Improved self-confidence was a mechanism of action in two geriatric trials evaluating physical interventions

Community-based complex interventions to sustain independence in older people, stratified by frailty: a systematic review and network meta-analysis

Background

Sustaining independence is important for older people, but there is insufficient guidance about which community health and care services to implement.

Objectives

To synthesise evidence of the effectiveness of community services to sustain independence for older people grouped according to their intervention components, and to examine if frailty moderates the effect.

Review design

Systematic review and network meta-analysis.

Eligibility criteria

Studies: Randomised controlled trials or cluster-randomised controlled trials. Participants: Older people (mean age 65+) living at home. Interventions: community-based complex interventions for sustaining independence. Comparators: usual care, placebo or another complex intervention.

Main outcomes

Living at home, instrumental activities of daily living, personal activities of daily living, care-home placement and service/economic outcomes at 1 year.

Data sources

We searched MEDLINE (1946-), Embase (1947-), CINAHL (1972-), PsycINFO (1806-), CENTRAL and trial registries from inception to August 2021, without restrictions, and scanned reference lists.

Review methods

Interventions were coded, summarised and grouped. Study populations were classified by frailty. A random-effects network meta-analysis was used. We assessed trial-result risk of bias (Cochrane RoB 2), network meta-analysis inconsistency and certainty of evidence (Grading of Recommendations Assessment, Development and Evaluation for network meta-analysis).

Results

We included 129 studies (74,946 participants). Nineteen intervention components, including 'multifactorial-action' (multidomain assessment and management/individualised care planning), were identified in 63 combinations. The following results were of low certainty unless otherwise stated. For living at home, compared to no intervention/placebo, evidence favoured: multifactorial-action and review with medication-review (odds ratio 1.22, 95% confidence interval 0.93 to 1.59; moderate certainty) multifactorial-action with medication-review (odds ratio 2.55, 95% confidence interval 0.61 to 10.60) cognitive training, medication-review, nutrition and exercise (odds ratio 1.93, 95% confidence interval 0.79 to 4.77) and activities of daily living training, nutrition and exercise (odds ratio 1.79, 95% confidence interval 0.67 to 4.76). Four intervention combinations may reduce living at home. For instrumental activities of daily living, evidence favoured multifactorial-action and review with medication-review (standardised mean difference 0.11, 95% confidence interval 0.00 to 0.21; moderate certainty). Two interventions may reduce instrumental activities of daily living. For personal activities of daily living, evidence favoured exercise, multifactorial-action and review with medication-review and self-management (standardised mean difference 0.16, 95% confidence interval -0.51 to 0.82). For homecare recipients, evidence favoured the addition of multifactorial-action and review with medication-review (standardised mean difference 0.60, 95% confidence interval 0.32 to 0.88). Care-home placement and service/economic findings were inconclusive.

Limitations

High risk of bias in most results and imprecise estimates meant that most evidence was low or very low certainty. Few studies contributed to each comparison, impeding evaluation of inconsistency and frailty. Studies were diverse; findings may not apply to all contexts.

Conclusions

Findings for the many intervention combinations evaluated were largely small and uncertain. However, the combinations most likely to sustain independence include multifactorial-action, medication-review and ongoing review of patients. Some combinations may reduce independence.

Future work

Further research is required to explore mechanisms of action and interaction with context. Different methods for evidence synthesis may illuminate further.

Study registration

This study is registered as PROSPERO CRD42019162195.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: NIHR128862) and is published in full in Health Technology Assessment; Vol. 28, No. 48. See the NIHR Funding and Awards website for further award information.

Recovery from Severe Disability that Develops Progressively Versus Catastrophically: Incidence, Risk Factors, and Intervening Events

BACKGROUND

Few prior studies have evaluated recovery after the onset of severe disability or have distinguished between the two subtypes of severe disability.

OBJECTIVES

To identify the risk factors and intervening illnesses and injuries (i.e., events) that are associated with reduced recovery after episodes of progressive and catastrophic severe disability.

DESIGN

Prospective longitudinal study of 754 nondisabled community-living persons, aged 70 years or older.

SETTING

Greater New Haven, CT, March 1998 to December 2016.

