Nature-based social interventions to address loneliness among vulnerable populations: a common study protocol for three related randomized controlled trials in Barcelona, Helsinki, and Prague within the RECETAS European project

BACKGROUND

The negative effects of loneliness on population health and wellbeing requires interventions that transcend the medical system and leverage social, cultural, and public health system resources. Group-based social interventions are a potential method to alleviate loneliness. Moreover, nature, as part of our social and health infrastructure, may be an important part of the solutions that are needed to address loneliness. The RECETAS European project H2020 (Re-imagining Environments for Connection and Engagement: Testing Actions for Social Prescribing in Natural Spaces) is an international research project aiming to develop and test the effectiveness of nature-based social interventions to reduce loneliness and increase health-related quality of life.

METHODS

This article describes the three related randomized controlled trials (RCTs) that will be implemented: the RECETAS-BCN Trial in Barcelona (Spain) is targeting people 18+ from low socio-economic urban areas; the RECETAS-PRG Trial in Prague (Czech Republic) is addressing community-dwelling older adults over 60 years of age, and the RECETAS-HLSNK trial is reaching older people in assisted living facilities. Each trial will recruit 316 adults suffering from loneliness at least sometimes and randomize them to nature-based social interventions called "Friends in Nature" or to the control group. "Friends in Nature" uses modifications of the "Circle of Friends" methodology based on group processes of peer support and empowerment but including activities in nature. Participants will be assessed at baseline, at post-intervention (3 months), and at 6- and 12-month follow-up after baseline. Primary outcomes are the health-related quality-of-life according to 15D measure and The De Jong Gierveld 11-item loneliness scale. Secondary outcomes are health and psychosocial variables tailored to the specific target population. Nature exposure will be collected throughout the intervention period. Process evaluation will explore context, implementation, and mechanism of impact. Additionally, health economic evaluations will be performed.

DISCUSSION

The three RECETAS trials will explore the effectiveness of nature-based social interventions among lonely people from various ages, social, economic, and cultural backgrounds. RECETAS meets the growing need of solid evidence for programs addressing loneliness by harnessing the beneficial impact of nature on enhancing wellbeing and social connections.

TRIAL REGISTRATION

Barcelona (Spain) trial: ClinicalTrials.gov, ID: NCT05488496. Registered 29 July 2022. Prague (Czech Republic) trial: ClinicalTrials.gov, ID: NCT05522140. Registered August 25, 2022. Helsinki (Finland) trial: ClinicalTrials.gov, ID: NCT05507684. Registered August 12, 2022.

Effect of Milk Fat Globule Membrane- and Protein-Containing Snack Product on Physical Performance of Older Women-A Randomized Controlled Trial

INTRODUCTION

Sarcopenia is common in people 70+ years of age, and its prevalence increases with further aging. Insufficient energy and protein intake accelerates muscle loss, whereas sufficient protein intake and milk fat globule membrane (MFGM) may suppress age-associated deterioration of muscle mass and strength. Our objective was to test whether a snack product high in MFGM and protein would improve physical performance in older women.

METHODS

In this 12-week randomized controlled trial, women ≥ 70 years, with protein intake < 1.2 g/body weight (BW) kg/day (d), were randomized into intervention (n = 51) and control (n = 50) groups. The intervention group received a daily snack product containing ≥ 23 g of milk protein and 3.6-3.9 g of MFGM. Both groups were advised to perform a five-movement exercise routine. The primary outcome was the change in the five-time-sit-to-stand test between the groups. Secondary outcomes included changes in physical performance, cognition, hand grip strength, and health-related quality of life.

RESULTS

The change in the five-time-sit-to-stand test did not differ between the intervention and the control groups. The change in the total Short Physical Performance Battery score differed significantly, favoring the intervention group (p = 0.020), and the balance test showed the largest difference. Protein intake increased significantly in the intervention group (+14 g) compared to the control group (+2 g). No other significant changes were observed.

CONCLUSIONS

Our results indicate that the combination of MFGM and protein may improve the physical performance-related balance of older women.

Clinical trials in older people

Randomised controlled trials (RCTs) usually provide the best evidence for treatments and management. Historically, older people have often been excluded from clinical medication trials due to age, multimorbidity and disabilities. The situation is improving, but still the external validity of many trials may be questioned. Individuals participating in trials are generally less complex than many patients seen in geriatric clinics.

Recruitment and retention of older participants are particular challenges in clinical trials. Multiple channels are needed for successful recruitment, and especially individuals experiencing frailty, multimorbidity and disabilities require support to participate. Cognitive decline is common, and often proxies are needed to sign informed consent forms. Older people may fall ill or become tired during the trial, and therefore, special support and empathic study personnel are necessary for the successful retention of participants.

Besides the risk of participants dropping out, several other pitfalls may result in underestimating or overestimating the intervention effects. In nonpharmacological trials, imperfect blinding is often unavoidable. Interventions must be designed intensively and be long enough to reveal differences between the intervention and control groups, as control participants must still receive the best normal care available. Outcome measures should be relevant to older people, sensitive to change and targeted to the specific population in the trial. Missing values in measurements are common and should be accounted for when designing the trial.

Despite the obstacles, RCTs in geriatrics must be promoted. Reliable evidence is needed for the successful treatment, management and care of older people.

Monetary value of informal caregiving in dementia from a societal perspective

BACKGROUND

Dementia is a condition which results in a high cost of care, a significant proportion of which is the cost associated with informal care. In previous studies, informal caregiving has been challenging to assess due to difficulties in estimating the true time spent on caregiving work and how to value caregivers' time. The aim of this study was to compare the costs of dementia among patients living alone and among those living with a caregiver to show the monetary value of informal caregiving from a societal perspective.

METHODS

Data from our four dementia trials using the same measures were combined, allowing the inclusion of 604 participants. Participants were followed up for 2 years or until death for their use of health and social services. Use of all services was retrieved from medical/social records. We also included the costs of lost productivity of those caregivers who were not retired.

RESULTS

The total mean cost of services and lost productivity was €22,068/person-year (pyrs). Participants living alone had a mean cost of €45,156/pyrs, whereas those living with a spouse had a mean cost of €16,416/pyrs (mean cost ratio 2.99, 95% confidence interval 2.64-3.39). Participants living alone and having <15 Mini-Mental State Examination points had higher costs than people with dementia in institutional care.

CONCLUSIONS

Detailed data of service use and characteristics of people with dementia showed that from a societal perspective, living alone is a very strong determinant of service use in dementia. Informal caregivers do invaluable work for society.

Secular trends in functional abilities, health and psychological well-being among community-dwelling 75- to 95-year-old cohorts over three decades in Helsinki, Finland

Background: Life expectancy has increased markedly in the past decades. Thus, it is of great importance to understand how people are ageing and if the trajectories of health and disability are changing over time. This study aimed to examine trends in functional abilities and health in independent cohorts of people aged 75–95 over three decades. Methods: This Helsinki Ageing Study consists of repeated cross-sectional postal surveys examining independent cohorts of old people (75, 80, 85 and 90+ years old). This study combined data from four waves (1989, 1999, 2009 and 2019). Results: In the most recent wave, there was an increase in the portion of participants who were able to walk outdoors easily (75-year-olds p=0.03, 80-year-olds p=0.002, 85-year-olds p<0.001; p for linearity for the study year effect, all adjusted for sex). Fewer people in the youngest age group (75-year-olds) needed daily help from another person in 2019 compared to the earlier waves (p=0.02 for linearity for the study year). Over the past three decades, the proportions of self-reported good mobility have risen 8.7% (95% confidence interval (CI) 2.3–15.1) in 75-year-olds, 11.7% (95% CI 3.9–19.6) in 80-year-olds and 20.1% (95% CI 10.7–29.4) in 85-year-olds, after adjusting for sex. Furthermore, in 2019, more people rated their health as good and scored better in psychological well-being than in the previous waves among 75-, 80- and 85-year-olds. However, no improvements were found among 90+-year-olds in any of these variables. Conclusions: People between 75 and 85 years old are presently feeling and functioning better than their predecessors. This may be an important objective for both economics and health policy.

