Randomized intervention trial on preventive home visits to older people: Baseline and follow-up characteristics of participants and non-participants

Community-based complex interventions to sustain independence in older people, stratified by frailty: a systematic review and network meta-analysis

Background

Sustaining independence is important for older people, but there is insufficient guidance about which community health and care services to implement.

Objectives

To synthesise evidence of the effectiveness of community services to sustain independence for older people grouped according to their intervention components, and to examine if frailty moderates the effect.

Review design

Systematic review and network meta-analysis.

Eligibility criteria

Studies: Randomised controlled trials or cluster-randomised controlled trials. Participants: Older people (mean age 65+) living at home. Interventions: community-based complex interventions for sustaining independence. Comparators: usual care, placebo or another complex intervention.

Main outcomes

Living at home, instrumental activities of daily living, personal activities of daily living, care-home placement and service/economic outcomes at 1 year.

Data sources

We searched MEDLINE (1946-), Embase (1947-), CINAHL (1972-), PsycINFO (1806-), CENTRAL and trial registries from inception to August 2021, without restrictions, and scanned reference lists.

Review methods

Interventions were coded, summarised and grouped. Study populations were classified by frailty. A random-effects network meta-analysis was used. We assessed trial-result risk of bias (Cochrane RoB 2), network meta-analysis inconsistency and certainty of evidence (Grading of Recommendations Assessment, Development and Evaluation for network meta-analysis).

Results

We included 129 studies (74,946 participants). Nineteen intervention components, including 'multifactorial-action' (multidomain assessment and management/individualised care planning), were identified in 63 combinations. The following results were of low certainty unless otherwise stated. For living at home, compared to no intervention/placebo, evidence favoured: multifactorial-action and review with medication-review (odds ratio 1.22, 95% confidence interval 0.93 to 1.59; moderate certainty) multifactorial-action with medication-review (odds ratio 2.55, 95% confidence interval 0.61 to 10.60) cognitive training, medication-review, nutrition and exercise (odds ratio 1.93, 95% confidence interval 0.79 to 4.77) and activities of daily living training, nutrition and exercise (odds ratio 1.79, 95% confidence interval 0.67 to 4.76). Four intervention combinations may reduce living at home. For instrumental activities of daily living, evidence favoured multifactorial-action and review with medication-review (standardised mean difference 0.11, 95% confidence interval 0.00 to 0.21; moderate certainty). Two interventions may reduce instrumental activities of daily living. For personal activities of daily living, evidence favoured exercise, multifactorial-action and review with medication-review and self-management (standardised mean difference 0.16, 95% confidence interval -0.51 to 0.82). For homecare recipients, evidence favoured the addition of multifactorial-action and review with medication-review (standardised mean difference 0.60, 95% confidence interval 0.32 to 0.88). Care-home placement and service/economic findings were inconclusive.

Limitations

High risk of bias in most results and imprecise estimates meant that most evidence was low or very low certainty. Few studies contributed to each comparison, impeding evaluation of inconsistency and frailty. Studies were diverse; findings may not apply to all contexts.

Conclusions

Findings for the many intervention combinations evaluated were largely small and uncertain. However, the combinations most likely to sustain independence include multifactorial-action, medication-review and ongoing review of patients. Some combinations may reduce independence.

Future work

Further research is required to explore mechanisms of action and interaction with context. Different methods for evidence synthesis may illuminate further.

Study registration

This study is registered as PROSPERO CRD42019162195.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: NIHR128862) and is published in full in Health Technology Assessment; Vol. 28, No. 48. See the NIHR Funding and Awards website for further award information.

Current Approaches to Following Up Women and Newborns After Discharge From Childbirth Facilities: A Scoping Review

INTRODUCTION

The postpartum period is critical for the health and well-being of women and newborns, but there is limited research on the most effective methods of post-childbirth follow-up. This scoping review synthesizes evidence from high-, middle-, and low-income countries on approaches to following up individuals after discharge from childbirth facilities.

METHODS

Using a systematic search in Ovid MEDLINE, we identified quantitative studies describing post-discharge follow-up methods deployed up to 12 months postpartum. We searched for English-language, peer-reviewed articles published between January 1, 2007 and November 2, 2022, with search terms covering 2 broad areas: "postpartum/postnatal period" and "surveillance." We single-screened titles and abstracts and double-extracted all included articles, recording study design and location, population, health outcome, method, timing and frequency of data collection, and percentage of study participants reached.

RESULTS

We identified 1,654 records, of which 31 studies were included. Eight studies used in-person visits to follow up participants, 10 used telephone calls, 7 used self-administered questionnaires, and 6 used multiple methods. Across studies, the minimum length of follow-up was 1 week after delivery, and up to 4 contacts were made within the first year after delivery. Follow-up (response) rates ranged from 23% to100%. Postpartum infection was the most common outcome investigated. Other outcomes included maternal (ill-)health, neonatal (ill-)health and growth, maternal mental health and well-being, care-giving/-seeking behaviors, and knowledge and intentions.

CONCLUSION

Our scoping review identified multiple follow-up methods after discharge, ranging from home visits to self-administered electronic questionnaires, which could be implemented with high response rates. The studies demonstrated that post-discharge follow-up of women and newborns was feasible, well received, and important for identifying postpartum illness or complications that would otherwise be missed. Therefore, the identified methods have the potential to become an important component of fostering a continuum of care and measuring and addressing postpartum morbidity.

The Hospital Frailty Risk Score Identifies Fewer Cases of Frailty in a Community-Based Cohort of Older Men Than the FRAIL Scale and Frailty Index

OBJECTIVES

The recently developed Hospital Frailty Risk Score (HFRS) allows ascertainment of frailty from administrative data. We aimed to compare the HFRS against the widely used FRAIL Scale and Frailty Index.

DESIGN

Population-based cohort study linked to Western Australian Hospital Morbidity Data Collection and Death Registrations.

SETTING AND PARTICIPANTS

The Health in Men Study with frailty determined at Wave 2 (2001/2004), mortality in the 1-year period following Wave 2, and disability at Wave 3 (2008). Participants were 4228 community-based men aged ≥75 years, followed until Wave 3.

MEASUREMENTS

We used multivariable regression to determine the association between each frailty measure and outcomes of length of stay (LOS), death, and disability. We also determined if the additional cases of frailty identified by one measure over the other was associated with these outcomes.

