Health-related Quality of Life among hospitalized older people awaiting residential aged care

Older persons living with dementia and their use of acute care services over 2 years in Alberta

OBJECTIVE

To characterize transitions to acute and residential care and identify variables associated with specific transitions among community-based persons living with dementia (PLWD).

DESIGN

Retrospective cohort study using primary care electronic medical record data linked with health administrative data.

SETTING

Alberta.

PARTICIPANTS

Adults aged 65 years or older living in the community who had been diagnosed with dementia and who saw a Canadian Primary Care Sentinel Surveillance Network contributor between January 1, 2013, and February 28, 2015.

MAIN OUTCOME MEASURES

All emergency department visits, hospitalizations, residential care (supportive living and long-term care) admissions, and deaths within a 2-year follow-up period.

RESULTS

In total, 576 PLWD were identified who had a mean (SD) age of 80.4 (7.7) years; 55% were female. In 2 years, 423 (73.4%) had at least 1 transition and, of these, 111 (26.2%) had 6 or more. Emergency department visits, including multiple visits, were common (71.4% had ≥1, 12.1% had ≥4). Of those hospitalized (43.8%), nearly all were admitted from the emergency department; the average (SD) length of stay was 23.6 (35.8) days, and 32.9% had at least 1 alternate level of care day. In total, 19.3% entered residential care, most admitted from hospital. Those admitted to hospital and those admitted to residential care were older and had greater historical health system use, including home care. One-quarter of the sample did not have any transitions (or die) during follow-up; they were typically younger and had limited historical health system use.

CONCLUSION

Older PLWD experienced frequent, and frequently compound, transitions that have implications for them, their family members, and the health system. There was also a large proportion without transitions suggesting that appropriate supports enable PLWD to do well in their own communities. The identification of PLWD who are at risk of or who make frequent transitions may allow for more proactive implementation of community-based supports and smoother transitions to residential care.

Quality of life of older Australians receiving home nursing services for complex care needs

Older Australians may live up to 10 years in ill health, most likely chronic disease-related. Those with multimorbidity report more healthcare visits, poorer health and take more medications compared with people with a single chronic disease. They are also at higher risk of hospital admission and poor quality of life. People living with multimorbidity are considered to have "complex care" needs. A person-centred approach to healthcare has led to increasing use of in-home nursing support, enabling older people to receive care at home. Our prospective observational study describes the profile and management of home-based care for older people with complex care needs and examines changes in their quality of life over 12 months. Routinely collected data were analysed, including demographics, medical history, medications and the visit activity of staff providing care to participants. Additional health-related quality of life and hospitalisation data were collected via quarterly surveys and analysed. Fifty-two participants (mean age 76.6 years, 54% female) with an average of eight diagnosed health conditions, received an average of four home care visits per week. Almost half the participants were hospitalised once during the 12-month period and experienced a significant decline in overall quality of life and in the dimensions measuring independent living and relationships over the study period. If ageing in place with good quality of life is to be realised by older adults with multimorbidity, support services including home nursing need to consider both the biomedical and social determinants perspectives when addressing health and social care needs.

Clinical impact of antipsychotic and benzodiazepine reduction: findings from a multicomponent psychotropic reduction program within long-term aged care

OBJECTIVES

To explore the relationships between dose changes to antipsychotic and/or benzodiazepine medications and resident outcomes, including variations in neuropsychiatric symptoms, quality of life (QoL), and social withdrawal, within a multicomponent, interdisciplinary antipsychotic and benzodiazepine dose reduction program.

DESIGN

Prospective, observational, longitudinal study.

INTERVENTION

The Reducing Use of Sedatives (RedUSe) project involved 150 Australian Long-Term Care Facilities (LTCFs) incorporating auditing and benchmarking of prescribing, education, and multidisciplinary sedative reviews.

SETTING

A convenience sample of LTCFs (n = 28) involved in RedUSe between January 2015 and March 2016.

PARTICIPANTS

Permanent residents (n = 206) of LTCFs involved in RedUSe taking an antipsychotic and/or benzodiazepine daily. Residents were excluded if they had a severe psychiatric condition where antipsychotic therapy should generally be maintained long-term (e.g., bipolar disorder, schizophrenia) or were considered end-stage palliative.

MEASUREMENTS

Neuropsychiatric symptoms (Neuropsychiatric Inventory, Cohen-Mansfield Agitation Inventory (CMAI)), QoL (Assessment of Quality of Life-4D), and social withdrawal (Multidimensional Observation Scale for Elderly Subjects-withdrawal subscale) were measured at baseline and 4 months where nursing staff completed psychometric tests as proxy raters.

RESULTS

There was no evidence that psychometric measures were worsened following dose reductions. In fact, dose reduction was associated with small, albeit non-statistically significant, improvements in behavior, particularly less physically non-aggressive behavior with both drug groups (-0.36 points per 10% reduction in antipsychotic dose, -0.17 per 10% reduction in benzodiazepine dose) and verbally agitated behavior with benzodiazepine reduction (-0.16 per 10% dose reduction), as measured with the CMAI. Furthermore, antipsychotic reduction was associated with non-statistically significant improvements in QoL and social withdrawal.

