City Government's Adoption of Housing Adaptation Policy Innovation for Older Adults: Evidence From China.

OBJECTIVES: Utilizing policy innovation and diffusion theory, this study aims to explain why city governments adopt housing adaptation policies that primarily benefit older people based on the case of China. METHODS: The data are drawn from an event history data set of a housing adaptation policy for older people collected from 283 Chinese cities from 2010 to 2018. Piecewise constant exponential models are utilized. RESULTS: The results indicate that cities facing greater internal pressure and a higher political status are more likely to adopt a housing adaptation policy for older people. Policy adoption by neighboring cities could further facilitate this process. DISCUSSION: Policy innovation and diffusion theory provide a useful framework for this study. That is, the Chinese city government's adoption of housing adaptation policy for older adults is initially driven by local needs and then accelerated by interactions among neighboring governments.

Trends in the Use of Residential Settings Among Older Adults.

OBJECTIVES: As the U.S. population ages, the prevalence of disability and functional limitations, and demand for long-term services and supports (LTSS), will increase. This study identified the distribution of older adults across different residential settings, and how their health characteristics have changed over time. METHODS: A cross-sectional analysis of older adults residing in traditional housing, community-based residential facilities (CBRFs), and nursing facilities using 3 data sources: the Medicare Current Beneficiary Survey (MCBS), 2008 and 2013; the Health and Retirement Study (HRS), 2008 and 2014; and the National Health and Aging Trends Study, 2011 and 2015. We calculated the age-standardized prevalence of older adults by setting, functional limitations, and comorbidities and tested for health characteristics changes relative to the baseline year (2002). RESULTS: The proportion of older adults in traditional housing increased over time, relative to baseline (p < .05), while the proportion of older adults in CBRFs was unchanged. The proportion of nursing facility residents declined from 2002 to 2013 in the MCBS (p < .05). The prevalence of dementia and functional limitations among traditional housing residents increased, relative to the baseline year in the HRS and MCBS (p < .05). DISCUSSION: The proportion of older adults residing in traditional housing is increasing, while the nursing facility population is decreasing. This change may not be due to better health; rather, older adults may be relying on noninstitutional LTSS.

Real-World Treatment Patterns and Characteristics Among Patients with Agitation and Dementia in the United States: Findings from a Large, Observational, Retrospective Chart Review.

BACKGROUND: Few studies have examined patient characteristics and treatment patterns among patients with dementia and agitation in the United States (US). OBJECTIVE: To examine real-world treatment patterns and characteristics of patients with agitation related to dementia who were treated with antipsychotics in US residential care and community-based settings. METHODS: This retrospective chart review collected US physician-level data from patients 55 to 90 years old initiated on an antipsychotic medication for the treatment of agitation related to dementia from January 2018 to May 2018. Clinical characteristics and treatment patterns were assessed overall and stratified by residential care and community-based settings. RESULTS: A total of 313 participating physicians, 59.5% of whom were primary care physicians, abstracted 801 patient charts (residential care: n = 312; community-based: n = 489). Of patients with agitation who were initiated on an antipsychotic, most patients (74.5%) were initiated within 3 months of the onset of their studied agitation episode, and 62.8% experienced multiple agitation episodes before initiation. While non-pharmacological therapies are recommended first-line approach for agitation in dementia, use of non-pharmacological therapy before initiation of antipsychotics was reported for only 37.8% of patients in residential care and 21.3% in community-based settings. CONCLUSION: Most patients were initiated on an antipsychotic treatment after multiple episodes of agitation and largely without initial non-pharmacological therapy, suggesting that current treatment guideline recommendations for first-line non-pharmacological intervention may not be adequately followed in clinical practice. Understanding the clinical burden and treatment patterns among dementia patients with agitation is imperative for effective disease management.

Development and Psychometrics Test of Home Environment Assessment Checklist for Community-Dwelling Older Adults with Dementia.

BACKGROUND: Home environment is a core domain in the care of community-dwelling older adults with dementia, but there is no suitable instrument to measure it in China. OBJECTIVE: To develop and psychometrically test the home environment assessment checklist for community-dwelling older adults with dementia. METHODS: A three-step process was performed to develop and test this instrument: 1) based on the evidence-based theory, the checklist was summarized as the main points of evidence from living environment settings among older adults with dementia, 2) the draft tool was assigned to an iterative process of evaluation by a panel of examiners consisting of experts from treatment, nursing and caring, people with dementia and their caregivers, 3) inter-rater reliability and internal consistency were calculated with a sample of 348 caregivers of the older adults with dementia. RESULTS: The HEAC consisted of 71 items in domains addressing safety, stability and familiarity, visual cues, and sensory stimulation. Psychometric evaluation showed that this tool demonstrated sound reliability and validity. Content validity was 0.969 which was established by a panel of experts (n = 10). Inter-rater reliability of two researchers was 0.978, and 0.848 for researchers and caregivers. Test-retest reliability was excellent (ICC = 0.757-0.877) in community-dwelling older adults with dementia 2 week apart. CONCLUSION: The HEAC is a new tool to help collect the reliable information on the barriers and facilitators of home environment for community-dwelling older adults with dementia and to precipitate the home modification process to improve the quality of care for people with dementia and their caregivers in daily life.

