Laura Coll-Planas

International Association of Gerontology and Geriatrics: A Global Agenda for Clinical Research and Quality of Care in Nursing Homes

A workshop charged with identifying the main clinical concerns and quality of care issues within nursing homes was convened by the International Association of Gerontology and Geriatrics, with input from the World Health Organization. The workshop met in Toulouse, France, during June 2010. Drawing on the latest evidence and mindful of the international development agenda and specific regional challenges, consensus was sought on priority actions and future research. The impetus for this work was the known variation in the quality of nursing home care experiences of older people around the world. The resulting Task Force recommendations include instigation of sustainable strategies designed to enhance confidence among older people and their relatives that the care provided within nursing homes is safe, mindful of their preferences, clinically appropriate, and delivered with respect and compassion by appropriately prepared expert doctors, registered nurses, administrators, and other staff. The proposals extend across 4 domains (Reputational Enhancement and Leadership, Clinical Essentials and Care Quality Indicators, Practitioner Education, and Research) that, in concert, will enhance the reputation and status of nursing home careers among practitioners, promote effective evidence-informed quality improvements, and develop practice leadership and research capabilities.

Physical Exercise Interventions for Improving Performance-Based Measures of Physical Function in Community-Dwelling, Frail Older Adults: A Systematic Review and Meta-Analysis

OBJECTIVE To conduct a systematic review to determine the efficacy of exercise-based interventions on improving performance-based measures of physical function and markers of physical frailty in community-dwelling, frail older people. DATA SOURCES Comprehensive bibliographic searches in MEDLINE, the Cochrane Library, PEDro, and CINAHL databases were conducted (April 2013). STUDY SELECTION Randomized controlled trials of community-dwelling older adults, defined as frail according to physical function and physical difficulties in activities of daily living (ADL). Included trials had to compare an exercise intervention with a control or another exercise intervention, and assess performance-based measures of physical function such as mobility and gait, or disability in ADL. DATA EXTRACTION Two review authors independently screened the search results and performed data extraction and risk of bias assessment. Nineteen trials were included, 12 of them comparing exercise with an inactive control. Most exercise programs were multicomponent. DATA SYNTHESIS Meta-analysis was performed for the comparison of exercise versus control with the inverse variance method under the random-effects models. When compared with control interventions, exercise was shown to improve normal gait speed (mean difference [MD]=.07m/s; 95% confidence interval [CI], .04-.09), fast gait speed (MD=.08m/s; 95% CI, .02-.14), and the Short Physical Performance Battery (MD=2.18; 95% CI, 1.56-2.80). Results are inconclusive for endurance outcomes, and no consistent effect was observed on balance and the ADL functional mobility. The evidence comparing different modalities of exercise is scarce and heterogeneous. CONCLUSIONS Exercise has some benefits in frail older people, although uncertainty still exists with regard to which exercise characteristics (type, frequency, duration) are most effective.

Relationship of urinary incontinence and late-life disability: Implications for clinical work and research in geriatrics

