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Background

The demands and consequences of caregiving are considerable. However, such outcomes are not commonly investigated in the evaluation of interventions targeting frailty. This study aims to explore family carers’ reactions to caregiving during an intervention targeting frailty in community living older people.

Method

A study of carers (n=119) embedded in a 12 month randomised controlled intervention targeting frailty in people 70 years or older, compared to usual care. Reactions to caregiving were measured in the domains of health, finance, self-esteem, family support and daily schedule. Anxiety and depression levels were also evaluated. Carer outcomes were measured at baseline, 6 months and 12 months and at 3 months post frailty intervention.

Results

Carers of frail older people in the intervention group showed a sustained improvement in health scores during the intervention targeting frailty, while health scores for carers of the frail older people in the control group, decreased and therefore their health worsened (F=2.956, p=0.034). The carers of the frail older people in the intervention group reported overall better health (F=5.303, p=0.023) and self-esteem (F=4.158, p=0.044), and co-resident carers reported higher self-esteem (F=4.088, p=0.046). Anxiety levels increased for carers in both intervention and control groups (F=2.819, p=0.04).

Conclusion

The inclusion of carers in trials targeting frail older people may assist in the identification of at-risk carers and facilitate the provision of information and support that will assist them to continue providing care. Further research that explores the features of frailty interventions that impact on the caregiving experience is recommended.

Trial registration

Australian New Zealand Clinical Trials Registry: ACTRN12608000565347

Background

The Happy Life Club™ is an intervention that utilises health coaches trained in behavioural change and motivational interviewing techniques to assist with the management of type 2 diabetes mellitus (T2DM) in primary care settings in China. Health coaches will support participants to improve modifiable risk factors and adhere to effective self-management treatments associated with T2DM.

Methods/Design

A cluster randomised controlled trial involving 22 Community Health Centres (CHCs) in Fengtai District of Beijing, China. CHCs will be randomised into a control or intervention group, facilitating recruitment of at least 1320 individual participants with T2DM into the study. Participants in the intervention group will receive a combination of both telephone and face-to-face health coaching over 18 months, in addition to usual care received by the control group. Health coaching will be performed by CHC doctors and nurses certified in coach-assisted chronic disease management. Outcomes will be assessed at baseline and again at 6, 12 and 18 months by means of a clinical health check and self-administered questionnaire. The primary outcome measure is HbA1c level. Secondary outcomes include metabolic, physiological and psychological variables.

Discussion

This cluster RCT has been developed to suit the Chinese health care system and will contribute to the evidence base for the management of patients with T2DM. With a strong focus on self-management and health coach support, the study has the potential to be adapted to other chronic diseases, as well as other regions of China.

Trial Registration

Current Controlled Trials ISRCTN01010526

Background

Many older adults with dementia require constant assistance from a caregiver when completing activities of daily living (ADL). This study examines the efficacy of a computerized device intended to assist people with dementia through ADL, while reducing caregiver burden. The device, called COACH, uses artificial intelligence to autonomously guide an older adult with dementia through the ADL using audio and/or audio-video prompts.

Methods

Six older adults with moderate-to-severe dementia participated in this study. Handwashing was chosen as the target ADL. A single subject research design was used with two alternating baseline (COACH not used) and intervention (COACH used) phases. The data were analyzed to investigate the impact of COACH on the participants' independence and caregiver burden as well as COACH's overall performance for the activity of handwashing.

Results

Participants with moderate-level dementia were able to complete an average of 11% more handwashing steps independently and required 60% fewer interactions with a human caregiver when COACH was in use. Four of the participants achieved complete or very close to complete independence. Interestingly, participants' MMSE scores did not appear to robustly coincide with handwashing performance and/or responsiveness to COACH; other idiosyncrasies of each individual seem to play a stronger role. While the majority (78%) of COACH's actions were considered clinically correct, areas for improvement were identified.

Conclusion

The COACH system shows promise as a tool to help support older adults with moderate-levels of dementia and their caregivers. These findings reinforce the need for flexibility and dynamic personalization in devices designed to assist older adults with dementia. After addressing identified improvements, the authors plan to run clinical trials with a sample of community-dwelling older adults and caregivers.

Background

Older people usually prefer staying at home rather than going into residential care. The Belgian National Institute for Health and Disability Insurance wishes to invest in home care by financing innovative projects that effectively help older people to stay at home longer. In this study protocol we describe the evaluation of 34 home care projects. These projects are clustered according to the type of their main intervention such as case management, night care, occupational therapy at home and psychological/psychosocial support. The main goal of this study is to identify which types of projects have the most effect in delaying institutionalization of frail older persons.

Methods/design

This is a longitudinal intervention study based on a quasi-experimental design. Researchers use three comparison strategies to evaluate intervention - comparison among different types of projects, comparisons between older persons in the projects and older persons not benefiting from a project but who are still at home and between older persons in the projects and older persons who are already institutionalized. Projects are asked to include clients who are frail and at risk of institutionalization. In the study we use internationally validated instruments such as the interRAI Home Care instrument, the WHO-QOL-8 and the Zarit Burden Interview-12. These instruments are filled out at baseline, at exit from the project and 6 months after baseline. Additionally, caregivers have to do a follow-up every 6 months until exit from the project. Criteria to exit the cohort will be institutionalization longer than 3 months and death. The main analysis in the study consists of the calculation of incidence rates, cumulative incidence rates and hazard rates of definitive institutionalization through survival analyses for each type of project.

