What matters to people aged 80 and over regarding ambulatory care? A systematic review and meta-synthesis of qualitative studies

[Aging with meaning. A qualitative and multicultural study]

INTRODUCTION

Currently in Catalonia, multiculturalism is increasing, also among older people. However, little is known about the aspects that give meaning to aging or whether there are differences by origin and culture.

OBJECTIVES

Identify what it means to age meaningfully for people over 50 years of age from different origins and cultures.

METHOD

We present a study carried out with people over 50 years of age from different cultures who live together in the Alt Empordà region (Girona). We have worked with qualitative methodology, 7 focus groups and 2 in-depth interviews.

RESULTS

We identified 9 factors to age meaningfully: 1- Having basic needs covered. 2- Spirituality. 3- Family. 4- Contributing socially/feeling useful. 5- Carrying out leisure activities. 6- Accepting aging. 7- Being able to choose where and how to grow old and die. 8- Visualize the elderly and 9- Personalized attention. The differences between the priorities of these 9 factors have led us to describe three ways of aging with meaning: a) Aging of contemplation, b) Aging enjoying opportunities and c) Aging claiming to be full-fledged agents.

CONCLUSIONS

The group of older people is heterogeneous in the same way as the rest of society. This heterogeneity implies different ways of understanding old age with meaning as well as the needs that arise. It is important to work with social and health professionals so that they understand the need to know the person and their interests to better personalize care.

[Ageing in the host country]

OBJECTIVE

To explore the perceptions of elderly people from diverse cultures regarding the factors relevant to aging, identifying similarities and differences, and describing elements that facilitate or hinder this process, with a focus on the impact of care services.

METHOD

Qualitative study with 48 participants over 50 years old, residing in the Alt Empordà region, Catalonia. Seven focus groups were conducted, including one exploratory multicultural group and six stratified by origin: native, Western Europe, Eastern Europe, Latin America, North Africa, and West Africa.

RESULTS

All groups valued health and the desire to remain in their homes or communities for as long as possible. African groups emphasized the importance of free health services, while the Latin American group valued personalized end-of-life care. The native group pointed out deficiencies in home care and residential care services. Western European participants mentioned language barriers and challenges with digitalization as the only means of accessing information, and Eastern European participants highlighted the need for empowerment and social participation. Additionally, the importance of new family models, restrictions on non-Catholic funeral practices, and the need for community integration were mentioned.

CONCLUSION

While there are differences in perceptions of aging among the different groups, common factors were identified that either facilitate or hinder this process, regardless of whether there is a migration background.

An Early Supported Discharge (ESD) Model of Care for Older Adults Admitted to Hospital: A Descriptive Cohort Study

Background

Early supported discharge (ESD) facilitates early discharge from acute hospitals with continued rehabilitation in the home environment from a multi-disciplinary team at the same intensity as would be received in the inpatient setting. Emerging evidence suggests it can have a positive impact on the care of older adults on discharge from the acute hospital setting to home. This study aims to characterize an inreach model of ESD for older adults discharged from four hospitals in the Mid-West of Ireland and describe its impact on clinical and process outcomes at 30 and 180 days.

Methods

Consecutive older adults referred for ESD from four hospitals were recruited over six-months. Baseline assessments were carried out on initial review, and patients were followed up at 30 and 180 days by an independent outcome assessor. Outcomes measured include functional status, frailty, health related quality of life, mortality, and healthcare utilization.

Results

One hundred and thirty older adults (mean age 76.62 years, SD 9.81 years) were recruited, 44 for surgical complaints and 86 for medical complaints. The ESD service was provided over a median of 31 (medical) - 44 (surgical) days, primarily by physiotherapy and occupational therapy. The incidence of functional decline was 16.41% at 30 days and 27.5% at 180 days. There was a significant improvement in the self-reported function from index visit 72.94 (19.50) mean standard deviation (SD) to 30 days 84.05 (21.08) mean (SD) which was maintained at 180 days 80.53 (30.93) mean (SD). Frailty was independently associated with incidence of functional decline at 30 days (OR 2.06, 95% CI 1.39 to 3.06) and 180 days (OR 1.7, 95% CI 1.29 to 2.24).

Conclusion

An ESD model of care can have significant effects on patient outcomes for older adults admitted to hospital at 30 and 180 days, without increasing the risk of unscheduled Emergency Department re-presentation. Future research should explore the impact of an ESD model of care on specific older adult cohorts.

