Navigating the future of Alzheimer's care in Ireland - a service model for disease-modifying therapies in small and medium-sized healthcare systems.

BACKGROUND: A new class of antibody-based drug therapy with the potential for disease modification is now available for Alzheimer's disease (AD). However, the complexity of drug eligibility, administration, cost, and safety of such disease modifying therapies (DMTs) necessitates adopting new treatment and care pathways. A working group was convened in Ireland to consider the implications of, and health system readiness for, DMTs for AD, and to describe a service model for the detection, diagnosis, and management of early AD in the Irish context, providing a template for similar small-medium sized healthcare systems. METHODS: A series of facilitated workshops with a multidisciplinary working group, including Patient and Public Involvement (PPI) members, were undertaken. This informed a series of recommendations for the implementation of new DMTs using an evidence-based conceptual framework for health system readiness based on [1] material resources and structures and [2] human and institutional relationships, values, and norms. RESULTS: We describe a hub-and-spoke model, which utilises the existing dementia care ecosystem as outlined in Ireland's Model of Care for Dementia, with Regional Specialist Memory Services (RSMS) acting as central hubs and Memory Assessment and Support Services (MASS) functioning as spokes for less central areas. We provide criteria for DMT referral, eligibility, administration, and ongoing monitoring. CONCLUSIONS: Healthcare systems worldwide are acknowledging the need for advanced clinical pathways for AD, driven by better diagnostics and the emergence of DMTs. Despite facing significant challenges in integrating DMTs into existing care models, the potential for overcoming challenges exists through increased funding, resources, and the development of a structured national treatment network, as proposed in Ireland's Model of Care for Dementia. This approach offers a replicable blueprint for other healthcare systems with similar scale and complexity.

The state of health in the European Union (EU-27) in 2019: a systematic analysis for the Global Burden of Disease study 2019.

BACKGROUND: The European Union (EU) faces many health-related challenges. Burden of diseases information and the resulting trends over time are essential for health planning. This paper reports estimates of disease burden in the EU and individual 27 EU countries in 2019, and compares them with those in 2010. METHODS: We used the Global Burden of Disease 2019 study estimates and 95% uncertainty intervals for the whole EU and each country to evaluate age-standardised death, years of life lost (YLLs), years lived with disability (YLDs) and disability-adjusted life years (DALYs) rates for Level 2 causes, as well as life expectancy and healthy life expectancy (HALE). RESULTS: In 2019, the age-standardised death and DALY rates in the EU were 465.8 deaths and 20,251.0 DALYs per 100,000 inhabitants, respectively. Between 2010 and 2019, there were significant decreases in age-standardised death and YLL rates across EU countries. However, YLD rates remained mainly unchanged. The largest decreases in age-standardised DALY rates were observed for "HIV/AIDS and sexually transmitted diseases" and "transport injuries" (each -19%). "Diabetes and kidney diseases" showed a significant increase for age-standardised DALY rates across the EU (3.5%). In addition, "mental disorders" showed an increasing age-standardised YLL rate (14.5%). CONCLUSIONS: There was a clear trend towards improvement in the overall health status of the EU but with differences between countries. EU health policymakers need to address the burden of diseases, paying specific attention to causes such as mental disorders. There are many opportunities for mutual learning among otherwise similar countries with different patterns of disease.

Comparing frailty prevalence between countries: validation of the Global Burden of Disease study Frailty Index (GBD-FI) in the survey of health, ageing and retirement in Europe.

