Abstract Objective To deepen the knowledge of frail elderly patients’ preferences for participation in medical decision making during hospitalization. Methods Qualitative study using content analysis ...of semi-structured interviews. Results Patient participation to frail elderly means information , not the wish to take part in decisions about their medical treatments. They view the hospital care system as an institution of power with which they cannot argue. Participation is complicated by barriers such as the numerous persons involved in their care who do not know them and their preferences, differing treatment strategies among doctors, fast patient turnover in hospitals, stressed personnel and linguistic problems due to doctors not always speaking the patient's own language. Conclusion The results of the study show that, to frail elderly patients, participation in medical decision making is primarily a question of good communication and information, not participation in decisions about medical treatments. Practice implications More time should be given to thorough information and as few people as possible should be involved in the care of frail elderly. Linguistic problems should be identified to make it possible to take the necessary precautions to prevent negative impact on patient participation.
The prevalence of multimorbidity is increasing worldwide, and older people with multimorbidity are frequent users of health care services. Since multimorbidity has a significant negative impact on ...Health-related Quality of Life (HrQoL) and is more common in older age it would be expected that factors related to HrQoL in this group might have been thoroughly researched, but this is not the case. Furthermore, it is important to look at old people living at home, considering the shift from residential to home-based care. Therefore, we aim to investigate factors that are related to HrQoL in older people with multimorbidity and high health care consumption, living at home.
This is a secondary analysis of a RCT study conducted in a municipality in south-eastern Sweden. The study had a longitudinal design with a two-year follow-up period assessing HrQoL, symptom burden, activities of daily living, physical activity and depression.
In total, 238 older people with multimorbidity and high health care consumption, living at home were included (mean age 82, 52% female). A multiple linear regression model including symptom burden, activities of daily living and depression as independent variables explained 64% of the HrQoL. Higher symptom burden, lower ability in activities of daily living and a higher degree of depression were negatively related to HrQoL. Depression at baseline and a change in symptom burden over a two-year period explained 28% of the change in HrQoL over a two-year period variability. A higher degree of depression at baseline and negative change in higher symptom burden were related to a decrease in HrQoL over a two-year period.
In order to facilitate better delivery of appropriate health care to older people with high health care consumption living at home it is important to assess HrQoL, and HrQoL over time. Symptom burden, activities of daily living, depression and change in symptom burden over time are important indicators for HrQoL.
Clinicaltrials.gov identifier: NCT01446757 , the trial was registered prospectively with the date of trial registration October 5
, 2011.
Background
Multimorbidity and frailty are often associated and Comprehensive Geriatric Assessment (CGA) is considered the gold standard of care for these patients.
Aims
This study aimed to evaluate ...the effect of outpatient Comprehensive Geriatric Assessment (CGA) on frailty in community-dwelling older people with multimorbidity and high health care utilization.
Methods
The Ambulatory Geriatric Assessment—Frailty Intervention Trial (AGe-FIT) was a randomized controlled trial (intervention group,
n
= 208, control group
n
= 174) with a follow-up period of 24 months. Frailty was a secondary outcome. Inclusion criteria were: age ≥ 75 years, ≥ 3 current diagnoses per ICD-10, and ≥ 3 inpatient admissions during 12 months prior to study inclusion. The intervention group received CGA-based care and tailored interventions by a multidisciplinary team in an Ambulatory Geriatric Unit, in addition to usual care. The control group received usual care. Frailty was measured with the Cardiovascular Health Study (CHS) criteria. At 24 months, frail and deceased participants were combined in the analysis.
Results
Ninety percent of the population were frail or pre-frail at baseline. After 24 months, there was a significant smaller proportion of frail and deceased (
p
= 0.002) and a significant higher proportion of pre-frail patients in the intervention group (
p
= 0.004). Mortality was high, 18% in the intervention group and 26% in the control group.
Conclusion
Outpatient CGA may delay the progression of frailty and may contribute to the improvement of frail patients in older persons with multimorbidity.
Aim
The aim of this study was to follow the symptom trajectory of community‐dwelling older people with multimorbidity and to explore the effect on symptom burden from an ambulatory geriatric care ...unit, based on comprehensive geriatric assessment.
