The reduction of disability in community-dwelling frail older people: design of a two-arm cluster randomized controlled trial

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

Background

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

Objectives

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

Review design

Systematic review and network meta-analysis.

Eligibility criteria

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

Main outcomes

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

Data sources

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

Review methods

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

Results

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

Limitations

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

Conclusions

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

Future work

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

Study registration

This study is registered as PROSPERO CRD42019162195.

Funding

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

Case management for integrated care of older people with frailty in community settings

BACKGROUND

Ageing populations globally have contributed to increasing numbers of people living with frailty, which has significant implications for use of health and care services and costs. The British Geriatrics Society defines frailty as "a distinctive health state related to the ageing process in which multiple body systems gradually lose their inbuilt reserves". This leads to an increased susceptibility to adverse outcomes, such as reduced physical function, poorer quality of life, hospital admissions, and mortality. Case management interventions delivered in community settings are led by a health or social care professional, supported by a multidisciplinary team, and focus on the planning, provision, and co-ordination of care to meet the needs of the individual. Case management is one model of integrated care that has gained traction with policymakers to improve outcomes for populations at high risk of decline in health and well-being. These populations include older people living with frailty, who commonly have complex healthcare and social care needs but can experience poorly co-ordinated care due to fragmented care systems.

OBJECTIVES

To assess the effects of case management for integrated care of older people living with frailty compared with usual care.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL, Health Systems Evidence, and PDQ Evidence and databases from inception to 23 September 2022. We also searched clinical registries and relevant grey literature databases, checked references of included trials and relevant systematic reviews, conducted citation searching of included trials, and contacted topic experts.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that compared case management with standard care in community-dwelling people aged 65 years and older living with frailty.

DATA COLLECTION AND ANALYSIS

We followed standard methodological procedures recommended by Cochrane and the Effective Practice and Organisation of Care Group. We used the GRADE approach to assess the certainty of the evidence.

MAIN RESULTS

We included 20 trials (11,860 participants), all of which took place in high-income countries. Case management interventions in the included trials varied in terms of organisation, delivery, setting, and care providers involved. Most trials included a variety of healthcare and social care professionals, including nurse practitioners, allied healthcare professionals, social workers, geriatricians, physicians, psychologists, and clinical pharmacists. In nine trials, the case management intervention was delivered by nurses only. Follow-up ranged from three to 36 months. We judged most trials at unclear risk of selection and performance bias; this consideration, together with indirectness, justified downgrading the certainty of the evidence to low or moderate. Case management compared to standard care may result in little or no difference in the following outcomes. • Mortality at 12 months' follow-up (7.0% in the intervention group versus 7.5% in the control group; risk ratio (RR) 0.98, 95% confidence interval (CI) 0.84 to 1.15; I2 = 11%; 14 trials, 9924 participants; low-certainty evidence) • Change in place of residence to a nursing home at 12 months' follow-up (9.9% in the intervention group versus 13.4% in the control group; RR 0.73, 95% CI 0.53 to 1.01; I2 = 0%; 4 trials, 1108 participants; low-certainty evidence) • Quality of life at three to 24 months' follow-up (results not pooled; mean differences (MDs) ranged from -6.32 points (95% CI -11.04 to -1.59) to 6.1 points (95% CI -3.92 to 16.12) when reported; 11 trials, 9284 participants; low-certainty evidence) • Serious adverse effects at 12 to 24 months' follow-up (results not pooled; 2 trials, 592 participants; low-certainty evidence) • Change in physical function at three to 24 months' follow-up (results not pooled; MDs ranged from -0.12 points (95% CI -0.93 to 0.68) to 3.4 points (95% CI -2.35 to 9.15) when reported; 16 trials, 10,652 participants; low-certainty evidence) Case management compared to standard care probably results in little or no difference in the following outcomes. • Healthcare utilisation in terms of hospital admission at 12 months' follow-up (32.7% in the intervention group versus 36.0% in the control group; RR 0.91, 95% CI 0.79 to 1.05; I2 = 43%; 6 trials, 2424 participants; moderate-certainty evidence) • Change in costs at six to 36 months' follow-up (results not pooled; 14 trials, 8486 participants; moderate-certainty evidence), which usually included healthcare service costs, intervention costs, and other costs such as informal care.