Discussion

This research will provide knowledge on the functional status of frail older persons who are still living at home. This is important information to identify determinants of risk for institutionalization. The identification of effective home care projects in delaying institutionalization will be useful to inform and empower home care providers, policy and related decision makers to manage and improve home care services.

Background

The PEACH study is based on an innovative 'telephone coaching' program that has been used effectively in a post cardiac event trial. This intervention will be tested in a General Practice setting in a pragmatic trial using existing Practice Nurses (PN) as coaches for people with type 2 diabetes (T2D). Actual clinical care often fails to achieve standards, that are based on evidence that self-management interventions (educational and psychological) and intensive pharmacotherapy improve diabetes control. Telephone coaching in our study focuses on both. This paper describes our study protocol, which aims to test whether goal focused telephone coaching in T2D can improve diabetes control and reduce the treatment gap between guideline based standards and actual clinical practice.

Methods/design

In a cluster randomised controlled trial, general practices employing Practice Nurses (PNs) are randomly allocated to an intervention or control group. We aim to recruit 546 patients with poorly controlled T2D (HbA1c >7.5%) from 42 General Practices that employ PNs in Melbourne, Australia. PNs from General Practices allocated to the intervention group will be trained in diabetes telephone coaching focusing on biochemical targets addressing both patient self-management and engaging patients to work with their General Practitioners (GPs) to intensify pharmacological treatment according to the study clinical protocol. Patients of intervention group practices will receive 8 telephone coaching sessions and one face-to-face coaching session from existing PNs over 18 months plus usual care and outcomes will be compared to the control group, who will only receive only usual care from their GPs. The primary outcome is HbA1c levels and secondary outcomes include cardiovascular disease risk factors, behavioral risk factors and process of care measures.

Discussion

Understanding how to achieve comprehensive treatment of T2D in a General Practice setting is the focus of the PEACH study. This study explores the potential role for PNs to help reduce the treatment and outcomes gap in people with T2D by using telephone coaching. The intervention, if found to be effective, has potential to be sustained and embedded within real world General Practice.

Background

Interventions that enhance mobility in frail older people are needed to maintain health and independence, yet definitive evidence of effective interventions is lacking. Our objective was to assess the impact of a multifactorial intervention on mobility-related disability in frail older people.

Methods

We conducted a randomised, controlled trial with 241 frail community-dwelling older people in Sydney, Australia. Participants were classified as frail using the Cardiovascular Health Study definition, did not have severe cognitive impairment and were recently discharged from an aged care and rehabilitation service. The experimental group received a 12 month multifactorial, interdisciplinary intervention targeting identified frailty components. Two physiotherapists delivered a home exercise program targeting mobility, and coordinated management of psychological and medical conditions with other health professionals. The control group received usual care. Disability in the mobility domain was measured at baseline and at 3 and 12 months using the International Classification of Functioning, Disability and Health framework. Participation (involvement in life situations) was assessed using the Life Space Assessment and the Goal Attainment Scale. Activity (execution of mobility tasks) was measured using the 4-metre walk and self-report measures.

Results

The mean age of participants was 83.3 years (SD: 5.9 years). Of the participants recruited, 216 (90%) were followed-up at 12 months. At this time point, the intervention group had significantly better scores than the control group on the Goal Attainment Scale (odds ratio 2.1; 95% confidence interval (CI) 1.3 to 3.3, P = 0.004) and Life Space Assessment (4.68 points, 95% CI 1.4 to 9.9, P = 0.005). There was no difference between groups on the global measure of participation or satisfaction with ability to get out of the house. At the activity level, the intervention group walked 0.05 m/s faster over 4 m (95% CI 0.0004 to 0.1, P = 0.048) than the control group, and scored higher on the Activity Measure for Post Acute Care (P < 0.001).

Conclusions

The intervention reduced mobility-related disability in frail older people. The benefit was evident at both the participation and activity levels of mobility-related disability.

Trial registration

Australia and New Zealand Clinical Trials Register (ANZCTR): ANZCTRN12608000507381.

Objective

To evaluate the effectiveness of a population based, multifaceted shared care intervention for late life depression in residential care.

Design

Randomised controlled trial, with control and intervention groups studied one after the other and blind follow up after 9.5 months.

Setting

Population of residential facility in Sydney living in self care units and hostels.

Participants

220 depressed residents aged ⩾65 without severe cognitive impairment.

Intervention

The shared care intervention included: (a) multidisciplinary consultation and collaboration, (b) training of general practitioners and carers in detection and management of depression, and (c) depression related health education and activity programmes for residents. The control group received routine care.

Main outcome measure

Geriatric depression scale.

Results

Intention to treat analysis was used. There was significantly more movement to “less depressed” levels of depression at follow up in the intervention than control group (Mantel-Haenszel stratification test, P=0.0125). Multiple linear regression analysis found a significant intervention effect after controlling for possible confounders, with the intervention group showing an average improvement of 1.87 points on the geriatric depression scale compared with the control group (95% confidence interval 0.76 to 2.97, P=0.0011).

Conclusions

The outcome of depression among elderly people in residential care can be improved by multidisciplinary collaboration, by enhancing the clinical skills of general practitioners and care staff, and by providing depression related health education and activity programmes for residents.

