Comprehensive Geriatric Assessment for community-dwelling, high-risk, frail, older people

Perspectives on which health settings geriatricians should staff: a qualitative study of patients, care providers and health administrators

BACKGROUND

With a shortage of geriatricians and an aging population, strategies are needed to optimise the distribution of geriatricians across different healthcare settings (acute care, rehabilitation and community clinics). The perspectives of knowledge users on staffing geriatricians in different healthcare settings are unknown. We aimed to understand the acceptability and feasibility (including barriers and facilitators) of implementing a geriatrician-led comprehensive geriatric assessment (CGA) in acute care, rehabilitation, and community clinic settings.

METHODS

A qualitative description approach was used to explore the experience of those implementing (administrative staff), providing (healthcare providers), and receiving (patients/family caregivers) a geriatrician-led CGA in acute care, rehabilitation and community settings. Semi-structured interviews were conducted in Toronto, Canada. The theoretical domains framework and consolidated framework for implementation research informed the interview guide development. Analysis was conducted using a thematic approach.

RESULTS

Of the 27 participants (8 patients/caregivers, 9 physicians, 10 administrators), the mean age was 53 years and 14 participants (52%) identified as a woman (13 [48%] identified as a man). CGAs were generally perceived as acceptable but there was a divergence in opinion about which healthcare setting was most important for geriatricians to staff. Acute care was reported to be most important by some because no other care provider has the intersection of acute medicine skills with geriatric training. Others reported that community clinics were most important to manage geriatric syndromes before hospitalization was necessary. The rehabilitation setting appeared to be viewed as important but as a secondary setting. Facilitators to implementing a geriatrician-led CGA included (i) a multidisciplinary team, (ii) better integration with primary care, (iii) a good electronic patient record system, and (iv) innovative ways to identify patients most in need of a CGA. Barriers to implementing a geriatrician-led CGA included (i) lack of resources or administrative support, (ii) limited team building, and (iii) consultative model where recommendations were made but not implemented.

CONCLUSIONS

Overall, participants found CGAs acceptable yet had different preferences of which setting to prioritise staffing if there was a shortage of geriatricians. The main barriers to implementing the geriatrician-led CGA related to lack of resources.

CLINICAL TRIAL NUMBER

Not applicable.

Multidisciplinary home-based interventions in adverse events and quality of life among frail older people: A systematic review and meta-analysis

Objective

To determine the effects of multidisciplinary home-based interventions delivered by multidisciplinary teams to prevent adverse events (mortality, emergency visits, and hospital readmissions) and improve quality of life (QoL) among frail older adults.

Methods

A systematic search of PubMed/MEDLINE, Scopus, the Cochrane Central Register of Controlled Trials, Web of Science, and the Cumulative Index to Nursing and Allied Health Literature was conducted until November 2023. The Risk of bias of the randomized controlled trials was assessed via the Cochrane risk of bias tool (RoB 2.0), and the synthesis and quality of evidence for each outcome were assessed via the Grading of Recommendation, Assessment, Development and Evaluation (GRADE). The effect size (ES), pooled OR (p-OR), and 95 % confidence intervals (95 % CIs) were calculated for QoL and adverse events. Subgroup analyses and meta-regressions were conducted.

Results

Twenty-seven studies were included in the systematic review. The p-OR for the effect of home-based interventions on mortality was 0.88 (95 % CI: 0.75 to 1.02; I2 = 27.6 %), that for visits to the emergency department was 0.88 (95 % CI: 0.78 to 1.00; I2 = 56.4 %), that for hospital admissions in days was 0.85 (95 % CI: 0.52 to 1.37; I2 = 85.2 %), and that for hospital admissions was 0.90 (95 % CI: 0.79 to 1.01; I2 = 52.0 %). In addition, the pooled ES for the effect of home-based interventions on QoL was 0.08 (95 % CI: 0.02 to 0.17; I2 = 60.7 %). The type of intervention, type of control, evaluation of the risk of bias, duration of the intervention, mean age of the intervention group, and percentage of women in the intervention group did not modify the effect of MHBIs to prevent adverse events or to improve quality of life (QoL) among frail older adults.

Conclusions

Multidisciplinary home-based interventions do not appear to reduce adverse events (mortality, visits to the emergency department, or hospital admissions/readmissions) in older people defined and/or considered frail. In addition, these interventions do not improve QoL in older people, or the evidence is unclear.

Unleashing frailty from laboratory into real world: A critical step toward frailty-guided clinical care of older adults

Understanding patients' degree of frailty is crucial for tailoring clinical care for older adults based on their physiologic reserve and health needs ("frailty-guided clinical care"). Two prerequisites for frailty-guided clinical care are: (1) access to frailty information at the point of care and (2) evidence to inform decisions based on frailty information. Recent advancements include web-based frailty assessment tools and their electronic health records integration for time-efficient, standardized assessments in clinical practice. Additionally, database frailty scores from administrative claims and electronic health records data enable scalable assessments and evaluation of the effectiveness and safety of medical interventions across different frailty levels using real-world data. Given limited evidence from clinical trials, real-world database studies can complement trial results and help treatment decisions for individuals with frailty. This article, based on the Thomas and Catherine Yoshikawa Award lecture I gave at the American Geriatrics Society Annual Meeting in Long Beach, California, on May 5, 2023, outlines our group's contributions: (1) developing and integrating a frailty index calculator (Senior Health Calculator) into the electronic health records at an academic medical center; (2) developing a claims-based frailty index for Medicare claims; (3) applying this index to evaluate the effect of medical interventions for patients with and without frailty; and (4) efforts to disseminate frailty assessment tools through the launch of the eFrailty website and the forthcoming addition of the claims-based frailty index to the Centers for Medicare and Medicaid Services Chronic Conditions Data Warehouse. This article concludes with future directions for frailty-guided clinical care.

Veteran comfort and satisfaction with comprehensive geriatric assessment via video telehealth to home

BACKGROUND

The purpose of this project was to measure satisfaction with virtual comprehensive geriatric assessments (CGA) among older Veterans (OVs).

METHODS

The CGA involved five different healthcare providers and four one-hour VA Video Connect (VVC) calls. Using specific enrollment criteria, OVs were recruited in four cohorts separated by time. After completing the CGA, participants were asked to complete a 10-statement telephone questionnaire. Before analyses, responses to each statement were dichotomized as Agree (Agree/Strongly agree) or Do not Agree (Neutral/Disagree/Strongly Disagree). Descriptive statistics and Binomial generalized linear models (GLMs) were used to analyze the data.

