Effectiveness of home based support for older people: systematic review and meta-analysis

Navigating the Health Care Landscape for an Ageing Population: An International Survey of Strategies and Priorities

OBJECTIVES

The global increase in the older population, which is expected to reach 1.5 billion by 2050, poses significant challenges for publicly funded health care systems. Life expectancy, although positive, is leading to an increase in chronic diseases requiring complex and costly health and social solutions. This study explores key strategies to address these challenges.

DESIGN

Qualitative interviews followed by a survey.

SETTING AND PARTICIPANTS

The study involved experts, students, artificial intelligence, and participants at a congress.

METHODS

We first interviewed 5 experts from different countries representing health care management and psychology from Belgium, health economics from Canada, sociology from France, and geriatrics from Switzerland. In addition, a focus group session with medical students in physical therapy and queries to ChatGPT increased the range of perspectives. A synthesis of all opinions or insights was used to formulate concrete strategies. These strategies were incorporated into an online survey that was distributed to 215 participants of the Geriatric and Gerontologic Congress in Montreal, Canada, in September 2023.

RESULTS

All 20 potential solutions were duly acknowledged, with particular attention paid to the following 5 priorities: the urgent need to integrate geriatric training into the education of future health professionals, the promotion of home-based care models, the establishment of comprehensive and integrated care systems, the strengthening of primary care services, and the emphasis on primary prevention strategies.

CONCLUSION AND IMPLICATIONS

This study highlights key priorities for addressing the health needs of the older population. By emphasizing education, home-based care, and integrated services and strengthening primary care and prevention, health systems can respond effectively to the challenges of an ageing population. Although these needs may not be entirely unmet, they indicate areas where existing services are insufficient in providing adequate coverage and support to ensure tailored and sustainable health care solutions for older people.

Effectiveness and Feasibility of Home-Based Palliative Care Interventions for Geriatric Oncology Patients: A Systematic Review Using Narrative Synthesis

BACKGROUND

Due to an urgent need to develop palliative care services for geriatric patients with advanced cancer, an overview of available information regarding home-based palliative care interventions would be valuable.

AIM

To summarize current literature for interventions targeted to homebound, older patients with incurable cancer, and investigate whether these patients can be benefited from home-based palliative care and achieve improved outcomes.

DESIGN

A search strategy consisting of terms related to home care, palliation, oncology, and geriatrics was employed. A protocol following PRISMA guidelines was prospectively uploaded at PROSPERO (ID = CRD42023404675).

DATA SOURCES

Pubmed (MEDLINE), Cochrane Central Register of Controlled Trials (CENTRAL), ClinicalTrials.gov, and Epistemonikos.org databases were searched from inception until the present day. Eligibility criteria were selected based on the research question, the population of interest, and the research design. The Risk of Bias Assessment Tool version 2 (RoB-2) was used to appraise study quality.

RESULTS

A total of 10 articles including 871 patients (out of 1236 titles and 141 fully-reviewed texts) were selected. Four studies assessed exercise interventions, two evaluated multi-component home-care models, two focused on supervision services, and two had nutrition and activity components. Eight studies reported improved outcomes in either specified or mixed cancer geriatric populations.

CONCLUSIONS

There is a scarcity of clinical trials regarding home-based palliative care for geriatric oncology patients, resulting in poor information and a lack of evidence. At-home interventions seem feasible and have a positive effect on pain management and functional status, but more high-quality studies are required.

Interventions for loneliness in older adults: a systematic review of reviews

Loneliness in older persons is a major risk factor for adverse health outcomes. Before the COVID-19 pandemic led to unprecedented isolation and hampered programs aimed at preventing or reducing loneliness, many interventions were developed and evaluated. However, previous reviews provide limited or conflicting summaries of intervention effectiveness. This systematic review aimed to assess previous review quality and bias, as well as to summarize key findings into an overarching narrative on intervention efficacy. The authors searched nine electronic databases and indices to identify systematic reviews of interventions to reduce loneliness in older people prior to the COVID-19 pandemic; 6,925 records were found initially. Of these, 19 reviews met inclusion criteria; these encompassed 101 unique primary intervention studies that varied in research design, sample size, intervention setting, and measures of loneliness across 21 nations. While 42% of reviews had minimal risk of bias, only 8% of primary studies appraised similarly. Among the 101 unique articles reviewed, 63% of tested interventions were deemed by article author(s) as effective or partially effective. Generally, interventions that included animals, psychological therapies, and skill-building activities were more successful than interventions focused on social facilitation or health promotion. However, interventions that targeted multiple objectives aimed at reducing loneliness (e.g., improving social skills, enhancing social support, increasing social opportunities, and changing maladaptive social cognition) were more effective than single-objective interventions. Future programs should incorporate multiple approaches, and these interventions should be rigorously tested.

The effectiveness of preventive home visits on resilience and health-related outcomes among community dwelling older adults: A systematic review

BACKGROUND

This research aimed to assess the effectiveness of preventive home visits (PHVs) in enhancing resilience and health-related outcomes among older adults living in the community.

METHODS

A comprehensive literature search was conducted in nine databases (PubMed, MEDLINE, CINAHL, Embase, Emcare, Web of Science (WOS), Scopus, PsycINFO and Cochrane Library. The search was undertaken between March 15 and 31, 2022 with subsequent updates performed on October 15, 2023 and April 10, 2024. This review also included grey literature sourced via Google, Google Scholar and backward citation searches.

RESULTS

Out of 5,621 records, 20 articles were found to meet the inclusion criteria with a total of 8,035 participants involved and the mean age ranged from 74.0 to 84.4 years. Using McMaster Critical Review Form for Quantitative Studies, we ascertained that the studies included in our analysis had moderate to high levels of quality. In addition to health-related outcomes, PHV interventions were also conducted to evaluate psychological effects (16 studies) and social outcomes (seven studies). Five studies conducted financial assessment to evaluate the costs of health and social care utilisation during PHV interventions. Regarding the results of the review, seven studies showed favourable outcomes, five indicated no effect and eight had equivocal findings. Only one study assessed resilience and determined that PHV had no effect on the resilience of the subjects.

CONCLUSION

This review found that the effectiveness of PHV interventions was uncertain and inconclusive. PHV interventions often prioritise health-related objectives. The incorporation of a holistic approach involving psychosocial health into PHV interventions is relatively uncommon. Due to the paucity of research on resilience as PHV outcome, we are unable to draw a conclusion on the effectiveness of PHV on resilience. Resilience should be prioritised as a psychological assessment in the future development of comprehensive PHV interventions, as it enables older adults to adapt, manage, and respond positively to adversities that may arise with age. Performing financial analysis such as costs and benefits analysis to incorporate the return on investment of PHV interventions is an added value for future research on this topic.

CLINICAL TRIAL REGISTRATION

PROSPERO registration number: CRD42022296919.

Preventive interventions to improve older people's health outcomes: systematic review and meta-analysis

BACKGROUND

Systematic reviews of preventive, non-disease-specific primary care trials for older people often report effects according to what is thought to be the intervention's active ingredient.

AIM

To examine the effectiveness of preventive primary care interventions for older people and to identify common components that contribute to intervention success.

DESIGN AND SETTING

A systematic review and meta-analysis of 18 randomised controlled trials (RCTs) published in 22 publications from 2009 to 2019.

METHOD

A search was conducted in PubMed, MEDLINE, Embase, Web of Science, CENTRAL, CINAHL, and the Cochrane Library. Inclusion criteria were: sample mainly aged ≥65 years; delivered in primary care; and non-disease-specific interventions. Exclusion criteria were: non-RCTs; primarily pharmacological or psychological interventions; and where outcomes of interest were not reported. Risk of bias was assessed using the original Cochrane tool. Outcomes examined were healthcare use including admissions to hospital and aged residential care (ARC), and patient-reported outcomes including activities of daily living (ADLs) and self-rated health (SRH).

RESULTS

Many studies had a mix of patient-, provider-, and practice-focused intervention components (13 of 18 studies). Studies included in the review had low-to-moderate risk of bias. Interventions had no overall benefit to healthcare use (including admissions to hospital and ARC) but higher basic ADL scores were observed (standardised mean difference [SMD] 0.21, 95% confidence interval [CI] = 0.01 to 0.40) and higher odds of reporting positive SRH (odds ratio [OR] 1.17, 95% CI = 1.01 to 1.37). When intervention effects were examined by components, better patient-reported outcomes were observed in studies that changed the care setting (SMD for basic ADLs 0.21, 95% CI = 0.01 to 0.40; OR for positive SRH 1.17, 95% CI = 1.01 to 1.37), included educational components for health professionals (SMD for basic ADLs 0.21, 95% CI = 0.01 to 0.40; OR for positive SRH 1.27, 95% CI = 1.05 to 1.55), and provided patient education (SMD for basic ADLs 0.28, 95% CI = 0.09 to 0.48). Additionally, admissions to hospital in intervention participants were fewer by 23% in studies that changed the care setting (incidence rate ratio [IRR] 0.77, 95% CI = 0.63 to 0.95) and by 26% in studies that provided patient education (IRR 0.74, 95% CI = 0.56 to 0.97).

