European models of long-term care in the home and community

Health, social care and technological interventions to improve functional ability of older adults living at home: An evidence and gap map

Background

By 2030, the global population of people older than 60 years is expected to be higher than the number of children under 10 years, resulting in major health and social care system implications worldwide. Without a supportive environment, whether social or built, diminished functional ability may arise in older people. Functional ability comprises an individual's intrinsic capacity and people's interaction with their environment enabling them to be and do what they value.

Objectives

This evidence and gap map aims to identify primary studies and systematic reviews of health and social support services as well as assistive devices designed to support functional ability among older adults living at home or in other places of residence.

Search Methods

We systematically searched from inception to August 2018 in: MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, CENTRAL, CINAHL, PsycINFO, AgeLine, Campbell Library, ASSIA, Social Science Citation Index and Social Policy & Practice. We conducted a focused search for grey literature and protocols of studies (e.g., ProQuest Theses and Dissertation Global, conference abstract databases, Help Age, PROSPERO, Cochrane and Campbell libraries and ClinicalTrials.gov).

Selection Criteria

Screening and data extraction were performed independently in duplicate according to our intervention and outcome framework. We included completed and on-going systematic reviews and randomized controlled trials of effectiveness on health and social support services provided at home, assistive products and technology for personal indoor and outdoor mobility and transportation as well as design, construction and building products and technology of buildings for private use such as wheelchairs, and ramps.

Data Collection and Analysis

We coded interventions and outcomes, and the number of studies that assessed health inequities across equity factors. We mapped outcomes based on the International Classification of Function, Disability and Health (ICF) adapted categories: intrinsic capacities (body function and structures) and functional abilities (activities). We assessed methodological quality of systematic reviews using the AMSTAR II checklist.

Main Results

After de-duplication, 10,783 records were screened. The map includes 548 studies (120 systematic reviews and 428 randomized controlled trials). Interventions and outcomes were classified using domains from the International Classification of Function, Disability and Health (ICF) framework. Most systematic reviews (n = 71, 59%) were rated low or critically low for methodological quality.The most common interventions were home-based rehabilitation for older adults (n = 276) and home-based health services for disease prevention (n = 233), mostly delivered by visiting healthcare professionals (n = 474). There was a relative paucity of studies on personal mobility, building adaptations, family support, personal support and befriending or friendly visits. The most measured intrinsic capacity domains were mental function (n = 269) and neuromusculoskeletal function (n = 164). The most measured outcomes for functional ability were basic needs (n = 277) and mobility (n = 160). There were few studies which evaluated outcome domains of social participation, financial security, ability to maintain relationships and communication.There was a lack of studies in low- and middle-income countries (LMICs) and a gap in the assessment of health equity issues.

Authors' Conclusions

There is substantial evidence for interventions to promote functional ability in older adults at home including mostly home-based rehabilitation for older adults and home-based health services for disease prevention. Remotely delivered home-based services are of greater importance to policy-makers and practitioners in the context of the COVID-19 pandemic. This map of studies published prior to the pandemic provides an initial resource to identify relevant home-based services which may be of interest for policy-makers and practitioners, such as home-based rehabilitation and social support, although these interventions would likely require further adaptation for online delivery during the COVID-19 pandemic. There is a need to strengthen assessment of social support and mobility interventions and outcomes related to making decisions, building relationships, financial security, and communication in future studies. More studies are needed to assess LMIC contexts and health equity issues.

Resistance Training for Older Adults: Position Statement From the National Strength and Conditioning Association

Fragala, MS, Cadore, EL, Dorgo, S, Izquierdo, M, Kraemer, WJ, Peterson, MD, and Ryan, ED. Resistance training for older adults: position statement from the national strength and conditioning association. J Strength Cond Res 33(8): 2019-2052, 2019-Aging, even in the absence of chronic disease, is associated with a variety of biological changes that can contribute to decreases in skeletal muscle mass, strength, and function. Such losses decrease physiologic resilience and increase vulnerability to catastrophic events. As such, strategies for both prevention and treatment are necessary for the health and well-being of older adults. The purpose of this Position Statement is to provide an overview of the current and relevant literature and provide evidence-based recommendations for resistance training for older adults. As presented in this Position Statement, current research has demonstrated that countering muscle disuse through resistance training is a powerful intervention to combat the loss of muscle strength and muscle mass, physiological vulnerability, and their debilitating consequences on physical functioning, mobility, independence, chronic disease management, psychological well-being, quality of life, and healthy life expectancy. This Position Statement provides evidence to support recommendations for successful resistance training in older adults related to 4 parts: (a) program design variables, (b) physiological adaptations, (c) functional benefits, and (d) considerations for frailty, sarcopenia, and other chronic conditions. The goal of this Position Statement is to a) help foster a more unified and holistic approach to resistance training for older adults, b) promote the health and functional benefits of resistance training for older adults, and c) prevent or minimize fears and other barriers to implementation of resistance training programs for older adults.

