Multicomponent intervention to prevent mobility disability in frail older adults: randomised controlled trial (SPRINTT project)

OBJECTIVE

To determine whether a multicomponent intervention based on physical activity with technological support and nutritional counselling prevents mobility disability in older adults with physical frailty and sarcopenia.

DESIGN

Evaluator blinded, randomised controlled trial.

SETTING

16 clinical sites across 11 European countries, January 2016 to 31 October 2019.

PARTICIPANTS

1519 community dwelling men and women aged 70 years or older with physical frailty and sarcopenia, operationalised as the co-occurrence of low functional status, defined as a short physical performance battery (SPPB) score of 3 to 9, low appendicular lean mass, and ability to independently walk 400 m. 760 participants were randomised to a multicomponent intervention and 759 received education on healthy ageing (controls).

INTERVENTIONS

The multicomponent intervention comprised moderate intensity physical activity twice weekly at a centre and up to four times weekly at home. Actimetry data were used to tailor the intervention. Participants also received personalised nutritional counselling. Control participants received education on healthy ageing once a month. Interventions and follow-up lasted for up to 36 months.

MAIN OUTCOME MEASURES

The primary outcome was mobility disability (inability to independently walk 400 m in <15 minutes). Persistent mobility disability (inability to walk 400 m on two consecutive occasions) and changes from baseline to 24 and 36 months in physical performance, muscle strength, and appendicular lean mass were analysed as pre-planned secondary outcomes. Primary comparisons were conducted in participants with baseline SPPB scores of 3-7 (n=1205). Those with SPPB scores of 8 or 9 (n=314) were analysed separately for exploratory purposes.

RESULTS

Mean age of the 1519 participants (1088 women) was 78.9 (standard deviation 5.8) years. The average follow-up was 26.4 (SD 9.5) months. Among participants with SPPB scores of 3-7, mobility disability occurred in 283/605 (46.8%) assigned to the multicomponent intervention and 316/600 (52.7%) controls (hazard ratio 0.78, 95% confidence interval 0.67 to 0.92; P=0.005). Persistent mobility disability occurred in 127/605 (21.0%) participants assigned to the multicomponent intervention and 150/600 (25.0%) controls (0.79, 0.62 to 1.01; P=0.06). The between group difference in SPPB score was 0.8 points (95% confidence interval 0.5 to 1.1 points; P<0.001) and 1.0 point (95% confidence interval 0.5 to 1.6 points; P<0.001) in favour of the multicomponent intervention at 24 and 36 months, respectively. The decline in handgrip strength at 24 months was smaller in women assigned to the multicomponent intervention than to control (0.9 kg, 95% confidence interval 0.1 to 1.6 kg; P=0.028). Women in the multicomponent intervention arm lost 0.24 kg and 0.49 kg less appendicular lean mass than controls at 24 months (95% confidence interval 0.10 to 0.39 kg; P<0.001) and 36 months (0.26 to 0.73 kg; P<0.001), respectively. Serious adverse events occurred in 237/605 (39.2%) participants assigned to the multicomponent intervention and 216/600 (36.0%) controls (risk ratio 1.09, 95% confidence interval 0.94 to 1.26). In participants with SPPB scores of 8 or 9, mobility disability occurred in 46/155 (29.7%) in the multicomponent intervention and 38/159 (23.9%) controls (hazard ratio 1.25, 95% confidence interval 0.79 to 1.95; P=0.34).

CONCLUSIONS

A multicomponent intervention was associated with a reduction in the incidence of mobility disability in older adults with physical frailty and sarcopenia and SPPB scores of 3-7. Physical frailty and sarcopenia may be targeted to preserve mobility in vulnerable older people.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02582138.

Predicting unplanned hospital visits in older home care recipients: a cross-country external validation study

Background

Accurate identification of older persons at risk of unplanned hospital visits can facilitate preventive interventions. Several risk scores have been developed to identify older adults at risk of unplanned hospital visits. It is unclear whether risk scores developed in one country, perform as well in another. This study validates seven risk scores to predict unplanned hospital admissions and emergency department (ED) visits in older home care recipients from six countries.

Methods

We used the IBenC sample (n = 2446), a cohort of older home care recipients from six countries (Belgium, Finland, Germany, Iceland, Italy and The Netherlands) to validate four specific risk scores (DIVERT, CARS, EARLI and previous acute admissions) and three frailty indicators (CHESS, Fried Frailty Criteria and Frailty Index). Outcome measures were unplanned hospital admissions, ED visits or any unplanned hospital visits after 6 months. Missing data were handled by multiple imputation. Performance was determined by assessing calibration and discrimination (area under receiver operating characteristic curve (AUC)).

Results

Risk score performance varied across countries. In Iceland, for any unplanned hospital visits DIVERT and CARS reached a fair predictive value (AUC 0.74 [0.68–0.80] and AUC 0.74 [0.67–0.80]), respectively). In Finland, DIVERT had fair performance predicting ED visits (AUC 0.72 [0.67–0.77]) and any unplanned hospital visits (AUC 0.73 [0.67–0.77]). In other countries, AUCs did not exceed 0.70.

Conclusions

Geographical validation of risk scores predicting unplanned hospital visits in home care recipients showed substantial variations of poor to fair performance across countries. Unplanned hospital visits seem considerably dependent on healthcare context. Therefore, risk scores should be validated regionally before applied to practice. Future studies should focus on identification of more discriminative predictors in order to develop more accurate risk scores.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02521-2.

Benchmarking European Home Care Models for Older Persons on Societal Costs: The IBenC Study

This study aims to benchmark mean societal costs per client in different home care models and to describe characteristics of home care models with the lowest societal costs. In this prospective longitudinal study in 6 European countries, 6-month societal costs of resource utilization of 2060 older home care clients were estimated. Three care models were identified and compared based on level of patient-centered care (PCC), availability of specialized professionals (ASP) and level of monitoring of care performance (MCP). Differences in costs between care models were analyzed using linear regression while adjusting for case mix differences. Societal costs incurred in care model 2 (low ASP; high PCC & MCP) were significantly higher than in care model 1 (high ASP, PCC & MCP, mean difference €2230 (10%)) and in care model 3 (low ASP & PCC; high MCP, mean difference €2552 (12%)). Organizations within both models with the lowest societal costs, systematically monitor their care performance. However, organizations within one model arranged their care with a low focus on patient-centered care, and employed mainly generalist care professionals, while organizations in the other model arranged their care delivery with a strong focus on patient-centered care combined with a high availability of specialized care professionals.

Development and Validation of a Prediction Model for 6-Month Societal Costs in Older Community Care-Recipients in Multiple Countries; the IBenC Study

This study aims to develop and validate a prediction model of societal costs during a period of 6-months in older community care-recipients across multiple European countries. Participants were older community care-recipients from 5 European countries. The outcome measure was mean 6-months total societal costs of resource utilisation (healthcare and informal care). Potential predictors included sociodemographic characteristics, functional limitations, clinical conditions, and diseases/disorders. The model was developed by performing Linear Mixed Models with a random intercept for the effect of country and validated by an internal-external validation procedure. Living alone, caregiver distress, (I)ADL impairment, required level of care support, health instability, presence of pain, behavioural problems, urinary incontinence and multimorbidity significantly predicted societal costs during 6 months. The model explained 32% of the variation within societal costs and showed good calibration in Iceland, Finland and Germany. Minor model adaptations improved model performance in The Netherland and Italy. The results can provide a valuable orientation for policymakers to better understand cost development among older community care-recipients. Despite substantial differences of countries’ care systems, a validated cross-national set of key predictors could be identified.

The Prevalence and Persistence of Dizziness in Older European Home Care Recipients: A Prospective Cohort Study

OBJECTIVES

The prevalence of different geriatric syndromes in older home care (HC) recipients is yet to be determined. Dizziness is often regarded as a geriatric syndrome. The natural course of dizziness in older people is still unknown, because of a lack of longitudinal studies. The objective of this study was to investigate the prevalence and persistence of dizziness in HC recipients.

