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Maintaining independence in older people

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Appropriate social and medical interventions may help maintain independence in older people. Determinants of functional decline, disability and reduced independence are recognized and specific interventions target the treatment of clinical conditions, multiple health problems and geriatric conditions, prevention of falls and fractures, and maintenance of physical and cognitive function and social engagement. Preventive strategies to identify and treat diverse unmet needs of older people have been researched extensively. We reviewed systematically recent randomized controlled trials evaluating these ‘complex’ interventions and incorporated the findings of 21 studies into an established meta-analysis that included 108,838 people in 110 trials. There was an overall benefit of complex interventions in helping older people to live at home, explained by reduced nursing home admissions rather than death rates. Hospital admissions and falls were also reduced in intervention groups. Benefits were largely restricted to earlier studies, perhaps reflecting general improvements in health and social care for older people. The wealth of high-quality trial evidence endorses the value of preventive strategies to help maintain independence in older people.
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Reviews in Clinical Gerontology 2010 20; 128–153 First published online 7 April 2010
C
Cambridge University Press 2010 doi:10.1017/S0959259810000079
Maintaining independence in older people
AD Beswick,1R Gooberman-Hill,1ASmith,
1VWylde
1and S Ebrahim2
1Department of Clinical Science at North Bristol, University of Bristol, UK and 2Department of Epidemiology and
Population Health, London School of Hygiene and Tropical Medicine, London, UK
Summary
Appropriate social and medical interventions may help
maintain independence in older people. Determinants of
functional decline, disability and reduced independence
are recognized and specific interventions target the
treatment of clinical conditions, multiple health problems
and geriatric conditions, prevention of falls and fractures,
and maintenance of physical and cognitive function and
social engagement.
Preventive strategies to identify and treat diverse
unmet needs of older people have been researched ex-
tensively. We reviewed systematically recent randomized
controlled trials evaluating these ‘complex’ interventions
and incorporated the findings of 21 studies into an
established meta-analysis that included 108,838 people
in 110 trials. There was an overall benefit of complex
interventions in helping older people to live at home,
explained by reduced nursing home admissions rather
than death rates. Hospital admissions and falls were
also reduced in intervention groups. Benefits were largely
restricted to earlier studies, perhaps reflecting general
improvements in health and social care for older people.
The wealth of high-quality trial evidence endorses
the value of preventive strategies to help maintain
independence in older people.
Keywords: geriatric assessment, randomized controlled
trials (as topic), systematic review, aged, independence,
complex intervention.
Introduction
In its most general sense, independence in older age
denotes self-reliance or autonomy.1Promotion of
‘successful ageing’ often includes the idea that in-
dependence is essential to good physical, emotional
and cognitive health. In addition to improved
life expectancy, life satisfaction and psychological
health, the main constituents of healthy ageing
relate to independence including personal growth,
Address for correspondence: Andrew Beswick, Ortho-
paedic Surgery, Department of Clinical Science at North
Bristol, University of Bristol, Bristol BS2 8HW.
Email: andy.beswick@bristol.ac.uk
physical functioning, psychological perceptions
and social participation.2
The value placed on independence in older age is
rooted in the ideology that individuals should have
responsibility for their own wellbeing. However,
this does not preclude appropriate intervention
(social and medical) to facilitate or enhance that
wellbeing. Indeed, many older people require
encouragement to assert their rights to health care
andsocialbenets.
Successful ageing – in terms of autonomy and
wellbeing – can occur in people who are very
dependent on others for daily living. Ageing takes
place most successfully in the context of strong
social engagement,3and social interdependence has
been identified as a desirable element of successful
ageing.4
Causes of reduced independence
The onset of disability in activities of daily living
performed by older people in their daily lives is one
of the greatest threats to the ability of older adults
to live independently.5The determinants of func-
tional decline, disability and reduced independence
have been studied extensively. In a systematic re-
view of 78 longitudinal studies published between
1985 and 1997, Stuck et al. assessed the strength of
risk factors for functional decline on the basis of the
number of studies and the effect size.6The highest
strength of evidence was for risk factors relating to
co-morbidities, physical and psychosocial health,
environmental conditions, social circumstances,
and nutrition and lifestyle.6Updating this review
to 2001, Spiers et al. emphasized the link
between depression and cognitive impairment, and
subsequent functional decline.7
Ayis et al. studied the predictors of rapid global
deterioration in mobility over one year in people
aged 65 years and older in a UK Office of National
Statistics Omnibus survey.8The incidence of this
‘catastrophic decline’ was one in twenty people per
year. Predictors of decline were older age, previous
Maintaining independence in older people 129
self-report of deterioration including hearing loss,
low functional reserve (stamina, muscle strength
and flexibility), psychological problems and low
social engagement.
Specific determinants of reduced independence
and unifactorial interventions
Co-morbidities
In the 2002 UK General Household survey, 53%
of adults aged 75 years and older had a long-
standing illness that limited their activities.9Older
people frequently have more than one clinical
condition and the extent of activity limitations
increases with the number of co-morbidities.10 In
an Australian population aged 75 years and older,
60% reported one and 33.4% had two or more
health problems.11 More recently in data from the
Kungsholmen Project population, Marengoni et al.
looked at patterns of co-morbidity in people aged
77 years and older.12 The authors observed that
in older age some co-morbidities exist in clusters
centred on vascular diseases, dementia, diabetes
and malignancy.
Conditions that contribute to disability and
impact on independence are numerous and
include coronary heart disease, stroke, cognitive
impairment, affective disorders, respiratory condi-
tions, and musculoskeletal conditions. Treatment,
rehabilitation and secondary prevention of all these
clinical conditions is beyond the scope of this
review. However, as the leading cause of disability
in older people, the importance of identification
and management of musculoskeletal conditions is
discussed briefly.
Musculoskeletal conditions
In the UK Office of National Stastistics 1996 cross-
sectional study of disability in 8683 people,
Adamson et al. found that musculoskeletal
diseases lead to the largest number of people being
disabled in the UK.13 In an older population in
the MRC-CFAS study, Spiers et al. explored risk
factors for disability in 7913 people followed
up for two years.7In people who reported no
disability at baseline examination, arthritis was
the most important predictor of incident disability
with a population attributable risk of 11.4%. In
the prospective US Health and Retirement Study
of 7758 adults aged 65 years or older, Song et al.
concluded that 24% of new cases of disability
were due to arthritis.14
In older people, mild symptoms of osteoarthritis
are managed and treated in the community through
the provision of education, assistive devices,
exercise, weight loss advice and other lifestyle
modifications.15 However, in more advanced cases
of osteoarthritis, use of analgesics, physiotherapy
and joint replacement surgery may be required.
When surgery is identified as the only treatment
option remaining for the alleviation of symptoms,
the timing of the intervention is crucial, as
the severity of pre-operative joint symptoms is
highly predictive of pain reduction and restoration
of functional ability after surgery.16 Although
generally considered an effective intervention for
alleviating joint symptoms, joint replacement is
not a success for all patients, with up to 30% of
patients continuing to experience chronic joint pain
and disability after surgery.17, 18
Appropriate prescribing of medication
In older people, prescribing of medication for
specific conditions is problematic. Evidence for ef-
fectiveness of new treatments in older populations
is frequently limited due to under-representation
of older people in trials, inadequate reporting
of age in trials, or delay in the conduct of ap-
propriate trials. Examples include heart failure,19
cardiovascular disease prevention,20 Parkinson’s
disease,21 Alzheimer’s disease,22 cancer23, 24 and
depression.25 Older people have complex medical
conditions with treatment strategies that require
several medications, and this is further complicated
in those with multiple conditions. Specific classes
of medications are associated with orthostatic
hypertension and an increased risk of falling.
However, it has been shown that co-morbidity,
rather than polypharmacy, is the more important
factor for both conditions in older British
women.26
Potentially serious implications for the older
person arise from prescribing of medications with
a high risk of adverse events or those with
no appropriate clinical indication, misprescribing
pertaining to frequency and duration of treatment,
interactions with other medications, and the non-
prescribing of effective treatments.27 However,
there is no ideal measure of appropriateness of pre-
scribing or evidence from randomized controlled
trials for effectiveness of particular strategies.28
130 AD Beswick et al.
Geriatric conditions
As with clinical co-morbidities there is an
association between geriatric conditions and
disability. In the US Health and Retirement
Study of 11,093 people aged 65 years and
older, Cigolle et al. studied a range of geriatric
conditions specifically: falls, incontinence, low
body mass index, dizziness, impaired vision,
impaired hearing and cognitive impairment.29
Individually all geriatric conditions with the
exception of hearing impairment were related to
disability in cross-sectional analysis. Even after
adjusting for chronic diseases, people with more
than one geriatric condition had higher risk
ratios for disability that ranged from 2.1 for one
condition, to 3.6 for two conditions and 6.6 for
three or more conditions. The authors concluded
that geriatric conditions have a similar prevalence
to chronic diseases in older people and in some
cases a comparable impact on disability.
Physical activity
Nusselder et al. analysed two prospective studies
conducted in the Netherlands (GLOBE) and USA
(Longitudinal Study of Aging) including 8513
people aged 50–80 years with self-reported leisure
time physical activity measured at baseline and
follow-up at two yearly intervals.30 In people with
no initial disability, moderate physical activity was
associated with a reduced incidence of disability.
The authors concluded that moderate physical
activity extends the number of years lived free of
disability and reduces the number of years lived
with disability. In the AHEAD cohort of 4228
people aged 70 years or older, Reynolds et al. noted
reduced onset of disability in people who had par-
ticipated in vigorous physical activity regularly.5
There is debate on the amount and intensity
of exercise required to prevent decline in physical
function and associated loss of independence. Chin
APawet al. conducted a systematic review of
exercise interventions aiming to improve physical
function in frail older people.31 Although some
studies, mainly in the frailest individuals, showed
no benefit, the authors concluded that regular
exercise can improve the functional performance
of older people with different levels of abilities.
However, the authors did not consider the
evidence sufficient to define the best type, intensity,
frequency or duration of exercise.
The benefit of exercise may be on an individual’s
balance. In a Cochrane systematic review, Howe
et al. concluded that exercise programmes in
older people were associated with short-term
improvements in balance.32 However, only the trial
of Wolf et al. reported a long-term follow-up.33
The authors noted that improvement in balance
persisted for at least one month after completion
of a 4–6 week exercise programme, but no benefit
was seen at one year.
Rehabilitation
Community-based physical and occupational
therapy interventions are potentially valuable in
maintaining independent living by older people. In
a systematic review of occupational interventions,
Steultjens et al. identified training of skills and the
instruction of assistive devices as effective measures
in improving functional ability in older people.34 In
a more general overview Ryburn et al. concluded
that multi-component restorative approaches
resulted in improved function and reduced need
for home and community care services.35
Falls
Falls are an important cause of disability and
reduced independence in older people. Widely
quoted figures for the incidence of falls in people
aged 65 years or older are 29 and 35%, and in those
aged 75 years or older 32%.36– 38 Although the
majority of falls identified in these studies did not
result in serious injury, the psychological sequelae
can be significant. In people aged 70 years and older
multiple falls are associated with increased risk of
functional impairment.39
The incidence of more serious falls can be
assessed according to the involvement of a general
practitioner or attendance at an accident and
emergency department. Data reported by Gribbin
et al. from The Health Improvement Network
(THIN) primary care database show a rise in fall
incidence recorded in UK general practice from
1.6 per 100 person years in the age group 65–
69 years, to 6.2 in people aged 80–84 years.40
To determine accident and emergency attendance
after a fall, Scuffham et al. extracted data for 1999
from the UK Home Accident Surveillance System
and Leisure Accident Surveillance System.41 The
fall incidence rates identified in these data sets
were 2.9 per 100 person years for people aged
Maintaining independence in older people 131
65–69 years, rising to 9.5 per 100 person years
in people aged 75 years or older.