RESULTS

All 269 enrolled OVs completed all components of the CGA. This included 79, 57, 61, and 72 Veterans in cohorts 1 to 4, respectively. Their average age was 76.0 ± 5.9 years, and they were predominately white (82%), male (94%), and residents of rural settings (64%). Of the 236 (88%) OVs who completed the telephone survey, 57% indicated they were comfortable using VVC and 57% expressed willingness to use VVC again; 44% felt that VVC was easier than going to in-person visits. The OVs in Cohort 1 were more likely to agree with these statements than those in the remaining cohorts, especially Cohorts 2 and 4. Differences in demographics partially explained some of these findings. The majority (89% or higher) of survey participants agreed with the remaining seven survey statements indicating they were satisfied with the CGA program.

CONCLUSION

OVs were very satisfied with their participation in a program of CGA, although not necessarily the mode of delivery. The percentage of participants who indicated discomfort using VVC for the CGA visits appeared to increase with time. Further work is needed to determine which OVs would be the best candidates to use VVC to complete all or part of a CGA.

Effectiveness of comprehensive geriatric assessment adapted to primary care when provided by a nurse or a general practitioner: the CEpiA cluster-randomised trial

BACKGROUND

The benefits of comprehensive geriatric assessment (CGA) are well established for hospital care but less so for primary care. Our primary objective was to assess the effect of two multifaceted interventions based on a CGA adapted for primary care on a composite criterion combining all-cause mortality, emergency department visits, unplanned hospital admissions, and institutionalisation.

METHODS

This open-label, pragmatic, three-arm, cluster-randomised controlled trial involved 39 general practices in France. It included 634 patients aged 70 years or over with chronic health conditions and/or an unplanned hospital admission in the past 3 months, between 05/2016 and 08/2018. Interventions were in arm 1: a systematic nurse-led CGA; arm 2: a GP-led CGA, at the GP's discretion; arm 3: standard care. The primary composite endpoint was assessed at 12 months. The secondary endpoints included: components of the composite endpoint, health-related quality of life (Duke Health Profile), functional status (Katz Activities of Daily Living Index) and medications (number) at 12 months. Pairwise comparisons between the experimental groups and the control were tested. The main analysis was performed on the intention-to-treat (ITT) population, after imputing missing information and adjusting for baseline imbalances by mixed effects regressions.

RESULTS

For the primary composite outcome, no statistically significant difference was found between arm 1 and the control (adjusted odds ratio [aOR] = 0.81 [95%CI 0.54-1.21], P = 0.31), whereas arm 2 and the control differed significantly (aOR = 0.60 [0.39-0.93], P = 0.022). A statistically lower risk of unplanned hospital admission in arm 2 vs control (aOR = 0.57 [0.36-0.92], P = 0.020)) was observed, while no statistically significant differences were found for the other components and between arm 1 and the control. None of the other secondary endpoints differed between arms.

CONCLUSIONS

Our study led in community-dwelling older patients with chronic conditions found no significant effect of a CGA adapted for primary care on mortality, functional independence and quality of life, but suggests that a GP-led CGA may reduce the risk of unplanned hospital admission. Our study demonstrates the feasibility of incorporating CGA into clinical practice and highlights its potential benefits when applied on a case-by-case basis, guided by the GPs who develop the resulting PCP.

TRIAL REGISTRATION

NCT02664454.

The care of non-institutionalized ADL-dependent people in the Orcasitas neighborhood of Madrid (Spain) during the Covid-19 pandemic and its relationship with social inequalities, intergenerational dependency and survival

Background

Mortality among people with dependency to perform basic activities of daily living (ADL) is higher than that of non-dependent people of the same age. Understanding the evolutionary course and factors involved in non-institutionalized ADL dependency, including the influence of the family structure that supports this population, would contribute to improved health planning.

Methods

A longitudinal study carried out in the ADL-dependent population of the Orcasitas neighborhood, Madrid (Spain), between June 2020, when the nationwide COVID-19 lockdown ended, and June 2023. A total of 127 patients participated in the study, 78.7% of whom were women and 21.3% were men. Risk analysis was performed via odds ratios (OR) and hazard ratios (HR). Survival analysis was performed using Cox regression.

Results

A total of 54.33% of the ADL-dependent persons did not live with their adult children and 45.67% did, being associated living independently with economic capacity and the married marital status but not with the dependency level. In women, being married increased the probability of living independently of their adult children (OR = 12.632; 95% CI = 3.312-48.178). Loss of mobility (OR = 0.398; 95% CI = 0.186-0.853), economic capacity of the dependent (HR = 0.596; 95% CI = 0.459-0.774), and living independently and having better economic capacity (HR = 0.471; 95% CI = 0.234-0.935) were associated with 3-year survival. Those who lived with their adult children had a worse autonomy profile and higher mortality (HR = 1.473; 95% CI = 1.072-2.024). Not being employed, not being married, and not owning a home were significantly associated with being an essential family caregiver. Caregivers were mostly women (OR = 1.794; 95% CI = 1.011-3.182).

Conclusion

Among ADL-dependent persons, economic capacity influenced the ability to living independently and affected survival after 3 years. Loss of mobility (wheelchair use) was a predictor of mortality. Social inequalities promote that adult children end up as essential family caregivers. This generates reverse dependency and maintains a vulnerability that is transmitted from generation to generation, perpetuating social and gender inequalities. Dependent parent care in this cohort maintained an archaic pattern in which the eldest daughter cared for her parents. This study made it possible to show that ADL dependence is accompanied by complex interrelationships that must be considered in socio-health planning.

A multicomponent personalized prevention program in the primary care setting: a randomized clinical trial in older people with noncommunicable chronic diseases (Primacare_P3 study)

BACKGROUND

Multicomponent interventions based on a comprehensive geriatric assessment (CGA) could promote active aging and improve health status in older people with Noncommunicable Chronic Diseases (NCDs), but conflicting evidences are available.

AIM

To evaluate the efficacy of a CGA-based multicomponent personalized preventive program (PPP) in reducing unplanned hospitalization rates during 12-month follow-up in community-dwelling older people with NCDs.

MATERIALS AND METHODS

In this randomized clinical trial (RCT), 1216 older adults recruited by 33 general practitioners (GPs) will be randomly allocated to intervention group (IG) or usual care control group (CG). The IG will receive a multicomponent PPP developed on the findings of the CGA-based Multidimensional Prognostic Index short-form (Brief-MPI), including structured interventions to improve functional, physical, cognitive, and nutritional status, to monitor NCDs and vaccinations, and to prevent social isolation. Participants in the CG will receive usual care. Brief-MPI, resilience, and health-related quality of life will be assessed after 6 and 12 months. Moreover, saliva samples will be collected at baseline in IG to measure biomarkers of oxidative stress, inflammatory cytokines, and oral microbiome.