DESIGN

Prospective cohort study.

SETTING

Home care organizations in 6 European countries participating in the EU-funded Identifying best practices for care-dependent elderly by Benchmarking Costs and outcomes of community care (IBenC) project.

PARTICIPANTS

2616 community-dwelling long-term HC recipients aged 65 years or older.

METHODS

Data were collected at baseline and 6 and 12 months by using the interRAI Home Care instrument (interRAI-HC). Dizziness status was assessed by the number of days people experienced dizziness in the last 3 days (0-3) and later dichotomized for analyses (present or not in the last 3 days). Dizziness persistence was defined as the odds for dizzy people at baseline to also report dizziness at subsequent follow-up moments, compared with people who were not dizzy at baseline. The pattern of dizziness was descriptively analyzed in recipients who completed all measurements. Generalized estimating equations analysis was used to determine the persistence of dizziness symptoms.

RESULTS

The prevalence of dizziness of 2616 eligible HC recipients at baseline was 25.1%, ranging from 16.2% (Belgium) to 39.7% (Italy). The majority of dizzy recipients at baseline also experienced dizziness after 6 and 12 months (79.1%). Dizziness persistence was high at 6 months [odds ratio (OR) 57.8, 95% confidence interval (CI) 43.1-77.5] and at 12 months (OR 30.2, 95% CI 22.3-41.1).

CONCLUSIONS AND IMPLICATIONS

Dizziness in older HC recipients in Europe is common, and dizziness persistence is high. This warrants a more active approach in treating dizziness in older HC recipients.

Associations of Quadriceps Torque Properties with Muscle Size, Attenuation, and Intramuscular Adipose Tissue in Older Adults

Background

Atrophy and fatty infiltration of muscle with aging are associated with fractures and falls, however, their direct associations with muscle function are not well described. It was hypothesized that participants with lower quadriceps muscle attenuation, area, and greater intramuscular adipose tissue (IMAT) will exhibit slower rates of torque development (RTD) and lower peak knee extension torques.

Methods

Data from 4,842 participants (2,041 men, 2,801 women) from the Age Gene/Environment Susceptibility Reykjavik Study (mean age 76 ± 0.1 years) with complete thigh computed tomography and isometric knee testing. Regression models were adjusted for health, behavior, and comorbidities. Muscle attenuation was further adjusted for muscle area and IMAT; muscle area adjusted for IMAT and attenuation; and IMAT adjusted for muscle area and attenuation. Standardized betas (β) indicate association effect sizes.

Results

In the fully-adjusted models, attenuation (men β = 0.06, 95% CI: 0.01, 0.11; women β = 0.07, 95% CI: 0.03, 0.11) and muscle area (men β = 0.13, 95% CI: 0.07, 0.19; women β = 0.10, 95% CI: 0.06, 0.15) were associated with knee RTD. Attenuation (men β = 0.12, 95% CI: 0.08, 0.16; women β = 0.12, 95% CI: 0.09, 0.16) and muscle area (men β = 0.38, 95% CI: 0.33, 0.43; women β = 0.33, 95% CI: 0.29, 0.37) were associated with peak torque.

Conclusions

These data suggest that muscle attenuation and area are independently associated with RTD and peak torque; and that area and attenuation demonstrate similar contributions to RTD.

Development of a novel benchmark method to identify and characterize best practices in home care across six European countries: design, baseline, and rationale of the IBenC project

Background

Europe’s ageing society leads to an increased demand for long-term care, thereby putting a strain on the sustainability of health care systems. The ‘Identifying best practices for care-dependent elderly by Benchmarking Costs and outcomes of Community Care’ (IBenC) project aims to develop a new benchmark methodology based on quality of care and cost of care utilization to identify best practices in home care. The study’s baseline data, methodology, and rationale are reported.

Methods

Home care organizations in Belgium, Finland, Germany, Iceland, Italy, and the Netherlands, home care clients of 65 years and over receiving home care, and professionals working in these organizations were included. Client data were collected according to a prospective longitudinal design with the interRAI Home Care instrument. Assessments were performed at baseline, after six and 12 months by trained (research) nurses. Characteristics of home care organizations and professionals were collected cross-sectionally with online surveys.

Results

Thirty-eight home care organizations, 2884 home care clients, and 1067 professionals were enrolled. Home care clients were mainly female (66.9%), on average 82.9 years (± 7.3). Extensive support in activities of daily living was needed for 41.6% of the sample, and 17.6% suffered cognitive decline. Care professionals were mainly female (93.4%), and over 45 years (52.8%). Considerable country differences were found.

Conclusion

A unique, international, comprehensive database is established, containing in-depth information on home care organizations, their clients and staff members. The variety of data enables the development of a novel cost-quality benchmark method, based on interRAI-HC data. This benchmark can be used to explore relevant links between organizational efficiency and organizational and staff characteristics.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4109-y) contains supplementary material, which is available to authorized users.

Predictors of Societal Costs of Older Care-Dependent Adults Living in the Community in 11 European Countries

Background:

The objective was to identify predictors of societal costs covering formal and informal care utilization by older home care clients in 11 European countries.

Methods:

Societal costs of 1907 older clients receiving home care for 12 months from the Aged in Home care (AdHoc) study were estimated using the InterRAI Minimum Data Set for Home Care’s (MDS-HC) resource use items. Predictors (medical, functional, and psychosocial domains) of societal costs were identified by performing univariate and multivariate generalized linear model analyses.

Results:

Mean societal costs per participant were €36 442, ranging from €14 865 in Denmark to €78 836 in the United Kingdom. In the final multivariate model, country, being married, activities of daily living (ADL) dependency, cognitive impairment, limitations of going out, oral conditions, number of medications, arthritis, and cerebro vascular accident (CVA) were significantly associated with societal costs.

Conclusions:

Of the predictors, ADL dependency and limitations of going out may be modifiable. Developing interventions targeted at improving these conditions may create opportunities to curtail societal costs.

The "Sarcopenia and Physical fRailty IN older people: multi-componenT Treatment strategies" (SPRINTT) randomized controlled trial: Case finding, screening and characteristics of eligible participants

BACKGROUND

The ongoing "Sarcopenia and Physical fRailty IN older people: multi-componenT Treatment strategies (SPRINTT)" randomized controlled trial (RCT) is testing the efficacy of a multicomponent intervention in the prevention of mobility disability in older adults with physical frailty & sarcopenia (PF&S). Here, we describe the procedures followed for PF&S case finding and screening of candidate participants for the SPRINTT RCT. We also illustrate the main demographic and clinical characteristics of eligible screenees.

METHODS

The identification of PF&S was based on the co-occurrence of three defining elements: (1) reduced physical performance (defined as a score on the Short Physical Performance Battery between 3 and 9); (2) low muscle mass according to the criteria released by the Foundation for the National Institutes of Health; and (3) absence of mobility disability (defined as ability to complete the 400-m walk test in 15 min). SPRINTT was advertised through a variety of means. Site-specific case finding strategies were developed to accommodate the variability across centers in catchment area characteristics and access to the target population. A quick "participant profiling" questionnaire was devised to facilitate PF&S case finding.

RESULTS

During approximately 22 months, 12,358 prescreening interviews were completed in 17 SPRINTT sites resulting in 6710 clinic screening visits. Eventually, 1566 candidates were found to be eligible for participating in the SPRINTT RCT. Eligible screenees showed substantial physical function impairment and comorbidity burden. In most centers, project advertisement through mass media was the most rewarding case finding strategy.

CONCLUSION

PF&S case finding in the community is a challenging, but feasible task. Although largely autonomous in daily life activities, older adults with PF&S suffer from significant functional impairment and comorbidity. This subset of the older population is therefore at high risk for disability and other negative health-related events. Key strategies to consider for successfully intercepting at-risk older adults should focus on mass communication methods.

Interactions between drugs and geriatric syndromes in nursing home and home care: results from Shelter and IBenC projects

AIM

Drugs may interact with geriatric syndromes by playing a role in the continuation, recurrence or worsening of these conditions. Aim of this study is to assess the prevalence of interactions between drugs and three common geriatric syndromes (delirium, falls and urinary incontinence) among older adults in nursing home and home care in Europe.

