An Old Challenge with New Promises: A Systematic Review on Comprehensive Geriatric Assessment in Long-Term Care Facilities

The epigenetics of frailty

The conceptual change of frailty, from a physical to a biopsychosocial phenotype, expanded the field of frailty, including social and behavioral domains with critical interaction between different frailty models. Environmental exposures - including physical exercise, psychosocial factors and diet - may play a role in the frailty pathophysiology. Complex underlying mechanisms involve the progressive interactions of genetics with epigenetics and of multimorbidity with environmental factors. Here we review the literature on possible mechanisms explaining the association between epigenetic hallmarks (i.e., global DNA methylation, DNA methylation age acceleration and microRNAs) and frailty, considered as biomarkers of aging. Frailty could be considered the result of environmental epigenetic factors on biological aging, caused by conflicting DNA methylation age and chronological age.

Effectiveness of holistic assessment-based interventions for adults with multiple long-term conditions and frailty: an umbrella review of systematic reviews

Holistic assessment-based interventions (HABIs) are effective in older people admitted to hospital, but it is unclear whether similar interventions are effective in adults with multiple long-term conditions or frailty in the community. We conducted an umbrella review to comprehensively evaluate the literature on HABIs for adults (aged ≥18 years) with multiple long-term conditions, and frailty. We searched eight databases for systematic reviews reporting on experimental or quasi-experimental studies. Of 9803 titles screened, we identified 29 eligible reviews (14 with meta-analysis) reporting on 14 types of HABIs. The evidence for the effectiveness of HABIs was largely inconsistent across different types of interventions, settings, and outcomes. We found evidence of no benefit from hospital HABIs on health-related quality of life (HRQoL) and emergency department re-attendance, and evidence of no benefit from community HABIs on overall health-care utilisation rates, emergency department attendance, nursing home admissions, and mortality. The best evidence of effectiveness was for hospital comprehensive geriatric assessment (CGA) on nursing home admissions, keeping patients alive and in their own homes. There was some evidence of benefit from community CGA on hospital admissions, and from CGA spanning community and hospital settings on HRQoL. Patient-centred medical homes had beneficial effects on HRQoL, mental health, self-management, and hospital admissions.

The role of primary health care in long-term care facilities during the COVID-19 pandemic in 30 European countries: a retrospective descriptive study (Eurodata study)

BACKGROUND AND AIM

Primary health care (PHC) supported long-term care facilities (LTCFs) in attending COVID-19 patients. The aim of this study is to describe the role of PHC in LTCFs in Europe during the early phase of the pandemic.

METHODS

Retrospective descriptive study from 30 European countries using data from September 2020 collected with an ad hoc semi-structured questionnaire. Related variables are SARS-CoV-2 testing, contact tracing, follow-up, additional testing, and patient care.

RESULTS

Twenty-six out of the 30 European countries had PHC involvement in LTCFs during the COVID-19 pandemic. PHC participated in initial medical care in 22 countries, while, in 15, PHC was responsible for SARS-CoV-2 test along with other institutions. Supervision of individuals in isolation was carried out mostly by LTCF staff, but physical examination or symptom's follow-up was performed mainly by PHC.

CONCLUSION

PHC has participated in COVID-19 pandemic assistance in LTCFs in coordination with LTCF staff, public health officers, and hospitals.

Clinical practice guidelines for frailty vary in quality but guide primary health care: a systematic review

OBJECTIVES

To appraise the methodological quality, clinical applicability, and reporting quality of clinical practice guidelines (CPGs) for frailty in primary care and identify research gaps using evidence mapping.

STUDY DESIGN AND SETTING

We conducted a systematic literature search in PubMed, Web of Science, Embase, CINAHL, guideline databases, and frailty or geriatric society websites. Appraisal of Guidelines Research and Evaluation II, AGREE-Recommendations Excellence, and Reporting Items for Practice Guidelines in Healthcare checklist were used to evaluate overall quality for frailty CPGs as "high", "medium", or "low" quality. We used bubble plots to show recommendations in CPGs.

