Rasch analysis reveals comparative analyses of activities of daily living/instrumental activities of daily living summary scores from different residential settings is inappropriate

Development and validation of the patient-reported outcome for older people living with HIV/AIDS in China (PROHIV-OLD)

BACKGROUND

The involvement of quality of life as the UNAIDS fourth 90 target to monitor the global HIV response highlighted the development of patient-reported outcome (PRO) measures to help address the holistic needs of people living with HIV/AIDS (PLWHA) beyond viral suppression. This study developed and tested preliminary measurement properties of a new patient-reported outcome (PROHIV-OLD) measure designed specifically to capture influences of HIV on patients aged 50 and older in China.

METHODS

Ninety-three older people living with HIV/AIDS (PLWHA) were interviewed to solicit items and two rounds of patient cognitive interviews were conducted to modify the content and wording of the initial items. A validation study was then conducted to refine the initial instrument and evaluate measurement properties. Patients were recruited between February 2021 and November 2021, and followed six months later after the first investigation. Classical test theory (CTT) and item response theory (IRT) were used to select items using the baseline data. The follow-up data were used to evaluate the measurement properties of the final instrument.

RESULTS

A total of 600 patients were recruited at the baseline. Of the 485 patients who completed the follow-up investigation, 483 were included in the validation sample. The final scale of PROHIV-OLD contained 25 items describing five dimensions (physical symptoms, mental status, illness perception, family relationship, and treatment). All the PROHIV-OLD dimensions had satisfactory reliability with Cronbach's alpha coefficient, McDonald's ω, and composite reliability of each dimension being all higher than 0.85. Most dimensions met the test-retest reliability standard except for the physical symptoms dimension (ICC = 0.64). Confirmatory factor analysis supported the structural validity of the final scale, and the model fit index satisfied the criterion. The correlations between dimensions of PROHIV-OLD and MOS-HIV met hypotheses in general. Significant differences on scores of the PROHIV-OLD were found between demographic and clinical subgroups, supporting known-groups validity.

CONCLUSIONS

The PROHIV-OLD was found to have good feasibility, reliability and validity for evaluating health outcome of Chinese older PLWHA. Other measurement properties such as responsiveness and interpretability will be further examined.

Multimorbidity patterns in older persons and their association with self-reported quality of life and limitations in activities of daily living

BACKGROUND

As populations age, multimorbidity (the presence of two or more chronic morbidities) is increasingly more common. These evolving demographics demand further research into the identification of morbidity patterns in different settings as well as the longitudinal effects of these patterns.

METHODS

Prospectively collected data on 12,755 older persons aged 65+ years were derived from The Older Persons and Informal Caregivers Survey Minimum DataSet (TOPICS-MDS, www.topics-mds.eu). Latent class analyses were performed to identify unobserved relationship patterns between morbidities in older persons. Using linear mixed models, the average difference in health-related quality of life (EQ-5D) and general quality of life scores (Cantril's Self Anchoring Ladder) as well as limitations in Activities of Daily Living and Instrumental Activities of Daily Living (ADL/IADL) were examined over a 12-month period.

RESULTS

Five multimorbidity patterns were identified: sensory (n = 3882), cardio-metabolic (n = 2627), mental health (n = 920), osteo-articular (n = 4486), and system decline (n = 840). Relative to older persons in the sensory group, multimorbidity patterns did not have a strong effect on health-related quality of life, general quality of life or ADL/IADLs over a one-year period.

CONCLUSIONS

The observed multimorbidity patterns are similar to others based on different methodologies and study populations. When examining the effect of such patterns on quality of life, the EQ-5D and Cantril's Ladder may be insufficient outcome measures. Further investigations into the prognostic value of morbidity patterns would be of benefit.

Development and validation of a chemotherapy tolerance prediction model for Chinese multiple myeloma patients: The TM frailty score

Objective

The physical fitness of older individuals is heterogeneous, making it difficult to know their chemotherapy tolerance. The toxicities may offset the benefits of anti-myeloma therapy in frail patients. The accurate evaluation of frailty status before chemotherapy is essential. We aimed to explore the applicability of the IMWG GA and develop a new frailty screening tool more suitable for Chinese MM patients.

