Luc P. de Witte

Effects of preventive home visits to elderly people living in the community: systematic review

Abstract Objective: To assess the effects of preventive home visits to elderly people living in the community. Design: Systematic review. Setting: 15 trials retrieved from Medline, Embase, and the Cochrane controlled trial register. Main outcome measures: Physical function, psychosocial function, falls, admissions to institutions, and mortality. Results: Considerable differences in the methodological quality of the 15 trials were found, but in general the quality was considered adequate. Favourable effects of the home visits were observed in 5 out of 12 trials measuring physical functioning, 1 out of 8 measuring psychosocial function, 2 out of 6 measuring falls, 2 out of 7 measuring admissions to institutions, and 3 of 13 measuring mortality. None of the trials reported negative effects. Conclusions: No clear evidence was found in favour of the effectiveness of preventive home visits to elderly people living in the community. It seems essential that the effectiveness of such visits is improved, but if this cannot be achieved consideration should be given to discontinuing these visits.

Predicting ADL disability in community-dwelling elderly people using physical frailty indicators: a systematic review

BackgroundDisability in Activities of Daily Living (ADL) is an adverse outcome of frailty that places a burden on frail elderly people, care providers and the care system. Knowing which physical frailty indicators predict ADL disability is useful in identifying elderly people who might benefit from an intervention that prevents disability or increases functioning in daily life. The objective of this study was to systematically review the literature on the predictive value of physical frailty indicators on ADL disability in community-dwelling elderly people.MethodsA systematic search was performed in 3 databases (PubMed, CINAHL, EMBASE) from January 1975 until April 2010. Prospective, longitudinal studies that assessed the predictive value of individual physical frailty indicators on ADL disability in community-dwelling elderly people aged 65 years and older were eligible for inclusion. Articles were reviewed by two independent reviewers who also assessed the quality of the included studies.ResultsAfter initial screening of 3081 titles, 360 abstracts were scrutinized, leaving 64 full text articles for final review. Eventually, 28 studies were included in the review. The methodological quality of these studies was rated by both reviewers on a scale from 0 to 27. All included studies were of high quality with a mean quality score of 22.5 (SD 1.6). Findings indicated that individual physical frailty indicators, such as weight loss, gait speed, grip strength, physical activity, balance, and lower extremity function are predictors of future ADL disability in community-dwelling elderly people.ConclusionsThis review shows that physical frailty indicators can predict ADL disability in community-dwelling elderly people. Slow gait speed and low physical activity/exercise seem to be the most powerful predictors followed by weight loss, lower extremity function, balance, muscle strength, and other indicators. These findings should be interpreted with caution because the data of the different studies could not be pooled due to large variations in operationalization of the indicators and ADL disability across the included studies. Nevertheless, our study suggests that monitoring physical frailty indicators in community-dwelling elderly people might be useful to identify elderly people who could benefit from disability prevention programs.

Interventions to prevent disability in frail community-dwelling elderly: a systematic review

BackgroundThere is an interest for intervention studies aiming at the prevention of disability in community-dwelling physically frail older persons, though an overview on their content, methodological quality and effectiveness is lacking.MethodsA search for clinical trials involved databases PubMed, CINAHL and Cochrane Central Register of Controlled Trials and manually hand searching. Trials that included community-dwelling frail older persons based on physical frailty indicators and used disability measures for outcome evaluation were included. The selection of papers and data-extraction was performed by two independent reviewers. Out of 4602 titles, 10 papers remained that met the inclusion criteria. Of these, 9 were of sufficient methodological quality and concerned 2 nutritional interventions and 8 physical exercise interventions.ResultsNo evidence was found for the effect of nutritional interventions on disability measures. The physical exercise interventions involved 2 single-component programs focusing on lower extremity strength and 6 multi-component programs addressing a variety of physical parameters. Out of 8 physical exercise interventions, three reported positive outcomes for disability. There was no evidence for the effect of single lower extremity strength training on disability. Differences between the multi-component interventions in e.g. individualization, duration, intensity and setting hamper the interpretation of the elements that consistently produced successful outcomes.ConclusionThere is an indication that relatively long-lasting and high-intensive multicomponent exercise programs have a positive effect on ADL and IADL disability for community-living moderate physically frail older persons. Future research into disability prevention in physical frail older persons could be directed to more individualized and comprehensive programs.

