The impact of caregiving on caregivers of older persons and its associated factors: a cross-sectional study

INTRODUCTION

Many older people rely on caregivers for support. Caring for older people can pose significant burdens for caregivers yet may also have positive effects. This study aimed to assess the impact on the caregivers and to determine factors associated with caregivers who were burdened.

METHODS

This was a cross-sectional study of 385 caregivers of older people who attended a community clinic in Malaysia. Convenience sampling was employed during the study period on caregivers who were aged ≥ 21 years and provided ≥ 4 hours of unpaid support per week. Participants were asked to complete a self-administered questionnaire, which included the Carers of Older People in Europe (COPE) index and the EASYCare Standard 2010 independence score. The COPE index was used to assess the impact of caregiving. A highly burdened caregiver was defined as one whose scores for all three COPE subscales were positive for burden. Care recipients' independence was assessed using the independence score of the EASYCare Standard 2010 questionnaire. Multiple logistic regression was used to determine the factors associated with caregiver burden.

RESULTS

73 (19.0%) caregivers were burdened, of whom two were highly burdened. Caregivers' median scores on the positive value, negative impact and quality of support scales were 13.0, 9.0 and 12.0, respectively. Care recipients' median independence score was 18.0. Ethnicity and education levels were found to be associated with caregiver burden.

CONCLUSION

Most caregivers gained satisfaction and felt supported in caregiving. Ethnicity and education level were associated with a caregiver being burdened.

Application of EASY-Care Standard 2010 instrument in a population-based survey in transitional Kosovo

BACKGROUND

The aim of this study was to assess the health needs and priorities of older people in Kosovo, the newest state in Europe striving for a functional democracy after the breakdown of former Yugoslavia and the following war in the region.

METHODS

A cross-sectional study was conducted in Kosovo in 2011 including a nationwide representative sample of 1890 individuals aged ≥65 years (949 men, mean age: 73 ± 6 years; 941 women, mean age: 74 ± 7 years; overall response rate: 84%). All individuals were administered the full version of EASY-Care Standard 2010 instrument, inquiring about the need for support in activities of daily living ('independence'), the 'risk of breakdown in care' (leading to emergency admission to hospital) and the 'risk of falls'.

RESULTS

The degree of 'independence' was lower, whereas the 'risk of breakdown in care' and the 'risk of falls' were significantly higher in: older women; the oldest individuals (≥85 years); rural residents; participants living alone; those perceiving themselves as poor; participants who could not access medical care; those who perceived their general health status as poor; and older people who reported at least one chronic condition.

CONCLUSIONS

This is one of the very few reports from Southeast European region informing about the health needs and priorities of older people in a large and representative population-based sample of older men and women. The poor health status of older people, especially evident in the socio-demographic disadvantaged categories, should raise the awareness of policymakers and decision-makers for appropriate health and social care of elderly in Kosovo and in other European countries.

Threats to Health and Well-Being Perceived by Older People in Poland and Portugal

INTRODUCTION

According to the OECD, Portugal and Poland rank below average in several well-being measures such as income and wealth, and health status. Investigating how people perceive the threats to health in these two countries, is an important issue to address priority needs. To meet this need, the objective of this paper was to compare the perceptions of the threats to the health and well-being among the Polish and Portuguese older persons and explore differences between the countries in respect of patterns of self-rated health.

MATERIAL AND METHODS

A Cross-sectional study with two convenience samples from primary health care services of Poland and Portugal was conducted; 480 adults aged 65 and over (247 Portuguese) were included. The EASYCare standard assessment of 2010 was applied under a joint project of both countries. The association between 'self-rated unhealthy' and socio-demographic and threats to health variables was examined using logistic regression.

RESULTS

In both countries about two thirds of the older persons self-rated their health as unhealthy. Having more than enough finances was associated with a significant lower odds of being unhealthy compared with those without enough finances at the end of the month (Portugal: OR = 0.25, 95% CI 0.10 to 0.63; Poland: OR = 0.33, 95% CI 0.12 to 0.88). Visual problems, bodily pain, memory loss, feeling bored or lonely and reporting shortness of breath during normal activities was consistently associated with fair or poor self-rated health.

DISCUSSION

These findings provide important information regarding the health profile of older people which can help in the development of people-centred health systems where their lives and well-being can be improved.

CONCLUSION

The unhealthy perception of older people was consistently associated with indicators of major health threats.

The theoretical and empirical basis of a BioPsychoSocial (BPS) risk screener for detection of older people's health related needs, planning of community programs, and targeted care interventions

Background

This study introduces the conceptual basis and operational measure, of BioPyschoSocial (BPS) health and related risk to better understand how well older people are managing and to screen for risk status. The BPS Risk Screener is constructed to detect vulnerability at older ages, and seeks to measure dynamic processes that place equal emphasis on Psycho-emotional and Socio-interpersonal risks, as Bio-functional ones. We validate the proposed measure and describe its application to programming.

