Randomised controlled trial of unsolicited occupational therapy in community-dwelling elderly people: the LOTIS 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.

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

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

Interventions to Reduce Loneliness in Community-Living Older Adults: a Systematic Review and Meta-analysis

BACKGROUND

The problem of loneliness has garnered increased attention from policymakers, payors, and providers due to higher rates during the pandemic, particularly among seniors. Prior systematic reviews have in general not been able to reach conclusions about effectiveness of interventions.

METHODS

Computerized databases were searched using broad terms such as "loneliness" or "lonely" or "social isolation" or "social support" from Jan 1, 2011 to June 23, 2021. We reference mined existing systematic reviews for additional and older studies. The Social Interventions Research & Evaluation Network database and Google were searched for gray literature on Feb 4, 2022. Eligible studies were RCTs and observational studies of interventions to reduce loneliness in community-living adults that used a validated loneliness scale; studies from low- or middle-income countries were excluded, and studies were excluded if restricted to populations where all persons had the same disease (such as loneliness in persons with dementia).

RESULTS

A total of 5971 titles were reviewed and 60 studies were included in the analysis, 36 RCTs and 24 observational studies. Eleven RCTs and 5 observational studies provided moderate certainty evidence that group-based treatment was associated with reduced loneliness (standardized mean difference for RCTs =  - 0.27, 95% CI - 0.48, - 0.08). Five RCTs and 5 observational studies provided moderate certainty evidence that internet training was associated with reduced loneliness (standardized mean difference for RCTs =  - 0.22, 95% CI - 0.30, - 0.14). Low certainty evidence suggested that group exercises may be associated with very small reductions in loneliness. Evidence was insufficient to reach conclusions about group-based activities, individual in-person interactions, internet-delivered interventions, and telephone-delivered interventions.

DISCUSSION

Low-to-moderate certainty evidence exists that group-based treatments, internet training, and possibly group exercises are associated with modest reductions in loneliness in community-living older adults. These findings can inform the design of supplemental benefits and the implementation of evidence-based interventions to address loneliness.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO ( CRD42021272305 ).

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 of home-based interventions in improving loneliness and social connectedness among older adults: a systematic review and meta-analysis

OBJECTIVES

To evaluate the effectiveness of home-based interventions in improving loneliness and social connectedness (primary outcomes), and depressive symptoms (secondary outcome) among older adults.

METHODS

Eight electronic databases were searched from inception dates to February 2022. Meta-analyses were conducted using a random-effect model. Heterogeneity was assessed using I2 statistics and Cochran's Q chi-squared test. The Cochrane risk of bias tool and the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) was used to appraise the included studies.

RESULTS

Fourteen randomized controlled trials were included. Home-based interventions were found to significantly increase older adults' social connectedness (social support and social engagement) and reduce their loneliness and depressive symptoms. Subgroup analyses suggested that interventions which lasted more than three months and were delivered using mixed platforms were more favorable. Both professional-led and volunteer-led interventions showed favorable results.

CONCLUSIONS

Future studies could be conducted in varied geographical regions and consider carrying out follow-up assessments. Home-based interventions could be improved by being more than months, delivered by mixed personnel, and using mixed platforms. Considering the low-quality rating by the GRADE approach, future research is needed to confirm current findings.

Effects of non-pharmacological interventions on loneliness among community-dwelling older adults: A systematic review, network meta-analysis, and meta-regression

BACKGROUND

The highly prevalent late-life loneliness, together with its deleterious health impacts, calls for increasing attention to the need for effective interventions targeting on this growing public health problem. With the increasing evidence on interventions for combating loneliness, it is timely to identify their comparative effectiveness.

OBJECTIVE

This systematic review, meta-analysis and network meta-analysis was to identify and compare the effects of various non-pharmacological interventions on loneliness in community-dwelling older adults.

METHODS

Systematic search was conducted in nine electronic databases from inception to 30th March 2023 for studies investigating the effects of non-pharmacological interventions on loneliness among community-dwelling older adults. The interventions were categorized according to the nature and purpose of use. Pairwise meta-analysis and network meta-analyses were sequentially performed to identify the effects of each category of interventions and their comparative intervention effectiveness, respectively. Meta-regression was performed to examine any influence of study design and participants' characteristics on the intervention effectiveness. The study protocol was registered at PROSPERO (CRD42022307621).