Key messagesLarge numbers of depressed elderly people live in residential care but few receive appropriate managementA population based, multifaceted shared care intervention for late life depression was more effective than routine care in improving depression outcomeThe outcome of late life depression can be improved by enhancing the clinical skills of general practitioners and care staff and by providing depression related health education and activity programmes for residentsThe intervention needs further refining and evaluation to improve its effectiveness and to determine how best to implement it in other residential care settings

Background

Care for older adults is facing a number of challenges: health problems are not consistently identified at a timely stage, older adults report a lack of autonomy in their care process, and care systems are often confronted with the need for better coordination between health care professionals. We aim to address these challenges by introducing the geriatric care model, based on the chronic care model, and to evaluate its effects on the quality of life of community-dwelling frail older adults.

Methods/design

In a 2-year stepped-wedge cluster randomised clinical trial with 6-monthly measurements, the chronic care model will be compared with usual care. The trial will be carried out among 35 primary care practices in two regions in the Netherlands. Per region, practices will be randomly allocated to four allocation arms designating the starting point of the intervention. Participants: 1200 community-dwelling older adults aged 65 or over and their primary informal caregivers. Primary care physicians will identify frail individuals based on a composite definition of frailty and a polypharmacy criterion. Final inclusion criterion: scoring 3 or more on a disability case-finding tool. Intervention: Every 6 months patients will receive a geriatric in-home assessment by a practice nurse, followed by a tailored care plan. Expert teams will manage and train practice nurses. Patients with complex care needs will be reviewed in interdisciplinary consultations. Evaluation: We will perform an effect evaluation, an economic evaluation, and a process evaluation. Primary outcome is quality of life as measured with the Short Form-12 questionnaire. Effect analyses will be based on the “intention-to-treat” principle, using multilevel regression analysis. Cost measurements will be administered continually during the study period. A cost-effectiveness analysis and cost-utility analysis will be conducted comparing mean total costs to functional status, care needs and QALYs. We will investigate the level of implementation, barriers and facilitators to successful implementation and the extent to which the intervention manages to achieve the transition necessary to overcome challenges in elderly care.

Discussion

This is one of the first studies assessing the effectiveness, cost-effectiveness and implementation process of the chronic care model for frail community-dwelling older adults.

Trial registration

The Netherlands National Trial Register NTR2160.

Background

Although self-management support improves diabetes outcomes, it is not consistently provided in health care settings strained for time and resources. One proposed solution to personnel and funding shortages is to utilize peer coaches, patients trained to provide diabetes education and support to other patients. Coaches share similar experiences about living with diabetes and are able to reach patients within and beyond the health care setting. Given the limited body of evidence that demonstrates peer coaching significantly improves chronic disease care, this present study examines the impact of peer coaching delivered in a primary care setting on diabetes outcomes.

Methods/Design

The aim of this multicenter, randomized control trial is to evaluate the effectiveness of utilizing peer coaches to improve clinical outcomes and self-management skills in low-income patients with poorly controlled diabetes. A total of 400 patients from six primary health centers based in San Francisco that serve primarily low-income populations will be randomized to receive peer coaching (n = 200) or usual care (n = 200) over 6 months. Patients in the peer coach group receive coaching from patients with diabetes who are trained and mentored as peer coaches. The primary outcome is change in HbA1c. Secondary outcomes include change in: systolic blood pressure, body mass index (BMI), LDL cholesterol, diabetes self-care activities, medication adherence, diabetes-related quality of life, diabetes self-efficacy, and depression. Clinical values (HbA1c, LDL cholesterol and blood pressure) and self-reported diabetes self-efficacy and self-care activities are measured at baseline and after 6 months for patients and coaches. Peer coaches are also assessed at 12 months.

Discussion

Patients with diabetes, who are trained as peer health coaches, are uniquely poised to provide diabetes self management support and education to patients. This study is designed to investigate the impact of peer health coaching in patients with poorly controlled diabetes. Additionally, we will assess disease outcomes in patients with well controlled diabetes who are trained and work as peer health coaches.

Trial Registration

ClinicalTrials.gov identifier: NCT01040806

BACKGROUND—Growth monitoring consists of routine measurements to detect abnormal growth, combined with some action when this is detected. It aims to improve nutrition, reduce the risk of death or inadequate nutrition, help educate carers, and lead to early referral for conditions manifest by growth disorders. As primary care workers world wide invest time in this activity, evidence for its benefits and harms was sort.
INCLUSION CRITERIA—Studies: randomised or quasi-randomised controlled trials of growth monitoring. Interventions: regular growth monitoring, combined with some intervention targeted at abnormal growth, compared with controls. Outcomes: anthropometric measures; referrals to primary and specialist care, or community services; maternal knowledge, anxiety, and satisfaction; child morbidity and mortality.
COMPARISONS—Routine growth monitoring compared with no routine growth monitoring; routine growth monitoring by plotting onto a standard chart compared with monitoring with no chart.
SEARCH STRATEGY—Cochrane controlled trials register; World Health Organisation and World Bank publications; contact with specialist community paediatricians working in the field.
RESULTS—Two trials met the inclusion criteria. One compared growth monitoring with no growth monitoring, in a cluster randomised trial nested in a nutritional intervention programme, and detected no difference in nutritional outcomes between the two groups. Another trial compared growth monitoring with and without a standard chart, measuring maternal knowledge of women about nutrition. It showed small numerical differences in test scores.
DISCUSSION AND IMPLICATIONS—Current policies appear to be based on the opinion that investment in the activity has worthwhile health benefits, and does no harm. No reliable evidence was found to support or refute this.