RESULTS

Twelve CPGs were identified. According to the overall quality evaluation, five CPGs were considered as high quality, six as medium quality, and one as low quality. The recommendations in CPGs were generally consistent and mainly focused on frailty prevention, identification, multidisciplinary, nonpharmacological, and other treatments. However, evidence was lacking in some areas, such as effective prevention strategies and implementation of recommendations.

CONCLUSION

The frailty CPGs vary in quality but have consistent recommendations that can guide clinical practice in primary care. This could point the way for future research to address existing gaps and facilitate the development of trustworthy CPGs for frailty.

Taxonomy of Interventions to Reduce Acute Care Transfers From Long-term Care Homes: A Systematic Scoping Review

OBJECTIVE

To develop a taxonomy of interventions aimed at reducing emergency department (ED) transfers and/or hospitalizations from long-term care (LTC) homes.

DESIGN

A systematic scoping review.

SETTING AND PARTICIPANTS

Permanent LTC home residents.

METHODS

Experimental and comparative observational studies were searched in MEDLINE, CINAHL, Embase Classic + Embase, the Cochrane Library, PsycINFO, Social Work Abstracts, AMED, Global Health, Health and Psychosocial Instruments, Joanna Briggs Institute EBP Database, Ovid Healthstar, and Web of Science Core Collection from inception until March 2020. Forward/backward citation tracking and gray literature searches strengthened comprehensiveness. The Mixed Methods Appraisal Tool was used to assess study quality. Intervention categories and components were identified using an inductive-deductive thematic analysis. Categories were informed by 3 intervention dimensions: (1) "when/at what point(s)" on the continuum of care they occur, (2) "for whom" (ie, intervention target resident populations), and (3) "how" these interventions effect change. Components were informed by the logistical elements of the interventions having the potential to influence outcomes. All interventions were mapped to the developed taxonomy based on their categories, components, and outcomes. Distributions of components by category and study year were graphically presented.

RESULTS

Ninety studies (25 randomized, 23 high quality) were included. Six intervention categories were identified: advance care planning; palliative and end-of-life care; onsite care for acute, subacute, or uncontrolled chronic conditions; transitional care; enhanced usual care (most prevalent, 31% of 90 interventions); and comprehensive care. Four components were identified: increasing human resource capacity (most prevalent, 93%), training or reorganization of existing staff, technology, and standardized tools. The use of technology increased over time. Potentially avoidable ED transfers and/or hospitalizations were measured infrequently as primary outcomes.

CONCLUSIONS AND IMPLICATIONS

This proposed taxonomy can guide future intervention designs. It can also facilitate systematic reviews and precise effect size estimations for homogenous interventions when outcomes are comparable.

Anemia in Elderly Patients-The Impact of Hemoglobin Cut-Off Levels on Geriatric Domains

Background: The primary aim of this study was to evaluate the impact of anemia—according to the WHO criteria—on cognitive performances, mood, functional and nutritional status, and comorbidities in a population of subjects aged 65 years or older. The secondary aim of this study was to understand if different hemoglobin cut-off levels are associated with a variation of the mentioned domains’ impairment. Methods: We designed a cross-sectional study, including subjects aged 65 or more consecutively evaluated in an outpatient setting from July 2013 to December 2019. A sum of 1698 subjects met the inclusion criteria. They were evaluated with: MMSE and CDT (cognitive assessment), GDS (mood), BADL, IADL, PPT, and POMA (autonomies), MNA (nutritional status), and CIRS (comorbidities). Results: According to the WHO criteria, non-anemic patients reported significantly better performances than the anemics in BADL (p < 0.0001), IADL (p = 0.0007), PPT (p = 0.0278), POMA (p = 0.0235), MNA, CIRS TOT, CIRS ICC, and CIRS ISC (p < 0.0001). The same tendency has been found by considering the 12 g/dL- and the 13 g/dL-cut-off level in the whole population. The multivariate analysis showed that, considering the 12 g/dL-cut-off level, age (OR: 1.03, p = 0.0072), CIRS (OR: 1.08, p < 0.0001), and gender (OR: 0.57, p = 0.0007) were significant regressors of anemia, while considering the 13 g/dL-cut-off level, age (OR: 1.04, p = 0.0001), POMA (OR: 1.03, p = 0.0172), MNA (OR = 0.95, p = 0.0036), CIRS (OR: 1.17, p < 0.0001), ICC (OR = 0.83, p = 0.018), and gender (OR = 0.48, p < 0.0001) were significant regressors of anemia, while the other CGA variables were excluded by the model (p > 0.01). Conclusions: Our study showed that anemia negatively impact on geriatric people’s general status, regardless of which hemoglobin cut-off level is considered. It also highlighted that hemoglobin concentrations < 13 g/dL, regardless of gender, have an association with the impairment of the affective-functional-nutritional state as well as an increase in comorbidities; therefore, it should be pursuable to consider the elderly person “anemic” if Hb < 13 g/dL regardless of gender.