An ecological study on the relationship between supply of beds in long-term care institutions in Italy and potential care needs for the elderly

Background

The ageing population in Europe is putting an ever increasing demand on the long-term care (LTC) services provided by these countries. This study analyses the relationship between the LTC institutional supply of beds and potential care needs, taking into account the social and health context, the supply of complementary and alternative services, along with informal care.

Methods

An observational, cross-sectional, ecological study was carried out. Statistical data were obtained from the Italian National Institute of Statistics and Ministry of Health. Indicators, regarding 5 areas (Supply of beds in long term care institutions, Potential care needs, Social and health context, Complementary and alternative services for the elderly, Informal care), were calculated at Local Health Unit (LHU) level and referred to 2004.

Two indicators were specifically used to measure supply of beds in long term care institutions and potential care needs for the elderly. Their values were grouped in tertiles. LHU were classified according to the combination of tertiles in three groups: A. High level of supply of beds in long term care institutions associated with low level of potential care needs; B. Low level of supply of beds in long term care institutions associated with high level of potential care needs; C. Balanced level of supply of beds in long term care institutions with potential care needs. For each group the indicators of 5 areas were analysed.

The Index Number (IN) was calculated for each of these indicators.

Results

Specific factors that need to be carefully considered were highlighted in each of the three defined groups. The highest level of alternative services such as long-stay hospital discharges in residence region (IN = 125), home care recipients (HCR) (IN = 123.8) were reported for Group A. This group included North regions. The highest level of inappropriate hospital discharges in (IN = 124.1) and out (IN = 155.8) the residence region, the highest value of families who received help (IN = 106.4) and the lowest level of HCR (IN = 68.7) were found in Group B. South regions belong to this group. The highest level of families paying a caregiver (IN = 115.8) was shown in Group C. Central regions are included in third group.

Conclusion

Supply of beds in long term care institutions substantially differs across Italian regions, showing in every scenario some imbalances between potential care needs and other studied factors. Our study suggests the need of a comprehensive rethinking of care delivery "system".

The influence of nursing home residency on the capacities of low-dependency older adults

OBJECTIVE

With the growing number of low-dependency older adults in long-stay care and the lack of categorisation of these institutions in the Republic of Ireland, it can be asked if such facilities are truly beneficial. This paper presents an explorative investigation of the influence of the nursing home environment on the capacities of low-dependency older adults.

METHOD

The participants consisted of 50 community residents, as a control group, and 50 nursing home residents ranging in age from 65 to 95 years. The methodology was based on a triangulation of three data sources: a battery of cognitive, sensory, sensorimotor and psychological well-being assessments; a semi-structured participant interview; and an institutional questionnaire. Cluster analysis was then used to identify natural performance groupings within the assessment battery data.

RESULTS

There were two performance groupings within the dataset. Interestingly, two community residents were grouped with the majority of nursing home residents and six nursing home residents were grouped with the majority of community residents. The interpretation of the results was informed by the semi-structured interviews and the institutional questionnaires.

CONCLUSION

Although causality cannot be attributed, findings indicate an association between the nursing home environment and the capacities of older adult residents.

Case management and risk of nursing home admission for older adults in home care: results of the AgeD in HOme Care Study

OBJECTIVES

To explore the relationship between a case management approach and the risk of institutionalization in a large European population of frail, old people in home care.

DESIGN

Retrospective cohort study.

SETTING

Eleven European countries.

PARTICIPANTS

Three thousand two hundred ninety-two older adults receiving home care (mean age 82.3+/-7.3).

MEASUREMENTS

Data on nursing home admission were collected every 6 months for 1 year.

RESULTS

One thousand one hundred eighty-four (36%) persons received a home care program based on case management, and 2,108 (64%) received a traditional care approach (no case manager). During the 1-year follow-up, 81 of 1,184 clients (6.8%) in the case management group and 274 of 2,108 (13%) in the traditional care group were admitted to a nursing home (P<.001). After adjusting for potential confounders, the risk of nursing home admission was significantly lower for participants in the case management group than for those in a traditional care model (adjusted odds ratio=0.56, 95% confidence interval=0.43-0.63).

CONCLUSION

Home care services based on a case management approach reduce risk of institutionalization and likely lower costs.

The effectiveness of the around-the-clock in-home care system: did it prevent the institutionalization of frail elderly?