RESULTS

Of 4228 men studied, the HFRS (n = 689) identified fewer men as frail than the FRAIL Scale (n = 1648) and Frailty Index (n = 1820). In the fully adjusted models, all 3 frailty measures were associated with longer LOS and mortality, whereas only the FRAIL Scale and Frailty Index were significantly associated with disability. The additional cases of frailty identified by the FRAIL Scale and Frailty Index had longer LOS and greater risks of death and disability. The fully adjusted hazard ratio for death among the additional cases of frailty identified by the FRAIL Scale (compared to being not frail on both HFRS and FRAIL Scale) was 2.14 (95% CI 1.48-3.08).

CONCLUSIONS AND IMPLICATIONS

The HFRS is associated with adverse outcomes. However, it identified approximately 60% fewer men who were frail than the FRAIL Scale and Frailty Index, and the additional cases identified were also at high risks of adverse outcomes. Users of the HFRS should be aware of the differences with other frailty measures.

Generalizability and reach of a randomized controlled trial to improve oral health among home care recipients: comparing participants and nonparticipants at baseline and during follow-up

Background

The generalizability of randomized controlled trials (RCTs) with a low response can be limited by systematic differences between participants and nonparticipants. This participation bias, however, is rarely investigated because data on nonparticipants is usually not available. The purpose of this article is to compare all participants and nonparticipants of a RCT to improve oral health among home care recipients at baseline and during follow-up using claims data.

Methods

Seven German statutory health and long-term care insurance funds invited 9656 home care recipients to participate in the RCT MundPflege. Claims data for all participants (n = 527, 5.5% response) and nonparticipants (n = 9129) were analyzed. Associations between trial participation and sex, age, care dependency, number of Elixhauser diseases, and dementia, as well as nursing, medical, and dental care utilization at baseline, were investigated using multivariable logistic regression. Associations between trial participation and the probability of (a) moving into a nursing home, (b) being hospitalized, and (c) death during 1 year of follow-up were examined via Cox proportional hazards regressions, controlling for baseline variables.

Results

At baseline, trial participation was positively associated with male sex (odds ratio 1.29 [95% confidence interval 1.08–1.54]), high (vs. low 1.46 [1.15–1.86]) care dependency, receiving occasional in-kind benefits to relieve caring relatives (1.45 [1.15–1.84]), having a referral by a general practitioner to a medical specialist (1.62 [1.21–2.18]), and dental care utilization (2.02 [1.67–2.45]). It was negatively associated with being 75–84 (vs. < 60 0.67 [0.50–0.90]) and 85 + (0.50 [0.37–0.69]) years old. For morbidity, hospitalizations, and formal, respite, short-term, and day or night care, no associations were found. During follow-up, participants were less likely to move into a nursing home than nonparticipants (hazard ratio 0.50 [0.32–0.79]). For hospitalizations and mortality, no associations were found.

Conclusions

For half of the comparisons, differences between participants and nonparticipants were observed. The RCT’s generalizability is limited, but to a smaller extent than one would expect because of the low response. Routine data provide a valuable source for investigating potential differences between trial participants and nonparticipants, which might be used by future RCTs to evaluate the generalizability of their findings.

Trial registration

German Clinical Trials Register DRKS00013517. Retrospectively registered on June 11, 2018.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06470-y.

Targeting preventive home visits to older adults in disadvantaged communities: Perspectives of professionals

This study explored the implementation of multidimensional preventive home visits targeted to older adults living in a disadvantaged community in Denmark. The intervention was adapted to include the following key components: involvement of community members in recruitment processes; a combination of individual and group-based dissemination; adaptation of materials to overcome language barriers; and diversity-sensitivity training for professionals. The study took place over 12 months between August 2016 and August 2017 and used various data sources: registry-based data, participant observations, combined with individual and focus group interviews with the target population (n = 22) and relevant health care professionals (n = 8). Here, we report on findings pertaining to implementation barriers and facilitators as seen from the perspective of professionals. Socioeconomic vulnerability was prominent, and uptake of health care services was low, indicating under-utilisation. Implementation facilitators and barriers were identified including potentials in nurturing local partnerships and proximity during recruitment; overcoming language barriers; offering diversity-sensitivity training for professionals; and a need for a more multidisciplinary, comprehensive scope of preventive visits for diverse older adults in disadvantaged communities. Thus, more focus on participatory, comprehensive and community-based health promotion are needed to ensure healthy ageing in the context of social inequality and ethnic diversity.

The role of home visits by a nurse to improve palliation in patients treated with self-expandable metallic stents due to incurable esophageal cancer

Self-expandable metallic stent (SEMS) is a preferred option to relieve dysphagia and to palliate patients with incurable esophageal or gastro-esophageal junction (GEJ) cancer. Health Related Quality of Life (QoL) represents a clinically relevant outcome measure in research focused on palliation of patients with advanced GI cancer. In this context, home visits by a nurse carry the potential to offer important advantages. Eighty patients with incurable esophageal or GEJ cancer were randomized to either standard follow up or to an intervention containing regular home visits by a nurse. The primary outcome variable QoL was assessed by EORTC QLQ-C30 and OES-18 before insertion of SEMS, and at 2, 7 and 12 weeks thereafter. Secondary outcomes were; need for re-interventions, number of patients receiving palliative oncological therapy and overall survival. Sixty-six males and 13 females, with a median age of 71, were included. Self-reported overall QoL was significantly higher in the intervention group (P = 0.03). The organ specific module OES-18 revealed a significant reduction in dysphagia by the intervention (P = 0.03) as well as fewer eating disabilities (P = 0.04). No differences were observed in secondary outcomes except for overall survival, where the median survival was increased from 114 to 183 days by the active intervention (P = 0.02). Home visits by a nurse seem to play an important palliative role after placement of SEMS in patients with incurable esophageal or GEJ cancer by improving QoL and may carry the potential to increase overall survival.

Self-rated health, lifestyle habits and risk assessment in 75-year-old persons attending preventive clinic visits with a nurse in primary health care: a cross-sectional study

AIM

To describe self-rated health in relation to lifestyle and illnesses and to identify risk factors for ill health such as pressure ulcers, falls and malnutrition among 75-year-old participants in a new clinical routine involving health assessment followed by tailored one-to-one health promotion at preventive clinic visits to a nurse at primary health care centres (PHCC).