Multidisciplinary residential home intervention to improve outcomes for frail residents

BACKGROUND

Residential homes provide accommodation and assistance with personal care only and are not required to have registered nurses on site. However, their residents often have a combination of comorbidity, polypharmacy, frailty and mental-health conditions with poor access to healthcare to meet these needs. Integrated healthcare for older people is a key NHS priority in the Long-Term Plan and the Five-Year Forward View. We describe development and implementation of multi-disciplinary intervention to integrate healthcare and promote interprofessional education.

METHODS

A multi-disciplinary residential home quality improvement project in two cycles by a team comprising senior and trainee general practitioners, trainees in geriatrics, psychiatry, pharmacist and residential home senior staff. The intervention was underpinned by the framework for enhanced health in care homes including Comprehensive Geriatric Assessment (CGA) and mental-health review. Each intervention session included an educational presentation by a team member consideration of each resident in a pre-evaluation multi-disciplinary discussion followed by a structured clinical assessment and discussion of proposed management.

RESULTS

Three residential homes participated with a total 34 residents receiving intervention. In one residential home, there was a 75% reduction in admissions for those reviewed and a reduction in overall admission costs. Polypharmacy was reduced by an average of 2 medications per resident across the three sites. There was a 63% increase in cardio-pulmonary resuscitation decisions and 76% increase in advance care planning discussions.

CONCLUSION

This was an effective model for multi-disciplinary trainees working with a perceived impact on physical and mental health, and valuable opportunities for sharing learning.

The uptake and use of a minimum data set (MDS) for older people living and dying in care homes: a realist review

BACKGROUND

Care homes provide long term care for older people. Countries with standardised approaches to residents' assessment, care planning and review (known as minimum data sets (MDS)) use the aggregate data to guide resource allocation, monitor quality, and for research. Less is known about how an MDS affects how staff assess, provide and review residents' everyday care. The review aimed to develop a theory-driven understanding of how care home staff can effectively implement and use MDS to plan and deliver care for residents.

METHODS

The realist review was organised according to RAMESES (Realist And Meta-narrative Evidence Synthesis: and Evolving Standards) guidelines. There were three overlapping stages: 1) defining the scope of the review and theory development on the use of minimum data set 2) testing and refining candidate programme theories through iterative literature searches and stakeholders' consultations as well as discussion among the research team; and 3) data synthesis from stages 1 and 2. The following databases were used MEDLINE via OVID, Embase, CINAHL (Cumulative Index to Nursing and Allied Health Literature), ASSIA [Applied Social Sciences Citation Index and Abstracts]) and sources of grey literature.

RESULTS

Fifty-one papers informed the development of three key interlinked theoretical propositions: motivation (mandates and incentives for Minimum Data Set completion); frontline staff monitoring (when Minimum Data Set completion is built into the working practices of the care home); and embedded recording systems (Minimum Data Set recording system is integral to collecting residents' data). By valuing the contributions of staff and building on existing ways of working, the uptake and use of an MDS could enable all staff to learn with and from each other about what is important for residents' care CONCLUSIONS: Minimum Data Sets provides commissioners service providers and researchers with standardised information useful for commissioning planning and analysis. For it to be equally useful for care home staff it requires key activities that address the staff experiences of care, their work with others and the use of digital technology.

