Use of social and health services by elderly people during the terminal 18 months of life

In a randomised and controlled intervention study elderly people aged 75 or more were visited regularly in their own homes over a period of three years. An age and sex matched control group was not contacted until the conclusion of the study period. In the present study, the use of social and health services during the terminal 18 months of life was computed for each individual member of the study group. The categories of services included the bed usage in hospitals, the stays in nursing homes, the provisions of home help and home nursing care as well as contacts with general practitioners. No differences in the use of social and health services were found between the visited elderly (n = 25) and the control group (n = 46). About 50% of the elderly had a considerable use of public services during the months prior to death, and only 14% received no public support, disregarding the terminal phase. Among those elderly people belonging to the study group, and who died within the study period, an increased use of the above mentioned services was seen during all 18 months. However, an increased use of hospital beds was only computed during the terminal 6 months of life. 58% of the bed days were used for patients who died during the next few months.     

An implementation intentions intervention, the use of a planning strategy, and physical activity after myocardial infarction

The paper investigates the relations between involvement in an implementation intention intervention programme, frequency of the use of a self-regulatory physical activity planning strategy, and moderate physical activity among patients who had suffered myocardial infarction (MI). It examines whether effects of the implementation intention intervention on behavior change was mediated by change in the use of a planning strategy. A total of 114 patients from central and northern Poland took part in the study after their first uncomplicated MI. Data were collected individually at approximately 1 week after MI (Time 1), 2 weeks after short-term rehabilitation (about 8 weeks after MI: Time 2), and 8 months after MI (Time 3). After data collection at Time 2, patients were randomly assigned to the control group or the intervention group. Patients who participated in the implementation intention intervention maintained the same number of sessions of moderate physical activity at 8 months after MI (Time 3) as at 2 weeks after rehabilitation (Time 2). By contrast, patients from the control group performed significantly fewer sessions of moderate physical activity at Time 3, compared to Time 2. The intervention resulted in the more frequent use of a planning strategy at 8 months after MI. Change in the frequency of the use of a planning strategy completely mediated effects of the intervention on change in physical activity. Only patients who participated in the implementation intention intervention and increased their use of a planning strategy adhered to the recommended three or more sessions of moderate physical activity per week.     

Evaluation of a client-centred paediatric rehabilitation programme using goal attainment scaling

Goal attainment scaling is a method to evaluate services based on the attainment of individual client or programme goals. This method was used to evaluate the effectiveness of a client-centred cognitive rehabilitation programme designed to teach compensatory strategies for planning daily activities. In this application, an 8-year-old boy long-term after traumatic brain injury and his family participated. The evaluation results revealed an overall goal attainment T-score of 68.70, indicating that the programme goal was attained above the expected level. The application of goal attainment scaling as an evaluation method for client-centred paediatric programmes is discussed.     

A pilot study of how information and communication technology may contribute to health promotion among elderly spousal carers in Norway

The objective of this pilot Norwegian intervention study was to explore whether use of information and communication technology (ICT) by informal carers of frail elderly people living at home would enable them to gain more knowledge about chronic illness, caring and coping, establish an informal support network and reduce stress and related mental health problems. Potential participants were close relatives of an elderly person with a diagnosis of a chronic illness dwelling in the same household who wished to continue caring for their relative at home, were 60 years of age or older, had been caring for less than 2 years, were a computer novice and had Norwegian as their first language. Nineteen elderly spousal carers participated in the study from two municipalities in eastern Norway. The project commenced in January 2004 and consisted of a multimethod evaluation model. Outcomes measured included carers' social contacts (measured by the Family and Friendship Contacts scale); burden of care (measured by the Relative Stress scale); and knowledge about chronic disease and caring, stress and mental health and use of ICT (examined via a composite carer questionnaire). These quantitative data were collected immediately prior to the study and at 12 months. Qualitative data were also collected via focus group interviews with participant carers at 7 months. At follow-up, quantitative measures did not reveal any reduction in carer stress or mental health problems. However, carers reported extensive use of the ICT service, more social contacts and increased support and less need for information about chronic illness and caring. Contact with and support from other carers with similar experiences was particularly valued by participants. The intervention also enhanced contacts with family and friends outside the carer network. Thus, it can be seen that ICT has the potential to contribute to health promotion among elderly spousal carers.     