Predictors of health status and life satisfaction in spinal cord injury

OBJECTIVE To analyze relationships between injury-related variables, demographic variables, functional health status, and life satisfaction of people with spinal cord injury (SCI). DESIGN Cross-sectional survey. SETTING A community in the Netherlands. SUBJECTS Three hundred eighteen people with SCI, aged 18 to 65 years. Mean age was 39.4 years and mean time after injury was 3.6 years. MAIN OUTCOME MEASURES Health status was measured with the SIP68. Its six scales were aggregated to three dimensions, measuring physical, psychologic, and social functioning. Life satisfaction was measured with the Life Satisfaction Questionnaire. Data were analyzed by path analysis using LISREL V8. RESULTS Obtained scores showed that respondents suffered from serious limitations in physical functioning and social functioning, had only a few limitations in psychologic functioning, and were satisfied with their lives in general and with most life domains. Physical functioning was accurately predicted by injury-related variables, but psychologic functioning was not. Next to level and completeness of the injury, the number of secondary complications turned out to be a predictor of functional health. In a path model that had a close fit with the data, injury-related variables were related to health status but not to life satisfaction. Social functioning (-.48), marital status (-.38), psychologic functioning (-.19), and age (-.16) were significant predictors of life satisfaction (total R2=.44). CONCLUSIONS This study points out the high prevalence of secondary complications and their importance to the health status of people with SCI. Level of social and psychologic functioning are more important predictors of life satisfaction than the seriousness of the injury.

Risk factors for burn-out in caregivers of stroke patients, and possibilities for intervention:

Objective: To identify which caregivers of stroke patients living at home experience the highest levels of strain and are at risk of burn-out, and to investigate how support for caregivers of stroke patients could best be organized, and when this support should be offered. Design and setting: Caregivers of stroke patients were recruited in four regions of the Netherlands. A total of 212 caregivers were interviewed. Multiple stepwise regression analysis was performed to determine the effects of patient and caregiver characteristics, resources, coping strategies and duration of the caregiver role on caregiver strain, mental well-being and vitality. Subjects:The majority of the caregivers were female spouses. Their mean age was 64 years, and their socioeconomic status middle class. Stroke had occurred about 3.5 years ago on average. Main outcome measures:The following main outcome measures were used: the Caregiver Strain Index, and two scales of the Short Form-36 to measure caregivers’ mental well-being and vitality. Results: Severe cognitive, behavioural and emotional changes in the patient constitute the main risk factors for caregiver burn-out. Women, younger caregivers and caregivers in poor physical health were also identified as risk groups. Caregivers with high perceived self-efficacy, satisfied with social support, and frequently using the coping strategy confronting, experience less strain, higher mental well-being and greater vitality. Duration of the caregiver role does not influence caregivers’ strain, mental well-being or vitality. Conclusions: Women, younger caregivers, caregivers in poor physical health, and caregivers of patients with severe changes are at risk of burn-out. Support programmes should focus on self-efficacy, social support, and the coping strategy confronting. No specific moment could be identified at which support programmes should be offered.

Socially Assistive Robots in Elderly Care: A Systematic Review into Effects and Effectiveness

The ongoing development of robotics on the one hand and, on the other hand, the foreseen relative growth in number of elderly individuals suffering from dementia, raises the question of which contribution robotics could have to rationalize and maintain, or even improve the quality of care. The objective of this review was to assess the published effects and effectiveness of robot interventions aiming at social assistance in elderly care. We searched, using Medical Subject Headings terms and free words, in the CINAHL, MEDLINE, Cochrane, BIOMED, PUBMED, PsycINFO, and EMBASE databases. Also the IEEE Digital Library was searched. No limitations were applied for the date of publication. Only articles written in English were taken into account. Collected publications went through a selection process. In the first step, publications were collected from major databases using a search query. In the second step, 3 reviewers independently selected publications on their title, using predefined selection criteria. In the third step, publications were judged based on their abstracts by the same reviewers, using the same selection criteria. In the fourth step, one reviewer made the final selection of publications based on complete content. Finally, 41 publications were included in the review, describing 17 studies involving 4 robot systems. Most studies reported positive effects of companion-type robots on (socio)psychological (eg, mood, loneliness, and social connections and communication) and physiological (eg, stress reduction) parameters. The methodological quality of the studies was, mostly, low. Although positive effects were reported, the scientific value of the evidence was limited. The positive results described, however, prompt further effectiveness research in this field.

Effects of a programme of multifactorial home visits on falls and mobility impairments in elderly people at risk: randomised controlled trial

Abstract Objective: To evaluate whether a programme of multifactorial home visits reduces falls and impairments in mobility in elderly people living in the community. Design: Randomised controlled trial with 18 months of follow up. Setting: Six general practices in Hoensbroek, the Netherlands. Participants: 316 people aged 70 and over living in the community, with moderate impairments in mobility or a history of recent falls. Intervention: Five home visits by a community nurse over a period of one year. Visits consisted of screening for medical, environmental, and behavioural factors causing falls and impairments in mobility, followed by specific advice, referrals, and other actions aimed at dealing with the observed hazards. Main outcome measures: Falls and impairments in mobility. Results: No differences were found in falls and mobility outcomes between the intervention and usual care groups. Conclusion: Multifactorial home visits had no effects on falls and impairments in mobility in elderly people at risk who were living in the community. Because falls and impairments in mobility remain a serious problem among elderly people, alternative strategies should be developed and evaluated.

