A trial of annual in-home comprehensive geriatric assessments for elderly people living in the community

[Feasibility, Reliability, and Validity of the VIG-Express Questionnaire as an Instrument for Rapid Multidimensional Geriatric Assessment: A Multicenter Study]

OBJECTIVE

To evaluate the feasibility, reliability and validity of the VIG-express questionnaire.

DESIGN

Descriptive, observational, cross-sectional and multicenter study.

SETTING

Catalonia.

PARTICIPANTS

24 professionals from 18 centers: 10 from Primary Care, 5 from hospitals acute, 2 intermediate care and 3 residential.

MAIN MEASUREMENTS

For the feasibility analysis, the administration time -mean and standard deviation (SD)-. The questionnaire was administered twice to the same patient by the same professional (intraobserver agreement), or by two different professionals (interobserver agreement), evaluating the intraclass correlation coefficient (ICC). Discriminant validity was calculated by comparing the responses of subgroup with higher fragility (percentile >75) and subgroup with lower fragility (percentile <25), for each item of the questionnaire.

RESULTS

195 questionnaires were administered, 59 repeatedly, in a group of elderly (mean age of 79 years) and fragile (mean score of 0.33 in the Fragile Index-VIG). The average administration time was 6.52minutes (DE: 6.02). The concordance in the degree of fragility score obtained a ICC of 0.95 (intraobserver) and 0.72 (interobserver). In discriminant validity, the differences in response frequencies between the two subgroups ranged from 1.7 (oncological disease) to 67.1 (medication management), all of which were statistically significant (p<0.05), with the sole exceptions of the presence of oncological and neurological diseases.

CONCLUSIONS

The VIG-express questionnaire appears to be a feasible, reliable and valid tool for rapid multidimensional/geriatric assessment.

Disparities in Rehabilitation Services for Victims of Violence

INTRODUCTION

Access to rehabilitation services after a traumatic injury improves functional outcomes. No study has examined the association between injury intent, violent versus nonviolent, and receipt of rehabilitation services after injury.

MATERIALS AND METHODS

We conducted a retrospective cohort study of injured adult patients admitted to our level I trauma center from January 1, 2014 to December 31, 2021. The primary exposure was violent injury, and the primary outcome was receipt of rehabilitation services upon discharge. An exploratory subgroup analysis evaluated differences in recommended disposition and the reasons for rejection from services.

RESULTS

Among 7500 patients, 1677 (22.4%) were violently injured and 5823 (77.6%) were nonviolently injured. Patients were 45% White, 67% male, and 52% had public insurance. Adjusting for age, sex, race, ethnicity, injury severity score, insurance, and length of stay, violently injured patients were 77% less likely to receive inpatient rehabilitation (relative risk ratio 0.23 95% confidence interval [0.18, 0.30], P < 0.001) and 46% less likely to have home services (relative risk ratio 0.54, 95% confidence interval[0.43, 0.69], P < 0.001). A subgroup analysis (n = 328) demonstrated that violently injured patients were more likely to have a downgrade in discharge recommendation (27.8% versus 9.4%, P = 0.04) and more likely to have an emergency department visit within 30 d (32.0% versus 13.3%, P < 0.001).

CONCLUSIONS

Violent injury is associated with lower likelihood of receiving rehabilitation services. Subgroup analysis indicates this finding associated with facilities' selection bias, and this warrants additional study. Efforts should focus on protecting victims of violence from discrimination during the rehabilitation screening process.

How to make a shared decision with older persons for end-stage kidney disease treatment: the added value of geronto-nephrology

Improving care for older people with end-stage kidney disease (ESKD) requires the adaptation of standards to meet their needs. This may be complex due to their heterogeneity in terms of multimorbidity, frailty, cognitive decline and healthcare priorities. As benefits and risks are uncertain for these persons, choosing an appropriate treatment is a daily challenge for nephrologists. In this narrative review, we aimed to describe the issues associated with healthcare for older people, with a specific focus on decision-making processes; apply these concepts to the context of ESKD; identify components and modalities of shared decision-making and suggest means to improve care pathways. To this end, we propose a geronto-nephrology dynamic, described here as the necessary collaboration between these specialties. Underscoring gaps in the current evidence in this field led us to suggest priority research orientations.

Development and Validation of PRE-SARC (PREdiction of SARCopenia Risk in Community Older Adults) Sarcopenia Prediction Model

OBJECTIVE

Reliable identification of high-risk older adults who are likely to develop sarcopenia is essential to implement targeted preventive measures and follow-up. However, no sarcopenia prediction model is currently available for community use. Our objective was to develop and validate a risk prediction model for calculating the 1-year absolute risk of developing sarcopenia in an aging population.

METHODS

One prospective population-based cohort of non-sarcopenic individuals aged 60 years or older were used for the development of a sarcopenia risk prediction model and model validation. Sarcopenia was defined according to the 2019 Asian Working Group for Sarcopenia consensus. Stepwise logistic regression was used to identify risk factors for sarcopenia incidence within a 1-year follow-up. Model performance was evaluated using the area under the receiver operating characteristics curve (AUROC) and calibration plot, respectively.

RESULTS

The development cohort included 1042 older adults, among whom 87 participants developed sarcopenia during a 1-year follow-up. The PRE-SARC (PREdiction of SARCopenia Risk in community older adults) model can accurately predict the 1-year risk of sarcopenia by using 7 easily accessible community-based predictors. The PRE-SARC model performed well in predicting sarcopenia, with an AUROC of 87% (95% CI, 0.83-0.90) and good calibration. Internal validation showed minimal optimism, with an adjusted AUROC of 0.85. The prediction score was categorized into 4 risk groups: low (0%-10%), moderate (>10%-20%), high (>20%-40%), and very high (>40%). The PRE-SARC model has been incorporated into an online risk calculator, which is freely accessible for daily clinical applications (https://sarcopeniariskprediction.shinyapps.io/dynnomapp/).

CONCLUSIONS

In community-dwelling individuals, the PRE-SARC model can accurately predict 1-year sarcopenia incidence. This model serves as a readily available and free accessible tool to identify older adults at high risk of sarcopenia, thereby facilitating personalized early preventive approaches and optimizing the utilization of health care resources.

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.

The effectiveness of preventive home visits on resilience and health-related outcomes among community dwelling older adults: A systematic review

BACKGROUND

This research aimed to assess the effectiveness of preventive home visits (PHVs) in enhancing resilience and health-related outcomes among older adults living in the community.

METHODS

A comprehensive literature search was conducted in nine databases (PubMed, MEDLINE, CINAHL, Embase, Emcare, Web of Science (WOS), Scopus, PsycINFO and Cochrane Library. The search was undertaken between March 15 and 31, 2022 with subsequent updates performed on October 15, 2023 and April 10, 2024. This review also included grey literature sourced via Google, Google Scholar and backward citation searches.

RESULTS

Out of 5,621 records, 20 articles were found to meet the inclusion criteria with a total of 8,035 participants involved and the mean age ranged from 74.0 to 84.4 years. Using McMaster Critical Review Form for Quantitative Studies, we ascertained that the studies included in our analysis had moderate to high levels of quality. In addition to health-related outcomes, PHV interventions were also conducted to evaluate psychological effects (16 studies) and social outcomes (seven studies). Five studies conducted financial assessment to evaluate the costs of health and social care utilisation during PHV interventions. Regarding the results of the review, seven studies showed favourable outcomes, five indicated no effect and eight had equivocal findings. Only one study assessed resilience and determined that PHV had no effect on the resilience of the subjects.

CONCLUSION

This review found that the effectiveness of PHV interventions was uncertain and inconclusive. PHV interventions often prioritise health-related objectives. The incorporation of a holistic approach involving psychosocial health into PHV interventions is relatively uncommon. Due to the paucity of research on resilience as PHV outcome, we are unable to draw a conclusion on the effectiveness of PHV on resilience. Resilience should be prioritised as a psychological assessment in the future development of comprehensive PHV interventions, as it enables older adults to adapt, manage, and respond positively to adversities that may arise with age. Performing financial analysis such as costs and benefits analysis to incorporate the return on investment of PHV interventions is an added value for future research on this topic.

CLINICAL TRIAL REGISTRATION

PROSPERO registration number: CRD42022296919.

Community based complex interventions to sustain independence in older people: systematic review and network meta-analysis

OBJECTIVE

To synthesise evidence of the effectiveness of community based complex interventions, grouped according to their intervention components, to sustain independence for older people.

DESIGN

Systematic review and network meta-analysis.

DATA SOURCES

Medline, Embase, CINAHL, PsycINFO, CENTRAL, clinicaltrials.gov, and International Clinical Trials Registry Platform from inception to 9 August 2021 and reference lists of included studies.

ELIGIBILITY CRITERIA

Randomised controlled trials or cluster randomised controlled trials with ≥24 weeks' follow-up studying community based complex interventions for sustaining independence in older people (mean age ≥65 years) living at home, with usual care, placebo, or another complex intervention as comparators.

MAIN OUTCOMES

Living at home, activities of daily living (personal/instrumental), care home placement, and service/economic outcomes at 12 months.

DATA SYNTHESIS

Interventions were grouped according to a specifically developed typology. Random effects network meta-analysis estimated comparative effects; Cochrane's revised tool (RoB 2) structured risk of bias assessment. Grading of recommendations assessment, development and evaluation (GRADE) network meta-analysis structured certainty assessment.