AUTHORS' CONCLUSIONS

We found uncertain evidence regarding whether case management for integrated care of older people with frailty in community settings, compared to standard care, improved patient and service outcomes or reduced costs. There is a need for further research to develop a clear taxonomy of intervention components, to determine the active ingredients that work in case management interventions, and identify how such interventions benefit some people and not others.

Core components and impact of nurse-led integrated care models for home-dwelling older people: A systematic review and meta-analysis

BACKGROUND

Integrated care models are highly recommended to overcome care fragmentation in the multimorbid older population. Nurses are potentially ideally situated to fulfil the role as care coordinator to guide integrated care. No systematic review has been conducted specifically focusing on the impact of nurse-led integrated care models for older people in community settings.

OBJECTIVES

To identify core components of nurse-led integrated care models for the home-dwelling older population; to describe patient, service and process outcomes; and to evaluate the impact of these care models on quality of life, activities of daily living, hospitalisation, emergency department visits, nursing home admissions and mortality.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

English, Dutch, French, German and Spanish articles selected from PubMed and CINAHL, hand-search of reference lists of the included articles and grey literature.

REVIEW METHODS

A systematic search was conducted to identify prospective experimental or quasi-experimental studies detailing nurse-led integrated care models in the older home-dwelling population. Study characteristics and reported outcomes were tabulated. The core components of the models were mapped using the Sustainable intEgrated chronic care modeLs for multi-morbidity: delivery, FInancing, and performancE (SELFIE) framework. A random effects meta-analysis was conducted to study the overall effectiveness of the included care models on health-related quality of life, activities of daily living, hospitalisation, emergency department visits, nursing home admissions or mortality. Risk of bias was appraised using the revised Cochrane risk-of-bias tool for randomized trials and ROBINS-I tool for non-randomized studies.

RESULTS

Nineteen studies were included studying a total of 22,168 patients. Core components of integrated care for multimorbid patients such as the involvement of a multidisciplinary team, high risk screening, tailored holistic assessment and an individualized care plan, were performed in a vast majority of the studies; however variability was observed in their operationalisation. Twenty-seven different patient, provider and service outcomes were reported, ranging from 1 to 13 per study. The meta-analyses could not demonstrate a beneficial impact on any of the predefined outcomes. Most included studies were of high risk for several biases.

CONCLUSION

The summarized evidence on nurse-led integrated care models in home-dwelling older people is inconclusive and of low quality. Future studies should include key components of implementation research, such as context analyses, process evaluations and proximal outcomes, to strengthen the evidence-base of nurse-led integrated care.

Performance-based instrument to assess functional capacity in community-dwelling older adults

Functional capacity (FC) is a mediator between neuropsychological functions and real-world functioning, but there is a lack of evidence of its correlation in community-dwelling older adults.

OBJECTIVE

The study aim was to determine the FC level of community-dwelling older adults using the UCSD Performance-based Skills Assessment (UPSA) and to evaluate correlation with cognitive screening tests.

METHODS

Senior center participants were selected according to inclusion criteria: Portuguese fluency, age ≥60 years and self-reported independent living. The subject exclusion criteria were: dementia or other DSM-5 diagnoses, suicidal ideation or intent, non-completion of assessment battery, enrollment in another psychosocial intervention or pharmacotherapy study. FC level was determined by the UPSA, brief UPSA (UPSA-B) and Instrumental Activities of Daily Living scale (IADL's). The Mini-Mental State Examination (MMSE), Memory of Figure Test (MFT), Verbal Fluency Test (VFT) and Clock Drawing Test (CDT) were used for cognitive assessment. A total of 35 subjects that had a mean age of 72 years, were predominantly females(88.6%) and had mean education level of 11.25 years were evaluated.

RESULTS

Mean UPSA and UPSA-B scores were 78.5 and 70, respectively. A statistically significant correlation was observed between the UPSA and IADL, MMSE and VFT.

