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Comprehensive Clinical Assessment in Community Setting: Applicability of the MDS-HC
Abstract
To describe the results of an international trial of the home care version of the MDS assessment and problem identification system (the MDS-HC), including reliability estimates, a comparison of MDS-HC reliabilities with reliabilities of the same items in the MDS 2.0 nursing home assessment instrument, and an examination of the types of problems found in home care clients using the MDS-HC.
Independent, dual assessment of clients of home-care agencies by trained clinicians using a draft of the MDS-HC, with additional descriptive data regarding problem profiles for home care clients.
Reliability data from dual assessments of 241 randomly selected clients of home care agencies in five countries, all of whom volunteered to test the MDS-HC. Also included are an expanded sample of 780 home care assessments from these countries and 187 dually assessed residents from 21 nursing homes in the United States.
The array of MDS-HC assessment items included measures in the following areas: personal items, cognitive patterns, communication/hearing, vision, mood and behavior, social functioning, informal support services, physical functioning, continence, disease diagnoses health conditions and preventive health measures, nutrition/hydration, dental status, skin condition, environmental assessment, service utilization, and medications.
Forty-seven percent of the functional, health status, social environment, and service items in the MDS-HC were taken from the MDS 2.0 for nursing homes. For this item set, it is estimated that the average weighted Kappa is .74 for the MDS-HC and .75 for the MDS 2.0. Similarly, high reliability values were found for items newly introduced in the MDS-HC (weighted Kappa = .70). Descriptive findings also characterize the problems of home care clients, with subanalyses within cognitive performance levels.
Findings indicate that the core set of items in the MDS 2.0 work equally well in community and nursing home settings. New items are highly reliable. In tandem, these instruments can be used within the international community, assisting and planning care for older adults within a broad spectrum of service settings, including nursing homes and home care programs. With this community-based, second-generation problem and care plan-driven assessment instrument, disability assessment can be performed consistently across the world.
... The HCRS database contains clinical assessment information for all persons in Canada assessed with the validated RAI-HC instrument [12,13]. The RAI-HC assessment is administered as standard of practice for non-palliative, longstay home care clients (i.e. ...
... Information from the RAI-HC assessment is used to guide care planning [15], inform resource allocation at the client-level [16] and evaluate quality of care [17]. The inter-rater reliability of the items included on the RAI-HC [13], and the internal consistency of items used in summary measures for instrumental and basic activity of daily living dependence [18] are strong. ...
Background:
The Hospital Frailty Risk Score (HFRS) is scored using ICD-10 diagnostic codes in administrative hospital records. Home care clients in Canada are routinely assessed with Resident Assessment Instrument-Home Care (RAI-HC) which can calculate the Clinical Frailty Scale (CFS) and the Frailty Index (FI).
Objective:
Measure the correlation between the HFRS, CFS and FI and compare prognostic utility for frailty-related outcomes.
Design:
Retrospective cohort study.
Setting:
Alberta, British Columbia and Ontario, Canada.
Subjects:
Home care clients aged 65+ admitted to hospital within 180 days (median 65 days) of a RAI-HC assessment (n = 167,316).
Methods:
Correlation between the HFRS, CFS and FI was measured using the Spearman correlation coefficient. Prognostic utility of each measure was assessed by comparing measures of association, discrimination and calibration for mortality (30 days), prolonged hospital stay (10+ days), unplanned hospital readmission (30 days) and long-term care admission (1 year).
Results:
The HFRS was weakly correlated with the FI (ρ 0.21) and CFS (ρ 0.28). Unlike the FI and CFS, the HFRS was unable to discriminate for 30-day mortality (area under the receiver operator characteristic curve (AUC) 0.506; confidence interval (CI) 0.502-0.511). It was the only measure that could discriminate for prolonged hospital stay (AUC 0.666; CI 0.661-0.673). The HFRS operated like the FI and CFI when predicting unplanned readmission (AUC 0.530 CI 0.526-0.536) and long-term care admission (AUC 0.600; CI 0.593-0.606).
Conclusions:
The HFRS identifies a different subset of older adult home care clients as frail than the CFS and FI. It has prognostic utility for several frailty-related outcomes in this population, except short-term mortality.
... Since 2002, the Resident Assessment Instrument-Home Care (RAI-HC) has been used by case managers and care coordinators in Ontario to determine the needs of persons expected to be, or currently are, long-term recipients of home care or those applying for admission into a long-term care facility [34]. This standardized, wellvalidated [35][36][37], and highly reliable [35][36][37] assessment is routinely administered to record information on the client's physical, cognitive, and social functions, service use, and their caregivers' characteristics and caregiving profile [33]. While all persons assessed by the RAI-HC have additional care needs, not everyone receives home care as some may decline home care or are admitted to other care settings while waiting for home care. ...
... Since 2002, the Resident Assessment Instrument-Home Care (RAI-HC) has been used by case managers and care coordinators in Ontario to determine the needs of persons expected to be, or currently are, long-term recipients of home care or those applying for admission into a long-term care facility [34]. This standardized, wellvalidated [35][36][37], and highly reliable [35][36][37] assessment is routinely administered to record information on the client's physical, cognitive, and social functions, service use, and their caregivers' characteristics and caregiving profile [33]. While all persons assessed by the RAI-HC have additional care needs, not everyone receives home care as some may decline home care or are admitted to other care settings while waiting for home care. ...
Background
To our knowledge, no population-based studies have examined whether family or friend caregivers of men and women differ in their experience of distress over time. Thus, we aimed to describe, on a population-level and longitudinally, how older men and women care-receivers differed in their health and care needs, compare their caregivers’ distress trajectories, and identify factors that contribute to the observed differences.
Methods
This is a population-based, retrospective cohort study using routinely collected data. We examined longitudinally 485,407 community-dwelling Ontario residents, aged over 50 years, who have received at least one Residential Assessment Instrument-Home Care (RAI-HC) assessment between April 2008 and June 2015. Descriptive analyses were performed on the demographic characteristics, health profiles, and care needs of men and women. We also compared their caregivers’ baseline and one-year change in distress status. Logistic regressions were performed to examine if the effect of gender on caregiver distress is reduced after controlling for care-receiver’s health and functional status as well as their caregiver’s kinship and co-residence status.
Results
Men (39.5% of our cohort) were frailer, required more care, were mostly cared for by their spouses (52%), and mostly lived with their caregiver (66%). In contrast, women (60.5%) were more likely cared for by their child/child-in-law (60%), less likely to live with caregivers (47%), and received less care. Caregivers of men were more likely to be distressed at baseline (27.7% versus 20.4% of women caregivers) and remain distressed (74.6% versus 69.5%) or become distressed (19.3% versus 14.3%) throughout the year. In logistic regression modelling, the effect of care-receiver’s gender on caregiver distress is reduced from an unadjusted odds ratio of 1.49 (95% CI: 1.47–1.51) to 1.17 (95% CI: 1.15–1.19) when care-receiver’s health and caregiving factors are controlled for.
Conclusion
Older men and women differed in health and care needs. Caregivers, especially those caring for men, were often distressed and remained so through time. These results highlight the need for policies that account for the differential care needs and caregiver profiles of men and women in order to offer targetted and appropriate support.
... The Minimal Data Set within the Resident Assessment Instrument (RAI) for people living in the community, as well as RAI-Home (for home care) and RAI-NH (for nursing homes), is completed by a nurse taking a clinical perspective, is available in a number of languages, and used in various countries around the globe [20]. The Minimal Data Set consists of 16 different domains and 238 items to be completed by a qualified nurse together with the patient/resident [21]. For the acute hospital sector, the Comprehensive Geriatric Assessment tool can be used, as it takes a person-centred approach, and is completed by the multidisciplinary team [22]. ...
... While these assessment instruments are in use in a variety of settings, it remains unclear whether they can be used to fully elicit and manage people with dementia experienced needs and accompanying symptoms, because i) some instruments are very long and are therefore may not be practical at the bedside [21], ii) others are completed by healthcare professionals, who do not necessarily know the person with dementia well [22,23], and iii) often only appropriately trained staff can complete the assessment instrument [20,22], excluding others in the workforce such as for instance nursing assistants [23]. ...
Background
People with dementia are most at risk of experiencing serious health related suffering, if they do not have a palliative care approach introduced early enough in the illness. It can be challenging for nurses to assess experienced needs of people, who are thought no longer able to self-report such as people with dementia. Assessment help to understand the care the patient and their family need promptly. It is unknown how nurses recognise holistic palliative care needs in people with dementia during routine care.
Methods
Scoping review where EMBASE, MEDLINE, CINAHL, PsycInfo databases, and references were searched with an advanced search strategy, which was built on three concepts (nurses, dementia, and nursing assessment) using corresponding Medical Subject Headings. Data were charted in a piloted extraction form, based on the assessment domains within the nursing process followed by summarise and synthesise results narratively.
Results
37 out of 2,028 qualitative and quantitative articles published between 2000 and 2021, and relating to 2600 + nurses, were identified. Pain was sole focus of assessment in 29 articles, leaving 8 articles to describe assessment of additional needs (e.g., discomfort). Nurses working in a nursing home assess pain and other needs by observing the persons with dementia behaviour during routine care. Nurses in the acute care setting are more likely to assess symptoms with standard assessment tools at admission and evaluate symptoms by observational methods. Across settings, about one third of pain assessments are supported by person-centred pain assessment tools. Assessments were mostly triggered when the person with dementia vocalised discomfort or a change in usual behaviour was observed. Nurses rely on family members and colleagues to gain more information about needs experienced by people with dementia.
Conclusion
There is a scarcity of evidence about techniques and methods used by nurses to assess needs other than pain experienced by people with dementia. A holistic, person-centred screening tool to aid real-time observations at the bedside and used in conversations with health care professionals and families/friends, may improve need recognition other than pain, to ensure holistic needs could then be addressed timely to improve care in people with dementia.
... The Resident Assessment Instrument for Home Care (RAI-HC) is a comprehensive assessment instrument, developed to identify the needs of home care clients with disabilities. The RAI-HC collects information on the service use of clients and the clients' physical, mental, social, and cognitive domains of health [19]. Its reliability and validity have been tested in international studies [19][20][21]. ...
... The RAI-HC collects information on the service use of clients and the clients' physical, mental, social, and cognitive domains of health [19]. Its reliability and validity have been tested in international studies [19][20][21]. In earlier studies, some scales of the RAI-HC instrument have been associated with negative outcomes or the risk for unplanned hospitalization among home care clients [4,[22][23][24][25]. ...
Purpose
To identify predictive case finding tools for classifying the risk of unplanned hospitalization among home care clients utilizing the Resident Assessment Instrument-Home Care (RAI-HC), with special interest in the Detection of Indicators and Vulnerabilities for Emergency Room Trips (DIVERT) Scale.
Methods
A register-based, retrospective study based on the RAI-HC assessments of 3,091 home care clients (mean age 80.9 years) in the City of Tampere, Finland, linked with hospital discharge records. The outcome was an unplanned hospitalization within 180 days after RAI-HC assessment. The Area Under the Curve (AUC) and the sensitivity and specificity were determined for the RAI-HC scales: DIVERT, Activities of Daily Living Hierarchy (ADLh), Cognitive Performance Scale (CPS), Changes in Health, End-Stage Diseases, Signs, and Symptoms Scale (CHESS), and Method for Assigning Priority Levels (MAPLe).
Results
Altogether 3091 home care clients had a total of 7744 RAI-HC assessments, of which 1658 (21.4%) were followed by an unplanned hospitalization. The DIVERT Scale had an AUC of 0.62 (95% confidence interval 0.61–0.64) when all assessments were taken into account, but its value was poorer in the older age groups (< 70 years: 0.71 (0.65–0.77), 70–79 years: 0.66 (0.62–0.69), 80–89 years: 0.60 (0.58–0.62), ≥ 90 years: 0.59 (0.56–0.63)). AUCs for the other scales were poorer than those of DIVERT, with CHESS nearest to DIVERT. Time to hospitalization after assessment was shorter in higher DIVERT classes.
Conclusion
The DIVERT Scale offers an approach to predicting unplanned hospitalization, especially among younger home care clients. Clients scoring high in the DIVERT algorithm were at the greatest risk of unplanned hospitalization and more likely to experience the outcome earlier than others.
... All home care recipients participating in the two studies were assessed using the interRAI-HC, which is a comprehensive and structured geriatric instrument [20,21]. The instrument is used in several countries in health care settings in routine care to support assessment and care planning for vulnerable patients' groups as well as in research studies. ...
... The instrument is used in several countries in health care settings in routine care to support assessment and care planning for vulnerable patients' groups as well as in research studies. The health status of an individual, as well as health problems, are extensively covered, providing an assessment of medical, psychological, social, and functional skills and care needs of dependent elderly living in the community [20][21][22][23][24][25]. ...
Background
Policymakers advocate extended residence in private homes as people age, rather than relocation to long-term care facilities. Consequently, it is expected that older people living in their own homes will be frailer and have more complex health problems over time. Therefore, community care for aging people is becoming increasingly important to facilitate prevention of decline in physical and cognitive abilities and unnecessary hospital admission and transfer to a nursing home. The aim of this study was to examine changes in the characteristic of home care clients and home care provided in five European countries between 2001 and 2014 and to explore whether home care clients who are most in need of care receive the care required.
Methods
This descriptive study used data from two European research projects, Aged in Home Care (AdHOC; 2001–2002) and Identifying best practices for care-dependent elderly by Benchmarking Costs and outcomes of Community Care (IBenC; 2014–2016). In both projects, the InterRAI-Home Care assessment tool was used to assess a random sample of home care clients 65 years and older in five European countries. These data facilitate a comparison of physical and cognitive health and the provided home care between countries and study periods.
Results
In most participating countries, both cognitive (measured on the Cognitive Performance Scale) and functional ability (measured on the Activities of Daily Living Hierarchy scale) of home care clients deteriorated over a 10-year period. Home care provided increased between the studies. Home care clients who scored high on the physical and cognitive scales also received home care for a significantly higher duration than those who scored low.
Conclusion
Older people in several European countries remain living in their own homes despite deteriorating physical and cognitive skills. Home care services to this group have increased. This indicates that the government policy of long-term residence at own home among older people, even in increased frailty, has been realised.
... inter rai. org), and its reliability and validity have been reported in previous studies [15,16]. Tampere city has utilised the RAI-HC in the development of home care services since 2007 and all clients were assessed by a member of the educated nursing staff. ...