Methods

We undertook a quantitative cross-sectional, psychometric study with n = 1325 older Singaporeans, aged 60 and over. We adapted the EASYCare 2010 and Lubben Social Network Scale questionnaires to help determine the BPS domains using factor analysis from which we derive the BPS Risk Screener items. We then confirm its structure, and test the scoring system. The score is initially validated against self-reported general health then modelled against: number of falls; cognitive impairment; longstanding diseases; and further tested against service utilization (linked administrative data).

Results

Three B, P and S clusters are defined and identified and a BPS managing score (‘doing’ well, or ‘some’, ‘many’, and ‘overwhelming problems’) calculated such that the risk of problematic additive BPS effects, what we term health ‘loads’, are accounted for. Thirty-five items (factor loadings over 0.5) clustered into three distinct B, P, S domains and were found to be independently associated with self-reported health: B: 1.99 (1.64 to 2.41), P: 1.59 (1.28 to 1.98), S: 1.33 (1.10 to 1.60). The fit improved when combined into the managing score 2.33 (1.92 to 2.83, < 0.01). The score was associated with mounting risk for all outcomes.

Conclusions

BPS domain structures, and the novel scoring system capturing dynamic BPS additive effects, which can combine to engender vulnerability, are validated through this analysis. The resulting tool helps render clients’ risk status and related intervention needs transparent. Given its explicit and empirically supported attention to P and S risks, which have the potential to be more malleable than B ones, especially in the older old, this tool is designed to be change sensitive.

Electronic supplementary material

The online version of this article (10.1186/s12877-018-0739-x) contains supplementary material, which is available to authorized users.

Reliability and validity of the EASYCare-2010 Standard to assess elderly people in Portuguese Primary Health Care

Introduction

The EASYCare is a multidimensional assessment tool for older people, which corresponds to the concerns and priorities of older people in relation to their needs, health, and quality of life. The EASYCare instrument has been used in many countries worldwide. Lack of reliability evidence has recently been raised by researchers. This study aimed to test the validity and reliability of the EASYCare-2010 instrument in community-dwelling Portuguese older people attended in Primary Health Care centres.

Methods

The sample for this transversal study (N = 244) was collected from Portuguese Primary Health Care Centers. Categorical Principal Component Analysis was used to assess the underlying dimensions of EASYCare-2010. Construct validity was evaluated through correlation with the World Health Organization Quality of Life Assessment Instrument-Short Form.

Results

A two-factor model (labelled “mobility and activities of daily life”, and “general well-being and safety”) was found. The EASYCare-2010 instrument showed acceptable levels for internal consistency (≥0.70). The EASYCare-2010 factors were correlated with measures of quality of life. Results showed that in most polytomous items, some of the more extreme categories were not considered at all or only by a residual number of participants.

Conclusion

EASY Care -2010 version is a valid and reliable instrument for holistic assessment of the older people attended in Primary Health Care centres in Portugal.

Predicting Post-Discharge Outcome

The ability of members of the multidisciplinary team and of elderly patients themselves to predict how patients will cope at home influences the successful outcome of discharge from hospital. Following the introduction of structured assessment of the physical, psychological and social function of patients on an acute elderly care unit, a study was undertaken to compare the predictive ability of the primary nurse, the patient and the occupational therapist.

Overall, results suggested a high level of accuracy of predictions. There was a trend for the occupational therapist to predict more accurately (83.6%) than the patient (80.7%) or the primary nurse (72.5%). Where the predictions were incorrect, the patients erred on the side of optimism (78% optimistic) whereas the nurses were more pessimistic (69% pessimistic). Further studies to look at the reliability of outcome predictions by health professionals and the patients themselves would be useful in the overall management of the discharge of elderly people from hospital.

Calibrating EASY-Care independence scale to improve accuracy

Background

there is currently limited support for the reliability and validity of the EASY-Care independence scale, with little work carried out in low- or middle-income countries. Therefore, we assessed the internal construct validity and hierarchical and classical scaling properties among frail dependent older people in the community.

Objective

we assessed the internal construct validity and hierarchical and classical scaling properties among frail dependent older people in the community.

Methods

three primary care physicians administered EASY-Care comprehensive geriatric assessment for 150 frail and/or dependent older people in the primary care setting. A Mokken model was applied to investigate hierarchical scaling properties of EASY-Care independence scale, and internal consistency (Cronbach's alpha) of the scale was also examined.