BACKGROUND: Accurate comparable prevalence proportions are required to better understand the epidemiology of frailty. Estimates in many countries are missing or incomparable. The Global Burden of Disease Frailty Index (GBD-FI) applies the deficit accumulation model to generate frailty scores from items available in the Global Burden of Disease study. OBJECTIVE: To externally validate the GBD-FI. METHODS: Data were obtained from the Survey of Health Ageing and Retirement in Europe (SHARE). A 20-item modified GBD-FI was compared with established frailty measures: a 70-item frailty index (FI-70), the Clinical Frailty Scale (CFS), Frailty Phenotype (FP) and SHARE-FI. Area under receiver operating characteristic curves (AUC) were fitted to examine diagnostic accuracy for frailty and predictive validity for 2-year mortality. RESULTS: In total, 31,624 participants aged ≥50 years from 15 countries were included. Frailty prevalence was 22% using the GBD-FI (ranging from 8% in Switzerland to 41% in Poland). The GBD-FI had good to excellent diagnostic accuracy for frailty, irrespective of approach; the AUC ranged from 0.86 (95% confidence interval: 0.85-0.87) measuring frailty using the CFS to 0.94 (0.93-0.94) with the FI-70. The GBD-FI had similar accuracy for 2-year mortality (AUC 0.71, 0.69-0.74) compared with the CFS (0.73; P = 0.186), FP (0.73; P = 0.392) and SHARE-FI (0.70; P = 0.255) but lower than the FI-70 (0.76; P < 0.001). CONCLUSION: The GBD-FI demonstrated concurrent and predictive validity, suggesting it is a valid measure of frailty. It has the potential to be an efficient, replicable and consistent approach to comparing frailty between countries and regions across time using GBD data.

Burden of disease among older adults in Europe-trends in mortality and disability, 1990-2019.

BACKGROUND: It is important to understand the effects of population ageing on disease burden and explore conditions that drive poor health in later life to prevent or manage these. We examined the development of disease burden and its components for major disease groups among older adults in Europe over the last 30 years. METHODS: Using data from the Global Burden of Disease 2019 Study, we analyzed burden of disease trends between 1990 and 2019 measured by years of life lost (YLL), years lived with disability (YLD) and disability-adjusted life years (DALYs) among older adults (65+ years) in Western, Central and Eastern Europe using cause groups for diseases and injuries. RESULTS: Between 1990 and 2019, the crude numbers of DALYs for all causes increased substantially among older Western Europeans. In Eastern Europe, the absolute DALYs also increased from 1990 to 2005 but then decreased between 2006 and 2013. However, DALY rates declined for all European regions over time, with large differences in the magnitude by region and gender. Changes in the YLL rate were mainly driven by the contribution of cardiovascular diseases. CONCLUSIONS: This study found an increased overall absolute disease burden among older Europeans between 1990 and 2019. The demographic change that has taken place in Eastern European countries implies a potential problem of directed resource allocation to the health care sector. Furthermore, the findings highlight the potential health gains through directing resources to health promotion and treatment to reduce YLDs and to prevent YLLs, primarily from cardiovascular diseases.

Informant-Administered Cognitive Screening as a Component of Memory Clinic Assessment: Overcoming Ethical and Practical Challenges.

Possin and Rosen provide a robust commentary exploring the challenges of using caregivers as cognitive testers. Informants have an important and often overlooked role in diagnosing cognitive impairment. O'Caoimh et al. show they can support cognitive screening in advance of clinic, suggesting new research avenues including the potential for home-monitoring. Although concerns testing may engender bias, introduce practice effects, and impact patient autonomy are valid and require examination, these should be viewed in light of patient preference, clinical need, and the broader ethics of assessing dementia. The importance of distinguishing concerns over accuracy and ethical appropriateness is also discussed.

Methodological considerations in injury burden of disease studies across Europe: a systematic literature review.