CONCLUSION

The UPSA serves as a screening assessment of FC in community-dwelling older adults, showing a positive correlation with cognitive screening tests.

Comprehensive geriatric assessments in integrated care programs for older people living at home: A scoping review

In many integrated care programs, a comprehensive geriatric assessment (CGA) is conducted to identify older people's problems and care needs. Different ways for conducting a CGA are in place. However, it is still unclear which CGA instruments and procedures for conducting them are used in integrated care programs, and what distinguishes them from each other. Furthermore, it is yet unknown how and to what extent CGAs, as a component of integrated care programs, actually reflect the main principles of integrated care, being comprehensiveness, multidisciplinarity and person-centredness. Therefore, the objectives of this study were to: (a) describe and compare different CGA instruments and procedures conducted within integrated care programs for older people living at home, and (b) describe how the principles of integrated care were applied in these CGAs. A scoping review of the scientific literature on CGAs in the context of integrated care was conducted for the period 2006-2018. Data were extracted on main characteristics of the identified CGA instruments and procedures, and on how principles of integrated care were applied in these CGAs. Twenty-seven integrated care programs were included in this study, of which most were implemented in the Netherlands and the United States. Twenty-one different CGAs were identified, of which the EASYcare instrument, RAI-HC/RAI-CHA and GRACE tool were used in multiple programs. The majority of CGAs seemed to reflect comprehensiveness, multidisciplinarity and person-centredness, although the way and extent to which principles of integrated care were incorporated differed between the CGAs. This study highlights the high variability of CGA instruments and procedures used in integrated care programs. This overview of available CGAs and their characteristics may promote (inter-)national exchange of CGAs, which could enable researchers and professionals in choosing from the wide range of existing CGAs, thereby preventing them from unnecessarily reinventing the wheel.

Treatment fidelity in Model of Human Occupation research

Introduction

Treatment fidelity is an important consideration in occupational therapy efficacy research. It involves methodological strategies that enhance quantitative rigor and improves confidence in research outcomes. This study examines treatment fidelity in Model of Human Occupation efficacy literature because it is a widely used, occupation-focused theory with a substantial evidence base.

Method

Relevant articles ( n = 17) were coded for treatment fidelity with the Treatment Fidelity Measure. Percentages of articles reporting treatment fidelity strategies and mean adherence to fidelity strategies were calculated. One-way analysis of variance was used to examine fidelity over time.

Results

Only one study reported provider training strategies and measured nonspecific treatment effects. Overall mean adherence to treatment fidelity strategies for Model of Human Occupation research was 0.57; one study demonstrated high fidelity with a score of ≥0.80. Model of Human Occupation efficacy literature trends toward higher levels of treatment fidelity over time.

Conclusion

Model of Human Occupation research demonstrates a moderate level of treatment fidelity overall; it has stronger treatment fidelity from 2001 to the present. As the model progresses toward more outcomes studies, Model of Human Occupation scholars should report provider training and strategies that monitor treatment delivery to improve the quality and applicability of research outcomes.

The Asia-Pacific Clinical Practice Guidelines for the Management of Frailty

OBJECTIVE

To develop Clinical Practice Guidelines for the screening, assessment and management of the geriatric condition of frailty.

METHODS

An adapted Grading of Recommendations, Assessment, Development, and Evaluation approach was used to develop the guidelines. This process involved detailed evaluation of the current scientific evidence paired with expert panel interpretation. Three categories of Clinical Practice Guidelines recommendations were developed: strong, conditional, and no recommendation.

RECOMMENDATIONS

Strong recommendations were (1) use a validated measurement tool to identify frailty; (2) prescribe physical activity with a resistance training component; and (3) address polypharmacy by reducing or deprescribing any inappropriate/superfluous medications. Conditional recommendations were (1) screen for, and address modifiable causes of fatigue; (2) for persons exhibiting unintentional weight loss, screen for reversible causes and consider food fortification and protein/caloric supplementation; and (3) prescribe vitamin D for individuals deficient in vitamin D. No recommendation was given regarding the provision of a patient support and education plan.