Symptom Burden Is Associated with Psychological Wellbeing and Mortality in Older Adults

IMPORTANCE

Over half of outpatient visits are due to physical symptoms; yet, the significance of symptoms in relation to older people's wellbeing and prognosis has gained very little research attention.

OBJECTIVES

This study aims to analyze the prognostic value of symptom burden, derived from symptom count and frequency, in an older cohort aged 75 to 95. We also explore the association between symptom burden and psychological wellbeing.

DESIGN

Randomly assigned cohorts of community-dwelling people aged 75-95 filled in the postal questionnaire of the Helsinki Aging Study in 2009.

SETTING

Community-based, postal questionnaires (survey response rate 74%).

PARTICIPANTS

1583 community-dwelling people aged 75-95 in the urban Helsinki area. Main outcomes and measures: The inquired symptoms were dizziness, back pain, joint pain, chest pain or discomfort, shortness of breath, leg pain when walking, loss of appetite, and urinary incontinence. Symptom burden was calculated according to the number of symptoms and their frequency (score range: 0-8). The participants were subdivided into four groups according to their symptom burden. Mortality data was extracted from the Finnish Population Register in 2014. Psychological wellbeing (PWB) was measured using the validated PWB score.

RESULTS

Of 1583 participants, 18% reported no symptoms over the past 2 weeks (Group 0), 31% scored 0.5-1 in the symptom burden score (Group 1), 23% scored 1.5-2 (Group 2), and 28% scored 2.5-8 (Group 3). There was a linear relationship between symptom burden and comorbidities, functional status, falls, and PWB. The groups showed a significant difference in 5-year mortality, even adjusted for age, sex, and comorbidities: Group 1 1.18, 95% CI 0.84-1.66; Group 2 1.63, 95% CI 1.15-2.31, and Group 3 2.08, 95% CI 1.49-2.91 compared to Group 0 (p for linearity <0.001). Conclusion and relevance: Symptom burden is associated with higher mortality and lower PWB independent of comorbidities in community-dwelling people aged 75-95. We conclude that somatic symptoms need to be assessed when examining the general health status of an aging patient. Self-reported symptoms seem to convey information about health that cannot be derived from medical diagnoses only.

Associations of perceived poor societal treatment among the oldest-old

BACKGROUND

Previous studies of perceived ageism among older people have focused on younger age groups with the respondents' mean age far below 80.

OBJECTIVE

To explore the perceptions of poor societal treatment of older people among home-dwelling people aged 75-100+ and how their perceptions are associated with demographic characteristics, health, functioning, and wellbeing.

METHODS

In the Helsinki Aging Study, a random sample of 2,917 home-dwelling people aged 75-104 received a postal questionnaire inquiring about their health, wellbeing and experiences. The response rate was 74%. We asked: 'How in your opinion are older people treated in Finland?' (well/moderately/poorly) and categorized the respondents according to their responses. A multivariable forward stepwise ordered logistic regression model was used to determine the independent associations of the variables on the ordinal level of perceptions of treatment.

RESULTS

Of the participants, 1,653 responded to the index item. Of these, only 13% thought that older people are treated well in society, and 66% and 21% were of the opinion that older people are treated moderately or poorly in society, respectively. Perceived poor societal treatment was more common among women, the younger respondents, and those with lower incomes, as well as family caregivers and those with lower self-rated health and lower psychological wellbeing. Those who were able to walk outside unassisted and those with a regular hobby perceived poor societal treatment more often.

CONCLUSIONS

Several demographic factors, self-rated health, psychological wellbeing and better functioning were associated with perceptions of poor treatment among the oldest-old.

Staff Training Interventions to Improve End-of-Life Care of Nursing Home Residents: A Systematic Review

OBJECTIVES

The aim was to review evidence from all randomized controlled trials (RCTs) using palliative care education or staff training as an intervention to improve nursing home residents' quality of life (QOL) or quality of dying (QOD) or to reduce burdensome hospitalizations.

DESIGN

A systematic review with a narrative summary.

SETTING AND PARTICIPANTS

Residents in nursing homes and other long-term care facilities.

METHODS

We searched MEDLINE, CINAHL, PsycINFO, the Cochrane Library, Scopus, and Google Scholar, references of known articles, previous reviews, and recent volumes of key journals. RCTs were included in the review. Methodologic quality was assessed.

RESULTS

The search yielded 932 articles after removing the duplicates. Of them, 16 cluster RCTs fulfilled inclusion criteria for analysis. There was a great variety in the interventions with respect to learning methods, intensity, complexity, and length of staff training. Most interventions featured other elements besides staff training. In the 6 high-quality trials, only 1 showed a reduction in hospitalizations, whereas among 6 moderate-quality trials 2 suggested a reduction in hospitalizations. None of the high-quality trials showed effects on residents' QOL or QOD. Staff reported an improved QOD in 1 moderate-quality trial.

CONCLUSIONS AND IMPLICATIONS

Irrespective of the means of staff training, there were surprisingly few effects of education on residents' QOL, QOD, or burdensome hospitalizations. Further studies are needed to explore the reasons behind these findings.

The associations of body mass index, bioimpedance spectroscopy-based calf intracellular resistance, single-frequency bioimpedance analysis and physical performance of older people

BACKGROUND

Bioimpedance skeletal muscle indices (SMI) are used as a surrogate for skeletal muscle mass, but their associations with physical functioning and obesity need further evaluation.

AIMS

To compare the associations of body mass index (BMI), bioimpedance spectroscopy-based calf intracellular resistance (Cri-SMI), and single-frequency bioimpedance analysis (SF-SMI) indices with physical performance and the functioning of community-dwelling older people at risk of or already suffering from sarcopenia.

METHODS

Pre-intervention measurements of the screened subjects and the participants of the Porvoo sarcopenia trial (N = 428) were taken. Cri-SMI, whole-body SF-SMI, and BMI were related to hand-grip strength, walking speed, short physical performance battery (SPPB), and the physical component of the RAND-36.

RESULTS

Among the older people (aged 75-96), Cri-SMI correlated inversely with age (men r = - 0.113, p < 0.001; women r = - 0.287, p < 0.001), but positively with SPPB (r = 0.241, p < 0.001) and the physical component of the RAND-36 (r = 0.114, p = 0.024), whereas BMI was inversely associated with SPPB (r = - 0.133, p < 0.001) and RAND-36 (r = - 0.286, p < 0.001). After controlling for age, gender, and comorbidity, one unit of Cri-SMI (cm²/Ω) was associated with a 3.3-fold probability of good physical performance (SPPB ≥ 9 points, OR = 3.28, p < 0.001) and one unit of BMI (kg/m²) decreased the respective probability 4% (OR= 0.96, p = 0.065). Physical inactivity partly explained the negative association of BMI. When Cri-SMI and BMI were controlled for, a 1% difference in Cri-SMI was associated with a 0.7% (p < 0.001) higher probability of good performance, the respective figure being - 2.2% (p = 0.004) for BMI. The associations of SF-SMI with physical functioning indices were insignificant.

CONCLUSIONS

Independent of each other, Cri-SMI was positively and BMI was inversely associated with the physical performance and functioning of community-dwelling older people who were at risk of or already suffering from sarcopenia. We found no association between SF-SMI and physical functioning.

Effect of Clinical Geriatric Assessments and Collaborative Medication Reviews by Geriatrician and Family Physician for Improving Health-Related Quality of Life in Home-Dwelling Older Patients Receiving Polypharmacy: A Cluster Randomized Clinical Trial

IMPORTANCE

Polypharmacy and inappropriate drug regimens are major health concerns among older adults. Various interventions focused on medication optimization strategies have been carried out, but the effect on patient-relevant outcomes remains uncertain.

OBJECTIVE

To investigate the effect of clinical geriatric assessments and collaborative medication reviews by geriatrician and family physician (FP) on health-related quality of life and other patient-relevant outcomes in home-dwelling older patients receiving polypharmacy.

DESIGN, SETTING, AND PARTICIPANTS

Cluster randomized, single-blind, clinical trial. Norwegian FPs were recruited from March 17, 2015, to March 16, 2017, to participate in the trial with their eligible patients. Participants were home-dwelling patients 70 years or older, using at least 7 medications regularly, and having their medications administered by the home nursing service. Patients in the control group received usual care. Randomization occurred at the FP level. A modified intent-to-treat analysis was used.

