Mikkel Vass

Structured home visits to older people. Are they only of benefit for women? A randomised controlled trial.

Objective – To investigate whether education of primary care professionals improved functional ability in home-dwelling older people, with special focus on gender differences. Design – A prospective controlled three-year follow-up study (1999–2001) with randomisation and intervention at municipality level and outcomes measured at individual level. Intervention municipality visitors received regular education and GPs were introduced to a short assessment programme. Control municipalities received no education but conducted the preventive programme in their own way. Setting – Primary care, 34 municipalities. Subjects – 5788 home-dwelling 75- and 80-year-olds were invited. 4060 (70.1%) participated: 2104 in 17 intervention- and 1956 in 17 matched control-municipalities. The main outcome measure was obtained from 3383 (95.6%) of 3540 surviving participants. Main outcome measure – Functional ability. Results – Municipality intervention in coordination with GPs was associated with better functional ability in women (OR: 1.26; CI95: 1.08–1.47, p=0.004), but not in men (OR: 1.04; CI95: 1.85–1.27). Accepting and receiving free preventive home visits was associated with better functional ability among women (OR: 1.36; CI95: 1.16–1.60, p=0.0002), but not among men (OR: 0.98; CI95: 0.80–1.21). Conclusion – A brief, feasible educational intervention for primary care professionals and to accept and receive preventive home visits may have effect in older women, but not in older men.

Preventive home visits to older people in Denmark--why, how, by whom, and when?

In Denmark, political decisions improved the implementation of ‘preventative thinking’ into every-day clinical work. The potential benefits of preventive efforts have been supported by legislative and administrative incentives, and an ongoing effort to remain focused on the benefits of these initiatives towards older people is politically formulated and underlined as part of the new structured municipality reform.Evidence of beneficial effects of health promotion and prevention of disease in old age is well documented. In-home visits with individualised assessments make it possible to reach older persons not normally seen in the health care system. In-home assessment is not just a health check, but also an opportunity to meet individual needs that may be of importance for older people to stay independent. Preventive home visits may be part of an overall culture and strategy to avoid or prevent functional decline. There is an urgent need of an interdisciplinary teamwork and management for such programmes, incorporating flexible cooperation between the primary and secondary health care sector. The value and importance of geriatric and gerontological education is evidence based.ZusammenfassungPolitische Entscheidungen haben in Dänemark die Verankerung präventiven Denkens in der alltäglichen Praxis erleichtert. Der mögliche Nutzen präventiver Maßnahmen wurde durch die Gesetzgebung und administrative Anreize unterstützt. Der politische Wille zur weiteren Förderung dieser Initiativen für alte Menschen findet seinen Ausdruck in Teilen der neuen Gemeindereform.Die Evidenz günstiger Effekte durch Gesundheitsförderung und Krankheitsprävention im höheren Lebensalter ist gut dokumentiert. Hausbesuche unter Verwendung individueller Assessments erreichen ältere Menschen, die normaler Weise nicht im Gesundheitssystem erreicht werden. Häusliches Assessment ist nicht nur ein Gesundheitscheck, sondern bietet die Möglichkeit, sich mit individuellen Bedürfnissen zu beschäftigen, die für die Selbstständigkeit älterer Menschen von Bedeutung sind. Präventive Hausbesuche könnten Teil einer Gesamtstrategie sein, die zum Ziel hat, die Entwicklung von funktionellen Einbußen zu verhindern. Es gibt einen dringenden Bedarf für interdisziplinäre Teamarbeit in derartigen Programmen, die flexible Zusammenarbeit zwischen dem primären und sekundären Gesundheitssektor einschließt. Der Nutzen und die Bedeutung geriatrischer und gerontologischer Ausbildung ist evident.