PARTICIPANTS

A total of 431 episodes of severe disability were evaluated from 385 participants: 116 progressive (115 participants) and 315 catastrophic (270 participants).

MEASUREMENTS

Candidate risk factors were assessed every 18 months. Functional status and exposure to intervening events leading to hospitalization, emergency department visit, or restricted activity were assessed each month. Severe disability was defined as the need for personal assistance with three or more of four essential activities of daily living. Recovery was defined as return to independent function (no disability) within 6 months of developing severe disability.

RESULTS

Recovery occurred among 35.3% (95% confidence interval [CI] = 26.0%-48.0%) and 61.6% (95% CI = 53.5%-70.9%) of the 116 progressive and 315 catastrophic severe disability episodes, respectively. In the multivariable analyses, lives alone, frailty, and intervening hospitalization were each independently associated with reduced recovery from progressive disability, with adjusted hazard ratios (95% CIs) of 0.31 (0.15-0.64), 0.23 (0.12-0.45), and 0.27 (0.08-0.95), respectively, whereas low functional self-efficacy, intervening restricted activity, and intervening hospitalization were each independently associated with reduced recovery from catastrophic disability, with adjusted hazard ratios (95% CIs) of 0.56 (0.40-0.81), 0.55 (0.35-0.85), and 0.45 (0.31-0.66), respectively.

CONCLUSIONS

Recovery of independent function is considerably more likely after the onset of catastrophic than progressive severe disability, the risk factors for reduced recovery differ between progressive and catastrophic severe disability, and subsequent exposure to intervening illnesses and injuries considerably diminishes the likelihood of recovery from both subtypes of severe disability.

A concept analysis of confidence related to older people living with frailty

Aim

To describe and define a concept of confidence in the context of older people living with frailty, which is important to the worldwide healthy-ageing agenda preventing decline in independence and well-being.

Design

Concept analysis informed by Walker and Avant's eight-stage approach.

Methods

Electronic databases (MEDLINE, CINAHL and PsychINFO) from 1994-2018 were searched. Published studies exploring confidence and excerpts of papers referencing older people, frailty and confidence informed the concept analysis. Extracted attributes informed model case and additional case development. Appraisal of antecedents, consequences and empirical referents informed the final concept's construction.

Results

Three overall defining attributes of confidence were identified in this concept analysis: physical, psychological and social. A central feature is personal control, influencing internal and external factors. These control factors can be enabling factors (positive factors) or dis-enabling factors (negative factors), affecting the frail older persons overall physical health and mental well-being.

Factors Associated with Functional Recovery among Older Intensive Care Unit Survivors

RATIONALE

Most of the 1.4 million older adults who survive the intensive care unit (ICU) annually in the United States face increased disability, but little is known about those who achieve functional recovery.

OBJECTIVES

Our objectives were twofold: to evaluate the incidence and time to recovery of premorbid function within 6 months of a critical illness and to identify independent predictors of functional recovery among older ICU survivors.

METHODS

Potential participants included 754 persons aged 70 years or older who were evaluated monthly in 13 functional activities (1998-2012). The analytic sample included 218 ICU admissions from 186 ICU survivors. Functional recovery was defined as returning to a disability count less than or equal to the pre-ICU disability count within 6 months. Twenty-one potential predictors were evaluated for their associations with recovery.

MEASUREMENTS AND MAIN RESULTS

Functional recovery was observed for 114 (52.3%) of the 218 admissions. In multivariable analysis, higher body mass index (hazard ratio [HR], 1.07; 95% confidence interval [CI], 1.03-1.12) and greater functional self-efficacy (HR, 1.05; 95% CI, 1.02-1.08), a measure of confidence in performing various activities, were associated with recovery, whereas pre-ICU impairment in hearing (HR, 0.38; 95% CI, 0.22-0.66) and vision (HR, 0.59; 95% CI, 0.37-0.95) were associated with a lack of recovery.

CONCLUSIONS

Among older adults who survived an ICU admission with increased disability, pre-ICU hearing and vision impairment were strongly associated with poor functional recovery within 6 months, whereas higher body mass index and functional self-efficacy were associated with recovery. Future research is needed to evaluate whether interventions targeting these factors improve functional outcomes among older ICU survivors.