In a prospective study of risk factors for falls
in older people, two-thirds of falls were attributed
to multiple risk factors.42 Individual risk factors
differed between men and women but included
low physical activity, specific clinical conditions,
impaired gait and body sway, medication, postural
hypotension and muscle weakness. In a study in
people aged 85 years and older, van Bemmel
found that hazards in the home environment were
associated with increased risk of falling even in
those who had not fallen before.43
Fragility fractures
The sequelae of relatively minor falls may be partic-
ularly serious in older people with osteoporosis and
other less common conditions. ‘Fragility fractures’
in older people commonly affect the hip, femur
and forearm, and the incidence of these fractures
increases markedly with age.44 Fractures of the hip
are particularly common and are associated with
a high risk of death, nursing home admission and
disability. In a US case-control study, one-year
mortality in older people with hip fracture was
twice that in the unaffected group, and nursing
home admissions were three times more likely.45
Early identification of osteoporosis by measure-
ment of bone mineral density and treatment with
antiresorptive or bone anabolic agents, calcium
and vitamin D, and exercise may be effective in
reducing the risk of fracture.46
Fall prevention
In a systematic review of interventions to prevent
falls, Gillespie et al. concluded that multiple-
component exercise interventions are effective in
reducing falls.47 Sherrington et al. reached a
similar conclusion in their systematic review of
44 trials with 9603 participants.48 However, they
observed greater benefits in exercise programmes
that targeted balance and in those with a
higher dose of exercise. No benefit was evident
in those that included a walking programme.
Indeed, in a randomized trial of brisk walking
in women who had fractured their upper arms,
an increased risk of falling was found, which
was interpreted as evidence of adherence to the
intervention.49 Notwithstanding the importance of
greater intensity physical activity, more moderate
physical exercise including walking may have
benefits to an older individual beyond reduction
of fall risk.
Social factors
The association between social engagement and
disability is not straightforward. Cross-sectional
studies show reduced disability in those with
greater social engagement.50 However, Mendes de
Leon et al. found only a weak effect of disability
on social engagement in longitudinal studies. They
suggested that losses in physical function and
ability of a person to care for themselves lead to
reduced social engagement, and that this in turn
accelerates functional decline.
Mental health
In the AHEAD study in people aged 70 years or
older, Reynolds and Silverstein found that affect
and cognition were associated with an increased
likelihood of future disability.5Onset of disability
may be delayed by early diagnosis and treatment
of depressive symptoms.51
Further areas for consideration in preventive
strategies
Numerous areas of potential value in preventive
strategies have been reported. These include foot
and leg problems,52 dental health,53 nutrition and
obesity,54, 55 lifestyle,56 home environment,43, 57
vaccinations,58 continence,59 eyesight60, 61 and
hearing.61
Interventions to support independence
Unmet needs. In surveys conducted among older
people in Scotland in the early 1960s, Williamson
et al. noted the large extent of unmet needs in
primary care.62 They concluded that a preventive
strategy was required, targeting older people based
around identification and treatment of diverse risk
factors.
Following a series of randomized controlled
trials, the American College of Physicians
recommended that primary care practitioners
incorporate within their routine medical man-
agement of people aged 75 years and older
procedures for measuring functional deficits and
identifying dependency needs.63 Promoting and
supporting independence among older people is an
132 AD Beswick et al.
explicit goal of UK health and social care policy
through endeavours including health promotion
and intermediate care services.64 In the UK a
requirement for multidimensional assessments of
physical and cognitive health for people aged
75 years and older was introduced into the terms
of service for general practitioners in 1989.65
More recently a targeted approach to the care of
older people with long-term conditions has been
favoured, typically with a case management-style
approach.66
Barriers and facilitators of independence. In a
series of focus groups, Belle Brown et al. looked
at the barriers and facilitators of independence
reported by older people, carers and health care
providers.67 Key issues in maintaining independ-
ence related to the attitudes and attributes of older
people, service accessibility, communication and
co-ordination, and continuity of care.
The effectiveness of complex interventions
in maintaining independence in older people:
an update
Simple unifactorial interventions in controlled
conditions may help prevent disability and
support independence in older people. However,
preventive strategies with multifactorial assessment
and management, considered here as ‘complex’
interventions, have potential value that exceeds the
unifactorial approach.
According to the UK Medical Research Council
framework a complex intervention has a number
of interacting components, a number of behaviours
and level of difficulty required by those delivering
or receiving the intervention, a number of groups
or organizational levels targeted, a number and
variability of outcomes, and a degree of flexibility
or tailoring of the intervention permitted.68
Numerous systematic reviews reporting on the
effectiveness of multifactorial preventive interven-
tions have been published. These have focused on
community and frail older populations,69– 76 older
people discharged from hospital,77, 78 and older
people at risk of falling.47, 79– 82
The need for another review
Our previously published systematic review of the
effects of complex interventions on health of older
people reviewed data from 1966 to 2005.76 This
is known to be a highly active field of research
and at the time of our previous searches there were
several protocols for randomized controlled trials
published.
Our previous review differed from others in
that it considered interventions in a range of
settings. While other reviews evaluated geriatric
assessment and management in community or
frail older populations, multifactorial interventions
targeting fall prevention, or care for patients being
discharged from hospital, each addressed issues of
preventive visits for older people with care based
on assessment of medical and social need. Each can
be considered as a complex intervention largely
sharing the goal of maintained independence
through identification and treatment of diverse
risk factors. The development of risk factors in
an individual, time spent in hospital and being at
risk of falling represents the common experience
of many older people. For example, in the Health
Survey for England 2000, 16% of men and 13%
of women aged 65–79 living in private households
reported that they had been a hospital in-patient in
the previous year.83
Only our review and that of Huss et al.
have considered the large MRC trial of assessment
and management of elderly people in the
community. This included over 43,000 older
people randomized into a trial with a cluster
trial design. We included the trial in our
review, whereas Huss et al. did not on the
grounds of lack of a control group receiving no
assessment and management and inadequate level
of nursing follow-up according to their inclusion
criteria. Certainly, in the context of contemporary
anticipatory care for older people no review can
ignore this important trial.
Outcomes
In this review we have chosen six outcomes relating
to independence. An issue in successful ageing
and maintenance of independence is the desire to
continue living ‘at home.’ Home is strongly linked
to independence,84 and for older people and their
carers, the home is the preferred residence in which
to grow old.57 We used the outcome living at home
(reported as ‘not living at home’ for consistency in
effect direction) at follow-up as a simple measure
of major loss of independence. It is an outcome
Maintaining independence in older people 133
potentially available for all participants in a trial
and in practical terms reported as an outcome or
reason for loss to interview follow-up in many
studies.
The components contributing to not living
at home are nursing home, skilled nursing
facility or institutional residence at follow-up,
and death. Reduction in mortality is occasionally
the stated objective of an intervention and is
frequently reported as an outcome. However,
over-emphasis of this as an outcome is likely
to mask potential benefits from interventions
relating to their primary objectives of maintaining
independence. Other outcomes relevant to older
people and widely reported in studies relate to
hospital admissions, falls and physical function.
What constitutes a complex intervention
in the context of maintaining independence
in older people?
In the context of this review a complex intervention
comprises a preventive strategy with multifactorial
assessment and subsequent active management,
referrals or recommendations.
In a typical intervention, an older person receives
a home visit for assessment of health and social
needs. As a participant in a trial they may
be above a specified age, have been discharged
from hospital, have recently fallen, or have some
reason to be considered frail or functionally
limited. The assessment may be conducted by
a nurse, health visitor or member of research
staff, or an interdisciplinary team may be involved
with direct contributions by a geriatrician, nurse,
physiotherapist and other health professionals. The
assessment may be a one-off examination or may
be conducted annually or more frequently.
Specific areas covered in the assessment vary
between studies but may include aspects of:
medical assessment collecting information
on chronic conditions and their treatment,
review of medication and immunizations, and
measurement of blood pressure and blood
tests.
vision, hearing, dental health, foot health and
continence.
physical function to include balance and transfer
skills, walking and joint problems and any
appropriate aids and appliances.
mental function including depressive symptoms
and cognitive function.
social conditions to include social contacts,
housing problems and financial difficulties.
lifestyle including smoking habit, diet and
alcohol consumption.
a home safety assessment to cover hazards,
access, lighting, and aids and appliances.
On the basis of these assessments and some-
times a multi-disciplinary conference, advice
and recommendations are given and referrals
made – in some studies there is active management
with contributions from specific designated
professionals.
Referrals may be to the general practitioner
or a geriatric clinic, or to other healthcare
professionals including occupational therapists
and physiotherapists, pharmacists, social workers
and other relevant specialists. There may be an
invitation to education and exercise classes, and
there may be occupational therapist input with
assistance with aids and home safety
Methods
Criteria for considering studies for this review
We included randomized controlled trials of at
least six months duration with parallel group
design. People in trials were randomized by
individual or by group (for example by general
practice).
Participants
Study populations had a mean age of 65 years
or older and participants were living at home or
preparing for hospital discharge to home. They
can be considered as community populations with
a wide representation of older people, or may be
more selected populations considered frail, having
recently fallen or being discharged from hospital
into the community. We did not search for studies
conducted in people living in nursing homes.
Types of interventions
We looked for community-based multifacto-
rial interventions with control groups receiving
134 AD Beswick et al.
‘usual care.’ Studies were not excluded on the
basis of whether specific outcome measures were
reported.
Search strategy
The original search up to January 2005 was
conducted in Cochrane CENTRAL, MEDLINE,
EMBASE, CINAHL, PsycINFO, and ISI Science
and Social Science Citation Index. Updates to June
2009 were based on citation searches of systematic
reviews and key trials (including recent ones) as
described previously.76 The literature database was
stored in Endnote version X2.
Data abstraction and analysis
For the updated searches, titles and abstracts
obtained were screened by one reviewer (ADB)
to eliminate those studies that were definitely not
relevant to the review. Potentially relevant articles
were obtained and data extracted from studies
fulfilling the inclusion criteria by one reviewer
(ADB). Information was recorded on an Excel
spreadsheet and all data included in the final
review was checked against source publications
independently by another reviewer (VW).
Authors of all studies in the update of the
review were contacted and given the opportunity
to provide additional relevant data and to check
outcome data.
Categorical variables were expressed as relative
risks with 95% confidence intervals and combined
in fixed effect meta-analysis except where there
was significant heterogeneity of effects when a
random effects analysis was also undertaken using
the method of DerSimonian and Laird.85
For the continuous variable we extracted,
data were summarized as the standardized mean
difference. As described in the original review,
fixed effects meta-analysis was chosen a priori as
we reasoned that the complex interventions we
studied have common characteristics and aims.
Heterogeneity was explored by sensitivity analysis
and meta-regression.
The I2statistic measures the percentage of total
variation across studies that is due to heterogeneity
rather than chance. It ranges between 0 and 100%,
with lower values representing less heterogeneity.
In this review we considered I2greater than 50%
as significant heterogeneity.
Analyses were conducted using Stata version 11
and Review Manager version 4 statistical software.
Outcomes
The outcomes we studied were living at home
(reported as not living at home for consistency),
death, people with a nursing home or hospital
admission, or fall during follow-up, and physical
function at follow-up. If not living at home was
unavailable, the sum of deaths and nursing home
admissions was used. This may count people twice
who were admitted to a nursing home and who
subsequently died. Analyses were done with or
without estimates. For nursing home admissions
outcomes reported were permanent admission or
individuals living in a nursing home at follow-up.
Results were analysed combined and separately.
