Identifying common impairments in frail and dependent older people: validation of the COPE assessment for non-specialised health workers in low resource primary health care settings

A community-based cross-sectional survey of orthostatic hypotension among elderly from south India

BACKGROUND

Orthostatic hypotension (OH) increases the risk of falls and associated morbidity and mortality in elderly. Hence, determining the prevalence of OH and its associated factors is important, especially in understudied LMIC settings.

METHODS

A community-based cross-sectional study was conducted among randomly selected 240 community-dwelling elderly from Thiruvananthapuram, Kerala. The OH symptoms were assessed by standard clinical measurements and frailty was assessed by modified Fried frailty phenotype. Logistic regression analysis was conducted to assess the factors associated with OH.

RESULTS

The prevalence of OH and frailty among participants was 9.6 and 29.2 percent respectively. In the first minute, OH was associated with increased odds of falls (OR = 1.97 [95%CI = 1.05, 3.72]). Increase in number of co-morbidities (OR_adj = 1.82 [95%CI = 1.36, 2.48]), number of medicines used (OR_adj = 1.73 [95%CI = 1.28, 2.34]), and orthostatic intolerance (OR_adj = 3.67 [95%CI = 1.13, 11.94]) increased the odds of having OH. Elderly with diabetes (OR_adj = 4.81 [95%CI = 1.57, 14.77]), hypertension (OR_adj = 4.97 [95%CI = 1.01, 24.46]) and cognitive impairment (OR_adj = 5.01 [95%CI = 1.40, 18.51]) were at a higher odds of having OH.

CONCLUSIONS

OH and frailty are prevalent in community dwelling elderly in Thiruvananthapuram district. Frailty may be a risk factor for OH in the first minute. The number of co-morbidities may be an independent risk factor for OH. Hence, elderly people with comorbidities and cognitive impairment may be actively assessed for OH to prevent falls and associated injuries.

Intrinsic capacity and its associations with incident dependence and mortality in 10/66 Dementia Research Group studies in Latin America, India, and China: A population-based cohort study

BACKGROUND

The World Health Organization (WHO) has reframed health and healthcare for older people around achieving the goal of healthy ageing. The recent WHO Integrated Care for Older People (ICOPE) guidelines focus on maintaining intrinsic capacity, i.e., addressing declines in neuromusculoskeletal, vitality, sensory, cognitive, psychological, and continence domains, aiming to prevent or delay the onset of dependence. The target group with 1 or more declines in intrinsic capacity (DICs) is broad, and implementation may be challenging in less-resourced settings. We aimed to inform planning by assessing intrinsic capacity prevalence, by characterising the target group, and by validating the general approach-testing hypotheses that DIC was consistently associated with higher risks of incident dependence and death.

METHODS AND FINDINGS

We conducted population-based cohort studies (baseline, 2003-2007) in urban sites in Cuba, Dominican Republic, Puerto Rico, and Venezuela, and rural and urban sites in Peru, Mexico, India, and China. Door-knocking identified eligible participants, aged 65 years and over and normally resident in each geographically defined catchment area. Sociodemographic, behaviour and lifestyle, health, and healthcare utilisation and cost questionnaires, and physical assessments were administered to all participants, with incident dependence and mortality ascertained 3 to 5 years later (2008-2010). In 12 sites in 8 countries, 17,031 participants were surveyed at baseline. Overall mean age was 74.2 years, range of means by site 71.3-76.3 years; 62.4% were female, range 53.4%-67.3%. At baseline, only 30% retained full capacity across all domains. The proportion retaining capacity fell sharply with increasing age, and declines affecting multiple domains were more common. Poverty, morbidity (particularly dementia, depression, and stroke), and disability were concentrated among those with DIC, although only 10% were frail, and a further 9% had needs for care. Hypertension and lifestyle risk factors for chronic disease, and healthcare utilisation and costs, were more evenly distributed in the population. In total, 15,901 participants were included in the mortality cohort (2,602 deaths/53,911 person-years of follow-up), and 12,939 participants in the dependence cohort (1,896 incident cases/38,320 person-years). One or more DICs strongly and independently predicted incident dependence (pooled adjusted subhazard ratio 1.91, 95% CI 1.69-2.17) and death (pooled adjusted hazard ratio 1.66, 95% CI 1.49-1.85). Relative risks were higher for those who were frail, but were also substantially elevated for the much larger sub-groups yet to become frail. Mortality was mainly concentrated in the frail and dependent sub-groups. The main limitations were potential for DIC exposure misclassification and attrition bias.