REGISTRATION

PROSPERO registration number CRD42020171323.

Impact of a patient-centered medical home demonstration on quality of life and patient activation for older adults with complex needs in Singapore

BACKGROUND

The first Patient-Centered Medical Home (PCMH) demonstration in Singapore was launched in November 2016, which aimed to deliver integrated and patient-centered care for patients with bio-psycho-social needs. Implementation was guided by principles of comprehensiveness, coordinated care, shared decision-making, accessible services, and quality and safety. We aimed to investigate the impact of implementing the PCMH in primary care on quality of life (QoL) and patient activation.

METHODS

The study design was a prospective single-arm pre-post study. We applied the 5-level EuroQol 5-dimension (EQ-5D-5L) and Visual Analog Scale (EQ VAS) instruments to assess health-related QoL. The CASP-19 tool was utilised to examine the degree that needs satisfaction was fulfilled in the domains of Control, Autonomy, Self-realisation, and Pleasure. The 13-item Patient Activation Measure (PAM-13) was used to evaluate knowledge, skills and confidence in management of conditions and ability to self-care. Multivariable linear regression models with random intercepts were applied to examine the impact of the PCMH intervention on outcome measures at 3 months and 6 months post-enrolment, compared to baseline.

RESULTS

We analysed 165 study participants enrolled into the PCMH from November 2017 to April 2020, with mean age 77 years (SD: 9.9). Within-group pre-post (6 months) EQ-5D-5L Index (β= -0.01, p-value = 0.35) and EQ VAS score (β=-0.03, p-value = 0.99) had no change. Compared to baseline, there were improvements in CASP-19 total score at 3 months (β = 1.34, p-value = 0.05) and 6 months post-enrolment (β = 1.15, p-value = 0.08) that were marginally out of statistical significance. There was also a significant impact of the PCMH on the CASP-19 Pleasure domain (β = 0.62, p = 0.03) at 6 months post-enrolment, compared to baseline. We found improved patient activation from a 15.2 % reduction in the proportion of participants in lower PAM levels, and a 23.4 and 16.7 % rise in proportion for higher PAM levels 3 and 4, respectively, from 3 months to 6 months post-enrolment.

CONCLUSIONS

Preliminary demonstration of the PCMH model shows evidence of improved needs satisfaction and patient activation, with potential to have a greater impact after a longer intervention duration.

NUrsing Homes End of Life care Program (NUHELP): developing a complex intervention

BACKGROUND

Nursing homes are likely to become increasingly important as end-of-life care facilities. Previous studies indicate that individuals residing in these facilities have a high prevalence of end-of-life symptoms and a significant need for palliative care. The aim of this study was to develop an end-of-life care program for nursing homes in Spain based on previous models yet adapted to the specific context and the needs of staff in nursing homes in the country.

METHODS

A descriptive study of a complex intervention procedure was developed. The study consisted of three phases. The first phase was a prospective study assessing self-efficacy in palliative care (using the SEPC scale) and attitudes towards end-of-life care (using the FATCOD-B scale) among nursing home staff before and after the completion of a basic palliative care training program. In the second phase, objectives were selected using the Delphi consensus technique, where nursing home and primary care professionals assessed the relevance, feasibility, and level of attainment of 42 quality standards. In phase 3, interventions were selected for these objectives through two focus group sessions involving nursing home, primary care, and palliative care professionals.

RESULTS

As a result of the training, an improvement in self-efficacy and attitudes towards end-of-life care was observed. In phase 2, 14 standards were selected and grouped into 5 objectives: to conduct a comprehensive assessment and develop a personalized care plan adapted to the palliative needs detected; to provide information in a clear and accessible way; to request and record advance care directives; to provide early care with respect to loss and grief; to refer patients to a specialized palliative care unit if appropriate, depending on the complexity of the palliative care required. Based on these objectives, the participants in the focus group sessions designed the 22 interventions that make up the program.