CONCLUSION

Preventive primary care interventions are beneficial to older people's functional ability and SRH but not other outcomes. To improve primary care for older people, future programmes should consider delivering care in alternative settings, for example, home visits and phone contacts, and providing education to patients and health professionals as these may contribute to positive outcomes.

Investigation of factors associated with pressure ulcer in patients receiving home care services via path analysis

BACKGROUND

Recent trends indicate a rise in the number of elderly and bedridden patients enrolled in home care programs, leading to an increased occurrence of complications such as pressure ulcers within the home health care setting.

OBJECTIVE

The primary objective of this research was to ascertain the prevalence of pressure ulcers and identify the associated factors in adults who were recipients of home health care services.

METHOD

This study, adopting a cross-sectional design, encompassed a sample of 566 patients who sought services from the Home Health Care Unit in a specific province in Turkey. The timeframe for data collection spanned from August to November 2022, during which two primary instruments were employed: the "Demographic Characteristics Form" and two specific scales - the "Braden Pressure Ulcer Risk Assessment Scale" and the "ITAKI Falls Risk Scale."

FINDINGS

In this study, the average age of patients receiving home health care services was identified as 75.9 years, with a standard deviation of 15.1 years. Furthermore, 73.7 % of these patients were classified as being at risk for developing pressure ulcers. The study identified a direct correlation between the risk of BRADEN pressure ulcers and the escalation in scores across several parameters. These parameters included "Addiction Status," delineated as a spectrum from addicted to non-addicted, the "Number of Medical Diagnoses," quantified on a scale, the "State of Consciousness," categorized from clear to confused, and the scores derived from the "ITAKI" scale.

CONCLUSION

The findings of this study highlight the significance of pressure ulcers as a critical health issue among patients receiving home care services. It underscores the necessity for home care nurses to be acutely aware of the risk factors associated with pressure ulcers among high-risk patients.

Expanding Access to Comprehensive Geriatric Evaluation via Telehealth: Development of Hybrid-Virtual Home Visits

BACKGROUND

In response to the aging population, the Department of Veterans Affairs (VA) seeks to expand access to evidence-based practices which support community-dwelling older persons such as the Geriatric Resources for Assessment and Care of Elders (GRACE) program. GRACE is a multidisciplinary care model which provides home-based geriatric evaluation and management for older Veterans residing within a 20-mile drive radius from the hospital. We sought to expand the geographic reach of VA-GRACE by developing a hybrid-virtual home visit (TeleGRACE).

OBJECTIVES

The objectives were to: (1) describe challenges encountered and solutions implemented during the iterative, pre-implementation program development process; and (2) illustrate potential successes of the program with two case examples.

DESIGN

Quality improvement project with longitudinal qualitative data collection.

PROGRAM DESCRIPTION

The hybrid-virtual home visit involved a telehealth technician travelling to patients' homes and connecting virtually to VA-GRACE team members who participated remotely.

APPROACH & PARTICIPANTS

We collected multiple data streams throughout program development: TeleGRACE staff periodic reflections, fieldnotes, and team meeting notes; and VA-GRACE team member interviews.

KEY RESULTS

The five program domains that required attention and problem-solving were: telehealth connectivity and equipment, virtual physical examination, protocols and procedures, staff training, and team integration. For each domain, we describe several challenges and solutions. An example from the virtual physical examination domain: several iterations were required to identify the combination of telehealth stethoscope with dedicated headphones that allowed remote nurse practitioners to hear heart and lung sounds. The two cases illustrate how this hybrid-virtual home visit model provided care for patients who would not otherwise have received timely healthcare services.

CONCLUSIONS

These results provide a blueprint to translate an in-person home-based geriatrics program into a hybrid-virtual model and support the feasibility of using hybrid-virtual home visits to expand access to comprehensive geriatric evaluation and ongoing care for high-risk, community-dwelling older persons who reside geographically distant from the primary VA facility.

Lack of patient and primary care physician follow-up in geriatric emergency department patients with head trauma from a fall

STUDY OBJECTIVE

Falls are the leading cause of injuries in the US for older adults. Follow-up after an ED-related fall visit is essential to initiate preventive strategies in these patients who are at very high risk for recurrent falls. It is currently unclear how frequently follow-up occurs and whether preventive strategies are implemented. Our objective is to determine the rate of follow-up by older adults who sustain a fall related head injury resulting in an ED visit, the rate and type of risk assessment and adoption of preventive strategies.

METHODS

This 1-year prospective observational study was conducted at two South Florida hospitals. All older ED patients with an acute head injury due to a fall were identified. Telephone surveys were conducted 14 days after ED presentation asking about PCP follow-up and adoption of fall prevention strategies. Clinical and demographic characteristics were compared between patients with and without follow up.

RESULTS

Of 4951 patients with a head injury from a fall, 1527 met inclusion criteria. 905 reported follow-up with their PCP. Of these, 72% reported receiving a fall assessment and 56% adopted a fall prevention strategy. Participants with PCP follow-up were significantly more likely to have a history of cancer or hypertension.

CONCLUSION

Only 60% of ED patients with fall-related head injury follow-up with their PCP. Further, 72% received a fall assessment and only 56% adopted a fall prevention strategy. These data indicate an urgent need to promote PCP fall assessment and adoption of prevention strategies in these patients.

Effectiveness of a home health monitoring and education program for complex chronic patients, led by primary care nurses

Background

The challenge of chronicity has led developed countries to design strategies to respond to the new needs of complex chronic patients (CCP). There is evidence supporting better beneficial effects and more efficient care for CCP when home-base care programs are provided by Primary Health Care professionals. The main objective of the present study was to assess the effectiveness of a nursing intervention program of home visits for CCP analyzing the use of health services in terms of hospital admissions, emergency care unit visits, and mortality rate.

Methods

A quasi-experimental study was designed to retrospectively evaluate the effectiveness of a 3-year proactive, individualized nursing intervention in improving health outcomes measured by health service utilization (hospitalization, emergency care, and nursing home visits) in these patients. Of the 344 complex chronic patients participating in the study, 93 were assigned to the intervention group (IG) and 251 to the control group (CG).

Results

Along the period of study, the number of home visits in the IG almost tripled in relation to the CG (14.29 ± 4.49 vs. 4.17 ± 2.68, p < 0.001). Admissions in the first and second year of the study period were lower in the intervention group p = 0.002 and p < 0.001 respectively. All the participants in the control group were admitted at least once during the study period. In contrast, 29.0% of the participants in the intervention group never had a hospital admission during the 3-years study period. The number of ED visits to the emergency department was significantly lower in the IG during the 3 years of the study periods. The cumulative number of emergency visits in the IG was half that in the CG (5.66 ± 4. vs. 11.11 ± 4.45, p < 0.001, Cohen'd,1.53). A total of 35.5% of the participants in the intervention group visited the emergency department on three or fewer occasions compared to 98% of the subjects in the control group who visited the emergency department on more than six occasions (p < 0.001). The 3-year overall mortality rate was 23.5% in the control group and 21.6% in the nursing home visit program. These differences were not statistically significant.

Conclusion

The program demonstrated its effectiveness in reduction of hospital admissions and visits to the emergency department. The program had no impact on mortality rate. This program of home visits reinforces the role of primary care nurses in advanced competencies in chronicity.

A Physiotherapy-Led Transition to Home Intervention for Older Adults Following Emergency Department Discharge: A Pilot Feasibility Randomised Controlled Trial (ED PLUS)

Background

Older adults frequently attend the emergency department (ED) and experience high rates of subsequent adverse outcomes including functional decline, ED re-presentation and unplanned hospital admission. The development of effective interventions to prevent such outcomes is a key priority for research and service provision. Our aim was to evaluate the feasibility of a physiotherapy-led integrated care intervention for older adults discharged from the ED (ED PLUS).

Patients and Methods

Older adults presenting to the ED of a university teaching hospital with undifferentiated medical complaints and discharged within 72 hours were computer randomised in a ratio of 1:1:1 to deliver usual care, Comprehensive Geriatric Assessment (CGA) in the ED, or ED PLUS. ED PLUS is an evidence-based and stakeholder-informed intervention to bridge the care transition between the ED and community by initiating a CGA in the ED and implementing a six-week, multi-component, self-management programme in the patient's home. Feasibility and acceptability were assessed quantitatively and qualitatively. All clinical and process outcomes were assessed by a research nurse blinded to group allocation. Data analyses were primarily descriptive.

Results

Twenty-nine participants were recruited indicating a 67% recruitment rate. At 6 months, there was 100% retention in the usual care group, 88% in the CGA group and 90% in the ED PLUS group. ED PLUS participants expressed positive feedback, and there was a trend towards improved function and quality of life and less ED revisits and unscheduled hospitalisations in the ED PLUS group.

Conclusion

ED PLUS bridges the transition of care between the index visit to the ED and the community and is feasible using systematic recruitment strategies. Despite recruitment challenges in the context of COVID-19, the intervention was successfully delivered and well received by participants. There was a lower incidence of functional decline and improved quality of life in the ED PLUS group.