Several measures of physical function were
reported and we classified these as pertaining
to severity of disability such as limitations in
activities of daily living or generic physical
function. Differences in activities of daily living
and generic physical function at follow-up were
analysed separately and combined.
If standard deviations were unavailable from the
published reports or after contact with authors,
we used values calculated as described in the
Cochrane handbook for systematic reviews of
interventions,85 baseline values, or those from a
trial in a similar population or from appropriate
population statistics. Scales were re-coded such
that high values indicated poor physical function.
Funnel plots were inspected at all stages of the
review to identify possible publication bias.
Potential sources of heterogeneity
We used ‘losses to follow-up’ as our indicator
of methodological quality. Clear description of
an adequate randomization process was also
checked.
For the updated review we amalgamated studies
into three new contexts of intervention: community
populations, frail older people, and older people
who had fallen. This removes the community-
based care after hospital discharge category and
makes a clear category of interventions looking at
secondary prevention of falls.
Several sources of heterogeneity were explored
as in the original review: context of intervention
Maintaining independence in older people 135
Figure 1. Review flow diagram.
(geriatric assessment in community or frail older
populations, community-based care after hospital
discharge and fall prevention), randomization by
individual or cluster, quality of studies (losses to
follow-up and clarity of randomization process),
mortality rate, date of recruitment commencement,
mean age, intervention intensity and control group
activity.
In the original review group education
and counselling was used as a context of
intervention. This is often a component of other
interventions and as few studies of this type
have been identified, we assimilated them into the
appropriate category of community or frail older
population.
For this update we have included two
additional sources of heterogeneity that concerned
intervention conduct. These reflect the suggestion
that active management in response to assess-
ment may be more effective than referral or
recommendations,86 and comments on the original
review relating to the extent of clinician input.87
Results
The review process is summarized in Figure 1. The
updated search identified 311 articles, of which 19
studies reported 21 interventions relevant to the
inclusion criteria.
136 AD Beswick et al.
Interventions identified
In the updated review 19 studies evaluated
21 interventions. These are described briefly
in Table 1. Four interventions were applied
in community populations of older people,88– 90
nine interventions targeted frail older people,91– 99
and eight interventions specifically included
people who had fallen (or in one study were
sedentary).100– 106 Overall, these recent studies
included 10,854 people to give a total of 108,838
people randomized into 110 trials of complex
interventions. In three studies two interventions
were evaluated with a shared control group, giving
a total of 109,661 participants in randomized
groups. Trials ranged in size from 54 to 43,219
people randomized with a median of 375 in the
update and 350 overall. Randomization in trials
was by individual or household in 96 interventions
evaluated and by cluster in 14. The mortality rate
across all trials was 6.5% per year.
One randomized controlled trial evaluating
a multifactorial intervention in older people
identified in the search was excluded as only
random samples of people allocated to study
groups were followed up in the report.107
Details of all trials included in the original review
are available in Beswick et al.76
Outcomes
Results are summarized in Table 2.
Not living at home. Not living at home was
available for 72 out of 110 interventions (65%)
with a total of 84,627 people randomized. There
was an overall benefit for interventions, relative
risk 0.95 (95% CI: 0.93–0.97) that was identical
to the original review. Excluding the large MRC
trial the relative risk was similar at 0.94 (95% CI:
0.91–0.98).
Death. As with not living at home as an outcome,
the risk of death was similar in original and
updated reviews and showed no benefit for inter-
ventions in 106 studies (96%) with 105,431 people
randomized, relative risk 0.99 (95% CI: 0.97–
1.02). Omitting the large MRC trial the relative
risk of death was 0.97 (95% CI: 0.93–1.01).
Nursing home admission. There was an overall
benefit of reduced nursing home admission in in-
tervention groups (64% of trials reporting outcome
with 85,475 people), relative risk was 0.87 (95%
CI: 0.83–0.90) and again this was similar to that
seen in the original review. The magnitude of
the benefit was somewhat reduced after exclusion
of the MRC trial, relative risk of nursing home
admission was 0.91 (95% CI: 0.84–0.99).
Hospital admissions. Data on admission to
hospital were available in 51 studies with 24,424
people randomized. Admissions were reduced in
intervention groups, relative risk of one or more
hospital admission was 0.94 (95% CI: 0.92–0.97).
Falls. The incidence of one or more falls in
participants was available in 32 studies with
18,858 people randomized. Falls were reduced in
intervention groups, relative risk was 0.93 (95%
CI: 0.90–0.97).
Physical function. Physical function as an outcome
was available in 54 studies with 25,701 people
randomized and with follow-up data. The
standardized mean difference between intervention
and control groups was –0.07 (95% CI: –0.10 to
–0.05), suggesting better physical function at
follow-up in intervention groups.
Possible sources of heterogeneity
and subgroup analyses
Given the diversity of trials included in this review,
results for both fixed effects and random effects
models were compared. Substantial heterogeneity
was apparent for the outcome of falls (I2=57.0%).
However, the reduction in events in intervention
groups was still apparent in random effects meta-
analysis with a relative risk of 0.93 (95% CI: 0.87–
0.99). Results for other outcomes were similar for
both fixed effects and random effects models. Fixed
effects meta-analysis was chosen a priori because
the complex interventions for older people we have
defined had common characteristics and aims.
Study quality. Using clarity of randomization,
adequacy of allocation concealment or extent of
losses to follow-up as markers of study quality,
there was little difference in effect sizes in studies of
different quality. Similarly, studies with a control
group that received some form of intervention
activity showed similar effects to those with none.
Maintaining independence in older people 137
Table 1. Characteristics of randomized controlled trials included in the systematic review update
Context
Study
Country and date
Study setting
Number of participants
(intervention:control)
Mean age in intervention
group (% men)
Mortality rate
Intervention
Intensity
Control group activity
Follow-up
Outcomes
Losses to follow-up
Community
Counsell et al. 200788
USA 2002
Cluster RCT
Primary care physicians
N=951 (474:477)
Mean age 71.8 years
(24.5%)
Mortality rate 3.7%
Annual in-home comprehensive assessment of geriatric conditions by
advanced practice nurse and social worker. Implementation of care
plan consistent with patient goals in collaboration with primary care
physician, geriatrician, pharmacist, physical therapist, mental health
social worker and community-based services
24 months. Mean 13 patient contacts
Usual care including access to out-patient geriatric assessment
Follow-up 24 months
Death, SF-36 physical
function, AHEAD ADL
and IADL, hospital
admissions
Losses to follow up 14.7%
Phelan et al. 200789
USA 2002
Cluster RCT
Primary care providers
N=874 (432:442)
Mean age 81.5 (36%)
Mortality rate 4.5%
Clinic based assessment by nurse of medication, activities of daily living
and geriatric syndromes. Medication review by pharmacist. Long-term
health goals reviewed by geriatrician and primary care physician. Home
visit to develop action plan with individual and family based on
problems identified in assessment and follow-up focusing on self
management and barriers
2 months. 2 or more contacts as required
Usual care
Follow-up 24 months
Death, hospital admissions,
Arthritis Impact
Measurement Scale Short
Form (AIMS2-SF)
physical subscale
Losses to follow-up 0–13%
Thomas et al. 2007
intervention 190
Canada 2001
Individual RCT
Random telephone sample
N=350 (175:175)
Mean age 80.7 (37.6%)
Mortality rate 4.4%
Four annual functional assessments by nurse. Elders and primary
caregivers received the results and were invited to take appropriate
actions
48 months with 4 visits
No assessment or advice
Follow-up 48 months
Death, institutionalization
Losses to follow-up 1.9%
Thomas et al. 2007
intervention 290
Canada 2001
Individual RCT
Random telephone sample
N=345 (170:175)
Mean age 80.4 (27.4%)
Mortality rate 4.5%
Four annual functional assessments by nurse. Elders and primary
caregivers were offered referrals to health/social services
48 months with 4 visits
No assessment or advice
Follow-up 48 months
Death, institutionalization
Losses to follow-up 1.9%
Selected as frail
B´
eland et al. 200691
Canada 1999
Individual RCT
Health centre and
community service
N=1230 (606:624)
Mean age 82 (29%)
Mortality rate 10.8%
Community health and social services provided by multidisciplinary team.
Co-ordination of hospital and nursing home care. Intensified
community-based health and social care
Average enrolment 19 months
Usual care with no case management
Follow-up 22 months
Death, hospital and nursing
home use
Losses to follow-up 7.7%
138 AD Beswick et al.
Boult et al. 200892
USA 2006
Cluster RCT
Primary care
N=904 (485:419)
Mean age 77.2 years
(45.8%)
Mortality rate 11·5%
Guided care nursing intervention. Home based assessment with care
guide and action plan in collaboration with primary care provider.
Self efficacy classes. Monitoring and co-ordination of care transitions.
Education and support for carers
6 months with 1 visit and 6 classes
Control group completed baseline interview
Follow up 6 months
Death
Losses to follow-up 4.8%
Bouman et al. 200893
Netherlands 2003
Individual RCT
Postal questionnaire
screening
N=330 (160:170)
Mean age 75.8 (40%)
Mortality rate 7.9%
Two-monthly nurse home visit and telephone follow-up. Assessment of
health problems, depression, mobility problems and risks. Advice
given or referral to professional and community services. Information
and problems reported to GP
8 visits over 18 months
Usual care
Follow-up 24 months
Death, ADL (Groningen
Activity Restriction Scale)
Losses to follow-up 10%
Gitlin et al. 200894
USA 2000
Individual RCT
Social services and media
N=319 (160:159)
Mean age 79.5 (17.5%)
Mortality rate 3.8%
Home based assessment of safety, efficiency and difficulties and presence
of environmental barriers by occupational therapist. Problem solving,
specific strategies and equipment. Physiotherapist home visit to
provide education on balance, muscle strengthening and fall-recovery
techniques. Telephone and home visit follow-up
6 visits over 10 months
Home safety educational booklet after 12 months
Follow-up 24 months
(death), 6 months (ADL)
Death, ADL/ IADL
(Lawton)
Losses to follow-up 0–3.8%
Holland et al. 200595
USA 2001
Individual RCT
Medicare-managed care
programme
N=504 (255:249)
Mean age 73.1 (40%)
Mortality rate 1.8%
Health assessment and health action plan developed at nurse home visit.
Education instruction and classes, social worker consultation and
counselling, fitness programme and referrals to community
programmes including disease management
Contributions from social worker and geriatrician
12 months with average 11 hours coaching
Access to same resources but no health coaching
Follow-up 12 months
Death, long-term care,
NLAH estimated
Losses to follow-up 1.4%
Markle-Reid et al. 200696
Canada 2001
Individual RCT
Community care access
centre
N=288 (144:144)
Mean age 83.4 (22.5%)
Mortality rate 11.8%
Home-based nurse health assessment and regular home visits or
telephone contact. Health plan and goal setting. Education about
management of illness, co-ordination of community services, and use
of empowerment strategies to enhance independence. Referral to
community services and providing caregiver support
6 months with 5 visits
Minimal case planning
Follow-up 6 months
SF-36 physical function
Losses to follow-up 10.1%
Maintaining independence in older people 139
Table 1. (continued)
Context
Study
Country and date
Study setting
Number of participants
(intervention:control)
Mean age in intervention
group (% men)
Mortality rate
Intervention
Intensity
Control group activity
Follow-up
Outcomes
Losses to follow-up
Melis et al. 200897
Netherlands 2003
(Pseudo) cluster RCT
Primary care physician
N=151 (85:66)
Mean age 81.7 (24.7%)
Mortality rate 11.9%
Patients with geriatric problems identified by primary care physician.