CONCLUSIONS

The objectives and interventions of the NUHELP program constitute an end-of-life care program which can be implemented in nursing homes to improve the quality of end-of-life care in these facilities by modifying their clinical practice, organization, and relationship with the health system as well as serving as an example of an effective health intervention program.

Integration of geriatric assessment into clinical oncology practice: A scoping review

Sixty percent of newly diagnosed cancers occur in older adults and more complex planning is required to sustain quality care for older populations. Individualized care incorporating geriatric assessment can predict early mortality and treatment toxicity for older cancer patients. We mapped and summarized the available evidence on the integration of geriatric assessment into clinical oncology practice, and ascertained which domains have been implemented. We systematically searched bibliographic databases and trial registries for reports of clinical studies, clinical practice guidelines, systematic and non-systematic reviews, and grey literature published in English. We gathered data on study characteristics, geriatric domains and strategies evaluated, and relevant study objectives and findings. From a total of 10,124 identified citations, 38 articles met our eligibility criteria, 3 of which were clinical practice guidelines. Nearly half of these articles came from the United States. Domains of the geriatric assessment implemented in studies ranged from 1 to 12, with varied combinations. We identified 27 studies on strategies for implementing geriatric assessment and 24 studies on feasibility of implementing geriatric assessment, into clinical oncology practice. We also identified 3 main geriatric assessment models: 2 from the United States and 1 from Australia. Furthermore, we identified 2 reviews that reported varied components of geriatric assessment models. There is increasingly robust evidence to implement formal geriatric assessment in oncology practice. There remains a great deal of variation in the tools recommended to address each of the domains in a geriatric assessment, with only 1 guideline (American Society of Clinical Oncology guideline) settling on a specific best practice. Protocol registration: Open Science Framework osf.io/mec93.

Comparison of 6 frailty screening tools in diagnostic properties among Chinese community-dwelling older people

We aimed to compare the diagnostic test accuracy (DTA) of six frailty screening tools against comprehensive geriatric assessment (CGA) in the community. A total of 1177 community-dwelling older people were recruited. Frailty was assessed by purely physical tools including Physical Frailty Phenotype (PFP), FRAIL (fatigue, resistance, ambulation, illness and loss of weight), Study of Osteoporotic Fracture (SOF), and multidimensional tools including Tilburg Frailty Indicator (TFI), Groningen Frailty Indicator (GFI) and Comprehensive Frailty Assessment Instrument (CFAI). The receiver operating characteristic curve analyses were performed. The GFI, TFI and CFAI [areas under the curve (AUCs): 0.78-0.80] had better diagnostic accuracy than SOF, PFP and FRAIL (AUCs: 0.69-0.72) (χ²: 6.37-26.76, P<.05). The optimal cut-offs for the PFP, FRAIL and SOF were identical to their original prefrail cut-offs. These results implicate that the multidimensional tools are more effective to identify frailty in the whole community setting, while the self-report FRAIL may be used to identify the prefrail and facilitate early interventions particularly in the community setting with adequate healthcare resources.

Postacute Management of Older Adults Suffering an Osteoporotic Hip Fracture: A Consensus Statement From the International Geriatric Fracture Society

BACKGROUND

The majority of patients require postacute care (PAC) after a hip fracture. Despite its importance, there is no established consensus regarding the standards of care provided to hip fracture patients in PAC facilities.

METHODOLOGY

A writing group was created by professionals from the International Geriatric Fracture Society (IGFS) with representation from other organizations. The focus of the statements included in this article is toward PAC providers located in nursing facilities. Contributions were integrated in a single document that underwent several reviews by each author and then underwent a final review by the lead and senior authors. After this process was completed, the document was appraised by reviewers from IGFS.

RESULTS/CONCLUSION

A total of 15 statements were crafted. These statements summarize the best available evidence and is intended to help PAC facilities managing older adults with hip fractures more efficiently, aiming toward overall better outcomes in the areas of function, quality of life, and with less complications that could interfere with their optimal recovery.