This study compares two communities in Japan from the perspective of community health care resources and their use by the elderly during 1992-98. In one community, programs of home care services for the elderly were reorganized to provide around-the-clock in-home nursing and home help services seven days a week (ACC). Official records were the major sources of data. Evidence from the analysis indicated that ACC might contribute to less use of institutionalization as an alternative to home care, even though, in some instances, institutionalization is the only appropriate alternative.

The everlasting trial of strength and patience': transitions in home care nursing as narrated by patients and family members

The aim of this study was to describe and interpret patients' and their family members' lived experiences of caring at home. Twelve tape-recorded narratives, with seven patients and five family members, were interpreted in accordance with a phenomenological-hermeneutic method inspired by Ricoeur. The findings revealed life situations where natural caring was changed into patient-care-giver relations and the home became a public room. The patients had to deal with decreased abilities and the family members with adjusting to caring needs. The changes in the life situations were interpreted as long lasting and trying transitions. Implications for nursing and further research are proposed.

Ageing in Portugal: regional iniquities in health and health care

The health of the Portuguese has improved considerably in the last twenty years. Economic and social transformations that have contributed to the progressive amelioration of problems of feeding, sanitation, hygiene, housing and social conditions in general, as well as health services, have had decisive effect on this phenomenon. The spectacular regression of the indicators related to transmitted diseases, infant, perinatal (more than 50% between 1985 and 1994) and maternal mortality, and the mortality of children 1 to 4 yr old, also reflects this impact. The positive changes that took place in health indicators were reflected in the growth of life expectancy at birth (2.2 yr more for male and 2.3 more for women between 1985 and 1994) in spite of the fact that the difference in life expectancy in relation to EU countries has grown. Improvement in life expectancy, especially in the older age groups, is not normally associated with significant reductions in morbidity. In fact, increased longevity has become more generally associated with chronic illness or other disabilities requiring more medical services and other forms of personal care. This paper reviews some of the evidence for regional differences in the health status of elderly people in Portugal and considers how health services have reacted to these differences. A preliminary study of health status and patterns of utilisation of elderly people was undertaken. After 30 yr of a National Health Service (NHS) in Portugal we may ask why do inequities in health and access to health care of the elderly population persist? Proactive policies to prevent illness and promote health are still relatively underdeveloped in the Portuguese NHS, and the factors that influence health, such as housing, diet and occupational health hazards, remain largely absent from health and welfare policies. Poor accessibility to health services is the most serious barrier consumers have to face in order to get a medical appointment, and this is more relevant to the oldest part of the population. Geographical location of health care facilities unequally affects the ease of access of different groups of consumers and influences utilisation patterns. Examining the distribution of health services resources is an important way to understand the inequities of access to health and to health care.

A model for integrated home care of frail older patients: the Silver Network project. SILVERNET-HC Study Group

Home care programs for the treatment of frail elderly have been developed in many countries around the world. In the Silver Network project all services are provided in an integrated fashion by one "single entry" center, differently from the traditional fee-for-service or not integrated systems. The delivery of health and social services for frail elderly individuals are integrated and coordinated by a case manager who uses a "second generation" assessment instrument, the Minimum Data Set for Home Care (MDS-HC). We describe the principal clinical and functional characteristics of nearly 1300 patients admitted between 1997 and 1998 to such an integrated home care program in eleven Italian Health Agencies. The database, derived from the serial MDS-HC assessments of each patient, provides a unique opportunity to delineate the different criteria for eligibility for home care, and compare the selected populations of the participating Health Agencies.

[Preventive nutritional services for the elderly]

Population aging is a global. These demographic transitions have brought about dramatic changes in the world's health needs and status. Chronic diseases of aging account for nearly half of population morbidity and mortality in the developing regions of the world 85% of deaths and disability in developed regions. Chronic diseases in the elderly is, in over 60%, associated with malnutrition. Malnutrition is one of the few preventable risk factors for chronic diseases. Carefully planned population-based nutrition interventions can lower risk malnutrition and thus for chronic diseases and as well as for their adverse outcomes. Nutrition interventions can also be used to reach particularly vulnerable segments of the population, such as extremely frail elders, to reduce the prevalence of nutrient deficiencies. Clearly, the prevention of nutrition-related problems in the population, including older persons, has important global health implications.

The economic consequences of Alzheimer's disease in the context of new drug developments

The first national symptomatic treatment for Alzheimer's disease has received a very mixed and perhaps ageist reception from purchasers of health care in the UK. This is largely because detailed information on the long-term effects of this class of drugs is scarce. However, by looking at the published evidence on the economic burden of Alzheimer's disease, some observations and assumptions can be made as to the influence of the new drug treatments. The drug therapies available and those most likely to become licensed are reviewed and the potential economic impact is discussed. Long-term outcome studies would properly address this, but as these drugs have now demonstrated efficacy, particularly in non-cognitive behaviours, it will be ethically more difficult to maintain patients on placebo for long periods. Some assumptions therefore have to be made from long-term open-label studies. Those drugs currently available, and those in development, may offer effective treatment for some of the core symptoms of Alzheimer's disease, slowing the rate of cognitive decline and preserving competence in activities of daily living for longer. If handled correctly, these treatments have the potential to offer cost savings for many patients, and cost-effectiveness improvements look probable.

