Maintaining independence in older people

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.

Significance of an Interprofessional Healthy Aging Program for Community-Dwelling Older Adults: A Narrative Study

Participation is widely recognized as an important health determinant for older adults. Exploring interventions to promote active participation of community-dwelling older adults is an important step in translating current knowledge into practice. Few studies have examined community-level interventions to support older adults' participation. The study purpose was to examine the significance of the lived experiences of community-dwelling older adults who participated in an interprofessional healthy aging promotion program. The specific aims were to uncover the narrative significance of the lived experiences and how they evolved and intertwined with the life histories of the older adults 2 years after the intervention ended. A narrative inquiry design was used. Four key informants participated in two semi-structured interviews and a member-checking process. The data were analyzed from a three-dimensional inquiry space of time and continuity, place and context, and social interactions. The findings affirmed three core threads that wove the participants' lived experiences within the program together with their life histories after the intervention. These were enjoyment, learning, and sharing. Four themes revealed the essential elements of the lived experience, and three others exposed participants' growth and life enrichment, all being fundamental to participation. The 3-year community-level intervention was valued and a novel opportunity for facilitating participation and successful aging. It allowed the participants to acquire an evolved vision of self, have meaningful interactions, develop the means to engage in future community activities, implement new self-care strategies, and establish memories and friendships significant for life participation.

Comparing a new multimorbidity index with other multimorbidity measures for predicting disability trajectories

BACKGROUND

The optimal multimorbidity measures for predicting disability trajectories are not universally agreed upon. We developed a multimorbidity index among middle-aged and older community-dwelling Chinese adults and compare its predictive ability of disability trajectories with other multimorbidity measures.

METHODS

This study included 17,649 participants aged ≥50 years from the China Health and Retirement Longitudinal Survey 2011-2018. Two disability trajectory groups were estimated using the total disability score differences calculated between each follow-up visit and baseline. A weighted index was constructed using logistic regression models for disability trajectories based on the training set (70 %). The index and the condition count were used, along with the pattern identified by the latent class analysis to measure multimorbidity at baseline. Logistic regression models were used in the training set to examine associations between each multimorbidity measure and disability trajectories. C-statistics, integrated discrimination improvements, and net reclassification indices were applied to compare the performance of different multimorbidity measures in predicting disability trajectories in the testing set (30 %).

RESULTS

In the newly developed multimorbidity index, the weights of the chronic conditions varied from 1.04 to 2.55. The multimorbidity index had a higher predictive performance than the condition count. The condition count performed better than the multimorbidity pattern in predicting disability trajectories.

LIMITATION

Self-reported chronic conditions.

CONCLUSIONS

The multimorbidity index may be considered an ideal measurement in predicting disability trajectories among middle-aged and older community-dwelling Chinese adults. The condition count is also suggested due to its simplicity and superior predictive performance.

Growing Old in the Bible Belt: Resources for Aging LGBT Adults Living in the South

There has been an increase in the literature about LGBT older adults in recent years; however, there is a need for further sociological quantitative research examining the impact of geographic region on LGBT aging. Utilizing data from a nationwide survey, this study focuses on the availability of LGBT-specific resources for LGBT aging adults living in the South. We examine the effects of community type and sociodemographics on the availability of LGBT-specific resources as well as the type of resources available. Findings reveal that in the South, community type, having a partner, household income, and education affect the LGBT-specific resources available. Of particular interest, LGBT-affirming faith organizations are identified as the resource most frequently available for LGBT aging adults in this region often referred to as the Bible Belt. Overall, this study sheds light on the LGBT-specific resources that are available to provide social support and help meet the unique needs of LGBT adults aging in the South.

Does CGA Improve Health Outcomes in the Community? An Umbrella Review

OBJECTIVES

To perform an umbrella review of systematic reviews with meta-analyses (MAs) examining the effectiveness of comprehensive geriatric assessment (CGA) delivered within community settings to general populations of community-dwelling older people against various health outcomes.

DESIGN

Umbrella review of MAs of randomized controlled trials (RCTs).

SETTING AND PARTICIPANTS

Systematic reviews with MAs examining associations between CGA conducted within the community and any health outcome, where participants were community-dwelling older people with a minimum mean age of 60 years or where at least 50% of study participants were aged ≥60 years. Studies focusing on residential care, hospitals, post-hospital care, outpatient clinics, emergency department, or patients with specific conditions were excluded.

METHODS

We examined CGA effectiveness against 12 outcomes: not living at home, nursing home admission, activities of daily living (ADLs) and instrumental ADLs (IADLs), physical function, falls, self-reported health status, quality of life, frailty, mental health, hospital admission, and mortality, searching the MEDLINE/PubMed, Cochrane Library, CINAHL, Embase databases from January 1, 1999, to August 10, 2022. AMSTAR-2 was used to assess the quality of included systematic reviews, including risk of bias.

RESULTS

We identified 10 MAs. Only not living at home (combined mortality and nursing home admission) demonstrated concordance between effect direction, significance, and magnitude. Significant effects were more typically observed in earlier rather than later studies.

CONCLUSION AND IMPLICATIONS

Given the widespread adoption of CGA as a component of usual care within geriatric medicine, the lack of strong evidence demonstrating the protective effects of CGA may be indicative of a cohort effect. If so, future RCTs examining CGA effectiveness are unlikely to demonstrate significant findings. Future studies of CGA in the community should focus on implementation and adherence to key components.

TRIAL REGISTRATION

Study protocol registered in PROSPERO 2020 CRD42020169680.

Impact of community care services on the health of older adults: evidence from China

Introduction

The rapid growth in the population of older adults has put tremendous pressure on medical and social services in countries including China. Community care services are a feasible solution for promoting healthy aging in developing countries. This study investigated the association between community care services and the health of older adults in China.

Method

Using nationally representative survey data from China, consisting of four waves conducted in 2005, 2008, 2011, and 2014, a balanced panel dataset was constructed using a sample of 4,700 older adults (33.1% aged 80 years or older, 51.0% residing in rural areas, and 48.8% women). We employed linear regression models with time-fixed effects and instrumental variable approaches to estimate the effect of community care services on the health of older adults, as well as the differences in these effects across subgroups.

Results

The results showed that community care services lead to a significant improvement in both the objective and subjective health and wellbeing of older adults. Among the various service offerings, spiritual recreation services led to a significant increase in both objective and subjective health scores, while medical care services significantly improved wellbeing. This suggests a varied effect of subdivided service types. Further evidence suggests that spiritual recreation services have a significant health-enhancing effect on multiple groups of older adults, and the effect of medical care services is more effective for those living in rural areas, women, and those who are older than 80 years (all p < 0.05).

Discussion

Few studies have examined the impact of community care services on the health of older adults in developing countries. The findings present important implications for improving the health status of older adults and provide suggestions for establishing a socialized aged care system in China.

