Psychometric evaluation of the Decision Support Tool for Functional Independence in community-dwelling older people

Background

The aging population is increasingly faced with daily life limitations, threatening their Functional Independence (FI). These limitations extend different life domains and require a broad range of community-care professionals to be addressed. The Decision Support Tool for Functional Independence (DST-FI) facilitates community-care professionals in providing uncontradictory recommendations regarding the maintenance of FI in community-dwelling older people. The current study aims to determine the validity and reliability of the DST-FI.

Methods

Sixty community-care professionals completed a twofold assessment. To assess construct validity, participants were asked to assign predefined recommendations to fifty cases of older people to maintain their level of FI. Hypotheses were tested regarding the expected recommendations per case. Content validity was assessed by questions on relevance, comprehensiveness, and comprehensibility of the current set of recommendations. Twelve participants repeated the assessment after two weeks to enable both within- and between rater reliability properties, expressed by an Intraclass Correlation Coefficient.

Results

Seven out of eight predefined hypotheses confirmed expectations, indicating high construct validity. As the recommendations were indicated 'relevant' and 'complete', content validity was high as well. Agreement between raters was poor to moderate while agreement within raters was moderate to excellent, resulting in moderate overall reliability.

CONCLUSION

The DST-FI suggests high validity and moderate reliability properties when used in a population of community-dwelling older people. The tool could facilitate community-care professionals in their task to preserve FI in older people. Future research should focus on psychometric properties like feasibility, acceptability, and developing and piloting strategies for implementation in community-care.

The Ambassador Project: Evaluating a Five-Year Nationwide Leadership Program to Bridge the gap Between Policy and District Nursing Practice

District nurses have a crucial position in healthcare provision and are expected to use leadership practices to ensure optimal quality patient care. To better equip them, a leadership program named the ambassador project was developed to support the development of a liaison role between policy and district nursing practice. This research aims to evaluate from different perspectives the impact of this nationwide, five-year leadership program for district nurses at the organizational, regional, and societal levels. A mixed-methods study was conducted using two focus groups based on peer-to-peer shadowing (n = 14), semistructured interviews (n = 13), and an online questionnaire (n = 45). The analysis shows that the impact of a nationwide leadership program for district nurses was perceived as predominantly positive, and nurses experienced an increase in courage, assertiveness, professional pride, and leadership skills. They obtained confidence in representing the group of district nurses at the organizational, regional, and societal levels when speaking with various key stakeholders from the healthcare system. They were able to bridge the gaps among daily practice, policymaking, and politics by using translations and shaping actions and information into terms suiting the needs of those involved.

Exploring Associations between Oral Health and Frailty in Community-Dwelling Older People

BACKGROUND

In frail older people with natural teeth factors like polypharmacy, reduced salivary flow, a decrease of oral self-care, general healthcare issues, and a decrease in dental care utilization contribute to an increased risk for oral complications. On the other hand, oral morbidity may have a negative impact on frailty.

OBJECTIVE

This study explored associations between oral health and two frailty measures in community-dwelling older people.

DESIGN

A cross-sectional study.

SETTING

The study was carried out in a Primary Healthcare Center (PHC) in The Netherlands.

PARTICIPANTS

Of the 5,816 persons registered in the PHC, 1,814 persons were eligible for participation at the start of the study.

MEASUREMENTS

Two frailty measures were used: 1. Being at risk for frailty, using Electronical Medical Record (EMR) data, and: 2. Survey-based frailty using 'The Groningen Frailty Indicator' (GFI). For oral health measures, dental-record data (dental care utilization, dental status, and oral health information) and self-reported oral problems were recorded. Univariate regression analyses were applied to determine the association between oral health and frailty, followed by age- and sex-adjusted multivariate logistic regressions.

RESULTS

In total 1,202 community-dwelling older people were included in the study, 45% were male and the mean age was 73 years (SD=8). Of all participants, 53% was at risk for frailty (638/1,202), and 19% was frail based on the GFI (222/1,202). A dental emergency visit (Odds Ratio (OR)= 2.0, 95% Confidence Interval (CI)=1.33;3.02 and OR=1.58, 95% CI=1.00;2.49), experiencing oral problems (OR=2.07, 95% CI=1.52;2.81 and OR=2.87, 95% CI= 2.07;3.99), and making dietary adaptations (OR=2.66, 95% CI=1.31;5.41 and OR=5.49, 95% CI= 3.01;10.01) were associated with being at risk for frailty and survey-based frailty respectively.