EXPECTED RESULTS

The CGA-based PPP might reduce unplanned hospitalization rates and potentially institutionalization rates, emergency department (ED) and unplanned GP visits, and mortality. Further outcomes explored in the IG will be the adherence to PPP, resilience, health-related quality of life, and multidimensional frailty as assessed by the Brief-MPI.

CONCLUSIONS

Results will suggest whether the CGA-based multicomponent PPP is able to improve specific outcomes in a primary care setting.

TRIAL REGISTRATION

ClinicalTrials.gov; identifier: NCT06224556 ; Registered January 25, 2024.

Inappropriate prescribing and association with readmission or mortality in hospitalised older adults with frailty: a systematic review and meta-analysis

BACKGROUND

Inappropriate prescribing (IP) is common in hospitalised older adults with frailty. However, it is not known whether the presence of frailty confers an increased risk of mortality and readmissions from IP nor whether rectifying IP reduces this risk. This review was conducted to determine whether IP increases the risk of adverse outcomes in hospitalised middle-aged and older adults with frailty.

METHODS

A systematic review was conducted on IP in hospitalised middle-aged (45-64 years) and older adults (≥ 65 years) with frailty. This review considered multiple types of IP including potentially inappropriate medicines, prescribing omissions and drug interactions. Both observational and interventional studies were included. The outcomes were mortality and hospital readmissions. The databases searched included MEDLINE, CINAHL, EMBASE, World of Science, SCOPUS and the Cochrane Library. The search was updated to 12 July 2024. Meta-analysis was performed to pool risk estimates using the random effects model.

RESULTS

A total of 569 studies were identified and seven met the inclusion criteria, all focused on the older population. One of the five observational studies found an association between IP and emergency department visits and readmissions at specific time points. Three of the observational studies were amenable to meta-analysis which showed no significant association between IP and hospital readmissions (OR 1.08, 95% CI 0.90-1.31). Meta-analysis of the subgroup assessing Beers criteria medicines demonstrated that there was a 27% increase in the risk of hospital readmissions (OR 1.27, 95% CI 1.03-1.57) with this type of IP. In meta-analysis of the two interventional studies, there was a 37% reduced risk of mortality (OR 0.63, 95% CI 0.40-1.00) with interventions that reduced IP compared to usual care but no difference in hospital readmissions (OR 0.83, 95% CI 0.19-3.67).

CONCLUSIONS

Interventions to reduce IP were associated with reduced risk of mortality, but not readmissions, compared to usual care in older adults with frailty. The use of Beers criteria medicines was associated with hospital readmissions in this group. However, there was limited evidence of an association between IP more broadly and mortality or hospital readmissions. Further high-quality studies are needed to confirm these findings.

Evaluate a comprehensive geriatric assessment service framework targeting frail older people who had high risk of requiring long-term care services in Japan: a community-based pilot study

BACKGROUND

Frailty has become a key concern in an aging population. A comprehensive geriatric assessment (CGA) service framework was developed and evaluated aiming to target and connect frail older adults who are at high risk of requiring long-term care services.

METHODS

A community-based pilot study was conducted in fiscal year 2016 and 2017 in Kure city, Hiroshima, Japan. Participants aged 65 and over living in Kure city, and 393 persons were extracted from the Kihon Check List (KCL) responses. Among the eligible individuals, 101 consented to participate and received CGA and referred to services based on individual health needs. The efficacy was evaluated by referral rate of services, continuity of the service usage, evaluation of participant's health condition and the quality of life (QoL) after the 6-month follow-up.

RESULTS

Ninety-nine (98.0%) participants needed support for the instrumental activity of daily living, 97 (96.0%) were categorized as locomotive syndrome, and 64 (63.4%) had a depressive tendency. Afterward, 60 participants (59.4%) subsequently accepted the referral services, however, 34 (33.7%) used the services and the remaining 26 (25.7%) did not use the services. The health condition improvements in the service-uses group were statistically significant (p < 0.001), however, QoL score did not change between the baseline and 6th -month.

CONCLUSION

KCL extracted high-risks older people, and CGA revealed related diseases and health conditions. However, the high refusal rate of referral services indicates a necessity to modify the service framework such as by collaborating with community general support centers, which could increase the efficacy of service framework.

Association between vitamin D insufficiency and depressive symptoms, and functional disability in community-dwelling Brazilian older adults: results from ELSI-Brazil study

Low serum 25(OH)D levels (< 30 nmol/L) have been associated with increased depressive symptom scores over time, and it is believed that functionality may play a mediating role in the relationship between 25(OH)D and depressive symptoms. To comprehend the association between these factors could have significant implications for public health policy. The aim of this study was to verify the association between simultaneous vitamin D insufficiency and depressive symptoms, and functional disability in community-dwelling older adults. This was a cross-sectional study with data from the Brazilian Longitudinal Study of Aging (ELSI-Brazil), collected between 2015 and 2016. The outcomes were functional disability assessed through basic activities of daily living (ADL) and instrumental activities of daily living (IADL). The exposures were vitamin D insufficiency (< 30 nmol/L) and depressive symptoms (≥ 4 points in 8-item version of the Center for Epidemiological Studies-Depression). Crude and adjusted Poisson regression was performed to estimate associations. A total of 1781 community-dwelling older adults included in this study, 14.6% had disability in ADL and 47.9% in IADL; 59.7% had vitamin D insufficient levels, and 33.2% depressive symptoms. The concomitant presence of vitamin D insufficient and depressive symptoms increased the prevalence of ADL by 2.20 (95% CI: 1.25; 3.86) and IADL by 1.54 (95% CI: 1.24; 1.91), respectively. Therefore, preventive strategies to keep older adults physically and socially active, with a good level of vitamin D, are essential to avoid depression and functional disability.

The impact of long-term care interventions on healthcare utilisation among older persons: a scoping review of reviews

BACKGROUND

As the ageing population grows, the demand for long-term care (LTC) services will rise, concurrently amplifying healthcare utilisation. This review aims to examine and consolidate information on LTC interventions that influence healthcare utilisation among older persons.

