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Promoting Health and Wellbeing in Later LifeInterventions in Primary Care and Community Settings

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Promoting Health and Wellbeing in Later Life. Interventions in Primary Care and Community Settings.

Helen Frost, Sally Haw and John Frank

Scottish Collaboration for Public Health Research and Policy

MRC Human Genetics Unit building

Western General Hospital

Crewe Road

Edinburgh EH4 2XU Scotland U.K.

Available on the internet at www.SCPHRP.ac.uk

ISBN: 978-0-9565655-5-6

Copyright ©Scottish Collaboration for Public Health Research and Policy 2010

This work was funded by the Medical Research Council and the Chief Scientist Office of the Scottish Government. Views expressed in this publication are those of the authors and do not necessarily reflect those of the Medical Research Council or the Chief Scientist Office of the Scottish Government.

Helen Frost PhD, MSc, MCSP

Sally Haw BSc, HnMFPH

John Frank MD, CCFP, MSc, FRCP (C), FCAHS, FFPH

Promoting Health and Wellbeing in Later Life. Interventions in Primary Care and Community Settings.

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Acknowledgements

• MembersoftheLaterLifeWorkingGroupoftheScottishCollaborationforPublicHealthResearchandPolicy.

• DonnaCiliska,ScientificDirectorandSharonPeck-Reid,ResearchAssistant,NationalCollaboratingCentrefor(PublicHealth)MethodsandToolsatMcMasterUniversity,Canada.

• SamBainandCarolineRees,AdministratorsfortheScottishCollaborationforPublicHealthResearchandPolicy.

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Table of contents

Glossary

Executive summary

Background

Methods

Results

Conclusion

Chapter 1: Introduction Populationdemographics

Determinantsofhealth

WorldHealthOrganizationclassificationoffunctioning,disabilityandhealth(ICF)

TheDisablementProcess

Socioeconomicinequalities

Frailty

Riskfactorsforfunctionaldecline

Identificationofolderpeopleatrisk

BackgroundoftheScottishCollaborationforPublicHealthResearchandPolicy(SCPHRP)

Aimofscan

Objectives

Chapter 2: Literature search methods

Peer-reviewedliteraturesearch

Keysearchwords

InclusionCriteria

ExclusionCriteria

PublicationSelection

Websitesearch

Assessmentofqualityofreviews

Chapter 3: International and scottish policies for older people

Introduction

Internationalpolicies

ScottishGovernmentpolicies

Peopleandsociety

Healthandcommunitycare

Chapter 4: Literature search results

Introduction

Results

Classificationofolderpeople

Classificationofinterventions

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Chapter 5: Complex interventions

Summary

Introduction

Definitions

Reviewliterature:complexinterventions

Comprehensivegeriatricassessmentandhomevisitsforgeneralandfrailolderpeople

Homevisitsforfrailolderpeople

Homevisitsforolderpeoplewithdisability

Multidimensionalpreventativehomevisitprogrammesforgeneralandfrailolderpeople

Integratedservicedeliveryandcasemanagement

Reviewsofintegratedcasemanagement

Primarystudiesofcomplexinterventions

Casemanagement

Primarystudiesofscreeningforunmethealthneeds

Chapter 6: Interventions to prevent falls and fractures

Summary

Introduction

Categoriesoffallsprevention

Outcomemeasuresforfallsprevention

Reviewliterature:fallspreventioninterventions

Reviewsofindividual-levelinterventionsforfallsprevention

Multi-factorialassessmentandtargetedinterventionforpreventingfallsandinjuryamongolderpeopleinthecommunity

Individualandcommunityfallpreventionstrategies

Reviewofpopulation-basedstudiesoffallsprevention

Costeffectivenessoffallspreventioninterventions

Disparityinthefallsliterature

Chapter 7: Physical activity and exercise interventions Summary

Introduction

Reviewliterature:exerciseinterventions

Progressiveresistancetrainingprogrammes

Effectsofaerobicandphysicalactivityinterventions

Interventionstopreventdisabilityinfrailcommunity-dwellingolderpeople

Physicalactivityandpsychologicalwellbeinginolderpeople

Behaviouralfactors

Limitations

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Chapter 8: Nutritional interventions

Summary

Introduction

Reviewliterature:nutritionalandsupplementinterventions

Chapter 9: Information and communication technology interventions

Summary

Introduction

Reviewliterature:Informationcommunicationtechnologyinterventions

Hometelecareforfrailolderpeopleandthosewithlongtermconditions

Socioeconomicimpactoftelehealthandtelemedicine

Greyliteraturereviewsandreports

Chapter 10: Interventions to prevent social isolation and loneliness

Summary

Introduction

Reviewliterature:interventionstopreventsocialisolation

Chapter 11: Medication review

Summary

Introduction

Reviewliterature:medicationreview(pharmacyandGP-ledinterventions)

Chapter 12: Discussion

Introduction

Complexinterventions

Fallsprevention

Specificproblemsassociatedwithageing

Specificinterventions

Policiesforhealthyageing

Thebroaderpicture

Limitationsofthereview

Gapsinevidence

Conclusions

Recommendations

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Appendices

Appendix1MEDLINE(OVID)searchterms

Appendix2AMSTARqualityassessmentscoringsystem

Appendix3Reviewofreviewsofcomplexinterventions

Appendix4Reviewsofcomplexinterventions

Appendix5Randomisedcontrolledtrialsofcomplexinterventions.

Appendix6Reviewsofexerciseandphysicalactivityinterventions

Appendix7Reviewsofinformationcommunicationtechnologyinterventions

Appendix8Reviewsoffallspreventioninterventions

Appendix9Reviewsofinterventionsaimingtopreventsocialisolationandloneliness

Appendix10Reviewsofvisionscreening,nutritioninterventionsandmedicationreview

Appendix11ThePRISMAmodelofintegratedservicedelivery

Appendix12Effectivenessofinterventionsfortheriskoffalls

REfERENCE LIst

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Disabilityreferstorestrictionorlackofabilitytoperformanactivityinanormalmanner.

Disablementreferstotheimpactthatchronicandacuteconditionshaveonbodilyfunctionandtheabilityofindividualstocopeinsociety.Themainpathwaysleadfrompathology,toimpairment,tofunctionallimitationsanddisability.

Impairmentreferstolossorabnormalityofpsychological,physiologicaloranatomicalstructureorfunction.

Theoddsofaneventhappeningintheexperimentalgroupexpressedasaproportionoftheoddsofaneventhappeninginthecontrolgroup.TheclosertheORistoone,thesmallerthedifferenceineffectbetweentheexperimentalinterventionandthecontrolintervention.IftheORisgreater(orless)thanone,thentheeffectsofthetreatmentaremore(orless)thanthoseofthecontroltreatment.Notethattheeffectsbeingmeasuredmaybeadverse(e.g.deathordisability)ordesirable(e.g.survival).

Theprobabilitythatanobservedorgreaterdifferenceoccurredbychance,ifitisassumedthatthereisinfactnorealdifferencebetweentheeffectsoftheinterventions.Whentheprobabilityislessthan1/20(P<0.05),thentheresultisregardedasbeing‘statisticallysignificant’.

Randomisedcontrolledtrial.

Therateoffallsreferstothetotalnumberoffallsoveraperiodoftimeincludingrepeatfallsofthesameperson:forexample,numberoffallsperpersonperyear.Thisisthestatisticallypreferredoutcomealthoughmaynotbeasusefulinstudiesthatarefocusedonprimaryprevention.

Thenumberoftimesmorelikely(RR>1)orlesslikely(RR<1)aneventistohappeninonegroupcomparedwithanother.

Theriskoffallscomparesthenumberofparticipantsineachgroupwithoneormorefalleventsduringthetrial,orduringanumberoftrialsifthedataarepooledi.e.theoccurrenceofmorethanonefallperpersonisessentiallyignoredandtreatedthesameasonefall.

Ameasureofeffectsizeusedwhenoutcomesarecontinuous(suchasheight,weightorsymptomscores)ratherthandichotomous(suchasdeathormyocardialinfarction).Themeandifferencesinoutcomebetweenthegroupsbeingstudiedarestandardisedtoaccountfordifferencesinscoringmethods(suchaspainscores).Themeasureisaratio;therefore,ithasnounits.

Ameasureofeffectsizeusedwhenoutcomesarecontinuous(suchassymptomscoresorheight)ratherthandichotomous(suchasdeathormyocardialinfarction).Themeandifferencesinoutcomebetweenthegroupsbeingstudiedareweightedtoaccountfordifferentsamplesizesanddifferingprecisionbetweenstudies.TheWMDisanabsolutefigureandsotakestheunitsoftheoriginaloutcomemeasure.

Disability

Disablement

Impairment

Odds ratio (OR)

P value

RCT

Rate of falls (RaR)

Relative risk (RR)

Risk of falls (RR)

Standardised mean difference (SMD)

Weighted mean difference (WMD)

Glossary

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Background

ThepopulationofolderpeopleinScotlandhasbeengrowingoverthelastcenturyandprojectionsestimatethat26%(1.3million)ofthetotalpopulationwillbeaged60oroverby2031.Thedependency-ratio1isprojectedtoremainmoreorlessstableuntil2018butby2033itisexpectedtoincreaserapidlyto68per100(1).Inadditionprojectionsfor2031comparedwith2008,suggestthattherewillbean84%increaseinthenumberofpeopleagedover75,theageatwhichadramaticincreaseintheprevalenceofphysicaldisabilityoccurs.Thisisaconcernasitwillbecomeincreasinglydifficulttomaintainadequatepensionandsocialsecuritysystemsforolderpeople.Itisnotinevitablethatallolderpeoplewilllivewithdisabilityandillhealth,butthesetrendsarestronglypatternedbysocioeconomicposition.InScotlandthebalanceofevidencesuggeststhatthetopsocialandeconomicgroupsarelivinglongerandhealthierliveswhereasthebottomgroupsaredisabledearlier,andtheirperiodoflivingwithdisabilityismoreprolonged.ThescanaimstoprovideanoverviewoftheevidenceforinterventionsthatpreventordelayphysicaldisablementinlaterlifewithaviewtoinformingpolicymakersanddevelopingequitableinterventionstrategiesinScotland.

Inordertoprepareforthechallengeofanincreasingolderpopulation,theLaterLifeWorkingGroupoftheScottishCollaborationforPublicHealthResearchandPolicychosetofocustheirpriorityoninterventionsinprimarycareandcommunitysettingsthatpreventordelayfunctionaldeclineinolderpeople.Functionaldeclineisintegraltothe‘disablementprocess’whichreferstotheimpactthatchronicandacuteconditionshaveonbodilyfunctionandtheabilityofindividual’stocopeandliveindependentlyinsociety(2).

Theoverallobjectiveoftheenvironmentalscanistoinvestigateinterventionsinprimarycareandcommunitysettingsthataimtopreventordelayphysicaldisablementinolderpeopleandpromotehealthyageing.Thescanincludes:1)abriefsummaryofrelevantinternationalandScottishpoliciesforhealthyageing;and2)areviewofevidenceforinterventionsinprimarycareandcommunitysettingsthatfocusonpreventingphysicaldisablementinolderpeople.

Methods

Asearchofwebsiteswasconductedtofindinformation,resourcesanddocumentsrelevanttoresearch,interventions,policiesandprogrammesdeliveredinScotlandorinternationallythataimtoimpactonhealthandreduceinequalitiesinolderpeople.

AliteraturesearchwascarriedoutinconjunctionwiththeNationalCollaboratingCentrefor(PublicHealth)MethodsandToolsatMcMasterUniversity,Canada.ThesearchwascarriedoutfortheperiodSeptember1999toSeptember2009,ofthefollowingdatabases:OvidMEDLINE,EMBASE(ovid)andCINAHL(CumulativeIndextoNursingandAlliedHealth).Thesearchfocusedonreviewarticles,randomisedcontrolledtrials(RCTs)andexperimentalstudiesthataimedtopreventdisablementofolderpeople(50+years)livinginacommunitysetting.Studiescarriedoutinnursinghomesandhospitalswereexcludedalongwithinterventionsprimarilyfocusedontreatmentormanagementofspecificdiseaseorproblems(i.e.chronicheartdisease,stroke,diabetes,incontinenceanddementia),asmanyolderpeoplesufferfromcomorbiditiesandsynthesisofalldisease-specificinterventionswouldhavebeenuntenablewithinthetimeframe.

1Thedependency ratioisanage-populationratioofthosetypicallynotinthelabourforce(thedependentpart)andthosetypicallyinthelabourforce(theproductivepart).

Executive Summary

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Results

Policy review: International

InternationalpoliciesforactiveageinghavebeenadvocatedbytheWorldHealthOrganization,andmorerecentlytheOrganisationforEconomicCo-operationandDevelopment(OECD).Theyallaimtopromotehealthyageingamongstpeopleover50years.Policyrecommendationsparticularlyrelevanttotheaimsofthisscaninclude:1)improvingsocialintegrationtopreventloneliness/isolationandtoprovideopportunitiesforvoluntaryworkforolderpeople;2)addressingsocialrelationships,poverty,discriminationthathaveanimpactonmentalhealth;3)improvingaccesstosafeandstimulatingindoorandoutdoorenvironments;4)promotinghealthyfoodandeatinghabits;5)increasinglevelofphysicalactivitytoreachrecommended30minutesperday;6)initiatingsafetypromotionandinjuryprevention;7)promotingsmokingcessationandreducingalcoholconsumption;8)usingqualityindicatorsfordruguseandimprovingcoordinationamongcareproviders;9)improvingpreventativehealthservices(e.g.immunisationprogrammes)andconsideringpreventativehomevisitsundercertainconditions.InadditionthemorerecentlypublishedpoliciesforhealthyageingfromtheOECD(Oxley2009)(3)recommendadaptinghealthsystemstotheneedsofolderpeopletomakethemmorepatient-centredandcoordinated.

Policy review: Scottish

ThereareanumberofoverarchingScottishpoliciesthathavebeenintroducedsincetheKerrReportin2005thatarerelevanttothehealthandwellbeingofolderpeople.TheBuilding a Health Service Fit for the Future (2005)policyoutlinesplansovera20yearperiodtoshifttheemphasisofcarefromhospitaltocommunitycare.Italsoadvocatespreventativeratherthanreactivemanagementandimprovingsystemsofcaredeliverythroughaframeworkforjointservices.

TheEqually Well (2008)policyemphasisesthattheoverallgoalofthegovernment,sustainableeconomicgrowth,canonlybeachievedthroughareductioninhealthinequalities.Thisisachallengingproblemtotackleasresearchsuggeststhatwhilstthehealthofthecountryasawholeisimproving,someinequalitiesarewideningandvirtuallynonearenarrowing(4).TacklingpovertyisalsoaddressedinAchieving Our Potential(2008),aframeworkaimedattacklingpovertyandincomeinequalityinScotland.ThispolicysetsouttheapproachoftheScottishGovernmentinthefightagainstpoverty.Theactionplansspecificallyaimedatolderpeopleincludeabolishingprescriptioncharges,providingassistanceforcentralheatingandsupportingcommunityplanningpartnerships.

Variousinitiativeshavebeenproposedthataimtosupporttheoverarchingpolicies.TheLongTermConditionsCollaborative(2008–2009)hasbeendesignedanddevelopedbytheImprovementandSupportTeam(IST)andNHShealthboardswithanaimtoimprovethequalityofcareprovidedforpeoplewithlongtermconditionsandthatgenerally,althoughnotexclusively,involvesolderpeople.Tenactionsareidentifiedasbeingimportantfactorsinthemanagementofolderpeople.Theseincludestratifyingandidentifyingthoseatrisk,introducinganticipatorycareplans,targetinganddeliveringaproactivecase/caremanagementapproach,communicatingandsharingdataacrossthesystem,developingintermediatecarealternativestoacutehospital,providingtelehealthandtelecaresupport,developingfallspreventionpathwaysandservices,providingpharmaceuticalcareandensuringtimelyaccess,flexiblehomecareandcarersupport.

Themostrecentproposal,Reshaping Care for Older People(Dec2009–ongoing),isbasedondemographicprojections.Currentarrangementsforthecareofolderpeoplearenotsustainableduetotheinevitabledramaticincreaseinthepopulationofolderpeople,consequentrisingcostofcare,andlackofsufficienthumanresourcestodeliverthecare(5).Theproposaltoreshapethecareofolderpeopleisbeingdevelopedthroughaframeworkofeightworkstreamsandcollaborationwithclinicalexperts,MSPs,governmentpolicymakersandmembersofspecialinterestgroups.Fiveoftheworkstreams

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focusonservicedesign(carehomes,careathome,carepathways,planningforageingcommunitiesandhealthylifeexpectancy),twoondemographicsandfunding,andonerelatestotheworkforce.Thereisanover-ridingthemeofsupportingunpaidvoluntarycareinthecommunitytoreduceunnecessaryhospitaladmissions.TheworkstreamPromotingHealthyLifeExpectancyisthemostrelevanttothecontentofthisscanasitfocusesonevidenceforeffectiveinterventionstopromotehealthierlifestylechoicesandpreventfunctionaldeclineinolderage.Incontrastwiththisscantheproposaltakesalargelydisease-specificapproachtomanagementthatdoesn’tencompassallfactorsassociatedwithdisablementinolderpeople.

Literature review

Thesearchidentified62structuredreviewsormeta-analysisofcomplexandspecificinterventionsinthepeer-reviewedandgreyliteraturethatpredominantlyincludedrandomisedcontrolledtrials.Itwasnotpossibletoincludeallprimarystudiesintheliteraturereviewalthoughthemostrecentstudieswerediscussed,iftheywerenotincludedinthereviewsoriftheywereparticularlyhighqualityorrelevanttopolicymakers.Thereviewsweregroupedintocomplex(comprehensivegeriatricassessment,preventivehomevisits,fallsprevention,casemanagementandintegratedservicedelivery)andspecificorsingleinterventions(exercise,nutritionalinterventions,informationcommunicationtechnology[telecare/telehealth],socialintegration,environmentalmodifications/adviceonassistivedevicesandvisionscreening)butthereweremanyoverlappingcomponents.

Complex interventions

Overall,therewasalotofinconsistencyintheliteratureanddeterminingthebenefitsofcomplexinterventionsisdifficultduetoheterogeneityofthepopulationsstudied,contentandcontextoftheinterventionsandparticularlythelackofstandardisationofoutcomemeasures.Outcomesofcomplexinterventionsforolderpeoplearegenerallyfocusedonpreventinghospitaladmission,althoughthereisgoodevidencethatsimplymonitoringadmissionratescannotassesstheeffectivenessofinterventionswithoutamatchedcontrol(6)anditisimportanttoconsiderotherNHSuseandnon-NHSinstitutionaladmissioninordertoaccuratelymeasuretheeffectsofintervention.Inaddition,improvementinfunctionisnotalwaysassociatedwithareductioninhospitalorinstitutionaladmission,suggestingthatthedriverforinstitutionaladmissionmayhavemoretodowithfactorssuchaspoverty,supportathomeorcarer/patientpreferences.

Evidencefromreviewlevelandprimarystudiessuggestthatthecaseforimplementationofcomplexinterventionsisrelativelyweakbuttherearesomeareasofpotentiallypromisingdevelopment.

Forthegeneralolder population, comprehensive geriatric assessmentfollowedbymulti-factorialinterventioncanbeeffective,intermsofbothreducinginstitutionaladmission,riskoffallsandimprovingphysicalfunctionbuteffectsaregenerallysmallandmoreresearchisneededtoidentifywhichcomponentsofcarearemosteffective.Promisingevidencefromreview-leveldatasuggeststhat,atleastforthegeneralpopulationofolderpeople,nursinghomeadmissionmaybereducedbyapproximately14%(7).Afocusonnursinghomeadmissionmaybemoreworthwhilethanotheroutcomessuchasmortalityrates,whichareclearlymoredifficulttomodify.Ideally,itseemsimportanttoassessallinstitutionalandprivatenursinghomeadmissionsalongsidemortalityrates,asassessingonewithouttheothermayleadtomisinterpretationoftheeffectivenessofinterventions.

Forfrail older people at higher risktheevidenceforcomprehensive geriatric assessmentismixedandlessrobust.Thechallengeforresearchersistoidentifywhichgroupofolderpeoplearemostlikelytobenefitfromthistypeofintervention.

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Multi-factorial home visitsinterventionshavethepotentialtoachievesmallpositivebenefitsbutevidenceisnotconsistentandmaybedependentonfactorssuchastheexperienceofthecareprovider,easyaccesstoprovisionoffollowupservicesandlengthoffollowup.Acomprehensiveapproachthatincorporatesavarietyofinterventionstrategies(e.g.diseasemanagementandhealthpromotion)targetingriskfactors,addressingtheperson’smultipleco-existingmedical,functional,psychologicalandenvironmentalproblems,mayhavepotentialtopreventanddelayphysicaldisablement,buttheevidenceisfarfromconclusive.Thisscandidnotfocusoninterventionsforolderpeopledischargedfromhospitalbuthomevisitsforthisgroupofolderpeople,whoaremostlikelytobefrail,havebeenshowntobeeffectiveinreducingtheriskofnursinghomeadmissions.

Thereisinadequateevidencetosupportstrategiestodeliverhealthpromotionandpreventativecareinolderpeoplethroughuniversalbroad-basedscreeningandassessmentinprimarycare.Preventativestrategiesbasedonadvicealonedonotappeartobeeffectiveforolderpeople(8).

Integrated service delivery programmeshavebeenshowntopreventfunctionaldeclinebutlongtermfollowupisessentialandmoreevidenceisrequiredtosupporttheimplementationofalarge-scaleprogrammeintheScottishcontext.

Thereisapaucityofgoodqualitydataoncost-effectivenessbutprogrammesprovidingintensivefollowuparemorelikelytobebeneficialwhethertheybepreventativehomevisitsorincludeanall-inclusiveintegratedapproach.RecentlypublishedRCTssuggestthatmultidisciplinary,geriatricassessmentisaneffectiveadditiontoprimarycare,forfrailolderpeople,ata‘reasonable’costandintegratedcare,includingcasemanagementforolderpeoplewithmoderatedisability,hasthepotentialtoshiftinstitutionalcaretohomecareserviceswithoutadditionalcosts(9–11).Thisisnottosaythattheseinterventionsreducedisablementpersebuttheymayallowolderpeopletoremainintheirownhomesforlongerwithnoadditionalcoststothepublicsector.

Falls prevention

Alargebodyofwork,includingavastnumberofRCTs,hasbeencarriedoutinthefieldoffallspreventionandmanydiverseprogrammeshavealreadybeenimplementedacrossScotland.Thereisconsistentevidenceforthebenefitsofexerciseinpreventingtheriskandrateoffalls(12;13),particularlyforlongtermexerciseprogrammesandtheymaybecost-effective(14;15).Thereisnostrongevidencethatanyspecifictypeofexerciseisbetterthananotheralthoughbalanceexercisesarepreferabletowalking.Theevidenceformulti-factorialprogrammesislessconvincing(12).Multi-factorialassessmentfollowedbytargetedinterventionappearstobeeffectiveinreducingtherateoffalls,butnotriskoffalls.Inlayterms,theeffectsarestrongerforreducingfallrecurrencesthanfirstfallsand,whilstitappearsdifficulttopreventfallscompletely,peoplewhofallfrequentlymaybehelpedtofallless.Thesuccessofmulti-factorialfallspreventionprogrammesislikelytodependontwomainfactors:1)targetingspecificgroupsofolderpeoplewithmodifiableriskfactorsand;2)adequateintegrationofservicedeliveryworkingacrossthecommunity-hospitalinterface,incorporatingarangeofprofessionalcare.Multi-factorialprogrammesthatrelyonreferralratherthandirectmanagementarelesslikelytobeeffective.

Specific interventions

Evidenceforspecificinterventionsisalsomixed.Thereisgoodevidencethatexerciseprogrammesforolderpeoplecanimprovestrength,aerobiccapacity,balanceandfunction.Themagnitudeofeffectsrangefromsmalltolarge,reducewithageandaresmallestfortheolderagegroup(80+)andthosewithpre-existingdisability.Thereisalsoevidencethataerobicexercisehasaneffectonsomemeasuresofcognitivefunction,suchascognitivespeed,butthemagnitudeofeffectissmall,andnotconsistentforall

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measures.Thereisalackofevidencetolinkgainsinimpairment2withreductionofdisability3perse–anoutcomemuchmorerelevanttotheabilitytomaintainindependenceandliveinthecommunity.However,thismaybeduetotheoutcomemeasuresusedtoassessfunctioninolderpeoplethatmaynotbesensitiveenoughtodetectimportantchange.

Benefitsgainedfromexercisearedependentonlongtermadherenceandingrainedexercisebehaviour,whichisgenerallyestablishedearlierinlifeanddifficulttoshift.Themostpromisingprimary-care-basedinterventionsforincreasingphysicalactivityinolderpeoplearethosethatofferwrittenmaterialasremindersandaretailoredtoparticipants’characteristics.Inaddition,itappearstobeimportanttomakeanimpact‘upstream’beforeretirement,andfocusonactivitiesthatgeneratefeelingsofenjoymentandsatisfaction(16).

Theevidence-basefortheeffectivenessofnutritional interventionsandvision screeningisrelativelyweakforolderpeople.Thereissomeevidencethatdietaryadvice,incombinationwithsupplementsimprovedietaryintakeandweightgain(at1year)inundernourishedolderpeople,butthereisnoevidenceofeffectonmortalityorhospitaladmissionrates.Medication reviewbypharmacistorotherhealthprofessionalsdoesnothaveanyeffectonreducingmortalityorhospitaladmission.Effectsonqualityoflifeareminimal,althoughthereisevidence(fromtwostudies)thatmedicationreviewmayreducetherateoffalls.Thereislimitedevidencethatadvice on assistive devicesandenvironmentalmodification,givenbyoccupationaltherapists,canimprovefunctionalabilityandreducetheriskoffallsinolderpeople,butnoneoftheseratherspecificinterventionsarelikelytohavealargeimpactonreducingdisablement,whendeployedinisolation.

The information and communication technology (telecare and telehealth interventions)literatureisanewlyemergingfieldthathasnotbeensubjectedtohighqualityevaluationandmostoftheevidenceisbasedonobservationalcohortstudieswithoutcontrolgroupsorsmall,lowquality,RCTs.Thereisverylittleevidencefortheimpactoftelecareatthepopulationlevelforolderpeople.Thebestevidencefortelecareisimprovedclinicaloutcomes,suchasenhancedqualityoflifeforfrailolderpeopleandtheircarers,byincreasingtheirabilitytoliveindependentlyintheirownhomes.Thereislimitedevidencethattelemedicineisacost-effectivemeansofdeliveringhealthcareandwhilstthereissomeevidencefromobservationalstudiesinScotlandthatsuggestcostsavingsmaybemadeintermsofreducedhospitaladmission,homecheckvisitsandsleepovernightsfromtelecare(safetyandsecuritymonitoringsystems),thispotentialneedstobeassessedinacontrolledstudy.Expertsinthefieldofinformationandcommunicationtechnologyadvisethatoverlyoptimisticassessmentoftheeffectsoftelecareonthedemandforinstitutionalcare,bothintheshortandlongterm,shouldbeavoided(17).

Social isolationisacommonprobleminlaterlifeandisassociatedwithpoorphysicalhealthandincreasedmortality,mentalillhealth,depression,suicideanddementia(18)butithasnotbeenextensivelyresearchedinolderpeople,particularlyintheUK.Thereislimitedevidence(fromsmallRCTsofvariablequality)fortheeffectivenessofgroupactivities,thatincludesomeformofeducationalortraininginputandsocialactivitiesthattargetspecificgroupsofpeople,buttheeffectsarelikelytobesmallandnotgeneralisable.One-to-oneinterventions(homevisits),telephonefriendshipsandnurse-moderatedcomputerlinksarenoteffectiveinreducinglonelinessorsocialisolation(19;20).Theresearchtodatehasfocusedonafewpotentialcausesofsocialisolationandloneliness,butinrealitythecausesarecomplexandrelatedtomanyenvironmental,socialandculturalfactors.Itisthereforenotsurprisingthattheeffectivenessoftheinterventionsstudiedtodateisvariableandgenerallysmall.

2Impairment(lossorabnormalityofpsychological,physiologicaloranatomicalstructureorfunction).3Disability(restrictionorlackofabilitytoperformanactivityinanormalmanner).

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Conclusion

Scottishpoliciesadvocatemanyoftheinterventionsreviewedinthisscansuchasfallsprevention,telecareandintegratedservicedelivery.Overall,thecaseforimplementationofcomplexandspecificstrategiestopreventphysicaldisablementinolderpeopleisweakandthereisverylittleevidencefrompopulation-basedinterventionsthatfocusonlow-socioeconomicgroups,suggestingthatmuchoftheevidencemaynotbegeneralisabletothoselivingindeprivedareasofScotland.

Aplethoraoftoolsareinuseforscreening,case-findingandoutcomeassessmentwhichmakescomparisonacrossstudypopulationsdifficult.Manytoolsthataimtoidentifyandtargetolderpeopleatriskofdisablementhavenotbeenfullyvalidatedindifferentcontextsandfurtherdevelopmentofthesetoolsisessentialinordertoaccuratelytargetindividualsatriskandassessinterventionsforolderpeople.Moststudiesfocusoutcomeonhospitalandinstitutionaladmission,butadmissiondataneedstobeviewedwithcaution(6).Thereisnostandardisationofoutcomesacrossstudiesformeasurementofqualityoflifeforolderpeople.ThemostextensiveevidenceforuseofgenericqualityoflifeandhealthstatusmeasureshasbeenreportedfortheSF-36andEQ-5Dbutthereislimitedevidenceofreliabilityandinparticular,limitedevidenceofresponsivenesstochange,formostofthediseasespecifichealthmeasures(21;22).

Thisscanidentifiedmanyareasofconflictingevidence,alongwithareasofunknowneffectiveness,partlyduetonon-standardiseduseofoutcomesandpoorexperimentaldesign,butalsobecausemodifyingdisablementriskfactorsforolderpeopleisdifficultandsometimessimplynotpossible.Thereviewislimitedbythelackofdetailreportedinthereview-levelliteraturewhichmakesitdifficulttoconcludewhetherornotaninterventionhasfailedduetothepoormethodologicaldesignofthestudy,aninadequatetheoreticalbasistotheintervention,orpoorimplementation.Researchersshouldendeavourtodesignstudiesthattakeintoaccountboththesocial(personalandenvironmental)andmedicalaspectsofdisabilitythatareintegraltothedisablementprocess,andalsofollowrecommendedguidelinesforevaluationofcomplexinterventions(23).

Inthemeantimepolicymakershavelittlechoicebuttobasedecisionsaboutallocationofscarceresourcesonthemostpromisinginterventions.Oneofthebiggestchallengesforresearchersandpolicymakersistodeterminewhichgroupofolderpeoplearelikelytobenefitmostfromintervention.Somewouldarguethatfrailolderpeoplehavealottogainfromcomprehensivegeriatricassessmentandmulti-factorialinterventionbutoverall,theevidenceisgenerallystrongerformulti-factorialinterventionstargetedatolderpeopleatlowerrisk.Ideallystrategiesshouldbedevelopedforbothhighandlowriskgroupsthatfocusoninterventionsthataretailoredtotheindividuals’needs.

Thefeasibility,affordability,sustainability,effectsonequity,potentialsideeffectsandacceptabilitytostakeholdersneedstobeconsideredintheprocessofdevelopinganynewandinnovativeintervention(24).Thereisclearevidenceforencouragingexercise-relatedactivitiesforolderpeoplebutinisolation,theimpactofanyexerciseintervention,atapopulation-levelisprobablylow,unlessstartedearlierinlife.Thefactthatmostriskfactorsforchronicdiseaseandphysicaldeclineoriginateinearlylifeanddevelopinsidiously,hasalargeparttoplayinshapingthehealthandwellbeingofolderpeople(25).Thatisnottosaythatinterventionsforolderpeopleshouldbeoverlookedasthereareareasofpromisingresearch,suchasexerciseprogrammesforfallspreventionandintegratedservicedeliveryprogrammesforfrailordisabledolderpeople,butatpresentthepreciseimpactoftheseservicesinScotlandisunknown.

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Chapter 1 – Introduction1Theageingprocessisabiologicalrealitywhichhasitsowndynamic,largelybeyondhumancontrolalthoughitisinfluencedbyanumberoffactors,someofwhicharedifficult,ifnotalmostimpossibletomodify.Theageof60or65,roughlyequivalenttoretirementagesinmostdevelopedcountriesissaidtobethebeginningofoldagebutageisnotareliableindicatorofhealthandwellbeing.Inmanypartsofthedevelopingworld,chronologicaltimehaslittleornoimportanceinthemeaningofoldageandothersociallyconstructedmeaningsofagearemoresignificantsuchastherolesassignedtoolderpeople.Insomecasesitisthelossofrolesaccompanyingphysicaldeclinewhichissignificantindefiningoldage.Thus,incontrasttothechronologicalmilestoneswhichmarklifestagesinthedevelopedworld,oldageinmanydevelopingcountriesisseentobeginatthepointwhenactivecontributionisnolongerpossible(4;26).

Thetermsactiveageing,healthyageingandsuccessfulageingareusedcommonlybypolicymakersandresearchers.TheWorldHealthOrganizationdefinedactiveageingas:

‘The process of optimising opportunities for health, participation and security in order to enhance Quality of Life as people age.’ (World Health Organization 2002) (27)

ThistermwasdefinedfurtherbytheHealthyAgeingProjectGroupas:

‘The process of optimising opportunities for physical, social, and mental health to enable older people to take active part in society, without discrimination, and to enjoy an independent and good quality of life.’

Population demographics

ThepopulationofScotlandisprojectedtorisefrom5.17millionin2008to5.36millionin2018anditisthenexpectedtocontinuetoriseto5.54millionin2033(anincreaseof7%overthe25yearperiod).Thepopulationofolderpeopleisexpectedtoriserapidly,reaching1.34millionin2033(anincreaseofaround31%comparedto2008)(1).Thenumberofpeopleaged75andoverisprojectedtoincreasebyaround23%from0.39millionin2008to0.48millionin2018.Itisthenprojectedtocontinuetorise,reaching0.72millionin2033(anincreaseof84%overthe25yearperiod–seefigure1.1).ThisisduetotheageingofthebabyboomersbornaftertheSecondWorldWarandtheeffectofimprovedmortalityrates.Figure1.2showsthattheagestructureofthepopulationisprojectedtochangemarkedlybetween2008and2033.Thedependency-ratio4isprojectedtoremainmoreorlessstableataround60per100until2018;itisthenexpectedtoincreaseslightlybetween2018and2023to62per100.Itthenremainsmoreorlesssteadyuntil2028beforeincreasingrelativelyrapidlyto68by2033(1).Figure1.2showstheprojectedpercentagechangeinScotland’spopulationbyagegroupbetween2008and2033.Thisaconcernasitwillbecomeincreasinglydifficulttomaintainadequatepensionandsocialsecuritysystemsforolderpeople.

4Thedependency ratioisanage-populationratioofthosetypicallynotinthelabourforce(thedependentpart)andthosetypicallyinthelabourforce(theproductivepart).

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figure 1.1. PopulationprojectionsforScotland.

figure 1.2. TheprojectedpercentagechangeinScotland’spopulationbyagegroup,2008–2033.

Promoting Health and Wellbeing in Later Life

Source:RegistrarGeneralforScotland,2005(28)

Source:RegistrarGeneralforScotland,2009(1)

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Thereareuncertaintiesaboutthepastandfuturetrendsofage-specificillhealthanddependencyamongolderpeopleandexpertsareunwillingtomakedefinitepredictions(29).TheimportantissuetoconsiderconcernstherelationshipbetweenincreasinglifeexpectancyandchangesinhealthylifeexpectancyandtherearearangeofviewsaboutcurrenttrendsandlikelypatternsinScotland.Thetheoryofcompressionofmorbiditydescribesaparadigmofareductionincumulativelifetimemorbiditybypostponingtheageofonsetofmorbiditytoagreaterdegreethanlifeexpectancyprimarilybyreducinglifestylehealthrisks(30).Analternativeview,theexpansionofmorbiditytheory,postulatesthatasmedicaladvancesleadtogreaterlifeexpectancy,mortalityintheolderagegroupfallsbutincreaseintotallifeexpectancycomesattheexpenseofanincreaseintimespentwithchronicillhealth.Thethirdtheory,thedynamicequilibriumtheory,combinesbothcompressionandexpansionofmorbidityinthattheproportionoflifespentwithseriousdisablingdiseasewilldecreasewhiletheproportionoflifespentwithlessseveredisabilitywillincrease(31).ThebalanceofevidenceinScotlandsuggeststhatsomeolderpeoplehavebeenlivinglongerandhealthierliveswhilstsomearelivinglongerwithillhealth(32).Thesetrendsarestronglypatternedbysocioeconomicposition,thetopsocialandeconomicgroupsarelivinglongerandhealthierliveswhilethebottomgroupsaredisabledearlierandtheirperiodoflivingwithdisabilityhasbecomelonger.IntheUSA,theoverallprevalenceofdisabilitystarteddecliningin1982particularlytheprevalenceofchronicdisabilityinolderpeople(33).TheevidencefordisabilitydeclineinthepopulationofolderpeopleintheUSAisencouragingbuttheriskfactortrendsforfuturedisability,suchaspotentialdisabilitycausedbyobesitysuggestthatthisoptimisticviewmaybereversedinfuturedecades.

Alifecourseapproachtoactiveageinghighlightstheimportanceoffocusingonlifelongchange.Figure1.3demonstratesthatphysicalcapabilitygenerallyrisesrapidlyuntilmaturityandthendeclineswithage.Healthyactiveageingisdeterminedbyanumberoffactorssuchassocioeconomicposition(SEP)diet,exerciseandgenes,anddependsonboththepeakofhealthattainedandtherateofdecline.ThefocusofthisscanistoinvestigateinterventionsthatmayreducetherateofdeclineandtherebyhavethepotentialtoshiftthecurvefrompositionDtoA.

figure 1.3. Alifecourseapproachtohealthyageing,frailtyandcapability.

Chapter1

Source:KalacheandKirkbusch,1997

18

Determinants of health

ThemaindeterminantsofhealtharewelldocumentedandthemodelwidelycitedbyDahlgrenandWhitehead(34)(figure1.4)illustratesthatwhilstthehealthcaresystemisimportant,otherfactorsplayalargerpartindetermininglifetimehealthandwellbeing.Healthandsocialwellbeingareintrinsicallyconnectedbuttheservicesthatprovideforthemgenerallyoperateindisconnectedwayswithdifferentperspectivesonhowtooptimisethehealthandwellbeingoftheageingpopulation(35).

Socialandcommunitynetworksareparticularlyimportantdeterminantsofhealth.Inarecentstudyofhealthpromotionforolderpeopletheimportantsocialfactorsdetermininghealth,thatwereprioritisedbyolderpeopleandserviceproviderswere;recentlifeevent;housingandgardenmaintenance;transport,bothpublicandprivate;financialmanagementandcarerstatusandneeds(35).

figure 1.4. Modelofdeterminantsofhealth.

Promoting Health and Wellbeing in Later Life

Source:DahlgrenandWhitehead,1991(34)

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World Health Organization classification of functioning, disability and health (ICF)

TheWorldHealthOrganization(WHO)developedataxonomyofdiseasesanddescribedtheInternationalClassificationofImpairment,DisabilityandHandicapin1988(ICIDH)(36).Ithasthreecentralconcepts:

• Impairment(lossorabnormalityofpsychological,physiologicaloranatomicalstructureorfunctiondisability).

• Disability(restrictionorlackofabilitytoperformanactivityinanormalmanner).

• Handicap(disadvantageduetoimpairmentordisabilitythatlimitsorpreventsfulfillmentofanormalrole).

Thistaxonomywasupdatedin2001toincludeaclassificationsystemthatplaceslessemphasisondiseaseandmoreemphasisonfunctioninrelationtopersonalandenvironmentalfactors(seefigure1.5.).

figure 1.5. Frameworkofdisability.

Chapter1

Termssuchasdisability,impairmentandfunctionallimitationhavevariousinterchangeablemeaningsandthedisablementprocesswasreportedbyVerbruggeandJettein1994(2)asanalternativetaxonomytotheWHOdefinitiontoencompassintra-individualfactors(lifestyleandbehaviouralchanges),extra-individualfactorsandriskfactors.

Source:WorldHealthOrganizationInternationalClassificationofFunctioning,DisabilityandHealth(ICF)2001(37)

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The disablement process

Disablementreferstotheimpactthatchronicandacuteconditionshaveonbodilyfunctionandtheabilityofindividual’stocopeinsociety.Themainpathwaysleadfrompathology,toimpairment,tofunctionallimitationsanddisability.Riskfactorsplayacentralroleinthedisablementprocess.Riskfactorscanbedemographic,social,lifestyle,behavioural,environmentalandbiologicalcharacteristicsthatcanaffectthepresenceandseverityofimpairment,functionallimitationanddisability.Inaddition,extra-individual(medicalcareandrehabilitation,medicationandothertherapeuticregimens,externalsupportandbuiltphysicalenvironment)andintra-individualfactors(lifestyleandbehaviourchanges,copingmechanisms,psychosocialattributesandactivityinvolvement)contributetothedisablementprocess.Themodelhelpstoisolatethemultiplefactorsthatcontributetothedevelopmentofdisabilityandisoftenusedasaframeworkforresearch.

Socioeconomic inequalities

Socioeconomicinequalitiesinhealthpersistintooldageandtheseincludethosebetweenmenandwomen,peoplefromdifferentethnicbackgroundsandsocioeconomiccircumstancesandthoselivingindifferentgeographicalareas.Thepotentialforcompressionofmorbidityinapopulationisdeterminedbymanyfactorsprimarilythosethatinfluencedevelopmentinearlylife.Thereisgrowingevidencethatsocial,behaviouralandpsychologicalexposureinearlylifeisassociatedwithphysicalandcognitivecapabilityinlaterlifebutthisshouldnotdeterusfromimplementingeffectiveevidence-basedinterventionsinlaterlife(38).Whilstsomelifecoursefactorsmaynotbemodifiable,therearesubstantialopportunitiestoinfluencehowpeopleage.

Asystematicreviewoftheeffectsofinterventiononhealthinequalitiesconcludedthatevidencewasunclear,butcertaincategoriesofinterventions(mainlyinthefieldofhousing)mayimpactpositivelyoninequalities(39).Thechallengeforpolicymakersandhealthprofessionalsistotargetthosethataremostlikelytobenefitfrompreventativeinterventionsinordertomaximisehealthylifeyears,andpreventdisablementatanearlystage,ratherthansimplyprovidecrisisreactivehealthandsocialcaremanagementforall.

Frailty

Thetermfrailtyisusedthroughouttheliteraturealthoughthereisnoconsensusonthedefinitionamongstexpertsanddifferenttermsareusedtodescribedifferentconcepts.Somedefinitionsarebasedpurelyonbiomedicalfactorsandothersincludepsychologicalfactors(40).Ithasbeendefinedsimplyas:

‘A decreased ability to withstand illness without loss of function.’ (41)

Campbelldefinesfrailtyinamorecomplexmanner:

‘A condition or syndrome which results from a multi-system reduction in reserve capacity to the extent that a number of physiological systems are close to, or past the threshold of symptomatic failure. As a result the frail person is at risk of disability or death from minor external stresses.’ (42)

Friedet al(2001)formulatedspecificcriteriathatdefinethefrailtysyndromebasedonthepresenceofatleastthreeormoredefinedcharacteristics.Theseincludeunexplainedweightloss,muscleweakness,self-reportedexhaustion,poorendurance,andlowactivitylevels(43).Frailtycanappearsuddenlyandshouldnotbeconfusedwithdisability(aphysicalormentalimpairmentthatsubstantiallylimitsoneormoreofessentiallifeactivities)orcomorbidity(theconcurrentpresenceoftwoormorechronicdiseasesorconditions).Frailtycanleadtoanincreasedriskofmultipleadversehealth-relatedoutcomes,disability,morbidity,falls,institutionalisation,hospitalisationanddeath(40).Anumberoffrailtymeasureshavebeendevelopedwithdifferentdomainsanddifferentfunctionseitherascasefinders,screeninginstrumentsorassessmenttools(44).

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Ferrucci(2004)(45)describedeightindicatorsandpotentialoutcomemeasuresthatareoftenusedintrials(table1.1)butthereisnoconsensusontheclassificationoffrailtyorstandardisationofoutcomemeasuresandhenceconclusionsaboutinterventionsareoftendifficulttodraw.Cognitiveindicatorsarerecognisedasimportantbuttherearemethodologicalandethicaldifficultiesassociatedwithmeasuringolderpeoplewithdementia.Thatisnottosaythatolderpeoplewithdementiashouldbeexcludedfrominterventionsorresearchbutcarefulconsiderationshouldbegiventhattakesintoaccountthecognitivefactors.

Whilstattemptshavebeenmadetoimproveclinicaloutcomesforfrailpeopletherearenointerventionsdevelopedthatspecificallyreversethesyndromeoffrailty(46).

Chapter1

Source:Ferrucciet al.AConsensusReport.JAmGeriatrSoc,2004.

Indicator

Mobility

Strength

Endurance

Nutrition

Physical inactivity

Balance

Motor processing

Cognition

Possible measure

Gait speed.

Grip strength, chair rise, knee extensor strength.

Lack of energy, tiredness, oxygen-uptake.

Under-nutrition, weight loss, body mass index, obesity.

Frequency and duration of walking and cycling in previous weeks and average amount of time spent monthly on hobbies, gardening, odd jobs and sport.

Items from Berg scale, sitting to standing, standing support, standing to sitting.

Coordination, movement planning and speed.

Cognitive status measures.

Table 1.1 Frailty indicators

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Risk factors for functional decline

Stucket al(1999)(47)conductedasystematicliteraturereviewoflongitudinalstudiesthatanalysedtheassociationofindividualriskfactorswithfunctionalstatusoutcomeincommunity-livingoldersubjects.ThehigheststrengthofevidenceforincreasedriskfactorsoffunctionaldeclineinolderpeopleispresentedinBox1.1.

Identification of older people at risk

Identificationofolderpeopleinthecommunitythatareatriskofbecomingdisabledisconsideredtobeanimportantcomponentofcare.RiskpredictiontoolshavebeendevelopedacrossScotlandalthoughtheyaregenerallyfocusedonriskofunscheduledhospitaladmissionanddespitepolicyrecommendations,theyarenotuseduniversally.Thisisprobablyduetothefactthatitisdifficultlogisticallytoadequatelyscreenolderpeople(45).Distinctionshouldbemadebetweentoolsthataimtoscreenforhealthproblemsandthosethataimtodetectdisability.Raicheet al(2008)distinguishbetweencase-findingandscreening:

Source:Stucket al.SocSciMed.1999;Feb48(4):445–69.

ThehighestpredictorsofnursinghomeadmissionintheUSAwerethreeormoreactivitiesofdailylivingdependency.Inanothermeta-analysisofriskfactors,thatpredictnursinghomeadmissionintheUSA,Gaugleret al(2007)foundthatactivityofdailylivingdependencies,cognitiveimpairment,non-caucasianrace/ethnicity,priornursinghomeadmissionandsocialsupport/caregiverfactorswereidentifiedasthemostimportantprecursorsofentry(48).

The highest strength of evidence for an increased risk of functional decline in older people includes:

• Cognitiveimpairment.

• Depression.

• Diseaseburden(comorbidity).

• Increasedordecreasedbodymassindex.

• Lowerextremityfunctionallimitation.

• Lowfrequencyofsocialcontacts.

• Lowlevelofphysicalactivity.

• Highlevelofalcoholuseinmen.

• Noalcoholusecomparedtosmall.

• Poorself-perceivedhealth.

• Smoking.

• Visionimpairment

Box 1.1. Riskfactorsforfunctionaldeclineinolderpeople

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• Case-findingreferstoidentifyingindividualswhoarealreadyaffectedbyacondition(currentstate:prevalentcases).

• Screeningreferstoidentifyingindividualswhowillbeaffectedbyacondition(predictionofincidentcases)(49).

Theevidence-baseforidentifyingpeopleathigh-riskofhospitaladmissionwasdevelopedextensivelyintheUSAduetothenatureofinsurance-basedUSAhealthcaresystems,butfewhavebeendevelopedintheUK(50).ExamplesoftoolsthathavebeenusedtheUKare:

ThePatientsatRiskofRe-Hospitalisation(PARR)case-findingtoolcommissionedbytheDepartmentofHealthanddevelopedinEngland.Thistoolusesretrospectivehospital-basedinpatientandoutpatientinformationaspredictorsofhighriskolderpeopleandisthereforefocused’downstream’(51).

TheScottishversionofPARRcalledtheScottishPatientatRiskofReadmissionandAdmission(SPARRA)useshistoricdataandisbasedonpatientswhohaveanemergencyadmissioninthepreviousthreeyears(52).

ThePEONY(PredictingEmergencyAdmissionOvertheNextYear)modeldevelopedinTaysideisapopulation-derivedalgorithmthatwasdevelopedforusebycliniciansandpolicymakersinpredictingfutureadmissionstohospital(53).

TheEmergencyAdmissionRiskLikelihoodIndex(EARLI)developedinRuncorn,UKisasimpletriagetoolusedtoidentifyolderpeopleathighriskofanacuteadmissiontohospitalintheUKinthefollowing12months.Itdiffersfromothertoolsasitdoesnotrelyonaretrospectivetime-consumingsearchthroughhospitalandprimarycaredatabases,thedisadvantageofthismethodofdatacollectionisthatitrequiresanadditionaladministrativecostofpostalquestionnairesandthevalidityofthequestionnairewoulddependonahighresponserate(54).

Health Risk Appraisal in Older People (HRA-O)

TheHealthRiskAppraisaltoolwasdevelopedinitiallyintheUSAandmorerecentlyinaEuropeansettingbythePRO-AGEprojectgroup(PreventioninOlderPeople-AssessmentinGeneralists’Practices)(55).TheHRA-Otakesasystematicapproachtocollectingdatafromindividualsthatidentifiesriskfactorsbyquestionnaireandprovidesindividualisedfeedbackusingcomputersoftware,totheindividual,generalpractitioner(GP)orhealthcareprovider.Itwasdesignedforahealthcaresettingandincludesalistof19domainsinaquestionnaireofover30pageslong(http://www.biomedcentral.com/content/supplementary/1471-2288-7-1-S1.pdf).

Thedomainsinclude:accidentprevention,alcoholuse,falls,functionalstatus,healthstatus,hearing,incontinence,mediationuse,medicalhistory,memory,mood,nutrition,oralhealth,pain,physicalactivity,preventativecare,socialfactors,tobaccouseandvision.Eachindividual’sanswersareenteredintoacomputerthatanalysesanswerstoquestionsusingan’expertsystem’whichcomparestheresponsewithanevidence-basedknowledgeset.Thesystemthenproducesaseriesofrecommendationsforchange.Itwouldobviouslybedifficulttointegratethistoolintoaclinicalsettingwithoutadditionaladministrativesupport.However,theHRA-OhasbeenpilotedandevaluatedinBritishgeneralpracticeandithasrecentlybeendevelopedfurthertoincorporateadditionalquestionsrelatingtothesocialdeterminantofhealth(35).

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Therearemanyotherpredictivetoolsthathavebeendevelopedelsewhere.Examplesofsomeofthesetoolsinclude:

Functional Autonomy Measurement System (SMAF).Thismulti-domaintoolfocusesonidentifyingolderpeoplewithmoderate-to-severedisabilityratherthanthosethathavealreadybeenadmittedtohospitalanditcanbeadministeredinacommunitysetting(56).Itincludesfivedimensionsofdisability:activitiesofdailyliving(ADL),communication,mentalfunction,mobility,andinstrumentalactivitiesofdailyliving(IADL).TheSMAFwasusedtodevelopasimple-to-administercase-findingtool(PRISMA-7).ThePRISMA-7wasvalidatedinacross-sectionalstudyof594community-dwellingolderpeopleinCanada(49).SeeAppendix11forfurtherdetails.

The Vulnerable Elders Survey (VES-13).TheVES-13wasdevelopedintheUSAbytheAssessingCareofVulnerableElders(ACOVE)group.Itisasimplefunction-basedscreeningtoolforcommunity-dwellingpopulationsthataimstoidentifyolderpeopleatriskofdeterioratinghealth.TheVEStoolincludesmeasuresofage,self-ratedhealth,limitationsinphysicalfunctionandfunctionaldisabilities(57).