Proud but Powerless: A Qualitative Study of Homecare Workers´ Work Experiences and Their Suggestions for How Care for Homebound Older Adults Can Be Improved

Many older adults with complex care needs live at home due to ageing-in-place policies. This study explored homecare workers' experiences and suggestions for improvements of care. Twelve semi-structured interviews were analyzed thematically, and revealed pride, capability, and satisfaction in their work, yet they feel undervalued and lack support. They advocate for integrated care models, recognition of their competence, flexible work approaches, and committed leadership. This would enhance patient care and address their own working conditions, addressing concerns from being relegated to the bottom of the hierarchy. They emphasize the need for comprehensive approaches, spanning from housekeeping to end-of-life palliative care.

What patient-reported outcome measures may be suitable for research involving older adults with frailty? A scoping review

INTRODUCTION

The need to develop and evaluate frailty-related interventions is increasingly important, and inclusion of patient-reported outcomes is vital. Patient-reported outcomes can be defined as measures of health, quality of life or functional status reported directly by patients with no clinician interpretation. Numerous validated questionnaires can thus be considered patient-reported outcome measures (PROMs). This review aimed to identify existing PROMs currently used in quantitative research that may be suitable for older people with frailty.

METHOD

PubMed and Cochrane were searched up to 24/11/22. Inclusion criteria were quantitative studies, use of a PROM, and either measurement of frailty or inclusion of older adult participants. Criteria were created to distinguish PROMs from questionnaire-based clinical assessments. 197 papers were screened. PROMs were categorized according to the domain assessed, as derived from a published consensus 'Standard Set of Health Outcome Measures for Older People'.

RESULTS

88 studies were included. 112 unique PROMs were used 289 times, most frequently the SF-36 (n = 21), EQ-5D (n = 21) and Barthel Index (n = 14). The most frequently assessed outcome domains included Mood and Emotional Health and Activities of Daily Living, with fewer assessments of Participation in Decision-Making and Carer Burden.

CONCLUSIONS

PROM usage in frailty research is highly heterogeneous. Frequently used PROMs omit important outcomes identified by older adults. Further research should evaluate the importance of specific outcomes and identify PROMs relevant to people at different stages of frailty. Consistent and appropriate PROM use in frailty research would facilitate more effective comparisons and meaningful evaluation of frailty interventions.

Towards a better uptake of home dialysis in Europe: understanding the present and looking to the future

Use of peritoneal dialysis and home haemodialysis remains low in Europe, with the highest use in Scandinavian countries and the lowest in Eastern and Central Europe despite the advantages for people on dialysis and economic advantages for healthcare systems. This is partly due to the impact of the haemodialysis industry resulting in proliferation of haemodialysis units and nephrologist reimbursement related to use of haemodialysis. Equally important is the bias against home dialysis at both clinician and healthcare system levels. The underlying causes of this bias are discussed in relation to a mechanistic view of the human body, lack of compassion, failure to adjust dialysis provision for older age and frailty, proliferation of small dialysis centres, and complexity of decision-making and clinical care. For home dialysis to flourish, we need to foster a change in attitude to and vision of the aims of healthcare so that enabling meaningful activities of people requiring dialysis, as explored in the Standardized Outcomes in Nephrology initiative, rather than achieving biological numbers become the focus of care delivery.

How do the existing homecare services correspond with the preferred service ecosystem for senior citizens living at home? A qualitative interview study with multiple stakeholders

Introduction

Often, homecare services are task-focused rather than person-based and fragmented instead of integrated. Consequently, several stakeholders have requested a transformation of the service ecosystem for senior citizens living at home. This transformation may be facilitated by an idealized design approach. However, few studies have applied such an approach. Moreover, previous research did not assess the ways in which the existing homecare services correspond with the preferred service ecosystem for senior citizens living at home. Therefore, the purpose of this study is to gain an understanding of how the existing homecare services correspond with the preferred service ecosystem for senior citizens living at home, according to different stakeholders.

Methods

Four stakeholder groups (n = 57) from a Norwegian municipality participated in an interview study (2019-2020): senior citizens, carers, healthcare professionals and managers. A directed qualitative content analysis was applied, guided by a four-category framework for the preferred service ecosystem.