CONCLUSIONS

A dental emergency visit and self-reported oral health problems are associated with frailty irrespective of the approach to its measurement. Healthcare professionals should be aware of the associations of oral health and frailty in daily practice.

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

Purpose

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

Methods design

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

Setting

primary care sector.

Interventions

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

Main outcome

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

Secondary outcomes

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

Analysis

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

Results

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

Conclusion

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

The Effectiveness of a PRoactive Multicomponent Intervention Program on Disability in Independently Living Older People: A Randomized Controlled Trial

BACKGROUND

There is an increase in functional limitations and a decline in physical and mental well-being with age. Very few effective lifestyle interventions are available to prevent adverse outcomes such as disability in (pre-) frail older people. The effectiveness of an interdisciplinary multicomponent intervention program to prevent disability in older people in the community was tested.

METHOD

A randomized controlled trial (RCT) with a one-year follow-up was conducted in the Netherlands. Community-dwelling pre-frail older people aged 65 years and over were invited to participate. Frailty was measured with the Groningen Frailty Indicator (GFI) and categorized into non-frail (GFI=0), pre-frail (GFI = 1-3) and frail (GFI ≥ 4). The intervention program consisted of four components: a medication review, physical fitness, social skills, and nutrition.

OUTCOMES

The primary outcome was activity of daily living (ADL) measured with the Katz-6. Secondary outcomes were quality of life (SF-12) and healthcare consumption such as hospital admission, nursing home admission and primary care visits. Additional outcomes measured in the intervention group were physical fitness, Instrumental Activities of Daily Living (IADL), muscle strength, walking speed, functional capacity, mobility, feelings of depression and loneliness and nutritional status. The data were collected at baseline, after each intervention component and at a 12-month follow-up. An intention to treat analysis was used.

RESULTS

In total, there were 290 participants, and 217 (74.8%) completed the study. The mean age was 74 (SD: 7.2), most were pre-frail (59.9%), the majority were female (55.2%), and the individuals were not living alone (61.4%). After the 12-month follow-up, the median Katz-6 score did not change significantly between the two groups; adjusted Odds Ratio (OR) = 0.96 (95% Confidence Interval (CI): 0.39-2.35, p-value 0.92). No statistically significant differences were observed between the groups for quality of life and healthcare consumption. Among the participants in the intervention group, IADL (Friedman's test p <=0.04, X2 =6.50), walking speed (Friedman's test p <0.001, X2 =19.09) and functional capacity (Friedman's test p <0.001, X2 =33.29) improved significantly after the one-year follow-up. Right-hand grip strength improved immediately after completion of the intervention (Wilcoxon signed-rank test p=0.00, z= -3.39) but not after the 12-month follow-up.

CONCLUSION

The intervention program did not significantly improve daily functioning, quality of life and healthcare consumption among (pre) frail community-dwelling older persons at the one-year follow-up. Participants in the intervention group experienced improvements in walking speed, functional capacity and instrumental activities of daily living. More research is needed to better understand why may benefit and how to identify the target population.

Disability in the Individual ADL, IADL, and Mobility among Older Adults: A Prospective Cohort Study

OBJECTIVES

To examine the risk of disability in 15 individual ADL, IADL, and mobility in older adults by age; and to assess the association of multimorbidity, gender, and education with disability.

DESIGN AND SETTING

A prospective cohort study. The sample included 805 community-dwelling older people aged 60+ living in the Netherlands.

MEASUREMENTS

Disability was assessed using the Katz-15 Index of Independence in Basic Activities of Daily Living (ADL), Instrumental Activities of Daily Living (IADL) and one mobility item. Disability in any of these activities was defined as the inability to perform the activity without assistance. The risk of disability by age for each individual ADL, IADL, and for mobility was assessed using Generalized mixed models.

RESULTS

Disability in activities as household tasks, traveling, shopping, and continence had the highest risk and increased rapidly with age. The risk traveling disability among people aged 65 with two comorbidities increase from 9% to 37% at age 85. Disability in using the telephone, managing medications, finances, transferring, and toileting, had a very low risk and hardly increased with age. Compared to those without chronic conditions, those with ≥ 3 chronic conditions had a 3 to 5 times higher risk of developing disability. Males had a higher risk of disability in managing medication (P=0.005), and preparing meals (P=0.019), whereas females had a higher risk of disability with traveling (P=0.001). No association between education and disability on the individual ADL, IADL, and mobility was observed.