... In the catchment area, circa 85% of home care clients were assessed with the RAI-HC during 2014, so the representativeness of the population of interest was quite good. Despite the often challenging context, the RAI-HC assessments have been considered reliable [16], and missing values were very rare in the present study. Although there may be miscoding or inaccurate evaluations at the level of the individual client, this should not systematically bias the present observations. ...
Purpose
To examine which client characteristics and other factors, including possible adverse effects, identified in the Resident Assessment Instrument—Home Care (RAI-HC) are associated with daily opioid use among aged home care clients.
Methods
The study sample comprised 2584 home care clients aged ≥ 65 years, of which 282 persons used opioids daily. Clients using opioids less than once daily were excluded. The cross-sectional data were gathered from each client’s first assessment with the RAI-HC during 2014. Multivariable logistic regression was used to study associations of daily opioid use with the clients’ characteristics and symptoms.
Results
Cognitive impairment was associated with less frequent opioid use after adjusting for pain-related diseases, disabilities and depressive symptoms (OR 0.43, 95% CI 0.32–0.58). The association was not explained by the estimated severity of pain. Osteoporosis, cancer within previous 5 years and greater disabilities in Instrumental Activities of Daily Living (IADL) were associated with daily opioid use regardless of the estimated severity of pain. Depressive symptoms and Parkinson’s disease were associated with daily opioid use only among clients with cognitive impairment, and disabilities in Activities of Daily Living, cancer, arthritis, fractures and pressure ulcers only among clients without cognitive impairment. Constipation was the only adverse effect associated with daily opioid use.
Conclusion
The pain of home care clients with cognitive impairment may not be treated optimally, whereas there might be prolonged opioid use without a sufficient evaluation of current pain among clients with osteoporosis, cancer within previous 5 years and disabilities in IADLs.
... With regard to the recommended interventions, intercaregiver agreement was weak in the current study. Morris et al. (1997) reported moderate agreement for the MDS 2.0 with an average kappa of κ = 0.7 for oral-dental items [48]. However, detailed information on data collection and prevalence of oral health problems were not reported, impeding interpretation and comparison of results. ...
... With regard to the recommended interventions, intercaregiver agreement was weak in the current study. Morris et al. (1997) reported moderate agreement for the MDS 2.0 with an average kappa of κ = 0.7 for oral-dental items [48]. However, detailed information on data collection and prevalence of oral health problems were not reported, impeding interpretation and comparison of results. ...
Objectives
An optimized oral health-related section and a video training were developed and validated for the interRAI suite of instruments. The latter is completed by professional non-dental caregivers and used in more than 40 countries to assess care needs of older adults.
Methods
The optimized oral health–related section (ohr-interRAI) consists of nine items and a video training that were developed in consecutive phases. To evaluate psychometric properties, a study was conducted in 260 long-term care residents. Each resident was assessed by a dentist and by four caregivers (two who received the video training, two who did not).
Results
Mean kappa values and percent agreement between caregivers and dentist ranged between κ = 0.60 (80.2%) for dry mouth and κ = 0.13 (54.0%) for oral hygiene. The highest inter-caregiver agreement was found for dry mouth with κ = 0.63 [95% CI: 0.56–0.70] (81.6%), while for the item palate/lips/cheeks only κ = 0.27 [95% CI: 0.18–0.36] (76.7%) was achieved. Intra-caregiver agreement ranged between κ = 0.93 [95% CI: 0.79–1.00] (96.4%) for dry mouth and κ = 0.45 [95% CI: 0.06-0.84] (82.8%) for gums. Logistic regression analysis showed only small differences between caregivers who watched the video training and those who did not.
Conclusions
Psychometric properties of the optimized ohr-interRAI section were improved compared to previous versions. Nevertheless, particularly the items based on inspection of the mouth require further refinement and caregiver training needs to be improved.
Clinical Relevance
Valid assessment of oral health by professional caregivers is essential due to the impaired accessibility of regular dental care for care-dependent older adults.
... The Resident Assessment Instrument -Home Care (RAI-HC) [9] is a comprehensive, standardized tool implemented as part of routine clinical practice across several Canadian provinces. The RAI-HC is completed upon admission into a long-stay home care programs and includes person-level data elements and outcome scores [9]. ...
... The Resident Assessment Instrument -Home Care (RAI-HC) [9] is a comprehensive, standardized tool implemented as part of routine clinical practice across several Canadian provinces. The RAI-HC is completed upon admission into a long-stay home care programs and includes person-level data elements and outcome scores [9]. Outputs from the RAI-HC can be used to guide practice and identify home care recipients at risk for negative events or outcomes, such as fractures. ...
Background:
Fractures have dire consequences including pain, immobility, and death. People receiving home care are at higher risk for fractures than the general population. Yet, current fracture risk assessment tools require additional testing and assume a 10-year survival rate, when many die within one year. Our objectives were to develop and validate a scale that predicts one-year incident hip fracture using the home care resident assessment instrument (RAI-HC).
Methods:
This is a retrospective cohort study of linked population data. People receiving home care in Ontario, Canada between April 1st, 2011 and March 31st, 2015 were included. Clinical data were obtained from the RAI-HC which was linked to the Discharge Abstract Database and National Ambulatory Care Reporting System to capture one-year incident hip fractures. Seventy-five percent (n = 238,011) of the sample were randomly assigned to a derivation and 25% (n = 79,610) to a validation sample. A decision tree was created with the derivation sample using known fracture risk factors. The final nodes of the decision tree were collapsed into 8 risk levels and logistic regression was performed to determine odds of having a fracture for each level. c-Statistics were calculated to compare the discriminative properties of the full, derivation, and validation samples.
Results:
Approximately 60% of the sample were women and 53% were 80 years and older. A total of 11,526 (3.6%) fractures were captured over the 1-year time period. Of these, 5057 (43.9%) were hip fractures. The proportion who experienced a hip fracture in the next year ranged from 0.3% in the lowest risk level to 5.2% in the highest risk level. People in the highest risk level had 18.8 times higher odds (95% confidence interval, 14.6 to 24.3) of experiencing a hip fracture within one year than those in the lowest. c-Statistics were similar for the full (0.658), derivation (0.662), and validation (0.645) samples.
Conclusions:
The FRS-HC predicts hip fracture over one year and should be used to guide clinical care planning for home care recipients at high risk for fracture. Our next steps are to develop a fracture risk clinical assessment protocol to link treatment recommendations with identified fracture risk.
... The instrument is a standardized assessment tool to assess long-stay home care clients' health status, need for care, and basic background information on housing and informal caregivers. The instrument RAI-HC [8][9][10][11][12][13] and its clinically based scales (e.g. Cognitive Performance Scale, Depression Rating Scale) [14][15][16][17][18][19][20] have been validated in several international studies. ...
... In contrast to the RAI-HC QIs, the psychometric properties of the instrument RAI-HC, i.e. its items and scales, has been tested more thoroughly. These validation studies show overall acceptable reliability results [8,10,11,13]. Nevertheless, good reliability of RAI-HC data does not guarantee the reliability of QIs based on these data nor the ability to be applied in quality comparisons over time or between providers [51,52]. ...
Background:
One way of measuring the quality of home care are quality indicators (QIs) derived from data collected with the Resident Assessment Instrument-Home Care (RAI-HC). In order to produce meaningful results for quality improvement and quality comparisons across home care organizations (HCOs) and over time, RAI-HC QIs must be valid and reliable. The aim of this systematic review was to identify currently existing RAI-HC QIs and to summarize the scientific knowledge on the validity and reliability of these QIs.
Methods:
A systematic review was performed using the electronic databases PubMed, CINAHL, Embase, PsycINFO and Cochrane Library. Studies describing the development process or the psychometric characteristics of RAI-HC QIs were eligible. The data extraction involved a general description of the included studies as well as the identified RAI-HC QIs and information on validity and reliability. The methodological quality of the identified RAI-HC QI sets was assessed using the Appraisal of Indicators through Research and Evaluation (AIRE) instrument.
Results:
Four studies out of 659 initial hits met the inclusion criteria. The included studies described the development and validation process of three RAI-HC QI sets comprising 48 unique RAI-HC QIs, which predominantly refer to outcome of care. Overall, the validity and reliability of the identified RAI-HC QIs were not sufficiently tested. The methodological quality of the three identified RAI-HC QI sets varied across the four AIRE instrument domains. None of the QI sets reached high methodological quality, defined as scores of 50% and higher in all four AIRE instrument domains.
Conclusions:
This is the first review that systematically summarized and appraised the available scientific evidence on the validity and reliability of RAI-HC QIs. It identified insufficient reporting of RAI-HC QIs validation processes and reliability as well as missing state-of-the-art methodologies. The review provides guidance as to what additional validity and reliability testing are needed to strengthen the scientific soundness of RAI-HC QIs. Considering that RAI-HC QIs are already implemented and used to measure and compare quality of home care, further investigations on RAI-HC QIs reliability and validity is recommended.
... No significant differences were found between appetite status and body mass index of the participants. Those with anorexia of ageing were also shown to have worse cognitive performance as measured with the Minimum Data Set-Home Care (MDS-HC) tool [34]. In general, old adults diagnosed with dementia are at a high risk for development of malnutrition. ...
Anorexia of aging is a common problem in older adults. Depending on the setting, its prevalence varies from about 10% (among community-dwelling older adults) to over 30% in acute wards and nursing homes. The objective of this systematic review was to establish the prevalence of poor appetite in frail persons ≥60 years of age. We performed a literature search for studies where the prevalence of anorexia of aging among frail and pre-frail old adults was reported. 957 articles on this topic were identified. After eligibility assessment, three articles were included in the review. The studies included 4657 community-dwelling older adults. The weighted total prevalence of anorexia of aging in all the included studies was 11.3%. Among frail and pre-frail participants, loss of appetite was reported in 20.5% (weighted estimate). Overall, robust status was associated with a 63% lower probability of concomitant anorexia of ageing (OR 0.37, 95%CI 0.21-0.65, p = 0.0005). Frailty or risk of frailty are associated with more prevalent anorexia of ageing. This has potential practical implications; however, more research, especially to elucidate the direction of the relation, is needed.
... Physician visits were identified using the Ontario Health Insurance Plan database and hospital admissions using the Discharge Abstract Database. Home care clinical assessments were obtained from the databases containing the Resident Assessment Instrument-Home Care (RAI-HC) 24 and the updated version, the international Resident Assessment Instrument-Home Care (interRAI HC). 25 These clinical assessments are periodically used with publicly funded home care patients receiving on-going care. ...
Background:
Research on factors associated with recurrent emergency department (ED) visits and their implications for improving dementia care is lacking. The objective of this study was to examine associations between the individual characteristics of older adults living with dementia and recurrent ED visits.
Methods:
We used health administrative databases to conduct a population-based retrospective cohort study among older adults with dementia in Ontario, Canada. We included community-dwelling adults 66 years and older who visited the ED between April 1, 2010, and March 31, 2019 and were discharged home. We recorded all ED visits within one year after the baseline visit. We used recurrent event Cox regression to examine associations between repeat ED visits and individual clinical, demographic, and health service use characteristics. We fit conditional inference trees to identify the most important factors and define subgroups of varying risk.
Results:
Our cohort included 175,863 older adults with dementia. ED use in the year prior to baseline had the strongest association with recurrent visits (3+ vs.0 adjusted hazard ratio (aHR): 1.92 (1.89, 1.94), 2vs.0 aHR: 1.45 (1.43, 1.47), 1vs.0 aHR: 1.23 (1.21, 1.24)). The conditional inference tree utilized history of ED visits and comorbidity count to define 12 subgroups with ED revisit rates ranging from 0.79 to 7.27 per year. Older adults in higher risk groups were more likely to live in rural and low-income areas and had higher use of anticonvulsants, antipsychotics, and benzodiazepines.
Conclusions:
History of ED visits may be a useful measure to identify older adults with dementia who would benefit from additional interventions and supports. A substantial proportion of older adults with dementia have a pattern of recurrent visits and may benefit from dementia-friendly and geriatric-focused EDs. Collaborative medication review in the ED and closer follow-up and engagement with community supports could improve patient care and experience.
... The CRA was developed by identifying items from of interRAI (https://interRAI.org) assessments for persons living independently in the community (10,11), receiving home care (12)(13)(14), post-acute hospital (15) and residential long-term care (16) that are relevant to persons receiving care in ambulatory rehabilitative care. Items from the CRA can be used to calculate several validated interRAI summary scales, such as the ADL Long-form and Hierarchy Scale (17), Cognitive Performance Scale (18) and the Pain Scale (19). ...
Objectives:
The interRAI Community Rehabilitation Assessment (CRA) is a comprehensive health assessment designed to collect essential health and function information for rehabilitation care planning, benchmarking, and evaluation of clinic and home-based programs. A portion of the CRA is completed through patient self-report. The objective of this study was to demonstrate how the CRA can be used to describe the baseline clinical characteristics of patients participating in ambulatory rehabilitation programs and measure change across numerous domains of function, health, and wellbeing over time.
Design:
Cohort study.
Setting and participants:
In total, 709 patients were assessed with the CRA across 25 ambulatory clinics in Ontario, Canada between January 1st, 2018, to December 31st, 2018. We examined sub-groups of patients receiving rehabilitation following stroke (n = 82) and hip or knee total joint replacement (n = 210).
Methods:
Frequency responses and means were compared between admission and discharge from the ambulatory rehabilitation programs. Measures of interest included self-reported difficulty in completing instrumental activities of daily living, locomotion, fear of falling, and pain.
Results:
Significant improvement relative to at admission was detected for the overall cohort and both sub-samples on individual instrumental activities of daily living, stair difficulty, use of mobility aides, distance walked, fear of falling, and pain.
Conclusions and implications:
The standardized and comparable information collected by the CRA is expected to provide clinicians, clinic, and health system administrators with essential health and function information that can be used for care planning, benchmarking, and evaluation.
... The MDS 3.0 9 in the USA is mandated for all nursing home residents funded by Medicare or Medicaid. The International Resident Assessment Instrument (interRAI), 10 initially derived from the MDS, is used in multiple countries including Canada and New Zealand, France, Belgium, Netherlands, Australia and Switzerland. These datasets enable care coordination, governance and audit, remuneration for services, service design and planning, and policy decisions. ...