"I Hear the Music and My Spirits Lift!" Pleasure and Ballroom Dancing for Community-Dwelling Older Adults

Physical activity for older adults is recommended to encourage the maintenance of functional autonomy and improve mental health. Ballroom dancing involves aerobic, strength, and balance work and is an inherently a social activity. This 12-month qualitative study considered the influence of ballroom dancing on health and well-being in community-dwelling older adults. It explores an underreported aspect of physical activity, which may incentivize older people to participate, that is, pleasure. Qualitative data were managed and analyzed using the Framework Analysis approach. Semistructured interviews were conducted with 26 older adult ballroom dancers. Five typologies of pleasure were identified. In addition to "sensual pleasure," "pleasure of habitual action," and "pleasure of immersion," as suggested by Phoenix and Orr, the "pleasure of practice" and "pleasure of community" were also identified. Ballroom dancing produces a strong sense of embodied pleasure for older adults and should be promoted by health and exercise professionals for community-dwelling older adults.

Models of integrated care for older people with frailty: a horizon scanning review

OBJECTIVES

Frailty, a multifaceted geriatric condition, is an emerging global health problem. Integrated care models designed to meet the complex needs of the older people with frailty are required. Early identification of innovative models may inform policymakers and other stakeholders of service delivery alternatives they can introduce and locally adapt so as to tackle system fragmentation and lack of coordination. This study used horizon scanning methodologies to systematically search for, prioritise and assess new integrated care models for older people with frailty and investigated experts' views on barriers and facilitators to the adoption of horizon scanning in health services research.

METHODS

A four-step horizon scanning review was performed. Frailty-specific integrated care models and interventions were identified through a review of published literature supplemented with grey literature searches. Results were filtered and prioritised according to preset criteria. An expert panel focus group session assessed the prioritised models and interventions on innovativeness, impact and potential for implementation. The experts further evaluated horizon scanning for its perceived fruitfulness in aiding decision-making.

RESULTS

Nine integrated care models and interventions at system level (n=5) and community level (n=4) were summarised and assessed by the expert panel (n=7). Test scores were highest for the Walcheren integrated care model (system-based model) and EuFrailSafe (community-based intervention). The participants stated that horizon scanning as a decision-making tool could aid in assessing knowledge gaps, criticising the status quo and developing new insights. Barriers to adoption of horizon scanning on individual, organisational and wider institutional level were also identified.

CONCLUSION

Study findings demonstrated that horizon scanning is a potentially valuable tool in the search for innovative service delivery models. Further studies should evaluate how horizon scanning can be institutionalised and effectively used for serving this purpose.

Proactive primary care model for frail older people in New Zealand delays aged-residential care: A quasi-experiment

BACKGROUND/OBJECTIVES

To determine the effect of a proactive primary care program on acute hospitalization and aged-residential care placement for frail older people.

DESIGN

Controlled before and after, and controlled after only quasi-experimental studies, with a comparison group created via propensity score matching. One-year follow-up.

SETTING

Nine general practices in Auckland, New Zealand.

PARTICIPANTS

Community-dwelling people aged 75 and older identified as at increased risk of hospitalization. One thousand and eighty five patients are compared with 3750 comparison patients matched by propensity score based on known risks.

INTERVENTION

Primary healthcare based, registered nurse-led, comprehensive geriatric assessment, goal-setting, care planning, and regular follow-up. Patients were also provided self-management education, health and social care navigation, and transitional care for hospital discharges. Practices received program support, workforce development, and mentoring of primary healthcare nurses by gerontology nurse specialists.

MEASUREMENTS

Outcomes from routinely collected administrative data. Primary: aged-residential care placement.

SECONDARY OUTCOMES

acute hospitalization, mortality, and other health service utilization.

RESULTS

Aged-residential care placement (odds ratio [OR] 0.66, 95% confidence interval (CI) = 0.48-0.91) and mortality (OR 0.66, 95% CI = 0.49-0.88) were significantly lower over the first year in Kare patients compared with matched controls. There was no difference in acute hospitalization (+0.06 admissions per year, 95% CI = -0.01-0.13). Support service use (allied health therapists and assessment for social support) was increased, and emergency department use decreased.

CONCLUSION

The Kare participants had lower aged-residential care placement and mortality in the first year, but no decrease in acute hospitalization. Because the design is nonexperimental caution is required in interpreting these results.

What works in managing complex conditions in older people in primary and community care? A state-of-the-art review

The number of older people living with complex health conditions is increasing, with the majority of these managed in primary and community settings. Many models of care have been developed to support them, however, there is mixed evidence on their value and they include multiple overlapping components. We aimed to synthesise the evidence to learn what works for managing complex conditions in older people in primary and community care. We carried out a state-of-the-art review of systematic reviews. We searched three databases (January 2009 to July 2019) for models of primary and community care for long-term conditions, frailty, multimorbidity and complex neurological conditions common to older people such as dementia. We narratively synthesised review findings to summarise the evidence for each model type and identify components which influenced effectiveness. Out of 2,129 unique titles and abstracts, 178 full texts were reviewed and 54 systematic reviews were included. We found that the models of care were more likely to improve depressive symptoms and mental health outcomes than physical health or service use outcomes. Interventions including self-management, patient education, assessment with follow-up care procedures, and structured care processes or pathways had greater evidence of effectiveness. The level of healthcare service integration appeared to be more important than inclusion of specific professional types within a team. However, more experienced and qualified nurses were associated with better outcomes. These conclusions are limited by the overlap between reviews, reliance on vote counting within some included reviews and the quality of study reports. In conclusion, primary and community care interventions for complex conditions in older people should include: (a) clear intervention targets; (b) explicit theoretical underpinnings; and (c) elements of self-management and patient education, structured collaboration between healthcare professionals and professional support. Further work needs to determine the optimal intensity, length, team composition and role of technology in interventions.

Factors associated with physical activity in elderly nursing home residents: a path analysis

BACKGROUND

Physical activity (PA) is low among elderly residents in nursing homes in China. We aimed to determine the factors that influence PA among elderly nursing home residents and their direct or indirect effects on PA levels.

METHODS

The PA levels of the participants were measured using the International Physical Activity Questionnaire, and their health beliefs were assessed using a self-developed 18-item questionnaire titled the 'Health Beliefs of Nursing Home Residents Regarding Physical Activity' in accordance with Health Belief Model (HBM) constructs. The correlations between HBM constructs and PA levels were analyzed and a regression-based path analysis was conducted to examine the relationships between HBM constructs and PA levels.

RESULTS

A total of 180 residents with a mean age of 82.5 years (standard deviation = 5.76) were recruited. Linear regression analysis revealed that self-efficacy (p < 0.001), perceived severity (p < 0.01), and cues to action (p < 0.01) were associated with the level of PA among nursing home residents. In the conceptual path model, self-efficacy, perceived severity, and cues to action had positive direct effects on the PA level, while perceived benefits and perceived barriers had indirect effects on the PA level.

CONCLUSION

The residents' self-efficacy, perceived severity, and cues to action were found to be important factors that can affect the design and implementation of educational programs for PA. A better understanding of such associations may help healthcare providers design informed educational interventions to increase PA levels among nursing home residents.

Evaluating Canadian Radiation Therapists and UK Therapeutic Radiographers' Experiences and Opinions of a Safety Strap to Secure Patients during Radiotherapy

INTRODUCTION

A serious patient safety incident at a cancer centre in Ontario, Canada, saw a patient fall from an elevated treatment couch. A regional investigation recommended the use of a securing safety strap. The authors evaluate the value of the strap through the experiences of the radiation therapists' who use it. A secondary aim is to explore the potential for using a securing safety strap with UK therapeutic radiographers.