Prognostic score for frailty.Ravagliaet al(2008)developedaneasy-to-collectscreeningtoolthatincludesonlyself-reportedinformationandeasy-to-performstandardisedmeasurementrecommendedinroutinegeriatriccare.Nineindependentmortalitypredictorsareincludedinthetool:age>80years,malegender,lowphysicalactivity,comorbidity,sensorydeficits,calfcircumference<31cm,independentactivityofdailylivingdependence,poorgaitandperformance(Tinnettitest<24)andpessimismabouthealth.Thisscoringsystemispromisingbutstillinthedevelopmentphaseandisnotrecommendedfordetectionoffrailtyinclinicalpracticeuntilithasundergonefurtherresearch(58).

Tools that predict risk of falls

Avastnumberofdifferentobjectiveandsubjectivetools,suchaswalkingtestsandthefunctionalreachtesthavebeendevelopedtoassesstheriskoffalling.AstudyofriskassessmenttoolsformobilitysuggeststhatthemostsensitivetoolsaretheSittoStandtesttimes5(STS-5),theAlternateStepTest(AST)andthe6mWalkingTest(SMWT),butthesedonottakeintoaccountotherriskfactorssuchasmedicationuseandpsychologicalfactors(59).Nosingletoolcanberecommendedforuseinthecommunity,nursinghomeormentalhealthsettingtomeasurebaselineriskoffalling.Inarecentsystematicreviewof29differentscreeningtools,Gateset al(2008)foundthatthetoolsdiscriminatedpoorlybetweenfallersandnon-fallersandnostrongevidenceexiststhatanyscreeningtestisusefulforidentifyingpeoplewhoaremostlikelytofall(60).Ahistoryoffallsandreportedabnormalitiesofgaitorbalanceareconsistentlyfoundtobethebestpredictorsoffuturefallsandlittleornoadditionalvalueisgainedbyfurtherscreening(61).

Predictivetools,suchasPARRandSPARRA,primarilyfocusonidentifyingolderpeopleathighriskofhospitaladmissionbypreviousadmissionhistoryandcautionisneededwhenattributingreductioninadmissionrateinhighriskpatientstoaparticularinterventionwithoutcarefulcomparisonofacontrolgroup.RecentworkinthisfieldbyLaMantia(2010)suggeststhatusingreturnemergencyadmissionasaqualityindicatormaybeinappropriatebecauseofthedifficultyinidentifyingthoselikelytoreturn(62).Sociodemographicfactorscanaffectoutcomeandthereisevidencethat‘regressiontothemean’mayresultinmisrepresentationofhospitaladmissiondataasrateshavebeenshowntofallwithoutintervention(6).Toolsthatdotakeintoaccountotherhealthandsocialdeterminantstendtobetimeconsumingandcostlytoadministerinclinicalpractice.

TheSPARRAriskpredictortoolisbeingusedsporadicallyinScotlandtoidentifypeoplewithcomplexorfrequentlychangingneeds,whoarelikelytobenefitfromproactive,plannedandcoordinatedcaremanagement.However,screeningandcase-findingisunlikelytobenefitolderpeopleifthereisnoclearpathwayforanynecessaryintervention,orifthescreeningorinterventionisnotfullyacceptedbyhealthcareworkers.

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Background of the Scottish Collaboration for Public Health Research and Policy (SCPHRP)

Inmid-2006theScottishCollaborationforPublicHealthResearchandPolicy(SCPHRP)wasestablishedtostrengthenthefieldsofpublichealthresearchandpolicyinScotland.Thecollaboration’scoremandateisto:

• IdentifykeyareasofopportunityfordevelopingnovelpublichealthinterventionsthatequitablyaddressmajorhealthproblemsinScotland,andmovethoseforward.

• Fostercollaborationbetweengovernment,researchersandthepublichealthcommunityinScotlandtodevelopanationalprogrammeofinterventiondevelopment,large-scaleimplementationandrobustevaluation.

• Buildcapacitywithinthepublichealthcommunityforcollaborativeresearchofthehighestquality,withmaximumimpactonScottishpolicies,programmesandpractice.

Theinitialworkshopsresultedintheformationoffourworkinggroupsthroughwhichthecollaborationaimstoexecuteitsmandate.Eachgroupwaschargedwithdraftingathree-yearworkplanfocusingononeofthefourlife-coursestagesforpublichealthinterventions.TheLaterLifeWorkingGroupidentifiedtwopriorityareas:

• Interventionsinprimarycare/communitysettingsthatoptimisetheearlydetectionof,andslowingdown/preventionof,decliningfunction.

• Newmodelsofintegratedsocialandhealthcaretomorepromptlydetecttheneedforandprovideappropriatesupporttoallowolderpeopletolivelongerathome.

Thefirstandmostimportantpublichealthpriorityistoidentifyinterventionsthatmayhelptopreventfunctionaldeclineanddisablement.Anenvironmentalscanisaprocessofgathering,synthesising,analysinganddispensinginformationforstrategicpurposesinpublichealth.Thisenvironmentalscantakesapragmaticapproachwhichaimstousethebestevidenceavailablewithinalimitedtime-frametakingaccountofinterventionsthattargetindividualsaswellascommunitiesorpopulations.

Aim of scan

Theoverallaimoftheenvironmentalscanisto:

• Investigateinterventionsinprimarycareandcommunitysettingsthataimtopreventordelayphysicaldisablementinolderpeopleandpromotehealthyageingatanationalandgloballevel.

Objectives

Theobjectivesoftheenvironmentalscanareto:

• Identifyhighlevelpolicies,recommendationsorstrategiesinternationallyandinScotlandthataimtoimprovethehealthandwellbeingofolderpeopleanddeterminewhetherthepoliciesareevidence-informed.

• Identifyandsynthesizeevidencefromtheglobalpeer-reviewedandgreyliteratureofinterventionsinprimarycareandcommunitysettingsthataimtopreventordelayphysicaldisablementinolderpeople.

• Identifypotentialevidence-basedinterventionsfordevelopmentbytheLaterLifeWorkingGroup.

• Enabletransferofevidence-basedknowledgeintoeffectivehealthpolicyandpractice.

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Furtherwork,ledbyProfessorSallyWykeandcolleagues,willextendthefindingsofthisscanwithanaimto:

1. Identifyanddescribecurrentpolicies,programmesandinterventionsdeliveredinScotlandthataredesignedtoenablehealthandwellbeinginolderpeople.

2. Idenitfygapsinpoliciesandprogrammesdesignedtopromoteinnovationinprimaryandcommunitysettings.

2Promoting Health and Wellbeing in Later Life

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2 Chapter 2 – Literature search methods

Areviewofpeer-reviewedandgreyliterature,publishedbetweenSeptember1999andSeptember2009,wasconducted.Thefocusofthereviewwasonsystematicreviews,meta-analysesandevidencesummaries.Review-leveldatawassupplementedbykey,highqualityprimarystudieswherefurtherdetailswererequiredtoinvestigatethecomponentsoftheinterventionsinmoredepthorwheremorerecentstudieswereexcludedfromthereviews.

Peer-reviewed literature search

AsearchwascarriedoutwiththeNationalCollaboratingCentrefor(PublicHealth)MethodsandToolsatMcMasterUniversity,Canada,fortheperiodSeptember1999andSeptember2009,ofthefollowingdatabases:OvidMEDLINE,EMBASE(ovid)andCINAHL(CumulativeIndextoNursingandAlliedHealth).AnexampleofthesearchstrategyforMEDLINEisshowninAppendix1.Thiswasadaptedfortheotherdatabases.InadditionextensivehandsearchingofreferencelistsinrelevantpublicationswasundertakenalongwithcitationtrackingusingWebofScience.Expertsinthefieldwerecontactedbyemailforadditionalreportsandopinions.

Key search words

Population:adults,mid-life,middle-aged,elderly,frail,primarycare,primaryhealthcare,familypractice,oldage,aging,olderpeople,community,laterlife,elderlypersons,community,homebased.

Intervention:prevention,exerciseprogramme/program,activity,lifestylechange,socialintegration,diseasemanagement,cognitivebehavioural,multidisciplinary,nurse-led,nutrition,anticipatorycare,community-basedmulti-factorial,social,rehabilitation,casemanagement.

Outcomes:cognitivedecline,functionaldecline,disability,disablement,activityofdailyliving,mortality,lifeexpectancy,healthstatus,socioeconomic,physicalfunction,lifestylechange,functionalstatus,functionaloutcomes,falls/falling,drugmisuse,longevity,costs,management,hospitalandnursinghomeadmissions.

General:effectivenessevaluation;interventionstudies;randomised(randomised)controlledtrial,meta-analysis,systematicreview,quasi-randomised(randomised).

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Inclusion criteria

• Reviews,meta-analysisandrandomisedcontrolledtrials,clusterrandomisedcontrolledtrials,quasi-experimentalstudiesfocusedonpreventionofdisablementinthecommunityandprimarycaresettingpublishedbetweenSeptember1999–September2009.

• Olderpeople(overtheageof50)includingthegeneralandfrailolderpopulation,andthosewithimpairmentordisabilitylivingindependently(aloneorwithapartner).

• Studiesincludingatleastoneofthefollowingoutcomes:impairment,physicalfunction,cognitivefunction,socialfunction(e.g.isolationandloneliness),disability,qualityoflife(e.g.depression,SF-36),activitiesofdailyliving,nursinghomeandhospitaladmission,mortality,riskorrateoffallsandcosteffectiveness.

• Interventionsaimedatpreventingdisablementatapopulationand/orindividuallevele.g.promotingphysicalactivity,injuryprevention,healthyeatingandhealthierbehaviour,improvingmentalhealth,improvingenvironmentandsocialcontact,anticipatorycareandcasemanagement,homevisitsorcomprehensivegeriatricassessment.

Exclusion criteria• Interventionsincludingsurgeryand/orspecificdrugs.

• Interventionprimarilyfocusedontreatmentormanagementofspecificdisease(i.e.chronicheartdisease,stroke,diabetes).

• Interventionsfocusedonolderpeoplealreadyinnursinghomeinstitutionsandthosealreadyinorrecentlydischargedfromhospital.

• PapersnotwritteninEnglish.

Publication selection

Tworeviewers(HFandSP-R)independentlysearchedtheliteratureandonereviewer(HF)selectedrelevanttitlesandabstractsandidentifiedpapersthatmettheselectioncriteria.

Promoting Health and Wellbeing in Later Life

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Website search

Asearchofwebsiteswasconductedtofindadditionalinformationinthegreyliterature.Thisincludedresourcesanddocumentsrelevanttoresearch,interventions,policiesandprogrammesdeliveredinScotlandorinternationally.Furtherinformationwasdrawnfromthefollowingwebsites:

www.scotgov.ukTheScottishGovernment

www.gro-scotland.gov.uk/files2/stats/projected-population-of-scotland-2008-basedRegistrarGeneralforScotland

www.who.intWorldHealthOrganization

www.oecd.org/healthOrganisationforEconomicCo-operationandDevelopment

www.nice.org.ukNationalInstituteforClinicalExcellence

www.sign.ac.ukScottishIntercollegiateGuidelinesNetwork

www.hta.ac.ukHealthTechnologyAssessment

www.opensigle.inist.frSystemforinformationongreyliteratureinEurope

www.isdscotland.orgInformationServicesDivision,Scotland

www.healthyageing.nuHealthyAgeingProject,Europe

www.keepwellscotland.comKeepWell(formerlyPrevention2010)

www.achp.scot.nhs.org.ukAssociationofCommunityHealthPartnership

www.scotpho.org.ukTheScottishPublicHealthObservatory(ScotPHO)collaboration

www.sdo.lshtm.ac.ukTheNationalInstituteforHealthResearchServiceDeliveryandOrganisation

www.effectiveolderpeoplecare.orgCochraneLibraryofSystematicReviews

www.campbellcollaboration.orgLibraryofSystematicReviews

www.profane.eu.orgPreventionofFallsNetworkEurope

www.health.gov.on.ca/english/providers/program/mas/mas_about.htmlOntarioHealthTechnologyAdvisoryCommittee

www.hsmc.bham.ac.uk/publications/policy-papersHealthServicesManagementCentre,SchoolofSocialPolicy

www.otseeker.comOccupationaltherapyreviews

www.Pedro.org.auPhysiotherapyevidencedatabase

Assessment of quality of reviews

Thequalityofthemeta-analysesandsystematicreviewswasassessedusingtheAMSTARmeasurementtool(63).Thisisarelativelynewinstrumentbasedondatafromotherwellvalidatedtools,andconsensusofexpertopinion.DetailsofthescoringsystemareshowninAppendix2.Thenarrativereviewsweresummarisedinthediscussionsection,iftheyincludedadditionalinformationregardingthetheoreticalbasisofinterventions,ortheyincludeddetailsofthecontentandcontextofinterventionsthatwerenotreportedinthehigherqualitysystematicreviews.

Chapter2

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3Promoting Health and Wellbeing in Later Life

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3 Chapter 3 – International and Scottish policies for older people

Introduction

Numerouspolicies,strategiesandframeworkshavebeenpublishedinScotlandoverthelast10yearsthatincluderecommendationsforcareofolderpeople.Somepoliciescoveraspectsofthedeterminantsofageingandfocusonageneralvisionofcarefortheincreasingageingpopulation,whilstothersaremorespecifictothecontextofthisreview.ThischaptersummarisessomeofthekeypoliciesandframeworksthathavebeenpublishedinternationallyandinScotland.Abriefoverviewofthepolicydocumentsthatarerelevanttothisscanarepresentedinfigure3.1.

International policies

The WHO Active Ageing Policy Framework (2002)

ThepolicyframeworkforactiveageingwasguidedbytheUnitedNationsprinciplesforolderpeople.Theframeworkisbroadandcrosscuttingbutalsofocusesonspecificagegroups.Thepolicyisbasedonthreepillars:

• Health.Policiesaimtokeepriskfactorsbothenvironmentalandbehavioral,forchronicdiseaseandfunctionaldecline,lowandprotectivefactorshigh.

• Participation.Policiesaimtosupportfullparticipationinsocioeconomic,culturalandspiritualactivities.

• Security.Policiesaimtoaddresssocial,financialandphysicalsecurityneedsandrightsofpeopleastheyage.

The Healthy Ageing Project. A Challenge for Europe (2004–2007)

ThisprojectwasinitiatedbytheEUPublicHealthProgrammeandsupportedbytheSwedishNationalInstituteofPublicHealth,theEuropeanCommissionandtwelveotherpartnersincludingWHO,AGE,EuroHealthNet,publichealthinstitutes,ministriesanduniversities(64).Thehealthyageingprojectwasco-fundedbytheEuropeanCommissionbetween2004and2007withanaimtopromotehealthyageingamongpeopleover50years.Theprojectmembersreviewedtheliterature,statistics,policyandgoodpracticethroughoutEurope.Theobjectivesweretoexchangeideas,knowledgeandexperienceamongEuropeanmemberstatesandproviderecommendationstoEUandWHOactiveageingpolicyframework.Thetenmajortopicswereretirementandpre-retirement,socialcapital,mentalhealth,environment,nutrition,physicalactivity,injuryprevention,substanceuse/misuse,useofmedicationandpreventativehealthservices.Thereportmaderecommendationsforresearchwithafocusondevelopmentofprojectstoassesstheeffectivenessandcosteffectivenessofhealth-promotioninterventionsforthepreventionofdiseaseorillhealthespeciallyinlaterlife.

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32

Therecommendedprioritypolicytopicsforactioninclude:

• Increasingparticipationofolderpeopleinmeaningfulworkwithoutdiscriminationandsupportstressfreetransitionfromworktoretirement.

• Improvingsocialintegrationtopreventloneliness/isolationandtoprovideopportunitiesforvoluntaryworkforolderpeople.

• Addressingsocialrelationships,poverty,discriminationthathasanimpactonmentalhealth.

• Improvingaccesstosafeandstimulatingindoorandoutdoorenvironments.

• Promotinghealthyfoodandeatinghabits.

• Increasinglevelofphysicalactivitytoreachrecommended30minutesperday.

• Initiatingsafetypromotionandinjuryprevention.

• Promotingsmokingcessationandreducingalcoholconsumption.

• Usequalityindicatorsfordruguseandimprovecoordinationamongcareproviders.

• Improvingpreventativehealthservices(e.g.immunisationprogrammes)andconsideringpreventativehomevisitsundercertainconditions.

Policies for Healthy Ageing. Organisation for Economic Co-operation and Development (Oxley 2009)

TheOrganisationforEconomicCo-operationandDevelopmentdiscusseshealthyageingpoliciesacrossEuropewithaparticularfocusonevidenceforprogrammeeffectivenessonhealthoutcomesandcost-effectiveness(3).Thepoliciesaregroupedintofourbroadheadings:

1. Improvedintegrationintheeconomyandintosociety.

2. Betterlifestyles–specificallytacklingincreasedphysicalactivity,nutritionandsubstanceuseormisuse.

3. Adaptinghealthsystemstotheneedsofolderpeople.Theneedforbettercoordinatedandmorepatient-centeredcare.

4. Attackingunderlyingsocialandenvironmentalfactorsaffectinghealthyageing.

Thereviewsuggeststhatimprovementinthehealthandwelfareofolderpeoplemaybepossiblefromsomecombinationof:delayedretirement,increasedcommunityactivities,improvedlifestyles,healthcaresystemsthatarebetteradaptedtotheneedsofolderpeoplebutitremainsunclearastowhicharethemostcost-effective.

Promoting Health and Wellbeing in Later Life

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Scottish Government policies

Building a Health Service Fit for the Future (Kerr Report, May 2005)

Thispolicysetsouta20yearplanfortheNHSthataimstoshifttheemphasisofcarefromhospital-basedcaretopreventativemanagement.Ithasanumberofkeymessagesrelevanttothecareofolderpeople:

• Ashiftofcarefromhospitaltocommunity.

• Preventativeoranticipatorycareratherthanreactivemanagement.

• BetterintegrationoftheNHStoimprovethesystemofcaredelivery.

• Developmentofasystematicapproachforcaringforthemostvulnerablewithlongtermconditions.

• Targetingactionindeprivedareasincludingusinganticipatorycaretopreventill-health.

• Improvesupportforcarers.

• ImproveCommunityHealthPartnershipsbetweenprimaryandsecondarycareincludingbetterintegrationofsocialcare.

Delivering for Health (2005)

Delivering for HealthwaslaunchedbytheScottishHealthMinisterinOctober2005.ItbuildsonthevisionandprinciplesoftheKerrReportanddescribesapolicyagendaforNHSScotlandthataimstoimprovethehealthofthepeopleofScotland,andclosethegapinlifeexpectancy.Thepolicyemphasisestheneedtoencouragepeopletotakegreatercontrolovertheirownhealthandavoidunnecessaryhospitaladmissionbyincreasinglocalprimarycareservice.SpecificchangesplannedforolderpeopleincludeshiftingcarelocallytoGPpractice,communitypharmacies,communityhealthcentresanddaycarecentres.Ithighlightstheneedtodevelopdedicatedresourcesinprimarycareforthosewithlongtermconditionsparticularlythoselivingindeprivedareas.

Better Health, Better Care (2007)

Better Health, Better Care(2007)followsonfromtheBuilding a Heath Service Fit for the Future(KerrReport,May2005).Thethreemaincomponentsofthepolicyarehealthimprovement,tacklinghealthinequalityandimprovingthequalityofhealthcare.TheactionplansetsouttheScottishGovernment’splanstoextendanticipatorycareapproaches.Thereisaparticularemphasisoncommitmentstopublicparticipation,improvingpatientexperiences,patientrightsandenhancedlocaldemocracyandamoremutualapproachtohealthcare.Thereportemphasisestheneedtoensurethatolderpeoplegettheservicesandsupporttheyneedtoliveasindependentlyastheycan,whethertheyarelivingathome,withcarersorinacarehome.

Thereportoftheministerialtaskforceonhealthinequalities,Equally Well (2008),emphasisesthattheoverallgoalofthegovernment,sustainableeconomicgrowth,canonlybeachievedthroughareductioninhealthinequalities.ReducinginequalitiesinhealthisthereforecriticaltoachievingtheScottishGovernment’saimofmakingScotlandabetter,healthierplaceforeveryone,nomatterwheretheylive.Howeverthisisachallengingareatotackleasresearchsuggeststhatwhilstthehealthofthecountryasawholeisimproving,someinequalitiesarewideningandvirtuallynonearenarrowing.Despitetheentiremedical,publichealth,social,economic,andpoliticalchangesoverthelastcenturypatternsofUKpovertyandmortalityhavenotchangedmuchoverthelastcentury(4).

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Better Outcomes for Older People: A Framework for Joint Services (2008)

TheFrameworkpromotesthedevelopmentandmainstreamingofjointandintegratedservices,aspartoftheJointFuturedriveforbetteroutcomesforindividualsandtheircarers.ItsetsouttherequirementswhichthelocalpartnershipsofNHShealthboardsandlocalauthoritiesshouldmeetindevelopinganddeliveringjointandintegratedservicessuchasaugmentedcareathome,extracarehousing,equipmentandadaptations,tosupportolderpeoplebetterintheirownhomes.TheFrameworkfocusesondevelopmentofjointandintegratedserviceswhichassistolderpeopletoleadmoreindependentlivesandhavemorepersonalcontrolovertheirlifestyles,careandenvironment.Theframeworkemphasisestheneedforjointservicesforhealthpromotion,preventionandearlyintervention(suchasGPexercisereferralschemes)whichcanassistolderpeopletoleadhealthyandactivelivesintheirownhomes.

Achieving Our Potential (2009)

Achieving Our PotentialisaframeworkaimedattacklingpovertyandincomeinequalityinScotlandlaunchedbytheScottishGovernmenton24November2008.Supportedbyfundingof£7.5million,Achieving Our PotentialsetsouttheapproachoftheScottishGovernmentinthefightagainstpoverty.Ithighlightsthatin2006–07relativepovertyaffected20%oftheScottishpopulation.Theactionplansspecificallyaimedatolderpeopleincludeabolishingprescriptioncharges,providingassistanceforcentralheatingandsupportingcommunityplanningpartnerships.

Promoting Health and Wellbeing in Later Life

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figure 3.1. ScottishGovernmentpolicies,framework,strategiesandactionplansrelevanttothecareofolderpeoplelivinginthecommunity

Chapter3

Building a Health Service fit for the Future ( Kerr report 2005)

(20 year plan)

Delivering for Health (2005)

Builds on vision of Kerr report

Better Health, Better Care (2007)

Health improvementHealth inequality

Improving quality of care

Better Outcome for Older people

(2008)Framework for joint services

Achieving our Potential (2009)Framework for

tackling poverty

People and

Health and Community Careand

societyAll our

Futures: Planning for a Scotland

with an Ageing

Population

Community care

Range and Capacity Review (2006)

Improving Health

Keep Well (2010)(Well North,Equally Well)

Dementia Strategy (2010)

Mental Health and Well Being

in Later Life (2006)

Action Plan for Health

and WellBeing

NHS Health Scotland

Joint Joint Improvement

Team (JIT)(2004)

The Long Term The Long Term Conditions

Collaborative(2008-2009)

Reshaping Care Reshaping Care for Older People

(2009-2010)

Seizing the Opportunity Telecare Strategy (2008)

Delivery Framework for Adult Rehabilitation (2008)

Healthy Ageing Project (2003-

2007)

Falls Group (2003)Up and About. Prevention and

Management of Falls and Fractures (2008)

The Future Care of Older People (2009)

Free Personal

Care (2008)

Shifting the Balance of

Care (2008)

36

People and society All Our Futures: Planning for a Scotland with an Ageing Population

All Our Futures: Planning for a Scotland with an Ageing PopulationwaspublishedinMarch2007anddealswiththeissuesaroundthedemographicageingofthepopulationinScotland.All Our FuturessetsavisionforafutureScotlandwhichvaluesandbenefitsfromthetalentsandexperienceofolderpeople.InparticularAll Our FuturesseesolderpeopleascontributorstolifeinScotland,seekstobreakdownbarriersbetweengenerations,andaimstoensurethatservicesareinplacesothatpeoplecanlivelifetothefull,asfaraspossible,astheygrowolder.TheextensiveconsultationandengagementprocessthatledtoAll Our Futuresidentifiedsixpriorityareasforaction:

1. Improvingopportunitiesandremovingbarriers.

2. Forgingbetterlinksbetweenthegenerations.

3. Improvingandmaintaininghealthandwellbeing.

4. Improvingcare,supportandprotectionforolderpeople.

5. Developinghousing,transportandplanningservices.

6. Offeringlearningopportunitiesthroughoutlife.

Towards a Mentally Flourishing Scotland. Policy and Action Plan (2009–2011)

TheScottishGovernmentisplanningtoimprovethetreatmentandcareforthosesufferingwithdementiaaswellasimprovingsupportforcarers.Fiveareashavebeenidentifiedasimportant:tacklingdiscrimination,supportingparticipationinmeaningfulactivity,supportingpositiverelationships,improvingphysicalhealthandtacklingpoverty.

Health and community careCommunity care

Free Personal Care (2008)

The Free Personal Carepolicy,uniquetoScotland,offersolderpeopleagedover65yearsaccesstofreepersonalcareathome,arrangedviathelocalauthoritysocialservice.Assessmentandinterventionincludesanyofthefollowing:

Continencemanagement;foodanddiet;problemswithimmobility;counsellingandsupport;simpletreatment(behaviourmanagement,psychologicalsupport,remindingdevices,assistancewithmedication[includingeyedrops],applicationofcreamsandlotions,simpledressings);personalassistanceincludingassistancewithdressing,surgicalappliances,prostheses,mechanicalandmanualaidsandmobilityandhelpwithpersonalhygiene.

Whilstmanytheseinterventionsareassociatedmorewithend-of-lifecare,interventionssuchashelpwithfoodandnutritionandmedicationintakemayimpactonhealthandfunctionaldeclineincommunity-livingolderpeople.

Range and Capacity Review Group. The Future Care of Older People in Scotland (2006)

FacedwiththechallengesofanageingpopulationtheRangeandCapacityReviewGroupfocusesonthefutureprovisionofcareservicesforolderpeopleoverthenext15yearswithaviewtodevelopanappropriatemodelofcare.Thegrouprecommendsmoreflexibleservicedeliveryincluding:increaseduseoftechnologyandtelecareservices;betterintermediatecare;activeageingprogrammes;increasedanticipatorycareanddevelopmentofforwardlookingcapacityplansincommunitypartnerships.

Promoting Health and Wellbeing in Later Life

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Falls Group (2003)

TheFallsGroupwasestablishedin2003withaviewtoprovidinghelpfuladvice,primarilyforCommunityHealthPartnerships(CHPs).NHSHealthScotlandsentafallspreventionresourcepack,includingtheconferencereportTakingPositiveStepstoAvoidTripsandFallsto5,000healthprofessionalsthroughoutScotland.Commissionedresearchfollowedin2003toassessthenatureanduptakeofthefallspreventionresourcepack(HealthinLaterLife:EvaluationoftheNHSHealthScotlandFallsPreventionScheme.November2003).AfinalreportwaspublishedinFebruary2007.ThegrouprecommendeddevelopmentoffallspreventionstrategieslinkedwiththeDeliveryFrameworkforAdultRehabilitationinScotland(65).

NHS Quality Improvement Scotland: Up and about. Pathways for the prevention and management of falls and fragility fractures (2010)

CommunityandPracticeNHSQualityImprovementScotland,inconjunctionwithNHSEducationforScotland,launchedaPreventionandManagementofFallsCommunityofPracticeStrategyinApril2008.ThefinalPathwaysfortheManagementofFallsreporthasrecentlybeenpublished.UpandAboutaimstoassistplanninganddevelopmentoffallspreventionservicesacrossScotland.Theserangefromfootclinics,rehabilitationandexerciseclasses,multidisciplinaryfallsservice(GreaterGlasgow&Clyde),environmentalinterventions(Perth),telecare(NHSWestLothian),homesafetyeducation,screeningforvisualproblems(Perth&Kinross)andspecialistpharmacymedicationreviews(Glasgow&Clyde).Initially,CommunityHealthPartnershipFallsLeadersinScotlandformedthecoremembership,butsincethenithasexpanded.Nowthecommunitycomprisesanumberofactivesubgroupswithspecificinterestsorpurposes,andawider,onlinefallscommunity(www.fallscommunity.scot.nhs.uk).

Improving health

AswellastheHealthy Ageing ProjectotherpoliciesaimingtopromotementalandphysicalhealthinolderpeopleincludetheMental Health and Wellbeing in Later LifeprojectandKeep Well.

Mental Health and Wellbeing in Later Life (2006)

Mental Health and Wellbeing in Later LifewasdevelopedinpartnershipwithAgeConcernScotland,theMentalHealthFoundationandNHSScotland.Theoverallaimoftheprojectwastopromotehealthyageingwithmentalhealthandwellbeingidentifiedasbeingcentraltothesuccessofthepolicy.Thefirstthreeyearsoftheprogrammefocusedondevelopingresearchtounderpinhealthpromotingactivitieswitholderpeople,buildingolderpeople’scapacitytoengageinactivitiesatalocal,nationalandregionallevelanddevelopeducationandinformationresources.

Keep Well (formerly Prevention 2010)

www.keepwellscotland.com

Keep Wellisanexampleofanticipatorycareinpractice,developedaspartofplanstotacklehealthinequalitiesinScotland.Theprogrammefocusesonspecificdiseases,primarilycoronaryheartdiseaseanddiabetesandaimstoincreasetherateofhealthimprovementin45–64yearoldsinareasofgreatestneed.Itisnotdirectlyfocusedonolderpeoplebutcouldbeviewedaspartofanupstreampreventativestrategyforolderpeople.Theintentionistofurtherdevelopprimarycareservicestodeliveranticipatorycare,andwhereappropriatelinkwithotherpartneragencies.Thisapproachinvolves:

• Identifyingandtargetingthoseatparticularriskofpreventableseriousill-health(includingthosewithundetectedchronicdisease).

• Offeringappropriateinterventionsandservicestothem.

• Providingmonitoringandfollowup.

Keep Wellwasevaluatedovertwophases.Phase1focusedonlessonslearntduringtheimplementationphase.Phase2doesnotprovideevidenceofefficacybutprovidescasestudiesofthemostpromisingapproachesidentifiedinphase1.

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Action Plan for Health and Wellbeing (2007)

TheAction PlanoutlinestheactionsthegovernmentplanstotaketoimprovehealthandisbasedonthestrategiesoutlinedinBetter Health, Better Care.ThecentralthemesoftheAction Planarepatientparticipation,improvementinhealthcareaccess,andafocusonthetwinchallengesofimprovingScotland’spublichealthandtacklinghealthinequalities.

NHS Health Scotland

Joint Improvement Team (2004)

TheJointImprovementTeam(JIT)wasestablishedinlate2004toworkdirectlywithlocalhealthandsocialcarepartnershipsacrossScotland.OneofthetasksoftheJITistoworkinpartnershipwiththeScottishGovernmenttohelpreshapecareforolderpeople.TheJIThasbeeninvolvedinevaluationofprojectssuchasthere-ablementservicesthatinvolveaholistic,needs-ledassessmentwithserviceuser-activeparticipationintheprocess.There-ablementapproachfollowskeypolicyobjectivesofsupportingpeopletolivehealthyandindependentlivesathome,foraslongaspossible.AnotherexampleofastrategydevelopedbytheJITincludesthetelecarestrategythataimsto‘helpthousandsofpeopletoliveathomeforlongerwithsafetyandsecuritybypromotingtheuseoftelecareandtherebyprovidingthefoundationonwhichtelecaresystemscanbecomeanintegralpartofcommunitycareservicesinScotland’(66).

Shifting the Balance of Care Framework (2008)

TheoverallaimoftheImprovementFrameworkistofocusoncollaborationbetweenlocalhealthboardsandtheirpartnersonthekeyareaswhereshiftingthebalanceofcareisnecessaryforthedeliveryofSingleOutcomeAgreements,HEATtargetsandLocalDeliveryPlans.Eightimprovementareashavebeenidentifiedaskeytothedeliveryofnationalandlocaloutcomesandtargets,mostofwhicharerelevanttoreducingdisablementinthecommunity.Theeightimprovementareasare:

1. Maximiseflexibleandresponsivecareathomewithsupportforcarers.

2. Integratehealthandsocialcareforpeopleinneedandatrisk.

3. Reduceavoidableunscheduledattendancesandadmissionstohospital.

4. Improvecapacityandflowmanagementforscheduledcare.

5. Extendtherangeofservicesoutsideacutehospitalsprovidedbynonmedicalpractitioners.

6. Improveaccesstocareforremoteandruralpopulations.

7. Improvepalliativeandend-of-lifecare.

8. Improvejointuseofresources(revenueandcapital).

Promoting Health and Wellbeing in Later Life

39

The Long Term Conditions Collaborative (2008–2009)

TheLong Term Conditions CollaborativeisoneofanumberofinitiativeswithintheScottishGovernmentthataimtoimprovethequalityofcareprovidedforpeoplewithlongtermconditionsandthatgenerally,althoughnotexclusivelyinvolvesolderpeople.TheLong Term Conditions CollaborativehasbeendesignedanddevelopedbytheImprovementandSupportTeamandNHShealthboardsinsupportofBetter Health, Better Care aspartofanewandambitiousimprovementagenda.ThemainchangesoutlinedbytheCollaborationare:

• Toempowerandsupportpeoplelivingwithlongtermconditions,theircarersandthevoluntarysectortobefullpartnersinplanning,improvingqualityandenhancingtheexperienceofcare.

• Tocommissionpeersupportgroupsforpeoplewithlongtermconditionsandtheircarersandproviderelevant,accessibleinformationandtotrainstafftodeliverthecare.

• Toprovidebetter,localandfasteraccesstoservicesforlongtermconditions.

• Tohaveinformationsystemsthatsupportregistration,recallandreviewforpeoplewithmultipleconditionsandsupportdatasharing.

Inarecentlypublishedreport(LongTermConditionsCollaborative:ImprovingComplexCare2009)tenactionswereidentifiedasbeingimportantfactorsinthemanagementofolderpeople:

1.Stratifyyourpopulationandidentifythoseathighrisk.

2.Targetanddeliveraproactivecase/caremanagementapproach.

3.Introduceadvanced/anticipatorycare.

4.Communicateandsharedataacrossthesystem.

5.Developintermediatecarealternativestoacutehospital.

6.Providetelehealthandtelecaresupport.

7.Developafallspreventionpathwayandservices.

8.Providepharmaceuticalcare.

9.Ensuretimelyaccess,flexiblehomecareandcarersupport.

10.Promotementalhealthandwellbeinginlaterlife.

Reshaping Care for Older People (Dec 2009–ongoing)

Theoverallfocusofthisstrategyisbasedondemographicprojections.Currentarrangementsforthecareofolderpeoplearenotsustainableduetotheinevitabledramaticincreaseinthepopulationofolderpeopleandconsequentrisingcostofcare,alongwithlackofsufficienthumanresourcestodeliverthecare(5).Theproposaltoreshapethecareofolderpeopleisbeingdevelopedthroughaframeworkofeightworkstreamsandcollaborationwithclinicalexperts,MSPs,governmentpolicymakersandmembersofspecialinterestgroups.Fiveoftheworkstreamsfocusonservicedesign(carehomes,careathome,carepathways,planningforageingcommunitiesandhealthylifeexpectancy),twoondemographicsandfunding,andonerelatestotheworkforce.TheworkstreamPromotingHealthyLifeExpectancyisthemostrelevanttothecontentofthisscanasitfocusesonprimaryandsecondarypreventionstrategiesandevidenceforeffectiveinterventionstopromotehealthierlifestylechoicesandpreventfunctionaldeclineinolderage.

Chapter3

40

4Promoting Health and Wellbeing in Later Life

41

4 Chapter 4 – Literature search results

Introduction

Thereareinherentproblemsinvolvedinreviewingtheeffectivenessofhighlycomplexinterventionsthataredeliveredtodiversepopulationsbydifferentprofessionalgroups.TheMedicalResearchCouncildefinescomplexinterventionsasthosecomprising‘anumberofseparateelementswhichseemessentialtotheproperfunctioningoftheinterventions,althoughtheactiveingredientsoftheintervention,thatiseffective,aredifficulttospecify’(67).Inordertoimprovethedescriptionandconceptualunderstandingofthecontentofacomplexintervention,Shepperdet al(2009)adviseusingtypologiestoguidetheclassificationofinterventionsintohomogenousgroupsandtoincludewherepossible,supplementaryevidencefromqualitativeresearch(67).Unfortunatelycompliancewiththeserecommendationsisnotevidentinmostoftheresearchliteraturerelatingtoolderpeople.Thischaptersummarisestheoverallresultsofthesearchanddescribestheframeworkusedthroughoutthescan.

Results

Thepublishedliteraturesearchidentified3,185papersinEMBASE(1647),CINAHL(28)andMEDLINE(1665).Atotalof2,737remainedafterduplicationswereremoved.Titleswerescreenedtoidentifythosethatfitthecriteria,and541abstractsofreviewsandmeta-analyseswerecheckedcarefullytocheckforinclusion.Furtherscreeningresultedin30reviewsandmeta-analysesbeingidentifiedasfittingthestudycriteria.Afurther32reviewswereidentifiedthroughhandsearchingandcitationtracking.SimilarlythedatabasewascheckedtoidentifyRCTsandcontrolledexperimentalcohortstudies.1,133abstractswerereadand94studieswereidentifiedasfittingthereviewcriteria.Onlyrecentlypublished,primarystudiesofhighqualitywereincludedinthereviewduetotimeconstraints.

Classification of older people

TherecommendationpublishedbyGomezet al(2008)wasusedtoclassifythepopulationswherepossible.Theclassificationincludesfivegroups(68):

• General/healthyolderpeople.

• Frailoratriskolderpeople.

• Olderpeoplewithchronicdisease.

• Dependentolderpeople.

• Olderpeopleattheendoflife.

Thisreviewfocusesonthefirstthreegroupssinceolderpeoplewhoarealreadydependentorattheendoflifearenoteligibleforinterventionsaimedatpreventionofdisablement.

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42

Classification of interventions

Interventionsaregroupedintocomplexorspecificinterventionsalthoughthereareclearlyoverlappingcomponentsineachcategory.Adistinctionismadebetweeninterventionsthatfocusonspecificproblemsrelatedtoageing(fallsandsocialisolation)andspecificinterventionsthataremoregenerallyimplemented.Theresultsofeachreviewareconsideredinthecontextoftheclassificationofpopulation,thetypeofintervention(i.e.primary,secondaryortertiaryprevention5)andcontentofintervention.

Theinterventionsaimedeithertodelayorpreventphysicaldisablementandsubsequenthospital/institutionaladmissionsbyprimaryprevention(e.g.exercise,adaptionofslipperyfloorsurfacesforthepreventionoffalls),secondaryprevention(e.g.detectionofuntreatedproblem/casemanagement)andtertiaryprevention(e.g.improvementinmedicationuse).Theframeworkfortheclassificationispresentedinfigure4.1andabriefsummaryofcontentoftheinterventions,outcomesandmainconclusionsofthereviews,thatmettheinclusioncriteria,aresummarisedinAppendix3to10.

Thetypeandnumberofmeta-analysesandsystematicreviewsidentifiedinthesearcharepresentedintable4.1.

figure 4.1. Classificationofreviews

Promoting Health and Wellbeing in Later Life

5Primary preventionstrivestopreventactivitylimitationanddisease. Secondary preventionfocusesondiscoveringearlysignsofactivitylimitationsandtakingurgent,relevantstepstopreventthedisablementprocessfromspirallingortorestoredailyactivities.

Tertiary preventionaimstoavoidfurtherdeclineincaseswhereimpairment,activitylimitations,andnonparticipationareirreversible.

Classsification of population

•Generalolderpeople.

•Frailoratriskolder people.

•Olderpeoplewithchronicdisease/disability.

Health promotion and disease prevention

Classification of interventions

Prevention of functional decline

(Primaryandsecondaryprevention)

(Tertiaryprevention)

ComplexHomevisits,casemanagement,comprehensivegeriatricassessment,preventionprogrammes,integratedservicedelivery,fallsprevention.

specificExercise,nutrition/vitaminsupplements,medicationreview,informationcommunicationtechnology(telecare/telehealth),visionscreening,socialintegration,environmentalmodificationandassistivedevices.

43

Thefollowingdocumentswereidentifiedinthegreyliteratureasrelevanttotheaimsofthescanalthoughnotallcontainreviewlevelinformation:

• WorldHealthOrganization(WHO).ActiveAgeingFrameworkPolicy(2002)(27)

• HealthyAgeing.AChallengeforEurope(2007)(64)

• PoliciesforHealthyAgeing(2009)(3)

• ProvenStrategiestoImproveOlderPeople’sHealth(1999)(3)

• TheHealthandWellbeingofOlderPeopleinScotland(2001)(32)

• WhatistheEffectivenessofHomeVisitingorHome-basedHelpSupportforOlderPeople?(69)

• TheEffectivenessofDomiciliaryHealthVisiting:ASystematicReviewofInternationalStudiesandaSelectiveReviewoftheBritishliterature(70)

• OlderPeopleLivingintheCommunity-NutritionalNeed,BarriersandInterventions:ALiteratureReview(71)

• ScopingExerciseonFallers’Clinics(72)

• Telecare:ACrucialOpportunitytoHelpSaveOurHealthandSocialCareSystem.Yeandle(2009)(5)

• Case-ManagingLongTermConditions:WhatImpactDoesitHaveintheTreatmentofOlderPeople?(73)

• Telecare:ARapidReviewoftheEvidence.AReportPreparedfortheWestMidlandsStrategicHealthAuthority2005–2008(74)

• BuildinganEvidenceBaseforSuccessfulTelecareImplementation:UpdatedReportoftheEvidenceWorkingGroupoftheTelecarePolicyCollaborative(17)

• UpandAbout.PathwayforPreventionandManagementofFallsandFragilityFractures.QuickReferenceGuide2010(75)

• MedicalAdvisorySecretariat.OntarioHealthTechnologyAssessmentSeries2008(76)

Chapter4

Type of intervention

Complex

Comprehensive geriatric assessment

Preventative home visits by healthcare professionals

Integrated service delivery/case management

Falls prevention

Specific

Exercise

Nutritional needs (one review of exercise also included nutrition)

Medication review

Telecare/telehealth

Social integration

Vision screening

Total

Number of reviews

3

9

3

17

15

3

2

5

3

2

62

Table 4.1 Number and type of interventions included in reviews

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5Promoting Health and Wellbeing in Later Life

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5 Chapter 5 – Complex interventions

Summary

General points

• Determiningthebenefitsofcomplexinterventionsisdifficultduetotheheterogeneityoftheliteratureandparticularlythelackofstandardisationofoutcomemeasures.

• Thereiswidespreadconfusionintheliteratureregardingtheterminologyofcomplexinterventionsforolderpeople.

• Thereislittleevidenceprovidedfromreviewsofthedifferentintensitiesofprogrammesi.e.thereisnocleardoseresponseeffect.

• Thereisinadequateevidencetosupportstrategiestoachievehealthpromotionandpreventativecareinolderpeoplethroughbroad-basedscreeningandassessmentinprimarycare.Thereisnoevidencetosupportpreventativestrategiesbasedonadvicealone.

• Thereisnoevidencetosupporttheuseoflayorvoluntarycaregiversinthecareofolderpeopleasameansofachievingeitherhealthorfunctionalimprovementorreducedinstitutionaladmission,butthatdoesnotmeansuchassistanceisnotcriticaltothequalityoflifeforolderpeople.

• Evidencefromreviewlevelandprimarystudiessuggestthatthecaseforimplementationofcomplexinterventionsisrelativelyweakbuttherearesomeareasofpotentiallypromisingdevelopment.

Interventions for older people at low risk.

• Universalassessmentofallolderpeopleagedover75yearsisnomoreeffectivethantargetedassessmentandisnotrecommended.

• Forolderpeopleatlowerrisk,comprehensivegeriatricassessmentfollowedbymultidimensionalinterventionmaybemoderatelybeneficialinreducingnursingadmissionbutmoreresearchisneededtoidentifywhichcomponentsofcarearemosteffective.

Evidence for frail or disabled older people.

• Multi-dimensionalhomevisitsinterventionshavethepotentialtoachievesmallpositiveimprovementsindisabilitybutevidenceisnotconsistentandmaybedependentonfactorssuchastheexperienceofthecareprovider,easyaccesstoprovisionoffollowupserviceandlengthoffollowup.

• Acomprehensiveapproachthatincorporatesavarietyofinterventionstrategies(e.g.diseasemanagementandhealthpromotion)addressingthemultipleco-existingmedical,functional,psychologicalandenvironmentalproblems,andallrisksofolderpeople,mayhavepotentialtopreventanddelaydisablementbuttheevidenceisnotconclusive.

• IntegratedservicedeliveryprogrammeshavethepotentialtopreventfunctionaldeclinebutlongtermfollowupisessentialandmoreevidenceisrequiredtosupportimplementationintheUKsetting.

• ThereisevidencefromtwohighqualityRCTsthatadviceandinstructiongivenbyoccupationaltherapistsonassistivedevicesandhomehazardassessmentincreasesfunctionalability.

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Critical components of care

• Homevisitinterventionsassociatedwithfavourableoutcomeincludethosethatemployprofessionalswithexperienceinassessment,multiplevisits,healthprovidercollaboration,multidimensionalassessmentandthosethatuseatheoreticalapproachtointervention.

• Toensurethatlongertermriskfactormodificationrespondstochangeovertime,homevisitprogrammesmayneedtobetailoredtotheindividualneedsandpreferences.

• Coordinationofcarebetweenhealthandsocialservicesmaybethecrucialfactorindeterminingwhetheraprogrammeisbeneficialornot.

• Longtermfollowupisessentialtomonitorchangeovertime.

• Mostoftheinterventionsrelyonhighcompliancebutthisisoftenloworunrecorded.Interventionsshouldincludestrategiestoimprovecompliance.

Outcomes

• Aplethoraofoutcomevariableswereidentifiedinthereviewsmakingcomparisonsdifficult.Standardisationofoutcomessuchasdisabilityandhospitaladmissionsareneededtohelpcomparisonoftrialdata.

• Outcomesusedtoassesscomplexinterventionsforolderpeoplearegenerallyfocusedonhospitaladmission.

• Thereisgoodevidencethatsimplymonitoringadmissionratescannot reliably assess interventionswithoutamatchedcontrol.ItseemsimportanttomeasureemergencyhospitaladmissionaswellasNHSandprivatenursinghomeadmissions,asassessingonewithouttheothermayleadtomisinterpretationoftheeffectivenessofinterventions.

• Improvementinfunctionaloutcomeisnotalwaysassociatedwithareductioninhospitalandinstitutionaladmissionsuggestingthatthedriverforinstitutionaladmissionmayhavemoretodowithotherfactorssuchaspoverty,supportathomeorcarer/clientpreferences.

• Followupistooshortinmanytrialstodemonstrateadifferenceineffectbetweenexperimentalandcontrolgroups.

Promoting Health and Wellbeing in Later Life

47

Introduction

In1964Williamsonet al(77)reportedthatmanyolderScottishpeoplelivingwithhealthproblemsanddisabilitywerenotknowntotheirGPandscreeningforsocialandmedicalproblemsinthecommunitymaypreventfunctionalimpairment.Thisobservationledtothedevelopmentofnumerouspreventativescreeningprogrammesandinterventions.Thischapterprovidesasummaryofcomplexinterventionstargetingolderpeoplelivingindependentlyinthecommunitysetting.Thetermsusedtodescribetheinterventionsarelistedbelowbutareusedlooselyandareinterchangeable.

Definitions

Anticipatory care.Plannedinterventiontoachieveearlydiagnosisand/ortreatmentofaconditionwhichmaynotyetbeproducingsymptoms,orrecognisedascausingsymptoms.

Preventative home visits.Visitstoolderpeoplelivinginthecommunity,whichareaimedatmultidisciplinarymedical,functional,psychological,environmentalevaluationoftheirproblemandresources.Theobjectivesofthevisitsaretoimproveormaintainqualityoflifeandoptimisefunctionalhealthstatusandindependence.Theultimategoalsarenotonlytocontributetoqualityoflifebutalsotopreventhospital/institutionaladmission.

Comprehensive geriatric assessment (CGA). Multidimensionalinterdisciplinarydiagnosticprocess,focusedondetermininganolderperson’smedical,psychologicalandfunctionalcapabilities,inordertodevelopacoordinatedandintegratedplanfortreatmentandlongtermfollowup.

Case management.Thecoordinationofvarioussystemcomponentsforasuccessfuloutcome(integratedandcoordinatedcare).Thisentailstheassessmentofaperson’slongertermcareneedsfollowedbyappropriaterecommendationsforcare,monitoringandfollowup.Therearesixcoreelementsandanyorallofthemmaybeused;case-findingorscreening,assessment,careplanning,implementation/management,monitoringandreview.

Integrated service delivery.Amodelofcaredeliverythatusesallpublic,privateorvoluntaryhealthandsocialserviceorganisationsinvolvedincaringforolderpeople.Themodelscanbefullyorpartiallyintegrated.Theseservicesultimatelyincludeservicessuchascasemanagementandgeriatricassessmentbutthefocusisonthesystemoforganisation.

Itwasnotpossible,duetotimeconstraints,toincludeadescriptionofallprimarystudiesidentifiedinthesearch.However,recenthigh-qualitystudieshavebeenincludediftheywerenotidentifiedinthereviewsorinthecaseofthelargeMRCfundedtrialofmultidimensionalassessmentofolderpeopleinUKgeneralpractice(8),iftheywereparticularlyinfluentialtopolicydecisionmaking.

Review literature: complex interventions

Theinterventionsincludedinthereviewsweregenerallypoorlydescribedandtherewasconsiderableoverlapbetweenthedifferenttypesofinterventions,particularlyinreviewsofpreventativehomevisitsthatsometimesincludecomprehensivegeriatricassessment.Whilsttherearefundamentaldifferencesinthewayinwhichtheseprogrammesaredeliveredintermsofwhoassessestheparticipantsandiftheyareassessedusingacasefindingtoolornot,theintensityandfrequencyofanysuggestedintervention,numberoffollowupsessionsandlengthoffollowup,therearealsomanysimilarities.Forexamplemostincludeassessmentofmobilityandsometypeoftrainingeitherbyanurse,physiotherapistoroccupationaltherapist.Mostofthereviewsfailedtoincludeenoughdetailofthecontent,durationandfrequencyoftheinterventionsandforthisreasondetailsfromsomeofprimarystudiesareincludedinAppendix5.

Mostofthereviewsinthissectionincludesomeformofhomevisitprogrammeeitherasanindividualinterventionorpartofamultidisciplinarypackageofcasemanagement.Table5.1and5.2illustratesthat

Chapter5

48

theconclusionsdrawnfromthereviewsaregenerallyinconsistent.Thisispartlyduetothedifferencesinthepopulationsstudied,thevariationintypeofinterventionsincluded,heterogeneityoftheRCTsincludedinthereviews,differencesinbaselinedisabilitylevelsacrosstheRCTsreviewedandthequalityofthereviewsthemselves.Thischapterfocusesontheresultsofthemostrecent,higherqualityreviewsasmanyoftheearlypapersincludedthesameRCTsasthosepublishedin2008and2009.Noneofthereviewsfocusedentirelyonthegeneralolderpopulationalthoughfivereviewsselectedonlyfrailolderpeople(78)(79)orthosewithdisability(80;81).

Promoting Health and Wellbeing in Later Life

49

Chapter5

Reference No of studies

Byles 2000 (81)21 RCTs

Elkan et al 2001 (82)15 studies (13 RCTs)

Steultjens et al (2004) (83)17 studies

Huss et al (2008) (84)

21 RCTs

Van Haastregt et al (2000) (85)

15 RCTs

Markel–Reid et al (2006) (86)12 RCTs

Stuck et al (2002) (87)

18 RCTs

Bouman (2008) (78)

8 RCTs

Liebel et al (2009) (80) 10 RCTs

6 1=research question and criteria included; 2=duplicate assessors; 3=comprehensive search; 4=list of included and excluded studies reported; 5=status of publication stated; 6=characteristics of included studies provided; 7=quality assessment documented; 8=quality assessment used appropriately; 9= appropriate test for heterogeneity if meta-analysis used; 10=assessment of publication bias; 11=conflict of interest stated for included studies and review. y=yes, n=no, na=not applicable, ca =can’t answer.

Intervention

Home visits/ health assessments.

Preventative home visits.

Occupational therapy home visits.

Preventative home visits and geriatric assessment.

Preventative home visits.

Home visits (nurse only).

Preventative home visits.

Home visits (at least 4).

Multiple home visits.

Health category

Older people with chronic disease.

General population and frail older people.

General population and impaired older people.

General population and impaired older people.

General population and impaired older people.