RESULTS

The review included 129 studies (74 946 participants). Nineteen intervention components, including "multifactorial action from individualised care planning" (a process of multidomain assessment and management leading to tailored actions), were identified in 63 combinations. For living at home, compared with no intervention/placebo, evidence favoured multifactorial action from individualised care planning including medication review and regular follow-ups (routine review) (odds ratio 1.22, 95% confidence interval 0.93 to 1.59; moderate certainty); multifactorial action from individualised care planning including medication review without regular follow-ups (2.55, 0.61 to 10.60; low certainty); combined cognitive training, medication review, nutritional support, and exercise (1.93, 0.79 to 4.77; low certainty); and combined activities of daily living training, nutritional support, and exercise (1.79, 0.67 to 4.76; low certainty). Risk screening or the addition of education and self-management strategies to multifactorial action from individualised care planning and routine review with medication review may reduce odds of living at home. For instrumental activities of daily living, evidence favoured multifactorial action from individualised care planning and routine 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: combined activities of daily living training, aids, and exercise; and combined activities of daily living training, aids, education, exercise, and multifactorial action from individualised care planning and routine review with medication review and self-management strategies. For personal activities of daily living, evidence favoured combined exercise, multifactorial action from individualised care planning, and routine review with medication review and self-management strategies (0.16, -0.51 to 0.82; low certainty). For homecare recipients, evidence favoured addition of multifactorial action from individualised care planning and routine review with medication review (0.60, 0.32 to 0.88; low certainty). High risk of bias 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.

CONCLUSIONS

The intervention most likely to sustain independence is individualised care planning including medicines optimisation and regular follow-up reviews resulting in multifactorial action. Homecare recipients may particularly benefit from this intervention. Unexpectedly, some combinations may reduce independence. Further research is needed to investigate which combinations of interventions work best for different participants and contexts.

REGISTRATION

PROSPERO CRD42019162195.

The impact of age-related syndromes on ICU process and outcomes in very old patients

In this narrative review, we describe the most important age-related "syndromes" found in the old ICU patients. The syndromes are frailty, comorbidity, cognitive decline, malnutrition, sarcopenia, loss of functional autonomy, immunosenescence and inflam-ageing. The underlying geriatric condition, together with the admission diagnosis and the acute severity contribute to the short-term, but also to the long-term prognosis. Besides mortality, functional status and quality of life are major outcome variables. The geriatric assessment is a key tool for long-term qualitative outcome, while immediate severity accounts for acute mortality. A poor functional baseline reduces the chances of a successful outcome following ICU. This review emphasises the importance of using a geriatric assessment and considering the older patient as a whole, rather than the acute illness in isolation, when making decisions regarding intensive care treatment.

Complex interventions for improving independent living and quality of life amongst community-dwelling older adults: a systematic review and meta-analysis

BACKGROUND

community-based complex interventions for older adults have a variety of names, including Comprehensive Geriatric Assessment, but often share core components such as holistic needs assessment and care planning.

OBJECTIVE

to summarise evidence for the components and effectiveness of community-based complex interventions for improving older adults' independent living and quality of life (QoL).

METHODS

we searched nine databases and trial registries to February 2022 for randomised controlled trials comparing complex interventions to usual care. Primary outcomes included living at home and QoL. Secondary outcomes included mortality, hospitalisation, institutionalisation, cognitive function and functional status. We pooled data using risk ratios (RRs) or standardised mean differences (SMDs) with 95% confidence intervals (CIs).

RESULTS

we included 50 trials of mostly moderate quality. Most reported using holistic assessment (94%) and care planning (90%). Twenty-seven (54%) involved multidisciplinary care, with 29.6% delivered mainly by primary care teams without geriatricians. Nurses were the most frequent care coordinators. Complex interventions increased the likelihood of living at home (RR 1.05; 95% CI 1.00-1.10; moderate-quality evidence) but did not affect QoL. Supported by high-quality evidence, they reduced mortality (RR 0.86; 95% CI 0.77-0.96), enhanced cognitive function (SMD 0.12; 95% CI 0.02-0.22) and improved instrumental activities of daily living (ADLs) (SMD 0.11; 95% CI 0.01-0.21) and combined basic/instrumental ADLs (SMD 0.08; 95% CI 0.03-0.13).

CONCLUSIONS

complex interventions involving holistic assessment and care planning increased the chance of living at home, reduced mortality and improved cognitive function and some ADLs.

In-home Visits and Subsequent Health Outcomes in Medicare Advantage Beneficiaries With Coronary Artery Disease, Diabetes, Hypertension, and Depression

BACKGROUND

Coronary artery disease, diabetes, hypertension, and depression are common burdensome conditions.

OBJECTIVES

To examine whether multidimensional preventive in-home visits were associated with fewer emergency and inpatient care episodes and higher quality of care.

RESEARCH DESIGN

An observational, retrospective data analysis.

SUBJECTS

A nationwide Medicare Advantage population from the Optum Labs Data Warehouse.

MEASURES

We compared beneficiaries with 1 or more of the conditions with an in-home visit in 2018 ("Exposure") with those without a visit in 2018 but with a future visit in 2019 ("Wait List Control") using a difference-in-differences analysis. Primary outcomes were 1-year all-cause inpatient care and emergency visit counts. Secondary outcomes included primary care visits, major adverse cardiovascular events, and select quality-of-care metrics. An exploratory outcome was the time-to-first primary care visit after the index date.

RESULTS

Among those eligible to receive an in-home visit, a total of 48,566 patients had an in-home visit in 2018 (the "Exposure" group), and 36,549 beneficiaries constituted the "Wait List" control group. Receiving an in-home visit early was associated with a greater decrease in inpatient stays for all 4 conditions (change score range for any stay: -5.22% to -2.47%) (P<0.001, depression <0.05); decrease in emergency visits (change score range for any stay: -4.39% to -3.67%) (P<0.0.001, depression <0.05); and fewer major adverse cardiovascular events for coronary artery disease and depression (P<0.001 and <0.025, respectively) 1 year later. Minimal differences were noted for change in ambulatory and primary care visits, with no consistent increase in quality-of-care metrics. Time-to-first primary care visit was shorter for the "Exposure" versus the Wait List control group in all conditions (difference between 2.45 and 4.95 d).

CONCLUSIONS

The feasibility and impact of a nationwide multidimensional preventive in-home visit were demonstrated, targeting common and high morbidity conditions. Benefits were observed against a Wait List control group, resulting in less resource-intense care.

Effectiveness of home visit nursing on improving mortality, hospitalization, institutionalization, satisfaction, and quality of life among older people: Umbrella review

This umbrella review followed the JBI methodology and synthesized systematic reviews of the effectiveness of long-term home visit nursing for older people (≥ 60 years) on improving mortality, hospitalization, institutionalization, patient satisfaction, and quality of life. Eight bibliographic databases were searched, and 10 reviews with 22 distinct relevant trials (n = 10,765 participants) were included. Mortality was the most frequently examined outcome and satisfaction was the least examined (n = nine and one reviews, respectively). Home visit nursing had a favorable effect on reducing the number of admissions to hospital (n = 1,152 participants in two trials vs. 788 participants in three trials) and no effect on other outcomes. The evidence of the effectiveness of long-term home visit nursing for older people is minimal. Future research needs to be based on a theoretical foundation that explains how interventions are expected to work.

Comparison of the predictive value of intrinsic capacity and comorbidity on adverse health outcome in community-dwelling older adults

OBJECTIVES

To compare the predictive value of intrinsic capacity (IC) and comorbidity on all-cause mortality and falls.

METHODS

This prospective cohort study included 220 older adults (84.0±4.4 years) followed for 3 years in a community in Beijing. The methodology recommended by the World Health Organization was used to assess IC, and comorbidity was assessed by the Cumulative Illness Rating Scale for Geriatrics.

RESULTS

The areas under the characteristic curve of IC and comorbidity were 0.78 vs. 0.67 (p=0.033), respectively, in predicting all-cause mortality, and 0.69 vs. 0.61 in predicting falls (p=0.032). The vitality domain impairment (odds ratio [OR]=3.28, p=0.013), and cognition domain impairment (OR=3.97, p=0.004) were significantly associated with all-cause mortality. Locomotion domain impairment (OR=2.35, p=0.010) was associated with higher fall risk.

CONCLUSION

IC might be a better predictor than comorbidity in community-dwelling older adults, in which the vitality, locomotion and cognition domains should be given more attention.

Dining comfort in elderly care facility dining rooms and influencing factors before and after the outbreak of the COVID-19 pandemic

Introduction

The COVID-19 pandemic has changed dining modes in elderly care facilities. This study explores the relationship between the dining environment of four elderly care facilities and the sensitivity of the elderly residents to it before and after the outbreak of the COVID-19 pandemic.

Methods

The study examined differences in subjective comfort levels by measuring the facilities' physical environment, analysing dining behavior, and surveying the elderly residents. And the study examined how the interaction between the physical environment factors, demographic factors, and dining mode affected the residents' evaluation of their dining comfort.

Results

(1) The physical environmental parameters of the four dining rooms differed between the pre- and post-epidemic periods, as shown by increased Sound Pressure Level (SPL), humidity, and temperature levels. (2) The residents' evaluations of physical environment comfort also changed after the outbreak of the COVID-19 pandemic. The subjective comfort levels of the 'dining with baffle' and 'dining across a seat' modes decreased, though the level of the former was slightly higher than that of the latter. The elderly had stronger SPL tolerance in the dining with baffle mode and dining across a seat mode, and their subjective comfort levels for thermal environment and air quality were higher in the dining across a seat mode. (3) When dining time, crowd density, and communication frequency were kept equal, the subjective comfort level of the elderly in the dining with baffle mode and dining across a seat mode was lower than that in the 'normal' dining mode, when the level in the dining with baffle mode was lower than that in the dining across a seat mode. (4) Differences were observed in subjective comfort levels according to age, education level, and residence duration across the dining modes.

Discussion

The need for changes in dining modes during the COVID-19 isolation period require dining rooms in elderly care facilities to design their physical environments in a way that improves dining comfort for the elderly.