The role of urinary incontinence (UI) in the disablement process model has been mainly defined according to its impact on quality of life, global wellbeing, life satisfaction, institutionalization and death, which are global outcomes of disability. Recent research focused on the “active” role of UI in the main pathway of the disablement process model, i.e. actively involved in the causes of disability. The aim of this paper is to review the complex current scientific evidence on this second active role and to define the implications for further research and for clinical work in geriatrics. The relationship between UI and disability can be classified in the following five pathways:1) UI as risk factor for functional decline and reduced physical activity through the increased risk of falls and fractures.2) Functional decline and reduced physical activity as risk factors for the onset of UI.3) Shared risk factors for UI and functional decline: white matter changes, stroke and other neurological conditions.4) UI in a unifying conceptual framework: the multifactorial etiology of geriatric syndromes.5) UI as an indicator of frailty.Understanding these pathways could improve insight into clinical, pharmacological, environmental, behavioral and rehabilitative mechanisms to define measures for the prevention and treatment of the geriatric syndromes cascade. However, research on effective interventions on these overlapping areas is still quite rare. Additionally there is an urgent need to use the standardized terminology of lower urinary tract symptoms (LUTS), established by the International Continence Society (ICS) to find a common language in disability research. To conclude, the relationship of UI and disability is evident in different pathways. Understanding these associations can have substantial implications for both clinical work and research in this area.ZusammenfassungDie Rolle der Harninkontinenz wurde im Modell des „Disablement Process“ bislang hauptsächlich anhand globaler Endpunkte von Behinderung, wie Lebensqualität, allgemeinem Wohlbefinden, Lebenszufriedenheit, Institutionalisierung und Tod untersucht. Aktuelle Forschungsprojekte behandeln stattdessen die aktive Rolle der Harninkontinenz im Hauptpfad des „Disablement Process-Modells“, womit ihr eine direkte Rolle bei der Entstehung von funktioneller Einschränkung und Behinderung zugesprochen wird. Das Ziel dieses Artikels ist es, einen Überblick über die komplexen Zusammenhänge dieser zweiten, „aktiven“ Rolle der Harninkontinenz zu geben und mögliche Auswirkungen für Forschung und klinisch geriatrische Arbeit aufzuzeigen. Der Zusammenhang zwischen Harninkontinenz und Beeinträchtigung kann anhand der folgenden 5 Pfade dargestellt werden:1) Harninkontinenz als Risikofaktor für funktionellen Abbau und reduzierte körperliche Aktivität durch eine Erhöhung des Sturz- und Frakturrisikos.2) Funktionsminderung im Alltag und reduzierte körperliche Aktivität als Risikofaktoren für den Beginn einer Harninkontinenz.3) Gemeinsame Risikofaktoren für das Entstehen von Harninkontinenz und Funktionsminderung im Alltag: Marklagerveränderungen, Schlaganfall und andere neurologische Erkrankungen.4) Harninkontinenz in einem vereinheitlichenden Rahmenkonzept: die multifaktorielle Ätiologie geriatrischer Syndrome.5) Harninkontinenz als Gebrechlichkeits- Indikator.Die Anwendung dieser Pfade könnte zu einem besseren Verständnis klinischer, pharmakologischer, rehabilitativer und verhaltenstherapeutischer Zusammenhänge führen, um Maßnahmen zur Prävention und Behandlung geriatrischer Syndrome zu definieren. Die Zahl von Forschungsprojekten zur weiteren Charakterisierung dieser sich überschneidenden Gebiete ist jedoch weiterhin sehr gering. Zudem besteht dringender Bedarf, die neue und standardisierte Terminologie von Symptomen des unteren Harntrakts (LUTS) der International Continence Society (ICS) zu verwenden, um in zukünftigen Forschungsprojekten mit dem Thema Behinderung im Alter eine gemeinsame Sprache zu finden.Zusammenfassend kommt die Beziehung von Behinderung und Inkontinenz in verschiedenen Pfaden deutlich zum Ausdruck. Das Verständnis dieser Zusammenhänge kann bedeutende Auswirkungen für klinische Arbeit und geriatrische Forschung haben.

Evaluation of the short form of the late-life function and disability instrument in geriatric inpatients-validity, responsiveness, and sensitivity to change.

OBJECTIVES: To evaluate the function component of the Short Form of the Late‐Life Function and Disability Instrument (SF‐LLFDI, German version) in geriatric inpatients and compare it with established performance‐based and self‐rated assessment tools.

Evaluation of a urinary incontinence unit for community-dwelling older adults in Barcelona: implementation and improvement of the perceived impact on daily life, frequency and severity of urinary incontinence.