Background
Older community‐dwelling people with multimorbidity suffer from a high symptom burden with a wide range of co‐occurring symptoms often resulting to decreased health‐related quality of life. There is a need to move from a single‐disease model and address the complexity of older people living with multimorbidity.
Design
Secondary outcome data from the randomized controlled Ambulatory Geriatric Assessment Frailty Intervention Trial (AGe‐FIT).
Methods
Symptom trajectory of 31 symptoms was assessed with the Memorial Symptom Assessment Scale. Data from 247 participants were assessments at baseline, 12 and 24 months, 2011–2013. Participants in the intervention group received care from an ambulatory geriatric care unit based on comprehensive geriatric assessment in addition to usual care.
Results
Symptom prevalence and symptom burden were high and stayed high over time. Pain was the symptom with the highest prevalence and burden. Over the 2‐year period 68–81% of the participants reported pain. Other highly prevalent and persistent symptoms were dry mouth, lack of energy and numbness/tingling in the hands/feet, affecting 38–59% of participants. No differences were found between the intervention and control group regarding prevalence, burden or trajectory of symptoms.
Conclusions
Older community‐dwelling people with multimorbidity had a persistent high burden of symptoms. Receiving advanced interdisciplinary care at an ambulatory geriatric unit did not significantly reduce the prevalence or the burden of symptoms.
Purpose: Assessment of frailty is a key method to identify older people in need of holistic care. However, agreement between different frailty instrument varies. Thus, groups classified as frail by ...different instruments are not completely overlapping. This study evaluated differences in sociodemographic factors, cognition, functional status, and quality of life between older persons with multimorbidity who were discordantly classified by five different frailty instruments, with focus on the Clinical Frailty Scale (CFS) and Fried's Frailty Phenotype (FP). Participants and Methods: This was a cross-sectional study in a community-dwelling setting. Inclusion criteria were as follows: greater than or equal to75 years old, greater than or equal to3 visits to the emergency department the past 18 months, and greater than or equal to3 diagnoses according to ICD-10. 450 participants were included. Frailty was assessed by CFS, FP, Short Physical Performance Battery (SPPB), Grip Strength and Walking Speed. Results: 385 participants had data on all frailty instruments. Prevalence of frailty ranged from 34% (CFS) to 75% (SPPB). Nine percent of participants were non-frail by all instruments, 20% were frail by all instruments and 71% had discordant frailty classifications. Those who were frail according to CFS but not by the other instruments had lower cognition and functional status. Those who were frail according to FP but not CFS were, to a larger extent, women, lived alone, had higher cognitive ability and functional status. Conclusion: The CFS might not identify physically frail women in older community-dwelling people with multimorbidity. They could thus be at risk of not be given the attention their frail condition need. Keywords: geriatrics, frailty phenotype, clinical frailty scale, outpatient assessment
Abstract
Background
The proportion of older people in the population has increased globally and has thus become a challenge in health and social care. There is good evidence that care based on ...comprehensive geriatric assessment (CGA) is superior to the usual care found in acute hospital settings; however, the evidence is scarcer in community-dwelling older people.
This study is a secondary outcome of a randomized controlled trial of community-dwelling older people in which the intervention group (IG) received CGA-based care by a geriatric mobile geriatric team (GerMoT). The aim of this study is to obtain a better understanding, from the patients’ perspective, the experience of being a part of the IG for both the participants and their relatives.
Methods
Qualitative semistructured interviews of twenty-two community dwelling participants and eleven of their relatives were conducted using content analysis for interpretation.
Results
The main finding expressed by the participants and their relatives was in the form of feelings related to safety and security and being recognized. The participants found the care easily accessible, and that contacts could be taken according to needs by health care professionals who knew them. This is in accordance with person-centred care as recommended by the World Health Organisation (WHO) for older people in need of integrated care. Other positive aspects were recurrent health examinations and being given the time needed when seeking health care. Not all participants were positive as some found the information about the intervention to be unclear especially regarding whom to contact when in different situations.
Conclusions
CGA-based care of community-dwelling older people shows promising results as the participants in GerMoT found the care was giving a feeling of security and safety. They found the care easily accessible and that it was provided by health care professionals who knew them as a person and knew their health care problems. They found this to be in contrast to the usual care provided, but GerMoT care did not fulfill some people’s expectations.