BACKGROUND

There is a rapidly growing ageing population worldwide. It is central to health policy to promote active and healthy ageing. Preventive clinic visits to a nurse in primary health care were introduced as a new clinical intervention in a region in Sweden to improve the quality of health for the older adults.

DESIGN

A quantitative cross-sectional population-based study.

METHODS

The sample consisted of 306 individuals in six primary health care centres in Sweden aged 75 years who attended preventive clinic visits to a nurse. Data were collected from March 2014 to May 2015 during structured conversations with a nurse based on self-administered questionnaires, clinical examinations, risk assessments and after the clinic visit existing register data were collected by the researcher.

FINDINGS

Participants experienced good self-rated health despite being overweight and having chronic illnesses. Daily exercise such as walking and housework was more common than aerobic physical training. The majority had no problems with mobility but reported anxiety, pain and discomfort and had increased risk of falls.

CONCLUSION

It is important to encourage the older adults to live actively and independently for as long as possible. The healthy older adults may benefit from the clinical intervention described here to support the individual's ability to maintain control over their health. Such supportive assessments might help the healthy older adult to achieve active ageing, reducing morbidity and preventing functional decline.

The Importance of Risk and Subgroup Analysis of Nonparticipants in a Geriatric Intervention Study

Background. A major concern in intervention studies is the generalizability of the findings due to refusal of intended participants to actually take part. In studies including ill older people the number of those declining to participate may be large and the concern is therefore relevant. Objectives. To compare patients characteristics, rates of acute readmission, and mortality after one and six months among older persons who agreed and those who declined to participate in a randomized controlled trial and to describe subgroups of nonparticipants. Design. Comparative study based on a randomized controlled trial. Setting. University hospital in the Capital Region of Denmark. Participants. Patients ≥70 years discharged home after a short Emergency Department stay. 399 were requested to participate; 271 consented, whereas 128 refused. Results. Refusers were more likely to be readmitted (p < 0.001) or die (p = 0.006). The largest subgroup of refusers described as "too ill" had the highest risk of readmission (OR = 3.00, 95% CI = 1.61-5.47, p = 0.001) and of mortality within six months (OR = 3.50, 95% CI = 1.64-7.49, p = 0.002). However, this seems not to have affected the results of our randomized study. Conclusion. We recommend that intervention studies among older people or other fragile patient groups include analysis of relevant risk and subgroup analyses of refusers.

Baseline participation in a health examination survey of the population 65 years and older: who is missed and why?

Background

Public health monitoring depends on valid health and disability estimates in the population 65+ years. This is hampered by high non-participation rates in this age group. There is limited insight into size and direction of potential baseline selection bias.

Methods

We analyzed baseline non-participation in a register-based random sample of 1481 inner-city residents 65+ years, invited to a health examination survey according to demographics available for the entire sample, self-report information as available and reasons for non-participation. One year after recruitment, non-responders were revisited to assess their reasons.

Results

Five groups defined by participation status were differentiated: participants (N = 299), persons who had died or moved (N = 173), those who declined participation, but answered a short questionnaire (N = 384), those who declined participation and the short questionnaire (N = 324), and non-responders (N = 301). The results confirm substantial baseline selection bias with significant underrepresentation of persons 85+ years, persons in residential care or from disadvantaged neighborhoods, with lower education, foreign citizenship, or lower health-related quality of life. Finally, reasons for non-participation could be identified for 78 % of all non-participants, including 183 non-responders.

Conclusion

A diversity in health problems and barriers to participation exists among non-participants. Innovative study designs are needed for public health monitoring in aging populations.

Specialist rehabilitation for people with Parkinson’s disease in the community: a randomised controlled trial

Background

Multidisciplinary rehabilitation is recommended for Parkinson’s disease, but evidence suggests that benefit is not sustained.

Objectives

(1) Implement a specialist domiciliary rehabilitation service for people with Parkinson’s and carers. (2) Provide continuing support from trained care assistants to half receiving the rehabilitation. (3) Evaluate the clinical effectiveness of the service, and the value added by the care assistants, compared with usual care. (4) Assess the costs of the interventions. (5) Investigate the acceptability of the service. (6) Deliver guidance for commissioners.

Design

Pragmatic three-parallel group randomised controlled trial.

Setting

Community, county of Surrey, England, 2010–11.

Participants

People with Parkinson’s, at all stages of the disease, and live-in carers.

Interventions

Groups A and B received specialist rehabilitation from a multidisciplinary team (MDT) – comprising Parkinson’s nurse specialists, physiotherapists, occupational therapists, and speech and language therapists – delivered at home, tailored to individual needs, over 6 weeks (about 9 hours’ individual therapy per patient). In addition to the MDT, participants in group B received ongoing support for a further 4 months from a care assistant trained in Parkinson’s (PCA), embedded in the MDT (1 hour per week per patient). Participants in control group (C) received care as usual (no co-ordinated MDT or ongoing support).

Main outcome measures

Follow-up assessments were conducted in participants’ homes at 6, 24 and 36 weeks after baseline. Primary outcomes: Self-Assessment Parkinson’s Disease Disability Scale (patients); the Modified Caregiver Strain Index (carers). Secondary outcomes included: for patients, disease-specific and generic health-related quality of life, psychological well-being, self-efficacy, mobility, falls and speech; for carers, strain, stress, health-related quality of life, psychological well-being and functioning.

Results

A total of 306 people with Parkinson’s (and 182 live-in carers) were randomised [group A,n = 102 (n = 61); group B,n = 101 (n = 60); group C,n = 103 (n = 61)], of whom 269 (155) were analysed at baseline, pilot cohort excluded. Attrition occurred at all stages. A per-protocol analysis [people with Parkinson’s,n = 227 (live-in carers,n = 125)] [group A,n = 75 (n = 45); group B,n = 69 (n = 37); group C,n = 83 (n = 43)] showed that, at the end of the MDT intervention, people with Parkinson’s in groups A and B, compared with group C, had reduced anxiety (p = 0.02); their carers had improved psychological well-being (p = 0.02). People with Parkinson’s in groups A and B also had marginally reduced disability (primary outcome,p = 0.09), and improved non-motor symptoms (p = 0.06) and health-related quality of life (p = 0.07), compared with C. There were significant differences in change scores between week 6 (end of MDT) and week 24 (end of PCA for group B) in favour of group B, owing to worsening in group A (no PCA support) in posture (p = 0.001); non-motor symptoms (p = 0.05); health-related quality of life (p = 0.07); and self-efficacy (p = 0.09). Carers in group B (vs. group A) reported a tendency for reduced strain (p = 0.06). At 36 weeks post recruitment, 3 months after the end of PCA support for group B, there were few differences between the groups. Participants reported learning about Parkinson’s, and valued individual attention. The MDT cost £833; PCA support was £600 extra, per patient (2011 Great British pounds).