CONCLUSIONS

Antipsychotic and benzodiazepine dose reduction in LTCFs was not associated with deterioration in neuropsychiatric symptoms, QoL, or social withdrawal. Trends toward improved agitation with antipsychotic and benzodiazepine dose reduction require further evaluation in larger, prospective, controlled studies.

Health Service Use and Quality of Life Recovery 12 Months Following Major Osteoporotic Fracture: Latent Class Analyses of the International Costs and Utilities Related to Osteoporotic Fractures Study (ICUROS)

Major osteoporotic fractures (MOFs) are associated with a rapid decline in health-related quality of life (HRQoL); however, there is limited knowledge about which healthcare services positively affect HRQoL postfracture. This study aimed to identify specific combinations of health service use associated with recovery of HRQoL 12 months post-MOF. The analyses included 4126 adults aged ≥50 years with an MOF (1657 hip, 1354 distal forearm, 681 vertebrae, 434 humerus) participating in the International Costs and Utilities Related to Osteoporotic fractures Study (ICUROS), a multinational observational study (Australia, Austria, Estonia, France, Italy, Lithuania, Mexico, Russia, Spain, United Kingdom, and United States). HRQoL at prefracture and 12 months postfracture was measured using the EuroQoL questionnaire (EQ-5D-3L). Health service use data were collected via participant interviews and medical record reviews including in-hospital care; outpatient care; community services; and medication use. Data analyses involved two stages: (i) latent class analyses to identify different combinations of health service use ("classes"); and (ii) logistic regression to assess effects of classes on HRQoL recovery. Analyses were repeated excluding hip fractures (non-hip MOFs). Overall, 2057 MOF participants (49.9%) recovered to their prefracture HRQoL at 12-month follow-up; this proportion was higher for non-hip MOFs (n = 1439; 58.3%). Several distinct classes were identified across countries (range, 2-5 classes). Classes that were associated with increased odds of HRQoL recovery were characterized by a combination of hospital presentations without admission; outpatient department visits; allied health visits; vitamin D/calcium supplementation; and/or non-opioid analgesic use. Similar classes were observed for non-hip MOFs. Understanding country-specific healthcare service pathways that influence greater recovery of HRQoL, particularly services that are uncommon in some countries and routine in others, could improve postfracture care on a global scale. © 2020 American Society for Bone and Mineral Research (ASBMR).

Strength and Endurance Training in Older Women in Relation to ACTN3 R577X and ACE I/D Polymorphisms

The purpose of this study is to analyze the effect of two genetic polymorphisms, ACTN3R577X, and ACE I/D, on physical condition in a sample of active older women after a two-year training period. The sample was composed of 300 healthy women over the age of 60 who underwent a two-year training program. Adapted tests from the Senior Fitness Test were used. The genotyping of the polymorphisms was obtained from the participants’ DNA via buccal swabs. The analysis of the ACE polymorphism did not reveal differences between genotypes. The analysis of the R577X polymorphism showed a favorable effect for the ACTN3 XX genotype in tests for leg strength (p: 0.001) after training, compared to the other genotypes, and also in the analysis of the combined effect of the polymorphism (ACE II + ACTN3 RX/XX). The intragroup effect revealed an improvement in arm strength for carriers of the X allele after 24 months of training (p < 0.05). The endurance values significantly worsened in all study groups. Conclusions: The R577X polymorphism of ACTN3 may have an important role in capacities related to muscle strength, providing a beneficial effect for carriers of the X allele.

"I Didn't Even Make My Bed": Hospital Relocations and Resident Adjustment in Long-Term Care Over Time

PURPOSE OF THE STUDY

This prospective longitudinal qualitative study sought to identify the conditions that help or hinder older adults' capacities to adjust to long-term care (LTC) when relocating from hospital.

DESIGN AND METHODS

Informed by the principles of constructivist grounded theory, this study employed semi-structured interviews with LTC home residents. Participants were interviewed 4 weeks after their initial relocation, and again every 6 months until they had either resided in their final LTC home for at least 3 months or been enrolled in the study for 2 years. Transcribed interviews were analyzed using the constant comparative method that employs the principle of comparison to guide the analytic process.

FINDINGS

A total of nine residents participated in 24 interviews and most had undergone two or more moves. Analysis of the data revealed that multiple forced moves challenged residents' capacities to find home in LTC by contributing to anxiety and uncertainty, hindering resident-staff relations, and interfering with residents' desires to connect with one another. Analysis of the data further revealed that relocation frameworks may require adaptations to more accurately reflect older adults' experiences with relocation from hospital to LTC.

IMPLICATIONS

Hospital relocations pose many challenges to residents' capacities to find home in LTC, in part, because they initiate a process of multiple moves. Until the moving process from hospital truly acknowledges and explores residents' preferences, offers choices, and supports joint decision making, it will remain challenging for the LTC home sector to help residents find meaning, purpose, and home in LTC.