The International Consortium for Health Outcomes Measurement (ICHOM) was founded in 2012 to propose consensus-based measurement tools and documentation for different conditions and populations.This ...article describes how the ICHOM Older Person Working Group followed a consensus-driven modified Delphi technique to develop multiple global outcome measures in older persons. The standard set of outcome measures developed by this group will support the ability of healthcare systems to improve their care pathways and quality of care. An additional benefit will be the opportunity to compare variations in outcomes which encourages and supports learning between different health care systems that drives quality improvement. These outcome measures were not developed for use in research. They are aimed at non researchers in healthcare provision and those who pay for these services.
A modified Delphi technique utilising a value based healthcare framework was applied by an international panel to arrive at consensus decisions.To inform the panel meetings, information was sought from literature reviews, longitudinal ageing surveys and a focus group.
The outcome measures developed and recommended were participation in decision making, autonomy and control, mood and emotional health, loneliness and isolation, pain, activities of daily living, frailty, time spent in hospital, overall survival, carer burden, polypharmacy, falls and place of death mapped to a three tier value based healthcare framework.
The first global health standard set of outcome measures in older persons has been developed to enable health care systems improve the quality of care provided to older persons.
To compare the effects of care based on comprehensive geriatric assessment (CGA) as a complement to usual care in an outpatient setting with those of usual care alone. The assessment was performed 36 ...months after study inclusion.
Randomized, controlled, assessor-blinded, single-center trial.
A geriatric ambulatory unit in a municipality in the southeast of Sweden.
Community-dwelling individuals aged ≥ 75 years who had received inpatient hospital care 3 or more times in the past 12 months and had 3 or more concomitant medical diagnoses were eligible for study inclusion. Participants were randomized to the intervention group (IG) or control group (CG).
Participants in the IG received CGA-based care for 24 to 31 months at the geriatric ambulatory unit in addition to usual care.
Mortality, transfer to nursing home, days in hospital, and total costs of health and social care after 36 months.
Mean age (SD) of participants was 82.5 (4.9) years. Participants in the IG (n = 208) lived 69 days longer than did those in the CG (n = 174); 27.9% (n = 58) of participants in the IG and 38.5% (n = 67) in the CG died (hazard ratio 1.49, 95% confidence interval 1.05-2.12, P = .026). The mean number of inpatient days was lower in the IG (15.1 SD 18.4) than in the CG (21.0 SD 25.0, P = .01). Mean overall costs during the 36-month period did not differ between the IG and CG (USD 71,905 SD 85,560 and USD 65,626 SD 66,338, P = .43).
CGA-based care resulted in longer survival and fewer days in hospital, without significantly higher cost, at 3 years after baseline. These findings add to the evidence of CGA's superiority over usual care in outpatient settings. As CGA-based care leads to important positive outcomes, this method should be used more extensively in the treatment of older people to meet their needs.
Older people with multi-morbidity are increasingly challenging for today's healthcare, and novel, cost-effective healthcare solutions are needed. The aim of this study was to assess the ...cost-effectiveness of comprehensive geriatric assessment (CGA) at an ambulatory geriatric unit for people ≥75 years with multi-morbidity.
The primary outcome was the incremental cost-effectiveness ratio (ICER) comparing costs and quality-adjusted life years (QALYs) of a CGA strategy with usual care in a Swedish setting. Outcomes were estimated over a lifelong time horizon using decision-analytic modelling based on data from the randomized AGe-FIT trial. The analysis employed a public health care sector perspective. Costs and QALYs were discounted by 3% per annum and are reported in 2016 euros.
Compared with usual care CGA was associated with a per patient mean incremental cost of approximately 25,000 EUR and a gain of 0.54 QALYs resulting in an ICER of 46,000 EUR. The incremental costs were primarily caused by intervention costs and costs associated with increased survival, whereas the gain in QALYs was primarily a consequence of the fact that patients in the CGA group lived longer.
CGA in an ambulatory setting for older people with multi-morbidity results in a cost per QALY of 46,000 EUR compared with usual care, a figure generally considered reasonable in a Swedish healthcare context. A rather simple reorganisation of care for older people with multi-morbidity may therefore cost effectively contribute to meet the needs of this complex patient population.
The trial was retrospectively registered in clinicaltrial.gov, NCT01446757 . September, 2011.
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