Randomized controlled trial to evaluate a prevention program for frail community-dwelling older adults: a D-SCOPE protocol

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.

Preventive Home Visits Among Frail Community-Dwelling Older Adults. The Added Value of Follow-Up Telephone Calls

People in need of care and support do not always find appropriate services. This paper aims to explore the content and added value of monthly follow-up telephone calls after preventive home visits. We used both monitoring data and qualitative semi-structured interviews (with older adults, formal and informal caregivers). Results indicate that a majority of older adults (N = 95) received a regular follow-up of four telephone calls. Social connection and involvement were mentioned by all three groups as positive aspects of the program. Although time-consuming, this paper draws attention to the added value of follow-up telephone calls after preventive home visits.

Community based complex interventions to sustain independence in older people: systematic review and network meta-analysis

OBJECTIVE

To synthesise evidence of the effectiveness of community based complex interventions, grouped according to their intervention components, to sustain independence for older people.

DESIGN

Systematic review and network meta-analysis.

DATA SOURCES

Medline, Embase, CINAHL, PsycINFO, CENTRAL, clinicaltrials.gov, and International Clinical Trials Registry Platform from inception to 9 August 2021 and reference lists of included studies.

ELIGIBILITY CRITERIA

Randomised controlled trials or cluster randomised controlled trials with ≥24 weeks' follow-up studying community based complex interventions for sustaining independence in older people (mean age ≥65 years) living at home, with usual care, placebo, or another complex intervention as comparators.

MAIN OUTCOMES

Living at home, activities of daily living (personal/instrumental), care home placement, and service/economic outcomes at 12 months.

DATA SYNTHESIS

Interventions were grouped according to a specifically developed typology. Random effects network meta-analysis estimated comparative effects; Cochrane's revised tool (RoB 2) structured risk of bias assessment. Grading of recommendations assessment, development and evaluation (GRADE) network meta-analysis structured certainty assessment.

RESULTS

The review included 129 studies (74 946 participants). Nineteen intervention components, including "multifactorial action from individualised care planning" (a process of multidomain assessment and management leading to tailored actions), were identified in 63 combinations. For living at home, compared with no intervention/placebo, evidence favoured multifactorial action from individualised care planning including medication review and regular follow-ups (routine review) (odds ratio 1.22, 95% confidence interval 0.93 to 1.59; moderate certainty); multifactorial action from individualised care planning including medication review without regular follow-ups (2.55, 0.61 to 10.60; low certainty); combined cognitive training, medication review, nutritional support, and exercise (1.93, 0.79 to 4.77; low certainty); and combined activities of daily living training, nutritional support, and exercise (1.79, 0.67 to 4.76; low certainty). Risk screening or the addition of education and self-management strategies to multifactorial action from individualised care planning and routine review with medication review may reduce odds of living at home. For instrumental activities of daily living, evidence favoured multifactorial action from individualised care planning and routine 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: combined activities of daily living training, aids, and exercise; and combined activities of daily living training, aids, education, exercise, and multifactorial action from individualised care planning and routine review with medication review and self-management strategies. For personal activities of daily living, evidence favoured combined exercise, multifactorial action from individualised care planning, and routine review with medication review and self-management strategies (0.16, -0.51 to 0.82; low certainty). For homecare recipients, evidence favoured addition of multifactorial action from individualised care planning and routine review with medication review (0.60, 0.32 to 0.88; low certainty). High risk of bias 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.

CONCLUSIONS

The intervention most likely to sustain independence is individualised care planning including medicines optimisation and regular follow-up reviews resulting in multifactorial action. Homecare recipients may particularly benefit from this intervention. Unexpectedly, some combinations may reduce independence. Further research is needed to investigate which combinations of interventions work best for different participants and contexts.

REGISTRATION

PROSPERO CRD42019162195.

Effectiveness, satisfaction and meaningfulness of a 6-step detection and prevention program for frail community-dwelling older adults: a mixed-method evaluation

Background:

As people age, the risk of becoming frail increases, often leading to negative outcomes and less well-being. Within the light of prevention, early detection and guidance to the right care and support is crucial. This study aimed to give an overview of the descriptive results of the D-SCOPE program and evaluate the process.

Methods:

The D-SCOPE program was developed as a detection and prevention program for frail community-dwelling older adults. The program creates a continuum of care and support, consisting of 6 steps: (1) Targeted case-finding using risk profiles for purposeful selection, (2) Preventive home-visit by an older volunteer, (3) Home visits by a professional, (4), Warm referral, (5) Monthly follow-up and (6) Long-term follow-up by home visit. The effectiveness of this program, in terms of satisfaction and meaningfulness, was studied quantitatively by means of a randomized controlled trial amongst 869 people with a frailty risk profile and qualitatively by 15 focus groups interviews.