An Empirical Comparison of the EQ-5D-5L, DEMQOL-U and DEMQOL-Proxy-U in a Post-Hospitalisation Population of Frail Older People Living in Residential Aged Care

OBJECTIVE

To empirically compare the measurement properties of the DEMQOL-U and DEMQOL-Proxy-U instruments to the EQ-5D-5L and its proxy version (CEQ-5D-5L) in a population of frail older people living in residential aged care in the post-hospitalisation period following a hip fracture.

METHODS

A battery of instruments to measure health-related quality of life (HRQoL), cognition, and clinical indicators of depression, pain and functioning were administered at baseline and repeated at 4 weeks' follow-up. Descriptive summary statistics were produced and psychometric analyses were conducted to assess the levels of agreement, convergent validity and known group validity between clinical indicators and HRQoL measures.

RESULTS

There was a large divergence in mean (SD) utility scores at baseline for the EQ-5D-5L and DEMQOL-U [EQ-5D-5L mean 0.21 (0.19); DEMQOL-U mean 0.79 (0.14)]. At 4 weeks' follow-up, there was a marked improvement in EQ-5D-5L scores whereas DEMQOL-U scores had deteriorated. [EQ-5D-5L mean 0.45 (0.38); DEMQOL-U mean 0.58 (0.38)]. The EQ-5D and CEQ-5D-5L were more responsive to the physical recovery trajectory experienced by frail older people following surgery to repair a fractured hip, whereas the DEMQOL-U and DEMQOL-Proxy-U appeared more responsive to the changes in delirium and dementia symptoms often experienced by frail older people in this period.

CONCLUSIONS

This study presents important insights into the HRQoL of a relatively under-researched population of post-hospitalisation frail older people in residential care. Further research should investigate the implications for economic evaluation of self-complete versus proxy assessment of HRQoL and the choice of preference-based instrument for the measurement and valuation of HRQoL in older people exhibiting cognitive decline, dementia and other co-morbidities.

The social network among the elderly and its relationship with quality of life

INTRODUCTION

Attention to the needs of the elderly is a social necessity, and it seems that evaluating the social network and quality of life of the elderly can be useful in a better understanding of their needs. This study was performed to determine the relationship between the social network and the quality of life of the elderly in the city of Bojnoord in Iran.

METHODS

In this cross-sectional study, 201 elderly people aged 60 years or more were selected by continuous and consecutive sampling method in Bojnoord, Iran in 2014. Data were collected using demographic questionnaire, Lubben social network scale and LEIPAD elderly quality of life questionnaire. Data were analyzed by SPSS 16 and using descriptive statistics and independent-samples t-test, ANOVA and Pearson product-moment coefficient.

RESULTS

The results showed that 30.3% of elderly people studied, were subjected to a high risk of isolation. The highest mean in social network dimensions was in the family (19.68%), friends (12.01%) and the neighbors (9.90%), respectively. The mean score for quality of life of the elderly was as moderate to high (63.90±13.73), and among the quality of life dimensions, the highest mean was related to the self-care dimension (15.59%), and the lowest mean was related to the sexual functioning dimension (1.53%). The findings suggested a positive and significant relationship between social network and quality of life in the elderly who were studied (p<0.000, r=0.468).

CONCLUSION

This study was a step toward understanding the social network status and quality of life of the elderly. It is necessary to say that health care professionals, especially nurses, display a significant role in the community to help people in this regard.

Effects of interventions on trajectories of health-related quality of life among older patients with hip fracture: a prospective randomized controlled trial

Background

Health-related quality of life (HRQoL) has been used to assess subjects’ prognosis and recovery following hip fracture. However, evidence is mixed regarding the effectiveness of interventions to improve HRQoL of elders with hip fracture. The purposes of this study were to identify distinct HRQoL trajectories and to evaluate the effects of two care models on these trajectories over 12 months following hip-fracture surgery.

Methods

For this secondary analysis, data came from a randomized controlled trial of subjects with hip fracture receiving three treatment care models: interdisciplinary care (n = 97), comprehensive care (n = 91), and usual care (n = 93). Interdisciplinary care consisted of geriatric consultation, discharge planning, and 4 months of in-home rehabilitation. Comprehensive care consisted of interdisciplinary care plus management of malnutrition and depressive symptoms, fall prevention, and 12 months of in-home rehabilitation. Usual care included only in-hospital rehabilitation and occasional discharge planning, without geriatric consultation and in-home rehabilitation. Mental and physical HRQoL were measured at 1, 3, 6, and 12 months after discharge by the physical component summary scale (PCS) and mental component summary scale (MCS), respectively, of the Medical Outcomes Study Short Form 36, Taiwan version. Latent class growth modeling was used to identify PCS and MCS trajectories and to evaluate how they were affected by the interdisciplinary and comprehensive care models.

Results

We identified three quadratic PCS trajectories: poor PCS (n = 103, 36.6 %), moderate PCS (n = 96, 34.2 %), and good PCS (n = 82, 29.2 %). In contrast, we found three linear MCS trajectories: poor MCS (n = 39, 13.9 %), moderate MCS (n = 84, 29.9 %), and good MCS (n = 158, 56.2 %). Subjects in the comprehensive care and interdisciplinary care groups were more likely to experience a good PCS trajectory (b = 0.99, odds ratio [OR] = 2.69, confidence interval [CI] = 7.24–1.00, p = 0.049, and b = 1.32, OR = 3.75, CI = 10.53–1.33, p = 0.012, respectively) than those who received usual care. However, neither care model improved MCS.