METHODS

A scoping review was performed through a systematic search in PubMed, EBSCO CINAHL, EBM Reviews - Cochrane Database of Systematic Reviews, Embase, APA PsycInfo, EBM Reviews - Health Technology Assessment, and EBM Reviews - NHS Economic Evaluation Database. Systematic reviews with meta-analyses published between 1 January 2010 and 2 June 2022 among older persons aged 60 and above were included. The characteristics of LTC interventions were mapped to the World Health Organization (WHO) Healthy Ageing Framework. The effect sizes of healthcare utilisations for LTC interventions were recalculated using a random-effects model. The methodological quality was assessed with the AMSTAR-2 checklist, while the quality of evidence for each association was evaluated using GRADE.

RESULTS

Thirty-seven meta-analyses were included. The most prominent domain of the healthy ageing framework was managing chronic conditions. One hundred twelve associations between various LTC interventions and healthcare utilisations were identified, with 22 associations impacting healthcare utilisation. Four interventions were supported by suggestive or convincing evidence. Preventive home visits were found to reduce hospital admission (OR: 0.73, 95% CI: 0.59, 0.91, p = 0.005), caregiver integration during discharge planning (OR: 0.68, 95% CI: 0.57, 0.81, p < 0.001), and continuity of care (OR: 0.76, 95% CI: 0.61, 0.95, p = 0.018) reduced hospital readmission, and perioperative geriatric interventions reduced the length of hospital stay (MD: -1.50, 95% CI: -2.24, -0.76, p < 0.001). None of the associations impacted emergency department visits, medication use, and primary care utilisations with convincing evidence. Most reviews received low methodological quality.

CONCLUSION

The findings suggest that LTC interventions could benefit from transitioning to a community-based setting involving a multidisciplinary team, including carers. The spectrum of services should incorporate a comprehensive assessment to ensure continuous care.

Development and Evaluation of a Software Designed by a Nursing and Technology Team to Assess the Health Status of Adults over 65 Years of Age

Objective

This work sought to develop the Actuasalud platform as a useful tool for nursing that permits assessing health, in term of frailty, in population over 65 years of age.

Methods

For the design and development of Actuasalud, two working groups were formed: one from nursing with different profiles, to identify the scientific content and a computer science group responsible for the software programming and development. Both teams adapted the scientific content to the technology so that the tool would allow for population screening with detection of health problems and frailty states.

Results

The software was developed in three large blocks that include all the dimensions of frailty: a: sociodemographic variables, b: comorbidities, and c: assessment tools of autonomy-related needs that evaluate the dimensions of frailty. At the end of the evaluation, a detailed report is displayed through bar diagram with the diagnosis of each of the dimensions assessed. The assessment in the participating elderly showed that 44.7% (n = 38) of the population was considered not frail, and 55.3%; (n = 47) as frail. Regarding associated pathologies, high blood pressure (67.1%; n = 57), osteoarthritis and/or arthritis (55.3%; n = 47), diabetes (48.2%; n = 41) and falls during the last year (35.3%; n = 30) were highlighted.

Conclusion

Actuasalud is an application that allows nursing professionals to evaluate frailty and issue a quick diagnosis with ordered sequence, which helps to provide individualized care to elderly individuals according to the problems detected during the evaluation.

Community-based person-centred integrated care (PIC) networks for healthy ageing in place: a scoping review protocol

INTRODUCTION

The economic case for preventive care delivered in or near citizens' homes is strong, and there is growing evidence of the role of local-level support in supporting people's health and well-being as they age. However, effective and consistent delivery of person-centred integrated care (PIC) at the community level remains elusive. Previous systematic reviews have focused on specific processes such as case management, but none have focused on the operational delivery of community-based care networks. In this study, we aim to identify what practice-based models of PIC networks exist at the local/neighbourhood level and what evidence is available as to their effectiveness for healthy ageing in place.

METHODS AND ANALYSIS

We will undertake a scoping review following the framework proposed by Arksey and O'Malley and updated guidance by the Joanna Briggs Institute. Peer-reviewed sources will be identified through searches of seven databases, and relevant grey literature will be identified through websites of policy and voluntary sector organisations focused on integrated care and/or healthy ageing. Data from included studies will be extracted for relevance to the research questions, including aims and anticipated outcomes of network models, financial and management structures of networks, and evidence of evaluation. Summary tables and narrative comparisons of key PIC network features across settings will be presented.

ETHICS AND DISSEMINATION

As no primary data will be collected, ethical approval is not required to conduct this scoping review. In addition to publication as a peer-reviewed article, the results of this review will be summarised as shorter discussion papers for use in follow-up research.

Comprehensive geriatric assessment predicts radiation-induced acute toxicity in prostate cancer patients

PURPOSE

The purpose of the present prospective study was to evaluate the significance of geriatric conditions measured by a comprehensive geriatric assessment (GA) for the prediction of the risk of high-grade acute radiation-induced toxicity.

METHODS

A total of 314 prostate cancer patients (age ≥ 65 years) undergoing definitive radiotherapy at a tertiary academic center were included. Prior to treatment, patients underwent a GA. High-grade toxicity was defined as acute toxicity grade ≥ 2 according to standard RTOG/EORTC criteria. To analyze the predictive value of the GA, univariable and multivariable logistic regression models were applied.

RESULTS

A total of 40 patients (12.7%) developed acute toxicity grade ≥ 2; high grade genitourinary was found in 37 patients (11.8%) and rectal toxicity in 8 patients (2.5%), respectively. Multivariable analysis revealed a significant association of comorbidities with overall toxicity grade ≥ 2 (odds ratio [OR] 2.633, 95% confidence interval [CI] 1.260-5.502; p = 0.010) as well as with high-grade genitourinary and rectal toxicity (OR 2.169, 95%CI1.017-4.625; p = 0.045 and OR 7.220, 95%CI 1.227-42.473; p = 0.029, respectively). Furthermore, the Activities of Daily Living score (OR 0.054, 95%CI 0.004-0.651; p = 0.022), social status (OR 0.159, 95%CI 0.028-0.891; p = 0.036), and polypharmacy (OR 4.618, 95%CI 1.045-20.405; p = 0.044) were identified as independent predictors of rectal toxicity grade ≥ 2.

CONCLUSION

Geriatric conditions seem to be predictive of the development of high-grade radiation-induced toxicity in prostate cancer patients treated with definitive radiotherapy.

Factors Related to the Need for Informal Care Among Community-Dwelling Older Adults in Chile

PURPOSE

To identify factors contributing to the need for informal care among community-dwelling older adults with functional impairment in Chile.

METHOD

A secondary data analysis was conducted using cross-sectional data from 540 Chilean older adults aged ≥60 years (mean age = 72.2 years, SD = 6.22 years).