Objective To evaluate the effect of a video decision support tool on the preferences for future medical care in older people if they develop advanced dementia, and the stability of those preferences after six weeks.

Design Randomised controlled trial conducted between 1 September 2007 and 30 May 2008.

Setting Four primary care clinics (two geriatric and two adult medicine) affiliated with three academic medical centres in Boston.

Participants Convenience sample of 200 older people (≥65 years) living in the community with previously scheduled appointments at one of the clinics. Mean age was 75 and 58% were women.

Intervention Verbal narrative alone (n=106) or with a video decision support tool (n=94).

Main outcome measures Preferred goal of care: life prolonging care (cardiopulmonary resuscitation, mechanical ventilation), limited care (admission to hospital, antibiotics, but not cardiopulmonary resuscitation), or comfort care (treatment only to relieve symptoms). Preferences after six weeks. The principal category for analysis was the difference in proportions of participants in each group who preferred comfort care.

Results Among participants receiving the verbal narrative alone, 68 (64%) chose comfort care, 20 (19%) chose limited care, 15 (14%) chose life prolonging care, and three (3%) were uncertain. In the video group, 81 (86%) chose comfort care, eight (9%) chose limited care, four (4%) chose life prolonging care, and one (1%) was uncertain (χ2=13.0, df=3, P=0.003). Among all participants the factors associated with a greater likelihood of opting for comfort care were being a college graduate or higher, good or better health status, greater health literacy, white race, and randomisation to the video arm. In multivariable analysis, participants in the video group were more likely to prefer comfort care than those in the verbal group (adjusted odds ratio 3.9, 95% confidence interval 1.8 to 8.6). Participants were re-interviewed after six weeks. Among the 94/106 (89%) participants re-interviewed in the verbal group, 27 (29%) changed their preferences (κ=0.35). Among the 84/94 (89%) participants re-interviewed in the video group, five (6%) changed their preferences (κ=0.79) (P<0.001 for difference).

Conclusion Older people who view a video depiction of a patient with advanced dementia after hearing a verbal description of the condition are more likely to opt for comfort as their goal of care compared with those who solely listen to a verbal description. They also have more stable preferences over time.

Trial registration Clinicaltrials.gov NCT00704886.

Background

Many older people presenting to Acute Medical Units (AMU) are discharged after only a short stay (< 72 hours), yet many re-present to hospital or die within 1 year. Comprehensive Geriatric Assessment may improve patient outcomes for this group.

Method

Participants

Patients aged > 70 years and scoring positive on a risk screening tool ('Identification of Seniors At Risk') who are discharged within 72 hours of attending an AMU with a medical crisis, recruited prior to discharge. Sample size is 400. Carers of participants will also be recruited.

Intervention

Assessment on the AMU and further out-patient management by a specialist physician in geriatric medicine. Assessment and further management will follow the principles of Comprehensive Geriatric Assessment, providing advice and support to primary care services.

Design

Multi-centre, individual patient randomised controlled trial comparing intervention with usual care.

Outcome measurement

Follow up is by postal questionnaire 90 days after randomisation, and data will be entered into the study database by a researcher blind to allocation. The primary outcome is the number of days spent at home (for those admitted from home), or days spent in the same care home (if admitted from a care home). Secondary outcomes include mortality, institutionalisation, health and social care resource use, and scaled outcome measures, including quality of life, disability, mental well-being. Carer strain and well being will also be measured at 90 days.

Analyses

Comparisons of outcomes and costs, and a cost utility analysis between the intervention and control groups will be carried out.

Trial Registration

ISRCTN: ISRCTN21800480

Background

Patients with diabetes are at increased risk for depression, compounding the burden of disease. When comorbid with diabetes, depression leads to poorer health outcomes and often complicates diabetes self-management. Unfortunately, treatment options for these complex patients are limited and comprehensive services are rarely available for patients in rural settings.

Methods

A small open trial was conducted to test the acceptability, feasibility and preliminary outcomes of a telephone-delivered coaching intervention for rural-dwelling older adults with uncontrolled diabetes and comorbid, clinically significant depressive symptoms. A total of eight older adults were enrolled in Healthy Outcomes through Patient Empowerment (HOPE), a 10-session (12-week), telephone-based coaching intervention. Primary study constructs included measures of diabetes control (Hemoglobin [Hb] A1c), depressive symptoms (Patient Health Questionnaire-9 [PHQ-9]), and diabetes-related distress (Problem Areas in Diabetes Scale [PAID]). Assessments were conducted at baseline, post-intervention, and 6-month follow-up. Acceptability and feasibility were evaluated using patient surveys, focused exit interviews, and session attendance data.

Results

Clinically significant improvements were realized post-intervention and at 6-month follow-up for outcomes related to diabetes and depression. Effect sizes using Cohen's d were determined post-intervention and at 6-month follow-up, respectively, for HbA1c (d=0.36; d=0.28), PHQ-9 (d=1.48; d=1.67, and PAID (d=1.50; d=1.06) scores. Among study participants, HbA1c improved from baseline by a mean (M) of 1.13 (SD=1.70) post-intervention and M=0.84 (SD=1.62) at 6 months. Depression scores, measured by the PHQ-9, improved from baseline by M=5.14 (SD=2.27) post-intervention and M=7.03 (SD=4.43) at 6-month follow-up. PAID scores also improved by M=17.68 (SD=10.7) post-intervention and M=20.42 (SD=20.66) from baseline to 6-month follow-up. Case examples are provided for additional context and to more fully articulate salient intervention concepts.