Buying time II: an economic evaluation of a joint NHS/Social Services residential rehabilitation unit for older people on discharge from hospital

The study's aim was to investigate the cost-effectiveness of an NHS/Social Services short-term residential rehabilitation unit (a form of intermediate care) for older people on discharge from community hospital compared with 'usual' community services. An economic evaluation was conducted alongside a prospective controlled trial, which explored the effectiveness of a rehabilitation unit in a practice setting. The aim of the unit was to help individuals regain independence. A matched control group went home from hospital with the health/social care services they would ordinarily receive. The research was conducted in two matched geographical areas in Devon: one with a rehabilitation unit, one without. Participants were recruited from January 1999 to October 2000 in 10 community hospitals and their eligibility determined using the unit's strict inclusion/exclusion criteria, including 55 years or older and likely to benefit from a short-term rehabilitation programme: potential to improve, realistic, achievable goals, motivation to participate. Ninety-four people were recruited to the intervention and 112 to the control group. Details were collated of the NHS and Social Services resources participants used over a 12-month follow-up. The cost of the resource use was compared between those who went to the unit and those who went straight home. Overall, costs were very similar between the two groups. Aggregated mean NHS/Social Services costs for the 12 months of follow-up were pound 8542.28 for the intervention group and pound 8510.68 for the control. However, there was a clear 'seesaw' effect between the NHS and Social Services: the cost of the unit option fell more heavily on Social Services (pound 5011.56, whereas pound 3530.72 to the NHS), the community option more so on the NHS (pound 5146.74, whereas pound 3363.94 to Social Services). This suggests that residential rehabilitation for older people is no more cost-effective over a year after discharge from community hospital than usual community services. The variability in cost burden between the NHS and Social Services has implications for 'who pays' and being sure that agencies share both pain and gain.     

A feasible model for prevention of functional decline in older home-dwelling people--the GP role. A municipality-randomized intervention trial

Background. Danish municipalities are required by state lawto offer two annual home visits to all non-disabled citizens75 years. Visits are primarily carried out by district nurses.GPs are rarely directly involved. Objective. To evaluate the effects of offering an educationalprogramme to home visitors and GPs on mortality, functionalability and nursing home admissions among home-dwelling olderpeople. Methods. Design: Municipality pair-matched randomized trial. Setting: Danish primary care. Subject: 2863 home-dwelling 75-year-olds and 1171 home-dwelling80-year-olds living in 34 municipalities. Intervention: Home visitors received regular education for aperiod of 3 years. In nine of 17 intervention municipalities,GPs participated in one small group training session duringthe first year. Main outcome measures: Mortality, functional ability and nursinghome admission during 4 years of follow-up. Results. Intervention was not associated with mortality. Homevisitor education was associated with reduction in functionaldecline among home-dwelling 80-year-olds after the three interventionyears in municipalities where GPs accepted and participatedin small group-based training. Effects did not persist afterthe intervention ended. When analyses were restricted to baselinenon-disabled persons, intervention was associated with beneficialeffects on functional ability after three intervention yearsamong 80-year-olds, regardless of education was given to homevisitors alone or to visitors and GPs. Nursing home admissionrates were lower among the 80-year-olds living in the interventionmunicipalities. Conclusion. A brief, practicable interdisciplinary educationalprogramme for primary care professionals postponed functionaldecline in non-disabled 80-year-old home-dwelling persons. Keywords. Education, municipality intervention, older people, preventive home visits, primary care.     

Co-financing as a means to improve collaboration between primary health care,social insurance and social service in Sweden. A qualitative study of collaboration experiences among rehabilitation partners

Collaboration between services has often been suggested as a means to increase effectiveness and reduce costs especially in the care and rehabilitation of long-term illness. In Sweden, a special legislation named SOCSAM was introduced in 1994, enabling financial collaboration between governmental and municipal authorities. In this paper we report on a qualitative study on collaboration around patients with musculoskeletal diseases. The aim of the study was to assess differences in goal formulation, collaboration and communication between staff in intervention health centres that have implemented co-financing projects and health centres working under conventional conditions. Focus group interviews were performed with staff at intervention and control health care centres. We found that the interdisciplinary collaboration had improved in the intervention health care centres compared to the controls. Our findings suggest that co-financing can enhance development of better forms of interdisciplinary and interorganisational collaboration through legitimising formulation of common long-term goals, while emphasising mutual benefits.     