Introduction:
Health and care data are routinely collected about care home residents in England, yet there is no way to collate these data to inform benchmarking and improvement. The Developing research resources And minimum data set for Care Homes' Adoption and use study has developed a prototype minimum data set (MDS) for piloting.
Methods and analysis:
A mixed-methods longitudinal pilot study will be conducted in 60 care homes (approximately 960 residents) in 3 regions of England, using resident data from cloud-based digital care home records at two-time points. These will be linked to resident and care home level data held within routine National Health Service and social care data sets. Two rounds of focus groups with care home staff (n=8-10 per region) and additional interviews with external stakeholders (n=3 per region) will explore implementation and the perceived utility of the MDS. Data will be assessed for completeness and timeliness of completion. Descriptive statistics, including percentage floor and ceiling effects, will establish data quality. For validated scales, construct validity will be assessed by hypothesis testing and exploratory factor analysis will establish structural validity. Internal consistency will be established using Cronbach's alpha. Longitudinal analysis of the pilot data will demonstrate the value of the MDS to each region. Qualitative data will be analysed inductively using thematic analysis to understand the complexities of implementing an MDS in care homes for older people.
Ethics and dissemination:
The study has received ethical approval from the London Queen's Square Research Ethics Committee (22/LO/0250). Informed consent is required for participation. Findings will be disseminated to: academics working on data use and integration in social care, care sector organisations, policy makers and commissioners. Findings will be published in peer-reviewed journals. Partner NIHR Applied Research Collaborations, the National Care Forum and the British Geriatrics Society will disseminate policy briefs.
... b Dietary supplements were also included. c Calculated. d InterRAI Minimum Data Set for Home Care instrument, MDS-HC76 . e Data were obtained from publication by Sikora et al.77 . ...
We aimed to systematically review the prevalence of potentially inappropriate prescribing (PIP) in older adults in Central and Eastern Europe (CEE) in all care settings. We searched Embase and MEDLINE (up to June 2019) and checked the reference lists of the included studies and relevant reviews. Eligible studies used validated explicit or implicit tools to assess the PIP prevalence in older adults in CEE. All study designs were considered, except case‒control studies and case series. We assessed the risk of bias using the Joanna Briggs Institute Prevalence Critical Appraisal Tool and the certainty of evidence using the GRADE approach. Meta-analysis was inappropriate due to heterogeneity in the outcome measurements. Therefore, we used the synthesis without meta-analysis approach—summarizing effect estimates method. This review included twenty-seven studies with 139,693 participants. Most studies were cross-sectional and conducted in high-income countries. The data synthesis across 26 studies revealed the PIP prevalence: the median was 34.6%, the interquartile range was 25.9–63.2%, and the range was 6.5–95.8%. The certainty of this evidence was very low due to the risk of bias, imprecision, and inconsistency. These findings show that PIP is a prevalent issue in the CEE region. Further well-designed studies conducted across countries are needed to strengthen the existing evidence and increase the generalizability of findings.
... interRAI's research focuses on the development and application of standardized assessments to inform clinical, management, and policy decisions in populations with complex needs of all ages, including palliative care clients. The interRAI instruments have been shown to have strong reliability and validity, and they include a series of common items that are relevant in all health care settings [19][20][21][22][23][24][25][26][27][28][29][30][31][32][33][34]. The interRAI PC includes the Changes in Health, End-Stage Disease, Signs and Symptoms (CHESS) Scale, which was initially developed with individuals in complex continuing care (CCC) and was found to be a strong predictor of mortality in several studies [27,29,30,[35][36][37][38][39][40]. ...
Background
Prognostic accuracy is important throughout all stages of the illness trajectory as it has implications for the timing of important conversations and decisions around care. Physicians often tend to over-estimate prognosis and may under-recognize palliative care (PC) needs. It is therefore essential that all relevant stakeholders have as much information available to them as possible when estimating prognosis.
Aims
The current study examined whether the interRAI Changes in Health, End-Stage Disease, Signs and Symptoms (CHESS) Scale is a good predictor of mortality in a known PC population and to see how it compares to the Palliative Performance Scale (PPS) in predicting 90-day mortality.
Methods
This retrospective cohort study used data from 2011 to 2018 on 80,261 unique individuals receiving palliative home care and assessed with both the interRAI Palliative Care instrument and the PPS. Logistic regression models were used to evaluate the relationship between the main outcome, 90-day mortality and were then replicated for a secondary outcome examining the number of nursing visits. Comparison of survival time was examined using Kaplan-Meier survival curves.
Results
The CHESS Scale was an acceptable predictor of 90-day mortality (c-statistic = 0.68; p < 0.0001) and was associated with the number of nursing days (c = 0.61; p < 0.0001) and had comparable performance to the PPS (c = 0.69; p < 0.0001). The CHESS Scale performed slightly better than the PPS in predicting 90-day mortality when combined with other interRAI PC items (c = 0.72; p < 0.0001).
Conclusion
The interRAI CHESS Scale is an additional decision-support tool available to clinicians that can be used alongside the PPS when estimating prognosis. This additional information can assist with the development of care plans, discussions, and referrals to specialist PC teams.
... Good to excellent inter-rater reliability has been reported for the RAI-MDS HC and interRAI HC in several countries (Hirdes et al., 2008;Kim et al., 2015;Kwan et al., 2000;Morris et al., 1997a). Data reliability reported inaccurate records in demographic and height or weight variables of the interRAI HC (Schluter et al., 2016). ...
Background
Comprehensive Geriatric Assessments (CGAs) have been incorporated as an integrated care approach effective to face the challenges associated to uncoordinated care, risk of hospitalization, unmet needs, and care planning experienced in older adult care. As they assessed different dimensions, is important to inform about the content and psychometric properties to guide the decisions when selecting and implementing them in practice. This systematic review provides a comprehensive insight on the strengths and weaknesses of the CGAs used in long-term care settings and community care.
Methods
A systematic search was conducted in PubMed, CINAHL, and Web of Science Core Collection. Studies published up to July 13, 2021, were considered. Quality appraisal was performed for the included studies.
Results
A total of 10 different CGAs were identified from 71 studies included. Three instruments were reported for long-term care settings, and seven for community care. The content was not homogenous and differed in terms of the detail and clearness of the areas being evaluated. Evidence for good to excellent validity and reliability was reported for various instruments.
Conclusions
Setting more specific and clear domains, associated to the special needs of the care setting, could improve informed decisions at the time of selecting and implementing a CGA. Considering the amount and quality of the evidence, the instrument development trajectory, the validation in different languages, and availability in different care settings, we recommend the interRAI LTCF and interRAI HC to be used for long-term facilities and community care.
... [64][65][66] In previous research, the RAI-HC, MDS 2.0 and the newer interRAI instruments have been found to have strong data quality in terms of reliability, validity and completeness. [67][68][69][70][71] The interRAI suite of assessment tools also have strong clinical utility and are intended to support care planning at the point-of-care in the settings where they are used; facilitated by the various Open access outcome and risk scales and clinical assessment protocols derived from assessment data. 63 72-74 Phase 1: quantitative phase Sample Size The rapid step will use CIHI's 2017/2018 HCRS data to understand the demographic and clinical profile of the population of home care clients assessed with the RAI-HC in Ontario. ...
Introduction
The COVID-19 pandemic exacerbated existing challenges within the Canadian healthcare system and reinforced the need for long-term care (LTC) reform to prioritise building an integrated continuum of services to meet the needs of older adults. Almost all Canadians want to live, age and receive care at home, yet funding for home and community-based care and support services is limited and integration with primary care and specialised geriatric services is sparse. Optimisation of existing home and community care services would equip the healthcare system to proactively meet the needs of older Canadians and enhance capacity within the hospital and residential care sectors to facilitate access and reduce wait times for those whose needs are best served in these settings. The aim of this study is to design a model of long-term ‘life care’ at home (LTlifeC model) to sustainably meet the needs of a greater number of community-dwelling older adults.
Methods and analysis
An explanatory sequential mixed methods design will be applied across three phases. In the quantitative phase, secondary data analysis will be applied to historical Ontario Home Care data to develop unique groupings of patient needs according to known predictors of residential LTC home admission, and to define unique patient vignettes using dominant care needs. In the qualitative phase, a modified eDelphi process and focus groups will engage community-based clinicians, older adults and family caregivers in the development of needs-based home care packages. The third phase involves triangulation to determine initial model feasibility.
Ethics and dissemination
This study has received ethics clearance from the University of Waterloo Research Ethics Board (ORE #42182). Results of this study will be disseminated through peer-reviewed publications and local, national and international conferences. Other forms of knowledge mobilisation will include webinars, policy briefs and lay summaries to elicit support for implementation and pilot testing phases.
... The interRAI Home Care assessment (or its earlier version RAI-Home Care) and interRAI Contact Assessment have been used in Ontario's publicly funded home care system since 2002 and 2010, respectively. Previous research has established the validity and reliability of these assessments [13][14][15][16][17][18][19]. The interRAI Contact Assessment (about 50 items) is used to screen new home care patients for key health and social needs and serves as a minimum data set for those who do not require further assessment. ...
Objective
The objective was to compare home care episode, standardised assessment, and service patterns in Ontario’s publicly funded home care system during the first wave of the COVID-19 pandemic (i.e., March to September 2020) using the previous year as reference.
Study design and setting
We plotted monthly time series data from March 2019 to September 2020 for home care recipients in Ontario, Canada. Home care episodes were linked to interRAI Home Care assessments, interRAI Contact Assessments, and home care services. Health status measures from the patient’s most recent interRAI assessment were used to stratify the receipt of personal support, nursing, and occupational or physical therapy services. Significant level and slope changes were detected using Poisson, beta, and linear regression models.
Results
The March to September 2020 period was associated with significantly fewer home care admissions, discharges, and standardised assessments. Among those assessed with the interRAI Home Care assessment, significantly fewer patients received any personal support services. Among those assessed with either interRAI assessment and identified to have rehabilitation needs, significantly fewer patients received any therapy services. Among patients receiving services, patients received significantly fewer hours of personal support and fewer therapy visits per month. By September 2020, the rate of admissions and services had mostly returned to pre-pandemic levels, but completion of standardised assessments lagged behind.
Conclusion
The first wave of the COVID-19 pandemic was associated with substantial changes in Ontario’s publicly funded home care system. Although it may have been necessary to prioritise service delivery during a crisis situation, standardised assessments are needed to support individualised patient care and system-level monitoring. Given the potential disruptions to home care services, future studies should examine the impact of the pandemic on the health and well-being of home care recipients and their caregiving networks.
... Também não havia consenso sobre as medidas de qualidade nos resultados e a melhor forma de implementar tal avaliação (3,5). Na elaboração do OASIS houve consenso sobre a necessidade de combinar indicadores de estrutura, processo e resultado, além de formar grupos homogêneos dos pacientes, de acordo com os problemas de saúde apresentados, facilitando assim, a comparação entre as empresas (3,14). ...
O trabalho apresenta uma proposta de indicadores para o monitoramento e avaliação dos cuidados aos idosos no domicilio. A atenção domiciliar ganha força dentro da estratégia de saúde do SUS à medida que diminui as internações hospitalares com potencial para melhorar a qualidade de vida dos usuários. Nesse sentido, devido às altas taxas de morbidades e incapacidade, a população idosa é um dos grupos que mais se beneficia da internação domiciliar. O trabalho apresenta os indicadores propostos para capacitar médicos e enfermeiras para o monitoramento e avaliação na internação domiciliar de idosos. Os indicadores para a garantia da qualidade foram propostos após revisão da literatura sobre os instrumentos e indicadores utilizados em âmbito mundial. Serviços de boa qualidade auxiliam na recuperação da independência e a manutenção do idoso na comunidade reduzindo o custo em saúde ao prevenir institucionalizações. No início do acompanhamento é necessário avaliar as condições do ambiente domiciliar, de saúde dos indivíduos e as comorbidades, de modo a auxiliar no planejamento do cuidado e o estabelecimento de parâmetros para próximas avaliações. A avaliação ampliada inclui diferentes facetas da saúde do indivíduo e sua família, entre elas, o estado psicológico, funcional, o conhecimento relacionado com cuidados em saúde, a satisfação com o cuidado recebido, a aceitação e a participação do usuário na produção do cuidado.O debate sobre quais os melhores instrumentos e indicadores para monitorar a qualidade na assistência domiciliar precisa ser suscitado no país, incluindo os aspectos da estrutura dos serviços, do processo de trabalho e dos resultados. Esta necessidade é premente diante da expansão e consolidação da estratégia de saúde da família e da política de atenção domiciliar.
... Recruitment occurred in six metropolitan areas, including community-dwelling adults aged 65 years and older. They were excluded if they had severe cognitive impairment (i.e., score less than 22 on the Mini Mental State Examination (MMSE); Folstein et al., 1975), functional impairment (i.e., dependency or regular assistance on the Minimum Data Set (MDS) Home Care questionnaire; Morris et al., 1997), self-reported diagnosis of AD, or history of other medical conditions. In total, enrolment consisted of a sample of 2,802 individuals. ...
Objective:
Verbal memory is a predictor of later functional deficits. However, it is unclear if a specific aspect of immediate free-recall is driving this relationship. Serial position effects (i.e., relationship between a word's placement on a word-list and its likelihood of being recalled) have been shown to predict conversion from mild cognitive impairment (MCI) to Alzheimer's disease (AD). The goal of this study was to determine if serial position effects predict functioning 10-year postbaseline when controlling for demographic variables and total cognitive scores.
Method:
Data from 2,802 participants in the Advanced Cognitive Training for Independent and Vital Elderly trial were examined to predict subjective (i.e., Minimum Data Set Home Care questionnaire subscales) and performance-based (i.e., Observed Tasks of Daily Living and Everyday Problems Test) functioning 10-year postbaseline. Multilevel modeling was used to examine the association between functioning 10-year postbaseline and scores at baseline.
Results:
Primacy performance demonstrated the most consistent associations with overall subjective and performance-based functioning measures 10-year postbaseline. Specifically, higher primacy performance was associated with less decline in subjective and performance-based functioning over time, particularly when primacy was analyzed from the Rey Auditory Verbal Learning Test. Fewer associations were found between middle and recency scores with subjective and performance-based functioning measures.
Conclusion:
The present study suggests that serial position effects predict future subjective and performance-based functional changes, beyond demographic information and global cognition. The study adds to a growing literature about the relative importance of primacy, especially in the prediction of functional changes. (PsycInfo Database Record (c) 2022 APA, all rights reserved).