Effects of Comprehensive Follow-up Home Visits after Hospitalization on Functional Ability and Readmissions among Old Patients. A Randomized Controlled Study

The aim was to examine whether regular interdisciplinary comprehensive home visits after discharge from hospital have an effect on the functional ability of elderly patients and on readmissions. The design is a prospective randomized and controlled study with outcome assessed 3 months after hospital discharge. The study includes 149 patients who were discharged to their homes from geriatric and medical wards. All patients were randomly assigned to receive either comprehensive geriatric assessment with follow-up by the interdisciplinary geriatric team at least five times during the first 6 weeks after discharge or the existing discharge procedures. The main outcome measures were functional ability and readmissions. The most important result is that the intervention had a beneficial effect on functional ability among patients who had been hospitalized at a medical ward. This was not the case among patients who had been hospitalized at a geriatric ward. In addition, there was a beneficial effect on functional ability among pulmonary patients and patients with fractures, but not among patients with cardiac failure. The results point at a need for the expertise of the interdisciplinary geriatric team in preparation of discharge among special groups of patients (e.g. home visit, contact to relevant persons in primary care, aids, etc.) and at a need for follow-up visits.

Preventive home visits to elderly people in Denmark.

SummaryDuring the last 20 years several randomised controlled trials have been published about preventive home visits to old people, but the benefit of the visits is still controversial and under debate.Based on a state law from the Ministry of Social Affairs in 1998, the municipalities in Denmark are obliged to offer home visits twice a year to all citizens 75 years and older. After six years with this law, there is still variation of how the law is managed and implemented. About 60% of the elderly people accept and receive the visits.Less than 50% of the municipalities have made specific guidelines and quality assurance indicators. More than the half have systematically used the visits to collect information of community needs and older people’ wishes to be used for administrative and political purposes.In a prospective, controlled, feasibility study conducted over a 3-year period we found that a brief, manageable and ongoing educational intervention towards professionals working with preventive home visits is feasible and improves older people’s functional mobility.ZusammenfassungIn den letzten 20 Jahren sind verschiedene randomisierte kontrollierte Studien über Hausbesuche bei alten Menschen veröffentlicht worden, aber der Nutzen dieser Besuche wird noch immer kontrovers diskutiert.Aufgrund eines Gesetzes aus dem Sozialministerium von 1998 sind alle Gemeinden in Dänemark verpflichtet, jedem Bürger ab 75 Jahren 2-mal jährlich Hausbesuche anzubieten. Nachdem das Gesetz 6 Jahre in Kraft ist, wird es in der Durchführung immer noch uneinheitlich gehandhabt. Etwa 60% der älteren Menschen akzeptieren und empfangen Besuche. Weniger als die Hälfte der Gemeinden haben spezielle Leitlinien oder Qualitätskontrollmechanismen erarbeitet. Mehr als die Hälfte haben bei den Besuchen systematisch Informationen erhoben über die Bedürfnisse und die Wünsche der älteren Menschen, um sie für die Verwaltung und die Politik zu nutzen.In einer prospektiven, kontrollierten Machbarkeitsstudie über den Zeitraum von 3 Jahren, haben wir herausgefunden, dass kurze, praktikable und wiederholte Fortbildungseinheiten für diejenigen, die beruflich mit der Durchführung der präventiven Hausbesuche betraut sind, machbar sind und die funktionale Mobilität älterer Menschen verbessern.

