Comprehensive geriatric assessment of frail older people: ideals and reality.

We explored different professionals' views on and experiences of comprehensive geriatric assessment (CGA) of frail older people. Forty-six professionals working in hospitals, primary care, or municipal health and social care participated in 10 focus groups. Professional groups comprised of occupational therapists, physiotherapists, nurses, physicians, and social workers. Participants shared an ideal image of how the CGA of frail elderly people should be conducted. Experience-based competence was more often used as an assessment tool than standardized tests. The ideal image contrasted with reality, listening to the needs expressed, with the person's problems, needs, and priorities in the foreground, as described by the categories: a need that can be met; different perspectives on needs; needs can be hidden; and needs assessment is affected by the collaboration around the person, by the context, and by the dialogue. The health and social care professionals' first priority is to make a person-centred tailor-made comprehensive geriatric assessment and not be bound to instruments. Clear guidelines need to be developed, stating which profession assesses what, when and how in order to ensure that person-centred needs are assessed including structures and procedures for how communication and collaboration within the team as well as between the organizations are achieved in order to perform a good person-centred CGA.

For whom is a health-promoting intervention effective? Predictive factors for performing activities of daily living independently.

BACKGROUND: Health-promoting interventions tailored to support older persons to remain in their homes, so-called "ageing in place" is important for supporting or improving their health. The health-promoting programme "Elderly Persons in the Risk Zone," (EPRZ) was set up for this purpose and has shown positive results for maintaining independence in activities of daily living for older persons 80 years and above at 1- and 2 year follow-ups. The aim of this study was to explore factors for maintaining independence in the EPRZ health-promoting programme. METHODS: Total of 459 participants in the original trial was included in the analysis; 345 in the programme arm and 114 in the control arm. Thirteen variables, including demographic, health, and programme-specific indicators, were chosen as predictors for independence of activities of daily living. Logistic regression was performed separately for participants in the health promotion programme and in the control arm. RESULTS: In the programme arm, being younger, living alone and self-rated lack of tiredness in performing mobility activities predicted a positive effect of independence in activities of daily living at 1-year follow-up (odds ratio [OR] 1.18, 1.73, 3.02) and 2-year, (OR 1.13, 2.01, 2.02). In the control arm, being less frail was the only predictor at 1-year follow up (OR 1.6 1.09, 2.4); no variables predicted the outcome at the 2-year follow-up. CONCLUSIONS: Older persons living alone - as a risk of ill health - should be especially recognized and offered an opportunity to participate in health-promoting programmes such as "Elderly Persons in the Risk Zone". Further, screening for subjective frailty could form an advantageous guiding principle to target the right population when deciding to whom health-promoting intervention should be offered. TRIAL REGISTRATION: The original clinical trial was registered at ClinicalTrials.gov. Identifier: NCT00877058 , April 6, 2009.

Self-determination among community-dwelling older persons: explanatory factors.

BACKGROUND: Although it is acknowledged that exercising self-determination in daily activities affects older people's health and well-being, few studies have focused on the explanatory factors for self-determination in daily life. OBJECTIVE: To investigate explanatory factors for self-determination in the context of community-dwelling older persons. METHOD: This cross-sectional study combined two sets of data that included community-dwelling persons 80 years and older (n = 456). A bivariate logistic regression was performed to analyse the association of self-determination and a set of explanatory factors. RESULTS: The final bivariate logistic regression model revealed five explanatory factors that were significantly associated with perceiving reduced self-determination: high education (OR = 2.83), frailty (OR = 2.70), poor self-rated health (OR = 2.54), dissatisfaction with physical health (OR = 6.50), and receiving help from public homecare service (OR = 2.46). CONCLUSION: Several explanatory factors related to the ageing body and environmental aspects were associated with reduced self-determination. To help older people maintain self-determination, healthcare professionals should consider using a person-centred and capability approach to care.