General population.

General population of older people and at risk.

Frail older people at risk.

Older people with disability.

Outcome

Inconsistent findings.

Positive for nursing home admission. No effect on function.

Positive for advising on assistive devices for QoL and function.

Little effect on function OR 0.89 (95% CI 0.76 to 1.03). Positive for younger age group <77 on mortality OR 0.74 (95% CI 0.58 to 0.94).

No clear evidence. Only 1-out-of-12 RCTs focused on specific risk factors.

Inconsistent findings.

Positive for selected groups>9 visits RR =0.66 (95% CI 0.48 to 0.92)< visits RR 1.05 (95% CI 0.85 to 1.30).

No long term benefit for mortality, health status, service use or cost.

Inconsistent findings.

Scores for methodological criteria6 Total score

1 2 3 4 5 6 7 8 9 10 11

y n y n n n y y na na ca 4/9

y y y y n y y y na na ca 7/11

y y y y n y y y na na ca 7/9

y y y y n y y y y y ca 9/11

y y y y n y y y na na ca 7/9

y y y y n y y y na na ca 7/9

y y y y n y y y y y ca 9/11

y y y n n y y y na na ca 6/9

y n y n n y y y na na ca 5/9

Table 5.1 Brief summary of findings and quality of reviews of home visit interventions

50

Promoting Health and Wellbeing in Later Life

Reference No of studies

Beswick et al (2008) (7)

89 RCTs

McCusker and Verdon (2006) (88)

26 controlled studies

Wieland (2003) (89)22 trials and reviews

Hallberg and Kristensson2004 (90)26 studies

Johri 2003 (91)

7 controlled studies

Eklund and Wilhelmson2009 (79)9 controlled studies

7 1=research question and criteria included; 2=duplicate assessors; 3=comprehensive search; 4=list of included and excluded studies reported; 5=status of publication stated; 6=characteristics of included studies provided; 7=quality assessment documented; 8=quality assessment used appropriately; 9= appropriate test for heterogeneity if meta-analysis used; 10=assessment of publication bias; 11=conflict of interest stated for included studies and review. y=yes, n=no, na=not applicable, ca =can’t answer.

Intervention

Complex including home visits, geriatric assessment and falls.

Geriatricassessment and casemanagement.

Geriatricassessment.

Casemanagement.

Integratedservice delivery.

Integratedservice delivery and case man-agement.

Health category

General population and frail older people.

High risk older people.

General population and impaired older people.

General population and frail older people.

General population and frail older people.

Frail older people.

Outcome

Modest effects for reduction of hospitals admissions, nursing home admissions, fall. Small effect for improvement in physical function. Not consistent across groups.

Inconsistent findings for emergency admission.

Inconsistent. Targeting people at risk most promising.

Inconsistent findings.

Inconsistent but overall positive. Mainly based on downstream care.

Inconsistent but overall results in favour of intervention.

Scores for methodological criteria7 Total score

1 2 3 4 5 6 7 8 9 10 11

y y y y n y y y y y ca 9/11

y y y n n y n n na na ca 4/9

y n n n n n n ca na na ca 1/9

y n y n n n n n na na ca 2/9

y n y n n y n n na na ca 3/9

y y y n n y y y na na ca 6/9

Table 5.2 Brief summary of findings and quality of peer-reviewed reviews of geriatric assessment, case management and integrated service delivery

51

Comprehensive geriatric assessment and home visits for general and frail older people

Beswicket al(2008)publishedacomprehensivemeta-analysisofcomplexinterventionsincluding89RCTspublishedbetween1945andJanuary2005(7).Theinterventionsweregroupedintothefollowingcategories:

• Comprehensivegeriatricassessment(CGA)forthegeneralolderpopulation(28RCTs).

• CGAforthefrailpopulation(24RCTs).

• Homevisitsafterhospitaldischargeforfrailanddisabledolderpeople(21RCTs).

• Fallspreventionforgeneralandfrailolderpeople(13RCTs).

• Groupcounsellingandeducation(3RCTs).

Onlytrialsincludinganintention-to-treatanalysiswereincludedinthemeta-analysis.Themajorityofthetrials(40%)werecarriedoutintheUSAand19%intheUK(table5.3).VeryfewtrialscarriedoutintheUKtargetedfrailolderpeople.Noeffectswereseenfortheintensityoftheinterventionsorforthoseinterventionswithmultidisciplinaryassessmentandinterventioncomparedwithsinglecomponentintervention(singlecomponentinterventionsRR0.95,95%CI0.93to0.97;atleast3componentintervention0.97,95%CI0.89to1.07).Inadditionnobenefitwasseenforintensityoftheinterventionswhentheinterventionswereclassifiedintogroups(i.e.CGAinthegeneralolderpeopleoratriskgroup).Overall,theeffectsofcomplexinterventionsforallgroupsweremodest(riskofhospitalandnursinghomeadmissionwerereducedfrom40.5%to38.2%[numberneededtotreat=44]and10.6%to9.2%respectively(numberneededtotreat=71).

Chapter5

Source:ReproducedfromComplexInterventionstoImprovePhysicalFunctionandMaintainIndependentLivinginElderlyPeople:ASystematicReviewandMeta-Analysis.Beswicket al.Lancet;2008,371(9614):1022–102withpermissionfromElsevier.

USA

UK

Australia

Netherlands

Denmark

Thailand

Sweden

Italy

Canada

Japan

Germany

China

Switzerland

Total

8

8

3

2

4

1

2

28

CGA (general older people)

15

1

1

1

5

1

24

CGA (frail older people)

6

5

3

2

1

1

2

1

21

Community care after hospital discharge

3

3

4

1

2

13

Falls

3

3

Group education or counselling

Table 5.3 Number of trials from different countries in review by Beswick et al (2008)

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Promoting Health and Wellbeing in Later Life

Source:ReproducedfromComplexInterventionstoImprovePhysicalFunctionandMaintainIndependentLivinginElderlyPeople:ASystematicReviewandMeta-Analysis.Beswicket al.Lancet;2008,371(9614):1022–102withpermissionfromElsevier.

na=not applicable. #Activities of daily living −0·08 (−0·11 to −0·04, I2=37·5%) and generic physical function −0·09 (−0·13 to −0·05, I2=64·0%). *p<0.05. ‡Negative value for the standardised mean differences for physical function indicates benefit of intervention compared with control.

Study context

Geriatric assessment of general older people

I2

Geriatric assessment of older people selected as frail

I2

Community-based care after hospital discharge

I2

Fall prevention

I2

Group education and counselling

I2

All complex interventions

I2

Not living at home N=79578

0·95 (0·93 to 0·98)*

35·3%

1·00 (0·87 to 1·15)

43·3%

0·90 (0·82 to 0·99)*

2·2%

0·86 (0·63 to 1·19)

0

0·62 (0·43 to 0·88)*

0

0·95 (0·93 to 0·97)*

29·3%

Death N=93754

1·00 (0·98 to 1·03)

39·7%

1·03 (0·89 to 1·19)

0

0·97 (0·89 to 1·05)

5·2%

0·79 (0·66 to 0·96)*

0

0·80 (0·42 to 1·55)

0

1·00 (0·97 to 1·02)

10·6%

Nursing home admission N=79575

0·86 (0·83 to 0·90)*

47·5%

1·01 (0·83 to 1·23)

28·8%

0·77 (0·64 to 0·91)*

0

1·26 (0·70 to 2·27)

0

0·50 (0·05 to 5·49)

na

0·87 (0·83 to 0·90)*

29·0%

Hospital admission N=20047

0·98 (0·92 to 1·03)

61·4%

0·90 (0·84 to 0·98)*

11·0%

0·95 (0·90 to 0·99)*

57·0%

0·84 (0·61 to 1·16)

0

0·75 (0·51 to 1·09)

na

0·94 (0·91 to 0·97)*

43·0%

People with falls N=15607

0·76 (0·67 to 0·86)*

0

0·99 (0·89 to 1·10)

0

0·82 (0·61 to 1·08)

40·3%

0·92 (0·87 to 0·97)*

65·8%

na

na

0·90 (0·86 to 0·95)*

52·8%

Physical function N=21651(SMD‡)

−0·12 (−0·16 to −0·08)

0

−0·01 (−0·06 to 0·04)

57·9%

−0·05 (−0·15 to 0·04)

0

−0·25 (−0·36 to −0·13)

4·1%

0·05 (−0·20 to 0·30)

na

−0·08 (−0·11 to–0·06)

45·9%#

Table 5.4. Relative risk (95% confidence intervals) of outcome by intervention context (standardised mean difference8 for physical function) and I2 heterogeneity statistic 9

8 A measure of effect size used when outcomes are continuous (such as symptom scores). The mean differences in outcome between the groups being studied are standardised to account for differences in scoring methods.

9 I2 test for heterogeneity. Classification suggests 25% low, 50% medium and 75% high heterogeneity. Random effect models are used for high heterogeneity. Fixed effect model used for low heterogeneity as it is assumed that the estimated effect sizes only differ by sampling error.

53

Asmallreducedrisk(5%)wasreportedfor‘nolongerlivingathome’andlargerreducedrisk(14%)for‘nursinghomeadmission’inthecomprehensivegeriatricassessment(CGA)grouptargetinggeneralolderpeople(table5.4)althoughtheinterventionhadlittleimpactoverallonmortalityandhospitaladmissioninthisgroup.ItseemsimportanttomeasurehospitaladmissionaswellasNHSandprivatenursinghomeadmissions,asassessingonewithouttheothermayleadtomisinterpretationoftheeffectivenessofinterventions.Interestingly,theriskofnursinghomeadmissionisreduced(23%)inthegroupoffrailanddisabledolderpeoplewhoreceivedcommunity-basedcarefollowingdischargefromhospital.Whilstthisscandidnotfocusoninterventionsaimedatfrailolderpeopledischargedfromhospitalthisriskreductionshouldnotbeover-looked.

Only30ofthe89trialswereincludedinthemeta-analysisforassessmentofphysicalfunctionand19(63%)reportednoimprovement.ThebenefitsweremoreconsistentlyinfavourofCGAforgeneralolderpeoplethanforfrailolderpeople.Overallimprovement(includingallsubgroups)inphysicalfunction/disabilityequatedtoa0.5pointincreaseonthe20pointBarthelIndexwhichisasmalleffect.ThetenvariablesaddressedintheBarthelIndexare:presenceorabsenceoffaecalincontinence;presenceorabsenceofurinaryincontinence;helpneededwithgrooming;helpneededwithtoiletuse;helpneededwithfeeding;helpneededwithtransfers(e.g.fromchairtobed);helpneededwithwalking;helpneededwithdressing;helpneededwithclimbingstairs;helpneededwithbathing.

Anoverallincreaseof0.5ontheBarthelIndexmayequatetoasmallimprovementintheabilitytotransferfrombedtochair,orbeingabletodressindependentlyornot.Whilstthatmayseemtobeaminorchange,onanindividuallevelitmaybethedifferencebetweenindependenceandinstitutionalisation.Closerinspectionofthedatarevealsthattheoverallimprovementinphysicalfunctionwasderivedfromdatacalculatedforthegeneralolderpopulationandfallpreventionprogrammeswhilstthefrailoldergroupshowedalmostnoimprovementinphysicalfunction(seetable5.4).Thissuggeststhatcomprehensivegeriatricassessmentaloneisnoteffectiveforfrailolderpeopleandinterventionsdesignedtoreducedisabilityinthisgroupmayneedtoincludemorecomplexstrategiesofcare.

FurtherdetailsofthecontentoftheinterventionsarepresentedinAppendix5withothertrialsthatwerealsoincludedinthereviewsbyBeswicketal(2008)(8;92–95).Methodologicalproblemssuchashighattritionratesandlargevariationsininterventionslimittheinterpretationofsomeofthesestudies.

Key summary points of review of complex interventions to improve physical function and maintain independent living in older people (Beswick et al, 2008)

• No‘doseresponsegradient’wasfoundforintensityoftheinterventions.

• OverallimprovementinphysicalfunctionwassmallforallinterventionsmeasuredontheBarthelIndex.

• Combinedeffectsofinterventions(includingallgroups)reducedtheriskofnolongerlivingathomeandnursinghomeadmissionbuttheriskwasnotuniformacrossthegroups.ThemostimpressivereductioninriskofnursinghomeadmissionwasreportedforCGAforthegeneralolderpopulationandcommunity-basedcareforolderpeopleafterhospitaldischarge(althoughthelattergroupwasnotthefocusofscan).

• Therewasnooverallimprovementinphysicalfunction,noeffectonmortality,noreducedriskofnolongerlivingathomeandnoreducedriskofnursinghomeadmissioninthegroupoffrailolderpeopleasaresultoftheCGAinterventions.

• Thereweresmall-to-moderatechangesseeninphysicalfunctionandnursinghomeadmission,noeffectonmortality,asmallreducedriskofnolongerlivingathome,andnoeffectonhospitaladmissioninthegroupofgeneralolderpeople.

Chapter5

54

Home visits for frail older people

ThereviewcarriedoutbyBoumanetalin2008(96)appliedstrictentrycriteria,includingonlyRCTsthattargetedfrailolderpeoplewithfunctionalimpairmentandonlyhomevisitprogrammeswithmultidimensionalassessmentandmultiplefollowups(atleastfour)overaperiodofatleastoneyear.ThereviewersassessedthequalityoftheRCTsandexcludedunderpoweredpost-hoc,sub-groupanalysis.Onlyeightpapers,allgenerallyofhighquality,wereincludedinthereview.Noneofthetrialsshowedasignificanteffect(betweenthecontrolandinterventionsgroup)onmortality,healthstatus,serviceuseorcost.Noevidencewasfoundthatintensivehomevisitprogrammescarriedoutbyanursealonewerebeneficialforfrailolderpeoplewithinthehealthcaresettingofwesterncountries.

Key summary points of effects of intensive home visiting programmes for older people with poor health status.

• Interventionsincludedmultidimensionalnursevisitsoflowintensityrangingfrom4.5to7.5visitsover1to2years.

• Theonetrialthatdemonstratedpositiveeffectsofhomevisitswasofpoormethodologicalquality.

• Thereviewdidnotincludetargetedmultidimensionalinterventions.

• Analysisfromthetrialsofadequatemethodologicalqualityshowednoeffectofhomevisitsonmortality,healthstatus,serviceuseorcosts.

Home visits for older people with disability

ThereviewbyLiebelet al(2009)ofnurse-ledhomevisitinterventionsforcommunity-dwellingolderpeoplewithdisabilityincluded10trials(80).Allthestudiesinthereviewusedfocusedinterventioncomponentsandstrategiestopreventorpostponedisabilityworsening.Improvementindisabilitywasreportedinonlythreeoftheeightstudies,tworeportednochangeandthreetrialsreporteddeterioration(97–99).DetailsoftheinterventionsincludedinthesestudiesarereportedinAppendix5.Onlyoneofthesetrialsreportedsufficientdatatocalculateaneffectsizeandthatwassmall(0.2)(98).In4ofthe10studiesfrequent,multiplevisitswereassociatedwithpositiveoutcomesuchasimprovedphysicalfunction(measuredusingSF-36)anddisability.Theserangedfrommonthlytoquarterlyvisitsperyear,withanaverageof6to34visitsof,onaverage,60minutesduration.

Key summary points of review of nurse home visiting interventions for community dwelling older persons (Liebel et al, 2009)

• Therewasgreatvariabilityincomponentsoftheinterventionsandevaluation.

• Therewasnostandardmethodforrecruitingorscreeningpeopleforinclusion.

• Whilstthereviewaimedtoassesshomevisitsitalsoincludedtrialsofcasemanagementandallthestudiesincludedacomprehensivegeriatricassessmentcarriedoutbenurses.

• Onlyfouroftheninestudiesusinganextensivecasemanagementapproachreportedpositivedisabilityoutcomes.

• Only4ofthe10studiesshowedafavourableeffectofamultidisciplinary,team-basedapproach.

• Mostofthesuccessfulinterventionsusedacomprehensiveapproachthatincorporatedavarietyofinterventionstrategies(e.g.diseasemanagementandhealthpromotion)andtargetedthemultipleriskfactorsassociatedwithdisability.

• Ineffectiveinterventionswereassociatedwithlackofprocessevaluationmeasures,poorphysiciancollaboration,inadequatedocumentationregardingdoseandcontent,insufficienttrainingofcaregiversandlackofspecificstrategiestotargetdisability.

• Onlytwostudiesreportedstatisticallysignificantdifferencesbetweentheexperimentalandcontrolgroupindisabilitymeasures.

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Multidimensional preventative home visit programmes for general and frail older people

ThereviewbyHusset al(2008)(84)reportedresultsofameta-analysisthataddtothefindingsofBeswicket al(2008)(84).ThereviewincludesmorerecentlypublishedRCTsofinterventionsthatincorporatedmultiplefollowupassessments.TwentyoneRCTswereidentifiedofwhichonlyfivewerecarriedoutintheUK.Theeffectsoftheprogrammesvariedandwereaffectedbyfourmajorfactors:

• Characteristicsoftheintervention.

• Characteristicsofthepopulation.

• Adherence.

• Setting(i.e.underlyingpatternsofhealthcareuse).

Theconfidenceintervalsoftheoutcomesfornursinghomeadmission,functionaldeclineandmortalitywerewideandnotstatisticallysignificant,althoughgenerallyinfavouroftheintervention.Theoverallchanceoftheseprogrammesmakingalargeimpactonfunctionaldecline,inisolation,issmall.Morefavourableeffectsonfunctionalstatuswereshownforthoseprogrammesthatincludedclinicalexaminationintheassessment.Effectsonmortalitywerealsomorefavourableforthegroupofolderpeoplewithameanagelessthan77.Asummaryoftheresultsispresentedintable5.5.

Key points of review of multidimensional preventative home visits programs for community–dwelling older adults (Huss et al, 2008)

• Thereviewersreportedwidespreadconfusionaboutterminology.

• Overalltherewasnobeneficialeffectofnursehomevisitsonratesofnursinghomeadmission,evenintrialsofintensiveintervention.

• Insomecasesnursinghomeadmissionincreasedintheinterventiongroupsuggestingthathomevisitsmightevenincreasenursinghomeadmissionperhapsbecauseunmetneedswereidentifiedbythehealthcarers.

• Heterogeneityamongtrialswashigh.

• Themostpromisinginterventionsincludedmulti-dimensionalgeriatricassessmentwithaclinicalexaminationandregularfollowup.

Chapter5

Source:ReproducedfromJournalsofGerontologySeriesA–BiologicalSciencesandMedicalScienceswithpermissionHusset al(2008)

Combined odds ratio10

(random effects)*p>0.05

I2 Test for heterogeneity11

Nursing home admission (95% CI)

0.86 (0.68–1.10)*

42.5% p=0.037

Functional status decline (95% CI)

0.89 (0.77–1.03)*

52.4% p=0.008

Mortality (95% CI)

0.92 (0.80–1.05)*

35.6% p=0.055

Table 5.5. Multidimensional home visits programmes for general and frail older people. Combined odds ratios from 21 trials for nursing home admission, functional status decline and mortality (84).

10 The odds ratio is a way of comparing whether the probability of a certain event is the same for two groups. An odds ratio of 1 implies that the event is equally likely in both groups.

11 I2 test for heterogeneity. Classification proposed by Higgins and Thompson (2002) suggests 25% low, 50% medium and 75% high heterogeneity. Random effect models are used for high heterogeneity.

56

Integrated service delivery and case management

Integratedservicedelivery(ISD)hasbeenakeypolicyobjectiveofScotlandandaimstoreducethefrustration,delay,inefficiencyandgapsthatfrequentlyexistincaresystems(100).Integratedservicedeliveryhasbeendescribedasfullyintegrated,linkedorcoordinatedandtherearesubtledifferencesbetweenthem.Fullyintegratedmodelsarearrangedunderoneorganisationthatisresponsibleforallservices,eitherunderonestructureorbycontractingservices.Linkedservicedeliverysystemsdevelopprotocolstofacilitatereferralorcollaborationbetweenservicedeliveryproviders.Coordinatedintegratedservicedeliveryinvolvesthedevelopmentandimplementationofstructurestomanagepatientswherebyeachorganisationkeepsitsownstructurebutagreestocollaborateandadaptitsoperationandresourcestotheagreedrequirementandprocess(101).

TheobjectivesofISDprogrammesinclude:

• Implementationofcasemanagement.

• Maintainingfrailolderpeopleinthecommunityforaslongaspossible.

• Reductionofunnecessaryinstitutional/hospitaladmission.

• Improvegeneralhealth.

• Improvesatisfactionofservicedelivery.

• Promotetheautonomyoffrailolderpeople.

• Improvetheburdenoninformalcaregivers.

CasemanagementisintegraltoISD,andbecameakeycomponentoftheNHSnational‘communitymatron’policyinEngland,in2005.Englandadopted‘theEvercareProgrammefromtheUSAcompany,UnitedHealthGroup’andevaluationfollowed.EvaluationoftheEvercareProgrammewasaimedatolderpeoplealreadyininstitutionalcareandthereforeliesoutsidethescopeofthisscan(102),howeveritisworthyofnoteduetotheinterestincasemanagementinScotland.

TherewerethreekeyelementsoftheEvercarecasemanagementprogrammeinEngland:

1. Analysisofdatatoidentifyhighriskpatientsusinghistoryofunplannedadmissionsasameansofidentifyingpatients.

2. Redesigningstaffrolesthroughanewroleofadvancedprimarynursecarewithextendedgeneralistskills.

3. Organisationofcarearoundthepatient’sneedsratherthanorganisationalboundaries.

Sixty-twoEvercareinterventionpracticeswereincludedinthestudybuttheyfoundnosignificanteffectsonratesofemergencyadmissions,emergencybeddays,ormortalityforahighriskpopulationagedover65withahistoryoftwoormoreemergencyadmissionsinthepreceding13monthscomparedwiththecontrolgroup.WithuncertainimpactfromcommunitymatronsinEnglandtherewasnoincentivetodevelopnewpostsinScotland.

Reviews of integrated case management

Tworeviewsofintegratedservicedeliverywithcasemanagementwereidentified.Onehighqualityreviewofcoordinatedandintegratedinterventionstargetingfrail olderpeopleincluded9RCTspublishedbetween1998and2006(79).TheRCTsoriginatedfromItaly(1),theUSA(3)andCanada(5).Ameta-analysiswasnotcarriedoutinthisreviewduetothebiasidentifiedinthequalityassessmentoftheRCTs,theheterogeneoussettings,interventionsandoutcomemeasures(generalhealthandphysicalfunctionmeasures,alongwithbenefitstothecaregiver).Thisreviewprovidessomeevidencethatintegratedandcoordinatedcareisbeneficialforthefrailolderpeople.Thereisalsosomeevidencethatintegratedandcoordinatedcarecandecreasehealthcareutilisation.

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Key summary points of review of coordinated and integrated interventions targeting frail older people (Eklund and Wilhelmson, 2009)

• Therewasnosignificantdifferenceinthemajorityofoutcomemeasuresbetweentheexperimentalandcontrolgroups,includingperceivedhealth,depression,qualityoflife,physicalfunction,activitiesofdailylivingandcognitivestatus.

• SevenofthenineRCTsreportedatleastoneoutcomemeasuresignificantlyinfavouroftheinterventionincludingimprovementinqualityoflifeandmentalhealth.OneRCTreportednodifference,andonewasinfavourofthecontrolgroup.

• Overalltheresultsinfavouroftheinterventionexceededthoseinfavourofthecontrol.

• Theonlytwostudiesthatfocusedonthecaregiverreportedsignificantresultsinfavouroftheinterventionforcaregiversatisfaction,butnoeffectonthe‘burdenofcaregiving’.

• Fiveoutofninestudiesreportedsignificant‘healthsystembenefits’intermsofreducedhealthcareutilisation.

International experiments in integrated care for older people

AreviewbyJohriet al(2003)includedsevenprogrammesofacuteandchronicintegratedcareservicesincludingfivequasi-experimentalcontrolledtrialandtwoRCTs.ThestudieswereimplementedinCanada(1)Italy(2)USA(3)andDarlingtonUK(1)(91).TheUKstudyincludedinthisreviewwasaquasi-experimental,controlled,non-randomiseddesignthataimedtocomparetheeffectsofcommunitycarewithinstitutionalcare,forfrailolderpeoplewhowerebeingdischargedfromhospital(thereforenotthedirectfocusofthisscan).Thecommonkeyfeaturesthatarethoughttobeeffectivecomponentsofintegratedservicedelivery(ISD)interventionarepresentedinbox5.1.

ThesevenISDprogrammeswerenotdirectlycomparable,somefocusedonfrailanddisabledindividualsbeingdischargedfromhospital,whilstothersweremorebroadlyfocusedincludinggeneralolderpeopleaswellasfrailandsomestudieswerelimitedtosixmonthsfollowup.Theonlystudy(USA)toincludegeneralolderpeopleaswellasfrailolderpeoplefailedtoshowcostsavingsorimprovementinoutcomesbutthismayhavebeenduetothecasemanager’slackofauthorityforprovisionofcareandthelackofmultidisciplinaryteamwork(103).However,reductioninunscheduledhospitalvisitswasshowninthreeofthestudies(104–106).

• Singleentrypoint.

• Comprehensivegeriatricassessment.

• Centraluseofcasemanagerstopromotecost-effectivenessandintegrateddelivery.

• Casemanagersorganiseandprovidesupportformembersofamultidisciplinaryteamtoassessneeds,plancareandensureconcertedactionamongsthealthandsocialservices.

Box 5.1. Keyfeaturesofintegratedservicedeliveryintervention

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Primary studies of complex interventions

Amorerecentstudy,investigatedtheimpactofacoordinated,integratedservicedeliveryprogramme(ISD)atapopulationlevel,onfrailolderpeopleinQuebec.Avalidatedinstrument,theFunctionalAutonomyMeasurementSystem(SMAF),designedtoassessdisabilitiesrelatedto29functions,includingmeasuresofActivityofDailyLiving(ADL),mobility,communication,mentalfunctionswasusedintheevaluation(107).DetailsofthePRISMAmodelareshowninfigure5.1andafurtherdescriptionoftheSMAFtoolisreportedinAppendix11.Thestudydesignwasapopulation-basedquasi-experimentaldesignwithpre-test,multipleposttestsandcomparisongroup.2,019peopleaged75orolderwereidentifiedforinclusioninthestudy.Atotalof920olderpeople(501experimentaland419controls)agreedtoparticipateoverfouryears.

Theannualincidenceoffunctionaldecline(definedasanincreaseof5pointsormoreontheSMAF;admissiontonursinghomeorlongtermhospitalcareordeath)wasnotsignificantlydifferentoverthefirstthreeyearsbutitwaslowerby137casesper1,000intheexperimentalgroupinthefourthyearofthestudy.Overthefirst3yearsofthestudytherewasnodifferenceinfunctionaldeclinebetweentheexperimentalandcontrolgroupsbutinthefourthyeartheincidenceoffunctionaldeclinewassignificantlylowerby314(95%CI57%to216%)casesper1,000intheexperimentalgroup.Satisfactionandempowermentwerealsosignificantlyhigherintheexperimentalgroup(p<0.001).ThestudyfailedtoshowastatisticallysignificantimpactofISDonhospitaladmission,aswasthecasefortheEvercarecasemanagementstudyintheUKthattargetedolderpeopleininstitutionalcare(102).However,aRCTofintegratedcareforolderpeopleinCanadawithmoderatedisabilitydemonstratedaclearshiftfrominstitutionalservicestohomecareserviceswithoutadditionalcosts(9).

figure 5.1. ThePRISMAmodelofcoordinatedintegratedservicedelivery

Promoting Health and Wellbeing in Later Life

Source:Hebertet al.PRISMA:ANewModelofIntegratedServiceDeliveryfortheFrailOlderPeopleinCanada.IntJIntegrCare;2003(101).

Single point of entry

SCREENING

GP

Home care, nursing care, OT, PT

Hospital and Rehab. services

Long term care institution

Voluntary agency

Social care services

Meals of wheels

Domestic tasks

Day centreInstitutionalisation (temp of permanent

Geriatric servicesSpecialised servicesRehabilitation

ConsultantSpecialist

single Point of Entry

sCREENING

CAsE MANAGER

GP

Day centre Institutionalisation (temporary or permanent)

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Case management

Alargemultinationalcohortstudyexploredtherelationshipbetweenacasemanagementapproachandriskofnursinghomeadmissionin11EuropeancountriesincludingtheUK(MaidstoneandAshford,England)forolderpeopleover65withcomorbiditywhowerealreadyreceivinghomecareservices(108).Theinterventionincludedcasemanagerswhoweretrainedtomanageproblems,monitortheprovisionofservicesandprovideadditionalservicesasrequestedbyparticipants.Amultidisciplinaryteamprovidedtheserviceswhilstthecasemanagerfacilitatedtheservice.AstandardisedandcomprehensiveMinimumDataSetforHealthCareversion2.0(MDS-HC)wasincludedintheassessmentinall11countries.TheMDS-HCcontainsmorethan350questionsincludingsociodemographicvariables,numerousclinicalitems,physicalandcognitivestatusandclinicaldiagnoses(109).Thestudyincluded1,184(36%)olderpeoplewhoreceivedahomecareprogrammeand2,108(64%)olderpeoplewhoreceivedatraditionalcareapproach,withoutcasemanagement.Duringtheoneyearfollowup81ofthe1,184(6.8%)peopleinthecasemanagementgroupcomparedwith274of2,108(13%)inthetraditionalgroup(p<0.001)wereadmittedtoinstitutionalcarehomes.Afteradjustmentforconfounderstheriskofnursinghomeadmissionwaslowerinthecasemanagementgroup(adjustedoddsratio0.56,95%CI0.43to0.63).Whilstthestrengthofthisevidenceislimitedbythelackofrandomisationtheresultsarepromisingandprovidesomeevidencethatcasemanagementhaspotentialtoreduceinstitutionalisationinolderpeoplewithchronicdisease.However,inanRCT,including951olderpeopleonlowincome,Counsellet al(2007)(110)investigatedtheeffectivenessofacasemanagementinterventiongroup,includingcomprehensivegeriatricassessmentcomparedwithacontrolofusualcare.Improvementinfouroutofeightcomponentsofaqualityoflifescale(SF-36)wasreportedintheinterventiongroupbuttherewasnodifferenceinotheroutcomessuchashospitaladmissionrates(furtherdetailsinAppendix5).

Primary studies of screening for unmet health needs

ThelargeMRCfundedpopulation-basedBritishtrialofcomprehensivescreeningforunmethealthneedsforolderpeopleover75,failedtodemonstrateanybenefitsinqualityoflifeorhealthoutcomes(8)(seeAppendix5forfurtherdetails).Thetrialcomparedatargetedapproachwithauniversalapproachtohomevisitassessmentandmanagement.Itisthelargesttrialofgeriatricassessmenteverpublished.Generalorfrailolderpeople(75+)wereincludedandnodifferenceswerefoundbetweenthegroupsinmortality,institutionalorhospitaladmissionorfunction.Theconclusionsofthistrialwerelimitedbyanumberoffactors.Themainlimitationwasthatthetriallackedatruecontrolgroupandthereforeitwasimpossibletoconcludethattheinterventionhadnoeffect,ratherthetrialshowedthatofferingCGAuniversallytoallpatientswasnomoreeffectivethantargetedintervention.Inadditiontherewaslittlelongtermfollowupinvolvedintheintervention.However,itwasahigh-qualitytrialandresultedinthewithdrawalofapolicyforpreventativehomevisitsforthe75+agegroupinEngland.

Inanotherhigh-qualityRCT(n=792)ofscreeningandcasefindingforhighriskcommunity-dwellingolderpeopleintheUSA,Rubensteinet al(2007)alsofailedtoshowdifferencesinfunctionalstatusandhospitaladmissionratesbetweentheinterventionandcontrolgroupat1,2and3yearfollowupassessment(111).

Oneoftheproblemswithtrialsofhealthpromotionisthattheyaredependentonuptakeofadviceortreatmentoffered.Lifestyleinterventionsbasedingeneralpracticeoftenshowpromiseineffectingsmallchangesinbehaviourbutnoneappeartohavealargeimpactonhealth(112).Arecentlarge-scaleBritishRCT(partofacollaborativeEuropeanproject[PRO-AGEpreventioninolderpeople–assessmentingeneralistspractice(55)]),usedtheHealthRiskAppraisalforOlderPersons(HRA-O)toolincorporatedintoelectronicpatientrecordstoevaluatetheeffectonhealthbehaviourandpreventativecareuptakeinlow-riskolderpeopleinprimarycare(113).TheRCTincluded2,503peopleover65yearsold.Eightypercent(n=2006)respondedtotheself-administeredHealthRiskAppraisalquestionnaireresultingina20–35pageindividualisedfeedbackreportincludingadviceonmodifyingbehaviourandhealthchecklistsandsourcesofsupportsuchasexerciseclassesforolderpeople.Thoserandomisedtotheinterventiongroupreceivedfeedbackincludingadviceonmodifyinghealthrisks,apersonalisedpreventativehealthchecklist,

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sourcesofsupport(suchaslocalexerciseschemesforolderpeople)andnationalhelplinesadvertisinginformationonwhentoseekmedicalorothersocialadvice.FeedbacktoGPssummarisedclinicalinformationtobeusedforreinforcementofpreventativehealthandhealthbehaviour.Theinterventiongrouprespondentsreportedslightlyhigherpneumococcalimmunisationuptakeandimprovementinphysicalactivitylevels(>5timesaweekmoderate-to-strenuousexercise10.8%versus7.8%;interventionversuscontrolrespectivelyp=0.03)butnosignificantdifferenceswereobservedforanyothercategoriesofhealthbehaviourorpreventativecaremeasuresatoneyearfollowup.Healthriskassessmentresultedinminimalimprovementofhealthbehaviouroruptakeofpreventativecaremeasuressuggestingthatsimpleadviceisnoteffectiveinchangingbehaviourinolderpeople.

Overall,theevidenceforhealthpromotion,casemanagementandintegratedservicedeliveryprogrammesforolderpeopleismixed,andfewstudiesprovidestrongevidenceforanylargedifferenceinhealthoutcomes.Thismayreflectthelackoflongtermfollowupofmoststudies,lackofsensitivityoftheoutcomesusedtomeasurechangeinphysicalfunctionandqualityoflifeorbecauseitisdifficulttomodifyhealthoutcomesinolderpeople.

However,thereappeartobepromisingareasofdevelopment,thatrequireasystemicchangeofhealthandsocialservicessystemdelivery,thathavethepotentialtoreduceratesofinstitutionalisation,healthcarecostsandfunctionaldeclineinfrailolderpeople.Integratedservicedeliveryiscompellingbutrequirescoordinationandsupportatalocalandregionallevelalongwitheasilyaccessiblesharedinformationsystems.Somewouldalsoarguethatmanyofthecomplexinterventions,suchasintegratedservicedelivery,simplyaltertheplaceofcareratherthaninterruptthedisablementprocessandinputprobablyatanearlierlifestagewouldbenecessarytomakeagreaterimpactondisablementlaterinlife.

Integratedservicedeliveryhasnotbeensuccessfullyimplementedorevaluatedonalarge-scaleinScotlandbutcomponentsoftheseprogrammesarerecommendedinScottishstrategydocuments(114)toimprovethecareofolderpeople.Potentialinvestmentintoanylarge-scaleprojectshouldcarefullyconsideraffordability,feasibility,sustainability,effectsonequity,potentialsideeffectsandacceptabilityforstakeholdersandcareworkers(24).

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6 Chapter 6 – Interventions to prevent falls and fractures

Summary

• Alargebodyofwork,includingavastnumberofRCTs,hasbeencarriedoutinthefieldoffallspreventionandmanydiverseprogrammeshavealreadybeenimplementedacrossScotland.

• Theeconomicburdenoffallsishigh.Clinicalandcost-effectivenessanalysisishinderedbyalackofstandardisedoutcomesandanalysis.

• Thereisconsistentevidenceforthebenefitsofexerciseinpreventingtherisk and rate of falls,particularlyforlongtermexerciseprogrammesandtheymaybecost-effective.

• Thereisnostrongevidencethatanyonetypeofexerciseisbetterthananotheralthoughprogrammesthatincludebalanceexercisesareadvised.

• Theevidenceformulti-factorialinterventionprogrammesismixedbutmulti-factorialassessmentfollowedbytargetedinterventionappeartobeeffectiveinreducingtherateoffalls,butnotriskoffalls.Inotherwordstheeffectsarestrongerforreducingfallrecurrencesthanfirstfalls.Multi-factorialprogrammesthatrelyonreferralratherthandirectmanagementarelesslikelytobeeffective.

• Thedeliveryofasingle-factorinterventionmaybeaseffective,inreducingfalls,asdeliveringmulti-factorialintervention;researchisunderwayintheUKtoinvestigatethispossibility.

• Thereisnoevidencethatreferralforcorrectionofvisionasasingleinterventioniseffectiveinreducingthenumberofpeoplefalling.

• Thereislimitedevidence(1trial)thatinterventionstargetingwithdrawalofunnecessaryorhazardouspsychotropicmedicationreducestherateoffallsandmaybecosteffective.

• Thereislimitedevidencethatfallspreventioninterventionsimprovephysicalfunctionbuttheeffectsaresmall.

• VitaminDsupplementsalonedonotappeartobeeffectiveforpreventingfracturesinhealthyolderpeopleinthecommunityalthoughtheymayhelpthosewithlowvitaminDlevels.

• VitaminDsupplementsincombinationwithcalciumareeffectiveinreducingtheriskoffractureinwomenandthisinterventionmaybecosteffective.

• Thereislimitedevidencefrompopulation-based, controlled studiesoffallspreventionprogrammes,ofatrendtowardsareductioninfall-relatedinjuries,butnoneofthesestudieswerecarriedoutintheUKandresultsmaynotbegeneralisable.

• Thesuccessofmulti-factorialfallspreventionprogrammesislikelytodependonintegration of service deliveryworkingacrossthecommunity-hospitalinterfaceandincorporatingarangeofprofessionalcare.

• Therearegapsinknowledgeandseriousquestionsrelatingtothegeneralisabilityofinterventionsacrosscultures,countriesandsettings.

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Introduction

Falls12areamajorproblemforolderpeoplelivinginthecommunityandamajorinternationalpublichealthchallenge.Morethan30%ofpeopleover65,livinginthecommunity,falleachyearandmanyfallmorethanonce(115).IntheUKprimarycarepopulations,therateriseswithageandisgenerallyhigherinwomen,andinsocioeconomicallydeprivedpopulations(116).Fallscancausefracturesandheadinjuriesalongwithlongertermproblemssuchaslossoffunction,disability,lossofindependenceandsocialisolation(117).Hipfracturesarethemostcommonfall-relatedinjuryandbetween25%and75%ofpeoplewhofalldonotrecovertheirpre-fracturefunction(118).IntheUK,thecostoffallsinolderpeoplelivinginthecommunityhasbeenestimatedtobe£981millionperyear(119).Alargeamountofresearchhasbeenpublishedinthisfield,incomparisonwithotherinterventionsaimedspecificallyatolderpeople,andrecommendationsformanagementofolderpeopleatriskoffallingwerereportedbytheNationalInstituteforClinicalExcellence(NICE)in2004(120).Thischapterprovidesasummaryofup-to-dateevidencefortheeffectivenessoffallpreventioninterventions,aimedatolderpeopleinthecommunity.

Categories of falls prevention

There are two main categories of falls prevention:

1) Servicesforindividualpatientsreferredforspecialistmanagemente.g.fallers’clinics.Thesearegenerallybasedonscreening,comprehensivepatientassessmentanddiagnosisfollowedbyamultidisciplinaryteamapproachandonwardreferral.

2) Communityprogrammesdirectedatapopulationofolderpeoplelivinginthecommunityandathighriskoffalling.Theseprogrammesaregenerallydeliveredbyasinglehealthprofessional,workingtoaprotocol,andsuitableforwidespreaddissemination(121).

Inaddition,interventionsaregroupedintoeithersingle(e.g.exercise,homesafety,medicationeducation,physiotherapy[PT]oroccupationaltherapy[OT])ormulti-factorial(e.g.acombinationofassessmentandtargetedintervention,exercise,fallsclinics,PT,OT,medicationadjustment,advice,environmentalassessment).

Outcome measures for falls prevention

Thecauseoffallinginolderpeopleiscomplexanddependentonanumberofriskfactorsrelatedtotheperson’shealthandenvironment.Thestrongestriskfactorsforfallingare:previous falls, low muscle strength, unsteady gait, balance impairments and use of specific medication(122).Theriskoffallingincreasesfrom8%amongstgeneralolderpeople,to78%amongstthosewithfourormoreriskfactors(115).

Commonlyusedassessments,basedonthe2004NICEguidelines(120),frommostcommontoleastcommonare:gaitandbalance,environmentalandhomehazards,medicationreview,cardiovascularhealth,vision,incontinence,cognitivefunction,footcare,geriatricassessment,dietandnutrition,bonehealth,hearingandothers(mobility,personalprotection,dailyfunctioning,fearoffalling)(72).

Promoting Health and Wellbeing in Later Life

12AfallisdefinedbythePreventionofFallsNetworkEurope(ProFaNE)as‘anunexpectedeventinwhichtheparticipantscometorestontheground,floororlowerlevel’.Itisnotthefall,perse,thatistheproblembutthelossofmobilityorinjurythatitcauses.

63

Trialsgenerallymeasurerate of falls13orthenumber of people falling14duringfollowupbutalsoreportproportionoffallsinagiventime,numberofrecurrentfallers(twoormorefallersinagiventimeframe),timetofirstfallandfallrelatedinjuries.Otheroutcomesincludeadmissiontohospital,unscheduledcontactwithhealthservices,death,movetoinstitutionalcare,health-relatedqualityoflifeandphysicalactivityormobility(123).Itmaybeusefultomeasure‘fallsforunitofactivity’butavalidatedandreliabletoolwouldbeneededtomeasureactivitylevels.

Review literature: falls prevention interventions

Onereviewofreviewsoffallspreventioninterventionswasidentified(124)alongwith14systematicreviewsthatassessedservicesforindividual,olderpeoplelivinginthecommunity(seeAppendix8),andonereviewofcommunityprogrammesdirectedatapopulationofolderpeople.Onereviewofcosteffectiveness,publishedin2010aftertheinitialsearch,isincludedasitprovidesrarereviewlevelinformationoncosts.

Overall,thequalityofthereviewliteratureonfallspreventionwashigherthanotherinterventionsdiscussedinthisscan.Thecomprehensivemeta-analysisbyGillespieet al(2009)(13)included111RCTsandscored10/11ontheAMSTARqualityscale.MostoftheRCTsreportedinotherreviewsbetween1999and2009werealsoincludedinthereviewbyGillespieet al(2009)andthereforeemphasisisplacedonthislarger,highqualityreview.Theothermostrecentlypublishedreviews,reportedslightlyconflictingfindings,andarepresentedinthischapterforcomparison(table6.1andAppendix8).

Chapter6

13Therateoffallersisthetotalnumberoffallsoveraperiodoftimeincludingrepeatfallsofthesameperson:forexample,numberoffallsper-person-per-year.Thestatisticusedtoreportthisistherate ratio (RaR)whichcomparestherateofallevents(falls)inthetwogroupsduringtheperiodoffollowupinthetrial,orduringanumberoftrialsifthedataarepooled.Thisisthestatisticallypreferredoutcomealthoughmaynotbeasusefulinstudiesthatarefocusedonprimaryprevention.

14Thenumberoffallscomparesthenumberofparticipantsineachgroupwithoneormorefalleventsduringthetrial,orduringanumberoftrialsifthedataarepooled.Thestatisticusedtoreportthisistherisk ratio (RR).Theriskratioisthemostfrequentlyreportedstatistic.Itisusedtoreportwhetheraninterventionhasasignificanteffectontheriskoffallingoneormoretimes,acrosstheindividualsstudiedi.e.theoccurrenceofmorethanonefallperpersonisessentiallyignoredandtreatedthesameasonefall.Thisisstatisticallynotidealsinceitignoresimportantrecurrenteventsinthesameperson,althoughitisthemostfrequentlyreportedstatistic.

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Promoting Health and Wellbeing in Later Life

Reference No of studies

Campbell and Roberston (2007) (121)45 RCTs

Davis et al (2010) (15)9 RCTs(cost effectiveness studies only)

Gates et al (2007) (12)19 RCTs

Gillespie et al (2009) (13)111 RCTs

Medical Advisory Secretariat (2008) (125)60RCTs

McClure et al (2008) (126)6 Controlled studies

Sherrington et al (2008) (134)

Vaapio et al (2009) (127)12 RCTs

15 1=research question and criteria included; 2=duplicate assessors; 3=comprehensive search; 4=list of include and excluded studies reported; 5=status of publication stated; 6=characteristics of included studies provided; 7=quality assessment documented; 8=quality assessment used appropriately; 9= appropriate test for heterogeneity if meta-analysis used; 10=assessment of publication bias; 11=conflict of interest stated for included studies and review.

y=yes, n=no, na=not applicable ca =can’t answer16 2010 publication identified after initial search.

Intervention

Single and multi-factorial interventions.

Single, multi-factorial and population based multi-factorial.

Multi-factorial assessment and targeted intervention.

Single and multi-factorial interventions.

Single (11 interventions) and multi-factorial interventions.

Population based multi-strategy interventions.

Exercise programmes

Single and multi-factorial interventions with focus on QOL.

Health category

General and frail high risk older people.

General and frail high risk older people.

Frail and high risk older people.

Frail and high risk older people.

General and frail high risk older people.

General and frail older people.

General older people

General and frail older people.

Outcome

Targeted single interventions are as effective as multi-factorial.

Best value for money from single factor interventions in older group (>80). (Otago exercise programme.)16

Limited evidence for multi-factorial falls prevention in reducing number of falls.

Exercise interventions reduce risk and rate of falls. Variable for multi-factorial.

High quality evidence for exercise and environmental modifications.

Coordinated programme using multi-strategy initiatives have positive effect.

Greater effects for exercise that challenge balance and use high dose.

6 out of 12 studies showed positive effect on QOL.

Scores for AMSTAR methodological criteria15 Total score

1 2 3 4 5 6 7 8 9 10 11

y y y n n y y y y y ca 8/11

y y y n n y y y na na ca 6/9

y y y y n y y y y y ca 9/11

y y y y y y y y y y ca 10/11

y n y n y y y y y y ca 8/11

y y y y y y y y na na ca 8/9

y y y y n y n n y y ca 7/11

n n y y n y y y na na ca 5/9

Table 6.1 Brief summary of findings and quality of reviews of falls prevention interventions. (Most recent high quality reviews only.)

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Reviews of individual-level interventions for falls prevention

Gillespieet al(2009),inacomprehensivereviewof111RCTs,foundevidenceofeffectivenessforanumberofdifferentapproachestofallspreventioninthecommunityforolderpeoplewithoutcognitiveimpairment(13).Theeffectoftheinterventionsonrateoffalling(RaR)riskoffalling(RR)andriskoffracture(RRfracture)areshownintable6.2.

Exercise ExercisewasgroupedintocategoriesaccordingtotheProFaNE(thePreventionofFallsNetworkEurope)taxonomywhichinclude:gait,balance,functionaltraining,strength/resistancetraining,flexibility,3D(taichi,dance),generalphysicalexercise,enduranceandothers.Ingeneral,exercisewasfoundtobeaneffectiveinterventioninreducingtheriskandrateoffallswhencomparedwithacontrolgroup.Theeffectsarereportedintable6.2.Multi-componentgroupexercises,thatincludeacombinationoftwoormoretypesofexercise,andindividuallyprescribedhome-basedexercise,iseffectiveinreducingtherateoffallsandriskoffalling.Taichi,asagroupexercise,reducesrateoffallsandriskoffalling.Gait,balanceandfunctionaltrainingexercisereducedrateoffallsbutnotriskoffalling.Noneoftheothercomparisons(i.e.strengthtraining)achievedstatisticalsignificanceandmusculoskeletalinjurywasmorecommoningroupsparticipatinginresistancetraining(intervention18/112(16%)versuscontrol5/110(5%),RR3.5495%CI1.36to9.19).Nostatisticallysignificantdifferenceswerefoundforrateorriskoffallingbetweendifferenttypesofexercisee.g.strengthversusbalance.

Multi-factorial interventionsMulti-factorialinterventions,integratingassessmentwithindividualisedintervention,usuallyinvolvingamulti-professionalteam,areeffectiveinreducingrateoffallsbutnotriskoffalling.Thereisnostrongevidencethatanyspecifictypesofservicedeliveryisanybetterthananotherandnoevidencethatmulti-factorialinterventionsaremoreeffectiveinparticipantsselectedasbeingathigherriskoffalling.

Environmental assessment and interventionOverall,homesafetyinterventions,includinghipprotectors,donotappeartoreducerateoffallsorriskoffalling.Althoughevidencesofarpublishedisrelativelylimited,peopleathigherriskoffallingmaybenefit.Ananti-slipshoedeviceforicyconditionssignificantlyreducedwinteroutsidefallsinonestudybutthatisirrelevantinmostcountrieswhereiceandsnowareuncommon.Interventionstoimprovevisionappeartohaveanegativeeffectontheriskandrateoffallspossiblybecauseolderpeoplegooutmoreiftheirvisionisimproved(seetable6.2).

Medication interventionsThereislimitedevidence(fromtwoRCTs)fortheeffectivenessofinterventionstargetingmedications(e.g.withdrawalofpsychotropics,educationalprogrammesforfamilyphysicians).

Nutritional interventions Overall,vitaminDalonedoesnotappeartobeaneffectiveinterventionforpreventingfallsinolderpeoplelivinginthecommunity,butthereisprovisionalevidencethatitmayreducefallsriskinwomenwithlowvitaminDlevelsparticularlywhencombinedwithcalcium.

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Promoting Health and Wellbeing in Later Life

Intervention

Multiple-component group exercise versus control

Home exercise (including>1 exercise) versus control

Tai chi (balance and strength) versus control

Gait, balance and functional training versus control

Pooled data for all exercise (risk of fracture) versus control

Vitamin D versus control

Withdrawal of psychotropic medication versus placeboGP education with medication review

Environment (home safety and aids for personal mobility)

Environment (intervention to improve vision)(non slip devices on shoes)

Multiple interventions (exercise, home safety and education)

Multifactorial interventions based on individual assessment

Number of trials (participants)

14 trials (2,364)17 RCTs (2,492)

4 RCTs (666) 3 RCTs (566)

4 RCTs (1,294)4 RCTs (1,278)

3 RCTs (461)3 RCTs (461)

5 trials (719)

5 RCTs (3,929)10 RCTs (21,110)7 RCTs (21,377)

1 RCT (93)

1 RCT (849)

3 RCTs (2367)

1 RCT (616)

1RCT (109)

1 RCT (285)

15 RCTs (8141)26 RCTs (11173)7 RCTs (2195)

Effect (pooled in the case of >1 RCT)

RaR 0.78 95% CI 0.71 to 0.86RR 0.83, 95% CI 0.72 to 0.97

RaR 0.66 95% CI 0.53 to 0.82RR 0.77 95% CI 0.61 to 0.97

RaR 0.63 95% CI 0.52 to 0.78RR 0.65 95% CI 0.51 to 0.82

RaR 0.73 95% CI 0.54 to 0.98RR 0.77 95% CI 0.58 to 1.03

RR (fracture) 0.36 95%CI 0.19 to 0.70

RaR 0.95 95% CI 0.80 to 1.14RR 0.96 95% CI 0.92 to 1.01RR (fracture) 0.98 95% CI 0.89 to 1.07

RaR 0.34 95% CI 0.16 to 0.73RR 0.61 95% CI 0.32 to 1.17RR (fracture) 2.83 95% CI 0.12 to 67.7 RR 0.61 95% CI 0.41 to 0.91

RaR 0.90 95% CI 0.79 to 1.03RR 0.89 95% CI 0.80 to 1.00

RaR 1.57 95% CI 1.19 to 2.06RR 1.54 95% CI 1.24 to 1.91RaR 0.42 95% CI 0.22 to 0.78

RaR 0.69 95% CI 0.50 to 0.96

RaR 0.75 95% CI 0.65 to 0.86RR 0.95 95% CI 0.88 to 1.02RR (fracture) 0.70 95% CI 0.47 to 1.04

Significance levelNS= non significant

P<0.05P<0.05

P<0.05P<0.05

P<0.05P<0.05

P<0.05NS

P<0.05

NSNSNS

P<0.05NSNSP<0.05

NSNS

P<0.05 (negative effect of intervention)P<0.05 (negative effect of intervention)P<0.05 for outdoor falls

P<0.05

P<0.05NSNS

Table 6.2. Effect of interventions on rate of falling (RaR) risk of falling (RR) and risk of fracture (RR fracture)

Source: Gillespieetal.CochraneDatabaseSystRev.(2009)(13)

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Multi-factorial assessment and targeted intervention for preventing falls and injury among older people in the community

Gateset al(2008)evaluatedinterventionsdesignedtopreventfallsandfallrelatedinjuriesintrialsthatincludedanassessmentofmultipleriskforfalling,toidentifymodifiablerisksandtargetedintervention(12).All18studiesinvolvedinterventionsthattargetedtheriskfactorsviahealthservicedeliverysystemseitherinprimarycare,thecommunityoranemergencydepartment.Theyexcludedpopulation-levelstudiesandstudiesthatdidnotreportfallsoutcome.Noclearreductionwasfoundinthenumberofpeoplewithatleastonefallduringfollowup(18studies:RR0.9195%CI0.82to1.02),thenumberofpeoplewithfallrelatedinjuries(8studies0.9095%CI0.68to1.20)oranyotheroutcomeswiththeexceptionofattendanceataGP’ssurgery,whichincreasedintheinterventiongroupinonestudy(seetable6.3).Theheterogeneityamongststudieswashighinthisreview,particularlyinthefourstudiesthatanalysedthenumberofpeoplefalling(I2=74.6%),andthereforetheresultsshouldbeviewedwithsomecaution.