A Group Learning Programme for Old People with Hip Fracture: A Randomized Study

The aim of this study was to examine whether a group learning programme would influence the participants' perceived activity performance and ability to participate in social life after a hip fracture. The study comprised 35 people aged 54-90 years with hip fracture who had completed ordinary care and rehabilitation after their hip fractures. They were randomized to an intervention group (n=21) or to a control group (n=14). The intervention group participated in the group learning programme, while the control group received no intervention. Directly after the intervention and at 12 months after the intervention, no significant change was seen in either group, regarding the ability to perform ADL activities measured by the Barthel ADL index, or the performance of activities that were identified as important to the individual. However, in the intervention group, the number of ADL items perceived to be performed with difficulties decreased, and the perceived ability to participate in social life increased. These changes were not found in the control group. When analysed between groups, however, the only significant difference was the ability to participate in social life after the intervention. Further research is needed to investigate whether an intensive or prolonged period of rehabilitation, at the hospital or in the patient's home, would increase the ability to resume meaningful participation in social life.     

护理干预对老年高血压患者自我管理行为的影响

目的 提高老年高血压患者临床康复疗效.方法 将90例老年高血压病患者随机分为干预组与对照组,其中对照组患者予以用药指导护理,而干预组则采取全面性护理干预.结果 干预组患者自我管理行为及血压控制显著优于对照组.结论 全面的护理干预能提高老年高血压患者自我管理行为能力,确保远期治疗效果,临床价值显著     

A prospective randomised controlled trial of nutritional supplementation in malnourished elderly in the community: clinical and health economic outcomes

BACKGROUND & AIMS: Malnutrition is common in sick elderly people on admission to hospital and in the community. We conducted a randomised controlled trial to determine if nutritional supplementation after discharge from hospital improved nutritional status and functional outcomes, or reduced health-care costs. METHODS: Elderly malnourished subjects were randomised to 8 weeks of supplementation or no supplementation post discharge, and followed up for 24 weeks. Weight, body mass index, anthropometrics, handgrip strength, quality of life and requirements for health-care professionals' services and social services were measured throughout the study. RESULTS: Nutritional status improved significantly from baseline to week 24 in the intervention group (P<0.05), but not in the control group. There was no significant difference in nutritional status between groups at week 24. Handgrip strength improved significantly in the intervention group during supplementation, and was significantly different from that of the control group at week 8, but decreased thereafter. There was no significant difference in quality of life or health economic outcomes between groups at week 24. CONCLUSIONS: In already malnourished elderly subjects, it may be too late to expect to improve function or quality of life or to reduce health-care costs simply by providing nutritional supplements after hospitalisation. Prevention is key. All elderly patients should be nutritionally assessed as part of their routine care, and appropriate intervention initiated early.     

The effects of exercise and protein-energy supplements on body composition and muscle function in frail elderly individuals: a long-term controlled randomised study

Fighting against inactivity and inadequate nutritional intake are of utmost importance in the elderly. To our knowledge, the few studies which have been performed were conducted for only a short period and the results do not permit formal conclusions to be drawn. We therefore tried to fill this gap in our knowledge by determining whether an intervention combining an acceptable progressive exercise programme and nutritional supplements would be feasible for a long-term period in the very frail elderly, and would bring about concomitant benefits in body composition and muscle power. Accordingly, this exercise and nutritional combination was assessed in the frail elderly in a 9-month randomised trial with a factorial design. Fifty-seven elderly volunteers over 72 years, from sixteen retirement homes in Lyon, France participated in the study. Dietary supplements were compared with placebo, and physical exercise was compared with memory training. Main outcome measures were fat-free mass (FFM) and muscle power. FFM was determined by labelled water, and muscle power was measured by a leg-extensor machine. At 9 months, the compliance was 63 % for exercise sessions, and 54 % for nutritional supplements. In patients with dietary supplements, muscle power increased by 57 % at 3 months (P=0.03), and showed only a tendency at 9 months; although FFM increased by 2.7 % at 9 months, the difference was not significant (P=0.10). Exercise did not improve muscle power at 9 months, but improved functional tests (five-time-chair rise, P=0.01). BMI increased with supplements (+3.65 %), but decreased with placebo (-0.5 %) at 9 months (P=0.007). A long-term combined intervention is feasible in frail elderly individuals with a good rate of compliance. Nutritional supplements and exercise may improve muscle function. Despite no significant results on FFM, due to the limited number of volunteers, combined intervention should be suggested to counteract muscle weakness in the frail elderly.     

The effects of exercise in a coronary rehabilitation programme.

Twenty-two male and female patients who had recently suffered a myocardial infarction were randomly assigned to a treatment group who participated in a 10-week exercise-based cardiac rehabilitation programme or a routine care group who did not participate in the rehabilitation programme. Physiological and psychological function were assessed before the programme started and after it finished. Results indicated that the treatment group did not improve physiological functioning more than the control group but they did evidence statistically significant improved psychological functioning. This investigation appears to be the first attempt to assess the potential benefits of an exercise-based cardiac rehabilitation programme in Glasgow and supports the suggestion that exercise-based cardiac rehabilitation has psychological benefits.     