The meaning of confidence for older people living with frailty: a qualitative systematic review

BACKGROUND

In many countries, the oldest old (those aged 85 years and older) are now the fastest growing proportion of the total population. This oldest population will increasingly be living with the clinical condition of frailty. Frailty syndromes negatively impact on the person as they do the healthcare systems supporting them. Within healthcare literature "loss of confidence" is occasionally connected to older people living with frailty, but ambiguously described. Understanding the concept of confidence within the context of frailty could inform interventions to meet this growing challenge.

OBJECTIVES

The objective of this systematic review was to explore the meaning of confidence from the perspective of older people living with frailty through synthesis of qualitative evidence to inform healthcare practice, research and policy.

INCLUSION CRITERIA TYPES OF PARTICIPANTS

Studies that included frail adults, aged over 60 years, experiencing acute hospital and or post-acute care in the last 12 months.

PHENOMENA OF INTEREST

The concept of "confidence" and its impact on the physical health and mental well-being of older people living with frailty.

CONTEXT

Studies that reported on the older person's descriptions, understanding and meaning of confidence in relation to their frailty or recent healthcare experiences.

TYPES OF STUDIES

Studies of qualitative design and method.

SEARCH STRATEGY

A three step search strategy was used. The search strategy explored published studies and gray literature. Publications in English from the last 20 years were considered for inclusion.

METHODOLOGICAL QUALITY

All included articles were assessed by two independent reviewers using the Joanna Briggs Institute Qualitative Assessment Review Instrument (JBI-QARI).

DATA EXTRACTION

Data were extracted from included studies using the data extraction tools developed by the Joanna Briggs Institute.

DATA SYNTHESIS

Qualitative research findings were collated using a meta-aggregative approach and JBI-QARI software.

RESULTS

Synthesized findings of this review were drawn from just four research studies that met the inclusion criteria. Only six findings contributed to the creation of three categories. These informed a single synthesized finding: Vulnerability, described as a fragile state of well-being that is exposed to the conflicting tensions between physical, emotional and social factors. These tensions have the capability to enhance or erode this state.

CONCLUSIONS

Assertions that an understanding of the concept confidence has been reached cannot be made. The review data offer limited insight into the concept of confidence being described by the cohort of older people living with frailty.

Just the facts: changes in older driver attitudes after exposure to educational interventions

OBJECTIVES

To examine the change in cognitive processing as measured by consciousness raising and attitudes toward driving following educational interventions for older adults.

METHODS

Older adults who viewed a research-based applied theater production about older driver safety (n = 110) were compared to those who were exposed to a print-based publication available to all drivers (n = 100).

RESULTS

After viewing the play developed with input from older adults and others, older adult viewers' attitudes toward driving shifted in a manner consistent with an increased openness or willingness to consider changing their driving behavior. Conversely, after reading the print-based materials, the older adults felt more empowered to continue drive.

CONCLUSIONS

Demonstrating that an intervention that takes into account the views of older drivers can lead to attitudinal outcomes that differ from those achieved with typical "just the facts" programs is an important step in understanding how program content and format affect outcomes. Future interdisciplinary work such as this may enhance our capabilities to understand more about the processes involved in influencing change in attitudes and behaviors.

Sex differences in the incidence of peripheral neuropathy among Kenyans initiating antiretroviral therapy

BACKGROUND

Peripheral neuropathy (PN) is common among patients receiving antiretroviral therapy (ART) in resource-limited settings. We report the incidence of and risk factors for PN among human immunodeficiency virus (HIV)-infected Kenyan adults initiating ART.

METHODS

An inception cohort was formed of adults initiating ART. They were screened for PN at baseline and every 3 months for 1 year. We used the validated Brief Peripheral Neuropathy Screen (BPNS) that includes symptoms and signs (vibration perception and ankle reflexes) of PN.