CONCLUSIONS

Older adults were mostly disabled in physical related activities, whereas disability in more cognitive related activities was less often experienced. The impact of multimorbidity on disability in each activity was substantial, while education was not.

Validity and reliability of the Katz-15 scale to measure unfavorable health outcomes in community-dwelling older people

OBJECTIVES

To predict the risk of future unfavourable health outcomes in older people it is common to assess the level of both basic and instrumental activities of daily living. To accomplish this, the commonly used Katz-6 and the Lawton IADL questionnaires can be combined to form the 'Modified Katz ADL' scale, also known as the Katz-15 scale. So far, the validity and reliability of the Katz-15 scale is unknown. The objective of the current study is to investigate how well the Katz-15 is able to predict future unfavorable health outcomes and how this is related to the existing Katz-6 scale.

DESIGN

We performed a follow-up study using data from a group of 60 year and older participants from a large Dutch clinical trial.

PARTICIPANTS

We included 2321 participants in the analysis. The average age of the study population was 74 years and 44% was male.

MEASUREMENTS

We studied the relation between the Katz-15 scale and a number of unfavourable health outcomes, such as hospitalization, admission to a nursing home, admission to a home for the aged and death within one year of follow-up.

RESULTS

We found the Katz-15 to be both internally consistent and strongly associated with quality of life measures. We observed moderate to strong associations between the Katz-15 and the unfavourable health outcomes All associations studied were stronger for the Katz-15 scale as compared to the Katz-6 scale.

CONCLUSION

The results of our study indicate that the Katz-15 scale is able to reliably and validly predict future unfavorable health outcomes. This makes the scale a valuable measure in determining both basic and instrumental activities of daily living.

Associations between Frailty, Complex Care Needs and Quality of Life in Multi-Morbid Older People

BACKGROUND

Little is known regarding the complex care needs, level of frailty or quality of life of multi-morbid older patients.

OBJECTIVES

The objective of this study was to determine the relationship between frailty, complexity of care and quality of life in multi-morbid older people.

DESIGN

Cross-sectional study.

SETTING

Thirteen primary care practices in the Netherlands.

PARTICIPANTS

1,150 multi-morbid older people living in the community.

MEASUREMENTS

The level of frailty was assessed with the Groningen Frailty Indicator. Complexity of care needs was measured with the Intermed for the Elderly Self-Assessment. Quality of life (QoL) was measured with two items of the RAND-36.

RESULTS

In total, 758 out of 1,150 (65.9%) patients were frail, 8.3% had complex care needs, and the mean QoL score was 7.1 (standard deviation 1.2). Correlations between frailty and complexity, frailty and QoL, and complexity of care and QoL were 0.67, -0.51 and -0.52 (all p<0.001) respectively. All patients with complex care needs were frail, but, only 12.5% of the frail patients had complex care needs. Problems at climbing up stairs was associated with higher levels of frailty and complexity of care but with a lower QoL.

CONCLUSIONS

Higher levels of frailty and complexity of care are associated with a lower QoL in multi-morbid older people. The results of this study contribute to a better understanding these concepts and are valuable for the development of tailored interventions for older persons in the future.

[Proactive and structured care for the elderly in primary care]

BACKGROUND

Currently, primary care for the older, vulnerable patient is reactive, fragmented and does not meet patients needs. Given the expected increase of home-dwelling frail elderly people a transition is needed to proactive and integrated care.

METHODS

In the described study, we explore two innovative interventions in primary care. First we describe a newly developed screening and monitoring program for frail elderly patients based on routine care information in general practice. Second, we describe a multidisciplinary intervention program by trained nurses for frail elderly patients in general practice. The effectiveness of the interventions is examined in a three-armed, cluster randomized trial, taking place in 58 primary care practices in Utrecht, the Bilt and Maarsenbroek.

RESULTS

Three thousand eight patients are included. Primary outcome measure is the impact of the interventions on the daily activities, measured with the Katz questionnaire. Secondary outcomes measures are the quality of life, mortality, recording in a care or nursing home, visit to an emergency room or outpatient unit, recording in the hospital and volunteer caregivers tax.