INTERVENTION

The intervention consisted of 3 main parts: (1) clinical geriatric assessment of the patients combined with a thorough review of their medications; (2) a meeting between the geriatrician and the FP; and (3) clinical follow-up.

MAIN OUTCOMES AND MEASURES

The primary outcome was health-related quality of life as assessed by the 15D instrument (score range, 0-1; higher scores indicate better quality of life, with a minimum clinically important change of ±0.015) at week 16. Secondary outcomes included changes in medication appropriateness, physical and cognitive functioning, use of health services, and mortality.

RESULTS

Among 174 patients (mean [SD] age, 83.3 [7.3] years; 67.8% women; 87 randomized to the intervention group and 87 randomized to the control [usual care] group) in 70 FP clusters (36 intervention and 34 control), 158 (90.8%) completed the trial. The mean (SD) 15D instrument score at baseline was 0.708 (0.121) in the intervention group and 0.714 (0.113) in the control group. At week 16, the mean (SD) 15D instrument score was 0.698 (0.164) in the intervention group and 0.655 (0.184) in the control group, with an estimated between-group difference of 0.045 (95% CI, 0.004-0.086; P = .03). Several secondary outcomes were also in favor of the intervention. There were more drug withdrawals, reduced dosages, and new drug regimens started in the intervention group.

CONCLUSIONS AND RELEVANCE

This study's findings indicate that, among older patients exposed to polypharmacy, clinical geriatric assessments and collaborative medication reviews carried out by a geriatrician in cooperation with the patient's FP can result in positive effects on health-related quality of life.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02379455.

The Effects of Preventive Home Visits on Older People’s Use of Health Care and Social Services and Related Costs

Background

We use data from a randomized controlled trial on preventive home visits exploring effectiveness on health-related quality of life. In this article, we examine the intervention’s cost-effectiveness and effects on quality-adjusted life years in older home-dwelling adults.

Methods

There were 422 independently home-dwelling participants in the randomized, controlled trial, all aged more than 75 years, with equal numbers in the control and intervention groups. The intervention took place in a municipality in Finland and consisted of multiprofessional preventive home visits. We gathered the data on health care and social services use from central registers and medical records during 1 year before the intervention and 2 years after the intervention. We analyzed the total health care and social services use and costs per person-years and the difference in change in health-related quality of life as measured using the 15D measure. We calculated quality-adjusted life years and incremental cost-effectiveness ratios.

Results

There was no significant difference in baseline use of services or in the total use and costs of health care and social services during the 2-year follow-up between the two groups. In the intervention group, health-related quality of life declined significantly more slowly compared with the control group (–0.015), but there was no significant difference in quality-adjusted life years gained between the groups. The cost-effectiveness plane showed 60% of incremental cost-effectiveness ratios lying in the dominant quadrant, representing additional effects with lower costs.

Conclusions

This multiprofessional preventive home visit intervention appears to have positive effects on health-related quality of life without accruing additional costs.

The clinical trial registration number

ACTRN12616001411437.

Bioimpedance analysis and physical functioning as mortality indicators among older sarcopenic people

OBJECTIVES

To assess the prognostic significance of various characteristics and measurements of sarcopenia and physical functioning on all-cause mortality among home-dwelling older people with or at-risk of sarcopenia.

DESIGN

Cross-sectional and longitudinal analyses.

SETTING

Porvoo sarcopenia trial in open care.

PARTICIPANTS

Community-dwelling people aged 75 and older (N = 428, of which 182 were re-examined at one year) with four years of follow-up.

MEASUREMENTS

Body mass index (BMI), physical functioning (physical component of the RAND-36) and physical performance tests (Short Physical Performance Battery (SPPB)), hand grip strength, walking speed, Charlson Comorbity Index, bioimpedance-based surrogates for muscle mass: Single Frequency Skeletal Muscle Index (SF-SMI), and Calf Intracellular Resistance Skeletal Muscle Index (CRi-SMI). Date of death was retrieved from central registers. Survival analyses were performed using Life-Table analyses and Cox models.

RESULTS

Most test variables (except BMI) were associated with four-year mortality in a dose-dependent fashion. After controlling for age, gender and co-morbidity, physical performance and functioning (both SPPB and RAND-36), muscle strength (hand grip strength) and CRi-SMI appeared to be independent mortality risk indicators (p < 0.001) whereas SF-SMI was not. When CRi-SMI values were grouped by gender-specific cut-off points, the probability of surviving for four years decreased by 66% among the older people with low CRi-SMI (HR = 0.34, 95%CI 0.15-0.78, p = 0.011). When low CRi-SMI was further controlled for SPPB, the prognostic significance remained significant (HR = 0.55, 95%CI 0.33-0.92, p = 0.021). After controlling for age, gender, comorbidity, and CRi-SMI, the physical component of the RAND-36 (p = 0.007), SPPB (p < 0,001) and hand grip strength (p = 0.009) remained significant mortality predictors. Twelve-month changes were similarly associated with all-cause mortality during the follow-up period.

CONCLUSION

CRi-SMI, muscle strength, physical performance and physical functioning are each strong independent predictors of all-cause mortality among home-dwelling older people. Compared to these indicators, BMI seemed to be clearly inferior. Of two bioimpedance-based muscle indices, CRi SMI was better predictor of mortality than SF-SMI. In this regard, muscle mass, muscle strength and physical performance are all suitable targets for the prevention of sarcopenia-related over-mortality.

Effects of preventive home visits on health-related quality-of-life and mortality in home-dwelling older adults

OBJECTIVE

We explored the effectiveness of preventive home visits on the health-related quality-of-life (HRQoL) and mortality among independently community-dwelling older adults.

DESIGN

A randomised controlled trial.

SUBJECTS

Independently home-dwelling older adults 75 years and older, consisting of 211 in the intervention and 211 in the control group.

SETTING

Hyvinkää town municipality, Finland.

MAIN OUTCOME MEASURES

We used the change in HRQoL measured by the 15D scale as our primary outcome. Mortality at two years was retrieved from central registers.

RESULTS

At the one-year time point, the HRQoL according to the 15D scores deteriorated in the control group, whereas we found no change in the intervention group. The difference between the 15D score changes between the groups was -0.015 (95% CI -0.029 to -0.0016; p = 0.028, adjusted for age, sex, and baseline value). At the two-year time point as the visits ended, that difference diminished. There was no difference in mortality between the groups during the 24-month follow-up.

CONCLUSION

Preventive home visits implemented by a multidisciplinary team with CGA appear to help slow down the decline in HRQoL among older adults, although the effect diminishes when the visits end. Key points We are exploring preventive home visits as means to support the health-related quality-of-life (HRQoL) of home-dwelling older adults Multiprofessional preventive home visits in this intervention study helped to maintain the HRQoL when measured using 15D The effects on HRQoL diminished when the intervention ended, so could further benefits be attained with a longer intervention?The clinical trial registration number: ACTRN12616001411437.

Burden of Oral Symptoms and Health-Related Quality of Life in Long-Term Care Settings in Helsinki, Finland

OBJECTIVES

Poor oral health may complicate eating and deteriorate nutritional status. However, little is known about how the burden of oral symptoms (OS) is associated with the health-related quality of life (HRQoL) of vulnerable older people in institutional settings. This study explores how the burden of certain OS (chewing problems, swallowing difficulties, dry mouth) is associated with functioning, morbidity, nutritional status and eating habits. It also examines the association between the OS burden and HRQoL.

DESIGN

A cross-sectional study in 2017.

SETTING

All long-term care wards in Helsinki, Finland.

PARTICIPANTS

2401 older residents (74% females, mean age 83.9).

MEASUREMENTS

Nurses assessed the residents and completed questionnaires on the participants' demographics, functional status, diagnoses, OS and eating habits. Nutritional status was assessed using the Mini Nutritional Assessment (MNA) and HRQoL with a 15-dimensional instrument (15D).

