Rachel Milte

Musculoskeletal health, frailty and functional decline.

Frailty in older people is associated with a vulnerability to adverse events. While ageing is associated with a loss of physiological reserves, identifying those with the syndrome of frailty has the potential to assist clinicians to tailor treatments to those at the risk of future decline into disability with an increased risk of complications, morbidity and mortality. Sarcopenia is a key component of the frailty syndrome and on its own puts older people at risk of fragility fractures; however, the clinical syndrome of frailty affects the musculoskeletal and non-musculoskeletal systems. Hip fractures are becoming a prototype condition in the study of frailty. Following a hip fracture, many of the interventions are focused on limiting mobility disability and restoring independence with activities of daily living, but there are multiple factors to be addressed including osteoporosis, sarcopenia, delirium and weight loss. Established techniques of geriatric evaluation and management allow systematic assessment and intervention on multiple components by multidisciplinary teams and deliver the best outcomes. Using the concept of frailty to identify older people with musculoskeletal problems as being at the risk of a poor outcome assists in treatment planning and is likely to become more important as effective pharmacological treatments for sarcopenia emerge. This review will focus on the concept of frailty and its relationship with functional decline, as well as describing its causes, prevalence, risk factors, potential clinical applications and treatment strategies.

Economic evaluation for protein and energy supplementation in adults: opportunities to strengthen the evidence

Malnutrition is a costly problem for health care systems internationally. Malnourished individuals require longer hospital stays and more intensive nursing care than adequately nourished individuals and have been estimated to cost an additional £7.3 billion in health care expenditures in the United Kingdom alone. However, treatments for malnutrition have rarely been considered from an economic perspective. The aim of this systematic review was to identify the cost effectiveness of using protein and energy supplementation as a widely used intervention to treat adults with and at risk of malnutrition. Papers were identified that included economic evaluations of protein or energy supplementation for the treatment or prevention of malnutrition in adults. While the variety of outcome measures reported for cost-effectiveness studies made synthesis of results challenging, cost-benefit studies indicated that the savings for the health system could be substantial due to reduced lengths of hospital stay and less intensive use of health services after discharge. In summary, the available economic evidence indicates that protein and energy supplementation in treatment or prevention of malnutrition provides an opportunity to improve patient wellbeing and lower health system costs.

What are frail older people prepared to endure to achieve improved mobility following hip fracture? A Discrete Choice Experiment

OBJECTIVE To investigate the preferences of frail older people for individualised multidisciplinary rehabilitation to promote recovery from a hip fracture. DESIGN Discrete Choice Experiment. SETTING Acute and Rehabilitation Hospitals in Adelaide, South Australia. SUBJECTS Eighty-seven patients with recent hip fracture (16 living in residential care facilities prior to fracture). METHODS Patients providing informed consent (or consenting family carer proxies in cases where patients were unable to provide informed consent (n = 10)) participated in a face to face interview following surgery to repair a fractured hip to assess their preferences for different configurations of rehabilitation programs. RESULTS Overall, participants expressed a strong preference for improvements in mobility and a willingness to participate in rehabilitation programs involving moderate pain and effort. However, negative preferences were observed for extremely painful interventions involving high levels of effort (2 h per day for 2 months). Subgroup analysis revealed consistently similar preferences according to place of residence (residential care vs community). CONCLUSIONS Improvements in mobility are highly valued by frail older people recovering from hip fracture, including those living in residential care. Further research should be directed towards achieving greater equity in access to rehabilitation services for the wide spectrum of patients attending hospital with hip fractures.

Cognitive Overload? An Exploration of the Potential Impact of Cognitive Functioning in Discrete Choice Experiments with Older People in Health Care

OBJECTIVES This exploratory study sought to investigate the effect of cognitive functioning on the consistency of individual responses to a discrete choice experiment (DCE) study conducted exclusively with older people. METHODS A DCE to investigate preferences for multidisciplinary rehabilitation was administered to a consenting sample of older patients (aged 65 years and older) after surgery to repair a fractured hip (N = 84). Conditional logit, mixed logit, heteroscedastic conditional logit, and generalized multinomial logit regression models were used to analyze the DCE data and to explore the relationship between the level of cognitive functioning (specifically the absence or presence of mild cognitive impairment as assessed by the Mini-Mental State Examination) and preference and scale heterogeneity. RESULTS Both the heteroscedastic conditional logit and generalized multinomial logit models indicated that the presence of mild cognitive impairment did not have a significant effect on the consistency of responses to the DCE. CONCLUSIONS This study provides important preliminary evidence relating to the effect of mild cognitive impairment on DCE responses for older people. It is important that further research be conducted in larger samples and more diverse populations to further substantiate the findings from this exploratory study and to assess the practicality and validity of the DCE approach with populations of older people.