Results

we found that EASY-Care independence scale is highly internally consistent and is a strong hierarchical scale, hence providing strong evidence for unidimensionality. However, two items in the scale (unable to use telephone and manage finances) had much lower item Loevinger H coefficients than others. Exclusion of these two items improved the overall internal consistency of the scale.

Conclusions

the strong performance of the EASY-Care independence scale among community-dwelling frail older people is encouraging. This study confirms that EASY-Care independence scale is highly internally consistent and a strong hierarchical scale.

Analysis and Design of the eSAP: An Integrated Health and Social Care Information System

Health care information systems are becoming more and more computerized. A huge amount of health related information needs to be stored and analysed, and with the aid of computer systems this can be done faster and more efficiently. The Agent Oriented paradigm provides an alternative way of developing medical based systems.

This article presents an initial exploration of the analysis and design of a multi-agent system to deliver the Single Assessment Process, an integrated health and social care information system for older people. The article concludes by making the following observations: Agent technology has the potential to support the development of medical and health and social care systems for older people. Nevertheless there are not many real-life agent based applications successfully applied in the health care sector. One of the main reasons is the limitation of the existing analysis and design methodologies. Thus, in order for the agent-technology to be widely accepted in the development of computer based medical information systems for older people (and in extent any medical system) it is necessary to develop a complete and mature analysis and design methodology to support the development of agent based medical systems.

A Novel Agent-Based System to Support the Single Assessment Process of Older People

Older people often have a complex mixture of health and social care needs and several different health and social care professionals are involved in their care. National policy in England is to promote the single assessment process (SAP), an integrated assessment of health and social care needs of older people. However, most of the current information systems do not adequately provide the functionality that is required by health and social care professionals. In this paper we discuss the suitability of agent technology, explaining why we selected it as offering the greatest potential for efficient and flexible information collection and sharing, and for supporting effective care planning. Also, we point out benefits derived from the use of agent technology in the development of health and social care systems, such as the minimization of health and social care professionals' workload. In addition, we describe how we have developed a model for an integrated information system, based on agent technology, for health and social care needs assessment of older people. Finally, we discuss issues, such as security and mobility, involved in the development of such a system, which will need to be designed and tested prior to its implementation in health and social care practice.

Predictive validity of a two-step tool to map frailty in primary care

BACKGROUND

EASY-Care Two step Older people Screening (EASY-Care TOS) is a stepped approach to identify frail older people at risk for negative health outcomes in primary care, and makes use of General Practitioners' (GPs) readily-available information. We aimed to determine the predictive value of EASY-Care TOS for negative health outcomes within the year from assessment.

METHODS

A total of 587 patients of four GP practices in and around Nijmegen (The Netherlands) consented to participate in a longitudinal primary care registry based cohort study. Participants' frailty was judged by their GP following the EASY-Care TOS procedure and by a Comprehensive Geriatric Assessment (CGA) at baseline. After one year health outcomes of the participants were measured by reassessment with the EASY-Care TOS procedure.

RESULTS

Follow up information was available for 520 of 587 participants. In the non-frail group 9% showed any negative health outcomes (death, ADL decline, institutionalisation, too ill to undergo assessment), against 30% in the frail group (95% confidence interval of the difference (CI): 14%-28%). Area under the receiver operating curve (AUC) of the EASY-Care TOS frailty judgement for a composite of negative health outcomes mentioned was 0.67 (95% CI: 0.62-0.73). Compared with discrimination on the basis of age, sex and GP practice (AUC 0.70), adding EASY-Care TOS frailty judgement increased the AUC to 0.75 (+0.05, p = 0.02). The AUC on the basis of a full CGA is almost comparable to the AUC of the model with age, sex, and frailty judgement with EASY-Care TOS: 0.76 (+0.07, p = 0.005).

CONCLUSIONS

GPs applying the EASY-Care TOS procedure, where they only perform additional assessment when they judge this as necessary, can predict negative health outcomes in their older populations efficiently and almost as accurately as a complete specialist CGA.

Identifying common impairments in frail and dependent older people: validation of the COPE assessment for non-specialised health workers in low resource primary health care settings

Background

Frail and dependent older people in resource-poor settings are poorly served by health systems that lack outreach capacity. The COPE (Caring for Older PEople) multidimensional assessment tool is designed to help community health workers (CHWs) identify clinically significant impairments and deliver evidence-based interventions

Methods

Older people (n = 150) identified by CHWs as frail or dependent, were assessed at home by the CHW using the structured COPE assessment tool, generating information on impairments in nutrition, mobility, vision, hearing, continence, cognition, mood and behaviour. The older people were reassessed by local physicians who reached a clinical judgment regarding the presence or absence of the same impairments based upon clinical examination guided by the EASY-Care assessment tool.

