A simple validated questionnaire predicted functional decline in community-dwelling older persons: prospective cohort studies

Prediction models for functional status in community dwelling older adults: a systematic review

Background

Disability poses a burden for older persons, and is associated with poor outcomes and high societal costs. Prediction models could potentially identify persons who are at risk for disability. An up to date review of such models is missing.

Objective

To identify models developed for the prediction of functional status in community dwelling older persons.

Methods

A systematic review was performed including studies of older persons that developed and/or validated prediction models for the outcome functional status. Medline and EMBASE were searched, and reference lists and prospective citations were screened for additional references. Risk of bias was assessed using the PROBAST-tool. The performance of models was described and summarized, and the use of predictors was collated using the bag-of-words text mining procedure.

Results

Forty-three studies were included and reported 167 evaluations of prediction models. The median c-statistic values for the multivariable development models ranged between 0.65 and 0.76 (minimum = 0.58, maximum = 0.90), and were consistently higher than the values of the validation models for which median c-statistic values ranged between 0.6 and 0.68 (minimum = 0.50, maximum = 0.81). A total of 559 predictors were used in the models. The five predictors most frequently used were gait speed (n = 47), age (n = 38), cognition (n = 27), frailty (n = 24), and gender (n = 22).

Conclusions

No model can be recommended for implementation in practice. However, frailty models appear to be the most promising, because frailty components (e.g. gait speed) and frailty indexes demonstrated good to excellent predictive performance. However, the risk of study bias was high. Substantial improvements can be made in the methodology.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03156-7.

Impact of organizational context on patient outcomes in a proactive primary care program:a longitudinal observational study

BACKGROUND

The effectiveness of health care interventions is co-determined by contextual factors. Unknown is the extent of this impact on patient outcomes. Therefore, the aim of this study is to explore which characteristics of general practices are associated with patient outcomes in a proactive primary care program, the U-PROFIT 2.0.

METHODS

A longitudinal observational study was conducted from January 2016 till October 2017. Two questionnaires were send out, one to collect characteristics of general practices such as practice neighbourhood socio-economic status, general practice versus healthcare centre (involving multiple primary care professionals), and professional- frail older patient ratio per practice of general practitioners and practice nurses. Regarding delivering the program, the practice or district nurse who delivered the program, number of years since the start of the implementation, and choice of age threshold for frailty screening were collected. Patient outcomes collected by the second questionnaire and send to frail patients were daily functioning, hospital admissions, emergency department visits, and general practice out-of-hours consultations. Linear and generalized linear mixed models were used.

RESULTS

A total of 827 frail older people were included at baseline. Delivery of the program by a district nurse compared to a practice nurse was significantly associated with a decrease in daily functioning on patient-level (β = 2.19; P = < 0.001). Duration since implementation of 3 years compared to 9 years was significantly associated with less out-of-hours consultations to a general practice (OR 0.11; P = 0.001). Applying frailty screening from the age of 75 compared to those targeted from the age of 60 showed a significant increase in emergency visits (OR 5.26; P = 0.03).

CONCLUSION

Three associations regarding the organizational context 1) the nurse who delivered the program, 2) the number of years the program was implemented and 3) the age threshold for defining a frail patient are significant and clinically relevant for frail patients that receive a proactive primary care program. In general, contextual factors need more attention when implementing complex primary care programs which can result in better balanced choices to enhance effective proactive care for older people living in the community.

'Don't forget the mouth!': a process evaluation of a public oral health project in community-dwelling frail older people

BACKGROUND

Older people are encouraged to remain community dwelling, even when they become care-dependent. Not every dental practice is prepared or able to provide care to community-dwelling frail older people, while their ability to maintain oral health and to visit a dentist is decreasing, amongst others due to multiple chronic diseases and/or mobility problems. The public oral health project 'Don't forget the mouth! (DFTM!) aimed to improve the oral health of this population, by means of early recognition of decreased oral health as well as by establishing interprofessional care. A process evaluation was designed to scientifically evaluate the implementation of this project.

METHODS

The project was implemented in 14 towns in The Netherlands. In each town, health care professionals from a general practice, a dental practice, and a homecare organization participated. The process evaluation framework focused on fidelity, dose, adaptation, and reach. Each of the items were examined on levels of implementation: macro-level, meso-level, and micro-level. Mixed methods (i.e., quantitative and qualitative methods) were used for data collection.

RESULTS

The experiences of 50 health care professionals were evaluated with questionnaires, 22 semi-structured interviews were conducted, and the oral health of 407 community-dwelling frail older people was assessed. On each level of implementation, oral health care was integrated in the daily routine. On macro-level, education was planned (dose, adaption), and dental practices organized home visits (adaption). On meso-level, health care professionals attended meetings of the project (fidelity), worked interprofessionally, and used a screening-referral tool of the project DFTM! in daily practice (dose, adaption, reach). On micro-level, the frail older people participated in the screening of oral health (fidelity, dose), had their daily oral hygiene care observed (adaption) and supported if necessary, and some had themselves referred to a dental practice (reach). The semi-structured interviews also showed that the project increased the oral health awareness amongst health care professionals.

CONCLUSIONS

The project DFTM! was, in general, implemented and delivered as planned. Factors that contributed positively to the implementation were identified. With large-scale implementation, attention is needed regarding the poor accessibility of the oral health care professional, financial issues, and increased work pressure. Trial registration The Netherlands Trial Register NTR6159, registration done on December 13th 2016. URL: https://www.trialregister.nl/trial/6028.