Health Promotion Can Postpone Frailty: Results from the RCT Elderly Persons in the Risk Zone.

OBJECTIVE: Very old persons (80+) are often described as "frail", implying that they are particularly vulnerable to adverse health outcomes. Elderly Persons in the Risk Zone was designed to determine whether a preventive home visit or multiprofessional senior group meetings could postpone deterioration in frailty if the intervention is carried out when the person is not so frail. DESIGN AND SAMPLE: The study was a RCT with follow-ups at 1 and 2 years. A total of 459 persons (80+), still living at home, were included. Participants were independent in activities of daily life and cognitively intact. MEASURES: Frailty was measured in two complementary ways, with the sum of eight frailty indicators and with the Mob-T Scale measuring tiredness in daily activities. RESULTS: Both interventions showed favorable effects in postponing the progression of frailty measured as tiredness in daily activities for up to 1 year. However, neither of the two interventions was effective in postponing frailty measured with the sum of frailty indicators. CONCLUSIONS: The results in this study show the potential of health promotion to older persons. The multiprofessional approach, including a broad spectrum of information and knowledge, might have been an important factor contributing to a more positive view of aging.

Speech production, intelligibility and oromotor function in seven individuals with Möbius sequence.

PURPOSE: Möbius sequence is a rare disease characterized by congenital facial and abducent nerve palsy. Other cranial nerves may be affected. Cleft palate, intellectual disability and neuropsychiatric disorders are associated with the diagnosis. The aim was to explore speech production, intelligibility and oromotor function in a group of individuals with Möbius sequence. METHOD: Three children (5-11 years) and four adults (26-54 years) were recruited to the study via the Swedish Möbius syndrome association. In addition to cranial nerve dysfunction, two had a hearing impairment, one Asperger syndrome and one a cleft palate. Perceptual assessments included an evaluation of intelligibility in single words and spontaneous speech, the percentage of phonemes correct (PPC) and screening of orofacial functions (NOT-S). Objective measurements were used for the evaluation of nasality, lip force and tongue force. RESULT: Three individuals had severely impaired intelligibility, two slightly impaired and two had fully intelligible speech. The PPC varied between 59.3-100%. Five individuals had bilateral facial palsy, two unilateral facial palsy and six tongue impairment. One had a slightly increased nasalance score. Compensatory strategies were being effectively used. CONCLUSION: This case series contributes more in-depth knowledge of speech production, intelligibility and oromotor function in this rare condition.

Self-rated health and health-strengthening factors in community-living frail older people.

AIM: The aim of this study was to analyse the explanatory power of variables measuring health-strengthening factors for self-rated health among community-living frail older people. BACKGROUND: Frailty is commonly constructed as a multi-dimensional geriatric syndrome ascribed to the multi-system deterioration of the reserve capacity in older age. Frailty in older people is associated with decreased physical and psychological well-being. However, knowledge about the experiences of health in frail older people is still limited. DESIGN: The design of the study was cross-sectional. METHOD: The data were collected between October 2008 and November 2010 through face-to-face structured interviews with older people aged 65-96 years (N = 161). Binary logistic regression was used to analyse whether a set of explanatory relevant variables is associated with self-rated health. RESULTS: The results from the final model showed that satisfaction with one's ability to take care of oneself, having 10 or fewer symptoms and not feeling lonely had the best explanatory power for community-living frail older peoples' experiences of good health. CONCLUSION: The results indicate that a multi-disciplinary approach is desirable, where the focus should not only be on medical problems but also on providing supportive services to older people to maintain their independence and experiences of health despite frailty.

Shifting between self-governing and being governed: a qualitative study of older persons' self-determination.