Conclusions

The interdisciplinary and comprehensive care models improved recovery from hip fracture by increasing subjects’ odds for following a trajectory of good physical functioning after hospitalization.

Trial registration

ClinicalTrials.gov (NCT01350557)

A systematic review of instruments for measuring outcomes in economic evaluation within aged care

BACKGROUND

This paper describes the methods and results of a systematic review to identify instruments used to measure quality of life outcomes in older people. The primary focus of the review was to identify instruments suitable for application with older people within economic evaluations conducted in the aged care sector.

METHODS

Online databases searched were PubMed, Medline, Scopus, and Web of Science, PsycInfo, CINAHL, Embase and Informit. Studies that met the following criteria were included: 1) study population exclusively above 65 years of age 2) measured health status, health related quality of life or quality of life outcomes more broadly through use of an instrument developed for this purpose, 3) used a generic preference based instrument or an older person specific preference based or non-preference based instrument or both, and 4) published in journals in the English language after 2000.

RESULTS

The most commonly applied generic preference based instrument in both the community and residential aged care context was the EuroQol - 5 Dimensions (EQ-5D), followed by the Adult Social Care Outcomes Toolkit (ASCOT) and the Health Utilities Index (HUI2/3). The most widely applied older person specific instrument was the ICEpop CAPability measure for Older people (ICECAP-O) in both community and residential aged care.

CONCLUSION

In the absence of an ideal instrument for incorporating into economic evaluations in the aged care sector, this review recommends the use of a generic preference based measure of health related quality of life such as the EQ-5D to obtain quality adjusted life years, in combination with an instrument that has a broader quality of life focus like the ASCOT, which was designed specifically for evaluating interventions in social care or the ICECAP-O, a capability measure for older people.

ACE and UCP2 gene polymorphisms and their association with baseline and exercise-related changes in the functional performance of older adults

Maintaining high levels of physical function is an important aspect of successful ageing. While muscle mass and strength contribute to functional performance in older adults, little is known about the possible genetic basis for the heterogeneity of physical function in older adults and in how older adults respond to exercise. Two genes that have possible roles in determining levels of muscle mass, strength and function in young and older adults are angiotensin-converting enzyme (ACE) and mitochondrial uncoupling protein 2 (UCP2). This study examined whether polymorphisms in these two individual genes were associated with baseline functional performance levels and/or the training-related changes following exercise in previously untrained older adults. Five-eight Caucasian older adults (mean age 69.8 years) with no recent history of resistance training enrolled in a 12 week program of resistance, balance and cardiovascular exercises aimed at improving functional performance. Performance in 6 functional tasks was recorded at baseline and after 12 weeks. Genomic DNA was assayed for the ACE intron 16 insertion/deletion (I/D) and the UCP2 G-866A polymorphism. Baseline differences among genotype groups were tested using analysis of variance. Genotype differences in absolute and relative changes in physical function among the exercisers were tested using a general linear model, adjusting for age and gender. The genotype frequencies for each of the studied polymorphisms conformed to the Hardy-Weinberg equilibrium. The ACE I/D genotype was significantly associated with mean baseline measures of handgrip strength (II 30.9 ± 3.01 v. ID 31.7 ± 1.48 v. DD 29.3 ± 2.18 kg, p < 0.001), 8ft Up and Go time (II 6.45 ± 0.48 v. ID/DD 4.41 ± 0.19 s, p < 0.001) and 6 min walk distance (II 458 ± 28.7 v. ID/DD 546 ± 12.1m, p = 0.008). The UCP2 G-866A genotype was also associated with baseline 8ft Up and Go time (GG 5.45 ± 0.35 v. GA 4.47 ± 0.26 v. AA 3.89 ± 0.71 s, p = 0.045). After 12 weeks of training, a significant difference between UCP2 G-886A genotype groups for change in 8ft Up and Go time was detected (GG −0.68 ± 0.17 v. GA −0.10 ± 0.14 v. AA +0.05 ± 0.31 s, p = 0.023). While several interesting and possibly consistent associations with older adults’ baseline functional performance were found for the ACE and UCP2 polymorphisms, we found no strong evidence of genetic associations with exercise responses in this study. The relative equivalence of some of these training-response findings to the literature may have reflected the current study’s focus on physical function rather than just strength, the relatively high levels of baseline function for some genotype groups as well as the greater statistical power for detecting baseline differences than the training-related changes.

Economic modelling of a public health programme for fall prevention

BACKGROUND

despite evidence on what works in falls prevention, falls in older people remain an important public health problem.

AIMS

the purpose of this study was to model the impact and cost-effectiveness of a public health falls prevention programme, from the perspective of the health funder.