Frailty screening in dermato-oncology practice: a modified Delphi study and a systematic review of the literature

Background

Appropriate management and prevention of both under‐ and overtreatment in older skin cancer patients can be challenging. It could be helpful to incorporate frailty screening in dermato‐oncology care, since frailty is associated with adverse health outcomes.

Objectives

This study aimed to identify and prioritize the requirements a frailty screening tool (FST) should fulfil in dermato‐oncology practice and to select the best existing FST(s) for this purpose.

Methods

A modified two‐round Delphi procedure was performed among 50 Italian and Dutch specialists and patients to review and prioritize a list of potential FST requirements, using a 5‐point Likert scale. Consensus was defined as a mean score of ≥4.0. A systematic literature search was performed to identify existing multidomain FSTs, which were then assessed on the requirements resulting from the modified Delphi procedure.

Results

Consensus was achieved on evaluation of comorbidities (4.3 ± 0.7), polypharmacy (4.0 ± 0.9) and cognition (4.1 ± 0.8). The FST should have appropriate measurement properties (4.0 ± 1.0), be quickly executed (4.2 ± 0.7), clinically relevant (4.3 ± 0.7), and both easily understandable (4.1 ± 1.2) and interpretable (4.3 ± 0.7). Of the 26 identified FSTs, four evaluated the content‐related domains: the Geriatric‐8 (G8), the modified Geriatric‐8 (mG8), the Groningen Frailty Indicator (GFI) and the Senior Adult Oncology Program 2 (SAOP2) screening tool. Of these, the G8 was the most extensively studied FST, with the best psychometric properties and execution within 5 min.

Conclusions

The G8 appears the most suitable FST for assessing frailty in older adults with skin cancer, although clinical studies assessing its use in a dermato‐oncology population are needed to further assess whether or not frailty in this particular patient group is associated with relevant outcomes (e.g. complications and mortality), as seen in previous studies in other medical fields.

AMPI-AB validity and reliability: a multidimensional tool in resource-limited primary care settings

Background

The early identification of individuals at high risk for adverse outcomes by a Comprehensive Geriatric Assessment (CGA) in resource-limited primary care settings enables tailored treatments, however, the evidence concerning its benefits are still controversial. The main objective of this study was to examine the validity and reliability of the “Multidimensional Assessment of Older People in Primary Care (AMPI-AB)”, a CGA for primary care in resource-limited settings.

Methods

Longitudinal study, with median follow-up time of 16 months. Older adults from a public primary care unit in São Paulo, Brazil, were consecutively admitted. Reliability was tested in a sample from a public geriatric outpatient clinic. Participants were classified by the AMPI-AB score as requiring a low, intermediate or high complexity of care. The Physical Frailty Phenotype was used to explore the AMPI-AB’s concurrent validity. Predictive validity was assessed with mortality, worsening of the functional status, hospitalizations, emergency room (ER) visits and falls. The area under the ROC curve and logistic regression were calculated for binary outcomes, and a Cox proportional hazards model was used for survival analysis.

Results

Older adults (n = 317) with a median age of 80 (74–86) years, 67% female, were consecutively admitted. At the follow-up, 7.1% of participants had died, and increased dependency on basic and instrumental activities of daily living was detected in 8.9 and 41.1% of the participants, respectively. The AMPI-AB score was accurate in detecting frailty (area under the ROC curve = 0.851), predicted mortality (HR = 1.25, 95%CI = 1.13–1.39) and increased dependency on basic (OR = 1.26, 95%CI = 1.10–1.46) and instrumental (OR = 1.22, 95%CI = 1.12–1.34) activities of daily living, hospitalizations (OR = 2.05, 95%CI = 1.04–1.26), ER visits (OR = 1.20, 95%CI = 1.10–1.31) and falls (OR = 1.10, 95%CI = 1.01–1.20), all models adjusted for sex and years of schooling. Reliability was tested in a sample of 52 older adults with a median age of 72 (85–64) years, 63.5% female. The AMPI-AB also had good interrater (ICC = 0.87, 95%CI = 0.78–0.92), test-retest (ICC = 0.86, 95%CI = 0.76–0.93) and proxy reliability (ICC = 0.84, 95%CI = 0.67–0.93). The Cronbach’s alpha was 0.69, and the mean AMPI-AB administration time was 05:44 ± 02:42 min.

Conclusion

The AMPI-AB is a valid and reliable tool for managing older adults in resource-limited primary care settings.

Fit4SurgeryTV At-home Prehabilitation for Frail Older Patients Planned for Colorectal Cancer Surgery: A Pilot Study

OBJECTIVE

The preoperative phase is a potential window of opportunity. Although frail elderly patients are known to be more prone to postoperative complications, they are often not considered capable of accomplishing a full prehabilitation program. The aim of this study was to assess the feasibility of Fit4SurgeryTV, an at-home prehabilitation program specifically designed for frail older patients with colorectal cancer.

DESIGN

The Fit4SurgeryTV program consisted of a daily elderly adapted computer-supported strength training workout and two protein-rich meals. Frail patients 70 yrs or older with colorectal cancer were included. The program was considered feasible if 80% of the patients would be able to complete 70% of the program.

RESULTS

Fourteen patients (median age, 79 yrs; 5 males) participated. At baseline, 86% patients were physically impaired and 64% were at risk for malnourishment. The median duration of the program was 26 days. The program was feasible as patients followed the exercises for 6 (86%) of 7 days and prepared the recipes 5 (71%) of 7 d/wk. Patients specifically appreciated at-home exercises.

CONCLUSIONS

This study showed that at-home prehabilitation in frail older patients with colorectal cancer is feasible. As a result, patients might be fitter for surgery and might recover faster. The perioperative period could serve as a pivotal time point in reverting complications of immobility.

