Emily You

Effects of case management in community aged care on client and carer outcomes: a systematic review of randomized trials and comparative observational studies

BackgroundCase 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.MethodsWe 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.ResultsTen 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.ConclusionsAvailable 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.

Case Managed Community Aged Care What Is the Evidence for Effects on Service Use and Costs

Objective: To evaluate the effects of case management in community aged care (CMCAC) interventions on service use and costs. Method: Five databases were searched from inception to 2011 July to include randomized control trials and comparative observational English studies. Results were summarized by using the best-evidence synthesis approach. Results: Twenty-one studies were included. Available studies supported improvements in clients’ use of case management services (all of the four studies), some community services (8 of the 10) and nursing home admission and stay (around one half), delay of nursing home placement (all of the two studies), and achieving cost neutrality (8 of the 11). The effects on medical care utilization were varying. Discussion: In general, these positive effects justify the further development and refinement of CMCAC programs. Result applicability is limited by only including English studies. Cost studies applying a societal perspective, and full economic appraisals where appropriate are warranted.

Risk of death or hospital admission among community-dwelling older adults living with dementia in Australia

BackgroundOlder people living with dementia prefer to stay at home to receive support. But they are at high risk of death and/or hospital admissions. This study primarily aimed to determine risk factors for time to death or hospital admission (combined) in a sample of community-dwelling older people living with dementia in Australia. As a secondary study purpose, risk factors for time to death were also examined.MethodsThis study used the data of a previous project which had been implemented during September 2007 and February 2009. The original project had recruited 354 eligible clients (aged 70 and over, and living with dementia) for Extended Aged Care At home Dementia program services during September 2007 and 2008. Client information and carer stress had been collected from their case managers through a baseline survey and three-monthly follow-up surveys (up to four in total). The principal data collection tools included Global Deterioration Scale, Modified Barthel Index, Instrumental-Dependency OARS, Adapted Cohen-Mansfield Agitation Inventory, as well as measures of clients’ socio-demographic characteristics, service use and diseases diagnoses. The sample of our study included 284 clients with at least one follow-up survey. The outcome variable was death or hospital admission, and death during six, nine and 16-month study periods. Stepwise backwards multivariate Cox proportional hazards analysis was employed, and Kaplan-Meier survival analysis using censored data was displayed.ResultsHaving previous hospital admissions was a consistent risk factor for time to death or hospital admission (six-month: HR = 3.12; nine-month: HR = 2.80; 16-month: HR = 2.93) and for time to death (six-month: HR = 2.27; 16-month: HR = 2.12) over time. Previously worse cognitive status was a consistent risk factor over time (six- and nine-month: HR = 0.58; 16-month: HR = 0.65), but no previous use of community care was only a short-term risk factor (six-month: HR = 0.42) for time to death or hospital admission.ConclusionsPrevious hospital admissions and previously worse cognitive status are target intervention areas for reducing dementia clients’ risk of time to death or hospital admission, and/or death. Having previous use of community care as a short-term protective factor for dementia clients’ time to death or hospital admission is noteworthy.

Befriending to Relieve Anxiety and Depression Associated with Chronic Obstructive Pulmonary Disease (COPD): A Case Report

ABSTRACT Chronic obstructive pulmonary disease (COPD) is a chronic lung disease characterized by airflow obstruction and shortness of breath, which as a result can severely limit activities of daily living. COPD sufferers are 85% more likely to develop anxiety disorders than healthy matched controls. Some of the factors that have been suggested to be associated with high anxiety in people with COPD include dyspnoea, the inability to perform daily activities or fulfil social roles, rehospitalisation and some COPD treatments. There is substantial evidence that cognitive behaviour therapy (CBT) is effective in managing mood disorders, but there is also some evidence that befriending can assist people. Befriending is an intervention that focuses on everyday conversation topics and can be delivered by volunteers with training and supervision. The case presented here illustrates the use of befriending provided over the phone for a participant with severe anxiety and depression. It was part of a larger RCT comparing CBT and befriending for the management of anxiety and depression in people with COPD. Symptoms were alleviated after a course of 8 weeks of befriending telephone calls from a volunteer. While befriending is not a substitute for CBT it may be useful in circumstances where CBT is not easily accessible.

Study protocol for a randomized controlled trial of telephone-delivered cognitive behavior therapy compared with befriending for treating depression and anxiety in older adults with COPD

Background COPD is an umbrella term to describe chronic lung diseases that cause limitations in lung airflow, including emphysema and chronic bronchitis. The prevalence of depression and anxiety in people with COPD is high, although these comorbidities are often undiagnosed, untreated, or undertreated. There is a need to identify efficacious treatments for depression and anxiety in people with COPD. Cognitive behavior therapy (CBT) for the treatment of anxiety and depression has a strong evidence base. There has been some success delivering this treatment over the telephone in limited studies. The aim of this study is to evaluate the efficacy of both telephone-administered CBT and befriending on outcomes for patients with diagnosed COPD who have at least mild levels of depression and/or anxiety. Methods The protocol described in this paper is of a pragmatic randomized controlled trial comparing eight sessions of telephone CBT to an active social control, referred to as befriending. Primary outcome measures will include depression and anxiety symptoms, and secondary outcome measures will include quality of life, self-efficacy, and COPD symptom severity. Participants’ satisfaction with the intervention and therapeutic alliance will also be assessed. Measures will be taken pre- and postdelivery of the intervention and again at 8 weeks following the intervention. Conclusion People with COPD often have limitations to their mobility because of their breathlessness. They are often already attending many medical appointments and could be reluctant to attend for face-to-face psychological treatment. The results of this study should identify the relative efficacy of CBT delivered over the telephone to this population, which, if successful, may be a cost-effective and more palatable alternative to face-to-face treatment of depression or anxiety for this population.