Cases and methods

We performed the IMWG GA and the full CGA in 167 MM patients and validated the applicability of the IMWG GA to chemotherapy and prognosis. The CGA domains were screened for their predictive value to improve IMWG GA and develop new frailty screening tools.

Results

The results showed that the IMWG GA had limitations in distinguishing the risk of grade ≥3 adverse events (AEs) between fit and int-fit patients. Of the CGA domains, TUG and MNA-SF were independent prognostic factors for grade ≥3 AEs and OS and further stratified the risk of grade ≥3 AEs in the IMWG GA int-fit subgroup (P< 0.05). We combined TUG and MNA-SF to construct the TM frailty score. The frail subgroup had a higher proportion of adverse outcomes, a higher hazard ratio (HR) in Cox regression and a higher Harrell's C-index for distinguishing the risk of grade ≥3 AEs and OS than the IMWG GA frail subgroup.

Conclusion

The TM frailty score is more suitable than the IMWG GA for evaluating chemotherapy tolerance and prognosis in the Chinese population.

Measuring self-reported ability to perform activities of daily living: a Rasch analysis

Background

Since the number of persons diagnosed with multi-morbidity is increasing, there is a need for generic instruments to be able to assess, measure and compare ADL ability across diagnoses. Accordingly, the ADL-Interview (ADL-I) was developed to be used in rehabilitation research and clinical practice. The aim of this study was to investigate if the ADL-I can be used to provide valid and reliable ADL ability measures across gender and diagnostic groups.

Methods

ADL-I data were extracted from an existing research database on persons with chronic conditions including medical, rheumatological, oncological, neurological, geriatric and psychiatric diagnoses. Data were analysed based on Rasch Measurement methods to examine: the psychometric properties of the rating scale; ADL item and person fit to the Rasch model; if the difficulty of the ADL tasks differs across gender and diagnostic groups, and if the ADL-I provides precise and reliable measures of ADL ability.

Results

Data on n = 2098 persons were included in the final analysis. Initial evaluation of the 0–3 rating scale revealed threshold disordering between categories 1 and 2. After removal of 16 underfitting items, the variance explained by the Rasch dimension increased from 54.3 to 58.0%, thresholds were ordered, but the proportion of persons with misfitting ADL-I measures increased slightly from 8.7 to 9.1%. The person separation index improved slightly from 2.75 to 2.99 (reliability = 0.90). Differential test function analysis, however, supported that the 16 underfitting items did not represent a threat to the measurement system. Similarly, ADL items displaying differential item functioning across gender and diagnoses did not represent a threat to the measurement system. The ADL items and participants were well distributed along the scale, with item and person measures well targeted to each other, indicating a small ceiling effect and no floor effect.

Conclusions

The study results overall suggest that the ADL-I is producing valid and reliable measures across gender and diagnostic groups among persons within a broad range of ADL ability, providing evidence to support generic use of the ADL-I.

Trial registration

N/A.

Realizing the Potential of Robotics for Aged Care Through Co-Creation

Socially assistive robots have the potential to improve aged care by providing assistance through social interaction. While some evidence suggests a positive impact of social robots on measures of well-being, the adoption of robotic technology remains slow. One approach to improve technology adoption is involving all stakeholders in the process of technology development using co-creation methods. To capture relevant stake holders' priorities and perceptions on the ethics of robotic companions, we conducted an interactive co-creation workshop at the 2019 Geriatric Services Conference in Vancouver, BC. The participants were presented with different portrayals of robotic companions in popular culture and answered questions about perceptions, expectations, and ethical concerns about the implementation of robotic technology. Our results reveal that the most pressing ethical concerns with robotic technology, such as issues related to privacy, are critical potential barriers to technology adoption. We also found that most participants agree on the types of tasks that robots should help with, such as domestic chores, communication, and medication reminders. Activities that robots should not help with, according to the stakeholders, included bathing, toileting, and managing finances. The perspectives that were captured contribute to a preliminary outline of the areas of importance for geriatric care stake holders in the process of ethical technology design and development.

Health status, care needs, and assessment for beneficiaries with or without dementia in a public long-term care insurance pilot in Guangzhou, China

Background

Chinese government launched a pilot study on public long-term care insurance (LTCI) recently. Guangzhou is one of the fifteen pilot cities, officially started providing LTCI in August 2017. An in-depth analysis of experimental data from the pilot city may provide suggestions for developing a fair and effective LTCI system. This study aimed to evaluate the LTCI pilot by exploring the characteristics and care needs of claimants, and performance of the assessment tool.