RESULTS

Of the residents, 25.4% had one OS and 16.6% two or three OS. OS burden was associated linearly with poorer cognitive and physical functioning and a higher number of comorbidities, edentulousness without dentures, and less frequent teeth brushing/denture cleaning. OS burden was also associated with malnutrition, lower BMI and eating less during main meals. In the multivariate analyses adjusted for various confounding factors, a higher number of OS was associated with lower HRQoL. OS burden correlated with nearly all dimensions of HRQoL.

CONCLUSION

Oral symptoms are associated with generic HRQoL. Therefore, OS should be regularly assessed and managed in daily care.

Associations between Nutritional Status and Health-Related Quality of Life among Long-Term Care Residents in Helsinki

OBJECTIVES

We evaluated the associations between nutritional status and health-related quality-of-life (HRQoL) among older long-term care residents in Helsinki.

DESIGN AND PARTICIPANTS

All 3767 older (≥65 years) long-term care residents in Helsinki in 2017 were invited to participate in this cross-sectional study. After refusals and exclusions of residents without sufficient information, 2160 residents remained.

MEASUREMENTS

Data on characteristics, nutritional status (Mini Nutritional Assessment, MNA) and HRQoL (15D) were collected by trained nurses.

RESULTS

Of the participants, 64% were at-risk of malnutrition and 18% suffered from malnutrition. Residents in the "malnourished" group were more dependent in activities of daily living (ADL) functioning, suffered more often from dementia, had lower cognitive level, used less medications, and were eating more often inadequately. HRQoL was statistically significantly associated with MNA total score in both female and male residents. There was a curvilinear correlation between MNA and 15D score in females: 0.50 (95% CI 0.46 to 0.53) and males: 0.56 (95% CI 0.50 to 0.61). In partial correlation analysis, all dimensions of 15D, except for sleeping and breathing, were positively associated with MNA score. In these analyses no significant differences emerged between males and females when the results were adjusted for age and dementia.

CONCLUSIONS

Nutrition plays an important role in HRQoL among older long-term care residents.

How Do Community-Dwelling Persons with Alzheimer Disease Fall? Falls in the FINALEX Study

BACKGROUND

People with dementia are at high risk for falls. However, little is known of the features causing falls in Alzheimer disease (AD). Our aim was to investigate how participants with AD fall.

METHODS

In the FINALEX (Finnish Alzheimer Disease Exercise Trial) study, participants' (n = 194) falls were followed up for 1 year by diaries kept by their spouses.

RESULTS

The most common reason for falls (n = 355) was stumbling (n = 61). Of the falls, 123 led to injuries, 50 to emergency department visits, and 13 to fractures. The participants without falls (n = 103) were younger and had milder dementia than those with 1 (n = 34) or ≥2 falls (n = 57). Participants with a Mini Mental State Examination score of around 10 points were most prone to fall. In adjusted regression models, good nutritional status, good physical functioning, and use of antihypertensive medication (incident rate ratio [IRR] 0.68, 95% confidence interval [CI] 0.54-0.85) protected against falls, whereas fall history (IRR 2.71, 95% CI 2.13-3.44), osteoarthritis, diabetes mellitus, chronic obstructive pulmonary disease, higher number of drugs, drugs with anticholinergic properties, psychotropics, and opioids (IRR 4.27, 95% CI 2.92-6.24) were risk factors for falls.

CONCLUSIONS

Our study provides a detailed account on how and why people with AD fall, suggesting several risk and protective factors.

Do you want to live to be 100? Answers from older people

BACKGROUND

little is known about the oldest-olds' views on ageing.

OBJECTIVE

to investigate older people's desire and the reasons they give for wanting to live to 100.

DESIGN

a postal questionnaire, analysed both quantitatively and qualitatively.

SETTING

population based in Helsinki, Finland.

SUBJECTS

a random sample (response rate 64%; N = 1,405) of community-dwelling older people (aged 75-96).

METHODS

a structured self-completed questionnaire with an open-ended question on the reasons why/why not participants wished/did not wish to live to 100.

RESULTS

one-third (32.9%) of home-dwelling older people wanted to live to be 100. Those who did were older, more often male and self-rated their health better than those who did not. Often the desire for long life was conditional: 'Yes, if I stay healthy'. Among the reasons is that many were curious to see what would happen. Many stated that they loved life, they had twinkle in their eye or significant life roles. Those who did not want to live extremely long lives gave various rationales: they would become disabled, life would be meaningless, they were reluctant to become a burden to others or they feared loss of autonomy or suffering pain or loneliness. Some people also shared the view that they should not intervene in destiny or they felt that they had accomplished what they wanted in life.

CONCLUSIONS

one-third of the oldest-old participants wanted to live to 100. Identifying what motivated them to desire long life could be a resource in their care plans.

Recommendations on Physical Activity and Exercise for Older Adults Living in Long-Term Care Facilities: A Taskforce Report

A taskforce, under the auspices of The International Association of Gerontology and Geriatrics-Global Aging Research Network (IAGG-GARN) and the IAGG European Region Clinical Section, composed of experts from the fields of exercise science and geriatrics, met in Toulouse, in December 2015, with the aim of establishing recommendations of physical activity and exercise for older adults living in long-term care facilities (LTCFs). Due to the high heterogeneity in terms of functional ability and cognitive function that characterizes older adults living in LTCFs, taskforce members established 2 sets of recommendations: recommendations for reducing sedentary behaviors for all LTCF residents and recommendations for defining specific, evidence-based guidelines for exercise training for subgroups of LTCF residents. To promote a successful implementation of recommendations, taskforce experts highlighted the importance of promoting residents' motivation and pleasure, the key factors that can be increased when taking into account residents' desires, preferences, beliefs, and attitudes toward physical activity and exercise. The importance of organizational factors related to LTCFs and health care systems were recognized by the experts. In conclusion, this taskforce report proposes standards for the elaboration of strategies to increase physical activity as well as to prescribe exercise programs for older adults living in LTCFs. This report should be used as a guide for professionals working in LTCF settings.

Eight-Year Trends in the Use of Opioids, Other Analgesics, and Psychotropic Medications Among Institutionalized Older People in Finland

IMPORTANCE

It is recognized that pain has been undertreated and psychotropic medications overused in institutional settings.

OBJECTIVE

To investigate the change in prevalence of opioids, other analgesics, and psychotropic medications in institutional settings over an 8-year period.

SETTINGS

Institutional settings in Helsinki, Finland.

PARTICIPANTS

Older residents in nursing homes in 2003 (n = 1987) and 2011 (n = 1576) and in assisted living facilities in 2007 (n = 1377) and 2011 (n = 1586).

OUTCOME MEASURES

Comparable audits of medication use were conducted among institutionalized residents at 3 time points over 8 years. The prevalence of regular opioid, other analgesic, and psychotropic medications was compared across the 3 time periods.

RESULTS

Nursing home and assisted living facility residents were older; more disabled, had a higher prevalence of dementia, and greater comorbidity in the latter cohorts. The prevalence of regular opioid use was 11.8% and 22.9% in nursing homes in 2003 and 2011 (P < .001), and 8.6% and 17.3% in assisted living facilities in 2007 and 2011 (P < .001), respectively. The prevalence of regular acetaminophen and pregabalin/gabapentin increased and NSAIDs decreased in both nursing homes and assisted living facilities. The prevalence of regular antipsychotic use decreased from 42.6% to 27.8% in nursing homes (P < .001) but increased from 26.9% to 32.0% in assisted living facilities (P = .0017). The mean number of psychotropic medications (antipsychotics, antidepressants, anxiolytics, hypnotics) per resident decreased from 1.9 in 2003 to 1.0 in 2011 in nursing homes (P < .001) but increased from 1.1 to 1.2 in assisted living facilities (P = .040).

CONCLUSIONS

The prevalence of opioid use in institutional settings has doubled during the past decade. The prevalence of psychotropic medications has decreased in nursing homes but increased in assisted living facilities. The increase in opioid use may reflect improved recognition and treatment of pain. However, initiatives are needed to monitor opioid-related adverse drug events and ensure appropriate use of psychotropic medications, particularly in assisted living facilities.