Individual and community fall prevention strategies

CampbellandRoberston(2007)(121)comparedtrialsofmulti-componentinterventionswithsingleinterventionsthataddressedasingleriskfactor,incommunity-basedfallsprogrammes,withfollowupforatleast12months.Fourteentrials(5,968participants)outof90wereidentifiedthatmetthereviewcriteria.Meta-analysisshowedthatinterventionswithmultiplecomponentsreducedfallsby22%(pooledRaR0.78,95%CI0.68to0.89)andsingleinterventionsby23%(pooledrateratio95%CI0.67to0.89)suggestingthatdeliveryofasinglefactorinterventionmaybeaseffectiveinreducingfallsasdeliveringmulti-factorialinterventions.ThisevidenceconflictswithNICEguidelinethatrecommendmulti-factorialinterventions(120).

ThecomprehensivereviewcarriedoutbytheMedicalAdvisorySecretariatinCanadaassessed11interventionsforpreventionoffalls:exerciseprogrammes,visionassessmentandreferral,cataractsurgery,environmentalmodifications,vitaminDsupplementation,vitaminDpluscalciumsupplementation,hormonereplacementtherapy(HRT),medicationwithdrawal,gait-stabilisingdevices,hipprotectors,andmulti-factorialinterventions(125).

Chapter6

Recurrent falls

Admission to hospital

Attendance at Emergency Dept

Attendance at GP’s surgery

Death

Move to institutional care

na=not applicable

Source:ReproducedfromMultifactorialAssessmentandTargetedInterventionforPreventingFallsandInjuriesAmongOlderPeopleinCommunityandEmergencyCareSettings.BMJ.2008Jan19;336(7636):130–3(copyrightnoticeyear2010)withpermissionfromBMJPublishinggroup.

No of studies

4

9

4

1

15

5

Risk ratio (random effects) (95% CI)

0.81 (0.54 to 1.21)

0.82 (0.63 to 1.07)

0.96 (0.72 to 1.27)

1.39 (1.11 to 1.74)

1.08 (0.87 to 1.34)

0.92 (0.59 to 1.43)

74.6

0

38.9

na

0

0

I2 (%) 17

Table 6.3 Results of meta-analyses of multi-factorial interventions for falls

17 I2 =Test for heterogeneity. Classification proposed by Higgins and Thompson (2002) suggests 25% low, 50% medium and 75% high heterogeneity. Random effect models are used for high heterogeneity. Fixed effect model used for low heterogeneity as it is assumed that the estimated effect sizes only differ by sampling error.

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ThisreviewaddstotheresultsofGillespieet al(2009)asitstratifiedexerciseintotargetedprogrammeswheretheexerciseroutinewastailoredtotheindividuals’needs,anduntargetedprogrammesthatwereidenticalamongsubjects.Furthermore,analyseswerestratifiedbyexerciseprogrammeduration(<6monthsand≥6months)andfallriskofstudyparticipants.Atotalof17studiesinvestigatingmulti-factorialinterventionswereincludedinthereview.Ofthesestudies,10reportedresultsforahigh-riskpopulationwithpreviousfalls,whilesixreportedresultsforstudyparticipantsrepresentativeofthegeneralpopulation.ThesummaryoftheresultsareshowninAppendix12.

Overall,theauthors’conclusionsweresimilartothatofGillespieet al(2009)otherthantheyreporthighqualityevidencethatlongtermexerciseprogrammesandenvironmentalmodificationsinthehomesoffrailolderpeoplereducestheriskoffalling(RR=0.76;95%CI0.64to0.91),vitaminDinadditiontocalciumiseffectiveinreducingtheriskoffallingandvisioninterventionsincludingassessmentandreferralisnoteffective(RR1.12;95%CI0.82to1.53).Chouet al(2009)alsoreportedthatdirectscreeningforvisualimpairmentforolderadultsinprimarycaresettingsisnotassociatedwithimprovedvisionoranyotherclinicaloutcomeandmaybeassociatedwithanincreaseinfalls(128).InaseparatereviewofcosteffectivenesscarriedoutbytheMedicalAdvisorySecretariat(2008)(14),theauthorsreport:

• High-qualityevidencetosuggestthatlongtermexerciseprogrammesandenvironmentalmodificationsinthehomesoffrailolderpeoplearecost-effectiveinreducing rate of fallsinOntario’solderpopulation.

• AcombinationofvitaminDandcalciumsupplementationinolderwomeniscost-effectiveinreducingrateoffalls.

• Theuseofoutdoorgait-stabilisingdevicesformobileolderpeople,duringthewinterinOntario,iscosteffectiveinreducingfalls(basedon1trialofmoderatequality).

• Withdrawalofpsychotropicmedicationmaybeacost-effectivemethodforreducingfallsbutevidenceislimitedandlongtermcompliancehasbeendemonstratedtobedifficulttoachieve.

Review of population-based studies of falls prevention

McClureet al(2008)assessedtheeffectivenessofpopulation-basedinterventions,definedas:coordinated,community-wide,multi-strategyinitiativesforreducingfall-relatedinjuriesamongstolderpeople(126).ThesixcontrolledstudiesincludedinthereviewwerecarriedoutinAustralia,Sweden,Taiwan,DenmarkandNorway.Theinterventionswereprimarilyeducational,somewerebasedontheWHOSafeCommunityStrategy(129–131),andothersincludedtaichiexercise(132)homevisitsandhomehazardadaption(133).Theeducationalcomponentsweredeliveredviabrochures,posters,mediaandpolicydevelopment,localcliniciansandhealthprofessionals.Ameta-analysiswasnotpossibleduetotheheterogeneityofthestudiesandonlyanon-statisticallysignificanttrendtowardsareductioninfall-relatedinjuriesacrossallsixprogrammeswasreported.NoneofthetrialswerecarriedoutintheUK,makingconclusionsdifficulttogeneralise,particularlyinthecaseoftaichiinTaiwanwherethespecificinterventionmaydependonculturalpatternsofbehaviour.

Cost effectiveness of falls prevention interventions

Inthemostup-to-datereviewofthecostofstrategiestopreventfallsinolderpeoplelivinginthecommunity,Davieset al(2010)(15)identifiedninestudiesincludingeightcost-effectivenessanalyses,onecost-utilityandonecost-benefitanalysis18.Thereviewincludedonemulti-factorial,communitylevelinterventionbasedinAustralia(StayonYourFeetCampaign(133)),individualisedmulti-factorialinterventionsandsinglefactorinterventions(i.e.exercise),butonlyoneoftheninestudieswascarriedoutintheUK.

Promoting Health and Wellbeing in Later Life

18Therearethreemaintypesofeconomicanalysis;cost-effectivenessbenefitsaremeasuredusingclinicallyrelevantoutcomessuchaslifeyearsgainedornumberoffallsprevented.Theprimaryoutcomeusedistheincrementalcost-effectivenessbenefit(ICER=thedifferencebetweenthecostofprovidingthecompetinginterventiondividedbythedifferenceineffectivenessi.e.numberoffallsprevented).Cost-utilityanalysis;healthbenefitsaremeasuredinqualityadjustedlifeyearsandforcost–benefitsinmonetaryunits.

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Thereviewwaslimitedbythelackofgoodqualitydatamainlybecausehospitalcostsareoftenskewedandthefactthatthetrialswerepoweredfortheprimaryoutcomes(i.e.numberfalls)ratherthancosts.OveralltheauthorsconcludedthatthebestvalueformoneycamefromsinglefactorinterventionssuchastheOtagoExerciseprogrammewhichproducedcostsavingsinthehigherriskgroupofadultsover80yearsold.Otherprogrammesthatappearedtobecost-effectivewereamulti-factorialprogrammethattargetedeightfallriskfactorsandahomesafetyprogrammeforthoserecentlydischargedfromhospital.Thissuggeststhattargetingthehigh-riskgroupmaybeacost-effectivestrategyforfallsprevention.

Disparity in the falls literature

Expertstendtoagreethatvarioustypesofexerciseareeffective,whenusedinisolation.ThereviewbyGillespieet al(2009)showsconsistentevidencefortheeffectofexerciseinterventioninreducingtheriskandrateoffalling,althoughsometypesofexercise(resistancetraining)arelesseffectiveandhavebeenshowntooccasionallycauseinjury.Sherringtonet al2008pooleddatafrom44trialsofexerciseinterventionsincluding9,603participants,andfoundastatisticallysignificant(17%)reductioninrateoffalls(RaR0.83,95%CI0.75to0.91)(134).Theyfoundastatisticallygreaterrelativeeffectinprogrammesthatincludedbalanceexercises,usedahigherdoseofexercise,ordidnotincludeawalkingprogramme.OtherwisetheoverallfindingsofthereviewbySherringhamet al(2008)weresimilartothatofGillespieet al(2009)(13).

Themaininconsistencyinreportingofreviewsoffallspreventionappearstobeconcernedwithmulti-factorialinterventionsaimedattargetingriskfactors.Thefourmostrecentreviewsthatfocusedonmulti-factorialinterventionsforfallspreventionreportdifferentoutcomes.Beswick2008(7)reportedthattheriskoffallingwasreducedby8%(RR0.92,95%CI0.87to0.97)andphysicalfunctionimprovedbyasmallamount(standardisedmeandifference-0.25[-0.36to-0.13]).Theyincluded12trials,allofwhichwerealsoincludedinthereviewbyGillespieet al(2009).However,theresultsdifferedfromGillespieet al(2009)(basedon26studies)andGateset al(2009)(basedon19RCTs)whoreportednon-significanteffectsfortheriskoffalling.

Afallratecomparison(consideredtheoptimalanalytictechniqueforassessingfallspreventiontrials)wasnotpossibleinthereviewbyGateset al(2008)(12)andthereforetheircomparisonwasbasedonthecrudercomparisonoftherelativenumberoffallersbetweengroups.Interestingly,thesub-groupanalysisinthereviewbyGateset al(2008)showedthattheeffectsizeintrials,wheremoreintensiveinterventionswereprovided,wassimilartothatreportedbyCampbellandRobertson(2008)(121).Thedegreeofheterogeneityinmostofthecomparisonswashigh,forexampleintheprimaryanalysiscarriedoutbyGateset altheI2was59.8%,suggestingthatcautionshouldbeexercisedwhenconsideringtheconclusions(13).Inaddition,theinterventionsinthereviewbyGateset al(2008)includedtentrialsthatassessedriskfactorsandreferralforinterventionofwhichonlythreewerepositive,whereasfourofthesixtrialsthatprovideddirecttreatmentreportedpositiveresults.Thisraisesthequestionofwhetheritisthereferralanddeliverysystemthatfailsratherthantheinterventionperse.Lowadherenceanduptakearecrucialfactorsininterventionstudiesand‘higherintensityprogrammesthatprovideinterventionstoaddressriskfactorsratherthaninformationandreferralmaybemoreeffective’(12).Itseemsintuitivethatsimplyscreeninghighriskindividualsandadvisingcareprovidersaboutpeoplewhofall,withoutadequate,quickaccesstoappropriateintervention,isveryunlikelytobeasuccessfulmanagementapproach.

Overall,thedifferencesinresultsacrossthereviewsappeartobeduetotheinclusionofadditionaltrialsinthemorerecentreviews,thetypeandintensityoftheinterventionand/orthemethodofanalysis,suggestingthatthetrueeffectsofmulti-factorialinterventionsareprobablymodestatbest,andfurtherinvestigationisneededtoteaseoutwhicharethemosteffectivecomponents.

Chapter6

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7Promoting Health and Wellbeing in Later Life

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7 Chapter 7 – Physical activity and exercise interventions Summary

• Thereisconsistentevidencethatexerciseprogrammesforolderpeoplecanimprovestrength,balance,aerobiccapacityandfunction,particularlywalking.Thisisevidentforprimary,secondaryandtertiaryprevention.Themagnitudeofeffectsrangefromsmalltolarge.Effectsizesaresmallerfortheolderagegroup(80+)andthosewithpre-existingdisability.

• Thereislimitedevidencethataerobicexercisehasaneffectonsomemeasuresofcognitivefunction,suchascognitivespeed,butthemagnitudeofeffectissmall,andnotconsistentforallmeasuresofcognitivefunction.

• Thereisevidencethataerobicexercisecanimprovesomemeasuresofpsychologicalwellbeingbutthemagnitudeofeffectissmall.

• Thereisalackofevidencetolinkgainsinimpairmentandfunctionaloutcomeswithreductionofdisability.

• Moreresearchisnecessarytoevaluatetheeffectsofexercise‘dose’,includingtypeanddurationofeachexercise,numberofsessionsperweek,numberofweeksofparticipationaswellasintensity,onoutcome.

• Lackofstrongevidenceforthebenefitsofspecifictypesofexercise,suchasprogressiveresistancetraining,ondisabilityoutcomes(e.g.theBarthelIndexandSF-36)suggestthat,inordertobesuccessfulinpreventingdisablement,amoreeclecticapproachisneededincludingacombined,taskspecificapproach.

• Outcomemeasuresusedtoassessfunctioninolderpeoplemaynotbesensitiveenoughtodetectimportantchangeinolderpeopleandmoreresearchisneededinthisarea.

• Mostexercisetrialsdonotaddresssocialinequalityorincludepeoplewhoaremostinneedofexercise.Olderpeoplewhosignuptotrialsofexercisearethosemostlikelytobeinthehighersocioeconomicgroups.

Chapter7

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Physicalactivityisdefinedas‘anybodilymovementproducedbycontractionofskeletalmusclethatsubstantiallyincreasesenergyexpenditureabovebasalrate’.

Exerciseisdefinedas‘plannedstructured,repetitivebodilymovementsthatareperformed,withorwithouttheexplicitintentofimprovingoneormorecomponentsofphysicalfitness.’

Box 7.1. Definitionofphysicalactivityandexercise

Introduction

Preventativeexerciseprogrammesaregenerallyrecommended,inbothpolicydocumentsandthepeerreviewedliterature,tobestronglylinkedtoimprovedhealthandwellbeinginallagegroups,includingolderpeople.Muscleweaknessinoldageismainlydeterminedbysarcopenia,atermusedtodescribethenaturalprocessofagerelatedmuscleloss.Numerousarticleshavebeenpublishedoverthelastdecadethatreviewfactorsassociatedwithsarcopenia.Thereisevidencethatsarcopeniacanbedelayed,butnoevidencethatitcanbepreventedcompletely(135).Physicalactivityandexercisearetermsthatarepoorlydefinedandoftenusedinterchangeably,whichhasledtosomeofthediscrepanciesintheinterpretationoftheliterature(136).

AdefinitionofexerciseandphysicalactivityusedbyCaspersenset al(1985)isgiveninbox7.1(137).Thereviewsinthissectionfocusonexerciseorphysicalactivityinterventionsaimedatreducingimpairment,functionanddisabilityoutcomes,ratherthanhospitalorinstitutionaladmission.ReviewsspecificallyfocusedonfallpreventionprogrammesarereportedinChapter6.

Review literature: exercise interventions

Differenttypesofexercisewereincludedinavarietyofphysicalactivityprogrammes.Thereviewsincludedthefollowinggroupsofexercise,butthemajorityincludedacombinationofalltypesofexercise:

• Flexibilityexerciseincludingyoga,taichiandstretching.

• Progressiveresistancetraining(PRT)orstrengthtrainingusingweightsorpowertraining.

• Aerobicexerciseincludingaquatic,lowimpactaerobics,walkingandcycling.

• Balance/proprioceptiveexercise.

Aplethoraofoutcomeswereusedtoassessthevariousexerciseprogrammeswhicharesummarisedintable7.1.Fifteenreviewpaperswereidentifiedasfittingthereviewcriteriaincludingonereviewofreviewsandninemoderatetohighqualityreviews(table7.2).Thischapterfocusesonthemostrecenthigher-qualityreviewsandreportseffectsizedataforinterventions,whereavailable.

Promoting Health and Wellbeing in Later Life

Table 7.1. Examples of outcomes used in trials of exercise and physical activity for older people

Measures of disablement

Impairment

Function

Disability

Physical

Social

Emotional

Overall

Example of outcome measure

Strength measures including dynamometry, single maximum lifts, strain gauge load cell and single maximum lift, range of motion, goniometry, sit and reach tests for flexibility.

Walking distance, speed and gait assessment, chair rising, weighted lift tasks, general mobility e.g. sit-to-stand and floor-to-stand tests, stair climbing and balance.

ADL and IADL outcomes e.g. SF-36 physical component, Sickness Impact Profile (SIP), Barthel Index.

SF-36 social role subscale.

Centre for Epidemiology studies – Depression Scale, SF-36 emotional sub scale, the State-Trait Anxiety Inventory.

SF-36 physical and mental scores and Sickness Impact Profile (SIP).

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Reference No of studies

Angevaren (2008) (138)

11 RCTs

Bean (2004) (139)

Columbe and Kramer (2003) (140)18 RCTs

Conn (2003) (141)17 RCTs

Cyarto et al (2004) (142)21 RCTs

Daniels et al (2008) (143)10 RCTs

Howe et al (2008) (144)34 RCTs

Keysor and Jette (2001) (145)31 Studies (29 RCTs)

Keysor (2003) (145)

4 Reviews

Latham et al (2004) (146)66 RCTs

Netz et al (2005) (147)36 studies

Orr et al (2008)(148)29 studies

Taylor et al (2004) (149)Number not specified

Van der Bij et al (2002) (150)38 studies

Yeom et al (2009) (151)28 RCTs

19 1=research question and criteria included; 2=duplicate assessors; 3=comprehensive search; 4=list of included and excluded studies reported; 5=status of publication stated; 6=characteristics of included studies provided; 7=quality assessment documented; 8=quality assessment used appropriately; 9= appropriate test for heterogeneity if meta-analysis used; 10=assessment of publication bias; 11=conflict of interest stated for included studies and review.

y=yes, n=no, na=not applicable ca =can’t answer.20 SMD=the standardised mean difference is the difference in means divided by a standard deviation. The standard deviation is usually the pooled standard deviation.

Intervention

Aerobic and combined exercise.

Combined exercise.

Aerobic and combined exercise.

Combined exercise.

General physical activity and PRT exercise (health promotion).

Combined exercise and nutritional interventions.

Balance exercise.

Aerobic and combined.

Combined.

Progressive resistance training.

Combined.

Progressive resistance training.

Aerobic exercise and combined.

Aerobic and combined.

Aerobic and combined.

Health category

General population without chronic disease (CD)/ cognitive impairment

General population and CD.

General population and CD.

General population and with CD.

General population.

Frail older people.

General population and frail older people.

General population and CD.

General population and older people with arthritis.

General population and with CD.

General Population and frail older people (OP).

General population, frail OP with chronic disease.

General population, frail OP with CD.

General population and frail OP.

General population and frail OP.

Outcome

Positive effects on cognitive function (effect size 1.17, 0.52, 0.5).

Positive for physical activity

Positive for cognitive function (combined effect size 0.5).

Inconsistent findings.

Positive effect of health promotion on activity levels.

Positive for aerobic exercise of high intensity.

Positive effects on balance ability in short term.

Positive for physical function.Unclear for disability.

Positive for physical function. Unclear for disability. Effect size 0.28, 0.23 for ADL.

Positive for impairment (SMD 0.68, 95% CI 0.52 to 0.84).Unclear for disability20

Positive for psychological wellbeing. (WMD effect size for experimental group=0.24 compared with 0.09 for control.)

Inconsistent effects of PRT on balance.

Positive for cognitive and physical function.

Positive effect on activity levels.

Positive effect of exercise (USA studies only)

Scores for methodological criteria19 Total score

1 2 3 4 5 6 7 8 9 10 11

y y y y y y y y y n ca 9/11

y n n n n n n n na na ca 1/9

y n y n n n n n y n ca 3/11

y n n n n y n n na na ca 2/9

n n y n n n n n na na ca 1/9

y y y y n y y y na na ca 7/9

y y y y y y y y na na ca 8/9

y y y n n n y y na na ca 5/9

y n y n n y n n na na ca 3/9

y y y y y y y y y n ca 9/11

y n y n n y n n y n ca 4/11

y y y n n n y y na na ca 5/9

n n ca ca n n n c na na ca 0/9

y y y n n y n n na na ca 4/9

y n n n n y n n na na ca 2/9

Table 7.2. Brief summary and quality of reviews of exercise interventions. (Further details in Appendix 6.)

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Progressive resistance training programmes

AhighqualityCochraneReviewaimedtoquantifytheeffectivenessofprogressiveresistancestrengthtraining(PRT)toreducephysicaldisabilityinolderpeople.Itincluded66RCTs,mainlytargetinggeneralolderpeople(34RCTs),publishedupto2003.TheeffectsofPRTprogrammeswerecomparedwithcontrolgroupsandanumberofotherinterventionsintermsofphysicaldisability,impairmentandfunctionalmeasures.Themainresultsareshownintable7.3.

Pooledanalysisof41trials(1,955participants)assessingtheeffectofPRTonstrengthofthelowerlimbextensormusclegroupfoundamoderatetolargebeneficialeffect(SMD0.68,95%CI0.52to0.84).Astherewassignificantheterogeneityintheseresults,asub-groupanalysiswasalsoconductedofthetenhighestqualitytrials.Thisanalysisstillfoundaslightlyreducedbutpositiveeffect.ThirtytwotrialsusedhighintensityPRTandninelowtomoderateintensity.Theanalysissuggeststhatbothtrainingapproachesareeffectiveinimprovingstrength,buthigherintensity,notsurprisingly,hasalargereffectonstrength(highintensity:32trials,SMD0.81,95%CI0.60to1.01=<0.001;lowintensity:9trials,SMD0.34,95%CI0.18to0.51p<0.001).Analysisofgeneral,frailandimpairedolderpeoplealsoshowedeffectsofPRTexercisealthoughtheeffectsizeforthosewithfunctionalimpairmentwaslowerthanthoseforhealthyindividuals(generalolderpeopleSMD0.76[95%CI0.59,0.94;p<0.0001]:impairedolderpeople0.36[95%CI0.11to0.60;p<0.004]).Interestingly,despiterelativelylargeeffectsofPRTonlegpower,benefitswerenottransferredtoanygainsinphysicalfunctionordisabilitymeasuressuggestingthatexercisespecificallylinkedtofunctionaltasksmaybemoreusefulinpreventingdisablementinolderpeople.However,thishastobebalancedagainsttheevidencethatexerciseisoftenprescribedbelowthethresholdforphysiologicaladaptionortherapeuticefficacy(152).Inaddition,whilsttherearenumerousarticlesthatprovideevidenceofshorttermefficacythereisalackofevidenceforbenefitsoflongtermadherence(150).Assessmentofriskofexercisewasnotmeasuredalthoughsomeadverseeffects,mainlymusculoskeletal,weredocumentedinsometrials.Highdrop-outratessuggestthatriskofinjurymaybeunder-reported.

Promoting Health and Wellbeing in Later Life

*Lower score indicates better performance otherwise higher score indicated better performance. Physical function domain of the SF-36 (range 0–100). WMD=weighted mean difference. SMD=standardised mean difference.

Source:Lathametal.JGerontol(ABiolSciMedSci),2004(146).

Number of trials

Effect size (95% confidence Interval)

Probability of effectP>0.05 =non significant

Table 7.3 Summary of main results of effects of PRT training on strength and disability

Strength (leg power)

Balance

Chair rise

Speed (metres per sec)

Timed walk* (seconds)

Physical disability

Higher score=less disability

Lower score=less disability*

Physical function of SF-36

41

12

4

14

4

10

6

7

SMD 0.68 (0.52 to 0.84)

SMD 0.11 (-0.03 to 0.25)

SMD -0.67 (-1.31 to -0.2)

WMD 0.07 (0.04 to 0.09)

WMD 0.77 (-0.65 to 2.2)

SMD 0.01 (-0.14 to 0.16)

SMD-0.17 (-0.53 to 0.18)

WMD 0.96 (-3.35 to 5.26)

P< 0.0001

P=0.11

P<0.04

P<0.0001

P=0.3

P=0.9

P=0.4

P=0.7

Outcome

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Chapter7

ThereviewbyOrret al(2008)focusedonPRTasasingleinterventionforimprovingbalanceperformanceinolderadults(148).Twenty-nineRCTs,ofvariablequality,wereincludedandduetoheterogeneousoutcomesandinterventionsameta-analyseswasnotperformed.Effectsizeswerehighlyvariableacrossthe29studiesrangingfromnoeffect(0.00;95%CI-0.53to0.53)tolargeeffects(0.8;95%CI0.34to1.25),themajoritybeingsmallinmagnitude.OveralltheresultsofPRTonbalancewereinconsistent,withsmallornoeffectsreportedin78%oftheoutcomes.Whilstgainscanbemadeinlegstrengththesebenefitsdon’tnecessarilyimpactonbalance,suggestingthatstrengthisprobablynotthemajorunderlyingmechanismforpoorbalance.

Key summary points of review of progressive resistance training in older adults

• Overallthequalityofthetrialsincludedinthereviewswaspoor.ThelowqualitytrialsoverestimatedtheeffectsofPRT.Thesensitivityanalysisshowedthatthehigherqualitytrialsshowedpositive,butsmaller,effects.

• OverallPRThasamoderatetolargeeffectonlowerlegstrength,animportantmeasureofimpairment,andasmalltomoderatepositiveeffectonotheraspectsofimpairmentsuchaswalkingspeed.

• Gainsinmusclestrengthcanbemadeinhealthyolderpeopleandthosewithpre-existingfunctionalimpairmentbuttheeffectsofexercisearelessforolderpeoplewithimpairment.

• Lowerlimbstrengthgainscanbeachievedfromlowintensityexercise(SMDeffectsize0.34)butgainsaregreaterforhighintensity(SMDeffectsize0.81).

• Theimprovementsinstrengthdidnottranslatetoreducedphysicaldisabilityorimprovebalance.

Effects of aerobic exercise and physical activity interventions

Theotherreviewsidentifiedinthissectionallassessedsomeformofaerobicexerciseincombinationwithotherexerciseprogrammesorphysicalactivity.Angeveranetal(2008)assessedtheeffectofaerobicexerciseoncognitivefunctioninolderpeoplewithoutimpairment.Thiswasahigh-qualityreview(qualityscore9/11)including11RCTs.Significantpositiveeffectsofaerobicexercisecomparedtoanyotherinterventionwereshownforcognitivespeed(SMD0.26,95%CI0.04to0.48p<0.02)andvisualattention(SMD0.26,95%CI0.02to0.49,p<0.03).Inaddition,positiveeffectsofaerobicexercisecomparedwithacontrolwereshownforauditoryattention(WMD0.53,95%CI0.13to0.91,p<0.01)andmotorfunction(WMD1.17,95%CI0.19to2.15,p<0.02)22.However,nineofthe11cognitivefunctionoutcomesyieldednoeffectsoftheinterventions,comparedwithcontrolsoranyotherinterventions.

Inasimilarreviewpublishedin2003,ColumbeandKramer(2003)examinedthehypothesisthataerobictrainingenhancesthecognitivevitalityofhealthy,sedentaryolderadults.Theyconcludedthatexecutiveprocesses(relatingtoplanning,inhibitionandschedulingofmentalprocedures)weresignificantlyandpositivelyrelatedtoaerobicexerciseandthatphysicalactivityisbeneficialforallthecognitivefunctionstheyanalysed.However,theseconclusionsshouldbeconsideredwithcautionasthequalityofthereviewwaspoor(4/11)andtheconclusionswerebasedonnon-randomisedtrials.ThereviewbyAngeveranetal(2008)isamorereliablesummaryoftheevidence.

Howeetal(2008)assessedtheeffectofexerciseinterventionsinvolvinggaitassessment,balance,functionalexercisesandmusclestrengtheningonbalanceinolderpeoplelivinginthecommunityandinstitutionalcare.Thirtyfourstudieswereincludedandstatisticallysignificantbenefitswerefoundforbalanceabilityintheshortterm.However,manyofthestudieshadmethodologicalweaknessesandtherewasalackofstandardisedoutcomemeasuresorlongtermfollowupmakingconclusionsdifficulttodraw.

22WMD=weightedmeandifference,SMD=Standardisedmeandifference.

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Interventions to prevent disability in frail community-dwelling older people

Danielset al(2008)reviewedRCTsofinterventionsaimingtopreventfurtherdisabilityinfrailolderpeople(143).Thereviewcriteriaspecifiedthatonlytrialsthatmeasureddisabilityoutcomeswereeligibleforinclusion.Thisresultedinonlytenstudiesofvariablequalityoutofthe58fullpapersscreenedforinclusion,twostudiesassessednutritionalinterventionsandeightassessedcombinedexerciseinterventions.Noevidencewasfoundforeffectivenessofnutritionalinterventionsforfrailolderpeopleondisabilitymeasures.Inadditionnoevidencewasfoundthatlowerlegstrengthtraining,despitetheimprovementsinwalkingfunction,hadaneffectondisabilitymeasures.Moststrikingwasthedifferenceintheintensityofinterventionsthatrangedfrom10weeksto18monthsduration,makingconclusionsdifficulttodraw.TheRCTsincludedinthisreviewthatdemonstratedsomebeneficialeffectsofaerobicexerciseondisabilityoutcomesincludedhigh-intensityexercise,andfollowedupsubjectsover12–18monthsperiod.BothRCTswerecarriedoutintheUSAandresultsmaynotbecomparableintheUKsetting(153;154).Itseemsthatwhilstexercisecanimproveimpairment and functional outcomestheevidenceforanyeffectondisabilityisweak.

Physical activity and psychological wellbeing in older people

Netzet al(2005)examinedtheeffectofphysicalactivityonpsychologicalwellbeinginolderpeopletogetherwithvariablesthatpotentiallymoderateanyeffect(147).Exercisehadasmallbutsignificanteffect(effectsizeWMD0.19)onwellbeinginhealthy older peoplewithanalmost3timesgreaterpre-test/post-testchangeintheexperimentalgroupscomparedwiththecontrol.Nostrongrelationshipwasfoundbetweensessionlengthandoutcome(overallpsychologicalwellbeing)butmoderateintensityexercisebenefitedolderpeople’spsychologicalwellbeingmorethanlightintensityexercise(WMD0.34CI95%CI0.26to0.42).Thelargestdifferences,betweentreatmentsandcontrolgroups,fortheeffectofphysicalactivitywereshowninmeasuresofself-efficacy(WMD0.38;95%CI0.24to0.52),overallwellbeing(WMD0.37;95%CI0.15to0.59),viewofself(WMD0.16;95%CI0.11to0.21)andeffectonanxietylevels(WMD0.2395%CI0.14to0.44).Itseemsthatthepotentialeffectsofincreasedcardiovascularfunctionandstrengthaddtotheoverallexperienceofimprovedwellbeing.Whilstthereweresignificanteffectsofphysicalactivityonwellbeingandmood,themagnitudeoftheeffectsizesweresmallandtheydecreasedintheolderagegroups(80+).

Behavioural factors

Thereisevidencetosupporttheefficacyofphysicalactivityandexerciseforolderpeopleintermsofimprovedstrength,aerobiccapacityandfunction,buttheeffectivenessofanyexerciseprogrammeisdependentonadherenceandcompliance.Olderpeoplewithorwithoutdisabilityencounterbarrierstoinitiatingandadheringtoexerciseprogrammes(155),suchaslackofconfidencetoexerciseandabeliefthatexerciseislikelytodomoreharmthangood.ThereviewbyVanBijet al(2002)doesnotprovideevidencetosupporttheeffectivenessoflongtermbehaviouralinterventions,suchascounsellingsessions,toencourageolderpeopletoexercise.Whilstolderpeoplecanbeencouragedtoexercise,theevidencetendstobederivedfromwhite,welleducatedpopulationswhichdon’tincludethosewhoareatgreatestriskoffunctionaldecline(150).

Eakinet al(2000)reviewedtheliteratureonprimary-care-basedinterventionsforincreasingphysicalactivity.Only4outof15studiesincludedinthereviewfocusedonolderpeople(156).However,forthesmallnumberofstudiesthatwerereportedonolderpeople,themostpromisingresultswerefoundforinterventionsthatweretailoredtoparticipants’characteristicsandthosethatofferedwrittenmaterialasreminders.Undoubtedlypolicyshouldfocusonencouragingadherencetoanactivelifestyleinearlylifewhenlifetimeactivityhabitsaredetermined.Inaddition,itappearstobeimportanttomakeanimpact‘upstream’beforeretirementandfocusonactivitiesthatgeneratefeelingsofenjoymentandsatisfaction(16).

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Chapter7

Limitations

Thereviewsofexerciserelyonthequalityofthetrialsincluded,ashasbeenthecaseforotherareasoftheliteratureandinmanycasesqualityoftheincludedRCTswasreportedaspoorornotassessed,makingfirmconclusionsdifficulttodraw.Thelackofeffectofexerciseandphysicalactivityondisabilitymeasuresmayreflectthelackofsensitivitytochangeovertimeoftheoutcomemeasures.TheSF-36hasbeenrecommendedforassessmentofgeneralhealthinolderpeople(21)butitmaynotbeasensitiveenoughtooltodetectchangesthatareimportanttoolderpeople.ThephysicalcomponentmeasureoftheSF-36includesonlythreecategoriesthatdefinelimitationofactivity(limitedalot,limitedalittleandnotlimited).Forolderpeople,evenifstrengthandfunctionimprovesitmaynotbeenoughtoshiftthescoresfrom‘limitedalittle’to‘nolimitation’inwalkingmorethanamile,climbingstairsorliftingandcarrying.

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8 Chapter 8 – Nutritional interventions

Summary

• Thereislimitedevidencetosupporttheuseofnutritionalsupplementsforolderpeoplelivinginthecommunity.

• Thereislimitedevidencethatdietaryadviceincombinationwithsupplementsimprovedietaryintakeandweightgain(atoneyear)inundernourishedolderpeoplebutthereisnoevidenceofeffectonmortalityorhospitaladmissionrates.

• Thereisnoconsistentevidencethatvitaminsupplements(vitaminBorfolicacid)haveanyeffectoncognitivefunctioninhealthyorcognitivelyimpairedolderpeople.

• ThereislimitedevidencefortheeffectivenessofvitaminDsupplementsincombinationwithcalciumforreducingriskoffallsinwomen.

Introduction

AnincreaseordecreaseinbodymasshasbeenshowntobeariskfactorassociatedwithfunctionaldeclineinolderpeopleandisoneofthesevenindicatorsoffrailtydescribedbyFerrucciet al(2003)(157).Goodnutritionplaysavitalpartinthehealthandwellbeingofolderpeople,andindelayingandreducingtheriskofcontractingdisease(47).Emphasisisplacedongooddiettopreventobesitybutitisgenerallyagreedthattheriskofunder-nutrition,ratherthanobesity,isthemaincauseofconcernforolderpeople(158).Ageingisassociatedwithdeteriorationintaste,smellandthestateofteethandallofthesefactorscanimpactondietaryintakeandnutritionalstatus.Thischapterincludesabriefsummaryoftheeffectivenessofnutritionalinterventionsonthehealthandwellbeingofolderpeoplelivinginthecommunity.

Review literature: nutritional and supplement interventions

Thesearchidentifiedalimitednumberofreviewsinthisfieldthatwererelevanttoolderpeoplelivinginthecommunity.Mostofthenutritionalresearchfocusedondietaryinterventionswithmulti-nutrientsupplements.TworeviewswereidentifiedinthepeerreviewedliteraturealongwithonerecentreviewinthegreyliteratureandoneCochraneReview.Detailsofthequalityofthereviewsaresummarisedintable8.1.

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80

Promoting Health and Wellbeing in Later Life

Reference No of studies

Daniels et al (2008) (143)

2 RCTs only

Milne et al (2009) (158)

62 RCTs

Jones et al (2009) (71)

19 studies

Jia et al (2008) (159)

22 RCTs

23 1=research question and criteria included; 2=duplicate assessors; 3=comprehensive search; 4=list of include and excluded studies reported; 5=status of publication stated; 6=characteristics of included studies provided; 7=quality assessment documented; 8=quality assessment used appropriately;

9= appropriate test for heterogeneity if meta-analysis used; 10=assessment of publication bias; 11=conflict of interest stated for included studies and review. y=yes, n=no, na=not applicable ca =can’t answer

Intervention

Nutritional interventions.

Nutritional supplement. Oral protein and energy supplements (62 trials).

Nutritional needs and interventions.

Nutritional supplements (22 trials).

Health category

Frail older people.

Frail older people.

Older adults living in the community.

Older people >65+ with subset of trials in community.

Outcome

No effect of nutritional interventions.

No reduction in mortality in total population(RR 0.92; 95% CI 0.81 to 1.04). Increase in weight gain (WMD of 2.2% (95% CI 1.8 to 2.5).

Limited benefits for nutritional supplements in community settings.

Little effect of vitamin B or antioxidant supplements on global cognitive function.

Scores for methodological criteria23 Total score

1 2 3 4 5 6 7 8 9 10 11

y y y n n y y y na na ca 7/9

y y y y n y y y y y ca 9/11

y n y n n y n n na na ca 3/9

y n y y n y y y y y ca 8/11

Table 8.1 Quality scores for reviews of nutritional interventions

81

Asystematicreviewofinterventionstopreventdisabilityinfrailcommunity-dwellingolderpeopleidentifiedonlytwostudiesthatfailedtoprovideevidencethatnutritionalinterventionshadapositiveeffectonreducingdisability,despiteanobservedeffectontotalenergyintakeandweightgain,inundernourishedfrailolderpeople(143).

Thehigh-qualityreviewbyMilneet al(2009)(158)included62trialsthatevaluatedwhetheradditionalproteinandenergysupplementshadabeneficialeffectonmortalityinolderpeople.Theoverallevidenceforthesupplementswasweak.Therewasastatisticallysignificantdifferenceinthepooledweightedmean(WMD24)betweenexperimentalandcontrolgroupsinweightgainof2.2%(95%CI1.8to2.5)buttherewasnosignificantdifferenceinmortality.However,whenthedatawaslimitedtoolder,undernourishedpeopletherewasasmallsignificantdifference(RR0.79,95%CI0.64to0.97)suggestingthatthistypeofinterventionmaybemoreeffectiveiftargetedatfrailolderpeople.

Arecentreport,commissionedbytheScottishGovernment,aimedtoreviewevidencetosupportcurrentpracticeandnutritionalinterventionsinScotland,inkeepingwiththeScottishGovernment’spolicytohelpolderpeoplereachtheirhealthpotential.Thereviewfocusedprimarilyonreviewofreviewsbutdidnottakeintoaccountthequalityoftheliterature.ThemainfindingsfromthereviewevidencebyJoneset al(2009)ofnutritionalinterventionsforolderpeoplearesummarisedintable8.2(71).

ArecentlypublisheddoubleblindRCT,carriedoutintheUK,suggeststhatacombinationofvitaminB12,B6andfolicacidcanslowtherateofacceleratedbrainatrophyinolderpeoplewithmildcognitiveimpairment(160).Thisnewresearchisencouragingbutthetrialwasrelativelysmall,the24monthfollowupratewaslow(62%)andthestudywasnotpoweredtodetecteffectsoftreatmentoncognitivetestscores.

OverallthereisverylimitedevidenceforthebenefitsofnutritionalinterventionsforolderpeoplelivinginthecommunityandwhilstJoneset al(2009)suggestthatvitaminDsupplementsshouldbeprovidedforpeopleover65yearsoldthereisonlylimitedevidencetosupporttheirrecommendation(13).

Chapter8

24Ameasureofeffectsizeusedwhenoutcomesarecontinuousratherthandichotomous(suchasdeathormyocardialinfarction).Themeandifferencesinoutcomebetweenthegroupsbeingstudiedareweightedtoaccountfordifferentsamplesizesanddifferingprecisionbetweenstudies.TheWMDisanabsolutefigureandsotakestheunitsoftheoriginaloutcomemeasure.

Intervention

Dietary interventions without supplements

Dietary interventions with supplements

Multi-nutrient supplements

Vitamin supplementation for cognition

Single nutrient supplementation

Source:Joneset al.ScottishGovernmentSocialResearch,2009.

Evidence

There is limited research on dietary interventions without supplements. Where there is evidence, dietary interventions improved dietary intake and weight gain at one year. There is no improvement in mortality or hospital admission rates.

Older people who took supplements in addition to dietary advice had higher nutritional intakes and greater weight gains but there was no difference in mortality rates.

Nutritional supplements have been shown to promote weight gain and reduce complications and mortality rates (mainly from hospital settings). However more evidence to support their use in older community-dwelling individuals has been called for.

There is no consistent evidence for vitamin supplementation to prevent or improve cognitive decline in older people.

Vitamin D: A vitamin D supplement should be provided to people over 65 to enable them to meet requirements.

Table 8.2 Summary of nutritional interventions

82

ImprovementindietandnutritionhasbeenidentifiedbytheScottishGovernmentasawayofoptimisingthehealthofolderpeopleandtheshiftinprovisionofcareinrecentyears,toincreasedcareinthecommunity,hashighlightedthesignificantproblemofpoorfoodpreparationanddietaryrequirements.Scotland’sFree Personal Care policyoffersassistancewithfoodpreparationandthefulfilmentofspecialdietaryneedsofolderpeople(aged65+)whoareconsideredbysocialservices,tobeatrisk.However,gooddietaryhabitsaresetinearlylifeandanyinterventiontoimprovenutritioninitiatedduringlaterlifeisunlikelytohavealargeimpactonthedisablementprocess.

9Promoting Health and Wellbeing in Later Life

83

9 Chapter 9 – Information and communication technology interventions Summary

• Theinformationandcommunicationtechnology(ICT)literatureisanewlyemergingfieldthathasnotbeensubjectedtohighqualityevaluation.

• Thereislittleevidenceavailableontheimpactoftelecareatthepopulationlevel.

• Thereislimitedevidenceofsmalleffectsfortelecareinclinicaloutcomes,suchasenhancedqualityoflifeforfrailolderpeopleandtheircarers.

• ThereislimitedevidencethatICTpreventsorreducesdisablementinfrailolderpeople.

• Thereislimitedevidencethattelemedicineisacost-effectivemeansofdeliveringhealthcare.

• Thereislimitedevidencefromobservationaldataonlythatsuggestcostsavingsmaybemadeintermsofhospitaladmission,homecheckvisitsandsleepovernightsfromtelecare(safetyandsecuritymonitoringsystems)inScotland.

• Thereisnostrongevidencethattelecarereduceshospitalorinstitutionaladmission.Overlyoptimisticassessmentoftheeffectsoftelecareonthedemandforinstitutionalcareintheshortandlongtermshouldbeavoided.

Introduction

Thedemographictrendtowardsagrowingpopulationofolderpeople,togetherwithfragmentedservicedelivery,andtherisingcostofhealthcare,havedrivenUKgovernmentstowardsdevelopingICTwithanaimtomodernisetheNHSandprovideamorecostefficient,person-centredservice.ICTinterventionsfallintotwomaincategories:

• Electronic integration dimension.ICTthathelpstointegrateservicedeliveryandaccesstoinformationbetweeninstitutionsandprofessionalswithanaimtoprovideasingleassessmentprocess.

• User-centred dimension.TheuseofICTtosupportolderpeopleandtheircarerstoremainlivingindependentlyinthecommunity.Theuser-centereddimensionofICTtendstobereferredtoastelecare(161).

SomeofthedefinitionsofICT,reportedintheliterature,areshowninbox9.1.

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84

Telecare/telehomecareinvolvethedeliveryofhealthandsocialcaretoindividualswithinthehomeorwidercommunityoutsideformalinstitutionalsettings,withthesupportofsystemsenabledbyinformationandcommunicationtechnology.Telecaresystemsaredesignedeitherforriskmanagementorforassessmentandinformationsharing.

Telemonitoring referstotelecommunicationdevicethatenablesautomatedtransmissionofapatient’shealthstatusandvitalsignsfromadistance,totherespectivehealthcaresetting.

Telehealthreferstoprovisionofhealthrelatedservices,homehealthandpatienteducationatadistanceusingtelecommunicationtechnologies.Telephonebasedcareservicescancombinetelemonitoringwithhealthmessages.

Telemedicineisdefinedasthedirectprovisionofclinicalcare,includingdiagnosing,treating,orconsultationviatelecommunicationforpatientsatadistance.

Box 9.1. Informationcommunicationtechnologydefinitions

Telecare,inparticular,isarapidlygrowingfieldthatpolicymakersandhealthprofessionalsalikeareembracing.AmbitioustargetshavebeensetforstrategiesinEnglandtoprovideallhomesthatneeditby2010(162).SimilarlyinScotland,acommitmenttoICT,andinparticulartelecare,wasmadein2006–8with£8.35millionfundingmadeavailableto32healthandsocialcarepartnerships.Theprimaryaimofthetelecarestrategyistokeepolderpeople,andthosewithdisability,livingindependentlyintheirownhomesbyprovidingincreasedsafetyandreassurancetothemandtheircarers(66).Theexpectationsfortelecarearehighwithhopesthatitwillreduceinstitutionalisationanddelayfrailtyprogression,bydetectingearlyindicationofthefirstsignsofdeterioration,andactinguponthem(163).Somearguethatmisplacedoptimismaboutthesuccessofpilotstudies,ofpoormethodology,mayresultininappropriatepolicyorpracticedecisions(164).ThischapteraimstoreviewtheliteratureonICTinterventionswithaviewtoestablishiftheclaimsofbenefitsforthehealthcaresystemareevidence-based.

Review literature: Information communication technology interventions

Informationcommunicationtechnology,andinparticulartelecare,isarelativelynewfieldwithanexpandingresearchliterature.Since1997,whenthefirstresearchpaperwasidentifiedtherehasbeenarapidriseinthepublicationrate(165).Theevidenceinthisfieldisdominatedbysmall-scalepilotstudiesorobservationalstudiesandtherearenohighqualityRCTs.SomewouldarguethatthisreflectsthefactthatICTinterventionsareservicedeliveryinnovations,supportedbynewtechnology,andRCTsaredifficulttoconductinthisfieldbecauseofthecomplexityofcaredelivery(17).

Fivereviewswereidentifiedthatincludedfrail,olderpeopleorolderpeoplewithcomorbidityasthemainpopulationoralargesub-groupinthereview.ThequalityofthereviewswasassessedusingtheAMSTARmethod(63)andwasgenerallypoor,rangingfrom2to5outof9(seetable9.1).FurtherdetailsofthereviewsarereportedinAppendix7.AnumberofreviewsevaluatingICTwereexcludedastheyeitherfocusedonspecificdisease,youngeradultsandchildren(166;167)(168)(169;170)orwerenarrativereviewsdescribingprocessofdeliveryratherthanevaluationofoutcome(161;163;169).

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Chapter9

Reference No of studies

Barlow et al (2007) (171)98 studies including 68 RCTs

Botsis et al (2008) (172)54 studies

Dellifraine (2008) (173)29 studies

Gaitwad (2009) (174)27 studies

Jennett et al (2003) (175)53 studies

25 1=research question and criteria included; 2=duplicate assessors; 3=comprehensive search; 4=list of include and excluded studies reported; 5=status of publication stated; 6=characteristics of included studies provided; 7=quality assessment documented; 8=quality assessment used appropriately; 9= appropriate test for heterogeneity if meta-analysis used; 10=assessment of publication bias; 11=conflict of interest stated for included studies and review.

y=yes, n=no, na=not applicable ca =can’t answer.

Intervention

Telecare.

Telecare.

Telehealth.

Telemonitor-ing.Telehealth. Telehome-care.

Telehealth.

Health category

Frail and chronic disease.

Chronic disease.

Sub-group of older people.

Sub-group of older people.

Sub-group of older people.

Outcome

Variable. Most benefit for vital signs monitoring.

Variable outcome.

Positive effect on clinical outcome. Effect size 0.41 (95% CI 0.10 to 0.73).

Positive effect on independence enhancement.

Positive for quality of life but limited generalisability.

Scores for methodological criteria25 Total score

1 2 3 4 5 6 7 8 9 10 11

y y n n n y n n na na ca 3/9

n n n n n y n n na na ca 1/9

y n n n n n n ct y n ca 2/11

y n n n n y n n na na ca 2/9

y n y n n n y y na na ca 4/9

Table 9.1 Quality scores for reviews of information and communication technology interventions for older people

86

Home telecare for frail older people and those with long term conditions

ThereviewbyBarlowet al(2007)wasoneofthehigherqualityreviewsinthissectionalthoughonlyscoring3outof9ontheAMSTARqualityscale(171).Failingtoreportdetailsoftheincludedandexcludedstudies,notassessingthequalityofthestudiesnorreportinganydescriptiveorquantitativemeasureofbenefit,werethemainlimitationsofthereview.Thereviewincluded68lowqualityRCTs,and30observationalstudies.MoststudiesoriginatedintheUSA(64%)withonly10%incarriedoutintheUK.InadditiontheRCTsincludedinthereviewweresmallsuggestingthattheymaybeunderpowered,withthepossibilityofunreportedtypeIIerrors26.Onlysixstudies(7%)focusedprimarilyonolderpeoplewiththemajorityconcentratingonheartdiseaseanddiabetes.Interventionswerecategorisedintovitalsignsmonitoring,safetyandsecuritymonitoring,andinformationandsupportservices.Overall,theauthorsreportedthemostbenefitfromvitalsignsmonitoringforreducinghealthserviceuse,andtelephonemonitoringbynursesforimprovingclinicalindicatorsandreducinghealthserviceuse.Inthefrailoldergroup,mostofthebenefitswereshownfor‘informationandsupportservices’wherecasemanagementbytelephonewasfoundtoimproveclinicaloutcomesandimproveadherencetotreatment.Nodetailsweregivenregardingthemagnitudeofeffectsinthestudiesmakingitdifficulttomakefirmconclusions.

Socioeconomic impact of telehealth and telemedicine

Jennettet al(2003)included53studiesofolderpeople,asasubgroupinalargersystematicreviewofthesocioeconomicimpactoftelehealth(175).Only16outof53studies(30%)providedgoodtofairscientificevidenceofbenefit,intermsofenhancedqualityoflife.Therewerenohighqualitycomparativestudiestosupporttelehealthwhichclearlydemonstratethesocioeconomicbenefitsofvideo-consultation.FurtherdetailsofbenefitsarereportedinAppendix7.Theauthorsidentifiedproblemsintheliteratureparticularlyregardingevaluationofcostssavingsandcosteffectiveness.Thelackofprecisioninthecostanalysescreateduncertaintyaroundthegeneralapplicabilityofresults,makingcomparisonbetweenstudiesandpopulationsmisleading(175).

Grey literature reviews and reports

Thesearchidentifiedthreerecentlypublishedreportsandreviewsoftelecareinterventionsthatprovidesummariesofeffectiveness(5;17;74).Thereviewswerevariableinqualityandwhilstallreportedbenefitsofdifferenttypesoftelecareinterventions,andcostsavingsintermsofhospitaladmissions,noneincludedcleardetailsofthemagnitudeofeffectsorconsideredthepotentialbiascausedbythelackofacontrolgroupinmanystudies.

TwoseparatereviewsofevidencefortelecareinterventionswerepublishedbyWestMidlandsNHSin2008(74)andtheDepartmentofHealthin2006(17).Thefindingsofbothreviewsarepresentedintable9.2.Itshouldbenotedthattheevidenceisbasedonsmall-scaleRCTs,feasibilityorpilotstudiesandobservationaldata,andalargepercentageoftheevidenceoriginatesfromstudiesofpeoplewithheartdiseaseanddiabetes,notspecificallyaimedatolderpeople.Barlow(2006)reportedlimitedevidencefortelecare,aimedatageneralpopulationoffrailolderpeople,oncareoutcomesandalmostnoevidenceofcostbenefits.