Trial Registration

The trial was registered in Clinical Trials Protocols and Results System as of 21st July 2021, with registration number NCT04983602.

The effectiveness of nurse-led interventions to manage frailty in community-dwelling older people: a systematic review

BACKGROUND

The global increase in the number of frail older people and the accompanying increase in chronic conditions underline the need to develop effective health promotion and preventive interventions for these population groups. Wide ranging of physical, psychological, and social health factors influence frailty in older people and leads to increased vulnerability to many adverse outcomes. To reverse or reduce the progression of frailty, nurses play a pivotal role in delivering health promotion and preventive interventions. The purpose of the review is to determine the effectiveness of nurse-led interventions in reducing frailty in community-dwelling older people.

METHODS

The following electronic databases: PubMed, MEDLINE, Web of Science, SCOPUS, CINAHL, PsychInfo, and WHO Global Index Medicus were searched until June 2022. Nurse-led, "nurse led", education, training, intervention, program, teaching, frail*, fragile*, "frailty syndrome", debility, infirmity, elder*, aged*, old*, geriatric, "community based settings", "community-based", "community setting", community were the search terms. Before data extraction, eligible articles were assessed for their methodological quality. The JBI critical appraisal checklist for reporting experimental studies was utilised to appraise the methodological quality of the studies. Data were systematically examined using a narrative review to determine the effectiveness of the intervention.

RESULTS

Of the 156 studies identified, from the search, six studies with samples ranging from 40 to 1387 older people were eligible for inclusion in the review. Two quasi-experimental studies and one Randomised Controlled Trial (RCT) showed a moderate risk of bias. The Nurse-led frailty interventions used a multi-component intervention approach across the studies. The interventions reversed frailty progression, improve physical functioning, nutritional status, and quality of life, enhance perceptions of social support, improve mental health, and reduce depression.

CONCLUSIONS

Few studies have explored the effectiveness of a nurse-led intervention to decrease frailty in older people. Evaluating physical functioning, nutritional status, mental health, and quality of life in community-dwelling frail older people can contribute to developing appropriate interventions.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO ID of CRD42022348064.

Acceptance of preventive home visits by nurses - The user perspective

OBJECTIVE

The aim of this study was to investigate acceptance of preventive home visits (PHVs) for older adults in rural Germany.

DESIGN

Qualitative descriptive approach.

SAMPLE

We investigated the personal, individual perspective of adults aged 65 to 85, who were not yet eligible for benefits from the long-term care insurance, were able to understand and speak German, and who lived in the municipality under study.

MEASUREMENTS

Fifteen semi-structured interviews were conducted between 02/2019 and 08/2020. They were transcribed, coded using MAXQDA, and content analyzed. Ethical approval was obtained.

RESULTS

The acceptance of PHVs was extremely high and characterized by five main effects: very close relationship with the nurse, well-being, empowerment, satisfaction, ambivalence. Participants wish to receive PHVs in the future and would recommend it to others. Even those with a healthy or health-promoting lifestyle are thankful to be able to refer to the counselling sessions if life circumstances should deteriorate. Those who became care-dependent wish to continue and perceive it as a valuable addition to their care.

CONCLUSION

From the participants' point of view, this low-threshold counselling-and-support approach should be maintained in the future. PHVs can support health and independence in older adults and therefore prevent them from becoming care-dependent.

The Association Between Frailty and a Nurse-Identified Need for Comprehensive Geriatric Assessment Referral from the Emergency Department

BACKGROUND

Emergency nurses commonly conduct geriatric assessments in the emergency department (ED). However, little is known about what geriatric syndromes or clinical presentations prompt a nurse to document an identified need for comprehensive geriatric assessment (CGA).

OBJECTIVES

To examine the association between geriatric syndromes, like frailty, and a nurse-identified need for a CGA following emergency care.

METHODS

We conducted a secondary analysis of a multi-province Canadian cohort from the InterRAI Multinational Cohort Study. We collected data at ED registration from patients 75 years of age and older (n = 2,274) from eight ED sites across Canada between November 2009 and April 2012. Geriatric syndromes were assessed by trained emergency nurses using the interRAI ED Contact Assessment; and we retrospectively calculated the ED frailty index. We employed binary logistic regression to determine the adjusted associations between geriatric syndromes and a nurse-identified need for a CGA.

RESULTS

Approximately one-quarter (28%) of older adults were identified to need a CGA following emergency care. A 0.1 unit increase in the ED frailty index increased the likelihood of a nurse identify a need for CGA (RD: 6.6; 95% CI = 5.5-7.9). Most geriatric syndromes increased the probability of a nurse documenting the need for a CGA.

CONCLUSION

When assessed by emergency nurses, the identified need for CGA is strongly linked to the presence of geriatric syndromes, including frailty. We provide face validity for the continued use of emergency nurses for screening and assessing older ED patients.

The health-related quality of life of older people through preventive home visits: A quantitative longitudinal study

AIMS AND OBJECTIVES

Preventive home visits are a low-threshold counselling and support approach. They have been reported to achieve heterogeneous effects. However, preventive home visits have the potential to reduce the risk of becoming dependent on long-term care. The aim of this study is to investigate the effect of preventive home visits as a nursing intervention on health-related quality of life of older people in a longitudinal survey and to develop recommendations for which target groups preventive home visits have the highest benefit. The sample consisted of 75 people, aged between 65 and 85, who were able to understand and speak German, had not yet been eligible for benefits from the long-term care insurance and lived in the municipality under study.

METHODOLOGICAL DESIGN AND JUSTIFICATION

A quantitative longitudinal study in order to investigate the effects of preventive home visits.

ETHICAL ISSUES AND APPROVAL

There were no ethical concerns. Accordingly, ethical approval was granted.

RESEARCH METHODS, RESULTS AND CONCLUSIONS

The health-related quality of life was recorded four times between 01/2017 and 08/2020 with the Short-Form-Health-Survey-12 and analysed using descriptive statistics. Results reveal that the physical health status cannot be easily influenced over a short period of time. The main effect, however, is that preventive home visits have a significant positive effect on the mental health status. The main topics during the home visits were mobility, nutrition and social participation. Increased knowledge and motivation for preventive behaviour extended the autonomy of older people. Accordingly, preventive home visits can support a self-determined life in a familiar environment. The results of the present study show that preventive home visits as a nursing intervention in rural areas are successful. In Germany, preventive home visits have not yet been implemented on a regular basis. In order to do so, a general definition of the concept is needed. Preventive home visits should be officially included in the regular health care services in Germany.

Effects of home visiting programmes on community-dwelling older adults with chronic multimorbidity: a scoping review

BACKGROUND

Chronic ultimorbidity is the most frequent and serious health problem in older adults. Home visiting programmes could be a strategy with potential benefits. However, there are no scoping reviews to date that examine the effects of home visiting programmes on community-dwelling older adults with chronic multimorbidity.

OBJECTIVE

To examine the effects of home visiting programmes on community-dwelling older adults with chronic multimorbidity.

METHODS

A scoping review was carried out following PRISMA-ScR reporting guidelines. The search was conducted in six databases (PubMed/Medline, Cochrane, CINAHL, Web of Science, Scopus and EMBASE) between October 2021 and April 2022.

RESULTS

Four RCTs with 560 patients were included. The visits were carried out by nurses, nursing students, volunteers, and other healthcare professionals. The interventions varied in the number of visits, frequency, duration of follow-up, and whether or not they were combined with other strategies such as telephone calls. Discrepancies were found in the effects of the interventions on quality of life, self-efficacy, self-rated health, and use and cost of health and social services.

CONCLUSION

This review shows that home visiting programmes could have potential benefits for older adults with chronic multimorbidity. However, its results have been inconclusive. There is a need for high quality studies involving a larger number of patients, in which home visits are the main intervention.

Effectiveness of outpatient geriatric evaluation and management intervention on survival and nursing home admission: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

The benefit of inpatient comprehensive geriatric assessment on patient survival and function has been demonstrated among frail older patients. However, the influence of outpatient geriatric evaluation and management (GEM) on clinical outcomes remains debated. This study aimed to update the research evidence detailing the effect of outpatient GEM on survival and nursing-home admission through a comparison with conventional care.

METHODS

Cochrane Library, EMBASE, and MEDLINE databases were searched up to January 29th, 2022, to identify randomized controlled trials (RCTs) including older people over age 55 that compared outpatient GEM with conventional care on mortality (primary outcome) and nursing-home admission (secondary outcome) during a follow-up period of 12 to 36 months.

RESULTS

Nineteen reports from 11 studies that recruited 7,993 participants (mean age 70-83) were included. Overall, outpatient GEM significantly reduced mortality (risk ratio (RR) = 0.87, 95% confidence interval (CI) = 0.77-0.99, I2 = 12%). For the subgroup analysis categorized by different follow-up periods, its prognostic benefit was only disclosed for 24-month mortality (RR = 0.68, 95% CI = 0.51-0.91, I2 = 0%), but not for 12- or 15 to 18-month mortality. Furthermore, outpatient GEM had significantly trivial effects on nursing-home admission during the follow-up period of 12 or 24 months (RR = 0.91, 95% CI = 0.74-1.12, I2 = 0%).