RESULTS

Informal care need was reported by 24.3% (n = 131) of participants. Among the variables that most influenced the need for informal care among older adults were hospitalization in the past 1 year, functionality, comorbidities, and multidimensional frailty (all p < 0.05).

CONCLUSION

This study identified factors that clinicians and nurses should be aware of when caring for this population to prevent or manage the need for informal care. [Journal of Gerontological Nursing, 50(2), 43-52.].

Exploring stakeholders' experiences of comprehensive geriatric assessment in the community and out-patient settings: a qualitative evidence synthesis

BACKGROUND

Comprehensive Geriatric Assessment (CGA) is a multidimensional interdisciplinary process that addresses an older adult's biopsychosocial capabilities to create an integrated and co-ordinated plan of care. While quantitative evidence that demonstrates the positive impacts of CGA on clinical and process outcomes has been synthesised, to date qualitative research reporting how older adults and service providers experience CGA has not been synthesised. This study aimed to systematically review and synthesise qualitative studies reporting community-dwelling older adults', caregivers' and healthcare professionals' (HCP) experiences of CGA in the primary care and out-patient (OPD) setting.

METHOD

We systematically searched five electronic databases including MEDLINE, CINAHL, PsycINFO, PsycARTICLES and Social Sciences Full Text targeting qualitative or mixed methods studies that reported qualitative findings on older adults', caregivers' and HCPs' experiences of CGA in primary care or out-patient settings. There were no language or date restrictions applied to the search. The protocol was registered with the PROSPERO database (Registration: CRD42021283167). The methodological quality of the included studies was appraised using the Critical Appraisal Skills Programme checklist for qualitative research. Results were synthesised according to Noblit and Hare's seven-step approach to meta-ethnography, which involves an iterative and inductive process of data synthesis.

RESULTS

Fourteen studies were included where CGA was completed in the home, general practice, out-patient setting in acute hospitals and in hybrid models across the community and hospital-based OPD settings. Synthesis generated four key themes: (1) CGA is experienced as a holistic process, (2) The home environment enhances CGA, (3) CGA in the community is enabled by a collaborative approach to care, and (4) Divergent experiences of the meaningful involvement of older adults, caregivers and family in the CGA process.

CONCLUSION

Findings demonstrate that CGA in a home-based or OPD setting allows for a holistic and integrated approach to care for community-dwelling older adults while increasing patient satisfaction and accessibility of healthcare. Healthcare professionals in the community should ensure meaningful involvement of older adults and their families or caregivers in the CGA process. Further robustly designed and well reported trials of different models of community-based CGA informed by the findings of this synthesis are warranted.

Acute care models for older people living with frailty: a systematic review and taxonomy

BACKGROUND

The need to improve the acute care pathway to meet the care needs of older people living with frailty is a strategic priority for many healthcare systems. The optimal care model for this patient group is unclear.

METHODS

A systematic review was conducted to derive a taxonomy of acute care models for older people with acute medical illness and describe the outcomes used to assess their effectiveness. Care models providing time-limited episodes of care (up to 14 days) within 48 h of presentation to patients over the age of 65 with acute medical illness were included. Care models based in hospital and community settings were eligible. Searches were undertaken in Medline, Embase, CINAHL and Cochrane databases. Interventions were described and classified in detail using a modified version of the TIDIeR checklist for complex interventions. Outcomes were described and classified using the Core Outcome Measures in Effectiveness Trials (COMET) taxonomy. Risk of bias was assessed using RoB2 and ROBINS-I.

RESULTS

The inclusion criteria were met by 103 articles. Four classes of acute care model were identified, acute-bed based care, hospital at home, emergency department in-reach and care home models. The field is dominated by small single centre randomised and non-randomised studies. Most studies were judged to be at risk of bias. A range of outcome measures were reported with little consistency between studies. Evidence of effectiveness was limited.

CONCLUSION

Acute care models for older people living with frailty are heterogenous. The clinical effectiveness of these models cannot be conclusively established from the available evidence.

TRIAL REGISTRATION

PROSPERO registration (CRD42021279131).

Not enough geriatricians or not where they are needed?

This editorial comments on the article by Hogeveen et al. in this issue.

Determinants of access of frail, community-residing older adults to geriatricians in Ontario

OBJECTIVES

Little is known about determinants of access to community-based geriatricians. The Geriatric 5Ms™ describe geriatricians' core competencies and inform referrals to specialists for older adults with complex needs. We explored the association of the Geriatric 5Ms™ and other characteristics with outpatient access to geriatricians by home care (HC) clients.

METHODS

This was a population-based, retrospective cohort study of frail community-dwelling HC clients (≥60 years) with complex needs (n = 196,444). Health assessment information was linked to health services data in Ontario, Canada, 2012-2015. Multivariable generalized estimating equations were used to identify characteristics associated with geriatrician contact (≥1 visit in 90 days post-HC admission), including derived Geriatric 5Ms™ score, and predisposing, enabling, and need factors obtained from clinical assessments.

RESULTS

Only 5.2% of the cohort had outpatient geriatrician contact in Ontario, Canada. Derived Geriatric 5Ms™ score was associated with higher odds of contact, but the model had modest discriminatory power (c-statistic = 0.67). In the broader multivariable model, based on empirically included factors and adjusted for regional differences, age, worsening of decision-making, dementia, hallucinations, Parkinsonism, osteoporosis, and caregiver distress/institutionalization risk were associated with higher odds of geriatrician contact. Female sex, difficulties accessing home, impaired locomotion, recovery potential, hemiplegia/hemiparesis, and cancer, were associated with lower odds of contact. This model had good discriminatory power (c-statistic = 0.77).

CONCLUSIONS

Few frail, community-dwelling older adults receiving HC had any outpatient geriatrician contact. While the derived Geriatric 5Ms™ score was associated with contact, a broader empirical model performed better than the Geriatric 5Ms™ in predicting contact with an outpatient geriatrician. Contact was mainly driven by conditions common in older adults, but evidence suggests that geriatricians are not evaluating the most medically complex and unstable older adults in the community. These findings suggest a need to re-examine the referral process for geriatricians and the allocation of limited specialized resources.

Association between homocysteine level and length of stay in patients with lower extremity atherosclerotic disease: a retrospective cohort study

OBJECTIVES

Homocysteine (Hcy) level has been widely identified as a risk factor associated with adverse outcomes in patients with lower extremity atherosclerotic disease (LEAD). However, there are still some knowledge gaps in research on the association between Hcy level and downstream adverse outcomes, such as length of stay (LOS). This study aims to explore whether and to what extent Hcy level is associated with LOS in patients with LEAD.