Conclusion

Although preliminary, data from this small open trial suggest that HOPE holds the potential to improve both physical (diabetes) and emotional (diabetes distress, depression) health outcomes and that changes can be maintained over a 6-month time period. As envisioned by the authors, HOPE may function as an extension of traditional primary care for rural-dwelling older adults with multiple comorbidities. A future randomized clinical trial will test HOPE’s broader effectiveness with rural-dwelling older adults.

Trial registration

NCT01274715

Background

Due to the ageing of the population, the number of frail older people who suffer from multiple, complex health complaints increases and this ultimately threatens their ability to function independently. Many interventions for frail older people attempt to prevent or delay functional decline, but they show contradicting results. Recent studies emphasise the importance of embedding these interventions into existing primary care systems and tailoring care to older people’s needs and wishes. This article presents the design of an evaluation study, aiming to investigate the effects and feasibility of the early detection of health problems among community-dwelling older people and their subsequent referral to appropriate care and/or well-being facilities by general practices.

Methods/Design

A longitudinal, quasi-experimental study is designed comparing 13 intervention practices with 11 control practices. General practices select eligible community-dwelling older people (≥ 75 years). Practice nurses from intervention practices (1) visit older people at home for a comprehensive assessment of their health and well-being; (2) discuss results with the GP; (3) formulate – if required – a care and treatment plan together with the patient; (4) refer patient to care and/or well-being facilities; and (5) monitor and coordinate care and follow-up. Control practices provide usual care and match the intervention practices on the presence of different primary care professionals within the practice. Primary outcome measures are health-related quality of life and disability. Additionally, attitude towards ageing, care satisfaction, health care utilisation, nursing home admission and mortality are measured. Some outcomes are assessed by means of a postal questionnaire (at baseline and after 6, 12, and 18 months follow-up), others through continuous registration over the 18-month period. A profound process evaluation will provide insight into barriers and facilitators for implementing the intervention protocol within general practices from both the patient and caregiver perspective.

Discussion

The proposed approach requires redesigning care delivery within general practices for accomplishing appropriate care for older people. A quasi-experimental design is chosen to closely resemble a real-life situation, which is desirable for future implementation after this innovation proves to be successful. Results of the effect and process evaluation will become available in 2013.

Trial registration

The Netherlands National Trial Register NTR2737

Objective To evaluate the effectiveness of multifactorial assessment and intervention programmes to prevent falls and injuries among older adults recruited to trials in primary care, community, or emergency care settings.

Design Systematic review of randomised and quasi-randomised controlled trials, and meta-analysis.

Data sources Six electronic databases (Medline, Embase, CENTRAL, CINAHL, PsycINFO, Social Science Citation Index) to 22 March 2007, reference lists of included studies, and previous reviews.

Review methods Eligible studies were randomised or quasi-randomised trials that evaluated interventions to prevent falls that were based in emergency departments, primary care, or the community that assessed multiple risk factors for falling and provided or arranged for treatments to address these risk factors.

Data extraction Outcomes were number of fallers, fall related injuries, fall rate, death, admission to hospital, contacts with health services, move to institutional care, physical activity, and quality of life. Methodological quality assessment included allocation concealment, blinding, losses and exclusions, intention to treat analysis, and reliability of outcome measurement.

Results 19 studies, of variable methodological quality, were included. The combined risk ratio for the number of fallers during follow-up among 18 trials was 0.91 (95% confidence interval 0.82 to 1.02) and for fall related injuries (eight trials) was 0.90 (0.68 to 1.20). No differences were found in admissions to hospital, emergency department attendance, death, or move to institutional care. Subgroup analyses found no evidence of different effects between interventions in different locations, populations selected for high risk of falls or unselected, and multidisciplinary teams including a doctor, but interventions that actively provide treatments may be more effective than those that provide only knowledge and referral.

Conclusions Evidence that multifactorial fall prevention programmes in primary care, community, or emergency care settings are effective in reducing the number of fallers or fall related injuries is limited. Data were insufficient to assess fall and injury rates.

Background

Family members are often required to act as substitute decision-makers when health care or research participation decisions must be made for an incapacitated relative. Yet most families are unable to accurately predict older adult preferences regarding future health care and willingness to engage in research studies. Discussion and documentation of preferences could improve proxies' abilities to decide for their loved ones. This trial assesses the efficacy of an advance planning intervention in improving the accuracy of substitute decision-making and increasing the frequency of documented preferences for health care and research. It also investigates the financial impact on the healthcare system of improving substitute decision-making.

Methods/Design

Dyads (n = 240) comprising an older adult and his/her self-selected proxy are randomly allocated to the experimental or control group, after stratification for type of designated proxy and self-report of prior documentation of healthcare preferences. At baseline, clinical and research vignettes are used to elicit older adult preferences and assess the ability of their proxy to predict those preferences. Responses are elicited under four health states, ranging from the subject's current health state to severe dementia. For each state, we estimated the public costs of the healthcare services that would typically be provided to a patient under these scenarios. Experimental dyads are visited at home, twice, by a specially trained facilitator who communicates the dyad-specific results of the concordance assessment, helps older adults convey their wishes to their proxies, and offers assistance in completing a guide entitled My Preferences that we designed specifically for that purpose. In between these meetings, experimental dyads attend a group information session about My Preferences. Control dyads attend three monthly workshops aimed at promoting healthy behaviors. Concordance assessments are repeated at the end of the intervention and 6 months later to assess improvement in predictive accuracy and cost savings, if any. Copies of completed guides are made at the time of these assessments.