BACKGROUND: Calculating the disease burden due to injury is complex, as it requires many methodological choices. Until now, an overview of the methodological design choices that have been made in burden of disease (BoD) studies in injury populations is not available. The aim of this systematic literature review was to identify existing injury BoD studies undertaken across Europe and to comprehensively review the methodological design choices and assumption parameters that have been made to calculate years of life lost (YLL) and years lived with disability (YLD) in these studies. METHODS: We searched EMBASE, MEDLINE, Cochrane Central, Google Scholar, and Web of Science, and the grey literature supplemented by handsearching, for BoD studies. We included injury BoD studies that quantified the BoD expressed in YLL, YLD, and disability-adjusted life years (DALY) in countries within the European Region between early-1990 and mid-2021. RESULTS: We retrieved 2,914 results of which 48 performed an injury-specific BoD assessment. Single-country independent and Global Burden of Disease (GBD)-linked injury BoD studies were performed in 11 European countries. Approximately 79% of injury BoD studies reported the BoD by external cause-of-injury. Most independent studies used the incidence-based approach to calculate YLDs. About half of the injury disease burden studies applied disability weights (DWs) developed by the GBD study. Almost all independent injury studies have determined YLL using national life tables. CONCLUSIONS: Considerable methodological variation across independent injury BoD assessments was observed; differences were mainly apparent in the design choices and assumption parameters towards injury YLD calculations, implementation of DWs, and the choice of life table for YLL calculations. Development and use of guidelines for performing and reporting of injury BoD studies is crucial to enhance transparency and comparability of injury BoD estimates across Europe and beyond.

Rethinking palliative care in a public health context: addressing the needs of persons with non-communicable chronic diseases.

Non-communicable chronic diseases (NCCDs) are the main cause of morbidity and mortality globally. Demographic aging has resulted in older populations with more complex healthcare needs. This necessitates a multilevel rethinking of healthcare policies, health education and community support systems with digitalization of technologies playing a central role. The European Innovation Partnership on Active and Healthy Aging (A3) working group focuses on well-being for older adults, with an emphasis on quality of life and healthy aging. A subgroup of A3, including multidisciplinary stakeholders in health care across Europe, focuses on the palliative care (PC) model as a paradigm to be modified to meet the needs of older persons with NCCDs. This development paper delineates the key parameters we identified as critical in creating a public health model of PC directed to the needs of persons with NCCDs. This paradigm shift should affect horizontal components of public health models. Furthermore, our model includes vertical components often neglected, such as nutrition, resilience, well-being and leisure activities. The main enablers identified are information and communication technologies, education and training programs, communities of compassion, twinning activities, promoting research and increasing awareness amongst policymakers. We also identified key 'bottlenecks': inequity of access, insufficient research, inadequate development of advance care planning and a lack of co-creation of relevant technologies and shared decision-making. Rethinking PC within a public health context must focus on developing policies, training and technologies to enhance person-centered quality life for those with NCCD, while ensuring that they and those important to them experience death with dignity.

Assessing Global Frailty Scores: Development of a Global Burden of Disease-Frailty Index (GBD-FI).

Frailty is an independent age-associated predictor of morbidity and mortality. Despite this, many countries lack population estimates with large heterogeneity between studies. No population-based standardised metric for frailty is available. We applied the deficit accumulation model of frailty to create a frailty index (FI) using population-level estimates from the Global Burden of Disease (GBD) 2017 study across 195 countries to create a novel GBD frailty index (GBD-FI). Standard FI criteria were applied to all GBD categories to select GBD-FI items. Content validity was assessed by comparing the GBD-FI with a selection of established FIs. Properties including the rate of deficit accumulation with age were examined to assess construct validity. Linear regression models were created to assess if mean GBD-FI scores predicted one-year incident mortality. From all 554 GBD items, 36 were selected for the GBD-FI. Face validity against established FIs was variable. Characteristic properties of a FI-higher mean score for females and a deficit accumulation rate of approximately 0.03 per year, were observed. GBD-FI items were responsible for 19% of total Disability-Adjusted Life Years for those aged ≥70 years in 2017. Country-specific mean GBD-FI scores ranged from 0.14 (China) to 0.19 (Hungary) and were a better predictor of mortality from non-communicable diseases than age, gender, Healthcare Access and Quality Index or Socio-Demographic Index scores. The GBD-FI is a valid measure of frailty at population-level but further external validation is required.