METHODS

A two-stage design was guided by an evidence-based practice framework. Stage one used a questionnaire to capture treating radiation therapists' experiences and opinions of the strap at a single cancer centre. Quantitative data were analysed descriptively and free-text data via a content analysis. Stage two used semistructured interviews with thematic analysis to explore views of three UK therapeutic radiographers.

RESULTS

Twenty-five of approximately 130 eligible staff responded to the Canadian questionnaire. Of the respondents, 24% (n = 6) 'strongly disagreed', 28% (n = 7) 'agreed' and 48% (n = 12) 'neither agreed nor disagreed' that they would recommend the strap to other departments. Most of the respondents think strap use should be at the staffs' discretion, with patients with dementia/cognitive impairment ranked as the group benefiting most. Ninety-two percent (n = 23) of respondents confirmed that patients sometimes refuse the strap. Themes arising from stage two interviews are as follows: patient benefit (use for select patients only); patient safety versus control (restraint); and practical implementation issues.

CONCLUSION

The policy of universal use of the strap should be reviewed. Those who use it are equivocal about its value and feel it should be reserved for select patients at the treating professional's discretion. Full evaluation of the effectiveness and acceptability of the device for different patients may promote both staff enthusiasm towards the device and evidence-based practice. Adequate resources are required to evaluate implementation of such safety initiatives.

Interventions to Prevent or Delay Long-Term Nursing Home Placement for Adults with Impairments-a Systematic Review of Reviews

BACKGROUND

With continued growth in the older adult population, US federal and state costs for long-term care services are projected to increase. Recent policy changes have shifted funding to home and community-based services (HCBS), but it remains unclear whether HCBS can prevent or delay long-term nursing home placement (NHP).

METHODS

We searched MEDLINE (OVID), Sociological Abstracts, PsycINFO, CINAHL, and Embase (from inception through September 2018); and Cochrane Database of Systematic Reviews, Joanna Briggs Institute Database, AHRQ Evidence-based Practice Center, and VA Evidence Synthesis Program reports (from inception through November 2018) for English-language systematic reviews. We also sought expert referrals. Eligible reviews addressed HCBS for community-dwelling adults with, or at risk of developing, physical and/or cognitive impairments. Two individuals rated quality (using modified AMSTAR 2) and abstracted review characteristics, including definition of NHP and interventions. From a prioritized subset of the highest-quality and most recent reviews, we abstracted intervention effects and strength of evidence (as reported by review authors).

RESULTS

Of 47 eligible reviews, most focused on caregiver support (n = 10), respite care and adult day programs (n = 9), case management (n = 8), and preventive home visits (n = 6). Among 20 prioritized reviews, 12 exclusively included randomized controlled trials, while the rest also included observational studies. Prioritized reviews found no overall benefit or inconsistent effects for caregiver support (n = 2), respite care and adult day programs (n = 3), case management (n = 4), and preventive home visits (n = 2). For caregiver support, case management, and preventive home visits, some reviews highlighted that a few studies of higher-intensity models reduced NHP. Reviews on other interventions (n = 9) generally found a lack of evidence examining NHP.

DISCUSSION

Evidence indicated no benefit or inconsistent effects of HCBS in preventing or delaying NHP. Demonstration of substantial impacts on NHP may require longer-term studies of higher-intensity interventions that can be adapted for a variety of settings. Registration PROSPERO # CRD42018116198.

Interventions aimed at loneliness and fall prevention reduce frailty in elderly urban population

Frailty is a pronounced symptom of aging associated with multiple comorbid states and adverse outcomes. The aim of this study was to evaluate the impact of 2 interventions, one based on prevention of falls and the other on prevention of loneliness, on total frailty and dimensions of frailty in urban community-dwelling elderly as well as associations with independent living.This prospective interventional study followed up 410 persons aged 75 to 95. The participants of the control and intervention groups were monitored through a public health intervention programme. The level of frailty was measured by the Tilburg Frailty Indicator (TFI) questionnaire and the factors of independent living were analyzed using validated questionnaires.After 1 year, physical frailty measured in the control group showed a statistically significant increase (r = -0.11), while in the intervention groups physical frailty did not increase (both P > .05). Psychological frailty measured after 1 year in the control group was significantly higher (r = -0.19), as well as in the group where the public health interventions to reduce loneliness were carried out (r = -0.19). Psychological frailty did not increase in the group in which public health interventions to prevent falls were carried out, and social frailty did not increase at all in the study period. The total level of frailty in the control group after 1 year was significantly increased (r = -0.19), while no increase was seen in the overall frailty in the intervention group. Multivariate analysis has shown that both interventions where independently associated with lower end frailty. Additionally, higher baseline frailty and visit to a physician in the last year were positively associated with higher end-study frailty level, while higher number of subjects in the household and higher total psychological quality of life (SF-12) were independently associated with lower end-study frailty. Only in the prevention of falls group there was no increase in restriction in the activities of daily living throughout study follow-up.Public health interventions to prevent falls and to prevent loneliness have a positive effect on the frailty and independent living of the elderly living in their own homes in an urban community.

Risk Assessment of Acute, All-Cause 30-Day Readmission in Patients Aged 65+: a Nationwide, Register-Based Cohort Study

BACKGROUND

Hospital readmission is considered an adverse health outcome in older people, adding additional pressure on clinical resources within health care services. Despite numerous studies on risk factors for readmissions, studies find different strengths of respective determinants and there is a need to explore and identify patterns of risk factors in larger cohorts.

OBJECTIVE

Exploring and identifying patterns of risk factors for acute, all-cause 30-day readmission in a Danish cohort of patients aged 65+.

DESIGN

Register-based cohort study using individual-level linkable information on demographics, social determinants, clinical conditions, health care utilization, and provider determinants obtained from primary and secondary health care.

PARTICIPANTS

Historic cohort of 1,267,752 admissions in 479,854 patients, aged 65+, discharged from Danish public hospitals from January 2007 to September 2010.

MAIN MEASURES

We included patient-level variables and admission-level variables. Outcome was acute, all-cause 30-day readmission. Data was analyzed by univariable and multivariable logistic regression. Strength of associations was analyzed using Wald test statistics. Receiver operating characteristic (ROC) analysis was used for quantification of predictive ability. For validation, we used split-sample design.

KEY RESULTS

Acute admission and number of days since previous hospital discharge were factors strongly associated with readmission. Patients at risk of future readmission suffered from comorbidity, consumed more drugs, and were frequent users of in- and outpatient health care services in the year prior to the index admission. Factors related to index admission were only weakly associated with readmission. The predictive ability was 0.709 (0.707-0.711) for acute readmission.

CONCLUSIONS

In a general population of older people, we found that pre-hospital factors rather than hospital factors account for increased risk of readmission and are dominant contributors to predict acute all-cause 30-day readmission. Therefore, risk for excess readmission should be shared across sectors and focus the care trajectory over time rather than distinct care episodes.