Impact of community care services on the health of older adults: evidence from China

Introduction

The rapid growth in the population of older adults has put tremendous pressure on medical and social services in countries including China. Community care services are a feasible solution for promoting healthy aging in developing countries. This study investigated the association between community care services and the health of older adults in China.

Method

Using nationally representative survey data from China, consisting of four waves conducted in 2005, 2008, 2011, and 2014, a balanced panel dataset was constructed using a sample of 4,700 older adults (33.1% aged 80 years or older, 51.0% residing in rural areas, and 48.8% women). We employed linear regression models with time-fixed effects and instrumental variable approaches to estimate the effect of community care services on the health of older adults, as well as the differences in these effects across subgroups.

Results

The results showed that community care services lead to a significant improvement in both the objective and subjective health and wellbeing of older adults. Among the various service offerings, spiritual recreation services led to a significant increase in both objective and subjective health scores, while medical care services significantly improved wellbeing. This suggests a varied effect of subdivided service types. Further evidence suggests that spiritual recreation services have a significant health-enhancing effect on multiple groups of older adults, and the effect of medical care services is more effective for those living in rural areas, women, and those who are older than 80 years (all p < 0.05).

Discussion

Few studies have examined the impact of community care services on the health of older adults in developing countries. The findings present important implications for improving the health status of older adults and provide suggestions for establishing a socialized aged care system in China.

Home-based primary care visits by nurse practitioners

BACKGROUND

With rapidly growing numbers of homebound older adults, the need for effective home-based health interventions is increasingly recognized. Advanced practice registered nurses (NPs) are one of the most common providers of home-based primary care. Limited information is available to address the scope and nature of NP-led home-based primary care and associated outcomes.

OBJECTIVE

To synthesize research evidence of NP visits in home-based primary care.

DATA SOURCES

Six electronic databases-PubMed, Cumulative Index to Nursing and Allied Health Literature, Embase, Cochrane, Web of Science, and Scopus-were searched to identify peer-reviewed research articles addressing home-based primary care interventions led by NPs. Independent screening resulted in 17 relevant articles from 14 unique studies to include in the review.

CONCLUSIONS

Nurse practitioners provided health assessments, education, care planning and coordination primarily by face-to-face home visits. Despite a variability in terms of study design, setting, and sample, NP-led home-based primary care was in general associated with less hospitalization and fewer emergency department visits. Evidence was mixed in relation to patient-reported outcomes such as subjective health, functional status, and symptoms. Costs and patient or caregiver satisfaction were additional outcomes addressed, but the findings were inconsistent.

IMPLICATIONS FOR PRACTICE

Recent policy changes to authorize NPs to independently assess, diagnose, and order home care services directly affect how NPs approach home-based primary care programs. Our findings support NP-led home-based primary care to decrease consequential health utilization and suggest the need for further evaluating the care models in diverse populations with more patient-reported and caregiver outcomes.

Indoor Environmental Quality of Residential Elderly Care Facilities in Northeast China

The indoor environmental quality is based on the indoor environmental performance of buildings, such as air temperature, lighting, and acoustics. These parameters have a specific impact on users' health and experience. This study explores the relationship between the indoor environment of residential elderly care facilities in cold regions and the sensitivity of the elderly to these facilities with the aim of improving the elderly care environment. This study measured the acoustic, lighting, and thermal environment in four residential elderly care facilities in Northeast China in spring, summer, autumn, and winter through a participant survey. In the residential elderly care facilities surveyed in this study, brightness and illuminance show a nonlinear relationship with lighting evaluation. With an increase in brightness and illuminance, the satisfaction of the lighting environment in different seasons first increases and then decreases. The relative humidity of the different types of rooms varies greatly in spring and less in winter. The average air quality score of the bedroom is higher than that of the activity room. The correlation between odor assessment and overall indoor environmental quality is very poor. The results of the questionnaire survey indicate that the participants were satisfied with the facilities' overall indoor environmental quality. This quality is affected by physical, environmental, and demographic factors. This study provides a reference for the design of other residential elderly care facilities.

Comprehensive Geriatric Assessment for community-dwelling, high-risk, frail, older people

BACKGROUND

Comprehensive Geriatric Assessment (CGA) is a multidimensional interdisciplinary diagnostic process focused on determining an older person's medical, psychological and functional capability in order to develop a co-ordinated and integrated care plan. CGA is not limited simply to assessment, but also directs a holistic management plan for older people, which leads to tangible interventions. While there is established evidence that CGA reduces the likelihood of death and disability in acutely unwell older people, the effectiveness of CGA for community-dwelling, frail, older people at risk of poor health outcomes is less clear.

OBJECTIVES

To determine the effectiveness of CGA for community-dwelling, frail, older adults at risk of poor health outcomes in terms of mortality, nursing home admission, hospital admission, emergency department visits, serious adverse events, functional status, quality of life and resource use, when compared to usual care.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL, three trials registers (WHO ICTRP, ClinicalTrials.gov and McMaster Aging Portal) and grey literature up to April 2020; we also checked reference lists and contacted study authors.

SELECTION CRITERIA

We included randomised trials that compared CGA for community-dwelling, frail, older people at risk of poor healthcare outcomes to usual care in the community. Older people were defined as 'at risk' either by being frail or having another risk factor associated with poor health outcomes. Frailty was defined as a vulnerability to sudden health state changes triggered by relatively minor stressor events, placing the individual at risk of poor health outcomes, and was measured using objective screening tools. Primary outcomes of interest were death, nursing home admission, unplanned hospital admission, emergency department visits and serious adverse events. CGA was delivered by a team with specific gerontological training/expertise in the participant's home (domiciliary Comprehensive Geriatric Assessment (dCGA)) or other sites such as a general practice or community clinic (community Comprehensive Geriatric Assessment (cCGA)).

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted study characteristics (methods, participants, intervention, outcomes, notes) using standardised data collection forms adapted from the Cochrane Effective Practice and Organisation of Care (EPOC) data collection form. Two review authors independently assessed the risk of bias for each included study and used the GRADE approach to assess the certainty of evidence for outcomes of interest.

MAIN RESULTS

We included 21 studies involving 7893 participants across 10 countries and four continents. Regarding selection bias, 12/21 studies used random sequence generation, while 9/21 used allocation concealment. In terms of performance bias, none of the studies were able to blind participants and personnel due to the nature of the intervention, while 14/21 had a blinded outcome assessment. Eighteen studies were at low risk of attrition bias, and risk of reporting bias was low in 7/21 studies. Fourteen studies were at low risk of bias in terms of differences of baseline characteristics. Three studies were at low risk of bias across all domains (accepting that it was not possible to blind participants and personnel to the intervention). CGA probably leads to little or no difference in mortality during a median follow-up of 12 months (risk ratio (RR) 0.88, 95% confidence interval (CI) 0.76 to 1.02; 18 studies, 7151 participants (adjusted for clustering); moderate-certainty evidence). CGA results in little or no difference in nursing home admissions during a median follow-up of 12 months (RR 0.93, 95% CI 0.76 to 1.14; 13 studies, 4206 participants (adjusted for clustering); high-certainty evidence). CGA may decrease the risk of unplanned hospital admissions during a median follow-up of 14 months (RR 0.83, 95% CI 0.70 to 0.99; 6 studies, 1716 participants (adjusted for clustering); low-certainty evidence). The effect of CGA on emergency department visits is uncertain and evidence was very low certainty (RR 0.65, 95% CI 0.26 to 1.59; 3 studies, 873 participants (adjusted for clustering)). Only two studies (1380 participants; adjusted for clustering) reported serious adverse events (falls) with no impact on the risk; however, evidence was very low certainty (RR 0.82, 95% CI 0.58 to 1.17).

AUTHORS' CONCLUSIONS

CGA had no impact on death or nursing home admission. There is low-certainty evidence that community-dwelling, frail, older people who undergo CGA may have a reduced risk of unplanned hospital admission. Further studies examining the effect of CGA on emergency department visits and change in function and quality of life using standardised assessments are required.

Association of Oncologist-Patient Communication With Functional Status and Physical Performance in Older Adults: A Secondary Analysis of a Cluster Randomized Clinical Trial

IMPORTANCE

The functional status and physical performance of older adults with cancer are underassessed and undertreated despite the high prevalence of impaired functional status and physical performance in this population and their associations with chemotherapy-induced toxic effects and mortality.

OBJECTIVE

To examine the association between providing oncologists with a geriatric assessment (GA) summary with recommendations and having oncologist-patient conversations about functional and physical performance.

DESIGN, SETTING, AND PARTICIPANTS

Data for this secondary analysis were collected from October 29, 2014, to April 28, 2017, for a national cluster randomized clinical trial conducted by the University of Rochester Cancer Center National Cancer Institute Community Oncology Research Program evaluating the effect of a GA intervention on patient satisfaction with communication about aging-related concerns. There were 17 practice clusters in the intervention group and 14 in the usual care group. All 541 participants underwent a GA including standardized functional and physical performance measures and had 1 clinical encounter audio-recorded, transcribed, and blindly coded to categorize conversations by GA domain. Participants were aged 70 years or older, with a stage III or IV solid tumor or lymphoma with palliative treatment intent, and impairment in 1 or more GA domain. Statistical analysis was performed from August 18, 2020, to January 10, 2022.

INTERVENTIONS

Oncologist practices randomized to the intervention received a GA summary and validated recommendations for each patient prior to the audio-recorded clinical encounter.

MAIN OUTCOMES AND MEASURES

The primary analysis of this clinical trial assessed the effect of the intervention on patient satisfaction with oncologist communication about aging-related concerns. This secondary analysis assessed the post hoc hypothesis that the intervention would be associated with an increase in the proportion of patients having conversations with their oncologists and receiving oncologist recommendations specific to functional and physical performance concerns.

