Annual visits to patients over the age of 75--who is missed?

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

Aims: In controlled intervention studies, a selective non-response or refusal to participate at baseline may bias measurable effects of the intervention. The aim of this study was to compare mortality and nursing home admission among older persons who accepted (participants) and older person who declined (non-participants) to join a controlled feasibility trial, and to describe and evaluate defined subgroups of non-participants. Methods: Prospective controlled three-year intervention study (1999—2001) in 34 Danish municipalities with five-year follow-up. Randomization and intervention (education of municipality employees) was done at municipality level. In total 5,788 home-dwelling 75- and 80-year-olds living in these municipalities were invited to participate in the study. Written consent was obtained from 4,060 persons (participation rate 71%). Results: During five-year follow-up non-participants had a higher mortality rate (survival analysis risk ratio RR=1.5, 95% CI=1.3—1.7, p<0.0001) and a higher rate of nursing home admissions (RR=1.7, 95% CI=1.3— 2.1, p<0.0001) compared with participants. Subgroups of non-participants describing themselves as ``too ill'' and persons ``not reached'' had a significantly higher mortality rate and risk of admission to nursing home than participants, whereas the subgroups of non-participants describing themselves as ``too healthy'' and having ``another reason for refusal'' did not differ from the participants. There was no difference in mortality rates between non-participants living in intervention municipalities compared with non-participants living in control municipalities. Conclusions: Mortality and nursing home admissions were higher among non-participants. Selection participation bias was of no clinical importance since subgroups of non-participants eligible for the intervention did not differ from the participants.

The role of sensory and cognitive function in the onset of activity restriction in older people

BACKGROUND

Extending healthy active life expectancy is a priority if we are to achieve gains in both the quality and quantity of life lived at older ages. We investigated the role of sensory (vision and hearing) and cognitive function on the onset of activity restriction in older people.

METHODS

A survey of a total population (N = 1579) of people aged 75 years and older, registered with a large general population in Melton Mowbray, Leicestershire, England, was undertaken in 1988 and linked with subsequent routine health assessments (up to a maximum of five) over 10 years. Activity restriction was defined as having difficulty performing on their own, requiring help or aids or not doing any one of seven Activities of Daily Living (ADLs). The study population comprised the 643 persons who were not restricted at baseline. Cox proportional hazard regression models were fitted to time of onset of activity restriction with those dying before activity restriction was reported being censored at time of death.

RESULTS

After adjustment for confounding factors (socio-demographic and psychosocial factors, physical health and physical functional limitations), difficulty with both vision and hearing conferred a doubling of risk of activity restriction (RR = 2.36, 95% CI 1.31 to 4.28). A unit decrease in the Information/Orientation subtest was associated with a 10% increase in risk (RR = 1.10, 95% CI 1.02 to 1.19), even after adjustment for vision and hearing as well as other confounding factors, though baseline Mini-Mental State Examination score was not indicative of increased risk (RR= 1.02, 95% CI 0.98 to 1.06).

CONCLUSION

Differentiating whether disability is a result of physical, sensory or cognitive functional limitations, is necessary to identify need and the direction in which efforts should be targeted to improve active life expectancy in older people.

Does socio-economic advantage lead to a longer, healthier old age?

The effect of socio-economic disadvantage on mortality is well documented and differences exist even at older ages. However, whether this translates into differences in the quality of life lived at older ages is less well studied, and in particular in the proportion of remaining life spent without ill health (healthy life expectancy), a key UK Government target. Although there have been studies exploring socio-economic differences in disability-free life expectancy (DFLE) worldwide, these have tended to focus on a single measure of socio-economic advantage, for example, education, race, social class or income, with the majority based on cross-sectional data from younger populations. In this prospective study we examine differences in DFLE and total life expectancy (TLE) at older ages using a range of measures of socio-economic advantage. We use a longitudinal study of 1480 participants aged 75 years or over in 1988 registered with a UK primary care practice, who were followed up until 2003 with measurements at up to seven time points. Disability was defined as difficulty with any one of five activities of daily living. The largest differences in DFLE for both men and women were found for housing tenure. Women aged 75 years living in owned or mortgaged property could expect to live 1 year extra without disability compared with those living in rented accommodation, while for men the difference was almost 1.5 years. The effect of socio-economic advantage on disability-free and total life expectancies appeared to be larger for men than women. In women, socio-economic advantage had more effect on DFLE than total life expectancy for all indicators considered, thus the socio-economically advantaged experienced a compression of disability.