... • Resident Assessment Instrument for Home Care (RAI-HC) (22) is mandated in both jurisdictions as part of regular clinical practice. The RAI-HC is a standardized, comprehensive assessment for use with adult and non-palliative home care clients. ...
Publicly funded home care in Canada supports older adults in the community to delay institutional care, which results in complex care populations with multimorbidity that includes mental health problems. The purpose of this study is to examine prevalence of psychiatric diagnoses and other mental health symptoms among older clients in two publicly funded Home Care (HC) Programs and their psychiatry service utilization (psychiatrist visits) after being admitted to home care. This retrospective cohort study examines clients age 60 years and older in the two Canadian provinces of Manitoba (MB), specifically the Winnipeg Regional Health Authority (WRHA) ( n = 5,278), and Nova Scotia (NS) ( n = 5,323). Clients were admitted between 2011 and 2013 and followed up to 4 years. Linked data sources include the InterRAI Resident Assessment Instrument for Home Care (RAI-HC), physician visit/billing data and hospital admission data. Both regions had similar proportions (53%) of home care clients with one or more psychiatric diagnoses. However, we observed over 10 times the volume of psychiatry visits in the WRHA cohort (8,246 visits vs. 792 visits in NS); this translated into a 4-fold increased likelihood of receiving psychiatry visits (17.2% of WRHA clients vs. 4.2% of NS clients) and 2.5 times more visits on average per client (9.1 avg. visits in MB vs. 3.6 avg. visits in NS). The location of psychiatry services varied, with a greater number of psychiatry visits occurring while in hospital for WRHA HC clients compared to more visits in the community for NS HC clients. Younger age, psychotropic medication use, depressive symptoms, dementia, and having an unstable health condition were significantly associated with receipt of psychiatry visits in both cohorts. Access to psychiatric care differed between the cohorts despite little to no difference in need. We conclude that many home care clients who could have benefitted from psychiatrist visits did not receive them. This is particularly true for rural areas of NS. By linking the RAI-HC with other health data, our study raises important questions about differential access to psychiatry services by site of care (hospital vs. community), by geographical location (MB vs. NS and urban vs. rural) and by age. This has implications for staff training and mental health resources in home care to properly support the mental health needs of clients in care. Study results suggest the need for a mental health strategy within public home care services.
... Rigorous reliability and validity studies have demonstrated strong psychometric properties across the family of assessment tools targeting various populations, including adults (41)(42)(43)(44)(45)(46), as well as children and youth (47)(48)(49)(50)(51)(52)(53)(54)(55)(56)(57)(58)(59)(60). For example, one study examined the inter-item reliability of a number of the scales embedded in the ChYMH and several other tools within the interRAI child/youth suite, such as the Anxiety Scale, Aggressive/Disruptive Behavior Scale, Peer Conflict Scale, and Caregiver Distress Scale. ...
Quality of life (QoL) is significantly lower in children with mental health issues compared to those who are typically developing or have physical health problems. However, little research has examined factors associated with QoL in this particularly vulnerable population. To address this limitation, 347 clinically referred children and adolescents were assessed using the interRAI Child and Youth Mental Health (ChYMH) Assessment and Self-reported Quality of Life- Child and Youth Mental Health (QoL-ChYMH). Hierarchical multiple linear regression analyses were conducted to examine QoL at the domain-specific level. Children and adolescents who experienced heightened anhedonia and depressive symptoms reported lower social QoL (e.g., family, friends and activities; p = 0.024, 0.046, respectively). Additionally, children and youth who experienced heightened depressive symptoms reported lower QoL at the individual level (e.g., autonomy, health; p = 0.000), and level of basic needs (e.g., food, safety; p = 0.013). In contrast, no mental state indicators were associated with QoL related to services (e.g., school, treatment). Due to the paucity of research examining predictors of QoL in children and youth with mental health challenges, this study contributes to the field in assisting service providers with care planning and further providing implications for practice.
... The reliability and validity of the RAI instruments have been established. [12][13][14] The project received approval from the University of Waterloo's Office of Research Ethics. ...
Aim
To determine the predictive validity of the 1stFall algorithm in long-term care (LTC) residents across four Canadian provinces.
Methods
This retrospective cohort study included all clients admitted to LTC between 2006-2017 with no history of falls in the past 30 days. The outcome was occurrence of a fall and logistic regression analysis was performed to assess predictive validity.
Results
A total of 199,997 LTC residents were studied (71% were >80 years old, 66% women, and 17% had severe cognitive impairment). For the total sample, clients in the 2nd, 3rd, 4th and 5th risk categories had 1.15, 1.58, 2.66, and 3.76 times greater odds of falling than the 1st category, respectively. Similar trends were observed across provinces.
Conclusions
1stFall was developed to predict the risk of a first-time fall event in individuals with no history of a recent fall. 1stFall identified LTC residents at risk of a first-time fall, supporting its use in routine care.
... The interRAI-HC is a standardized and reliable comprehensive geriatric assessment instrument designed to assist in care planning, outcome measurement, quality improvement, and resource allocation for clients who receive care at home. [24][25][26][27] The instrument contains several validated outcome scales. Cognitive functioning is assessed by the Cognitive Performance Scale (CPS, range 0-6). ...
This study aims to benchmark mean societal costs per client in different home care models and to describe characteristics of home care models with the lowest societal costs. In this prospective longitudinal study in 6 European countries, 6-month societal costs of resource utilization of 2060 older home care clients were estimated. Three care models were identified and compared based on level of patient-centered care (PCC), availability of specialized professionals (ASP) and level of monitoring of care performance (MCP). Differences in costs between care models were analyzed using linear regression while adjusting for case mix differences. Societal costs incurred in care model 2 (low ASP; high PCC & MCP) were significantly higher than in care model 1 (high ASP, PCC & MCP, mean difference €2230 (10%)) and in care model 3 (low ASP & PCC; high MCP, mean difference €2552 (12%)). Organizations within both models with the lowest societal costs, systematically monitor their care performance. However, organizations within one model arranged their care with a low focus on patient-centered care, and employed mainly generalist care professionals, while organizations in the other model arranged their care delivery with a strong focus on patient-centered care combined with a high availability of specialized care professionals.
... The assessment is akin to the Minimum Data Set used internationally and has strong validity and reliability. [19][20][21] Seventy percent of cancer patients use home care in the last year of life. 22 The assessment collects various quality-of-life related items, such as the presence of pain or symptoms of depression. ...
Background
Predictive cancer tools focus on survival; none predict severe symptoms.
Aim
To develop and validate a model that predicts the risk for having low performance status and severe symptoms in cancer patients.
Design
Retrospective, population-based, predictive study
Setting/Participants
We linked administrative data from cancer patients from 2008 to 2015 in Ontario, Canada. Patients were randomly selected for model derivation (60%) and validation (40%). Using the derivation cohort, we developed a multivariable logistic regression model to predict the risk of an outcome at 6 months following diagnosis and recalculated after each of four annual survivor marks. Model performance was assessed using discrimination and calibration plots. Outcomes included low performance status (i.e. 10–30 on Palliative Performance Scale), severe pain, dyspnea, well-being, and depression (i.e. 7–10 on Edmonton Symptom Assessment System).
Results
We identified 255,494 cancer patients (57% female; median age of 64; common cancers were breast (24%); and lung (13%)). At diagnosis, the predicted risk of having low performance status, severe pain, well-being, dyspnea, and depression in 6-months is 1%, 3%, 6%, 13%, and 4%, respectively for the reference case (i.e. male, lung cancer, stage I, no symptoms); the corresponding discrimination for each outcome model had high AUCs of 0.807, 0.713, 0.709, 0.790, and 0.723, respectively. Generally these covariates increased the outcome risk by >10% across all models: lung disease, dementia, diabetes; radiation treatment; hospital admission; pain; depression; transitional performance status; issues with appetite; or homecare.
Conclusions
The model accurately predicted changing cancer risk for low performance status and severe symptoms over time.
... To date, the only existing home care QIs are outcome indicators based on the Resident Assessment Instrument-Home Care (RAI-HC) Schweiz, an instrument widely used in Switzerland and internationally for home care planning. The validity and reliability of the RAI-HC have been tested in several studies showing overall good results [7][8][9][10]. The Swiss RAI-HC QIs have so far only been used for internal quality improvement processes. ...
Quality indicators (QIs) based on the Resident Assessment Instrument-Home Care (RAI-HC) offer the opportunity to assess home care quality and compare home care organizations’ (HCOs) performance. For fair comparisons, providers’ QI rates must be risk-adjusted to control for different case-mix. The study’s objectives were to develop a risk adjustment model for worsening or onset of urinary incontinence (UI), measured with the RAI-HC QI bladder incontinence, using the database HomeCareData and to assess the impact of risk adjustment on quality rankings of HCOs. Risk factors of UI were identified in the scientific literature, and multivariable logistic regression was used to develop the risk adjustment model. The observed and risk-adjusted QI rates were calculated on organization level, uncertainty addressed by nonparametric bootstrapping. The differences between observed and risk-adjusted QI rates were graphically assessed with a Bland-Altman plot and the impact of risk adjustment examined by HCOs tertile ranking changes. 12,652 clients from 76 Swiss HCOs aged 18 years and older receiving home care between 1 January 2017, and 31 December 2018, were included. Eight risk factors were significantly associated with worsening or onset of UI: older age, female sex, obesity, impairment in cognition, impairment in hygiene, impairment in bathing, unsteady gait, and hospitalization. The adjustment model showed fair discrimination power and had a considerable effect on tertile ranking: 14 (20%) of 70 HCOs shifted to another tertile after risk adjustment. The study showed the importance of risk adjustment for fair comparisons of the quality of UI care between HCOs in Switzerland.
... Prior research shows that nearly 70% of cancer patients in Ontario, Canada, used home care services in the last year of life [7]. We also have comprehensive symptom data on these patients because all home care recipients complete a comprehensive standardized assessment, called the Resident Assessment Instrument for Home Care (RAI-HC) in Canada [8], also known as the Minimum Data Set used in nursing homes in the USA [9]. The RAI-HC includes dozens of items capturing physical symptom domains and, thus, it can uniquely address prior noted limitations in cancer symptom research at end of life [10]. ...
Purpose:
To describe the trajectory of physical symptoms among cancer decedents who were receiving home care in the six months before death.
Patients and methods:
An observational cohort study of cancer decedents in Ontario, Canada, who received home care services between 2007 and 2014. To be included, decedents had to use at least one home care service in the last six months of life. Outcomes were the presence of pain and several other physical symptoms at each week before death.
Results:
Our cohort included 27,295 cancer decedents (30,368 assessments). Forty-seven percent were female and 56% were age 75 years or older. The prevalence of all physical symptoms increased as one approached death, particularly in the last month of life. In the last weeks of life, 69% of patients reported having moderate-severe pain; however, only 20% reported that the pain was not controlled. Loss of appetite (63%), shortness of breath (59%), high health instability (50%), and self-reported poor health (44%) were also highly prevalent in the last week of life. Multivariate regression showed that caregiver distress, high health instability, social decline, uncontrolled pain, and signs of depression all worsened the odds of having a physical symptom in the last 3 months of life.
Conclusion:
In this large home care cancer cohort, trajectories of physical symptoms worsened close to death. While presence of moderate-severe pain was common, it was also reported as mostly controlled. Covariates, such as caregiver distress and social decline, were associated with having more physical symptoms at end of life.
... The interRAI-HC is a standardised and reliable comprehensive geriatric assessment instrument designed to assist in care planning, outcome measurement, quality improvement and resource allocation for carerecipients who receive care at home. [20][21][22] Measures Dependent variable. The primary outcome measure was the mean total societal costs based on resource utilisation over a 6 months follow-up period. ...
This study aims to develop and validate a prediction model of societal costs during a period of 6-months in older community care-recipients across multiple European countries. Participants were older community care-recipients from 5 European countries. The outcome measure was mean 6-months total societal costs of resource utilisation (healthcare and informal care). Potential predictors included sociodemographic characteristics, functional limitations, clinical conditions, and diseases/disorders. The model was developed by performing Linear Mixed Models with a random intercept for the effect of country and validated by an internal-external validation procedure. Living alone, caregiver distress, (I)ADL impairment, required level of care support, health instability, presence of pain, behavioural problems, urinary incontinence and multimorbidity significantly predicted societal costs during 6 months. The model explained 32% of the variation within societal costs and showed good calibration in Iceland, Finland and Germany. Minor model adaptations improved model performance in The Netherland and Italy. The results can provide a valuable orientation for policymakers to better understand cost development among older community care-recipients. Despite substantial differences of countries’ care systems, a validated cross-national set of key predictors could be identified.
... One method would involve linking the subset of Ontario residents receiving publicly funded home care who have registered addresses containing certain and likely postal codes to health administrative databases, notably the RAI-Home Care database (Poss et al. 2017). The RAI-Home Care database is a standardized, reliable, valid and comprehensive clinical assessment system designed for home care, the use of which has been mandated in Ontario for all long-stay home care clients (≥60 days) since 2002 (Landi et al. 2000;Morris et al. 1997;Poss et al. 2017). The RAI-Home Care tool contains a mandatory data entry field (Section CC, Item 5) about the place of living, which could be used to investigate the proportion of individuals (who would all have registered addresses with certain and likely postal codes belonging to retirement homes) classified as living in a retirement home. ...
Background:
Retirement home residents represent a growing proportion of older Ontarians who cannot be identified within existing administrative databases.
Objective:
This article aims to develop an approach for determining, from an individual's postal code, their likelihood of residing in a retirement home.
Methods:
We identified 748 licensed retirement homes in Ontario as of June 1, 2018, from a public registry. We developed a two-step evaluation and verification process to determine the probability (certain, likely or unlikely) of identifying a retirement home, as opposed to other dwellings, within a postal code.
Results:
We identified 274 (36.7%) retirement homes within a postal code certain to indicate that a person was residing in a retirement home, 200 (26.7%) for which it was likely and 274 (36.7%) for which it was unlikely. Postal codes that were certain and likely identified retirement homes with a capacity for 59,920 residents (79.9% of total provincial retirement home capacity).
Conclusion:
It is feasible to identify a substantive cohort of retirement home residents using postal code data in settings where street address is unavailable for linkage to administrative databases.