RESULTS

A total of 541 patients (276 men [51%]; mean [SD] age, 77.5 [5.2] years [range, 70-96 years]) were analyzed at baseline. Excluding 13 patients without audio recordings, 86% of patients (95% CI, 78%-91%) in the intervention group vs 59% of patients (95% CI, 47%-69%; P < .001) receiving usual care had conversations about functional or physical performance. Conversations were more frequently initiated by oncologists in the intervention group (84%; 95% CI, 77%-90%) than oncologists in the usual care group (58%; 95% CI, 45%-70%; P < .001). Oncologists in the intervention group were more likely to address patients' concerns (43%; 95% CI, 33%-53%) than oncologists in the usual care group (17%; 95% CI, 10%-26%; P < .001).

CONCLUSIONS AND RELEVANCE

In this secondary analysis of a cluster randomized clinical trial, providing oncologists with a GA summary was associated with an increase in the number of oncologist-patient conversations about functional and physical performance-related concerns with recommendations to address these concerns. These findings support the use of the GA summary and recommendations as important tools in caring for older adults with advanced cancer and functional or physical impairments.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02107443.

Use of standardized brief geriatric evaluation compared with routine care in general practice for preventing functional decline: a pragmatic cluster-randomized trial

BACKGROUND

Although assessment of geriatric syndromes is increasingly encouraged in older adults, little evidence exists to support its systematic use by general practitioners (GPs). The aim of this study was to determine whether a systematic geriatric evaluation performed by GPs can prevent functional decline.

METHODS

We conducted a controlled, open-label, pragmatic cluster-randomized trial in 42 general practices in Switzerland. Participating GPs were expected to enrol an average of 10 community-dwelling adults (aged ≥ 75 yr) who understood French, and had visited their GP at least twice in the previous year. The intervention consisted of yearly assessment by the GP of 8 geriatric syndromes with an associated tailored management plan according to assessment results, compared with routine care. Our primary outcomes were the proportion of patients who lost at least 1 instrumental activity of daily living (ADL) and the proportion who lost at least 1 basic ADL, over 2 years. Our secondary outcomes were quality-of-life scores, measured using the older adult module of the World Health Organization Quality of Life Instrument, and health care use.

RESULTS

Forty-two GPs recruited 429 participants (63% women) with a mean age of 82.5 years (standard deviation 4.8 yr) at time of recruitment. Of these, we randomly assigned 217 participants to the intervention and 212 to the control arm. The proportion of patients who lost at least 1 instrumental ADL in the intervention and control arms during the course of the study was 43.6% and 47.6%, respectively (risk difference -4.0%, 95% confidence interval [CI] -14.9% to 6.7%, p = 0.5). The proportion of patients who lost at least 1 basic ADL was 12.4% in the intervention arm and 16.9% in the control arm (risk difference -5.1%, 95% CI -14.3% to 4.1%, p = 0.3).

INTERPRETATION

A yearly geriatric evaluation with an associated management plan, conducted systematically in GP practices, does not significantly lessen functional decline among community-dwelling, older adult patients, compared with routine care.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02618291.

The impact of community care services on the preference for ageing in place in urban China

This paper examines the relationship between community care services and ageing in place in urban China. Using data from the 2010 Sample Survey on Aged Population in Urban/Rural China, and within the framework of a revised version of Andersen's model, the paper applies multilevel models and analyses the effects of community care on the preference between ageing in place and institutional care, and reveals that ageing in place is preferred even in urban China. However, the existence of community care services had no significant effect on the preference for ageing in place. The paper concludes by arguing that China needs to develop its community care services and promote the idea of community care in both culture and policy. Realising ageing in place also requires a multidisciplinary approach. A model of shared care, between family and state, is particularly appropriate for China.

Discerning rural Appalachian stakeholder attitudes toward memory screening

OBJECTIVE

The aim of this descriptive study was to examine Appalachian stakeholder attitudes toward routine memory screening, and to compare and contrast results from a similar study conducted in an ethnically diverse rural Florida cohort. Determining perceptions about memory screening is essential prior to developing culturally relevant programs for increasing early dementia detection and management among rural underserved older adults at risk of cognitive impairment. Benefits of early detection include ruling out other causes of illness and treating accordingly, delaying onset of dementia symptoms through behavior management and medications, and improving long-term care planning (Dubois, Padovani, Scheltens, Rossi, & Dell'Agnello, 2016). These interventions can potentially help to maintain independence, decrease dementia care costs, and reduce family burdens (Frisoni, et al., 2017).

METHOD

Researchers applied a parallel mixed method design (Tashakkori & Newman, 2010) of semi-structured interviews, measurements of health literacy (REALM-SF) (Arozullah, et al., 2007), sociodemographics, and cognitive screening perceptions (PRISM-PC) (Boustani, et al., 2008), to examine beliefs and attitudes about memory screening among 22 FL and 21 WV rural stakeholders (residents, health providers, and administrators).

RESULTS

Findings included that > 90% participants across both cohorts were highly supportive of earlier dementia detection through routine screening regardless of sample characteristics. However, half of those interviewed were doubtful that provider care or assistance would be adequate for this terminal illness. Despite previous concerns of stigma associated with an Alzheimer's disease diagnosis, rural providers are encouraged to educate patients and community members regarding Alzheimer's disease and offer routine cognitive screening and follow-through.

Detecting dementia among older, ethnically diverse residents of rural subsidized housing

Rural, ethnically diverse residents face at least twice the risk of Alzheimer's disease than urban residents. Chronic diseases such as diabetes and hypertension which increase dementia risk are more prevalent in rural areas with less access to specialty providers. A home-based approach for increasing dementia detection and treatment rates was tested among rural residents of government-assisted independent living facilities (N = 139; 78% non-White, and 70% with health literacy below 5th grade). Of 28 residents identified at risk during cognitive screening, 25 agreed to further in-depth assessment by adult gerontological nurse practitioners (AGNP). Fifteen of 25 (60%) completing consequent primary provider referrals were diagnosed with dementia and receiving new care (statistically significant; [χ2(1) = 76.67, p < .001, Phi = 0.743]). Home-based dementia management through a community engagement approach can help to meet the Healthy People 2030 goals of earlier detection and treatment and reduce the length of costly institutionalizations.

Utilisation of general practice health assessments around an aged care assessment is associated with lower mortality risk in older Australians

OBJECTIVE

(i) to describe the general practitioner utilisation of health assessments, management plans, coordination of team care arrangements and medication review item numbers within 6 months of an aged care eligibility assessment for home care packages (HCP) and (ii) investigate the impact of health assessments on the risk of mortality and entry into permanent residential aged care (PRAC) of individuals accessing HCP.

DESIGN AND SETTING

retrospective cohort study utilising data from the Registry of Senior Australians (ROSA) was conducted.

SUBJECTS

75,172 individuals aged ≥75 years who received HCP between 2011 and 2015.

OUTCOME MEASURE

for objective 1: the use of comprehensive assessments (Medicare Benefits Schedule (MBS) items 705 or 707), management plans (MBS 721), coordination of team care arrangements (MBS 723), and medication reviews (MBS 900). For objective 2: time to death and entry into PRAC.

RESULTS

of the 75,172 individuals, 28.2% (95% confidence interval (CI): 27.8-8.5%) had comprehensive assessments, 36.7% (95% CI: 36.3-37.0%) had management plans, 33.0% (95% CI: 32.7-33.3%) received coordination of team care arrangements and 5.4% (95% CI: 5.2-5.5%) had medication reviews. Individuals with a comprehensive assessment had a 5% lower risk of mortality (adjusted hazard ratio (aHR), 95% CI = 0.95, 0.92-0.98) but 5% higher risk of transition to PRAC (adjusted subdistribution HRs, 95% CI = 1.05, 1.02-1.08) compared to those who did not have these services.

CONCLUSION

the utilisation of health assessments was associated with a lower risk of mortality. There is an opportunity for increased use of item numbers in frailer individuals.

Comprehensive geriatric assessment in older adults with cancer: Recommendations by the Italian Society of Geriatrics and Gerontology (SIGG)

INTRODUCTION

Optimizing the approach to older adults with cancer is now a priority given the increasing frequency of new cancer diagnoses that are made in the older population. The comprehensive geriatric assessment (CGA) represents the gold-standard for (1) defining prognosis and ability to withstand cancer treatments, (2) exploring the multiple aspects that define the complexity of frail older persons, and (3) designing person-tailored interventions.

MATERIALS AND METHODS

In this document, based on a comprehensive revision of the literature, the Italian Society for Geriatrics and Gerontology proposes a CGA model (ONCOGER CGA) to be adopted by oncology centers for their routine approach to older patients with cancer.

RESULTS AND DISCUSSION

A widespread use of this standardized CGA format will facilitate comparisons across institutions, promote studies based on a multidimensional patient assessment, and foster the inclusion of geriatric endpoints in oncological clinical trials. Furthermore, we predict that the use of a standardized CGA approach will increase the integration of geriatricians into oncology care teams with the final result of improving therapeutic choices and clinical outcomes.

External validation of the detection of indicators and vulnerabilities for emergency room trips (DIVERT) scale: a retrospective cohort study

Background

The Detection of Indicators and Vulnerabilities of Emergency Room Trips (DIVERT) scale was developed to classify and estimate the risk of emergency department (ED) use among home care clients. The objective of this study was to externally validate the DIVERT scale in a secondary population of home care clients.