Conclusions

Further research is needed into ways of sustaining benefits from rehabilitation including the use of care assistants.

Study registration

Current Controlled Trials: ISRCTN44577970.

Funding

This project was funded by the National Institute for Health Research Health Services and Delivery Research programme and the South East Coast Dementias and Neurodegenerative Disease Research Network (DeNDRoN), and the NHS South East Coast. The report will be published in full inHealth Services and Delivery Research; Vol. 2, No. 51. See the NIHR Journals Library website for further project information.

How do older persons understand the purpose and relevance of preventive home visits? A study of experiences after a first visit

The aim of this study was to explore and describe older persons' experiences of their first Preventive Home Visit. Preventive Home Visits (PHV) are health services that aim to promote older persons' health, prevent functional decline, and reduce the need for comprehensive healthcare. The knowledge base to guide the design of effective PHV interventions is scarce. Studies that explore older persons' experiences of the first visit are essential, as compliance with the service is a prerequisite for positive outcomes. An explorative and descriptive design was applied. Qualitative research interviews with ten older persons who had received the first PHV the previous year were analysed with regard to manifest and latent content. The findings revealed that the understanding of the purpose of PHV varied. For some participants, the concepts and aims of health promotion and disease prevention were difficult to comprehend. The possibility to prepare for the visit was sought. All participants appreciated the service; the dialogue quality was good and a trusted municipal contact person provided security. To enhance compliance and ensure effective PHV, the invitation to the PHV service should include clearly stated aims and specific information about the first visit. An individualised, person-centred approach should be applied.

Educational intervention and functional decline among older people: The modifying effects of social capital

Aim: To analyse if social capital modifies the effect of educational intervention of home visitors on mobility disability. Earlier studies have found that educational intervention of home visitors has a positive effect of older peoples′ functional decline, but how social capital might modify this effect is still unknown. Methods: We used the Danish Intervention Study on Preventive Home Visits – a prospective cohort study including 2863 75-year-olds and 1171 80-year-olds in 34 Danish municipalities – to analyse the modifying effect of different aspects of social capital on the effect of educational intervention of home visitors on functional decline. The three measures of social capital (bonding, bridging, and linking) were measured at contextual level. Data was analysed with multivariate linear regression model using generalised estimating equations to account for repeated measurements. Results: We found that 80-year-olds living in municipalities with high bonding ( B=0.089, p=0.0279) and high linking ( B=0.0929; p=0.0217) had significant better mobility disability in average at 3-year follow up if their municipality had received intervention. Conclusions: With the unique design of the Danish Intervention Study on Preventive Home Visits and with theory-based measures of social capital that distinguish between three aspects of social capital with focus on older people, this study contributes to the literature about the role of social capital for interventions on mobility disability.

Impact of persistent constipation on health-related quality of life and mortality in older community-dwelling women

OBJECTIVES

Very little is known about whether the reported health-related impact of constipation is worse in people who experience constipation over a long period of time vs. those with more transient symptoms. We aimed to determine the impact of persistent vs. transient constipation on health-related quality of life (QOL), depression, and mortality.

METHODS

We analyzed data from 5,107 women (aged 70-75 years in 1996) who answered "Have you had constipation in the past 12 months?" in all five surveys sent out every 3 years of the Australian Longitudinal Study on Women's Health.

RESULTS

Of the 5,107 women, 20.9, 54.1, and 24.7% reported having persistent constipation on at least 4 out of 5 surveys, transient constipation reported on 1-3 surveys, or none reported over the 15-year time frame, respectively. Women who reported persistent constipation had significantly lower scores for all domains of QOL on the SF-36 except role-emotional, and had higher levels of self-reported depression, even after adjusting for number of chronic illnesses and fluid intake. Mortality rates were increased when comparing women with no reported constipation with persistently reported constipation (8.2% vs. 11%, odds ratio = 1.32, 95% confidence interval 1.0, 1.74, P = 0.05) controlling for specific chronic illnesses.

CONCLUSIONS

Persistent constipation among older women is associated with poor health outcomes.

General health checks in adults for reducing morbidity and mortality from disease

BACKGROUND

General health checks are common elements of health care in some countries. These aim to detect disease and risk factors for disease with the purpose of reducing morbidity and mortality. Most of the commonly used screening tests offered in general health checks have been incompletely studied. Also, screening leads to increased use of diagnostic and therapeutic interventions, which can be harmful as well as beneficial. It is, therefore, important to assess whether general health checks do more good than harm.

OBJECTIVES

We aimed to quantify the benefits and harms of general health checks with an emphasis on patient-relevant outcomes such as morbidity and mortality rather than on surrogate outcomes such as blood pressure and serum cholesterol levels.

SEARCH METHODS

We searched The Cochrane Library, the Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Effective Practice and Organisation of Care (EPOC) Trials Register, MEDLINE, EMBASE, Healthstar, CINAHL, ClinicalTrials.gov and WHO International Clinical Trials Registry Platform (ICTRP) to July 2012. Two authors screened titles and abstracts, assessed papers for eligibility and read reference lists. One author used citation tracking (Web of Knowledge) and asked trialists about additional studies.

SELECTION CRITERIA

We included randomised trials comparing health checks with no health checks in adults unselected for disease or risk factors. We did not include geriatric trials. We defined health checks as screening general populations for more than one disease or risk factor in more than one organ system.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data and assessed the risk of bias in the trials. We contacted authors for additional outcomes or trial details when necessary. For mortality outcomes we analysed the results with random-effects model meta-analysis, and for other outcomes we did a qualitative synthesis as meta-analysis was not feasible.