Discussion

This study will determine whether the tested intervention guides proxies in making decisions that concur with those of older adults, motivates the latter to record their wishes in writing, and yields savings for the healthcare system.

Trial Registration

ISRCTN89993391

OBJECTIVE: To describe coaches' education in injury care and management and their club's access to medical care, to describe coaches' perceptions of how family physicians care for sports injuries, and to describe strategies used for overcoming perceived poor advice. DESIGN: A telephone survey using both closed and open-ended questions was conducted. Information was collected as background information to a larger study investigating coaches' decisions about allowing injured athletes to compete. SETTING: All 28 competitive gymnastics clubs in the province of Alberta. The clubs trained athletes for all competitive levels. PARTICIPANTS: All 70 coaches registered with the Alberta Gymnastics Federation as working with female gymnasts were approached; 64 coaches were interviewed. MAIN OUTCOME MEASURES: Injury education, access to medical care, perceptions of sports-injury treatment provided by family physicians, strategies employed for overcoming perceived poor advice. RESULTS: Education in injury care and management was varied, as was access to medical care. Direct access to sport-specific medical care was available at three of the five elite-level clubs, an arrangement stemming from dissatisfaction with the conventional health care system. At all competitive levels, most coaches were dissatisfied with the recommendations they received from family physicians. Various strategies were employed to acquire more suitable advice. CONCLUSIONS: The results point to a need for improved communication between family physicians and coaches.

Objective To evaluate the effectiveness of comprehensive geriatric assessment in hospital for older adults admitted as an emergency.

Search strategy We searched the EPOC Register, Cochrane’s Controlled Trials Register, the Database of Abstracts of Reviews of Effects (DARE), Medline, Embase, CINAHL, AARP Ageline, and handsearched high yield journals.

Selection criteria Randomised controlled trials of comprehensive geriatric assessment (whether by mobile teams or in designated wards) compared with usual care. Comprehensive geriatric assessment is a multidimensional interdisciplinary diagnostic process used to determine the medical, psychological, and functional capabilities of a frail elderly person to develop a coordinated and integrated plan for treatment and long term follow-up.

Data collection and analysis Three independent reviewers assessed eligibility and trial quality and extracted published data. Two additional reviewers moderated.

Results Twenty two trials evaluating 10 315 participants in six countries were identified. For the primary outcome “living at home,” patients who underwent comprehensive geriatric assessment were more likely to be alive and in their own homes at the end of scheduled follow-up (odds ratio 1.16 (95% confidence interval 1.05 to 1.28; P=0.003; number needed to treat 33) at a median follow-up of 12 months versus 1.25 (1.11 to 1.42; P<0.001; number needed to treat 17) at a median follow-up of six months) compared with patients who received general medical care. In addition, patients were less likely to be living in residential care (0.78, 0.69 to 0.88; P<0.001). Subgroup interaction suggested differences between the subgroups “wards” and “teams” in favour of wards. Patients were also less likely to die or experience deterioration (0.76, 0.64 to 0.90; P=0.001) and were more likely to experience improved cognition (standardised mean difference 0.08, 0.01 to 0.15; P=0.02) in the comprehensive geriatric assessment group.

Conclusions Comprehensive geriatric assessment increases patients’ likelihood of being alive and in their own homes after an emergency admission to hospital. This seems to be especially true for trials of wards designated for comprehensive geriatric assessment and is associated with a potential cost reduction compared with general medical care.

The purpose of this study was to compare the importance given by novice, intermediate and experienced basketball coaches to training contents. To achieve this purpose, a sample composed of Portuguese basketball coaches (n = 212) described how they rate the importance of technical, tactical, physical and drill contents. According to the results, there is a wide-ranging differential from novice to experienced coaches. First, while experienced coaches tend to focus on tactical development, novice and intermediate coaches seem to privilege the improvement of technical skills. Second, whereas significant differences between novice and intermediate coaches were found, evidence confirmed that they were higher (both in number and weight) when comparing experienced coaches against novice and intermediate. The study provided strong support to justify the necessity to adjust coaches’ knowledge to players’ biological developmental, and could form the basis of focused interventions in coaching development.

Objective

To compare the benefits and harms of a Dutch 10-session Community Occupational Therapy programme for patients with Alzheimer's disease with the impact of a one session consultation at home in German routine healthcare.

Design

A seven-centre, parallel group, active controlled randomised controlled trial. Patients and carers were not masked. Assessors were fully blind for treatment allocation for one of two primary-outcome measurements.

Setting

Patients' homes.

Participants

Patients with mild to moderate Alzheimer's disease (Mini-Mental State Examination 14–24), living in the community with primary carer available and without severe depression or behavioural symptoms, were eligible.

Interventions

Experimental 10 home visits within 5 weeks by an occupational therapist, educating patients in the performance of simplified daily activities and in the use of aids to compensate for cognitive decline; and educating carers in coping with behaviour of the patient and in giving supervision to the patient. Control one home visit including individual counselling of patient and carer and explanation of a leaflet on coping with dementia in daily life.