Methods

We conducted a retrospective cohort study, linking data from the Home Care Reporting System and the National Ambulatory Care Reporting System. Data were collected on older long-stay home care clients who received a RAI Home Care (RAI-HC) assessment. Data were collected for home care clients in the Canadian provinces of Ontario and Alberta, as well as in the cities of Winnipeg, Manitoba and Whitehorse, Yukon Territories between April 1, 2011 and September 30, 2014. The DIVERT scale was originally derived from the items of the RAI-HC through the use of recursive partitioning informed by a multinational clinical panel. This scale is currently implemented alongside the RAI-HC in provinces across Canada. The primary outcome of this study was ED visitation within 6 months of a RAI-HC assessment.

Results

The cohort contained 1,001,133 home care clients. The vast majority of cases received services in Ontario (88%), followed by Alberta (8%), Winnipeg (4%), and Whitehorse (< 1%). Across the four cohorts, the DIVERT scale demonstrated similar discriminative ability to the original validation work for all outcomes during the six-month follow-up: ED visitation (AUC = 0.617–0.647), two or more ED visits (AUC = 0.628–0.634) and hospital admission (AUC = 0.617–0.664).

Conclusions

The findings of this study support the external validity of the DIVERT scale. More specifically, the predictive accuracy of the DIVERT scale from the original work was similar to the accuracy demonstrated within a new cohort, created from different geographical regions and time periods.

The outcomes of nurse practitioner (NP)-Provided home visits: A systematic review

Background

With the shortage of primary care providers to provide home-based care to the growing number of homebound older adults in the U.S. Nurse Practitioners (NPs) are increasingly utilized to meet the growing demand for home-based care and are now the largest type of primary care providers delivering home-visits.

Purpose

The purpose of this study was to systematically examine the current state of the evidence on health and healthcare utilization outcomes associated with NP-home visits.

Method

Five Databases (PubMed, EMBASE, Cumulative Index to Nursing and Allied Health Literature and the Cochrane Library) were systematically searched to identify studies examining NP-home visits. The search focused on English language studies that were published before April 2019 and sought to describe the outcomes associated with NP-home visits. We included experimental and observational studies.  Quality appraisal was performed with the Kmet, Lee & Cook tool, and results summarized qualitatively. The impact of NP-home visits on clinical (functional status, quality of life [QOL]), and healthcare utilization (hospitalization, Emergency department(ED) visits) outcomes was evaluated.

Results/Discussion

A total of 566 citations were identified; 7 met eligibility criteria and were included in the review. The most commonly reported outcomes were emergency department (ED) visits and readmissions. Given the limited number of articles generated by our search and wide variation in intervention and outcomes measures. NP-home visits were associated with reductions in ED visits in 2 out of 3 studies and with reduction in readmissions in 2 out of 4 studies.

Conclusion

Published studies evaluating the outcomes associated with NP-home visits are limited and of mixed quality. Limitations include small sample size, and variation in duration and frequency of NP-home visits. Future studies should investigate the independent effect of NP-home visits on the health outcomes of older adults using large and nationally representative data with more rigorous study design.

Interventions to Prevent or Delay Long-Term Nursing Home Placement for Adults with Impairments-a Systematic Review of Reviews

BACKGROUND

With continued growth in the older adult population, US federal and state costs for long-term care services are projected to increase. Recent policy changes have shifted funding to home and community-based services (HCBS), but it remains unclear whether HCBS can prevent or delay long-term nursing home placement (NHP).

METHODS

We searched MEDLINE (OVID), Sociological Abstracts, PsycINFO, CINAHL, and Embase (from inception through September 2018); and Cochrane Database of Systematic Reviews, Joanna Briggs Institute Database, AHRQ Evidence-based Practice Center, and VA Evidence Synthesis Program reports (from inception through November 2018) for English-language systematic reviews. We also sought expert referrals. Eligible reviews addressed HCBS for community-dwelling adults with, or at risk of developing, physical and/or cognitive impairments. Two individuals rated quality (using modified AMSTAR 2) and abstracted review characteristics, including definition of NHP and interventions. From a prioritized subset of the highest-quality and most recent reviews, we abstracted intervention effects and strength of evidence (as reported by review authors).

RESULTS

Of 47 eligible reviews, most focused on caregiver support (n = 10), respite care and adult day programs (n = 9), case management (n = 8), and preventive home visits (n = 6). Among 20 prioritized reviews, 12 exclusively included randomized controlled trials, while the rest also included observational studies. Prioritized reviews found no overall benefit or inconsistent effects for caregiver support (n = 2), respite care and adult day programs (n = 3), case management (n = 4), and preventive home visits (n = 2). For caregiver support, case management, and preventive home visits, some reviews highlighted that a few studies of higher-intensity models reduced NHP. Reviews on other interventions (n = 9) generally found a lack of evidence examining NHP.

DISCUSSION

Evidence indicated no benefit or inconsistent effects of HCBS in preventing or delaying NHP. Demonstration of substantial impacts on NHP may require longer-term studies of higher-intensity interventions that can be adapted for a variety of settings. Registration PROSPERO # CRD42018116198.

Who Are the People Willing to Pay for Physician Home Visits?

BACKGROUND

Since the recently announced Community Care Policy, there has been an opinion that Korea needs to establish an alternative medical model such as physician home visits. This study aimed to assess the need and willingness to pay (WTP) for physician home visits among the community-dwelling Korean older population and to determine the most important factors that influence older adults to decide to use a physician home visit service.

METHODS

A total of 797 people aged 60 years or older who were randomly selected from a nationwide dataset using a multi-stage stratified sampling method answered a questionnaire on the need and WTP for physician home visits.

RESULTS

A total of 39.3% of participants reported that they would like a physician home visit when they need help. Among older adults who needed physician home visits (n = 313), the WTP amount for physician home visits was 21,982 ± 17,546 KRW. Logit and Tobit regression analyses showed that the higher valuated need and WTP for physician home visits was associated with a lower level of physical/psychosocial functioning measured by EuroQol-five dimensions score (odds ratio [OR], 1.13; 95% confidence interval [CI], 1.01-1.27; P = 0.035) and a higher level of satisfaction when using community-based services such as public health centers (OR, 1.32; 95% CI, 1.02-1.72; P = 0.034), social welfare centers and Gyeong-ro-dang (OR, 1.61; 95% CI, 1.04-2.50; P = 0.033; β = 8.39; standard error, 3.63; P = 0.021).

CONCLUSION

This study provides evidence that the decision to pay for a physician home visit service is based upon the complex interactions among an individual's physical and psychosocial functioning, personal experiences of service utilization, and demographic factors. The value for physician home visits should be qualified based on the empirical data of WTP, which comes from a consumer-centered perspective.

Association of serum adiponectin levels and body mass index with worsening depressive symptoms in elderly individuals: a 10-year longitudinal study

Objectives: Data regarding the association between adiponectin levels and body mass index (BMI) and long-term changes in depressive symptoms are limited and inconsistent. Thus, we investigated whether circulating adiponectin levels and BMI were independently and combinedly correlated to longitudinal changes in depressive symptoms.Methods: This prospective cohort study evaluated 269 elderly Japanese individuals aged ≥70 years who participated in the Tsurugaya Project conducted between 2002 and 2012. A short form of the Geriatric Depression Scale (GDS) was used to assess depressive status. Serum adiponectin levels were measured using an enzyme-linked immunosorbent assay or a latex particle-enhanced turbidimetric immunoassay. BMI was calculated as body weight (kg)/height (m²).Results: Multiple linear regression analysis revealed that baseline serum adiponectin levels were positively associated with changes in GDS scores (β = 0.14, P = 0.035). However, no association was observed after adjusting for BMI (β = 0.09, P = 0.185). Low BMI was associated with increased GDS scores at the 10-year follow-up (β = -0.14, P = 0.033). Participants with a combination of high adiponectin levels and low BMI had a 3.3-fold higher risk of worsening depressive symptoms than those with low adiponectin levels and high BMI (odds ratio: 3.35, 95% confidence interval: 1.60-7.00; P = 0.001).Conclusions: This longitudinal study indicated that high serum adiponectin levels and low BMI were both associated with worsening depressive symptoms among older Japanese individuals. Furthermore, the combination of high adiponectin levels and low BMI was associated with worsening depressive symptoms.

Potentially Avoidable Hospitalization among Long-Term Care Insurance Beneficiaries with Dementia

BACKGROUND

This study investigated the differences in the risk of potentially avoidable hospitalization (PAH) among eligible long-term care insurance (LTCI) beneficiaries with dementia for LTCI services in Korea. Nested case-control study was conducted using the National Health Insurance Service-Senior claim database.

METHODS

Cases of individuals who had a PAH incident diagnosis and controls were selected by incidence density sampling and matched to cases based on age, sex, and difficulty of daily living among dementia patients. We conducted incidence density sampling three times by PAH type.

RESULTS

Our main results were presented by conditional logistic regression analysis for the matched case-control studies. Out of the 7,352 eligible LTCI beneficiary patients, there were 1,231 cases (16.7%) in overall PAH, 132 cases (19.0%) in acute PAH and 1,114 cases (16.7%) in chronic PAH categories. In terms of individual risk of overall and chronic PAH, the odds ratios of those who did not receive any services were 1.336 time higher (95% confidence interval [CI], 1.159-1.540) and 1.280 time higher (95% CI, 1.103-1.485) compared to those who received home care, respectively. For risk of acute PAH, the odds ratios of those who did receive institutional care were 2.046 time higher (95% CI, 1.170-3.578) compared to those who received home care.

CONCLUSION

This study identified the differences in risk of PAH incidents according to the type of LTCI service in the elderly population in Korea. Therefore, it will require substantial effort and strategy from health policy makers to improve care quality.