MAIN RESULTS

We included 16 trials, 14 of which had available outcome data (182,880 participants). Nine trials provided data on total mortality (155,899 participants, 11,940 deaths), median follow-up time nine years, giving a risk ratio of 0.99 (95% confidence interval (CI) 0.95 to 1.03). Eight trials provided data on cardiovascular mortality (152,435 participants, 4567 deaths), risk ratio 1.03 (95% CI 0.91 to 1.17) and eight trials on cancer mortality (139,290 participants, 3663 deaths), risk ratio 1.01 (95% CI 0.92 to 1.12). Subgroup and sensitivity analyses did not alter these findings.We did not find an effect on clinical events or other measures of morbidity but one trial found an increased occurrence of hypertension and hypercholesterolaemia with screening and one trial found an increased occurence of self-reported chronic disease. One trial found a 20% increase in the total number of new diagnoses per participant over six years compared to the control group. No trials compared the total number of prescriptions, but two out of four trials found an increased number of people using antihypertensive drugs. Two out of four trials found small beneficial effects on self-reported health, but this could be due to reporting bias as the trials were not blinded. We did not find an effect on admission to hospital, disability, worry, additional visits to the physician, or absence from work, but most of these outcomes were poorly studied. We did not find useful results on the number of referrals to specialists, the number of follow-up tests after positive screening results, or the amount of surgery.

AUTHORS' CONCLUSIONS

General health checks did not reduce morbidity or mortality, neither overall nor for cardiovascular or cancer causes, although the number of new diagnoses was increased. Important harmful outcomes, such as the number of follow-up diagnostic procedures or short term psychological effects, were often not studied or reported and many trials had methodological problems. With the large number of participants and deaths included, the long follow-up periods used, and considering that cardiovascular and cancer mortality were not reduced, general health checks are unlikely to be beneficial.

Impact of Social Capital on 8-Year Mortality Among Older People in 34 Danish Municipalities

Objectives: To analyze the impact of social capital measures (bonding, bridging, and linking) on all-cause mortality at 8-year follow-up among older people aged 75 and 80 at baseline. Method: Prospective cohort study on preventive home visits including 2,863 seventy-five-year-olds and 1,171 eighty-year-olds in 34 Danish municipalities. The associations of the three aspects of social capital measures with mortality were tested in Cox regression models on time to death. Results: In the 80-year-old cohort significant associations were seen between mortality and both bridging (hazards ratio (HR) = 1.24, 95% CI [1.07, 1.45]) and linking (HR = 1.21, 95% CI [1.03, 1.43]), but the associations attenuated when controlling for relevant confounders. None of the social capital measures were associated with mortality among the 75-year-olds. Conclusion: The measures of social capital used in the present study include key aspects of social capital that are associated to mortality in older populations via physical activity and mobility disability.

HIV/AIDS related home based care practices among primary health care workers in Ogun state, Nigeria

BACKGROUND

HIV/AIDS is fast becoming a chronic disease with the advent of antiretroviral drugs, therefore making home based care key in the management of chronically ill HIV/AIDS patient. The objective of this study was to determine the perception and practice of health care workers on HIV/AIDS related home based care in the health facilities in Ogun state, Nigeria.

METHODS

This study is an analytical cross-sectional study. A multistage cluster sampling technique was used to obtain a representative sample of the primary health care workers in Ogun state. An interviewer administered structured questionnaire was administered by trained health workers to elicit the required information.

RESULT

A total of 350 health care workers were interviewed, 70% of the respondents could adequately describe the components of home based care. Only 38.7% were aware of the National guideline on home based care practices and 17.1% believe that home based care will not significantly improve the prognosis of PLWAs. Few 19.1% had ever been trained or ever involved 16.6% in home based care practices. Only 20 [5.7%] are involved on a weekly basis, 16 [4.6%] monthly and 22 [6.3%] quarterly. Reasons given for non implementation of home based care are inadequate number of healthcare workers 45%, lack of political will 24.4%, lack of implementation by facility managers 14% and inadequate funds 16.6%.Factors that were significantly associated with the practice of home based care were perception of its relevance in improving prognosis [OR = 54.21, C.I = 23.22-129.52] and presence of a support group in the facility [OR = 4.80, C.I = 2.40-9.57]. There was however no statistically significant relationship between adequate knowledge of home based care [OR = 0.78, C.I = 0.39-1.54] and previous training on home based care (OR = 1.43, C.I = 0.66-3.06].

CONCLUSION

The practice of home based care for HIV/AIDS among the study population is low and it is greatly influenced by perception of its effectiveness and relevance. The study recommends that the health care workers should be adequately educated on the importance of home based care in the management of chronic illnesses in order to enhance its practice.

Representations and practices of prevention in elderly populations: investigating acceptance to participate in and adhesion to an intervention study for the prevention of Alzheimer's disease (ACCEPT study)--the need for a multidisciplinary approach

BACKGROUND

In the domain of Alzheimer's disease (AD) prevention, various potentially protective factors have been identified in epidemiological studies. Although the results of these observational studies have been relatively consistent, the results of intervention studies remain disappointing. Methodological problems could explain these negative results, like the selection of the population; a plausible assumption is that the older people who agree to take part in these intervention studies differ from those who refuse, and are those that are least likely to benefit from such programs. The aim of this study was (i) to study the determinants of participation in and adhesion to a prevention trial in a population of older individuals via a quantitative approach using a questionnaire, (ii) to study the representations and practices of prevention in this population using a qualitative approach using semi-structured interviews and focus groups.

METHOD

The study population for the ACCEPT study was recruited at the time of inclusion of subjects in a prevention trial. The population was made up of persons aged 70 years or older, living at home and demonstrating some form of frailty, defined as a spontaneous memory complaint to their general practitioner or difficulties in carrying out instrumental activities of daily living. We used a quantitative approach based on the administration of a self-completed questionnaire sent to 1680 subjects having accepted to take part in the prevention trial, and to the sample of subjects meeting the inclusion criteria but having refused to take part. The qualitative approach, carried out at the moment of inclusion, involved subjects that having accepted to take part and subjects that having refused. Semi-structured interviews were carried out in order to understand the logic leading to refusal or acceptance.

CONCLUSION

The analysis of the results will combine the viewpoints of the different disciplines. It will allow us to better understand the logic at work, to characterise the populations at risk of refusal, and perhaps to remove some of the barriers to participation in prevention programs. The identification of such barriers will provide feedback in terms of the conception and management of prevention measures.