CONCLUSIONS

The recommendations provided herein are intended for use by healthcare providers in their management of older adults with frailty in the Asia Pacific region. It is proposed that regional guideline support committees be formed to help provide regular updates to these evidence-based guidelines.

Health status, health behaviors, and the ability to perform everyday activities in Poles aged ≥65 years staying in their home environment

Background

The incidence of chronic diseases increases with age; about 73% of people who are aged ≥60 years suffer from at least 1 chronic disease, and among those older than 70 years, chronic diseases afflict more than >84% of the population. According to epidemiological data, at least 4 chronic disease types coexist in senior citizens, causing their disability. These are mainly cardiovascular diseases; motor system diseases; ophthalmological, auditory, neurological, and mental diseases; and mental impairment. They worsen or limit self-dependence in everyday activities. The process begins with complex activities and advances with age. At first, functional performance deficits are discreet; then, they may gradually lead to complete dependence on other people or institutions.

Objective

This study aimed to assess the relationship between diseases and health behaviors, as well as the everyday functioning of people aged ≥65 years staying in their home environment.

Methods

The research involved 504 elderly people. The inclusion criteria were age (≥65 years) and staying in one's own home environment. The direct interview technique was applied, as well as use of proprietary interview questionnaire and standardized tools used in geriatrics: Barthel scale, measuring performance in everyday activities, and the Instrumental Activities of Daily Living scale, assessing complex everyday activities.

Results

The most frequent disease among the responders was arterial hypertension (77.58%), followed by degenerative joint disease (62.10%), and circulatory failure (43.23%). Lower functional performance was associated with circulatory failure, cerebral stroke, atherosclerosis, Alzheimer's disease, diabetes, Parkinson's disease, degenerative joint disease, and bronchial asthma. Performance worsening significantly influenced the frequency of hospitalizations, with a mean score of 4.31 per person. Medical rehabilitation was practiced by 18.65% of the responders.

Conclusion

Circulatory failure, cerebral stroke, atherosclerosis, bronchial asthma, diabetes, degenerative joint disease, Parkinson's disease, and Alzheimer's disease negatively affect functional performance in elderly people. Hospitalization rates increase with lowering independence in everyday functioning. Future research is needed with regard to the relationship between the practiced rehabilitation and independence in everyday functioning of the elderly.

How effective is integrated care for community-dwelling frail older people? The case of the Netherlands

Integrated care programs have been developed to enhance the quality care for older adults in primary care. These programs usually consist of a multidisciplinary approach, with personalised care based on comprehensive geriatric assessments. However, there is limited evidence for the effectiveness of these programs in frail older people. In this article, we review the results of three recent intervention studies carried out as part of the Dutch National Care for the Elderly Programme. The results illustrate how difficult it is to improve outcomes in community-dwelling frail older adults by means of integrated care. Furthermore, we discuss the implications of these studies for future research into frailty interventions.

Screening for frailty: older populations and older individuals

The concept of frailty as a health dimension in old age is recent and has its origin in the development of geriatric medicine. Initially an unformulated clinical intuition, it is now defined by a diminished physiological reserve of multiple organs that exposes older individuals to increased vulnerability to stressors and a higher risk of adverse outcomes.

The operational definition of frailty, however, is still debated. From a diversity of models, two emerged in the early 2000s from epidemiological studies conducted in large population-based aging cohorts. The body of research emphasized prospective associations between a frailty phenotype and a range of adverse outcomes or between a frailty index measuring the accumulation of deficits and death. A few studies showed promising spontaneous remissions in the early stages of frailty, raising expectations for effective interventions. Transitions between frailty stages and effective interventions on frailty nevertheless remain two fields needing further investigation.

More recently, these tools have been applied as screening instruments in clinical settings to guide individual decision-making and orient treatments. New questions are raised by the use of instruments developed to screen frailty in epidemiological research for assessing individual situations. Inquiring whether frailty screening is relevant opens a Pandora’s box of doubts and debates.

There are many reasons to screen for frailty both from a public health and a clinical perspective that are only exacerbated by the current demographic evolution. Open questions remain about the feasibility of frailty screening, the properties of screening tools, the relevance of an integration of socioeconomic dimensions into screening tools, and the effectiveness of interventions targeting frailty. Fifteen years after the publication of the Fried and Rockwood landmark papers proposing operational definitions of frailty, this article presents an overview of current perspectives and issues around frailty screening in populations and in individuals.