DESIGN

Retrospective cohort study.

SETTING

China.

PARTICIPANTS, PRIMARY AND SECONDARY OUTCOMES

We conducted a retrospective cohort study of 748 patients from inpatients with LEAD between January 2014 and November 2021 at the First Hospital of China Medical University in China. We used a slew of generalised linear models to evaluate the association between Hcy level and LOS.

RESULTS

The patients' median age was 68 years and 631 (84.36%) were males. A dose-response curve with an inflection point at 22.63 µmol/L was observed between Hcy level and LOS after the adjustment of potential confounders. LOS increased before Hcy level reached the inflection point (β: 0.36; 95% CI: 0.18 to 0.55; p<0.001).ConclusionOur results show that an Hcy level <22.63 µmol/L is associated with increased LOS in patients with LEAD, which was independent of some other risk factors. This might shed light on how Hcy can be used as a key marker in the comprehensive management of patients with LEAD during hospitalisation.

Effectiveness of outpatient geriatric evaluation and management intervention on survival and nursing home admission: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

The benefit of inpatient comprehensive geriatric assessment on patient survival and function has been demonstrated among frail older patients. However, the influence of outpatient geriatric evaluation and management (GEM) on clinical outcomes remains debated. This study aimed to update the research evidence detailing the effect of outpatient GEM on survival and nursing-home admission through a comparison with conventional care.

METHODS

Cochrane Library, EMBASE, and MEDLINE databases were searched up to January 29th, 2022, to identify randomized controlled trials (RCTs) including older people over age 55 that compared outpatient GEM with conventional care on mortality (primary outcome) and nursing-home admission (secondary outcome) during a follow-up period of 12 to 36 months.

RESULTS

Nineteen reports from 11 studies that recruited 7,993 participants (mean age 70-83) were included. Overall, outpatient GEM significantly reduced mortality (risk ratio (RR) = 0.87, 95% confidence interval (CI) = 0.77-0.99, I2 = 12%). For the subgroup analysis categorized by different follow-up periods, its prognostic benefit was only disclosed for 24-month mortality (RR = 0.68, 95% CI = 0.51-0.91, I2 = 0%), but not for 12- or 15 to 18-month mortality. Furthermore, outpatient GEM had significantly trivial effects on nursing-home admission during the follow-up period of 12 or 24 months (RR = 0.91, 95% CI = 0.74-1.12, I2 = 0%).

CONCLUSIONS

Outpatient GEM led by a geriatrician with a multidisciplinary team improved overall survival, specifically during the 24-month follow-up period. This trivial effect was demonstrated in rates of nursing-home admission. Future research on outpatient GEM involving a larger cohort is warranted to corroborate our findings.

Study protocol for The GOAL Trial: comprehensive geriatric assessment for frail older people with chronic kidney disease to increase attainment of patient-identified goals-a cluster randomised controlled trial

BACKGROUND

An increasing number of older people are living with chronic kidney disease (CKD). Many have complex healthcare needs and are at risk of deteriorating health and functional status, which can adversely affect their quality of life. Comprehensive geriatric assessment (CGA) is an effective intervention to improve survival and independence of older people, but its clinical utility and cost-effectiveness in frail older people living with CKD is unknown.

METHODS

The GOAL Trial is a pragmatic, multi-centre, open-label, superiority, cluster randomised controlled trial developed by consumers, clinicians, and researchers. It has a two-arm design, CGA compared with standard care, with 1:1 allocation of a total of 16 clusters. Within each cluster, study participants ≥ 65 years of age (or ≥ 55 years if Aboriginal or Torres Strait Islander (First Nations Australians)) with CKD stage 3-5/5D who are frail, measured by a Frailty Index (FI) of > 0.25, are recruited. Participants in intervention clusters receive a CGA by a geriatrician to identify medical, social, and functional needs, optimise medication prescribing, and arrange multidisciplinary referral if required. Those in standard care clusters receive usual care. The primary outcome is attainment of self-identified goals assessed by standardised Goal Attainment Scaling (GAS) at 3 months. Secondary outcomes include GAS at 6 and 12 months, quality of life (EQ-5D-5L), frailty (Frailty Index - Short Form), transfer to residential aged care facilities, cost-effectiveness, and safety (cause-specific hospitalisations, mortality). A process evaluation will be conducted in parallel with the trial including whether the intervention was delivered as intended, any issue or local barriers to intervention delivery, and perceptions of the intervention by participants. The trial has 90% power to detect a clinically meaningful mean difference in GAS of 10 units.

DISCUSSION

This trial addresses patient-prioritised outcomes. It will be conducted, disseminated and implemented by clinicians and researchers in partnership with consumers. If CGA is found to have clinical and cost-effectiveness for frail older people with CKD, the intervention framework could be embedded into routine clinical practice. The implementation of the trial's findings will be supported by presentations at conferences and forums with clinicians and consumers at specifically convened workshops, to enable rapid adoption into practice and policy for both nephrology and geriatric disciplines. It has potential to materially advance patient-centred care and improve clinical and patient-reported outcomes (including quality of life) for frail older people living with CKD.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04538157. Registered on 3 September 2020.

Case management for integrated care of older people with frailty in community settings

BACKGROUND

Ageing populations globally have contributed to increasing numbers of people living with frailty, which has significant implications for use of health and care services and costs. The British Geriatrics Society defines frailty as "a distinctive health state related to the ageing process in which multiple body systems gradually lose their inbuilt reserves". This leads to an increased susceptibility to adverse outcomes, such as reduced physical function, poorer quality of life, hospital admissions, and mortality. Case management interventions delivered in community settings are led by a health or social care professional, supported by a multidisciplinary team, and focus on the planning, provision, and co-ordination of care to meet the needs of the individual. Case management is one model of integrated care that has gained traction with policymakers to improve outcomes for populations at high risk of decline in health and well-being. These populations include older people living with frailty, who commonly have complex healthcare and social care needs but can experience poorly co-ordinated care due to fragmented care systems.

OBJECTIVES

To assess the effects of case management for integrated care of older people living with frailty compared with usual care.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL, Health Systems Evidence, and PDQ Evidence and databases from inception to 23 September 2022. We also searched clinical registries and relevant grey literature databases, checked references of included trials and relevant systematic reviews, conducted citation searching of included trials, and contacted topic experts.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that compared case management with standard care in community-dwelling people aged 65 years and older living with frailty.

DATA COLLECTION AND ANALYSIS

We followed standard methodological procedures recommended by Cochrane and the Effective Practice and Organisation of Care Group. We used the GRADE approach to assess the certainty of the evidence.