Tailored nutritional guidance for home-dwelling AD families: the Feasibility of and Elements Promoting Positive Changes in Diet (NuAD-Trial)

OBJECTIVES

To describe the process and feasibility of our randomised, controlled intervention study (NuAD trial) that positively affected the nutrition and quality of life, and prevented falls of home-dwelling persons with Alzheimer disease (AD).

DESIGN, SETTING, PARTICIPANTS

This qualitative study comprised 40 persons with AD and spousal caregivers of our trial. Our intervention during one year involved tailored nutritional guidance for these couples. The nutritionist's field notes (about 100 pages) and the participant feedback questionnaires (N = 28) served to analyse the feasibility of intervention, factors promoting the application of intervention and challenges hindering it. Thematic content analysis served to analyse our data with the grounded theory approach.

RESULTS

We identified several positive elements promoting better nutrition: positive attitudes on nutrition to participants including a participant-centred approach, positive feedback, findings of food diaries and practical suggestions. Home visits by the nutritionist were convenient and participants felt that someone cares. Group meetings which included protein-rich snacks strengthened the nutritional message by enabling discussions and socialising. The oral nutritional supplements (ONS) helped participants to regain their energy and to motivate them to exercise and make changes in their diets. Obstacles to making changes in diets included participants' false ideas about nutrition, especially with regard to weight gain. Health problems and functional limitations hampered food management, and some families had inveterate eating habits. The positive feedback from participants indicated the feasibility of our tailored nutritional guidance.

CONCLUSIONS

Assessment-based, tailored nutritional guidance implemented with a personal and positive approach may inspire and empower AD families to make positive changes in their diets, leading them to improved nutrition and quality of life.

Nutritional guidelines for older people in Finland

BACKGROUND

Ageing is associated with an increased risk of malnutrition, decreased nutrient intake, unintentional weight loss and sarcopenia, which lead to frailty, functional disabilities and increased mortality. Nutrition combined with exercise is important in supporting older people's health, functional capacity and quality of life.

OBJECTIVE

To identify nutritional needs in various groups of older individuals and to present the nutritional guidelines for older people in Finland.

DESIGN

A review of the existing literature on older people's nutritional needs and problems. The draft guidelines were written by a multidisciplinary expert panel; they were then revised, based on comments by expert organisations. The guidelines were approved by the National Nutritional Council in Finland.

RESULTS

The heterogeneity of the older population is highlighted. The five key guidelines are: 1. The nutritional needs in different age and disability groups should be considered. 2. The nutritional status and food intake of older individuals should be assessed regularly. 3. An adequate intake of energy, protein, fiber, other nutrients and fluids should be guaranteed. 4. The use of a vitamin D supplement (20 μg per day) recommended. 5. The importance of physical activity is highlighted. In addition, weight changes, oral health, constipation, obesity, implementing nutritional care are highlighted.

CONCLUSIONS

Owing to the impact that good nutrition has on health and well-being in later life, nutrition among older people should be given more attention. These nutritional guidelines are intended to improve the nutrition and nutritional care of the older population.

Caregivers' male gender is associated with poor nutrient intake in AD families (NuAD-trial)

OBJECTIVE

Alzheimer patients (AD) are known to be at risk for malnutrition and their older spouses may also have nutritional problems. The aim of our study was to clarify the association of caregivers' sex on the nutrient intake of AD couples.

SETTING

Our study uses the baseline data of a randomized nutritional trial exploring the effectiveness of nutrition intervention among home-dwelling AD patients.

PARTICIPANTS

The central AD register in Finland was used to recruit AD patients living with a spousal caregiver, 99 couples participated in our study.

MEASUREMENTS

Nutritional status was assessed using the Mini-Nutritional Assessment (MNA). Nutrient intakes for both AD patients and their spouses were calculated from 3-day food diaries.

RESULTS

The mean age of caregivers and AD spouses was 75.2 (SD 7.0) and 77.4 years (SD 5.6), respectively. According to the MNA, 40% of male and 52% of female AD spouses were at risk for malnutrition. Among male caregivers, the mean energy and protein intakes were 1605 kcal (SD 458) and 0.93 g/body kg (SD 0.30), whereas the respective figures for their female AD spouses were 1313 kcal (SD 340) and 0.86 g/body kg (SD 0.32), respectively. Among female caregivers, the mean energy and protein intakes were 1536 kcal (SD 402) and 1.00 g/body kg (SD 0.30), whereas the respective figures for their male AD spouses were 1897 kcal (SD 416) and 1.04 g/body kg (SD 0.30). The interaction between male caregiver sex and lower energy (p<0.001) and lower protein intake (p=0.0048) (adjusted for age and MMSE) was significant. Similar differences between caregiver sexes were observed with the intake of various nutrients.

CONCLUSIONS

A gender difference exists in the ability to cope with caregiver responsibilities related to nutrition. A need exists for tailored nutritional guidance among older individuals and especially among male caregivers.

Caregivers' male gender is associated with poor nutrient intake in AD families (NuAD-trial)

OBJECTIVE

Alzheimer patients (AD) are known to be at risk for malnutrition and their older spouses may also have nutritional problems. The aim of our study was to clarify the association of caregivers' sex on the nutrient intake of AD couples.

SETTING

Our study uses the baseline data of a randomized nutritional trial exploring the effectiveness of nutrition intervention among home-dwelling AD patients.

PARTICIPANTS

The central AD register in Finland was used to recruit AD patients living with a spousal caregiver, 99 couples participated in our study.

MEASUREMENTS

Nutritional status was assessed using the Mini-Nutritional Assessment (MNA). Nutrient intakes for both AD patients and their spouses were calculated from 3-day food diaries.

RESULTS

The mean age of caregivers and AD spouses was 75.2 (SD 7.0) and 77.4 years (SD 5.6), respectively. According to the MNA, 40% of male and 52% of female AD spouses were at risk for malnutrition. Among male caregivers, the mean energy and protein intakes were 1605 kcal (SD 458) and 0.93 g/body kg (SD 0.30), whereas the respective figures for their female AD spouses were 1313 kcal (SD 340) and 0.86 g/body kg (SD 0.32), respectively. Among female caregivers, the mean energy and protein intakes were 1536 kcal (SD 402) and 1.00 g/body kg (SD 0.30), whereas the respective figures for their male AD spouses were 1897 kcal (SD 416) and 1.04 g/body kg (SD 0.30). The interaction between male caregiver sex and lower energy (p<0.001) and lower protein intake (p=0.0048) (adjusted for age and MMSE) was significant. Similar differences between caregiver sexes were observed with the intake of various nutrients.

CONCLUSIONS

A gender difference exists in the ability to cope with caregiver responsibilities related to nutrition. A need exists for tailored nutritional guidance among older individuals and especially among male caregivers.

Detailed cognitive function and use of drugs with anticholinergic properties in older people: a community-based cross-sectional study

BACKGROUND

Many potentially inappropriate drugs prescribed to older people have anticholinergic properties and may therefore be harmful. Drugs with anticholinergic properties (DAPs) are associated with cognitive decline.

OBJECTIVE

Our aim was to study the profile of various cognitive functions related to current use of DAPs.

METHODS

A cross-sectional study was conducted in Helsinki, Finland, and included 400 home-dwelling individuals aged 75-90 years without major clinical dementia but with a history of stable atherosclerotic disease who were participants of the DEBATE (Drugs and Evidence-Based Medicine in the Elderly) study. The cognition of the users (n = 295) and non-users (n = 105) of DAPs was measured with the Consortium to Establish a Registry for Alzheimer's Disease (CERAD) test battery.

RESULTS

Use of DAPs was statistically significantly associated with a low score in verbal fluency, in naming, and on the Mini-Mental State Examination (MMSE). In the logistic regression analysis, the difference remained for low verbal fluency (odds ratio [OR] 1.84, 95 % CI 1.02-3.32; p = 0.044) and naming (OR 1.81, 95 % CI 1.09-3.00; p = 0.021) but not for MMSE score after adjusting for age, sex and education.

CONCLUSIONS

Performances for verbal fluency and naming were poorer in DAP users than in non-users, suggesting a possible impairment of executive functioning and semantic memory. The dimensions of the CERAD test assessing episodic memory-the subtests that are the most sensitive in terms of detecting early Alzheimer's disease-did not show differences between users and non-users of DAPs.