Developing a postal screening tool for frailty in primary care: a secondary data analysis

The purpose of this secondary data analysis (SDA) was to review a subset of quantitative and qualitative paired data sets from a returned postal screening tool (PST) completed by patients and compare them to the clinical letters composed by elderly care community nurses (ECCN) following patient assessment to ascertain the tool's reliability and validity. The aim was to understand to what extent the problems identified by patients in PSTs aligned with actual or potential problems identified by the ECCNs. The researcher examined this connection to establish whether the PST was a valid, reliable approach to proactive care. The findings of this SDA indicated that patients did understand the PST. Many appropriate referrals were made as a result of the ECCN visit that would not have occurred if the PST had not been sent. This article focuses specifically upon the physiotherapy section as this was the area where the most red flags were identified.

The effects of a life goal-setting technique in a preventive care program for frail community-dwelling older people: a cluster nonrandomized controlled trial

Background

Frailty among older people is associated with an increased risk of needing care. There have been many reports on preventive care programs for frail older people, but few have shown positive effects on disability prevention. Physical exercise programs for frail older people affect elements such as physical fitness and balance, but are less effective for disability outcomes and are not followed up in the longer term. We developed a life goal-setting technique (LGST). Our objective was to determine the effect of a LGST plus standard preventive care program for community-dwelling frail older people.

Methods

We used a cluster nonrandomized controlled trial with seven intervention and nine matched control groups, with baseline assessment and follow-up at 3, 6, and 9 months. Participants were 176 frail older people, aged 65 years or over, living in the community in Izumi, Osaka, Japan. All participants attended regular 120 min preventive care exercise classes each week, over 3 months. They also received oral care and nutrition education. The intervention groups alone received life goal-setting support. We assessed outcomes longitudinally, comparing pre-intervention with follow-up. The primary outcome measure was health improvement according to the Japanese Ministry of Health, Labour and Welfare’s “Kihon Checklist” for assessment of frailty and quality of life (QOL), analyzed with a two-way ANOVA and post-test comparison. Secondary outcomes included physical functions and assessment of life goals.

Results

The improvement on the Kihon Checklist for the intervention group was approximately 60 % from baseline to 9-months follow-up; the control group improved by approximately 40 %. The difference between groups was significant at 3-month (p = 0.043) and 6-month (p = 0.015) follow-ups but not at 9-month (p = 0.098) follow-up. Analysis of QOL yielded a significant time × group interaction effect (p = 0.022). The effect was significant at 3 months in the intervention group, but at no time in the control group.

Conclusion

A 3-month exercise program helped to decrease frailty and improve QOL in frail older people, and the addition of LGST increased its effectiveness. The LGST is a feasible and promising intervention for reducing risk of needing care.

Trial registration

UMIN000021485. Registered 15 March 2016.

Reducing disability in community-dwelling frail older people: cost-effectiveness study alongside a cluster randomised controlled trial

BACKGROUND

although proactive primary care, including early detection and treatment of community-dwelling frail older people, is a part of the national healthcare policy in several countries, little is known about its cost-effectiveness.

OBJECTIVE

to evaluate the cost-effectiveness of a proactive primary care approach in community-dwelling frail older people.

DESIGN AND SETTING

embedded in a cluster randomised trial among 12 Dutch general practitioner practices, an economic evaluation was performed from a societal perspective with a time horizon of 24 months.

METHOD

frail older people in the intervention group received an in-home assessment and interdisciplinary care based on a tailor-made treatment plan and regular evaluation and follow-up. Practices in the control group delivered usual care. The primary outcome for the cost-effectiveness and cost-utility analysis was disability and health-related quality of life, respectively.

RESULTS

multilevel analyses among 346 frail older people showed no significant differences between the groups regarding disability and health-related quality of life at 24 months. People in the intervention group used, as expected, more primary care services, but there was no decline in more expensive hospital and long-term care. Total costs over 24 months tended to be higher in the intervention group than in the control group (€26,503 versus €20,550, P = 0.08).