Impact of a Nurse-Led Health Promotion Intervention in an Aging Population: Results From a Quasi-Experimental Study on the "Community Health Consultation Offices for Seniors"

Objective: The study evaluated the nurse-led intervention "Community Health Consultation Offices for Seniors (CHCO)" on health-related and care needs-related outcomes in community-dwelling older people (⩾60 years). Method: With a quasi-experimental design, the CHCO intervention was evaluated on health-related and care needs-related outcomes after 1-year follow-up. Older people who received the intervention were frail, overweight, or were smoking. The comparison group received care as usual. In both groups, similar data were collected on health status, falls and fractures, and care needs. In the intervention group, additional data were collected on biometric measures and health-related behavior. Results: The intervention group and the care-as-usual group included 403 seniors and 984 seniors, respectively. Health-related outcomes, behaviors, and biometric measures, remained stable. After 1 year, care needs increased for both groups, but at a lower rate for the care-as-usual group. Discussion: The CHCO intervention showed no significant improvement on health-related outcomes or stability in care needs-related outcomes.

An update on dementia training programmes in home and community care

PURPOSE OF REVIEW

Many people living with dementia (PLWD) wish to continue living at home. The quality of home care services directly influences their ability to stay at home, their quality of life, and can promote independence for PLWD, and reduce burden for the family carer. For high-quality, effective, person-centred community-based dementia care, a knowledgeable and empathetic workforce is crucial. This article presents an up-to-date review and summary of the literature investigating dementia training programmes for community home care professionals and care workers, referred to collectively as home care workers (HCWs).

RECENT FINDINGS

We reviewed the literature between October 2016 and April 2018 on dementia training for HCWs. We found a significant lack of evidence-based, codesigned specialist dementia training programmes for HCWs that address the needs of all stakeholders in home care, and which formally measure outcomes.

SUMMARY

In order to enable PLWD to maintain living at home in the community, dementia-friendly and knowledgeable HCWs are needed. This review highlights the need for more research into the design and evaluation of evidence-based dementia specialist training programmes for community care.

Home-based health promotion for older people with mild frailty: the HomeHealth intervention development and feasibility RCT

BACKGROUND

Mild frailty or pre-frailty is common and yet is potentially reversible. Preventing progression to worsening frailty may benefit individuals and lower health/social care costs. However, we know little about effective approaches to preventing frailty progression.

OBJECTIVES

(1) To develop an evidence- and theory-based home-based health promotion intervention for older people with mild frailty. (2) To assess feasibility, costs and acceptability of (i) the intervention and (ii) a full-scale clinical effectiveness and cost-effectiveness randomised controlled trial (RCT).

DESIGN

Evidence reviews, qualitative studies, intervention development and a feasibility RCT with process evaluation.

INTERVENTION DEVELOPMENT

Two systematic reviews (including systematic searches of 14 databases and registries, 1990-2016 and 1980-2014), a state-of-the-art review (from inception to 2015) and policy review identified effective components for our intervention. We collected data on health priorities and potential intervention components from semistructured interviews and focus groups with older people (aged 65-94 years) (n = 44), carers (n = 12) and health/social care professionals (n = 27). These data, and our evidence reviews, fed into development of the 'HomeHealth' intervention in collaboration with older people and multidisciplinary stakeholders. 'HomeHealth' comprised 3-6 sessions with a support worker trained in behaviour change techniques, communication skills, exercise, nutrition and mood. Participants addressed self-directed independence and well-being goals, supported through education, skills training, enabling individuals to overcome barriers, providing feedback, maximising motivation and promoting habit formation.

FEASIBILITY RCT

Single-blind RCT, individually randomised to 'HomeHealth' or treatment as usual (TAU).

SETTING

Community settings in London and Hertfordshire, UK.

PARTICIPANTS

A total of 51 community-dwelling adults aged ≥ 65 years with mild frailty.

MAIN OUTCOME MEASURES

Feasibility - recruitment, retention, acceptability and intervention costs. Clinical and health economic outcome data at 6 months included functioning, frailty status, well-being, psychological distress, quality of life, capability and NHS and societal service utilisation/costs.

RESULTS

We successfully recruited to target, with good 6-month retention (94%). Trial procedures were acceptable with minimal missing data. Individual randomisation was feasible. The intervention was acceptable, with good fidelity and modest delivery costs (£307 per patient). A total of 96% of participants identified at least one goal, which were mostly exercise related (73%). We found significantly better functioning (Barthel Index +1.68; p = 0.004), better grip strength (+6.48 kg; p = 0.02), reduced psychological distress (12-item General Health Questionnaire -3.92; p = 0.01) and increased capability-adjusted life-years [+0.017; 95% confidence interval (CI) 0.001 to 0.031] at 6 months in the intervention arm than the TAU arm, with no differences in other outcomes. NHS and carer support costs were variable but, overall, were lower in the intervention arm than the TAU arm. The main limitation was difficulty maintaining outcome assessor blinding.

CONCLUSIONS

Evidence is lacking to inform frailty prevention service design, with no large-scale trials of multidomain interventions. From stakeholder/public perspectives, new frailty prevention services should be personalised and encompass multiple domains, particularly socialising and mobility, and can be delivered by trained non-specialists. Our multicomponent health promotion intervention was acceptable and delivered at modest cost. Our small study shows promise for improving clinical outcomes, including functioning and independence. A full-scale individually RCT is feasible.

FUTURE WORK

A large, definitive RCT of the HomeHealth service is warranted.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42014010370 and Current Controlled Trials ISRCTN11986672.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 73. See the NIHR Journals Library website for further project information.

Hospital readmission: Older married male patients' experiences of life conditions and critical incidents affecting the course of care, a qualitative study

BACKGROUND

Despite the frequency of hospital readmissions, there is still a relatively incomplete understanding of the broader array of factors pertaining to readmission in older persons. Few studies have explored how older persons experience readmission and their perceptions of circumstances affecting the course of care. Research indicates that males experience poorer health outcomes and are at higher risk of readmission compared to women.

AIM

To explore life conditions and critical incidents pertained to hospital readmission from the perspective of older males.

METHODS

The study used a qualitative explorative design using the Critical Incident Technique. A purposive sample of four males aged 65-75 were recruited from two internal medical wards. Data were collected through narrative double interviews. The study was registered by the North Denmark Region's joint notification of health research (ID 2008-58-0028).

FINDINGS

The analysis revealed four themes of life conditions: 'Ambiguity of ageing', 'Living with the burden of illness', 'Realisation of dependency' and 'Growing sense of vulnerability and mortality'. Critical incidents comprised four areas: 'Balancing demands and resources in everyday life', 'Back home again - a period of recovery', 'Care interaction' and 'Navigating within and between healthcare system(s)'.

CONCLUSION

This study illustrated the interconnectedness, dynamics and complexity of life conditions and critical incidents that over time and across diverse healthcare sectors affected the course of care in older persons. Hospital readmissions seem related to a complex web of interacting life conditions and critical incidents rather than growing age or specific illnesses.

Geriatrician-performed comprehensive geriatric care in older adults referred to an outpatient community rehabilitation unit: A randomized controlled trial

BACKGROUND

Older adults make increasing demands on all sectors of the healthcare system. We investigated the effect of geriatrician-performed comprehensive geriatric care (CGC) in older adults referred to an outpatient community rehabilitation unit.