METHODS

We performed a cross-sectional multicenter study among 4023 nursing home residents participating in the Services and Health for Elderly in Long-TERm care (Shelter) project and 1469 home care patients participating in the Identifying best practices for care-dependent elderly by Benchmarking Costs and outcomes of community care (IBenC) project. Exposure to interactions between drugs and geriatric syndromes was assessed by 2015 Beers criteria.

RESULTS

790/4023 (19.6%) residents in the Shelter Project and 179/1469 (12.2%) home care patients in the IBenC Project presented with one or more drug interactions with geriatric syndromes. In the Shelter project, 288/373 (77.2%) residents experiencing a fall, 429/659 (65.1%) presenting with delirium and 180/2765 (6.5%) with urinary incontinence were on one or more interacting drugs. In the IBenC project, 78/172 (45.3%) participants experiencing a fall, 80/182 (44.0%) presenting with delirium and 36/504 (7.1%) with urinary incontinence were on one or more interacting drugs.

CONCLUSION

Drug-geriatric syndromes interactions are common in long-term care patients. Future studies and interventions aimed at improving pharmacological prescription in the long-term care setting should assess not only drug-drug and drug-disease interactions, but also interactions involving geriatric syndromes.

Polypharmacy in Home Care in Europe: Cross-Sectional Data from the IBenC Study

BACKGROUND

Home care (HC) patients are characterized by a high level of complexity, which is reflected by the prevalence of multimorbidity and the correlated high drug consumption. This study assesses prevalence and factors associated with polypharmacy in a sample of HC patients in Europe.

METHODS

We conducted a cross-sectional analysis on 1873 HC patients from six European countries participating in the Identifying best practices for care-dependent elderly by Benchmarking Costs and outcomes of community care (IBenC) project. Data were collected using the interResident Assessment Instrument (interRAI) instrument for HC. Polypharmacy status was categorized into three groups: non-polypharmacy (0-4 drugs), polypharmacy (5-9 drugs), and excessive polypharmacy (≥ 10 drugs). Multinomial logistic regressions were used to identify variables associated with polypharmacy and excessive polypharmacy.

RESULTS

Polypharmacy was observed in 730 (39.0%) HC patients and excessive polypharmacy in 433 (23.1%). As compared with non-polypharmacy, excessive polypharmacy was directly associated with chronic disease but also with female sex (odds ratio [OR] 1.58; 95% confidence interval [CI] 1.17-2.13), pain (OR 1.51; 95% CI 1.15-1.98), dyspnea (OR 1.37; 95% CI 1.01-1.89), and falls (OR 1.55; 95% CI 1.01-2.40). An inverse association with excessive polypharmacy was shown for age (OR 0.69; 95% CI 0.56-0.83).

CONCLUSIONS

Polypharmacy and excessive polypharmacy are common among HC patients in Europe. Factors associated with polypharmacy status include not only co-morbidity but also specific symptoms and age.

Large Perivascular Spaces Visible on Magnetic Resonance Imaging, Cerebral Small Vessel Disease Progression, and Risk of Dementia: The Age, Gene/Environment Susceptibility-Reykjavik Study

Importance

With advancing age, an increased visibility of perivascular spaces (PVSs) on magnetic resonance imaging (MRI) is hypothesized to represent impaired drainage of interstitial fluid from the brain and may reflect underlying cerebral small vessel disease (SVD). However, whether large perivascular spaces (L-PVSs) (>3 mm in diameter) visible on MRI are associated with SVD and cognitive deterioration in older individuals is unknown.

Objective

To examine whether L-PVSs are associated with the progression of the established MRI markers of SVD, cognitive decline, and increased risk of dementia.

Design, Setting, and Participants

The prospective, population-based Age, Gene/Environment Susceptibility-Reykjavik Study assessed L-PVSs at baseline (September 1, 2002, through February 28, 2006) on MRI studies of the brain in 2612 participants. Participants returned for additional MRI from April 1, 2007, through September 30, 2011, and underwent neuropsychological testing at the 2 time points a mean (SD) of 5.2 (0.2) years apart. Data analysis was conducted from August 1, 2016, to May 4, 2017.

Exposures

The presence, number, and location of L-PVSs.

Main Outcomes and Measures

Incident subcortical infarcts, cerebral microbleeds, and progression of white matter hyperintensities detected on MRI; cognitive decline defined as composite score changes between baseline and follow-up in the domains of memory, information processing speed, and executive function; and adjudicated incident dementia cases diagnosed according to international guidelines.

Results

Of the 2612 study patients (mean [SD] age, 74.6 [4.8] years; 1542 [59.0%] female), 424 had L-PVSs and 2188 did not. The prevalence of L-PVSs was 16.2% (median number of L-PVSs, 1; range, 1-17). After adjusting for age, sex, and interval between baseline and follow-up scanning, the presence of L-PVSs was significantly associated with an increased risk of incident subcortical infarcts (adjusted risk ratio, 2.54; 95% CI, 1.76-3.68) and microbleeds (adjusted risk ratio, 1.43; 95% CI, 1.18-1.72) and a greater 5-year progression of white matter hyperintensity volume. The presence of L-PVSs was also associated with a steeper decline in information processing speed and more than quadrupled the risk of vascular dementia. All associations persisted when further adjusted for genetic and cerebrovascular risk factors. The associations with cognitive outcomes were independent of educational level, depression, and other SVD MRI markers.

Conclusions and Relevance

Large PVSs are an MRI marker of SVD and associated with the pathogenesis of vascular-related cognitive impairment in older individuals. Large PVSs should be included in assessments of vascular cognitive impairment in the older population and as potential targets for interventions.

Space and location of cerebral microbleeds, cognitive decline, and dementia in the community

OBJECTIVE

To assess the association of the number and anatomic location of cerebral microbleeds (CMBs), visible indicators of microvascular damage on MRI, with incident cognitive disease in the general population of older people.

METHODS

In the longitudinal population-based Age, Gene/Environment Susceptibility (AGES)-Reykjavik Study, 2,602 participants 66 to 93 years of age and free of prevalent dementia underwent brain MRI and cognitive testing of verbal memory, processing speed, and executive function at baseline and a mean of 5.2 years later. Adjudicated incident dementia cases were diagnosed according to international guidelines.

RESULTS

In the multiple linear regression models adjusted for demographic, genetic, cardiovascular risk, and other cerebrovascular MRI markers, the presence of CMBs located in deep or mixed (deep and lobar) areas was associated with a greater decline in all 3 cognitive domains. Mixed CMBs were the strongest correlate for decline in memory and speed. Compared to those with no CMBs, participants with ≥3 CMBs had a steeper decline in a composite measure of global cognitive function, memory, and speed. Among those with ≥3 deep or mixed CMBs, associations were strongest for memory; the association with speed was strongest in those having ≥3 strictly lobar CMBs. People with ≥3 CMBs, regardless of their locations, had a higher incidence of all-cause dementia and vascular dementia.

CONCLUSIONS

Mixed or a higher load of CMBs, with some specificity for location, is associated with accelerated cognitive decline in older people. These findings suggest a role for hypertensive vasculopathy and the combined effect of hypertensive and cerebral amyloid angiopathy in the pathogenesis of cognitive deterioration.

Associations of fat and muscle tissue with cognitive status in older adults: the AGES-Reykjavik Study

Background/Objective

studies on the association of dementia with specific body composition (BC) components are scarce. Our aim was to investigate associations of BC measures with different levels of cognitive function in late-life.

Methods

we studied 5,169 participants (mean age 76 years, 42.9% men) in the AGES-Reykjavik Study of whom 485 (9.4%) were diagnosed with mild cognitive impairment (MCI) and 307 (5.9%) with dementia. Visceral fat, abdominal and thigh subcutaneous fat, and thigh muscle were assessed by computed tomography. MCI and dementia were based on clinical assessment and a consensus meeting; those without MCI or dementia were categorised as normal. Multinomial regression models assessed the associations stratified by sex and in additional analyses by midlife body mass index (BMI).