CONCLUSIONS

Outpatient GEM led by a geriatrician with a multidisciplinary team improved overall survival, specifically during the 24-month follow-up period. This trivial effect was demonstrated in rates of nursing-home admission. Future research on outpatient GEM involving a larger cohort is warranted to corroborate our findings.

In-home Visits and Subsequent Health Outcomes in Medicare Advantage Beneficiaries With Coronary Artery Disease, Diabetes, Hypertension, and Depression

BACKGROUND

Coronary artery disease, diabetes, hypertension, and depression are common burdensome conditions.

OBJECTIVES

To examine whether multidimensional preventive in-home visits were associated with fewer emergency and inpatient care episodes and higher quality of care.

RESEARCH DESIGN

An observational, retrospective data analysis.

SUBJECTS

A nationwide Medicare Advantage population from the Optum Labs Data Warehouse.

MEASURES

We compared beneficiaries with 1 or more of the conditions with an in-home visit in 2018 ("Exposure") with those without a visit in 2018 but with a future visit in 2019 ("Wait List Control") using a difference-in-differences analysis. Primary outcomes were 1-year all-cause inpatient care and emergency visit counts. Secondary outcomes included primary care visits, major adverse cardiovascular events, and select quality-of-care metrics. An exploratory outcome was the time-to-first primary care visit after the index date.

RESULTS

Among those eligible to receive an in-home visit, a total of 48,566 patients had an in-home visit in 2018 (the "Exposure" group), and 36,549 beneficiaries constituted the "Wait List" control group. Receiving an in-home visit early was associated with a greater decrease in inpatient stays for all 4 conditions (change score range for any stay: -5.22% to -2.47%) (P<0.001, depression <0.05); decrease in emergency visits (change score range for any stay: -4.39% to -3.67%) (P<0.0.001, depression <0.05); and fewer major adverse cardiovascular events for coronary artery disease and depression (P<0.001 and <0.025, respectively) 1 year later. Minimal differences were noted for change in ambulatory and primary care visits, with no consistent increase in quality-of-care metrics. Time-to-first primary care visit was shorter for the "Exposure" versus the Wait List control group in all conditions (difference between 2.45 and 4.95 d).

CONCLUSIONS

The feasibility and impact of a nationwide multidimensional preventive in-home visit were demonstrated, targeting common and high morbidity conditions. Benefits were observed against a Wait List control group, resulting in less resource-intense care.

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

OBJECTIVES

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

DESIGN

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

SETTING AND PARTICIPANTS

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

METHODS

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

RESULTS

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

CONCLUSION AND IMPLICATIONS

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

TRIAL REGISTRATION

Study protocol registered in PROSPERO 2020 CRD42020169680.

Effectiveness of home visit nursing on improving mortality, hospitalization, institutionalization, satisfaction, and quality of life among older people: Umbrella review

This umbrella review followed the JBI methodology and synthesized systematic reviews of the effectiveness of long-term home visit nursing for older people (≥ 60 years) on improving mortality, hospitalization, institutionalization, patient satisfaction, and quality of life. Eight bibliographic databases were searched, and 10 reviews with 22 distinct relevant trials (n = 10,765 participants) were included. Mortality was the most frequently examined outcome and satisfaction was the least examined (n = nine and one reviews, respectively). Home visit nursing had a favorable effect on reducing the number of admissions to hospital (n = 1,152 participants in two trials vs. 788 participants in three trials) and no effect on other outcomes. The evidence of the effectiveness of long-term home visit nursing for older people is minimal. Future research needs to be based on a theoretical foundation that explains how interventions are expected to work.

Overactive Bladder and Cognitive Impairment: The American Urogynecologic Society and Pelvic Floor Disorders Research Foundation State-of-the-Science Conference Summary Report

IMPORTANCE

Overactive bladder (OAB) is prevalent in older adults in whom management is complicated by comorbidities and greater vulnerability to the cognitive effects of antimuscarinic medications.

OBJECTIVES

The aim of this study is to provide a comprehensive evidence-based summary of the 2021 State-of-the-Science (SOS) conference and a multidisciplinary expert literature review on OAB and cognitive impairment.

STUDY DESIGN

The American Urogynecologic Society and the Pelvic Floor Disorders Research Foundation convened a 3-day collaborative conference. Experts from multidisciplinary fields examined cognitive function, higher neural control of the OAB patient, risk factors for cognitive impairment in older patients, cognitive effects of antimuscarinic medications for OAB treatment, OAB phenotyping, conservative and advanced OAB therapies, and the need for a multidisciplinary approach to person-centered treatment. Translational topics included the blood-brain barrier, purine metabolome, mechanotransduction, and gene therapy for OAB targets.

RESULTS

Research surrounding OAB treatment efficacy in cognitively impaired individuals is limited. Short- and long-term outcomes regarding antimuscarinic effects on cognition are mixed; however, greater anticholinergic burden and duration of use influence risk. Oxybutynin is most consistently associated with negative cognitive effects in short-term, prospective studies. Although data are limited, beta-adrenergic agonists do not appear to confer the same cognitive risk.

CONCLUSIONS

The 2021 SOS summary report provides a comprehensive review of the fundamental, translational, and clinical research on OAB with emphasis on cognitive impairment risks to antimuscarinic medications. Duration of use and antimuscarinic type, specifically oxybutynin when examining OAB treatments, appears to have the most cognitive impact; however, conclusions are limited by the primarily cognitively intact population studied. Given current evidence, it appears prudent to minimize anticholinergic burden by emphasizing nonantimuscarinic therapeutic regimens in the older population and/or those with cognitive impairment.

Effectiveness of the VA-Geriatric Resources for Assessment and Care of Elders (VA-GRACE) program: An observational cohort study

BACKGROUND

As the Department of Veterans Affairs (VA) healthcare system seeks to expand access to comprehensive geriatric assessments, evidence-based models of care are needed to support community-dwelling older persons. We evaluated the VA Geriatric Resources for Assessment and Care of Elders (VA-GRACE) program's effect on mortality and readmissions, as well as patient, caregiver, and staff satisfaction.

METHODS

This retrospective cohort included patients admitted to the Richard L. Roudebush VA hospital (2010-2019) who received VA-GRACE services post-discharge and usual care controls who were potentially eligible for VA-GRACE but did not receive services. The VA-GRACE program provided home-based comprehensive, multi-disciplinary geriatrics assessment, and ongoing care. Primary outcomes included 90-day and 1-year all-cause readmissions and mortality, and patient, caregiver, and staff satisfaction. We used propensity score modeling with overlapping weighting to adjust for differences in characteristics between groups.

RESULTS

VA-GRACE patients (N = 683) were older than controls (N = 4313) (mean age 78.3 ± 8.2 standard deviation vs. 72.2 ± 6.9 years; p < 0.001) and had greater comorbidity (median Charlson Comorbidity Index 3 vs. 0; p < 0.001). VA-GRACE patients had higher 90-day readmissions (adjusted odds ratio [aOR] 1.55 [95%CI 1.01-2.38]) and higher 1-year readmissions (aOR 1.74 [95%CI 1.22-2.48]). However, VA-GRACE patients had lower 90-day mortality (aOR 0.31 [95%CI 0.11-0.92]), but no statistically significant difference in 1-year mortality was observed (aOR 0.88 [95%CI 0.55-1.41]). Patients and caregivers reported that VA-GRACE home visits reduced travel burden and the program linked Veterans and caregivers to needed resources. Primary care providers reported that the VA-GRACE team helped to reduce their workload, improved medication management for their patients, and provided a view into patients' daily living situation.

CONCLUSIONS

The VA-GRACE program provides comprehensive geriatric assessments and care to high-risk, community-dwelling older persons with high rates of satisfaction from patients, caregivers, and providers. Widespread deployment of programs like VA-GRACE will be required to support Veterans aging in place.

Community nurses' perspectives on a novel blended training approach: a qualitative study

Background

Transiting into the community setting often presents novel difficulties for nurses because the role demands skills that might not have been obtained through usual clinical experience or training. The Ageing-in-Place Community Care Team (AIP-CCT) Community Nurse Basic Training programme was developed to address this learning gap. This training programme prepares nurses to lead in a multi-disciplinary team in delivering patient-centred care to patients with progressive or life-limiting conditions in the community setting. This study evaluated the inaugural training programme provided to a group of nurses from an acute hospital in Singapore.

Methods

Qualitative in-depth interviews were carried out with 13 participants from the training programme three-months after completion of the AIP-CCT Community Nurse Basic Training programme provided by an acute hospital to understand the programme’s impact on their knowledge, skills and clinical practice, as well as barriers and facilitators to learning.