Quality of life and the ICIDH: towards an integrated conceptual model for rehabilitation outcomes research

Objective: The development of the International Classification of Impairments, Disabilities and Handicaps (ICIDH) has led to the assessment of a wider range of relevant rehabilitation outcomes, but a need for a further broadening exists. In this article, a new proposal for an extended ICIDH is made. Method: Review of the literature on quality of life and of attempts to integrate the World Health Organization (WHO) biopsychosocial model and the ICIDH. Results: Our review shows three operationalizations of the concept of quality of life: as health, as well-being and, preferably, as a superordinate construct. None of the attempts to integrate the WHO biopsychosocial model have been entirely successful. Our new proposal is characterized by (a) incorporation of the organ, person and social levels of the ICIDH, (b) distinction between objective and subjective aspects of quality of life as a second axis in the model, resulting in somatic sensations as the subjective part of the organ level, perceived health as the subjective part of the person level and domainspecific life satisfaction as the subjective part of the social level, and (c) separation of the concept of general well-being or happiness as being distinct from the ICIDH. The proposal model is intended to serve as a framework in which different outcomes can be positioned in relation to each other. Conclusion: Our model is intuitively appealing and remains close to familiar concepts and models. However, it is as yet far from perfect, and we hope to provoke discussion to help further refinement.

The psychometric properties of three self-report screening instruments for identifying frail older people in the community.

BackgroundFrailty is highly prevalent in older people. Its serious adverse consequences, such as disability, are considered to be a public health problem. Therefore, disability prevention in community-dwelling frail older people is considered to be a priority for research and clinical practice in geriatric care. With regard to disability prevention, valid screening instruments are needed to identify frail older people in time. The aim of this study was to evaluate and compare the psychometric properties of three screening instruments: the Groningen Frailty Indicator (GFI), the Tilburg Frailty Indicator (TFI) and the Sherbrooke Postal Questionnaire (SPQ). For validation purposes the Groningen Activity Restriction Scale (GARS) was added.MethodsA questionnaire was sent to 687 community-dwelling older people (≥ 70 years). Agreement between instruments, internal consistency, and construct validity of instruments were evaluated and compared.ResultsThe response rate was 77%. Prevalence estimates of frailty ranged from 40% to 59%. The highest agreement was found between the GFI and the TFI (Cohens kappa = 0.74). Cronbachs alpha for the GFI, the TFI and the SPQ was 0.73, 0.79 and 0.26, respectively. Scores on the three instruments correlated significantly with each other (GFI - TFI, r = 0.87; GFI - SPQ, r = 0.47; TFI - SPQ, r = 0.42) and with the GARS (GFI - GARS, r = 0.57; TFI - GARS, r = 0.61; SPQ - GARS, r = 0.46). The GFI and the TFI scores were, as expected, significantly related to age, sex, education and income.ConclusionsThe GFI and the TFI showed high internal consistency and construct validity in contrast to the SPQ. Based on these findings it is not yet possible to conclude whether the GFI or the TFI should be preferred; data on the predictive values of both instruments are needed. The SPQ seems less appropriate for postal screening of frailty among community-dwelling older people.

Effectiveness of interdisciplinary primary care approach to reduce disability in community dwelling frail older people: cluster randomised controlled trial.

Objective To evaluate whether an interdisciplinary primary care approach for community dwelling frail older people is more effective than usual care in reducing disability and preventing (further) functional decline. Design Cluster randomised controlled trial. Setting 12 general practices in the south of the Netherlands Participants 346 frail older people (score ≥5 on Groningen Frailty Indicator) were included; 270 (78%) completed the study. Interventions General practices were randomised to the intervention or control group. Practices in the control group delivered care as usual. Practices in the intervention group implemented the “Prevention of Care” (PoC) approach, in which frail older people received a multidimensional assessment and interdisciplinary care based on a tailor made treatment plan and regular evaluation and follow-up. Main outcome measures The primary outcome was disability, assessed at 24 months by means of the Groningen Activity Restriction Scale. Secondary outcomes were depressive symptomatology, social support interactions, fear of falling, and social participation. Outcomes were measured at baseline and at 6, 12, and 24 months’ follow-up. Results 193 older people in the intervention group (six practices) received the PoC approach; 153 older people in the control group (six practices) received care as usual. Follow-up rates for patients were 91% (n=316) at six months, 86% (n=298) at 12 months, and 78% (n=270) at 24 months. Mixed model multilevel analyses showed no significant differences between the two groups with regard to disability (primary outcome) and secondary outcomes. Pre-planned subgroup analyses confirmed these results. Conclusions This study found no evidence for the effectiveness of the PoC approach. The study contributes to the emerging body of evidence that community based care in frail older people is a challenging task. More research in this field is needed. Trial registration Current Controlled Trials ISRCTN31954692.