Results

among women, there was a decreased likelihood of dementia per SD increase in abdominal subcutaneous fat (OR 0.72; 95% CI: 0.59-0.88), thigh subcutaneous fat (0.81; 0.67-0.98) and thigh muscle (0.63; 0.52-0.76), but not visceral fat, adjusting for demographics, vascular risk factors, stroke and depression. Inverse associations of fat with dementia were attenuated by weight change from midlife and were strongest in women with midlife BMI <25. In men, one SD increase in thigh muscle was associated with a decreased likelihood of dementia (0.75; 0.61-0.92). BC was not associated with MCI in men or women.

Conclusion

a higher amount of abdominal and thigh subcutaneous fat were associated with a lower likelihood of dementia in women only, while more thigh muscle was associated with a lower likelihood of dementia in men and women.

Physical activity and incidence of sarcopenia: the population-based AGES-Reykjavik Study

BACKGROUND

the prevalence of sarcopenia increases with age. Physical activity might slow the rate of muscle loss and therewith the incidence of sarcopenia.

OBJECTIVE

to examine the association of physical activity with incident sarcopenia over a 5-year period.

DESIGN

data from the population-based Age, Gene/Environment, Susceptibility-Reykjavik Study were used.

SETTING

people residing in the Reykjavik area at the start of the study.

SUBJECTS

the study included people aged 66-93 years (n = 2309).

METHODS

the amount of moderate-vigorous physical activity (MVPA) was assessed by a self-reported questionnaire. Sarcopenia was identified using the European Working Group on Sarcopenia in Older People algorithm, including muscle mass (computed tomography imaging), grip strength (computerised dynamometer) and gait speed (6 m).

RESULTS

mean age of the participants was 74.9 ± 4.7 years. The prevalence of sarcopenia was 7.3% at baseline and 16.8% at follow-up. The incidence proportion of sarcopenia over 5 years was 14.8% in the least-active individuals and 9.0% in the most-active individuals. Compared with the least-active participants, those reporting a moderate-high amount of MVPA had a significantly lower likelihood of incident sarcopenia (OR = 0.64, 95% CI 0.45-0.91). Participants with a high amount of MVPA had higher baseline levels of muscle mass, strength and walking speed, but baseline MVPA was not associated with the rate of muscle loss.

CONCLUSION

a higher amount of MVPA seems to contribute to counteracting the development of sarcopenia. To delay the onset of sarcopenia and its potential adverse outcomes, attention should be paid to increasing physical activity levels in older adults.

Convergent validity of the interRAI-HC for societal costs estimates in comparison with the RUD Lite instrument in community dwelling older adults

BACKGROUND

The interRAI-Home Care (interRAI-HC) instrument is commonly used in routine care to assess care and service needs, resource utilisation and health outcomes of community dwelling home care clients. Potentially, the interRAI-HC can also be used to calculate societal costs in economic evaluations. The purpose of this study was to assess the convergent validity of the interRAI-HC instrument in comparison with the RUD Lite instrument for the calculation of societal costs among care-dependent community dwelling older adults.

METHODS

A within-subject design was used. Participants were 65 years and older and received professional community care in five countries. The RUD Lite was administered by trained (research) nurses or self-reports within 4 weeks after the interRAI-HC assessment. Agreement between the interRAI-HC and RUD Lite estimates was assessed using Spearman's correlation coefficients. We hypothesised that there was strong correlation (Spearman's ρ > 0.5) between resource utilisation estimates, costs of care estimates and total societal cost estimates derived from both instruments.

RESULTS

Strong correlation was found between RUD Lite and interRAI-HC resource utilisation assessments for eight out of ten resource utilisation items. Total societal costs according to the RUD Lite were statistically significantly lower than according to the interRAI-HC (mean difference €-804, 95 % CI -1340; -269). The correlation between the instruments for total societal costs and all six cost categories was strong.

CONCLUSIONS

The interRAI-HC has good convergent validity as compared with the RUD-Lite instrument to estimate societal cost of resource utilisation in community dwelling older adults. Since interRAI-HC assessments are part of routine care in many community care organisations and countries already, this finding may increase the feasibility of performing economic evaluations among community dwelling older adults.

Quality of care in European home care programs using the second generation interRAI Home Care Quality Indicators (HCQIs)

Background

Evaluating the quality of care provided to older individuals is a key step to ensure that needs are being met and to target interventions to improve care. To this aim, interRAI’s second-generation home care quality indicators (HCQIs) were developed in 2013. This study assesses the quality of home care services in six European countries using these HCQIs as well as the two derived summary scales.

Methods

Data for this study were derived from the Aged in Home Care (AdHOC) study - a cohort study that examined different models of community care in European countries. The current study selected a sub-sample of the AdHOC cohort from six countries whose follow-up data were complete (Czech Republic, Denmark, Finland, Germany, Italy and the Netherlands). Data were collected from the interRAI Home Care instrument (RAI-HC) between 2000 and 2002. The 23 HCQIs of interest were determined according to previously established methodology, including risk adjustment. Two summary measures, the Clinical Balance Scale and Independence Quality Scale were also determined using established methodology.

Results

A total of 1,354 individuals from the AdHOC study were included in these analyses. Of the 23 HCQIs that were measured, the highest proportion of individuals experienced declines in Instrumental Activities of Daily Living (IADLs) (48.4 %). Of the clinical quality indicators, mood decline was the most prevalent (30.0 %), while no flu vaccination and being alone and distressed were the most prevalent procedural and social quality indicators, respectively (33.4 and 12.8 %). Scores on the two summary scales varied by country, but were concentrated around the median mark.

Conclusions

The interRAI HCQIs can be used to determine the quality of home care services in Europe and identify areas for improvement. Our results suggest functional declines may prove the most beneficial targets for interventions.

Impairments in hearing and vision impact on mortality in older people: the AGES-Reykjavik Study

OBJECTIVE

to examine the relationships between impairments in hearing and vision and mortality from all-causes and cardiovascular disease (CVD) among older people.

DESIGN

population-based cohort study.

PARTICIPANTS

the study population included 4,926 Icelandic individuals, aged ≥67 years, 43.4% male, who completed vision and hearing examinations between 2002 and 2006 in the Age, Gene/Environment Susceptibility-Reykjavik Study (AGES-RS) and were followed prospectively for mortality through 2009.

METHODS

participants were classified as having 'moderate or greater' degree of impairment for vision only (VI), hearing only (HI), and both vision and hearing (dual sensory impairment, DSI). Cox proportional hazard regression, with age as the time scale, was used to calculate hazard ratios (HR) associated with impairment and mortality due to all-causes and specifically CVD after a median follow-up of 5.3 years.

RESULTS

the prevalence of HI, VI and DSI were 25.4, 9.2 and 7.0%, respectively. After adjusting for age, significantly (P < 0.01) increased mortality from all causes, and CVD was observed for HI and DSI, especially among men. After further adjustment for established mortality risk factors, people with HI remained at higher risk for CVD mortality [HR: 1.70 (1.27-2.27)], whereas people with DSI remained at higher risk of all-cause mortality [HR: 1.43 (1.11-1.85)] and CVD mortality [HR: 1.78 (1.18-2.69)]. Mortality rates were significantly higher in men with HI and DSI and were elevated, although not significantly, among women with HI.

CONCLUSIONS

older men with HI or DSI had a greater risk of dying from any cause and particularly cardiovascular causes within a median 5-year follow-up. Women with hearing impairment had a non-significantly elevated risk. Vision impairment alone was not associated with increased mortality.

Socioeconomic factors from midlife predict mobility limitation and depressed mood three decades later; findings from the AGES-Reykjavik Study

Background

Taking into account our rapidly ageing population, older people are of particular interest in studying health inequalities. Most studies of older persons only include measures of current socioeconomic status (SES) and do not take into account data from earlier stages of life. In addition, only classic SES measures are used, while alternative measures, such as car ownership and house ownership, might equally well predict health. The present study aims to examine the effect of midlife socioeconomic factors on mobility limitation and depressed mood three decades later.