The effectiveness of intermediate care including transitional care interventions on function, healthcare utilisation and costs: a scoping review.

BACKGROUND AND AIM: Intermediate care describes services, including transitional care, that support the needs of middle-aged and older adults during care transitions and between different settings. This scoping review aimed to examine the effectiveness of intermediate care including transitional care interventions for middle-aged and older adults on function, healthcare utilisation, and costs. DESIGN: A scoping review of the literature was conducted including studies published between 2002 and 2019 with a transitional care and/or intermediate care intervention for adults aged ≥ 50. Searches were performed in CINAHL, Cochrane Library, EMBASE, Open Grey and PubMed databases. Qualitative and quantitative approaches were employed for data synthesis. RESULTS: In all, 133 studies were included. Interventions were grouped under four models of care: (a) Hospital-based transitional care (n = 8), (b) Transitional care delivered at discharge and up to 30 days after discharge (n = 70), (c) Intermediate care at home (n = 41), and (d) Intermediate care delivered in a community hospital, care home or post-acute facility (n = 14). While these models were associated with a reduced hospital stay, this was not universal. Intermediate including transitional care services combined with telephone follow-up and coaching support were reported to reduce short and long-term hospital re-admissions. Evidence for improved ADL function was strongest for intermediate care delivered by an interdisciplinary team with rehabilitation at home. Study design and types of interventions were markedly heterogenous, limiting comparability. CONCLUSIONS: Although many studies report that intermediate care including transitional care models reduce hospital utilisation, results were mixed. There is limited evidence for the effectiveness of these services on function, institutionalisation, emergency department attendances, or on cost-effectiveness.

European Collaborative and Interprofessional Capability Framework for Prevention and Management of Frailty-a consensus process supported by the Joint Action for Frailty Prevention (ADVANTAGE) and the European Geriatric Medicine Society (EuGMS).

BACKGROUND: Interprofessional collaborative practice (ICP) is currently recommended for the delivery of high-quality integrated care for older people. Frailty prevention and management are key elements to be tackled on a multi-professional level. AIM: This study aims to develop a consensus-based European multi-professional capability framework for frailty prevention and management. METHODS: Using a modified Delphi technique, a consensus-based framework of knowledge, skills and attitudes for all professions involved in the care pathway of older people was developed within two consultation rounds. The template for the process was derived from competency frameworks collected in a comprehensive approach from EU-funded projects of the European Commission (EC) supported best practice models for health workforce development. RESULTS: The agreed framework consists of 25 items structured in 4 domains of capabilities. Content covers the understanding about frailty, skills for screening and assessment as well as management procedures for every profession involved. The majority of items focused on interprofessional collaboration, communication and person-centred care planning. DISCUSSION: This framework facilitates clarification of professionals' roles and standardizes procedures for cross-sectional care processes. Despite a lack of evidence for educational interventions, health workforce development remains an important aspect of quality assurance in health care systems. CONCLUSIONS: The multi-professional capability framework for frailty prevention and management incorporated interprofessional collaborative practice, consistent with current recommendations by the World Health Organization, Science Advice for Policy by European Academies and the European Commission.

Informal caregiving for dementia patients: the contribution of patient characteristics and behaviours to caregiver burden.

OBJECTIVES: The burden often associated with informal caregiving for patients with dementia is associated with negative effects on health, both physiologically and in terms of caregiver cognition. There is wide variation in the level of burden experienced by dementia caregivers. To better understand caregiver burden, it is thus important to understand the factors associated with level of burden. METHODS: In the current study, we collected carer burden and putative associated factors at baseline, 6 and 12 months. Hierarchical regression was used to assess the impact of these factors on caregiver burden. We assessed self-reported carer burden, patient behavioural and safety issues, and level of difficulty associated with providing assistance with activities of daily living (ADL). Patients' age was also recorded, and trained nurses assessed patient cognitive performance using the quick mild cognitive impairment screen. RESULTS: At baseline, patients' age, cognition and ADLs were associated with burden, and safety and challenging behaviour were both significantly associated with burden independent of the other factors. Change in burden was associated with change in carer-reported safety at 6-month follow-up, and with change in safety and change in carer-reported challenging behaviours at 12-month follow-up. CONCLUSIONS: Safety issues and challenging behaviours are associated with carer burden, even after accounting for cognitive and functional impairment in the person with dementia. As dementia progresses, monitoring these factors may help to inform stress-management strategies for caregivers.