Results

The COPE tool was considered easy to administer, and gave CHWs a sense of empowerment to understand and act upon the needs of older people. Agreement between COPE assessment by CHW and clinician assessors was modest (ranged from 45.8 to 91.3 %) for most impairments. However, the prevalence of impairments was generally higher according to clinicians, particularly for visual impairment (98.7 vs 45.8 %), cognitive impairment (78.4 vs. 38.2 %) and depression (82.0 vs. 59.9 %). Most cases identified by WHO-COPE were clinician confirmed (positive predictive values - 72.2 to 98.5 %), and levels of disability and needs for care among those identified by COPE were higher than those additionally identified by the clinician alone.

Conclusions

The COPE is a feasible tool for the identification of specific impairments in frail dependent older people in the community. Those identified are likely to be confirmed as having clinically relevant problems by clinicians working in the same service, and the COPE may be particularly effective at targeting attention upon those with the most substantial unmet needs.

Electronic supplementary material

The online version of this article (doi:10.1186/s12877-015-0121-1) contains supplementary material, which is available to authorized users.

National and sub-national trend of prevalence and burden of dementia in Iran, from 1990 to 2013; study protocol

BACKGROUND

Dementia is a disabling syndrome, which generally affects aged population more than any other age groups. This syndrome has a growing prevalence and incidence worldwide. The prevalence and burden of this group of diseases in Iran have not been estimated in a community-based study yet. This paper aims to explain the systematic approach, data sources, research methodology, and statistical analysis that will be used to quantify the prevalence and burden of dementia at national and sub-national levels.

METHODS

This is the protocol of a secondary data study that explains the design and method of conducting the study. We will use several sources of data that will include a systematic review of articles and gray literature which have reported the prevalence or incidence of dementia and its uncertainty at national and sub-national levels in Iran, in addition to data about dementia-specific drug sales per each year at provincial levels, as well as data extracted from 23 million health insurance prescriptions over 8 years and some data from medical documents of Iranian Alzheimer's Association members. The technical groups of National and Sub-national Burden of Disease will collect some covariate data, such as age and sex structure of population, urbanization status, mean years of schooling, plasma cholesterol, fasting plasma glucose, and systolic and diastolic blood pressure at provincial levels which will be used in our models. Two statistical models, namely spatio-temporal and hierarchical autoregressive models, will be used for interpolation and extrapolation of missing data.

CONCLUSION

It seems that the study of national and sub-national burden of dementia could provide more accurate estimation of prevalence and burden of dementia in Iran with an acceptable level of uncertainty than the previous studies.

Predicting risk of the fall among aged adult residents of a nursing home

BACKGROUND

Fall is one of the most important outcomes of geriatric medicine. The European Assessment System (EASY) Care Standard provides a tool for assessing the risk of the falls. We aimed to evaluate the validity of the Easy-Care risk of the falls (ECRF) sub-score among the residents of a large nursing home.

METHOD

A longitudinal study was conducted within a maximum of 34 months following up for falling in Kahrizak Charity Foundation. At the baseline the demographic, mental status and the depression data of 194 subjects aged ≥60 was collected. The Easy-Care standard tools and Performance-Oriented Mobility Assessment (POMA) were also used for data collecting. The time, location, and cause of the falls were recorded immediately after each fall incident. The Correlation between POMA and ECRF scores and the factor analysis of ECRF were considered as the concurrent and construct validity respectively. The Factor affecting the fall occurrence was assessed using the Cox-regression model.

RESULT

The mean age of the participants was 76.02 (SD 8.82). Fifty two individuals (27.3%) fell at least once during the mean 756 (SD 187)-day follow up. The Spearman correlation coefficient between ECRF and POMA scores was -0.458 (P<0.01). Three components were detected in the factor analysis of the ECRF. In the univariate Cox-regression model, the hazard ratio was 1.04 (CI: 1.00-1.07) for each score increase of the ECRF. For the six-month follow-up, at the ECRF cut-off point two of eight, the sensitivity and specificity were calculated as 85.7% and 64.5% respectively.

CONCLUSION

It seems that the ECRF is a valid tool for predicting the next 6 months' fall incidents in older adults.

Health needs of older Aboriginal people in Taiwan: a community-based assessment using a multidimensional instrument

AIMS AND OBJECTIVES

To explore the health needs of older Aboriginal people, using a multidimensional instrument. The gender differences related to their health needs were also addressed.

BACKGROUND

Health status and life expectancy between Aborigines and non-Aborigines have been shown to differ. The investigation of the health needs of Aboriginal people is however scarce, particularly among the older adult population. There is a need to address unmet health needs and improve information on the health needs assessment of the older Aboriginal population.

DESIGN

A cross-sectional design was used.