RESULTS

A total of 60 studies with 13,295 participants were included. The interventions were categorized as psychological interventions, social support interventions (by digital and non-digital means), behavioral activation, exercise intervention with and without social engagement, multi-component intervention and health promotion. Pairwise meta-analysis identified the positive effect of psychological interventions (Hedges' g = -2.33; 95%CI [-4.40, -0.25]; Z = -2.20, p = 0.003), non-digital social support interventions (Hedges' g = -0.63; 95%CI [-1.16, -0.10]; Z = 2.33, p = 0.02) and multi-component interventions (Hedges' g = -0.28 95%CI [-0.54, -0.03]; Z = -2.15, p = 0.03) on reducing loneliness. Subgroup analysis provided additional insights: i) social support and exercise interventions which integrated active strategies to optimize the social engagement demonstrated more promising intervention effects; ii) behavioral activation and multicomponent interventions worked better for older adults who were male or reported loneliness, respectively, and iii) counseling-based psychological interventions was more effective than mind-body practice. Network meta-analysis consistently pointed to the greatest therapeutic benefits of psychological interventions, and this was followed by exercise-based interventions, non-digital social support interventions and behavioral activation. Meta-regression further suggested that the therapeutic effects of the tested interventions were independent of the various factors relating to study design and participants' characteristics.

CONCLUSIONS

This review highlights the more superior effects of psychological interventions in improving loneliness among older adults. Interventions which have an attribute to optimize social dynamic and connectivity may also be effective.

TWEETABLE ABSTRACT

Psychological intervention is the best to beat late-life loneliness, but increasing social dynamic and connectivity may add an impact.

Social Prescription Interventions Addressing Social Isolation and Loneliness in Older Adults: Meta-Review Integrating On-the-Ground Resources

BACKGROUND

Social prescription programs represent a viable solution to linking primary care patients to nonmedical community resources for improving patient well-being. However, their success depends on the integration of patient needs with local resources. This integration could be accelerated by digital tools that use expressive ontology to organize knowledge resources, thus enabling the seamless navigation of diverse community interventions and services tailored to the needs of individual users. This infrastructure bears particular relevance for older adults, who experience a range of social needs that impact their health, including social isolation and loneliness. An essential first step in enabling knowledge mobilization and the successful implementation of social prescription initiatives to meet the social needs of older adults is to incorporate the evidence-based academic literature on what works, with on-the-ground solutions in the community.

OBJECTIVE

This study aims to integrate scientific evidence with on-the-ground knowledge to build a comprehensive list of intervention terms and keywords related to reducing social isolation and loneliness in older adults.

METHODS

A meta-review was conducted using a search strategy combining terms related to older adult population, social isolation and loneliness, and study types relevant to reviews using 5 databases. Review extraction included intervention characteristics, outcomes (social [eg, loneliness, social isolation, and social support] or mental health [eg, psychological well-being, depression, and anxiety]), and effectiveness (reported as consistent, mixed, or not supported). Terms related to identified intervention types were extracted from the reviewed literature as well as descriptions of corresponding community services in Montréal, Canada, available from web-based regional, municipal, and community data sources.

RESULTS

The meta-review identified 11 intervention types addressing social isolation and loneliness in older adults by either increasing social interactions, providing instrumental support, promoting mental and physical well-being, or providing home and community care. Group-based social activities, support groups with educational elements, recreational activities, and training or use of information and communication technologies were the most effective in improving outcomes. Examples of most intervention types were found in community data sources. Terms derived from the literature that were the most commonly congruent with those describing existing community services were related to telehealth, recreational activities, and psychological therapy. However, several discrepancies were observed between review-based terms and those addressing the available services.

CONCLUSIONS

A range of interventions found to be effective at addressing social isolation and loneliness or their impact on mental health were identified from the literature, and many of these interventions were represented in services available to older residents in Montréal, Canada. However, different terms were occasionally used to describe or categorize similar services across data sources. Establishing an efficient means of identifying and structuring such sources is important to facilitate referrals and help-seeking behaviors of older adults and for strategic planning of resources.

Interventions Associated With Reduced Loneliness and Social Isolation in Older Adults: A Systematic Review and Meta-analysis

Importance

Loneliness and social isolation are public health concerns faced by older adults due to physical, cognitive, and psychosocial changes that develop with aging. Loneliness and social isolation are associated with increased morbidity and mortality.

Objective

To evaluate interventions, targeting older adults, associated with a reduction in loneliness and social isolation.

Data Sources

OVID, CINAHL, CENTRAL, Embase, PsychINFO, Web of Science, and Scopus were searched from inception to March 2020.

Study Selection

Peer-reviewed randomized clinical trials measuring loneliness and social isolation or support in adults aged 65 years or older. Only English language articles were included.