... Rigorous reliability and validity studies have been conducted across the family of interRAI assessments displaying strong psychometric properties for adults (Burrows, Morris, Simon, Hirdes, & Phillips, 2000;Martin, Hirdes, Fries, & Smith, 2007;Morris, Carpenter, Berg, & Jones, 2000;Morris et al., 1997;Perlman & Hirdes, 2008) as well as children and youth (Phillips et al., 2012;Phillips & Hawes, 2015;Stewart, Baiden, & Ninan, 2013;Stewart, Currie, Arbeau, Leschied, & Kerry, 2015). In a forthcoming study, we also have found that the Risk for School Disruption (RSD) scale has strong interconsistency (.80), as well as strong inter-rater reliability (kappa = .43; ...
Previous research linking school disruption with mental health problems has largely relied on assessments of academic achievement to measure school disruption. Early disruptive classroom behaviour (e.g., conflict with school staff, negative attitudes toward school), however, may precipitate poor academic performance and may stem from emerging mental health concerns, particularly among young children. To address this gap in the literature, 912 clinically referred children and youth (ages 4–18 years old) were assessed using the interRAI Child and Youth Mental Health (ChYMH) assessment utilizing a cross-sectional study design. The ChYMH assessment evaluates school disruption independently of academic achievement, and includes a comprehensive assessment of the child’s mental health functioning, needs, and preferences. A logistic regression analysis revealed that various provisional mental health diagnoses (i.e., attention-deficit/hyperactivity disorder, disruptive behaviour, mood disorders, and, to a lesser extent, anxiety) were associated with disruption in the classroom. Implications for school-based care planning are discussed.
... 8 All patients expected to receive home care for 60 days or longer have a comprehensive standardized assessment completed, called the Resident Assessment Instrument for Home Care (RAI-HC), 9 akin to the Minimum Data Set used in nursing homes in the United states. 10 Because the RAI-HC includes dozens of items capturing physical and psychosocial domains, it has the potential to address prior limitations in end-of-life cancer symptom research. 11 For instance, the patterns of psychosocial decline have been reported for small numbers of patients with lung cancer, but have not been reported at a population-based level. ...
Purpose:
Understanding the end-of-life psychosocial needs of cancer patients at home is a knowledge gap. This study describes the trajectory of psychosocial symptoms in the last 6 months of life among cancer decedents who were receiving home care.
Methods:
Observational population-based cohort study of cancer decedents who were receiving home care services between 2007 and 2014. Decedents had to have at least one home care assessment in the last 6 months of life for inclusion. Outcomes were the presence of psychosocial symptoms (i.e., anxiety, loneliness, depression, social decline, caregiver distress, and cognitive decline) at each week before death.
Results:
Our cohort included 27,295 unique cancer decedents (30,368 assessments), of which 58% died in hospital. Fifty-six percent were older than 74, and 47% were female. The prevalence of all symptoms increased approaching death, except loneliness. Social decline (48%-78%) was the most prevalent psychosocial symptom, though loneliness was reported in less than 10% of the cohort. Caregiver distress rose over time from 15%-27%. A third of the cohort reported issues with cognitive impairment. Multivariate regression showed that physical symptoms such as uncontrolled pain, impairment in independent activities of daily living, and a high level of health instability all significantly worsened the odds of having a psychosocial symptom in the last 3 months of life.
Conclusion:
In this large home care cancer cohort, trajectories of psychosocial symptoms worsened close to death. Physical symptoms, such as uncontrolled pain, were associated with having worse psychosocial symptoms at end of life.
... The interRAI Check-Up instrument is based on a subset of around 90 items from the interRAI Home Care instrument [15,16,30]. The interRAI home care (interRAI-HC) is probably the most well-researched and supported community-based multi-domain assessment globally [6]. ...
Background:
Low and middle-income countries have growing older populations and could benefit from the use of multi-domain geriatric assessments in overcoming the challenge of providing quality health services to older persons. This paper reports on the outcomes of a study carried out in Cape Town, South Africa on the validity of the interRAI Check-Up Self-Report instrument, a multi-domain assessment instrument designed to screen older persons in primary health settings. This is the first criterion validity study of the instrument. The instrument is designed to identify specific health problems and needs, including psychosocial or cognition problems and issues related to functional decline. The interRAI Check-Up Self-Report is designed to be compatible with the clinician administered instruments in the interRAI suite of assessments, but the validity of the instrument against clinician ratings has not yet been established. We therefore sought to establish whether community health workers, rather than trained healthcare professionals could reliably administer the self-report instrument to older persons.
Methods:
We evaluated the criterion validity of the self-report instrument through comparison to assessments completed by a clinician assessor. A total of 112 participants, aged 60 or older were recruited from 7 seniors clubs in Khayelitsha, Cape Town. Each participant was assessed by one of two previously untrained, non-healthcare personnel using the Check-Up Self-report version and again by a trained assessor using the clinician version of the interRAI Check-Up within 48 h. Our analyses focused on the degree of agreement between the self-reported and clinician-rated versions of the Check-Up based on the simple or weighted kappa values for the two types of ratings. Binary variables used simple kappas, and ordinal variables with three or more levels were examined using weighted kappas with Fleiss-Cohen weights.
Results:
Based on Cohen's Kappa values, we were able to establish that high levels of agreement existed between clinical assessors and lay interviewers, indicating that the instrument can be validly administered by community health workers without formal healthcare training. 13% of items had kappa values ranging between 0.10 and 0.39; 51% of items had kappa values between 0.4 and 0.69; and 36% of items had values of between 0.70 and 1.00.
Conclusion:
Our findings indicate that there is potential for the Check-Up Self-Report instrument to be implemented in under-resourced health systems such as South Africa's.
... It contains clients' socio-demographic variables, clinical diagnoses, medications, and the physical, psychological, cognitive, and social status, and it features several standardized sum scales to measure clients' disabilities and state of health. The reliability and validity of the instrument have been reported previously elsewhere [21,22]. ...
Background
The increasing trend of opioid use for non-malignant pain among older people has raised concerns about whether opioids are used for appropriate indications. On the other hand, pain in patients with dementia may be undertreated.AimsTo examine the prevalence of and indications for daily opioid use among home care clients, and to determine opioid use differs between those with and without dementia.Methods
All home care clients aged ≥ 65 years using opioids daily (n = 282) were identified based on their first Resident Assessment Instrument–Home Care assessment in 2014. Exact indications for opioid use, the opioid substance used, the median duration of use, and changes in opioid medication within 12 months from study entry were obtained from the electronic medical records.ResultsThe prevalence of daily opioid use was 9.3%, and the median duration of use before the study entry was 357 days (interquartile range 126–719 days). The majority of clients continued to use opioids daily during the follow-up year. Vertebral osteoporotic fractures (21.6%), degenerative spinal disorders (20.9%), and osteoarthritis (20.6%) were the most common indications for opioid use. Buprenorphine was used more frequently in persons with dementia, but otherwise there were no differences between those with and without dementia.Discussion and conclusionsHome care clients use opioids for long periods of time for pain related mostly to musculoskeletal disorders, although the effectiveness of long-term opioid use is not clear. The lack of effective or suitable options for management of pain might explain the situation.
... The RAI-MDS consists of roughly 300 items across a variety of domains like mood, behaviour, communication, disease and mobility, to highlight a few (Brink & Stones, 2007). Because the assessment is conducted with trained assessors, both the reliability and validity of the RAI are excellent (Landi et al., 2000;Morris et al., 1994;Morris, Fries & Morris, 1999;Morris et al., 1997). ...
Context: There is currently little research examining the relationship between depression and aggressive behaviour among individuals receiving long-term care. Previous research has focused on older adults with neurocognitive disorders (e.g., Alzheimer’s). These studies have found a positive association between aggressive behaviour and depression and are additionally associated with cognitive impairment in older adults.
Objectives: The current study aims to better understand the relationship between aggressive behaviour and depression amongst older adults with and without cognitive impairment, as previous studies have not yet examined how these relationships may differ across levels of cognitive functioning.
Methods: Data from the Continuing Care Reporting System administered by the Canadian Institute for Health Information was used. At the time of analysis, data for individuals receiving continuing care was available across seven Canadian provinces and one territory.
Findings: Data from 2,682,612 individuals were extracted (Mage = 80.42, SD = 11.5). A positive relationship between aggressive behaviour and depressive symptoms was found for those with and without cognitive impairment. There was no evidence of a mediating effect of cognitive impairment on aggressive behaviour. Individuals with symptoms of depression demonstrated more aggressive behaviours.
Limitations: A limitation of the current work is the cross-sectional nature of the data examined. This restricts the ability to determine causation, and the questions of “Do depressive symptoms predict aggressive behaviour?” or “Are aggressive behaviours early symptoms of depression?” remain.
Implications: These findings indicate that, independent of cognition, those with depressive symptoms are more likely to exhibit aggressive behaviour. Recommendations on identification and treatment of depression in this population are discussed and related policy changes are considered.
... The interRAI Check-Up instrument is based on a sub-set of around 90 items from the interRAI Home Care instrument [15,16,30]. The interRAI home care (interRAI-HC) is probably the most well-researched and supported community-based multi-domain assessment globally [6]. ...
Background: Low and middle-income countries have growing older populations and could benefit from the use of multi-domain geriatric assessments in overcoming the challenge of providing quality health services to older persons. This paper reports on the outcomes of a study carried out in Cape Town, South Africa on the validity of the interRAI Check-Up Self-Report instrument, a multi-domain assessment instrument designed to screen older persons in primary health settings. This is the first criterion validity study of the instrument. The instrument is designed to identify specific health problems and needs, including psychosocial or cognition problems and issues related to functional decline. The interRAI Check-Up Self-Report is designed to be compatible with the clinician administered instruments in the interRAI suite of assessments, but the validity of the instrument against clinician ratings has not yet been established. We therefore sought to establish whether community health workers, rather than trained healthcare professionals could reliably administer the self-report instrument to older persons.
Methods: We evaluated the criterion validity of the self-report instrument through comparison to assessments completed by a clinician assessor. A total of 112 participants, aged 60 or older were recruited from 7 seniors clubs in Khayelitsha, Cape Town. Each participant was assessed by one of two previously untrained, non-healthcare personnel using the Check-Up Self-report version and again by a trained assessor using the clinician version of the interRAI Check-Up within 48 hours. Our analyses focused on the degree of agreement between the self-reported and clinician-rated versions of the Check-Up based on the simple or weighted kappa values for the two types of ratings. Binary variables used simple kappas, and ordinal variables with three or more levels were examined using weighted kappas with Fleiss-Cohen weights.
Results: Based on Cohen’s Kappa values, we were able to establish that high levels of agreement existed between clinical assessors and lay interviewers, indicating that the instrument can be validly administered by community health workers without formal healthcare training. 13% of items had kappa values ranging between 0.10 and 0.39; 51% of items had kappa values between 0.4 and 0.69; and 36% of items had values of between 0.70 and 1.00
Conclusion: Our findings indicate that there is potential for the Check-Up Self-Report instrument to be implemented in under-resourced health systems such as South Africa’s.
... The core data source of the "fraXity" study is the MDS of the interRAI-HC, Canadian French edition, v.9.1 [58]; the interRAI-HCSuisse [53] was not available when the study started. The interRAI-HC demonstrates a good inter-rater reliability [37,59] and a good content validity, at least with respect to items common to the interRAI Acute Care [60]. Questionnaires covering demographics and patient-reported health outcomes completed the interRAI-HC assessments. ...
Background: Today, the value of screening for frailty among older adults is undisputed; to this endeavor, care at-home professionals are the “frailty whistleblowers” of choice. Yet, they need quick at-hand tools for routine use. To this aim, this study proposes a frailty index (FI) directly derived from the interRAI-HC MDS. The FI is used to assess frailty in a panel of home service recipients to document the rate of frailty among types of users.
Methods: “fraXity” relies on a case-control design comparing community dwelling older adults receiving home care or assistance to peers who do not receive formal home services. The participants (N = 231) received the interRAI-HC at home from trained nurses. MDS data were used to derive a FI by following published guidelines. Regression modeling was used to assess group differences in the outcomes of interest.
Results: The FI was normally distributed, with a mean of 0.19 (SD 0.10), and a value of 0.46 at the 99th percentile. The effect of age was significant (B = 0.003, 95% CI = (0.001–0.005)). As compared to the control group (FI = 0.14 ± 0.07, m ± SD), the FI was higher among individuals who received assistance (B = 0.04, 95% CI = (0.02–0.07)) and care (B = 0.11, 95% CI = (0.08–0.14)). These differences were adjusted for age.
Conclusions: The results replicate demonstrations of MDS-based FI derivations and support the usefulness of a FI to distinguish different types of home service recipients. The study is a proof of concept supporting the need of a comprehensive assessment of health needs for all individuals who apply for homes services, including those admitted only for assistance. Further work is needed to evaluate the cost-benefit ratio of implementing the proposed methodology in homecare practice.
... The interRAI Check-Up instrument is based on a sub-set of around 90 items from the interRAI Home Care instrument [15,16,30]. The interRAI home care (interRAI-HC) is probably the most well-researched and supported community-based multi-domain assessment globally [6]. ...
Background: Low and middle-income countries have growing older populations and could benefit from the use of multi-domain geriatric assessments in overcoming the challenge of providing quality health services to older adults. This paper reports on the outcomes of a study carried out in Cape Town, South Africa on the validity of the interRAI Check-Up Self-Report instrument, a multi-domain assessment instrument designed to screen older adults in primary health settings. The instrument is designed to identify specific health problems and needs, including psychosocial or cognition problems and issues related to functional decline. The interRAI Check-Up Self-Report is designed to be compatible with the clinician administered instruments in the interRAI suite of assessments. We sought to establish whether community health workers, rather than trained healthcare professionals could reliably administer the instrument.
Methods: We evaluated the validity of the self-report instrument through comparison to assessments completed by clinicians. A total of 112 participants, aged 60 or older were recruited from 6 seniors clubs in Khayelitsha, Cape Town. Each participant was assessed by one of two previously untrained, non-healthcare personnel using the Check-Up Self-report version and again by a trained assessor using the clinician version of the interRAI Check-Up within 48 hours. Our analyses focused on the degree of agreement between the self-reported and clinician-rated versions of the Check-Up based on the simple or weighted kappa values for the two types of ratings. Binary variables used simple kappas, and ordinal variables with three or more levels were examined using weighted kappas with Fleiss-Cohen weights.