The Multidimensional Prognostic Index in general practice: One-year follow-up study

BACKGROUND

Older patients' health problems in general practice (GP) can often not be assigned to a specific disease, requiring a paradigm shift to goal-oriented, personalised care for clinical decision making.

PURPOSE

To investigate the predictive value of the comprehensive geriatric assessment (CGA)-based Multidimensional Prognostic Index (MPI) in a GP setting with respect to the main healthcare indicators during the 12 months following initial evaluation.

METHODS

One hundred twenty-five consecutive patients aged 70 years and older were enrolled in a GP and followed up to one year. All patients underwent a CGA based on which the MPI was calculated and subdivided into three risk groups (MPI-1, 0-0.33 = low risk, MPI-2, 0.34-0.66 = moderate risk and MPI-3, 0.67-1, severe risk). Grade of Care (GC), hospitalization rate, mortality, nursing home admission, use of home care services, falls, number of general practitioner contacts (GPC), of geriatric resources (GR) and geriatric syndromes (GS) during the 12 months following initial evaluation were collected.

RESULTS

The MPI was significantly associated with number of GS (P < .001), GR (P < .001), GC (P < .001) as well as with the average number of GPC per year (mean 10.4, P = .046). Interestingly, the clinical judgement of the general practitioner, in this case knowing his patients for 16 years on average, was associated with adverse outcomes to a similar extent than the prediction offered by the MPI (GP/adverse outcomes and MPI/adverse outcomes P < .001).

CONCLUSION

The MPI is strongly associated with adverse outcomes in older GP patients and strongly predicts the number of GPC up to one year after initial evaluation. Considering the feasibility and the strong clinimetric properties of the MPI, its collection should be encouraged as early as possible to disclose risk conditions, implement tailored preventive strategies and improve cost-effectiveness of healthcare resources use.

Effectiveness of the implementation project 'Don't forget the mouth!' of community dwelling older people with dementia: a prospective longitudinal single-blind multicentre study protocol (DFTM!)

BACKGROUND

The oral health of community dwelling frail older people is poor, and depends on the oral health care provisions available within their own community. The implementation project 'Don't forget the mouth!' (i.e., the intervention) was created with the aim of maintaining and improving the oral health and the general health of community dwelling frail older people, with education and interdisciplinary collaborations of health care professionals and informal caregivers. Critical scientific assessment of the intervention will be described in this study protocol, focused on community dwelling older people with dementia.

METHODS

This protocol describes a prospective longitudinal single-blind multicentre study, which will take place in 14 towns, each with an intervention and a control group receiving oral health care as usual. Assessment will take place four times during 12 months (i.e., at baseline, after 3, 6, and 12 months). Participants are 65 years and older, community dwelling, and suspected of dementia by their home care worker. The home care organizations will inform, and approach their clients about the study, before the researcher will reach out. The effectiveness of the intervention will be determined with the primary outcome variable 'oral hygiene', assessed through the presence of dental plaque (DP) or dental prosthetic plaque (DPP). The secondary outcome variables are: 'oral health', 'oral health related quality of life', 'oral health care behaviour', 'general health and care dependency', and 'compliance of the health care professionals'.

DISCUSSION

This protocol aims to assess the effectiveness of the implementation project 'Don't forget the mouth!' focused on community dwelling older people with dementia. The strengths of the current study are the national roll-out of the intervention, interdisciplinary collaborations and education, and the scientific evaluation over the course of 12 months. The threats and weaknesses are in the recruitment procedure, and the adherence and compliance of the health care professionals to the project.

TRIAL REGISTRATION

The Netherlands Trail Register NTR6159 .

[Functional decline risk in elderly patients not institutionalized]

OBJECTIVE

To assess the risk of functional decline (DF) by using several prediction scales.

MATERIAL AND METHODS

A multicentre, observational, cross-sectional study was conducted on a population of 70 years or more in the health area of ??Toledo. Institutionalised, terminal ill, and patients dependent for three or more basic activities of daily life, were excluded. The sample (480 patients) was calculated for an estimated DF prevalence of 15%, accuracy 2%, confidence level 95%, and 10% of estimated losses. Stratified sampling; first by conglomerates (Health Centres) and then systematic sampling (1/15) by list of patients ordered by age. Response rate: 98%.

VARIABLES

Sociodemographic, morbidity, questionnaires to assess the functional capacity for basic activities (Katz index), and tools (Lawton-Brody index) of daily life and risk prediction rules of DF (SHERPA, TRST, ISAR-PC and Inouye). Approved by the Clinical Research Ethics Committee of Toledo.

RESULTS

The mean age was 77.94 (SD: 6.27), with 54.4% women. Mean number of illnesses: 4.38 (SD: 2.17) and drugs: 5.57 (SD: 3.35). Risk of DF according to the prediction rules: SHERPA: 32.7% (95% CI: 28.52-36.88) (slight risk: 17.2% [95% CI: 13.83-20.57]; moderate: 9.7% [95% CI: 7.06-12.34] and high: 5.8% [95% CI: 3.72-7.88]); TRST: 42% (95% CI: 37.6-46.4); ISAR-PC: 75.4% (95% CI: 71.14-78.86); Inouye: 49.3% (95% CI: 44.84-53.76) (mean risk: 44.5% [95% CI: 40.07-48.93], and high: risk 4.8% [95% CI: 2.89-6.71]).

CONCLUSIONS

A significant percentage of patients are at risk of DF, but there is a wide variation between the different rules. In general, the risk is lower than that found in other studies, and it is necessary to validate new rules adapted to our environment.

