Utilisation des services d’aide et de soins à domicile pour les personnes âgées en situations complexes : comparaison entre trois types de coordination gérontologique

BackgroundOlder people with complex needs live mainly at home. Several types of gerontological coordinations have been established on the French territory to meet their needs and to implement social and primary health care services. But we do not have any information on the use of these services at home as a function of the coordination method used.MethodsWe compared the use of home care services for older people with complex needs in three types of coordination with 12 months’ follow-up. The three coordinations regrouped a gerontological network with case management (n = 105 persons), a nursing home service (SSIAD) with a nurse coordination (n = 206 persons) and an informal coordination with a non-professional caregiver (n = 117 persons).ResultsAt t0, the older people addressed to the gerontological network had less access to the services offered at home; those followed by the SSIAD had the highest number of services and of weekly interventions. Hours of weekly services were two-fold higher in those with the informal coordination. At t12, there was an improvement in access to services for the network group with case management and an overall increase in the use of professional services at home with no significant difference between the three groups.ConclusionThe use of social and primary health care services showed differences between the three gerontological coordinations. The one-year evolution in the use of home services was comparable between the groups without an explosion in the number of services in the network group with case management.     

The Global Activity Limitation Index mainly measured functional disability,whereas self-rated health measured physical morbidity

ObjectivesAs the Global Activity Limitation Index (GALI) has only recently been created and it is not yet known whether it adds any additional information to self-rated health (SRH), two hypotheses were tested: (1) GALI is primarily correlated with functional disability and secondarily with morbidity and (2) SRH is primarily correlated with morbidity and secondarily with functional disability.MethodsThe data source used was a subsample of the 2006 Spanish National Health Survey comprising people aged more than 64 years (N = 7,835). Age, sex, social class, physical and mental morbidities, and functional disability were selected as predictors in multinomial logistic regression models, in which GALI and SRH were the outcome variables. Fractional polynomials were used to handle the continuous predictors.ResultsThe results supported, generally, both hypotheses: functional disability was the main correlate of GALI and physical morbidity, rather than mental morbidity, was the main correlate of SRH. Furthermore, mental morbidity was as strong a correlate of GALI as SRH, but physical morbidity was notably less strong a correlate for GALI than for SRH.ConclusionIn older people, GALI mainly measured functional disability, whereas SRH mainly measured physical morbidity.     

The experiences and perspectives of family surrogate decision-makers: A systematic review of qualitative studies

ObjectiveSurrogate decision-makers play an increasingly important role in the lives of older adults who have lost their ability to make decisions. Currently, there is a lack of evidence to support family surrogates in making a variety of decisions. Additionally, a greater understanding of family caregivers’ experiences and perspectives toward making surrogate decisions is needed.MethodsThis study employed a qualitative systematic review and thematic synthesis of the research evidence using the methodologies of the Joanna Briggs Institute (2014) and Thomas and Harden (2008).ResultsDecisions were classified per three main types: intensive care treatment, end-of-life treatment, and placement. Six themes were identified concerning surrogates’ experiences: struggle and reluctance, seeking reassurance, communication with healthcare professionals, family support, older adults’ wishes, and negative impact.ConclusionFamily surrogates often lack adequate preparation and education regarding decision-making. Quality communication between surrogates and healthcare providers helps reduce the anxiety and guilt experienced when making surrogate decisions. Further research is required to elucidate these experiences with more cultural and racial nuances.Practice implicationsThis review informs healthcare providers’ awareness of the challenges faced by surrogates and fosters improved surrogate decision-making experiences.     

Cognitive impairment no dementia and associations with health literacy,self-management skills,and functional health status

ObjectivesTo determine the prevalence of cognitive impairment no dementia (CIND) among a diverse, community-based population, and establish associations between CIND and health literacy, chronic disease self-management and functional health status.Methods863 primary care adults without dementia aged 55–74. Adjusted logistic and linear regressions were used to assess associations between CIND (None, Mild, Moderate/Severe) and outcomes.Results36 % participants exhibited CIND. It was strongly associated with limited health literacy (Newest Vital Signs: Mild [OR 3.25; 95 % CI 1.93, 5.49], Moderate/Severe [OR 6.45; 95 % CI 3.16, 13.2]; Test of Functional Health Literacy in Adults: Mild [OR 3.46; 95 % CI 2.08, 5.75], Moderate/Severe [OR 8.82; 95 % CI 4.87, 16.0]; all p’s < 0.001) and poor chronic disease self-management (Mild [B = −11.2; 95 % CI −13.5, -8.90], Moderate/Severe CI [B = −21.0; 95 % CI −23.6, −18.4]; both p’s < 0.001). Associations between CIND and functional health status were non-significant.ConclusionsCIND was prevalent in this cohort, and strongly associated with requisite skills for managing everyday health needs.Practice ImplicationsAttention to subtle declines in chronic disease self-care may assist with CIND identification and care management within this population. When CIND is observed, clinicians should also expect and address difficulties with self-management.     