A comparison of specialist rehabilitation and care assistant support with specialist rehabilitation alone and usual care for people with Parkinson's living in the community: study protocol for a randomised controlled trial

BACKGROUND

Parkinson's Disease is a degenerative neurological condition that causes movement problems and other distressing symptoms. People with Parkinson's disease gradually lose their independence and strain is placed on family members. A multidisciplinary approach to rehabilitation for people with Parkinson's is recommended but has not been widely researched. Studies are needed that investigate cost-effective community-based service delivery models to reduce disability and dependency and admission to long term care, and improve quality of life.

METHODS

A pragmatic three parallel group randomised controlled trial involving people with Parkinson's Disease and live-in carers (family friends or paid carers), and comparing: management by a specialist multidisciplinary team for six weeks, according to a care plan agreed between the professionals and the patient and carer (Group A); multidisciplinary team management and additional support for four months from a trained care assistant (Group B); usual care, no coordinated team care planning or ongoing support (Group C). Follow up will be for six months to determine the impact and relative cost-effectiveness of the two interventions, compared to usual care. The primary outcomes are disability (patients) and strain (carers). Secondary outcomes include patient mobility, falls, speech, pain, self efficacy, health and social care use; carer general health; patient and carer social functioning, psychological wellbeing, health related quality of life. Semi structured interviews will be undertaken with providers (team members, care assistants), service commissioners, and patients and carers in groups A and B, to gain feedback about the acceptability of the interventions. A cost - effectiveness evaluation is embedded in the trial.

DISCUSSION

The trial investigates components of recent national policy recommendations for people with long term conditions, and Parkinson's Disease in particular, and will provide guidance to inform local service planning and commissioning.

TRIAL REGISTRATION

ISRCTN: ISRCTN44577970.

Measuring aspects of social capital in a gerontological perspective

Within the last 10 years, there has been a growing interest in the importance of social capital and older people. The aims of the study are to advance measurements of aspects of social capital based on bonding, bridging and linking that can be used to study the impact of the local community on community-dwelling older populations and to study the distribution of these three measurements of social capital in 34 municipalities. Data are from a Danish prospective cohort study on preventive home visits among 4,034 old people 75+ in 34 municipalities in Denmark. The measurements of aspects of social capital at community level are based on theory of bonding, bridging and linking social capital. It has been possible to analyse variations in the three measurements of social capital in the 34 municipalities and to characterize different municipalities according to high versus low social capital. There are interesting patterns in distribution of the three measurements. The two extreme groups of municipalities (high and low social capital) differ with regard to demography, social and structural conditions in the municipalities. We believe that the proposed measures of social capital will be relevant in future studies of social capital and health in older populations, since they are theoretically based and cover different aspects of social capital related to older people and their local community.

Impact of home and community-based services on hospitalisation and institutionalisation among individuals eligible for long-term care insurance in Japan

BACKGROUND

This population-based retrospective cohort study aimed to clarify the impact of home and community-based services on the hospitalisation and institutionalisation of individuals certified as eligible for long-term care insurance (LTCI) benefits.

METHODS

Health insurance data and LTCI data were combined into a database of 1,020 individuals in two farming communities in Hokkaido who were enrolled in Citizen's Health Insurance. They had not received long-term care services prior to April 1, 2000 and were newly certified as eligible for Long-Term Care Insurance benefits between April 1, 2000 and February 29, 2008. The analysis covered 565 subjects who had not been hospitalised or institutionalised at the time of first certification of LTCI benefits. The adjusted hazard ratios (HRs) of hospitalisation or institutionalisation or death after the initial certification were calculated using the Cox proportional hazard model. The predictors were age, sex, eligibility level, area of residence, income, year of initial certification and average monthly outpatient medical expenditures, in addition to average monthly total home and community-based services expenditures (analysis 1), the use or no use of each type of service (analysis 2), and average monthly expenditures for home-visit and day-care types of services, the use or no use of respite care, and the use or no use of rental services for assistive devices (analysis 3).

RESULTS

Users of home and community-based services were less likely than non-users to be hospitalised or institutionalised. Among the types of services, users of respite care (HR: 0.71, 95% confidence interval [CI]: 0.55-0.93) and rental services for assistive devices (HR: 0.70, 95% CI: 0.54-0.92) were less likely to be hospitalised or institutionalised than non-users. For those with relatively light needs, users of day care were also less likely to be hospitalised or institutionalized than non-users (HR: 0.77, 95% CI: 0.61-0.98).

CONCLUSIONS

Respite care, rental services for assistive devices and day care are effective in preventing hospitalisation and institutionalisation. Our results suggest that home and community-based services contribute to the goal of the LTCI system of encouraging individuals certified as needing long-term care to live independently at home for as long as possible.

The Copenhagen Oral Health Senior Cohort: design, population and dental health

BACKGROUND

  In order to study the way old age influence oral health, the Copenhagen Oral Health Senior Cohort (COHS) has been established.

OBJECTIVES

  To describe the design, measurement procedures, and baseline values for COHS including spatial distribution of restorations and dental caries as well as reasons for non-participation.

MATERIALS AND METHODS

  Seven hundred and eighty-three individuals aged 65 years or older, from a total of 1918 invited elderly people, underwent an interview regarding oral health-related behaviour and a clinical oral examination including measurement of unstimulated whole saliva flow rate.

RESULTS

  Twelve percent of the COHS was edentulous. The number of dental restorations was higher for women compared to men; however, men had more caries than women. Coronal caries was most frequent on mesial and distal surfaces and on the maxillary incisors and canines; root caries was most frequent on labial surfaces and evenly distributed within the dentition. Only 41% of all invited elderly people accepted the invitation, with old age and poor health being the primary reasons for non-participation.

CONCLUSION

  The baseline values for COHS show that a substantial proportion of the participants had retained a natural dentition and that dental caries was prevalent with the anterior maxillary teeth being most affected.

Relationship between home care service use and changes in the care needs level of Japanese elderly

Background

With the introduction of long-term care insurance (LTCI) in Japan, more home care services are available for the community-dwelling elderly. To deliver effective home care services, it is important to know the effects of service use. In this study, as the first step to determine this, we sought to describe different home service use in the sustained/improved group and deteriorated group in their care needs levels, and to report the relationship between the use of home care services and changes in care needs levels.