CONCLUSIONS

the intervention under study led to an increase in healthcare utilisation and related costs without providing any beneficial effects. This study adds to the scarce amount of evidence of the cost-effectiveness of proactive primary care in community-dwelling frail older people.

TRIAL REGISTRATION

Current Controlled Trials, ISRCTN 31954692.

Implementing care programmes for frail older people: a project management perspective

OBJECTIVE

To examine the issues that influenced the implementation of programmes designed to identify and support frail older people in the community in the Netherlands.

METHODS

Qualitative research methods were used to investigate the perspectives of project leaders, project members and members of the steering committee responsible for the implementation of the programmes. Interviews were conducted in 2009 (n = 10) and in 2012 (n = 13) and a focus group was organised in 2012 (n = 5).

MAIN FINDINGS

The interviews revealed that the implementation was influenced by the extent and quality of collaboration between organisations, adaptation to existing structures, future funding for the programmes and project leadership. A good relationship between participating organisations and professionals is required for successful implementation. A lack of clear project leadership and structural funding hampers the implementation of complex programmes in primary care settings.

IMPLICATIONS FOR PRACTICE

The findings of this study are useful for organisations and professionals who are planning to implement complex programmes. Identifying barriers concerning institutional collaboration, adaptation to existing structures, leadership and continuation of financial support at an early stage of the implementation process can support practitioners in overcoming them.

Losing connections and receiving support to reconnect: experiences of frail older people within care programmes implemented in primary care settings

AIMS AND OBJECTIVES

The objective of this study was to evaluate whether care provided in the care programmes matched the needs of older people.

BACKGROUND

Care programmes were implemented in primary-care settings in the Netherlands to identify frail older people and to prevent further deterioration of health.

DESIGN AND METHODS

In total, 23 older people participated in in-depth interviews. Within this study, three older people participated as co-researchers; they gathered and analysed the data together with the academic researchers. Content analysis was used to analyse the data.

RESULTS

Two categories emerged from the data: 'Losing connections' and 'Receiving support to reconnect.' 'Losing connections' reflects the needs of older people and 'Receiving support to reconnect' reflects their experience and the appreciated aspects of the provided care. A relationship of trust with the practice nurse (PN) appeared to be an important aspect of care, as it fostered the sharing of feelings and issues other than physical or medical problems that could not be shared with the general practitioner. The PNs are experienced as connectors, who help to restore feelings of connectedness and older peoples' access to resources in the community.

CONCLUSIONS

The relationship with the PN was experienced as valuable because of the feelings of 'connectedness' it created. Through this connectedness, older people could discuss feelings of loneliness, depression and frustration in receiving and acquiring the appropriate resources and services with the PNs. Furthermore, the relationship with the PN helped the older people to gain access to other health professionals and services.

IMPLICATIONS FOR PRACTICE

The results imply that care for frail older people should include an awareness of the importance of the trusting relationship. Nurses can play a vital role in creating a trusting relationship and are able to bridge the gap between older people and other professionals and services.

Are physically frail older persons more at risk of adverse outcomes if they also suffer from cognitive, social, and psychological frailty?

Frailty is considered a predictor for negative outcomes such as disability, decreased quality of life, and hospital admission. Frailty measures have been developed that include different dimensions. We examined whether people who are physically frail are more at risk for negative outcomes of frailty if they also suffer from psychological, cognitive, or social frailty. Frailty was measured at baseline by means of the Groningen Frailty Indicator (GFI), which comprises a physical, cognitive, social, and psychological dimension. Only frail persons were included in the study (GFI ≥ 5) that, in addition, had to be frail in the physical dimension (i.e., ≥1 on this dimension). IADL disability and quality of life were measured at baseline and at 12 months. Hospital admission was assessed during this period. In this, physically frail sample effects of the other three frailty dimensions were studied in regression models. The sample (n = 334, mean age 78.1, and range 70-92) included 40.1 % frail men and 59.9 % frail women. Overall, no additional effects for the cognitive, social, or psychosocial dimensions were found: other frailty dimensions did not have an additional impact on disability, quality of life, or hospital admission in people who already suffered from physical frailty. Higher scores of physical frailty were significantly related to IADL disability (p < 0.05) and hospital admission (p < 0.05). Additional analysis showed that the physical frailty score predicted IADL disability and hospital admission better than the GFI overall score. Results of this study suggest that persons, who are physically frail, according to the GFI, are not more at risk for negative outcomes of frailty (i.e., IADL disability, decreased quality of life, and hospital admission) if they in addition suffer from cognitive, social, or psychological frailty. In addition, for the prediction of IADL disability or hospital admission, the focus for screening should be on the physical frailty score instead of the GFI overall score including different dimensions.