Results

All stakeholder groups highlighted several limitations that hindered continuity of the services. There was also agreement on deficiencies in professionals' competence, yet professionals themselves did not focus on this as a significant aspect. Managers emphasised the importance of professionals' reablement competence, which was also considered to be deficient in the current homecare services. Contrary to the other stakeholder groups, most senior citizens seemed satisfied with the practical and social support they received. Together with carers, they also explained why they thought some professionals lack compassion. Their dependency on professionals may limit them in sharing honestly their opinions and preferences during care provision. Involvement of senior citizens in improvement of the current services was limited. Insufficient time and resources, as well as a complex organisation impacted the existing homecare services, and therefore served as barriers to the preferred service ecosystem.

Discussion

In this study there were different degrees of correspondence between the existing homecare services and the preferred service ecosystem according to four stakeholder groups. To develop the preferred service ecosystem, aspects such as predictability, adaptivity, and relationships are key, as well as continuous involvement of senior citizens and other stakeholders. The four-category framework applied in this study served as a tool to assess the existing homecare services.

Outreach dental care programme for older adults using long-term care services in Hong Kong: A qualitative study

OBJECTIVES

To explore the effects and improvement needs of an outreach dental care programme (ODCP) for older adults using residential care or daycare services from the perspectives of the caregivers, the dentists and administrative staff involved in the implementation of the ODCP.

METHODS

A qualitative study was conducted through semi-structured interviews with three stakeholders, long-term care (LTC) facility caregivers, administrative staff and dentists working for the ODCP. Combined maximum variation and snowball sampling strategies were adopted, and 22, 9 and 7 participants were interviewed from each stakeholder, respectively. The interviews were conducted via telephone, which were audio-recorded and transcribed verbatim for analysis. NVivo software was used for storing and analysing the data. Data analysis was conducted continuously during the study.

RESULTS

Most participants opined that the ODCP benefited older adults by raising their oral health conditions and awareness. However, they complained of the complicated administrative procedures, unmet dental treatment needs, inefficient coordination, unclear work guidelines and shortage of dental manpower. More advanced dental treatment options, better coordination among different parties, simpler administrative processes and better incentives for dentists were proposed to further improve the programme.

CONCLUSIONS

According to the stakeholders, ODCP seems beneficial to older adults using LTC services. Further improvements in the scope of dental treatments, cooperation between the outreach dental teams and caregivers, and streamlining of the administrative process are needed for the provision of effective outreach dental care to satisfy the unmet treatment needs of older adults who use LTC services. Better incentives are needed to attract and retain dentists.

Stakeholder perspectives on the preferred service ecosystem for senior citizens living at home: a qualitative interview study

BACKGROUND

Most senior citizens want to live independently at home as long as possible. The World Health Organization recommends an age-friendly community approach by transforming the service ecosystem for senior citizens and basing it on the question "What matters to you?". However, there is limited research-based knowledge to determine the characteristics of the preferred service ecosystem from the perspectives of multiple stakeholders. Therefore, the aim of the study was to gain a deeper understanding of multiple stakeholder perspectives on the preferred service ecosystem for senior citizens living at home.

METHODS

Four stakeholder groups (n = 57) from a Norwegian municipality participated in an interview study in 2019 and 2020: senior citizens, carers, healthcare professionals, and managers. Data were analysed according to qualitative content analysis.

RESULTS

Overall, there was considerable correspondence between the four stakeholder groups' perspectives on the preferred service ecosystem for senior citizens. Six themes were developed: (1) "self-reliance - living independently at home as long as possible"; (2) "remaining active and social within the community"; (3) "support for living at home as long as possible"; (4) "accessible information and services"; (5) "continuity of services"; and (6) "compassionate and competent healthcare professionals".

CONCLUSIONS

In order to adapt and meet changing needs, the preferred service ecosystem should support senior citizens' autonomy through interpersonal relationships and involvement. Healthcare managers and decision makers should consider a broader range of practical and social support services. Municipalities should plan for and develop age-friendly infrastructures, while healthcare professionals should rely on their compassion and competence to meet senior citizens' needs.