Results

Overall, perception towards the training course was mixed. Course content was found to be relevant, and participants reported that training led to improvement in their practice. However, experienced nurses felt that the content of some modules were lacking in depth. This could have explained why only junior nurses tended to hold favourable attitudes and felt that the training led to increase in their confidence level. Although medical content was assessed favourably, the course was not able to address some of the constraints faced by community nurses such as managing expectations and handling difficult patients in the home care setting. For some modules, face-to-face training was preferred and e-learning components can be improved to increase communication and interaction.

Conclusion

This study provided insights into how a community nurse training programme could be developed to meet the needs of community nurses. The training was able to reinforce skills and knowledge, address knowledge gaps and provide new clinical care approaches and communication strategies. These incremental effects on experienced community nurses could be extrapolated to have greater benefits for inexperienced community nurses. Based on findings of the study, potential changes to the training programme were discussed to improve training outcomes.

Total care expenditures and their drivers among older adults: A study on health and long-term care expenditures in South Korea

Background

South Korea operates two different national insurance systems: health care insurance covers medical services and long-term care (LTC) insurance covers residential care and home care services. Total care expenditures include benefits from both these insurance schemes and personal payments made for receiving these services. This study aims to identify total care expenditures per older person along with related factors and their effects on care expenditures.

Methods

We analyzed claims data of 2017 for LTC and health care insurance in Korea using multiple regression analysis. Participants were recipients of LTC insurance, aged 60 years or above (n = 650,059). The variables of interest included socioeconomic characteristics, disabilities, chronic diseases, and care needs levels.

Results

The total expenditures were approximately USD 9,808,922,016 for 650,059 older people (USD 15,089.28 ± 8,006.57 per person) in 2017. The benefits of national health insurance accounted for 86.03% of the total, while personal payments accounted for 13.97%. Comparing the expenditure across services, the total amount was found to be much higher for LTC services. The personal payments were similar for the two insurance schemes, and the proportion of expenses by service type (to total expenses) was greater for LTC (LTC versus health care expenditures: 63.25% versus 36.15% of the total expenditures). The total care expenditures differed significantly according to recipient characteristics. Older adults who were women, between 75–84 years old, with higher care needs levels, and who suffered from diseases and lived in the residential facilities were associated with an increase in total expenditures. Moreover, factors such as any type of disability and living alone were related to a decrease in total care expenditures.

Conclusions

The increase in care expenditures should be monitored from an integrated perspective on overall health care and LTC, and to reduce care needs. In addition, we should focus on the factors involved in using (receiving) services for older individuals and complementing the lack of or inadequate services to enhance and sustain the LTC and health care service systems. Older adults receiving full basic livelihood security and living alone should receive greater attention from the perspective of social equity.

Frailty and severe mental illness: A systematic review and narrative synthesis

OBJECTIVE

Emerging evidence suggests that people with severe mental illness (SMI) have an increased risk of frailty. We conducted a systematic review to investigate the prevalence and correlates of frailty, as well as the efficacy of frailty interventions, in this population.

METHODS

We searched databases from inception to 21 September 2021 for studies that assessed or intervened for frailty in relation to an SMI diagnosis. A narrative synthesis explored the characteristics and adverse health outcomes associated with frailty and the efficacy of interventions. The prevalence of frailty was investigated, and its relationship with age was analysed by a meta-regression.

RESULTS

Twenty-five studies involving 2499 patients, primarily older adults, were included in the narrative synthesis. Frailty was associated with higher rates of physical comorbidity, cognitive deficits, falls and mortality among those with SMI. The efficacy of a yoga intervention was investigated in one study, without sustained reductions in frailty. The prevalence of frailty varied between 10.2 and 89.7% and was high in comparison to the general population.

CONCLUSIONS

The prevalence of frailty was high in those with SMI and ranged widely due to heterogeneity of study populations. Assessing frailty enables the identification of patients who could benefit from interventions and assists in treatment-related decision making. Further research is required to develop appropriate frailty interventions for this population.

Health Information Systems for Older Persons in Select Government Tertiary Hospitals and Health Centers in the Philippines: Cross-sectional Study

Background

The rapid aging of the world’s population requires systems that support health facilities’ provision of integrated care at multiple levels of the health care system. The use of health information systems (HISs) at the point of care has shown positive effects on clinical processes and patient health in several settings of care.

Objective

We sought to describe HISs for older persons (OPs) in select government tertiary hospitals and health centers in the Philippines. Specifically, we aimed to review the existing policies and guidelines related to HISs for OPs in the country, determine the proportion of select government hospitals and health centers with existing health information specific for OPs, and describe the challenges related to HISs in select health facilities.

Methods

We utilized the data derived from the findings of the Focused Interventions for Frail Older Adults Research and Development Project (FITforFrail), a cross-sectional and ethics committee–approved study. A facility-based listing of services and human resources specific to geriatric patients was conducted in purposively sampled 27 tertiary government hospitals identified as geriatric centers and 16 health centers across all regions in the Philippines. We also reviewed the existing policies and guidelines related to HISs for OPs in the country.

Results

Based on the existing guidelines, multiple agencies were involved in the provision of services for OPs, with several records containing health information of OPs. However, there is no existing HIS specific for OPs in the country. Only 14 (52%) of the 27 hospitals and 4 (25%) of the 16 health centers conduct comprehensive geriatric assessment (CGA). All tertiary hospitals and health centers are able to maintain medical records of their patients, and almost all (26/27, 96%) hospitals and all (16/16, 100%) health centers have data on top causes of morbidity and mortality. Meanwhile, the presence of specific disease registries varied per hospitals and health centers. Challenges to HISs include the inability to update databases due to inadequately trained personnel, use of an offline facility–based HIS, an unstable internet connection, and technical issues and nonuniform reporting of categories for age group classification.

Conclusions

Current HISs for OPs are characterized by fragmentation, multiple sources, and inaccessibility. Barriers to achieving appropriate HISs for OPs include the inability to update HISs in hospitals and health centers and a lack of standardization by age group and disease classification. Thus, we recommend a 1-person, 1-record electronic medical record system for OPs and the disaggregation and analysis across demographic and socioeconomic parameters to inform policies and programs that address the complex needs of OPs. CGA as a required routine procedure for all OPs and its integration with the existing HISs in the country are also recommended.

Geriatric conditions do not predict stroke or bleeding in long-term care residents with atrial fibrillation

BACKGROUND

Long-term care (LTC) providers prescribe anticoagulation (AC) less frequently in residents with atrial fibrillation (AF) and geriatric conditions independent of CHA₂ DS₂ -VASc stroke risk score. Geriatric conditions include recent fall, activities of daily living dependency, mobility impairment, cognitive impairment, low body mass index, and weight loss. Multiple publications have suggested that patients with geriatric conditions are at increased risk for stroke. Understanding better the risk of stroke and bleeding in residents with AF and geriatric conditions would be valuable to LTC providers for AC decision-making.

METHODS AND RESULTS

We measured the association of geriatric conditions with composite of stroke/transient ischemic attack (TIA)/systemic embolism and bleeding in residents with AF and elevated stroke risk (CHA₂ DS₂ -VASc score ≥ 2) living in American LTC facilities in 2015. After merging nursing home assessments (Minimum Data Set) with medication and hospital utilization records, we identified 209,413 eligible residents. Using generalized estimating equations, we found that the incidence of stroke/TIA/systemic embolism ranged from 0.13% to 0.26% over 30 days (1.43%-3.08%/year) in residents off AC with and without geriatric conditions adjusting for other resident characteristics including CHA₂ DS₂ -VASc score and propensity to receive AC. Similarly, the monthly incidence of bleeding on AC ranged from 0.22% to 0.28% (2.61%-3.31%/year) without increased risk with geriatric conditions. Residents with a CHA₂ DS₂ -VASc score of ≥7 had a 2.4-fold increased risk of stroke compared with those with score of 2-4 (0.30% vs. 0.12%/month).

CONCLUSION

Calculating a CHA₂ DS₂ -VASc score can be helpful in AC decision-making for residents with and without geriatric conditions.

Designing a nurse-led assessment and care planning intervention to support frail older people in primary care: An e-Delphi study

Aim

To identify and establish expert consensus on important and feasible components of a nurse‐led, comprehensive geriatric assessment (CGA)‐based intervention for community‐dwelling older people who live with frailty.

Design

A three‐round modified e‐Delphi survey.

Methods

An expert panel of 33 UK specialist older people's, primary and community care nurses participated in the three‐round e‐Delphi survey over a 12‐month period in 2017–2018. Data from round 1 were analysed using content analysis. Descriptive statistics were used in the subsequent two rounds to demonstrate convergence of panel opinion and consensus.

Results

In round 1, experts proposed 30 CGA components that were combined with six additional components from a literature review and clustered into six domains. In round 2, components were rated for importance and feasibility. Rating scores for importance were high across all domains, with lower scores for feasibility. Round 3 revealed that 36 components achieved consensus on importance and 11 out of 36 components reached consensus on feasibility.

Conclusion

Based on expert panel opinion, the content of a nurse‐led CGA‐based intervention was established, with the aim of future feasibility testing in a randomized controlled trial.