ArecentreportbyTheBOWGroup27fromtheCentreforInternationalResearchonCare,LabourandEqualities(CIRCLE)publishedaverypositivereviewoftheeffectivenessoftelecare.Theauthorssuggestthat:‘telecareoffersaproven‘win-win’forthehealthandsocialcaresystem‘.Thebenefitsoftelecare

Promoting Health and Wellbeing in Later Life

26Instatistics,theterms‘typeIerror’or‘falsepositive’and‘typeIIerroror‘falsenegative’areusedtodescribepossibleerrorsmadeinastatisticaldecisionprocess.

TypeI(a):rejectthenullhypothesiswhenthenullhypothesisistrue–a‘falsepositive’finding. TypeII(ß):acceptthenullhypothesiswhenthenullhypothesisisfalse–a‘falsenegative’finding.27TheBowGroupistheoldest–andoneofthemostinfluential–centre-rightthink-tanksinBritain. TheGroupexiststodeveloppolicy,publishresearchandstimulatedebatewithintheConservativeParty.Ithasnocorporateview,butrepresentsallstrandsofConservativeopinion.

87

interventionsreportedbyTheBOWGroup(5)include:

• Delayedentryofpeoplewithdementiaandothercomorbiditiestoinstitutionalcare.

• Enablingmorepeopletobedischargedearlyfromhospital.

• Cuttingunnecessarycostsfromhealthandsocialservicecaresuchashomevisitsandovernightsleepingservices.

• Reducingriskssuchasfire,smoke,gasandfallsinthehomesofolderpeople.

• Assistinginthemanagementofspecificconditionse.g.monitoringvitalsigns,detectingproblemsatnightorenablingcarerstosleep.

• Enablingfrailolderpeopletosummonassistancerapidlywhenneeded.

• Providingsupportandre-assuranceforcarers.

ThereportwasbasedoninformationfromanumberofUKgovernmentdocumentsandthepeerreviewedliterature,includingsomeofthereviewsshownintable9.1.ThereportmakesreferencetocostsavingsintheScottishTelecareDevelopmentProgrammeof£11.15millionbetween2007–8(176)butitshouldberecognisedthatthesecostsareestimated.TheevaluationoftheScottishTelecareDevelopmentProgramme,carriedoutbytheYorkHealthEconomicsConsortium,predictedsavingsofaround£43millionfor2007to2010mainlyinreducedunplannedhospitaladmissions.Telecareinnovationincludinggeneralsafetyandsecuritymonitoring,hasbeenincorporatedinawiderangeofchangestoservicedeliveryinWestLothian,Scotland(SmartSupportatHomeScheme)(177).Furtherevaluationoftheseprogrammesisrecommended.

Chapter9

88

10Ta

ble

9.2.

Sum

mar

y of

res

ults

of t

elec

are

inte

rven

tions

Tele

care

type

Info

rmat

ion,

ad

vice

and

supp

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Vita

l sig

ns

mon

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g

Safe

ty a

nd

secu

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mon

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g

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re o

f evi

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se

Abse

nce

of la

rge-

scal

e RC

Ts

and

deta

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cost

-effe

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ness

an

alys

es.

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inat

ed b

y sm

all-s

cale

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serv

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nal s

tudi

es. A

bsen

ce

of lo

ngitu

dina

l and

cos

t-ef

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ivene

ss a

nalys

is.

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l-sca

le fe

asib

ility

stud

ies.

Evid

ence

of f

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bilit

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d im

pact

Evid

ence

of f

easib

ility

and

acce

ptab

ility.

Smal

l-sca

le

evid

ence

of i

ndivi

dual

and

sy

stem

ben

efits

.

Incr

easin

g ev

iden

ce o

f fe

asib

ility

and

acce

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ility

but

with

som

e ex

cept

ions

. Sm

all-

scal

e ev

iden

ce o

f ind

ividu

al

and

syst

em b

enefi

ts.

Obse

rvat

iona

l stu

dies

sug

gest

pa

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sat

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ce o

n sy

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ben

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.

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emen

tatio

n is

sues

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rtanc

e of

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pro

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l sup

port

and

com

mitm

ent t

o of

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lack

of f

ace-

to-

face

con

tact

. New

er te

chno

logi

es re

quire

gr

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r tec

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al s

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rt du

ring

and

follo

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tion.

Trai

ning

, edu

catio

n an

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cal s

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rt is

very

impo

rtant

. Eas

e of

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and

re

spon

se p

roto

cols

shou

ld b

e co

nsid

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in

impl

emen

tatio

n. In

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n w

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l inf

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and

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pr

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es w

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and

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ters

. Mul

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te o

f suc

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ful

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out

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evid

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for t

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sup

port

syst

ems

on c

ost b

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t.

No e

viden

ce fo

r old

er p

eopl

e.

No e

viden

ce fo

r old

er p

eopl

e.

Source:AdaptedfromWilliamsetal(2008)(74)andBarlowetal(2006)(17).

Indi

vidu

al o

utco

mes

Som

e ev

iden

ce fo

r tel

epho

ne s

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rt sy

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s fo

r im

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or c

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omes

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ports

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igns

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g fo

r pat

ient

s w

ith

diab

etes

. No

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ence

for o

lder

peo

ple

grou

p.

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ited

evid

ence

for t

elec

are

aim

ed

at th

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nera

l pop

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ion

of fr

ail

olde

r peo

ple

show

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impa

ct o

n ca

re

outc

omes

.

89

10 Chapter 10 – Interventions to prevent social isolation and loneliness Summary

• Socialisolationandlonelinesshasnotbeenextensivelyresearchedinolderpeople,andvirtuallynotatallintheUK.Themostrecentreviewonlyidentified11quantitativestudiesofdiverseinterventions.

• Thereislimitedevidencefromsixstudiesofvariablequalityforgroupactivitiesthatincludesomeformofeducationalortraininginputandsocialactivitiesthattargetspecificgroupsofpeople,buttheeffectsarelikelytobesmallandnotgeneralisable.

• Groupexerciseprogrammes,peerandprofessional-led(socialworker)supportgroupswereshowntobeeffectiveinreducingsocialisolationandloneliness,buttheyaredependentoncomplianceandlongtermfollowup.

• One-to-oneinterventions(homevisits)werenotfoundtobeeffectiveinreducinglonelinessorsocialisolation.

• Evidencefortechnology-assistedinterventionsforfrailolderpeopleandtheircarersislimitedtoafewstudiesandthestudieshavefocusedonbasictechnologyonly,suchasphoneorcomputer-mediatedsupportgroups.

• Mostinterventionsinvolveachangeinbehaviourandthereforetheoutcomesarelikelytobevariableacrosssettingsastheydependonpersonalfactorsand/orculturalcontext.

• Theresearchtodatehasfocusedonafewpotentialcausesofsocialisolationandloneliness,butinrealitythecausesarecomplexandrelatedtomanyfactorsincludingenvironmental,socialandhealth-related.Itisthereforenotsurprisingthattheeffectivenessoftheinterventionsisvariableandgenerallysmall.

• Targetinginterventionsinthecommunity,simplytoreducesocialisolationandloneliness,isunlikelytoreduceneitherhospitaladmissionsnorinstitutionalisation.

Introduction

Socialisolationisacommonprobleminlaterlifeandisassociatedwithpoorphysicalhealth,increasedmortality,mentalillhealth,depression,suicideanddementia(18).PreventionofsocialisolationhasbeenanaimoftheWorldHealthOrganizationformanyyearsandlowfrequencyofsocialcontacthasbeenshowntobeariskfactorforfunctionaldeclineinolderpeople(47).However,whilstthereisevidencefromepidemiologicalresearchofthedeleteriouseffectsofsocialisolationonhealth,thecausalassociationisnotwellunderstoodandpoliciesandinterventionsaimingtoimprovesocialparticipationinolderpeoplehavenotbeensubjectedtoextensiveresearch(178).Socialisolationisdefinedinvariouswaysintheliterature.VanBaarsenet al(2001)differentiatedbetweentwoconstructs:

• Socialisolation:anobjectivemeasureofsocialinteraction.

• Sociallonelinessoremotionalisolation;thesubjectiveexpressionordissatisfactionwithalownumberofsocialcontacts(179).

Thesetwoconstructshavealsobeencombinedinasingledefinition:

• Socialisolation:poororlimitedcontactwithothers,perceivedasinadequateand/orlimitedcontactcausingadversepersonalconsequencesfortheindividual(180).

Thischapterprovidesabriefsummaryoftheeffectivenessofinterventionsthataimtopreventoralleviatesocialisolationandlonelinessamongstolderpeoplelivinginthecommunity.

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Review literature: interventions to prevent social isolation

Tworeviewarticleswereidentifiedinthepeer-reviewedliteraturethatfocusedoninterventionstoreducesocialisolationamongstolderpeople(table10.1).Inaddition,arecentevidence-basedanalysisofsocialisolationincommunity-dwellingseniorswasidentifiedinthegreyliterature.

ThereviewswerescoredusingtheAMSTARmethodologicalcriteriaanddetailsarepresentedintable10.1andAppendix9.

Interventions to reduce social isolation amongst older people

ThelowerqualityreviewbyFindlayet al(2003)identified17evaluativestudiespublishedbetween1982and2002,ofwhichonlysixwereRCTs.EightofthepublishedstudieswereconductedintheUSA,theotherswereconductedinAustralia,Canada,theNetherlands,ItalyandSweden.Theinterventionsweregroupedintoone-to-oneinterventions(telephonesupportsystems,telecarealarmsystemsandtheGatekeeperProgramme);groupinterventions(discussiongroupsandeducationalprogrammes);serviceprovision(communitysupportnetworksandretirementvillageliving);andinternetusage(provisionofinformationandsupportviawebsitesandonlinecourse).Findlayet al(2003)concludedthattherewaslittleevidenceforinterventionsthattargetedsocialisolationinolderpeople.Theauthorsidentifiedmanylimitationsintheliteratureyethighlightedsomefactorsthatmaycontributetosuccessfulinterventions.Theysuggestedthatinterventionshadabetterchanceofsuccessiftheyinvolvedexistingcommunityresourcesandaimedtobuildcommunitycapacity.Thisseemsanimportantpoint,inviewoftheScottishGovernment’splantoinvolvecommunityandlayvolunteersinthecareofolderpeople.TheGatekeeperProgrammeisanexampleofatypeofcommunityprogrammethatfocusesonbuildingcapacityamongstvolunteers(181).TheGatekeeperProgrammewasestablishedintheWashingtonState,USAin1978

Promoting Health and Wellbeing in Later Life

Reference No of studies

Findlay (2003) (180)

17 studies (6 RCTs)

Cattan and White (2005) (19)

30 studies

Medical Advisory Secretariat (2008) (20)

11 RCTs

28 1=research question and criteria included; 2=duplicate assessors; 3=comprehensive search; 4=list of include and excluded studies reported; 5=status of publication stated; 6=characteristics of included studies provided; 7=quality assessment documented; 8=quality assessment used appropriately;

9= appropriate test for heterogeneity if meta-analysis used; 10=assessment of publication bias; 11=conflict of interest stated for included studies and review. y=yes, n=no, na=not applicable ca =can’t answer.29 Health promotion was defined as ‘ the process of enabling older people to increase control over and improve their health’.

Intervention

Interventions including telecare and home visits, social groups.

Health promotion intervention29

Single focused interventions(exercise, social work group activities).

Subjects

Socially isolated older people.

All older people.

Community dwelling older people aged >65.

Outcome

Weak evidence for interventions that target social isolation and loneliness.

Group interventions alleviate social isolation and loneliness.

Group activities reduce depression and loneliness.

Scores for AMSTAR methodological criteria28 Total score

1 2 3 4 5 6 7 8 9 10 11

y n y n n y n n na na ca 3/9

y y y n n y y y na na ca 6/9

y n y n n y y y na na ca 5/9

Table 10.1 Quality scores for reviews of interventions to prevent social isolation

91

andwasrolledoutacrosstheUSAandCanada.Itaimedtohelpmembersofthecommunitylearntoidentifythesignsofanolderpersonatriskofsocialisolation,whomayneedsupportservicestoensuresafetyandwellbeing.Theprogrammelinkedthesepeopletoprogrammesofcarebeforeacrisissituationdeveloped.Theprogrammereliedonvolunteerstoincreaseawarenessofthesignsofanolderpersonatrisk.Theseincluded:difficultycommunicating/memoryloss,becomingwithdrawn,hostileorangry,changestopersonalappearance,deterioratinghomeconditions,deterioratinghealth/difficultyseeing,speakingorhearing,poormobility,decreasedabilitytohandlemoneyorpaybills,neglectorabuse/isolationandwandering.

Thisprogrammewasassessedinanon-randomised,matchedcontrolledtrial.ResultssuggestthattheGatekeepermodeldoesnotresultinhighserviceutilisationandisinexpensivetoimplement,althoughitisamethodforidentifyingolderpeopleatriskofsocialisolationratherthananinterventionperse(182).

ThehigherqualityreviewbyCattanet al(2005)(19)includedstudiespublishedbetween1970and2002,involvinghealthpromotionforolderpeoplethattargetedsocialisolationandloneliness.Thirtystudieswereidentifiedofwhich19statedatheoreticalframeworkfortheintervention.Themajorityutilisedsomeformofbehaviouraltheorysuchascognitivebehaviouraleducationorsociallearning.Theinterventionsweregroupedinto:

• One-to-one.

• Serviceprovision.

• Groupactivitiesandcommunitydevelopmentprogrammes.

Onlythirteenstudieswerejudgedashighquality,ofwhichsixwereidentifiedasbeingeffective,onewaspartiallyeffective,althoughtheinterventionhadnoeffectonloneliness,andsixwereineffectiveorinconclusive.Thereviewsuggeststhatgroupactivitiesthatincludedsomeformofeducationalortraininginputandsocialactivitiesthattargetedspecificgroupsofpeoplewereeffectiveinreducingsubjectivefeelingofisolation.One-to-oneinterventions,conductedinpeople’sownhomeswerenotfoundtobeeffectiveinreducinglonelinessorsocialisolation.Thisisnotasurprisingoutcomeasinstinctivelyanyhomevisitorphonecall/internetintervention,carriedoutonaone-to-onebasis,seemsunlikelytohaveanyimpactonsocialintegration,although‘befriending’30isoneofthemostfrequentlyprovidedactivities.Thesuccessof‘befriendingschemes’probablyreliesonthevolunteersbeingofthesamegenerationandsocialbackgroundastheolderpersontheyarevisiting.Programmesthatenabledolderpeopletobeinvolvedintheplanning,developmentanddeliveryofactivitieswerethemostlikelytobeeffective.

ThereviewcarriedoutbytheMedicalAdvisorySecretariat(partoftheOntarioMinistryofHealthandLongTermCare)focusedoninterventionsforsocialisolationandlonelinessincommunity-dwellingolderpeople(20).Thecriteriaforthereviewexcludedpilotstudiesoflessthan30subjects,casereports,integratedmodelsofoutreachcare,andstudiesinwhichlonelinessandsocialisolationwerenotmeasuredquantitatively.Elevenquantitativestudies,publishedbetween1980and2008,ofsingle,focusedinterventionwereidentifiedasfittingthecriteria,interestinglyonlyonemorethanidentifiedbyCattanet alin2005(19).OnlysixoftheelevenwereRCTs,sevenwereconductedintheUSAandfourinEurope(noneintheUK).Mostofthestudiesincludedolderpeople(mainlywomen)lessthan75yearsofage.Thestudies’interventionswerecategorisedinto:

• Groupsupportactivities(focusgroupsledbysocialworkers,seniorcitizensgroups,exerciseandprofessionally-led,educationalgroups,selfhelpgroupsledbysocialworkers).

• Technology-assistedinterventions(socialwork‘crisis’phonelines,friendlyinterviewerphonevisits,telephonebasedsupportgroups,socialworker-ledtelephonesupportgroups).

Lonelinesswasmeasuredeitherasa1-itemresponsetoaquestionaboutfrequencyoflonelinessorbyspecificinstruments,suchastheUCLALonelinessScale(183).Measuresofsocialisolationandlonelinesswereextractedfromgenericassessmenttools,suchastheSF-36(184).Asummaryoftheeffectivenessoftheinterventionsareincludeintable10.2.Overallthequalityofthegroupinterventionswasreportedtobemoderate,whereastheoverallqualityofthetechnology-assistedinterventionswaslower.

Chapter10

30Befriendingisaschemethatencouragesvolunteerstovisitolderpeopleintheirownhomesonaone-to-onebasis.

92

Promoting Health and Wellbeing in Later Life

1. Wait list for senior apartments

2. Residents of senior apartments

3. Physically inactive seniors

4. Physically inactive seniors

5. Bereaved seniors

6. Users of mental health services at senior centres

7. Seniors experiencing mental health crisis

8. Seniors with low income and low perceived social support

9. Hearing-impaired seniors

10. Informal caregivers of persons with Alzheimer’s disease

11. Informal caregivers of persons with dementia

=decrease; NS=not significant; p>0.05; †P<0.05; ‡P<0.0; §P<0.001

Country, year

Sweden, 1985

Sweden, 1983

Netherlands, 2002

United States, 2000

United States, 1993

United States, 1982

United States, 1998

United States, 1991

Germany, 1997

United States, 1995

United States, 2007

Intervention type

Social worker–led self-help groups.

Support groups.

Group exercise programmes.

Group exercise programmes.

Peer- and professional- led self-help support groups.

Social worker–led self-help groups.

Social worker crisis phoneline.

Telephone friendships.

Hearing aids.

Nurse moderated computer link .

Social worker–led telephone-based support.

N

108

60

382

174

339

68

61

291

148

102

103

Findings

Isolation† Isolation†

Isolation‡ Loneliness‡

Loneliness†

NS

Isolation‡ Loneliness§

Isolation‡ Depression†

NS

Loneliness†

NS

Depression† (subgroup > 65 yr)

Table 10.2 Effectiveness of diverse interventions for social isolation, loneliness and depression

Source:ReproducedwithpermissionfromtheMedicalAdvisorySecretariat(2008)(20)

93

Oncloseinspectionofthedatathereareanumberoflimitations.Firstly,thelackofgeneralisabilityoftheevidencemakesitdifficulttoassessasmoststudieswerecarriedoutintheUSAonhighlyselectedgroups,includingmainlywomenandolderpeopleintheir60sand70s.Inadditionthefollowupperiodswereshort,generallylessthat12monthsinduration,whichisnotlongenoughtoadequatelyassesseffectiveness.Itisalsounclearifthereductioninisolationandlonelinesshadanyimpactonlongtermbehaviouralchange.Mostnotably,manyofthestudieswithpositivefindingshadverysmallsamplesizes(n=60–70)yetthetwolargerstudies,thatwerelesslikelytobeunder-powered,reportednon-significantresults.Thissuggeststhatsomeofthesmallerstudiesshouldbeviewedwithcautionandlargerstudieswouldbeneededtoconfirmthefindings.

Theinterventionsidentifiedinthisreviewwerealldirectedattheindividualorgrouplevel,werenarrowlybasedanddidnotincludeproactivecase-findingofthoseatriskofsocialisolationandloneliness.Inconclusion,socialisolationandlonelinessaredifficultoutcomestomeasureandfactorssuchasenvironmentalandeconomicaspectsthatinfluenceolderpeople’sviewsandbehaviourareimportantandnotgenerallytakenintoaccountinthesenarrowlybasedtrials.

Chapter10

94

11Promoting Health and Wellbeing in Later Life

95

11 Chapter 11 – Medication review

Summary

• Medicationreviewbypharmacistorotherhealthprofessionalshasnoeffectonreducingmortalityorhospitaladmission.

• Thereisnoevidenceofsignificantbenefitsforpharmacist-ledmedicationreviewonqualityoflife.

• Thereislimitedevidencefromonelargemulti-centreRCTthateducationalprogrammes,includinginformationaboutmedicationreviewforGPs,mayreduceriskoffallingandinjuryandimprovemedicationuseinolderpeople.

• ThereisverylimitedevidencefromonesmallRCTthatgradualwithdrawalofpsychometricmedicationcanreducetherateoffallsinolderpeople.

Introduction

Medicationintakecanimpactsignificantlyonthewellbeingofolderpeoplewhooftenfindthemselvesonacocktailofdrugsformultipleailments.Thecomplexityandtoxicityofsomedrugscanaffectthehealthofolderpeopleandcanhavemoreofanegativeeffectthanpositiveoutcome.Medicationrelatedadverseeffectsinprimarycarerepresentanimportantcommoncauseofmorbidityalthoughtherehasbeenlittleresearchaimedatevaluatinginterventionsthatmightleadtosaferprescribing(185).Medicationreviewisastructuredevaluationofapatient’smedicines,aimedatreachingagreementwiththepatientaboutdrugtherapy,optimisingtheimpactofmedicinesandminimisingthenumberofmedication-relatedproblems.Mostinterventionsincludemedicationreviewbypharmacistsorotherhealthprofessionals.Thischapterincludesabriefsummaryoftheeffectivenessofinterventionsthataimtopreventdrugrelatedmorbidityforolderpeoplelivinginthecommunity.

Review literature: medication review (pharmacy and GP-led interventions)

Threesystematicreviewswereidentifiedthatincludedstudiesofmedicationreviewandinterventionsinprimarycarethataimedtoreducemedicationrelatedadverseeventsinolderpeople.DetailsofthequalityoftwoofthereviewsaresummarisedinTable11.1.FurtherdetailsarepresentedinAppendix10.AsummaryofthethirdreviewbyGillespieet al(2009)(13)isincludedintables6.1and6.2inthepreviouschapteronfallspreventioninterventions.

Chapter11

96

Promoting Health and Wellbeing in Later Life

31 1=research question and criteria included; 2=duplicate assessors; 3=comprehensive search; 4=list of include and excluded studies reported; 5=status of publication stated; 6=characteristics of included studies provided; 7=quality assessment documented; 8=quality assessment used appropriately;

9= appropriate test for heterogeneity if meta-analysis used; 10=assessment of publication bias; 11=conflict of interest stated for included studies and review. y=yes, n=no, na=not applicable ca =can’t answer.

Review

Holland et al (2007) (186)

Royal et al (2006) (187)

Intervention

Medication review (pharmacy-led). (32 studies, 20 in community settings)

Interventions aiming to reduce drug related adverse effects.

Subjects

Older people with disease >65.

Older people with disease.

Outcome

No sig benefit on mortalityRR 0.96 (95% CI 0.82 to 1.13)hospital admission or QOL.

No evidence for pharmacist- led or other interventions. (OR 0.92 (95% CI 0.81 to 1.05)

Scores for AMSTAR methodological criteria31 Total score

1 2 3 4 5 6 7 8 9 10 11

y y y n n y y y y y ca 8/11

y y y y n y y y y y ca 9/11

Table 11.1 Quality scores for reviews of medication review

97

Royalet al(2006)included38observationalstudiesandRCTs,17werepharmacist-ledinterventions,eightwereledbyprimaryhealthcareprofessionalsand13wereinterventionsincludedaspartofamorecomplexfallspreventionprogramme(187).Whenallthedatawaspooledinameta-analysis,includingrandomisedandnon-randomisedtrialsthepharmacyledinterventionswerefoundtobeeffectiveatreducinghospitaladmission(OR0.64[95%CI0.43to0.96])however,whenasensitivityanalysiswascarriedoutthatrestrictedtheincludedstudiestoRCTs,therewasnosignificantdifferencebetweengroups(OR0.92[95%CI0.81to1.05])suggestingthatselectionbiasmayhaveskewedthedataintheinitialanalysis.Noothereffectswerefoundforthefallsgroupormedicationreviewbyotherprimaryhealthcareprofessions.

Thehighqualitymeta-analysisofpharmacist-ledmedicationreviewbyHollandet al(2007)alsofailedtodemonstrateanysignificanteffectonallcauseadmissiontohospital(RR0.9995%CI0.87to1.14p=0.92)ormortality(RR0.96[95%CI0.82to1.13p=0.62](186)buttheinterventionsappearedtohavepositiveeffectsonoutcomessuchasnumberofdrug-relatedproblems,knowledge,adherence,satisfactionandadversedrugreactionswhichareimportantoutcomes.Oncloserinspectionofthedataonlyonethirdofthetrialsthatmeasuredqualityoflifefoundanybenefitandtheywerenotstatisticallysignificant.Thelackofeffectdidnotseemtoberelatedtothetypeofpharmacistorintensityofthemedicationreview.ItissurprisingthattherearefewstudiesthatfocusonGP’sreviewofolderpeople’smedicationasgenerallyGPsaremostlikelytoberesponsibleforprescription.

Themeta-analysisoffallsinterventionsbyGillespieet al(2009)includedtwotrialsthatdemonstratedsomebenefitofmedicationreview.Oneplacebo-controlledtrialfoundasignificantreductionintherateoffalls(RaR0.3495%CI0.16to0.73)butnotriskoffallsorfractures.However,thiswasaverysmalltrial(188)carriedoutinNewZealandwithonly93participantsandresultsshouldbeviewedwithsomecaution.

Thehigher-qualitytrialreviewedbyGillespieet al(2009)(13)ofGP’smanagementofmedicationuse,investigatedtheeffectivenessofaneducationalprogrammeaimingtoimprovemedicationuseonnumberoffallsandqualityoflifeforpeopleaged65andover(189).ThetrialwasaclusterRCTdesignincluding849patientsfrom20GPpracticesinAustralia.Theinterventionconsistedofthreecomponents:

1. Education-academicprogramme,givingprescribinginformationandfeedback.

2. Medicationriskassessment.

3. Completionofmedicinereviewchecklist.

Doctorsreceivedpracticeincentivepaymentsaftercompletingtenmedicationreviewsandwerereimbursedfortheirtime,butdespitethisbonus,therewasalowdoctor’sresponseratetotheeducationalprogramme.Participantsintheexperimentalgrouphadaloweroddsratioforhavingafall(OR,0.61;95%CI,0.41to0.91),injury(OR,0.56;95%CI,0.32to0.96),andinjuryrequiringmedicalattention(OR,0.46;95%CI,0.30to0.70)at12months.Theincreasedoddsofhavinganimprovedmedicationuse(combineduseofbenzodiazepines,non-steroidalanti-inflammatorydrugs[NSAIDs]andthiazidediuretics)ofcompositescore(OR,1.86;95%CI,1.21to2.85)wassignificantat4-monthbutnotat12monthsfollowup.Qualityoflifescoreswereunaffectedbytheintervention.ThissuggeststhateducationprogrammesandsystemsformedicationreviewconductedbyGPscanleadtoimproveduseofmedicinesandpotentiallyreduceriskfactorsforfunctionaldeclineinolderpeoplebutitwouldrelyonagoodGPtake-uprate,andlongtermfollowup.

Chapter11

98

12Promoting Health and Wellbeing in Later Life

99

12 Chapter 12 – Discussion

Introduction

Thisscanofpolicydocumentsandresearchincludesinformationonawiderangeofdifferentinterventionsaimedatpreventingdisablementincommunity-dwellingolderpeople.Criticalappraisaloftheevidenceisdifficultbecauseoftheunstandardisedoutcomesanddifferentterminologiesusedformodelsofcaree.g.homevisits,comprehensivegeriatricassessmentandcasemanagementmodelsthatareheterogeneousandincludeoverlappingcomponents.Thedisablementprocesswasusedasaframeworktodevelopthesearchstrategyforidentifyinginterventions.Thecomplexityofthedisablementprocessmeansthatmanyriskfactorsandoutcomesarerelevantandthereforethisscanhasaverybroadfocus.Thereisalargedegreeofuncertaintyintheliteratureformanyinterventions.

Manyofthestudiesfocusonhospitaladmissionratesratherthanfunction,activitiesofdailylivingorqualityoflife,makingconclusionsregardingthepreventionofdisablementdifficult.Nursinghomeorinstitutionaladmission,althoughdifficulttomeasurepreciselyisprobablyoneofthemostimportantendpointsforpolicymakersandresearcherstoconsider,notleastbecauselossofindependenceisimportanttoolderpeople.Someofthereportedriskfactorsfornursinghomeadmissionaredifficulttomodify(48),butinterventionsthatimpactonactivityofdailylivingdependency,shouldbeencouraged.Overall,thereisgoodevidenceforexerciseinterventionsforanumberofoutcomes,particularlyforpreventionoffalls,buteffectsizeestimatesareoftenlowerinstudiesofhigherquality(146)andimpactatapopulationlevelisprobablylow.Mostoftheevidenceforotherinterventionsismixedwithsmallorinconsistenteffects,makingconclusionsdifficulttodrawwithconfidence.Thelackofclearevidenceispartlyduetothefactthattherearesomanydeterminantsofhealthyageing,asdescribedbyDahlgrenandWhitehead(34)includinghereditaryandindividuallifestylefactors.Thefactthatchronicdiseasesandphysicaldeclineoriginateinearlylifeanddevelopinsidiously,hasalargeparttoplayinshapingthehealthandwellbeingofolderpeople(25)andmodifyingthesedeterminantsofhealthinlaterlifeisdifficultandnotalwayspossible.Thatisnottosaythatinterventionsforolderpeoplearenotworthwhilebuttheevidence,feasibilityincontextofthesetting,andpotentialimpactshouldbecarefullyconsidered.

Thestrengthoftheevidenceforcomplexandspecificinterventionsissummarisedintables12.1and12.2.Thetablesaresplitintocomplexandspecificinterventionsalthoughtherearecommoncharacteristicswithinmanyoftheinterventions,suchasexerciseinfallspreventionprogrammesandcasemanagementwithinintegratedservicedeliveryprogrammes.Theevidenceinthetablesisbasedonreview-leveldataofmainlyrandomisedorcontrolledstudies,unlessotherwisestated.Wherepossiblethemagnitudeofeffectisstatedinthetablesaseffectsize,relativerisk(RR)oroddsratio(OR),SMDorWMD.Theevidenceiscategorisedas:evidenceofnoeffect(evidencethattheinterventionisineffective),limitedormixedevidence(conflictingevidenceorverysmalleffects),evidenceofeffect(wherethereisconsistentevidenceofsmalltomoderateeffects)orunknowneffectiveness(wherenoevidencewasfound).Theoverallpictureisinconclusiveandstrongevidenceofeffectisrareforalloutcomesrelatingtothedisablementprocess.Themostcommonlyreportedoutcomeswerehospitalandinstitutionaladmissionalthoughtheyaredifficulttomeasureaccuratelyandneedtobereportedalongsideacontrolgroup.

Chapter12

100

100Ta

ble

12.1

. Str

engt

h of

evi

denc

e fo

r ef

fect

iven

ess

of c

ompl

ex in

terv

entio

ns. (

RR

=ris

k ra

tio o

r O

R=o

dds

ratio

[95%

CI]

SMD

=sta

ndar

dise

d m

ean

diffe

renc

e.)

Inter

vent

ions

Prev

entat

ive ho

me

visits

Com

preh

ensiv

e ge

riatric

as

sess

men

t

Com

preh

ensiv

e ge

riatric

as

sess

men

t

Mult

iple-

factor

ial

falls

inter

venti

ons

Case

man

agem

ent

Integ

rated

servi

ce

deliv

ery

Targ

et p

opula

tion

Gene

ral a

nd fr

ail/

impa

ired o

lder p

eople

.

Gene

ral o

lder p

eople

.

Frail

/impa

ired o

lder

peop

le.

Frail

olde

r peo

ple.

Frail

olde

r peo

ple.

Frail

olde

r peo

ple.

Phys

ical f

unct

ion

Varia

ble re

sults

OR 0

.89

(0.7

7 to

1.

03).

Very

small

effec

t siz

eSM

D -0

.12

(-0.1

6 to

-0.0

8).

Effec

t size

dif

feren

ce S

MD

-0.0

1 (-0

.06

to

0.04

).

Small

effec

t on

phys

ical fu

nctio

n m

easu

res (

SF-3

6).

Use o

f diffe

rent

ou

tcom

es m

akes

co

mpa

rison

s dif

ficult

.

Larg

e pop

ulatio

n-ba

sed c

ontro

lled

study

show

s ↓ in

ciden

ce of

fun

ction

al de

cline

at

4 ye

ars.

Disa

bility

(ADL

)

2 ou

t of 8

stu

dies r

epor

ted

impr

ovem

ent

0.2

eff

ect s

ize.

Unkn

own

effec

tiven

ess.

Unkn

own

effec

tiven

ess.

Unkn

own

effec

tiven

ess.

Unkn

own

effec

tiven

ess.

Unkn

own

effec

tiven

ess.

Cogn

itive f

unct

ion

Unkn

own e

ffecti

vene

ss.

Unkn

own e

ffecti

vene

ss.

Unkn

own e

ffecti

vene

ss.

Unkn

own e

ffecti

vene

ss.

Impr

ovem

ent s

een i

n de

pres

sion s

cales

and

men

tal st

atus.

(1 R

CT on

ly)

Impr

ovem

ent in

men

tal

healt

h and

depr

essio

n.(1

RCT

only)

Quali

ty of

life

Diffe

renc

e in o

utcom

es

mak

es co

mpa

rison

dif

ficult

. Som

e ben

efits

in se

lf-effi

cacy

for

gene

ral p

opula

tion.

Unkn

own e

ffecti

vene

ss.

Unkn

own e

ffecti

vene

ss.

Fear

of fa

lling m

ay

be re

duce

d. 6

out

of 12

RCT

s sho

wed

impr

ovem

ent in

QOL

.

Unkn

own e

ffecti

vene

ss.

Impr

ovem

ents

in em

powe

rmen

t and

sa

tisfac

tion.

↓satis

factio

n for

care

giver

s.

Socia

l isola

tion

Unlik

ely be

nefit

of

one-

to-on

e. Ev

idenc

e for

hom

e vis

its is

uncle

ar.

Unkn

own

effec

tiven

ess.

Unkn

own

effec

tiven

ess.

Unkn

own

effec

tiven

ess.

Evide

nce f

rom

1

RCT o

f impr

oved

so

cial fu

nctio

n. (S

F-36

p<0.

008)

Unkn

own

effec

tiven

ess.

Risk

or ra

te of

falls

Evide

nce f

or O

T/nu

rse vi

sits f

or ho

me

mod

ificati

on.

24%

redu

ction

in ris

k RR

0.7

6 (0

.67

to 0.

86).

Very

limite

d effe

ctRR

0.9

9 (0

.89

to 1.

10).

Confl

icting

resu

lts R

aR

0.75

(0.6

5 to

0.86

) RR

0.9

5 ( 0

.88

to 1.

02).

Unkn

own e

ffecti

vene

ss.

Unkn

own e

ffecti

vene

ss.

Instit

ution

al ad

miss

ion

OR 0

.86

(0.6

8 to

1.10

). Ho

me v

isits

migh

t inc

reas

e adm

ission

due

to ide

ntific

ation

of un

met

ne

eds.

14%

redu

ction

in ris

k of

nu

rsing

hom

e adm

ission

RR=0

.86

(0.8

3 to

0.90

).

Very

limite

d to n

o effe

ct RR

1.

01 (0

.83

to 1.

23).

Evide

nce i

n fav

our o

f int

erve

ntion

but C

Is wi

de.

Base

d on 5

RCT

s R

R 0.

92 (0

.59

to 1.

43).

Incon

sisten

t evid

ence

from

stu

dies u

sing d

iffere

nt

mod

els of

care

. OR

for

coho

rt stu

dy 0

.56

(0.4

3 to

0.

63).

Poten

tial fo

r dela

ying n

ursin

g ho

me a

dmiss

ion. O

R 0.

56

(0.4

3 to

0.63

). Coh

ort s

tudy

only.

Evid

ence

of e

ffect

Lim

ited/

mix

ed e

vide

nce

or b

ased

on

RCTs

onl

yEv

iden

ce o

f no

effe

ct

Unkn

own

effe

ctiv

enes

s

Hosp

ital a

dmiss

ion (H

A)/

deat

h

HA de

pend

ent o

n num

ber o

f ho

me v

isits

OR fo

r dea

th 0.

92 (0

.80

to

1.05

).

Very

limite

d (HA

)(R

R 0.

98 (0

.92

to 1.

03).

Evide

nce o

f no e

ffect

for de

ath

1.00

(0.9

8 –1

.03)

.

Small

effec

t for

(HA.

RR 0

.90

(0.8

4 to

0.98

).Ev

idenc

e of n

o effe

ct for

death

1.

03 (0

.98–

1.03

).

Base

d on 9

RCT

s 0.

82 (0

.63

to 1.

07) fo

r HA

Base

d on 1

5 stu

dies R

R for

de

ath 1

.08

(0.8

7 to

1.34

).

Incon

sisten

t evid

ence

from

stu

dies u

sing d

iffere

nt m

odels

of

care

main

ly in

the U

SA.

Healt

h sys

tems b

enefi

ts an

d re

ducti

on in

emer

genc

y visi

ts re

porte

d but

size o

f effe

ct un

certa

in.

101

101Ta

ble

12.2

. Str

engt

h of

evi

denc

e fo

r ef

fect

iven

ess

of s

peci

fic in

terv

entio

ns (R

R=r

isk

ratio

or

OR

=odd

s ra

tio (9

5%C

I) SM

D=s

tand

ardi

sed

mea

n di

ffere

nce.

)

Inter

vent

ions

Exer

cise (

aero

bic,

prog

ress

ive

mus

cle tr

aining

tai

chi, b

alanc

e)

Assis

tive d

evice

s or

envir

onm

ental

m

odific

ation

s

Telec

are/

teleh

ealth

Socia

l inter

venti

ons

Med

icatio

n rev

iew

Nutrit

ional

inter

venti

ons

Vision

scre

ening

/co

rrecti

ve

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102

Complex interventions

Thesearchidentified9reviewsofpreventativehomevisitinterventionspublishedbetween2000and2009,threereportedpositivefindings,fourreportedinconsistentfindingsandtworeportednegativeresults.Themostrecentlypublished(negative)reviewbyBoumanetal(2008)(96)didnotfindanyevidenceofeffectforhomevisitsforfrailolderpeople(intensity4.5to7.5)butthetrialsincludedinthereviewdidnotuserisk-targetedassessment.Liebel(2009)alsoreportedinconsistentfindingsforhomevisitprogrammesbutthemostsuccessfulinterventionstargetedriskfactorsassociatedwithfunctionaldecline(80).Theauthorsthatreportbeneficialeffectsofhomevisitsadvocatemulti-dimensional,high-intensityfollowup,targetedattheappropriatepopulation.However,Beswicket al(2008)foundlittleevidencethatinterventionswithahigherintensityweremoreeffectiveinimprovingoutcomesthanthosethathadlesshealthcareinvolvement,shorterdurationornumberofvisits.Thestrengthofevidenceforeffectsofuntargetedhomevisitsonhospitalandnursinghomeadmissionisweak(84).

Overalltheeffectsofthecomplexinterventionsappearsmalltomodestatbest.Forinstance,whendatafromallinterventionsinthemeta-analysisbyBeswicketal(2008)werecombined,theriskofhospitalandnursinghomeadmissionwasreducedfrom40.5%to38.2%andfrom10.6%to9.2%(numbersneededtotreat42and7132)respectivelyandchangesinphysicalfunctionweresmall(7).Inaddition,whenthedatawasanalysedinsubgroupsforgeneralandfrailolderpeople,theeffectsforcomprehensivegeriatricassessment,forfrailolderpeople,isevensmallerandformostoutcomesnotstatisticallysignificant.Stottet al(2008)pointoutthat:

‘The true benefits are likely to be higher because of contamination of control groups and the use of intention-to-treat analysis, as this method of analysis generally underestimates the magnitude of benefits for those who receive an intervention because it also includes those that have not adhered to the intervention.’ (190)

Complexinterventionscontainseveralinteractingcomponentsandcharacteristicsthatneedtobeconsideredduringevaluation.Theseinclude:theinteractingcomponentswithintheexperimentalandcontrolintervention,behaviouralchangesrequiredbythosedeliveringorreceivingtheintervention,thegroupsororganisationallevelstargetedbytheinterventionsanddegreeofflexibilityortailoringoftheinterventionpermitted(23).Thesecomponentswereusuallynotdescribedwellinthereviewsorprimarystudies,makingdatasynthesisdifficult.

Thebeliefthatscreeningandcase-findingcanpreventfunctionaldeclineinolderpeopleisappealingtopolicymakers,researchersandclinicians.ThelargeMRCtrialofuniversalscreeningforpeopleover75yearsoldinEngland,thatfailedtoshowbeneficialeffectsofpopulation-basedscreeningwasagoodexampleofapolicy-drivenstrategy,implementedwithoutasoundevidence-baseorwellcoordinatedcarepathwaystofollow(8).AninterestingfindingoftheMRCtrialwasthatthespecialistingeriatricmedicineperformednobetterthantheGPswhenimplementingthecomprehensivegeriatricassessment.Thissuggeststhatmanagementofolderpeopleidentifiedasinneedofcomprehensivegeriatricassessmentwouldbebestplacedingeneralpractice,ifGPtimeallowed,theGPsreceivedadditionaltrainingandtime-consumingadministrationcouldbekepttoaminimum.Theincorporationofthe75+annualcheckintoGPscontractsinEnglandwasineffective,partlybecauseitwasresistedbyGPsandneverfullyintegratedproperly(191).

Theevidenceforcasemanagementandintegratedservicedeliveryforolderpeopleisequallycontradictory(192),butexpertssuggestthattheprogrammesmostlikelytobesuccessfularethosethataretargetedatfrailolderpeopleatlowrisk,focusingonmulti-dimensionalgeriatricassessmentandincludemultiplefollowupvisits(193).Arecenthigh-qualityprimaryRCTdemonstratedthatevenwithtargetedinterventionandlongtermfollowupofthreeyears,successisnotalwaysguaranteedintermsofreducingfunctionaldeclineanddisability(111).

Promoting Health and Wellbeing in Later Life

32Thenumberneededtotreat(NNT)isthenumberofpatientswhoneedtobetreatedinordertopreventoneadditionalbadoutcome(i.e.thenumberofpatientsthatneedtobetreatedforonetobenefitcomparedwithacontrolinaclinicaltrial).TheidealNNTis1,whereeveryoneimproveswithtreatmentandno-oneimproveswithcontrol.ThehighertheNNT,thelesseffectiveisthetreatment.

103

Cost effectiveness of complex intervention for older people

Therearerelativelyfewreportsonthecosteffectivenessofcomplexcareforolderpeople.Inalowqualityreviewofthecostofcomprehensivegeriatricassessment,Wielandet al(2003)(89)suggestthatimplementationofcase-managementmaynotincreasecarecostswhilstElkan(2000)concludedthathomevisitshavethepotentialforproducingcostsavings.Morerecently,Huntet al(2004)reviewedthecostandimpactofcasemanagementforlongtermconditionsandfoundthatthemethodologyvariedconsiderablybetweenstudies,duetodifferencesinreportedhospitalpaymentsystems,makingconclusionsdifficulttodraw.Huntet al(2004)foundthatonlyoneoutofnineRCTsreportedastatisticallysignificantreductionincosts,fourreportedincreasedcostsandsixreportednon-significantreductionsinoverallcosts(includingcostofcasemanagement,nursinghomeandhospital-beddaysandemergencydepartmentvisits)(192).TworecentlypublishedRCTs,notincludedinthereviews,reportpositivefindings.InasmallRCT(n=155),Melliset al(2008)comparedthecostsofamultidisciplinary,geriatricassessmentmodelwithusualcareinHolland,andfoundthattheinterventionwasaneffectiveadditiontoprimarycare,forfrailolderpeople,ata‘reasonable’cost(10).Belandet al(2006)inCanada,alsoshowedthatintegratedcare,includingcasemanagementforolderpeoplewithmoderatedisability,hasthepotentialtoshiftinstitutionalcaretohomecareserviceswithoutadditionalcosts(9).ThisisencouragingbutitisdifficulttocomparecosteffectivenessbetweencountriesthatofferdifferenthealthandsocialservicesandfurtherevaluationisneededinScotlandbeforefirmconclusionscanbemadeaboutcostsavings.Mostresearchtodateseemstosuggestthatwhilstcarecanbedeliveredsuccessfullyinthecommunity,withappropriateintegratedandcoordinatedservicedelivery,itmaynotresultinoverallcostsavings.

Integrated service delivery and case management

EvidenceforintegratedservicedeliveryfromthereviewliteratureislimitedandmanyoftheinterventionsdevelopedintheUSA(91)maynotbefeasibletoimplementinScotland.ThosethathavebeenimplementedintheUK,(suchastheEvercareProgrammeaimedatolderpeopleininstitutionalcare)failedtoprovideevidenceofeffectiveness(102).

Whilstthereareanumberofpromisinginterventionsforintegratedservicedeliverydeveloped,mainlyintheUSAandCanada,theyrelyonadequateinformationsystems.Thereareconcernsovertheadequacyofcare-coordinationacrossEuropebecauseinformationsystemsthatpermitthetransmissionofpatientinformationbetweenproviders,isonlyemerging,anditisoftennotfullycoordinated(3).Itseemsthat,unlessallthekeypointsforintegratingcareareinplace,suchassingleentrypoint,coordinationbetweendecisionmakersandmanagers,comprehensivegeriatricassessment,centraluseofcasemanagersandaneasilyaccessiblecomputerisedsystemforsharingdatabetweendifferentcaresystems(suchasNHS24andoutofhoursservices),thesuccessofanyinterventionislikelytobelimited.Inaddition,itseemsessentialthatalongtermfollowupprocessisdevelopedforevaluation,asdemonstratedbytheCanadianPRISMAmodelthatshowednodifferenceinfunctionaldeclineinfrailolderpeopleinthefirstthreeyearsofapopulation-basedtrialbutreportedsignificantreductioninfunctionaldeclineinthefourthyear,whenrecruitmenttotheprogrammeincreased(194).

Thereareanumberofimportantfactorsthatneedtobeinplaceinordertoachievesuccessfulintegrationofhealthcaresystems.Inacomprehensivereport,producedbytheOrganisationforEconomicCo-operationandDevelopment(OECD)onimprovedhealthsystemperformancethroughbettercarecoordination,Hofmarcheret al(2007)highlightfourkeyareasforpolicyconsiderationforimplementationanddevelopmentofintegratedcare:

• Theneedforbetterpatientinformationandsystemspermittingitstransferbetweenprovidersandacrossinstitutionalboundaries.

• Theneedforambulatorycare,andprimarycareinparticular,tohavethecapacitytorespondtoemergingpatientneeds.Keyelementsinthiscontextarewhetherscope-of-practicerulesforhealthprofessionalsareflexibleenough,andwhetheroverallresourcesintheambulatoryandlongtermcaresectorareadequate.

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• Howcoordinationcanbestbeorganisedandwhetherpaymentarrangementsforprovidershelptoencouragethedesiredcoordinationandcooperationamongproviders.

• Afinalchallengeconcernsbreakingdownbarriersbetweencaresilosthroughincreasedintegrationofcare(195).

StuckandKane(2008)suggestthatinvestmentincomplexpreventativecareshouldconsidertwostrategies(196):

1. Olderpeopleatlowrisk–multidimensional,preventativestrategies,addressingthemultiplepotentialco-existingmedical,functional,psychologicalandenvironmentalproblemsandrisksofolderpeople.Longtermfollowupneedstobeincludedtoensuremodificationoflongtermriskfactorsandrespondtochangeovertime.

2. Olderpeopleathigherriskorforthosethatarealreadydisabled–multidimensionalinterventionsthattargetspecificproblems.

Basedonthecurrentevidencetheserecommendationsseemsensiblebutitisnotclear:1)howthegroupsarebestidentifiedandtargeted;2)whatcontentofprogrammedeliveryisoptimal;or3)howfeasibletheinterventionsareintheScottishcontext.Interventionneedstobetailoredtotheindividuals’needsandaonesizefitsallapproachisunlikelytobeeffective.Thefocusonhealthserviceutilisationasthesuccessoftheseprogrammesislimitedbythefactthathospitalandnursinghomeadmissionareunreliablemeasureswithoutacontrolforcomparison(6).Moreemphasisisneededonevaluation,includinganunbiasedcontrolgroupforcomparison,anduseofreliableandvalidmeasuresofqualityofcareandpatientsatisfaction.

Falls prevention

ThesearchidentifiedavastnumberofpublicationsrelatingtofallspreventionbuttheheterogeneityofRCTs,intermofoutcomesandtypeofintervention,makecomparisonofreviewandRCTdatadifficult.Conclusionsfromreviewsandmeta-analysisappeartobehighlydependentonhowfallsaremeasuredandanalysed.Inaddition,thevariationinoutcomes,intrialsusingamulti-factorialapproach,maybeduetothemethodofservicedelivery.Thereviews’differentconclusionsarepotentiallyconfusingforthosecommittedtousingresearchevidencetoguideclinicalpracticeandpolicy,andhighlighttheimportanceofconsideringthemethodologicalqualityandlimitationsofsystematicreviews.

Exerciseappearstobethemaincomponentofsuccessfulinterventionforreducingtherateandriskoffalls.However,exerciseisusuallyincorporatedasasubstantialpartofmulti-factorialfallpreventioninterventionsthatappeartobeeffectiveinreducingtherateoffallsbutnottheriskoffalls.Oneoftheauthorsofthethreerecentreviewsoffallswascontactedforcommentonthediscrepancyintheliterature.ProfessorLamb’scommentonthecurrentliteratureisreportedbelow:

‘Some of the successful multi-factorial falls programmes (MFFPs) use very similar exercise programmes to ‘exercise alone’ studies i.e. one of the reasons why there is discrepancy in the literature is that the type of exercise used in MFFPs varies a lot, but more importantly, the sicker people tend to be recruited to MFFP, so it may just reflect that we can’t modify outcomes for people who are more sick. All in all, quite a complicated picture. The main question at the moment seems to be whether or not exercise alone is just as good as MFFP.’ (Lamb 2009; personal communication).

Otherexpertsinthefieldbelievethat:‘areturntoasingleinterventionapproachforallpatientsubgroupsisunlikelytoadvanceourabilitytomaximisehealthandfunctioninginpersonswithmultipleriskfactorsandmultiplecomorbidities.’(197).

Mostoftheresearchto-datehastargetedfrailolderpeople,excludingthosewithcognitiveimpairment,whoareprobablyatgreatestrisk.Whilstthisscanhasnotfocusedonolderpeoplewithspecificcognitivedisorders,suchasdementia,itappearsthattheeffectivenessoffallpreventioninthisgroupofolderpeopleremainsunknown(122).

Promoting Health and Wellbeing in Later Life

105

InspiteofconflictingresultspublishedbyGateset al(2008)(12)andtheNationalInstituteforHealthResearch(NIHR)scopingexerciseonfaller’sclinics(72)thatconclude‘theevidenceindicatesthatfaller’sclinicshaveanegligibleclinicaleffect’,currentNICEguidelinesrecommendmulti-componentfallpreventionprogrammes(120).Theseguidelineshavenotchangedsincethepublicationoftherecentlypublishednegativereviewsandtrials.Aswithallcomplexinterventionsforolderpeople,fallspreventionmanagementpresentsvariouschallengesandbarrierstosuccessfulimplementation,notleastthestandardisationofscreeningtoolstoprovidereliableandvalidbaselineassessment,aswellasintegratingservicedelivery,sothatcareiscoordinatedandcommunicatedacrossdifferentdisciplinesandbetweenprofessionalgroups.Onbalance,takingintoaccountallcurrentevidence,itseemsintuitivetosupportamultidimensionalapproach,butnotwithoutongoingevaluation.

Areportonmanagementoffalls,UpandAbout,waspublishedbyNHSQualityImprovementScotlandin2010andnumerousinterventionsforfallspreventionhavebeenimplementedacrossScotland.Theyincludeenvironmentalstreetandpavementaudit(Perth),homesafetyunits,riskassessmentandfallsclinics,visionscreening(Perth&Kinross)rehabilitationandexerciseclasses,multidisciplinaryfallsservice(NHSGreaterGlasgow&Clyde,NHSLanarkshire),interventionstoraisepublicawareness(Perth&Kinross),riskassessmentoffalls,fracturesandosteoporosis(NHSLothian,Edinburgh),pharmacyriskassessment(Glasgow),mobileemergencycareservice(FalkirkandNHSForthValley),fractureliaisonservices(NHSGreaterGlasgow),telecaretopreventfalls(WestLothian),fallsresponseservice,podiatryscreening(Fife),homebasedrehabilitation(NHSandSocialWork,IsleofBute),fallspreventionadvice(NHSBorders),occupationaltherapyassessment(NHSGrampian),fallstrainingpackages(Lanarkshire)andanintegratedhealthandcareservicedeliverymodeltrainingpackage(EastRenfrewshire).Itisunclearwhetherorhowtheseserviceshavebeenevaluatedandfurtherresearchinthisfieldmaybejustified.