Methods

Data were from 4,809 men and women aged 33–65 years who participated in the Reykjavik Study (1967–1992) and who were re-examined in old age in the Age, Gene/Environment Susceptibility (AGES) -Reykjavik Study (2002–2006).

Results

Education and occupation predicted mobility limitation and depressed mood. Independently, home and car ownership and the availability of housing features predicted mobility limitation. Shortages of food in childhood and lack of a car in midlife predicted depressed mood.

Conclusion

Socioeconomic factors from midlife and from childhood affect mobility limitation and depressed mood in old age. Prevention of health problems in old age should begin as early as midlife.

Admission profile is predictive of outcome in acute hospital care

BACKGROUND AND AIMS

The purpose of this study is to describe predictors for discharge and one-year outcomes of acute-care hospital patients, 75 years of age or over, based on admission status information. We carried out a prospective study of a randomly selected patient population, from one urban acute-care hospital in each of the Nordic countries. 763 persons aged 75+ were randomly selected from acute admissions to the participating hospitals. 749 observations at discharge and 655 observations at one year were used in analyses.

METHODS

Data were collected with the MDS-AC 1.1 instrument within 24 hours of admission, and at day 7 or discharge, whichever came first. Outcome information was collected either by interviewing the patient or from patient records or registers. Discharge and one-year outcome (home, institution, death) were modeled by multinomial logistic regression, with admission status variables as predictors.

RESULTS

At discharge, 84% of subjects returned home, 11% went to an institution and 5.6% had died. At one year, 64% were still living at home, 24% had died, and 12% had moved to an institution. For discharge outcome, those having hospital admission due to a new problem or exacerbation of an old one had a higher risk of dying (OR 3.3) than returning home. Moderate to severe cognitive problems predicted death (OR 2.2) and institutionalization (OR 8.6) compared with discharge home. Problems in instrumental activities of daily living predicted death (OR 3.1) and institutionalization (OR 6.0). At one year, those with exacerbation of an old problem (OR 2.1) or with a new or exacerbated existing problem (OR 2.3) had a higher risk of dying than of institutionalization or discharge home. Having some cognitive problems (OR 2.8) or moderate to severe cognitive problems (OR 6.6) predicted institutionalization, but not dying or discharge home. Those with some problems in activities of daily living had a higher risk of both dying (OR 1.7) and of institutional care (OR 2.7). Those with moderate to severe problems in activities of daily living had also a higher risk of institutional care (OR 4.7) compared with those living at home.

CONCLUSIONS

Evidence predictive of discharge and one-year outcomes in older acute hospital medical care patients seems to be visible from the beginning of the hospital stay. In order to increase the efficient use of health care services and quality of care, systematic standardized and streamlined assessment should be performed during the admission process.

Standardizing assessment of elderly people in acute care: the interRAI Acute Care instrument

OBJECTIVES

To examine the frequency distributions and interrater reliability of individual items of the interRAI Acute Care instrument.

DESIGN

Observational study of a representative sample of older inpatients; duplicate assessments conducted on a subsample by independent assessors to examine interrater reliability.

SETTING

Acute medical, acute geriatric and orthopedic units in 13 hospitals in nine countries.

PARTICIPANTS

Five hundred thirty-three patients aged 70 and older (mean age 82.4, range 70-102) with an anticipated stay of 48 hours or longer of whom 161 received duplicate assessments.

MEASUREMENTS

Sixty-two clinical items across 11 domains. Premorbid (3-day observation period before onset of the acute illness) and admission (the first 24 hours of hospital stay) assessments were conducted.

RESULTS

The frequency of deficits exceeded 30% for most items, ranging from 1% for physically abusive behavior to 86% for the need for support in activities of daily living after discharge. Common deficits were in cognitive skills for daily decision-making (38% premorbid, 54% at admission), personal hygiene (37%, 65%), and walking (39%, 71%). Interrater reliability was substantial in the premorbid period (average kappa=0.61) and admission period (average kappa=0.66). Of the 69 items tested, less than moderate agreement (kappa<0.4) was recorded for six (9%), moderate agreement (kappa=0.41-0.6) for 14 (20%), substantial agreement (kappa=0.61-0.8) for 40 (58%), and almost perfect agreement (kappa>0.8) for nine (13%).

CONCLUSION

Initial assessment of the psychometric properties of the interRAI Acute Care instrument provided evidence that item selection and interrater reliability are appropriate for clinical application. Further studies are required to examine the validity of embedded scales, diagnostic algorithms, and clinical protocols.

Variations in quality of Home Care between sites across Europe, as measured by Home Care Quality Indicators

BACKGROUND AND AIMS

The increase in the proportion of elderly people and a consequent increase in the demand for care have caused healthcare systems to become overloaded. This paper describes the use of Home Care Quality Indicators (HCQIs), derived from the Minimum Data Set for Home Care, for monitoring quality of care. Research questions were, "Do HCQI scores vary between home care organizations in different countries?" and "Are one or more country-specific sites consistently scoring better on most or all HCQIs"?

METHODS

a cross-sectional observational study of 65+ randomly selected clients of home care organizations in urban areas in 11 European countries who had been receiving home care for at least two weeks. Data were collected with the MDS-HC. The scoring of 16 prevalent quality indicators for home care, adjusted for population differences, was calculated with baseline data.

RESULTS

Population size at baseline was 4,007 clients. Among home care clients in Europe, "rehabilitation potential in Activities of Daily Living and no therapies" (average 75.9%) and "inadequate pain control" were the most common quality problems. The prevalence between populations studied in various countries varied substantially. No country-specific site consistently scored worst or best.

CONCLUSIONS

HCQIs derived from the MDS-HC detect variance in quality scores between home care in the 11 partner countries. The highest prevalence of unwanted outcomes were most often found in the Czech Republic, Italy and Germany. Although further research is necessary, we believe that HCQIs may be of great value for quality improvement in home care.

[Comparison of MDS-AC registration and conventional medical records in Iceland and other Nordic countries. A part of a Nordic study]

OBJECTIVE

Complex functional decline and comorbid state is an important indicator of outcome for hospital care of older adults. In today acute care it is important to quickly be able to target those who might benefit from geriatric assessment. The MDS-AC is an evaluation system for geriatric acute care patients that records functional impairment and co-morbid states. The object of this study was to compare the MDS-AC registration with the traditional nurses and doctors records for chosen variables important to older patient care in Iceland and other Nordic countries.

METHODS

This was a randomised prospective Nordic study. The study took place in Reykjavík, Copenhagen, Umeå, Oslo and Helsinki. Participants in each country were chosen from 75 year old and older patients admitted to acute care medical wards, 160 patients from each country. The results presented here show data from selected variables collected with the MDS-AC instrument version 1,1 in the first 24 hours of admission, compared with hospital notes for the first 48 hours.

RESULTS

For ADL and IADL impairments the medical record missed between 20 to 96% of items registered with the MDS-AC and between 33 to 100% when there is no impairment detected. This was true for all the participating Nordic countries but the Icelandic medical records were in comparison more often incomplete for the variables chosen.

CONCLUSION

The MDS-AC documents better than traditional medical records several important variables relating to function among the elderly. It may be possible to improve documentation with a standardized instrument such as the MDS-AC.

Potentially inappropriate medication use among elderly home care patients in Europe

CONTEXT

Criteria for potentially inappropriate medication use among elderly patients have been used in the past decade in large US epidemiological surveys to identify populations at risk and specifically target risk-management strategies. In contrast, in Europe little information is available about potentially inappropriate medication use and is based on small studies with uncertain generalizability.

OBJECTIVE

To estimate the prevalence and associated factors of potentially inappropriate medication use among elderly home care patients in European countries.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cross-sectional study of 2707 elderly patients receiving home care (mean [SD] age, 82.2 [ 7.2] years) representatively enrolled in metropolitan areas of the Czech Republic, Denmark, Finland, Iceland, Italy, the Netherlands, Norway, and the United Kingdom. Patients were prospectively assessed between September 2001 and January 2002 using the Minimum Data Set in Home Care instrument.