Impact

This study provides feasible components of a CGA‐based intervention that can be implemented in clinical practice by nurses in partnership with older people who live with frailty. Following further testing and evaluation, the components have the potential to improve clinical outcomes, maximize independence and improve the quality of life for community‐dwelling frail older people.

Overall mortality in older people receiving physician-led home visits: a multicentre prospective study in Japan

BACKGROUND

Japan has the most rapidly ageing population in the world. The Japanese government has, therefore, promoted physician-led home health care for frail and disabled people.

OBJECTIVES

To describe mortality among older people receiving physician-led health care at home or at a nursing home in Japan and to identify risk factors.

METHODS

This was a multicentre prospective cohort study. Participants were aged ≥65 years and had started to receive regular physician-led health care at home or at nursing homes from 13 facilities between 1 February 2013 and 31 January 2016. The observation period ended on 31 January 2017. We used a biopsychosocial approach for exploratory analysis of 13 variables to identify mortality risk factors.

RESULTS

The median (25th to 75th percentile) observation time was 417 (121-744) days. Of 825 participants, 380 died. The total cumulative survival for 180, 360, 720 and 1440 days was 73.4% (95% confidence interval: 70.2-76.3), 64.2% (60.8-67.5), 52.6% (48.8-56.3) and 34.6% (23.5-46.0). The Kaplan-Meier cumulative survival curve showed a steep drop during the first 6 months of observation. A multivariate Cox proportional hazard model showed that sex (male), high Charlson Comorbidity Index score, low serum albumin level, low Barthel Index score, receipt of oxygen therapy, high Cornell Scale for Depression in Dementia score and non-receipt of public assistance were associated with mortality.

CONCLUSIONS

Overall mortality in physician-led home visits in Japan was described and mortality risk factors identified. Public assistance receipt was associated with lower mortality.

Continuous Use of Home Care Services and Functional Performance: A Population-Based Approach

BACKGROUND

Home care (HC) services are the foundational service in Taiwan, such as personal care, housekeeping, showers, meal preparation, and so on. We used population-representative data to evaluate the effects of HC services use on the long-term functional performance of older adults.

METHOD

This longitudinal study used latent growth curve modeling, measured as trajectories in activities of daily living (ADL) ability. We retrieved data for 1,851 care recipients from the Long-Term Care Service Management System database.

RESULTS

Continuous use of HC services had positive effects on functional performance over time of declining functional capacity (β = .075, p < .05). While greater age was associated with slower increases in ADL scores, being female and living alone were associated with faster increases in ADL scores.

DISCUSSION

Continuous use of the HC services provided has a significant impact on maintaining or improving functional performance among older adults in the early stage of declined functional capacity.

[Thoracic surgery and co-morbid patients]

Patients undergoing lung resection are often active or former smokers who have chronic disease related to tobacco (coronary artery disease, chronic obstructive bronchitis, arteritis of the inferior limbs…). Those co-morbidities increase the operative risk for surgery in which morbi-mortality is relevant. On top of this, we are witnessing an increasing number of non-small cell lung cancers in an aging population that might show signs of frailty. The challenge for the surgeon is to identify early those co-morbid and/or frail patients by using predictive scores like Thoracoscore, mFI (modified frailty index) or MSK-F1 (Memorial Sloan-Kettering Frailty Index). Screening for those high-risk patients implies adapting surgical management through a multidisciplinary approach. That is the objective of co-managment, which allows geriatricians and surgeons to collaborate, or enhanced recovery after surgery which is more accessible to all group ages. The objective of this article is to review the management of co-morbid patients in thoracic surgery, by detailing certain predictive scores available and the multidisciplinary approaches developed to treat the patients screened.

Components, impacts and costs of dementia home support: a research programme including the DESCANT RCT

Background

Over half of people with dementia live at home. We know little about what home support could be clinically effective or cost-effective in enabling them to live well.

Objectives

We aimed to (1) review evidence for components of home support, identify their presence in the literature and in services in England, and develop an appropriate economic model; (2) develop and test a practical memory support package in early-stage dementia, test the clinical effectiveness and cost-effectiveness of routine home support in later-stage dementia and design a toolkit based on this evidence; and (3) elicit the preferences of staff, carers and people with dementia for home support inputs and packages, and evaluate the cost-effectiveness of these approaches in early- and later-stage dementia.

Design

We undertook (1) an evidence synthesis, national surveys on the NHS and social care and an economic review; (2) a multicentre pragmatic randomised trial [Dementia Early Stage Cognitive Aids New Trial (DESCANT)] to estimate the clinical effectiveness and cost-effectiveness of providing memory aids and guidance to people with early-stage dementia (the DESCANT intervention), alongside process evaluation and qualitative analysis, an observational study of existing care packages in later-stage dementia along with qualitative analysis, and toolkit development to summarise this evidence; and (3) consultation with experts, staff and carers to explore the balance between informal and paid home support using case vignettes, discrete choice experiments to explore the preferences of people with dementia and carers between home support packages in early- and later-stage dementia, and cost–utility analysis building on trial and observational study.

Setting

The national surveys described Community Mental Health Teams, memory clinics and social care services across England. Recruitment to the trial was through memory services in nine NHS trusts in England and one health board in Wales. Recruitment to the observational study was through social services in 17 local authorities in England. Recruitment for the vignette and preference studies was through memory services, community centres and carers’ organisations.

Participants

People aged > 50 years with dementia within 1 year of first attendance at a memory clinic were eligible for the trial. People aged > 60 years with later-stage dementia within 3 months of a review of care needs were eligible for the observational study. We recruited staff, carers and people with dementia for the vignette and preference studies. All participants had to give written informed consent.

Main outcome measures

The trial and observational study used the Bristol Activities of Daily Living Scale as the primary outcome and also measured quality of life, capability, cognition, general psychological health and carers’ sense of competence.

Methods

Owing to the heterogeneity of interventions, methods and outcome measures, our evidence and economic reviews both used narrative synthesis. The main source of economic studies was the NHS Economic Evaluation Database. We analysed the trial and observational study by linear mixed models. We analysed the trial by ‘treatment allocated’ and used propensity scores to minimise confounding in the observational study.

Results

Our reviews and surveys identified several home support approaches of potential benefit. In early-stage dementia, the DESCANT trial had 468 randomised participants (234 intervention participants and 234 control participants), with 347 participants analysed. We found no significant effect at the primary end point of 6 months of the DESCANT intervention on any of several participant outcome measures. The primary outcome was the Bristol Activities of Daily Living Scale, for which scores range from 0 to 60, with higher scores showing greater dependence. After adjustment for differences at baseline, the mean difference was 0.38, slightly but not significantly favouring the comparator group receiving treatment as usual. The 95% confidence interval ran from –0.89 to 1.65 (p = 0.56). There was no evidence that more intensive care packages in later-stage dementia were more effective than basic care. However, formal home care appeared to help keep people at home. Staff recommended informal care that cost 88% of formal care, but for informal carers this ratio was only 62%. People with dementia preferred social and recreational activities, and carers preferred respite care and regular home care. The DESCANT intervention is probably not cost-effective in early-stage dementia, and intensive care packages are probably not cost-effective in later-stage dementia. From the perspective of the third sector, intermediate intensity packages were cheaper but less effective. Certain elements may be driving these results, notably reduced use of carers’ groups.

Limitations

Our chosen outcome measures may not reflect subtle outcomes valued by people with dementia.

Conclusions

Several approaches preferred by people with dementia and their carers have potential. However, memory aids aiming to affect daily living activities in early-stage dementia or intensive packages compared with basic care in later-stage dementia were not clinically effective or cost-effective.

Future work

Further work needs to identify what people with dementia and their carers prefer and develop more sensitive outcome measures.

Study registration

Current Controlled Trials ISRCTN12591717. The evidence synthesis is registered as PROSPERO CRD42014008890.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 9, No. 6. See the NIHR Journals Library website for further project information.

Characterizing Quality of Life in Caregivers of People with Parkinson's Disease and Dysphagia

Caring for a family member with dysphagia can negatively impact caregiver wellbeing, although little is known about how dysphagia severity or specific symptoms influence this. The purpose of this study was to examine how objective measures of dysphagia in people with Parkinson's disease influenced their caregivers' quality of life. Fifty caregivers (mainly spouses) of people with Parkinson's disease completed a caregiver quality of life survey. Results were compared to medical chart reviews, interviews, and instrumental evaluations of swallowing from the care recipients. Outcomes included caregiver quality of life score, ratings of airway invasion and pharyngeal residue, and Parkinson's disease duration. Descriptive and regression analyses were completed. All caregivers reported reduced quality of life, with 28% having severely disturbed adaptation. Every care recipient with Parkinson's disease demonstrated airway invasion and/or pharyngeal residue. Together, the combination of older care recipient age and longer disease duration was associated with poorer caregiver quality of life [adj. R² = 0.10-0.12, p = 0.03-0.4]. Neither airway invasion nor pharyngeal residue was related to caregiver quality of life (p > 0.05). Findings confirmed that caregivers of people with Parkinson's disease and dysphagia experience reduced quality of life; however, current methods of assessing caregivers' quality of life may not adequately account for dysphagia-specific burden. Results highlight the urgent need for the development of dysphagia-specific assessments of caregivers' quality of life to facilitate identification of high-risk caregivers and aid the development of support systems to improve health outcomes for caregivers and care recipients.