DESIGN

Randomized controlled trial.

SETTING

Two Danish non-hospital based rehabilitation units.

PARTICIPANTS

Persons aged 65 or older admitted from home or hospital.

INTERVENTION

CGC performed by a geriatrician at the rehabilitation unit.

OUTCOMES

Primary outcome was number of hospital admissions and emergency department (ED) visits. Secondary outcomes were number of ambulatory contacts, general practitioner (GP) contacts, activities of daily living (ADL) and overall quality of life (OQoL). Outcomes were measured within 90 days of admission to the rehabilitation units.

RESULTS

368 persons were randomized: 185 to the intervention group (IG) vs 183 to the control group (CG). Groups were comparable at baseline. The number of hospital admissions and ED visits, ambulatory contacts and out of hour GP visits or phone calls did not differ between the groups. The number of daytime GP consultations and visits or phone and email consultations was lower in the IG (P < 0.001). There were no differences in the mean between the groups for ADL and OQoL, but more participants in the IG improved their OQoL (OR 1.63, 95% CI: 1.07-2.48, P = 0.023).

CONCLUSION

Geriatrician-performed CGC in older adults in an outpatient community rehabilitation unit had no effect on the secondary healthcare utilization, but may reduce primary healthcare utilization and improve OQoL during the 90-day follow-up period.

TRIAL REGISTRATION

ClinicalTrials.govNCT01506219.

Towards Changing the Long Term Care (LTC) Paradigm: Explicating the Concept of Thriving in Older Adults Living in LTC

A phenomenon of interest for nursing is the facilitation of humanistic health care experiences and quality of life (Willis, Grace, & Roy, 2008 ). Inquiry into the concept of thriving as it manifests in the older adult residing in long-term care aligns with this interest. Thriving has been described by scholars in various disciplines but no context-specific definition for the LTC resident currently exists. Contrary to the generally held negative view of LTC, there is emerging evidence that older adult LTC residents "do well" or thrive in this environment.

Usual primary care of older people in New Zealand: association between practice characteristics and practice activities

INTRODUCTION Information on the processes used by primary care practices to help identify older patients in need of assistance are limited in New Zealand. AIM To describe the processes used to promote early problem detection in older patients in primary care and the practice characteristics associated with the use of these proactive processes. METHODS Sixty practices were randomly selected from all primary care practices in three regions (52% response rate) and surveyed in 2010 to identify characteristics of practices performing the following activities: using assessment tools; auditing the practice; conducting specific clinics; providing home visits; and providing active patient follow-up. Practice level variables were examined. RESULTS Only 4 (7%) of 57 practices did not perform any of the activities. We found the following associations in the many comparisons done: no activities and greater level of deprivation of practice address (p = 0.048); more activities in main urban centres (p = 0.034); more main urban centre practices doing home visits (p = 0.001); less Canterbury practices conducting specific clinics for frail older patients (p = 0.010); and more Capital and Coast practices following-up patients who do not renew their prescriptions (p = 0.019). DISCUSSION There are proactive processes in place in most New Zealand practices interested in a trial about care of older people. Future research should determine whether different types of practices or the activities that they undertake make a difference to older primary care patients' outcomes.

An exploration of factors associated with older persons' perceptions of the benefits of and satisfaction with a preventive home visit service

BACKGROUND

Preventive home visits (PHVs) are healthcare services aimed at promoting the health of home-dwelling older people and to support their abilities to live independently. To enhance effectiveness, studies that explore older persons' experiences of PHVs are needed.

OBJECTIVE

To assess older persons' perceived benefits and opinions of a PHV service and explore associations between perceived benefits from PHV and relevant sociodemographic/health-related factors.

THEORY

The study was based on a comprehensive understanding of health, as including objective health/disease, subjective health/well-being and coping ability.

METHODS

A cross-sectional survey was administered during spring 2013 in a Norwegian municipality where nurses had offered annual PHVs to residents aged 75 years and older since 1999. We invited a stratified random sample of 393 PHV users to participate; of these, 161 volunteered. The main outcome variables in the questionnaire were perceived benefits from PHV. Logistic regression models were used to analyse the associations between each benefit and sociodemographic/health-related background variables.

RESULTS

Approximately 39% of the respondents reported that PHVs added to their feelings of safety; 66% reported support for ability to live at home; 72% reported support for having a good life, 83% were satisfied with the service, and 90% stated that PHVs are important for older people. Each benefit was associated with different sociodemographic/health-related factors. Support for feelings of safety increased with age. More support for living at home was associated with poor physical health and not living alone. Those without children perceived more support for a good life. Satisfaction with PHV increased with increasing scores on the Life Orientation Scale. Persons with poor mental health and those not living alone more often perceived PHV as important.

CONCLUSIONS

Annual, comprehensive PHVs to a general older population may support older persons' health and independence. Low response rate restricts the possibility to generalise the results.

Comparison of two health measurements among older adults

The aims of this study were to develop composite indices for measuring the life relative independence of older adults and to compare the results with the self-rated health status to evaluate the reliability. The life relative independence measures were developed using a representative cross-sectional survey of 2336 samples in Taiwan. The results indicated that older adults have poor social health and economic security, the life relative independence is more effective in health evaluation than the self-rated health status and psychological health is associated with independence. This study provides an improved understanding of scenarios of independence for older adults.

The MINDMAP project: mental well-being in urban environments : Design and first results of a survey on healthcare planning policies, strategies and programmes that address mental health promotion and mental disorder prevention for older people in Europe

Background

The MINDMAP consortium (2016–2019) aims to identify opportunities provided by the urban environment for the promotion of mental well-being and functioning of older people in Europe by bringing together European cities with urban longitudinal ageing studies: GLOBE, HAPIEE, HUNT, LASA, LUCAS, RECORD, Rotterdam Study, Turin Study. A survey on mental healthcare planning policies and programmes dedicated to older persons covering the range from health promotion to need of nursing care was performed for profound data interpretation in Amsterdam, Eindhoven, Hamburg, Helsinki, Kaunas, Krakow, London, Nord-Trøndelag, Paris, Prague, Rotterdam and Turin.

Objectives

To collect detailed information on healthcare planning policies and programmes across these European cities to evaluate variations and to delineate recommendations for sciences, policies and planners using experience from evidence-based practice feedback from the MINDMAP cities.

Materials and methods

The MINDMAP partners identified experts in the 12 cities with the best background knowledge of the mental health sector. After pretesting, semi-structured telephone interviews (1–2 h) were performed always by the same person. A structured evaluation matrix based on the geriatric functioning continuum and the World Health Organization (WHO) Public Health Framework for Healthy Ageing was applied.

Results

A complete survey (12 out of 12) was performed reporting on 41 policies and 280 programmes on the city level. It appeared from extensive analyses that the focus on older citizens, specific target groups, and multidimensional programmes could be intensified.

Conclusion

There is a broad variety to cope with the challenges of ageing in health, and to address both physical and mental capacities in older individuals and their dynamic interactions in urban environments.