EQ-5D-3L for Assessing Quality of Life in Older Nursing Home Residents with Cognitive Impairment

BACKGROUND

Quality of life (QoL) is recognized as an important patient-reported outcome measure. Assessing QoL in older people with cognitive impairment is a challenge due to discrepancies in the collection of data via proxies versus self-report. This study aimed to assess the psychometric properties of the self-reported EQ-5D (including the EQ index and EQ visual analog scale (VAS)) in nursing homes residents with cognitive impairment and to analyze its validity based on scales included in the comprehensive geriatric assessment.

METHODS

Cross-sectional, multicenter study analyzing the feasibility, acceptability, reliability, and validity of the EQ-5D based on 251 self-administered questionnaires in a sample of nursing home residents with cognitive impairment. Reference scales were those from the comprehensive geriatric assessment, equivalent to the five dimensions of the EuroQol.

RESULTS

The EQ index was 0.31 (0.37) and the EQ VAS was 35.96 (29.86), showing adequate acceptability and feasibility. Cronbach's alpha was 0.723. The EQ index and EQ VAS, as outcome variables for multiple linear regression models including CGA titration scales, showed better validity for the EQ index than the EQ VAS.

CONCLUSIONS

As a self-administered generic scale, the EQ-5D-3L could be a good tool for QoL assessment in nursing home residents with cognitive impairment.

Commentary on Some Recent Theses Relevant to Combating Aging: December 2019

Theses reviewed in this issue include "Atrophied Thymus, a Tumor Reservoir for Harboring Melanoma Cells," "Evolutionary Adaptations in Developmental Signaling Pathways Underlie Regenerative Scar-Free Wound Repair in African Spiny Mouse (Genus Acomys)," "Integrated Immunoassays on Paper/Polymer Hybrid Microfluidic Devices for Low-Cost Detection of Disease Biomarkers," "RNA Regulation in the Nervous System: CircRNA Expression Changes During Aging, and Function of the Calm1 Extended 3' UTR Isoform," "The Role of Amylin in Alzheimer's Disease," and "Therapeutic Monoclonal Antibodies to Detect and Halt ATTR Cardiac Amyloidosis and Neuropathy."

Comparing Diagnostic Properties of the FRAIL-NH Scale and 4 Frailty Screening Instruments among Chinese Institutionalized Older Adults

OBJECTIVE

To examine the diagnostic test accuracy (DTA) of the FRAIL-NH and four frailty screening instruments among institutionalized older adults.

DESIGN

Cross-sectional study.

SETTING

Institutionalized setting, Jinan, China.

PARTICIPANTS

A total of 305 older adults (mean age 79.3 ± 8.4 years, 57.0% female) were enrolled from nursing homes.

MEASUREMENTS

Frailty was assessed by the FRAIL-NH, Physical Frailty Phenotype (PFP), FRAIL, Tilburg Frailty Indicator (TFI), and Groningen Frailty Indicator (GFI), respectively. The Comprehensive Geriatric Assessment (CGA) was used as a reference standard of frailty. The receiver operating characteristic (ROC) curve was plotted to examine the DTA of five frailty screening instruments against the CGA. The optimal cut-point was determined by the maximum value of the Youden index (YI, calculated as sensitivity + specificity - 1).

RESULTS

The prevalence of frailty ranged from 25.9% (FRAIL) to 56.4% (GFI). Areas under the curve (AUCs) against the CGA ranged from 0.80 [95% confidence interval (CI) 0.74 - 0.85: FRAIL] to 0.83 (95% CI 0.78 - 0.88: PFP). At their original cut-points, all five frailty screening instruments presented low sensitivity (32.9% - 69.3%) and high specificity (80.0% - 93.8%), as well as high positive predictive values (90.7% - 94.9%) and low negative predictive values (33.2% - 48.1%). At their optimal cut-points, the sensitivity and specificity of the FRAIL-NH, PFP, and FRAIL tended to be balanced, and their correctly classified rates (76.1% - 81.3%) and kappa values (0.465 - 0.523) increased a lot. ROC contrasts showed that all five frailty screening instruments had similarly good diagnostic accuracy (χ2: 0.0003 - 1.38, P > .05).