[The "Hamburg home visit for older citizens" : Development, execution and acceptance in 4716 older people in 15 months]

BACKGROUND

Preventive home visits are part of communal programs for older citizens. The city of Hamburg promoted the pilot project "The Hamburg home visit for older citizens" in two city districts. The voluntary program is offered to persons on their 80th birthday, without comprehensive assessment and is performed by visitors with a background in healthcare or social work. The aim is to provide information, to identify need of help and to initiate contact with officials for support if wanted.

METHODS

The structural and administrative prerequisites were defined together with officials of the city of Hamburg and the two city districts. The data safety concept, provision of addresses, birthday letter, information to be provided, recruitment, qualification and training of the visitors, timing and performance of visits, guiding how to communicate during the home visit, documentation and quarterly reports are described in detail.

RESULTS

From September 2018 to December 2019, 1636 (35%) out of 4716 persons contacted were visited by 59 visitors. The most frequent reasons for refusal were no need because of good health (40%) or satisfaction with existing support (14%). Most issues addressed were health situation (51%), mobility (43%), housing conditions (42%) and social contacts (41%). There was need of support as documented in 399 out of 1636 home visits, and contacts for support were initiated as required by 55 persons.

CONCLUSION

The acceptance of this new approach was 10% higher than 25% per month that had been expected in both the concentrated urban as well as the more rural city districts. Home visits on the 80th birthday appear to be feasible provided that structural and operational prerequisites are considered. In 2020, they were offered to all districts of the city, i.e. to about 15,000 persons per year.

Effectiveness of a health and social care integration programme for home-dwelling frail older persons in Argentina

Introduction

The evidence of effectiveness of integrated care initiatives for home-dwelling frail older persons is still inconclusive. There is a need for more studies, especially in developing countries. Our objective was to assess the effectiveness of a health and social care integration programme versus the best standard of care to date in this population.

Methods

Quasi-experimental study performed in patients' homes in Buenos Aires, Argentina. The intervention arm had a health and social care counsellor that systematically reviewed the social and biological situation following a structured process, evaluating: functionality, nutrition, mobility, pain, cognition, medication reconciliation and adherence, need for care, quality of care, and environmental safety. The control group received the best standard of care to date, with access to the same health or social care services, but without the counsellor and related processes. The main outcome was the adjusted hazard ratio for hospitalizations after one year using a Cox-proportional hazards model.

Results

We recruited 121 persons in each group. The crude hazard ratio for hospital admissions, comparing the intervention to the control group was 0.622 (95% CI: 0.427–0.904; p = 0.013). The adjusted hazard ratio (aHR) was 0.503 (95% CI: 0.340–0.746; p = 0.001). The aHR for death was 0.993 (95% CI: 0.492–2.002; p = 0.984). The absolute difference in the quality of life was 16.59 points (95% CI: 12.03–21.14; p < 0.001).

Discussion

The integration programme had lower hospital admissions and better quality of life than the usual care. There was no significant difference in death rates.

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

BACKGROUND/OBJECTIVES

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

DESIGN

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

SETTING

Nine general practices in Auckland, New Zealand.

PARTICIPANTS

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

INTERVENTION

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

MEASUREMENTS

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

SECONDARY OUTCOMES

acute hospitalization, mortality, and other health service utilization.

RESULTS

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

CONCLUSION

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

Nurse Practitioners in Swiss Family Practices as Potentially Autonomous Providers of Home Visits: An Exploratory Study of Two Cases

In Swiss primary care, general practitioner (GP) home visits have decreased due to impending GP shortages particularly in rural areas. Nurse practitioners (NP) are newly introduced in family practices and could potentially offer home visits to the increasing number of multimorbid elderly. We analysed consultation data from two pilot projects (Practice A and Practice B) with the goal to measure the frequency and patient characteristics of NP consultations both in the practice and on home visits, and to determine the NPs’ autonomy based on the required GP supervision. In Practice A, 17% of all NP consultations were home visits, in Practice B 51%. In both practices, the NPs saw older patients and reported higher autonomy on home visits compared to consultations in the practice. In Practice A, the NP encountered a higher share of multimorbid patients on home visits than in the practice, and the NP’s proportion of autonomously conducted consultations increased from 0% in the first month to 19% after 13 months of GP supervision. In Practice B, the NP was autonomous in about three-quarters of consultations after 2 years on the job. These first cases provide some evidence that NPs could reach a relatively high degree of autonomy and might pose a potential solution for the decreasing numbers of GP home visits to multimorbid elderly in Swiss primary care.

Promote social participation among older persons by identifying physical challenges - An important aspect of preventive home visits

INTRODUCTION

Social participation can have a positive impact on health; however, physical challenges can be hindrances. During a preventive home visit a health professional (visitor) assesses different aspects of physical, mental and social health. However, there might be a challenge for the visitor to discover the interrelationship between physical factors that hinder social participation. Therefore, the aim of this study was, in the context of preventive home visits, to identify physical factors which can hinder older persons from taking part in social contexts.

METHODS

Cross-sectional register data from preventive home visits to older persons (n = 1245, ≥77 years old, without home care) was used. Data was collected during a period of 17 months, in seven Swedish municipalities. Logistic regression was used to analyze the association between physical factors and the item physical problems hindering social participation.

RESULTS

The mean age was 78.8 (standard deviation 1.8 years), and 55% were women. The physical factors significantly associated with physical problems hindering taking part in social contexts were: having urinary incontinence (women only), having pain, impaired endurance and using a mobility device.

CONCLUSIONS

This study provides insights into how to make the best use of the questions asked during preventive home visits, in order to enable older persons to take part in social contexts. The results recognize the importance of taking into account physical challenges to be able to support social participation. Furthermore, considering physical challenges for social participation on both an individual and a societal level might reduce inequalities among older persons.

Dysphagia-Related Caregiver Burden: Moving Beyond the Physiological Impairment

Purpose

The biopsychosocial ramifications of dysphagia are widespread. However, its influence on informal caregivers and families is often overlooked. Ultimately, the health and well-being of an entire family is central to care provision. This tutorial introduces readers to the current literature on dysphagia-related caregiver burden and third-party disability, illustrates the consequences of such burden on both caregivers and patients, and suggests strategies for better supporting patients' informal caregivers.

Conclusions

It is essential that speech-language pathologists recognize that the consequences of dysphagia are not limited to the impairment itself and acknowledge dysphagia's substantial impact on the entire family system. More general health care literature suggests that asking caregivers individual questions, modifying the language used to talk with them, providing them with targeted education and resources, and organizing support groups may all be beneficial for increased perceived support and self-efficacy. Ultimately, in order to best meet the needs of our patients with dysphagia, we must also better meet the needs of their families and other informal caregivers.

Improving a Web-Based Tool to Support Older Adults to Stay Independent at Home: Qualitative Study

Background

Older adults desire to stay independent at home for as long as possible. We developed an interactive website to inform older adults and caregivers about ways to achieve this.

Objective

This study aimed to perform an in-depth exploration among potential end users about how to improve the interactive website to better inform older adults and caregivers about ways to stay independent at home.

Methods

To complement the results of a quantitative survey on the usability and acceptability of the website before implementation, we conducted a qualitative descriptive study. Using multiple recruitment strategies, we recruited a purposeful sample of older adults (aged ≥65 years) and caregivers of older adults struggling to stay independent at home. We conducted face-to-face or telephonic interviews in either English or French. In addition, we collected sociodemographic characteristics, other characteristics of participants (eg, health, digital profile, and perception of retirement homes), and experiences with using the website (factors facilitating the use of the website, barriers to its use, and suggestions for improvement). Interviews were audio recorded, transcribed verbatim, and thematically analyzed by two researchers.

Results

We recruited 15 participants, including 5 older adults (mean age 75 years, SD 6) and 10 caregivers (mean age 57 years, SD 14). The mean interview time was 32 min (SD 14). Most older adults had either mobility or health problems or both, and many of them were receiving home care services (eg, blood pressure measurement and body care). Overall, participants found the website easy to navigate using a computer, reassuring, and useful for obtaining information. Barriers were related to navigation (eg, difficult to navigate with a cellphone), relevance (eg, no specific section for caregivers), realism (eg, some resources presented are not state funded), understandability (eg, the actors’ accents were difficult to understand), and accessibility (eg, not adapted for low digital literacy). Suggestions for improvement included a needs assessment section to direct users to the support appropriate to their needs, addition of information about moving into residential care, a section for caregivers, distinction between state-provided and private support services, simpler language, expansion of content to be relevant to all of Canada, and video subtitles for the hearing impaired.