Reducing inappropriate, anticholinergic and psychotropic drugs among older residents in assisted living facilities: study protocol for a randomized controlled trial

BACKGROUND

Use of inappropriate drugs is common among institutionalized older people. Rigorous trials investigating the effect of the education of staff in institutionalized settings on the harm related to older people's drug treatment are still scarce. The aim of this trial is to investigate whether training professionals in assisted living facilities reduces the use of inappropriate drugs among residents and has an effect on residents' quality of life and use of health services.

METHODS AND DESIGN

During years 2011 and 2012, a sample of residents in assisted living facilities in Helsinki (approximately 212) will be recruited, having offered to participate in a trial aiming to reduce their harmful drugs. Their wards will be randomized into two arms: one, those in which staff will be trained in two half-day sessions, including case studies to identify inappropriate, anticholinergic and psychotropic drugs among their residents, and two, a control group with usual care procedures and delayed training. The intervention wards will have an appointed nurse who will be responsible for taking care of the medication of the residents on her ward, and taking any problems to the consulting doctor, who will be responsible for the overall care of the patient. The trial will last for twelve months, the assessment time points will be zero, six and twelve months. The primary outcomes will be the proportion of persons using inappropriate, anticholinergic, or more than two psychotropic drugs, and the change in the mean number of inappropriate, anticholinergic and psychotropic drugs among residents. Secondary endpoints will be, for example, the change in the mean number of drugs, the proportion of residents having significant drug-drug interactions, residents' health-related quality of life (HRQOL) according to the 15D instrument, cognition according to verbal fluency and clock-drawing tests and the use and cost of health services, especially hospitalizations.

DISCUSSION

To our knowledge, this is the first large-scale randomized trial exploring whether relatively light intervention, that is, staff training, will have an effect on reducing harmful drugs and improving QOL among institutionalized older people.

TRIAL REGISTRATION

ACTRN12611001078943.

Nutritional treatment of aged individuals with Alzheimer disease living at home with their spouses: study protocol for a randomized controlled trial

Background

Nutritional status often deteriorates in Alzheimer’s disease (AD). Less is known about whether nutritional care reverses malnutrition and its harmful consequences in AD. The aim of this study is to examine whether individualized nutritional care has an effect on weight, nutrition, health, physical functioning, and quality of life in older individuals with AD and their spouses living at home.

Methods

AD patients and their spouses (aged >65 years) living at home (n = 202, 102 AD patients) were recruited using central AD registers in Finland. The couples were randomized into intervention and control groups. A trained nutritionist visited intervention couples 4–8 times at their homes and the couples received tailored nutritional care. When necessary, the couples were given protein and nutrient-enriched complementary drinks. All intervention couples were advised to take vitamin D 20 μg/day. The intervention lasted for one year. The couples of the control group received a written guide on nutrition of older people. Participants in the intervention group were assessed every three months. The primary outcome measure is weight change. Secondary measures are the intake of energy, protein, and other nutrients, nutritional status, cognition, caregiver’s burden, depression, health related quality of life and grip strength.

Discussion

This study provides data on whether tailored nutritional care is beneficial to home-dwelling AD patients and their spouses.

Trial registration

ACTRN 12611000018910

Definition of frailty in older men according to questionnaire data (RAND-36/SF-36): The Helsinki Businessmen Study

OBJECTIVE

To explore the association of frailty according to questionnaire data (modified Fried criteria) with important endpoints in older men.

DESIGN AND SETTING

Prospective cohort study (the Helsinki Businessmen Study) in Finland.

PARTICIPANTS AND MEASUREMENTS

In 1974, clinically healthy men (born 1919-1934, n=1815) of similar socioeconomic status were identified. After a 26-year follow-up in 2000 (mean age 73 years), disease prevalence, mobility-disability, and frailty status (80.9% of survivors, n=1125) were appraised using a postal questionnaire including RAND-36. Four criteria were used for definition: 1) >5% weight loss from midlife, or body mass index (BMI) <21 kg/m2; 2) reported physical inactivity; 3) low vitality (RAND-36); 4) physical weakness (RAND-36). Responders with 3-4, 1-2, and zero criteria were classified as frail (n=108), prefrail (n=567), and nonfrail (n=450), respectively. Eight-year mortality was assessed from registers, and in 2007, survivors were re-assessed with questionnaires.

RESULTS

Nonfrail as referent and adjusted for age, BMI and smoking, both prefrail (HR 2.26; 95% CI, 1.57-3.26), and frail status (4.09; 95% CI, 2.60-6.44) were significant predictors of mortality. Nonfrailty predicted better survival independently of the frailty components, diseases, and disability, and also predicted faster walking speed and less disability 7 years later.

CONCLUSIONS

Frailty, and also prefrailty, as defined using questionnaire data (RAND-36) independently predicted important endpoints in older men.

Prevalence of at-risk drinking among older adults and associated sociodemographic and health-related factors

OBJECTIVES

Recognition of alcohol-related health problems in the elderly is challenging. Alcohol use also tends to be a hidden issue. The aim of this study was to examine the prevalence and at-risk drinking patterns in community-dwelling older adults and their associations with socio-demographic and health-related factors.

DESIGN

The data were collected with a postal questionnaire from a random sample of 2100 elderly people (≥ 65 years) living in the medium-sized city of Espoo, Finland. The response rate was 71.6% from the community-dwelling sample. We defined the amount of at-risk drinking as 1) consuming >7 drinks per week or 2) >5 drinks on a typical drinking day or 3) using >3 drinks several times per week.

RESULTS

Of the respondents, 8.2% (N=114) were at-risk drinkers. At-risk drinking was associated with younger age and male sex, higher level of education, good income, living with a spouse, and current smoking. In addition, good functioning was associated with at-risk drinking. Although frequency and quantity of alcohol consumption declined with age, of our respondents nearly one-fifth of men aged 71-80 years and one-tenth of men aged 81-90 years could be classified as at-risk drinkers. At-risk drinkers had comorbidities and multiple medications as often as non-risk group. A significantly larger proportion of the at-risk drinking group relative to the non-risk group admitted falling or injuring themselves (5.3% vs. 0.7%) or forgotten to take their medications because of the use of alcohol.

CONCLUSIONS

At-risk drinking is prevalent among older adults, particularly among males, despite prevalent comorbidities and multiple medications. At-risk drinking is associated with adverse events such as a tendency for injuries.

Positive life orientation predicts good survival prognosis in old age

The purpose of this study is to investigate the value of life orientation as a screening tool and survival indicator in old age. A postal questionnaire answered by 2490 random older people (>75 years) included six questions concerning satisfaction with life, feeling needed, plans for future, zest for life, lack of feelings of depression and loneliness. The vital status was followed for 57 months. All-cause mortality rate was 19.1% and 30.3% among elderly with (22%) and without (78%) positive life orientation, respectively (p<0.001). The difference in mortality increased over time. After controlling for age, gender, and subjective health, the protective value of positive life orientation remained significant (hazard ratio, HR=0.78, 95%CI=0.63-0.98, p<0.03). Feeling needed was the strongest independent predictor (HR=0.72, p<0.001). A six-question life orientation identifies old people at risk. Positive life orientation predicts good survival prognosis independently of subjective health.

Association of anticholinergic drugs with hospitalization and mortality among older cardiovascular patients: A prospective study

BACKGROUND

Many potentially inappropriate drugs prescribed to older people have anticholinergic properties as adverse effects and are therefore potentially harmful. These effects typically include constipation, dry mouth, blurred vision, dizziness and slowing of urination. It has been shown that drugs with anticholinergic properties (DAPs) are associated with cognitive decline and dementia, may contribute to events such as falls, delirium and impulsive behaviour, are associated with self-reported adverse effects and physical impairment, and may even be associated with mortality. However, studies of the prognostic implications of DAPs remain scarce.

OBJECTIVE

To evaluate the impact of DAPs on hospitalization and mortality in older patients with stable cardiovascular disease (CVD).