Methodological features of quantitative studies on medication adherence in older patients with chronic morbidity: A systematic review

ObjectivesThe growing number of chronic, multimorbid older adults encourages healthcare systems to cope with polypharmacy and non-adherence. However, methodology on how to provide effective interventions to enhance medication adherence is still object of debate.MethodsTo describe methodological features of quantitative studies concerning older adults’ medication adherence, by means of a PRISMA systematic review (Scopus, PubMed, Medline). A specific focus was devoted to theoretical models and to the ABC Taxonomy model, as stated by the EMERGE guidelines.Results55 papers were included. Most of the studies were conducted using randomized control trials (63.6%) and focused on a single disease only (72.7%). Most of the interventions were provided by a single professional figure (70.9%). Medication adherence was mainly evaluated by means of questionnaires (61.8%) and by clinical records (30.9%). Sixteen studies considered a theoretical model in the intervention framework. The Initiation phase (ABC Taxonomy) was the most neglected.ConclusionsFuture studies upon medication adherence should account real-life challenges such as multimorbidity, polypharmacy and interdisciplinarity, analyzing adherence as a complex, holistic process.Practice implicationsTheoretical models may be useful to enhance the soundness of the results, to ease their comparability, to calibrate tailored strategies and to plan patient-centered interventions.     

Incorporating shared decision making into communication with older adults with cancer and their caregivers: Development and evaluation of a geriatric shared decision-making communication skills training module

ObjectiveThe purpose of this study was to evaluate a Communication Skills Training (CST) module for health care providers (HCPs) applying a shared decision-making approach to a meeting with an older adult with cancer and his/her family.MethodsNinety-nine HCPs from community-based centers, cancer centers, and hospitals in the Northeastern U.S. who worked primarily with older adult patients participated in a CST module entitled Geriatric Shared Decision Making. Participants completed pre- and post-training Standardized Patient Assessments (SPAs) and a survey on their confidence in and intent to utilize skills taught.ResultsResults indicated high HCP satisfaction with the module, with over 95 % of participants reporting high endorsement to all five evaluation items. HCPs’ self-efficacy in utilizing communication skills related to geriatric shared decision making significantly increased pre- to post-training. In standardized patient assessments among a subset of providers (n = 30), HCPs demonstrated improvements in three shared decision-making skills: declare agenda, invite agenda, and check preference.ConclusionA geriatric shared decision-making CST workshop for HCPs showed feasibility, acceptability, and improvement in self-efficacy as well as skill uptake.Practice implicationsThis Geriatric Shared Decision-Making CST module provides an intervention for improving provider-patient-family member communication in the context of cancer care for older adults.     

The efficacy and safety of influenza vaccination in older people: An umbrella review of evidence from meta-analyses of both observational and randomized controlled studies

Vaccination is the main public health intervention to prevent influenza. We aimed to evaluate the efficacy and safety of influenza vaccination including systematic reviews and meta-analyses of observational studies and randomized controlled trials (RCTs). Peer-reviewed systematic reviews with meta-analyses of prospective studies that investigated the association of influenza vaccination with any health-related outcome, as well as RCTs that investigated the efficacy and safety of influenza vaccination, were included. Among 1240 references, 6 meta-analyses were included. In cohort studies of community-dwelling older people influenza vaccination was associated with a lower risk of hospitalization for heart disease and for influenza/pneumonia (strength of evidence: convincing). Evidence in lowering the risk of mortality in community-dwelling older people, of all deaths/severe respiratory diseases in high risk community-dwelling older people and of hospitalization for influenza/pneumonia in case-control studies, was highly suggestive. In RCTs, influenza vaccination, compared to placebo/no intervention, was associated to higher risk of local tenderness/sore arm and to a reduced risk of influenza like-illness. Both these associations showed moderate evidence using the GRADE (Grading of Recommendations Assessment, Development and Evaluation). In conclusion, influenza vaccination in older people seems safe and effective. Further, the evidence on safety and efficacy of vaccines in this population might benefit by an extension of the follow-up period both in RCTs and in longitudinal studies, beyond the usual 6-month period, in order to be able to evaluate the impact of vaccination on long term outcomes.     