CONCLUSION

In the institutionalized setting, the specific FRAIL-NH, self-report FRAIL, TFI, and GFI as well as hybrid PFP, show similarly good diagnostic properties in identifying frailty against the CGA.

Role of comprehensive geriatric assessment in healthcare of older people in UK care homes: realist review

OBJECTIVES

Comprehensive geriatric assessment (CGA) may be a way to deliver optimal care for care home residents. We used realist review to develop a theory-driven account of how CGA works in care homes.

DESIGN

Realist review.

SETTING

Care homes.

METHODS

The review had three stages: first, interviews with expert stakeholders and scoping of the literature to develop programme theories for CGA; second, iterative searches with structured retrieval and extraction of the literature; third, synthesis to refine the programme theory of how CGA works in care homes.We used the following databases: Medline, CINAHL, Scopus, PsychInfo, PubMed, Google Scholar, Greylit, Cochrane Library and Joanna Briggs Institute.

RESULTS

130 articles informed a programme theory which suggested CGA had three main components: structured comprehensive assessment, developing a care plan and working towards patient-centred goals. Each of these required engagement of a multidisciplinary team (MDT). Most evidence was available around assessment, with tension between structured assessment led by a single professional and less structured assessment involving multiple members of an MDT. Care planning needed to accommodate visiting clinicians and there was evidence that a core MDT often used care planning as a mechanism to seek external specialist support. Goal-setting processes were not always sufficiently patient-centred and did not always accommodate the views of care home staff. Studies reported improved outcomes from CGA affecting resident satisfaction, prescribing, healthcare resource use and objective measures of quality of care.

CONCLUSION

The programme theory described here provides a framework for understanding how CGA could be effective in care homes. It will be of use to teams developing, implementing or auditing CGA in care homes. All three components are required to make CGA work-this may explain why attempts to implement CGA by interventions focused solely on assessment or care planning have failed in some long-term care settings.

TRIAL REGISTRATION NUMBER

CRD42017062601.

The development of a new tool for the evaluation of handicap in elderly: the Geriatric Handicap Scale (GHS)

BACKGROUND

To date, the comprehensive geriatric assessment (CGA) does not include an evaluation tool for handicap.

AIM

To develop a new instrument for assessing handicap in the elderly: the Geriatric Handicap Scale (GHS).

METHODS

656 community-dwelling elderly were enrolled in this study. We identified the thematic areas investigated by the CGA which showed a significant correlation with the handicap condition (handicap yes/not) to be included in our scale (Phase 1). Afterwards, we evaluated the possible correlations between: (1) the score obtained in each area of GHS and those obtained in CGA tests investigating similar dimensions, (2) GHS total score and the Multidimensional Prognostic Index (MPI) total score (Phase 2).

RESULTS

In Phase 1, data analysis showed several significant correlations between the handicap condition and the scores obtained to the CGA tests exploring cognition, mood, functional impairment, comorbidity, social and environmental variables. Thus, we developed a tool considering five variables: (1) cognition and mood; (2) functional impairment; (3) hearing/visual impairment; (4) any additional comorbidity factors; (5) environmental/social risk factors. In Phase 2, data analysis showed significant correlations between the score obtained in each area of GHS and those obtained in the CGA tests investigating similar dimensions. A positive correlation between GHS total score and MPI total score (r = 68; p = 0.001) was also reported. Cut-off score for the GHS was established. Psychometric properties of GHS were also investigated and adequate estimates of internal reliability were demonstrated.

CONCLUSIONS

Our tool could prove useful to correctly categorize the disadvantageous condition related to patient's disability.