Efficacy and cost-effectiveness of a community-based model of care for older patients with complex needs: a study protocol for a multicentre randomised controlled trial using a stepped wedge cluster design

BACKGROUND

Community-dwelling older persons with complex care needs may deteriorate rapidly and require hospitalisation if they receive inadequate support for their conditions in the community.

INTERVENTION

A comprehensive, multidimensional geriatric assessment with care coordination was performed in a community setting-Older Persons ENablement And Rehabilitation for Complex Health conditions (OPEN ARCH).

OBJECTIVES

This study will assess the acceptability and determine the impact of the OPEN ARCH intervention on the health and quality of life outcomes, health and social services utilisation of older people with multiple chronic conditions and emerging complex care needs. An economic evaluation will determine whether OPEN ARCH is cost-effective when compared to the standard care.

METHODS/DESIGN

This multicentre randomised controlled trial uses a stepped wedge cluster design with repeated cross-sectional samples. General practitioners (GPs; n ≥ 10) will be randomised as 'clusters' at baseline using simple randomisation. Each GP cluster will recruit 10-12 participants. Data will be collected on each participant at 3-month intervals (- 3, 0, 3, 6 and 9 months). The primary outcome is health and social service utilisation as measured by Emergency Department presentations, hospital admissions, in-patient bed days, allied health and community support services. Secondary outcomes include functional status, quality of life and participants' satisfaction. Cost-effectiveness of the intervention will be assessed as the change to cost outcomes, including the cost of implementing the intervention and subsequent use of services, and the change to health benefits represented by quality adjusted life years.

DISCUSSION

The results will have direct implications for the design and wider implementation of this new model of care for community-dwelling older persons with complex care needs. Additionally, it will contribute to the evidence base on acceptability, efficacy and cost-effectiveness of the intervention for this high-risk group of older people.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry, ACTRN12617000198325p . Registered on 6 February 2017.

Prediction of functional decline in community-dwelling older persons in general practice: a cohort study

BACKGROUND

A first step to offer community-dwelling older persons proactive care is to identify those at risk of functional decline within a year. This study investigates the predictive value of registered information, questionnaire and GP-opinion on functional decline.

METHODS

In this cohort study, embedded within the ISCOPE-trial, participants (≥75 years) completed the ISCOPE-screening questionnaire on four health domains. GPs gave their opinion on vulnerability of participants. Functional status was measured at baseline and 12 months (Groningen Activities Restriction Scale [GARS]). The outcome was functional decline (death, nursing home admission, 10% with greatest functional decline). The predictive value of pre-selected variables (age, sex, polypharmacy, multimorbidity, living situation; GPs' opinion on vulnerability, number of domains with problems [ISCOPE-score]) was compared with the area under the curves (AUC) for logistic regression models.

RESULTS

2018 of the 2211 participants (median age 82.1 years [IQR 78.8-86.5], 68.0% female, median GARS 31 [IQR 24-41]) were visited at 12 months (median GARS 34 [IQR 26-44]). 394 participants (17.8%) had functional decline (148 died, 45 nursing home admissions, 201 with greatest functional decline). The AUC for age and sex was 0.602, increasing to 0.620 (p = 0.029) with polypharmacy, multimorbidity and living situation. The GPs' opinion added more (AUC 0.672, p < 0.001) than the ISCOPE-score (AUC 0.649, p = 0.007). AUC with all variables was 0.686 (p = 0.016), and 0.643 for GPs' opinion alone.

CONCLUSIONS

The GPs' opinion and ISCOPE-score improve this prediction model for functional decline based on readily available variables. GPs could identify older patients for further assessment with their clinical judgement.

TRIAL REGISTRATION

Netherlands trial register, NTR1946 . Registered 10 August 2009.

Timed up and go test combined with self-rated multifactorial questionnaire on falls risk and sociodemographic factors predicts falls among community-dwelling older adults better than the timed up and go test on its own

BACKGROUND

Early detection of falls risk among older adults using simple tools may assist in fall prevention strategies. The aim of this study was to identify the best parameters associated with previous falls, either the timed up and go (TUG) test combined with sociodemographic factors and a self-rated multifactorial questionnaire (SRMQ) on falls risk or the TUG on its own. Falls risk was determined based on parameters associated with previous falls.

DESIGN

This was a retrospective cohort study.

SETTING

The study was conducted in a community setting.

PARTICIPANTS

The participants were 1,086 community-dwelling older adults, with mean age of 69.6±5.6 years. Participants were categorized into fallers and nonfallers based on their history of falls in the past 12 months.

METHOD

Participants' sociodemographic data was taken, and SRMQ consisting of five falls-related questions was administered. Participants performed the TUG test twice, and the mean was taken as the result.

RESULTS

A total of 161 participants were categorized as fallers (14.8%). Multivariate logistic regression analysis showed that the model (χ2(6)=61.0, p<0.001, Nagelkerke R2=0.10) consisting of the TUG test, sociodemographic factors (gender, cataract/glaucoma and joint pain), as well as the SRMQ items "previous falls history" (Q1) and "worried of falls" (Q5), was more robust in terms of falls risk association compared to that with TUG on its own (χ2(1)=10.3, p<0.001, Nagelkerke R2=0.02).

CONCLUSION

Combination of sociodemographic factors and SRMQ with TUG is more favorable as an initial falls risk screening tool among community-dwelling older adults. Subsequently, further comprehensive falls risk assessment may be performed in clinical settings to identify the specific impairments for effective management.

Short Physical Performance Battery, usual gait speed, grip strength and Vulnerable Elders Survey each predict functional decline among older women with breast cancer

OBJECTIVE

To determine the ability of three performance-based measures [Short Physical Performance Battery (SPPB), gait speed, and Grip Strength] and a self-report measure [Vulnerable Elders Survey (VES-13)] to predict functional decline among older women with breast cancer.