METHODS

a decision analytic Markov model compared the health benefits in quality-adjusted life years (QALYs) and costs of treatment and residential aged care with and without a population heath falls prevention programme. Different intervention costs, uptake levels and programme effectiveness were modelled in sensitivity analyses. Uncertainty was explored using univariate and probabilistic sensitivity analysis.

RESULTS

widespread rollout of a public health fall prevention programme could result in an incremental cost-effectiveness ratio (ICER) of $A28,931 per QALY gained, assuming a programme cost of $700 per person and at a fall prevention risk ratio of 0.75. This ICER would be considered cost-effective at a threshold value of $A50,000 per QALY gained. Sensitivity analyses for programme cost and effectiveness indicated that the public health programme produced greater health outcomes and was less costly than no programme when programme costs were $A500 or lower and risk ratio for falls was 0.70 or lower. At a cost of $A2,500, the public health falls prevention programme ceases to be a cost-effective option.

CONCLUSION

serious consideration should be given to implementation of a public health programme of falls prevention as a cost-effective option that enables population-wide access to the intervention strategies.

Resident health-related quality of life in Swiss nursing homes

BACKGROUND

Health-related quality of life (HRQOL) levels and their determinants in those living in nursing homes are unclear. The aim of this study was to investigate different HRQOL domains as a function of the degree of cognitive impairment and to explore associations between them and possible determinants of HRQOL.

METHOD

Five HRQOL domains using the Minimum Data Set - Health Status Index (MDS-HSI) were investigated in a large sample of nursing home residents depending on cognitive performance levels derived from the Cognitive Performance Scale. Large effect size associations between clinical variables and the different HRQOL domains were looked for.

RESULTS

HRQOL domains are impaired to variable degrees but with similar profiles depending on the cognitive performance level. Basic activities of daily living are a major factor associated with some but not all HRQOL domains and vary little with the degree of cognitive impairment.

LIMITATIONS

This study is limited by the general difficulties related to measuring HRQOL in patients with cognitive impairment and the reduced number of variables considered among those potentially influencing HRQOL.

CONCLUSION

HRQOL dimensions are not all linearly associated with increasing cognitive impairment in NH patients. Longitudinal studies are required to determine how the different HRQOL domains evolve over time in NH residents.

Response shift recalibration and reprioritization in health-related quality of life was identified prospectively in older men with and without stroke

OBJECTIVES

To prospectively consider evidence for response shift (RS) in health-related quality of life (HRQL) in older men who experienced stroke or remained stroke free. RS is a change in the meaning of self-evaluation; this includes recalibration, reprioritization, and reconceptualization.

STUDY DESIGN

A cohort of 3,983 male World War II Royal Canadian Air Force recruits has been followed since 1948. There were three prospectively determined groups: stroke survivors (n = 168; mean age, 80.1 years); older stroke-free group (n = 254; mean age, 82.8 years); and younger stroke-free group (n = 323; mean age, 74.7 years). The Short Form-36 (SF-36) was used to evaluate HRQL. Longitudinal structural equation models were developed using SF-36 subscales and three latent variables. Measurement invariance over two time points for each of the three groups was evaluated to identify RS.

RESULTS

All RS models had reasonable fit: stroke [root mean square error of approximation (RMSEA), 0.069; 90% confidence interval (CI): 0.052, 0.086], older (RMSEA, 0.055; 90% CI: 0.041, 0.068), and younger (RMSEA, 0.062; 90% CI: 0.051, 0.074). Recalibration of physical function occurred in all three groups. Reprioritization of role limitations due to physical health happened in both stroke-free groups.

CONCLUSION

This study is unique in our ability to prospectively identify RS recalibration and reprioritization in HRQL in aging men with stroke and remaining free of stroke. Changes in the meaning of self-evaluation of HRQL occur not only with stroke but also in men who remain free of stroke.

Physiotherapists have accurate expectations of their patients' future health-related quality of life after first assessment in a subacute rehabilitation setting

Background. Expectations held by health professionals and their patients are likely to affect treatment choices in subacute inpatient rehabilitation settings for older adults. There is a scarcity of empirical evidence evaluating whether health professionals expectations of the quality of their patients' future health states are accurate. Methods. A prospective longitudinal cohort investigation was implemented to examine agreement (kappa coefficients, exact agreement, limits-of-agreement, and intraclass-correlation coefficients) between physiotherapists' (n = 23) prediction of patients' discharge health-related quality of life (reported on the EQ-5D-3L) and the actual health-related quality of life self-reported by patients (n = 272) at their discharge assessment (using the EQ-5D-3L). The mini-mental state examination was used as an indicator of patients' cognitive ability. Results. Overall, 232 (85%) patients had all assessment data completed and were included in analysis. Kappa coefficients (exact agreement) ranged between 0.37–0.57 (58%–83%) across EQ-5D-3L domains in the lower cognition group and 0.53–0.68 (81%–85%) in the better cognition group. Conclusions. Physiotherapists in this subacute rehabilitation setting predicted their patients' discharge health-related quality of life with substantial accuracy. Physiotherapists are likely able to provide their patients with sound information regarding potential recovery and health-related quality of life on discharge. The prediction accuracy was higher among patients with better cognition than patients with poorer cognition.

