review of literature

Frailty is a central concept in geriatric medicine, but without a clear definition. Many regard it as a syndrome with its own clinical manifestations and pathophysiology, whilst others consider it to be the result of the accumulation of age-related deficits that predict adverse changes in health. We analysed, through a systematic review, the definitions and markers of the frailty syndrome. Twenty-five articles were included and divided, according to design, into observational, intervention, review and qualitative studies. There was a predominance of operational definitions that used only physical markers to identify frailty. The only qualitative study found that health professionals chose a multidimensional definition that took into account factors other than just the physical. We conclude that there is still no standard definition or agreement about markers of the frailty syndrome.

The reduction of disability in community-dwelling frail older people: design of a two-arm cluster randomized controlled trial

BACKGROUND

Frailty among older people is related to an increased risk of adverse health outcomes such as acute and chronic diseases, disability and mortality. Although many intervention studies for frail older people have been reported, only a few have shown positive effects regarding disability prevention. This article presents the design of a two-arm cluster randomized controlled trial on the effectiveness, cost-effectiveness and feasibility of a primary care intervention that combines the most promising elements of disability prevention in community-dwelling frail older people.

METHODS/DESIGN

In this study twelve general practitioner practices were randomly allocated to the intervention group (6 practices) or to the control group (6 practices). Three thousand four hundred ninety-eight screening questionnaires including the Groningen Frailty Indicator (GFI) were sent out to identify frail older people. Based on their GFI score (≥5), 360 participants will be included in the study. The intervention will receive an interdisciplinary primary care intervention. After a comprehensive assessment by a practice nurse and additional assessments by other professionals, if needed, an individual action plan will be defined. The action plan is related to a flexible toolbox of interventions, which will be conducted by an interdisciplinary team. Effects of the intervention, both for the frail older people and their informal caregivers, will be measured after 6, 12 and 24 months using postal questionnaires and telephone interviews. Data for the process evaluation and economic evaluation will be gathered continuously over a 24-month period.

DISCUSSION

The proposed study will provide information about the usefulness of an interdisciplinary primary care intervention. The postal screening procedure was conducted in two cycles between December 2009 and April 2010 and turned out to be a feasible method. The response rate was 79.7%. According to GFI scores 29.3% of the respondents can be considered as frail (GFI ≥ 5). Nearly half of them (48.1%) were willing to participate. The baseline measurements started in January 2010. In February 2010 the first older people were approached by the practice nurse for a comprehensive assessment. Data on the effect, process, and economic evaluation will be available in 2012.

TRIAL REGISTRATION

ISRCTN31954692.

Should the provision of home help services be contained?: validation of the new preventive care policy in Japan

Background

To maintain the sustainability of public long-term care insurance (LTCI) in Japan, a preventive care policy was introduced in 2006 that seeks to promote active improvement in functional status of elderly people who need only light care. This policy promotes the use of day care services to facilitate functional improvement, and contains the use of home help services that provide instrumental activity of daily living (IADL) support. However, the validity of this approach remains to be demonstrated.

Methods

Subjects comprised 241 people aged 65 years and over who had recently been certified as being eligible for the lightest eligibility level and had began using either home help or day care services between April 2007 and October 2008 in a suburban city of Tokyo. A retrospective cohort study was conducted ending October 2009 to assess changes in the LTCI eligibility level of these subjects. Cox's proportional hazards model was used to calculate the relative risk of declining in function to eligibility Level 4 among users of the respective services.

Results

Multivariate analysis adjusted for factors related to service use demonstrated that the risk of decline in functional status was lower for users of home help services than for users of day care services (HR = 0.55, 95% CI: 0.31-0.98). The same result was obtained when stratified by whether the subject lived with family or not. Furthermore, those who used two or more hours of home help services did not show an increase in risk of decline when compared with those who used less than two hours.

Conclusions

No evidence was obtained to support the effectiveness of the policy of promoting day care services and containing home help services for those requiring light care.

Improving the vaccination coverage of geriatric populations

Vaccination is an important component of disease prevention in the elderly; however, immunization coverage in this population is low. There is a clear need to improve vaccine coverage among this age group. To this end, various strategies can be employed. Raising awareness and improving the education of physicians and health care workers in the field of vaccination in geriatric populations play an important role. Active promotion of vaccination uptake should be implemented by health authorities and targeted to older adults. Other means, including the use of educational tools and guidelines to improve practice, should be more widely employed.