CONCLUSIONS

In this study we observed a high prevalence of DICs, particularly in older age groups. Those affected had substantially increased risks of dependence and death. Most needs for care arose in those with DIC yet to become frail. Our findings provide some support for the strategy of optimising intrinsic capacity in pursuit of healthy ageing. Implementation at scale requires community-based screening and assessment, and a stepped-care intervention approach, with redefined roles for community healthcare workers and efforts to engage, train, and support them in these tasks. ICOPE might be usefully integrated into community programmes for detecting and case managing chronic diseases including hypertension and diabetes.

Adaptation of an Evidence-Based Intervention for Disability Prevention, Implemented by Community Health Workers Serving Ethnic Minority Elders

INTRODUCTION

Changing demographics have created substantial unmet needs for mental health and physical disability services for immigrant and racial/ethnic minority elders. Workforce shortages can be reduced by task-shifting to community health workers (CHWs) who speak the same language and share the culture of these elders. Yet, implementation of interventions offered by CHWs requires adaptations of content and delivery, ideally under clinical supervision.

OBJECTIVE

To culturally adapt two evidence-based interventions, offered in community settings, to address mental health and physical disability prevention for diverse minority elders.

METHODS

We followed the Castro-Barrera stepped model for cultural adaptation of two evidence-based interventions into one combined program of disability management and prevention delivered by CHWs. We used feedback from key stakeholders, including four clinical supervisors, 16 CHWs, 17 exercise trainers, and 153 participants, collected at three time points to further adapt the intervention to a diverse population of elders.

RESULTS

Adaptations for administration by CHWs/exercise trainers included: systematization of supervision process, increased flexibility in sessions offered per participants' needs, inclusion of self-care content, modification of materials to better reflect elders' daily life experiences, and greater focus on patient engagement in care. Areas for additional adaptation included enhancing examples with culturally relevant metaphors, incorporating visual aids, and training CHWs in the importance of building trust.

CONCLUSION

This study identifies key aspects of the cultural adaptation process that facilitates broader cultural sensitivity of service delivery by CHWs to diverse elders in community settings.

Redesigning care for older people to preserve physical and mental capacity: WHO guidelines on community-level interventions in integrated care

Islene Araujo de Carvalho and coauthors discuss the WHO guidelines on integrated care for older people.

Training for hearing care providers

The lack of an appropriately trained global hearing-care workforce is recognized as a barrier to developing and implementing services to treat ear and hearing disorders. In this article we examine some of the published literature on the current global workforce for ear and hearing care. We outline the status of both the primary-care workforce, including community health workers, and specialist services, including audiologists, ear, nose and throat specialists, speech and language therapists, and teachers of the deaf. We discuss models of training health workers in ear and hearing care, including the role of task-sharing and the challenges of training in low and middle-income countries. We structure the article by the components of ear and hearing care that may be delivered in isolation or in integrated models of care: primary care assessment and intervention; screening; hearing tests; hearing rehabilitation; middle-ear surgery; deaf services; and cochlear implant programmes. We highlight important knowledge gaps and areas for future research and reporting.

Multimorbidity and care dependence in older adults: a longitudinal analysis of findings from the 10/66 study

BACKGROUND

In an ageing world facing an epidemic of chronic diseases, there is great interest in the burden of multimorbidity on individuals and caregivers, yet no studies have examined the longitudinal association between multimorbidity and care dependence in low and middle income countries. Mental and cognitive disorders are associated with dependence but little is known about their role in the pathway to dependence in the context of multimorbidity. This study aims to determine (1) the association of multimorbidity with the onset of care dependence in older adults, accounting for mortality and controlling for sociodemographic factors, and (2) the independent effects of physical multimorbidity, mental and cognitive disorders.

METHODS

A population-based cohort study of people aged 65 years and older in six countries in Latin America, and China. Data on chronic conditions and sociodemographic factors were collected at baseline. Multimorbidity was ascertained as a count of up to 15 mental, cognitive and physical health conditions. Dependence was ascertained through informant interviews at baseline and follow-up. We used competing risk regression to assess the association between multimorbidity and the onset of care dependence, acknowledging the possibility of dependence-free death. We also assessed the independent effects of physical multimorbidity and depression, anxiety and dementia individually.

RESULTS

12,965 participants, with no needs for care at baseline, were followed up for a median of 3.0-4.9 years. Each unit increase in multimorbidity count increased the cumulative risk of dependence by 20% in the fully adjusted model. Age was the only variable to confound this relationship. Physical multimorbidity was associated with only a modest increased risk of care dependence. Dementia, depression and anxiety were independently associated with incident care dependence at every level of physical multimorbidity, and depression and anxiety attenuated the effect of physical multimorbidity.

CONCLUSION

Multimorbidity consistently predicts care dependence with little variation between countries. Physical multimorbidity imparts a lower risk than multimorbidity with mental and cognitive disorders included. Mental and cognitive disorders independently increase the risk of care dependence. Comprehensive and holistic assessment of disorders of body, brain and mind can help to identify older people at high risk of care dependence.