Predictors of Workplace Disability in a Premanifest Huntington’s Disease Cohort

Huntingtons disease (HD) is an inherited neurodegenerative disease involving motor, cognitive, and psychiatric/behavioral impairments that will eventually affect work role functioning. Few objective data exist regarding predictors of workplace disability in HD. The authors explored the predictors of work impairment and disability in a cross-sectional cohort of 656 employed, premanifest HD (preHD) individuals. In this cohort-the majority of whom were female, urban-dwelling, married/partnered, and working full-time, with minimal cognitive impairment, good function, minimal motor abnormality, and no indication of significant mental health issues-the number of participants who reported that they had missed work due to HD was low (2.4%). However, 12% of the study sample reported experiencing impairment while working due to preHD, 12.2% reported work-related activity impairment due to preHD, and 12.7% reported impairment in their overall work ability. Higher numbers of CAG repeats on the mutant allele and having more motor symptoms were associated with significantly higher odds of experiencing workplace impairment. Importantly, several modifiable factors were also found to predict workplace disability. Specifically, higher levels of anxiety symptoms were associated with significantly higher odds of experiencing workplace impairment. Good mental and physical health served as protective factors, where good physical health was associated with 6% lower odds of experiencing impairment or missing work time and good mental health was associated with of 10%-12% lower. The results provide important new knowledge for the development of future targeted intervention trials to support preHD individuals in maintaining their work roles as long as possible.

Influences on Case-Managed Community Aged Care Practice

Case management has been widely implemented in the community aged care setting. In this study, we aimed to explore influences on case-managed community aged care practice from the perspectives of community aged care case managers. We conducted 33 semistructured interviews with 47 participants. We drew these participants from a list of all case managers working in aged care organizations that provided publicly funded case management program(s)/packages in Victoria, Australia. We used a multilevel framework that included such broad categories of factors as structural, organizational, case manager, client, and practice factors to guide the data analysis. Through thematic analysis, we found that policy change, organizational culture and policies, case managers’ professional backgrounds, clients with culturally and linguistically diverse backgrounds, and case management models stood out as key influences on case managers’ practice. In the future, researchers can use the multilevel framework to undertake implementation research in similar health contexts.

Important Case Management Goals in Community Aged Care Practice and Key Influences

Aim: To investigate important case management goals and key influences on the achievement of the goals in community aged care practice from the perspectives of case managers in Australia. Methods: We surveyed 154 case managers, representing 17.1% of the target population in the State of Victoria, Australia. The key information collected was case managers’ characteristics and their selections of important case management goals. We also conducted 33 interviews with 47 case managers to explore their perceptions of important case-managed community aged care goals and the key influences on the achievement of these goals. Descriptive analysis, logistic regression, and qualitative thematic analysis were performed. Results: The survey findings showed that important case management goals included improving client outcomes, improving care quality, enhancing care coordination and accessibility, and reducing nursing home admissions. The interview findings indicated that important case management goals were divided into client-centered goals (e.g., maintaining clients safely at home), case managers’ personal goals (e.g., gaining professional development), and organizational goals/expectations/values (e.g., expecting case managers to manage budgets wisely). Finally, the mixed research methods determined constraints of organizational resources and policies, clients’ risky decisions, and case managers’ work experience and employment status as key influences or significant factors associated with the achievement of case management goals. Conclusion: Client-centered goals are of particular importance among those important case management goals. Case managers helping clients establish reasonable expectations and organizations developing favorable professional development policies and establishing reasonable job requirements and expectations will facilitate the achievement of case management goals.

IMPROVEMENTS IN SUBTHRESHOLD ANXIETY AND DEPRESSION SYMPTOMS IN OLDER, SEDENTARY ADULTS AT RISK OF ALZHEIMER’S DISEASE WHO ENGAGE IN A PHYSICAL ACTIVITY INTERVENTION

Background:Aging is characterized by changes in cognitive function such as declines in executive function (EF), processing speed, and memory. Given the world’s aging population, it is important to identify strategies that promote healthy cognitive aging and minimize cognitive decline. Specifically, complex mental activity, such as cognitive training, may be a promising method to combat cognitive decline in older adults. Commercial computerized cognitive training programs are of increasing interest among the public as a method to maintain or improve cognitive functioning. However, unlike physical exercise, the efficacy of these products remains highly debated in the current scientific literature. Therefore, the aim of the current study was to investigate the effect of a computerized cognitive training intervention, alone and preceded by a short bout of physical activity, on EF in healthy older adults. Methods: The study sample of this 8-week proof of concept randomized controlled trial consisted of 124 community-dwelling older adults aged 65-85 years. Participants were randomly assigned to either 8-weeks of: 1) Thrice-weekly group-based computerized cognitive training (Fit Brains training; FBT) plus thrice weekly training sessions at home; 2) Thrice-weekly group-based computerized cognitive training combined with a 15-minute walk (Ex-FBT) plus thrice weekly training sessions at home; or 3) Thrice-weekly group-based balanced and toned (BAT) classes (i.e., control). At baseline and trial completion (i.e., 8-weeks) standard neuropsychological testing of EF was administered, including the Stroop test, which assesses selective attention and conflict resolution. Results: Compared with the BAT, participants assigned to FBT and ExFBT significantly improved executive functions, as measured by the Stroop test (p 1⁄4 .001 and p 1⁄4 .023, respectively). No differences in Stroop performance were found between FBT and Ex-FBT (p 1⁄4 .234). Conclusions:These findings suggest that an 8-week computerized cognitive training program could benefit executive cognitive process of selective attention and conflict resolution in community-dwelling older adults.