Predictors and effects of toxicity experienced by older adults with cancer receiving systemic therapy in a randomized clinical trial of geriatric assessment

INTRODUCTION

Older adults represent a large segment of the oncology population, however, they remain underrepresented in clinical research. Treatment of older adults is often extrapolated using data from younger and fitter patients, which may not be appropriate. Furthermore the implications of toxicity from treatment can be greater for this population. Predicting toxicity from treatment and its effect on quality of life and functional status for older adults therefore is important.

MATERIALS AND METHODS

We analyzed data from a clinical trial of geriatric assessment and management for Canadian elders with cancer (5C study). We assessed whether the baseline Cancer and Aging Research Group (CARG) toxicity score, G8 score, and Eastern Cooperative Oncology Group (ECOG) performance predicted grade 3-5 toxicity using logistic regression and pattern mixture models. We also assessed the impact of toxicity on quality of life and functional decline. Patients were followed for six months.

RESULTS

Three hundred sixteen patients were included. Mean age was 76 years old and 40% of patients were female. One hundred nineteen patients (38%) experienced at least one grade 3-5 toxicity. Neither the CARG toxicity score, G8, or ECOG were predictive of grade 3-5 toxicity. Patients who experienced grade 3-5 toxicity were more likely to have functional impairments over time (odds ratio 3.71, p = 0.03). However, they maintained their quality of life.

DISCUSSION

In this secondary analysis of a randomized controlled trial of geriatric assessment and management we did not find any predictors of grade 3-5 toxicity. Patients who did experience toxicity were more likely to report functional decline over time. Older adults who do experience treatment related toxicity may benefit from increased supports.

CLINICAL TRIAL INFORMATION

NCT0315467.

Outcomes of Gastrectomy for Gastric Cancer in Patients Aged >80 Years: A Systematic Literature Review and Meta-Analysis

This meta-analysis examined the surgical management of older patients (>80 years) with gastric cancer, who were often excluded from randomized controlled trials. We analyzed 23 retrospective cohort studies involving 18,372 patients and found that older patients had a higher in-hospital mortality rate (relative risk [RR], 3.23; 95% confidence interval [CI], 1.46-7.17; P<0.01) and more post-operative complications (RR, 1.36; 95% CI, 1.19-1.56; P<0.01) than did younger patients. However, the surgical complications were similar between the two groups. Older patients were more likely to undergo less extensive lymph node dissection and longer hospital stays. Although older patients had statistically significant post-operative medical complications, they were not deprived of surgery for gastric cancer. The comorbidities and potential risks of post-operative complications should be carefully evaluated in older patients, highlighting the importance of careful patient selection. Overall, this meta-analysis provides recommendations for the surgical management of older patients with gastric cancer. Careful patient selection and evaluation of comorbidities should be performed to minimize the risk of post-operative complications in older patients, while recognizing that they should not be deprived of surgery for gastric cancer.

Systemic Therapy in Older Patients With High-Risk Disease

Adjuvant systemic treatments for older patients with breast cancer require constant dose or schedule adjustments of standards established for younger ones. This is mainly due to frailty that increases according to age (40%-50% of signals in all comers after age 70 years) and remains difficult to spot or diagnose accurately and therefore is often overlooked. Older patients are at higher risk to develop side effects whether under chemotherapy, optimized endocrine treatment, or targeted therapies. Pharmacokinetic reflects poorly functional reserves that reduce with aging and is therefore misleading. The demonstration of significant long-term benefits provided by adjuvant treatments is challenged by life expectancy, driven by multimorbidity status that increases with age, competing with cancer outcome. When geriatric assessment is incorporated into the multidisciplinary team, treatment decision process shows 30%-50% changes, de-escalating initial age-agnostic treatment choices in two of three cases. Finally, expectations from treatment vary over the years: In older ones, although not being exclusive, there is a general shift of preference for protecting functionality, cognitive functions, and independence, as summarized in quality of life that many systemic adjuvant treatment may jeopardize. These provocative considerations show importance to pay more attention to expectations expressed by older patients to limit gaps between what is thought by health care professionals as right, often on the basis of dose intensity models strongly engrained in oncology and that older patients may assess counterintuitively differently. The most achieved molecular testing to identify high-risk luminal tumors should be combined with determinant geriatric factors to bring relevant global information in the adjuvant setting for older patients.