MAIN OUTCOME MEASURES

Prevalence of potentially inappropriate medication use was documented using all expert panels criteria for community-living elderly persons (Beers and McLeod). Patient-related characteristics independently associated with inappropriate medication use were identified with a multiple logistic regression model.

RESULTS

Combining all 3 sets of criteria, we found that 19.8% of patients in the total sample used at least 1 inappropriate medication; using older 1997 criteria it was 9.8% to 10.9%. Substantial differences were documented between Eastern Europe (41.1% in the Czech Republic) and Western Europe (mean 15.8%, ranging from 5.8% in Denmark to 26.5% in Italy). Potentially inappropriate medication use was associated with patient's poor economic situation (adjusted relative risk [RR], 1.96; 95% confidence interval [CI], 1.58-2.36), polypharmacy (RR, 1.91; 95% CI, 1.62- 2.22), anxiolytic drug use (RR, 1.82; 95% CI, 1.51-2.15), and depression (RR, 1.29; 95% CI, 1.06-1.55). Negatively associated factors were age 85 years and older (RR, 0.78; 95% CI, 0.65-0.92) and living alone (RR, 0.76; 95% CI, 0.64-0.89). The odds of potentially inappropriate medication use significantly increased with the number of associated factors (P<.001).

CONCLUSIONS

Substantial differences in potentially inappropriate medication use exist between European countries and might be a consequence of different regulatory measures, clinical practices, or inequalities in socioeconomic background. Since financial resources and selected patient-related characteristics are associated with such prescribing, specific educational strategies and regulations should reflect these factors to improve prescribing quality in elderly individuals in Europe.

[Retrospective analysis of health variables in a Reykjavík nursing home 1983-2002 (corrected)]

BACKGROUND

A municipal nursing home with 68 beds in Reykjavík, opened in mid-year 1982.

OBJECTIVES

To analyse changes in demographic, health and outcome variables over 20 years.

DESIGN

Retrospective analyses of data from medical records of all diseased persons with cross-sectional comparison of five four-year intervals.

SETTING

Droplaugarstadir Nursing Home in Reykjavík. The nursing home is supervised by fully qualified nurses and provides maintenance rehabilitation. Medical services are delivered from a specialist geriatric hospital department. RESIDENTS: All residents who died 1983 to 2002 [corrected].

MEASUREMENTS

Demographic data, type of dwelling before admission, Nursing Home Pre-admission Assessment Score (NAPA), mobility- and cognitive score, drug usage and a list of medical diagnoses. All recorded health events during stay, falls and fractures, medical and specialist consultations. Advance directives, as recorded and end-of-life treatment, place of death, clinical diagnosis of cause of death and length of stay.

RESULTS

The total number of medical records read numbered 385, including 279 females and 106 males. The mean age on admission was 85 (+/- 7) years. During the first 4 years the majority of residents came from their own private homes or residential settings but in the last four years, 60% were admitted directly from a hospital ward. The mortality rate was 17% per year in the first period and the majority died in a hospital. This ratio took a sharp turn as the mortality rate increased to 40%, and in the last period only 2 of 97 deaths took place in a hospital. Admission mobility- and cognitive scores showed increased disability with time. The most common diagnosis on admission was dementia (56%), ischemic heart disease (46%), fractures (35%) and strokes (27%). Parkinsonism and maturity onset diabetes had a low prevalence rate of 6%. A mean NHPA of 57 (+/- 17) points confirmed a high dependency selection. The mean number of drugs per patient was 5.3 (+/- 3), including 1.1 (+/- 1) for psychoactive drugs and sedatives. The most common health events during residents? stay were urinary and respiratory infections, heart failure, cardiac- and cerebral events and pulmonary disorders. Hip fractures occurred in 45 residents (12%) and other types of fractures in 47 during their stay in the nursing home. The number of medical visits and specialist referrals increased with time. Palliative care was the most common form of treatment at end of life. Pneumonia was most commonly recorded cause of death in medical notes. The yearly mortality rate was 29% and the mean length of stay was 3 (+/- 2,9) years for the whole period.

LIMITATIONS

Retrospective analyses have many inherent drawbacks and the information in medical records tend to be scanty. Analyses of disabilities, as described in the medical record, can only be descriptive and health events are likely to be underreported. Statistical methods have a less meaningful role for interpretation as only diseased persons were included and survivors excluded. However, the length of time, uniform medical care and turnover rate of residents generate useful information on the patterns of the nursing home service during a time of considerable change.

CONCLUSIONS

This retrospective analysis indicates increasing frailty in nursing home patients admitted over a period of 20 years. With time the residents are more often admitted directly from a hospital rather than from an individual dwelling. Most deaths took place in the nursing home and were preceded with informal or formal palliative care directives, which was a significant change over time. The data indicates growing efficiency in the nursing home selection processes due to the NHPA and improvements in holistic geriatric care. This development is in keeping with the Icelandic health care policy for elderly people to stay longer in their own home with access to a nursing home placement when needed.

[Expression of dementia in preadmission nursing home assessment for skilled nursing homes 1992-2001.]

OBJECTIVE

Dementia is a growing health issue and is currently the main reason for nursing home (NH) admission. The objective of this study is to describe the elderly who qualified for an admission to NH in the Reykjavík metropolitan area. Special attention is paid to the degree of dementia and how it affects various factors such as: waiting time for NH admission, factors that could possibly predict survival after preadmission nursing home assessment (PNHA) and survival in NH?s.

MATERIAL AND METHODS

Every PNHA evaluation is stored in a database by SKYRR Inc. Information from that database regarding all, who lived in the Reykjavík metropolitan area and had undergone their first PNHA during the period from January 1st 1992 to 31st of December 2001, was collected. Information about survival was collected from the Icelandic National Registry. There were 3417 individuals in the study group. SPSS was used for statistical analysis.

RESULTS

Dementia is a major risk factor for NH admission with about 79% of the elderly with some degree of dementia. Dementia correlated with lower age at admission for men, p<0,01. The degree of dementia had no effect on the age of women at admission. The total score of the PNHA correlated with higher degree of dementia. Higher dementia degree meant less survival for men after NH admission, p=0,02. The degree of dementia did not effect survival of women after admission. The death rate was highest in the first year after PNHA for all degrees of dementia. The ratio of men who were still alive after 3 years was 30% but 46% of the women were still alive, p<0,01. Factors predicting longer survival were lower age and good mobility for both sexes. In men with high or very high degree of dementia a high score for behavioral symptoms predicted shortened survival.

CONCLUSIONS

Dementia is the main reason for NH admission in Iceland and therefore special attention must be paid to it when NH beds are assigned. The priority of males should be revised so that men with higher degree of dementia be prioritized over other males.

[The Preadmission Nursing Home Assessment (PNHA) in Iceland in 1992-2001 - Relationship to survival and admission to a long term care facility.]

OBJECTIVE

PNHA is a standardized evaluation of the elderly which everyone who applies for an admission to long term care (LTC) in Iceland must undergo. The objective of this study is to describe the elderly who asked for an admission to LTC in The Reykjavík metropolitan area and in Akureyri over a 10 year period. A special attention is paid to factors that could possibly predict survival after PNHA.

MATERIAL AND METHODS

Every PNHA evaluation is stored in a database by SKYRR Inc. Information from that database regarding all who lived in the greater Reykjavík area and Akureyri and had undergone their first PNHA during the period from January 1st 1992 to 31st of December 2001, was collected. Information about survival was collected from the the Icelandic national registry. There were 4272 individuals in the study group. SPSS was used for statistical analysis.