METHODS

This was a prospective study with a mean follow-up of 3.3 years involving two study groups: users (n = 295) and non-users (n = 105) of DAPs. The participants were 400 community-dwelling older people (aged 75-90 years) with stable CVD participating in a secondary prevention study of CVD (DEBATE) in Helsinki, Finland. The use of DAPs was estimated using definitions from the previous scientific literature. The Charlson Comorbidity Index (CCI) was used to estimate the burden of co-morbidity and the Mini-Mental State Examination test was used to assess cognitive function. The risks in the two study groups for hospital visits, number of days spent in hospital care and mortality were measured from 2000 to the end of 2003.

RESULTS

The unadjusted follow-up mortality was 20.7% and 9.5% among the users and non-users of DAPs, respectively (p = 0.010). However, the use of DAPs was not a significant predictor of mortality in multivariate analysis after adjustment for age, sex and CCI score (hazard ratio 1.57; 95% CI 0.78, 3.15). The mean ± SD number of hospital days per person-year was higher in the DAP user group (14.9 ± 32.5) than in the non-user group (5.2 ± 12.3) [p < 0.001]. In a bootstrap-type analysis of covariance adjusted for age, sex and CCI score, the use of DAPs predicted the number of days spent in hospital (p = 0.011).

CONCLUSIONS

The use of DAPs in older patients with stable CVD was associated with an increased number of hospital days but not with mortality.

Exercise rehabilitation on home-dwelling patients with Alzheimer's disease--a randomized, controlled trial. Study protocol

BACKGROUND

Besides cognitive decline, Alzheimer's disease (AD) leads to physical disability, need for help and permanent institutional care. The trials investigating effects of exercise rehabilitation on physical functioning of home-dwelling older dementia patients are still scarce. The aim of this study is to investigate the effectiveness of intensive exercise rehabilitation lasting for one year on mobility and physical functioning of home-dwelling patients with AD.

METHODS

During years 2008-2010, patients with AD (n = 210) living with their spousal caregiver in community are recruited using central AD registers in Finland, and they are offered exercise rehabilitation lasting for one year. The patients are randomized into three arms: 1) tailored home-based exercise twice weekly 2) group-based exercise twice weekly in rehabilitation center 3) control group with usual care and information of exercise and nutrition. Main outcome measures will be Guralnik's mobility and balance tests and FIM-test to assess physical functioning. Secondary measures will be cognition, neuropsychiatric symptoms according to the Neuropsychiatric Inventory, caregivers' burden, depression and health-related quality of life (RAND-36). Data concerning admissions to institutional care and the use and costs of health and social services will be collected during a two year follow-up.

DISCUSSION

To our knowledge this is the first large scale trial exploring whether home-dwelling patients with AD will benefit from intense and long-lasting exercise rehabilitation in respect to their mobility and physical functioning. It will also provide data on cost-effectiveness of the intervention.

TRIAL REGISTRATION

ACTRN12608000037303.

Facing uncertainty as a medical student--a qualitative study of their reflective learning diaries and writings on specific themes during the first clinical year

OBJECTIVE

Tolerance of uncertainty related to the complex work is a major dimension of general practitioner's (GP) profession. Strategies for managing uncertainty have been studied among GPs but less is known about how medical students develop tolerance of uncertainty during their studies. The aim of this study was to investigate how the medical students experience uncertainty during their first clinical years and how their feelings develop with time as they progress from the 3rd year to the 4th year.

METHODS

The material consisted of 22 students' reflective learning diaries and writings on specific themes collected during the 3rd and 4th year of their medical studies. The analysis was performed using thematic content analysis. In this article we present the results related to the theme of uncertainty.

RESULTS

Uncertainty is a major cause of mental strain for medical students, particularly fear of making mistakes. Main themes related to facing uncertainty and found in the diaries and writings were insecurity of professional skills, own credibility, facing with the inexactness of medicine, fear of making mistakes, coping with responsibility, and tolerating oneself as incomplete and accepting oneself as a good-enough doctor-to-be. Common steps of development towards tolerance of uncertainty were found in diaries over a one-year time period as the students progressed in their clinical studies.

CONCLUSIONS

Reflective writing showed to be an effective means for the students of both expressing and dealing with uncertainty, both with the difficult and the pleasant feelings and the experiences the students had with their first patient contacts. It also gave some of them the means of self-reflection which they afterwards found worthwhile.

PRACTICE IMPLICATIONS

Reflective writing is powerful tool which medical students could use to facilitate their maturation process what comes to uncertainty during their first clinical year.

Effects of psychosocial group rehabilitation on health, use of health care services, and mortality of older persons suffering from loneliness: a randomized, controlled trial

BACKGROUND

Loneliness is a distressing feeling of a lack of satisfying human relationships. It is associated with poor quality of life, impaired health, and increased mortality among older individuals. The study aim was to determine the effects of new psychosocial group rehabilitation on the subjective health, use and costs of health services, and mortality of lonely older individuals.

METHODS

This randomized, controlled trial was performed in seven day care centers. A total of 235 older people (>74 years) suffering from loneliness participated. Intervention was implemented in 15 groups (each with 7-8 participants and 2 professional group leaders) meeting for 3 months altogether 12 times. Group intervention aimed to empower elderly people, and to promote their peer support and social integration. Intervention was based on the effects of closed-group dynamics. The groups had the following activities according to the participants' interests: (a) therapeutic writing and group psychotherapy, (b) group exercise and discussions, and (c) art activities. Group leaders received thorough training and tutoring. Subjective health, use and costs of health services, and mortality were measured.

RESULTS

At 2 years, survival was 97% in the intervention group (95% confidence interval [CI], 91-99) and 90% in the control group (95% CI, 85-95) (p = .047). The intervention group showed a significant improvement in subjective health, thus resulting in significantly lower health care costs during the follow-up: the difference between the groups was -943 euro/person per y (95% CI -1955 to -127; p = .039).

CONCLUSIONS

Psychosocial group rehabilitation was associated with lower mortality and less use of health services.

Predisposing and precipitating factors for delirium in a frail geriatric population

OBJECTIVE

The aim of this study was to assess the possible predisposing aetiologic and short-term precipitating factors for delirium in acutely ill hospital patients with a heavy burden of comorbidities and medications.

METHODS

Eighty-seven consecutive patients with acute delirium admitted to a general medicine unit were thoroughly examined, and the predisposing and precipitating factors of their delirium were assessed.

RESULTS

In this population, an average of 5.2 predisposing factors and 3.0 potential precipitating factors for delirium was revealed, meaning an average of over eight possible aetiological causes for each patient. The most common precipitating factors were infections (n=72), metabolic abnormalities (n=52), adverse drug effects (n=41), and cardiovascular events (n=38). In addition, a number of very rare conditions were diagnosed after thorough assessments.

CONCLUSION

Geriatric patients with acute delirium typically present with several concomitant predisposing factors for delirium exposing them to high vulnerability for the syndrome. In most patients, a number of possible etiological causes for delirium can be identified after a careful assessment, but their true pathogenetic pathway to the syndrome is unclear.

Multicomponent geriatric intervention for elderly inpatients with delirium: effects on costs and health-related quality of life

BACKGROUND

The detrimental effects of delirium on functioning and mortality are well known, but health-related quality of life (HRQoL) and costs of care have rarely been investigated among patients with delirium. We studied the effects of multicomponent geriatric treatment on costs of care and HRQoL in delirious inpatients.

METHODS

A randomized, controlled trial of 174 inpatients with delirium was performed in an acute geriatric hospital. The intervention was individually tailored geriatric treatment. The HRQoL was measured by the 15D instrument and subjective health by a four-level ordinal scale. Health care costs including intervention costs were calculated for 1 year after the delirium episode.

RESULTS

Mean age of the patients was 83 years; 31% had prior dementia. After the index hospitalization for delirium, a greater proportion in the intervention group than in the control group stated that they felt healthy (71% vs 49%, p =.050). HRQoL deteriorated in both groups as a consequence of delirium. Deterioration was, however, slower in the intervention group (-0.026, 95% confidence interval [CI], -0.051 to -0.001) than in the control group (-0.065, 95% CI, -0.09 to -0.040; p =.034). Counting all costs of hospital care, long-term care, skilled home nursing visits, and costs related to intervention, the intervention group used, on average, 19,737 euro during the follow-up year, whereas the respective figure for the control group was 19,557 euro. The difference between the groups was nonsignificant (180 euro [95% CI, -5,006 to 5,064 euro]).