A Computerized Frailty Assessment Tool at Points-of-Care: Development of a Standalone Electronic Comprehensive Geriatric Assessment/Frailty Index (eFI-CGA)

Background: Frailty is characterized by loss of biological reserves and is associated with an increased risk of adverse health outcomes. Frailty can be operationalized using a Frailty Index (FI) based on the accumulation of health deficits; items under health evaluation in the well-established Comprehensive Geriatric Assessment (CGA) have been used to generate an FI-CGA. Traditionally, constructing the FI-CGA has relied on paper-based recording and manual data processing. As this can be time-consuming and error-prone, it limits widespread uptake of this proven type of frailty assessment. Here, we report the development of an electronic tool, the eFI-CGA, for use on personal computers by frontline healthcare providers, to collect CGA data and automate FI-CFA calculation. The ultimate goal is to support early identification and management of frailty at points-of-care, and make uptake in Electronic Medical Records (EMR) feasible and transparent. Methods: An electronic CGA (eCGA) form was implemented to operate on Microsoft's WinForms platform and coded using C# programming language. Users complete the eCGA form, from which items under the CGA evaluation are automatically retrieved and processed to output an eFI-CGA score. A user-friendly interface and secured data saving methods were implemented. The software was debugged and tested using systematically designed simulation data, addressing different logic, syntax, and application errors, and then tested with clinical assessment. The user manual and manual scoring were used as ground truth to compare eFI-CGA input and automated eFI score calculations. Frontline health-provider user feedback was incorporated to improve the end-user experience. Results: The Standalone eFI-CGA software tool was developed and optimized for use on personal computers. The user interface adapted the design of paper-based CGA form to facilitate familiarity for clinical users. Compared to known scores, the software tool generated eFI-CGA scores with 100% accuracy to four decimal places. The eFI-CGA allowed secure data storage and retrieval of multiple types, including user input, completed eCGA form, coded items, and calculated eFI-CGA scores. It also permitted recording of actions requiring clinical follow-up, facilitating care planning. Application bugs were identified and resolved at various stages of the implementation, resulting in efficient system performance. Discussion: Accurate, robust, and reliable computerized frailty assessments are needed to promote effective frailty assessment and management, as a key tool in health care systems facing up to frailty. Our research has enabled the delivery of the standalone eFI-CGA software technology to empower effective frailty assessment and management by various healthcare providers at points-of-care, facilitating integrated care of older adults.

Implementation of Geriatric Recommendations by Doctors: A Comparison of Models of Geriatric Assessment for Mobile and Home-Ridden Patients

In the present study we assessed the rate of implementation of recommendations given following geriatric assessment for home-ridden patients; a retrospective review of medical records to evaluate the implementation of geriatric recommendations given to patients in the Home Geriatric Service (HGS) between 2015 and 2016. The patients were categorized into two groups: the HGS-clinic (HGS-C) group, in which the primary care physician was responsible for implementation of the recommendations, and the HGS-home care (HGS-H) group, in which the responsibility for implementation of the recommendations was on the geriatrician. The results were compared with the implementation of recommendations in other ambulatory models for mobile patients-Clinic-Based Geriatric Assessment Services (CBGAS). The study included 865 patients. The highest rate of implementation was in the HGS-H group (85.7%), compared with 66.6% in the HGS-C group and 52.7% in the CBGAS group (p < 0.0001). In the logistic regression model for prediction of patients with implementation rates above 75%, the only variable that entered the prediction model was affiliation with the HGS-H group (odds ratio [OR] = 4.8, 95% confidence interval [CI] 2.3-9.6, p < 0.0001) or the HGS-C group (OR = 1.7, 95% CI 1.0-2.9, p = 0.046). The implementation rate for geriatric recommendations is higher for home-ridden patients compared with mobile patients, with the maximum recommendation rate in the subgroup, where geriatricians implemented the recommendations themselves. These findings raise the possibility that the most successful model, in terms of the implementation of recommendations, is the model in which implementation is carried out by the same staff that conducted the assessment.

The Effects of Preventive Home Visits on Older People’s Use of Health Care and Social Services and Related Costs

Background

We use data from a randomized controlled trial on preventive home visits exploring effectiveness on health-related quality of life. In this article, we examine the intervention’s cost-effectiveness and effects on quality-adjusted life years in older home-dwelling adults.

Methods

There were 422 independently home-dwelling participants in the randomized, controlled trial, all aged more than 75 years, with equal numbers in the control and intervention groups. The intervention took place in a municipality in Finland and consisted of multiprofessional preventive home visits. We gathered the data on health care and social services use from central registers and medical records during 1 year before the intervention and 2 years after the intervention. We analyzed the total health care and social services use and costs per person-years and the difference in change in health-related quality of life as measured using the 15D measure. We calculated quality-adjusted life years and incremental cost-effectiveness ratios.

Results

There was no significant difference in baseline use of services or in the total use and costs of health care and social services during the 2-year follow-up between the two groups. In the intervention group, health-related quality of life declined significantly more slowly compared with the control group (–0.015), but there was no significant difference in quality-adjusted life years gained between the groups. The cost-effectiveness plane showed 60% of incremental cost-effectiveness ratios lying in the dominant quadrant, representing additional effects with lower costs.

Conclusions

This multiprofessional preventive home visit intervention appears to have positive effects on health-related quality of life without accruing additional costs.

The clinical trial registration number

ACTRN12616001411437.

Prolonged Wait Time Prior to Entry to Home Care Packages Increases the Risk of Mortality and Transition to Permanent Residential Aged Care Services: Findings from the Registry of Older South Australians (ROSA)

BACKGROUND

Older Australians prefer to live in their own homes for longer and reforms have attempted to increase the volume of home care packages (HCPs) accordingly but there remains a queue with the longer-term consequences unclear.

OBJECTIVES

This study aims to characterise older Australians according to their wait times for a home care package (HCP), evaluate the association between wait time and mortality and evaluate the association between wait time and transition to permanent residential aged care services after HCP.

DESIGN

A retrospective cohort study using data from the National Historical cohort (2003-2014) of the Registry of Older South Australians (ROSA) was conducted.

SETTING

Home based aged care services, national cohort.

METHODS

Wait time was estimated from approval date to date of receiving a HCP. Descriptive, survival estimates (95% confidence intervals (CIs)), and multivariable survival analyses (Cox-regression) were conducted to evaluate the risk of mortality and transition to permanent residential aged care services by quartiles of wait time for HCP.

RESULTS

The cohort was followed for 4.0 years (interquartile range IQR (1.8-7.2)) and 38% were alive at the end of the study period with a median wait time for HCP of 62 (21-187) days. From 178,924 older people who received a HCP during the study period (2003-2013), 33.2% people received HCP within 30 days, 74.3% within 6 months and 25.7% after 6 months. The effect of wait time on risk of mortality was time-dependent, with longer wait times associated with higher mortality in the longer term. Compared to people who waited ≤30 days for a HCP, individuals who waited more than 6 months had an almost 20% excess risk of death (adjusted hazard ratio (aHR), 95%CI = (1.18, 1.16-1.21)) 2 years after entry into a HCP. Those who waited more than 6 months also had a 10% (1.10, 1.06-1.13) higher risk of transition to permanent residential aged care services after two years.

CONCLUSION

Prolonged wait times for HCP is associated with a higher risk of long-term mortality as well as transition to permanent residential aged care. It remains to be seen if a shortening of this wait time translates into better health outcomes.

Practical Assessment and Management of Vulnerabilities in Older Patients Receiving Chemotherapy: ASCO Guideline for Geriatric Oncology

Purpose To provide guidance regarding the practical assessment and management of vulnerabilities in older patients undergoing chemotherapy. Methods An Expert Panel was convened to develop clinical practice guideline recommendations based on a systematic review of the medical literature. Results A total of 68 studies met eligibility criteria and form the evidentiary basis for the recommendations. Recommendations In patients ≥ 65 years receiving chemotherapy, geriatric assessment (GA) should be used to identify vulnerabilities that are not routinely captured in oncology assessments. Evidence supports, at a minimum, assessment of function, comorbidity, falls, depression, cognition, and nutrition. The Panel recommends instrumental activities of daily living to assess for function, a thorough history or validated tool to assess comorbidity, a single question for falls, the Geriatric Depression Scale to screen for depression, the Mini-Cog or the Blessed Orientation-Memory-Concentration test to screen for cognitive impairment, and an assessment of unintentional weight loss to evaluate nutrition. Either the CARG (Cancer and Aging Research Group) or CRASH (Chemotherapy Risk Assessment Scale for High-Age Patients) tools are recommended to obtain estimates of chemotherapy toxicity risk; the Geriatric-8 or Vulnerable Elders Survey-13 can help to predict mortality. Clinicians should use a validated tool listed at ePrognosis to estimate noncancer-based life expectancy ≥ 4 years. GA results should be applied to develop an integrated and individualized plan that informs cancer management and to identify nononcologic problems amenable to intervention. Collaborating with caregivers is essential to implementing GA-guided interventions. The Panel suggests that clinicians take into account GA results when recommending chemotherapy and that the information be provided to patients and caregivers to guide treatment decision making. Clinicians should implement targeted, GA-guided interventions to manage nononcologic problems. Additional information is available at www.asco.org/supportive-care-guidelines .