PATIENTS AND METHODS

Longitudinal data from a study of women ≥65years, with newly diagnosed stages I-III breast cancer, recruited from ambulatory oncology clinics between July 2010 and April 2014, was used. The primary outcome was functional decline, Yes or No, defined as a decrease in ≥1-point from baseline to 12months, on Activities of Daily Living Scales. Multivariable logistic regression and receiver operator curve analyses were conducted.

RESULTS

Among 123 participants 18 (15%) developed functional decline. The predictive abilities for measures were: SPPB [Adjusted odds ratio (AOR)=1.65 per unit decrease in scores, 95% confidence interval (CI)=1.33-2.05; area under the receiver operator curve (AUC)=0.93; sensitivity=94%, specificity=80%]; gait speed (AOR=1.76 per unit increase in usual walking time, CI=1.29-2.41; AUC=0.93; sensitivity=87%, specificity=79%); VES-13 (AOR=1.64 per unit increase in scores, CI=1.31-2.05; AUC=0.87; sensitivity=83%, specificity=84%); and grip strength: (AOR=1.18 per unit decrease in grip strength, CI=1.06-1.30; AUC=0.80; sensitivity=67%, specificity=77%).

CONCLUSION

SPPB, gait speed, grip strength and VES-13 all demonstrated excellent predictive abilities for functional decline. Larger studies are warranted to confirm the utility of these measures for identifying older adults with cancer at increased risk for functional decline, who may then be targeted for studies to explore the effects of interventions to improve function.

Cost-effectiveness of nurse-led multifactorial care to prevent or postpone new disabilities in community-living older people: Results of a cluster randomized trial

Objective

To evaluate the cost-effectiveness of nurse-led multifactorial care to prevent or postpone new disabilities in community-living older people in comparison with usual care.

Methods

We conducted cost-effectiveness and cost-utility analyses alongside a cluster randomized trial with one-year follow-up. Participants were aged ≥ 70 years and at increased risk of functional decline. Participants in the intervention group (n = 1209) received a comprehensive geriatric assessment and individually tailored multifactorial interventions coordinated by a community-care registered nurse with multiple follow-up visits. The control group (n = 1074) received usual care. Costs were assessed from a healthcare perspective. Outcome measures included disability (modified Katz-Activities of Daily Living (ADL) index score), and quality-adjusted life-years (QALYs). Statistical uncertainty surrounding Incremental Cost-Effectiveness Ratios (ICERs) was estimated using bootstrapped bivariate regression models while adjusting for confounders.

Results

There were no statistically significant differences in Katz-ADL index score and QALYs between the two groups. Total mean costs were significantly higher in the intervention group (EUR 6518 (SE 472) compared with usual care (EUR 5214 (SE 338); adjusted mean difference €1457 (95% CI: 572; 2537). Cost-effectiveness acceptability curves showed that the maximum probability of the intervention being cost-effective was 0.14 at a willingness to pay (WTP) of EUR 50,000 per one point improvement on the Katz-ADL index score and 0.04 at a WTP of EUR 50,000 per QALY gained.

Conclusion

The current intervention was not cost-effective compared to usual care to prevent or postpone new disabilities over a one-year period. Based on these findings, implementation of the evaluated multifactorial nurse-led care model is not to be recommended.

AGING AND INDIVIDUAL VULNERABILITY: A PANORAMA OF OLDER ADULTS ATTENDED BY THE FAMILY HEALTH STRATEGY

ABSTRACT Objective: identifying conditions of individual vulnerability in older adults and investigating the relationship with health indicators through a household survey. Method: a descriptive cross-sectional study conducted with 368 older adults attended by the Family Health Strategy. Data collection was performed through a structured interview, supported by instruments that include sociodemographic characterization, health indicators and the Vulnerable Elders Survey. A descriptive data analysis and Person's chi-square test were also performed. Results: a prevalence of 52.2% individual vulnerability was found among older adults, in addition to an association with health problems, negative self-perception of health, difficulty with mobility and in performing activities of daily living. Conclusion: identifying vulnerability among the aged population is a relevant initiative for the adequacy of health policies and programs that prioritize the promotion of aging with the maintenance of functional capacity.

Comprehensive geriatric assessment: recognition of identified geriatric conditions by community-dwelling older persons

OBJECTIVES

to study (i) the prevalence of geriatric conditions in community-dwelling older persons at increased risk of functional decline and (ii) the extent to which older persons recognise comprehensive geriatric assessment (CGA)-identified conditions as relevant problems.

METHODS

trained registered nurses conducted a CGA in 934 out of 1209 older persons at increased risk of functional decline participating in the intervention arm of a randomised trial in the Netherlands. After screening for 32 geriatric conditions, participants were asked which of the identified geriatric conditions they recognised as relevant problems.

RESULTS

at baseline, the median age of participants was 82.9 years (interquartile range (IQR) 77.3-87.3 years). The median number of identified geriatric conditions per participant was 8 (IQR 6-11). The median number of geriatric conditions that were recognised was 1 (IQR 0-2). Functional dependency and (increased risk of) alcohol and drug dependency were the most commonly identified conditions. Pain was the most widely recognised problem.

CONCLUSION

CGA identified many geriatric conditions, of which few were recognised as a problem by the person involved. Further study is needed to better understand how older persons interact with identified geriatric conditions, in terms of perceived relevance. This may yield a more efficient CGA and further improve a patient-centred approach.