Health-Related Problems and Changes After 1 Year as Assessed With the Geriatric ICF Core Set (GeriatrICS) in Community-Living Older Adults Who Are Frail Receiving Person-Centered and Integrated Care From Embrace

OBJECTIVE

To assess the prevalence, severity, and change in health-related problems in a sample of older adults who received individual care and support from Embrace, for the whole sample, per subgroup based on complexity of care needs and frailty, and for those who had at baseline a health-related problem.

DESIGN

A pretest-posttest study with assessments at baseline and after 12 months.

SETTING

Community.

PARTICIPANTS

Older adults aged 75 years and older (N=136) who are frail (n=56) or who have complex care needs (n=80).

INTERVENTION

Participants received care and support by Embrace, a person-centered and integrated care service for community-living older adults supporting them to age in place. A multidisciplinary team provided care and support, with intensity depending on the older adults' risk profile.

MAIN OUTCOME MEASURE

Health-related problems as perceived by older adults and measured with the Geriatric International Classification of Functioning, Disability and Health Core Set.

RESULTS

Health-related problems were related to 6 coherent clusters: (1) Mental Functions; (2) Physical Health; (3) Mobility; (4) Personal Care; (5) Nutrition; and (6) Support. The most prevalent and most severe problems at baseline were related to Mental Functions and Mobility. Changes in the prevalence of problems after 12 months varied. Severity scores decreased or remained stable, except for Mobility items which showed a varying changing pattern in participants with complex care needs. Prevalence and severity of problems for those with a problem at baseline decreased after 12 months. Frail participants with a problem had higher baseline severity scores than those with complex care needs experiencing a problem, but differences in changes between individuals who are frail and those with complex care needs were small.

CONCLUSIONS

The results are encouraging and may indicate that individual, person-centered and integrated care and support from Embrace offers a route to counteracting the decline in physical, cognitive and social functioning associated with aging.

The role of community health workers in addressing the global burden of ear disease and hearing loss: a systematic scoping review of the literature

Introduction

Community health workers (CHWs) have the potential to improve access to ear and hearing services for people across low-income or middle-income countries, remote, underserved, or resource-poor areas of the world. We performed a systematic scoping review to identify evidence on how CHWs are currently deployed in the prevention, screening, diagnosis, treatment and management of ear disease and hearing loss; methods to train and support CHWs in this context; and cost-effectiveness of CHWs.

Methods

We performed a systematic search of the literature from September 1978 to 18 March 2018 from 11 major databases and the grey literature.

Results

We identified 38 original studies that met the inclusion criteria, taking place across South Asia (n=13), Oceania (n=7), North America (n=7), South America (n=6) and Africa (n=5). 23 studies showed CHWs can increase community participation in screening. They can conduct screening using whispered voice tests, noisemakers for neonatal screening, automated audiological tests and otoscopy. Eight studies focused specifically on the evaluation of programmes to train CHWs, and three provided a general programme description. Three studies documented a role of CHWs in the treatment of ear disease or hearing loss, such as performing ear washouts, instillation of topical antibiotics or fitting of hearing aids. Only one study provided an indepth cost-utility analysis regarding the use of CHWs to conduct hearing screening, and no studies commented on the role of CHWs in the prevention of hearing loss.

Conclusion

CHWs have been employed in diverse ways to address the global burden of ear disease and hearing loss. Future research needs to explore the role of CHWs in preventative strategies, identify optimum methods to train and support CHWs, and explore their cost-effectiveness.

A review of the 10/66 dementia research group

BACKGROUND

In this review we discuss how the study of dementia epidemiology in Low- and Middle-Income Countries (LMICs) has changed in the last 20 years, and specifically to review the evidence created by the 10/66 Dementia Research Group (DRG) and discuss future directions for research.

METHODS

We identified and collated all the papers related to the 10/66 Dementia Research Group, including papers from groups who adopted the 10/66 methodology, that have been published in peer-reviewed journals.

RESULTS

Over 200 papers including data from Africa, Asia, Europe and Latin America and the Caribbean were identified by this review. Many of the findings revolved around the epidemiology of dementia, mental health and non-communicable diseases, including the cross-cultural development and validation of measurement tools of cognition and functioning, need for care, care arrangements and mental health. Social ageing, care dependence and caregiver interventions were also topics that the group had published on.

DISCUSSION

A body of evidence has been generated that has challenged the view, prevalent when the group started, that dementia is comparatively rare in LMICs. The experience of the 10/66 DRG has shown that descriptive epidemiological research can be important and impactful, where few data exist. Monitoring population trends in the prevalence and incidence of dementia may be our best chance to confirm hypotheses regarding modifiable risk factors of dementia.