Co-creation of a Patient-Reported Outcome Measure for Older People Living with Frailty Receiving Acute Care (PROM-OPAC)

Older people living with frailty emphasize autonomy and function as acute healthcare outcome goals. Existing Patient-Reported Outcome Measures (PROMs) measure function but do not comprehensively address autonomy. This initial development of a novel autonomy outcome measure used co-creation and cognitive interviews, working toward a PROM for Older People living with frailty receiving Acute Care (“PROM-OPAC”). Novel item question stems and responses considering autonomy were devised with lay research partners. Items were examined for content by lay volunteers, and then selected based on relevance, completeness, and accessibility. Retained items were cognitively tested with patient participants. Item selection considered content validity and feasibility and was undertaken collaboratively with lay research partners. The study involved 3 lay research partners and 4 further lay collaborators throughout all stages, and 14 patient participants were recruited for the cognitive interviews. Twenty-two novel items were appraised. Seven were selected for retention. This preliminary PROM-OPAC comprised 7 items to measure autonomy and was intended for administration alongside a function measure to capture meaningful acute healthcare outcomes. Development will continue with quantitative testing and validation.

Which features of ambulatory healthcare are preferred by people aged 80 and over? Findings from a systematic review of qualitative studies and appraisal of confidence using GRADE-CERQual

BACKGROUND

Despite healthcare providers' goal of patient-centeredness, current models for the ambulatory (i.e., outpatient) care of older people have not as yet systematically incorporated their views. Moreover, there is no systematic overview of the preferable features of ambulatory care from the perspective of people aged 80 and over. Therefore, the aim of this study was to summarize their specific wishes and preferences regarding ambulatory care from qualitative studies.

METHODS

The study was based on qualitative studies identified in a prior systematic review. Firstly, the findings of the qualitative studies were meta-summarized, following Sandelowski and Barroso. Secondly, a list of preferred features of care from the perspective of older people was derived from the included studies' findings through inductive coding. Thirdly, the review findings were appraised using the GRADE-CERQual tool to determine the level of confidence in the qualitative evidence. The appraisal comprised four domains: methodological limitations, coherence, data adequacy, and data relevance. Two reviewers independently evaluated every review finding in each domain. The final appraisals were discussed and ultimately summarized for the respective review finding (high, moderate, low, or very low confidence).

RESULTS

The 22 qualitative studies included in the systematic review were mainly conducted in Northern and Western Europe (n = 15). In total, the studies comprised a sample of 330 participants (n = 5 to n = 42) with a mean or median age of 80 and over. From the studies' findings, 23 preferred features of ambulatory care were identified. Eight features concerned care relationships (e.g., "Older people wish to receive personal attention"), and 15 features concerned healthcare structures (e.g., "Older want more time for their care"). The findings emphasized that older people wish to build strong relationships with their care providers. The majority of the review findings reached a moderate or high confidence appraisal.

CONCLUSIONS

While the listed features of healthcare structures are common elements of care models for older people (e.g., Geriatric Care Model), aspects of care relationships are somewhat underrepresented or are not addressed explicitly at all. Future research should further explore the identified preferred features and their impact on patient and care outcomes.

Older Persons' Views on Important Values in Swedish Home Care Service: A Semi-Structured Interview Study

Introduction

Knowledge of older person's experiences of important values in home care service can facilitate the development and delivery of high-quality services supporting their well-being, dignity and participation in the care provided. To date, few studies have explored older person's values and experiences of home care services.

Purpose

This study aimed to explore values that older person holds regarding home care services and their experiences of how these values manifest in home care service delivery.

Participants and Methods

The study has a qualitative exploratory design. Semi-structured interviews were conducted with 16 older persons aged 74-90 who received home care service. Data were analysed using qualitative content analysis.

Results

Two themes (each with sub-themes) of values relating to the experience of home care service from the perspective of the 16 older persons were identified: to be supported as an autonomous person and to be supported as a relational being. The participants experience that these two values were only partly manifested in the home care services they received. They also noted that their well-being was negatively affected when staff failed to implement these values. The fundamental values identified in study related to the older person feeling safe, being autonomous, maintaining control and independence, and having relationships. The values constitute help to guide practice from the perspective of older persons who receive home care services.

Conclusion

The identified values are primarily interpersonal-level values. However, such values are also of importance for home care service organisations when promoting delivery of person-centred care. Taking such a position implies adopting a relation-oriented rather than a task-oriented approach in providing home care services for older persons.