MAIN RESULTS

We included 20 trials (11,860 participants), all of which took place in high-income countries. Case management interventions in the included trials varied in terms of organisation, delivery, setting, and care providers involved. Most trials included a variety of healthcare and social care professionals, including nurse practitioners, allied healthcare professionals, social workers, geriatricians, physicians, psychologists, and clinical pharmacists. In nine trials, the case management intervention was delivered by nurses only. Follow-up ranged from three to 36 months. We judged most trials at unclear risk of selection and performance bias; this consideration, together with indirectness, justified downgrading the certainty of the evidence to low or moderate. Case management compared to standard care may result in little or no difference in the following outcomes. • Mortality at 12 months' follow-up (7.0% in the intervention group versus 7.5% in the control group; risk ratio (RR) 0.98, 95% confidence interval (CI) 0.84 to 1.15; I2 = 11%; 14 trials, 9924 participants; low-certainty evidence) • Change in place of residence to a nursing home at 12 months' follow-up (9.9% in the intervention group versus 13.4% in the control group; RR 0.73, 95% CI 0.53 to 1.01; I2 = 0%; 4 trials, 1108 participants; low-certainty evidence) • Quality of life at three to 24 months' follow-up (results not pooled; mean differences (MDs) ranged from -6.32 points (95% CI -11.04 to -1.59) to 6.1 points (95% CI -3.92 to 16.12) when reported; 11 trials, 9284 participants; low-certainty evidence) • Serious adverse effects at 12 to 24 months' follow-up (results not pooled; 2 trials, 592 participants; low-certainty evidence) • Change in physical function at three to 24 months' follow-up (results not pooled; MDs ranged from -0.12 points (95% CI -0.93 to 0.68) to 3.4 points (95% CI -2.35 to 9.15) when reported; 16 trials, 10,652 participants; low-certainty evidence) Case management compared to standard care probably results in little or no difference in the following outcomes. • Healthcare utilisation in terms of hospital admission at 12 months' follow-up (32.7% in the intervention group versus 36.0% in the control group; RR 0.91, 95% CI 0.79 to 1.05; I2 = 43%; 6 trials, 2424 participants; moderate-certainty evidence) • Change in costs at six to 36 months' follow-up (results not pooled; 14 trials, 8486 participants; moderate-certainty evidence), which usually included healthcare service costs, intervention costs, and other costs such as informal care.

AUTHORS' CONCLUSIONS

We found uncertain evidence regarding whether case management for integrated care of older people with frailty in community settings, compared to standard care, improved patient and service outcomes or reduced costs. There is a need for further research to develop a clear taxonomy of intervention components, to determine the active ingredients that work in case management interventions, and identify how such interventions benefit some people and not others.

GP-led adapted comprehensive geriatric assessment for frail older people: a multi-methods evaluation of the 'Living Well Assessment' quality improvement project in Scotland

BACKGROUND

Evidence to support comprehensive geriatric assessment (CGA) in primary care for frail older people is limited.

AIM

To evaluate a GP-led adapted CGA quality improvement project.

DESIGN & SETTING

Multi-methods evaluation in a large practice in Midlothian in Scotland.

METHOD

The intervention was conducted by 10 GPs in a practice of approximately 11 000 patients, initially in the patient's home, and then remotely (by telephone or video consultation) during the COVID-19 pandemic. Evaluation included a patient questionnaire, and qualitative interviews with GPs delivering the Living Well Assessment (LWA), analysed by thematic analysis.

RESULTS

A total of 165/220 (75%) patients responded to the survey, of which 86% reported a 'very good experience' of the LWA. The method of delivery did not significantly influence this although most (58%) stated a preference for face-to-face consultation. For the 31% who preferred remote LWA, most (23%) preferred telephone to video consultation (8%). Problems in remote consultations related to technical issues (video), poor vision (video), or deafness (telephone or video). GPs felt that home-based LWAs had real benefits but switching to remote during the pandemic had proven feasible. Concerns included potential increase in GP workload owing to the LWA and whether it was an efficient use of GPs' time.

CONCLUSION

GP-led adapted CGA was feasible in a large practice, even during the pandemic, and highly valued by frail patients. Questions regarding efficient use of GPs' time, effectiveness in terms of important patient outcomes and impact, and cost-effectiveness, requires further investigation in a larger study.

Comprehensive Geriatric Assessment for younger outpatients with severe mental illness: protocol for a feasibility study

INTRODUCTION

Individuals with severe mental illness are at risk of becoming prematurely frail. There is a critical unmet need for an intervention that reduces the risk of frailty and minimises the associated negative outcomes in this population. This study aims to provide novel evidence on the feasibility, acceptability and preliminary effectiveness of Comprehensive Geriatric Assessment (CGA) to improve health outcomes among people with co-occurring frailty and severe mental illness.

METHODS AND ANALYSIS

Twenty-five participants with frailty and severe mental illness, aged 18-64 years, will be recruited from Metro South Addiction and Mental Health Service outpatient clinics and provided with the CGA. Primary outcome measures will include the feasibility and acceptability of the CGA embedded in routine healthcare. Other variables of interest will include frailty status, quality of life, polypharmacy, and a range of mental and physical health factors.

ETHICS AND DISSEMINATION

All procedures involving human subjects/patients were approved by Metro South Human Research Ethics Committee (HREC/2022/QMS/82272). Study findings will be disseminated through peer-reviewed publications and conference presentations.

Total and regional appendicular skeletal muscle mass prediction from dual-energy X-ray absorptiometry body composition models

Sarcopenia, sarcopenic obesity, frailty, and cachexia have in common skeletal muscle (SM) as a main component of their pathophysiology. The reference method for SM mass measurement is whole-body magnetic resonance imaging (MRI), although dual-energy X-ray absorptiometry (DXA) appendicular lean mass (ALM) serves as an affordable and practical SM surrogate. Empirical equations, developed on relatively small and diverse samples, are now used to predict total body SM from ALM and other covariates; prediction models for extremity SM mass are lacking. The aim of the current study was to develop and validate total body, arm, and leg SM mass prediction equations based on a large sample (N = 475) of adults evaluated with whole-body MRI and DXA for SM and ALM, respectively. Initial models were fit using ordinary least squares stepwise selection procedures; covariates beyond extremity lean mass made only small contributions to the final models that were developed using Deming regression. All three developed final models (total, arm, and leg) had high R2s (0.88-0.93; all p < 0.001) and small root-mean square errors (1.74, 0.41, and 0.95 kg) with no bias in the validation sample (N = 95). The new total body SM prediction model (SM = 1.12 × ALM - 0.63) showed good performance, with some bias, against previously reported DXA-ALM prediction models. These new total body and extremity SM prediction models, developed and validated in a large sample, afford an important and practical opportunity to evaluate SM mass in research and clinical settings.