Methods

A retrospective cross-sectional study in which claims data between July 2018 and March 2019 in the Guangzhou pilot was analyzed. LTCI claimants during the study period were included. The care needs were determined based on claimants’ physical function assessed by the Barthel Index and their medical conditions. Rasch analysis was used to explore the performance of the Barthel Index.

Results

Among 4810 claimants included, 4582 (95.3%) obtained LTCI benefits. Of these beneficiaries, 4357 (95.1%) were ≧ 60 years old, and 791 (17.3%) had dementia. Among 228 (4.7%) unsuccessful claimants, 22 (0.5%) had dementia. The prevalence of stroke was high in beneficiaries with (38.1%) or without dementia (56.6%), as well as in unsuccessful claimants with (40.9%) or without dementia (52.4%). Beneficiaries without dementia needed more support for basic activities of daily living and nursing care than those with dementia, while beneficiaries with dementia were more likely to be institutionalized. Five (22.7%) unsuccessful claimants with dementia and 48 (23.3%) unsuccessful claimants without dementia were disabled in at least two basic self-care activities. Regarding Barthel Index, Rasch analysis showed threshold disordering in “mobility” and “climbing stairs”, and the narrow interval was observed between all the adjacent categories of the ten items (< 1.4 logits).

Conclusions

Stroke and dementia were two common reasons for needing long-term care in LTCI claimants. The Barthel Index is not suitable for assessing and dividing LTCI claimants, because of inappropriate items and narrow category responses. A comprehensive assessment and grading system is required, together with needs-led care services. The eligibility should be expanded gradually based on balance finance solutions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-020-05965-1.

Measuring daily functioning in older persons using a frailty index: a cohort study based on routine primary care data

BACKGROUND

Electronic health records (EHRs) are increasingly used for research; however, multicomponent outcome measures such as daily functioning cannot yet be readily extracted.

AIM

To evaluate whether an electronic frailty index based on routine primary care data can be used as a measure for daily functioning in research with community-dwelling older persons (aged ≥75 years).

DESIGN AND SETTING

Cohort study among participants of the Integrated Systemic Care for Older People (ISCOPE) trial (11 476 eligible; 7285 in observational cohort; 3141 in trial; over-representation of frail people).

METHOD

At baseline (T0) and after 12 months (T12), daily functioning was measured with the Groningen Activities Restriction Scale (GARS, range 18-72). Electronic frailty index scores (range 0-1) at T0 and T12 were computed from the EHRs. The electronic frailty index (electronic Frailty Index - Utrecht) was tested for responsiveness and compared with the GARS as a gold standard for daily functioning.

RESULTS

In total, 1390 participants with complete EHR and follow-up data were selected (31.4% male; median age = 81 years, interquartile range = 78-85). The electronic frailty index increased with age, was higher for females, and lower for participants living with a partner. It was responsive after an acute major medical event; however, the correlation between the electronic frailty index and GARS at T0 and over time was limited.

CONCLUSION

Because the electronic frailty index does not reflect daily functioning, further research on new methods to measure daily functioning with routine care data (for example, other proxies) is needed before EHRs can be a useful data source for research with older persons.

Trends in Risk of Limitations in Instrumental Activities of Daily Living Over Age in Older Persons With and Without Multiple Chronic Conditions

Background

To investigate trends over age by comorbidity status for the risk of limitations in individual activities of daily living for community-living older persons.

Methods

A longitudinal population-based study was conducted in 9,319 community-living Dutch persons aged 60 years and older. Self-reported multiple chronic conditions (MCC) and nine instrumental activities of daily livings (IADLs) were assessed in 15 studies of the Dutch National Care for the Elderly Program (TOPICS-MDS). Risks of limitations in IADLs, odds ratios (per 5 years), and rate ratios (per 5 years) were calculated with mixed logistic and negative binomial regression models with age as the underlying timescale, stratified by number of MCC (no, 1–2, ≥ 3 MCC), and corrected for confounders.

