frail older people: can rehabilitation assist?.conference.co.nz/files/docs/aocprm/1200 ngaire...
TRANSCRIPT
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Frail older people: Can Rehabilitation assist?.
Ngaire Kerse, PhD, FRNZCGP
GP and Head, School of Population Health
Wednesday, 5 December 2018
The answer:
290, 577, 814 people in 2000
612, 888, 500 people in 2050
How many people need daily care?
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NZ population projection
3 Statistics New Zealand
4
Diversity of older people
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Specific diseasesFrailty
Spectrum of impairments
Spectrum of disability
SES
psy
cho
soci
alSo
cial
cap
ital
A
ge fr
ien
dly
en
viro
nm
ents
Health services, rehabilitation
Public/ population
health initiatives
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Specific diseasesFrailty
Spectrum of impairments
Spectrum of disability
GP education
Physical Activity
promotion
Fall prevention
BRIGHT trialSystematic case finding
Dementia prevention
Dance & Ronnie Gardner Method
Dementia treatmentCognitive
Stimulation Therapy and
exercise
Cohort study, LiLACS NZ Māori, non-Māori 80+, bicultural engagement,
6 yrs data.
Assistive technologies
Enablement
Rehabilitation
eg.
muscle strength
30 Age (time) 80
thresholdreserve
Acute illness
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eg.
Aerobic capacity
30 Age (time) 80
reserve
Athletes
Hodgeson
LiLACS NZ, Health Independence and caregiving
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Gender
FEMALEMALE
Me
an
am
ou
nt
of
ac
tiv
ity
ov
er
2 w
ee
ks
(m
inu
tes
)
800
600
400
200
0
other
housework
sports
gardening
walking
Usual physical activity
• 164 women, 103 men
• age 73.6 (65-97yrs)
• Walking, (min/ 2 wks)
137min
• Oldest old had similar pattern
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The most frail• Residential care
– 22% of those over 75yrs
– Rest homes, Private hospitals
– Less activity, more dependence
• Specific groups– Visually impaired
– Those who fall
– Those with low mood
• Activity can be a life preserver
Frailty
– Proven success
– The PIRC trial – residential care
– DeLLITE trial – those with depression
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Ian Cameron
Activity, gait speed, depression, HRQOL
Home discharge from inpatient geriatric rehab.
Intervention • 12m multi-disciplinary team
• Frailty category targeted
– Wt loss – dietitian, delivered meals
– Exhaustion – psychologist, social intervention
– Slow, weak, low activity – 10 home based physio visits, programme,
• Case management with regular review
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Residential care – PIRC- Kathy Peri
• Aims
– ADL based activity with goal setting• Function
• QOL
• falls
Randomisation (no statification)
Randomly selected: rest-homes in Christchurch and Auckland
Falls surveillance begun, Baseline Data (Fnc QOL) collected
Outcome evaluation •Function, QOL 6m
•Continued falls surveillance 1yr
•(12m all measures)
Methods PIRC
Social Group•Everyday worlds
interview x2•falls surveillance
Activity Group•PIRC, goal set, functional
assessment, PIP to caregiver
• falls surveillance
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Intervention• Goal setting program that uses activities of daily
living to increase function and quality of life for those older people residing in rest homes.
• Change in culture from one of dependence to independence.
• Ownership of resident and goal orientate self empowerment / proactive in self care.
• Health care assistants supervised the program with the older person.
Types of Goals Older Residents Set
• To walk to top of drive to visit family
• Attend a family wedding in two months time
• To grow vegetables in the raised garden
• To go to the Flower show
• To learn the computer at senior net
• To walk outside around the garden
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Overall function
Falls – no difference
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ADL rehab in residential care
Understand your population
Match the strategy to the individual
Measure meaningful outcomes
Not all strategies good for all
Kerse et al BMJ 2008:337;7675
Randomisation (no cluster)
Randomly selected: GPs, letters to all >75 yrs (2407), screen for
depression (2/3 qu+, 355, 15%), Baseline Data (depression, function,
QOL) collected. 32 GPs, 193 older people (70% of those cleared by GP)
Outcome evaluation •Function, QOL 6m, 12m
•70% completed follow up
•falls
Depression - DeLLITE trial
Social visits• 7 visits over 6
months,• social spaces
Activity Group• Enhanced Otago Exercise Prog
• Goal setting, upper limb, social
helper, 7 visits in 6 m
Funded by the HRC
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Results • Group Characteristics
mean (SD) or n (%) Activity
N = 97
Social
N = 96
Total
N = 193
Female n (%) 62 (63.9%) 51 (53.1%) 113 (58.5%)
Age 81.4 (4.8) 80.8 (3.9) 81.1 (4.4)
Widowed 46 (47.4%) 42 (43.8%) 88 (45.6%)
Lives alone 54 (55.7%) 46 (47.9%) 100 (51.8%)
Hospitalised in the last 12
months n (%)
32 (33.0%) 33 (34.4%) 65 (33.7%)
Total prescription medications 6.7 (3.7) 6.2 (3.8) 6.5 (3.7)
Depression sx, GDS >4 21 (21.6%) 35 (36.5%) 56 (29.0%)
Any depression criteria met
on CIDI 29 (29.9%) 40 (41.7%) 69 (35.8%)
Antidepressants 28 (28.9%) 23 (24.0%) 51 (26.4%)
Results • Walking behaviour
0
50
100
150
200
250
300
350
400
0 6 12
Month
Walk
ing
(m
ins/f
ortn
igh
t)
Physical activity
Social activity
0.049
0.016
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Results • Reported function - NEADL
16.8
17
17.2
17.4
17.6
17.8
18
18.2
18.4
18.6
0 6 12
Month
NE
AD
L
Physical activity
Social activity
0.003
0.559
Results • Quality of life – SF-36 mental health (MCS)
42
44
46
48
50
52
54
56
58
0 6 12
Month
SF
-36 M
HC
Physical activity
Social activity
<0.001
0.084
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Results • Depression - GDS-15
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
5
0 6 12
Month
GD
S-1
5
Physical activity
Social activity
<0.001
0.293
Kerse et al AnnFamMed 2009
Conclusion
• Social participation as good as physical activity in improving outcomes for older people with depression
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Summary
• Rehabilitation is useful in those with frailty
• Holistic approach with as much resource as possible
• Social integration needs more consideration
Things to do state of mind