Costs and economic consequences of a help-at-home scheme for older people in England

Solutions to support older people to live independently and reduce the cost of an ageing population are high on the political agenda of most developed countries. Help-at-home schemes offer a mix of community support with the aim to address a range of well-being needs. However, not much is currently known about the costs, outcomes and economic consequences of such schemes. Understanding their impact on individuals' well-being and the economic consequences for local and central government can contribute to decisions about sustainable long-term care financing. This article presents results from a mixed-methods study of a voluntary sector-provided help-at-home scheme in England for people of 55 years and older. The study followed a participatory approach, which involved staff and volunteers. Data were collected during 2012 and 2013. Social care-related quality of life was measured with the Adult Social Care Outcomes Toolkit for 24 service users (59% response rate) when they started using the scheme and 4-6 months later. A customised questionnaire that captured resource use and well-being information was sent to 1064 service users (63% response rate). The same tool was used in assessment with service users who started using the scheme between November 2012 and April 2013 (100% response rate). Costs of the scheme were established from local budget and activity data. The scheme was likely to achieve a mean net benefit of £1568 per person from a local government and National Health Service (NHS) perspective and £3766 from the perspective of the individual. An expenditure of £2851 per person accrued to central government for the additional redistribution of benefit payments to older people. This article highlights the potential contribution of voluntary sector-run help-at-home schemes to an affordable welfare system for ageing societies.

Impact of home care versus alternative locations of care on elder health outcomes: an overview of systematic reviews

Background

Many elders struggle with the decision to remain at home or to move to an alternative location of care. A person’s location of care can influence health and wellbeing. Healthcare organizations and policy makers are increasingly challenged to better support elders’ dwelling and health care needs. A summary of the evidence that examines home care compared to other care locations can inform decision making. We surveyed and summarized the evidence evaluating the impact of home care versus alternative locations of care on elder health outcomes.

Methods

We conducted an overview of systematic reviews. Data sources included MEDLINE, the Cochrane Library, EMBASE, and CINAHL. Eligible reviews included adults 65+ years, elder home care, alternative care locations, and elder health outcomes. Two independent reviewers screened citations. We extracted data and appraised review quality using the Assessing the Methodological Quality of Systematic Reviews (AMSTAR) checklist. Results were synthesized narratively.

Results

The search yielded 2575 citations, of which 19 systematic reviews were eligible. Three hundred and forty studies with 271,660 participants were synthesized across the systematic reviews. The categories of comparisons included: home with support versus independent living at home (n = 11 reviews), home care versus institutional care (n = 3 reviews), and rehabilitation at home versus conventional rehabilitation services (n = 7 reviews). Two reviews had data relevant to two categories. Most reviews favoured home with support to independent living at home. Findings comparing home care to institutional care were mixed. Most reviews found no differences in health outcomes between rehabilitation at home versus conventional rehabilitation services. Systematic review quality was moderate, with a median AMSTAR score of 6 (range 4 - 10 out of 11).

Conclusions

The evidence on the impact of home care compared to alternative care locations on elder health outcomes is heterogeneous. Our findings support positive health impacts of home support interventions for community dwelling elders compared to independent living at home. There is insufficient evidence to determine the impact of alternative care locations on elders’ health. Additional research targeting housing and care options for the elderly is needed.

Electronic supplementary material

The online version of this article (doi:10.1186/s12877-016-0395-y) contains supplementary material, which is available to authorized users.

Disability in the Individual ADL, IADL, and Mobility among Older Adults: A Prospective Cohort Study

OBJECTIVES

To examine the risk of disability in 15 individual ADL, IADL, and mobility in older adults by age; and to assess the association of multimorbidity, gender, and education with disability.

DESIGN AND SETTING

A prospective cohort study. The sample included 805 community-dwelling older people aged 60+ living in the Netherlands.

MEASUREMENTS

Disability was assessed using the Katz-15 Index of Independence in Basic Activities of Daily Living (ADL), Instrumental Activities of Daily Living (IADL) and one mobility item. Disability in any of these activities was defined as the inability to perform the activity without assistance. The risk of disability by age for each individual ADL, IADL, and for mobility was assessed using Generalized mixed models.

RESULTS

Disability in activities as household tasks, traveling, shopping, and continence had the highest risk and increased rapidly with age. The risk traveling disability among people aged 65 with two comorbidities increase from 9% to 37% at age 85. Disability in using the telephone, managing medications, finances, transferring, and toileting, had a very low risk and hardly increased with age. Compared to those without chronic conditions, those with ≥ 3 chronic conditions had a 3 to 5 times higher risk of developing disability. Males had a higher risk of disability in managing medication (P=0.005), and preparing meals (P=0.019), whereas females had a higher risk of disability with traveling (P=0.001). No association between education and disability on the individual ADL, IADL, and mobility was observed.

CONCLUSIONS

Older adults were mostly disabled in physical related activities, whereas disability in more cognitive related activities was less often experienced. The impact of multimorbidity on disability in each activity was substantial, while education was not.

Supplementation of Mussel Peptides Reduces aging Phenotype, Lipid Deposition and Oxidative Stress in D-Galactose-Induce Aging Mice

OBJECTIVES

Aging is associated with glucose and lipid metabolism disorder. We aimed to examine the effects of mussel peptides on protecting against aging by regulating glucose and lipid metabolism.

METHODS

For the aging model, d-galactose (200 mg/kg) was administered subcutaneously to 8-month-old mice for 8 weeks. Mussel peptides (1,000 mg/kg) were simultaneously administered by intragastric gavage. The glucose and lipid metabolism profiles, aging phenotype and peroxisome proliferator-activated receptors (PPARs) expression in the liver and adipose tissue of ICR mice were measured.

RESULTS

D-galactose-treated mice showed pronounced fat deposition and impaired glucose and lipid homeostasis, along with increased oxidative damage and aging. Mussel peptides improved metabolic status by reducing serum glucose and triglyceride levels, insulin resistance and hepatic free fatty acid, as well as enhancing serum high-density lipoprotein (HDL) level and hepatic glycogen content, accompanied with amelioration of aging phenotype and fat deposition. Moreover, mussel peptides ameliorated oxidative stress in aged liver tissues and promoted expression of peroxisome proliferator activated receptors alpha (PPARα) and gamma (PPARγ) in liver and adipose tissues.

CONCLUSIONS

These results indicate that mussel peptides protect against lipid metabolic disorders associated with aging via maintaining oxidative stress homeostasis and elevated expression levels of PPARs.

For whom is a health-promoting intervention effective? Predictive factors for performing activities of daily living independently

BACKGROUND

Health-promoting interventions tailored to support older persons to remain in their homes, so-called "ageing in place" is important for supporting or improving their health. The health-promoting programme "Elderly Persons in the Risk Zone," (EPRZ) was set up for this purpose and has shown positive results for maintaining independence in activities of daily living for older persons 80 years and above at 1- and 2 year follow-ups. The aim of this study was to explore factors for maintaining independence in the EPRZ health-promoting programme.

METHODS

Total of 459 participants in the original trial was included in the analysis; 345 in the programme arm and 114 in the control arm. Thirteen variables, including demographic, health, and programme-specific indicators, were chosen as predictors for independence of activities of daily living. Logistic regression was performed separately for participants in the health promotion programme and in the control arm.