BACKGROUND: Older persons' right to exercise self-determination in daily life is supported by several laws. Research shows that older persons' self-determination is not fully respected within the healthcare sector. In order to enable and enhance older persons' self-determination, extensive knowledge of older persons' self-determination is needed. The aim of this study was to explore experiences of self-determination when developing dependence in daily activities among community-dwelling persons 80 years and older. METHODS: Qualitative interviews were performed in accordance with a grounded theory method, with 11 persons aged 84-95 years who were beginning to develop dependence in daily activities. RESULTS: The data analysis revealed the core category, "Self-determination - shifting between self-governing and being governed". The core category comprised three categories: "Struggling against the aging body", "Decision-making is relational", and "Guarding one's own independence". Self-determination in daily activities was related to a shifting, which was two-fold, and varied between self-governing and being governed by the aging body, or by others. CONCLUSIONS: The findings imply a need to adopt a person-centered approach where the older persons' own preferences and needs are in focus, in order to enhance their possibilities to exercise self-determination.

Positive health outcomes following health-promoting and disease-preventive interventions for independent very old persons: long-term results of the three-armed RCT Elderly Persons in the Risk Zone.

UNLABELLED: The aim of this study was to analyze the long-term effect of the two health-promoting and disease-preventive interventions, preventive home visits and senior meetings, with respect to morbidity, symptoms, self-rated health and satisfaction with health. The study was a three-armed randomized, single-blind, and controlled trial, with follow-ups at one and two years after interventions. A total of 459 persons aged 80 years or older and still living at home were included in the study. Participants were independent in ADL and without overt cognitive impairment. An intention-to-treat analysis was performed. The result shows that both interventions delayed a progression in morbidity, i.e. an increase in CIRS-G score (OR=0.44 for the PHV and OR=0.61 for senior meetings at one year and OR=0.60 for the PHV and OR=0.52 for the senior meetings at two years) and maintained satisfaction with health (OR=0.49 for PHV and OR=0.57 for senior meetings at one year and OR=0.43 for the PHV and OR=0.28 for senior meetings after two years) for up to two years. The intervention senior meetings prevented a decline in self-rated health for up to one year (OR=0.55). However, no significant differences were seen in postponing progression of symptoms in any of the interventions. This study shows that it is possible to postpone a decline in health outcomes measured as morbidity, self-rated health and satisfaction with health in very old persons at risk of frailty. Success factors might be the multi-dimensional and the multi-professional approach in both interventions. TRIAL REGISTRATION: NCT0087705.

Self-determination and older people--a concept analysis.

BACKGROUND: Self-determination has emerged as an important concept within health care, used to emphasize clients' control and independence as they participate in rehabilitation. To strengthen clients' self-determination is a central aim in occupational therapy. However, there is a lack of a clear definition of self-determination concerning community-dwelling older people. The definition should be flexible in different contexts, such as cultural. OBJECTIVE: To define and clarify the concept of self-determination in relation to community-dwelling frail older people. METHOD: Walker & Avant's analysis procedure was carried out to identify textual attributes to the concept of self-determination, supplemented by a content analysis of 21 articles that were used to define and further justify the textual attributes. RESULTS: Self-determination was used in diverse contexts for community-dwelling older people, concerning: decision-making in everyday life, professionals' views, health, and legal/ethical rights. Different textual attributes were identified, to propose a conceptual definition of self-determination in relation to community-dwelling frail older people: A process in which a person has control and legal/ethical rights, and has the knowledge and ability to make a decision of his/her own free choice. PRINCIPAL CONCLUSION: This concept analysis has contributed to clarifying the concept for the convenience of research with community-dwelling frail older people.

Impact on Participation and Autonomy: Test of Validity and Reliability for Older Persons.