Results

At inclusion, the number of IADL limitations was highest for the “≥3 MCC” group (2.00 interquartile range [1.00–4.00]) and equal for “no MCC” or “1–2 MCC” (1.00 interquartile range [0.00–2.00]). Trends of individual IADLs depicted a higher risk in IADL limitation with increasing age over 2 years of follow-up, except for handling finances for the “no MCC” group. The longitudinal age effect on IADL limitations varied subject to MCC, being strongest for the “no MCC” group for most IADLs; grooming and telephone use were almost unaltered by age and MCC.

Conclusion

We observed a decline in IADL functioning with increasing age over 2 years of follow-up in persons with and without MCC. The impact of MCC on IADL decline varied per IADL activity.

Is Barthel Index Suitable for Assessing Activities of Daily Living in Patients With Dementia?

OBJECTIVES

To evaluate application of the Barthel Index (BI) in assessing basic activities of daily living (ADL) of patients with dementia using Rasch analysis.

DESIGN

A multi-country cross-sectional study.

SETTING AND PARTICIPANTS

Nineteen long-term care facilities located in China, Japan, South Korea, and Thailand. A total of 644 patients with dementia were included.

METHODS

Unidimensionality, global and item fit, local dependence, person-item targeting, threshold disordering, and differential item functioning (DIF) were examined. Negative correlations between scores for DIF items and Neuropsychiatric Inventory Nursing Home version (NPI-NH) were evaluated.

RESULTS

Item reliability (1.0) and person reliability (.88) were acceptable. The Rasch dimension explained 72.9% of the variance (Eigenvalue = 27), while the first contrast explained 6.6% (Eigenvalue = 2.4). The "mobility" was misfitting to the Rasch model (infit mean square = 1.86). The overall difficulty of the BI exceeded patients' ability (person location = -2.27 logits). The "stairs climbing" and "mobility" showed narrow category thresholds (< 1.4 logits). The location of "controlling bladder" and "toilet use" overlapped. Removing "stairs climbing", collapsing categories with narrow threshold widths in "mobility", and combining "controlling bowel" and "controlling bladder" into one item, improved unidimensionality, and item fit of the scale. Only three items ("grooming", "dressing", and "toilet use") were free from DIF across countries. The scores for "feeding" were negatively related to scores for "disinhibition" (r = -0.46, P < 0.01), and scores for "controlling bowel" were negatively related to scores for "disinhibition" (r = -0.44, P < 0.01), "agitation" (r = -0.32, P < 0.05), and "aggression" (r = -0.27, P < 0.01) in Japanese samples.

CONCLUSIONS AND IMPLICATIONS

The performance of the BI for assessing patients with dementia might be compromised by misfit items, person-item mistargeting, measurement gaps, redundant items, narrow threshold width, and item bias. Mobility ability might not be helpful for determining capability of basic ADL in the patients. Comparisons of BI scores between countries should be undertaken with caution due to item bias. Neuropsychiatric symptoms might interact with basic ADL abilities of the patients. We will not suggest using the instrument in patients with dementia, without future refining to improve its performance.

Exergaming as a Physical Exercise Strategy Reduces Frailty in People With Dementia: A Randomized Controlled Trial

OBJECTIVES

People with dementia are known to be physically frailer, more sedentary, and participate less in regular physical exercise compared to their healthy peers. Physical activity interventions have the potential to reduce the level of frailty in community-dwelling older adults. Exergaming combines physical exercise with cognitive stimulation in a virtual environment. It is an innovative and fun way of exercising, which may aid people with dementia to be more physically active. The primary aim of this study was to investigate the efficacy of a 12-week exergame training and equally long aerobic training, both compared to an active control group, on frailty in people with dementia.

DESIGN

A 3-armed randomized controlled trial compared exergame training, aerobic training, and an active control intervention.

PARTICIPANTS

115 people with dementia [mean (standard deviation [SD]) age = 79.2 (6.9) years; mean (SD) Mini-Mental State Examination score = 22.9 (3.4)].

METHODS

Participants were randomized and individually trained 3 times a week during 12 weeks. The Evaluative Frailty Index for Physical activity (EFIP) was used to assess the level of frailty at baseline and after the 12-week intervention period. Between-group differences were analyzed with analysis of covariance.