Supportive Care: Time to Change Our Prognostic Tools and Their Use in CKD

In using a patient-centered approach, neither a clinician nor a prognostic score can predict with absolute certainty how well a patient will do or how long he will live; however, validated prognostic scores may improve accuracy of prognostic estimates, thereby enhancing the ability of the clinicians to appreciate the individual burden of disease and the prognosis of their patients and inform them accordingly. They may also facilitate nephrologist's recommendation of dialysis services to those who may benefit and proposal of alternative care pathways that might better respect patients' values and goals to those who are unlikely to benefit. The purpose of this article is to discuss the use as well as the limits and deficiencies of currently available prognostic tools. It will describe new predictors that could be integrated in future scores and the role of patients' priorities in development of new scores. Delivering patient-centered care requires an understanding of patients' priorities that are important and relevant to them. Because of limits of available scores, the contribution of new prognostic tools with specific markers of the trajectories for patients with CKD and patients' health reports should be evaluated in relation to their transportability to different clinical and cultural contexts and their potential for integration into the decision-making processes. The benefit of their use then needs to be quantified in clinical practice by outcome studies including health-related quality of life, patient and caregiver satisfaction, or utility for improving clinical management pathways and tailoring individualized patient-centered strategies of care. Future research also needs to incorporate qualitative methods involving patients and their caregivers to better understand the barriers and facilitators to use of these tools in the clinical setting. Information given to patients should be supported by a more realistic approach to what dialysis is likely to entail for the individual patient in terms of likely quality and quantity of life according to the patient's values and goals and not just the possibility of life prolongation.

Comparison of 10 single and stepped methods to identify frail older persons in primary care: diagnostic and prognostic accuracy

Background

Many instruments have been developed to identify frail older adults in primary care. A direct comparison of the accuracy and prevalence of identification methods is rare and most studies ignore the stepped selection typically employed in routine care practice. Also it is unclear whether the various methods select persons with different characteristics. We aimed to estimate the accuracy of 10 single and stepped methods to identify frailty in older adults and to predict adverse health outcomes. In addition, the methods were compared on their prevalence of the identified frail persons and on the characteristics of persons identified.

Methods

The Groningen Frailty Indicator (GFI), the PRISMA-7, polypharmacy, the clinical judgment of the general practitioner (GP), the self-rated health of the older adult, the Edmonton Frail Scale (EFS), the Identification Seniors At Risk Primary Care (ISAR PC), the Frailty Index (FI), the InterRAI screener and gait speed were compared to three measures: two reference standards (the clinical judgment of a multidisciplinary expert panel and Fried’s frailty criteria) and 6-years mortality or long term care admission. Data were used from the Dutch Identification of Frail Elderly Study, consisting of 102 people aged 65 and over from a primary care practice in Amsterdam. Frail older adults were oversampled. The accuracy of each instrument and several stepped strategies was estimated by calculating the area under the ROC-curve.

Results

Prevalence rates of frailty ranged from 14.8 to 52.9 %. The accuracy for recommended cut off values ranged from poor (AUC = 0.556 ISAR-PC) to good (AUC = 0.865 gait speed). PRISMA-7 performed best over two reference standards, GP predicted adversities best. Stepped strategies resulted in lower prevalence rates and accuracy. Persons selected by the different instruments varied greatly in age, IADL dependency, receiving homecare and mood.

Conclusion

We found huge differences between methods to identify frail persons in prevalence, accuracy and in characteristics of persons they select. A necessary next step is to find out which frail persons can benefit from intervention before case finding programs are implemented. Further evidence is needed to guide this emerging clinical field.

Electronic supplementary material

The online version of this article (doi:10.1186/s12875-016-0487-y) contains supplementary material, which is available to authorized users.

Effects of Nurse-Led Multifactorial Care to Prevent Disability in Community-Living Older People: Cluster Randomized Trial

BACKGROUND

To evaluate the effects of nurse-led multifactorial care to prevent disability in community-living older people.

METHODS

In a cluster randomized trail, 11 practices (n = 1,209 participants) were randomized to the intervention group, and 13 practices (n = 1,074 participants) were randomized to the control group. Participants aged ≥ 70 years were at increased risk of functional decline based on a score ≥ 2 points on the Identification of Seniors at Risk- Primary Care, ISAR-PC. Participants in the intervention group received a systematic comprehensive geriatric assessment, and individually tailored multifactorial interventions coordinated by a trained community-care registered nurse (CCRN) with multiple follow-up home visits. The primary outcome was the participant's disability as measured by the modified Katz activities of daily living (ADL) index score (range 0-15) at one year follow-up. Secondary outcomes were health-related quality of life, hospitalization, and mortality.

RESULTS

At baseline, the median age was 82.7 years (IQR 77.0-87.1), the median modified Katz-ADL index score was 2 (IQR 1-5) points in the intervention group and 3 (IQR 1-5) points in the control group. The follow-up rate was 76.8% (n = 1753) after one year and was similar in both trial groups. The adjusted intervention effect on disability was -0.07 (95% confidence interval -0.22 to 0.07; p = 0.33). No intervention effects were found for the secondary outcomes.

CONCLUSIONS

We found no evidence that a one-year individualized multifactorial intervention program with nurse-led care coordination was better than the current primary care in community-living older people at increased risk of functional decline in The Netherlands.

TRIAL REGISTRATION

Netherlands Trial Register NTR2653.

Vulnerable elders survey and socioeconomic status predict functional decline and death among older women with newly diagnosed nonmetastatic breast cancer

BACKGROUND

The purpose of this study was to determine the ability of the Vulnerable Elders Survey (VES-13) to predict the composite outcome of functional decline and death within 12 months of breast cancer treatment among women 65 years old or older with newly diagnosed stage I to III breast cancer.