ThePreventionofFallsNetworkEurope(ProFaNEwww.profane.eu.org)haspublishedhigh-qualitystandardiseddefinitionstoassistinthedevelopmentandreportingofresearchthatisbasedonevidenceandconsensusofexperts.Theguidelinesrecommend:

• Acommondefinitionoffallsshouldbeused.

• Falldatashouldbesummarisedasnumberoffalls,numberoffallers/nonfallers/frequentfallers,fallrate-per-person-per-yearandtimetofirstfall.

• Themethodofdatacollectionshouldconsidertheproblemofrecallofinformation,particularlyover3–6months,assomeolderpeoplehaveproblemswithshortandlongtermmemory.

• Thenumberofradiologicallyconfirmedfractureeventsperyearshouldberecordedaccurately.InjuriesshouldbeclassifiedaccordingtotheInternationalClassificationofDiseaseandInjuries(ICDI).

• Psychologicalconsequencesoffallsshouldbeconceptualisedintermsoffall-relatedself-efficacyandmeasuredusingthemodifiedFallsEfficacyScale(mFES)(198).

• Health-relatedqualityoflifeshouldbemeasuredusingtheshortform12version2(SF-12)andEuropeanQualityofLifeInstrument(EuroQolEQ-5D)(123).

Fallspreventionisanotherexampleofacomplexinterventionforwhichthereissomeevidenceofeffectivenessbuttheoptimumcontentanddeliveryoftheinterventionneedsfurtherinvestigation.Thekeycomponentsoftheinterventionneedtobe‘teasedout’andprioritygiventoactivitiesthataremostlikelytobebeneficial.Similartoothercomplexinterventions,fallpreventionprogrammescanbedeliveredaspartofanintegratedservicedeliverypackage.Martin(2009)describesasystematicapproachtofallsandfracturepreventionthatsetsoutkeycomponenttobeconsideredbycommissionersandcareproviders(seefigure11.1)(199).Thesuccessofthisapproachreliesonintegratingcareacrossthehospital-communityinterfaceasdescribedintheDeliveryFrameworkforAdultRehabilitationinScotland.

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figure 12.1. Asystematicapproachtofallsandfractureprevention

Cost effectiveness of falls preventions interventions

Inarecentreviewofthecostoffallsinolderpeople,Heinrichet al(2010)(200)included32studiesthatfocusedonfall-relatedinjuries.Theauthorsconcludedthatfallsarearelevanteconomicburdenbutmorecomprehensiveandstandardisedcost-ofinjurystudiesoffallsarerequired,inparticularthesocietalcosts(directandindirectcost),NHSandprivatecostsneedtobedocumentedfullyinordertoclarifytheoverallcosts.SimilarconclusionswerealsodrawnbyDaviset al(2010)inaninternationalcomparisonsofthecostoffallsandclearlyaconsensusisneededtoaddress:(1)variationinthedefinitionoffallsandfall-relatedinjuries;(2)variationinclinicaloutcomes(thecostitemscollectedandunitsreported);(3)thepopulationdenominatorthatcostestimatesarebasedon;(4)variationintimeintervalswhencostsaremeasured;and(5)perspectiveoftheanalysis(201).Bothreviewssuggestthattheeconomiccostoffallsislikelytobemorethanpolicymakersappreciate.

Reviewsofcost-effectivenessoffallspreventionprogrammeshavebeenpublishedbytheMedicalSecretariat(2008)(14),andDaviset al2010)(15).Botharelimitedbythelackofcomprehensiveandstandardisedcostmeasures.

Promoting Health and Wellbeing in Later Life

Source:ReproducedfromNextStepsforFallsandFractureReduction.AgeandAgeing,2009Nov;38(6):640–3.MartinF,2009withpermission.

107

Specific problems associated with ageing

Manyofthecomplexinterventions,suchashomevisitsandcomprehensivegeriatricassessment,tendtofocusonaplethoraofdiverseproblemsassociatedwithageing(falls,activitiesofdailyliving,cognitiveimpairment,communication,incontinence,infection,nutrition,oralinfection,visualimpairment,swallowingandsocialisolation).Someriskfactorshavebeenidentifiedasthestrongestpredictorsoffunctionaldeclineandadmissiontoinstitutionalcare(47).Ithasnotbeenpossibletoreviewindividually,alltheproblemsassociatedwithageinginthisscan,althoughsomewereidentifiedintheoriginalsearch.Somereviewshavefocusedmorespecificallyontheindividualriskfactorsassociatedwithageing,butolderpeopleoftensufferwithcomorbidityandconsideringindividualriskfactorsinisolationdoesnotaccountforthemajorityofolderpeople.

TheOntarioHealthTechnologyAssessment(2008)(76)identifieddementia,falls,socialisolationandurinaryincontinenceasthemainriskfactorsforfunctionaldecline.

Dementia,inparticular,affectsatleast6%ofpeopleover65yearsinScotlandandthetotalnumberofpeoplewithdementiamayincreaseby75%inthenext25years.ForthisreasontheScottishGovernmenthaslaunchedaresearchnetworkbuiltaroundfourresearchhubsinGlasgow,Grampian,LothianandTayside,withanaimtodevelopnewtreatmentsforthisdevastatingillness.Primaryprevention,inparticular,regularexerciseandregularleisure-timephysicalactivity,preferablystartinginearlytomid-life,hasbeenshowntobeassociatedwithreducedriskofdementiainlaterlife(76),althoughotherfactorssuchaslevelofbasiceducationprobablyplayalargerpartinpreventionoflaterlifedementia(202).Thereisverylimited,inconclusiveevidencethatlaterlifecognitivetrainingcanoffsetdeteriorationintheperformanceofself-reportedactivityofdailyliving.

Urinaryincontinenceisahealthproblemthataffectsasubstantialnumberofolderpeopleandcanimpactonhealth,socialintegration,wellbeingandqualityoflife.Theliteratureinthisfieldislimitedtosubjectiveoutcomes,measuresderivedfrompatientobservationsandsymptoms,andthereisverylimiteddatabasedonlongtermfollowup.Themostpromisinginterventionsforpreventionsaremulti-componentbehaviouralinterventionsincludingacombinationofbladdercontrolstrategies,pelvicfloormuscletrainingandselfmonitoringtechniques(76;203)buttheseareprobablymoreeffectiveifstartedinearlytomid-life.

Specific interventions

Overall,thereviewofspecificinterventionsdemonstratedalackofstrongevidenceofeffectivenesswiththeexceptionoffairlygoodevidenceforeffectsofexerciseonphysicalandcognitivefunction,andfalls,wheretheevidenceisrelativelyclear.Asummaryofthespecificinterventionsisshownintable12.2.

Exercise

Thereviewofexercisewasfocusedonreview-leveldataofmainlyRCTsofinterventionanddidnottakeintoaccountwell-conducted,high-qualityobservationalstudiesthatshowaprotectiveeffectofphysicalactivityonincidentdisabilityandage-relatedmorbidity.Alargepopulation-basedstudyfromtheEstablishedPopulationofEpidemiologicalStudies(EPESE)forolderpeopleshowedthatolderpeoplewhoreportedhighlevelsofphysicalactivity(frequencyofwalking,gardeningandvigorousactivity)weremorelikelytodiewithoutdisabilitycomparedtosedentaryolderpeople(oddsratio=1.86;95%CI,1.24to2.79)(204).However,changingbehaviourinlaterlifeisdifficultandthelimitationofobservationalstudiesisthattheycanbeentirelyrelatedtoself-selectionandtheseresultsshouldthereforebeviewedwithcaution.Overall,thereisgoodevidencethatolderpeoplecanimprovetheirmusclestrength,jointflexibilityandbalancethroughregularmoderateactivityandthiscanbecrucialforfrailolderpeopleintermsofperformingactivitiesofdailylivingandcompressingmorbidity.

Therearefewstudiesthathaveassessedthethresholdorintensityofexerciserequiredtoproduceandmaintaingainsinfunction,particularlyforprogressiveresistancetraining.Epidemiologicaldatasuggestthatthereappearstobeaminimalthresholdofatleastmoderate,ifnotmoderatelyvigorousactivity,intherangeof60%–70%VO2max

33thatisrequiredtoelicitimprovementinaerobicfitnessinolderpeople

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(135).Thiscanbeachievedbythreehoursormoreofmoderateintensityexerciseperweek,suchasbriskwalking.Thisisasubstantialamountofexerciseforsomeolderpeoplebutitappearsthatroutinephysicalactivity,suchashousework,isnotenoughtopreventlossofaerobiccapacity(205)althoughitmayhelpflexibilityandgeneralstrength.Frailandolderpeopleofbothsexescanimprovetheiraerobicfunctionsimilarlytoyoungadults,andlongtermbenefitsofexercisecan‘compressmorbidity’andallowlongerperiodsofactiveindependence(135).However,thechallengeremainstofindwhatdegreeofimprovementinstrengthandpowerisneededtotransferthepositivegainsofexercisetofunctionalchangeineverydaylifeandpreventorreducedisability(206).

TheOntarioHealthTechnologyAdvisoryCommitteefoundmoderatetohighqualityevidencethatregularexercisecansignificantlyimprovehealthoutcomesincommunity-dwellingolderpeoplethroughbothprimaryandsecondarypreventionoffalls,urinaryincontinence,dementiaandsocialisolation.PhysicalactivityrecommendationsforolderpeoplehavebeenpublishedbytheWorldHealthOrganizationandInternationalSocietyforAgeingandPhysicalActivity(www.isapa.org/guidleines/index.cfm)andmorespecificallyintheUK,Canada,USAandAustralia(135).

Exercise and health promotion

Exerciseisoneofthemostcommonlyrecommendedinterventionsforpreventionofdisablementinolderpeople.TheSwedishNationalInstituteofPublicHealth(2007)concludedthatexerciseis‘thebestpreventativemedicineforoldageandsignificantlyreducestheriskofdependencyinoldage’.Moreemphasisshouldbeplacedonencouragingandpromotingphysicalactivityinolderadults.Recommendationsinclude:

1. Reducingsedentarybehaviour.

2. Increasingmoderateactivityandgivinglessemphasistoattaininghighlevelsofactivity.

3. Takingagradualstepwiseapproach.

Basicrecommendationsforhealthyolderpeopleover65are:

‘Do moderately intense aerobic exercise 30 minutes a day, five days a week or do vigorously intense aerobic exercise 20 minutes a day, 3 days a week and do 8-to-10 strength-training exercises, 10–15 repetitions of each exercise twice to three times per week. If you are at risk of falling, perform balance exercises and have a physical activity plan.’ (207;208).

Thereisdoubtabouthowbesttopersuadeolderpeopletobemoreactiveandtosustainthisovertimeasinterventions,suchas‘exerciseonprescriptionschemes’,havenothadasignificantimpactonactivityparticipationofolderpeople(16).

Thereissomeevidencethatprimary-care-ledhealthpromotionstrategiescanimprovephysicalactivitylevelsinolderpeoplebuthealthpromotionstrategiesareunlikelytobeeffectiveunlesstheyincorporatesubstantialfollowupandemploydedicatedprofessionalinput(113).Simplyadvisingpeopletoengageinexerciseappearstobeineffective(209;210).Inaddition,adversesocioeconomicpositionacrossthelife-courseisassociatedwithanincreasedcumulativeriskoflowphysicalactivityandthosepeoplelivinginthemostdeprivedareastendtohavelessaccesstoexercisefacilities(211;212).Limitedevidenceexiststhatexplainthefactorsthatinfluenceexerciseadherenceamongolderpeopleasmostoftheevidenceonexerciseisderivedfromresearchonyoungerpeople.Variablesthatareoftenassociatedwithcontinuedphysicalactivityincludeperceivedself-efficacy34andbehaviouralcontrol(213).

ThereissubstantialscopetoimprovethehealthoftheScottishpopulationthroughincreasingactivitybutthereisnoclearevidencethatcurrentrecommendationsarebeingfollowedinScotland,where

Promoting Health and Wellbeing in Later Life

33VO2max(maximaloxygenconsumption,maximaloxygenuptakeoraerobiccapacity)isthemaximumcapacityofanindividual’sbodytotransportandutiliseoxygenduringincrementalexercise,whichreflectsthephysicalfitnessoftheindividual.ThenameisderivedfromV–volumepertime,O2–oxygen,max–maximum.

34Perceivedself-efficacyisdefinedaspeople’sbeliefsabouttheircapabilitiestoproducedesignatedlevelsofperformancethatexerciseinfluenceovereventsthataffecttheirlives.Self-efficacybeliefsdeterminehowpeoplefeel,think,motivatethemselvesandbehave.Suchbeliefsproducethesediverseeffectsthroughfourmajorprocesses.Theyincludecognitive,motivational,affectiveandselectionprocesses.

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themajorityofolderpeopledonottaketheminimumrecommendedamountofphysicalexercise,andapproximatelyoneinfivepeopleaged65–74yearsinScotlandareinactive(32).Meetingcurrentrecommendationswillrequireconsiderablepublichealthinput.Oxleyet al(2009)recommendfocusingonopportunitiesforaffordable,accessibleandattractiveexerciseinareasthataresafewithprofessionalsupportinbothhomeandcommunitysettings(3).InScotland,whenforatleast2–3monthsoftheyearinthewinter,itcanbedifficulttogooutsideforawalk,duetoriskoffalling,itmaybebettertofocuspoliciesonincentivesforindooractivitiesofamoreinformalnature(214).

Nutritional interventions

Overall,someoftheinterventionsfornutritionalneedsmayhavepotentialbutrequirelongtermcommitmentandcontinuedreinforcementofanyeducationalcomponentisneeded,tobesuccessful.

Nutritionalinterventionsfocusmainlyonnutritionalsupplementsratherthanoninterventionsthatchangedietaryhabits.Thisisnotsurprisingconsideringthedifficultiesfacedbymostpeopletochangedietaryhabits.Joneset al(2009)suggestthattheevidencetosupporttheuseofsomenutritionalsupplementsisgenerallystrongalthoughnotnecessarilyforcommunity-dwellingolderadults(71).Incombinationwithexercise,nutritionalinterventionsmayhavepotentialtohelpreducedisablementbutnostudieshavecombinedtheseinolderundernourishedpeoplelivinginthecommunity.

Medication review

Itseemsunlikelythatmedicationreviewalonewouldhavealargeimpactondisablementinolderpeople.Itislikelytobemoreeffectiveifimplementedasanintegralpartofaprogrammeofriskassessmentandtargetedlongtermintervention.

Themostpromisingeffectsofmedicationreviewappeartobeforfallspreventionalthoughtheevidenceisbasedonasingletrial.Withdrawalofpsychotropicdrugsappearstoreducetherateoffallsbutnottheriskoffallingorrisksoffracture.Inotherwords,medicationreviewcanpreventrecurrentfallsbutnotnecessarilyfirstfalls.Howeveritisimportanttonotethatolderpeoplecansufferunrecordedadverseeffectsofmedicationandchangesinmedicationcanhavedramaticeffectsontheirhealthandwellbeing.Gillespieet al(2009)(13)pointoutthat:

‘Medication withdrawal involves a fine balance between benefit and risk, and cannot be as accurately implemented as other initiatives and that psychotropic medications are not prescribed unless there are specific needs (such as wandering, inability to sleep, hitting and other abusive behaviour). In these cases, it is difficult (and perhaps inappropriate) to withdraw medication since doing so can greatly increase caregiver burden.’ (13)

Vision screening

Poorvisionisassociatedwithdecreasedfunctionaldeclineandqualityoflifeinolderpeopleyetthereisnoevidencetosupportvisionscreeninginprimarycareorcommunitysettings(128;215).Theaimofvisionscreeningistoimproveotheroutcomessuchasfallsandfractures,independentactivitiesofdailylivingandoverallqualityoflife.However,thetwohigh-qualityreviewsthatassessedtheeffectofvisionscreeningincommunity-based(215)andprimarycaresettings(128)bothconcludedthattheinterventiondidnotresultinimprovementinvision.Thismayhavebeenduetothefactthatwhilstscreeningidentifiestheproblem,compliancewithrecommendedtreatmentdoesnotalwaysfollowandbarrierstointerventionsuchascostorlackofeasyaccesstotreatmentmayreducetheimpactofscreeninginterventions.Inaddition,Cummingset al(2007)inaRCTof616frailolderpeople,foundthatvisionscreeningfollowedbyintervention(e.g.newglasses,homevisitfromanoccupationaltherapist,glaucomamanagement,andcataractsurgery)didnotreducetheriskoffallsandfracturesandcouldpossiblyevenincreasetherisk(216).Confidenceintervalswerewideinthistrialandthereforetheresultsshouldbeviewedwithsomecaution.Thereissomeevidencetosupportcorrectiveinterventionforolderpeoplewithseverevisionimpairmentbutfurtherresearchisneededinthisfield,includinginterventionsthatintroducegradualstepwisechangestopreventoverwhelmingfrailandvulnerableolderpeople(217).

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Social integration

Socialintegrationisconsideredtobeanimportantissue,globallyandnationally,yetinterventionresearchaddressingsocialisolationhasnotbeencarriedoutextensively,particularlyintheUK.InareviewoffactorsassociatedwithsocialparticipationinolderpeopleDahan-Olielet al(2008)conclude,fromlongitudinalstudies,thathigherlevelsofparticipationindifferenttypesofleisureactivitiesisassociatedwithsurvival,improvedhealth-relatedqualityoflife,wellbeingandfunction.Inadditiontheauthorssuggestthatengagementindifferenttypesofsocialactivities,mostlikelymediatedbypersonalfactorssuchaseducationandfinancialresources,isassociatedwithadecreasedriskofdevelopingdementia.However,therearelimitationswithlongitudinalstudiesinthisfield,notleastduetotheproblemsofmaintainingastablepopulationover-time,andmoreresearchwouldbenecessarytoconfirmthesefindings(218).

Theinterconnectingcausalpathwaysofsocialisolationarecomplexanditishighlyunlikelythatasingle,focusedinterventionwouldprovideacomprehensiveandsustainedsolutiontotheproblem(20).Inaddition,itisassumedbypolicymakersandcliniciansthatisolatedolderpeoplewillneedmorehealthandsocialservicesandthosepoliciesthatreducesocialisolationcouldreduceillnessburdenandhaveimplicationsforservicedelivery.Howeverthisassumptionhasbeenchallenged(18).Iliffeet al(2007)conductedacross-sectionalstudyofcommunity-dwelling,non-disabledpeopleaged65andoverintheUK(London).Theauthorsfoundthat15%ofolderpeople,outofacohortof2,598(82%oftotalsample),wereatriskofsocialisolationandtheriskincreasedwithadvancingage.However,thoseatriskofsocialisolationdidnotappeartomakegreaterdemandsonthemedicalservicesnorweretheyatgreaterriskofhospitalisation(18).

Itwasnotpossiblewithinthescopeofthisreviewtoincludeinterventionsonincome,housingandbroadenvironmentalfactors,althoughtheyareconsideredtobecentraltohealthandqualityoflife,andshouldprobablybefactoredintohealthimplementationstrategiesforcommunity-livingolderpeople(219).

Takingintoaccountthesmallpotentialeffectofsometheinterventionsfromthereviewliterature,assumptionsshouldnotbemadebyservicecommissionersthateventhemoreeffectivegroup-basedinterventions,suchasexerciseandgroupactivities,willreduceprimarycareserviceuseorhospitaladmission.Inisolation,theseinterventionsareunlikelytomakeasignificantimpactonthedisablementprocess.

Information communication technology (telecare and telehealth)

Informationcommunicationtechnology(ICT)innovationsarewidelyadvocated,inpolicydocumentsinScotland,tohelpreorganisehealthandsocialcaremanagementforolderpeople.Atfirstglance,theuseofICTinmodernisationoftheNHSiscompelling,withpotentialtoenablemore‘joinedup,integratedserviceprovision’asadvocatedintheScottishGovernmentpolicyBetter Outcomes for Older People: A Framework for Joint Services (2008).Italsoappearstoofferthepossibilityofempoweringolderpeople,toenablethemtoliveindependentlyintheirownhomes.

WhilstICTtechnologiesareconsideredasaspecificinterventiontheyalsofallintothe‘complexinterventioncategory’asdefinedbytheMRC(23).TelecareinvolvesservicestargetedatindividualswithawidevarietyofconditionsandbringstogetheranumberofdifferentstakeholdersacrosstheNHSandhousingsystems(161).Randomisedcontrolledtrialsareparticularlydifficulttoimplementinthisfieldandmoreemphasishasbeenplaced,inpolicydocumentandthepeer-reviewedliterature,on‘evidence-informeddecision-making’andpragmaticevaluation(17).

Thepositiveinterpretationoftheevidenceinpolicydocumentsshouldbeconsidered,alongwiththemorecriticalreviewsthatreportlessfavourableconclusions(170;220).Ahigh-qualitysystematicreviewofcost-effectivenessoftelemedicineinterventions(nottobeconfusedwithtelecareinnovation)forallagegroups,reportednogoodevidencethattelemedicineisacost-effectivemeansofdeliveringhealthcare.Theauthorsidentified600cost-relatedarticlesbutonly9%containedanycost-benefitanalysisandonly4%metthequalitycriteriatojustifyinclusioninaformalanalysis(221).Itappearstobeparticularlydifficult

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togeneralisetheresultsofindividualcost-effectivenessstudies.Forexample,atelemedicineservicethatiscost-effectiveintheremotehighlandsofScotlandisunlikelytogeneratethesamecosteffectivenessinthemiddleofGlasgow.Itisimportanttorecognisethataservicemaybehighlyclinicallyandcost-effectiveinonecontextbuthighlyineffectivewhentransferredtoanothercontextinwhichaccessibilityandqualityoflocalservicesarefarhigher.

MostoftheICTreviewliteraturedoesnotspecificallyrelatetoolderpeople,andageisanimportantdeterminantofpeople’suseofICTs.Olderpeoplehavenotembracedtheuseofcomputerandmobilephonetechnologyinthewaythatyoungergenerationshave,andanyattempttointegratenewtechnologyintothelivesofolderpeople,shouldconsiderthebeliefsandattitudesoftheusers,alongwithotherpotentialbarrierstosuccessfulimplementation.

TheelectronicintegrationdimensionofICTthataimstoassistin‘joinedup’informationsharingofhealthandsocialcareforolderpeopleisundoubtedlydesirable.Weineret al(2003)maintainthatinformationtechnologycanhelpcliniciansmeetthechallengesofcomplexityofcareforolderpeoplebutmovingthisscienceforwardsrequiresgeriatriciansworkingwithGPs,informaticsspecialistsandhealthserviceresearchers(222).

MostofthepolicydocumentsrelatingtoICTarebasedona‘bestguess’approach.Inanarrativeoverviewoftheimpactoftelecareinnovation,Bayeret al(2007)(163)concludefromdiscussionwithexpertsinthefieldthat:

• Telecarewillbeparticularlyeffectiveinpreventingadmissiontoinstitutionalcareinthe‘medium-frail’groupofolderpeople.

• Telecarewillbelesseffectiveinreducinghospitaladmissioninthehigh-frailtygroup.

• Itishopedthattelecarewillhavesomeeffectontheprogressionoffrailtybyputtingmeasuresintoplacetoslowdowntheprocess.

• Overlyoptimisticassessmentoftheeffectsoftelecare,onthedemandforinstitutionalcareintheshortandlongterm,shouldbeavoided.

Policies for healthy ageing

Thisscanhasfocusedonevidenceofinterventionsinprimarycareandcommunitysettingsthataimtopreventdisablementinolderpeople,withanoverarchingaimtoinformpolicy.Whilsttherearesomepromisinginterventions,itremainsunclearwhicharemosteffectiveandevenmoreimportantforpolicymakers,whicharemostcost-effective.Thereareotherhigh-levelpolicyinterventions,outsidethescopeofthisscanthatmaybestrongerdeterminantsofhealthandwellbeinginolderpeople.Theseincludeacombinationof:delayingtheageofnormalretirement,changestohousing,educationandreductionineconomicandsocialprecariousness(3).

InaconsensusreportoftheoutcomeoftheEuropeanSummitonage-relateddiseaseanumberofrecommendationsweremadeforhealthpromotionandpreventativeaction(223).Itseemsclearthateffectiveindividualprogrammessuchasexerciseneedtobeincorporatedinabroaderpolicyframeworkthatbringstogetherthefullrangeofmeasurestomakethemmutuallyreinforcing.Changinglifestyleriskfactorsforchronicdisease,preferablyinearlierlife,havebeenreportedtobethemostpromisingmeasuretoimprovethehealthofolderpeopleinparticular;cessationofsmoking,improvingnutrition,reducingalcoholintakeandtakingmoreexercise(3).Thesuccessofprogrammesaredependentonthewillingnessofolderpeopletotakeonnewandsometimesdifficultchangesandevidencesuggestthatitisdifficulttosustainchangesinbehaviourinlaterlife(64).

TheScottishLongTermConditionsCollaborative(2009)(114)advocateimplementationofmanyoftheinterventionsreviewedinthisscanincludingcasemanagement,telecare/telehealth,andfallsprevention,targetedriskassessmentandintegratedcaredeliveryviaasingleclinicalportal.Intheabsenceofstrongevidence,policydecisionsstillhavetobemadeandsensible,evidenceinformedjudgementiscrucial.Itisnotunusualforpolicytoadvancebeyondtheevidencebutstakeholdersshouldbeawareofthedearth

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ofstrongevidenceinthisfield.Whilsttheevidencedoesn’tfullysupportmanyoftheinterventionsitmaybethatacombined,targetedmulti-factorialapproach,deliveredwithinawellcoordinatedservicedeliverysystem,includingeasyaccesstonecessaryinterventionandlongtermfollowupwouldprovidemorepromisingresults.Ittakestime(often4–5years)toproperlyevaluatecomplexinterventions.Inmostcasesstudiesarelimitedto12–24monthsfollowupatbestandareoftennotcontrolledadequately,makingconclusionsdifficulttodraw.

The broader picture

Mostoftheinterventionsreviewedinthisscanarebasedonabiomedicalmodelofsuccessfulageingi.e.maintenanceofphysicalandmentalfunctioning.Fewstudieshaveconsideredthelaypersonviewofwhatsuccessfulageingmeanstotheindividual.Inapopulationsurveyofperceptionsofsuccessfulageingamong854peopleaged50ormore,livingathomeinBritain,themostcommonlymentioneddefinitionofsuccessfulageingwashavinggoodhealthandfunctioning(224).Thesefactorswererarelymentionedinisolation,andmostpeoplementionedmorethanonefactor(figure12.2).ThecurrentScottishpolicyfocusisonspecificdiseasepreventionyetolderpeoplearenotahomogenousgroupandusuallyhavemultipleproblemsthatcan’tbedealtwithinisolation.Healthisclearlyimportanttoolderpeoplebutotherfactorssuchassocialrelationshipsandbeingfinanciallysecuremayalsoimpactonsuccessfulageing.Thesefactorsmaybestrongerdeterminantsofhealththananyofinterventionsreviewedinthisscan.BowlingandDieppe(2005)pointoutthat‘thereislittlepointindevelopingpolicygoalsifolderpeopledonotregardthemasrelevant’(224).

figure 12.2. Mostcommondefinitionsofsuccessfulageinggivenby854peopleaged>50inBritain

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Source:ReproducedfromWhatIsSuccessfulAgeingandWhoShouldDefineIt?BowlingA,DieppeP.BMJ.2005Dec24;331(7531):1548–51.(Copyrightnoticeyear2010.)WithpermissionfromBMJPublishingGroup.

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Povertyisanimportantsocioeconomichealthdeterminantthathasanegativeeffectonhealth,lifeexpectancy,diseaseanddisability(64).Financialstressisclearlyimportanttoolderpeople,yetstatepensionsintheUKarethelowestinEurope(seetable12.3)whichislikelytohaveadetrimentaleffectontheageingprocessformanypensionersonlowincome.CurrentlyintheUK2.5millionpensionersarelivinginpoverty(definedaslivingbelowtheofficialpovertylineof£165aweekbeforehousingcosts)andthisissuemaybecomeanevenmoreimportantfactortoconsiderwhendevelopingstrategiestopreventdisablementinolderpeople.

Limitations of the review

Thesearchstrategycomponentofthisscanwasbasedonaverybroadquestion,coveringmanyinterventions,andconsequentlyitwasdifficulttofocusthesearchterms.Itispossiblethatsomereviewarticlesweremissedinthelimitedsearchofthethreemaindatabases.However,anextensivewebsitesearchalongwithcitationtrackingwasalsoutilisedandmanyadditionalreviewswereidentified.RigoroussystematicreviewsfollowingtheCochraneframeworktakeaconsiderableamountoftimetocompleteandpolicymakers,moreoftenthannot,needevidenceinamuchshortertimeframe.Windowsofopportunitytoelicitchangeinpolicyandpracticeopensporadically(225)andthebalancebetweenqualityandcontextwereseriouslyconsideredintheplanningphaseofthisscanandtimelinesswasconsideredtobeanimportantfactorintheprocess.Thereforethereviewendeavouredtoincluderecentevidence(1999–2009),onthebasisthatqualityofstudiestendtobehigherinrecentlypublishedstudies(226).Itisrecognisedthatsomeimportantresearchcarriedoutinthe1990smayhavebeenmissedbut

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Greece

Luxembourg

Netherlands

Spain

Denmark

Italy

Sweden

AVERAGE FOR THE EU

France

Germany

Estonia

Ireland

UK

95.7%

88.3%

81.9&

81.2%

79.8%

67.9%

62.1%

60%

51.2%

39.9%

32.9%

32.5%

30.8%

Table 12.3 ComparisonofstatepensionsacrossEUcountriesasaproportionoftheaverage workingpay

Source:TheGuardian.March27.2010

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asthestudiesincludedinthereviewsthemselveswerenotrestrictedtosuchashorttimeframeitislikelythatanylargeinfluentialprimarystudieswouldhavebeencapturedinthereviews.

ThequalityofevidenceisanimportantconsiderationwhenreviewingprimaryandreviewleveldataandtheAMSTAR(63)methodwasusedtoassessthequalityofthereportingofthereviews.Whilstthismethodwasusefulintermsofrecognisingthelimitationsofsomeofthereviewsitwaslimitedbythelackoffocusonthequalityoftheinterpretationoftheincludedstudies,thequalityoftheinterventionsorthequalityoftheoutcomesusedtomeasurethem.

Theheterogeneityofthestudiesandinparticular,oftheoutcomemeasuresusedmadeconclusionsdifficulttodraw,particularlyintheareaoffallsprevention.ThisproblemhasbeenrecognisedbymanyotherresearchersandthecollaborativeworkoftheProFaNEgroup(www.profane.eu.org),thathasdevelopedinternationallyagreed-upontaxonomyforfallspreventionandstandardisationofoutcomesforfalls,shouldhelptoimprovethequalityoftheliteratureinthisfield.Thereareavastnumberofgenericandspecificoutcomesreportedintheliterature,manyofwhichhavenotbeenfullyvalidatedorcheckedforresponsiveness.InahighqualityreviewofhealthandqualityoflifemeasuresforusewitholderpeopleHaywoodet al(2004)identified15genericand18specificmeasures(21;22).ThemostextensiveevidenceforgenericmeasureswasfoundfortheSF-36andEuroQol(EQ-5D),buttherewaslimitedevidenceofreliabilityandinparticular,limitedevidenceofresponsiveness,formostofthespecificmeasures.Thissuggeststhatthefindingsofsomeofthestudiesthatmeasurehealthstatusandqualityoflifemaybequestionable.Inaddition,hospitalandnursinghomeadmissionratesneedtobeviewedwithcautionwithoutacontrolgroupforcomparison.Inacohortstudyofpeopleaged65andover(n=227,206)withahistoryofemergencyadmission,Rolandet al(2005)demonstratedthattheeffectivenessofadmissionavoidanceschemescannotbejudgedbytrackingemergencyadmissionrateswithoutcarefulcomparisonwithacontrolgroup(seefigure12.3)becauseratesfallwithoutinterventionduetofactorssuchasnursinghomeadmission,scheduledhospitaladmissionordeath(6).

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figure 12.3. Emergencyadmissionsandemergencybeddaysperpersonforpatients>=65in1997–89:comparisonofthosewithtwoormoreemergencyadmissionsin1997–8(‘highrisk’)withgeneralpopulation(England)

Intheabsenceofhigh-qualityevidenceforimplementationofinterventions,ajudgmentcallhastobemadewhichtakesintoaccountalltheevidenceandmanyotherfactorssuchasacceptabilityandfeasibility.WhilstRCTsarethemostrigorousformofevaluation,andgenerallyconsideredthegoldstandardforeffectivenessevaluation,theyarenotalwaysidealforevaluatingcomplexinterventionsastheyoftenfailtocapturetheprocessofinteractionsandrelationshipsbetweenhealthprofessionalsandtheclient.Inadditiontheydonotalwaysincludedetailsofimportantfactorsassociatedwithsuccessfulimplementationsuchasthetheoreticalbasisoftheinterventions,thecontext,andtheextenttowhicholderpeopleexceptandcomplywithinterventions.

Afocusedreviewofspecificprimarystudieswasnotpossiblewithinthetimeframeandscopeofthisscanandthereforeonlyselectedhigh-quality,primarystudieswerediscussed.Thismayhavecausedsomebiasinreporting.Mostofthereviewpapersdidnotgiveadequatedetailsofthespecificcontent

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Source:ReproducedfromFollowUpofPeopleAged65andOverwithaHistoryofEmergencyAdmission:AnalysisofRoutineAdmissionData.RolandMetal.2005;330,289–29(copyrightnoticeyear2010)withpermissionfromBMJPublishingGroup.

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ofinterventionsandduetothelargenumberofprimarystudiesitwasnotpossible,forallstudies,todescribetheexactcontentandcontextoftheinterventions(e.g.duration,intensityandfollowupofintervention).Arecentlypublishedreviewofinterventionstopreventdisabilityinfrailcommunity-dwellingolderpeopleprovidesanupdateofprimarystudies.Danielset al(2010)(227)reviewed48RCTsandcontrolledstudiesincluding49interventionsevaluatingcomprehensivegeriatricassessment,exercise,nutritionandtechnologyassistedinterventions.For18ofthe49interventions,disabilitywasstatisticallysignificantlyreducedintheexperimentalgroup.Overalltheconclusionssupportthefindingsofthisreview.However,thereviewfocusesondisabilityonlyandtheauthorsmadenoattempttoreporteffectsizesmakingconclusionsaboutanypotentialimpactdifficulttodrawwithconfidence.

Itwasnotpossiblewithinthebroadscopeofthisscantoincludeallpossibleinterventions.Thoseinterventionstargetingspecificdiseasesuchasdementia,heartdiseaseandstrokewerenotspecificallyincludedinthereviewasitwouldhavebeenunmanageabletosynthesisethedatainthisheterogeneousliterature.Inaddition,focusingonspecificdiseasedoesnotgenerallycapturethemultiplenatureofcomorbiditiesassociatedwithfrailtyandageing.

ThemandateoftheSCPHRPistoidentifykeyareasofopportunityfordevelopingnovel,publichealthinterventionsthatequitablyaddressmajorhealthproblemsinScotland.Therewereveryfewstudiesinthisreviewthatfocusedonminoritygroupsorspecificallyincludedthoseindeprivedareassoithasnotbeenpossibletoexplicitlyaddresstheissueofinequality.Itisnote-worthythatmoststudiesdonotincludeolderpeoplelivingindeprivedareas(228)butfocusonsubjectsofrelativelyhighersocioeconomicstatus,whichisamajorlimitation.Itisthereforenotpossibletogeneralisationsomeoftheresearchfindings,todeprivedareasofScotland.

Gaps in evidence

• Therearenoguidelinesforstandardisationofoutcomemeasures,case-findingorassessmenttoolsandwhilstsomeoftheseissuesarebeingtackledbytheProFaNEgroupforfallspreventionmoreresearchandconsensusisneededinthisfield.Itwouldbeusefultoknowwhichtoolsworkbestforcasefindinginprimarycare,whichworkbestfordiagnosisandwhichforassessingintervention(44).

• Whilsthealthserviceresources(hospitaladmissionandemergencydepartmentvisits)havebeenextensivelymeasured,lessinteresthasbeenfocusedonqualityoflifeandpsychologicalwellbeingmeasures.

• Thereareveryfewstudiesthatincludelongtermfollowup,makingitdifficulttoassessifbenefitsaresustained.

• TherewereveryfewRCTsidentifiedthatincludeinformationoncarers.

• Moststudiesdonotincludeolderpeoplelivingindeprivedareasbutfocusonsubjectsofhighsocioeconomicstatussuggestingthanmoreresearchisneededinthisfield(228).

• Nostudiesevaluatedinterventionsdeliveredbylaypeopleorvolunteers.

• Therearesignificantgapsintheevidence-baserelatingtokeymeasuresoftheimpactofhealthandsocialservicesintegration,especiallyaroundidentifyingchangeinperformanceacrosstime,costs,useofhealthcareresources,healthoutcomesandpatientexperience.

• Therearegapsinknowledgeandseriousquestionsrelatingtothegeneralisabilityofinterventionsacrosscultures,countriesandsettings.ThesearchdidnotidentifyanyRCTsofdisabilitypreventionfocusingonthegeneralorfrailpopulationinScotland.Acase-controlstudyofcoordinatedcomprehensivegeriatricassessmenthasbeenreportedinScotlandwithpromisingresults(229)butfurtherresearchisrequiredtodeterminewhetherthisapproachcanreducefunctionaldeclineand/ornon-electivehospitaladmissioninScotland.

• Interventionsdesignedforotherhealthcaresystemsmaynotbetransferable.

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Conclusions

Theglobalcaseforimplementationofspecificstrategiestopreventdisablementinolderpeopleisweakandathoroughevaluationofavailableprogrammes,infrastructureandlocalexperienceofservicedeliverywouldbenecessary,beforeanystrongrecommendationscanbemadethatarespecifictothecurrentScottishsituation.Thereviewhasidentifiedmanyareasofconflictingevidencealongwithareasofunknowneffectiveness.Thereareareasofpromisinginterventions,suchasexerciseprogrammesforpreventionoffallsandintegratedservicedeliveryprogrammesforfrailolderpeoplebuttheaffordability,feasibility,sustainability,effectsonequity,potentialsideeffectsandacceptabilitytostakeholdersneedstobeconsideredintheprocessofdevelopinginnovativeinterventionsinScotland(24).TheresearchagendaisclearthatdevelopmentofanycomplexinterventionsshouldfollowtheMRCrecommendedguidelines(23)andresearchersshouldendeavourtodesignstudiesthattakeintoaccountboththesocial(personalandenvironmental)andmedicalaspectsofdisabilitythatareintegraltothedisablementprocess.

FollowingcompletionofworkcarriedoutbyProfessorSallyWykeandcolleaguesthataimstoreportonpoliciesandprogrammesalreadyimplementedinScotlandwerecommenda‘managedconsensusprocess’toincludekeypolicymakers,researchers,managers,cliniciansandlaypeopletodiscussthedevelopmentofstrategiesforimplementationofinterventionsforolderpeopleinScotland.Thisisneededto:

1. Defineapopulationofolderpeopletotargetthatismostlikelytobenefitfromintervention.

2. Discussthebestmethodsandtoolstoidentify,targetandassessolderpeopleatmostriskofdisablement.

3. Discussthecontentofanypotentialinterventionbasedoncurrentevidence.

4. Considerthefeasibilityofimplementingaprogrammeofcoordinated,integratedinterventioninScotland,withaviewtorobustevaluation.

Recommendations

• Programmesmostlikelytobesuccessfulinpreventingdisablementarethosethatuseatargetedapproachtoidentifyfrailolderpeopleatlowerriskandincludemulti-dimensional,comprehensivegeriatricassessmentwithlongtermfollowup.

• FutureinterventionstudiesshouldfollowrecommendationsoutlinedbytheInterventionsonFrailtyWorkingGroup(45)anddevelopwell-documentedinterventionsbasedonatheoreticalframework(23)includingdetailsofintensity,longtermfollowup(>1year),definedtargetpopulation,exactcharacteristicsofsettingandofthepreciseinterventionsutilisedandpreferablyincludetheimpactoncarerswhereappropriate.

• RecommendationsuggestedbyShepperdet al(2009),tousetypologiestoguidetheclassificationofinterventionsintohomogenousgroupsandtoincludewherepossible,supplementaryevidencefromqualitativeresearchareparamount(67).

• Standardisationofmeaningfuloutcometoolsforcase-findingandhealthassessmentforfrailolderpeoplewouldimprovetheprocessofevaluationandallowcomparisonsacrossstudiesandbetweencountries.

• Studiesevaluatinginterventionsthataimtoreducehospitaladmissionsorinstitutionalisationneedtoincludeacontrolgroupforcomparisonandshouldpreferablyincludeathoroughanalysisofallcosts,privateandNHS,inordertodrawconclusionsaboutNHSuseandcostbenefits.

• Interventionsaimedatpreventingfunctionaldeclineshouldincludestrategiesthatencourageolderpeopletobeasactiveaspossibleandbuildincomponentsthatimpactonactivityofdailylivingdependency.

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Appendix 1: MEDLINE (OVID) search terms

Effectiveness

effect*

evidence

evaluat*

efficacy

outcome*

impact

Primary care community-based

community

community-based

primarycare

healthpromotion/

primaryhealthcare/

homebound

housebound

familypractice/

Interventions

intervention*

program*

strateg*

counsel*

project*

activit*

initiative*

Prevent

prevent*

preserv*

reduc*

improv*

influenc*

promot*

declin*

Declining function

chroniccondition*

chronicdisease/

lifestyle/

activitiesofdailyliving/

physicalfunction*

healthcareutilisation

healthcareutilisation

healthstatus/

frail

disable*

disabilit*

qualityoflife/

Adulthood

aged/

middle-aged

Study type

metaanalysis

systematic

review

randomised

controlled

NOT

drugtherapy[sh]

surgery[sh]

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Appendix 2: AMSTAR quality assessment scoring system

Source:Sheaet al,2009(63).

1. Was an ‘a priori’ design provided? Theresearchquestionandinclusioncriteriashouldbeestablishedbeforetheconductofthereview.

2. Was there duplicate study selection and data extraction? Thereshouldbeatleasttwoindependentdataextractorsandaconsensusprocedurefordisagreements

shouldbeinplace.

3. Was a comprehensive literature search performed? Atleasttwoelectronicsourcesshouldbesearched.Thereportmustincludeyearsanddatabasesused

(e.g.Central,EMBASE,andMEDLINE).Keywordsand/orMESHtermsmustbestatedandwherefeasiblethesearchstrategyshouldbeprovided.Allsearchesshouldbesupplementedbyconsultingcurrentcontents,reviews,textbooks,specialisedregisters,orexpertsintheparticularfieldofstudy,andbyreviewingthereferencesinthestudiesfound.

4. Was the status of publication (i.e. grey literature) used as an inclusion criterion? Theauthorsshouldstatethattheysearchedforreportsregardlessoftheirpublicationtype.Theauthors

shouldstatewhetherornottheyexcludedanyreports(fromthesystematicreview),basedontheirpublicationstatus,languageetc.

5. Was a list of studies (included and excluded) provided? Alistofincludedandexcludedstudiesshouldbeprovided.(Thosethatincludedadetailedlistofincluded

studiesandadetailedlistofreasonswhystudieswereexcludedwereawarded1point)

6. Were the characteristics of the included studies provided? Inanaggregatedformsuchasatable,datafromtheoriginalstudiesshouldbeprovidedonthe

participants,interventionsandoutcomes.Therangesofcharacteristicsinallthestudiesanalysede.g.age,race,sex,relevantsocioeconomicdata,diseasestatus,duration,severity,orotherdiseasesshouldbereported.

7. Was the scientific quality of the included studies assessed and documented? ‘Apriori’methodsofassessmentshouldbeprovided(e.g.foreffectivenessstudiesiftheauthor(s)chose

toincludeonlyrandomised,double-blind,placebocontrolledstudies,orallocationconcealmentasinclusioncriteria);forothertypesofstudiesalternativeitemswillberelevant.

8. Was the scientific quality of the included studies used appropriately in formulating conclusions? Theresultsofthemethodologicalrigorandscientificqualityshouldbeconsideredintheanalysisandthe

conclusionsofthereview,andexplicitlystatedinformulatingrecommendations.

9. Were the methods used to combine the findings of studies appropriate? Forthepooledresults,atestshouldbedonetoensurethestudieswerecombinable,toassesstheir

homogeneity(i.e.Chi-squaredtestforhomogeneity,I²).Ifheterogeneityexistsarandomeffectsmodelshouldbeusedand/ortheclinicalappropriatenessofcombiningshouldbetakenintoconsideration(i.e.isitsensibletocombine?).

10. Was the likelihood of publication bias assessed? Anassessmentofpublicationbiasshouldincludeacombinationofgraphicalaids(e.g.funnelplot,other

availabletests)and/orstatisticaltests(e.g.Eggerregressiontest).

11. Was the conflict of interest stated? Potentialsourcesofsupportshouldbeclearlyacknowledgedinboththesystematicreviewandthe

includedstudies.

(Answer:Yes,no,can’tanswerornotapplicable.Onepointgivenforeachyesanswer.Min=0,Max=11)

120

Auth

or

Wiel

and

(200

3)

(89)

Elkan

et a

l (2

004)

(82)

Num

ber o

f stu

dies

(s

ubje

cts)

and

age

22 tr

ials a

nd re

views

.

65+

year

s.

60+

year

s. 4

revie

ws.

Heal

th c

ateg

ory a

nd se

tting

Gene

ral o

lder p

eople

and

frail

pe

ople

at ri

sk.

Com

mun

ity.

Gene

ral

and

frail o

lder p

eople

at

risk

.

Inte

rven

tions

Com

preh

ensiv

e ge

riatri

c as

sess

men

t (CG

A)

and

mult

i-com

pone

nt

treat

men

t or p

reve

ntat

ive

hom

e vis

its.

Prev

enta

tive

hom

e vis

its

and

CGA.

Outc

omes

Mor

tality

, gen

eral

and

men

tal

healt

h m

easu

res,

phys

ical

func

tion,

cogn

itive

func

tion,

ADL.

Mor

tality

, gen

eral

healt

h,

func

tiona

l sta

tus.

Mai

n fin

ding

s and

aut

hors

con

clusio

ns

Posit

ive b

ut in

cons

isten

t res

ults.

Targ

eting

pat

ient a

t risk

, mult

idim

ensio

nal

asse

ssm

ent a

nd m

anag

emen

t with

long

te

rm fo

llow

up is

mos

t pro

misi

ng. P

aucit

y of

dat

a on

costs

. Som

e ev

idenc

e th

at th

ere

is an

‘inve

stmen

t effe

ct’ i.

e. pr

ogra

mm

es

prov

iding

follo

w up

are

mor

e lik

ely to

be

bene

ficial

whe

ther

they

be

prev

enta

tive

hom

e vis

its o

r all i

nclus

ive in

tegr

ated

ap

proa

ch.

Over

all re

sults

of m

eta-

analy

sis sh

owed

litt

le ef

fect

on fu

nctio

nal s

tatu

s unle

ss

mult

i-dim

ensio

nal w

ith lo

ng te

rm fo

llow

up. S

ome

evide

nce

that

hom

e vis

its

can

redu

ce m

orta

lity a

nd n

ursin

g ho

me

adm

ission

s and

they

hav

e th

e po

tent

ial to

be

cost

effe

ctive

.

AMST

AR Q

ualit

y sco

re (A

QS) c

omm

ents

/ lim

itatio

ns

Poor

qua

lity re

view.

Ca

tego

rised

CGA

into

hos

pital

base

d,

com

mun

ity, n

ursin

g ho

me,

integ

rate

d se

rvice

mod

el.

AQS=

1/9

Only

four

stud

ies in

clude

d in

the

met

a-an

alysis

. Con

fiden

ce in

terv

als fo

r met

a-an

alysis

of f

uncti

onal

decli

ne w

ere

wide

su

gges

ting

that

conc

lusion

s sho

uld b

e dr

awn

with

caut

ion.

AQS=

7/11

App

endi

x 3:

Rev

iew

of r

evie

ws

of c

ompl

ex in

terv

enti

ons

121

App

endi

x 4:

Rev

iew

s of

com

plex

inte

rven

tion

s.

Auth

or

Besw

ick e

t al

(200

8) (7

)

Boum

an e

t al

(200

8) (7

8)

Byle

s et a

l (2

000)

(81)

Eklu

nd a

nd

Wilh

elm

son

(2

009)

(79)

Elka

n et

al

(200

1) (8

2)

Num

ber o

f stu

dies

(s

ubje

cts)

and

age

89 R

CTs (

97,9

84)

Mea

n ag

e 65

+ ye

ars.

8 RC

Ts.

65+

year

s.

21 R

CTs.

65+

year

s.

9 stu

dies (

1 Ita

ly, 3

US

A, 5

Can

ada).

15 st

udies

. 13

RCTs

an

d 2

quas

i RCT

s.

65+

year

s.

Heal

th c

ateg

ory a

nd se

tting

Gene

ral o

lder p

eople

.

Frail

olde

r peo

ple.

Frail

olde

r peo

ple w

ith p

oor

healt

h/fu

nctio

nal im

pairm

ent,

depe

nden

cy.

Com

mun

ity se

tting

.

Gene

ral o

lder p

eople

an

d th

ose

with

mult

iple

mor

biditie

s.

Frail

olde

r peo

ple a

t risk

.

Com

mun

ity/p

rimar

y car

e.

Gene

ral a

nd fr

ail o

lder p

eople

liv

ing a

t hom

e.

Com

mun

ity se

tting

.

Inte

rven

tions

Com

plex i

nter

vent

ions,

hom

e vis

its, a

ntici

pato

ry

care

with

varia

ble fo

llow

up.

Prev

enta

tive

hom

e vis

its

with

follo

w up

per

iod o

f 12

+ m

onth

s and

mult

iple

follo

w up

for a

t lea

st 4

mon

ths.

Healt

h as

sess

men

ts.

Integ

rate

d an

d co

ordin

ated

inte

rven

tions

, ca

se m

anag

emen

t, ho

me

and

com

mun

ity-b

ased

se

rvice

, risk

facto

r plan

an

d he

alth

prom

otion

.

Hom

e vis

its th

at o

ffer

healt

h pr

omot

ion a

nd

prev

entio

n.

Outc

omes

Living

at h

ome,

deat

h,

adm

ission

s to

hosp

ital a

nd

nurs

ing h

omes

, fall

s, ph

ysica

l fu

nctio

n.

Func

tiona

l sta

tus,

hosp

ital a

nd

nurs

ing h

ome

adm

ission

and

m

orta

lity.

Clini

cal o

utco

mes

(bloo

d pr

essu

re, w

eight

, visi

on e

tc).

Clien

t out

com

es, H

ealth

care

ut

ilisat

ion, c

areg

iver o

utco

mes

, go

al at

tainm

ent s

cale,

costs

, de

pres

sion,

healt

h be

havio

ur

and

attit

udes

, ADL

, Qua

lity o

f Lif

e (S

F-36

).

Mor

tality

, hos

pital

and

instit

ution

al ad

miss

ion,

func

tion,

healt

h sta

tus.

Mai

n fin

ding

s and

aut

hors

con

clusio

ns

Com

bined

inte

rven

tions

redu

ced

risk o

f not

liv

ing a

t hom

e, nu

rsing

hom

e ad

miss

ions (

14%

re

ducti

on fo

r the

gen

eral

popu

lation

) and

falls

. Ph

ysica

l fun

ction

impr

ovem

ents

were

small

. No

diff

eren

ce fo

r mor

tality

. Com

bined

mod

est

effe

cts. 4

0.5%

to 3

8.2%

hos

pitals

adm

ission

s. 10

.6%

to 9

.2%

nur

sing

hom

e ad

miss

ions,

falls

33.

6% to

30.

5%, im

prov

emen

t in

phys

ical

func

tion

0.5

point

on

Barth

el Ind

ex. W

hen

analy

sed

in su

bgro

ups t

he b

enefi

ts we

re

mini

mal

for t

he g

roup

of f

rail o

lder p

eople

.

Hom

e vis

its a

lone

targ

eting

olde

r peo

ple w

ith

poor

hea

lth st

atus

are

not

effe

ctive

. No

long

term

ben

efits

beyo

nd 1

2 m

onth

s in

term

s of

mor

tality

, hea

lth st

atus

, ser

vice

use

or co

st.