Self-reported exhaustion, physical activity, and grip strength predict frailty transitions in older outpatients with chronic diseases

Effective screening instruments are necessary for evaluating the outcomes of early interventions for the prevention or delay of disability in older persons. This study examined how transitions in frailty items over 1 year and the baseline components of a comprehensive geriatric assessment were associated with improvements in frailty at a 2-year follow-up in a sample of older patients.This was a single-center prospective observational study of older patients aged 65 years and over with chronic diseases (n = 103), who were followed through a hospital-based program over 2 years. Frailty was evaluated via the modified Fried Frailty Index and a comprehensive geriatric assessment.We noted significant improvements in weight loss (P = .016) and self-reported exhaustion (P = .006), and a less decrease in grip strength (P = .009) at the 1-year follow-up. Furthermore, baseline cerebral vascular accident diagnosis (P = .022), high polypharmacy (P = .037), a higher Geriatric Depression Scale score (P = .033), and a lower Mini Nutritional Assessment score (P = .039) were significantly associated with improved frailty at the 2-year follow-up. Furthermore, improvement in self-reported exhaustion (odds ratio [OR]: 4.7, 1.4-16.1, P = .014) and physical activity (OR: 3.8, 1.0-13.7, P = .046), and a less decrease in grip strength (OR: 4.0, 1.3-12.5, P = .017) at the 1-year follow-up were significantly associated with improved frailty at the 2-year follow-up.Self-reported exhaustion, physical activity, and grip strength are easy, quick, and feasible screening tests for improvements in frailty in clinical practice.

Impact of the applied simulated and integrated learning approach on nursing assistants' knowledge and confidence caring for frail seniors in nursing homes

Background

Increasing importance is being placed on optimizing the role of Nursing Aides (NAs) in improving quality of care for nursing home (NH) residents. One approach to do so is to have NAs participate in assessments embedded within the Minimum Data Set (MDS). This pilot study aimed to design and evaluate the Applied Simulated and Integrated Learning Approach (ASILA) program, a novel innovative training program for NAs employed in NHs to enhance their ability to assess residents within an inter-professional framework.

Methods

A mixed quantitative and qualitative repeated measures design was used to assess changes in NAs' knowledge and perception of assessments and resident clinical outcomes. Additionally, focus groups were conducted with NAs upon completion of the ASILA program. A total of 23 NAs and nurses in NHs in two Canadian provinces participated. The ASILA pilot program consisted of three selected modules; each module including an evidence-informed case-scenario, assessments, the use of appropriate MDS tools and documentation, care planing and reporting systems. ASILA was delivered over the course of two days per home. The primary outcome measure focused on the impact of ASILA on NA knowledge and confidence in assessing residents and understanding the relevance and use of elements if the MDS tools. Secondary outcomes included NAs' satisfaction with ASILA and the impact of ASILA on resident clinical outcomes. Data were collected one week prior, immediately after, and three months after the ASILA program.

Results

Following ASILA, NAs reported increased knowledge test scores and confidence in assessing residents by using MDS tools, although this did not reach significance after multiple testing (p = 0.0256 and p = 0.1541 respectively). NAs reported more confidence in providing care to residents (77.8%) and felt that the care provided was more resident-centered (83.3%) than before the ASILA program. There were no significant trends in improved resident outcomes following ASILA.

Conclusion

Pilot findings indicate that the ASILA program could be a successful approach to support NAs to enhance their ability to assess residents in an inter-professional framework.

Aging in HIV-Infected Subjects: A New Scenario and a New View

The prevalence of HIV-infected people aged 50 years or older is increasing rapidly; the proportion will increase from 28% to 73% in 2030. In addition, HIV-infected individuals may be more vulnerable to age-related condition. There is growing evidence that the prevalence of comorbidities and other age-related conditions (geriatric syndromes, functional or neurocognitive/mental problems, polypharmacy, and social difficulties) is higher in the HIV-infected population than in their uninfected counterparts. However, despite the potential impact of this situation on health care, little information exists about the optimal clinical management of older HIV-infected people. Here we examine the age-related conditions in older HIV-infected persons and address clinical management according to author expertise and published literature. Our aim is to advance the debate about the most appropriate management of this population, including less well-studied aspects, such as frequency of screening for psychological/mental and social and functional capabilities.