METHODS

Two hundred and six participants were recruited from ambulatory oncology clinics at an academic center between April 2008 and April 2013. Participants competed the VES-13 at baseline just before neoadjuvant/adjuvant treatment. The primary outcome, functional decline/death, was defined as either a decrease of at least 1 point on the Activities of Daily Living scale and/or the Instrumental Activities of Daily Living scale or death between baseline and 12 months (yes or no).

RESULTS

One hundred and eighty four participants (89%) completed 12 months of follow-up. Twenty-two percent functionally declined (n = 34) or died (n = 7). Univariately, with increasing VES-13 scores, the estimated risk of functional decline/death rose from 23% for participants with a VES-13 score of 3 to 76% for participants with a VES-13 score of 10. In multivariate logistic regression analysis, VES-13 scores (adjusted odds ratio, 1.37; 95% confidence interval, 1.18-1.57) and having a high school education or less (adjusted odds ratio, 2.47; 95% confidence interval, 1.08-5.65) were independent predictors of functional decline/death (area under the receiver operator curve, 0.79).

CONCLUSIONS

Among older women with newly diagnosed nonmetastatic breast cancer, approximately 1 in 5 functionally declined and/or died within 12 months of breast cancer treatment initiation. Women with high school education or less were disproportionately affected. The VES-13 is a useful instrument for the early identification of those at risk for functional decline and/or death. Cancer 2016;122:2579-86. © 2016 American Cancer Society.

Current Development in Elderly Comprehensive Assessment and Research Methods

Comprehensive geriatric assessment (CGA) is a core and an essential part of the comprehensive care of the aging population. CGA uses specific tools to summarize elderly status in several domains that may influence the general health and outcomes of diseases of elderly patients, including assessment of medical, physical, psychological, mental, nutritional, cognitive, social, economic, and environmental status. Here, in this paper, we review different assessment tools used in elderly patients with chronic diseases. The development of comprehensive assessment tools and single assessment tools specially used in a dimension of CGA was discussed. CGA provides substantial insight into the comprehensive management of elderly patients. Developing concise and effective assessment instruments is helpful to carry out CGA widely to create a higher clinical value.

Factors associated with recognition and prioritization for falling, and the effect on fall incidence in community dwelling older adults

BACKGROUND

Recent trials have shown that multifactorial fall interventions vary in effectiveness, possibly due to lack of adherence to the interventions. The aim of this study was to examine what proportion of older adults recognize their falls risk and prioritize for fall-preventive care, and which factors are associated with this prioritization.

METHODS

Observational study within the intervention arm of a cluster randomized controlled trial (RCT) on the effect of preventive interventions for geriatric problems in older community-dwellers at risk of functional decline.

SETTING

 general practices in the Netherlands. Participants were community dwellers (70+) in whom falling was identified as a condition. A comprehensive geriatric assessment (CGA) was performed by a registered community care nurse. Participants were asked which of the identified conditions they recognized and prioritized for in a preventive care plan, and subsequent interventions were started. Multivariable logistic regression was performed to identify which factors were associated with this prioritization. Fall-incidence was measured during one-year follow-up.

RESULTS

The RCT included 6668 participants, 3430 were in the intervention arm. Of those, 1209 were at risk of functional decline, of whom 936 underwent CGA. In 380 participants (41 %), falling was identified as a condition; 62 (16 %) recognized this and 37 (10 %) prioritized for it. Factors associated with prioritization for falls-prevention were: recurrent falls in the past year (OR 2.2 [95 % CI 1.1-4.4]), severe fear-of-falling (OR 2.7 [1.2-6.0]) and use of a walking aid (2.3 [1.1-5.0]). Sixty participants received a preventive intervention for falling; 29 had prioritized for falling. Incidence of falls was higher in the priority group than the non-priority group (67 % vs. 37 % respectively) during first six months of follow-up, but similar between groups after 12 months (40.7 % vs. 44.4 %).

CONCLUSIONS

The proportion of community-dwellers at risk of falls that recognizes this risk and prioritizes for preventive care is small. Recurrent falls in the past year, severe fear-of-falling and use of a walking aid were associated with prioritization. Prioritization was associated with a greater fall-risk during first six months, which appeared to level out at one-year follow-up. These results could aid in the identification of community-dwellings likely to benefit from fall-preventive interventions.

TRIAL REGISTRATION

NTR2653 , 17 December 2010.

Predictive validity of a two-step tool to map frailty in primary care

BACKGROUND

EASY-Care Two step Older people Screening (EASY-Care TOS) is a stepped approach to identify frail older people at risk for negative health outcomes in primary care, and makes use of General Practitioners' (GPs) readily-available information. We aimed to determine the predictive value of EASY-Care TOS for negative health outcomes within the year from assessment.

METHODS

A total of 587 patients of four GP practices in and around Nijmegen (The Netherlands) consented to participate in a longitudinal primary care registry based cohort study. Participants' frailty was judged by their GP following the EASY-Care TOS procedure and by a Comprehensive Geriatric Assessment (CGA) at baseline. After one year health outcomes of the participants were measured by reassessment with the EASY-Care TOS procedure.

RESULTS

Follow up information was available for 520 of 587 participants. In the non-frail group 9% showed any negative health outcomes (death, ADL decline, institutionalisation, too ill to undergo assessment), against 30% in the frail group (95% confidence interval of the difference (CI): 14%-28%). Area under the receiver operating curve (AUC) of the EASY-Care TOS frailty judgement for a composite of negative health outcomes mentioned was 0.67 (95% CI: 0.62-0.73). Compared with discrimination on the basis of age, sex and GP practice (AUC 0.70), adding EASY-Care TOS frailty judgement increased the AUC to 0.75 (+0.05, p = 0.02). The AUC on the basis of a full CGA is almost comparable to the AUC of the model with age, sex, and frailty judgement with EASY-Care TOS: 0.76 (+0.07, p = 0.005).