Home-based multidimensional assessment by nurse. Integrated
individual treatment plan. After interdisciplinary consultation with
geriatrician and nurse, the primary care physician made referrals,
medication changes and other interventions
3 months, mean 3.8 visits
Usual unrestricted care
Follow-up 6 months
Death, ADL/ IADL
(Groningen Activity
Restriction Scale)
Losses to follow-up 7.1–9%
Ollonqvist et al.
200898 Finland 2002
Individual RCT
Rehabilitation centre
N=708 (343:365)
Mean age 77.8 (14.5%)
Mortality rate 4.4%
In-patient rehabilitation programme. Group activities: physical
activation, life situation and possible problems, promotion of
self-care, psychological counselling, discussions about medical
aspects, advice on social services, and recreational activities. Physical
therapy
6 months with 3 periods of 7 days in in-patient rehabilitation
Standard social and healthcare services
Follow-up 12 months
Death, ADL/ IADL (authors’
own)
Losses to follow-up 0.5–8.9
Rubenstein et al.
200799 USA 1996
Individual RCT
Ambulatory care centre
N=792 (380:412)
Mean age 74.6 (96.3%)
Mortality rate 7.3%
Telephone-based assessment by physician assistant case manager.
Referrals and recommendations on basis of unmet needs to: geriatric
assessment clinic, home-based primary care programme, primary care
provider or other specific services (audiology, ophthalmology, social
work, mental health). Co-ordinated out-patient follow-up by case
manager. 3 monthly telephone follow-up
36 months with estimated 2 clinic visits additional to telephone contact
Patient healthcare provider informed of serious conditions
Follow-up 36 months
Not living at home,
death, nursing home
admission, falls, hospital
admissions, ADL (FSQ)
Losses to follow-up
7.4–10.9%
Fall prevention
Elley et al. 2008100
New Zealand 2005
Individual RCT
General practice. Recent fall
N=312 (155:157)
Mean age 80.4 (32%)
Mortality rate 3.5%
Home-based nurse assessment of falls-and-fracture risk factors and home
hazards. Referral to family physician, optometrist, podiatrist, physical
therapist, or occupational therapist appropriate community
interventions, and home-based strength and balance exercise
programme
12 months with 6 visits
Usual care with social visits
Follow-up 12 months
Death, NLAH, nursing
home admissions, falls,
ADL (Nottingham
extended activities of daily
living score), SF36
physical component
Losses to follow-up 0–3.5%
140 AD Beswick et al.
Hendriks et al. 2008101
Netherlands 2003
Individual RCT
Discharged from hospital
after fall
N=333 (166:167)
Mean age 74.5 (33.1%)
Mortality rate 1.8%
Clinic-based comprehensive assessment by geriatrician, nurse and
rehabilitation physician. Results to GP. Home visit by OT for
functional and environmental assessment
Recommendations and referrals to social and community services
including physiotherapy and balance exercise plan
Approximately 1 months with 2 visits
Usual care
Follow-up 12 months
Death, falls, ADL/ IADL
(Groningen Activity
Restriction Scale and
Frenchay Activities Index)
Losses to follow-up 20.7%
Mahoney et al. 2007102
USA 2002
Individual RCT
Senior centres and
apartments. History of
falls
N=349 (174:175)
Mean age 79.6 (21.3%)
Mortality rate 4.9%
Home-based nurse or physical therapist assessment of predisposing
factors for falls. Geriatrician review
Recommendations to, and patient review with, primary physician at
1 month. Participants given recommendations and linked to existing
medical care and service networks
2 visits over 3 weeks
Home safety recommendations and advice to see their doctor about falls
Follow-up 12 months
Death, nursing home
admission falls, hospital
admission, ADL (Barthel)
Losses to follow-up 14.3%
Shumway-Cook et al.
2007103
USA 2003
Individual RCT
Publicity in newspapers,
newsletters, TV and post
Sedentary older people
N=453 (226:227)
Mean age 75.6 (23%)
Mortality 1.1%
Fall risk assessment. Nurse and exercise instructor-led group exercise
classes and fall prevention education classes at community site.
Results of assessment sent to primary care physician
3 exercise classes per week for 12 months and 1 education class per
month for 6 months
Fall prevention brochures
Follow-up 12 months
Death, falls
Losses to follow-up 4.2%
Spice et al. 2009
intervention 1104
UK 2000
Cluster RCT
Fallers identified by
community health
professionals and social
services
N=303 (141:162)
Mean age 83 (25.7%)
Mortality rate 10.2%
Primary care clinic-based nurse assessment to identify fall risk factors.
Referrals to GP, OT, physiotherapist, optician, home safety inspection
service, and social services
1 visit
Baseline assessment without specific guidance
Follow-up 12 months
Death, institutional
admission, falls, ADL
(Barthel)
Losses to follow-up 7.9%
Spice et al. 2009
intervention 2104
UK 2000
Cluster RCT
Fallers identified by
community health
professionals and social
services
N=375 (213:162)
Mean age 81 (28.6%)
Mortality rate 7.5%
Multidisciplinary out-patient clinic assessment by doctor, nurse,
physiotherapist and occupational therapist. Referral for
investigations, interventions including home safety inspection and
follow-up if necessary
1 visit
Baseline assessment without specific guidance
Follow-up 12 months
Death, institutional
admission, falls, ADL
(Barthel)
Losses to follow-up 7.5%
Maintaining independence in older people 141
Table 1. (continued)
Context
Study
Country and date
Study setting
Number of participants
(intervention:control)
Mean age in intervention
group (% men)
Mortality rate
Intervention
Intensity
Control group activity
Follow-up
Outcomes
Losses to follow-up
Vaapio et al. 2007105
Finland 2003
Individual RCT
Publicity in community and
health services and
invitations from health
professionals. Recent fall
N=591 (293:298)
Mean age 69.6 (15%)
Mortality rate 1.75%
Geriatric assessment and classes with geriatrician, nurse, nursing students
and physiotherapist. Counselling by nurse and guidance in fall
prevention. Home hazards assessment and modification, group and
home physical exercise, education classes and psychosocial group
activities
12 months with contact approximately weekly
1 counselling session at baseline
Follow-up 12 months
(36 months for death)
Death, falls
Losses to follow-up 11.7%
Vind et al. 2008106
Denmark 2005
Individual RCT
People treated in emergency
department for fall
N=392 (196:196)
Mean age 74.2 (27%)
Mortality rate 2.0%
Doctor, nurse and physiotherapist assessment at out-patient clinic
Individual medical, physiotherapy and exercise interventions planned
and offered to patient at falls clinic. Referral to specialists. Prescribed
home exercise and information about community exercise
Median 13 weeks with median 6 visits
Usual care
Follow-up 12 months
Death, falls
Losses to follow-up 5.1%
ADL, activities of daily living; IADL, instrumental activities of daily living; NLAH, not living at home.
142 AD Beswick et al.
Table 2. Relative risk (95% CIs) of outcome by intervention grouping (standardized mean difference for physical function) and I2statistic
Not living at
home at follow-up
N=84,627
One or more
nursing home
admission
N=85,475
Death
N=105,431
One or more
hospital admission
N=24,424
Oneormorefalls
N=18,858
Physical function
N=25,701
Overall 0.95 (0.93, 0.97)
I2=26.3%
0.87 (0.83, 0.90)
I2=24.9%
0.99 (0.97, 1.02)
I2=9.0%
0.94 (0.92, 0.97)
I2=44.3%
0.93 (0.90, 0.97)
I2=57.0%
0.07 (0.10, 0.05)
I2=42.1%
Population selected Community 0.96 (0.93, 0.98)
I2=28.7%
0.87 (0.83, 0.91)
I2=42.7%
1.00 (0.97, 1.03)
I2=33.1%
0.94 (0.90, 0.98)
I2=62.7%
0.89 (0.84, 0.94)
I2=62.9%
0.10 (0.14, 0.07)
I2=10.8%
Frail 0.94 (0.87, 1.00)
I2=30.9%
0.87 (0.75, 0.98)
I2=20.5%
0.96 (0.90, 1.02)
I2=3.4%
0.96 (0.92, 1.00)
I2=45.6%
1.00 (0.92, 1.10)
I2=1.0%
0.03 (0.07, 0.01)
I2=47.1%
Previous fall 0.84 (0.65, 1.06)
I2=0.0%
0.93 (0.61, 1.40)
I2=0.0%
0.95 (0.74, 1.23)
I2=0%
0.81 (0.66, 1.00)
I2=0%
0.94 (0.89, 1.00)
I2=64.0%
0.11 (0.19, 0.02)
I2=44.4%
Mortality rate
(quartiles)
0 to 4.0 1.05 (0.92, 1.19)
I2=50.0%
1.02 (0.89, 1.25)
I2=64.2%
1.02 (0.88, 1.17)
I2=0.0%
0.91 (0.85, 0.98)
I2=0.0%
0.91 (0.86, 0.96)
I2=61.4%
0.03 (0.08, 0.01)
I2=57.7%
4.1 to 6.5 0.92 (0.86, 0.98)
I2=0.0%
0.96 (0.82, 1.12)
I2=12.7%
0.94 (0.88, 1.01)
I2=16.7%
0.88 (0.80, 0.96)
I2=0.0%
0.99 (0.86, 1.14)
I2=0.0%
0.11 (0.14, 0.07)
I2=42.4%
6.6 to 10.7 0.96 (0.93, 0.98)
I2=27.7%
0.86 (0.82, 0.90)
I2=0.0%
1.00 (0.97, 1.03)
I2=49.1%
0.97 (0.92, 1.02)
I2=70.0%
1.01 (0.93, 1.11)
I2=63.1%
0.05 (0.12, 0.02)
I2=0.6%
10.8 or more 0.89 (0.81, 0.98)
I2=8.2%
0.78 (0.66, 0.92)
I2=0.0%
1.00 (0.92, 1.07)
I2=0%
0.97 (0.92, 1.02)
I2=54.8%
0.63 (0.50, 0.78)
I2=0.0%
0.11 (0.20, 0.03)
I2=49.0%
Start date of
recruitment
Up to 1989 0.89 (0.85, 0.94)
I2=16.4%
0.78 (0.70, 0.87)
I2=19.4%
0.94 (0.89, 0.99)
I2=22.5%
0.98 (0.93, 1.03)
I2=59.0%
1.05 (0.84, 1.32)
I2=77.7%
0.12 (0.16, 0.07)
I2=29.7%
1990–1994 0.87 (0.76, 1.00)
I2=0%
1.10 (0.87, 1.40)
I2=0.0%
0.98 (0.89, 1.08)
I2=0%
0.91 (0.86, 0.96)
I2=39.6%
0.89 (0.83, 0.96)
I2=60.6%
0.04 (0.11, 0.03)
I2=0%
MRC trial 0.96 (0.93, 0.98) 0.86 (0.82, 0.90) 1.02 (0.99, 1.06)
1995–1999 1.05 (0.96, 1.14)
I2=38.1%
0.91 (0.78, 1.06)
I2=31.8%
1.03 (0.94, 1.13)
I2=0.3%
0.92 (0.86, 0.98)
I2=46.9%
0.87 (0.80, 0.94)
I2=55.5%
0.09 (0.13, 0.05)
I2=64.1%
2000 on 1.03 (0.92, 1.15)
I2=20.6%
1.18 (0.98, 1.43)
I2=0.0%
0.91 (0.82, 1.01)
I2=13.2%
0.98 (0.90, 1.08)
I2=28.5%
0.99 (0.94, 1.05)
I2=29.4%
0.03 (0.07, 0.02)
I2=0%
Maintaining independence in older people 143
Table 2. (continued)
Not living at
home at follow-up
N=84,627
One or more
nursing home
admission
N=85,475
Death
N=105,431
One or more
hospital admission
N=24,424
Oneormorefalls
N=18,858
Physical function
N=25,701
Consequences of
assessment
Active
management
0.92 (0.86, 0.99)
I2=0.0%
0.80 (0.70, 0.92)
I2=0.0%
0.99 (0.93, 1.06)
I2=0.0%
0.94 (0.90, 0.99)
I2=47.1%
0.95 (0.90, 1.00)
I2=51.2%
0.07 (0.13, 0.02)
I2=44.3%
Referrals 0.96 (0.94, 0.98)
I2=47.1%
0.87 (0.83, 0.91)
I2=38.71%
1.00 (0.98, 1.04)
I2=42.5%
0.96 (0.91, 1.02)
I2=68.0%
0.98 (0.91, 1.04)
I2=71.9%
0.05 (0.09, 0.01)
I2=37.6%
Recommendations 0.90 (0.83, 0.97)
I2=31.7%
0.93 (0.78, 1.11)
I2=48.2%
0.91 (0.85, 0.99)
I2=15.7%
0.92 (0.85, 0.98)
I2=0.0%
0.82 (0.74, 0.90)
I2=12.2%
0.10 (0.14, 0.06)
I2=42.8%
Physician
involvement
Direct
physician
involvement
0.89 (0.83, 0.95)
I2=28.3%
0.91 (0.81, 1.03)
I2=20.7%
0.98 (0.93, 1.04)
I2=9.6%
0.92 (0.88, 0.96)
I2=39.1%
0.94 (0.86, 1.02)
I2=68.5%
0.09 (0.13, 0.06)
I2=53.1%
No direct
physician
involvement
0.96 (0.94, 0.98)
I2=21.3%
0.86 (0.83, 0.90)
I2=28.4%
1.00 (0.97, 1.02)
I2=19.1%
0.97 (0.93, 1.01)
I2=48.5%
0.93 (0.89, 0.97)
I2=53.0%
0.06 (0.09, 0.03)
I2=30.4%
Intensity score Low 0.96 (0.93, 0.98)
I2=11.7%
0.86 (0.82, 0.90)
I2=0.0%
1.01 (0.98, 1.04)
I2=19.7%
0.89 (0.83, 0.95)
I2=42.0%
0.81 (0.74, 0.88)
I2=77.2%
0.08 (0.14, 0.03)
I2=52.7%
Medium 0.95 (0.90, 1.00)
I2=38.1%
0.89 (0.81, 0.98)
I2=24.5%
0.96 (0.91, 1.01)
I2=16.8%
0.99 (0.94, 1.05)
I2=57.5%
0.97 (0.92, 1.02)
I2=52.9%
0.05 (0.09, 0.02)
I2=52.5%
High 0.92 (0.85, 1.02)
I2=7.5%
0.88 (0.75, 1.02)
I2=48.2%
0.96 (0.90, 1.03)
I2=6.1%
0.93 (0.90, 0.98)
I2=0.0%
0.95 (0.88, 1.02)
I2=39.1%
0.10 (0.15, 0.06)
I2=5.1%
Age of population
(quartiles)
Up to 74.4 years 0.85 (0.78, 0.93)
I2=11.3%
0.72 (0.58, 0.88)
I2=0.0%
0.94 (0.87, 1.01)
I2=31.7%