Outcome measures

The primary outcome was the patient's daily functioning measured with the Interview of Deterioration in Daily activities in Dementia and the Perceive, Recall, Plan and Perform System of Task Analysis. Assessments were at baseline, 6, 16 and 26 weeks, with a postal assessment at 52 weeks.

Results

141 patients were 1:1 randomised to the experimental (N=71) and control group (N=70). Data for 54 and 50 participants were analysed. Patients' daily functioning did not differ significantly between the experimental and control group at week 6, 16, 26 or 52 and remained stable over 26 weeks in both groups. No adverse events were associated with the interventions.

Conclusions

In German healthcare, a Dutch 10-session community occupational therapy was not better than a one-session consultation for the daily functioning of patients with Alzheimer's disease. Further research on the transfer of complex psychosocial is needed.

International Clinical Trials Registry Platform

DRKS00000053; Funded by the German Federal Ministry of Health.

Article summary

Article focus

Efficiency of community occupational therapy in dementia.

Pragmatic multicentre RCT in routine care context.

Key messages

A 10-session community occupational therapy programme did not work more effectively than a comprehensive one-session occupational therapy consultation within German routine healthcare.

Strengths and limitations of this study

The main strength of this trial was an elaborate multicentre RCT design within a routine care setting using an active control group, a prolonged follow-up and a strategy of video rating with fully blind assessors. However, the patients and carer could not be masked.

The main limitation was that the training time for the interventionists was shorter, and that they had less treatment experience with the experimental intervention than the therapists of the Dutch original trial.

Furthermore, we had to exclude 37 patients (26%) from the multivariate analysis of variance of the primary outcome because they withdrew; or the assessment at one or more time points was missing or not within the planned time period. However, the attrition in both groups did not demonstrate a systematic bias; the analysis of the reduced patient sample with valid data did not show a tendency to significant group differences; and an additional mixed model analysis of all randomised patients did not reveal any significant differences. Consequently, the hypothesis of better effects within the experimental group must be rejected.

Objective: to assess the effect of home versus day rehabilitation on patient outcomes.

Design: randomised controlled trial.

Setting: post-hospital rehabilitation.

Participants: two hundred and twenty-nine hospitalised patients referred for ambulatory rehabilitation.

Interventions: hospital-based day rehabilitation programme versus home-based rehabilitation programme.

Main Outcome Measures: at 3 months, information was collected on hospital readmission, transfer to residential care, functional level, quality of life, carer stress and carer quality of life. At 6 months, place of residence, hospital re-admissions and mortality status were collected.

Results: there were significant improvements in the functional outcomes from baseline to 3 months for all participants. At discharge, carers of patients in day hospital reported higher Caregiver Strain Index (CSI) scores in comparison to home rehabilitation carers (4.95 versus 3.56, P = 0.047). Patients in day hospital had double the risk of readmission compared to those in home rehabilitation (RR = 2.1; 95% CI 1.2–3.9). This effect persisted at 6 months.

Conclusions: day hospital patients are more likely to be readmitted to hospital possibly due to increased access to admitting medical staff. This small trial favours the home as a better site for post-hospital rehabilitation.

Background

Elderly persons admitted to the hospital are at risk for hospital related functional loss. This evaluation aims to compare the effects of different levels of (integrated) health intervention care programs on preventing hospital related functional loss among elderly patients by comparing a new intervention program to two usual care programs.

Methods/Design

This study will include an effect, process and cost evaluation using a mixed methods design of quantitative and qualitative methods. Three hospitals in the Netherlands with different levels of integrated geriatric health care will be evaluated using a quasi-experimental study design. Data collection on outcomes will take place through a prospective cohort study, which will incorporate a nested randomised controlled trial to evaluate the effects of a stay at the centre for prevention and reactivation for patients with complex problems. The study population will consist of elderly persons (65 years or older) at risk for functional loss who are admitted to one of the three hospitals. Data is prospectively collected at time of hospital admission (T0), three months (T1), and twelve months (T2) after hospital admission. Patient and informal caregiver outcomes (e.g. health related quality of life, activities of daily living, burden of care, (re-) admission in hospital or nursing homes, mortality) as well as process measures (e.g. the cooperation and collaboration of multidisciplinary teams, patient and informal caregiver satisfaction with care) will be measured. A qualitative analysis will determine the fidelity of intervention implementation as well as provide further context and explanation for quantitative outcomes. Finally, costs will be determined from a societal viewpoint to allow for cost effectiveness calculations.

Discussion

It is anticipated that higher levels of integrated hospital health care for at risk elderly will result in prevention of loss of functioning and loss of quality of life after hospital discharge as well as in lower burden of care and higher quality of life for informal caregivers. Ultimately, the results of this study may contribute to the implementation of a national integrated health care program to prevent hospital related functional loss among elderly patients.

Trial registration

The Netherlands National Trial Register: NTR2317

Background

Targeting social isolation in older people is a growing public health concern. The proportion of older people in society has increased in recent decades, and it is estimated that approximately 25% of the population will be aged 60 or above within the next 20 to 40 years. Social isolation is prevalent amongst older people and evidence indicates the detrimental effect that it can have on health and wellbeing. The aim of this review was to assess the effectiveness of interventions designed to alleviate social isolation and loneliness in older people.