CONCLUSIONS

Comprehensive geriatric intervention improved HRQoL without increasing overall costs of care.

How well do nurses recognize malnutrition in elderly patients?

BACKGROUND AND OBJECTIVE

Malnutrition is a common and underrecognized clinical problem among aged institutionalized patients. The aim of this study was to investigate how well nurses recognize malnutrition in elderly patients in long-term care hospitals in Helsinki.

SUBJECTS AND METHODS

In this descriptive, cross-sectional study, the nutritional status of 1043 elderly patients was assessed with the Mini Nutritional Assessment (MNA), their body mass indices (BMIs) (kg m(-2)) were counted, and factors related to their nutritional care were queried using a structured questionnaire. In addition, we asked the opinions of 53 nurses on whether they considered their patients to suffer from malnutrition. All the long-term care hospitals in Helsinki, Finland participated in this study.

RESULTS

The mean age of the patients was 81 years. The nurses considered only 15.2% of the patients to be malnourished, although the MNA showed that 56.7% were malnourished (MNA<17 points). Those recognized as malnourished were truly anorectic, with a mean BMI of 17.2. Of those patients having a BMI<20 and MNA<17, the nurses considered only one-third to be malnourished. Of those having a BMI>24 but MNA<17, only 2% were recognized as having malnutrition. Even those patients considered to be malnourished received snacks and nutritional supplements less than the patients that the nurses considered to have normal nutritional status. However, only one in six of the malnourished patients received oral nutritional supplements.

CONCLUSIONS

The nurses recognized malnutrition in their aged patients poorly. Nutrition education for nurses is urgently needed, as malnutrition and weight loss have been considered significant problems, and the benefits of nutritional care are well established.

Vitamin D and calcium supplementation among aged residents in nursing homes

BACKGROUND

Aged residents in nursing homes are at particularly high risk of fractures. Vitamin D and calcium have a preventative role.

OBJECTIVE

To describe the use of vitamin D and calcium supplementations, and their association with nutritional factors among nursing home residents.

METHODS

Our study is a cross-sectional assessment of long-term residents in all nursing homes in Helsinki during February 2003. We collected residents' background information, nutritional status (Mini Nutritional Assessment, MNA), and data on daily nursing routines in institutions, including nutritional care. Vitamin D and calcium supplementations were inquired after in the questionnaire and retrieved from residents' medication lists.

RESULTS

2,114 (87%) of all 2,424 eligible residents had available data on the use of vitamin D and calcium supplementation. Their mean age was 83 years, and 80.7% were female. Of all participants, 32.9% received vitamin D supplementation and 27.7% calcium supplementation. Altogether 20.0% received both. However, only 21.3% received vitamin D in the therapeutic dose of 10 mg (400 IU) or more, and 3.6% in the recommended dose of 20 microg (800 IU) or more. In logistic regression analysis, residents who received vitamin D supplementation also had better nutritional status (MNA), ate snacks between meals, did not have constipation and their weight was checked more frequently.

CONCLUSIONS

Regardless of the known benefit and recommendation of vitamin D supplementation for the elderly residing mostly indoors, the proportion of nursing home residents receiving vitamin D and calcium was surprisingly low.

Fermented cereal with specific bifidobacteria normalizes bowel movements in elderly nursing home residents. A randomized, controlled trial

OBJECTIVE

To assess how fermented oat drink with two selected Bifidobacterium longum strains influences bowel movements among elderly nursing home residents.

DESIGN

A randomized, double-blind, placebo-controlled trial.

SETTING

12 wards in two nursing homes in Finland.

PARTICIPANTS

209 residents.

INTERVENTION

Wards were randomized to receive daily a fermented oat drink with 1) 109 CFU/day Bifidobacterium longum strains or 2) 109 CFU/day Bifidobacterium lactis Bb12 or 3) without viable bacteria (placebo) for 7 months.

MEASUREMENTS

Regularity of bowel movements (no movements or functioning) and consistency of stools (normal, soft or diarrhoea) were recorded for each resident on a daily basis.

RESULTS

The fermented oat drinks were well taken by the subjects, compliance being 85%. The groups receiving active products had more frequent bowel movements than did the placebo group (B. longum group normal functioning 28.5% of follow-up days, B.lactis group 26.9%, and placebo group 20.0%, respectively). The differences between the B. longum and the placebo group (mean 7.1, 95% CI 2.3 - 11.9, p=0.004) and between the B.lactis group and the placebo (mean 6.7, 95% CI 2.5 - 10.9, p = 0.002) were significant even when diarrhoea and constipation in the 3 months prior to the study were used as covariates.

CONCLUSIONS

It is possible to normalize bowel movements in frail nursing home.

Interest in healthy lifestyle and adherence to medications: Impact on mortality among elderly cardiovascular patients in the DEBATE Study

OBJECTIVE

We examined how a patient-centered consultation can help the physician to evaluate older patients' adherence to medical care and a healthy lifestyle. We hypothesised that an accurate estimate of adherence should be shown in their prognosis.

METHODS

Cardiovascular patients (>74 years) in an intervention study (the DEBATE Study) were divided according to physician's clinical impression: (1) "Active adherents" (N=53): those having a healthy lifestyle and adherent to medications. (2) "Passive adherents" (N=65): those not showing any particular interest in a healthy lifestyle but adherent to medications. (3) "Interested scepticals" (N=66): those showing an interest in a healthy lifestyle but feeling sceptical about medications. (4) "Passive non-adherents" (N=15): those having a sedentary lifestyle and non-adherence to medical treatments. The combined endpoint was permanent institutionalisation or death during the average 4.5-year follow-up.

RESULTS

Mortality during the 4.5-year follow-up ranged among groups 1-4: 15, 19, 26, and 53% (p=0.01), and the proportions permanently institutionalised 0, 2, 6, and 20% (p=0.003). Multivariate analyses with age, gender, Charlson comorbidity index, dependence in ADL activities and with group 1 as the reference (1.0) showed that both group 3 (HR 2.73, 95% CI 1.11-6.52) and group 4 (HR 6.24, 95% CI 1.88-20.67) were at significantly increased risk for institutionalisation or death.

CONCLUSION

In a patient-centered consultation adherence can be accurately evaluated, and such an evaluation is of significant value in the prognosis of older cardiovascular patients.

PRACTICE IMPLICATIONS

A patient's expression of attitudes towards medications and healthy lifestyle may be elicited in a patient-centered consultation. This patient-centered approach may help in modifying care to support appropriate, tailored treatments for individual patients.

The effects of nutrition education on professionals' practice and on the nutrition of aged residents in dementia wards

OBJECTIVE

(1) To develop nutrition education for professionals in dementia wards. (2) To evaluate the effects of education and determine the outcome of the education on the nutrition of aged residents.

DESIGN

Educational intervention with before and after measurements. Both the learning outcomes of the professionals and the effect on the aged residents were assessed.

SETTING

Nursing home residents in dementia wards and professionals.

SUBJECTS AND METHODS

Twenty-eight professionals completed half-structured feedback questionnaires that were analysed quantitatively and qualitatively. Assessments of 21 residents' energy and nutrient intake and 19 residents' nutritional status with the MNA before and after the education.

RESULTS

The learning process included six half-day training sessions. The professionals learned to use and interpret the MNA and detailed food diaries. Keeping the food diaries and analysing them in multi-professional teams was experienced as the main source for learning insights. After calculating the diets and discussing with others, professionals felt easier about responding to the nutritional problems of the residents. After 1 year, the residents' mean energy intake had increased 21% from 1230 to 1487 kcal. Before the education none but after 1 year 16% had a good nutritional status according to the MNA.

CONCLUSIONS

We used the constructive learning theory to educate professionals. Keeping and analysing food diaries and reflecting on nutritional issues in small group discussions were effective training methods for professionals. The education had positive effects on the nutrition of the residents in dementia wards.