Methods

The participants included 624 of a total of 1,474 users of LTCI services in one city in Japan. Home care service users were stratified into a 'lower care needs level subgroup' and a 'higher care needs level subgroup' based on the baseline care needs level. Simple statistical comparison and multiple logistic regression analyses in which the change in care needs level was set as a dependent variable were performed. Gender, age, and baseline care needs level were designated as control variables. Home based services were treated as independent variables. In this study, home care services consisted of home help, home bathing services, a visiting nurse, home rehabilitation, nursing home daycare, health daycare, loan of medical devices, respite stay in a nursing home, respite stay in a health care facility, respite stay in a sanatorium-type medical care facility, and medical management by a physician.

Results

In the lower care needs level subgroup, age (OR = 1.04, CI, 1.01-1.08), use of respite stay in a nursing home (OR = 2.55; CI, 1.43-4.56), and the number of types of long-term care services (OR = 1.33; CI, 1.02-1.74) used during an 11 month period were significantly related to a deterioration of the user's care needs level. In the higher care needs level subgroup, use of medical management by a physician (OR = 6.99; CI, 1.42-41.25) was significantly related to a deterioration of the user's care needs level. There were no home based services significantly related to sustaining or improving the user's care needs level.

Conclusion

There were different home service use in two groups (the sustained/improved group and the deteriorated group). Respite stay in a nursing home service use and more types of service use were related to experiencing a deterioration of care needs level in lower care needs level community-dwelling elderly persons in Japan. Further, medical management by a physician service was related to experiencing a deterioration of care needs level in higher care needs level community-dwelling elderly persons.

Feasibility and effects of preventive home visits for at-risk older people: design of a randomized controlled trial

BACKGROUND

The search for preventive methods to mitigate functional decline and unwanted relocation by older adults living in the community is important. Preventive home visit (PHV) models use infrequent but regular visits to older adults by trained practitioners with the goal of maintaining function and quality of life. Evidence about PHV efficacy is mixed but generally supportive. Yet interventions have rarely combined a comprehensive (biopsychosocial) occupational therapy intervention protocol with a home visit to older adults. There is a particular need in the USA to create and examine such a protocol.

METHODS/DESIGN

The study is a single-blind randomized controlled pilot trial designed to assess the feasibility, and to obtain preliminary efficacy estimates, of an intervention consisting of preventive home visits to community-dwelling older adults. An occupational therapy-based preventive home visit (PHV) intervention was developed and is being implemented and evaluated using a repeated measures design. We recruited a sample of 110 from a population of older adults (75+) who were screened and found to be at-risk for functional decline. Participants are currently living in the community (not in assisted living or a skilled nursing facility) in one of three central North Carolina counties. After consent, participants were randomly assigned into experimental and comparison groups. The experimental group receives the intervention 4 times over a 12 month follow-up period while the comparison group receives a minimal intervention of mailed printed materials. Pre- and post-intervention measures are being gathered by questionnaires administered face-to-face by a treatment-blinded research associate. Key outcome measures include functional ability, participation, life satisfaction, self-rated health, and depression. Additional information is collected from participants in the experimental group during the intervention to assess the feasibility of the intervention and potential modifiers. Fidelity is being addressed and measured across several domains.

DISCUSSION

Feasibility indications to date are positive. Although the protocol has some limitations, we expect to learn enough about the intervention, delivery and effects to support a larger trial with a more stringent design and enhanced statistical power.

TRIAL REGISTRATION

ClinicalTrials.gov ID NCT00985283.

Barriers to participation in a hospital-based falls assessment clinic programme: an interview study with older people

AIMS

To gain new knowledge about barriers to participation in hospital-based falls assessment.

METHODS

Semi-structured interviews with 20 older people referred to falls assessment at a hospital-based clinic were conducted. A convenience sample of 10 refusers and 10 accepters was collected. Those who refused referral were recruited in relation to a systematic falls screening programme performed by preventive home visitors. Accepters were selected among 72 participants successively completing the falls assessment clinic programme. The time between the interviews was 12 months; different levels of knowledge were expected, owing to accepters' participation in the programme. Interview transcriptions were thematically analysed. The analysis was directed towards identification of barriers to falls assessment.

RESULTS

Barriers to participation were categorized as being either within or outside the falls clinic, and included administration, time, communication, attitudes to fall prevention, and expected future costs. Accepters completing the programme expressed a feeling of being ''met'' in the system and maintaining authority over their own life, while the refusers expressed concern about the healthcare system taking over their life.

CONCLUSIONS

This study indicates that older at-risk patients acknowledge their falls problem, but refuse to participate in hospital-based assessment programmes because they expect to lose their authority and to be caught up in the healthcare system. In order to transform the findings of this study to a public health message, we have to consider moving the focus of falls prevention strategies from disease control to the domain of health promotion in order to engage older adults in preventive healthcare.

A feasible model for prevention of functional decline in older home-dwelling people--the GP role. A municipality-randomized intervention trial

BACKGROUND

Danish municipalities are required by state law to offer two annual home visits to all non-disabled citizens > or =75 years. Visits are primarily carried out by district nurses. GPs are rarely directly involved.

OBJECTIVE

To evaluate the effects of offering an educational programme to home visitors and GPs on mortality, functional ability and nursing home admissions among home-dwelling older people.

DESIGN

Municipality pair-matched randomized trial.

SETTING

Danish primary care.

SUBJECT

2863 home-dwelling 75-year-olds and 1171 home-dwelling 80-year-olds living in 34 municipalities.

INTERVENTION

Home visitors received regular education for a period of 3 years. In nine of 17 intervention municipalities, GPs participated in one small group training session during the first year.

MAIN OUTCOME MEASURES

Mortality, functional ability and nursing home admission during 4(1/2) years of follow-up.

RESULTS

INTERVENTION was not associated with mortality. Home visitor education was associated with reduction in functional decline among home-dwelling 80-year-olds after the three intervention years in municipalities where GPs accepted and participated in small group-based training. Effects did not persist after the intervention ended. When analyses were restricted to baseline non-disabled persons, intervention was associated with beneficial effects on functional ability after three intervention years among 80-year-olds, regardless of education was given to home visitors alone or to visitors and GPs. Nursing home admission rates were lower among the 80-year-olds living in the intervention municipalities.

CONCLUSION

A brief, practicable interdisciplinary educational programme for primary care professionals postponed functional decline in non-disabled 80-year-old home-dwelling persons.

How likely are older people to take up different falls prevention activities?

OBJECTIVE

To determine the extent to which older people are willing to engage in different falls prevention activities, and how this may vary in different sectors of the older population.