Results: Based on Cohen’s Kappa values, we were able to establish that high levels of agreement existed between clinical assessors and lay interviewers, indicating that the instrument can be validly administered by community health workers without formal healthcare training.
Conclusion: Our findings indicate that there is potential for the Check-Up Self-Report instrument to be implemented in under-resourced health systems such as South Africa’s.
... Data were primarily obtained through RAI 2.0 for Nursing Homes, which is a comprehensive and standardized instrument originally developed for residential facilities for the elderly, 13 with additional information provided by the InterRAI Assessment for Home Care. 14 We assessed cognitive function using the MDS Cognitive Performance Scale (CPS), which combines selected MDS 2.0 items expressing different measures of cognitive function on a seven-category scale, ranging from 0 (intact) to 6 (severe impairment). 15 The CPS is hierarchical and based on an assessment of several measures of cognitive function; a 1-unit change is a reflection of distinct and measurable changes in at least one cognitive domain. ...
Background
Sequence variants, including the ε4 allele of apolipoprotein E, have been associated with the risk of the common late-onset form of Alzheimer's disease. Few rare variants affecting the risk of late-onset Alzheimer's disease have been found.
Methods
We obtained the genome sequences of 2261 Icelanders and identified sequence variants that were likely to affect protein function. We imputed these variants into the genomes of patients with Alzheimer's disease and control participants and then tested for an association with Alzheimer's disease. We performed replication tests using case–control series from the United States, Norway, the Netherlands, and Germany. We also tested for a genetic association with cognitive function in a population of unaffected elderly persons.
Results
A rare missense mutation (rs75932628-T) in the gene encoding the triggering receptor expressed on myeloid cells 2 (TREM2), which was predicted to result in an R47H substitution, was found to confer a significant risk of Alzheimer's disease in Iceland (odds ratio, 2.92; 95% confidence interval [CI], 2.09 to 4.09; P=3.42×10⁻¹⁰). The mutation had a frequency of 0.46% in controls 85 years of age or older. We observed the association in additional sample sets (odds ratio, 2.90; 95% CI, 2.16 to 3.91; P=2.1×10⁻¹² in combined discovery and replication samples). We also found that carriers of rs75932628-T between the ages of 80 and 100 years without Alzheimer's disease had poorer cognitive function than noncarriers (P=0.003).
Conclusions
Our findings strongly implicate variant TREM2 in the pathogenesis of Alzheimer's disease. Given the reported antiinflammatory role of TREM2 in the brain, the R47H substitution may lead to an increased predisposition to Alzheimer's disease through impaired containment of inflammatory processes. (Funded by the National Institute on Aging and others.)
Background:
Treatments that delay progression of cognitive impairment in older adults are of great public health significance. This manuscript outlines the protocol, recruitment, baseline characteristics, and retention for a randomized controlled trial of cognitive and aerobic physical training to improve cognition in individuals with subjective cognitive dysfunction, the "Cognitive and Aerobic Resilience for the Brain" (CARB) study.
Methods:
Community-dwelling, older adults with self-reported memory loss were randomly assigned to receive either computer-based cognitive training, aerobic physical training, combined cognitive and physical training, or education control. Treatment was delivered 2- to 3-times per week in 45- to 90-min sessions for 12 weeks by trained facilitators videoconferencing into subject's home. Outcome assessments of were taken at the baseline, immediately following training, and 3-months after training.
Results:
191 subjects were randomized into the trial (mean age, 75.5 years; 68% female; 20% non-white; mean education, 15.1 years; 30% with 1+ APOE e4 allele). The sample was generally obese, hypertensive, and many were diabetic, while cognition, self-reported mood, and activities of daily living were in the normal range. There was excellent retention throughout the trial. Interventions were completed at high rates, participants found the treatments acceptable and enjoyable, and outcome assessments were completed at high rates.
Conclusions:
This study was designed to determine the feasibility of recruiting, intervening, and documenting response to treatment in a population at risk for progressive cognitive decline. Older adults with self-reported memory loss were enrolled in high numbers and were well engaged with the intervention and outcome assessments.
Objectives:
Little is known about determinants of access to community-based geriatricians. The Geriatric 5Ms™ describe geriatricians' core competencies and inform referrals to specialists for older adults with complex needs. We explored the association of the Geriatric 5Ms™ and other characteristics with outpatient access to geriatricians by home care (HC) clients.
Methods:
This was a population-based, retrospective cohort study of frail community-dwelling HC clients (≥60 years) with complex needs (n = 196,444). Health assessment information was linked to health services data in Ontario, Canada, 2012-2015. Multivariable generalized estimating equations were used to identify characteristics associated with geriatrician contact (≥1 visit in 90 days post-HC admission), including derived Geriatric 5Ms™ score, and predisposing, enabling, and need factors obtained from clinical assessments.
Results:
Only 5.2% of the cohort had outpatient geriatrician contact in Ontario, Canada. Derived Geriatric 5Ms™ score was associated with higher odds of contact, but the model had modest discriminatory power (c-statistic = 0.67). In the broader multivariable model, based on empirically included factors and adjusted for regional differences, age, worsening of decision-making, dementia, hallucinations, Parkinsonism, osteoporosis, and caregiver distress/institutionalization risk were associated with higher odds of geriatrician contact. Female sex, difficulties accessing home, impaired locomotion, recovery potential, hemiplegia/hemiparesis, and cancer, were associated with lower odds of contact. This model had good discriminatory power (c-statistic = 0.77).
Conclusions:
Few frail, community-dwelling older adults receiving HC had any outpatient geriatrician contact. While the derived Geriatric 5Ms™ score was associated with contact, a broader empirical model performed better than the Geriatric 5Ms™ in predicting contact with an outpatient geriatrician. Contact was mainly driven by conditions common in older adults, but evidence suggests that geriatricians are not evaluating the most medically complex and unstable older adults in the community. These findings suggest a need to re-examine the referral process for geriatricians and the allocation of limited specialized resources.
Background
Researchers in the Netherlands proposed the Pillars for Positive Health (PPH) as a broadly encompassing health definition to support more realistic and meaningful care planning for people living with chronic disease and other life-long health conditions. The PPH was subsequently converted to a My Positive Health (MPH) spider web visualization tool. The study sought to identify opportunities for more person-centred care planning at the point of care in home care, using the MPH tool as a framework to link comprehensive assessment and dialogue-based goal-setting.
Methods
A modified eDelphi method was used to conduct domain mapping with a purposively sampled expert panel (n = 25). The panel consisted of researchers, health care providers, older adults and caregivers. A two-stage Delphi process was conducted, with each stage consisting of three survey rounds. In the first stage, participants were asked to map 201 elements of the interRAI Home Care (interRAI HC) comprehensive assessment tool to the six MPH domains or “No pillar of best fit”. The second stage focused on identifying opportunities to adapt or expand comprehensive assessment as it relates to the MPH domains.
Results
In stage 1, 189 of 201 elements reached consensus in domain mapping. These included: 80 elements for Bodily Functions, 32 for Daily Functioning, 32 for Mental Wellbeing, 24 for Quality of Life, 10 for Participation, and 1 for Meaningfulness. Ten elements were identified to have no pillar of best fit. The 12 elements that did not reach consensus in stage 1 formed the basis for Stage 2, where expert panel participants proposed four new assessment elements in Meaningfulness and Participation and 11 additional descriptors across the six MPH domains. Of these, two elements, each in both the Meaningfulness and Participation domains, and 9 of the 11 descriptors reached consensus.
Conclusion
Findings show that elements in the interRAI HC are oriented toward the physical, functional, and mental health domains. Consequently, complementary assessment elements and/or tools may be needed to support comprehensive assessment of ‘Meaningfulness’ and ‘Participation’ in home and community care. Additional descriptors may also be needed to aid communication regarding the understanding and application of MPH domains.
Background
Health instability, measured with the Changes in Health and End-stage disease Signs and Symptoms (CHESS) scale, predicts hospitalizations and mortality in home care clients. Heart failure (HF) is also common among home care clients. We seek to understand how HF contributes to the odds of death, hospitalization or worsening health among new home care clients depending on admission health instability.
Methods
We undertook a retrospective cohort study of home care clients aged 65 years and older between January 1st 2010 and March 31st 2015 from Alberta, British Columbia, Ontario, and the Yukon, Canada. We used multistate Markov models to derive adjusted odds ratios (OR) for transitions to different health instability states, hospitalization, and death. We examined the role of HF and CHESS at 6 months after home care admission.
Results
The sample included 286,232 clients. Those with HF had greater odds of worsening health instability than those without HF. At low-moderate admission health instability (CHESS 0-2), clients with HF had greater odds of hospitalization and death than those without HF. Clients with HF and high health instability (CHESS≥3) had slightly greater odds of hospitalization (OR 1.08, 95% Confidence Interval 1.02-1.13) but similar odds of death (OR 1.024, 95% CI 0.937-1.120) compared to clients without HF.
Conclusions
Among new home care clients, a HF diagnosis predicts death, hospitalization and worsening health, predominantly among those with low-moderate admission health instability. A HF diagnosis and admission CHESS score provide complementary information to support care planning in this population.
Objectives:
To assess the feasibility, acceptability, and psychometric properties of the self-report version of the interRAI Check-Up (CUSR).
Design:
Cross-sectional study of participant ratings of item content and difficulty completing the CUSR. Participants were also randomly assigned to complete the assessment by themselves or with help from a lay interviewer.
Settings and participants:
A total of 184 older adults from diverse backgrounds, served by 6 Canadian organizations in Ontario and Nova Scotia were recruited. Settings ranged from retirement communities for healthy older adults to assisted living facilities.
Measures/methods:
Time to complete the interRAI CUSR was tracked automatically. Participants self-reported on what items they wanted to have modified, added, or deleted. The also rated whether items were embarrassing or difficult to complete. Psychometric properties were examined between the 2 approaches to completion and were benchmarked against existing reports on psychometric properties of clinician-led home care assessments.
Results:
The interRAI CUSR takes about 28 minutes to complete with both self-administered and lay interviewer approaches. The convergent validity and reliability of CUSR is comparable to those of clinician-based assessments like the Resident Assessment Instrument-Home Care. Most participants had no difficulty completing the assessment, and none rated the task as very difficult. Poor self-rated health and difficulty with phone use were predictive of any difficult in completing the assessment in a multivariate logistic regression. Most participants reported that CUSR adequately described their health needs, but arthritis, hypertension, and mental health issues were identified as items to be added by participants.
Conclusions and implications:
The CUSR is an appropriate, feasible assessment system with good psychometric properties for use with general populations, including primary care, community services, and patient-reported outcome measurement studies. Interoperability with other interRAI assessments makes it an ideal system to use to obtain a longitudinal view of the person's needs over time.
Background
The extent by which the degree of baseline frailty, as measured using standardized multidimensional health assessments before admission to hospital, predicts survival among older adults following admission to an intensive care unit (ICU) remains unclear.
Research Question
Is baseline frailty an independent predictor of survival among older adults receiving care in an ICU?
Study Design and Methods
Retrospective cohort study of community-dwelling older adults (age ≥65 years) receiving public home services that were admitted to any ICU in Ontario, Canada between April 1st, 2009 and March 31st, 2015. All individuals had an interRAI-Home Care (RAI-HC) assessment completed within 180 days of ICU admission; these assessments were linked to hospital discharge abstract records. Patients were categorized using frailty measures each calculated from the RAI-HC: a classification tree version of the Clinical Frailty Scale (CFS); the Frailty Index - Acute Care (FI-AC); and the Changes in Health, End-Stage Disease, Signs, and Symptoms Scale (CHESS). One-year survival models were used to compare their performance. Patients were stratified based on the receipt of mechanical ventilation in the ICU.
Results
Of 24,499 individuals admitted to an ICU within 180 days of a RAI-HC assessment, 264% (6,467) received mechanical ventilation. Overall, 43.0% (95% CI 42.4% - 43.6%) survived 365 days after ICU admission. In general, among the overall cohort and both mechanical ventilation sub-groups, mortality hazards increased with the severity of baseline frailty. Models predicting survival 30, 90 and 365 days after admission to an ICU that adjusted for one of the frailty measures were more discriminant than reference models that adjusted only for age, sex, major clinical category, and area income quintile.
Interpretation
Severity of baseline frailty is independently associated with survival after ICU admission and should be considered when determining goals-of-care and treatment plans for persons with critical illness.
Cognitive training programs are aimed at alleviating the decline in cognitive functions, which is associated with a deterioration in the performance of daily life activities. This chapter proposes a reconcepetualization of functional autonomy for all ages in order to overcome some of the limitations of cognitive training programs: 1. The effects of cognitive training on daily activities are modest or absent 2. The focus of these programs on compensation and mitigation of decline in aging adults instead of growth. The solutions offered to these limitations are: 1. A new neuroscientific paradigm of the evaluation of everyday life. 2. Given that adaptation for growth is at the core of resilience and neuroplasticity, we suggest a perspective of aging in development that is committed to adaptation for growth via learning new skills.
Objectives:
The purpose of our study was to identify factors that predict 1-year incident hip and major osteoporotic non-hip fractures (ie, wrist, spine, pelvis, humerus) for home care recipients while accounting for the competing risk of death.
Design:
We conducted a retrospective cohort study with linked population data.
Setting and participants:
All home care recipients in Ontario, Canada, receiving services for more than 6 months with an admission assessment between April 1, 2011, and March 31, 2015, were included.
Methods:
Clinical data from the Resident Assessment Instrument Home Care were linked to fracture data from the Discharge Abstract Database and the National Acute Care Reporting System. Competing risk proportional hazard regressions using the Fine and Grey method were performed to model the association between potential risk factors and fracture.
Results:
Previous fall, previous fracture, cognitive impairment, unsteady gait, alcohol use, tobacco use, and Parkinson disease were consistently associated with all fracture types. Cognitive impairment (hazard ratio 2.09; 95% confidence interval 1.86-2.36) and wandering [1.66 (1.06-1.27)] were most predictive of hip fractures and being female [1.86 (1.76-1.98)] and experiencing a previous fracture [1.86 (1.76-1.98)] were most predictive of non-hip fractures. Risk factors unique to non-hip fractures as compared with hip fractures were locomotion ability outdoors and psychotropic medication use.
Conclusions and implications:
Our results indicate that, in addition to typical fracture risk factors, home care recipients have unique characteristics that increase their risk. Fracture risk assessment tools and subsequent prevention strategies should be modified to accurately identify home care recipients at risk for imminent 1-year fracture.
