Enabling health and maintaining independence for older people at home (HomeHealth trial): a multicentre randomised controlled trial

BACKGROUND

NHS frailty services commonly target more severely frail older people, despite evidence suggesting frailty can be prevented or reversed when addressed at an earlier stage. HomeHealth is a new home-based, manualised voluntary sector service supporting older people with mild frailty to maintain their independence through behaviour change. Over six appointments, a trained HomeHealth worker discusses what matters to the older person and supports them to set and achieve goals around mobility, nutrition, socialising and/or psychological wellbeing. The service showed promising effects in a feasibility trial. We aimed to test the clinical and cost-effectiveness of HomeHealth for maintaining independence in older people with mild frailty compared with treatment as usual.

METHODS

In this single-blind multicentre randomised controlled trial, we recruited community-dwelling older people aged 65 years or older with mild frailty from 27 general practices, community groups and sheltered housing in London, Yorkshire, and Hertfordshire. Participants were randomly assigned (1:1) to receive either HomeHealth monthly for 6 months or treatment as usual (usual GP and outpatient care, no specific frailty services). Our primary outcome was independence in activities of daily living, measured by blinded outcome assessors using the modified Barthel Index, and analysed using linear mixed models, including 6-month and 12-month data and controlling for baseline Barthel score and site. The study was approved by the Social Care Research Ethics Committee, and all participants provided written or orally recorded informed consent. This study is registered with the ISRCTN registry, ISRCTN54268283.

FINDINGS

This trial took place between Jan 18, 2021, and July 4, 2023. We recruited 388 participants (mean age 81·4 years; 64% female [n=250], 94% White British/European [n=364], 2·5% Asian [n=10], 1·5% Black [n=6], 2·0% other [n=8]). We achieved high retention for 6-month follow-up (89%, 345/388), 12-month follow-up (86%, 334/388), and medical notes data (89%, 347/388). 182 (93%) of 195 participants in the intervention group completed the intervention, attending a mean of 5·6 appointments. HomeHealth had no effect on Barthel Index scores at 12 months (mean difference 0·250, 95% CI -0·932 to 1·432). At 6 months, there was a small reduction in psychological distress (-1·237, -2·127 to -0·348) and frailty (-0·124, -0·232 to -0·017), and at 12 months, we found small positive effects on wellbeing (1·449, 0·124 to 2·775) in those receiving HomeHealth. Other outcomes in analysis to date showed no significant difference. Health economic outcomes (including quality of life, capability, health services use and care needs or burden) are pending.

INTERPRETATION

This high-quality trial showed that HomeHealth did not maintain independence in older people with mild frailty, and had limited effects upon secondary outcomes. Future studies need to explore different ways to promote health in this population.

FUNDING

National Institute for Health and Care Research Health Technology Assessment (NIHR HTA).

Mother and clinician experiences of a trial of a video feedback parent-infant intervention for mothers experiencing difficulties consistent with 'personality disorder': A qualitative interview study

OBJECTIVES

We explored mothers' and clinicians' experiences of a video feedback intervention adapted for perinatal 'personality disorder' (VIPP-PMH) and the acceptability of a randomised controlled trial (RCT) examining its effectiveness.

DESIGN

In-depth qualitative interviews with participants from a two-phase feasibility study of the VIPP-PMH intervention. Participants were mothers experiencing enduring difficulties in managing emotions and relationships, consistent with a 'personality disorder', and their 6- to 36-month-old children.

METHODS

Forty-four qualitative interviews were conducted, including all nine mothers receiving VIPP-PMH during the pilot phase, 25 of the 34 mothers participating in the RCT (14 allocated to the VIPP-PMH arm and 9 from the control arm), 11 of the 12 clinicians delivering VIPP-PMH and one researcher. Interview data were thematically analysed.

RESULTS

Mothers described feeling motivated to take part in the research and understood the need for randomisation. Research visits were largely experienced positively, with some suggestions for improvement in questionnaire timing and accessibility. Almost all mothers initially felt anxious about being filmed, but reported positive experiences of the intervention, particularly valuing its non-judgemental, positive and child-focussed nature, their supportive relationship with the therapist and the insights they gained on their child.