Socioeconomic factors associated with the onset of disability in older age: a longitudinal study of people aged 75 years and over

Although the association between socioeconomic status and mortality is well documented, there is less work focusing on the association with morbidity in older people. This is partly due to the difficulties of measuring socioeconomic status at older ages. The work that does exist tends to use cross-sectional data and objective measures of socioeconomic status such as education, social class or income. However, these standard measures may be less relevant for older people. In this study, we explore the association between socioeconomic status and disability in older people using a range of individual, household and area level indicators of socioeconomic status, including a subjective measure of adequacy of income. We use cross-sectional data of 1470 participants aged 75 years or over on 31/12/1987 and registered with a UK primary care practice. Of these 719 participants with no disability at baseline were followed up until 2003 with measurements at up to seven time points to determine onset of disability. Disability was defined as difficulty with any one of five activities of daily living. In cross-sectional multivariate analysis, age, housing tenure, living status and a subjective measure of income adequacy were associated with prevalence of disability. In longitudinal analyses, self-perceived adequacy of income showed the strongest association with onset of disability; with those reporting difficulties managing having a median age of onset 80.5 years, 7 years younger than those who felt their income was adequate (median age 87.8 years). The prospective association between self-perceived adequacy of income and onset of disability decreased with age. This subjective measure of income adequacy may signify difficulties in budgeting, but could also capture differences in objective indicators of status not recorded in this study, such as wealth. Further work is needed to explore what causes older people to experience difficulty in managing their money and to understand the mechanisms behind its impact on their physical health.

Are gender differences in the relationship between self-rated health and mortality enduring? Results from three birth cohorts in Melton Mowbray, United Kingdom

PURPOSE

The purpose of this study was to assess whether there is an enduring gender difference in the ability of self-rated health to predict mortality and investigate whether self-reported physical health problems account for this difference.

DESIGN AND METHODS

Cox models for 4-year survival were fitted to data from successive cohorts aged 75-81 years registered with a primary care practice in the U.K. Midlands surveyed in 1981, 1988, and 1993-1995.

RESULTS

Self-rated health was consistently a stronger predictor in men (hazard ratio [HR] = 2.7; 95% confidence interval [CI] = 2.1-3.5) than it was in women (HR = 1.9; 95% CI = 1.5-2.4). Women surveyed in 1993-1995 were more likely than men to report problems that were disabling but not life-threatening, whereas men were more likely to report potentially life-threatening problems. However, these differences did not explain the association of self-rated health with mortality. More than half of those who reported a potentially life-threatening problem said that their health was good.

IMPLICATIONS

Self-rated health is more strongly associated with mortality in men, but this is unlikely to be explained by differences in the nature of their physical health problems.

Geriatric drug therapy and healthcare utilization in the United kingdom

OBJECTIVE

To describe the use of prescription drug therapy, especially polypharmacy, in an elderly general population; to relate that use to age, gender, and different types of healthcare utilization; and to investigate the influence of selection of different time windows on the result of the quantity as well as the categories of drugs used.

METHODS

Data on a sample of 5000 patients aged 65-90 years in 1996 were derived from the General Practice Research Database (GPRD). The population covered by GPRD is broadly representative of the UK population treated in general practice. Drug use was assessed using 2 time windows - current use of individual drugs on a random day (index date) and 1 month following the index date. Healthcare utilization was analyzed by use of information on visits to general practitioners (GPs), hospitalizations, and referrals to specialists.

RESULTS

Women used more drugs than men; however, the prevalence of polypharmacy, defined as concomitant use of > or =5 drugs, was similar in both genders. The most frequently used therapeutic groups were cardiovascular, central nervous, and gastrointestinal system drugs. Almost 80% of both women and men visited a GP at least once a year. Overall, women used more ambulatory care services and men were hospitalized more often. Use of random date compared with 1-month period resulted in a significant underestimation of the amount of drugs used for acute conditions and, consequently, the risk of polypharmacy.

CONCLUSIONS

The overall results confirm the findings in earlier studies suggesting that the GPRD might be a useful tool in further studies on prescription drug use among elderly persons. More information on the appropriateness of drug use is needed to prevent overuse as well as underuse of medications among the elderly.

Patterns of Onset of Disability in Activities of Daily Living with Age

OBJECTIVES

To investigate the order in which activities of daily living (ADLs) are lost and whether the order is invariant between the sexes and age groups.