Medication for older people

SummaryThis paper discusses GP perspectives on the principles underlying rational pharmacotherapy for older people. The rising use of prescription medicine forces the GP to balance the benefit of evidence group-based appropriate drug use against the problems arising when medication is given to older people and to consider different approaches when evaluating evidence of risk and benefit for the individual. Old people are facing a considerable risk of adverse drug reactions and recent initiatives, including the Continuous Medical Educational Efforts Programme, address issues of inappropriate prescribing practices.The authors recommend and present tools enabling the GP to focus on ‘the core prescribing situation’. The logistics to optimise medication including compliance, the use of modern IT and better collaboration and communication between primary and secondary care are discussed. The authors state that a number of pharmacological regimens for older people are outperformed by non-pharmacological treatment alternatives involving competent individualised counselling and public provision of easy (transportation) possibilities for joining centres offering staff and equipment for physical and social activity (including basal aids for hearing and sight).ZusammenfassungDiese Arbeit befasst sich mit der hausärztlichen Perspektive der Prinzipien rationaler Pharmakotherapie für ältere Patienten. Steigender Verbrauch verordneter Medikamente fordert den Hausarzt, zwischen medikamentenbedingten Problemen älterer Patienten und dem Nutzen evidenzbasierten, angemessenen Medikamentengebrauchs abzuwägen. Verschiedene Ansätze zur Nutzen-Risiko-Ermittlung sollten bedacht werden. Für ältere Patienten besteht ein beachtliches Risiko durch unerwünschte Arzneimittelwirkungen. Neuere Initiativen, die Fortbildungskonzepte (CME) einschließen, behandeln die Themen inadäquater Verordnungspraxis.Die Autoren sprechen Empfehlungen aus, die schwerpunktmäßig auf das Wesentliche der Verordnungssituation fokussieren. Hierbei wird auf die Rahmenbedingungen für optimierte Medikamentenverschreibung eingegangen. Dies sind u. a. die Berücksichtigung der Patienten-Compliance sowie die verbesserte Zusammenarbeit zwischen primärem und sekundärem Versorgungssektor.Die Autoren betonen und unterstreichen, dass durchaus manche medikamentöse Therapie durch nicht-medikamentöse Alternativen zu ersetzen ist. Hierzu zählen professionelle und individuelle Beratung, öffentliche, für ältere Menschen einfach verfügbare Transportmittel zur Nutzung und Teilhabe an Möglichkeiten körperlicher und sozialer Aktivitäten. Dies schließt eine grundlegende Versorgung mit Seh- und Hörhilfen ein.

Statin utilization according to indication and age: A Danish cohort study on changing prescribing and purchasing behaviour

OBJECTIVE Introduced to reduce mortality after myocardial infarction (MI), statins are now recommended for a range of other conditions, including asymptomatic individuals without cardiovascular disease or diabetes. The aim was to describe trends in Danish statin utilization according to indication and age during 1996-2009, and to analyse changing prescribing and purchasing behaviour during time intervals (driver periods) a priori defined by potential influential factors. METHODS A nationwide cohort (N=4,998,580) was followed in Danish individual-level registries. Based on a hierarchy of register markers of indications for statin prescribing, we analysed incidence and prevalence of use by age and indication (age ≥ 40). Applying Poisson regression, we calculated Incidence Rate Ratios (IRR) of statin treatment for the last year of each driver period, applying the first year as reference. RESULTS Treatment prevalence increased from 7/1000 to 187/1000, representing a shift towards lower-level indications and increased relatively more in individuals aged 75+. While treatment prevalence in MI-patients reached 780/1000, asymptomatic individuals represented 50% of incident statin-users in 2009. A marked increase in incidence of statin use occurred during 1999-2003 (IRR=3.05) across all indications, followed by a more moderate rise during 2003-2006 (IRR=1.29) and 2006-2008 (IRR=1.15) - most marked increases in asymptomatic individuals. A sudden decrease was observed in 2009 (IRR=0.82) for all indications and ages. CONCLUSION While patent expiry and lower prices most likely boosted the general increase in statin utilization, the gradually altered indication and age pattern seems to be driven by guidelines, influencing both reimbursement rules and general healthcare policies. A media debate on statin side effects may have modified the general attitudes.

Impact of Social Capital on 8-Year Mortality Among Older People in 34 Danish Municipalities

Objectives: To analyze the impact of social capital measures (bonding, bridging, and linking) on all-cause mortality at 8-year follow-up among older people aged 75 and 80 at baseline. Method: Prospective cohort study on preventive home visits including 2,863 seventy-five-year-olds and 1,171 eighty-year-olds in 34 Danish municipalities. The associations of the three aspects of social capital measures with mortality were tested in Cox regression models on time to death. Results: In the 80-year-old cohort significant associations were seen between mortality and both bridging (hazards ratio (HR) = 1.24, 95% CI [1.07, 1.45]) and linking (HR = 1.21, 95% CI [1.03, 1.43]), but the associations attenuated when controlling for relevant confounders. None of the social capital measures were associated with mortality among the 75-year-olds. Conclusion: The measures of social capital used in the present study include key aspects of social capital that are associated to mortality in older populations via physical activity and mobility disability.