BackgroundUrinary incontinence >(UI) is one of the most important and frequent geriatric syndromes. It is considered a silent but great social problem. Conservative management of UI, in a multidisciplinary and comprehensive approach, has been successful in previous studies, leading to a partial or total remission of the syndrome.AimsTo investigate the acceptance of a geriatric incontinence unit and the effect of a multidimensional intervention on the improvement of UI regarding frequency, severity and perceived impact on daily life of community-dwelling older adults.MethodologyProspective study with a multifactorial intervention with pre-post analyses. 92 patients aged 60 years and over were assessed for UI at an outpatient geriatric unit. They received an individualized conservative treatment and were followed up for 3 months. The International Consultation on Incontinence modular Questionnaire-Short Form (ICIQ-SF) was translated into Catalan. The difference of the perceived impact on the daily life before and 3 months after treatment was used as a primary outcome. The global score and the subscores on frequency and severity were used as secondary outcomes.Results77.2% patients had an improvement in their perceived impact of UI on daily life. Concerning the ICIQ-SF global score, 82.6% improved. There was a significant improvement of about 30% in all dimensions measured. Many patients pointed out that being able to talk about the problem with a healthcare professional, in some cases for the first time, was very important to them.ConclusionsA conservative and multidisciplinary management of UI improved the impact of UI on daily life among comorbid geriatric patients. The Catalan ICIQ-SF was successfully implemented. Outpatient geriatric incontinence units seem to be effective and should be implemented to improve detection and management of this important geriatric syndrome.ZusammenfassungHintergrundDie Harninkontinenz ist eines der wichtigsten und häufigsten geriatrischen Syndrome. Sie wird als stilles, dabei jedoch großes soziales Problem betrachtet. Dennoch hat die konservative Behandlung der Harninkontinenz in einem multidisziplinären und globalen Ansatz, bereits erfolgreiche Ergebnisse aufzuweisen und in vorausgegangenen Studien zu einer partiellen oder sogar totalen Remission der Syndrome geführt.Ziele der StudieUntersuchung der Akzeptanz einer geriatrischen Inkontinenz-Ambulanz und des Effektes eines multidimensionalen Therapieansatzes auf die Verbesserung der Harninkontinenz hinsichtlich der Häufigkeit, des Schweregrades und der Wahrnehmung der Beeinträchtigung des Alltagslebens bei zu Hause lebenden älteren Menschen.MethodenProspektive Studie mit einer multifaktoriellen Intervention und Vorher-Nachher-Analyse. 92 Patienten, älter als 60 Jahre, wurden in einer geriatrischen Ambulanz für Harninkontinenz gezielt untersucht. Es wurde eine individualisierte konservative Behandlung und eine Nachbeobachtung von drei Monaten durchgeführt. Der „International Consultation on Incontinence modular Questionnaire-Short Form“ (ICIQ-SF) wurde ins Katalanische übersetzt. Als primärer Outcome wurde der Unterschied der subjektiven Wahrnehmung der Beeinträchtigung des Alltagslebens vor und nach dreimonatiger Behandlung gewählt. Der globale Score und die Subscores Häufigkeit und Schweregrad wurden als sekundäre Outcomes benutzt.Ergebnisse:Bei 77,2% der Patienten wurde eine Verbesserung der subjektiven Wahrnehmung der Beeinträchtigung des Alltagslebens durch die Harninkontinenz erreicht. Bezüglich des globalen Scores verbesserten sich sogar 82,6%. In allen untersuchten Dimensionen konnte eine signifikante Verbesserung um etwa 30% nachgewiesen werden. Viele Patienten betonten, dass Sie es als sehr positiv empfunden hätten, in einigen Fällen sogar zum ersten Mal, über dieses Problem mit ausgebildetem Gesundheitspersonal sprechen zu können.SchlussfolgerungEin konservatives und multidimensionelles Behandlungskonzept der Harninkontinenz verbesserte die Wahrnehmung der Alltagsbeeinträchtigung bei komorbiden, geriatrischen Patienten. Die katalanische Übersetzung des ICIQ-SF konnte erfolgreich eingesetzt werden. Geriatrische Ambulanzen für Harninkontinenz scheinen wirksam zu sein und sollten in Zukunft vermehrt eingerichtet werden, um die Erkennung und Behandlung dieses wichtigen geriatrischen Syndroms zu verbessern.

Promoting social capital to alleviate loneliness and improve health among older people in Spain