The implications of late-life cannabis use on brain health: A mapping review and implications for future research

While medical and recreational cannabis use is becoming more frequent among older adults, the neurocognitive consequences of cannabis use in this age group are unclear. The aim of this literature review was to synthesize and evaluate the current knowledge on the association of cannabis use during older-adulthood with cognitive function and brain aging. We reviewed the literature from old animal models and human studies, focusing on the link between use of cannabis in middle- and old-age and cognition. The report highlights the gap in knowledge on cannabis use in late-life and cognitive health, and discusses the limited findings in the context of substantial changes in attitudes and policies. Furthermore, we outline possible theoretical mechanisms and propose recommendations for future research.The limited evidence on this important topic suggests that use in older ages may not be linked with poorer cognitive performance, thus detrimental effects of early-life cannabis use may not translate to use in older ages. Rather, use in old ages may be associated with improved brain health, in accordance with the known neuroprotective properties of several cannabinoids. Yet, firm conclusions cannot be drawn from the current evidence-base due to lack of research with strong methodological designs.     

Age-related macular degeneration and 5-year incidence of impaired activities of daily living

Objectives

We aimed to assess the prospective association between age-related macular degeneration (AMD) and impaired activities of daily living (ADL) among a large cohort of older adults.

Study design

Functional status was determined by the Older Americans Resources and Services ADL scale from 2002–2004 to 2007–2009 among 761 participants aged 60+ years. AMD was assessed from retinal photographs.

Results

After adjusting for age, sex, living status, self-rated poor health, smoking, body mass index, visual impairment, hypertension, diabetes, hospital admissions in the past year, walking disability, probable depression, mini-mental state examination scores, having any AMD or late AMD increased the risk of incident impaired total ADL 5 years later, odds ratio, OR 2.87 (95% confidence intervals, CI 1.44–5.71) and OR 12.95 (95% CI 3.78–44.35), respectively. Having any AMD increased the risk of developing instrumental ADL disability over the 5 years, multivariable-adjusted OR 2.06 (95% CI 1.11–3.83).

Conclusions

This study shows that the presence of AMD could independently signal an increased risk of functional disability, particularly in performing instrumental ADL tasks.     

A predictive model of vitamin D insufficiency in older community people: From the São Paulo Aging & Health Study (SPAH)

Objective

To evaluate the prevalence of 25-hydroxyvitamin D insufficiency (25OHD < 20 ng/mL) and to develop a predictive model for this status.

Methods

This is a cross-sectional study including 908 community-dwelling older subjects, 18% (158) of which were randomly selected to be a “test” sample, with the remaining (750) composing a “development” sample. A radioimmunoassay technique was used to measure 25OHD levels. Anthropometrical data, information about lifestyle habits and co-morbidities were obtained. Multiple logistic regression models were created. An Index Risk of Vitamin D Insufficiency (IRVDI) was designed and subsequently validated. The performance of this tool was assessed through ROC analysis.

Results

The prevalence of 25OHD < 20 ng/mL was of 58.0% (CI 95% 51.6–64.6). The clinical independent factors for 25OHD < 20 ng/mL were female gender (OR = 2.16; 95%CI 1.13–4.13; p = 0.020), diabetes (OR = 1.84; 95%CI 1.23–2.74; p = 0.003) and season (winter/spring) (OR = 3.63, 95%CI 2.62–4.88; p < 0.001). After statistical adjustments, the IRVDI was able to identify older people at risk for vitamin D insufficiency with a sensitivity of 55.9%, specificity 72.3% and ROC area of 0.685 (p < 0.001).

Conclusions

Our results suggest that vitamin D insufficiency is common among Brazilian community-dwelling elderly. Female gender, diabetes and the season (winter/spring) were the important parameters that predicted this status. The clinical use of these parameters can be help to design and target appropriate public health interventions. The IRVDI is a convenient tool for the selection of older people at risk for vitamin D insufficiency.