0.96 (0.91, 1.02)
I2=35.7%
0.92 (0.87, 0.98)
I2=70.0%
0.11 (0.16, 0.06)
I2=38.5%
74.5–77.6 years 1.04 (0.93, 1.16)
I2=32.3%
1.15 (0.93, 1.43)
I2=0.0%
0.94 (0.85, 1.04)
I2=14.9%
0.93 (0.87, 0.99)
I2=38.1%
0.93 (0.86, 1.00)
I2=64.3%
0.08 (0.14, 0.02)
I2=56.7%
77.7–81 years 0.92 (0.87, 0.98)
I2=15.6%
0.84 (0.75, 0.94)
I2=26.3%
0.94 (0.88, 1.00)
I2=0.0%
0.95 (0.89, 1.00)
I2=66.3%
0.91 (0.83, 0.99)
I2=55.9%
0.09 (0.15, 0.03)
I2=47.5%
81.1 years and
over
0.96 (0.94, 0.99)
I2=17.6%
0.87 (0.83, 0.92)
I2=49.3%
1.02 (0.99, 1.05)
I2=11.2%
0.92 (0.86, 0.99)
I2=16.8%
0.97 (0.89, 1.06)
I2=32.0%
0.03 (0.09, 0.02)
I2=0%
Note: results for one or more falls from a random effects model are: 0.93 (0.87, 0.99).
144 AD Beswick et al.
Cluster or individual randomization. Ideally in
meta-analysis we would have considered cluster
size and cluster variability and presented summary
statistics adjusted appropriately. This information
was not generally available and we looked at the
effect of clustering with sensitivity analysis.
The main implication of exclusion of studies
with cluster randomization was the loss of
the MRC trial from the analysis. Outcomes
were reasonably similar in trials with individual
compared with cluster randomization unless the
MRC trial was excluded when the benefit for most
outcomes was lost in cluster trials.
Population. Looking at the studies including a
community population of older people there were
benefits for all outcomes except death. Nursing
home admission was reduced in those considered
frail. Other categorical outcomes showed trends
for benefit in intervention groups but in all
cases confidence intervals included unity. Physical
function was better at follow-up in intervention
groups in community older populations and in
those with a previous fall, but not in frail
populations.
Mortality rate. Benefits for not living at home
and nursing home admission were apparent in
populations with highest mortality rates. However,
there was little difference in deaths in intervention
compared with control groups at any mortality
rate. Hospital admissions were only lower in
intervention groups in the two lowest quartiles of
mortality rate but heterogeneity was high in the
highest mortality rate groups.
Falls were reduced in intervention groups in
studies with lowest mortality rates. Although few
studies with higher mortality rates reported falls as
an outcome there was a suggestion of benefit based
on three studies.
There was no consistent trend in benefit for the
outcome physical function across mortality rates.
Intensity. As described in our previous review we
classified interventions according to an intensity
score based on multidisciplinary input, number of
scheduled visits and duration. There was little to
suggest improved outcomes in those interventions
with highest intensity.
Physician involvement. Interventions were classi-
fied by extent of direct medical input. In 42
studies (38%) direct contact between patients and
a geriatrician, physician, general practitioner or
primary care provider was reported as part of the
intervention. There was no suggestion of specific
benefit for interventions with this physician input.
Consequences of assessment. We classified studies
according to whether the results of the assessment
were followed up with active management,
referrals or recommendations. There was no
suggestion of particular benefit with active
management or any format of follow-up care.
Age of participants. Studies were divided into
quartiles by the mean age of the intervention
group. There was a trend for greater benefit for
physical function in younger populations. In other
outcomes there were no consistent trends but living
at home was improved in youngest intervention
groups.
Date of study. It was not possible to divide studies
into equal groups according to the start date
of recruitment as many studies shared the same
dates. An attempt was made to divide studies
by significant dates in the evaluation of geriatric
assessment and management. Thus ‘1989 and
earlier’ represents the period leading up to the
American College of Physicians recommendations
on routine medical management of people aged
75 years and older,63 and the requirement for
multidimensional assessments for people aged
75 years and older in the Terms of service for
general practitioners in the UK.65 1990 to 1994
was the period leading up to the start of the
UK MRC trial (considered separately in this
analysis). From 1995 there was an awareness of
the issue of geriatric assessment after several widely
reported trials and the first meta-analysis, and
also a developing interest in multifactorial fall
prevention. Trials conducted from 2000 onwards
are mainly new studies not included in our previous
review.
For the outcome of not living at home, meta-
regression confirmed that the benefit was apparent
in the earliest studies but not in studies with
more recent recruitment dates. Similarly, meta-
regression indicated that only the earliest studies
showed any effect for reduction in deaths, hospital
admissions, and nursing home admissions in the
intervention groups. Physical function outcomes
showed no trend with date.
Maintaining independence in older people 145
Only three studies reporting the falls outcome
started recruitment before 1990 and there was
substantial heterogeneity. Considering only those
studies recruiting people from 1990 there was a
suggestion that interventions in earlier studies were
effective in preventing falls but there was no benefit
apparent in those recruiting from 2000 onwards.
Discussion
The interventions that we include in our review
share the common aim of providing combinations
of interdisciplinary teamwork for health and social
problems. They aim to limit decline in, preserve
or improve independence in older people through
the identification and treatment of risk factors
including predisposition to falling.
Overall the benefit of complex interventions in
helping older people to live at home that was
observed in the original review is still apparent
across all trials, relative risk of not living at
home being 0.95 (95% CI: 0.93–0.97). This is
largely due to reduced nursing home admissions
rather than deaths in those receiving interventions.
Community populations and those considered frail
were less likely to be admitted to a nursing home
in those who received intervention.
In this review frailty is a broad term including
people with limitations in activities of daily living,
chronic conditions, and those considered to be at
risk of functional decline or hospital admission.
Mortality rate in the study populations may be a
better indication of health status of the population.
Benefits for not living at home and nursing
home admission were most evident in populations
with highest mortality rates. There was also
some suggestion that studies including younger
people had more favourable outcomes for living
at home, nursing home admission and physical
function.
As previously noted, studies with greater
multidisciplinary input, duration and number of
visits were not associated with improved outcomes.
Neither was the direct involvement of a physician
in the intervention, or active management com-
pared with referral or recommendations.
Benefit for living at home was largely restricted
to earlier studies and the trend for reduced benefit
over time was confirmed by meta-regression.
Benefits for reduced nursing home admission and
death were limited to earlier studies and in the
case of nursing home admission the MRC trial as
well. Interventions in those who had fallen showed
improvements in physical function but no overall
benefit for reduction in number of people with one
or more fall.
The overall effect size reflecting benefit for
interventions is small. However, it has been argued
that in the context of complex interventions
this may be an underestimate because adherence
may be poor in some trials and because control
groups may have received some components of the
intervention, particularly in recent trials.87
A simple explanation for why more recent
studies do not show benefit is that early trials
were comparing a new intervention with a control
group receiving no anticipatory care whatsoever.
Subsequently, in the light of early randomized
controlled trials, systematic reviews and the
incorporation of their findings into guidelines,
usual care has included features of assessment and
management. For example, the control group in the
MRC trial of geriatric assessment and management
received a brief assessment and for those
participants with three or more health problems
or serious symptoms, a detailed examination by
a nurse.108 In the context of geriatric care in the
UK after introduction of the GMS terms of service
for general practitioners in 1989 this targeted
assessment control group is about as little care as
any older person could ethically receive in a trial
in the UK in 1995, and in this review represents a
true ‘usual care’ control group.
AsdescribedintheMRCtrial,onethical
grounds it would not be possible to have an
untreated control group in more recent trials.
Therefore later trials may reflect alternative
provision of care with the primary aims of
reducing costs and improving professional and
patient compliance with care. The experience of
the control patients in a trial may frequently reflect
optimal current practice and adherence. In this
review the possibility that the benefit in trials was
limited by a ‘Hawthorne effect’ is unlikely as little
difference was seen in effects in trials where no
activity occurred in control groups compared with
those where assessments or interventions were
conducted.
The trends in trial effects over time may reflect
a growing improvement in the care of older people
in primary and secondary care with diffusion
of traditional ‘geriatric medicine’ approaches to
management. However, in the UK uptake of
146 AD Beswick et al.
regular assessment and management of older
people has been patchy. Fletcher et al. noted
that annual assessments as promoted in the UK
were poorly implemented during the course of
their study.108 However, even in a population
where the implementation of health assessment
was estimated at only 20% the uptake of influenza
vaccination was 80%,11 suggesting the delivery of
some anticipatory care. In a survey in an Italian
population Piccoliori et al. noted a mean of 6.4
out of 7.8 health or social problems identified were
known to the general practitioner.109
This latter study also shows that older people
still have some unmet needs. While most problems
were known, the general practitioner was unaware
of a mean of 1.4 problems per individual and
about two-thirds of these were of significance to
the general practitioner or patient.109
The value of assessment and individualized care
was highlighted in the focus group study of Belle
Browne et al.67 The authors explored the barriers
and facilitators of independence reported by older
people, carers and health care providers. Lack
of knowledge about services and resources was
identified as a major barrier to independence. Key
potential facilitators of independence were a co-
ordinated system of health care and continuity of
care.