Mult

idisc

iplina

ry m

easu

res o

f high

er in

tens

ity

that

targ

et sp

ecific

pro

blem

s may

be

nece

ssar

y.

Resu

lts in

cons

isten

t, be

tter q

uality

pap

ers

sugg

est i

mpr

ovem

ent i

n he

alth.

Som

e ev

idenc

e th

at ca

se m

anag

emen

t is

bene

ficial

for f

rail o

lder p

eople

and

can

decr

ease

hea

lthca

re co

sts. M

any o

utco

mes

sh

owed

no

diffe

renc

e be

twee

n gr

oups

. Mos

t co

mm

on o

utco

me

was A

DL. L

ack o

f kno

wled

ge

on e

ffects

of c

are

giver.

Only

two

RCTs

repo

rted

care

giver

out

com

e. Po

sitive

effe

ct on

care

giver

sa

tisfa

ction

but

no

effe

ct on

care

giver

bur

den.

Mixe

d res

ults.

7 stu

dies s

howe

d no s

ignific

ant a

ffect

on A

DL. 2

stud

ies sh

owed

impr

ovem

ent in

ADL

. Ho

me vi

sits c

an re

duce

mor

tality

and n

ursin

g hom

e ad

miss

ion fo

r gen

eral

older

peop

le an

d tho

se at

risk.

Prev

entat

ive ho

me vi

sit m

ust in

volve

asse

ssme

nt or

sc

reen

ing co

mbine

d with

regu

lar ho

me vi

sits.

AMST

AR Q

ualit

y sco

re (A

QS) c

omm

ents

/ lim

itatio

ns

Bene

fits m

ore

evide

nt p

rior t

o 19

93

sugg

estin

g qu

ality

bias.

Mos

t of t

he a

nalys

is of

the

inter

vent

ion a

imed

at t

he fr

ail o

lder

peop

le is

non-

signifi

cant

. Lar

ge a

mou

nt o

f he

tero

gene

ity in

the

studie

s.AQ

S=9/

11

Includ

ed o

nly tr

ials t

hat s

core

d ov

er 4

out

of 8

in

quali

ty as

sess

men

t. AQ

S =7

/9

Met

hodo

logy u

nclea

r. No

evide

nce

that

ta

rget

ing a

sses

smen

t im

prov

ed o

utco

me.

AQS=

4/9

Good

qua

lity re

view

with

clea

r sea

rch

strat

egy

and

crite

ria. L

arge

het

erog

eneit

y with

in th

e gr

oups

. Inte

rven

tions

not

des

cribe

d we

ll.AQ

S=6/

9

Good

qua

lity b

ut m

eta-

analy

sis o

f fun

ction

al ou

tcom

e on

ly inc

luded

4 st

udies

. No

data

on

inten

sity o

f visi

ts.

AQS=

7/11

122

App

endi

x 4

Con

t.: R

evie

ws

of c

ompl

ex in

terv

enti

ons.

Auth

or

Hallb

erg

et a

l (2

004)

(90)

Huss

et a

l (2

008)

(84)

Johr

i et a

l (2

003)

(91)

Liebe

l et a

l (2

009)

(80)

Num

ber o

f stu

dies

(s

ubje

cts)

and

age

26 st

udies

.

65+

year

s.

21 (5

UK)

146

03

peop

le.70

+ ye

ars.

7 stu

dies.

10 R

CTs.

Heal

th c

ateg

ory a

nd se

tting

Frail

olde

r peo

ple.

Com

mun

ity se

tting

.

Gene

ral o

lder p

eople

and

th

ose

with

chro

nic d

iseas

e.

Com

mun

ity se

tting

.

Gene

ral a

nd fr

ail o

lder p

eople

.

Com

mun

ity se

tting

.

Gene

ral o

lder p

eople

with

ch

ronic

dise

ase.

Com

mun

ity se

tting

.

Inte

rven

tions

Case

man

agem

ent

inter

vent

ions.

Hom

e vis

it pr

ogra

mm

es.

Integ

rated

servi

ce de

liver

y inc

luding

sing

le en

try po

int

syste

m, c

ase m

anag

emen

t, ge

riatri

c eva

luatio

n, m

ultidi

scipl

inary

team

. Pr

ogra

mm

es im

plem

ented

in

Cana

da, U

K (D

arlin

gton),

US

A, Ita

ly.

Prev

enta

tive

hom

e vis

its

carri

ed o

ut b

y nur

ses o

nly.

Outc

omes

Healt

hcar

e co

nsum

ption

and

co

sts, q

uality

of c

are,

patie

nt’s

healt

h an

d fu

nctio

nal a

bility

.

Mor

tality

, nur

sing

hom

e ad

miss

ions,

func

tiona

l dec

line.

Hosp

ital a

dmiss

ion o

r lon

g te

rm ca

re in

stitu

tiona

lisat

ion,

healt

h ou

tcom

es a

nd im

pact

on

pro

cess

of c

are.

Disa

bility

out

com

es in

cludin

g Ba

rthel,

SF-

36.

Mai

n fin

ding

s and

aut

hors

con

clusio

ns

Few

inter

vent

ions i

nclud

ed se

cond

ary a

nd

terti

ary a

nd/o

r reh

abilit

ation

app

roac

h us

ing

psyc

ho e

duca

tiona

l foc

us. F

ocus

on

the

cont

ent

of in

terv

entio

n is

nece

ssar

y.

Non

signifi

cant

(fav

oura

ble) e

ffects

on

mor

tality

, fu

nctio

nal d

eclin

e, nu

rsing

hom

e ad

miss

ions.

Nurs

ing h

ome

adm

ission

: red

uctio

n in

risk o

f ad

miss

ion w

as m

odes

t OR

0.86

95%

CI 0

.68

to 1

.10)

. Hom

e vis

its w

ith <

3 ho

me

visits

had

sim

ilar e

ffect

to p

rogr

amm

es o

f >3

visits

per

ye

ar. L

ittle

effe

ct on

func

tiona

l sta

tus o

r 0.8

9 (9

5% C

I 0.7

6 to

1.0

3). S

tudie

s inc

luding

a

clinic

al ex

amina

tion

show

ed b

enefi

cial e

ffect

on

func

tiona

l sta

tus O

R 0.

64 (9

5% C

I 0.4

8 to

0.8

7). P

reve

ntion

focu

sing

on th

e yo

unge

r po

pulat

ion sh

owed

favo

urab

le re

sults

on

mor

tality

OR

0.74

(95%

CI 0

.58

to 0

.94)

.

Includ

es co

mm

on d

esign

feat

ures

of i

nteg

rate

d ca

re th

at a

re th

ough

t to

be e

ffecti

ve.

Case

man

agem

ent.

Geria

tric a

sses

smen

t.M

ultidi

scipl

inary

team

work

.

Hom

e vis

its ta

rget

ed a

t pat

ients

who

are

alrea

dy

disab

led h

ave

pote

ntial

to re

duce

disa

bility

. M

ultipl

e vis

its n

eede

d to

impa

ct on

out

com

e. Re

sear

ch d

esign

s nee

d to

inclu

de co

ntex

tual

deta

ils.

AMST

AR Q

ualit

y sco

re (A

QS) c

omm

ents

/ lim

itatio

ns

No st

atist

ical a

nalys

is. N

arra

tive

revie

w de

scrib

ing co

nten

t of i

nter

vent

ions a

nd

outco

mes

. AQ

S=2/

9

Good

qua

lity. O

nly in

clude

d RC

Ts w

ith m

ultipl

e fo

llow

up e

ither

hom

e vis

its o

r tele

phon

e. Ex

clude

d po

st ho

spita

l disc

harg

e pr

ogra

mm

es

or h

ome

base

d ca

se m

anag

emen

t. Im

porta

nt

dete

rmina

nts m

ay b

e cli

nical

exam

inatio

n an

d re

gular

follo

w up

on

func

tion

prev

entio

n m

ost

effe

ctive

if ta

rget

ed a

t the

youn

g.Nu

rsing

hom

e ad

miss

ion m

ay in

crea

se a

s a

resu

lt of

pre

vent

ative

hom

e vis

its.

AQS=

9/11

Narra

tive

revie

w inc

luding

qua

si-ex

perim

enta

l de

sign.

High

light

s lac

k of c

oord

inatio

n be

twee

n m

edica

l and

socia

l car

e, ac

ute

and

cont

inuou

s and

com

mun

ity a

nd in

stitu

tiona

l ca

re. M

ainly

base

d on

stud

ies ‘d

owns

tream

’ af

ter d

ischa

rge

from

hos

pital.

AQS=

3/9

Lack

of c

onsis

tenc

y in

studie

s.AQ

S=5/

9

123

App

endi

x 4

Con

t.: R

evie

ws

of c

ompl

ex in

terv

enti

ons.

Auth

or

Mar

kel-R

eid

et a

l (20

06)

(86)

McC

uske

r an

d Ve

rdon

(2

006)

(88)

Steu

ltjen

s et

al (2

004)

(83)

Num

ber o

f stu

dies

(s

ubje

cts)

and

age

12 R

CTs.

65+

year

s old.

26 st

udies

(16

RCTS

). 6

0+ye

ars.

17 R

CT.

60+

year

s.

Heal

th c

ateg

ory a

nd se

tting

Gene

ral o

lder p

eople

and

th

ose

at ri

sk.

Com

mun

ity.

Frail

olde

r peo

ple a

nd th

ose

at ri

sk.

9 Em

erge

ncy d

epar

tmen

ts,

4 ho

spita

ls, 1

0 pr

imar

y ca

re, 4

hom

e se

tting

and

1

com

mun

ity.

Gene

ral o

lder p

eople

and

th

ose

at ri

sk.

Com

mun

ity se

tting

.

Inte

rven

tions

Hom

e bas

ed nu

rsing

ca

re he

alth p

rom

otion

an

d pre

venta

tive c

are.

Nursi

ng ho

me v

isits

defin

ed

as in

cludin

g: 1)

hom

e vis

it in t

he co

mm

unity

; 2)

mult

idim

ensio

nal

asse

ssm

ent o

f hea

lth an

d fun

ction

; 3) id

entifi

catio

n of

need

s and

stre

ngth

lea

ding t

o spe

cific

reco

mm

enda

tions

; 4)

mult

iple f

ollow

up.

Com

preh

ensiv

e ge

riatri

c as

sess

men

t (CG

A)

carri

ed o

ut in

prim

ary a

nd

seco

ndar

y car

e se

tting

s.

Occu

patio

nal t

hera

py

and

advic

e int

erve

ntion

s inc

luding

: 1) t

raini

ng o

f se

nsor

y-m

otor

func

tion;

2)

train

ing a

nd co

gnitiv

e fu

nctio

n; 3

) tra

ining

of

skills

; 4) a

dvice

and

ins

tructi

on re

gard

ing th

e us

e of

ass

istive

dev

ices;

5) co

unse

lling

of p

rimar

y ca

re g

iver.

Outc

omes

Mor

tality

, adm

ission

to

instit

ution

, hea

lth st

atus

, fu

nctio

nal s

tatu

s, us

e of

hea

lth

and

socia

l ser

vices

, mor

tality

, AD

L, (B

arth

el Ind

ex) a

nd co

st.

Rate

s of e

mer

genc

y de

partm

ent u

tilisa

tion

(EDU

).

Func

tiona

l abil

ity, q

uality

of l

ife

and

incide

nce

of fa

lling.

Mai

n fin

ding

s and

aut

hors

con

clusio

ns

Desc

riptio

ns o

f int

erve

ntion

s wer

e ina

dequ

ate

in m

ost s

tudie

s. Go

als fo

r int

erve

ntion

wer

e ba

sed

on p

reve

ntat

ive ca

re o

r hea

lth p

rom

otion

goa

ls su

ch a

s aut

onom

y, em

powe

rmen

t, ind

epen

dent

de

cision

mak

ing. D

ivers

ity o

f hom

e vis

iting

inter

vent

ions c

arrie

d ou

t by n

urse

s can

affe

ct

healt

h, m

orta

lity ra

tes,

hosp

italis

ation

and

costs

.

Incon

clusiv

e find

ings d

ue to

heter

ogen

eity.

10

studie

s car

ried o

ut in

prim

ary c

are (

9 RC

Ts

and 1

cros

s sec

tiona

l). 6

were

integ

rated

with

pr

imar

y car

e. 1

study

of m

edica

tion r

eview

and

educ

ation

by p

harm

acist

s fou

nd re

ducti

on in

ED

visit

s fro

m 5

7% to

39%

durin

g 12

mon

ths.3

stu

dies i

ncre

ased

EDU

poss

ibly d

ue to

incre

ased

pe

rcepti

on of

need

. Rec

omm

end r

epor

ting b

oth

prop

ortio

n usin

g ED

and m

ean (

SD) n

umbe

r of

visits

.

Stro

ng ev

idenc

e for

advis

ing on

assis

tive d

evice

s on

incre

asing

func

tiona

l abil

ity, s

ome e

viden

ce

for ef

ficac

y of t

raini

ng sk

ills co

mbin

ed w

ith ho

me

haza

rd as

sess

men

t. Lim

ited e

viden

ce fo

r effic

acy

of OT

on fu

nctio

nal a

bility

, soc

ial pa

rticip

ation

, an

d Qua

lity of

Life

(QoL

) in ge

nera

l olde

r peo

ple

for re

ducin

g inc

idenc

e of f

alls i

n tho

se at

high

ris

k of f

alling

. Insu

fficien

t evid

ence

for e

fficac

y of

coun

sellin

g of p

rimar

y car

e give

r of p

atien

ts wi

th

dem

entia

or en

hanc

ing fu

nctio

nal a

bility

of th

ose

patie

nts.

AMST

AR Q

ualit

y sco

re (A

QS) c

omm

ents

/ lim

itatio

ns

Com

preh

ensiv

e re

view

desc

ribing

theo

ry

drive

n ap

proa

ch. U

sed

crite

ria fo

r ass

essm

ent

of q

uality

of s

tudie

s. AQ

S=7/

9

Focu

sed

on ch

arac

teris

tics o

f int

erve

ntion

s (si

te, t

ype

and

dura

tion)

ass

ociat

ed

with

EDU

. Use

d 5

cate

gorie

s. On

e-dim

ensio

nal a

sses

smen

t (UA

) with

refe

rral,

mult

idim

ensio

nal a

sses

smen

t (M

A)

with

refe

rral, U

A an

d m

anag

emen

t, M

A an

d m

anag

emen

t, ca

se m

anag

emen

t. St

anda

rdisa

tion

of m

easu

res a

pro

blem

. AQ

S=4/

9

Used

Jada

d’s q

uality

scor

e an

d be

st ev

idenc

e sy

nthe

sis i.

e. str

ong

evide

nce=

cons

isten

t sta

t sig

nifica

nt fi

nding

s in

outco

mes

mea

sure

s in

at le

ast 2

high

qua

lity R

CTs,

mod

erat

e ev

idenc

e=sta

t sig

findin

gs in

at l

east

1 hig

h qu

ality

RCT

and

1 Lo

w qu

ality

RCT,

limite

d ev

idenc

e+ st

at si

g fin

dings

in a

t lea

st 1

high

quali

ty RC

T. M

any t

rials

were

small

.AQ

S=7/

9

124

App

endi

x 4

Con

t.: R

evie

ws

of c

ompl

ex in

terv

enti

ons.

Auth

or

Stuc

k et

al

(200

2) (8

7)

Van

Haag

stre

gt e

t al

(200

0) (8

5)

Num

ber o

f stu

dies

(s

ubje

cts)

and

age

18 R

CTs (

1344

7).

65+

year

s.

15 R

CTs.

Age

65+

year

s.6

RCTs

focu

sed

on

75+

year

s.

Heal

th c

ateg

ory a

nd se

tting

Gene

ral o

lder p

eople

and

th

ose

at ri

sk.

Gene

ral p

racti

ce a

nd

com

mun

ity se

tting

.

Gene

ral p

opula

tion

of o

lder

peop

le an

d th

ose

at ri

sk.

Com

mun

ity se

tting

.

Inte

rven

tions

Prev

entat

ive ho

me v

isits

aimed

at de

laying

or

prev

entin

g fun

ction

al im

pairm

ent a

nd nu

rsing

ho

me a

dmiss

ion b

y prim

ary

prev

entio

n, se

cond

ary a

nd

tertia

ry pr

even

tion.

Hom

e visi

ts.

Outc

omes

Func

tiona

l sta

tus,

nurs

ing

hom

e ad

miss

ion a

nd m

orta

lity.

Phys

ical f

uncti

on, p

sych

osoc

ial

func

tion,

falls

, adm

ission

to

instit

ution

, mor

tality

.

Mai

n fin

ding

s and

aut

hors

con

clusio

ns

Effe

ct of

nur

sing

hom

e ad

miss

ion d

epen

ded

on

inten

sity o

f hom

e vis

its.

>9 vi

sits R

R=0.

66 (0

.48

to 0

.92)

<4

visit

s RR=

1.05

( 0.

85 to

1.3

0)Be

nefit

s on

mor

tality

in yo

unge

r age

gro

up (7

2 to

77)

. Ov

erall

little

ben

efit o

n fu

nctio

nal s

tatu

s but

re

sults

het

erog

eneo

us.

Bene

ficial

effe

cts w

ere

asso

ciate

d wi

th

mult

i-dim

ensio

nal a

sses

smen

t and

follo

w up

. Th

eref

ore

the

type

of in

terv

entio

n wa

s the

im

porta

nt fa

ctor. A

bsolu

te re

ducti

on in

risk

was

6.

7%.

Favo

urab

le re

sults

for p

hysic

al fu

nctio

n, bu

t no

clear

evid

ence

for p

reve

ntat

ive h

ome

visits

. Five

ou

t of 1

2 RC

Ts sh

owed

effe

ct of

inte

rven

tion

on

phys

ical f

uncti

oning

. Only

one

RCT

out

of e

ight

show

ed p

ositiv

e ef

fect

of p

sych

osoc

ial fu

nctio

n.

Any o

bser

ved

effe

cts w

ere

mod

est.

AMST

AR Q

ualit

y sco

re (A

QS) c

omm

ents

/ lim

itatio

ns

Good

met

hodo

logy b

ut su

b-gr

oup

analy

sis

may

hav

e int

rodu

ced

bias.

Com

plex m

eta-

analy

sis. H

eter

ogen

eity r

educ

es th

e po

ssibi

lity

of fi

nding

effe

ct.

Hom

e vis

its o

nly b

enefi

cial if

targ

eted

at

pers

ons w

ith lo

w ris

k for

dea

th a

nd yo

unge

r pe

ople.

Inte

rven

tion

need

s to

be b

ased

on

mult

i-dim

ensio

nal a

sses

smen

t and

inclu

de

mult

iple

follo

w up

. NN

T (vi

sit) t

o pr

even

t 1 a

dmiss

ion w

ith

frequ

ent f

ollow

up

is 40

.AQ

S=9/

11

Only

1 tri

al fo

cuse

d on

spec

ific ri

sk fa

ctors

, 9

trials

inte

rven

tions

laste

d m

ore

than

2 ye

ars,

mos

t tail

ored

to su

bjects

. AQ

S=7/

9

125

App

endi

x 5:

Ran

dom

ised

con

trol

led

tria

ls o

f com

plex

inte

rven

tion

s.

Refe

renc

e

Flet

cher

et a

l (U

K) 2

004

(8)

Vass

et a

l (D

enm

ark)

(230

)

Hebe

rt et

al

(Can

ada)

(2

001)

(231

)

Sahl

en (2

006)

Sw

eden

(94)

Heal

th c

lass

ifica

tion

Gene

ral o

lder p

eople

an

d old

er p

eople

at

low ri

sk.

Gene

ral o

lder p

eople

an

d old

er p

eople

at

low ri

sk.

Gene

ral o

lder p

eople

an

d old

er p

eople

at

low ri

sk.

Gene

ral o

lder p

eople

.

Num

ber o

f par

ticip

ants

an

d ag

e

N= 4

3,21

975

+ m

ean

age

81.5

.

N=4,

060

75–8

0 ye

ars

mea

n ag

e.

N=50

375

+yea

rs.

N=59

8 (5

42 in

clude

d in

analy

sis)

75+

year

s.

Mai

n pe

rson

nel

Nurse

. Gro

ups a

lso

rand

omise

d to g

eriat

ric

asse

ssm

ent o

r prim

ary

care

.

Hom

e visi

tors a

nd G

Ps.

Nurse

hom

e visi

t with

re

ferra

l to sp

ecial

ists.

Profe

ssion

al he

althc

are

worke

rs. 1

nurse

and 1

ca

re m

anag

er.

Cont

ent

Expe

rimen

tal g

roup

. Univ

ersa

l int

erve

ntion

. Brie

f ass

essm

ent

ques

tionn

aire

follo

wed

by 1

det

ailed

in-

dept

h ho

me

asse

ssm

ent a

nd re

ferra

l to

socia

l, med

ical o

r soc

ial se

rvice

s clin

ics

includ

ing o

phth

almolo

gy, c

hirop

ody,

audio

logy,

com

mun

ity n

ursin

g an

d ps

ychia

tric s

ervic

es. N

o co

mpli

ance

m

easu

re. C

ontro

l gro

up. R

eceiv

ed si

mila

r as

sess

men

t (92

.4%

) but

only

7.6

%

rece

ived

furth

er in

dep

th a

sses

smen

t.

Expe

rimen

tal g

roup

. Hom

e vis

its a

lread

y sta

ndar

d pr

actic

e in

Denm

ark.

Addit

ional

inter

vent

ion in

clude

d ed

ucat

ion fo

r hom

e vis

itors

and

GPs

. (Pr

imar

y pre

vent

ion.)

Cont

rol g

roup

Rec

eived

no

educ

ation

.

Expe

rimen

tal g

roup

. Res

ults o

f as

sess

men

t wer

e se

nt to

GP.

Nurs

e re

ferre

d to

phy

sioth

erap

y, OT

, bala

nce

and

gait

reha

b, die

tary

and

aud

iolog

y as

sess

men

t, ed

ucat

ion re

gard

ing

incon

tinen

ce, s

ocial

supp

ort,

hype

rtens

ion

and

falls

.Co

ntro

l gro

up R

eceiv

ed u

sual

care

.

Expe

rimen

tal g

roup

. Mult

idim

ensio

nal

ques

tionn

aire

with

stru

cture

d th

emes

inc

luding

a fo

cus o

n ph

ysica

l acti

vity,

prev

entio

n of

falls

imm

unisa

tion,

he

althy

food

and

pre

vent

ion o

f diab

etes

, kn

owled

ge a

bout

hom

e he

lp, lo

ng te

rm

care

and

den

tal c

are.

Cont

rol g

roup

. Rec

eived

usu

al ca

re.

Inte

nsity

and

follo

w u

p

Over

36

mon

ths.

Five

hom

e vis

its o

ver 3

year

s.

One

hom

e vis

it an

d ph

one

call

follo

w up

eve

ry m

onth

ove

r a

12 m

onth

per

iod.

Four

visit

s ove

r 2 ye

ars l

astin

g fo

r 1.5

to 3

hou

rs.

Outc

ome

and

limita

tions

No d

iffer

ence

bet

ween

ger

iatric

ass

essm

ent a

nd

GP ca

re. N

o co

ntro

l gro

up. N

o m

easu

re o

f foll

ow u

p as

sess

men

ts.

Educ

ation

of h

ome

visito

rs a

nd G

Ps im

prov

ed o

lder

peop

le’s f

uncti

onal

abil

ity b

ut O

dds r

atios

wer

e wi

de

1.2

(95%

CI 1

.01

to 1

.42)

.

Ther

e wa

s no

signifi

cant

diff

eren

ce b

etwe

en th

e gr

oups

in

func

tiona

l dec

line

at 1

year

follo

w up

(mea

sure

d us

ing th

e SM

AF d

isabil

ity sc

ore

(56)

).

Cont

rolle

d tri

al. IT

T an

alysis

not

inclu

ded.

Resu

lts d

o no

t sup

port

conc

lusion

that

pre

vent

ative

ho

me

visits

redu

ce m

orta

lity ra

tes.

Diffe

renc

e in

drop

out r

ate

betw

een

cont

rol a

nd e

xper

imen

tal g

roup

bia

s con

clusio

n.

Inte

rven

tions

126

App

endi

x 5

Con

t.: R

ando

mis

ed c

ontr

olle

d tr

ials

of c

ompl

ex in

terv

enti

ons.

Refe

renc

e

Mar

kel-R

eid

(200

6) (9

7)

Cana

da

Boum

an e

t al

(200

8) (2

32)

Coun

sell

et a

l (2

007)

(110

)US

A

Heal

th c

lass

ifica

tion

Gene

ral o

lder p

eople

.

Frail

olde

r peo

ple.

Low

incom

e hig

h ris

k fra

il olde

r peo

ple.

Num

ber o

f par

ticip

ants

an

d ag

e

N=28

8 (1

44 in

clude

d in

analy

sis).

N=33

0 70

–84

year

s mea

n ag

e 76

.

N=95

165

+ ye

ars.

Mai

n pe

rson

nel

Nurse

-led h

ome v

isit.

Auxil

iary n

urse

-led w

ith

supe

rvisio

n of p

ublic

he

alth n

urse

.

Nurse

prac

tition

er,

socia

l wor

ker i

n co

llabo

ratio

n with

GPs

an

d ger

iatric

team

s.

Cont

ent

Expe

rimen

tal g

roup

. Mult

iple

hom

e vis

its

with

telep

hone

follo

w up

, per

sona

lised

ca

re p

lan w

ith g

oal s

ettin

g, ind

ividu

alise

d ap

proa

ch to

care

, com

mun

ity re

sour

ce

acce

ss a

nd ca

regiv

er co

llabo

ratio

n. He

alth

prom

otion

and

em

powe

rmen

t stra

tegie

s.Co

ntro

l gro

up. U

sual

care

.

Expe

rimen

tal g

roup

. Eigh

t hom

e vis

its

over

18

mon

ths,

subje

cts vi

sited

ap

prox

imat

ely e

very

2 m

onth

by

com

mun

ity n

urse

that

inclu

ded

a m

ultidi

men

siona

l ger

iatric

ass

essm

ent o

f pr

oblem

s and

risk

s, ad

vice

and

refe

rral

to p

rofe

ssion

al an

d co

mm

unity

serv

ices.

Nutri

tiona

l defi

cienc

y was

the

mos

t co

mm

on p

roble

m fo

llowe

d by

med

icatio

n.Co

ntro

l gro

up. R

eceiv

ed u

sual

care

but

th

ey co

uld a

cces

s ava

ilable

care

.

Initia

l and

ann

ual in

-hom

e CG

A by

a

GRAC

E su

ppor

t tea

m. In

dividu

alise

d ca

re

plan

deve

loped

ann

ually

by t

eam

invo

lving

a

geria

tricia

n, ph

arm

acist

, phy

sical

ther

apist

, men

tal h

ealth

socia

l wor

ker,

and

com

mun

ity-b

ased

serv

ices l

iaiso

n.

Team

sugg

estio

ns fo

r car

e re

lated

to th

e 12

targ

eted

ger

iatric

cond

itions

: adv

ance

ca

re p

lannin

g, he

alth

main

tena

nce,

med

icatio

n m

anag

emen

t, dif

ficult

y wa

lking

/falls

, chr

onic

pain,

urin

ary

incon

tinen

ce, d

epre

ssion

, hea

ring

loss,

visua

l impa

irmen

t, m

alnut

rition

or w

eight

los

s, de

men

tia, a

nd ca

regiv

er b

urde

n Im

plem

enta

tion

of ca

re p

lan.

Inte

nsity

and

follo

w u

p

Mult

iple

visits

follo

wed

up o

ver

1 ye

ar o

nly.

Telep

hone

follo

w up

8 h

ome

visits

ove

r 18

mon

ths.

Wee

kly G

RACE

inte

rdisc

iplina

ry

team

mee

tings

to re

view

supp

ort t

eam

succ

ess i

n im

plem

entin

g ca

re p

roto

cols

and

prob

lem so

lving

bar

riers

to

imple

men

tatio

n.

Ongo

ing G

RACE

supp

ort

team

hom

e-ba

sed

care

m

anag

emen

t (inc

luding

at

least

mon

thly

patie

nt co

ntac

ts)

supp

orte

d by

an

electr

onic

med

ical r

ecor

d an

d Web

-bas

ed

track

ing sy

stem

, and

pro

viding

co

ordin

ation

and

cont

inuity

of

care

am

ong

all h

ealth

care

pr

ofes

siona

ls an

d sit

es o

f car

e.

Outc

ome

and

limita

tions

Impr

ovem

ent i

n QO

L, m

enta

l hea

lth a

nd d

epre

ssion

.

No d

iffer

ence

bet

ween

gro

ups i

n he

althc

are

use

and

a low

chan

ce o

f bein

g co

st ef

fecti

ve.

At 2

4 m

onth

s sign

ifican

t im

prov

emen

ts we

re se

en

in th

e int

erve

ntion

gro

up co

mpa

red

with

usu

al ca

re

in 4

of 8

SF-

36 sc

ales a

nd in

the

men

tal c

ompo

nent

su

mm

ary (

2.1

vs –

0.3,

P<0

.001

). No

gro

up d

iffer

ence

s we

re fo

und

for A

DLs o

r dea

th. T

he cu

mula

tive

2-ye

ar

emer

genc

y dep

artm

ent (

ED) v

isit r

ate

per 1

000

was

lower

in th

e int

erve

ntion

gro

up (1

445

[n=4

74] v

s 174

8 [n

=477

], P=

0.03

) but

hos

pital

adm

ission

rate

s per

10

00 w

ere

not s

ignific

antly

diff

eren

t bet

ween

gro

ups

(700

[n=4

74] v

s 740

[n=4

77],

P=0.

66).T

his w

as a

hig

h qu

ality

trial

with

acc

epta

ble a

ttritio

n ra

te. T

here

we

re n

o dif

fere

nces

in fu

nctio

nal o

utco

me

betw

een

grou

ps.

Inte

rven

tions

127

App

endi

x 5

Con

t.: R

ando

mis

ed c

ontr

olle

d tr

ials

of c

ompl

ex in

terv

enti

ons.

Refe

renc

e

Gitli

n et

al

(200

6) (2

33)

Mel

lis e

t al

(200

8) (1

0)

Gill

et a

l (2

002)

(234

)

Heal

th c

lass

ifica

tion

Com

mun

ity-d

wellin

g old

er p

eople

with

fu

nctio

nal d

ifficu

lties.

Frail

olde

r peo

ple w

ith

disab

ility.

Frail

olde

r peo

ple

living

at h

ome.

Num

ber o

f par

ticip

ants

an

d ag

e

N=31

970

+ ye

ars.

N=15

1 (7

0+ ye

ars.

Mea

n ag

e 82

.)

N=18

875

+ ye

ars.

Mai

n pe

rson

nel

Phys

iothe

rapis

t and

oc

cupa

tiona

l ther

apy.

Nurse

hom

e visi

t.

Phys

ical th

erap

ist

asse

ssm

ent a

t hom

e.

Cont

ent

A m

ulti c

ompo

nent

inte

rven

tion

targ

eting

m

odifia

ble e

nviro

nmen

tal a

nd b

ehav

ioura

l fa

ctors

.

Expe

rimen

tal g

roup

. Sub

jects

selec

ted

using

a p

roble

m-b

ased

selec

tion

tool

includ

ing a

sses

smen

t of c

ognit

ion,

nutri

tion,

beha

viour,

moo

d or

mor

bidity

. Ge

riatri

c ass

essm

ent a

nd in

terv

entio

n inc

luding

an

indivi

dual

treat

men

t plan

ca

rried

out

by a

nur

se..

GPs w

ere

also

involv

ed. T

hey m

ade

med

icatio

n ch

ange

s an

d re

ferre

d fo

r oth

er m

ultidi

scipl

inary

int

erve

ntion

whe

n ne

cess

ary.

Cont

rol

grou

p ha

d us

ual c

are.

Inter

vent

ion g

roup

. Phy

sical

ther

apist

as

sess

men

t of m

obilit

y, AD

L, ba

lance

, RO

M, a

nd p

rese

nce

of e

nviro

nmen

tal

haza

rds.

Reco

mm

ende

d int

erve

ntion

s inc

luded

Instr

uctio

n in

safe

, effe

ctive

te

chniq

ues t

o fa

cilita

te a

ctivit

ies, t

raini

ng,

traini

ng in

pro

per u

se o

f ass

istive

dev

ices,

rem

oval

or e

nviro

nmen

tal h

azar

ds (lo

ose

rugs

, clut

ter, i

mpr

ovem

ent i

n lig

hting

, re

pair

of w

alking

surfa

ces,

stairw

ays a

nd

railin

gs, in

stalla

tion

of a

dapt

ive e

quipm

ent

in ba

thro

om),

prog

ress

ive co

mpe

tenc

y-ba

sed

exer

cise.

Inte

nsity

and

follo

w u

p

Five

occu

patio

nal t

hera

py

cont

acts

(four

90-

minu

te vi

sits

and

one

20-m

inute

telep

hone

co

ntac

t) an

d on

e ph

ysica

l th

erap

y visi

t.(9

0 m

inute

s) 6

mon

th d

urat

ion.

Up to

6 vi

sits p

lanne

d ov

er 3

m

onth

s.

Prot

ocol

was 1

6 vis

its o

ver 6

m

onth

(actu

al ra

nge

7–19

). M

onth

ly ph

one

calls

ther

eafte

r to

chec

k and

feed

back

Outc

ome

and

limita

tions

Quali

ty of

life

impr

ovem

ents

with

mos

t ben

efits

reta

ined

over

a ye

ar. A

t 6 m

onth

s, int

erve

ntion

par

ticipa

nts h

ad

less d

ifficu

lty th

an co

ntro

ls wi

thins

trum

enta

l acti

vities

of d

aily l

iving

(P=0

.04,

95%

co

nfide

nce

inter

val (C

I)=-0

.28

to 0

.00)

and

acti

vities

of

daily

living

(P=0

.03,

95%

CI=

-0.2

4 to

-0.0

1)

Trial

show

ed re

ducti

on in

func

tiona

l dec

line

and

wellb

eing

over

3 b

ut n

ot 6

mon

ths.

Num

ber n

eede

d to

trea

t was

4.7

and

aut

hors

sugg

est i

t is a

n ef

fecti

ve

addit

ion to

prim

ary c

are

at a

reas

onab

le low

cost.

Sm

all tr

ial n

ot in

cludin

g ITT

ana

lysis

and

high

attri

tion

(23%

) with

wide

confi

denc

e int

erva

ls. C

onclu

sions

sh

ould

be d

rawn

with

caut

ion.

Func

tiona

l dec

line

in th

e int

erve

ntion

gro

up w

as

signifi

cant

ly re

duce

d at

3, 7

and

12

mon

ths.

(Mea

sure

d by

a su

mm

ary d

isabil

ity sc

ore).

Sub

grou

p an

alysis

sh

owed

no

signifi

cant

diff

eren

ce in

thos

e th

at w

ere

class

ified

as se

vere

ly dis

abled

. Po

or co

mpli

ance

rate

inte

rven

tion

(65%

) lim

its th

e re

sults

of t

he st

udy.

No d

iffer

ence

bet

ween

gro

ups

in ad

miss

ion ra

te to

nur

sing

hom

es su

gges

ts th

at

func

tiona

l dec

line

is no

t the

only

facto

r ass

ociat

ed w

ith

instit

ution

alisa

tion.

Inte

rven

tions

128

App

endi

x 5

Con

t.: R

ando

mis

ed c

ontr

olle

d tr

ials

of c

ompl

ex in

terv

enti

ons.

Refe

renc

e

Rube

nste

in

et a

l (20

07)

(111

)

Heal

th c

lass

ifica

tion

High

risk

olde

r pe

ople.

(D

ept o

f Vet

eran

Af

fairs

Car

e Ce

ntre

.)

Num

ber o

f par

ticip

ants

an

d ag

e

N=79

2.

Mai

n pe

rson

nel

Phys

ician

assis

tant.

Cont

ent

Stru

cture

d te

lepho

ne g

eriat

ric

asse

ssm

ent,

indivi

duali

sed

refe

rrals

and

reco

mm

enda

tions

, sele

cted

refe

rral t

o ou

tpat

ient g

eriat

ric a

sses

smen

t, an

d on

going

telep

hone

case

man

agem

ent.

Outco

mes

wer

e ev

aluat

ion o

f tar

get

geria

tric c

ondit

ions (

depr

essio

n, co

gnitiv

e im

pairm

ent,

urina

ry in

cont

inenc

e, fa

lls,

and

func

tiona

l impa

irmen

t), fu

nctio

nal

statu

s and

hos

pitali

satio

n.

Inte

nsity

and

follo

w u

p

1, 2

and

3 ye

ar fo

llow

up.

Outc

ome

and

limita

tions

Inter

vent

ion in

crea

sed

reco

gnitio

n an

d ev

aluat

ion

of ta

rget

ger

iatric

cond

itions

(dep

ress

ion, c

ognit

ive

impa

irmen

t urin

ary i

ncon

tinen

ce, f

alls,

and

func

tiona

l im

pairm

ent)

but d

id no

t im

prov

e fu

nctio

nal s

tatu

s or

dec

reas

e ho

spita

lisat

ion. A

chiev

ing m

easu

rable

im

prov

emen

t in

func

tiona

l sta

tus o

r hos

pitali

satio

n ra

tes

is lik

ely to

requ

ire a

mor

e-int

ensiv

e int

erve

ntion

than

un

targ

eted

refe

rrals

and

shor

t-ter

m co

nsult

ation

s. Th

e at

tritio

n ra

te in

this

trial

was r

elativ

ely h

igh (2

5% in

the

inter

vent

ion g

roup

at 3

year

s) bu

t the

sam

ple si

ze w

as

highe

r tha

n ex

pecte

d an

d th

e lac

k of e

ffect

was u

nlike

ly to

be

due

to la

ck o

f pow

er.

Inte

rven

tions

129

App

endi

x 6:

Rev

iew

s of

exe

rcis

e an

d ph

ysic

al a

ctiv

ity

inte

rven

tion

s.

Auth

or

Ange

vare

n

et a

l (20

08)

(138

)

Bean

et a

l 20

04 (1

39)

Conn

et a

l(2

003)

(235

)

Cyar

to e

t al

(200

04) (

142)

Colco

mbe

and

Kr

amer

(200

3)

(140

)

Num

ber o

f stu

dies

(s

ubje

cts)

and

age

Mea

n ag

e 55

+ ye

ars.

11 R

CTs.

Not s

pecifi

ed.

17 (6

,391

).65

+ ye

ars.

21 tr

ials.

18 R

CTs a

nd q

uasi

RCTs

.Ag

e 55

–80

year

s.

Heal

th c

ateg

ory a

nd se

tting

Gene

ral p

opula

tion

of o

lder

peop

le.

Com

mun

ity-d

wellin

g.

Gene

ral p

opula

tion

and

older

pe

ople

with

chro

nic d

iseas

e.

Com

mun

ity-d

wellin

g.

Gene

ral p

opula

tion

of o

lder

peop

le.

Com

mun

ity, p

rimar

y he

althc

are.

Gene

ral p

opula

tion

of o

lder

peop

le an

d old

er p

eople

with

ch

ronic

dise

ase.

Com

mun

ity, p

rimar

y he

althc

are.

Gene

ral p

opula

tion

of o

lder

peop

le an

d old

er p

eople

with

ch

ronic

dise

ase.

Com

mun

ity-d

wellin

g.

Inte

rven

tions

Phys

ical a

ctivit

y.

Prog

ress

ive re

sista

nce

traini

ng, a

erob

ic tra

ining

, dy

nam

ic ex

ercis

e, ta

i ch

i, high

veloc

ity tr

aining

e.

g. co

ncen

tric t

raini

ng

perfo

rmed

at h

igh sp

eed.

Phys

ical a

ctivit

y, en

dura

nce

exer

cise,

mot

ivatio

nal in

terv

entio

ns.

Phys

ical a

ctivit

y int

erve

ntion

s and

pr

ogre

ssive

resis

tanc

e tra

ining

.

Aero

bic fi

tnes

s and

co

mbin

ation

stre

ngth

tra

ining

.

Outc

omes

Aero

bic ca

pacit

y tes

t.Ca

rdiov

ascu

lar fi

tnes

s link

ed

to co

gnitiv

e fu

nctio

n (sp

eed)

inc

luding

mot

or fu

nctio

n,

audit

ory a

ttent

ion a

nd d

elaye

d m

emor

y.

Med

ical a

nd d

isable

men

t ou

tcom

es, s

elf e

ffica

cy a

nd

Quali

ty of

Life

(QoL

).

Phys

ical t

ests

walki

ng, h

eart

foun

datio

n m

easu

res o

f ove

rall

phys

ical fi

tnes

s.

Func

tiona

l tas

ks a

nd st

reng

th

mea

sure

s.

VO2

max

and

cogn

itive

proc

ess (

spee

d, vis

io-sp

atial

, co

ntro

lled

proc

essin

g an

d ex

ecut

ive co

ntro

l).

Mai

n fin

ding

s and

aut

hors

con

clusio

ns

Larg

est e

ffects

on co

gnitiv

e fun

ction

wer

e fou

nd

on m

otor f

uncti

on, a

udito

ry att

entio

n and

delay

ed

mem

ory (

effec

t size

1.1

7, 0.

52, 0

.5) o

nly m

oder

ate

effec

ts for

cogn

itive s

peed

(0.2

6) an

d visu

al att

entio

n (0.

26). I

ntens

ity ra

ther t

han d

urati

on of

ex

ercis

e dete

rmine

s ben

efit f

or co

gnitio

n. M

ajorit

y of

com

paris

ons y

ielde

d NS

effec

ts.

Exer

cise

has t

hera

peut

ic ef

fects

for a

lmos

t all

com

mun

ity-d

wellin

g old

er a

dults

inclu

ding

redu

ction

in m

orbid

ity a

nd m

orta

lity, a

nd

enha

nced

phy

siolog

ic ca

pacit

y, lea

ding

to

impr

ovem

ent i

n ov

erall

func

tion

but r

elatio

nship

be

twee

n fu

nctio

n an

d im

pairm

ent i

s non

linea

r. A

thre

shold

exis

ts af

ter w

hich

enha

ncem

ent

in im

pairm

ent (

e.g.

stren

gth)

will

not i

ncre

ase

func

tion.

10 st

udies

repo

rted

signifi

cant

incr

ease

in

phys

ical a

ctivit

y. Se

x and

eth

nic d

iffer

ence

s not

re

porte

d. Sm

all sa

mple

size

s mak

es co

nclus

ions

diffic

ult to

dra

w.

Incre

ased

stre

ngth

repo

rted

but f

urth

er

popu

lation

-bas

ed st

udies

inclu

ding

hom

e an

d wh

ole co

mm

unity

inte

rven

tions

are

requ

ired.

Aero

bic tr

aining

had

robu

st bu

t sele

ctive

be

nefit

s on

cogn

ition

proc

ess p

artic

ularly

for

exec

utive

cont

rol p

roce

ss (t

asks

relat

ing to

pla

nning

, inhib

ition

and

sche

dulin

g of

men

tal

proc

edur

es).

AMST

AR Q

ualit

y sco

re (A

QS) c

omm

ents

/ lim

itatio

ns

Coch

rane

Rev

iew.

Diffi

cult

to co

nclud

e if

effe

cts a

re d

ue to

ca

rdiov

ascu

lar e

xerc

ise a

lone

or co

uld b

e ac

hieve

d wi

th o

ther

type

s of e

xerc

ise i.

e. ba

lance

, pow

er a

nd st

reng

th e

xerc

ise.

AQS=

9/11

No se

arch

stra

tegy

. Rec

omm

enda

tions

for

exer

cise

given

for s

pecifi

c dise

ase.

Gene

rally

2–

3 tim

es w

eek P

RT a

nd a

erob

ic tra

ining

at

13–

17 o

n th

e Bo

rg sc

ale o

f per

ceive

d ex

ertio

n. Im

prov

emen

t in

impa

irmen

t and

fu

nctio

n do

n’t a

lway

s lea

d to

dec

reas

ed

disab

ility.

AQS=

1/9

Poor

qua

lity re

view.

AQS=

2/9

Pauc

ity o

f stro

ng e

viden

ce lin

king

PRT

to

redu

ction

/pre

vent

ion o

f fun

ction

al de

cline

or

impr

oved

QOL

.AQ

S=1/

9

Com

plex c

oding

syste

m u

sed

to ca

tego

rise

resu

lts b

ut u

nclea

r exp

lanat

ion a

nd n

o qu

ality

scor

e fo

r tria

ls.AQ

S=3/

11

130

App

endi

x 6

Con

t.: R

evie

ws

of e

xerc

ise

and

phys

ical

act

ivit

y in

terv

enti

ons.

Auth

or

Dani

els e

t al

(200

8) (1

43)

How

e et

al

(200

8) (1

44)

Keys

or a

nd

Jette

(200

1)

(145

)

Keys

or (2

003)

(2

36)

Lath

am e

t al

(200

4) (1

46)

Num

ber o

f stu

dies

(s

ubje

cts)

and

age

10 tr

ial76

–83

year

s.

34 R

CTs a

nd q

uasi-

expe

rimen

tal d

esign

.

31 st

udies

29

RCTs

, 2

quas

i-RCT

s.

60+

year

s.

4 re

views

.

65+

year

s.

66 tr

ials

(n=3

,783

).

60+

year

s.

Heal

th c

ateg

ory a

nd se

tting

Frail

olde

r peo

ple a

t risk

.

Com

mun

ity.

Gene

ral p

opula

tion

and

frail o

f old

er p

eople

.

Com

mun

ity a

nd in

stitu

tions

.

Gene

ral p

opula

tion

of o

lder

peop

le, a

nd fr

ail o

lder p

eople

wi

th ch

ronic

dise

ase.

Com

mun

ity a

nd n

ursin

g ho

me.

Gene

ral p

opula

tion

and

frail o

f old

er p

eople

and

olde

r peo

ple

with

chro

nic d

iseas

e (ar

thrit

is on

ly).

Gene

ral p

opula

tion

of o

lder

peop

le an

d old

er p

eople

with

ch

ronic

dise

ase.

Com

mun

ity-d

wellin

g.

Inte

rven

tions

Nutri

tiona

l and

acti

vity/

exer

cise.

Rang

ing in

int

ensit

y fro

m 1

0 we

eks t

o 18

mon

ths

Exer

cise

inter

vent

ions

aiming

spec

ificall

y to

impr

ove

balan

ce.

Exer

cise

cate

gorie

s wer

e: 1)

flex

ibility

inclu

ding

yoga

and

stre

tching

; 2)

stre

ngth

ening

or

resis

tanc

e; 3

) aer

obic;

4)

bala

nce

(tai c

hi); 5

) co

mbin

ed e

xerc

ise.

Phys

ical a

ctivit

y and

ex

ercis

e.

Gym

and

hom

e ba

sed

exer

cise

prog

ram

mes

wh

ere

PRT

was d

efine

d as

a st

reng

th tr

aining

pr

ogra

mm

e wh

ere

parti

cipan

ts ex

ercis

e ag

ainst

resis

tanc

e th

at

was p

rogr

esse

d.

Outc

omes

Activ

ities o

f dail

y livi

ng,

disab

ility,

nutri

tiona

l inta

ke,

balan

ce, w

alking

func

tion,

ae

robic

capa

city.

Gait,

balan

ce, c

oord

inatio

n,

func

tiona

l exe

rcise

.

Mus

cle st

reng

th, R

OM,

flexib

ility,

max

oxy

gen

upta

ke,

neur

omus

cular

cont

rol a

nd

body

com

posit

ion. D

irect

im

pact

on d

isabil

ity. M

easu

res

of h

ealth

stat

us S

F-3,

sick

ness

im

pact

profi

le an

d ot

her

gene

ric d

isabil

ity sc

ores

.

Disa

blem

ent o

utco

mes

(fu

nctio

n, im

pairm

ent a

nd

disab

ility).

Limita

tion

in th

e pe

rform

ance

of

socia

lly d

efine

d ro

les a

nd

task

s (se

lf ca

re, w

ork)

Barth

el,

HRQO

L SF

-36,

phy

sical

impa

irmen

t stre

ngth

and

ae

robic

capa

city,

falls

, hos

pital

adm

ission

and

dea

th.

Mai

n fin

ding

s and

aut

hors

con

clusio

ns

9 tri

als re

porte

d im

prov

emen

t in, s

treng

th, ae

robic

ca

pacit

y, fitn

ess,

balan

ce, a

nd O

2 up

take o

r weig

ht

gain.

Sub

gro

up an

alysis

sugg

ests

gains

wer

e m

ainly

obtai

ned i

n peo

ple w

ith m

oder

ate fr

ailty.

No

evide

nce t

hat n

utritio

nal in

terve

ntion

s res

ult

in re

duce

d disa

bility

. Lon

g las

ting h

igh in

tensit

y ex

ercis

e for

mod

erate

phys

ical fr

ailty

may

have

eff

ect o

n disa

bility

.

Limite

d evid

ence

for i

mpr

ovem

ent in

balan

ce bu

t m

any s

tudies

are m

ethod

ologic

ally w

eak.

No st

rong

evide

nce f

or ex

ercis

e as e

ffecti

ve m

eans

alo

ne of

redu

cing d

isabil

ity. E

ffect

size o

f sele

cted

studie

s >10

0 su

bjects

0.2

8, 0.

23 (A

DL), 0

.30,

0.

26 (p

hysic

al dis

abilit

y). 8

–12

week

s inte

rventi

on

may

dem

onstr

ate ph

ysica

l and

func

tiona

l im

prov

emen

t but

not b

ehav

ioura

l cha

nge.

Best

evide

nce f

or a

com

binati

on of

exer

cise w

ith

cogn

itive b

ehav

ioura

l com

pone

nts.

Aero

bic ex

ercis

e, pa

rticu

larly

walki

ng, in

creas

es

mus

cle st

reng

th an

d red

uces

func

tiona

l lim

itatio

n bu

t less

clea

r for

redu

cing d

isabil

ity.

Prog

ress

ive re

sistan

ce tr

aining

has l

arge

effec

t on

stre

ngth

and s

mall

to m

oder

ate ef

fect o

n othe

r as

pects

of im

pairm

ent a

nd fu

nctio

nal li

mita

tion b

ut

unab

le to

show

tran

slatio

n into

impr

ovem

ents

in ph

ysica

l disa

bility

.

AMST

AR Q

ualit

y sco

re (A

QS) c

omm

ents

/ lim

itatio

ns

Impr

ovem

ent i

n ex

ercis

e ou

tcom

es d

id no

t ne

cess

arily

lead

to re

duce

d dis

abilit

y. St

rict

adhe

renc

e to

frail

ty de

finitio

n inc

luded

. AQ

S=7/

9

Failu

re to

use

stan

dard

ised

mea

sure

s mak

es

firm

conc

lusion

s diffi

cult.

AQS

=8/1

1

Small

sam

ple si

ze in

a n

umbe

r of s

tudie

s may

ha

ve le

d to

type

II er

ror. P

ossib

le ex

plana

tion

of la

ck o

f lar

ge e

ffects

of e

xerc

ise a

lone

due

to o

ther

facto

rs lin

ked

to d

isable

men

t suc

h as

ind

ividu

al’s b

elief

s, em

otion

s, co

ping

strat

egies

an

d ph

ysica

l and

socia

l env

ironm

ents.

AQ

S=5/

9

Lack

of c

onsis

tenc

y in

the

RCTs

rega

rding

be

nefit

s of e

xerc

ise o

n dis

abilit

y. AQ

S=3/

9

Quali

ty as

sess

men

t car

ried

out o

n RC

Ts. P

oor

met

hodo

logica

l qua

lity o

f RCT

s.AQ

S=9/

11

131

App

endi

x 6

Con

t.: R

evie

ws

of e

xerc

ise

and

phys

ical

act

ivit

y in

terv

enti

ons.

Auth

or

Netz

et a

l (2

005)

(147

)

Orr e

t al

(200

8)(1

48)

Taylo

r et a

l (2

004)

(237

)

Van

der B

ij et

al (

2002

) (1

50)

Yeom

(200

9)

(151

)

Num

ber o

f stu

dies

(s

ubje

cts)

and

age

36 st

udies

.Ag

e 54

–64

(22

studie

s) 65

–74

(50

studie

s). 7

5+ ye

ars

(9 st

udies

).

29 st

udies

(2,1

74).

50+

year

s. M

ean

60.

Num

ber n

ot sp

ecifie

d.

65+

year

s.

38 st

udies

. 50

+ ye

ars.

28 R

CTs.

60+

year

s.