METHODS

Aboriginal people aged 65 and over were randomly sampled to take part in the present study. A multidimensional instrument consisting of eight domains and three cross-domain categories was used to assess their health needs.

RESULTS

A group of older Aboriginal people was recruited (n = 90, mean age = 73·5). The top three identified needs were 'mental health and well-being', 'staying healthy' and 'social participation'. The female participants had statistically significant higher scores for the 'mental health and well-being', 'getting around' domains and in the 'risk of falls' than the male ones. A regression model demonstrated that the health need of 'looking after oneself' was associated with all cross-domain categories of health need, which are 'independence', 'risk of breakdown in care' and 'risk of falls'.

CONCLUSIONS

The present study has revealed major health needs among older Aboriginal people and found that older female Aborigines have more health needs than older male Aborigines. Further study to identify effective approaches to address these needs among this group is warranted.

RELEVANCE TO CLINICAL PRACTICE

The findings can be used to identify effective approaches to addressing health needs among older Aboriginal people with a consideration of gender. Only then can resources be allocated and prioritised in a culturally sensitive and gender-specific manner nationally and globally.

The contribution of geriatric medicine to integrated care for older people

AIMS

to describe contribution of geriatric medicine to the development of integrated care for older people and to suggest future directions for the further development of integrated care for older people.

METHODS

literature review and case studies.

RESULTS

geriatricians have made a significant contribution to the development of integrated care for older people. The feasibility of this approach has been shown in demonstration projects. Although there is only limited evidence from randomised controlled trials, integrated care seems likely to be beneficial. There is an opportunity to develop new approaches to integrated care for older people in prevention and provision of community alternatives to hospital care.

CONCLUSION

the principles and practice of geriatric medicine have been shown to underpin the successful development of integrated care for older people and should continue to do so as new challenges emerge.

Evaluation of the Post Stroke Checklist: A Pilot Study in the United Kingdom and Singapore

Background

There is currently no standardized process for long-term follow-up care. As a result, management of post-stroke care varies greatly, and the needs of stroke survivors are not fully addressed. The Post Stroke Checklist was developed by the Global Stroke Community Advisory Panel as a means of standardizing long-term stroke care. Since its development, the Post Stroke Checklist has gained international recognition from various stroke networks and is endorsed by the World Stroke Organization to support improved stroke survivor follow-up and care.

Aims

The aim of this study was to evaluate the feasibility and usefulness of the Post Stroke Checklist in clinical practice and assess its relevance to stroke survivors in pilot studies in the United Kingdom and Singapore.

Methods

The Post Stroke Checklist was administered to stroke survivors in the United Kingdom ( n = 42) and Singapore ( n = 100) by clinicians. To assess the feasibility of the Post Stroke Checklist in clinical practice, an independent researcher observed the assessment and made notes relating to the patient–clinician interaction and their interpretations of the Post Stroke Checklist items. Patient and clinician satisfaction with the Post Stroke Checklist was assessed by three questions, responded to on a 0–10 numerical rating scale. Clinicians also completed a Pragmatic Face and Content Validity test to evaluate their overall impressions of the Post Stroke Checklist. In the United Kingdom, a subset of patients ( n = 14) took part in a concept elicitation interview prior to being administered the Post Stroke Checklist, followed by a cognitive debriefing interview to assess relevance and comprehension of the Post Stroke Checklist.

Results

The Post Stroke Checklist identified frequently reported problems for stroke survivors including cognition (reported by 47·2% of patients), mood (43·7%), and life after stroke (38%). An average of 3·2 problems per patient was identified across both countries (range 0–10). An average of 5 and 2·6 problems per patient were identified in the United Kingdom and Singapore, respectively. The average time taken to administer the Post Stroke Checklist was 17 mins (standard deviation 7·5) in Singapore and 13 mins (standard deviation 7·6) in the United Kingdom. Satisfaction ratings were high for patients (8·6/10) and clinicians (7·7/10), and clinician feedback via the Pragmatic Face and Content Validity test indicated that the Post Stroke Checklist is ‘useful’, ‘informative’, and ‘exhaustive’. All concepts measured by the Post Stroke Checklist were spontaneously discussed by patients during the concept elicitation interviews, suggesting that the Post Stroke Checklist is relevant to stroke survivors. Cognitive debriefing data indicated that the items were generally well understood and relevant to stroke. Minor revisions were made to the Post Stroke Checklist based on patient feedback.

Conclusions

The findings suggest that the Post Stroke Checklist is a feasible and useful measure for identifying long term stroke care needs in a clinical practice setting. Pilot testing indicated that the Post Stroke Checklist is able to identify a wide range of unmet needs, and patient and clinician feedback indicated a high level of satisfaction with the Post Stroke Checklist assessment. The items were generally well understood and considered relevant to stroke survivors, indicating the Post Stroke Checklist is a feasible, useful, and relevant measure of poststroke care.