Relationship between health-related quality of life, and acute care re-admissions and survival in older adults with chronic illness

Background

Australia’s ageing population means that there is increasing emphasis on developing innovative models of health care delivery for older adults. The assessment of the most appropriate mix of services and measurement of their impact on patient outcomes is challenging. The aim of this evaluation was to describe the health related quality of life (HRQoL) of older adults with complex needs and to explore the relationship between HRQoL, readmission to acute care and survival.

Methods

The study was conducted in metropolitan Melbourne, Australia; participants were recruited from a cohort of older adults enrolled in a multidisciplinary case management service. HRQoL was measured at enrolment into the case-management service using The Assessment of Quality of Life (AQoL) instrument. In 2007–2009, participating service clinicians approached their patients and asked for consent to study participation. Administrative databases were used to obtain data on comorbidities (Charlson Comorbidity Index) at enrolment, and follow-up data on acute care readmissions over 12 months and five year mortality. HRQoL was compared to aged-matched norms using Welch’s approximate t-tests. Univariate and multivariate logistic regression models were used to explore which patient factors were predictive of readmissions and mortality.

Results

There were 210 study participants, mean age 78 years, 67% were female. Participants reported significantly worse HRQoL than age-matched population norms with a mean AQOL of 0.30 (SD 0.27). Seventy-eight (38%) participants were readmitted over 12-months and 5-year mortality was 65 (31%). Multivariate regression found that an AQOL utility score <0.37 (OR 1.95, 95%CI, 1.03 – 3.70), and a Charlson Comorbidity Index ≥6 (OR 4.89, 95%CI 2.37 – 10.09) were predictive of readmission. Multivariate analysis demonstrated that age ≥80 years (OR 7.15, 95%CI, 1.83 – 28.02), and Charlson Comorbidity Index ≥6 (OR 6.00, 95%CI, 2.82 – 12.79) were predictive of death.

Conclusion

This study confirms that the AQoL instrument is a robust measure of HRQoL in older community-dwelling adults with chronic illness. Lower self-reported HRQoL was associated with an increased risk of readmission independently of comorbidity and kind of service provided, but was not an independent predictor of five-year mortality.

The comparison of quality of life among people with mild dementia in nursing home and home care—a preliminary report

Background

Living arrangements play an important role in determining the quality of life (QoL) of people with dementia. Although informal care (home-based) is favored, the transition to formal (institutional) care often becomes necessary, especially in the later stages of dementia. Nevertheless, there is currently no definitive evidence showing that informal or formal care provides a higher QoL for those with dementia.

Objective

To compare the QoL of people with dementia in the nursing home and home care, and identify factors that differentiate their QoL.

Design and methods

This was a cross-sectional survey. A total of 49 people with dementia ≥60 years old were recruited from government nursing homes and hospitals (home care). Consenting participants were assessed on cognitive severity, QoL, activities of daily living (ADLs), depression, and social isolation/connectedness by the Short Mini Mental State Examination (SMMSE), the WHO-8 (the EUROHIS-QOL), Short Assessment of Quality of Life (AQoL-8), Barthel Index (BI), Cornell Scale for Depression (CSDD), and Friendship Scale (FS).

Results

There were significant differences in QoL, HRQoLs, ADLs, and social connectedness among people with dementia in home care ( n = 19) and those in nursing homes ( n = 30) ( p < 0.01). No significant differences were found by socio-demographic factors, cognitive severity, or depression between the study cohorts.

Conclusions

Older adults with dementia who were living at home experienced higher QoL, ADLs, and social connectedness compared with those living in institutional care. Support should be provided enabling home care and empowering caregivers to provide better care for people with dementia.

Quality of life of older frail persons receiving a post-discharge program

Background

A key goal for services treating older persons is improving Quality of Life (QoL). This study aimed to 1) determine the QoL and utility (i.e. satisfaction with own quality of life) for participants of a discharge program for older people following an extended hospital episode of care and 2) examine the impact of the intensity of this program on utility gains over time.

Methods

A prospective observational cohort study with baseline and repeated measures follow up of 351 participants of the transition care program in six community sites in two states of Australia was conducted. All participants who gave consent to participate were eligible for the study. QoL and utility of the participants were measured at baseline, end of program, three and six months post baseline using the EQ-5D and ICECAP-O. Association between the intensity of the program, measured in hours of care given, and improvement in utility were tested using linear regression.

Results

The ICECAP-O yielded consistently higher utility values than the EQ-5D at all time points. Baseline mean (sd) utility scores were 0.55 (0.20) and 0.75(0.16) and at six months were 0.60 (0.28) and 0.84 (0.25) for the EQ-5D and ICECAP-O respectively. The ICECAP-O showed a significant improvement over time. The intensity of the post-acute program measured by hours delivered was positively associated with utility gains in this cohort.

Conclusions

A discharge program for older frail people following an extended hospital episode of care appears to maintain and generate improvements in QoL. The amount of gain was positively influenced by the intensity of the program.