RESULTS

Twenty-two (11%) of 199 patients had PN at baseline screening. One hundred fifty patients without evidence of PN at baseline were followed for a median of 366 days (interquartile range, 351-399). The incidence of PN was 11.9 per 100 person-years (95% confidence interval [CI], 6.9-19.1) and was higher in women than men (17.7 vs 1.9 per 100 person-years; rate ratio, 9.6; 95% CI, 1.27-72, P = .03). In stratified analyses, female sex remained statistically significant after adjustment for each of the following variables: age, CD4 cell count, body mass index, ART regimen, and tuberculosis treatment. Stratifying hemoglobin levels decreased the hazard ratio from 9.6 to 7.40 (P = .05), with higher levels corresponding to a lower risk of PN.

CONCLUSIONS

HIV-infected Kenyan women were almost 10 times more likely than men to develop PN in the first year of ART. The risk decreased slightly at higher hemoglobin levels. Preventing or treating anemia in women before ART initiation and implementing BPNS during the first year of ART, the period of highest risk, could ameliorate the risk of PN.

The effectiveness of exercise interventions for the management of frailty: a systematic review

This systematic review examines the effectiveness of current exercise interventions for the management of frailty. Eight electronic databases were searched for randomized controlled trials that identified their participants as “frail” either in the title, abstract, and/or text and included exercise as an independent component of the intervention. Three of the 47 included studies utilized a validated definition of frailty to categorize participants. Emerging evidence suggests that exercise has a positive impact on some physical determinants and on all functional ability outcomes reported in this systematic review. Exercise programs that optimize the health of frail older adults seem to be different from those recommended for healthy older adults. There was a paucity of evidence to characterize the most beneficial exercise program for this population. However, multicomponent training interventions, of long duration (≥5 months), performed three times per week, for 30–45 minutes per session, generally had superior outcomes than other exercise programs. In conclusion, structured exercise training seems to have a positive impact on frail older adults and may be used for the management of frailty.

Test Acceptability and Confidence Levels in Older Adults Referred for Fitness-to-Drive Evaluations

In this study, we examined confidence and face validity or client acceptability of tests used in a Veterans Affairs Medical Center driving clinic. The clinic used evidence-based off-road tests and adopted the Washington University Road Test (WURT) as a performance-based on-road examination. Forty-three clients consented to participate in the study; most were male with an average age of 78.2 years (standard deviation = 12.6). In general, a trend existed toward higher client acceptability of tests adopted from the Neuropsychological Assessment Battery (Stern & White, 2003) and the WURT than of other off-road measures. Confidence decreased after administration of the psychometric test battery, yet it increased after the on-road evaluations despite a 47% failure rate in the sample. Additional study is needed on test acceptability because it may have the potential to increase understanding, compliance, or both with driving recommendations. Additional research is also needed to examine client confidence levels and their potential impact on performance during the driving evaluation process.

Predisposing factors and precipitants for bathing disability in older persons

OBJECTIVES

To identify potential predisposing factors and precipitants for bathing disability.

DESIGN

Prospective cohort study.

SETTING

Greater New Haven, Connecticut.

PARTICIPANTS

Seven hundred fifty-four community-living residents aged 70 and older.

MEASUREMENTS

Potential predisposing factors were measured every 18 months for 6 years during comprehensive home-based assessments. Participants were followed with monthly telephone interviews for a median of 61 months to ascertain exposure to potential precipitants, which included illnesses and injuries leading to hospitalization or restricted activity, and to determine the occurrence of persistent disability in bathing.

RESULTS

Over the course of nearly 8 years, 333 (44.2%) participants developed persistent disability in bathing. After accounting for age, sex, and race, nine predisposing factors were independently associated with persistent bathing disability. The strongest associations were found for inability to rise from a chair, low bathing self-efficacy, and low physical activity, each of which more than doubled the risk of persistent bathing disability. After the potential precipitants were added to the final model, the associations between the predisposing factors and persistent bathing disability were only modestly diminished. The effects of the precipitants on persistent bathing disability were large, with multivariable hazard ratios of 24.6 for hospitalization and 3.01 for restricted activity only. The relative contributions of the predisposing factors and precipitants to the development of persistent bathing disability were 47.7% and 27.1%, respectively.

CONCLUSION

Disability in bathing is attributable to a combination of predisposing factors that make community-living older persons vulnerable and intervening illnesses or injuries that act as precipitants. These factors and precipitants may be suitable targets for the prevention of bathing disability.