Multidimensional fall prevention
The systematic reviews of Gillespie et al.from
2003, Hill-Westmoreland et al., Chang et al.,
Campbell and Robertson, and Beswick et al.
concluded that multifactorial falls interventions
were effective in preventing falls.76, 79– 81, 110
However, several more recent trials have been
included in the review of Gillespie et al. from 2009,
which suggests that multifactorial interventions are
not effective in reducing the risk of falling.47 This
was largely a consequence of the ineffectiveness
of interventions in more recent trials. Gates et al.
found only limited benefit for multifactorial fall
prevention programmes in their review.82 In the
present review, interventions in people who had
previously fallen were not significantly associated
with a reduction in number of people with a fall,
relative risk being 0.94 (95% CI: 0.89–1.00). This
was consistent with the relative risk of 0.92 (95%
CI: 0.87–0.97) in the previous review of trials
classified as fall prevention.76
Authors of recent trials discussed the lack
of benefit reported. Elley et al. attributed the
lack of effectiveness of their multifactorial fall
prevention intervention to lack of adherence to
diverse interventions.100 They noted the need to
make all aspects of a multifactorial intervention
work and recognized the possible value of
personal preferences in improving adherence by
participants. The ineffectiveness of the intervention
evaluated in the trial reported by Hendriks
et al. may have been explained by lack of
adherence.101 Looking at process factors in this
trial, Bleijlevens et al. found that there had been
few referrals resulting from medical assessment
and poor uptake of these by participants.111 The
population mortality rate was 1.8% compared
with 11.6% in a previous randomized trial of the
intervention model in the UK.112 In this earlier
evaluation Close et al. recruited people between
1995 and 1996 and reported substantially reduced
falls and better physical function in people who
received the intervention. However, there was little
difference between intervention and control groups
in numbers of people living at home, admitted to
nursing home or who had died.
In their systematic review of randomized con-
trolled trials of falls interventions, Campbell and
Robertson compared trials with an intervention
targeting more than one falls risk factor with trials
evaluating a single intervention.81 The six trials
with a multifactorial intervention showed similar
benefit for reduced falls as recorded in patient
diaries (rate ratio 0.78, 95% CI: 0.68–0.89) to the
ten trials reporting a single intervention (rate ratio
0.77, 95% CI: 0.67–0.89). The authors concluded
that targeting single interventions is an acceptable
and achievable approach for community-based fall
prevention. They also speculate that there may be
interactions within a multifactorial intervention,
which leads to reduced effectiveness of each
component. This may be due to conflicting
advice on the level of activities recommended for
home safety compared with strength and balance
training, or the imposition of too much change to
an older person’s lifestyle and environment.
In another meta-analysis of recent research
in fall prevention, Petridou et al. identified ten
studies published between 2004 and February
2008.113 Their conclusions were similar to those
of Campbell and Robertson and they reported
that interventions comprising exercise alone were
considerably more effective than multifactorial
Maintaining independence in older people 147
interventions. The authors discussed the protrac-
ted nature of multifactorial interventions and
compared them unfavourably with shorter term
small group interventions. They also suggested
that older people may understand the potential
value of exercise interventions and thus be more
willing to participate. In interventions such as
home modification there may be less opportunity
for active participation and less potential for
enhancement of self-efficacy.
Tinetti noted that in the trials of Elley et al.
and Hendriks et al. the adherence to referrals and
completion of recommended interventions was left
to the participants and the health care providers.86
She concluded that fall risk assessment with referral
alone was ineffective in reducing fall risk and that
active management was required.
However, it is also noteworthy that the lack
of effectiveness of more recent multifactorial
falls interventions is consistent with the limited
apparent overall benefit of complex interventions
in more recent studies identified in the present
review. This may be a consequence of improved
general health and social care for older people.
A further possibility is the better educational
attainment, social circumstances (e.g. central
heating) and fitness of more recent generations of
older people which is improving their resilience in
the face of environmental challenges.
In the present review we have included the
fall-related outcome ‘people with one or more
falls during follow-up.’ Clearly in a focused
review considering any form of fall prevention
intervention a wider range of outcomes would
be studied including time to first fall, total falls,
injurious falls, falls with hospital attendance, and
falls with fracture. Here we have considered more
severe sequelae of falls and undertreatment of risk
factors, specifically not living at home, nursing
home or hospital admission, and death. The
number of these events are generally low in the
studies of fall prevention which, with the exception
of the study reported by Spice et al., were evaluated
in relatively healthy people. In total, trials targeting
secondary prevention of falls contributed 4.0% of
people and 1.2% of deaths to the analysis.
Selection of relatively healthy populations
for evaluation of these methods is reasonable
as the opportunities exist to intervene in a
truly multifactorial sense with exercise classes
incorporating strength and balance training, as
well as home safety, and lifestyle modification.
Populations for fall prevention programmes may
be too highly selected and for interventions to be
applicable more generally there may be need for
incorporation of patient choice and more tailored
interventions.114 Furthermore, Gillespie et al.
suggest that differences in healthcare systems may
explain difficulties in developing and replicating
methods.47
Campbell and Robertson highlighted the
potential overloading of older people with
information and intervention. Weerdesteyn et al.
reported good compliance and willingness to
participate in low intensity exercise interventions
of short duration.115
Bunn et al. identified 24 quantitative and
qualitative studies exploring participation in
fall prevention programmes.116 They identified
a number of issues described by patients
that influenced participation, specifically: denial,
fatalism, self-efficacy, past exercise habits, fear
of falling, general health and functional ability,
health expectations, under-estimation of personal
risk of falling, stigma, embarrassment, and the
inconvenience of assistive devices. Methods to
improve participation and adherence in fall
prevention programmes related to social support
and engagement, lower intensity exercise including
walking, and education. The authors conclude
that better understanding of older people’s
attitudes towards fall prevention and methods to
promote participation will improve effectiveness of
strategies.
In a recent UK survey in people aged 54 years
and older, Yardley et al. explored willingness
to engage in fall prevention activities.117 They
found that only 22.6% of people surveyed would
definitely attend strength and balance training
classes and that 60% would maybe not or definitely
not attend. Home safety modifications were more
acceptable, with 57.6% reporting that they were
willing to consider them. On this basis the recent
trials reporting low levels of adherence to fall
prevention measures may represent a realistic
pragmatic evaluation.
Future research in complex interventions
With such a wealth of high quality trial data
showing the effectiveness of complex interventions
in older people in maintaining independence, it
seems reasonable that all older people are given
148 AD Beswick et al.
the opportunity to receive appropriate preventive
strategies. In those people with specific morbidities
the challenge is to establish effective monitoring
and to incorporate a more general approach to
assessment and management. Similarly for those
with disabilities in activities of daily living, social
and medical care, if delivered appropriately, may
be effective.
For those older people with no specific
indication for health and social care the challenge
is to identify those likely to develop problems or in
the early stages of frailty, the ‘pre-frail’ stage.118
One-off or yearly assessment is probably not
frequent enough to monitor the onset of frailty. De
Lepeleire et al. suggest the potential value of case-
finding strategies in primary care.118 However, the
acceptability of approaches that lead to greater
‘medicalization’ of generally healthy older people
will require further research.
For pragmatic reasons we included outcomes
in our review that were widely available in
published trials. However, these may not be
the best outcomes to describe effectiveness of
interventions. For example, in some situations
prevention of nursing home or hospital admission
and maintenance of living at home can be an
unfavourable situation for the individual and carer.
This point is important, since if independence
comes at a price, such as loneliness, there may be
negative implications for older people’s health.119
In addition, the value placed on independence
and its definition is constrained by cultural
norms. For instance, studies in African-Caribbean
or South Asian communities living in the UK
indicate that relationships of informal care and
a degree of dependence on younger relatives are
valued highly.120 In future reviews sufficient data
may be available from trials to consider other
independence-related outcomes that are important
to each older person.
Randomized trials are underway or planned
to evaluate new assessment tools including the
PRO-AGE study of health risk appraisal, feedback
and personalized education,121 and the Evercare
case management model.122 Several screening tools
to identify older people at risk of falling are
available including HOME FAST,123 and they
may have value incorporated into a multifactorial
intervention.
Interventions that provide support and educa-
tion to general practitioners and other healthcare
professionals in conducting effective assessment
and management may lead to improved care for
older people. Vass et al. used this approach in
their study of structured home visits to older
people.124
In all the interventions included in the review
there is individualized assessment. There may also
be some degree of individualization in treatment
and management. In numerous studies shared
decision-making has been shown to improve
patient satisfaction and health outcomes,125 and
the need for health and social care services to ‘treat
older people as individuals and enable them to
make choices about their own care’ is a standard
in the National Service Framework for Older
People in England.64 More options and different
formats of care may lead to better uptake and
adherence by older people and address some of
the problems described in recent studies. Future
evaluations and synthesis of evidence would benefit
from assessments of cost-effectiveness, which is
increasingly recognized as an important element
of policy making and implementation of evidence
in health services.
Declaration of interests
None of the authors has any conflicts of interest to
declare.
Acknowledgements
We are fortunate to be able to include such a large
number of high quality studies in our review. We
particularly thank all the authors who were able to
provide additional data for our meta-analysis.
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... Seven reviews quantified it purely in terms of frequency, defining high intensity as one or more contacts a month for more than 3 months (Coulter et al., 2015), six or more face-to-face contacts a week (Fens et al., 2013), six or more home visits (Hildebrand, 2015), more than 14.4 contacts per 12 months (Backhouse et al., 2017) or one or more visits a month (Baker et al., 2018); and one used number of sessions in a meta-regression (Ekers et al., 2013). Three reviews scored intensity according to multidisciplinary input, number of scheduled visits and duration (Beswick et al., 2010) and caseload, patient complexity, frequency of visits and range of services provided (Corvol et al., 2017) or a combination of 18 different criteria (Somme et al., 2012). A final review simply used the authors' subjective judgement (Low et al., 2011). ...
... showing effects in reviews upon some conditions and outcomes but not others. More intense interventions appeared to have little effect on frailty in comparison to usual care (Beswick et al., 2010). ...
... Regarding other health professionals, evidence suggested that there was little effect on outcomes from including the following in care teams: social workers (Stokes et al., 2015), patient navigators (Tricco et al., 2014), direct physician contact (Beswick et al., 2010) and occupational therapists (OTs) (Hildebrand, 2015). The only outcomes affected by professional type were potential effects upon depression and increased respite service use from OT-led case management in stroke (Hildebrand, 2015;Piersol et al., 2017) and reduced costs from inclusion of a pharmacist (Kane & Shamliyan, 2011). ...