Comparative Study on the Difference in Functional Outcomes at Discharge between Proximal and Total Gastrectomy

Several studies have regarded proximal gastrectomy (PG) as optimal compared to total gastrectomy (TG) for upper stomach cancer. In addition to the traditional outcomes of complication and mortality, change in functional status should be considered as another relevant outcome in aging generations. However, there has been no community-based appraisal of functional outcomes between PG and TG. Using an administrative database, we compared functional outcomes between PG and TG. Among 12,508 patients who survived for ≥15 years and underwent open gastrectomy between 2008 and 2010, we examined patient characteristics, comorbidities, functional status estimated by the Barthel index (BI) at admission and discharge, complications, ICU care, ventilation administration, blood transfusion, operating room time, resumption of oral intake, length of stay and total charges. With reference to distal gastrectomy (DG), we performed multivariate analyses to assess the impacts of PG and TG on complications and BI deterioration. A total of 434 PGs and 4,941 TGs were observed in 148 and 295 hospitals, respectively. Patient characteristics, care process, resumption of oral intake, operating room time, length of stay and total charges were also significantly different among the three gastrectomy types. PG, TG and DG were not associated with complications or functional deterioration. Patient characteristics, preoperative blood transfusion and longer operating room time were significantly associated with more complications and BI deterioration. Since patient case mix and longer operating room time were associated with poor outcomes, physicians should recognize the role of PG and might optimally challenge and complete gastrectomies within the appropriate indications.

Canadian rural-urban differences in end-of-life care setting transitions

Few studies have focused on the care setting transitions that occur in the last year of life. A three part mixed-methods study was conducted to gain an understanding of the number and implications or impact of care setting transitions in the last year of life for rural Canadians. Provincial health services utilization data, national online survey data, and local qualitative interview data were analyzed to gain general and specific information for consideration. Rural Albertans had significantly more healthcare setting transitions than urbanites in the last year of life (M=4.2 vs 3.3). Online family respondents reported 8 moves on average occurred for family members in the last year of life. These moves were most often identified (65%) on a likert-type scale as “very difficult,” with the free text information revealing these trips were often emotionally painful for themselves and physically painful for their ill family member. Eleven informants were then interviewed until data saturation, with constant-comparative data analysis conducted for a more in-depth understanding of rural transitions. Moving from place to place for needed care in the last year of life was identified as common and concerning for rural people and their families, with three data themes developing: (a) needed care in the last year of life is scattered across many places, (b) travelling is very difficult for terminally-ill persons and their caregivers, and (c) local rural services are minimal. These findings indicate planning is needed to avoid unnecessary end-of-life care setting transitions and to make needed moves for essential services in the last year of life less costly, stressful, and socially disruptive for rural people and their families.

Glycosylated hemoglobin and functional decline in community-dwelling nursing home-eligible elderly adults with diabetes mellitus

OBJECTIVES

To determine whether glycosylated hemoglobin (HbA1c) levels predict functional decline in older adults.

DESIGN

Longitudinal cohort study.

PARTICIPANTS

Community-dwelling, nursing home (NH)-eligible individuals with diabetes mellitus enrolled at On Lok between October 2002 and December 2008 (367 participants, 1,579 HbA1c measurements).

SETTING

On Lok Lifeways, the original model for Programs of All-Inclusive Care for the Elderly.

MEASUREMENTS

The outcomes were functional decline or death at 2 years. The primary predictor was HbA1c. Age, sex, race and ethnicity, baseline function, comorbid conditions, length of time enrolled at On Lok, insulin use, and clustering of HbA1c within participants were adjusted for with mixed-effects Poisson regression.

RESULTS

Mean age was 80, and 185 participants (50%) were taking insulin. Sixty-three percent of participants experienced functional decline, and 75% experienced death or functional decline during the study period. At 2 years, higher HbA1c was associated with less functional decline or death (P for trend = .006). Accounting for clustering and confounding factors, HbA1c of 8.0% to 8.9% was associated with a lower likelihood (relative risk = 0.88, 95% confidence interval = 0.79-0.99) of functional decline or death than HbA1c of 7.0% to 7.9%.

CONCLUSION

In community-dwelling, NH-eligible individuals with diabetes mellitus, HbA1c of 8.0% to 8.9% is associated with better functional outcomes at 2 years than HbA1c of 7.0% to 7.9%, suggesting that the current American Geriatrics Society guideline recommending a HbA1c target of 8.0% or less for older adults with limited life expectancy may be lower than necessary to maintain function.

Can post-acute care programmes for older people reduce overall costs in the health system? A case study using the Australian Transition Care Programme

There is an increasing demand for acute care services due in part to rising proportions of older people and increasing rates of chronic diseases. To reduce pressure and costs in the hospital system, community-based post-acute care discharge services for older people have evolved as one method of reducing length of stay in hospital and preventing readmissions. However, it is unclear whether they reduce overall episode cost or expenditure in the health system at a more general level. In this paper, we review the current evidence on the likely costs and benefits of these services and consider whether they are potentially cost-effective from a health services perspective, using the Australian Transition Care Programme as a case study. Evaluations of community-based post-acute services have demonstrated that they reduce length of stay, prevent some re-hospitalisations and defer nursing home placement. There is also evidence that they convey some additional health benefits to older people. An economic model was developed to identify the maximum potential benefits and the likely cost savings from reduced use of health services from earlier discharge from hospital, accelerated recovery, reduced likelihood of readmission to hospital and delayed entry into permanent institutional care for participants of the Transition Care Programme. Assuming the best case scenario, the Transition Care Programme is still unlikely to be cost saving to a healthcare system. Hence for this service to be justified, additional health benefits such as quality of life improvements need to be taken into account. If it can be demonstrated that this service also conveys additional quality of life improvements, community-based programmes such as Transition Care could be considered to be cost-effective when compared with other healthcare programmes.