Data Extraction and Synthesis

Two independent reviewers screened studies, extracted data, and assessed risk of bias. Random-effects models were performed to pool the overall effect size by intervention. Statistical heterogeneity was evaluated with the I2 statistic and by estimating prediction intervals. Data were analyzed from November 2021 to September 2022.

Main Outcomes and Measures

Quantitative measures of loneliness, social isolation, or social support based on an effect size of standardized mean differences.

Results

Seventy studies were included in the systematic review (8259 participants); 44 studies were included in the loneliness meta-analysis (33 in the community with 3535 participants; 11 in long-term care with 1057 participants), with participants' ages ranging from 55 to 100 years. Study sizes ranged from 8 to 741 participants. Interventions included animal therapy, psychotherapy or cognitive behavioral therapy, multicomponent, counseling, exercise, music therapy, occupational therapy, reminiscence therapy, social interventions, and technological interventions. Most interventions had a small effect size. Animal therapy in long-term care, when accounting for studies with no active controls, had the largest effect size on loneliness reduction (-1.86; 95% CI, -3.14 to -0.59; I2 = 86%) followed by technological interventions (videoconferencing) in long-term care (-1.40; 95% CI, -2.37 to -0.44; I2 = 70%).

Conclusions and Relevance

In this study, animal therapy and technology in long-term care had large effect sizes, but also high heterogeneity, so the effect size's magnitude should be interpreted with caution. The small number of studies per intervention limits conclusions on sources of heterogeneity. Overall quality of evidence was very low. Future studies should consider measures of social isolation in long-term care and identify the contextual components that are associated with a reduction in loneliness.

Effectiveness and cost-effectiveness of proactive and multidisciplinary integrated care for older people with complex problems in general practice: an individual participant data meta-analysis

Purpose

to support older people with several healthcare needs in sustaining adequate functioning and independence, more proactive approaches are needed. This purpose of this study is to summarise the (cost-) effectiveness of proactive, multidisciplinary, integrated care programmes for older people in Dutch primary care.

Methods design

individual patient data (IPD) meta-analysis of eight clinically controlled trials.

Setting

primary care sector.

Interventions

combination of (i) identification of older people with complex problems by means of screening, followed by (ii) a multidisciplinary integrated care programme for those identified.

Main outcome

activities of daily living, i.e. a change on modified Katz-15 scale between baseline and 1-year follow-up.

Secondary outcomes

quality of life (visual analogue scale 0–10), psychological (mental well-being scale Short Form Health Survey (SF)-36) and social well-being (single item, SF-36), quality-adjusted life years (Euroqol-5dimensions-3level (EQ-5D-3L)), healthcare utilisation and cost-effectiveness.

Analysis

intention-to-treat analysis, two-stage IPD and subgroup analysis based on patient and intervention characteristics.

Results

included were 8,678 participants: median age of 80.5 (interquartile range 75.3; 85.7) years; 5,496 (63.3%) women. On the modified Katz-15 scale, the pooled difference in change between the intervention and control group was −0.01 (95% confidence interval −0.10 to 0.08). No significant differences were found in the other patient outcomes or subgroup analyses. Compared to usual care, the probability of the intervention group to be cost-effective was less than 5%.

Conclusion

compared to usual care at 1-year follow-up, strategies for identification of frail older people in primary care combined with a proactive integrated care intervention are probably not (cost-) effective.

Interventions for alleviating loneliness among older persons: a critical review

OBJECTIVES

Loneliness is common among older persons and has been associated with health and mental health risks. This systematic review examines the utility of loneliness interventions among older persons.

DATA SOURCE

Thirty-four intervention studies were used. STUDY INCLUSION CRITERIA: The study was conducted between 1996 and 2011, included a sample of older adults, implemented an intervention affecting loneliness or identified a situation that directly affected loneliness, included in its outcome measures the effects of the intervention or situation on loneliness levels or on loneliness-related measures (e.g., social interaction), and included in its analysis pretest-posttest comparisons.

DATA EXTRACTION

Studies were accessed using the databases PsycINFO, MEDLINE, ScienceDirect, AgeLine, PsycBOOKS, and Google Scholar for the years 1996-2011.

DATA SYNTHESIS

Interventions were classified based on population, format, and content and were evaluated for quality of design and efficacy.

RESULTS

Twelve studies were effective in reducing loneliness according to the review criteria, and 15 were evaluated as potentially effective. The findings suggest that it is possible to reduce loneliness by using educational interventions focused on social networks maintenance and enhancement.