Loneliness is especially frequent among older people in Southern Europe. Furthermore, promoting social capital to tackle loneliness and its health effects is an understudied intervention strategy. Therefore, a complex intervention was piloted in Spain in a pre-post study with a 2-year follow-up. Its aims were to explore the feasibility of the intervention and its short- and long-term effects. It was conducted in one mixed rural-urban and two urban areas of diverse socioeconomic levels from 2011 to 2012. The intervention framework was based on social capital theory applying a behaviour change model and care co-ordination. The intervention comprised: (i) a co-ordinated action aimed at building a network between primary healthcare centres and community assets in the neighbourhood and (ii) a group-based programme, which promoted social capital among lonely older people, especially social support and participation. Older people active in senior centres volunteered as gatekeepers. The main outcome domain was loneliness. Secondary outcome domains were participation, social support, self-perceived health, quality of life, depressive symptoms and use of health resources. Pre-post changes were assessed with t-test, Wilcoxon signed-rank test and McNemars test. Differences between the three time points were assessed with a one-way ANOVA with repeated measures. Social workers and nurses were successfully involved as group leaders, 10 volunteers took part and 38 participants were included. After the intervention, loneliness decreased while social participation and support significantly increased. Furthermore, the number of visits to nurses increased. Exactly 65.8% of the participants built social contacts within the group and 47.4% became engaged in new activities. Two years later, social effects were maintained and depressive symptoms had decreased. Exactly 44.7% of the participants continued to be in contact with at least one person from the group and 39.5% continued participating. The intervention contributes a novel and feasible social capital-based approach for alleviating loneliness among older adults while prompting meaningful changes in their lives.

Social capital interventions targeting older people and their impact on health: a systematic review

Background Observational studies show that social capital is a protective health factor. Therefore, we aim to assess the currently unclear health impact of social capital interventions targeting older adults. Methods We conducted a systematic review based on a logic model. Studies published between January 1980 and July 2015 were retrieved from MEDLINE, EMBASE, CINAHL, PsycINFO, Cochrane Central Register of Controlled Trials and Web of Science. We included randomised controlled trials targeting participants over 60 years old and focused on social capital or its components (eg, social support and social participation). The comparison group should not promote social capital. We assessed risk of bias and impact on health outcomes and use of health-related resources applying a procedure from the Canadian Agency for Drugs and Technologies in Health (CADTH) based on vote-counting and standardised decision rules. The review protocol was registered in PROSPERO (reference number CRD42014015362). Results We examined 17 341 abstracts and included 73 papers reporting 36 trials. Trials were clinically and methodologically diverse and reported positive effects in different contexts, populations and interventions across multiple subjective and objective measures. According to sufficiently reported outcomes, social capital interventions showed mixed effects on quality of life, well-being and self-perceived health and were generally ineffective on loneliness, mood and mortality. Eight trials with high quality showed favourable impacts on overall, mental and physical health, mortality and use of health-related resources. Conclusions Our review highlights the lack of evidence and the diversity among trials, while supporting the potential of social capital interventions to reach comprehensive health effects in older adults.

Rehabilitation profiles of older adult stroke survivors admitted to intermediate care units: A multi-centre study

Background Stroke is a major cause of disability in older adults, but the evidence around post-acute treatment is limited and heterogeneous. We aimed to identify profiles of older adult stroke survivors admitted to intermediate care geriatric rehabilitation units. Methods We performed a cohort study, enrolling stroke survivors aged 65 years or older, admitted to 9 intermediate care units in Catalonia-Spain. To identify potential profiles, we included age, caregiver presence, comorbidity, pre-stroke and post-stroke disability, cognitive impairment and stroke severity in a cluster analysis. We also proposed a practical decision tree for patient’s classification in clinical practice. We analyzed differences between profiles in functional improvement (Barthel index), relative functional gain (Montebello index), length of hospital stay (LOS), rehabilitation efficiency (functional improvement by LOS), and new institutionalization using multivariable regression models (for continuous and dichotomous outcomes). Results Among 384 patients (79.1±7.9 years, 50.8% women), we identified 3 complexity profiles: a) Lower Complexity with Caregiver (LCC), b) Moderate Complexity without Caregiver (MCN), and c) Higher Complexity with Caregiver (HCC). The decision tree showed high agreement with cluster analysis (96.6%). Using either linear (continuous outcomes) or logistic regression, both LCC and MCN, compared to HCC, showed statistically significant higher chances of functional improvement (OR = 4.68, 95%CI = 2.54–8.63 and OR = 3.0, 95%CI = 1.52–5.87, respectively, for Barthel index improvement ≥20), relative functional gain (OR = 4.41, 95%CI = 1.81–10.75 and OR = 3.45, 95%CI = 1.31–9.04, respectively, for top Vs lower tertiles), and rehabilitation efficiency (OR = 7.88, 95%CI = 3.65–17.03 and OR = 3.87, 95%CI = 1.69–8.89, respectively, for top Vs lower tertiles). In relation to LOS, MCN cluster had lower chance of shorter LOS than LCC (OR = 0.41, 95%CI = 0.23–0.75) and HCC (OR = 0.37, 95%CI = 0.19–0.73), for LOS lower Vs higher tertiles. Conclusion Our data suggest that post-stroke rehabilitation profiles could be identified using routine assessment tools and showed differential recovery. If confirmed, these findings might help to develop tailored interventions to optimize recovery of older stroke patients.