Development of a poststroke checklist to standardize follow-up care for stroke survivors

BACKGROUND

Long-term care for stroke survivors is fragmented and lacks an evidence-based, easy-to-use tool to identify persistent long-term problems among stroke survivors and streamline referral for treatment. We sought to develop a poststroke checklist (PSC) to help health care professionals identify poststroke problems amenable to treatment and subsequent referral.

METHODS

An instrument development team, supported by measurement experts, international stroke experts, and poststroke care stakeholders, was created to develop a long-term PSC. A list of long-term poststroke problem areas was generated by an international, multidisciplinary group of stroke experts, the Global Stroke Community Advisory Panel. Using Delphi methods, a consensus was reached on which problem areas on the list were most important and relevant to include in a PSC. The instrument development team concurrently created the actual checklist, which provided example language about how to ask about poststroke problem areas and linked patient responses to a specific referral process.

RESULTS

Eleven long-term poststroke problem areas were rated highly and consistently among stroke experts participating in the Delphi process (n = 12): secondary prevention, activities of daily living, mobility, spasticity, pain, incontinence, communication, mood, cognition, life after stroke, and relationship with caregiver. These problem areas were included in the long-term PSC.

CONCLUSIONS

The PSC was developed to be a brief and easy-to-use tool, intended to facilitate a standardized approach for health care providers to identify long-term problems in stroke survivors and to facilitate appropriate referrals for treatment.

Development and evidence base of a new efficient assessment instrument for international use by nurses in community settings with older people

In a world where 12% of the population, and 22% of that of more developed regions, will be older than 65 years by 2030, new targeted programs and social protections will be needed for older people in many countries. As economic and human resources become more scarce, efficient instruments are needed to realize sustainable health care for these large populations of older subjects. To address this need a new assessment instrument was developed. The core of the instrument consists of focused geriatric assessment by a health or social care practitioner working in primary or community care, most often a nurse. The assessment data result in an efficiently targeted care and welfare action plan based on the patients' priorities. This instrument was initially developed, tested and spread within Europe, and then in validation studies across all WHO regions of the world. Because of the urgent societal questions on quality and sustainability of primary health care, especially for older people, we briefly review and summarize the development and evidence base of the instrument, which was called EASY-Care Standard. In a series of studies across many populations it proved to have high acceptability, reliability, validity and cost-effectiveness. Therefore, EASY-Care has great potential as a universal tool for global use in promoting independence in old age, and can make an important contribution to the quality and sustainability of health and social care in our aging societies.

Quality assurance in gerontological and geriatric training programs: the European case

Quality assurance (QA) in gerontological and geriatric education programs is regarded as essential to maintain standards, strengthen accountability, improve readability of qualifications, and facilitate professional mobility. In this article the authors present a summary of international developments in QA and elaborate four international trends, including the pros and cons of QA. Furthermore, the authors focus on accreditation and credit transfer opportunities in vocational and academic education programs for primary care practitioners, including nurses, home care workers, social workers, physiotherapists, and family doctors involved in the care of older people in nine European countries and highlight changes that have occurred over the last decade. Vocational education and professional training in elderly care at the basic and postgraduate specialization level remains extremely diversified, reflecting the lack of standardization for programs outside the higher education sector. The situation is ripe for the implementation of the European Qualifications Framework, which is intended to promote transparency, comparability and portability of qualifications at different levels and the introduction of a credit transfer system for vocational education to be established in 2012.

Measuring case-mix and outcome for older people in acute hospital care across Europe: the development and potential of the ACMEplus instrument

AIM

To identify case-mix variables measured shortly after admission to be included in a patient classification system (ACMEplus) that best explains hospital outcome for older people in different health care systems.

DESIGN

Observational prospective cohort study collecting patient factors (sociodemographics, functional, mental, clinical, administrative and perceived health) at different time assessments.

METHODS

Multicentre study involving eight hospitals in six European countries (United Kingdom, Spain, Italy, Finland, Greece and Poland). It included consecutive patients aged 65 years or older admitted to hospital for acute medical problems.

MAIN OUTCOME MEASURES

discharge status, hospital readmission, mortality and length of stay.

RESULTS

Of the 1667 included patients (mean age = 78.1 years; male gender = 43.5%) two-third had at least one 'Geriatric Giant' (immobility, confusion, incontinence or falls) on admission or shortly after. The most frequently affected system was cardiovascular (29.2%) and 31% of patients declared poor or very poor health. Mean length of stay was 17.9 days, 79% of patients were discharged to their usual residence; in-hospital and 1-month follow up mortality were 7.4% and 11.6%, respectively. Physical function explained the highest variation (between 8% and 21%), followed by cognitive status and number of Geriatric Giants, for almost all outcomes except readmission.