Direct health and residential care costs of people living with dementia in Australian residential aged care

This analysis estimates the whole‐of‐system direct costs for people living with dementia in residential care by using a broad health and social care provision perspective and compares it to people without dementia living in residential care.

A Systematic Review and Meta-Analysis Comparing Carer Focused and Dyadic Multicomponent Interventions for Carers of People With Dementia

Objective: The aim of this study was to compare the efficacy of two approaches: multicomponent interventions that focus on working with the carer and dyadic interventions that work with both the carer and the person with dementia. Method: A systematic review involving a search of Medline, EMBASE, and PsycINFO in October 2015 was performed. Randomized controlled trials involving carers of people with dementia and comparing multicomponent interventions with usual care were included. Results: Pooling of all studies demonstrated that multicomponent interventions can reduce depressive symptoms, improve quality of life, reduce carer impact, and reduce behavioral and psychological symptoms of dementia as well as caregiver upset with these symptoms. We were unable to find a significant difference in the effects of dyadic interventions in comparison with carer focused interventions for these outcomes. Discussion: Although effect sizes associated with intervention are small, multicomponent interventions are relatively inexpensive to deliver, acceptable, and widely applicable.

Clustered domestic residential aged care in Australia: fewer hospitalisations and better quality of life

Objective: To compare the outcomes and costs of clustered domestic and standard Australian models of residential aged care.

An empirical comparison of the measurement properties of the EQ-5D-5L, DEMQOL-U and DEMQOL-Proxy-U for older people in residential care

PurposeThis study aimed to empirically compare the measurement properties of self-reported and proxy-reported (in cases of severe cognitive impairment) generic (EQ-5D-5L) and condition-specific (DEMQOL-U and DEMQOL-Proxy-U) preference-based HRQoL instruments in residential care, where the population is characterised by older people with high rates of cognitive impairment, dementia and disability.MethodsParticipants were recruited from seventeen residential care facilities across four Australian states. One hundred and forty-three participants self-completed the EQ-5D-5L and the DEMQOL-U while three hundred and eight-seven proxy completed (due to the presence of severe dementia) the EQ-5D-5L and DEMQOL-Proxy-U. The convergent validity of the outcome measures and known group validity relative to a series of clinical outcome measures were assessed.ResultsResults satisfy convergent validity among the outcome measures. EQ-5D-5L and DEMQOL-U utilities were found to be significantly correlated with each other (p < 0.01) as were EQ-5D-5L and DEMQOL-Proxy-U utilities (p < 0.01). Both self-reported and proxy-reported EQ-5D-5L utilities demonstrated strong known group validity in relation to clinically recognised thresholds of cognition and physical functioning, while in contrast neither DEMQOL-U nor DEMQOL-Proxy-U demonstrated this association.ConclusionsThe findings suggest that the EQ-5D-5L, DEMQOL-U and DEMQOL-Proxy-U capture distinct aspects of HRQoL for this population. The measurement and valuation of HRQoL form an essential component of economic evaluation in residential care. However, high levels of cognitive impairment may preclude self-completion for a majority. Further research is needed to determine cognition thresholds beyond which an individual is unable to reliably self-report their own health-related quality of life.

Struggling to maintain individuality – Describing the experience of food in nursing homes for people with dementia

PURPOSE OF THE STUDY To describe the food and dining experience of people with cognitive impairment and their family members in nursing homes. DESIGN AND METHODS Interviews and focus groups with people with cognitive impairment and their family members (n=19). Thematic analysis was undertaken using NVivo10 data analysis software package to determine key themes. RESULTS The main themes identified tracked a journey for people with cognitive impairment in nursing homes, where they initially sought to have their individual needs and preferences recognised and heard, expressed frustration as they perceived growing barriers to receiving dietary care which met their preferences, and ultimately described a deterioration of the amount of control and choice available to the individual with loss of self-feeding ability and dysphagia. IMPLICATIONS Further consideration of how to incorporate individualised dietary care is needed to fully implement person-centred care and support the quality of life of those receiving nursing home care.

COST-EFFECTIVENESS OF INDIVIDUALIZED NUTRITION AND EXERCISE THERAPY FOR REHABILITATION FOLLOWING HIP FRACTURE

OBJECTIVE To undertake a cost-utility analysis of the Individual Nutrition Therapy and Exercise Regime: A Controlled Trial of Injured, Vulnerable Elderly (INTERACTIVE) trial. DESIGN Cost-utility analysis of a randomized controlled trial. SUBJECTS A total of 175 patients following a hip fracture were allocated to receive either alternate weekly visits from a physical therapist and dietitian (intervention group), or social visits for 6 months (control group). METHODS Costs for utilization of hospitals, health and community services were compared with quality-adjusted life years gained, calculated from responses to the Assessment of Quality of Life instrument. RESULTS There were minimal differences in mean costs between the intervention (