Accidental falls among community-dwelling older adults : improving the identification process of persons at risk by nursing staff

SummaryElderly persons living in the community are a heterogeneous population. Among them, the screening of persons at risk of falling is still a matter of debate. The aim of this analysis was to improve the identification process of elderly persons living in the community at risk for falling by nursing staff of community- based services. A secondary analysis was performed with the data from a prospective non-randomized interventional trial. The study included 268 community-dwelling older adults (mean age of 82 years, 81.3% female) from Ulm and Neu-Ulm with a followup period of 12 months. Fall risk indicators were extracted from the nursing assessment and analysis with crude odds ratios revealed the following risk indicators for falls: assistance when transferring, bathing and climbing a flight of stairs as well as fall history. Afterwards, fall risk indicators were selected by backward elimination in a multiple logistic regression. Variable selection identified a positive fall history and the need for assistance when bathing as important risk indicators. These two risk indicators could be used as a screening tool, which would be easy to perform by nursing staff in their daily work. This screening test defined as more than one fall in the last 12 months or bathing assistance, the first ADL to be affected in the disablement process, has a sensitivity of 85.3% and a specificity of 42.1%.ZusammenfassungZu Hause lebende ältere Menschen stellen eine heterogene Population dar. In dieser ist das Screening nach Menschen mit einem erhöhten Sturzrisiko noch in der Diskussion. Ziel dieser Analyse war, diesen Identifikationsprozess für Mitarbeiter aus der ambulanten Pflege zu verbessern. Eine Sekundäranalyse der Daten einer prospektiven, nicht-randomisierten Interventionsstudie wurde durchgeführt. Die Studie schloss 268 zu Hause lebende ältere Menschen (Durchschnittsalter 82 Jahre, 81,3% Frauen) aus Ulm und Neu-Ulm ein. Die Nachuntersuchung erfolgte nach 12 Monaten. Sturzrisikoindikatoren wurden aus dem Pflegeassessment entnommen und eine Analyse mit rohen Odds Ratios zeigte folgende Sturzrisikoindikatoren: Hilfsbedarf beim Transfer, beim Baden und beim Treppensteigen sowie vorausgegangene Stürze. Danach wurden Sturzindikatoren mit Backward Elimination in einer multiplen logistischen Regression selektiert. Als wichtige Sturzindikatoren wurden nur vorausgegangene Stürze und Hilfsbedarf beim Baden identifiziert. Diese beiden Risikoindikatoren könnten als Screening-Test genutzt werden. Die Durchführung ist einfach und kann vom Pflegepersonal im täglichen Arbeitsalltag erfolgen. Dieser Screening-Test definiert als mehrere Stürze in den letzten 12 Monaten oder Hilfsbedarf beim Baden, die erste betroffene ADL im Alterungsprozess, hat eine Sensitivität von 85,3% und eine Spezifität von 42,1%.

The assessment of physical activity in inpatient rehabilitation-an important aspect of the identification of frailty in hospitalized older people.

ACKNOWLEDGMENTS Financial Disclosure: None. Author Contributions: Study concept and design: M. Ouaı̈ssi, I. Sielezneff, S. Benoist, B. Sastre, B. Nordlinger. Acquisition of data: M. Ouaı̈ssi, N. Pirrò, S. Benoist, E. Cretel. Analysis and interpretation of data: M. Ouaı̈ssi, S. Benoist, I. Sielezneff, E. Cretel. Drafting of letter: M. Ouaı̈ssi, E. Cretel, J. B. Chaix, F. Peschaud. Critical revision of the letter for important intellectual content: B. Sastre, B. Nordlinger, R. Malafosse, B. Consentino, C. Penna. Statistical analysis: M. Ouaı̈ssi, S. Benoist. Study supervision: S. Benoist, B. Nordlinger, B. Sastre. Sponsor’s Role: None. The authors wish to thank Dr. Ali Ouaissi, Head of Research at INSERM for his precious help and advice.