Results:

The quantitative study revealed that 83.9% of the participants found the different home visits within the D-SCOPE program useful. The focus group interviews shed light on several issues and advantages: a more efficient case finding due to the applied risk factors for frailty, a more intensive tailor-made care and support due to the warm referral, the importance of both small-scaled and larger interventions based on the wishes irrespective of the state of frailty of the older persons, the focus on a strengths-based instead of a deficit-based approach and the follow up as being one of the greatest strengths of the project. However, to fully understand the benefits of the program a shift in mind from intervention to prevention is necessary.

Conclusions:

Our quantitative data show that most participants found the home visits meaningful and were satisfied with the intervention. The qualitative findings provided more insights into the experiences of the participants with the process. Based on these insights of the 6-step model of preventive home visits, municipalities and organizations can apply this model to carry out more targeted home visits.

Trial registration:

This trial was registered at ClinicalTrials.gov, on 30/05/2017, identifier: NCT03168204.

A search for relevant contextual factors in intervention studies: a stepwise approach with online information

OBJECTIVE

The aim of the present study is to describe a stepwise approach to study which contextual factors might moderate the effect of healthcare interventions and to test feasibility of this approach within the D-SCOPE project.

DESIGN

Exploratory case study.

SETTING

In the D-SCOPE project, a complex intervention by means of home visits was set up to improve access to tailored care in three municipalities (Ghent, Knokke-Heist and Tienen).

METHODS

One designed and tested an approach including five steps: (1) a theoretical/conceptual discussion of relevant contextual factor domains was held; (2) a search was done to find appropriate web-based public datasets which covered these topics with standardised information; (3) a list of all identified contextual factors was made (inventory); (4) to reduce the long list of contextual factors, a concise list of most relevant contextual factors was developed based on the opinion of two independent reviewers and (5) a nominal grouping technique (NGT) was applied.

RESULTS

Three public web-based datasets were found resulting in an inventory of 157 contextual factors. After the selection by two independent reviewers, 41 contextual factors were left over and presented in a NGT which selected 10 contextual factors. The NGT included seven researchers, all familiar with the D-SCOPE intervention, with various educational backgrounds and expertise and lasted approximately 1 hour.

CONCLUSION

The present study shows that a five-step approach is feasible to determine relevant contextual factors that might affect the results of an intervention study. Such information may be used to correct for in the statistical analyses and for interpretation of the outcomes of intervention studies.NCT03168204.

Negative old-age life events and well-being in later life: the moderating and mediating role of loneliness

OBJECTIVES

Although older adults often experience negative life events or loss experiences, they rarely experience large decreases in their quality of life or well-being. Emotionally satisfying relationships in older adults may serve as a protective factor that reduces the impact of negative events in decreasing well-being. The availability of these close social contacts is essential, and their potential for alleviating feelings of loneliness after negative events could have an important role in promoting well-being. The aim of this study was to test the hypothetical moderation and mediation effects of social and emotional loneliness on the occurrence of negative old-age life events and well-being in later life.

DESIGN

This was a cross-sectional survey conducted as part of the Detection, Support and Care for older people - Prevention and Empowerment research project (2015-2018).

SETTING

Participants were community-dwelling older adults in Flanders (Belgium).

PARTICIPANTS

The sample composed of 770 participants aged 60 years and over.

MEASUREMENTS

Participant demographics, social and emotional loneliness, and subjective well-being were measured. Moderation and mediation analyses were performed using the regression-based approach as conducted by Hayes and Rockwood (2017).

RESULTS

Results indicated that a low degree of (social) loneliness is a protective, moderating factor and (emotional) loneliness is a mediating factor on the effects of negative life events on well-being in later life.

CONCLUSIONS

Findings highlight the importance of emotionally and socially satisfying social contacts in order to maintain positive subjective well-being in later life when negative life events may occur.