Preventive home visitation programmes for older people: the role of municipality organisation

The organisational influence on benefits of preventive home visitation programmes for older people has escaped scientific evaluation. This study aims to investigate organisational structures and processes in relation to preventive home visits. As part of a randomised controlled trial investigating whether educational intervention towards municipality health care professionals could enhance active life expectancy, information of municipality leadership, home visit approach, strengths and limitations of communication within the organisation were obtained using individual and focus group interviews. Thirty-four municipalities in four counties participated. Data was systematically condensed using a phenomenological approach upon which general patterns were categorised into a theory-based formal typology of the preventive home visitation management in the municipalities. Three distinct strategies for preventive home visitation programmes were identified. Eighteen municipalities were categorised as “Framework Management”, 15 as “Management by Rules” and one as “Project Management”. Small municipality size was associated with the “Framework Management” type. “Management by Rules” municipalities had higher population densities and their overall expenses for older people were higher. “Framework Management” municipalities used more resources on preventive home visits, communicated better, experienced less staff changing and had higher social capital than “Management by Rules” municipalities. Municipality structures and management processes of preventive home visitation programmes varied considerably in 34 Danish municipalities, but the majority could be categorised as using either a “Framework Management” or a “Management by Rules” strategy. Each strategy is associated with particular advantages and disadvantages, which may explain differences in the overall benefit of the programme between municipalities.

Childhood socioeconomic position, young adult intelligence and fillings of prescribed medicine for prevention of cardiovascular disease in middle-aged men

Objectives To explore the relationship between childhood socioeconomic position (SEP) and filling of medicine prescriptions for prevention of cardiovascular diseases (CVDs), with young adult intelligence (IQ) as a potential mediator. Design Birth cohort study with logistic and Cox-proportional hazard regression analyses of associations between childhood SEP, retrieved from birth certificates, and prevalence, initiation of and refill persistency for CVD preventive medicine. Setting Denmark. Participants 8736 Danish men born in 1953, who had no CVD at the start of follow-up in 1995, were followed in the Danish National Prescription Register for initiation of and refill persistency for antihypertensives and statins, until the end of 2007 (age 54 years). Results Low childhood SEP at age 18 was not associated with prescription fillings of antihypertensives, but was weakly associated with initiation of statins (HR = 1.19 (95% CI 1.00 to1.42)). This estimate was attenuated when IQ was entered into the model (HR=1.10 (95% CI 0.91 to 1.23)). Low childhood SEP was also associated with decreased refill persistency for statins (HR=2.23 (95% CI 1.13 to 4.40)). Thus, the HR for SEP only changed slightly (HR=2.24 (95% CI 1.11 to 4.52)) when IQ was entered into the model, but entering other covariates (education and body mass index in young adulthood and income in midlife) into the model attenuated the HR to 2.04 (95% CI 1.00 to 4.16). Conclusions Low childhood SEP was related to more frequent initiation of and poorer refill persistency for statins. IQ in young adulthood explained most of the association between childhood SEP and initiation of statins, but had no impact on refill persistency.

Educational intervention and functional decline among older people: The modifying effects of social capital

Aim: To analyse if social capital modifies the effect of educational intervention of home visitors on mobility disability. Earlier studies have found that educational intervention of home visitors has a positive effect of older peoples′ functional decline, but how social capital might modify this effect is still unknown. Methods: We used the Danish Intervention Study on Preventive Home Visits – a prospective cohort study including 2863 75-year-olds and 1171 80-year-olds in 34 Danish municipalities – to analyse the modifying effect of different aspects of social capital on the effect of educational intervention of home visitors on functional decline. The three measures of social capital (bonding, bridging, and linking) were measured at contextual level. Data was analysed with multivariate linear regression model using generalised estimating equations to account for repeated measurements. Results: We found that 80-year-olds living in municipalities with high bonding (B=0.089, p=0.0279) and high linking (B=0.0929; p=0.0217) had significant better mobility disability in average at 3-year follow up if their municipality had received intervention. Conclusions: With the unique design of the Danish Intervention Study on Preventive Home Visits and with theory-based measures of social capital that distinguish between three aspects of social capital with focus on older people, this study contributes to the literature about the role of social capital for interventions on mobility disability.