RESULTS

The average enrolment age of men in nursing homes(NH) in Reykjavík was 82.7 -/+ 0.5 years and for women 84.4 -/+ 0.4 (p<0.01). Men were about one third of residents in NH's. The average waiting time for men from the first PNHA to NH placement was 219 -/+ 20 days and for women 290 -/+ 22 days (p<0.01). Of those who were waiting for NH's, 22% of men and 14% of women died without being admitted (p<0,01). The mean survival of men in NH's in Reykjavík was 2.5 -/+ 0.2 years and for women 3.1 -/+ 0.2 years (p<0.01). Factors predicting longer survival for men in Reykjavík were lower age, good mobility and being able to eat but for women the factors were lower age and good mobility.

CONCLUSIONS

It's in all stakeholders' interest that elderly people are enabled to live at home for as long as possible. Factors that predict survival should be taken into account when the elderly are prioritized for admission to NH's so that elderly who are predicted to have the lowest survival rate of assessed are those admitted first.

Geriatric rehabilitation as an integral part of geriatric medicine in the Nordic countries

OBJECTIVES

First, to outline the theoretical and practical framework for geriatric rehabilitation in the Nordic countries and second, to survey the scientific medical publications for evidence-based geriatric rehabilitation.

METHODS

Brainstorming on geriatric rehabilitation in a working group of Nordic teachers in geriatric medicine. Papers on scientific programmes for geriatric rehabilitation from Internet sources were collected and analyzed. All articles describing randomized studies in geriatric rehabilitation were selected for meta-analyses. The papers were divided into four groups according to diseases, infirmity and resource settings: stroke, hip-fractures, acute admissions and programmes conducted in nursing homes, day hospitals and home services.

RESULTS

The literature survey included 30 scientific studies (9496 patients) in randomized trials with valid endpoints. Geriatric rehabilitation programmes for stroke patients in geriatric settings (six papers, 1138 patients) reduced mortality and the need for nursing home placement, but the outcome for ADL function was not significantly changed. Function and length of stay varied between the studies. The outcome of geriatric rehabilitation was even more decisive in the randomized hip-fracture studies (seven articles, 2414 patients): the readmission rate and cost were significantly better. Ten studies were found, comparing the outcome of acute admissions of frail elderly patients (4683) with either geriatric (GEMU, GRU) or general medical wards. The effect of rehabilitation regarding mortality rate at one year, placement in a nursing home, physical function, contentment with services, readmission rate and cost was significant improvement in the geriatric settings. Internal comparisons of geriatric programmes in nursing homes, day hospitals and in-home services (seven studies, 1261 patient) revealed some differences in outcomes regarding function, contentment and costs.

CONCLUSION

Specialized geriatric rehabilitation is complicated but effective when properly performed. Interdisciplinary teamwork, targeting of patients, comprehensive assessment and intensive and patient-targeted rehabilitation seem to characterize the most effective programmes. Rehabilitation of frail elderly people poses a major future challenge and has to be developed further for the sake of elderly people's quality of life as well as economic reasons.

[Health care needs and quality of life of elderly in home care in Reykjavik, 1997.]

OBJECTIVE

It is increasingly emphasized that the elderly should be supported to live at home as long as possible. The purpose of this study was to describe the health and conditions of people in home care.

MATERIAL AND METHODS

Individuals who received home care in the Reykjavik area in autumn of 1997 were assessed with the Minimum Data Set-Resident Assessment Instrument for Home Care, MDS-RAI HC.

RESULTS

The study evaluated 257 individuals at four primary care health centers. The mean age was 82.7 years, women were 78.6%, living alone were 62.5%, and they had received home care on average of 2.4 years. Almost all were independent in primary activities of daily living, ADL, but about half needed help with instrumental activities of daily living (IADL). Impaired cognition was observed in 40% of individuals, depressive symptoms in 18%, daily pain was noted in 47% and 47% assessed their health as poor. Loneliness was expressed by 21%, 18% had not gone out doors in over 30 days and 27% were always alone during the day. The mean number of hours during two weeks was 3.5 hours in nursing care and 9.5 hours in home help. Thirty-four percent took 9 or more medications.

CONCLUSION

Individuals in home care were independent in ADL but needed assistance with IADL. There are important quality of life issues that are of concern. Further research is needed in home care with particular emphasis on improvement of well being.

Challenges of current geriatric education-inspired by the Nordic geriatric professors' meetings

Geriatric educators are faced with several different challenges. The rapid growth of aged population in the Western world has led to a growing need for health and social services and thus, an increased need for trained professionals in this field. In addition, new learning theories and activating learning methods have achieved wide acceptance in academic medicine. How has geriatric education applied these new learning methods? In this article we review the current status of academic geriatric education in Western countries in these respects. We especially review the literature of how geriatric training has been experimenting with the new learning methods.

[Geriatric rehabilitation as an integral part of geriatric medicine in the nordic countries.]

OBJECTIVE

Firstly to outline the theoretical and practical framework for geriatric rehabilitation in Iceland and other Nordic countries and secondly to survey the scientific medical publications for evidence based geriatric rehabilitation.

METHODS

Brain storming on geriatric rehabilitation in a working group of Nordic teachers in geriatric medicine. Papers on scientific programs for geriatric rehabilitation from Internet sources were collected and analyzed. All articles describing randomized studies in geriatric rehabilitation were selected for overview. The papers were divided into four groups according to diseases, infirmity and resource settings; 1) stroke, 2) hip-fractures, 3) acute admissions and 4) programs conducted in nursing homes, day hospitals and home services.

RESULTS

A spectrum of biological and social events creates the conditions underlying most causes for illness and disability in old people. The process of established geriatric services promotes the efficiency of geriatric rehabilitation. The literature survey included 27 scientific studies (8586 patients) on randomized studies with valid endpoints. Geriatric rehabilitation programs for stroke patients in geriatric settings, six studies (1138 patients), reduced mortality and the need for nursing home placement but the outcome for ADL. Function and length of stay was more variable between the studies. The outcome of geriatric rehabilitation was even more decisive in the randomized hip-fracture studies, six studies (2171 patients). Eight studies were found comparing the outcome between acute admission of frail elderly to either geriatric (GEMU, GRU) or general medical wards. The outcome as regards to mortality rate at one year, placement to a nursing home, physical function, contentment with services, readmission rate and cost was all significantly better in the geriatric settings. Internal comparisons of geriatric programs in nursing homes, day hospitals and in home service, seven studies (1261 patient), revealed some differences in outcomes in function, contentment and costs.

CONCLUSIONS

Specialized geriatric rehabilitation is complicated but effective when properly performed. Interdisciplinary teamwork, targeting of patients, comprehensive assessment and intensive and patient-targeted rehabilitation seem to characterize the most effective programs. Rehabilitation of frail elderly people poses a major challenge for the future and has to be developed further for the sake of quality of life of elderly people as well as for economic reasons.

The impact of legislation on psychotropic drug use in nursing homes: a cross-national perspective

OBJECTIVES

To quantify the impact of legislation on nursing home residents, psychotropic drug use, and the occurrence of falls in the US compared with five countries with no such regulation.

DESIGN

A retrospective cross-sectional study

SETTING

Nursing homes in five US states and selected nursing homes in Denmark, Iceland, Italy, Japan, and Sweden.

PARTICIPANTS

Residents in nursing homes in five US states and the aforementioned countries during 1993-1996.

MAIN OUTCOME MEASURES

Using data collected using the Minimum Data Set, logistic regression provided estimates of the legislative effects on the use of antipsychotics and antianxiety/hypnotics while simultaneously adjusting for potential confounders. The occurrence of falls was evaluated similarly.

RESULTS

Prevalence of antipsychotic and/or antianxiety/ hypnotic use varied substantially across countries. After adjustment for differences in age, gender, presence of psychiatric/neurologic conditions, and physical and cognitive functioning, residents in Denmark, Italy, and Sweden were at least twice as likely to receive these drugs (Denmark Odds Ratio (OR)=2.32; 95% Confidence Intervals (CI), 2.15-2.51; Italy OR=2.05; 95% CI, 1.78-2.34; Sweden OR=2.50; 95% CI, 2.16-2.90); in Iceland, the risk was increased to greater than 6 times (OR=6.54; 95% CI, 5.75-7.44) that of the US. Residents were less likely to fall in Italy, Iceland, and Japan compared with the US, despite more extensive use of psychotropic medication, whereas residents in Sweden and Denmark were more likely to fall.