Effectiveness of interdisciplinary primary care approach to reduce disability in community dwelling frail older people: cluster randomised controlled trial

OBJECTIVE

To evaluate whether an interdisciplinary primary care approach for community dwelling frail older people is more effective than usual care in reducing disability and preventing (further) functional decline.

DESIGN

Cluster randomised controlled trial.

SETTING

12 general practices in the south of the Netherlands

PARTICIPANTS

346 frail older people (score ≥ 5 on Groningen Frailty Indicator) were included; 270 (78%) completed the study.

INTERVENTIONS

General practices were randomised to the intervention or control group. Practices in the control group delivered care as usual. Practices in the intervention group implemented the "Prevention of Care" (PoC) approach, in which frail older people received a multidimensional assessment and interdisciplinary care based on a tailor made treatment plan and regular evaluation and follow-up.

MAIN OUTCOME MEASURES

The primary outcome was disability, assessed at 24 months by means of the Groningen Activity Restriction Scale. Secondary outcomes were depressive symptomatology, social support interactions, fear of falling, and social participation. Outcomes were measured at baseline and at 6, 12, and 24 months' follow-up.

RESULTS

193 older people in the intervention group (six practices) received the PoC approach; 153 older people in the control group (six practices) received care as usual. Follow-up rates for patients were 91% (n=316) at six months, 86% (n=298) at 12 months, and 78% (n=270) at 24 months. Mixed model multilevel analyses showed no significant differences between the two groups with regard to disability (primary outcome) and secondary outcomes. Pre-planned subgroup analyses confirmed these results.

CONCLUSIONS

This study found no evidence for the effectiveness of the PoC approach. The study contributes to the emerging body of evidence that community based care in frail older people is a challenging task. More research in this field is needed.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN31954692.

Measures of frailty in population-based studies: an overview

Background

Although research productivity in the field of frailty has risen exponentially in recent years, there remains a lack of consensus regarding the measurement of this syndrome. This overview offers three services: first, we provide a comprehensive catalogue of current frailty measures; second, we evaluate their reliability and validity; third, we report on their popularity of use.

Methods

In order to identify relevant publications, we searched MEDLINE (from its inception in 1948 to May 2011); scrutinized the reference sections of the retrieved articles; and consulted our own files. An indicator of the frequency of use of each frailty instrument was based on the number of times it had been utilized by investigators other than the originators.

Results

Of the initially retrieved 2,166 papers, 27 original articles described separate frailty scales. The number (range: 1 to 38) and type of items (range of domains: physical functioning, disability, disease, sensory impairment, cognition, nutrition, mood, and social support) included in the frailty instruments varied widely. Reliability and validity had been examined in only 26% (7/27) of the instruments. The predictive validity of these scales for mortality varied: for instance, hazard ratios/odds ratios (95% confidence interval) for mortality risk for frail relative to non-frail people ranged from 1.21 (0.78; 1.87) to 6.03 (3.00; 12.08) for the Phenotype of Frailty and 1.57 (1.41; 1.74) to 10.53 (7.06; 15.70) for the Frailty Index. Among the 150 papers which we found to have used at least one of the 27 frailty instruments, 69% (n = 104) reported on the Phenotype of Frailty, 12% (n = 18) on the Frailty Index, and 19% (n = 28) on one of the remaining 25 instruments.

Conclusions

Although there are numerous frailty scales currently in use, reliability and validity have rarely been examined. The most evaluated and frequently used measure is the Phenotype of Frailty.