Validation of the Persian version of the comprehensive frailty assessment instrument plus in community-dwelling older adults

This study aimed to examine the validity and reliability of the Persian Version of the Comprehensive Frailty Assessment Instrument Plus (CFAI-Plus) among community-dwelling older adults. It was completed by 340 older adults ≥60 years. The content and face validity were confirmed based on the opinion of the target group and experts. In the exploratory factor analysis, seven factors were extracted, explaining 62.8% of the total variance. Confirmatory factor analysis showed acceptable fit indices (Root Mean Square Error of Approximation = 0.045; Comparative Fit Index = 0.93; Tucker-Lewis Index = 0.92). Internal consistency was adequate for factors (Cronbach's alpha: range 0.47 to 0.88), and the test-retest reliability was acceptable (intra-class correlation coefficient: range 0.76 to 0.92). A higher CFAI-Plus score were found in those who were older, female, less-educated, single, lived alone, and had inadequate income. This study supports the reliability and validity of the Persian CFAI-Plus in community-dwelling older adults.

Towards a more effective strategy to detect community-dwelling frail older adults: validation of risk factors

Purpose

In the context of early detection of frail older people, prior research found several risk factors of multidimensional frailty. The current study aims to validate these risk factors.

Design/methodology/approach

Two data sets, Belgian Ageing Studies and Detection, Support and Care for older people: Prevention and Empowerment (BAS and D-SCOPE), in three Belgian municipalities (Ghent, Knokke-Heist and Thienen) were used and compared. The BAS data set (N = 1496) is a representative sample of community-dwelling older adults (60+), while the recruitment of the D-SCOPE sample (validation sample, N = 869) is based on risk factors (e.g. age, marital status, moved in the past 10 years). Frailty was measured with the comprehensive frailty assessment instrument (CFAI). The validity was examined by means of prevalence rates, distribution and the odds rates within both data sets.

Findings

The validation sample had an increase in the percentage of elderly who were mildly and highly frail for physical frailty (men: +17.0 percent point, women: +20.7 percent point), for psychological frailty (men: +13.4 percent point, women: +13.7 percent point), for social frailty (men: +24.8 percent point, women: +4.8 percent point) and environmental frailty (men: +24.2 percent point, women: +6.8 percent point). The present results indicate that the risk of being mildly or highly frail was higher in the validation sample in comparison with the BAS data.

Originality/value

The present study proved the validity of aforementioned risk factors. Selecting older people based on these risk factors proved to be an effective strategy for detecting frail older people.

The association between perceived social and physical environment and mental health among older adults: mediating effects of loneliness

Objectives: Despite growing interest in the impact of physical and social environment on mental health, data are lacking on the potential mediating effects of loneliness. We examined it in the association of several social and physical environmental characteristics with mental health among older adults in three municipalities in Flanders (Belgium).Methods: A total of 869 people aged 60 and over were interviewed. Loneliness was assessed through the De Jong Gierveld short scales for emotional and social loneliness. Social participation and social cohesion were assessed following the Neighborhood scales whereas physical environment characteristics were selected from the Neighborhood Environment Walkability Scale. Mental health was assessed through subscale psychological frailty of the Comprehensive Frailty Assessment Instrument plus (CFAI-plus). Linear regression models, including mediation analysis, were used to analyze the survey data.Results: After adjusting for individual characteristics, physical and social environment factors were significantly related to mental health with the significant mediation of emotional and social loneliness. Percentages mediated by both dimensions together were 61% for social cohesion, 43% for social participation, 35% for safety and 25% for mobility. Compared with social loneliness, emotional loneliness was a stronger mediating factor, particularly for mobility and safety. No significant associations between traffic density or basic service availability and mental health were found.Discussion: Improving the social and physical environment might result in a reduction in the prevalence of loneliness and in consequent improvement of mental health among older adults. Special attention should be paid to different types of loneliness.

Gender-related differences in the relationship between social and activity participation and health and subjective well-being in later life

A growing body of work suggests that social and activity participation (SAP) may contribute to health and well-being. Studies examining the effects of these activities largely focused on healthy older adults and older adults with more resources, not on frail older adults. On the latter, there is a lack of information about which activities contribute most and whether their effects vary between men and women given the gender-differentiated social roles. To address these gaps we extracted longitudinal data from the D-SCOPE frailty program for 380 participants aged 60 years or older residing in Belgium. Structural equation models tested the relationships between six levels of SAP based on a taxonomy of social activities (Levasseur et al., 2010) - from level 1 (for oneself) to level 6 (for others) - on longitudinal changes in physical and mental deterioration, well-being, and gender differences within these relationships. Results first show that older adults at risk of frailty benefit longitudinally from participating in activities in terms of their physical deterioration and well-being. Second, socially oriented activities were significantly associated with lower levels of physical deterioration and higher levels of subjective well-being (SWB), and volunteering with higher levels of SWB. Heterogeneity of activities, regardless of level on the taxonomy of social activities, seems to benefit SWB and counteract physical deterioration. Third, gender differences were confirmed by two activities for women (alone, task-oriented) and three activities for men (alone, being with others, task-oriented e.g. associational membership). Results imply that the activity itself may play a more important role than the nature of social involvement and social interaction in relation to health and wellbeing.