CONCLUSION

Factors other than diagnosis (physical function, cognition and presenting problems) are important in predicting key outcomes of acute hospital care for older people and are consistent across countries. Their inclusion in a standardized system of measurement may be a way of improving quality and equity of medical care in older people.

Cognitive screening for people from minority ethnic backgrounds

This article explores the reasons why traditional short cognitive tests underestimate the abilities of people from minority ethnic backgrounds living in the UK and assesses the suitability to newer 'culture-fair' tests. The authors offer recommendations on minimising bias in cognitive assessment and conclude that although cultural bias is common in traditional brief screening tests it can be minimised by sensitive administration and interpretation of results. The article also suggests that there are sources of under-performance for minority ethnic elders living in the UK in tests previously thought to be culture-fair.

A multi-centre European study of factors affecting the discharge destination of older people admitted to hospital: analysis of in-hospital data from the ACMEplus project

OBJECTIVES

to examine the relationship between seven predictor variables (recorded on Day 3 of hospital admission) and discharge destination in non-elective medical patients aged 65+ years.

DESIGN

prospective cohort.

SETTING

eight centres in six European countries.

PREDICTOR VARIABLES

age, gender, living alone, physical function (three categories based on Barthel Index), cognition (Katzman's orientation-memory-concentration test), main body system affected (based on International Classification of Diseases), number of geriatric giants (GGs) involved in the referral (a GG being a problem with falling, mobility, continence or cognition).

MAIN OUTCOME MEASURES

discharge destination (by Day 90) in three categories: 'HOMESAME' (return to previous residence), 'INSTIN90' (discharge to alternative residence or still in hospital at 90 days), 'DEADINHO' (death in hospital),

RESULTS

in 1,626 patients, discharge destination was HOMESAME in 84.7%, DEADINHO in 8.9% and INSTIN90 in 6.4%. Mean duration of stay was 17.7 days, median 12. Univariate analyses showed a statistically significant relationship between all seven predictor variables and discharge destination. Physical function was the best single predictor with a seven-fold difference in adverse outcome rates between the best and worst categories. On multiple logistic regression, significant predictor variables were as follows. (i) For DEADINHO: physical function, cognition, gender; (ii) for INSTIN90: physical function, living alone, GGs, age, gender. Multiple linear regression identified physical function, GGs and living alone as predictors of loge length of stay.

CONCLUSION

case-mix systems to compare risk-adjusted hospital outcome in older medical patients need to incorporate information about physical function, cognition and presenting problems in addition to diagnosis.

Screening for cognitive impairment among older people in black and minority ethnic groups

There is a well-documented tendency for cognitive tests to underestimate the abilities of older people in black and minority ethnic groups. This gives rise to a substantially higher risk of mistaken diagnosis of dementia. Reasons include differences in extent or focus of formal education, lack of familiarity with English, lack of literacy in own first language, and culture-specific factors related to individual test items. Attempts to improve the accuracy of screening for these groups have included adaptation of existing tests, including adjustment of cut-points, translation and replacement of culture-specific items. So-called 'culture-free' tests have also been developed, which are less dependent on language, literacy and other skills developed during formal education. Cultural modifications and evidence of cross-cultural performance are summarized here for traditional tests (Mini-Mental State Examination, Short Portable Mental Status Questionnaire, Short Orientation-Memory-Concentration Test, Abbreviated Mental Test Score, Clifton Assessment Procedures for the Elderly), and for culture-free tests (Clock Drawing Test, Mini-Cog, 7-minute screening battery, Time and Change Test). The evidence on unadapted traditional tests shows that short ones perform at least as well as longer ones, and are more consistent across cultural and educational groups. Cut-point adjustments have not been universally found successful in improving accuracy, and do not address issues of acceptability. Translated and/or culturally adapted versions exist for a number of tests: it is important to establish cut-points appropriate to the target populations. There are promising results on culture-free tests, which are seen as less threatening and require little language interpretation, but they require further evaluation.