RESULTS

In the programme arm, being younger, living alone and self-rated lack of tiredness in performing mobility activities predicted a positive effect of independence in activities of daily living at 1-year follow-up (odds ratio [OR] 1.18, 1.73, 3.02) and 2-year, (OR 1.13, 2.01, 2.02). In the control arm, being less frail was the only predictor at 1-year follow up (OR 1.6 1.09, 2.4); no variables predicted the outcome at the 2-year follow-up.

CONCLUSIONS

Older persons living alone - as a risk of ill health - should be especially recognized and offered an opportunity to participate in health-promoting programmes such as "Elderly Persons in the Risk Zone". Further, screening for subjective frailty could form an advantageous guiding principle to target the right population when deciding to whom health-promoting intervention should be offered.

TRIAL REGISTRATION

The original clinical trial was registered at ClinicalTrials.gov. Identifier: NCT00877058 , April 6, 2009.

Occupation-focused health promotion for well older people — A cost-effectiveness analysis

Introduction

The aim of this study was to evaluate three occupational therapy interventions, focused on supporting continued engagement in occupation among older people, to determine which intervention was most cost effective, evaluated as the incremental cost/quality adjusted life year gained.

Method

The study was based on an exploratory randomized controlled trial. Participants were 77–82 years, single living and without home help. One hundred and seventy seven persons were randomized to an individual intervention, an activity group, a discussion group or a no intervention control group. All interventions focused on supporting the participants to maintain or improve occupational engagement. Outcomes were evaluated at baseline, three and 12 months and included general health and costs (intervention, municipality and health care). Based on linear regression models, we evaluated how outcomes had changed at each follow-up for each intervention group in relation to the control group.

Results

Both group interventions resulted in quality adjusted life years gained at three months. A sustained effect on quality adjusted life years gained and lower total costs indicated that the discussion group was the most cost-effective intervention.

Conclusion

Short-term, occupation-focused occupational therapy intervention delivered in group formats for well older people resulted in quality-adjusted life years gained. A one-session discussion group was most cost effective.

Factors associated with older people's independent living from the viewpoint of health and functional capacity: a register-based study

Aim

The aim of this study was to identify factors associated with independent living of older people from the point of view of health and functional capacity.

Background

Living independently at home is major wish for older people but is depending on health and functional capacity among others. Objective and subjective assessments have been considered important in determining threats for independent living but both of these views have rarely included in the same study.

Design

Descriptive, cross‐sectional register‐based study was conducted.

Methods

Data were collected using the Health and Functional Capacity survey by identifying the factors of health examinations of a cohort (N = 292) of 75‐year old's, born in 1936 (N = 388), in one Finnish medium‐sized municipality in 2011. This study is part of the Functional Ageing project Kaste 2013. The data were analysed statistically by using descriptive analysis, cross‐tabulation and logistic regression.

Results

Partly, different factors were associated with subjective and objective health and functional capacity showing wide range of individuality. Worsening subjective health was associated with worsened self‐assessment of life situation. Worsening subjective health threatens independent living. Factors statistically significantly associated with worsening subjective health were low physical activity, falls during the last 6 months, not managing heavy housework, being sometimes lonely or dejected, having diagnosed diseases or health problems and polypharmacy.

Healthy Aging Promotion through Neuroscientific Information-Based Strategies

To ensure the well-being of a rapidly growing elderly population, it is fundamental to find strategies to foster healthy brain aging. With this intention, we designed a program of scientific-based lectures aimed at dissemination by established neuroscientists about brain function, brain plasticity and how lifestyle influences the brain. We also carried out a pilot study on the impact of the lectures on attendees. The objective was to provide information to elderly people in order to encourage them to identify unhealthy and healthy daily habits, and more importantly, to promote behavioral changes towards healthy brain aging. Here we report on our experience. In order to determine the impact of the lectures in the daily routine of the attendees, we asked them to fill out questionnaires. Preliminary results indicate that neuroscientific information-based strategies can be a useful method to have a positive impact on the lives of elderly, increase their awareness on how to improve brain function and promote positive lifestyle modifications. Furthermore, based on self-reported data, we also found that through this strategy it is possible to promote behavioral changes related to nutrition, sleep, and realization of physical and cognitively stimulating activities. Finally, based on the results obtained, the importance of promoting self-efficacy and the empowerment of the older populations is highlighted.

Older users' perspectives on the benefits of preventive home visits

In this article we explore older people's perspectives on the benefits of preventive home visits (PHVs), after long-term follow-up. PHVs are health services intended to promote older people's health and independence, prevent disease, and postpone functional decline. We applied an explorative and descriptive design and analyzed qualitative research interviews of 10 PHV users who had received multiple visits for at least 6 years. We sought manifest and latent content in our analysis. The participants reported benefits falling within four main categories: to feel safe, to manage everyday life, to live well, and to be somebody. Two latent themes emerged: living with an underlying, realistic concern about an uncertain future, and striving to maintain oneself as a person. The perceived benefits of PHVs differed significantly from the outcome measures commonly used in randomized, controlled trials. PHV interventions should have a longitudinal approach and support each person's current needs and valued goals.

Employment as a Social Determinant of Health: A Systematic Review of Longitudinal Studies Exploring the Relationship Between Employment Status and Physical Health

Purpose:To explore employment as a social determinant of health through examining the relationship between employment status and physical health.

Method:The authors explored the causal relationship between employment status and physical health through conducting a systematic review of 22 longitudinal studies conducted in Finland, France, the Netherlands, Nigeria, Sweden, United Kingdom, and the United States.

Results:Five common trajectories were identified as employment, unemployment, job loss, reemployment, and retired. Unemployment and job loss were associated with poorer physical health. Employment and reemployment were associated with better physical health.

Conclusion:To enhance employment outcomes, it is important for service providers to acknowledge the interaction between the client’s physical health and employment status, and assess client physical functioning. Additional research is necessary to further elucidate this interaction.

Best practice guidelines for the management of frailty: a British Geriatrics Society, Age UK and Royal College of General Practitioners report

Older people are majority users of health and social care services in the UK and internationally. Many older people who access these services have frailty, which is a state of vulnerability to adverse outcomes. The existing health care response to frailty is mainly secondary care-based and reactive to the acute health crises of falls, delirium and immobility. A more proactive, integrated, person-centred and community-based response to frailty is required. The British Geriatrics Society Fit for Frailty guideline is consensus best practice guidance for the management of frailty in community and outpatient settings.

RECOGNITION OF FRAILTY

The BGS recommends that all encounters between health and social care staff and older people in community and outpatient settings should include an assessment for frailty. A gait speed <0.8m/s; a timed-up-and-go test >10s; and a score of ≥3 on the PRISMA 7 questionnaire can indicate frailty. The common clinical presentations of frailty (falls, delirium, sudden immobility) can also be used to indicate the possible presence of frailty.