RESULTS

The exergame group showed a trend toward higher adherence compared to the aerobic group (87.3% vs 81.1%, P = .05). A significant reduction on the EFIP was found in the exergame group (EG) compared to the active control group (CG) [mean difference (95% confidence interval) between EG and CG: -0.034 [-0.062, -0.007], P = .012], with a small-to-moderate effect size (partial η² = 0.055).

CONCLUSIONS AND IMPLICATIONS

This is the first study to show that a 12-week exergame intervention reduces the level of frailty in people with dementia. This is an important and promising result, because frailty is a powerful predictor for adverse health outcomes, and its reduction may have positive effects on health status. Moreover, exergaming resulted in high adherence rates of physical exercise, which makes it an effective strategy to engage people with dementia in physical activity.

Development of a Patient-Reported Outcome Measure for Geriatric Care: The Older Persons and Informal Caregivers Survey Short Form

BACKGROUND

The Older Persons and Informal Caregivers Minimum Data Set (TOPICS-MDS) is a standardized data set that was developed to evaluate the quality of multidimensional geriatric care. There is an inherent need to reduce the number of TOPICS-MDS survey items to core outcomes to allow it to be more easily applied as a patient-reported outcome measure in clinical settings.

OBJECTIVES

To create a TOPICS-short form (TOPICS-SF) and examine its validity.

METHODS

Data in the TOPICS-MDS from persons aged 65 years and older in the Netherlands were used for the following analyses. Multiple linear regression analyses were performed to select the items and to derive domain weights of TOPICS-SF. A priori hypotheses were made on the basis of psychometric properties of the full-length TOPICS-MDS preference-weighted score (TOPICS-CEP). The validity of TOPICS-SF was evaluated by 1) examining the meta-correlation of the TOPICS-SF score with TOPICS-CEP and two quality-of-life measures, that is, the Cantril Ladder score and the EuroQol five-dimensional questionnaire utility index, and 2) performing mixed multiple regression of TOPICS-SF scores across key sociodemographic characteristics.

RESULTS

TOPICS-SF scores were strongly correlated with the TOPICS-CEP (r = 0.96) and had stronger correlation with the EuroQol five-dimensional questionnaire utility index compared with the Cantril Ladder (r = 0.61 and 0.38, respectively). TOPICS-SF scores were higher among older persons who were married, living independently, and having higher levels of education.

CONCLUSIONS

We have developed the 22-item TOPICS-SF and demonstrated its validity, supporting its use as a patient-reported outcome measure in geriatric care.

Socioeconomic inequalities in frailty and frailty components among community-dwelling older citizens

BACKGROUND

So far, it has not yet been studied whether socioeconomic status is associated with distinct frailty components and for which frailty component this association is the strongest. We aimed to examine the association between socioeconomic status and frailty and frailty components. In addition we assessed the mediating effect of the number of morbidities on the association between socioeconomic status and other frailty components.

METHODS

This is a cross-sectional study of pooled data of The Older Persons and Informal Caregivers Survey Minimum DataSet in the Netherlands among community-dwelling persons aged 55 years and older (n = 26,014). Frailty was measured with a validated Frailty Index that consisted of 45 items. The Frailty Index contained six components: morbidities, limitations in activities of daily living (ADL), limitations in instrumental ADL (IADL), health-related quality of life, psychosocial health and self-rated health. Socioeconomic indicators used were education level and neighbourhood socioeconomic status.

RESULTS

Persons with primary or secondary education had higher overall frailty and frailty component scores compared to persons with tertiary education (P < .001). Lower education levels were most consistently associated with higher overall frailty, more morbidities and worse self-rated health (P < .05 in all age groups). The strongest association was found between primary education and low psychosocial health for persons aged 55-69 years and more IADL limitations for persons aged 80+ years. Associations between neighborhood socioeconomic status and frailty (components) also showed inequalities, although less strong. The number of morbidities moderately to strongly mediated the association between socioeconomic indicators and other frailty components.

CONCLUSION

There are socioeconomic inequalities in frailty and frailty components. Inequalities in frailty, number of morbidities and self-rated health are most consistent across age groups. The number of morbidities a person has play an important role in explaining socioeconomic inequalities in frailty and should be taken into account in the management of frailty.

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.