Objective
To examine interrater reliability and concurrent validity of oral/dental items in the Resident Assessment Instrument Minimum Data Set (RAI‐MDS) 2.0.
Background
RAI‐MDS is a standardised instrument used in nursing to determine health status and nursing needs. The extent to which oral/dental items in the RAI‐MDS describe dental treatment needs concerning oral health has been questioned.
Materials and Methods
This study evaluated the interrater reliability (dentist vs. nurse) and validity of oral/dental items in the Swiss version of RAI‐MDS 2.0 (areas: K—nutritional status, L—oral/dental status) using professional oral examinations as a benchmark. Data of 168 residents of five long‐term care facilities in the canton of Zurich, Switzerland, were collected within 1 year between October 2017 and December 2018. The statistical evaluation used descriptive statistics and Cohen’s kappa (95% CI).
Results
RAI‐MDS items K1a, chewing (κ 0.098, 95% CI: 0.004‐0.19); K1c, pain (κ 0.039, 95% CI: −0.03 to 0.11); L1a, debris (κ 0.117, 95% CI: 0.02‐0.21); L1c, dental status (κ 0.229, 95% CI: 0.12‐0.34); L1d, dental disease (κ 0.129, 95% CI: 0.02‐0.24); L1e, periodontal diseases (κ −0.005, 95% CI: −0.07 to −0.03); and L1f, daily cleaning (κ −0.031, 95% CI: −0.05 to −0.01) showed weak or no agreement, whereas L1b, denture status (κ 0.634, 95% CI: 0.52‐0.75), showed substantial agreement.
Conclusion
Oral/dental items in RAI‐MDS lack reliability and validity. Recognition of oral health situation/treatment needs by nursing staff does not seem to be possible with the current version of this tool.
In view of the rapidly aging population, increasing attention has been paid to studying persons with dementia. Factors associated with its onset, prognosis, and treatment as well as ways to support caregivers in the community have been extensively studied. Despite the fact that older persons with dementia are at higher risk of abuse compared to their cognitively unimpaired counterparts in institutions and the community, however, relatively little attention has been paid to understanding such abuse. This review summarizes the available literature on abuse of older persons with dementia. It compares methodologies used across studies and highlights the implications of using different informants, sampling strategies, and abuse subtypes in studying abuse of persons with dementia and discussed the relevant cultural considerations for research. The results of this review provide important information for researchers, policy makers, and practitioners.
We propose a fuzzy approach to quantify a cash-benefit for older people in need of Long-Term Care, e.g., affected by limitations in daily-living activities. Many approaches exist at national or regional level in Europe, and most legislation determine eligibility to public care-programs using rule-based approaches which aggregate basic health-outcomes into main pillars and then into eligibility categories. Population ageing and improvements in longevity make access to care a crucial problem for Western economies. In this paper we focus on Italy, where public-care eligibility is decentralized at regional level and often based on check-lists, and in particular on the Toscana region. We investigate the extent to which the existing legislation violates basic properties of monotonicity and continuity, thus potentially increasing inequity in care access. We then propose the introduction of a fuzzy approach to the eligibility determination, which allows for smoother results and reduced inequality.
Importance
Existing prognostic cancer tools include biological and laboratory variables. However, patients often do not know this information, preventing them from using the tools and understanding their prognosis.
Objective
To develop and validate a prognostic survival model for all cancer types that incorporates information on symptoms and performance status over time.
Design, Setting, and Participants
This is a retrospective, population-based, prognostic study of data from patients diagnosed with cancer from January 1, 2008, to December 31, 2015, in Ontario, Canada. Patients were randomly selected for model derivation (60%) and validation (40%). The derivation cohort was used to develop a multivariable Cox proportional hazards regression model with baseline characteristics under a backward stepwise variable selection process to predict the risk of mortality as a function of time. Covariates included demographic characteristics, clinical information, symptoms and performance status, and health care use. Model performance was assessed on the validation cohort by C statistics and calibration plots. Data analysis was performed from February 6, 2018, to November 6, 2019.
Main Outcomes and Measures
Time to death from diagnosis (year 0) recalculated at each of 4 annual survivor marks after diagnosis (up to year 4).
Results
A total of 255 494 patients diagnosed with cancer were identified (135 699 [53.1%] female; median age, 65 years [interquartile range, 55-73 years]). The cohort decreased to 217 055, 184 822, 143 649, and 109 569 patients for each of the 4 years after diagnosis. In the derivation cohort year 0, and the most common cancers were breast (30 855 [20.1%]), lung (19 111 [12.5%]), and prostate (18 404 [12.0%]). A total of 47 614 (31.1%) had stage III or IV disease. The mean (SD) time to death in year 0 was 567 (715) days. After backward stepwise selection in year 0, the following factors were associated with increased risk of death by more than 10%: being hospitalized; having congestive heart failure, chronic obstructive pulmonary disease, or dementia; having moderate to high pain; having worse well-being; having functional status in the transitional or end-of-life phase; having any problems with appetite; receiving end-of-life home care; and living in a nursing home. Model discrimination was high for all models (C statistic: 0.902 [year 0], 0.912 [year 1], 0.912 [year 2], 0.909 [year 3], and 0.908 [year 4]).
Conclusions and Relevance
The model accurately predicted changing cancer survival risk over time using clinical, symptom, and performance status data and appears to have the potential to be a useful prognostic tool that can be completed by patients. This knowledge may support earlier integration of palliative care.
Comprehensive geriatric assessment is a technique for multidimensional diagnosis of frail elderly people with the purpose of planning and/or delivering medical, psychosocial, and rehabilitative care. When comprehensive geriatric assessment is coupled with some therapy, then the term geriatric evaluation and management (GEM) will be used. Following a brief history of comprehensive geriatric assessment, we describe the varied patterns of GEM program organization and review the literature of studies examining GEM effectiveness. Program diversity complicates drawing firm conclusions about GEM effects; however, the vast majority of studies report positive, if not uniformly significant, results. Our analysis suggests that much of the variability in findings is due to sample size limitations. In order to reach conclusions of program effects across studies and to avoid problems of small sample sizes, we undertook a formal meta-analysis. In this initial meta-analysis, we sought to evaluate the effect of GEM programs on a single outcome: mortality. We pooled all published GEM controlled trials into four major groups: inpatient consultation services, inpatient GEM units, home assessment services, and outpatient GEM programs. Meta-analysis of 6-month mortality demonstrates a 39% reduction of mortality for inpatient consultation services (odds ratio 0.61, 95% confidence interval 0.46-0.81, P = 0.0008) and a 37% reduction of mortality for inpatient GEM units (odds ratio 0.63, 95% CI 0.42-0.93, P = 0.02). Home assessment services reduced mortality by 29% (odds ratio 0.71, 95% CI 0.55-0.90, P = 0.005). On the other hand, no significant survival effect was found for outpatient GEM programs (odds ratio 0.96, 95% confidence interval 0.61-1.49).(ABSTRACT TRUNCATED AT 250 WORDS)
Comprehensive geriatric assessment is a technique for multidimensional diagnosis of frail elderly people with the purpose of planning and/or delivering medical, psychosocial, and rehabilitative care. When comprehensive geriatric assessment is coupled with some therapy, then the term geriatric evaluation and management (GEM) will be used. Following a brief history of comprehensive geriatric assessment, we describe the varied patterns of GEM program organization and review the literature of studies examining GEM effectiveness. Program diversity complicates drawing firm conclusions about GEM effects; however, the vast majority of studies report positive, if not uniformly significant, results. Our analysis suggests that much of the variability in findings is due to sample size limitations. In order to reach conclusions of program effects across studies and to avoid problems of small sample sizes, we undertook a formal meta-analysis. In this initial meta-analysis, we sought to evaluate the effect of GEM programs on a single outcome: mortality. We pooled all published GEM controlled trials into four major groups: inpatient consultation services, inpatient GEM units, home assessment services, and outpatient GEM programs. Meta-analysis of 6-month mortality demonstrates a 39% reduction of mortality for inpatient consultation services (odds ratio 0.61, 95% confidence interval 0.46-0.81, P = 0.0008) and a 37% reduction of mortality for inpatient GEM units (odds ratio 0.63, 95% CI 0.42-0.93, P = 0.02). Home assessment services reduced mortality by 29% (odds ratio 0.71, 95% CI 0.55-0.90, P = 0.005). On the other hand, no significant survival effect was found for outpatient GEM programs (odds ratio 0.96, 95% confidence interval 0.61-1.49).(ABSTRACT TRUNCATED AT 250 WORDS)
The prevention of disability in elderly people poses a challenge for health care and social services. We conducted a three-year, randomized, controlled trial of the effect of annual in-home comprehensive geriatric assessment and follow-up for people living in the community who were 75 years of age or older. The 215 people in the intervention group were seen at home by gerontologic nurse practitioners who, in collaboration with geriatricians, evaluated problems and risk factors for disability, gave specific recommendations, and provided health education. The 199 people in the control group received their regular medical care. The main outcome measures were the prevention of disability, defined as the need for assistance in performing the basic activities of daily living (bathing, dressing, feeding, grooming, transferring from bed to chair, and moving around inside the house) or the instrumental activities of daily living (e.g., cooking, handling finances and medication, housekeeping, and shopping), and the prevention of nursing home admissions.
At three years, 20 people in the intervention group (12 percent of 170 surviving participants) and 32 in the control group (22 percent of 147 surviving participants) required assistance in performing the basic activities of daily living (adjusted odds ratio, 0.4; 95 percent confidence interval, 0.2 to 0.8; P = 0.02). The number of persons who were dependent on assistance in performing the instrumental activities of daily living but not the basic activities did not differ significantly between the two groups. Nine people in the intervention group (4 percent) and 20 in the control group (10 percent) were permanently admitted to nursing homes (P = 0.02). Acute care hospital admissions and short-term nursing home admissions did not differ significantly between the two groups. In the second and third years of the study, there were significantly more visits to physicians among the participants in the intervention group than among those in the control group (mean number of visits per month, 1.41 in year 2 and 1.27 in year 3 in the intervention group, as compared with 1.11 and 0.92 visits, respectively, in the control group; P = 0.007 and P = 0.001, respectively). The cost of the intervention for each year of disability-free life gained was about $46,000.
A program of in-home comprehensive geriatric assessments can delay the development of disability and reduce permanent nursing home stays among elderly people living at home.
Controlled trials in a number of countries have documented benefits from different types of in-home assessment and treatment programs for various subgroups of elderly persons. We have developed a program to test, using a randomized controlled design, the concepts of in-home comprehensive geriatric assessment (CGA) coupled with follow-up, health education, and preventive care in an urban United States community. The intervention includes yearly in-home CGA by geriatric nurse practitioners (GNPs), who provide, following discussions with physician geriatricians, lists of specific recommendations for health and well-being enhancement. The GNPs provide follow-up visits quarterly and regular telephone contacts to improve compliance. We recruited for our trial 414 home-living subjects aged 75 years and over, 215 randomized to the intervention group and 199 to the control group. Subjects were generally representative of the overall elderly population of the city of Santa Monica, a seaside suburb of Los Angeles. Extensive baseline data (medical, functional, psychosocial and environmental) were collected from subjects prior to randomization, using validated instruments whenever possible. Follow-up data were collected from each subject every 4 months by trained research assistants throughout the 3-year intervention follow-up period. Our study was designed to assess effects of the intervention on the hypothesized outcomes of health status, functional status, psychosocial parameters, and service utilization. Careful documentation of the intervention will enhance our ability to make process-outcome comparisons. Preliminary analysis reveals that the in-home CGA uncovered many important health deficits for most subjects resulting in a number of substantial recommendations. We are confident that when it is completed, this study will succeed in answering important remaining questions about the feasibility and effectiveness of establishing a geriatric in-home prevention and health promotion program in the United States based on principles of CGA.
There is disagreement on the usefulness of comprehensive geriatric assessment (CGA) due to conflicting results from individual trials. We did a meta-analysis on 28 controlled trials comprising 4959 subjects allocated to one of five CGA types and 4912 controls. Published data were supplemented with reanalysed data provided by the original investigators. We calculated combined odds ratios of important outcomes by pooling data from individual trials with multivariate logistic regression. Combined odds ratio (95% confidence interval) of living at home at follow-up was 1.68 (1.17-2.41) for geriatric evaluation and management units, 1.49 (1.12-1.98) for hospital-home assessment services, and 1.20 (1.05-1.37) for home assessment services. Covariate analysis showed that programmes with control over medical recommendations and extended ambulatory follow-up were more likely to be effective. Our analysis suggests that CGA programmes linking geriatric evaluation with strong long-term management are effective for improving survival and function in older persons.
Objective.
—To determine whether a set of factors representing impairments in multiple areas could be identified that predisposes to falling, incontinence, and functional dependence.Design.
—Population-based cohort with a 1-year follow-up.Setting.
—General community.Participants.
—A total of 927 New Haven, Conn, residents, aged 72 years and older who completed the baseline and 1-year interviews.Main Outcome Measures.
—At least one episode of urinary incontinence per week, at least two falls during the follow-up year, and dependence on human help for one or more basic activities of daily living.Results.
—At 1 year, urinary incontinence was reported by 16%, at least two falls by 10%, and functional dependence by 20% of participants. The four independent predisposing factors for the outcomes of incontinence, falling, and functional dependence included slow timed chair stands (lower extremity impairment), decreased arm strength (upper extremity impairment), decreased vision and hearing (sensory impairment), and either a high anxiety or depression score (affective impairment). There was a significant increase in each of incontinence, falling, and functional dependence as the number of these predisposing factors increased. For example, the proportion of participants experiencing functional dependence doubled (7% to 14% to 28% to 60%) (X2=119.8; P<.001) as the number of predisposing factors increased from zero to one to two to at least three.Conclusions.
—Our findings suggest that predisposition to geriatric syndromes and functional dependence may result when impairments in multiple domains compromise compensatory ability. It may be possible to restore compensatory ability and prevent or delay the onset of several geriatric syndromes and, perhaps, functional dependence by modifying a shared set of predisposing factors. Perhaps it is time to take a more unified approach to the geriatric syndromes and functional dependence.(JAMA. 1995;273:1348-1353)
RÉSUMÉ
Au cours des dernières années, les méthodes de prévention face aux problèmes de santé chez les personnes âgées ont suscité un plus vif intérêt, particulièrement en raison de la hausse importante des coûts de soins de santé. Le présent article examine de façon critique la possible utilité des visites de prévention à domicile dans le contexte canadien et ce, à la lumière des projets pilotes menés dans d'autres régions. En conclusion de celui-ci, on retrouve une liste de recommandations de recherches à mener au Canada sur l'utilité de telles visites de prévention à domicile.