社会支持对老年肺癌患者术后康复的影响

目的探讨综合社会支持对老年肺癌患者术后康复的影响。方法采用便利抽样的方法,选取2018年1—7月在某院收治的108例老年肺癌手术患者为研究对象,按照随机数字表法分为观察组和对照组,每组54例,分别给予综合社会支持干预和常规护理,并比较两组患者对围手术期疾病知识掌握情况、患者健康相关生命质量各指标的差异。结果观察组患者对围手术期疾病知识掌握情况高于对照组(P<0.05);两组患者除了生命质量中的性生活维度效果不显著,其余各维度的差异均有统计学意义(P<0.05)。结论综合社会支持干预能够提高老年患者的生命质量,加速老年肺癌患者术后康复。     

Fitting fitness into women’s lives: effects of a gender-tailored physical activity intervention

Although regular exercise has important health benefits, women’s physical activity participation remains low. Addressing the gender- and generation-specific barriers in an intervention may help women become more physically active. Fifty women (mean AGE = 45 years) participated in a six-session cognitive-behavioral intervention. Baseline, post-intervention, and follow-up data were collected. Total physical activity levels increased from baseline to post-intervention and were maintained at long-term follow-up. This research suggests that participation in a comprehensive, cognitive-behavioral, and empowerment-based physical activity intervention, tailored to address women’s distinct constraints and pressures due to sociopsychological experiences, can facilitate increased physical activity among white, middle-aged women.     

Effects of home visits by home nurses to elderly people with health problems: design of a randomised clinical trial in the Netherlands [ISRCTN92017183]

BACKGROUND: Preventive home visits to elderly people by public health nurses aim to maintain or improve the functional status of elderly and reduce the use of institutional care services. A number of trials that investigated the effects of home visits show positive results, but others do not. The outcomes can depend on differences in characteristics of the intervention programme, but also on the selection of the target population. A risk group approach seems promising, but further evidence is needed. We decided to carry out a study to investigate the effects in a population of elderly with (perceived) poor health rather than the general population. Also, we test whether nurses who are qualified at a lower professional level (home nurses instead of public health nurses) are able to obtain convincing effects. The results of this study will contribute to the discussion on effective public health strategies for the aged. METHODS/DESIGN: The study is carried out as a parallel group randomised trial. To screen eligible participants, we sent a postal questionnaire to 4901 elderly people (70-84 years) living at home in a town in the south of the Netherlands. After applying inclusion criteria (e.g., self-reported poor health status) and exclusion criteria (e.g., those who already receive home nursing care), we selected 330 participants. They entered the randomisation procedure; 160 were allocated to the intervention group and 170 to the control group. The intervention consists of (at least) 8 systematic home visits over an 18 months period. Experienced home nurses from the local home care organisation carry out the visits. The control group receives usual care. Effects on health status are measured by means of postal questionnaires after 12 months, 18 months (the end of the intervention period) and after 24 months (the end of 6-months follow-up), and face-to-face interviews after 18 months. Data on mortality and service use are continuously registered during 24 months. A cost-benefit analysis is included. The design and setting of the study, the selection of eligible participants and the study interventions are described in this article. Other included items are: the primary and secondary outcome measures, the statistical analysis and the economic evaluation.     

Intergenerational interaction, social capital and health: results from a randomised controlled trial in Brazil

Recent years have seen a burgeoning of intergenerational programmes aiming to improve the well being of participants. However, very few programmes have been formally evaluated. In this paper we report results from a randomised controlled trial of a school-based intergenerational intervention undertaken in Brazil. Randomly selected samples of 253 adolescents and 266 elders aged 60 and over resident in the school's catchment area were administered a questionnaire including questions on cognitive components of social capital, family relationships, and self-rated health. Participants were then randomly allocated to control and intervention groups. The intervention comprised participation in a 4 month programme of intergenerational activities in which the elders shared their memories with the students. At the end of the intervention the questionnaire was re-administered to the samples. High proportions (85-95%) of both samples completed the questionnaires but compliance with the intervention was low in the elderly group. In the analysis of results from the elderly sample, we therefore compared the control group with the group assigned to the intervention (intention to treat analysis). Results showed that adolescents in the intervention group were nearly three times more likely to rate their health as good than those in the control group, but also more likely to judge that most people were selfish. In the elderly sample, those from the intervention group were over twice as likely as those from the control group to report positively on the helpfulness of neighbours; judge most people to be honest or consider their family relationships as good. There were no significant differences between groups on other outcome measures. These results suggest that structured intergenerational activities may have positive effects on some aspects of social capital for both adolescents and elderly people, although further research is needed to elucidate the processes involved and the extent to which the findings are context specific. This study is the first to use a controlled trial design to evaluate this type of intervention and is valuable in showing that this design can be used in interventions of this kind, and also the difficulties involved.     