Randomised trial of impact of model of integrated care and case management for older people living in the community

OBJECTIVE

To evaluate the impact of a programme of integrated social and medical care among frail elderly people living in the community.

DESIGN

Randomised study with 1 year follow up.

SETTING

Town in northern Italy (Rovereto).

SUBJECTS

200 older people already receiving conventional community care services.

INTERVENTION

Random allocation to an intervention group receiving integrated social and medical care and case management or to a control group receiving conventional care.

MAIN OUTCOME MEASURES

Admission to an institution, use and costs of health services, variations in functional status.

RESULTS

Survival analysis showed that admission to hospital or nursing home in the intervention group occurred later and was less common than in controls (hazard ratio 0.69; 95% confidence interval 0.53 to 0.91). Health services were used to the same extent, but control subjects received more frequent home visits by general practitioners. In the intervention group the estimated financial savings were in the order of 1125 ($1800) per year of follow up. The intervention group had improved physical function (activities of daily living score improved by 5.1% v 13.0% loss in controls; P<0.001). Decline of cognitive status (measured by the short portable mental status questionnaire) was also reduced (3.8% v 9.4%; P<0.05).

CONCLUSION

Integrated social and medical care with case management programmes may provide a cost effective approach to reduce admission to institutions and functional decline in older people living in the community.

Around-the-clock nursing care for the elderly in Japan

PURPOSE

To describe the first phase of creating a Japanese model of community-based long-term care, called around-the-clock care (ACC), by operationally defining the components of ACC, identifying those eligible for the program, clarifying methods of planning and organization, and exploring outcomes.

DESIGN

Exploratory evaluation for the population of frail elderly Japanese citizens living at home. A convenience sample of 44 patients receiving care from four visiting-nurse-service stations during 3 months in 1994 was used.

METHODS

Needs assessments; record reviews of patient encounters; evaluations by patients, families, and visiting nurses; and reviews of administrative data.

FINDINGS

Nurses perceived that ACC stabilized medical status, reduced the emotional and physical burden of treatment, and improved hygiene. It also reduced family caregiving burdens and the stress of family caregivers' employment responsibilities. The highest rating of ACC by patient and families was for those with the most complex physical needs. Skilled nursing at home permitted early identification and treatment of problems before they became crises or required hospitalization.

CONCLUSIONS

Early findings suggest 24-hour nurse-home helper teamwork may be an effective system of community-based long-term care and should be considered a key element of future Japanese health policy.

Trends in aging care in Scotland and Scandinavia

The proportion of older adults in Western European countries, as in the United States, continues to increase rapidly. Faced with geriatric care dilemmas decades earlier, however, these countries have had more experience on which to base the development of community-based, integrated care systems for the elderly. This article provides observations from a 1993 World Health Organization Fellowship study of long-term care facilities in four European countries: Scotland, Sweden, Norway and Denmark. Several emerging trends in geriatric care documented in the literature were confirmed. These included: moratoria on institutional long-term care, emphasis on informal care and support, provision of 24-hour assistance in the home, care management to individualize care, and an expanded set of providers within integrated delivery systems.

Deinstitutionalization of the elderly in Finland, 1981-91

The success of Finnish deinstitutionalization policy among the elderly in 1981-1991 was evaluated in terms of institutionalization rates and case-mix. Censuses of institutionalized people in all public and private residential homes and health centre hospitals (or nursing homes) were performed in 1981, 1986 and 1991. Data on demographic factors, diagnoses and dependency level were gathered. Censuses from the closest years of psychiatric patients were also used to obtain a comprehensive view of institutionalization. The eligibility criteria for the study were (1) age 65 years or more (2) currently in long-term care. In both men and women the overall relative reduction was 33%, and largest in psychiatric care, at over 67%. In residential home care the relative reduction was about 40%. In health centre hospitals a slight increase was seen, about 10%. Length of stay shortened in residential homes but increased in health centre wards. Dependency level increased among the elderly people in long-term institutional care during ten years. In conclusion, the deinstitutionalization rate was substantial among the elderly in Finland. However, because of rapid demographic change the absolute number of elderly in long-term care remained almost constant. The case-mix has become more demanding and the proportion of elderly in constant need of extensive help has risen.