CONCLUSIONS

Multiple approaches show promise, although flawed design often prevents proper evaluation of efficacy. The value of specific therapy techniques in reducing loneliness is highlighted and warrants a wider investigation. Studies of special populations, such as the cognitively impaired, are also needed.

Functional Assessments Used by Occupational Therapists with Older Adults at Risk of Activity and Participation Limitations: A Systematic Review

Introduction

The use of functional assessments to evaluate patient change is complicated by a lack of consensus as to which assessment is most suitable for use with older adults. Objective: To identify and appraise the properties of assessments used to evaluate functional abilities in older adults.

Methods

A systematic review of randomised controlled trials of occupational therapy interventions was conducted up to 2012 to identify assessments used to measure function. Two authors screened and extracted data independently. A second search then identified papers investigating measurement properties of each assessment. Studies from the second search were included if: i) published in English, ii) the assessment was not modified from its original published form, iii) study aim was to evaluate the quality of the tool, iv) and was original research. Translated versions of assessments were excluded. Measurement quality was rated using the COSMIN checklist and Terwee criteria.

Results

Twenty-eight assessments were identified from the systematic search of occupational therapy interventions provided to older adults. Assessments were of varied measurement quality and many had been adapted (although still evaluated as though the original tool had been administered) potentially altering the conclusions drawn about measurement quality. Synthesis of best evidence established 15 functional assessments have not been tested in an older adult population.

Conclusions

The Functional Autonomy Measurement System (SMAF) appears to be a promising assessment for use with older adults. Only two tools (the SMAF and the Assessment of Motor and Process Skills (AMPS)) were deemed to be responsive to change when applied to older adults. Health professionals should use functional assessments that have been validated with their population and in their setting. There are reliable and valid assessments to capture the functional performance of older adults in community and hospital settings, although further refinement of these assessments may be necessary.

Effectiveness and cost-effectiveness of a proactive, goal-oriented, integrated care model in general practice for older people. A cluster randomised controlled trial: Integrated Systematic Care for older People--the ISCOPE study

Background: older people often experience complex problems. Because of multiple problems, care for older people in general practice needs to shift from a ‘problem-based, disease-oriented’ care aiming at improvement of outcomes per disease to a ‘goal-oriented care’, aiming at improvement of functioning and personal quality of life, integrating all healthcare providers. Feasibility and cost-effectiveness of this proactive and integrated way of working are not yet established.

Design: cluster randomised trial.

Participants: all persons aged ≥75 in 59 general practices (30 intervention, 29 control), with a combination of problems, as identified with a structured postal questionnaire with 21 questions on four health domains.

Intervention: for participants with problems on ≥3 domains, general practitioners (GPs) made an integrated care plan using a functional geriatric approach. Control practices: care as usual.

Outcome measures: (i) quality of life (QoL), (ii) activities of daily living, (iii) satisfaction with delivered health care and (iv) cost-effectiveness of the intervention at 1-year follow-up.

Trial registration: Netherlands trial register, NTR1946.

Results: of the 11,476 registered eligible older persons, 7,285 (63%) participated in the screening. One thousand nine hundred and twenty-one (26%) had problems on ≥3 health domains. For 225 randomly chosen persons, a care plan was made. No beneficial effects were found on QoL, patients' functioning or healthcare use/costs. GPs experienced better overview of the care and stability, e.g. less unexpected demands, in the care.

Conclusions: GPs prefer proactive integrated care. ‘Horizontal’ care using care plans for older people with complex problems can be a valuable tool in general practice. However, no direct beneficial effect was found for older persons.

GPs' perspectives on preventive care for older people: a focus group study

BACKGROUND

Preventive care traditionally aims to prevent diseases or injuries. For older people, different aims of prevention, such as maintenance of independence and wellbeing, are increasingly important.

AIM

To explore GPs' perspectives on preventive care for older people.

DESIGN AND SETTING

Qualitative study comprising six focus groups with GPs in the Netherlands.

METHOD

The focus-group discussions with 37 GPs were analysed using the framework analysis method.

RESULTS

Whether or not to implement preventive care for older people depends on the patient's individual level of vitality, as perceived by the GP. For older people with a high level of vitality, GPs confine their role to standardised disease-oriented prevention on a patient's request; when the vitality levels in older people fall, the scope of preventive care shifts from prevention of disease to prevention of functional decline. For older, vulnerable people, GPs expect most benefit from a proactive, individualised approach, enabling them to live as independently as possible. Based on these perspectives, a conceptual model for preventive care was developed, which describes GPs' different perspectives toward older people who are vulnerable and those with high levels of vitality. It focuses on five main dimensions: aim of care (prevention of disease versus prevention of functional decline), concept of care (disease model versus functional model), initiator (older persons themselves versus GP), target groups (people with requests versus specified risk groups), and content of preventive care (mainly cardiovascular risk management versus functional decline).