Quality of life in dementia patients: nursing home versus home care

BACKGROUND

Care management providing a high quality of life (QoL) is a crucial issue in dealing with increasing numbers of dementia patients. Although the transition from informal (home-based) care to formal (institutional) care is often a function of dementia stage, for those with early dementia there is currently no definitive evidence showing that informal or formal care provides a higher QoL, particularly where informal care is favored for local cultural reasons. This paper outlines the research protocol for a study comparing formal and informal care in Malaysia. It seeks to provide evidence regarding which is more appropriate and results in higher QoL in early dementia.

METHODS

This is a quasi-experimental study design involving 224 early dementia patients from both nursing home and community settings. Participants will be assessed for cognitive severity, QoL, needs, activities of daily living, depression and social isolation/connectedness by using the Mini-Mental State Examination (MMSE), Cognitive Impairment Scale - 4 items (CIS-4), EUROPE Health Interview Survey-Quality of Life (WHO8), Assessment of Quality of Life (AQoL8), Camberwell Assessment of Need for the Elderly - Short Version (CANE-S), Barthel Index (BI), Cornell Scale for Depression (CSDD), Geriatric Depression Scale - 15 items (GDS-15), and Friendship Scale (FS) respectively.

CONCLUSION

This study aims to provide a better understanding of care needs in early dementia. Given population aging, the study findings will provide evidence assisting decision-making for policies aimed at reducing the burden of caregiving and preserving the QoL of dementia patients.

Older People's Quality of Life (OPQOL) scores and adverse health outcomes at a one-year follow-up. A prospective cohort study on older outpatients living in the community in Italy

Background

There is limited knowledge on the ability of a poor quality of life (QOL) and health-related QOL (HRQOL) to predict mortality and other adverse health events, independently of the frailty syndrome and other confounders, in older people living in the community and not selected on the basis of specific chronic conditions. Aim of this study was to evaluate the ability of the overall QOL and of the HRQOL to predict several adverse health outcomes at a one-year follow-up in an older outpatient population living in the community.

Methods

We carried out a prospective cohort study on 210 community-dwelling outpatients aged 65+ (mean age 81.2 yrs) consecutively referred to a geriatric clinic in Milan, Italy. At baseline participants underwent a comprehensive geriatric assessment including evaluation of overall QOL and HRQOL by means of the Older People's Quality of Life (OPQOL) questionnaire. At a one-year follow-up, between June and December 2010, we investigated nursing home placement and death in all 210 participants as well as any fall, any admission to the emergency department (ED), any hospitalisation and greater functional dependence among the subset of subjects still living at home.

Results

One year after the visit 187 subjects were still living at home (89%) while 7 had been placed in a nursing home (3.3%) and 16 had died (7.7%). At multiple logistic regression analyses the lowest score-based quartile of the OPQOL total score at baseline was independently associated with a greater risk of any fall and any ED admission. Also, the lowest score-based quartile of the health-related OPQOL sub-score was associated with a greater risk of any fall as well as of nursing home placement (odds ratio [OR] 10.03, 95% confidence interval [CI] 1.25-80.54, P = 0.030) and death (OR 4.23, 95% CI 1.06-16.81, P = 0.041). The correlation with the latter two health outcomes was found after correction for age, sex, education, income, living conditions, comorbidity, disability and the frailty syndrome.

Conclusions

In an older outpatient population in Italy the OPQOL total score and its health-related sub-score were independent predictors of several adverse health outcomes at one year. Notably, poor HRQOL predicted both nursing home placement and death even after correction for the frailty syndrome. These findings support and enhance the prognostic relevance of QOL measures.

Age-Based Differences in Care Setting Transitions over the Last Year of Life

Context. Little is known about the number and types of moves made in the last year of life to obtain healthcare and end-of-life support, with older adults more vulnerable to care setting transition issues. Research Objective. Compare care setting transitions across older (65+ years) and younger individuals. Design. Secondary analyses of provincial hospital and ambulatory database data. Every individual who lived in the province for one year prior to death from April 1, 2005 through March 31, 2007 was retained (N = 19, 397). Results. Transitions averaged 3.5, with 3.9 and 3.4 for younger and older persons, respectively. Older persons also had fewer ER and ambulatory visits, fewer procedures performed in the last year of life, but longer inpatient stays (42.7 days versus 36.2 for younger persons). Conclusion. Younger and older persons differ somewhat in the number and type of end-of-life care setting transitions, a matter for continuing research and healthcare policy.