METHODS

A survey sent to patients aged over 54 in ten general practices in the Southampton, Bristol and Manchester areas of the UK in 2006 yielded 5,440 respondents. The survey assessed willingness to attend classes of strength and balance training (SBT), carry out SBT at home, or accept support to reduce home hazards. Participants were asked their gender, age, education, home tenure, ethnic group, and how often they had fallen during the past year.

RESULTS

Over 60% of the sample would consider doing SBT at home and 36.4% said they would definitely do SBT at home. Only 22.6% would definitely attend group sessions and 41.1% would definitely not attend. Older age, recent falls and lower socioeconomic status were associated with a greater willingness to carry out SBT at home (but not in classes) and accept help with home hazards.

CONCLUSIONS

Health promotion programmes should give prominence to home-based performance of SBT as a method of encouraging the entire older population to engage in falls prevention, including those most in need.

Influence of psychological characteristics and social relations on receiving preventive home visits in older men and women

The purpose was to analyze whether psychological characteristics and social relations in older men and women were related to accepting and receiving preventive home visits during 3 years, when offered as part of a national scheme. The study was based on secondary data from the Danish Intervention Study on Preventive Home Visits in 34 municipalities. The study population included 3,377 men and women who answered questions about psychological characteristics and social relations at baseline, survived and took part in the three year follow-up study. Number of preventive home visits was registered during 3 years in a specially designed software installed in the municipalities. Psychological characteristics were measured by questions on sadness, aggressiveness, life satisfaction, mood, loneliness and sense of coherence. Social relations were measured by questions on cohabitation status, diversity in social relations and social participation. Covariates included age and disability. Older men with poor psychological rating on most of the variables had larger odds ratios of accepting and receiving preventive home visits compared to older men with higher ratings. Older women with poor rating on the psychological characteristics and high social participation had larger odds of accepting and receiving preventive home visits, and women with a strong sense of coherence had larger odds of receiving many visits. It is concluded that psychological characteristics and social relations in older persons seem to influence whether they accept and receive preventive home visits, but patterns of associations are complex and vary for men and women.

Multidimensional preventive home visit programs for community-dwelling older adults: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Multidimensional preventive home visit programs aim at maintaining health and autonomy of older adults and preventing disability and subsequent nursing home admission, but results of randomized controlled trials (RCTs) have been inconsistent. Our objective was to systematically review RCTs examining the effect of home visit programs on mortality, nursing home admissions, and functional status decline.

METHODS

Data sources were MEDLINE, EMBASE, Cochrane CENTRAL database, and references. Studies were reviewed to identify RCTs that compared outcome data of older participants in preventive home visit programs with control group outcome data. Publications reporting 21 trials were included. Data on study population, intervention characteristics, outcomes, and trial quality were double-extracted. We conducted random effects meta-analyses.

RESULTS

Pooled effects estimates revealed statistically nonsignificant favorable, and heterogeneous effects on mortality (odds ratio [OR] 0.92, 95% confidence interval [CI], 0.80-1.05), functional status decline (OR 0.89, 95% CI, 0.77-1.03), and nursing home admission (OR 0.86, 95% CI, 0.68-1.10). A beneficial effect on mortality was seen in younger study populations (OR 0.74, 95% CI, 0.58-0.94) but not in older populations (OR 1.14, 95% CI, 0.90-1.43). Functional decline was reduced in programs including a clinical examination in the initial assessment (OR 0.64, 95% CI, 0.48-0.87) but not in other trials (OR 1.00, 95% CI, 0.88-1.14). There was no single factor explaining the heterogenous effects of trials on nursing home admissions.

CONCLUSION

Multidimensional preventive home visits have the potential to reduce disability burden among older adults when based on multidimensional assessment with clinical examination. Effects on nursing home admissions are heterogeneous and likely depend on multiple factors including population factors, program characteristics, and health care setting.

Preventive home visits to home-dwelling older people and hospital admissions: a municipality-randomised intervention trial

Preventive home visits to older home-dwelling people have been part of national policy in Denmark since 1996. The aim was to evaluate whether education of home visitors and GPs was associated with hospital admission rates. In a population-based prospective controlled intervention trial in 34 municipalities, intervention municipality visitors received regular education during 3 years and GPs were introduced to a short assessment programme. Participation totalled 4,034 75- and 80-year-old home-dwelling persons, of which 3,132 (78%) had no mobility disability at baseline. Complete data on hospital services were obtained for all participants. No difference was observed in time to first admission between older people living in the intervention municipalities compared with people living in the control municipalities, HR 0.93 (95%CI: 0.85, 1.02, P = 0.17). Duration of first hospital stay was the same in the two groups (7.3 days). The mean number of admissions was not associated with intervention. Accepting and receiving home visits was associated with a reduced risk of hospital admission, HR 0.84 (95%CI: 0.76, 0.92), especially among the initially disabled. Hospital admission rates were associated with functional decline patterns. Persons experiencing catastrophic and progressive decline had the highest risk. Persons experiencing reversible functional decline were more often hospitalised in the intervention municipalities, and fewer persons living in the intervention municipalities experienced progressive decline. Education of primary care professionals was not associated with risk for first hospital admission among all older people living in the community, but may be associated with older people's different functional decline patterns.

Education of preventive home visitors: the effects on change in tiredness in daily activities

The objective was to investigate whether a 3-year educational intervention towards primary health care professionals had effect on change in tiredness in daily activities during a 3-year intervention period in non-disabled older adults. The design was a controlled 3-year intervention study in 34 Danish municipalities with randomization and intervention at municipality level. The 17 intervention municipality visitors received regular education and general practitioners were introduced to a short assessment program. The effect was measured among old non-disabled individuals living in the municipalities by a validated scale on tiredness in daily activities at baseline and at the end of the intervention period. In total 2,515, 75- and 80-year-old men and women participated in all parts of the present study. Eighty-year-old non-disabled men and women who lived in the control municipalities had larger odds ratios of sustained tiredness during the 3-year intervention period compared with 80-year-olds living in intervention municipalities where both GPs and home visitors participated in the educational programme (OR = 3.48; 95% CI 1.51-8.00) and in intervention municipalities where only the home visitors (OR = 2.63; 95% CI 0.97-7.12) were educated. The intervention had no effect on stability and change in tiredness among the 75-year-old men and women. A brief, feasible educational intervention for primary care professionals has beneficial effect on changes in feelings of tiredness in non-disabled 80-year-old men and women.