Development and validation of a prediction model for the prolonged length of stay in Chinese patients with lower extremity atherosclerotic disease: a retrospective study

OBJECTIVES

This study aims to develop and internally validate a prediction model, which takes account of multivariable and comprehensive factors to predict the prolonged length of stay (LOS) in patients with lower extremity atherosclerotic disease (LEAD).

DESIGN

This is a retrospective study.

SETTING

China.

PARTICIPANTS, PRIMARY AND SECONDARY OUTCOMES

Data of 1694 patients with LEAD from a retrospective cohort study between January 2014 and November 2021 were analysed. We selected nine variables and created the prediction model using the least absolute shrinkage and selection operator (LASSO) regression model after dividing the dataset into training and test sets in a 7:3 ratio. Prediction model performance was evaluated by calibration, discrimination and Hosmer-Lemeshow test. The effectiveness of clinical utility was estimated using decision curve analysis.

RESULTS

LASSO regression analysis identified age, gender, systolic blood pressure, Fontaine classification, lesion site, surgery, C reactive protein, prothrombin time international normalised ratio and fibrinogen as significant predictors for predicting prolonged LOS in patients with LEAD. In the training set, the prediction model showed good discrimination using a 500-bootstrap analysis and good calibration with an area under the receiver operating characteristic of 0.750. The Hosmer-Lemeshow goodness of fit test for the training set had a p value of 0.354. The decision curve analysis showed that using the prediction model both in training and tests contributes to clinical value.

CONCLUSION

Our prediction model is a valuable tool using easily and routinely obtained clinical variables that could be used to predict prolonged LOS in patients with LEAD and help to better manage these patients in routine clinical practice.

A non-randomised controlled study to assess the effectiveness of a new proactive multidisciplinary care intervention for older people living with frailty

Background

Integrated care may improve outcomes for older people living with frailty. We aimed to assess the effectiveness of a new, anticipatory, multidisciplinary care service in improving the wellbeing and quality of life (QoL) of older people living with severe frailty.

Methods

A community-based non-randomised controlled study. Participants (≥65 years, electronic Frailty Index ≥0.36) received either the new integrated care service plus usual care, or usual care alone. Data collection was at three time points: baseline, 2-4 weeks, and 10-14 weeks. The primary outcome was patient wellbeing (symptoms and other concerns) at 2-4 weeks, measured using the Integrated Palliative care Outcome Scale (IPOS); the secondary outcome was QoL, measured using EQ-5D-5L. To test duration of effect and safety, wellbeing and QoL were also measured at 10-14 weeks. Descriptive statistics were used to characterise and compare intervention and control groups (eligible but had not accessed the new service), with t-test, Chi-Square, or Mann-Whitney U tests (as appropriate) to test differences at each time point. Generalised linear modelling, with propensity score matching, was used for further group comparisons. Data were analysed using STATA v17.

Results

199 intervention and 54 control participants were recruited. At baseline, intervention and control groups were similar in age, gender, ethnicity, living status, and body mass index, but not functional status or area deprivation score. At 2-4 weeks, wellbeing had improved in the intervention group but worsened in the control (median IPOS -5 versus 2, p<0.001). QoL improved in the intervention group but was unchanged in the control (median EQ-5D-5L 0.12, versus 0.00, p<0.001). After adjusting for age, gender, and living status, the intervention group had an average total IPOS score reduction at 2-4 weeks of 6.34 (95% CI: -9.01: -4.26, p<0.05); this improvement was sustained, with an average total IPOS score reduction at 10-14 weeks of 6.36 (95% CI: -8.91:-3.80, p<0.05). After propensity score matching based on functional status/area deprivation, modelling showed similar results, with a reduction in IPOS score at 2-4 weeks in the intervention group of 7.88 (95% CI: -12.80: -2.96, p<0.001).

Conclusions

Our findings suggest that the new, anticipatory, multidisciplinary care service may have improved the overall wellbeing and quality of life of older people living with frailty at 2-4 weeks and the improvement in wellbeing was sustained at three months.

Ethics approval

NHS Research Ethics Committee 18/YH/0470 and IRAS-250981.

Trial registration

The trial was retrospectively registered at the International Standard Randomised Controlled Trial Number (ISRCTN) registry (registration date: 01/08/2022, registration number: ISRCTN10613839).

Effectiveness of home-based exercise delivered by digital health in older adults: a systematic review and meta-analysis

BACKGROUND

regular physical exercise is essential to maintain or improve functional capacity in older adults. Multimorbidity, functional limitation, social barriers and currently, coronavirus disease of 2019, among others, have increased the need for home-based exercise (HBE) programmes and digital health interventions (DHI). Our objective was to evaluate the effectiveness of HBE programs delivered by DHI on physical function, health-related quality of life (HRQoL) improvement and falls reduction in older adults.

DESIGN

systematic review and meta-analysis.

PARTICIPANTS

community-dwelling older adults over 65 years.

INTERVENTION

exercises at home through DHI.

OUTCOMES MEASURES

physical function, HRQoL and falls.

RESULTS

twenty-six studies have met the inclusion criteria, including 5,133 participants (range age 69.5 ± 4.0-83.0 ± 6.7). The HBE programmes delivered with DHI improve muscular strength (five times sit-to-stand test, -0.56 s, 95% confidence interval, CI -1.00 to -0.11; P = 0.01), functional capacity (Barthel index, 5.01 points, 95% CI 0.24-9.79; P = 0.04) and HRQoL (SMD 0.18; 95% CI 0.05-0.30; P = 0.004); and reduce events of falls (odds ratio, OR 0.77, 95% CI 0.64-0.93; P = 0.008). In addition, in the subgroup analysis, older adults with diseases improve mobility (SMD -0.23; 95% CI -0.45 to -0.01; P = 0.04), and balance (SMD 0.28; 95% CI 0.09-0.48; P = 0.004).

CONCLUSION

the HBE programmes carried out by DHI improve physical function in terms of lower extremity strength and functional capacity. It also significantly reduces the number of falls and improves the HRQoL. In addition, in analysis of only older adults with diseases, it also improves the balance and mobility.

[PAPPS update on older people 2022]

This article examines the latest available evidence on preventive activities in the elderly, including sleep disorders, physical exercise, deprescription, cognitive disorders and dementias, nutrition, social isolation and frailty.