CONCLUSIONS

Policy has had an impact on the prescribing of psychotropic medication in US nursing homes compared with other countries, but it is unclear if this is translated into better outcomes for residents.

[Study of medications use of elderly admitted to acute care hospital.]

OBJECTIVE

The prevalence of diseases increases with age and so does use of medications. Thus illness related to medications use does also become more prevalent. This study aims at evaluating medications of elderly people admitted to an acute care hospital, and demonstrate adverse reactions and quality indicators.

MATERIAL AND METHODS

This is a study of patients 75 years of age and older admitted acutely to internalmedicine at the Reykjavik Hospital over a three month period in the spring of 1995. All medications and diagnoses were registered and the medical records reviewed. The contribution of adverse medication effects to the admission was assessed. Quality of treatment was evaluated according to evidence based medicine for the diagnoses chosen. The study included 208 individuals, 133 women and 75 men with the mean age of 82.4 years.

RESULTS

Mean length of stay for women was 19.9 days and men 15.2 days. Number of drugs on admission and discharge ranged from 0 to 18. The mean number of drugs were for women 5.8 and 6.9 and men 6.6 and 7.7 on admission and discharge, respectively. In 16 cases or 7.7% it was judged that there was a high likelihood of the admission being due to an adverse effect. Potential drug interactions according to a computer software package were not judged to be of clinical importance in any case.

CONCLUSIONS

Treatment for coronary heart disease, heart failure, osteoporosis, insomnia and long term prednisolon treatment is not completely optimal according to evidence based medicine. The results of this study indicate that treatment could be improved for example with use of clinical guidelines.

International variation in the incidence of hip fractures: cross-national project on osteoporosis for the World Health Organization Program for Research on Aging

A cross-national study of hip fracture incidence was carried out in five geographic areas--Beijing, China; Budapest, Hungary; Hong Kong; Porto Alegre, Brazil; and Reykjavik, Iceland--during the years 1990-1992. Cases of hip fracture among women and men of age 20 years and older were identified using hospital discharge data in conjunction with medical records, operating room logs, and radiology logs. Estimated incidence rates varied widely, with Beijing reporting the lowest rates (age-adjusted rate per 100,000 population for men 20 years and older = 45.4; women = 39.6) and Reykjavik the highest rates (man = 141.3; women = 274.1). Rates were higher for women than for men in every area except Beijing. In every area except Budapest, review of the operating room or radiology logs identified additional cases that were not reported in the discharge list, increasing the estimated number of hip fractures by 11% to 62%, depending on the area. Review of medical records identified miscoding of hip fractures (ICD 9820) as 'shaft of femur and other femur fractures' (ICD 9821) in the discharge lists of every area except Budapest, increasing the estimated number of hip fractures by 1% to 30%. The final estimates of hip fracture incidence taking into account all investigated sources of undercount and overcount ranged from 15% lower to 89% higher than an estimate based on the discharge diagnoses alone. Although these results indicate substantial limitations in relying on hospital discharge data alone to estimate hip fracture incidence rates, the extent of errors found in the discharge lists is smaller than the large international variation found here and previously reported in incidence rates. The findings support the conclusion that the differences reported among countries mainly reflect genuine variation in the hip fracture incidence rates.

Letter from Reykjavik

Medical care in Iceland can be viewed as an experiment of nature. This small island society has combined the Nordic social and welfare structures with advanced international medicine. The Vikings settled Iceland in the ninth century, and the population has remained biologically homogeneous because of its remote isolation. This homogeneity may provide a unique opportunity to contribute to the understanding of the genetics of common disorders. Iceland's isolation has also limited the resources that are available for clinical training. Therefore, it has been necessary for most physicians who graduate from the medical school at the University of Iceland to obtain postgraduate training abroad. This has been of enormous benefit to Icelandic medicine. Fewer opportunities for foreign medical graduates to train in the United States would have a substantial effect on the future practice of Icelandic medicine. The Icelandic health care system faces many challenges. Because health care spending has been reined in, priorities must be set more clearly than in the past, and heated discussions have erupted about gatekeeping and merging of hospitals. These have been "interesting times" for Icelandic medicine. Other countries may learn lessons from our medical situation: a microcosm, to be sure, but no longer an isolated one.

Urinary incontinence and urinary tract infections in octogenarian women

BACKGROUND

Urinary incontinence and urinary tract infection are common problems among elderly women due to age-related changes in the urogenital tract, but information regarding prevalence and presentation among the aged is limited.

METHODS

A total of 97 randomly selected women aged 80-89 years, 47 living in homes for the elderly and 50 living at home, were asked about urogenital complaints in a structured interview. Medical records provided information about urinary tract infections and the use of estrogens.

RESULTS

Urinary incontinence affected 46%; half of them daily. Urge incontinence was most common (43%), then mixed incontinence (28%) and stress incontinence (26%). Urge and mixed incontinence caused significantly more discomfort than stress incontinence. During the past two years 33% of the women had experienced urinary tract infection and 11% had > or = 5 infections. A total of 22 women were receiving estrogen treatment, more often in homes for the elderly (p < 0.001). Paradoxically, these women had a higher prevalence of urinary incontinence, urinary tract infection, and other complaints than women not receiving estrogens. Considerable or great discomfort from the urogenital tract was reported by 23% of the women. A third of the women had discussed urogenital complaints with a physician.

CONCLUSION

In view of the prevalence of urogenital complaints, it is likely that more elderly women could benefit from early medical assessment and treatment. Indications for estrogen treatment need to be more clearly defined.

Approaching cross-national comparisons of nursing home residents

METHOD

since the 1990 implementation of the US nursing home Resident Assessment Instrument (RAI), researchers in other nations have begun to use the RAI to assess institutionalized elders for payment, research, or planning purposes. We report comparative statistics representing institutionalized residents in seven nations, describing from several hundred to hundreds of thousands of residents.

RESULTS

significant differences are seen in age and length of stay, and in summary measures of physical and cognitive functioning and case-mix. Countries also differ in their homogeneity across nursing homes.

CONCLUSION

these differences strengthen the position that 'nursing home' does not provide a sound basis for cross-national comparisons, and should be replaced with resident-specific descriptors. This also suggests that cross-national comparisons need to adjust at the level of the individual resident for differences in resident populations.

Efforts to establish the reliability of the Resident Assessment Instrument

BACKGROUND

since its original implementation in the USA, the Resident Assessment Instrument (RAI) has been used in many countries in languages other than English. This paper describes the efforts that have been made to test the inter-rater reliability of the core set of items forming the minimum data set items in the USA and in non-English speaking countries (Denmark, Iceland, Italy, Japan, Sweden and Switzerland).

RESULTS

a large proportion (from 70 to 96%) of the items in the RAI achieved an adequate to excellent level of reliability, with no substantial differences across countries. The RAI met the standard for good reliability (i.e. a kappa value of 0.6 or higher) in crucial areas of functional status, such as memory, activities of daily living self-performance and support, and bowel and bladder continence in most of the countries. Indicators of mood and behavioural problems achieved adequate reliability levels of 0.4 or higher.

An international study of social engagement among nursing home residents

METHOD

data using the Resident Assessment Instrument (RAI) from nursing home populations in five countries (Denmark, Iceland, Italy, Japan, USA) were assembled from 396277 residents. The distribution of a new quality of life measure, 'social engagement', embedded in the RAI and found to be reliable and valid in the USA, was examined and compared in the international samples.

RESULTS

in all five countries' nursing home populations engagement was highest among residents with adequate functioning in activities of daily living (ADL) and cognition, but the level of social engagement differed considerably by country among residents with poor ADL functioning, who had adequate cognition. The lowest scores were in Italy and Japan. The amount of time residents spend in activities stratified by ADL and cognition reveal the same pattern cross-culturally--cognitively impaired residents are least actively involved.

CONCLUSIONS

the Minimum Data Set measure of social engagement is stable across types of residents and across nations and can serve as a marker of nursing home quality.