DESIGN

Longitudinal data from the first five rounds of a routine health assessment by a nurse in participant's own home.

SETTING

One large UK general practice with a list size of 32,500.

PARTICIPANTS

Patients registered with the practice and age 75 and older.

MEASUREMENTS

Disability was measured by self-report of performance in seven ADLs: mobility around the home, getting to and from the toilet, transfer from chair, transfer from bed, feeding, dressing, and bathing. Disability in each ADL was classified as being independent but having difficulty, using aids or help, or being unable to perform. Age at onset of disability in each ADL was calculated and analyzed using Kaplan-Meier plots and Cox regression models. Subjects who had died or remained independent by their last assessment were not included.

RESULTS

The mean times between health assessments was approximately 20 months but with substantial variability both within and between individuals. A total of 1,344 people reported no difficulty in any ADL initially and 47.6% (640) subsequently reported disability. The order of activity restriction was bathing, mobility, toileting, dressing, transfers from bed and chair, and feeding. Women had a higher risk of disability in bathing (relative risk (RR) = 1.6, 95% confidence interval (CI) 1.3-1.9, P < .001) and toileting (RR = 1.7, 95% CI 1.2-2.5, P = .003), while for all ADLs there was a significant increase in the risk of disability with increasing age. The order of onset of disability for ADLs was invariant across sex and age groups.

CONCLUSION

Lower-extremity strength (bathing, mobility, toileting) appears to be lost in older people before upper-extremity strength (dressing, feeding). Further work is now needed to develop prevention strategies to delay the onset of these disabilities.

A thorough going over: evidence for health assessments for older persons

OBJECTIVE

To review published randomised controlled trials of health assessments for older people; consider the effects of assessments in maintaining health and quality of life for older people; and identify those factors associated with more successful health assessment programs.

METHODS

A systematic literature search and methodological review of published studies of health assessments for people aged 65 years and over, living in the community.

RESULTS

Twenty-one trials were identified. They were widely heterogeneous in terms of methodological quality, assessment content and outcome variables. While the studies' results are inconsistent, the majority of the more methodologically sound studies report improvements in health. The studies reporting positive health outcomes were not specifically targeted to particular groups at high need, but were applied to all people in the source population who had reached a set age, usually 75 plus. In the majority of studies reviewed, the assessments were conducted by non-medical personnel (nurse, lay interviewer/volunteer or office staff).

CONCLUSIONS

Health assessments have been associated with improved health outcomes for older people. An evidence base for specific components to be included in the assessments is yet to be derived.

IMPLICATIONS

In November 1999, new Medicare items to provide for health assessments for persons in Australia aged 75 years and over were introduced. The acceptability, adoption and effectiveness of these items needs careful monitoring.

[Health and utilization of health services in the elderly, according to the level of living arrangements]

OBJECTIVE

To assess the association between living arrangements (living alone, with company or in a nursing home) and the health status and the use of health and social services among the population over seventy with the purpose to help establishing health policies for the elderly.

METHODS

A cross sectional survey was performed, interviewing a random sample of 110 institutionalised and 290 community elderly of Castelldefels. Subjects and carers answered the following questionnaires: health status self-perception (SF-36), level of autonomy (test de Barthel), anxiety and depression levels (HAD), cognitive deficit (Short Portable Mental Status Questionnaire), availability and use of housing facilities an social and health resources.

RESULTS

77.2% of the institutionalised, and 92% of those coming from the community answered the questionnaire. 60 lived alone, 208 accompanied and 85 in nursing homes. The 67% were women and those living alone (77 +/- 4.8 years), or with company (78.3 +/- 6.4 years) where younger than the institutionalised ones (83.1 +/- 6.9 years) (p < 0.01). Housing facilities was similar in the three groups, although those living in the community had a higher level of use. The proportion of handicapped grew progressively from those living alone, with company or in institutions (13.3%; 19.6%. 86.7%; p < 0.01), as well as the cognitive deficit (7.8%; 15.3%; 20.8%, p < 0.01). Every group had similar health status, only those living with the family experienced higher scores in the emotional role or social function (SF-36). Non institutionalised population received support from relatives, friends and primary care services. Those institutionalised received health care in a more intensive and selective way, and benefited from formal cares.

CONCLUSIONS

Nursing homes host the population with highest level of cognitive deficit and dependence. The need of increasing formal care in the community, in special to people living alone, and of reorienting health services towards elderly care has been identified.