The role of geriatric intermediate care facilities in long-term care for the elderly in Japan

Geriatric intermediate care facilities (GICFs) were first established in 1987 to help the hospitalized elderly return home within 3 months. Users of the GICFs are the elders who do not require hospitalization, but are mentally or physically impaired. Rather than providing unnecessary medical services, GICFs emphasize nursing care and rehabilitation so that users can carry out their daily tasks independently. Due to the limited supply of institutional and in-home services for the elderly in long-term care systems in Japan, only half of the discharged users were able to return home and a quarter stayed at GICFs for over 1 year, contrary to the initial purpose. This suggests that in addition to serving as an intermediate facility between institutions and private homes, GICFs should enlarge their role of home care supporting facilities in ways that would enable them to provide frail elderly patients at home with respite care and daycare services.     

Unpacking the Cinderella black box of complex intervention development through the Partners at Care Transitions (PACT) programme of research

Introduction

Complex intervention development has been described as the ‘Cinderella’ black box in health services research. Greater transparency in the intervention development process is urgently needed to help reduce research waste.

Methods

We applied a new consensus-based framework for complex intervention development to our programme of research, in which we developed an intervention to improve the safety and experience of care transitions for older people. Through this process, we aimed to reflect on the framework's utility for intervention development and identify any important gaps within it to support its continued development.

Findings

The framework was a useful tool for transparent reporting of the process of complex intervention development. We identified potential ‘action’ gaps in the framework including ‘consolidation of evidence’ and ‘development of principles’ that could bracket and steer decision-making in the process.

Conclusions

We consider that the level of transparency demonstrated in this report, aided through use of the framework, is essential in the quest for reducing research waste.

Patient or Public Contribution

We have involved our dedicated patient and public involvement group in all work packages of this programme of research. Specifically, they attended and contributed to co-design workshops and contributed to finalizing the intervention for the pilot evaluation. Staff also participated by attending co-design workshops, helping us to prioritize content ideas for the intervention and supporting the development of intervention components outside of the workshops.     

The changing profile of the elderly: effects on future long-term care needs and financing.

Simulation techniques are used to analyze the changing profile of the elderly from 1990 to 2030. The results show that the future demand for long-term care services is likely to be greater than many realize. Increases in the number of elderly who are 85 years of age and older, who have health limitations, or who live alone are likely to outpace the general increase in the elderly population. Although there will be a very large group of elderly at risk, their economic status will be better than that of today's elderly population. The percentage of elderly who can afford insurance premiums for broad long-term care coverage will increase in the future, but most older Americans probably will not be able to afford insurance. Although policies that reduce the cost and encourage the purchase of long-term care insurance could help to expand coverage, a large long-term care financing gap is likely to remain for the future elderly population.     

A comparative study of the physical conditions of elderly people with care needs receiving rehabilitation services from a nurse or a physiotherapist from a visiting nurse service station

PURPOSE: The purpose of this study was to examine the roles of rehabilitation by a nurse, comparing the attributes of utilization of care services and physical conditions of elderly people receiving rehabilitation services from a nurse or a physiotherapist. METHOD: Two hundred and fifty four care receivers at the Saiseikai visiting nurse service station, Shiga Prefecture, were interviewed by a nurse or a physiotherapist. They were divided into two groups: 1) receivers of rehabilitation services by a nurse (RRSN group), and 2) receivers of rehabilitation services by a physiotherapist (RRSP group). The subjects were matched for gender and age, and 36 participants for each of the two groups were included in the analysis. Level of dementia, activities of daily living (ADL; Barthel Index), instrumental activities of daily living (IADL), the Glasgow Coma Scale (GCS) and use of visiting services were assessed in the interview. Analysis of variance and the chi2 test were used to compare values for the two groups. RESULTS: Level of dementia in the RRSN group was significantly severe than in the RRSP group (P<0.05). The number of patients who are required to be treated with visiting medical services was significantly more in the RRSN group (P<0.05). Physical status in the RRSN group was significantly lower for ADL, GCS than in the RRSP group. IADL of males in the RRSN group was significantly lower. CONCLUSIONS: Thus, we conclude that it is important for nurses to make opportunities to visit elderly people with physiotherapists to assess their physical conditions.