Validation of replacement questions for slowness and weakness to assess the Fried Phenotype: a cross-sectional study

Aim

What is the overall concordance between FRIED-P and FRIED-Q?

Findings

The concordance between the FRIED-P and FRIED-Q was substantial, characterized by a very high specificity but a moderate sensitivity.

Message

The FRIED-Q can be used as a step in a sequential process to detect frailty in a large population.

Electronic supplementary material

The online version of this article (10.1007/s41999-020-00337-8) contains supplementary material, which is available to authorized users.

Purpose

When screening large populations, performance-based measures can be difficult to conduct because they are time consuming and costly, and require well-trained assessors. The aim of the present study is to validate a set of questions replacing the performance-based measures slowness and weakness as part of the Fried frailty phenotype (FRIED-P).

Methods

A cross-sectional study was conducted among community-dwelling older adults (≥ 60 years) in three Flemish municipalities. The Fried Phenotype (FRIED-P) was used to measure physical frailty. The two performance-based measures of the Fried Phenotype (slowness and weakness) were also measured by means of six substituting questions (FRIED-Q). These questions were validated through sensitivity, specificity, Cohen’s kappa value, observed agreement, correlation analysis, and the area under the curve (AUC, ROC curve).

Results

196 older adults participated. According to the FRIED-P, 19.5% of them were frail, 56.9% were pre-frail and 23.6% were non-frail. For slowness, the observed sensitivity was 47.0%, the specificity was 96.5% and the AUC was 0.717. For weakness, the sensitivity was 46.2%, the specificity was 83.7%, and the AUC was 0.649. The overall Spearman correlation between the FRIED-P and the FRIED-Q was r = 0.721 with an observed agreement of 76.6% (weighted linear kappa value = 0.663, quadratic kappa value = 0.738).

Conclusions

The concordance between the FRIED-P and FRIED-Q was substantial, characterized by a very high specificity, but a moderate sensitivity. This alternative operationalization of the Fried Phenotype—i.e., including six replacement questions instead of two performance-based tests—can be considered to apply as screening tool to screen physical frailty in large populations.

Electronic supplementary material

The online version of this article (10.1007/s41999-020-00337-8) contains supplementary material, which is available to authorized users.

Concordances and differences between a unidimensional and multidimensional assessment of frailty: a cross-sectional study

Background

Many instruments to identify frail older people have been developed. One of the consequences is that the prevalence rates of frailty vary widely dependent on the instrument selected. The aims of this study were 1) to examine the concordances and differences between a unidimensional and multidimensional assessment of frailty, 2) to assess to what extent the characteristics of a ‘frail sample’ differ depending on the selected frailty measurement because ‘being frail’ is used in many studies as an inclusion criterion.

Method

A cross-sectional study was conducted among 196 community-dwelling older adults (≥60 years), which were selected from the census records. Unidimensional frailty was operationalized according to the Fried Phenotype (FP) and multidimensional frailty was measured with the Comprehensive Frailty Assessment Instrument (CFAI). The concordances and differences were examined by prevalence, correlations, observed agreement and Kappa values. Differences between sample characteristics (e.g., age, physical activity, life satisfaction) were investigated with ANOVA and Kruskall-Wallis test.

Results

The mean age was 72.74 (SD 8.04) and 48.98% was male. According to the FP 23.59% was not-frail, 56.92% pre-frail and 19.49% frail. According to the CFAI, 44.33% was no-to-low frail, 37.63% was mild frail and 18.04% was high frail. The correlation between FP and the CFAI was r = 0.46 and the observed agreement was 52.85%. The Kappa value was κ = 0.35 (quadratic κ = 0.45). In total, 11.92% of the participants were frail according to both measurements, 7.77% was solely frail according to the FP and 6.21% was solely frail according to the CFAI. The ‘frail sample respondents’ according to the FP had higher levels of life satisfaction and net income, but performed less physical activities in comparison to high frail people according to the CFAI.

Conclusion

The present study shows that the FP and CFAI partly measure the same ‘frailty-construct’, although differences were found for instance in the prevalence of frailty and the composition of the ‘frail participants’. Since ‘being frail’ is an inclusion criterion in many studies, researchers must be aware that the choice of the frailty measurement has an impact on both the estimates of frailty prevalence and the characteristics of the selected sample.