CONCLUSION

GPs' perspectives on preventive care are determined by their perception of the level of vitality of their older patients. Preventive care for older people with high levels of vitality may consist of a standardised disease-oriented approach; those who are vulnerable will need an individualised approach to prevent functional decline.

Evaluation of an agency-based occupational therapy intervention to facilitate aging in place

PURPOSE

The United States faces a growing population of older adults and accompanying functional disabilities, coupled with constrained public resources and diminishing informal supports. A variety of interventions that aim to improve client outcomes have been studied, but to date, there is limited translational research that examines the efficacy of moving such interventions from clinical trials to agency settings.

METHODS

A randomized controlled trial was conducted to evaluate a restorative occupational therapy intervention relative to "usual care" among community-dwelling older adults. The intervention included a detailed assessment from a person-environment perspective and provision of adaptive equipment and home modifications where appropriate. The intervention (n = 31) and control groups (n = 29) were evaluated at 3 months and assessed for changes in functional status, home safety, falls, health-related quality of life (HRQoL; EQ5D), depression, social support, and fear of falling; a 4 subgroup analysis also examined outcomes by waiting list status. An informal economic evaluation compared the intervention to usual care.

RESULTS

Findings indicated improvements in home safety (p < .0005, b = -15.87), HRQoL (p = .03, b = 0.08), and fear of falling (p < .05, b = 2.22). Findings did not show improvement in functional status or reduction in actual falls. The intervention resulted in a 39% reduction in recommended hours of personal care, which if implemented, could result in significant cost savings.

IMPLICATIONS

The study adds to the growing literature of occupational therapy interventions for older adults, and the findings support the concept that restorative approaches can be successfully implemented in public agencies.

A meta-analysis of interventions to reduce loneliness

Social and demographic trends are placing an increasing number of adults at risk for loneliness, an established risk factor for physical and mental illness. The growing costs of loneliness have led to a number of loneliness reduction interventions. Qualitative reviews have identified four primary intervention strategies: (a) improving social skills, (b) enhancing social support, (c) increasing opportunities for social contact, and (d) addressing maladaptive social cognition. An integrative meta-analysis of loneliness reduction interventions was conducted to quantify the effects of each strategy and to examine the potential role of moderator variables. Results revealed that single-group pre-post and nonrandomized comparison studies yielded larger mean effect sizes relative to randomized comparison studies. Among studies that used the latter design, the most successful interventions addressed maladaptive social cognition. This is consistent with current theories regarding loneliness and its etiology. Theoretical and methodological issues associated with designing new loneliness reduction interventions are discussed.

A randomized study of a multidisciplinary program to intervene on geriatric syndromes in vulnerable older people who live at home (Dutch EASYcare Study)

BACKGROUND

The effectiveness of community-based geriatric intervention models for vulnerable older adults is controversial. We evaluated a problem-based multidisciplinary intervention targeting vulnerable older adults at home that promised efficacy through better timing and increased commitment of patients and primary care physicians. This study compared the effects of this new model to usual care.

METHODS

Primary care physicians referred older people for problems with cognition, nutrition, behavior, mood, or mobility. One hundred fifty-one participants (mean age 82.2 years, 74.8% women) were included in a pseudocluster randomized trial with 6-month follow-up for the primary outcomes. Eighty-five participants received the new intervention, and 66 usual care. In the intervention arm, geriatric nurses visited patients at home for geriatric assessment and management in cooperation with primary care physicians and geriatricians. Modified intention-to-treat analyses focused on differences between treatment arms in functional abilities (Groningen Activity Restriction Scale-3) and mental well-being (subscale mental health Medical Outcomes Study [MOS]-20), using a mixed linear model.

RESULTS

After 3 months, treatment arms showed significant differences in favor of the new intervention. Functional abilities improved 2.2 points (95% confidence interval [CI], 0.3-4.2) and well-being 5.8 points (95% CI, 0.1-11.4). After 6 months, the favorable effect increased for well-being (9.1; 95% CI, 2.4-15.9), but the effect on functional abilities was no longer significant (1.6; 95% CI, -0.7 to 3.9).

CONCLUSIONS

This problem-based geriatric intervention improved functional abilities and mental well-being of vulnerable older people. Problem-based interventions can increase the effectiveness of primary care for this population.