Time to deliver with dignity

The appointment of a tsar for older people's services and the publication of a national service framework for older people are welcome developments in combating age discrimination in health care, and new technologies will be crucial in improving the quality of life in old age

The COPE index--a first stage assessment of negative impact, positive value and quality of support of caregiving in informal carers of older people

Data was collected in five countries from informal carers of older people (n = 577) via a common protocol. Carers completed: (1) a 17-item version of the Carers of Older People in Europe (COPE) Index, an assessment of carers' perceptions of their role : (2) a questionnaire on demographic and caregiving circumstances : and (3) three instruments included for the criterion validation of the COPE Index (the General Health Questionnaire, the Hospital Anxiety and Depression Scale, and the World Health Organization Quality of Life-BREF). Principal Component Analysis of the COPE Index was followed by internal consistency analysis of emergent components. Scales derived by summing items loading on the components were analyzed for their association with the criterion measures. Two components, negative impact and positive value, emerged consistently across countries. A third component, quality of support was less consistent across countries. Scales derived from the negative impact and positive value components were internally consistent and significantly associated with the criterion validity measures. These two scales and four items drawn from the quality of support component were retained in the final COPE Index. While further testing is required, the COPE Index has current utility in increasing understanding of the role perceptions of carers of older people.

Repeatability of standardized tests of functional impairment and well-being in older people in a rehabilitation setting

PURPOSE

The aim of this study was to establish the repeatability of standardized tests of vision (Snellen chart testing), hearing (whispered voice test), communication (Frenchay aphasia screening test), loneliness (UCLA loneliness scale), morale (Philadelphia geriatric centre morale scale), and a multidimensional instrument (EASY-care) when used in a rehabilitation setting.

METHOD

The tests were administered by a research nurse to 50 older subjects attending a day rehabilitation unit, with repeat administration one or two weeks later by a nurse on the unit. Kappa statistics were used for level of agreement for categorized data and interclass correlation coefficient were used for data based on scores.

RESULTS

Moderate repeatability for Snellen chart testing. whispered voice test; good to excellent for the FAST, UCLA loneliness scale and Philadelphia geriatric centre morale scale. Moderate to very good repeatability for all EASY-care items except communication, feeding, use of telephone and cognitive impairment, which had poor spread of data.

CONCLUSIONS

Poor repeatability for commonly used tests of vision and hearing is worrying, whereas the positive results for the other tests will increase confidence in using them more in routine practice.

UK geriatricians' attitudes to active voluntary euthanasia and physician-assisted death

AIM

To describe the views of British geriatricians on active voluntary euthanasia and physician-assisted death.

METHOD

Postal questionnaire to 742 consultant members of the British Geriatrics Society.

RESULTS

81% considered active voluntary euthanasia never to be justified ethically, although 23% supported legalization in some situations and 13% would be willing to administer active voluntary euthanasia in some situations. With regard to physician-assisted death, 68% opposed it on ethical grounds and 24% supported its legalization in some instances, with 12% stating they would be willing to provide such assistance in some situations. Free text comments frequently cited good palliative care as an important response to such issues in clinical practice.

Geriatric assessment in primary care: formulating best practice

Comprehensive geriatric assessment (CGA) is a structured approach to measuring physical, mental and social functioning of older people to identify needs and to plan care. Meta-analysis of trials of CGA suggest that it is cost-effective, but there is no agreed approach to its implementation in primary care. Our aim was to develop a best-practice model for geriatric assessment in primary care. We took an iterative approach to development, combining expert and local stakeholder opinion, and using semi-structured interviews to assess patient and practitioner experience in nine general practices in Sheffield. Patients were aged 75 and over, living at home. The best-practice model was the use of a standardized instrument (EASY-Care) to unselected patients aged 75 years and over living at home or in residential care, administered by a practice nurse in the context of an over-75s health check. There was high patient and practitioner acceptability, and significant cost savings were noted. Key beneficial features were the assessment of mental health and sources of support; goal-setting; generation of a disability score; and high patient satisfaction from contact with nursing staff. We conclude that geriatric assessment in primary care is feasible, economical and beneficial to patients and practitioners. Nursing staff are central to successful implementation of geriatric assessment in primary care.

The effectiveness of very short scales for depression screening in elderly medical patients

OBJECTIVE

To compare very short scales for screening for depression with longer, widely used scales.

METHODS

Eighty-seven patients over the age of 60 who were admitted to rehabilitation wards or were attending a day rehabilitation facility at a British teaching hospital were screened for depression using the 1-item mental health inventory, and the 4-item, 15-item and 30-item geriatric depression scales. The sensitivity, specificity, and areas under receiver operating characteristic curves were compared, with the diagnostic criteria for research of ICD-10 providing the criterion diagnosis of depressive episode.

RESULTS

All the scales had comparable sensitivity (82.4-100%), specificity (60.0-71.4%), and positive predictive values (33.3-42.9%). Comparison of receiver operating characteristic curves for each scale showed no statistically significant difference between them (range 0.80-0.88).

CONCLUSIONS

The very short scales performed just as well as the widely used longer screening scales in this population. They are worthy of further examination in elderly populations at risk of depression, and may be particularly suitable for older adults due to their brevity and ease of use.