In research and healthcare it is important to measure older persons' self-determination in order to improve their possibilities to decide for themselves in daily life. The questionnaire Impact on Participation and Autonomy (IPA) assesses self-determination, but is not constructed for older persons. The aim of this study was to examine the validity and reliability of the IPA-S questionnaire for persons aged 70 years and older. The study was performed in two steps; first a validity test of the Swedish version of the questionnaire, IPA-S, followed by a reliability test-retest of an adjusted version. The validity was tested with focus groups and individual interviews on persons aged 77-88 years, and the reliability on persons aged 70-99 years. The validity test result showed that IPA-S is valid for older persons but it was too extensive and the phrasing of the items needed adjustments. The reliability test-retest on the adjusted questionnaire, IPA- Older persons (IPA-O), showed that 15 of 22 items had high agreement. IPA-O can be used to measure older persons' self-determination in their care and rehabilitation.

One-year outcome of frailty indicators and activities of daily living following the randomised controlled trial: "Continuum of care for frail older people".

BACKGROUND: The intervention; "Continuum of Care for Frail Older People", was designed to create an integrated continuum of care from the hospital emergency department through the hospital and back to the older person's own home. The aim of this study is to evaluate the effects of the intervention on functional ability in terms of activities of daily living (ADL). METHODS: The study is a non-blinded controlled trial with participants randomised to either the intervention group or a control group with follow-ups at three-, six- and 12 months. The intervention involved collaboration between a nurse with geriatric competence at the emergency department, the hospital wards and a multi-professional team for care and rehabilitation of the older people in the municipality with a case manager as the hub. Older people who sought care at the emergency department at Sahlgrenska University Hospital/Mölndal and who were discharged to their own homes in the municipality of Mölndal, Sweden were asked to participate. Inclusion criteria were age 80 and older or 65 to 79 with at least one chronic disease and dependent in at least one ADL. Analyses were made on the basis of the intention-to-treat principle. Outcome measures were ADL independence and eight frailty indicators. These were analysed, using Chi-square and odds ratio (OR). RESULTS: A total of 161 participated in the study, 76 persons allocated to the control group and 85 to the intervention group were analysed throughout the study. There were no significant differences between the groups with regards to change in frailty compared to baseline at any follow-up. At both the three- and twelve-month follow-ups the intervention group had doubled their odds for improved ADL independence compared to the control (OR 2.37, 95% CI; 1.20 - 4.68) and (2.04, 95% CI; 1.03 - 4.06) respectively. At six months the intervention group had halved their odds for decreased ADL independence (OR 0.52, 95% CI; 0.27 - 0.98) compared to the control group. CONCLUSIONS: The intervention has the potential to reduce dependency in ADLs, a valuable benefit both for the individual and for society. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01260493.

Health despite frailty: exploring influences on frail older adults' experiences of health.

The aim of this study was to explore and identify influences on frail older adults' experience of health. A sample of older adults, 11 men and 11 women aged 67-92, with diverse ratings of self-perceived health ranging from poor to excellent were selected through a purposeful strategic sampling of frail older adults taken from a broader sample from a quantitative study on health. In total, 22 individual qualitative interviews were analyzed using qualitative content analysis in which themes were developed from raw data through a systematic reading, categorization of selected text, theme development and interpretation. To feel assured and capable was the main theme, which consisted of five subthemes: managing the unpredictable body, reinforcing a positive outlook, remaining in familiar surroundings, managing everyday life, and having a sense of belonging and connection to the whole. The importance of supporting frail older adults in subjective resilience in their context is emphasized.

Occupational therapists' experiences of rehabilitation of patients with limited awareness after stroke.

AIM: The aim of this study was to describe occupational therapists' experiences of rehabilitation of patients with limited awareness after stroke. METHODS: To capture occupational therapists' experiences, a qualitative approach was chosen using five focus groups consisting of 22 participants engaged in group discussions with open-ended questions based on the aim. Discussions were taped, transcribed verbatim, and analysed according to Kreuger's method. The analysis revealed one general description, constant adjustment, with three themes emerging during the analysis: adjustments in choice of activity, adjustments in choice of environment, and therapeutic adjustments. These themes interacted and were dependent on the desired effect of the interventions. Adjustments were made continuously depending on their effect. The occupational therapists strove for patients to avoid unnecessary risks, make realistic decisions, and live as independently as possible.