CONCLUSIONS

The findings indicate the likely feasibility and acceptability of undertaking a future definitive RCT of the VIPP-PMH intervention in this population. In designing a future trial, a positive and non-judgemental therapeutic relationship will be important to allay mothers' anxieties about being filmed, and careful consideration should be given to the timing and accessibility of questionnaires used.

Video feedback parent-infant intervention for mothers experiencing enduring difficulties in managing emotions and relationships: A randomised controlled feasibility trial

OBJECTIVES

Parents experiencing mental health difficulties consistent with "personality disorder", often related to a history of complex trauma, may face increased challenges in parent-child relationships and child socioemotional development. There are no published randomised controlled trials (RCTs) evaluating perinatal parent-child interventions for this population. We evaluated the feasibility and acceptability of undertaking an RCT of the video feedback intervention for positive parenting adapted for perinatal mental health (VIPP-PMH).

DESIGN

Feasibility study incorporating a pilot RCT.

METHODS

Mothers with enduring difficulties in managing emotions and relationships, consistent with a "personality disorder", and their 6- to 36-month old infants were randomly allocated to receive six sessions of VIPP-PMH (n = 20) or usual care alone (n = 14).

RESULTS

76% of eligible mothers consented to participate. Intervention uptake and completion rates were 95% (≥1 VIPP-PMH session) and 70% (6 sessions), respectively. Follow-up rates were 85% at month 5 and 65% at month 8 post-baseline. Blinded observer-ratings of maternal sensitivity in parent-child interaction favoured the intervention group at month 5 (RR = 1.94, 95% CI 0.67-5.63) and month 8 (RR = 1.91, 95% CI 0.68-5.33). Small changes over time in self-rated parenting confidence and stress favoured the intervention group. There were no clear intervention effects on maternal non-intrusiveness or mental health, or on child behaviour problems, emotional functioning, or self-regulation.

CONCLUSIONS

An RCT of VIPP-PMH is feasible and acceptable to implement with mothers experiencing difficulties consistent with perinatal "personality disorder". A fully powered definitive RCT should be undertaken.

Optimizing the rapid measurement of detection thresholds in infants

Accurate measures of perceptual threshold are difficult to obtain in infants. In a clinical context, the challenges are particularly acute because the methods must yield meaningful results quickly and within a single individual. The present work considers how best to maximize speed, accuracy, and reliability when testing infants behaviorally and suggests some simple principles for improving test efficiency. Monte Carlo simulations, together with empirical (visual acuity) data from 65 infants, are used to demonstrate how psychophysical methods developed with adults can produce misleading results when applied to infants. The statistical properties of an effective clinical infant test are characterized, and based on these, it is shown that (a) a reduced (false-positive) guessing rate can greatly increase test efficiency, (b) the ideal threshold to target is often below 50% correct, and (c) simply taking the max correct response can often provide the best measure of an infant's perceptual sensitivity.

Automated measurement of resolution acuity in infants using remote eye-tracking

PURPOSE

To validate a novel, automated test of infant resolution acuity based on remote eye-tracking.

METHODS

Infants aged 2 to 12 months were tested binocularly using a new adaptive computerized test of infant vision using eye tracking (ACTIVE), and Keeler infant acuity cards (KIAC). The ACTIVE test ran automatically, using remote eye-tracking to assess whether the infant fixated a black-and-white grating of variable spatial frequency. Test-retest reliability was assessed by performing each test twice. Accuracy was assessed by comparing acuity measures across tests and with established age-norms, and by comparing low-contrast acuity estimates in adults with data reported previously.

RESULTS

All infants completed the ACTIVE test at least once. Median test duration was 101 seconds. Measured visual acuity increased with age (P < 0.001), and 90% of mean acuity estimates were within previously published 90% tolerance limits (based on acuity-card age norms). Acuity estimates were also correlated, within-subjects, with results from the KIAC (P = 0.004). In terms of reliability, 86% of acuity estimates deviated by ≤1 octave, with no significant difference in test-retest reliability between the ACTIVE and KIAC procedures (P = 0.461). In adults, acuity estimates from the ACTIVE test did not differ significantly from values reported by previous authors (P > 0.183).

CONCLUSIONS

An adaptive computerized test of infant vision using eye-tracking provides a rapid, automated measure of resolution acuity in preverbal infants. The ACTIVE performed comparably to the current clinical gold standard (acuity cards) in terms of testability, reliability, and accuracy, and its principles can be extended to measure other visual functions.