Methods

Relevant electronic databases (MEDLINE, EMBASE, ASSIA, IBSS, PsycINFO, PubMed, DARE, Social Care Online, the Cochrane Library and CINAHL) were systematically searched using an extensive search strategy, for randomised controlled trials and quasi-experimental studies published in English before May 2009. Additional articles were identified through citation tracking. Studies were included if they related to older people, if the intervention aimed to alleviate social isolation and loneliness, if intervention participants were compared against inactive controls and, if treatment effects were reported. Two independent reviewers extracted data using a standardised form. Narrative synthesis and vote-counting methods were used to summarise and interpret study data.

Results

Thirty two studies were included in the review. There was evidence of substantial heterogeneity in the interventions delivered and the overall quality of included studies indicated a medium to high risk of bias. Across the three domains of social, mental and physical health, 79% of group-based interventions and 55% of one-to-one interventions reported at least one improved participant outcome. Over 80% of participatory interventions produced beneficial effects across the same domains, compared with 44% of those categorised as non-participatory. Of interventions categorised as having a theoretical basis, 87% reported beneficial effects across the three domains compared with 59% of interventions with no evident theoretical foundation. Regarding intervention type, 86% of those providing activities and 80% of those providing support resulted in improved participant outcomes, compared with 60% of home visiting and 25% of internet training interventions. Fifty eight percent of interventions that explicitly targeted socially isolated or lonely older people reported positive outcomes, compared with 80% of studies with no explicit targeting.

Conclusions

More, well-conducted studies of the effectiveness of social interventions for alleviating social isolation are needed to improve the evidence base. However, it appeared that common characteristics of effective interventions were those developed within the context of a theoretical basis, and those offering social activity and/or support within a group format. Interventions in which older people are active participants also appeared more likely to be effective. Future interventions incorporating all of these characteristics may therefore be more successful in targeting social isolation in older people.

Background

Geriatric assessment is a multidisciplinary diagnostic process that evaluates the older adult’s medical, psychological, social, and functional capacity. No systematic review of the use of geriatric assessment in oncology has been conducted. The goals of this systematic review were: 1) to provide an overview of all geriatric assessment instruments used in the oncology setting; 2) to examine the feasibility and psychometric properties of those instruments; and 3) to systematically evaluate the effectiveness of geriatric assessment in predicting or modifying outcomes (including the impact on treatment decision making, toxicity of treatment, and mortality).

Methods

We searched Medline, Embase, Psychinfo, Cinahl, and the Cochrane Library for articles published in English, French, Dutch, or German between January 1, 1996, and November 16, 2010, reporting on cross-sectional, longitudinal, interventional, or observational studies that assessed the feasibility or effectiveness of geriatric assessment instruments. The quality of articles was evaluated using relevant quality assessment frameworks.

Results

We identified 83 articles that reported on 73 studies. The quality of most studies was poor to moderate. Eleven studies examined psychometric properties or diagnostic accuracy of the geriatric assessment instruments used. The assessment generally took 10–45min. Geriatric assessment was most often completed to describe a patient’s health and functional status. Specific domains of geriatric assessment were associated with treatment toxicity in 6 of 9 studies and with mortality in 8 of 16 studies. Of the four studies that examined the impact of geriatric assessment on the cancer treatment decision, two found that geriatric assessment impacted 40%–50% of treatment decisions.

Conclusion

Geriatric assessment in the oncology setting is feasible, and some domains are associated with adverse outcomes. However, there is limited evidence that geriatric assessment impacted treatment decision making. Further research examining the effectiveness of geriatric assessment on treatment decisions and outcomes is needed.

Background

Case management has been applied in community aged care to meet frail older people’s holistic needs and promote cost-effectiveness. This systematic review aims to evaluate the effects of case management in community aged care on client and carer outcomes.

Methods

We searched Web of Science, Scopus, Medline, CINAHL (EBSCO) and PsycINFO (CSA) from inception to 2011 July. Inclusion criteria were: no restriction on date, English language, community-dwelling older people and/or carers, case management in community aged care, published in refereed journals, randomized control trials (RCTs) or comparative observational studies, examining client or carer outcomes. Quality of studies was assessed by using such indicators as quality control, randomization, comparability, follow-up rate, dropout, blinding assessors, and intention-to-treat analysis. Two reviewers independently screened potentially relevant studies, extracted information and assessed study quality. A narrative summary of findings were presented.

Results

Ten RCTs and five comparative observational studies were identified. One RCT was rated high quality. Client outcomes included mortality (7 studies), physical or cognitive functioning (6 studies), medical conditions (2 studies), behavioral problems (2 studies) , unmet service needs (3 studies), psychological health or well-being (7 studies) , and satisfaction with care (4 studies), while carer outcomes included stress or burden (6 studies), satisfaction with care (2 studies), psychological health or well-being (5 studies), and social consequences (such as social support and relationships with clients) (2 studies). Five of the seven studies reported that case management in community aged care interventions significantly improved psychological health or well-being in the intervention group, while all the three studies consistently reported fewer unmet service needs among the intervention participants. In contrast, available studies reported mixed results regarding client physical or cognitive functioning and carer stress or burden. There was also limited evidence indicating significant effects of the interventions on the other client and carer outcomes as described above.

Conclusions

Available evidence showed that case management in community aged care can improve client psychological health or well-being and unmet service needs. Future studies should investigate what specific components of case management are crucial in improving clients and their carers’ outcomes.