Validation to Spanish of the Caring Assessment Tool (CAT-V)

OBJECTIVE

to translate and validate to Spanish the Caring Assessment Scale tool, CAT-V, by Joanne Duffy, within the framework of Jean Watson; as a secondary objective, it is proposed to evaluate its psychometric properties. There are tools designed to measure the patient's perception of provided cares, including CAT-V, the subject of our interest, in a way that it can be used in Spanish-speaking patients.

METHODS

to meet the objectives, it was performed sequential translation and retro-translation of the scale to be validated, through a standardized procedure. The final version of that scale was validated in a sample of 349 patients from four public and two private hospitals in Madrid, Spain.

RESULTS

The instrument was translated and validated with high internal consistency (Cronbach's alpha .953). The subsequent factor analysis revealed a three-factor structure, not coincident with the data from the US population.

CONCLUSION

it is considered that the translation of CAT-V is a suitable instrument to be used in the evaluation of patient care in Ibero-american health centers whose language is Spanish.

A journey without maps-Understanding the costs of caring for dependent older people in Nigeria, China, Mexico and Peru

PURPOSE OF THE STUDY

Populations in Latin America, Asia and sub-Saharan Africa are rapidly ageing. The extent to which traditional systems of family support and security can manage the care of increased numbers of older people with chronic health problems is unclear. Our aim was to explore the social and economic effects of caring for an older dependent person, including insight into pathways to economic vulnerability.

DESIGN & METHODS

We carried out a series of household case studies across urban and rural sites in Peru, Mexico, China and Nigeria (n = 24), as part of a cross-sectional study, nested within the 10/66 Dementia Research Group cohort. Case studies consisted of in-depth narrative style interviews (n = 60) with multiple family members, including the older dependent person.

RESULTS

Governments were largely uninvolved in the care and support of older dependent people, leaving families to negotiate a 'journey without maps'. Women were de facto caregivers but the traditional role of female relative as caregiver was beginning to be contested. Household composition was flexible and responsive to changing needs of multiple generations but family finances were stretched.

IMPLICATIONS

Governments are lagging behind sociodemographic and social change. There is an urgent need for policy frameworks to support and supplement inputs from families. These should include community-based and residential care services, disability benefits and carers allowances. Further enhancement of health insurance schemes and scale-up of social pensions are an important component of bolstering the security of dependent older people and supporting their continued social and economic participation.

Applying systems thinking to task shifting for mental health using lay providers: a review of the evidence

OBJECTIVE

This paper seeks to review the available evidence to determine whether a systems approach is employed in the implementation and evaluation of task shifting for mental health using lay providers in low- and middle-income countries, and to highlight system-wide effects of task-shifting strategies in order to better inform efforts to strength community mental health systems.

METHODS

Pubmed, CINAHL, and Cochrane Library databases were searched. Articles were screened by two independent reviewers with a third reviewer resolving discrepancies. Two stages of screens were done to ensure sensitivity. Studies were analysed using the World Health Organization's building blocks framework with the addition of a community building block, and systems thinking characteristics to determine the extent to which system-wide effects had been considered.

RESULTS

Thirty studies were included. Almost all studies displayed positive findings on mental health using task shifting. One study showed no effect. No studies explicitly employed systems thinking tools, but some demonstrated systems thinking characteristics, such as exploring various stakeholder perspectives, capturing unintended consequences, and looking across sectors for system-wide impact. Twenty-five of the 30 studies captured elements other than the most directly relevant building blocks of service delivery and health workforce.

CONCLUSIONS

There is a lack of systematic approaches to exploring complexity in the evaluation of task-shifting interventions. Systems thinking tools should support evidence-informed decision making for a more complete understanding of community-based systems strengthening interventions for mental health.

Calibrating EASY-Care independence scale to improve accuracy

Background

there is currently limited support for the reliability and validity of the EASY-Care independence scale, with little work carried out in low- or middle-income countries. Therefore, we assessed the internal construct validity and hierarchical and classical scaling properties among frail dependent older people in the community.

Objective

we assessed the internal construct validity and hierarchical and classical scaling properties among frail dependent older people in the community.

Methods

three primary care physicians administered EASY-Care comprehensive geriatric assessment for 150 frail and/or dependent older people in the primary care setting. A Mokken model was applied to investigate hierarchical scaling properties of EASY-Care independence scale, and internal consistency (Cronbach's alpha) of the scale was also examined.

Results

we found that EASY-Care independence scale is highly internally consistent and is a strong hierarchical scale, hence providing strong evidence for unidimensionality. However, two items in the scale (unable to use telephone and manage finances) had much lower item Loevinger H coefficients than others. Exclusion of these two items improved the overall internal consistency of the scale.

Conclusions

the strong performance of the EASY-Care independence scale among community-dwelling frail older people is encouraging. This study confirms that EASY-Care independence scale is highly internally consistent and a strong hierarchical scale.