A survey of the health and social conditions of a representative sample of 967 persons aged 60 years and older from the city of Florence, Italy, was undertaken in 1980. In 1987, a follow-up survey of this cohort was performed. There were 391 documented deaths, 408 survivors, and 168 individuals who could not be located. Functional ability at baseline was assessed using a World Health Organization 14-item scale. Indicators of physical health status included chronic disease status, number of drugs, physician visits, and days of hospitalization. After adjustment for age and sex, both functional ability and indicators of physical health status were found to be independent, statistically significant predictors of mortality. The results of this study further support the view that biomedical and functional assessment are both necessary for a comprehensive evaluation of the older population.
To determine causes and clinical correlates of recurrent falls in ambulatory frail elderly people, we evaluated 70 recurrent fallers and 56 nonfallers (mean age = 87 years) from two long-term care facilities. Evaluations included a detailed history, physical examination, performance-oriented mobility assessment, and laboratory studies. Primary causes including stroke, parkinsonism, blindness, drug-related hypotension, and arthritis were established for the most recent fall in 51 (73%) fallers. Eighteen fallers (26%) had multiple conditions that could not be prioritized for their contribution to the fall. Fallers were more often women, were functionally more impaired, and were taking more medications than nonfallers. Specific diseases did not distinguish fallers from nonfallers. Fallers of both sexes took more steps to turn 360 degrees, could not stand up from a chair without pushing off, had a higher prevalence of antidepressant use, and had impaired position sensation. These easily obtained clinical variables characterized nearly three-quarters of ambulatory elderly nursing home residents with a history of recurrent falls.
In response to the Omnibus Reconciliation Act of 1987 mandate for the development of a national resident assessment system
for nursing facilities, a consortium of professionals developed the first major component of this system, the Minimum Data
Set (MDS) for Resident Assessment and Care Screening. A two-state field trial tested the reliability of individual assessment
items, the overall performance of the instrument, and the time involved in its application. The trial demonstrated reasonable
reliability for 55% of the items and pinpointed redundancy of items and initial design of scales. On the basis of these analyses
and clinical input, 40% of the original items were kept, 20% dropped, and 40% altered. The MDS provides a structure and language
in which to understand long-term care, design care plans, evaluate quality, and describe the nursing facility population for
planning and policy efforts.
To evaluate the process and outcome of outpatient consultative geriatric assessment compared with traditional community care.
Randomized, controlled clinical trial, with 12-month follow-up.
Four hospital-based ambulatory geriatric assessment clinics and community physicians' offices.
442 recruited older adults with a health problem or recent change in health status.
Outpatient consultative geriatric assessment or usual physician assessment.
Identification of health problems, mortality, nursing home admissions, health status, health services utilization, satisfaction with care, and caregiver well-being.
Geriatric assessment, in comparison with usual community care, resulted in the identification of a significantly greater number of patients with cognitive impairment (P < .0001), depression (P = .0004) and incontinence (P < .0001). The group receiving a geriatric assessment had greater improvement in anxiety levels at 1 year (P = .036). Caregivers of participants in the geriatric assessment group had less caregiver stress at 1 year (P = .002). No outcome differences in mortality, nursing home admissions, cognitive health, functional health, or health services utilization were observed. Some evidence of greater patient satisfaction with respect to qualities of the physician was found for the geriatric assessment group.
Consultative outpatient geriatric assessment led to significantly improved diagnosis of the common health problems of cognitive impairment, depression, and incontinence, to psychological and emotional benefits for patients, and to reduced levels of caregiver stress. Even with limited follow-up care and control of treatment, outpatient geriatric assessment has potential for significant positive effects.
The MDS is a core set of items, definitions, and response categories used to assess all of the nation's 1.5 million nursing home residents who reside in facilities participating in the Medicare or Medicaid programs. Further, the Health Care Financing Administration (HCFA) has proposed a rule that would require facilities to computerize MDS data and submit it to state and federal agencies, paving the way for a national database. This article describes the process of testing the reliability of the MDS items in 13 nursing homes in five states. The results demonstrate that MDS data gathered in a research effort attain reliabilities that make such data useful. MDS items met a standard for excellent reliability (i.e., intraclass correlation of .7 or higher) in key areas of functional status, such as cognition, ADLs, continence, and diagnoses. Sixty-three percent of the items achieved reliability coefficients of .6 or higher. Eighty-nine percent of the items in the MDS achieved .4 or higher.
The present study attempts to determine empirically the relationship of measures of functional status to other domains common to geriatric assessment, and to ascertain whether functional status can substitute for other domains of clinical assessment. A comprehensive research survey was administered in the home to a randomly selected population of 4163 community residents aged 65 and over in the Duke EPESE, one of the four sites of the National Institute on Aging-funded Established Populations for Epidemiologic Studies of the Elderly. Sample members were predominantly black (55%), female (65%), between 65 and 74 years of age (61%), and lived in five contiguous counties within the state of North Carolina. Measurements included three measures of functional status ranging from basic activities of daily living (ADL) to strenuous mobility items, and summary measures of cognition, depression, and overall physical health. The three functional status measures were inter-correlated. However, with the exception of cognitive status and performance of instrumental ADL, the functional status measures failed to show a clinically significant relationship with the domains of cognition, depression, or overall physical health status. Furthermore, even among those sample members impaired in all three domains, 8% could still perform strenuous activities, and over 50% could still perform the basic activities of daily living. The data show that functional status measures are not necessarily indicative of an elder's mental or physical health. Each domain of assessment contributes unique data, and no one area can fully substitute for another.
Chronic cognitive impairment is a major problem in U.S. nursing homes, yet traditional assessment systems in most facilities included only limited information on cognitive status. Following the Congressional mandate in the Omnibus Reconciliation Act of 1987 (OBRA '87), U.S. nursing homes now complete the Minimum Data Set (MDS), a standardized, comprehensive assessment of each resident's functional, medical, psychosocial, and cognitive status. We designed a Cognitive Performance Scale (CPS) that uses MDS data to assign residents into easily understood cognitive performance categories.
Information was drawn from three data sets, including two multistate data sets constructed for the Health Care Financing Administration. The prevalence and reliability of the MDS cognitive performance variables were established when assessed by trained nursing personnel. Five selected MDS items were combined to create the single, functionally meaningful seven-category hierarchical Cognitive Performance Scale.
The CPS scale corresponded closely with scores generated by the Mini-Mental State Examination and the Test for Severe Impairment, nursing judgments of disorientation, and neurological diagnoses of Alzheimer's disease and other dementias.
The new CPS provides a functional view of cognitive performance, using readily available MDS data. It should prove useful to clinicians and investigators using the MDS to determine a resident's cognitive assets.
To determine risk factors associated with the formation of stage II-IV pressure ulcers in nursing homes.
Since the incidence rate for pressure ulcer formation varies among nursing homes, the homes were divided into tertiles based on these rates. Pooled logistic regression was used to model which factors are associated with the formation of pressure ulcers in both high and low incidence homes.
78 National HealthCorp nursing homes.
We studied 4232 nursing home residents free of pressure ulcers on admission to a nursing facility and at 3-months follow-up. All remained in the home for at least 3 additional months to a maximum of 21 months.
The effects of age, gender, race, antipsychotic drug use, urinary incontinence, fecal incontinence, body mass index, diabetes mellitus, disorientation, ambulation, physical restraints, activities of daily living of bathing, feeding, or transferring, and nursing home bed size on the formation of a stage II-IV pressure ulcer while the subject was a resident in the nursing home were studied.
Significant factors associated with the formation of pressure ulcers in high incidence homes (21-month incidence = 19.3%) were ambulation difficulty (OR = 3.3; CI = 2.0, 5.3), fecal incontinence (OR = 2.5; CI = 1.6, 4.0), diabetes mellitus (OR = 1.7; CI = 1.2, 2.5), and difficulty feeding oneself (OR = 2.2; CI = 1.5, 3.3). In the low incidence homes (21-month incidence = 6.5%), significant factors associated with pressure ulcer incidence were ambulation difficulty (OR = 3.6; CI = 1.7, 7.4), difficulty feeding oneself (OR = 3.5; CI = 2.0, 6.3), and male gender (OR = 1.9; CI = 1.2, 3.6).
Although low and high incidence homes share similar risk factors, such as ambulation and feeding activities of daily living, the main difference was that diabetes and fecal incontinence played a major role only in high risk homes, while male gender was an important discriminator only in low incidence homes. Yet, it is unclear if these factors explain the three-fold difference in the incidence rates for pressure ulcers in these facilities. Baseline or resident clinical characteristic differences of any one factor between the high and low incidence homes varied by no more than 5%. While we identified certain conditions which are associated with pressure ulcer formation, there may be unknown or unmeasured facility effects in addition to the characteristics of a given resident in a particular home.
To describe the reliability of new assessment items and their clinical utility as judged by experienced nurse assessors, based on the results from the field test of Version 2.0 of the Resident Assessment Instrument (RAI).
Independent dual assessment of residents of nursing facilities by staff nurses using a draft of Version 2.0 of the minimum data set (MDS).
A total of 187 randomly selected residents from 21 nursing homes in seven states volunteered to test Version 2.0 of the MDS.
The full array of MDS assessment items included measures in the following areas: Background information, cognitive patterns, communication/hearing, vision, mood and behavior, psychosocial well-being, physical functioning and structural problems, continence, disease diagnoses, health condition, oral/nutritional status, dental status, skin condition, activity pursuit patterns, medications, special treatments and procedures, and discharge potential and overall status.
Evaluative data address issues of MDS item utility and reliability. For new items, almost all achieved a reasonably high-weighted Kappa interrater reliability; revised items also surpassed earlier items, and with the updated training materials, even the non-changed items had higher average reliability levels. Based on the success of the field test and the positive response of the industry, Version 2.0 of the RAI has been adopted, and HCFA has initiated a more long-range process to update further the RAI when necessary.
Findings support the reliability and clinical utility of the new and revised assessment items incorporated by HCFA in Version 2.0 of the MDS.
To compare the rates of hospitalization among cohorts of nursing home residents assembled before and after the implementation of the federally mandated Resident Assessment Instrument (RAI).
Subjects were nursing home residents chosen from 268 facilities in major Metropolitan Statistics Areas in 10 states and representing more than 1500 facilities and 60,000 residents. Two resident cohorts (1990 and 1993) were sampled (8 to 16 residents per facility, depending upon facility size) as part of an evaluation of the impact of implementing the RAI.
Research nurses reviewed records, interviewed staff, observed patients, and completed an RAI at baseline and 6 months later. All transitions during this interval (hospital admissions, nursing home transfers, returns home, death, etc.) were tracked. Using polytomous logistic regression, we tested the effect of cohort on the probability of being hospitalized in light of the competing risks of dying or remaining in the home, controlling for demographic and casemix variables, and having a DNR order in the chart.
A total of 4196 residents were studied, 2118 in 1990 (age 81.3, female 77.7%, LOS 6+ months 49.8%) and 2078 in 1993 (age 81.7, females 75.5%, LOS 6+ months 50.2%). The unadjusted probability of hospitalization dropped from .205 to .151. Multivariate analyses revealed a significant adjusted odds of hospitalization of .74 (95% CI .60-.91) and no cohort effect on home discharge or death. Among severely cognitively impaired residents, the adjusted odds of hospitalization in 1993 compared with the 1990 cohort was 0.74 (.53-1.03). Finally, among survivors in both cohorts who had a follow-up MDS performed, and whose ADL remained stable, 15.9% were hospitalized in 1990, whereas only 10.9% were hospitalized in 1993. On the other hand, ADL decliners were more likely to have been hospitalized in 1993 than in 1990 (40.6% vs 25.2%).
Although other changes in the industry, clinical practice, and health care policy may have influenced hospitalization of nursing home residents, the substantial reductions observed among the cognitively impaired and those with stable ADL suggest superior and uniform assessment information in the form of the RAI contributed significantly to this decline.
To evaluate the impact of the Resident Assessment Instrument (RAI) on changes in nursing home residents' functional status, cognitive status, and psychosocial well-being.
A quasi-experiment involving the collection of longitudinal data on two cohorts of nursing home residents. One cohort was assessed before the implementation of the RAI, and the other was assessed after the implementation of the new assessment process.
Over 2000 nursing home residents in 267 nursing homes located in 10 geographic areas were assessed during the pre-RAI period. In the post-RAI period, 2000 new residents in 254 of the same facilities were assessed.
RAI implementation began in October 1990 and continued until October 1991. The RAI includes a structured, multidimensional resident assessment and problem identification system designed to form the basis for residents' care plans.
All residents were assessed at baseline and at 6 months using the Minimum Data Set for Nursing Home Resident Assessment and Care Screening (MDS) and its protocols. All data were collected by research nurses employed and trained by the research team.
Implementation of the RAI significantly reduced the rate of decline in seven of the nine outcomes under consideration. Reductions in improvement were also observed in all outcomes. In activities of daily living, social engagement, and cognitive function, the reduced decline far outweighed any reductions in improvement. In mood problems, problem behaviors, and understanding others, however, reductions in improvement were greater than any reductions in decline. Changes in the rates of decline and improvement were not uniform across all residents.
The RAI may have improved the quality of care of nursing home residents by reducing overall rates of decline in important areas of resident function. However, this innovation may have generated trade-offs in that it may have reduced improvement rates in some areas of function. The system's implementation also seems to have focused staff's attention on the needs and strengths of specific subpopulations of residents. Revisions of the RAI must assist staff in generalizing their efforts to all residents and to increasing improvement rates, especially in areas related to mood and behavior.
From the Health Care Financing Administration
- Vladek
Assessment in continuing care homes: Towards a national standard instrument
- Challis DJ
- Carpenter GI
- Traskc KJ
Instruments for the functional assessment of older patients
- Applegare WB
- Blass JP
- Williams TF
Changes in hospitalization associated with introducing the RAI
- Mor V
- Lntrator O
- Fries BE
Instruments for the functional assessment of older patients
- Applegare