Implementation of long-term care and hospital utilization: Results of segmented regression analysis of interrupted time series study

This population-based time series study aimed to examine the effects of the long-term care insurance (LTCI) program on hospital utilization in Korea. Health insurance claim data and LTCI data were combined into a database of 92,596 individuals who were enrolled in Health Insurance at baseline. They were made of people who applied to LTCI program at least once since July 2008, and their hospital utilization records since 2002 were observed. Estimates of length of hospital stay (LOS) after the introduction of LTCI program were calculated using a segmented regression analysis. Although average LOS in hospitals implementation was lower pre-implementation period than post-implementation (16.865 days, SD: 4.864; 26.078 days, SD: 2.215, respectively, p < .0001), a decreasing trend was observed along the post-implementation period. The estimate for baseline trend, which reflect a trend in LOS before LTCI implementation, was 0.219 days (p < .0001). The estimate for Level change after intervention which is only indicated as the change of LOS was 2.821 days at the time of LTCI implementation, and was statistically significant (p < .0001). The estimate for Trend change after intervention, reflecting the trend in LOS after LTCI implementation, was -0.313, indicating a decreasing trend in LOS of -0.094 days (p = 0.0055), compared with the baseline trend. LTCI program was significantly associated with a decreasing trend in LOS. The results suggest that the introduction of LTCI program may have played a role in reducing LOS in older adults.

Using Nurse Practitioner Co-Management to Reduce Hospitalizations and Readmissions Within a Home-Based Primary Care Program

Nurse practitioner (NP) co-management involves an NP and physician sharing responsibility for the care of a patient. This study evaluates the impact of NP co-management for clinically complex patients in a home-based primary care program on hospitalizations, 30-day hospital readmissions, and provider satisfaction. We compared preenrollment and postenrollment hospitalization and 30-day readmission rates of home-bound patients active in the Nurse Practitioner Co-Management Program within the Mount Sinai Visiting Doctors Program (MSVD) (n = 87) between January 1, 2012, and July 1, 2013. Data were collected from electronic medical records. An anonymous online survey was administered to all physicians active in the MSVD in July 2013 (n = 13).After enrollment in co-management, patients have lower annual hospitalization rates (1.26 vs. 2.27, p = .005) and fewer patients have 30-day readmissions (5.8% vs. 17.2%, p = .004). Eight of 13 physicians feel "much" or "somewhat" less burned out by their work after implementation of co-management. The high level of provider satisfaction and reductions in annual hospitalization and readmission rates among high-risk home-bound patients associated with NP co-management may yield not only benefits for patients, caregivers, and providers but also cost savings for institutions.

Cost-effectiveness of a multicomponent primary care program targeting frail elderly people

BACKGROUND

Over the last 20 years, integrated care programs for frail elderly people aimed to prevent functional dependence and reduce hospitalization and institutionalization. However, results have been inconsistent and merely modest. To date, evidence on the cost-effectiveness of these programs is scarce. We evaluated the cost-effectiveness of the CareWell program, a multicomponent integrated care program for frail elderly people.

METHODS

Economic evaluation from a healthcare perspective embedded in a cluster controlled trial of 12 months in 12 general practices in (the region of) Nijmegen. Two hundred and four frail elderly from 6 general practices in the intervention group received care according to the CareWell program, consisting of multidisciplinary team meetings, proactive care planning, case management, and medication reviews; 165 frail elderly from 6 general practices in the control group received usual care. In cost-effectiveness analyses, we related costs to daily functioning (Katz-15 change score i.e. follow up score minus baseline score) and quality adjusted life years (EQ-5D-3 L).

RESULTS

Adjusted mean costs directly related to the intervention were €456 per person. Adjusted mean total costs, i.e. intervention costs plus healthcare utilization costs, were €1583 (95% CI -4647 to 1481) higher in the intervention group than in the control group. Incremental Net Monetary Benefits did not show significant differences between groups, but on average tended to favour usual care.

CONCLUSIONS

The CareWell primary program was not cost-effective after 12 months. From a cost-effectiveness perspective, widespread implementation of the program in its current form cannot be recommended.

TRIAL REGISTRATION

The study was registered in the ClinicalTrials.govProtocol Registration System: ( NCT01499797 ; December 26, 2011). Retrospectively registered.

Brief assessments and screening for geriatric conditions in older primary care patients: a pragmatic approach

This paper discusses the rationale behind performing a brief geriatric assessment as a first step in the management of older patients in primary care practice. While geriatric conditions are considered by older patients and health professionals as particularly relevant for health and well-being, they remain too often overlooked due to many patient- and physician-related factors. These include time constraints and lack of specific training to undertake comprehensive geriatric assessment. This article discusses the epidemiologic rationale for screening functional, cognitive, affective, hearing and visual impairments, and nutritional status as well as fall risk and social status. It proposes using brief screening tests in primary care practice to identify patients who may need further comprehensive geriatric assessment or specific interventions.

Breaking the cycle of functional decline in older dialysis patients

Currently, older adults comprise nearly one-third of prevalent US dialysis patients, and this proportion will increase as the population ages. Older dialysis patients experience greater morbidity and mortality than nondialysis patients of the same age, and in part, it is related to progressive functional decline. Progressive functional decline, characterized by need for assistance with more than 2 activities of daily living, contributes to risk of hospitalization, further functional decline, and subsequent nursing home placement when a patient no longer functions independently at home. Progressive functional decline may appear to be unavoidable for older dialysis patients; however, comprehensive geriatric assessment (CGA) may alleviate the prevalence and severity of functional decline. This editorial summarizes common risk factors of functional decline and introduces CGA as a potentially transformative approach to breaking the cycle of functional decline in older dialysis patients.

General recommendations paper on the management of older patients with cancer: the SEOM geriatric oncology task force's position statement

Population aging is associated with greater numbers of older people with cancer. Thanks to treatment advances, not only are more seniors diagnosed with cancer, but there are also more and more older cancer survivors. This upward trend will continue. Given the heterogeneity of aging, managing older patients with cancer poses a significant challenge for Medical Oncology. In Spain, a Geriatric Oncology Task Force has been set up within the framework of the Spanish Society for Medical Oncology (SEOM). With the aim of generating evidence and raising awareness, as well as helping medical oncologists in their training with respect to seniors with cancer, we have put together a series of basic management recommendations for this population. Many of the patients who are assessed in routine clinical practice in Oncology are older. CGA is the basic tool by means of which to evaluate older people with cancer and to understand their needs. Training and the correct use of recommendations regarding treatment for comorbidities and geriatric syndromes, support care, and drug–drug interactions and toxicities, including those of antineoplastic agents, as detailed in this article, will ensure that this population is properly managed.

Does long-term care subsidization reduce hospital admissions and utilization?

We use quasi-experimental evidence on the expansion of the public subsidization of long-term care to examine the causal effect of a change in caregiving affordability on the delivery of hospital care. More specifically, we examine a reform that both introduced a new caregiving allowance and expanded the availability of publicly funded home care services, on both hospital admissions (both on the internal and external margin) and length of stay. We find robust evidence of a reduction in both hospital admissions and utilization among both those receiving a caregiving allowance and, albeit less intensely, among beneficiaries of publicly funded home care, which amounts to 11% of total healthcare costs. These effects were stronger when regions had an operative regional health and social care coordination plan in place. Consistently, a subsequent reduction in the subsidy, five years after its implementation, is found to significantly attenuate such effects. We investigate a number of potential mechanisms, and show a number of falsification and robustness checks.

Community screening for visual impairment in older people

BACKGROUND

Visual problems in older people are common and frequently under-reported. The effects of poor vision in older people are wide reaching and include falls, confusion and reduced quality of life. Much of the visual impairment in older ages can be treated (e.g. cataract surgery, correction of refractive error). Vision screening may therefore reduce the number of older people living with sight loss.

OBJECTIVES

The objective of this review was to assess the effects on vision of community vision screening of older people for visual impairment.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (2017, Issue 10); Ovid MEDLINE; Ovid Embase; the ISRCTN registry; ClinicalTrials.gov and the ICTRP. The date of the search was 23 November 2017.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that compared vision screening alone or as part of a multi-component screening package as compared to no vision screening or standard care, on the vision of people aged 65 years or over in a community setting. We included trials that used self-reported visual problems or visual acuity testing as the screening tool.

DATA COLLECTION AND ANALYSIS

We used standard methods expected by Cochrane. We graded the certainty of the evidence using GRADE.

MAIN RESULTS

Visual outcome data were available for 10,608 people in 10 trials. Four trials took place in the UK, two in Australia, two in the United States and two in the Netherlands. Length of follow-up ranged from one to five years. Three of these studies were cluster-randomised trials whereby general practitioners or family physicians were randomly allocated to undertake vision screening or no vision screening. All studies were funded by government agencies. Overall we judged the studies to be at low risk of bias and only downgraded the certainty of the evidence (GRADE) for imprecision.Seven trials compared vision screening as part of a multi-component screening versus no screening. Six of these studies used self-reported vision as both screening tool and outcome measure, but did not directly measure vision. One study used a combination of self-reported vision and visual acuity measurement: participants reporting vision problems at screening were treated by the attending doctor, referred to an eye care specialist or given information about resources that were available to assist with poor vision. There was a similar risk of "not seeing well" at follow-up in people screened compared with people not screened in meta-analysis of six studies (risk ratio (RR) 1.05, 95% confidence interval (CI) 0.97 to 1.14, 4522 participants high-certainty evidence). One trial reported "improvement in vision" and this occurred slightly less frequently in the screened group (RR 0.85, 95% CI 0.52 to 1.40, 230 participants, moderate-certainty evidence).Two trials compared vision screening (visual acuity testing) alone with no vision screening. In one study, distance visual acuity was similar in the two groups at follow-up (mean difference (MD) 0.02 logMAR, 95% CI -0.02 to 0.05, 532 participants, high-certainty evidence). There was also little difference in near acuity (MD 0.02 logMAR, 95% CI -0.03 to 0.07, 532 participants, high-certainty evidence). There was no evidence of any important difference in quality of life (MD -0.06 National Eye Institute 25-item visual function questionnaire (VFQ-25) score adjusted for baseline VFQ-25 score, 95% CI -2.3 to 1.1, 532 participants, high-certainty evidence). The other study could not be included in the data analysis as the number of participants in each of the arms at follow-up could not be determined. However the authors stated that there was no significant difference in mean visual acuity in participants who had visual acuity assessed at baseline (39 letters) as compared to those who did not have their visual acuity assessed (35 letters, P = 0.25, 121 participants).One trial compared a detailed health assessment including measurement of visual acuity (intervention) with a brief health assessment including one question about vision (standard care). People given the detailed health assessment had a similar risk of visual impairment (visual acuity worse than 6/18 in either eye) at follow-up compared with people given the brief assessment (RR 1.07, 95% CI 0.84 to 1.36, 1807 participants, moderate-certainty evidence). The mean composite score of the VFQ-25 was 86.0 in the group that underwent visual acuity screening compared with 85.6 in the standard care group, a difference of 0.40 (95% CI -1.70 to 2.50, 1807 participants, high-certainty evidence).