Article
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The number of older people living with complex health conditions is increasing, with the majority of these managed in primary and community settings. Many models of care have been developed to support them, however, there is mixed evidence on their value and they include multiple overlapping components. We aimed to synthesise the evidence to learn what works for managing complex conditions in older people in primary and community care. We carried out a state‐of‐the‐art review of systematic reviews. We searched three databases (January 2009 to July 2019) for models of primary and community care for long‐term conditions, frailty, multimorbidity and complex neurological conditions common to older people such as dementia. We narratively synthesised review findings to summarise the evidence for each model type and identify components which influenced effectiveness. Out of 2,129 unique titles and abstracts, 178 full texts were reviewed and 54 systematic reviews were included. We found that the models of care were more likely to improve depressive symptoms and mental health outcomes than physical health or service use outcomes. Interventions including self‐management, patient education, assessment with follow‐up care procedures, and structured care processes or pathways had greater evidence of effectiveness. The level of healthcare service integration appeared to be more important than inclusion of specific professional types within a team. However, more experienced and qualified nurses were associated with better outcomes. These conclusions are limited by the overlap between reviews, reliance on vote counting within some included reviews and the quality of study reports. In conclusion, primary and community care interventions for complex conditions in older people should include: (a) clear intervention targets; (b) explicit theoretical underpinnings; and (c) elements of self‐management and patient education, structured collaboration between healthcare professionals and professional support. Further work needs to determine the optimal intensity, length, team composition and role of technology in interventions.
... Straps, foam wedges and detachable couch cot sides may be used selectively in the radiotherapy setting to promote comfort and safety for patients at greater risk of falling from the treatment couch. Patients perceived to be at an increased risk of falling include the anxious, obese or cognitively impaired [5][6][7] or those with lateral target volumes. The use of cot sides is limited by beam attenuation issues and gantry-couch conflicts for radical treatments [8]. ...
... Some respondents attributed enhanced patient relaxation and reassurance to the strap. Against this was the concern that ambulatory, able people were being secured with little benefit for the patient, thus threatening the autonomy that is vital for cognitive and physical health [5]. A balanced evaluation of the strap would appreciate how alien the treatment environment can be to the uninitiated patient [2,25]. ...
Article
Introduction A serious patient safety incident at a cancer centre in Ontario, Canada, saw a patient fall from an elevated treatment couch. A regional investigation recommended the use of a securing safety strap. The authors evaluate the value of the strap through the experiences of the radiation therapists’ who use it. A secondary aim is to explore the potential for using a securing safety strap with UK therapeutic radiographers. Methods A two-stage design was guided by an evidence-based practice framework. Stage one used a questionnaire to capture treating radiation therapists’ experiences and opinions of the strap at a single cancer centre. Quantitative data were analysed descriptively and free-text data via a content analysis. Stage two used semistructured interviews with thematic analysis to explore views of three UK therapeutic radiographers. Results Twenty-five of approximately 130 eligible staff responded to the Canadian questionnaire. Of the respondents, 24% (n = 6) ‘strongly disagreed’, 28% (n = 7) ‘agreed’ and 48% (n = 12) ‘neither agreed nor disagreed’ that they would recommend the strap to other departments. Most of the respondents think strap use should be at the staffs' discretion, with patients with dementia/cognitive impairment ranked as the group benefiting most. Ninety-two percent (n = 23) of respondents confirmed that patients sometimes refuse the strap. Themes arising from stage two interviews are as follows: patient benefit (use for select patients only); patient safety versus control (restraint); and practical implementation issues. Conclusion The policy of universal use of the strap should be reviewed. Those who use it are equivocal about its value and feel it should be reserved for select patients at the treating professional's discretion. Full evaluation of the effectiveness and acceptability of the device for different patients may promote both staff enthusiasm towards the device and evidence-based practice. Adequate resources are required to evaluate implementation of such safety initiatives.
... Maintaining independence, positive physical and mental well-being are seen as essential to preserving health and to prevent frailty as we age. Beswick et al. (2010) report that one in twenty over 65-year-olds will experience catastrophic decline in their mobility each year. Predictors of decline are older age, previous self-report of deterioration including hearing loss, low functional reserve, psychological problems and low levels of social engagement (Beswick et al., 2010: 128-129). ...
Thesis
Full-text available
Background Our human world is aging. The prevalence of older people living with syndromes of frailty is growing too. Frailty syndromes, such as falls, immobility, delirium, incontinence and susceptibility to medication side effects, are leading causes of acute hospitalisation of older people. Confidence is recognised to impact on individuals’ physical health and mental well-being, despite it not being clearly expressed in the literature. Health and social care policy and practice now focus on frailty interventions to reduce long-term demands of this growing population. Understanding the relationship of the concept of confidence and its associated impact on the physical health and mental well-being of older people living with frailty is important. It is fundamental that opportunities are identified for interventional practice-based developments that address confidence-related issues. Aim To explore and develop a concept of ‘confidence’ in the context of older people living with frailty and to consider implications for practice. Method The Knowledge-to-Action Framework’s knowledge creation funnel informed a four-stage interpretivist study design to explore and develop the concept of confidence. This sequential approach to knowledge growth included: qualitative systematic review meta-aggregation of the literature; primary concept construction; an interpretive phenomenological enquiry; and method triangulation to inform a final conceptual outcome. Findings Method triangulation identified convergence across the three studies to present a final concept of confidence from the perspectives of older people living with frailty. Four interdependent paradigms form this construct of confidence: social connectedness, fear, independence and control. This new concept connects the contemporary frailty care through the biopsychosocial and environmental cornerstones of Comprehensive Geriatric Assessment commonly adopted to manage frailty syndromes. It enables clearer understanding and opportunity for intervention along the continuums of health and frailty and of resilience and vulnerability. Conclusion Confidence is a word that can often be dismissed or misused. This research raises its status as a credible force in the lives of older people. The newly defined concept of confidence in older people living with frailty compellingly associates this with frailty models exposing assets as it does deficits. The new concept of confidence now needs empirical referents developing to measure and quantify impact across new interventional opportunities in practice. https://pearl.plymouth.ac.uk/handle/10026.1/16211
... PA recommendations for elderly adults are a minimum of 150 min of moderate-intensity aerobic PA or at least 75 min of vigorous-intensity aerobic PA or an equivalent combination of both throughout the week [8]. The amount of PA is one of the determinants of the maintenance of independence in older adults [9]. ...
Article
Full-text available
Background: Physical activity (PA) is low among elderly residents in nursing homes in China. We aimed to determine the factors that influence PA among elderly nursing home residents and their direct or indirect effects on PA levels. Methods: The PA levels of the participants were measured using the International Physical Activity Questionnaire, and their health beliefs were assessed using a self-developed 18-item questionnaire titled the 'Health Beliefs of Nursing Home Residents Regarding Physical Activity' in accordance with Health Belief Model (HBM) constructs. The correlations between HBM constructs and PA levels were analyzed and a regression-based path analysis was conducted to examine the relationships between HBM constructs and PA levels. Results: A total of 180 residents with a mean age of 82.5 years (standard deviation = 5.76) were recruited. Linear regression analysis revealed that self-efficacy (p < 0.001), perceived severity (p < 0.01), and cues to action (p < 0.01) were associated with the level of PA among nursing home residents. In the conceptual path model, self-efficacy, perceived severity, and cues to action had positive direct effects on the PA level, while perceived benefits and perceived barriers had indirect effects on the PA level. Conclusion: The residents' self-efficacy, perceived severity, and cues to action were found to be important factors that can affect the design and implementation of educational programs for PA. A better understanding of such associations may help healthcare providers design informed educational interventions to increase PA levels among nursing home residents.
... Meeting the needs of older persons regarding community and home-based care can greatly reduce older persons' future reliance on health services and assisted living facilities (Ferris et al. 2016). Beswick et al. (2010) have also noted that regular control of older persons in community-based centres and family homes can lead to a reduction in incidences of falls and admissions of older persons. ...
Article
Full-text available
This study evaluates an older person’s services in Gauteng Province, South Africa. The evaluation design was informed by a formative approach. This approach is used in research as a means of gaining insight into how an intervention work and how its weaknesses (if any) can be ameliorated. Three models of care have been found to exist in Gauteng Province, namely family care, residential care, and community care. Family care traditions for older persons in South Africa, including the care of older people, are regularly referred to as examples of good indigenous practices. Family care is mostly based on the “Solidarity Model” where generations use their vantage position to be of assistance to a generation in need. The situation in Gauteng shows that the extended family practice might not always be available for the care of the majority of its older persons. On the other hand, while residential facilities are well established in the province, most of them are privately owned and therefore expensive for the poor majority of older persons. Community-based care emerged in South Africa partly as a solution to the lack of suitable institutions for the majority of older persons and partly as an intervention to mitigate against abuse emanating from some of the institutions meant for older persons. Yet, despite the three models, older persons across Gauteng remain more or less like a flock of sheep without a Shepard. This study argues for the use of an integrated approach of the three existing care models, which is informed by the Convoy Model. The model emphasises the importance of taking a life span and a longitudinal perspective of social relations. Relationships are informed by personal factors such as age, gender, personality, and contextual factors such as poverty. The personal and contextual factors influence the welfare of an individual.
... [23] However, according to the research data, to be capable to live independently at home an elderly person needs a certain state of mental health and satisfactory functional capacity. [24,25] Therefore, in this research of independent living of the elderly, focus has been placed on the analysis of the functional capacity of the elderly. The recognition of frailty in the elderly and an early intervention within the framework of primary health care are important for the care of the elderly. ...
Article
Full-text available
Frailty is a pronounced symptom of aging associated with multiple comorbid states and adverse outcomes. The aim of this study was to evaluate the impact of 2 interventions, one based on prevention of falls and the other on prevention of loneliness, on total frailty and dimensions of frailty in urban community-dwelling elderly as well as associations with independent living.This prospective interventional study followed up 410 persons aged 75 to 95. The participants of the control and intervention groups were monitored through a public health intervention programme. The level of frailty was measured by the Tilburg Frailty Indicator (TFI) questionnaire and the factors of independent living were analyzed using validated questionnaires.After 1 year, physical frailty measured in the control group showed a statistically significant increase (r = -0.11), while in the intervention groups physical frailty did not increase (both P > .05). Psychological frailty measured after 1 year in the control group was significantly higher (r = -0.19), as well as in the group where the public health interventions to reduce loneliness were carried out (r = -0.19). Psychological frailty did not increase in the group in which public health interventions to prevent falls were carried out, and social frailty did not increase at all in the study period. The total level of frailty in the control group after 1 year was significantly increased (r = -0.19), while no increase was seen in the overall frailty in the intervention group. Multivariate analysis has shown that both interventions where independently associated with lower end frailty. Additionally, higher baseline frailty and visit to a physician in the last year were positively associated with higher end-study frailty level, while higher number of subjects in the household and higher total psychological quality of life (SF-12) were independently associated with lower end-study frailty. Only in the prevention of falls group there was no increase in restriction in the activities of daily living throughout study follow-up.Public health interventions to prevent falls and to prevent loneliness have a positive effect on the frailty and independent living of the elderly living in their own homes in an urban community.
... Of 7014 unique citations, 336 articles underwent full-text review and 47 eligible reviews on interventions were identified (Fig. 2). Most eligible reviews addressed older adults and/or those with dementia and evaluated caregiver support (n = 10), 20-29 respite care and adult day programs (n = 9), 30-38 case management (n = 8), [39][40][41][42][43][44][45][46] or preventive home visits (n = 6) 47-52 (see Text Box 1 for descriptions of main intervention categories). The remaining reviews 53-66 were either very broad in scope (e.g., all nonpharmacologic interventions for dementia) or 1-2 reviews addressing an intervention (e.g., home-based primary care). ...