CONCLUSIONS

GPs applying the EASY-Care TOS procedure, where they only perform additional assessment when they judge this as necessary, can predict negative health outcomes in their older populations efficiently and almost as accurately as a complete specialist CGA.

Fried phenotype of frailty: cross-sectional comparison of three frailty stages on various health domains

Background

The population ageing in most Western countries leads to a larger number of frail older people. These frail people are at an increased risk of negative health outcomes, such as functional decline, falls, institutionalisation and mortality. Many approaches are available for identifying frailty among older people. Researchers most often use Fried and colleagues’ description of the frailty phenotype. The authors describe five physical criteria. Other researchers prefer a combination of measurements in the social, psychological and/or physical domains. The aim of this study is to describe the levels of social, psychological and physical functioning according to Fried’s frailty stages using a large cohort of Dutch community-dwelling older people.

Methods

There were 8,684 community-dwelling older people (65+) who participated in this cross-sectional study. Based on the five Fried frailty criteria (weight loss, exhaustion, low physical activity, slowness, weakness), the participants were divided into three stages: non-frail (score 0), pre-frail (score 1–2) and frail (score 3–5). These stages were related to scores in the social (social network type, informal care use, loneliness), psychological (psychological distress, mastery, self-management) and physical (chronic diseases, GARS IADL-disability, OECD disability) domains.

Results

63.2 % of the participants was non-frail, 28.1 % pre-frail and 8.7 % frail. When comparing the three stages of frailty, frail people appeared to be older, were more likely to be female, were more often unmarried or living alone, and had a lower level of education compared to their pre-frail and non-frail counterparts. The difference between the scores in the social, psychological and physical domains were statistically significant between the three frailty stages. The most preferable scores came from the non-frail group, and least preferable scores were from the frail group. For example use of informal care: non-frail 3.9 %, pre-frail 23.8 %, frail 60.6 %, and GARS IADL-disability mean scores: non-frail 9.2, pre-frail 13.0, frail 19.7.

Conclusion

When older people were categorised according to the three frailty stages, as described by Fried and colleagues, there were statistically significant differences in the level of social, psychological and physical functioning between the non-frail, pre-frail and frail persons. Non-frail participants had consistently more preferable scores compared to the frail participants. This indicated that the Fried frailty criteria could help healthcare professionals identify and treat frail older people in an efficient way, and provide indications for problems in other domains.

[Identification of seniors at risk--primary care: a validated questionnaire predicting functional decline]

OBJECTIVES

To modify and validate in primary healthcare the Identification of Seniors At Risk (ISAR) screening questionnaire to identify older persons at increased risk of functional decline and to compare this strategy with risk stratification by age alone.

STUDY DESIGN AND SETTING

Prospective development (n=790) and validation cohorts (n=2,573) of community-dwelling persons aged ≥70 years. Functional decline at 12 months was defined as an increase of at least one point on the modified Katz-activities of daily living index score compared with baseline or death.

RESULTS

Three items were independently associated with functional decline: age (odds ratio [OR] 1.06 per year; 95% confidence interval [CI] 1.02, 1.10) dependence in instrumental activities of daily living (OR: 2.17; 95% CI: 1.46, 3.22), and impaired memory (OR: 2.22; 95% CI: 1.41, 3.51). The area under the receiver operating characteristics curve (AUC) range of the ISAR-primary care model was 0.67-0.70 and 40.6% was identified at increased risk. Validation yielded an AUC range of 0.63-0.64. Age≥75 years alone yielded an AUC range of 0.56-0.57 and identified 65.0% at increased risk in the validation cohort.

CONCLUSION

Although the ISAR-Primary Care (ISAR-PC) has moderate predictive value, application of the ISAR-PC is more efficient than selection based on age alone in identifying persons at increased risk of functional decline. This paper is a translated and adjusted version based on a publication in Journal of Clinical Epidemiology, 67 (2014) 1121-1130.

Risk prediction in the community: A systematic review of case-finding instruments that predict adverse healthcare outcomes in community-dwelling older adults

Few case-finding instruments are available to community healthcare professionals. This review aims to identify short, valid instruments that detect older community-dwellers risk of four adverse outcomes: hospitalisation, functional-decline, institutionalisation and death. Data sources included PubMed and the Cochrane library. Data on outcome measures, patient and instrument characteristics, and trial quality (using the Quality In Prognosis Studies [QUIPS] tool), were double-extracted for derivation-validation studies in community-dwelling older adults (>50 years). Forty-six publications, representing 23 unique instruments, were included. Only five were externally validated. Mean patient age range was 64.2-84.6 years. Most instruments n=18, (78%) were derived in North America from secondary analysis of survey data. The majority n=12, (52%), measured more than one outcome with hospitalisation and the Probability of Repeated Admission score the most studied outcome and instrument respectively. All instruments incorporated multiple predictors. Activities of daily living n=16, (70%), was included most often. Accuracy varied according to instruments and outcomes; area under the curve of 0.60-0.73 for hospitalisation, 0.63-0.78 for functional decline, 0.70-0.74 for institutionalisation and 0.56-0.82 for death. The QUIPS tool showed that 5/23 instruments had low potential for bias across all domains. This review highlights the present need to develop short, reliable, valid instruments to case-find older adults at risk in the community.