The frailty syndrome: a comprehensive review

The frailty syndrome is defined as unintentional weight and muscle loss, exhaustion, and declines in grip strength, gait speed, and activity. Evidence with respect to the clinical definition, epidemiology, mechanisms, interactions, assessment, prevention, and treatment of frailty in the older adult is reviewed.

A disability prevention programme for community-dwelling frail older persons

This series of articles for rehabilitation in practice aims to cover a knowledge element of the rehabilitation medicine curriculum. Nevertheless they are intended to be of interest to a multidisciplinary audience. The competency addressed in this article is ‘The trainee consistent demonstrates a knowledge of how evidence based methods and strategies can be incorporated in an integral and multidisciplinary programme for community-dwelling frail elderly.’

Abstract

Objective: To describe and justify a primary care interdisciplinary programme for community-dwelling frail older people aimed to prevent disability.

Background: Disability is a negative outcome of frailty among older persons. Policy reports and research studies emphasize the need for programmes to reduce disability progression. Between 2008 and 2010 we developed such a programme.

Development: Following the Intervention Mapping protocol, a research team and a multidisciplinary professional developed the programme. Literature reviews and an expert meeting led to identification of basic elements, theory-based methods and practical tools.

The programme: The general practitioner and the practice nurse comprise the core team that can be extended by other professionals such as occupational and physical therapist. The programme includes six steps: (1) screening, (2) assessment, (3) analysis and preliminary action plan, (4) agreement on an action plan, (5) execution of the action plan (toolbox parts) and (6) evaluation and follow-up. The main features are: identifying risks for developing disability and targeting risk factors using professional standards and the 5A Behavioural Change Model to support self management, and identifying problems in performing activities and enhancing meaningful activities based on the Model of Human Occupation. Screening, individual assessment, tailor-made and client-centred care, self-management support, case management and interdisciplinary cooperation are important principles in delivering the programme.

Discussion: The disability-prevention programme seems promising for addressing the needs of frail older people for independent living and for targeting risk factors. Its feasibility and effects are currently being tested in a randomized controlled trial.

Predictors of web-based follow-up response in the Prevention Of Low Back Pain In The Military Trial (POLM)

Background

Achieving adequate follow-up in clinical trials is essential to establish the validity of the findings. Achieving adequate response rates reduces bias and increases probability that the findings can be generalized to the population of interest. Therefore, the purpose of this study was to determine the influence of attention, demographic, psychological, and health status factors on web-based response rates in the ongoing Prevention of Low Back Pain in the Military (POLM) trial.

Methods

Twenty companies of Soldiers (n = 4,325) were cluster randomized to complete a traditional exercise program including sit-ups (TEP) with or without a psychosocial educational program (PSEP) or a core stabilization exercise program (CSEP) with or without PSEP. A subgroup of Soldiers (n = 371) was randomized to receive an additional physical and ultrasound imaging (USI) examination of key trunk musculature. As part of the surveillance program, all Soldiers were encouraged to complete monthly surveys via email during the first year. Descriptive statistics of the predictor variables were obtained and compared between responders and non-responders using two sample t-tests or chi-square test, as appropriate. Generalized linear mixed models were subsequently fitted for the dichotomous outcomes to estimate the effects of the predictor variables. The significance level was set at .05 a priori.

Results

The overall response rate was 18.9% (811 subjects) for the first year. Responders were more likely to be older, Caucasian, have higher levels of education and income, reservist military status, non smoker, lower BMI, and have received individualized attention via the physical/USI examination (p < .05). Age, race/ethnicity, education, military status, smoking history, BMI, and whether a Soldier received the physical/USI examination remained statistically significant (p < .05) when considered in a full multivariate model.

Conclusion

The overall web based response rate during the first year of the POLM trial was consistent with studies that used similar methodology, but lower when compared to rates expected for standard clinical trials. One year response rate was significantly associated with demographic characteristics, health status, and individualized attention via additional testing. These data may assist for planning of future trials that use web based response systems.

Trial Registration

This study has been registered at reports at http://clinicaltrials.gov (NCT00373009).