MANAGEMENT OF FRAILTY

The BGS recommends an holistic medical review based on the principles of comprehensive geriatric assessment (CGA) for all older people identified with frailty. This will: diagnose medical illnesses to optimise treatment; apply evidence-based medication review checklists (e.g. STOPP/START criteria); include discussion with older people and carers to define the impact of illness; work with the older person to create an individualised care and support plan.

SCREENING FOR FRAILTY

The BGS does not recommend population screening for frailty using currently available instruments.

Nurse-led health promotion interventions improve quality of life in frail older home care clients: lessons learned from three randomized trials in Ontario, Canada

OBJECTIVE

This paper explores the lessons learned from a series of three randomized controlled trials that included 498 community-living frail older adults (≥65 years) using home care services in Southern Ontario, Canada. Each study was designed to evaluate the effectiveness of different multi-component nurse-led health promotion and disease prevention (HPDP) interventions.

METHODS

The nurse-led HPDP interventions were 6- or 12-month multi-component and evidence-based strategies targeting known risk factors for functional decline and frailty. Across the three studies, a common approach was used to measure the change in health-related quality of life (HRQOL) (SF-36) and the costs of use of health services (Health and Social Services Utilization Inventory) from baseline to the end of the intervention.

RESULTS

The main lesson learned from the three studies is that nurse-led HPDP interventions for frail older home care clients provide greater improvements in HRQOL compared with usual home care. Such approaches are highly acceptable to this population and can be implemented using existing home care resources. Nurse-led HPDP interventions should include multiple home visits, multidimensional screening and assessment, multi-component evidence-based HPDP strategies, intensive case management, inter-professional collaboration, providers with geriatric training and experience, referral to and coordination of community services, and theory use.

CONCLUSION

The results of the three trials underscore the need to reinvest in nurse-led HPDP interventions in home care to optimize HRQOL and promote ageing in place in the target population of frail older adults. More studies are needed to evaluate the effectiveness of additional nurse-led HPDP interventions in other contexts and settings.

Early detection of health problems in potentially frail community-dwelling older people by general practices--project [G]OLD: design of a longitudinal, quasi-experimental study

Background

Due to the ageing of the population, the number of frail older people who suffer from multiple, complex health complaints increases and this ultimately threatens their ability to function independently. Many interventions for frail older people attempt to prevent or delay functional decline, but they show contradicting results. Recent studies emphasise the importance of embedding these interventions into existing primary care systems and tailoring care to older people’s needs and wishes. This article presents the design of an evaluation study, aiming to investigate the effects and feasibility of the early detection of health problems among community-dwelling older people and their subsequent referral to appropriate care and/or well-being facilities by general practices.

Methods/Design

A longitudinal, quasi-experimental study is designed comparing 13 intervention practices with 11 control practices. General practices select eligible community-dwelling older people (≥ 75 years). Practice nurses from intervention practices (1) visit older people at home for a comprehensive assessment of their health and well-being; (2) discuss results with the GP; (3) formulate – if required – a care and treatment plan together with the patient; (4) refer patient to care and/or well-being facilities; and (5) monitor and coordinate care and follow-up. Control practices provide usual care and match the intervention practices on the presence of different primary care professionals within the practice. Primary outcome measures are health-related quality of life and disability. Additionally, attitude towards ageing, care satisfaction, health care utilisation, nursing home admission and mortality are measured. Some outcomes are assessed by means of a postal questionnaire (at baseline and after 6, 12, and 18 months follow-up), others through continuous registration over the 18-month period. A profound process evaluation will provide insight into barriers and facilitators for implementing the intervention protocol within general practices from both the patient and caregiver perspective.

Discussion

The proposed approach requires redesigning care delivery within general practices for accomplishing appropriate care for older people. A quasi-experimental design is chosen to closely resemble a real-life situation, which is desirable for future implementation after this innovation proves to be successful. Results of the effect and process evaluation will become available in 2013.

Trial registration

The Netherlands National Trial Register NTR2737

Health-promoting interventions for persons aged 80 and older are successful in the short term--results from the randomized and three-armed Elderly Persons in the Risk Zone study

OBJECTIVES

To examine the outcomes of the Elderly Persons in the Risk Zone study, which was designed to evaluate whether it is possible to delay deterioration if a health-promoting intervention is made when an older adult (≥80) is at risk of becoming frail and whether a multiprofessional group intervention is more effective in delaying deterioration than a single preventive home visit with regard to frailty, self-rated health, and activities of daily living (ADLs) at 3-month follow-up.

DESIGN

Randomized, three-armed, single-blind, controlled trial performed between November 2007 and May 2011.

SETTING

Two urban districts of Gothenburg, Sweden.

PARTICIPANTS

Four hundred fifty-nine community-living adults aged 80 and older not dependent on the municipal home help service.

INTERVENTION

A preventive home visit or four weekly multiprofessional senior group meetings with one follow-up home visit.

MEASUREMENTS

Change in frailty, self-rated health, and ADLs between baseline and 3-month follow-up.

RESULTS

Both interventions delayed deterioration of self-rated health (odds ratio (OR) = 1.99, 95% confidence interval (CI) = 1.12-3.54). Senior meetings were the most beneficial intervention for postponing dependence in ADLs (OR = 1.95, 95% CI = 1.14-3.33). No effect on frailty could be demonstrated.

CONCLUSION

Health-promoting interventions made when older adults are at risk of becoming frail can delay deterioration in self-rated health and ADLs in the short term. A multiprofessional group intervention such as the senior meetings described seems to have a greater effect on delaying deterioration in ADLs than a single preventive home visit. Further research is needed to examine the outcome in the long term and in different contexts.

Bereavement care for older people in healthcare settings: qualitative study of experiences

AIM

This study aimed to explore the experiences of healthcare staff of caring for bereaved older people, and older people's experiences of bereavement care.

BACKGROUND

Loss through death of close family members, partners and friends inhibits the physical, emotional and social well being of older people. The rising population of older people and pressure on healthcare services to reduce costs indicate the necessity of developing strategies that enable coping and independence.

DESIGN

A qualitative design drawing on phenomenological methodology was used to understand interactions between healthcare staff and bereaved older people. The study was set in hospital wards, general practice and community nursing teams, and care homes. Healthcare staff and a sample of recently bereaved older people participated.

METHODS

Purposive sampling took place to recruit staff with a range of roles, and older people who were 65 years of age or more, and bereaved of a family member or friend for between 6 months and 5 years. Participants took part in in-depth interviews, and data were analysed systematically.

RESULTS

Thirty-nine participants were recruited, and three key themes arose from the data: (i) Bereavement care depends on an established relationship between healthcare staff and the patient's relatives; (ii) Preparation for the relative's death may not equate to being prepared for bereavement; (iii) The 'Open Door' to bereavement care is only slightly ajar.

CONCLUSIONS

The study identified the interactions of healthcare staff with bereaved older people in terms of the bereavement journey. Staff demonstrated awareness of difficulties the bereaved person may encounter and showed commitment to providing support. However, lack of flexibility in services restricts meaningful interactions.

IMPLICATIONS FOR PRACTICE

(i) Healthcare staff may identify gaps in services in terms of preparing relatives and follow-up post-bereavement; (ii) Therapeutic relationships between staff and relatives enable ongoing support; (iii) Development of practice guidelines is a key consideration.