Article
Background: With continued growth in the older adult population, US federal and state costs for long-term care services are projected to increase. Recent policy changes have shifted funding to home and community-based services (HCBS), but it remains unclear whether HCBS can prevent or delay long-term nursing home placement (NHP). Methods: We searched MEDLINE (OVID), Sociological Abstracts, PsycINFO, CINAHL, and Embase (from inception through September 2018); and Cochrane Database of Systematic Reviews, Joanna Briggs Institute Database, AHRQ Evidence-based Practice Center, and VA Evidence Synthesis Program reports (from inception through November 2018) for English-language systematic reviews. We also sought expert referrals. Eligible reviews addressed HCBS for community-dwelling adults with, or at risk of developing, physical and/or cognitive impairments. Two individuals rated quality (using modified AMSTAR 2) and abstracted review characteristics, including definition of NHP and interventions. From a prioritized subset of the highest-quality and most recent reviews, we abstracted intervention effects and strength of evidence (as reported by review authors). Results: Of 47 eligible reviews, most focused on caregiver support (n = 10), respite care and adult day programs (n = 9), case management (n = 8), and preventive home visits (n = 6). Among 20 prioritized reviews, 12 exclusively included randomized controlled trials, while the rest also included observational studies. Prioritized reviews found no overall benefit or inconsistent effects for caregiver support (n = 2), respite care and adult day programs (n = 3), case management (n = 4), and preventive home visits (n = 2). For caregiver support, case management, and preventive home visits, some reviews highlighted that a few studies of higher-intensity models reduced NHP. Reviews on other interventions (n = 9) generally found a lack of evidence examining NHP. Discussion: Evidence indicated no benefit or inconsistent effects of HCBS in preventing or delaying NHP. Demonstration of substantial impacts on NHP may require longer-term studies of higher-intensity interventions that can be adapted for a variety of settings. Registration PROSPERO # CRD42018116198.
Article
There has been an increase in the literature about LGBT older adults in recent years; however, there is a need for further sociological quantitative research examining the impact of geographic region on LGBT aging. Utilizing data from a nationwide survey, this study focuses on the availability of LGBT-specific resources for LGBT aging adults living in the South. We examine the effects of community type and sociodemographics on the availability of LGBT-specific resources as well as the type of resources available. Findings reveal that in the South, community type, having a partner, household income, and education affect the LGBT-specific resources available. Of particular interest, LGBT-affirming faith organizations are identified as the resource most frequently available for LGBT aging adults in this region often referred to as the Bible Belt. Overall, this study sheds light on the LGBT-specific resources that are available to provide social support and help meet the unique needs of LGBT adults aging in the South.
Article
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Objectives Frailty, a multifaceted geriatric condition, is an emerging global health problem. Integrated care models designed to meet the complex needs of the older people with frailty are required. Early identification of innovative models may inform policymakers and other stakeholders of service delivery alternatives they can introduce and locally adapt so as to tackle system fragmentation and lack of coordination. This study used horizon scanning methodologies to systematically search for, prioritise and assess new integrated care models for older people with frailty and investigated experts’ views on barriers and facilitators to the adoption of horizon scanning in health services research. Methods A four-step horizon scanning review was performed. Frailty-specific integrated care models and interventions were identified through a review of published literature supplemented with grey literature searches. Results were filtered and prioritised according to preset criteria. An expert panel focus group session assessed the prioritised models and interventions on innovativeness, impact and potential for implementation. The experts further evaluated horizon scanning for its perceived fruitfulness in aiding decision-making. Results Nine integrated care models and interventions at system level (n=5) and community level (n=4) were summarised and assessed by the expert panel (n=7). Test scores were highest for the Walcheren integrated care model (system-based model) and EuFrailSafe (community-based intervention). The participants stated that horizon scanning as a decision-making tool could aid in assessing knowledge gaps, criticising the status quo and developing new insights. Barriers to adoption of horizon scanning on individual, organisational and wider institutional level were also identified. Conclusion Study findings demonstrated that horizon scanning is a potentially valuable tool in the search for innovative service delivery models. Further studies should evaluate how horizon scanning can be institutionalised and effectively used for serving this purpose.
Article
Background/objectives: To determine the effect of a proactive primary care program on acute hospitalization and aged-residential care placement for frail older people. Design: Controlled before and after, and controlled after only quasi-experimental studies, with a comparison group created via propensity score matching. One-year follow-up. Setting: Nine general practices in Auckland, New Zealand. Participants: Community-dwelling people aged 75 and older identified as at increased risk of hospitalization. One thousand and eighty five patients are compared with 3750 comparison patients matched by propensity score based on known risks. Intervention: Primary healthcare based, registered nurse-led, comprehensive geriatric assessment, goal-setting, care planning, and regular follow-up. Patients were also provided self-management education, health and social care navigation, and transitional care for hospital discharges. Practices received program support, workforce development, and mentoring of primary healthcare nurses by gerontology nurse specialists. Measurements: Outcomes from routinely collected administrative data. Primary: aged-residential care placement. Secondary outcomes: acute hospitalization, mortality, and other health service utilization. Results: Aged-residential care placement (odds ratio [OR] 0.66, 95% confidence interval (CI) = 0.48-0.91) and mortality (OR 0.66, 95% CI = 0.49-0.88) were significantly lower over the first year in Kare patients compared with matched controls. There was no difference in acute hospitalization (+0.06 admissions per year, 95% CI = -0.01-0.13). Support service use (allied health therapists and assessment for social support) was increased, and emergency department use decreased. Conclusion: The Kare participants had lower aged-residential care placement and mortality in the first year, but no decrease in acute hospitalization. Because the design is nonexperimental caution is required in interpreting these results.
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Background: The quality of health care for older Americans with multiple chronic conditions is suboptimal. We designed "Guided Care" (GC) to enhance quality of care by integrating a registered nurse, intensively trained in chronic care, into primary care practices to work with physicians in providing comprehensive chronic care to 50-60 multimorbid older patients. Methods: We hypothesized that GC would improve the quality of health care for this population. In 2006, we began a cluster-randomized controlled trial of GC at eight practices (n = 49 physicians). Older patients of these practices were eligible to participate if they were at risk for using health services heavily during the coming year. Teams of two to five physicians and their at-risk older patients were randomized to either GC or usual care (UC). Six months after baseline, participants rated the quality of their health care by answering validated closed-ended questions from telephone interviewers who were masked to group assignment. Results: Of the 13,534 older patients screened, 2391 (17.7%) were eligible to participate in the study, of which 904 (37.8%) gave informed consent and were cluster-randomized. After 6 months, 93.8% and 93.2% of the GC and UC participants who remained alive and eligible completed telephone interviews. GC participants were more likely than UC participants to rate their care highly (adjusted odds ratio = 2.0, 95% confidence interval, 1.2-3.4, p =.006), and primary care physicians were more likely to be satisfied with their interactions with chronically ill older patients and their families (p <.05). Conclusions: GC improves important aspects of the quality of health care for multimorbid older persons. Additional data will become available as this trial continues.
Article
The substantial increases in life expectancy at birth achieved over the previous century, combined with medical advances, escalating health and social care costs, and higher expectations for older age, have led to international interest in how to promote a healthier old age and how to age "successfully." Changing patterns of illness in old age, with morbidity being compressed into fewer years and effective interventions to reduce disability and health risks in later life, make the goal of ageing successfully more realistic. Debate continues about whether disability has been postponed, although the Berlin ageing study and the US MacArthur study of ageing showed that greater longevity has resulted in fewer, not more, years of disability. A forward looking policy for older age would be a programme to promote successful ageing from middle age onwards, rather than simply aiming to support elderly people with chronic conditions. But what is successful ageing? And who should define it?
Article
Functional assessment screening by the physician is useful for evaluating the health status of elderly patients and determining their needs for in-home assistance, home-health services, or institutional placement. In the acute care setting, functional assessment in selected patients facilitates discharge planning, and is essential in patients over 75 years of age. The American College of Physicians recommends that primary care practitioners incorporate within their routine medical management of older adults procedures for measuring functional deficits and identifying dependency needs. Several assessment instruments are available that can either be self-administered by the patient or employed by ancillary staff in 10 minutes or less. Although no single test is universally recommended, selection of a comprehensive screen followed by a group of targeted instruments can be useful in systematically assessing functional deficits that otherwise might be overlooked by conventional examination methods. Relevant skills and procedures for assessing the functional capacity of elderly patients should be systematically integrated into the curricula of undergraduate and graduate education of physicians. Through continuing medical education, practicing physicians should be prepared to perform and to utilize such examinations. Medicare, and other agencies which set standards for payment for physicians' services, should recognize periodic assessment of functional status of the elderly as a discrete procedure, supplementary to the current standards of practice on which levels of reimbursement are based. Professional time and other resource costs for this procedure should qualify for specified reimbursement in fee schedules.
Article
Background: Protein and energy undernutrition is common in older people, and further deterioration may occur during illness. Purpose: To assess whether oral protein and energy supplementation improves clinical and nutritional outcomes for older people in the hospital, in an institution, or in the community. Data Sources: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, HealthStar, CINAHL, BIOSIS, and CAB s. The authors included English- and non-English-language studies and hand-searched journals, contacted manufacturers, and sought information from trialists. The date of the most recent search of CENTRAL and MEDLINE is June 2005. Study Selection: Randomized and quasi-randomized controlled trials of oral protein and energy supplementation compared with placebo or control treatment in older people. Data Extraction: Two reviewers independently assessed trials for inclusion, extracted data, and assessed trial quality. Differences were resolved by consensus. Data Synthesis: Fifty-five trials were included (n = 9187 randomly assigned participants). For patients in short-term care hospitals who were given oral supplements, evidence suggested fewer complications (Peto odds ratio, 0.72 [95% Cl, 0.53 to 0.97]) and reduced mortality (Peto odds ratio, 0.66 [Cl, 0.49 to 0.90]) for those undernourished at baseline. Few studies reported evidence that suggested any change in mortality, morbidity, or function for those given supplements at home. Ten trials reported gastrointestinal disturbances, such as nausea, vomiting, and diarrhea, with oral supplements. Limitations: The quality of most studies, as reported, was poor, particularly for concealment of allocation and blinding of outcome assessors. Many studies were too small or the follow-up time was too short to detect a statistically significant change in clinical outcome. The clinical results are dominated by 1 very large recent trial in patients with stroke. Although this was a high-quality trial, few participants were undernourished at baseline. Conclusions: Oral nutritional supplements can improve nutritional status and seem to reduce mortality and complications for undernourished elderly patients in the hospital. Current evidence does not support routine supplementation for older people at home or for well-nourished older patients in any setting.
Article
Objective: To assess the effects of preventive home visits to elderly people living in the community. Design: Systematic review. Setting: 15 trials retrieved from Medline, Embase, and the Cochrane controlled trial register. Main outcome measures: Physical function, psychosocial function, falls, admissions to institutions, and mortality. Results: Considerable differences in the methodological quality of the 15 trials were found, but in general the quality was considered adequate. Favourable effects of the home visits were observed in 5 out of 12 trials measuring physical functioning, 1 out of 8 measuring psychosocial function, 2 out of 6 measuring falls, 2 out of 7 measuring admissions to institutions, and 3 of 13 measuring mortality. None of the trials reported negative effects. Conclusions: No clear evidence was found in favour of the effectiveness of preventive home visits to elderly people living in the community. It seems essential that the effectiveness of such visits is improved, but if this cannot be achieved consideration should be given to discontinuing these visits.
Article
While the benefits of physical activity and exercise among older persons are becoming increasingly clear, the role of exercise stress testing and safety monitoring for older persons who want to start an exercise program is unclear. Current guidelines regarding exercise stress testing likely are not applicable to the majority of persons aged 75 years or older who are interested in restoring or enhancing their physical function through a program of physical activity and exercise. In addition to being expensive and of unproven benefit, the current policy of routine exercise stress testing potentially could deter many older persons from participating in an exercise program. Research is needed to investigate current physician practices, evaluate the risk of adverse cardiac events, determine the role of pharmacological stress testing, and measure and compare absolute and relative exercise intensities. To assist clinicians, we offer a set of recommendations regarding precautions that can be taken to minimize the risk of adverse cardiac events among previously sedentary older persons who do not have symptomatic cardiovascular disease and are interested in starting an exercise program.