AUTHORS' CONCLUSIONS

The evidence from RCTs undertaken to date does not support vision screening for older people living independently in a community setting, whether in isolation or as part of a multi-component screening package. This is true for screening programmes involving questions about visual problems, or direct measurements of visual acuity.The most likely reason for this negative review is that the populations within the trials often did not take up the offered intervention as a result of the vision screening and large proportions of those who did not have vision screening appeared to seek their own intervention. Also, trials that use questions about vision have a lower sensitivity and specificity than formal visual acuity testing. Given the importance of visual impairment among older people, further research into strategies to improve vision of older people is needed. The effectiveness of an optimised primary care-based screening intervention that overcomes possible factors contributing to the observed lack of benefit in trials to date warrants assessment; trials should consider including more dependent participants, rather than those living independently in the community.

International practice settings, interventions and outcomes of nurse practitioners in geriatric care: A scoping review

OBJECTIVES

To identify and summarize the common clinical settings, interventions, and outcomes of nurse practitioner care specific to older people.

DESIGN

Scoping review of the international published and grey literature.

DATA SOURCES

A structured literature search was conducted of CINAHL, EMBASE, MEDLINE, Google Scholar, and Cochrane Collaboration and Joanna Briggs Institute databases.

REVIEW METHODS

Following the Arksey and O'Malley framework, randomized controlled and quasi-experimental studies of Masters-prepared nurse practitioners providing care for patients over 65 years were included. Studies were reviewed independently by two investigators. Data were extracted, collated by setting, summarized in tables and synthesized for analysis.

RESULTS

In total, 56 primary research studies from four countries and 23 systematic reviews were identified. Primary studies were conducted in primary care (n=13), home care (n=14), long-term care (n=10), acute/hospital care (n=9), and transitional care (n=10). Nurse practitioner interventions included substitutive as well as a supplementation NP role elements to meet specific unmet patient care needs. Studies examined six main outcome measures: service utilization (n=41), cost (n=24), length of stay (n=14), health indices (n=44), satisfaction (n=14) and quality of life (n=7). Cumulatively, nurse practitioners demonstrated enhanced results in 83/144 (58%) of outcomes compared to physician-only or usual care. The most commonly measured financial-related outcome was service utilization (n=41) and benefits were frequently reported in home care (8/9, 89%) and long-term care (7/10, 70%) settings. Among patient and care-related outcomes health indices were most frequently measured (n=44). Primary care most frequently reported improved health indices (11/13, 85%). Transitional care reported improved outcomes across all measures, except for service utilization.

CONCLUSIONS

This review demonstrates improved or non-inferiority results of nurse practitioner care in older people across settings. More well-designed, rigorous studies are needed particularly in relation to costs. The results of this review could be used for future systemic review of effectiveness of NP care specific to older people. Despite the demonstrated NP role value, barriers to implementing the nurse practitioner role persist internationally and more work is needed to develop and promote these roles.

Delphi consensus of an expert committee in oncogeriatrics regarding comprehensive geriatric assessment in seniors with cancer in Spain

OBJECTIVES

The aim of this work was to reach a national consensus in Spain regarding the Comprehensive Geriatric Assessment (CGA) domains in older oncological patients and the CGA scales to be used as a foundation for widespread use.

MATERIAL AND METHODS

The Delphi method was implemented to attain consensus. Representatives of the panel were chosen from among the members of the Oncogeriatric Working Group of the Spanish Society of Medical Oncology (SEOM). Consensus was defined as ≥66.7% coincidence in responses and by the stability of said coincidence (changes ≤15% between rounds). The study was conducted between July and December 2016.

RESULTS

Of the 17 people invited to participate, 16 agreed. The panel concluded by consensus that the following domains should be included in the CGA:(and the scales to evaluate them): functional (Barthel Index, Lawton-Brody scale, gait speed), cognitive (Pfeiffer questionnaire), nutritional (Mini Nutritional Assessment - MNA), psychological/mood (Yesavage scale), social-familial (Gijon scale), comorbidity (Charlson index), medications, and geriatric syndromes (urinary and/or fecal incontinence, low auditory and/or visual acuity, presence of falls, pressure sores, insomnia, and abuse). Also by consensus, the CGA should be administered to older patients with cancer for whom there is a subsequent therapeutic intent and who scored positive on a previous frailty-screening questionnaire.

CONCLUSION

After 3 rounds, consensus was reached regarding CGA domains to be used in older patients with cancer, the scales to be administered for each of these domains, as well as the timeline to be followed during consultation.

The Rest of the Story: A Qualitative Study of Complementing Standardized Assessment Data with Informal Interviews with Older Patients and Families

BACKGROUND

While standardized health assessments capture valuable information on patients' demographic and diagnostic characteristics, health conditions, and physical and mental functioning, they may not capture information of most relevance to individual patients and their families. Given that patients and their informal caregivers are the experts on that patient's unique context, it is important to ensure they are able to convey all relevant personal information to formal healthcare providers so that high-quality, patient-centered care may be delivered. This study aims to identify information that older patients and families consider important but that might not be included in standardized assessments.

METHODS

Transcripts were analyzed from 29 interviews relating to eight patients with hip fractures from three sites (large urban, smaller urban, rural) in two provinces in Canada. These interviews were conducted as part of a larger ethnographic study. Each transcript was analyzed by two researchers using content analysis. Results were reviewed in two focus group interviews with older adults and family caregivers. Identified themes were compared with items from two standardized assessments used in healthcare settings.

RESULTS

Three broad themes emerged from the qualitative analysis that were not covered in the standardized assessments: informal caregiver and family considerations, insider healthcare knowledge, and patients' healthcare attitudes and experiences. The importance of these themes was confirmed through focus group interviews. Focus group participants also emphasized the importance of conducting assessments in a patient-centered way and the importance of open-ended questions.

CONCLUSIONS

A less structured interview approach may yield information that would otherwise be missed in standardized assessments. Combining both sources could yield better-informed healthcare planning and quality-improvement efforts.

A cross-sectional study investigating patient-centred care, co-creation of care, well-being and job satisfaction among nurses

BACKGROUND

Developments in the community health nursing sector have resulted in many changes in the activities of these nurses. The concepts of patient-centred care and co-creation of care are gaining importance in the work of community health nurses. Whether patient-centred care also contributes positively to nurses' well-being and job satisfaction is not known.

METHOD

In 2015, a cross-sectional survey was conducted among 153 community health nurses employed by 11 health care organisations in the southern part of the Netherlands. Correlation and regression analyses were performed to identify relationships among patient-centred care, co-creation of care, background characteristics, job satisfaction and well-being of community health nurses.

RESULTS

Patient-centred care and co-creation of care were correlated positively with community health nurses' well-being and job satisfaction. Both variables were predictors of well-being, and patient-centred care was a predictor of job satisfaction. The length of time in the present position was related negatively to community health nurses' job satisfaction and well-being.

CONCLUSIONS

Investment in patient-centred care and co-creation of care is important for the well-being and job satisfaction of community health nurses.

IMPLICATIONS FOR NURSING MANAGEMENT

To safeguard or improve job satisfaction and well-being of community health nurses, organisations should pay attention to the co-creation of care and patient-centred care.

Integrated Care for Older Adults Improves Perceived Quality of Care: Results of a Randomized Controlled Trial of Embrace

BACKGROUND

All community-living older adults might benefit from integrated care, but evidence is lacking on the effectiveness of such services for perceived quality of care.

OBJECTIVE

To examine the impact of Embrace, a community-based integrated primary care service, on perceived quality of care.

DESIGN

Stratified randomized controlled trial.

PARTICIPANTS

Integrated care and support according to the "Embrace" model was provided by 15 general practitioners in the Netherlands. Based on self-reported levels of case complexity and frailty, a total of 1456 community-living older adults were stratified into non-disease-specific risk profiles ("Robust," "Frail," and "Complex care needs"), and randomized to Embrace or control groups.

INTERVENTION

Embrace provides integrated, person-centered primary care and support to all older adults living in the community, with intensity of care dependent on risk profile.

MEASUREMENTS

Primary outcome was quality of care as reported by older adults on the Patient Assessment of Integrated Elderly Care (PAIEC). Effects were assessed using mixed model techniques for the total sample and per risk profile. Professionals' perceived level of implementation of integrated care was evaluated within the Embrace condition using the Assessment of Integrated Elderly Care.

KEY RESULTS

Older adults in the Embrace group reported a higher level of perceived quality of care than those in the control group (B = 0.33, 95 % CI = 0.15-0.51, ES d = 0.19). The advantages of Embrace were most evident in the "Frail" and "Complex care needs" risk profiles. We found no significant advantages for the "Robust" risk profile. Participating professionals reported a significant increase in the perceived level of implementation of integrated care (ES r = 0.71).

CONCLUSIONS

This study shows that providing a population-based integrated care service to community-living older adults improved the quality of care as perceived by older adults and participating professionals.