Conclusions

Users provided a wealth of information about the needs of older adults who were facing a loss of autonomy and about what such a website could usefully provide. The request for less generic and more personalized information reflects the wide range of needs that electronic health innovations, such as our interactive website, need to address. After integrating the changes suggested, the new website—Support for Older Adults to Stay Independent at Home (SUSTAIN)—will be implemented and made available to better assist older adults and caregivers in staying independent at home.

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

BACKGROUND

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

METHODS

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

RESULTS

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

DISCUSSION

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

Patterns of geriatric health assessment use among community dwelling older Australian women over a 14-year period

OBJECTIVE

To assess which older Australian women had Medicare subsidized health assessments between 1999 and 2013.

METHODS

This study used prospective, longitudinal survey data from the 1921 to 1926 birth cohort of Australian Longitudinal Study on Women's Health (ALSWH) linked with Medicare Australia data on health services use. Over 11,000 Australian women were included in the study. Latent class analysis was used to identify assessment patterns over time, accounting for death, and based on three categories ('no assessment'; 'assessment; 'deceased') for each year between 1999 and 2013. Further analysis explored the impact of health and sociodemographic characteristics on class membership.

RESULTS

Of the women included in the latent class analysis, 37% never had any assessment and the remainder had had at least one assessment. After a steady uptake from 1999 to 2003, there was decline in uptake from 2003 onwards. A six-class model with sufficient homogeneity and reliable estimation was selected to represent assessment patterns and mortality risk, labelled as: 'high mortality' rate with little chance for assessment (12.4%), 'intermediate mortality, low assessment' (14.1%), 'later mortality/low assessment' (13.1%), 'later mortality, high assessment' (7.0%), 'low mortality, low assessment' (31.8%), 'low mortality, high assessment' (21.6%). Older women with certain conditions (such as diabetes, depression, heart disease) were more likely to be in the low assessment groups, and women with difficulty managing on income were more likely to be in low assessment groups.

CONCLUSION

Distinct assessment and mortality patterns were seen, with many women not having assessment, in particular those who had certain health conditions, were taking 3+ medications, had difficulty in managing on income, needed help or were in respite care, and had caring responsibilities. The findings point to a need to promote these assessments among older women, and to reduce financial barriers, even within the context of a heavily subsidized health care system.

Cognitive impairment assessment and interventions to optimize surgical patient outcomes

For elderly patients undergoing elective surgical procedures, preoperative evaluation of cognition is often overlooked. Patients may experience postoperative delirium (POD) and postoperative cognitive decline (POCD), especially those with certain risk factors, including advanced age. Preoperative cognitive impairment is a leading risk factor for both POD and POCD, and studies have noted that identifying these deficiencies is critical during the preoperative period so that appropriate preventive strategies can be implemented. Comprehensive geriatric assessment is a useful approach which evaluates a patient's medical, psycho-social, and functional domains objectively. Various screening tools are available for preoperatively identifying patients with cognitive impairment. The Enhanced Recovery After Surgery (ERAS) protocols have been discussed in the context of prehabilitation as an effort to optimize a patient's physical status prior to surgery and decrease the risk of POD and POCD. Evidence-based protocols are warranted to standardize care in efforts to effectively meet the needs of these patients.

Factors associated with good health among older persons who received a preventive home visit: a cross-sectional study

Background

The ageing population is increasing worldwide, and this trend is bringing challenges both for the older person and for society. In order to meet the challenges a comprehensive approach is needed involving both health promotion and risk prevention. The preventive home visit is a public health intervention used around the world with the purpose of promoting health and preventing risk among older persons. However, most preventive home visits are focused on questions asking about risks. In order to strengthen the health promotion perspective during the preventive home visits, factors associated with good health need to be identified. The aim of this study was therefore to determine which factors were associated with good self-rated health among older persons who received preventive home visit.

Methods

This was a register study with a cross-sectional design, including older persons (≥75 years old), living in their own homes, and that had received preventive home visit. Data were collected during a period of 9 months, in two municipalities in the south of Sweden. A questionnaire covered mental, physical and lifestyle factors were used at home visit. Binary logistic regression was used to analyse the data.

Results

In total, 619 older persons were included in the study; 55.4% were women, and the mean age was 80.6 years (standard deviation 2.2 years). The following items were significantly associated with good health (after adjustment for age and gender): being able to do things that make one feel valuable, having no physical problems affecting participation in social activities, not feeling sad, not having reduced energy, and not having impaired endurance.

Conclusions

The main conclusion of this study is that questions focusing on risks could be seen from a health promotion perspective and could thus be turned into assets with a positive impact on older persons’ health. Furthermore, the mental and physical factors identified in the results as associated with good health have implications for the person’s ability to feel valuable and participate in social activities. The results suggest that issues regarding both health promotion as well as risk prevention must be brought up during the preventive home visit.

Bridging the intergenerational gap: the outcomes of a student-initiated, longitudinal, inter-professional, inter-generational home visit program

BACKGROUND

Older persons consume disproportionately more healthcare resources than younger persons. Tri-Generational HomeCare (TriGen), a service-learning program, aims to reduce hospital admission rates amongst older patients with frequent admissions. The authors evaluated the educational and patient outcomes of TriGen.

METHODS

Teams consisting of healthcare undergraduates and secondary school (SS) students - performed fortnightly home visits to patients over 6 months. Self-administered scales were used to evaluate the educational outcomes in knowledge and attitudes towards the older people and nine domains of soft skills pre- and post-intervention. Patients' reported satisfaction and clinical outcomes were also assessed.

RESULTS

Two hundred twenty-six healthcare undergraduates and 359 SS students participated in the program from 2015 to 2018. Response rates were 80.1 and 62.4% respectively. One hundred six patients participated in TriGen. There was a significant increase in Kogan's Attitudes towards Old People Scale (KOP) scores for healthcare undergraduates and SS students with a mean increase of 12.8 (95%CI: 9.5-16.2, p <  0.001) and 8.3 (95%CI: 6.2-10.3, p <  0.001) respectively. There was a significant increase in Palmore Facts on Aging Quiz (PFAQ) score for SS students but not for healthcare undergraduates. Most volunteers reported that TriGen was beneficial across all nine domains assessed. There was also a significant decrease in hospital admission rates (p = 0.006) and emergency department visits (p = 0.004) during the 6-month period before and after the program. Fifty-one patients answered the patient feedback survey. Of this, more than 80% reported feeling less lonely and happier.

CONCLUSION

TriGen, a student-initiated, longitudinal, inter-generational service-learning program consisting of SS students and healthcare undergraduates can reduce ageism, develop soft skills, inculcate values amongst SS students and healthcare undergraduates. In addition, TriGen potentially reduces hospital admissions and emergency department visits, and loneliness amongst frequently admitted older patients.

Profile of practitioners, and factors influencing home care physiotherapy model of practice in Nigeria

The present study investigated factors that influenced home care physiotherapy (HCP) services and profile of the practitioners in Nigeria. It also investigated if the service was registered with the Regulatory Agency. Three hundred and thirty conveniently sampled physiotherapists in Nigeria participated in the cross-sectional survey. A newly developed, nine-part, content-validated questionnaire was used to obtain information about the demographics, sources of referral, case types, frequency of treatment, costing, benefits, and challenges of the HCP, job satisfaction, and registration status. Data were analyzed using descriptive statistics. All the respondents (100%) were involved in HCP irrespective of their professional profile. The mean duration of practice experience was 9.09 ± 7.34 years. Stroke (41.8%) was the most prevalent case treated. Poor working environment (M = 4.16, R = 1-5), transportation cost (M = 4.16, R = 1-5) and intrusion by impostors (M = 3.66, R = 1-5), were some of the factors that had impact on the HCP services. A preponderance of HCP services was not registered with the Regulatory Agency in Nigeria.

Joining-the-dots: caring for patients in advanced age

Purpose

Managing patients in advanced age is complex, especially when it comes to multi-morbidities and polypharmacy. The purpose of this qualitative study is to investigate challenges, opportunities and potential solutions from a primary healthcare provider perspective.

Design/methodology/approach

Fifty-seven participants joined in group discussions on challenges and opportunities of working with advanced age. Participants included general practitioners (GPs), practice nurses, students and administration staff working in ten general practices. A thematic analysis was developed, supported by NVivo software.

Findings

Poor lines of communication and fragmentation of services between differing levels of health care services available for older people were highlighted. This has implications for quality of care and equity of services. Participants also reported challenges in treatment and funding regimes.

Research limitations/implications

The small sample size and regional nature of the study, along with the semi-structured nature of the group discussions and rigorous thematic analysis, indicate that this qualitative data is transferable, dependable, confirmable and credible. Comparing the views of tertiary and community services would be useful.

Practical implications

A range of potential strategies and solutions to the current fragmented services was offered by GPs. For example, adequately funded and staffed community-based health hubs; IT platforms enabling timely flow of patient information between primary and tertiary health providers and creation of medical, nursing and allied health roles aimed at improving synergy between GP and tertiary services.

Originality/value

Obtaining the perspectives of general practice highlights the challenges and complexities of caring for those in advanced age brings. These insights have not been previously been explored in-depth within this setting in New Zealand.