Interventions to Promote Early Discharge and Avoid Inappropriate Hospital (Re)Admission: A Systematic Review.

Increasing pressure on limited healthcare resources has necessitated the development of measures promoting early discharge and avoiding inappropriate hospital (re)admission. This systematic review examines the evidence for interventions in acute hospitals including (i) hospital-patient discharge to home, community services or other settings, (ii) hospital discharge to another care setting, and (iii) reduction or prevention of inappropriate hospital (re)admissions. Academic electronic databases were searched from 2005 to 2018. In total, ninety-four eligible papers were included. Interventions were categorized into: (1) pre-discharge exclusively delivered in the acute care hospital, (2) pre- and post-discharge delivered by acute care hospital, (3) post-discharge delivered at home and (4) delivered only in a post-acute facility. Mixed results were found regarding the effectiveness of many types of interventions. Interventions exclusively delivered in the acute hospital pre-discharge and those involving education were most common but their effectiveness was limited in avoiding (re)admission. Successful pre- and post-discharge interventions focused on multidisciplinary approaches. Post-discharge interventions exclusively delivered at home reduced hospital stay and contributed to patient satisfaction. Existing systematic reviews on tele-health and long-term care interventions suggest insufficient evidence for admission avoidance. The most effective interventions to avoid inappropriate re-admission to hospital and promote early discharge included integrated systems between hospital and the community care, multidisciplinary service provision, individualization of services, discharge planning initiated in hospital and specialist follow-up.

Identification of community-dwelling older adults at risk of frailty using the PERSSILAA screening pathway: a methodological guide and results of a large-scale deployment in the Netherlands.

BACKGROUND: Among community-dwelling older adults, frailty is highly prevalent and recognized as a major public health concern. To prevent frailty it is important to identify those at risk of becoming frail, but at present, no accepted screening procedure is available. METHODS: The screening process developed as part of the PERSSILAA project is a two-step screening pathway. First, older adults are asked to complete a self-screening questionnaire to assess their general health status and their level of decline on physical, cognitive and nutritional domains. Second, older adults who, according to step one, are at risk of becoming frail, are invited for a face-to-face assessment focusing on the domains in depth. We deployed the PERSSILAA screening procedure in primary care in the Netherlands. RESULTS: In total, baseline data were available for 3777 community-dwelling older adults (mean age 69.9 (SD ± 3.8)) who completed first step screening. Based on predefined cut-off scores, 16.8% of the sample were classified as frail (n = 634), 20.6% as pre-frail (n = 777), and 62.3% as robust (n = 2353). Frail subjects were referred back to their GP without going through the second step. Of the pre-frail older adults, 69.7% had evidence of functional decline on the physical domain, 67% were overweight or obese and 31.0% had evidence of cognitive decline. CONCLUSION: Pre-frailty is common among community-dwelling older adults. The PERSSILAA screening approach is a multi-factor, two-step screening process, potentially useful for primary prevention to identify those at risk of frailty and who will benefit most from preventive strategies.

Screening for cognitive impairment in an Australian aged care assessment team as part of comprehensive geriatric assessment.