Long-term outcome for ADL following the health-promoting RCT--elderly persons in the risk zone.

PURPOSE: To examine independence in activities of daily living (ADL) at the 1- and 2-year follow-ups of the health-promoting study Elderly Persons in the Risk Zone. DESIGN AND METHOD: A randomized, three-armed, single-blind, and controlled study. A representative sample of 459 independent and community-dwelling older adults, 80 years and older, were included. A preventive home visit was compared with four weekly multiprofessional senior group meetings including a follow-up home visit. RESULTS: Analysis showed a significant difference in favor of the senior meetings in postponing dependence in ADL at the 1-year follow-up (odds ratio [OR] = 1.92, 95% confidence interval [CI] = 1.19-3.10) and also in reducing dependence in three (OR = 0.52, 95% CI = 0.31-0.86) and four or more ADL (OR = 0.40, 95% CI = 0.22-0.72) at the 2-year follow-up. A preventive home visit reduced dependence in two (OR = 0.40, 95% CI = 0.24-0.68) and three or more ADL (OR = 0.37, 95% CI = 0.17-0.80) after 1 year. IMPLICATIONS: A long-term evaluation of Elderly Persons in the Risk Zone showed that both senior meetings and a preventive home visit reduced the extent of dependence in ADL after 1 year. The senior meetings were superior to a preventive home visit since additional significant effects were seen after 2 years. To further enhance the long-term effects of the senior meetings and support the process of self-change in health behavior, it is suggested that booster sessions might be a good way of reinforcing the intervention.

Comparison of visual acuity charts identifying visual impairment among older people outside the eye clinic.

PURPOSE: Evaluate the construct validity and describe sensitivity, specificity and predictive value of two short charts of visual acuity (VA) and examine whether these can identify and detect signs of visual impairment among older people. METHOD: The study included 43 persons, >65 years, with age related eye disease, living in their own homes. An ophthalmologist assessed the individuals' VA at an eye clinic with the 5 m KM chart. A research assistant assessed individuals' VA by the 1 m KM chart and the Visual Acuity Screening Test in their home environment. RESULTS: All persons with a VA level of <0.5 were correctly identified by both instruments. The instruments have good positive and negative predictive values for the 1 m KM chart (73% and 100%) and for the Visual Acuity Screening Test (69% and 100%). The construct validity between the instruments was good, but the assessment at the eye clinic assessed the participants as having higher VA level. CONCLUSIONS: Both instruments have good construct validity, considering they were carried out in poorer lighting conditions and a good predictive value for screening out VA levels <0.5. The 1 m KM chart showed the best agreement with the 5 m KM chart.

Positive Effects on Life Satisfaction Following Health-Promoting Interventions for Frail Older Adults: A Randomized Controlled Study.

Life satisfaction among older adults is known to decrease over time and with deteriorated health. The aim of this study was to analyze the effects of the health-promoting intervention study Elderly Persons in the Risk Zone on life satisfaction. A randomized, three-armed, single-blind, and controlled trial with follow-ups at 3 months, 1 and 2 years. A total of 459 community-dwelling persons at risk of frailty, 80-years or older were included. The participants were independent of help from others in ADL and cognitively intact. The two interventions were i) four weekly multi-professional senior group meetings including a follow-up home visit or ii) one preventive home visit. Life satisfaction was measured with eight questions from LiSat-11. Analyses were made in accordance with the intention-to-treat principle. Life satisfaction decreased over time, with a lower decrease in the intervention groups than in the control group. The proportion of satisfied persons was significantly higher in the intervention group of senior group meetings compared to the control group for five of the eight life satisfaction variables at one year and for all variables at the two-year follow-up. For preventive home visits, there was a significant difference compared to the control group at the one-year follow-up for three of the life satisfaction variables, and at the two-year follow-up for seven variables. We can conclude that a health-promoting intervention can delay the decline in life satisfaction among older adults (aged 80 or older) who are at risk of becoming frail.