Heal

th c

ateg

ory a

nd se

tting

Gene

ral p

opula

tion

of o

lder

peop

le an

d old

er p

eople

with

ch

ronic

dise

ase.

Com

mun

ity-d

wellin

g.

Gene

ral p

opula

tion

of o

lder

peop

le an

d th

ose

with

chro

nic

disea

se.

Com

mun

ity-d

wellin

g.

Gene

ral p

opula

tion

and

older

pe

ople

with

chro

nic d

iseas

e.

Gene

ral p

opula

tion

and

older

pe

ople

at ri

sk.

Com

mun

ity-d

wellin

g.

Gene

ral p

opula

tion

and

frail

older

peo

ple a

t risk

.

Com

mun

ity-d

wellin

g.

Inte

rven

tions

Exer

cise

prog

ram

mes

.

Resis

tanc

e tra

ining

an

d ba

lance

gen

erall

y co

nduc

ted

in gy

m/

com

mun

ity se

tting

.

Phys

ical a

ctivit

y.

Phys

ical a

ctivit

y int

erve

ntion

s. Ho

me

base

d acti

vity (

n=9)

gro

up

base

d acti

vity (

n=38

), ed

ucati

onal

phys

ical a

ctivit

y int

erve

ntion

s (n=

10)

wher

e adv

ice w

as g

iven o

n ex

ercis

e par

ticipa

tion.

Prom

oting

mob

ility,

aero

bic

and

resis

tance

train

ing,

tai ch

i.

Outc

omes

Stre

ngth

, flex

ibility

, aer

obic

fitne

ss, f

uncti

onal

capa

city,

psyc

holog

ical w

ellbe

ing (a

nger,

an

xiety,

conf

usion

, dep

ress

ion,

ener

gy).

Balan

ce o

utco

mes

(68

tests

). St

atic,

dyn

amic

and

func

tiona

l ba

lance

.

Stre

ngth

, ADL

, aer

obic

fitne

ss,

cost

effe

ctive

ness

.

Phys

ical a

ctivit

y lev

els, a

erob

ic fit

ness

, bon

e de

nsity

, fra

cture

ris

k. Pa

rticip

ation

leve

ls,

beha

viour

al re

infor

cem

ent.

Walk

ing sp

eed

and

endu

ranc

e, ba

lance

, stre

ngth

mea

sure

s.

Mai

n fin

ding

s and

aut

hors

con

clusio

ns

Small

but s

ignific

ant e

ffect

over

all of

exer

cise o

n we

llbein

g in h

ealth

y olde

r adu

lts (w

eighte

d mea

n dif

[0.1

9]). P

eople

with

chro

nic di

seas

e had

larg

er

effec

t of e

xerci

se su

gges

ting c

ausa

l effe

ct for

ph

ysica

l acti

vity o

n psy

cholo

gical

wellb

eing.

Limite

d evid

ence

, hete

roge

neou

s outc

omes

and

inter

venti

ons d

id no

t sho

w tha

t res

istan

ce tr

aining

in

isolat

ion im

prov

es ba

lance

. Rec

omm

enda

tions

to

use p

rogr

essiv

e res

istan

ce tr

aining

as an

isola

ted

inter

venti

on st

rateg

y to i

mpr

ove b

alanc

e can

not

be m

ade.

Age r

elated

chan

ges c

an be

reve

rsed b

y inc

reas

ing

levels

of ph

ysica

l fitne

ss. G

rowi

ng ev

idenc

e for

an

ti-de

pres

sant

effec

t of e

xerci

se an

d its

role

in im

prov

ing em

otion

al, co

gnitiv

e and

perce

ived

phys

ical fu

nctio

n. Im

porta

nt tha

t exe

rcise

is ta

ilore

d to

need

s. Pe

rsona

l cho

ice an

d per

ceive

d beh

aviou

r infl

uenc

e par

ticipa

tion.

Bene

fits ca

n outw

eigh

costs

base

d on m

uscle

powe

r, bala

nce a

nd fa

lls

prev

entio

n.

Prog

ram

mes

can r

esult

in in

creas

ed ac

tivity

lev

els bu

t no e

ffect

of be

havio

ural

reinf

orce

men

t on

initia

tion a

nd m

ainten

ance

of ph

ysica

l ac

tivity

. Par

ticipa

tion r

ate de

cline

the l

onge

r the

int

erve

ntion

dura

tion,

parti

cular

ly in

hom

e bas

ed

exer

cise.

Peop

le ov

er 6

0 ha

ve lo

wer p

artic

ipatio

n ra

te tha

n you

nger

parti

cipan

ts bu

t eve

n ver

y old

(80+

) can

be m

otiva

ted to

incre

ase a

ctivit

y rate

.

Effec

tive i

nterve

ntion

inclu

des w

alking

, aero

bic ex

ercise

an

d res

istan

ce tr

aining

focu

sing o

n stre

ngth,

balan

ce,

and fl

exibi

lity. S

ubjec

ts ne

ed to

partic

ipate

for at

leas

t 12

wee

ks. E

xerci

se do

se of

phys

ical a

ctivit

y 20–

60

mins

of ae

robic

exerc

ise 3

times

a we

ek. (A

CSM

recom

mend

ation

s are

60 m

ins fo

r olde

r adu

lts.)

AMST

AR Q

ualit

y sco

re (A

QS) c

omm

ents

/ lim

itatio

ns

Inves

tigat

ed p

rior e

xerc

ise p

artic

ipatio

n an

d fo

und

subje

cts fr

om se

dent

ary b

ackg

roun

d ex

perie

nced

larg

er e

ffects

. Com

plex m

ultipl

e re

gres

sion

analy

sis o

f effe

cts ca

rried

out

. AQ

S=4/

11

Stan

dard

isatio

n of

bala

nce

testi

ng n

eede

d.St

reng

th n

ot th

e m

ajor u

nder

lying

mec

hanis

m

for p

oor b

alanc

e an

d ot

her l

imitin

g fa

ctors

infl

uenc

e po

stura

l sta

bility

.AQ

S=5/

9

Narra

tive

revie

w co

mbin

ing co

hort,

case

co

ntro

l, RCT

and

revie

w lev

el da

ta. N

o se

arch

str

ateg

y. Fo

cus o

n ef

ficac

y and

effe

ctive

ness

. So

me

evide

nce

that

GPs

who

are

phy

sicall

y ac

tive

them

selve

s are

3–4

tim

es m

ore

likely

to

prom

ote

exer

cise.

AQS=

0/9

This

revie

w fo

cuse

d on

pro

mot

ing e

xerc

ise

rath

er th

an th

e be

nefit

s. M

ost p

artic

ipant

s we

re w

hite,

from

well

edu

cate

d ba

ckgr

ound

s an

d ha

d m

oder

ate

to h

igh in

com

e lev

el. G

ood

desc

riptio

n of

inte

rven

tions

. Par

ticipa

nts

advis

ed to

exe

rcise

3 ti

mes

a w

eek o

n ho

me-

base

d pr

ogra

mm

e.AQ

S=4/

9

Limite

d na

rrativ

e re

view

only

includ

ing st

udies

of

inte

rven

tions

in th

e US

A.

AQS=

2/9

132

App

endi

x 7:

Rev

iew

s of

info

rmat

ion

com

mun

icat

ion

tech

nolo

gy in

terv

enti

ons.

Auth

or

Barlo

w e

t al

(200

7) (1

71)

DelliF

rain

e an

d Da

nsky

(2

008)

(173

)

Botis

and

Ha

rtvig

sen

(200

8) (1

72)

Gaitw

ad a

nd

War

ren

(200

9)

(174

)

Jenn

et e

t al

(200

3) (1

75)

Num

ber o

f stu

dies

(s

ubje

cts)

and

age

98 st

udies

.68

RCT

s and

30

obse

rvat

ional.

29 st

udies

. No

age

limit

but

includ

ing o

lder p

eople

65

+ ye

ars.

54 st

udies

.

27 st

udies

inclu

ding

sub-

grou

p of

olde

r pe

ople.

53 st

udies

inclu

ding

revie

ws.

Heal

th c

ateg

ory a

nd se

tting

Olde

r peo

ple w

ith m

ultipl

e ch

ronic

dise

ase

and

frail o

lder

peop

le.Co

mm

unity

setti

ng.

Olde

r peo

ple w

ith ch

ronic

dis

ease

.Co

mm

unity

and

resid

entia

l se

tting

.

Olde

r peo

ple w

ith ch

ronic

dis

ease

.Co

mm

unity

.

Gene

ral p

opula

tion

of o

lder

peop

le wi

th ch

ronic

dise

ase.

Com

mun

ity.

Olde

r peo

ple w

ith ch

ronic

dis

ease

.

Com

mun

ity se

tting

.

Inte

rven

tions

Telec

are

(vita

l sign

s m

onito

ring,

safe

ty an

d se

curit

y mon

itorin

g,

infor

mat

ion a

nd su

ppor

t m

onito

ring)

.

Teleh

ealth

inte

rven

tions

, m

onito

r, int

erne

t, or

m

onito

r plus

hom

e he

alth,

vid

eo m

onito

ring.

Teleh

ealth

, tele

mon

itorin

g,

telec

omm

unica

tion

devic

es fo

r ass

essin

g ph

ysica

l and

cogn

itive

prob

lems.

Telem

onito

ring,

te

leass

istan

ce,

teleh

omec

are,

video

conf

eren

cing

and

telec

ardio

logy.

Teleh

ealth

Outc

omes

Bene

fits t

o pa

tient

s, cli

nical

indica

tors

, impr

oved

m

edica

tion

cont

rol, q

uality

of

life a

nd re

duce

d m

orta

lity.

Mult

iple

clinic

al ou

tcom

es.

1)Ef

fects

on

patie

nts a

nd

healt

hcar

e pr

ofes

siona

ls;2)

Effe

cts o

n ch

ronic

dise

ases

;3)

Effe

cts o

n he

alth.

Mult

iple

outco

mes

rang

ing

from

qua

litativ

e to

hea

lthca

re

costs

.

Mult

iple

outco

mes

, hea

lth

outco

mes

, qua

lity o

f life

, qu

ality

of ca

re, c

ost a

nd co

st ef

fecti

vene

ss, d

ecre

ased

he

alth

serv

ice u

tilisa

tion,

socia

l iso

lation

.

Mai

n fin

ding

s and

aut

hors

con

clusio

ns

Evide

nce

incon

siste

nt fo

r vita

l sign

s, ins

uffic

ient

evide

nce

for a

lert s

yste

ms s

uch

as fa

ll det

ecto

rs,

evide

nce

that

telep

hone

supp

ort c

an im

prov

e cli

nical

outco

mes

.

Sub

grou

p an

alysis

of o

lder p

eople

(10

trials

on

ly) e

ffect

size

for c

linica

l out

com

es; 0

.41

95%

CI

0.1

0 to

0.7

3.

No si

gnific

ant b

enefi

t for

Alzh

eimer

s com

pare

d to

trad

itiona

l met

hods

. Ben

efits

includ

ed

satis

facti

on a

nd re

duce

d tra

vel c

osts.

Ther

e ar

e or

ganis

ation

al, e

thica

l, leg

al, d

esign

s, us

abilit

y an

d ot

her m

atte

rs th

at n

eed

to b

e re

solve

d be

fore

wide

spre

ad im

plem

enta

tion

can

occu

r.

Teleh

ome

– 5

studie

sTe

lemon

itorin

g –

8 stu

dies.

Long

term

Ho

me

base

d int

erve

ntion

s tar

getin

g ap

prop

riate

gr

oups

of c

hron

ic dis

ease

who

are

high

use

rs o

f he

althc

are

can

impr

ove

quali

ty of

man

agem

ent.

No h

igh q

uality

com

para

tive

studie

s whic

h cle

arly

dem

onstr

ated

ben

efits

of vi

deo-

cons

ultat

ion.

Enha

nced

qua

lity o

f life

of o

lder p

eople

by

incre

asing

abil

ity to

live

indep

ende

ntly.

Healt

h ed

ucat

ion b

enefi

ts fro

m co

mpu

ter b

ased

ap

plica

tions

. Elec

tronic

net

work

s pro

vided

su

ppor

t for

care

rs. T

eleph

one

cons

ultat

ion

for p

rovis

ion o

f med

ical a

dvice

and

vide

o-co

nsult

ation

s reg

ardin

g wo

unds

can

redu

ce

costs

.

AMST

AR Q

ualit

y sco

re (A

QS) c

omm

ents

/ lim

itatio

ns

Mos

t evid

ence

mea

sure

d in

term

s of h

ealth

se

rvice

use

rath

er th

an im

prov

ing cl

inica

l ind

icato

rs.

AQS=

3/9

Small

sam

ple si

ze in

man

y stu

dies (

22 o

ut

of 2

9 les

s tha

n 10

0). N

o de

scrip

tion

of th

e cli

nical

outco

mes

.AQ

S=2/

9

Limite

d by

small

stud

ies a

nd sh

ort f

ollow

up

. Olde

r peo

ple n

ot e

ntire

ly fa

milia

r with

te

chno

logy a

nd la

ter g

ener

ation

may

gain

m

ore

bene

fit fr

om kn

owled

ge a

cquir

ed in

ea

rly lif

e.AQ

S=1/

9

Need

evid

ence

bas

ed o

utco

me

indica

tors

to

confi

rm su

staina

ble co

st be

nefit

s. On

ly 1

pape

r fro

m U

K. 1

0 fro

m U

SA.

AQS=

2/9

Only

16 o

f the

53

studie

s (30

%) o

f tele

healt

h fo

r olde

r peo

ple w

ere

rate

d go

od to

fair.

Mea

sure

men

t of c

osts,

cost

effe

ctive

ness

was

im

prec

ise. T

here

is u

ncer

taint

y abo

ut g

ener

al ap

plica

bility

.AQ

S=4/

9

133

App

endi

x 8:

Rev

iew

s of

fall

s pr

even

tion

inte

rven

tion

s.

Auth

or

Aven

ell e

t al

(200

9) (2

38)

Besw

ick e

t al

(200

8) (7

)

Chan

g et

al

(200

4) (2

39)

Cam

pbel

l and

Ro

berts

on

(200

7) (1

21)

Cum

min

g

(200

2) (2

40)

Num

ber o

f stu

dies

(s

ubje

cts)

and

age

45 R

CTs.

Hip

(24,

749)

.Ve

rt (9

,138

).Ot

her (

25,0

16).

89 R

CTs (

97,9

84).

Mea

n ag

e 65

+ ye

ars.

40 R

CTs.

90 R

CTs i

n th

e co

mm

unity

(32

in ins

titut

ional

care

).

65+

year

s.

21 R

CTs.

Heal

th c

ateg

ory a

nd se

tting

Gene

ral p

opula

tion

of o

lder

peop

le an

d fra

il.

Instit

ution

al ca

re a

nd

com

mun

ity.

Gene

ral p

opula

tion

and

frail

older

peo

ple.

Com

mun

ity se

tting

.

Gene

ral p

opula

tion

and

frail

older

peo

ple.

Com

mun

ity a

nd in

stitu

tion.

Gene

ral p

opula

tion

and

frail

older

peo

ple a

t risk

.

Com

mun

ity se

tting

.

Gene

ral p

opula

tion

and

frail

older

peo

ple a

t risk

.

Com

mun

ity se

tting

.

Inte

rven

tions

Vitam

in D

and

calci

um

supp

lemen

ts.

Com

plex i

nter

vent

ions

includ

ing fa

ll pre

vent

ion.

Mult

i-fac

toria

l fall

s ris

k ass

essm

ent a

nd

man

agem

ent,

exer

cise

inter

vent

ion, e

duca

tion

and

envir

onm

enta

l m

odific

ation

. Exe

rcise

ca

tego

rised

as b

alanc

e, en

dura

nce,

flexib

ility,

stren

gth.

Mult

i-fac

toria

l int

erve

ntion

s com

pare

d wi

th si

ngle

inter

vent

ion

strat

egy t

arge

ting

single

ris

k for

falls

pre

vent

ion.

Mult

ifacto

r int

erve

ntion

s.

Outc

omes

Falls

and

frac

ture

s.

Living

at h

ome,

deat

h,

adm

ission

s to

hosp

ital a

nd

nurs

ing h

omes

, fall

s, ph

ysica

l fu

nctio

n.

Fallin

g at

leas

t onc

e du

ring

a sp

ecifie

d pe

riod

and

mon

thly

fallin

g. Ri

sk ra

tio e

stim

ated

for

mos

t stu

dies.

Othe

r clin

ically

re

levan

t out

com

es n

ot

repo

rted

suffi

cient

ly.

Poole

d ra

te ra

tio fo

r fall

ing.

Falls

, insti

tutio

nal a

dmiss

ion.

Mai

n fin

ding

s and

aut

hors

con

clusio

ns

Vitam

in D

alone

inef

fecti

ve in

pre

vent

ing

fractu

res.

No st

rong

evid

ence

for r

educ

tion

of fr

actu

res.

Mod

est i

ncre

ase

in GI

and

rena

l sym

ptom

s. M

aybe

mor

e be

nefic

ial fo

r ins

titut

ionali

sed

older

pe

ople.

Inter

vent

ions r

educ

ed ri

sk o

f not

living

at h

ome,

nurs

ing h

ome

adm

ission

s and

falls

par

ticula

rly

in th

e ge

nera

l pop

ulatio

n.

Falls

33.

6% to

30.

5%, im

prov

emen

t in

phys

ical

func

tion

0.5

point

on

Barth

el Ind

ex.

Effe

ctive

in re

ducin

g ris

k of f

alls a

nd m

onth

ly ra

te o

f fall

s. M

ulti f

acto

rial f

alls r

isk a

sses

smen

t m

ost e

ffecti

ve, e

xerc

ise p

rogr

amm

es e

ffecti

ve in

re

ducin

g ris

k of f

alls.

Six i

nter

vent

ions w

ith m

ultipl

e co

mpo

nent

s re

duce

d fa

lls b

y 22%

(poo

led ra

te ra

tio 0

.78

95%

CI 0

.68

to 0

.89)

.10

sing

le int

erve

ntion

s red

uced

falls

by 2

3%

(poo

led ra

te ra

tio 9

5% C

I 0.6

7 to

0.8

9). T

here

wa

s no

sig d

if be

twee

n po

oled

rate

ratio

s for

sin

gle a

nd m

ulti f

acto

rial in

terv

entio

ns.

Conv

incing

evid

ence

that

exe

rcise

can

prev

ent

fall r

ecur

renc

e. Re

ducin

g us

e of

psy

chot

ropic

m

edica

tions

pre

vent

s fall

s, ta

i chi,

inte

nsive

str

engt

h an

d en

dura

nce,

hom

e-ba

sed

exer

cise.

AMST

AR Q

ualit

y sco

re (A

QS) c

omm

ents

/ lim

itatio

ns

Coch

rane

Rev

iew.

AQS=

10/1

1

Bene

fits m

ore

evide

nt p

rior t

o 19

93

sugg

estin

g qu

ality

bias.

Larg

e he

tero

gene

ity

mak

es co

nclus

ion d

ifficu

lt to

dra

w wi

th

confi

denc

e. AQ

S=8/

11

Over

all m

odes

t red

uctio

ns u

suall

y les

s tha

n 35

% re

ducti

on in

num

ber o

f olde

r peo

ple

fallin

g. Re

com

men

ds th

at O

P ov

er 7

5 sh

ould

have

targ

eted

ass

essm

ent

(bala

nce,

gait,

walki

ng a

nd m

ovem

ent

dysfu

nctio

n).

AQS=

10/1

1

Deliv

ery o

f sing

le fa

ctor i

nter

vent

ions t

o se

lecte

d po

pulat

ions i

s as e

ffecti

ve in

redu

cing

falls

as m

ulti f

acto

rial in

terv

entio

ns.

AQS=

8/11

Upda

ted

in 20

09 b

y Gille

spie

et a

l.

134

App

endi

x 8

Con

t.: R

evie

ws

of fa

lls

prev

enti

on in

terv

enti

ons.

Auth

or

Davis

et a

l (2

004)

(241

)

Davis

et a

l (2

010)

(15)

Gate

s et a

l (2

008)

(12)

Gille

spie

et a

l (2

009)

(13)

Gille

spie

et a

l (2

005)

(242

)

Low

et a

l 20

09 (2

43)

Num

ber o

f stu

dies

(s

ubje

cts)

and

age

13 st

udies

.

9 RC

Ts.

60+

year

s.

19 st

udies

.

65+

year

s.

111

RCTs

(5

5,30

3 pa

rticip

ants)

.

7 RC

Ts.

60+

year

s.

Heal

th c

ateg

ory a

nd se

tting

Olde

r peo

ple w

ith fa

lls re

lated

inj

uries

.

Gene

ral p

opula

tion

and

frail

older

peo

ple a

t risk

.

Com

mun

ity se

tting

.

Gene

ral p

opula

tion

and

frail

older

peo

ple a

t risk

.

Prim

ary c

are,

com

mun

ity a

nd

emer

genc

y car

e se

tting

s.

Gene

ral p

opula

tion

and

frail

older

peo

ple a

t risk

.

Com

mun

ity se

tting

.

Gene

ral p

opula

tion

and

frail

older

peo

ple a

t risk

.

Com

mun

ity se

tting

.

Gene

ral p

opula

tion

and

frail o

lder p

eople

at r

isk.

Com

mun

ity se

tting

an

d ca

re h

omes

(1 R

CT o

nly).

Inte

rven

tions

Balan

ce a

nd a

gility

ex

ercis

e.

Mult

i-fac

toria

l indiv

idual

level.

Sing

le int

erve

ntion

s.Po

pulat

ion-b

ased

m

ulti-f

acto

rial in

cludin

g aw

aren

ess c

ampa

ign.

Iinte

rven

tion

includ

ing

exer

cise,

educ

ation

, dr

ugs,

know

ledge

tra

nsfe

r and

ass

essm

ents

includ

ing b

alanc

e, ho

me

envir

onm

ent,

psyc

holog

ical, g

ait,

disab

ility.

Mult

i-com

pone

nt

grou

p ex

ercis

e, ta

i chi,

ex

ercis

e, a

sses

smen

t an

d m

ulti-f

acto

rial

inter

vent

ion, V

itam

in D,

ho

me

safe

ty int

erve

ntion

s, an

ti sli

p sh

oes,

redu

cing

psyc

hotro

pic d

rugs

.

Vitam

in D

supp

lemen

t

Tai c

hi.

Outc

omes

Falls

.

Incre

men

tal c

ost-e

ffecti

vene

ss,

cost-

utilit

y, an

d co

st-be

nefit

ra

tios.

Num

ber o

f fall

ers,

fall r

elate

d inj

ury,

adm

ission

to h

ospit

al,

deat

h, qu

ality

of lif

e, ph

ysica

l ac

tivity

, mov

e to

insti

tutio

n,

cont

act w

ith N

HS, d

isabil

ity

(Bar

thel

Index

).

Prim

ary:

Rate

of f

alls a

nd

num

ber o

f fall

ers

Seco

ndar

y: fa

ll rela

ted

fractu

res,

adve

rse

effe

cts o

f int

erve

ntion

econ

omic

outco

mes

.

Rate

of f

alls

Risk

of f

alls.

Num

ber o

f fall

s. Ra

te o

f fall

s.

Mai

n fin

ding

s and

aut

hors

con

clusio

ns

Agilit

y tra

ining

with

bala

nce

com

pone

nt is

likely

to

pre

vent

falls

.

Thre

e ef

fecti

ve fa

lls p

reve

ntion

stra

tegie

s: 1)

cu

stom

ised

mult

i-fac

toria

l pro

gram

me

for

high

risk o

lder p

eople

; 2) h

ome-

base

d Ot

ago

Exer

cise

prog

ram

me

in pe

ople

>80;

3) h

ome

safe

ty pr

ogra

mm

e in

subg

roup

s with

pre

vious

fa

lls.

Little

evid

ence

to su

ppor

t effe

ctive

ness

of m

ulti-

facto

rial r

isk a

sses

smen

t int

erve

ntion

s. M

ay

redu

ce n

umbe

r of f

alls b

ut n

ot b

y muc

h. Da

ta

insuf

ficien

t to

asse

ss fa

ll and

injur

y rat

e.

Exer

cise

inter

vent

ions r

educ

e ra

te a

nd ri

sk o

f fa

lls.

Rese

arch

nee

ded

to co

nfirm

the

cont

exts

in wh

ich h

ome

safe

ty, m

ultifa

ctoria

l ass

essm

ent

and

inter

vent

ion, v

itam

in D

and

othe

r int

erve

ntion

s are

effe

ctive

. Som

e ev

idenc

e th

at

falls

pre

vent

ion st

rate

gies c

an re

duce

costs

.

Unce

rtaint

y rem

ains a

bout

effe

ctive

ness

of

vitam

in D.

Tai c

hi ha

s pot

entia

l to

redu

ce fa

lls o

r risk

of

falls

in th

e yo

ung

and

healt

hy g

roup

. This

doe

s no

t app

ly to

the

frail g

roup

.

AMST

AR Q

ualit

y sco

re (A

QS) c

omm

ents

/ lim

itatio

ns

Poor

abs

tract.

Upd

ated

by G

illesp

ie et

al

(200

9).

Best

value

for m

oney

from

sing

le fa

ctor

inter

vent

ions s

uch

as O

tago

exe

rcise

pr

ogra

mm

e. Po

tent

ial fo

r bias

as r

eview

ers

were

aut

hors

on

RCT

of re

com

men

ded

inter

vent

ion.

AQS=

6/9

High

qua

lity re

view.

Use

d int

erna

tiona

lly

agre

ed ta

xono

my f

or fa

lls p

reve

ntion

. www

.pr

ofan

e.eu

.org

AQ

S=9/

11

High

qua

lity C

ochr

ane

met

a-an

alysis

. AQ

S=10

/11

Upda

ted

by G

illesp

ie et

al 2

009

Non

Engli

sh st

udies

not

repo

rted

and

inter

vent

ion sh

ould

be in

vesti

gate

d fu

rther.

AQS=

6/9

135

App

endi

x 8

Con

t.: R

evie

ws

of fa

lls

prev

enti

on in

terv

enti

ons.

Auth

or

Med

ical

Advis

ory

Secr

etar

iat

(200

8) (1

25)

McC

lure

et a

l (2

008)

(126

)

Saw

ka e

t al

(200

5) (2

44)

Rixt

Zijli

stra

et

al (2

45)

Sher

ringt

on

et a

l(2

008)

(134

)

Num

ber o

f stu

dies

(s

ubje

cts)

and

age

60 R

CTs.

6 co

ntro

lled

studie

s.60

+ ye

ars.

75,6

96 +

1,18

8 pa

rticip

ants.

8 RC

Ts.

19 R

CTs.

65+

year

s.

44 tr

ials (

9,60

3 su

bjects

) yiel

ding

49 e

stim

ates

of t

he

effe

cts o

f exe

rcise

.

Heal

th c

ateg

ory a

nd se

tting

Gene

ral p

opula

tion

and

frail

older

peo

ple a

t risk

.

Com

mun

ity se

tting

.

Gene

ral p

opula

tion

and

frail

older

peo

ple a

t risk

.

Com

mun

ity se

tting

.

Gene

ral p

opula

tion

and

frail

older

peo

ple a

t risk

.

Com

mun

ity se

tting

and

ins

titut

ional.

Gene

ral p

opula

tion

and

frail

older

peo

ple a

t risk

.

Com

mun

ity se

tting

and

ins

titut

ional.

Gene

ral p

opula

tion

and

frail

older

peo

ple a

t risk

.

Com

mun

ity se

tting

and

ins

titut

ional.

Inte

rven

tions

11 in

terv

entio

ns

includ

ing e

xerc

ise,

vision

ass

essm

ent a

nd

refe

rral, e

nviro

nmen

tal

mod

ificat

ion, v

itam

in D

and

calci

um su

pplem

ents,

hip

pro

tecto

rs, H

RT<

gait-

stabil

ising

dev

ices

and

mult

i-fac

toria

l pr

ogra

mm

es

Popu

lation

bas

ed

inter

vent

ions (

hom

e ha

zard

redu

ction

s, m

edica

tion

revie

w, a

nd

educ

ation

).

Hip

prot

ecto

rs.

Muli

tfacto

rial in

terv

entio

ns

includ

ing m

edica

tion

revie

w, vi

sion

scre

ening

, hip

pro

tecto

rs, t

ai ch

i and

ex

ercis

e int

erve

ntion

s.

Hom

e ex

ercis

e pr

ogra

mm

es o

f stre

ngth

an

d ba

lance

. Mos

t tail

ored

to

subje

ct.

Outc

omes

Risk

and

rate

of f

alls.

Cost

effe

ctive

ness

.

Fall r

elate

d inj

uries

.Ch

ange

in in

ciden

ce o

f all

relat

ed in

jury r

epor

ted

as

being

trea

ted

by a

med

ical

prac

tition

er.

Hip

fractu

res.

Fear

of f

alling

, fall

s self

-ef

ficac

y.

Num

ber o

f fall

ers,

fall r

ates

or

rate

of f

alls (

rand

om e

ffects

m

eta-

analy

sis).

Mai

n fin

ding

s and

aut

hors

con

clusio

ns

Exer

cise

inter

vent

ions s

tratifi

ed in

to h

igh a

nd

low ri

sk g

roup

s, un

targ

eted

and

targ

eted

pr

ogra

mm

es a

nd d

urat

ion o

f int

erve

ntion

. High

qu

ality

evide

nce

that

long

term

pro

gram

mes

in

mob

ile g

ener

al old

er p

eople

and

env

ironm

enta

l m

odific

ation

s in

the

hom

es o

f fra

il olde

r peo

ple

redu

ce ri

sk o

f fall

s and

injur

ies. C

ost-e

ffecti

ve

in re

ducin

g ra

te o

f fall

ing. M

ulti-f

acto

rial

inter

vent

ions i

n hig

h-ris

k olde

r peo

ple m

ay b

e ef

fecti

ve, b

ut q

uality

is lo

w an

d ef

fects

are

small

.

Trend

in re

porte

d re

ducti

on in

fall-

relat

ed

injur

ies a

cros

s all p

rogr

amm

es.

Little

evid

ence

to su

ppor

t the

use

of h

ip pr

otec

tors

out

side

nurs

ing h

ome

setti

ngs.

Frac

ture

rate

1.1

to 7

.4%

Rela

tive

risk 1

.07

(0.8

1 to

1.4

2).

NNT

= 25

(95%

CI 1

3,20

0)

Limite

d bu

t con

siste

nt e

viden

ce fr

om tr

ials o

f hig

h m

etho

dolog

y tha

t exe

rcise

and

mult

i-fa

ctoria

l inte

rven

tions

redu

ce fe

ar o

f fall

ing.

Prov

ides s

trong

evid

ence

that

exe

rcise

can

redu

ce fa

ll rat

es in

olde

r peo

ple. R

educ

tion

in fa

ll rat

e of

17%

. Bala

nce

traini

ng, h

igh

inten

sity e

xerc

ise d

ose

and

abse

nce

of w

alking

pr

ogra

mm

e ar

e as

socia

ted

with

effi

cacy

of

the

prog

ram

mes

. Stre

ngth

train

ing in

crea

ses

stren

gth

but h

as a

less

clea

r effe

ct on

bala

nce

AMST

AR Q

ualit

y sco

re (A

QS) c

omm

ents

/ lim

itatio

ns

Com

preh

ensiv

e re

view

that

use

d GR

ADE

syste

m to

judg

e qu

ality

of R

CTs.

Inter

vent

ions

were

stra

tified

into

targ

eted

pop

ulatio

ns (h

igh

and

low ri

sk)

AQS=

7/11

Rand

omise

d m

ultipl

e co

mm

unity

trial

s of

popu

lation

bas

ed a

ppro

ach

are

indica

ted.

AQ

S=8/

9

AQS=

9/11

Hi

gh Q

uality

Rev

iew

Limite

d by

lack

of e

viden

ce to

link f

ear o

f fa

lling

to ch

ange

in b

ehav

iour o

r actu

al fa

ll ra

te. N

eed

to d

evelo

p m

easu

res i

n th

is ar

ea.

AQS=

7/9

Walk

ing a

nd st

reng

th tr

aining

may

pro

vide

bene

fits f

or o

ther

asp

ects

of a

geing

but

is n

ot

optim

al int

erve

ntion

for p

reve

ntion

of f

alls.

AQS=

7/11

136

App

endi

x 8

Con

t.: R

evie

ws

of fa

lls

prev

enti

on in

terv

enti

ons.

Auth

or

Vaap

io e

t al

(200

9) (1

27)

Wea

ther

all

(200

4) (2

46)

Num

ber o

f stu

dies

(s

ubje

cts)

and

age

12 R

CTs.

19 R

CTs.

Heal

th c

ateg

ory a

nd se

tting

Gene

ral p

opula

tion

and

older

pe

ople

at ri

sk.

Com

mun

ity se

tting

.

Gene

ral p

opula

tion

and

frail

older

peo

ple a

t risk

.

Com

mun

ity se

tting

.

Inte

rven

tions

Falls

pre

vent

ative

pr

ogra

mm

es.

Inter

vent

ions c

ateg

orise

d int

o: 1)

exe

rcise

as s

ole

inter

vent

ion;

2) m

ultipl

e int

erve

ntion

s; 3)

ass

essm

ent a

d ad

vice.

Outc

omes

Quali

ty of

life.

SF-3

6, 1

5D,

WHO

QOL

-BRE

F, EU

ROQO

L, RA

ND-3

6, N

HP (N

ottin

gham

he

alth

profi

le).

Num

ber o

f peo

ple fa

lling

at

least

once

or n

umbe

r of p

eople

wi

th a

frac

ture

.

Mai

n fin

ding

s and

aut

hors

con

clusio

ns

6 ou

t of 1

2 sh

owed

pos

itive

resu

lts o

n qu

ality

of

life (s

ocial

and

phy

sical

func

tion,

vitali

ty, m

enta

l he

alth,

envir

onm

enta

l dom

ain).

Exer

cise

alone

. Odd

s rat

io 0.

79 (9

5% C

I 0.5

8 to

1.0

8).

Mult

iple

inter

vent

ions O

dds r

atio

0.65

(0.0

52

to 0

.81)

.Vis

its a

nd a

dvice

(0.7

7 (0

.54

to 1

.11)

. Ev

idenc

e fo

r fra

cture

pre

vent

ion is

spar

se.

AMST

AR Q

ualit

y sco

re (A

QS) c

omm

ents

/ lim

itatio

ns

Larg

er st

udies

nee

ded

with

long

er fo

llow

up

and

mult

iple

outco

me

mea

sure

s.AQ

S=4/

9

Revie

w of

guid

eline

s and

liter

atur

e re

view.

Ev

idenc

e fo

r exe

rcise

alon

e is

in fa

vour

of

inter

vent

ion b

ut co

nfide

nce

inter

vals

are

wide

. Au

thor

s rec

omm

end

trials

repo

rt nu

mbe

r of

falls

with

at l

east

1 fa

ll in

follo

w up

year.

AQS=

4/11

137

App

endi

x 9:

Rev

iew

s of

inte

rven

tion

s ai

min

g to

pre

vent

soc

ial i

sola

tion

and

lone

lines

s

Auth

or

Catta

n et

al

(200

5) (1

9)

Find

lay (

2003

) (1

80)

Med

ical

Advis

ory

Secr

etar

iat

(200

8) (2

0)

Num

ber o

f stu

dies

30 st

udies

.

17 st

udies

only

6

RCTs

.

11 q

uant

itativ

e RC

Ts.

Heal

th c

ateg

ory a

nd se

tting

Gene

ral p

opula

tion

of o

lder

peop

le.Co

mm

unity

setti

ng.

Com

mun

ity ce

ntre

s and

ho

me.

Gene

ral p

opula

tion

and

frail

older

peo

ple a

t risk

.

Com

mun

ity se

tting

.

Gene

ral p

opula

tion

and

frail

older

peo

ple a

t risk

.

Main

ly old

er w

omen

75+

ye

ars.

Inte

rven

tions

Socia

l hea

lth p

rom

oting

int

erve

ntion

s. M

ost

grou

p int

erve

ntion

s with

ed

ucat

ional

input

.

Healt

h pr

omot

ion, s

ocial

su

ppor

t, co

mm

unity

int

erve

ntion

pro

gram

mes

inc

luding

telec

are,

gate

keep

er p

rogr

amm

e 5

of 1

7 we

re 1

-to-1

int

erve

ntion

s, 6

grou

p int

erve

ntion

s, 4

discu

ssion

gr

oups

.

Grou

p su

ppor

t acti

vities

an

d te

chno

logy a

ssist

ed

inter

vent

ions m

ainly

base

d on

beh

aviou

ral

chan

ge.

Outc

omes

Valid

ated

mea

sure

men

t too

ls,

UCLA

lone

lines

s sca

le, d

e Jo

ng G

ierve

ld lon

eline

ss sc

ale.

Subje

ctive

feeli

ng o

f soc

ial

isolat

ion a

nd lo

nelin

ess,

mor

tality

rate

s, ide

ntific

ation

of

older

peo

ple a

t risk

.

Valid

ated

mea

sure

men

t too

ls,

UCLA

lone

lines

s sca

le, d

e Jo

ng G

ierve

ld lon

eline

ss sc

ale.

Mai

n fin

ding

s and

aut

hors

con

clusio

ns

Educ

ation

al an

d so

cial a

ctivit

y gro

up

inter

vent

ions t

hat t

arge

t spe

cific a

ctivit

ies

can

allev

iate

socia

l isola

tion

and

loneli

ness

. Ef

fecti

vene

ss o

f hom

e vis

its re

main

s unc

lear.

Dear

th o

f evid

ence

in th

is fie

ld.

Telec

onfe

renc

ing m

ay b

e co

st ef

fecti

ve in

ge

ogra

phica

lly is

olate

d ar

eas.

Socia

l sup

port

grou

ps d

ecre

ased

socia

l isola

tion.

Co

mm

unity

-bas

ed e

xerc

ise fe

atur

ing h

ealth

and

we

llnes

s for

phy

sicall

y ina

ctive

olde

r peo

ple w

as

effe

ctive

in re

ducin

g lon

eline

ss. In

terv

entio

ns fo

r inf

orm

al ca

re g

ivers

of s

enior

s with

dem

entia

ha

d lim

ited

effe

ctive

ness

. Ver

y lim

ited

rese

arch

of

tech

nolog

y-as

siste

d int

erve

ntion

s.

AMST

AR Q

ualit

y sco

re (A

QS) c

omm

ents

/ lim

itatio

ns

1 stu

dy a

sses

sing

com

mun

ity d

evelo

pmen

t. M

ost s

tudie

s in

USA

or C

anad

a. 7

of 1

to 1

int

erve

ntion

s wer

e ho

me

visits

.AQ

S=6/

9

Mon

ey m

ay b

e wa

sted

on p

rogr

amm

es th

at

are

not e

ffecti

ve.

High

qua

lity tr

aining

nee

d to

supp

ort

inter

vent

ions,

utilis

e ex

isting

com

mun

ity

capa

city.

Grea

ter c

hanc

e of

succ

ess i

f int

egra

ted

into

exist

ing co

mm

unity

reso

urce

s.AQ

S =3

/9

Not a

bro

ad-b

ased

rese

arch

liter

atur

e of

ta

rget

ed g

roup

s inv

olving

only

of a

few

of

the

man

y cau

ses o

f soc

ial is

olatio

n. RC

Ts

gene

rally

small

n=<

100

.AQ

S=5/

9

138

App

endi

x 10

: Rev

iew

s of

vis

ion

scre

enin

g, n

utri

tion

inte

rven

tion

s an

d m

edic

atio

n re

view

Auth

or

Chou

et a

l (2

009)

(128

)

Holla

nd e

t al

(200

7) (1

86)

Jia e

t al

(200

8) (1

59)

Jone

s et a

l (2

009)

(71)

Miln

e et

al

(200

9) (1

58)

Num

ber o

f stu

dies

(s

ubje

cts)

and

age

60 st

udies

includ

ing 3

8 RC

Ts.

Olde

r adu

lts 6

5+

year

s.

32 st

udies

. Only

17

includ

ed in

met

a-an

alysis

.M

ean

65+

year

s.

22 tr

ials.

Olde

r adu

lts 6

5+

year

s.

19 st

udies

. Ol

der p

eople

.

62 R

CTs a

nd q

uasi-

RCTs

with

10,

187

parti

cipan

ts 65

+ ye

ars.

Heal

th c

ateg

ory a

nd se

tting

Gene

ral p

opula

tion.

Prim

ary c

are

or e

ye sp

ecial

ist

setti

ngs.

Gene

ral p

opula

tion

in an

y se

tting

.

Mixe

d po

pulat

ion.

Com

mun

ity a

nd h

ospit

al.

Olde

r peo

ple liv

ing in

the

com

mun

ity.

Mixe

d po

pulat

ion e

xclud

ing

critic

al ca

re.

Inte

rven

tions

Scre

ening

and

trea

tmen

t fo

r im

paire

d vis

ion. F

ocus

on

scre

ening

, tre

atm

ent

and

pote

ntial

har

m(h

ealth

pro

mot

ion).

Phar

mac

ist-le

d re

view

of m

edica

tion

includ

ing

thos

e th

at re

com

men

d op

timisi

ng d

rug

regim

e.

Sing

le vit

amins

, mine

rals

and

omeg

a-3

fatty

acid

s.

All in

terv

entio

ns to

im

prov

e die

t and

food

ac

cess

and

use

of

supp

lemen

ts.

Inter

vent

ions a

imed

at

impr

oving

pro

tein

intak

e. Su

pplem

ents

in th

e fo

rm

of: c

omm

ercia

l sip

feed

s, m

ilk b

ased

supp

lemen

ts or

via

forti

ficat

ion o

f no

rmal

food

sour

ces.

Outc

omes

Dete

ction

of c

atar

acts,

re

fracti

ve e

rrors

, ris

k of f

alls.

Prop

ortio

n of

peo

ple w

ith o

ne

or m

ore

hosp

ital a

dmiss

ion

and

all ca

use

mor

tality

and

m

ean

drug

s pre

scrib

ed.

Chan

ge in

cogn

itive

perfo

rman

ce. 1

1 gr

oups

; glo

bal c

ognit

ion, a

ttent

ion

and

conc

entra

tion,

shor

t-ter

m

mem

ory,

long

term

mem

ory,

reco

gnitio

n, pr

oces

sing

spee

d,

exec

utive

func

tion,

verb

al ab

ility,

verb

al flu

ency

.

Weig

ht g

ain, c

ognit

ive a

nd

phys

ical f

uncti

on.

All c

ause

mor

tality

with

co

mpli

catio

ns (e

.g. D

VT,

infec

tion)

, mor

bidity

, fun

ction

al sta

tus,

cogn

itive

and

phys

ical.

Mai

n fin

ding

s and

aut

hors

con

clusio

ns

Foun

d no

ben

efit o

f scr

eenin

g alt

houg

h str

ong

effe

ct fo

r tre

atm

ent o

f com

mon

caus

es o

f im

paire

d vis

ual a

cuity

. W

eak e

viden

ce fo

r inc

reas

ed ri

sk o

f fall

s.

No e

ffect

on re

duce

d m

orta

lity o

r hos

pital

adm

ission

RR

0.99

(95%

CI 0

.87

to 1

.14)

. Sm

all e

ffect

on re

duce

d dr

ug u

se b

ut la

rge

hete

roge

neity

.

Little

evid

ence

of e

ffect

of a

ny vi

tam

ins o

r su

pplem

ents

on co

gnitiv

e fu

nctio

n.

Diet

ary a

dvice

and

supp

lemen

ts se

em to

be

effe

ctive

in m

anag

ing u

nder

-nut

rition

.

Poole

d we

ighte

d ch

ange

in b

ody m

ass w

as

signifi

cant

(2.2

% 9

5% C

I 1.8

to 2

/5).

No

signifi

cant

diff

eren

ce in

mor

tality

apa

rt fro

m su

b gr

oup

of u

nder

-nou

rishe

d old

er p

eople

.Sm

all b

ut co

nsist

ent w

eight

gain

s. Un

clear

ou

tcom

e fo

r oth

er m

easu

res.

AMST

AR Q

ualit

y sco

re (A

QS) c

omm

ents

/ lim

itatio

ns

AQS=

7/9

Diffi

cult

to re

ach

firm

conc

lusion

s due

to

relat

ively

small

num

ber o

f RCT

s with

goo

d m

etho

dolog

ical d

esign

and

wide

confi

denc

e int

erva

ls.

AQS=

8/1

1No

t eno

ugh

data

to re

view

quali

ty of

life.

AQS=

8/1

1On

ly 6

out o

f 22

trials

wer

e ca

rried

out

in th

e co

mm

unity

. Man

y tria

ls on

ly fo

llowe

d up

for

shor

t-ter

m <

6 m

onth

s.

AQS=

3/9

Bene

fits o

f nut

rition

al su

pplem

ents

for

older

peo

ple in

the

com

mun

ity a

re u

nclea

r. Sc

ientifi

c adv

isory

com

mitt

ee a

dvise

vita

min

D su

pplem

ents

for p

eople

ove

r 65.

AQS=

9/1

1Po

or q

uality

trial

s inc

luded

. Som

e ad

vers

e ef

fects

of n

ause

a an

d vo

mitin

g re

porte

d.

139

App

endi

x 10

Con

t.: R

evie

ws

of v

isio

n sc

reen

ing,

nut

riti

on in

terv

enti

ons

and

med

icat

ion

revi

ew

Auth

or

Roya

l et a

l 20

05 (1

87)

Smee

th a

nd

Iliffe

(200

8)

(215

)

Num

ber o

f stu

dies

(s

ubje

cts)

and

age

38 R

CTs a

nd

cont

rolle

d stu

dies.

5 RC

Ts (3

,494

pe

ople)

65+

year

s.

Heal

th c

ateg

ory a

nd se

tting

Prim

ary c

are

setti

ng,

com

mun

ity a

nd n

ursin

g ho

mes

.M

ixed

age

rang

e m

ainly

older

pe

ople.

Gene

ral p

opula

tion

of o

lder

peop

le in

the

com

mun

ity.

Inte

rven

tions

Inter

vent

ions a

pplie

d in

prim

ary c

are

aiming

to

redu

ce d

rug

relat

ed

mor

bidity

, hos

pitali

satio

n,

deat

h.

Mas

s scr

eenin

g.(H

ealth

pro

mot

ion.)

Outc

omes

Falls

, HA,

cogn

itive

func

tion,

de

pres

sion,

deat

h, ad

vers

e dr

ug e

vent

s.

Self-

repo

rted

mea

sure

s of

visua

l impa

irmen

t (N

ation

al Ey

e Ins

titut

e Visu

al Fu

nctio

n Qu

estio

nnair

e NE

IVFQ-

25) a

nd o

ther

non

-va

lidat

ed q

uesti

onna

ires.

Leng

th o

f foll

ow u

p 2–

4 ye

ars.

Mai

n fin

ding

s and

aut

hors

con

clusio

ns

Limite

d ev

aluat

ion u

sing

RCT

desig

n aim

ed a

t re

ducin

g m

edica

tion

relat

ed a

dver

se e

vent

s. W

eak e

viden

ce fo

und

that

pha

rmac

y led

m

edica

tion

revie

ws a

re e

ffecti

ve in

redu

cing

hosp

ital a

dmiss

ion. N

o ef

fect

of m

edica

tion

revie

w on

falls

. OR

0.91

95%

CI 0

.68

to 1

.21,

(9

studie

s inc

luded

in a

nalys

is).

No e

viden

ce th

at co

mm

unity

-bas

ed sc

reen

ing

inter

vent

ion im

prov

es vi

sion

of a

sym

ptom

atic

older

peo

ple. In

4 tr

ials t

hose

repo

rting

vis

ual p

roble

ms w

ere

given

adv

ice o

nly fo

r int

erve

ntion

. Scr

eenin

g an

d re

com

men

datio

n fo

r re

ferra

l only

led

to tr

eatm

ent i

n 50

% o

f cas

es

in 1

RCT.

Scre

ening

only

effe

ctive

if re

ferra

l sy

stem

s and

inte

rven

tion

is ad

equa

te a

nd

com

plian

ce is

high

.

AMST

AR Q

ualit

y sco

re (A

QS) c

omm

ents

/ lim

itatio

ns

AQS=

9/11

Quali

ty sc

ore

used

EPO

C Co

chra

ne cr

iteria

. Pa

ucity

of h

igh q

uality

eva

luatio

n of

int

erve

ntion

s aim

ed a

t pre

vent

ing m

edica

tion

relat

ed a

dver

se e

vent

s in

prim

ary c

are.

AQS

=9/1

1No

trial

s of v

ision

scre

ening

alon

e. Ne

ed

to in

vesti

gate

why

thos

e re

com

men

ded

for

treat

men

t wer

e no

t ref

erre

d or

com

plian

ce

was l

ow.

140

Appendix 11: The PRISMA model of integrated service delivery

ThecomponentsofthePRISMAmodel(ProgrammeofResearchtoIntegrateServicesfortheMaintenanceofAutonomy(101;194))aredescribedinbox1.

Measurement of functional decline

The five domains of the SMAF tool (56) are:• Functionalability.7items:eating,dressing,grooming,urinaryandfaecalincontinenceandusingthe

bathroom.• Communication.3items:seeing,hearing,andspeaking.• Mobility.6items:walkinginsideandout,puttingonprosthesis,transfers,usingstairs,movingaround

inawheelchair.• Mentalfunction.5items:memory,judgement,behaviour,orientationandunderstanding.• Instrumentalactivitiesofdailyliving.8items:shopping,doinghousework,preparingfood,managinga

budget,usingthetelephone,usingpublictransport,takingmedication,doinglaundry(49)(56).

Functional decline was defined as the occurrence of one of the following:• Anincreaseof5pointsormoreontheSMAF.• Admissiontonursinghomeorlongtermhospitalcare.• Death.

Inaddition,satisfactionandcaregiver’sburdenandcaregiver’sdesireforinstitutionalisationwasrecorded.

1. Coordinationbetweendecisionmakersandmanagersattheregionalandlocallevels.

2. Singleentrypoint.

3. Singleassessmentinstrumentcoupledwithcase-mixmanagementsystems.

4. Casemanagement.

5. Individualserviceplans.

6. Easilyaccessiblecomputerisedclinicalcharts.

Box 1. ThesixcomponentofthePRISMAmodel

141

Appendix 12: Effectiveness of interventions for the risk of falls

Interventions RR [95% CI] Grade of evidence (247)

Exerciseprogrammes

Targeted programmes

Generalpopulation 0.81[0.67–0.98] Low

High-riskpopulation 0.93[0.82–1.06] High

Shortduration 0.91[0.73–1.13] High

Longduration 0.89[0.79–1.01] Moderate

Untargeted programmes

Generalpopulation 0.78[0.66–0.91] Moderate

High-riskpopulation 0.89[0.72–1.10] Verylow

Shortduration 0.85[0.71–1.01] Low

Longduration 0.76[0.64–0.91] Moderate

Combined targeted vs untargeted programmes

Generalpopulation NA NA

High-riskpopulation 0.87[0.57–1.34] Moderate

Shortduration 1.11[0.73–1.70] High

Longduration 0.73[0.57–0.95] High

Vision intervention

Assessment/referral 1.12[0.82–1.53] Moderate

Cataractsurgery 1.11[0.92–1.35] Moderate

Environmental modifications

Low-riskpopulation 1.03[0.75–1.41] High

High-riskpopulation 0.66[0.54–0.81] High

Generalpopulation 0.85[0.75–0.97] High

Drugs/nutritional supplements

VitaminD(menandwomen) 0.94[0.77–1.14] High

VitaminD(womenonly) 0.55[0.29–1.08] Moderate

VitaminDandcalcium(menandwomen) 0.89[0.74–1.07] Moderate

VitaminDandcalcium(womenonly) 0.83[0.73–0.95] Moderate

Hormonereplacementtherapy 0.98[0.80–1.20] Low

Medicationwithdrawal 0.34[0.16–0.74]† Low

Gait-stabilisingdevice 0.43[0.29–0.64] Moderate

Multifactorialintervention

Geriatricscreening(generalpopulation) 0.87[0.69–1.10] Verylow

High-riskpopulation 0.86[0.75–0.98] Low

† HazardratioisreportedbecauseRRwasnotavailable.‡ TheRRforthegait-stabilisingdevicewasadjustedtoreflectthegeneralpopulationbecausethetrialreportedaRRfor

outdoorfallsonly.Riskwasadjustedasperrateofoutdoorfallsformalesandfemalesreportedintheliterature.

Source:ReproducedwithpermissionfromtheMedicalAdvisorySecretariat(2008)(125).

142

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