Accurate detection of mild cognitive impairment (MCI) is important to stratify and address risk. Yet, few short cognitive screening instruments are validated for this. . In Australia, all clients referred to an Aged Care Assessment Team (ACAT) receive comprehensive geriatric assessment (CGA) including the Standardized Mini-Mental State Examination (SMMSE). We compared the accuracy of the quick mild cognitive impairment (Qmci) screen to the SMMSE in 283 participants: 195 with dementia, 47 with MCI, and 41 with subjective cognitive decline (SCD) in an Australian community-based ACAT. Both had similar accuracy in identifying dementia, AUC of 0.86 for the Qmci versus 0.93 for the SMMSE (p = 0.10), but the Qmci was more accurate than the SMMSE in differentiating MCI from SCD, AUC of 0.84 versus 0.71, respectively, p = 0.046. These suggest that the new, short (3-5 min) Qmci screenis appropriate for use in an ACAT or other units conducting CGA.

Comparison of the Quick Mild Cognitive Impairment (Qmci) screen to the Montreal Cognitive Assessment (MoCA) in an Australian geriatrics clinic.

INTRODUCTION: The Montreal Cognitive Assessment (MoCA) accurately differentiates mild cognitive impairment (MCI) from mild dementia and normal controls (NC). While the MoCA is validated in multiple clinical settings, few studies compare it with similar tests also designed to detect MCI. We sought to investigate how the shorter Quick Mild Cognitive Impairment (Qmci) screen compares with the MoCA. METHODS: Consecutive referrals presenting with cognitive complaints to a teaching hospital geriatric clinic (Fremantle, Western Australia) underwent a comprehensive assessment and were classified as MCI (n = 72) or dementia (n = 109). NC (n = 41) were a sample of convenience. The Qmci and MoCA were scored by trained geriatricians, in random order, blind to the diagnosis. RESULTS: Median Qmci scores for NC, MCI and dementia were 69 (+/-19), 52.5 (+/-12) and 36 (+/-14), respectively, compared with 27 (+/-5), 22 (+/-4) and 15 (+/-7) for the MoCA. The Qmci more accurately identified cognitive impairment (MCI or dementia), area under the curve (AUC) 0.97, than the MoCA (AUC 0.92), p = 0.04. The Qmci was non-significantly more accurate in distinguishing MCI from controls (AUC 0.91 vs 0.84, respectively = 0.16). Both instruments had similar accuracy for differentiating MCI from dementia (AUC of 0.91 vs 0.88, p = 0.35). At the optimal cut-offs, calculated from receiver operating characteristic curves, the Qmci (≤57) had a sensitivity of 91% and specificity of 93% for cognitive impairment, compared with 87% sensitivity and 80% specificity for the MoCA (≤23). CONCLUSION: While both instruments are accurate in detecting MCI, the Qmci is shorter and arguably easier to complete, suggesting that it is a useful instrument in an Australian geriatric outpatient population. Copyright © 2016 John Wiley & Sons, Ltd.

Assessment of frailty in community-dwelling older adults residents in the Lazio region (Italy): A model to plan regional community-based services.

PURPOSE OF THE STUDY: The prevalence of frailty is expected to increase worldwide in parallel with demographic ageing. Despite this, little is known about the prevalence in different populations particularly community-based samples. This cross-sectional study evaluates the prevalence of frailty in a community-dwelling older adult population and describes a methodology to plan community-based interventions. METHODOLOGY: A random sample of 1331 older adults, resident in the Lazio-Region of Italy, were screened by trained public health nurses (PHNs) by administering a validated questionnaire (the Functional Geriatric Evaluation questionnaire). Prevalence of frailty was calculated using the Final Synthetic Score derived from the questionnaire's Final Score. Variables associated with frailty were selected through univariate and multivariate statistical analysis. RESULTS: Prevalence of frail (FS≥10,≤50) and very frail (FS<10) individuals was 13.9% and 7.6% respectively. Variables associated with frailty were age (older than 85 years), disability, living alone or the presence of a paid carer, lower education and neurological disorders like stroke, dementia, Parkinson disease and other neuropsychiatric diseases; Anaemia or cancer were also associated with a higher prevalence of frailty. DISCUSSION: The study provide a comprehensive picture of the prevalence of frailty and factors associated to this condition in community-dwelling older adults. On the basis of the study results, a plan of community-based services could address the needs of care of the elderly population. A trained team of PHNs may be the most appropriate personnel to carry out multidimensional frailty assessment in this setting.