Life Satisfaction and Frailty Among Older Adults.

Functional and physical impairment are factors believed to lead to declined life satisfaction among older adults. This study aimed to examine life satisfaction among older adults and the influence of frailty. Baseline data from two studies addressing frail older adults aged 80+ in Gothenburg, Sweden, (n=577) were used. Frailty was measured through eight indicators. Life satisfaction was measured with Fugl-Meyer's instrument LiSat-11. Perceived life satisfaction was rather high within the studied population, with 66% being satisfied with life as a whole. Most life satisfaction items were significantly associated with frailty status, with non-frail participants being satisfied to a higher extent for all items with the exception of financial situation, sexual life and partnership relation. The factors significantly explaining life satisfaction were psychological health, partner relationship, leisure and ADL. This study shows that older adults' satisfaction with life as a whole is almost as high as in younger age groups. Respondents with higher degree of frailty reported significantly lower degrees of life satisfaction, indicating a possibility to maintain life satisfaction by preventing or delaying the development of frailty.

Health-promoting interventions for persons aged 80 and older are successful in the short term--results from the randomized and three-armed Elderly Persons in the Risk Zone study.

OBJECTIVES: To examine the outcomes of the Elderly Persons in the Risk Zone study, which was designed to evaluate whether it is possible to delay deterioration if a health-promoting intervention is made when an older adult (≥80) is at risk of becoming frail and whether a multiprofessional group intervention is more effective in delaying deterioration than a single preventive home visit with regard to frailty, self-rated health, and activities of daily living (ADLs) at 3-month follow-up. DESIGN: Randomized, three-armed, single-blind, controlled trial performed between November 2007 and May 2011. SETTING: Two urban districts of Gothenburg, Sweden. PARTICIPANTS: Four hundred fifty-nine community-living adults aged 80 and older not dependent on the municipal home help service. INTERVENTION: A preventive home visit or four weekly multiprofessional senior group meetings with one follow-up home visit. MEASUREMENTS: Change in frailty, self-rated health, and ADLs between baseline and 3-month follow-up. RESULTS: Both interventions delayed deterioration of self-rated health (odds ratio (OR) = 1.99, 95% confidence interval (CI) = 1.12-3.54). Senior meetings were the most beneficial intervention for postponing dependence in ADLs (OR = 1.95, 95% CI = 1.14-3.33). No effect on frailty could be demonstrated. CONCLUSION: Health-promoting interventions made when older adults are at risk of becoming frail can delay deterioration in self-rated health and ADLs in the short term. A multiprofessional group intervention such as the senior meetings described seems to have a greater effect on delaying deterioration in ADLs than a single preventive home visit. Further research is needed to examine the outcome in the long term and in different contexts.

Getting used to assistive devices: ambivalent experiences by frail elderly persons.

The aim was to learn how frail elderly people experienced becoming assistive device users and how assistive devices affected their independence in daily activities. Focus-group methodology was used, including people 80 and older with multiple health problems. Five group discussions were conducted with a total of 18 people including 14 women and four men. Each group met once, for 90-120 minutes, and all discussions were audiotaped. Two themes emerged: Confidence in knowledge and experience and getting used to assistive devices in daily activities. Confidence in knowledge and experience was formed by two categories of experiences from the prescription procedure: trust the expert and trust yourself, and to have confidence in having the right information about assistive devices. Getting used to assistive devices in daily activities was formed by five categories of ambivalent experiences when using assistive devices in daily activities: creates opportunities and limitations; provides security but also raises concerns; the need is seen as transient or permanent; the social environment both encourages and restricts; the physical environment both facilitates and complicates, with less extreme experiences in between. This study indicates that frail elderly people need specifically developed support in the process of becoming assistive device users.