Economic (gross cost) analysis of systematically implementing a programme of advance care planning in three Irish nursing homes.

BACKGROUND: Although advance care planning (ACP) and the use of advanced care directives (ACD) and end-of-life care plans are associated with a reduction in inappropriate hospitalisation, there is little evidence supporting the economic benefits of such programmes. We assessed the economic impact (gross savings) of the Let Me Decide (LMD) ACP programme in Ireland, specifically the impact on hospitalisations, bed days and location of resident deaths, before and after systematic implementation of the LMD-ACP combined with a palliative care education programme. METHODS: The LMD-ACP was introduced into three long-term care (LTC) facilities in Southern Ireland and outcomes were compared pre and post implementation. In addition, 90 staff were trained in a palliative care educational programme. Economic analysis including probabilistic sensitivity analysis was performed. RESULTS: The uptake of an ACD or end-of-life care post-implementation rose from 25 to 76%. Post implementation, there were statistically significant decreases in hospitalisation rates from baseline (hospitalisation incidents declined from 27.8 to 14.6%, z = 3.96, p < 0.001; inpatient hospital days reduced from 0.54 to 0.36%, z = 8.85, p < 0.001). The percentage of hospital deaths also decreased from 22.9 to 8.4%, z = 3.22, p = 0.001. However, length of stay (LOS) increased marginally (7-9 days). Economic analysis suggested a cost-reduction related to reduced hospitalisations ranging between €10 and €17.8 million/annum and reduction in ambulance transfers, estimated at €0.4 million/annum if these results were extrapolated nationally. When unit costs and LOS estimates were varied in scenario analyses, the expected cost reduction owing to reduced hospitalisations, ranged from €17.7 to €42.4 million nationally. CONCLUSIONS: Implementation of the LMD-ACP (ACD/end-of-life care plans combined with palliative care education) programme resulted in reduced rates of hospitalisation. Despite an increase in LOS, likely reflecting more complex care needs of admitted residents, gross costs were reduced and scenario analysis projected large annual savings if these results were extrapolated to the wider LTC population in Ireland.

Which Part of a Short, Global Risk Assessment, the Risk Instrument for Screening in the Community, Predicts Adverse Healthcare Outcomes?

The Risk Instrument for Screening in the Community (RISC) is a short, global risk assessment to identify community-dwelling older adults' one-year risk of institutionalisation, hospitalisation, and death. We investigated the contribution that the three components of the RISC (concern, its severity, and the ability of the caregiver network to manage concern) make to the accuracy of the instrument, across its three domains (mental state, activities of daily living (ADL), and medical state), by comparing their accuracy to other assessment instruments in the prospective Community Assessment of Risk and Treatment Strategies study. RISC scores were available for 782 patients. Across all three domains each subtest more accurately predicted institutionalisation compared to hospitalisation or death. The caregiver network's ability to manage ADL more accurately predicted institutionalisation (AUC 0.68) compared to hospitalisation (AUC 0.57, P = 0.01) or death (AUC 0.59, P = 0.046), comparing favourably with the Barthel Index (AUC 0.67). The severity of ADL (AUC 0.63), medical state (AUC 0.62), Clinical Frailty Scale (AUC 0.67), and Charlson Comorbidity Index (AUC 0.66) scores had similar accuracy in predicting mortality. Risk of hospitalisation was difficult to predict. Thus, each component, and particularly the caregiver network, had reasonable accuracy in predicting institutionalisation. No subtest or assessment instrument accurately predicted risk of hospitalisation.