National Trends in Potentially Preventable Hospitalizations of Older Adults with Dementia.

BACKGROUND/OBJECTIVES: Dementia is associated with higher healthcare expenditures, in large part due to increased hospitalization rates relative to patients without dementia. Data on contemporary trends in the incidence and outcomes of potentially preventable hospitalizations of patients with dementia are lacking. DESIGN: Retrospective cohort study using the National Inpatient Sample from 2012 to 2016. SETTING: U.S. acute care hospitals. PARTICIPANTS: A total of 1,843,632 unique hospitalizations of older adults (aged ≥65 years) with diagnosed dementia. MEASUREMENTS: Annual trends in the incidence of hospitalizations for all causes and for potentially preventable conditions including acute ambulatory care sensitive conditions (ACSCs), chronic ACSCs, and injuries. In-hospital outcomes including mortality, discharge disposition, and hospital costs. RESULTS: The survey weighted sample represented an estimated 9.27 million hospitalizations for patients with diagnosed dementia (mean [standard deviation] age = 82.6 [6.7] years; 61.4% female). In total, 3.72 million hospitalizations were for potentially preventable conditions (40.1%), 2.07 million for acute ACSCs, .76 million for chronic ACSCs, and .89 million for injuries. Between 2012 and 2016, the incidence of all-cause hospitalizations declined from 1.87 million to 1.85 million per year (P = .04) while the incidence of potentially preventable hospitalizations increased from .75 million to .87 million per year (P < .001), driven by an increased number of hospitalizations of community-dwelling older adults. Among patients with dementia hospitalized for potentially preventable conditions, inpatient mortality declined from 6.4% to 6.1% (P < .001), inflation-adjusted median costs increased from $7,319 to $7,543 (P < .001), and total annual costs increased from $7.4 to $9.3 billion. Although 86.0% of hospitalized patients were admitted from the community, only 32.7% were discharged to the community. CONCLUSION: The number of potentially preventable hospitalizations of older adults with dementia is increasing, driven by hospitalizations of community-dwelling older adults. Improved strategies for early detection and goal-directed treatment of potentially preventable conditions in patients with dementia are urgently needed. J Am Geriatr Soc 68:2240-2248, 2020.

Medication exposure and frailty in older community-dwelling patients: a cross-sectional study.

Objective To investigate the association between the medication exposure, measured by the polypharmacy/excessive polypharmacy and the anticholinergic and/or sedative drug exposure, on frailty status among French older community-dwelling patients. Setting day-care unit in France (Lyon), with retrospective data from July, 2017 to March, 2018. Method This monocentric cross-sectional study included community-dwelling patients aged 65 years and over and admitted at the day-care unit for a geriatric evaluation. Frailty was assessed according to the frailty phenotype, described by Fried et al. Polypharmacy and excessive polypharmacy were defined as the concomitant use of 5-9 and 10 or more drugs, respectively. The cumulative anticholinergic and sedative exposure was measured using the drug burden index (DBI). The DBI score was presented in 4 differentiated scores: a null score (DBI = 0), a combined score (anticholinergic and sedative score), an anticholinergic score, and a sedative score. The association between medication and frailty was assessed by logistic regression models controlled for multiple potential confounders. Main outcome measure Association between medication exposure (polypharmacy, anticholinergic and sedative exposure) and frailty. Results In this study, 403 patients were included: 44.7% were frail and 40.7% were pre-frail. Polypharmacy and excessive polypharmacy affected 44.7% and 17.1% of the population respectively. The mean DBI was 0.33 ± 0.43, with 16.4% of patients with only sedative exposure, 9.7% with only anticholinergic exposure and 33.0% with both exposures. After adjustment, polypharmacy and excessive polypharmacy were associated with frailty with adjusted odds ratios (95% confidence interval) of 2.18 (1.03-4.22) and 2.72 (1.01-7.37) respectively. The cumulative exposure to anticholinergic and sedative drugs (combined score) was significantly associated to an increased risk for frailty with adjusted odds ratios (95% confidence interval) of 3.54 (1.47-8.57). Conclusion The study showed that polypharmacy and cumulative anticholinergic and sedative exposure are associated with frailty. Further research should address the potential benefit of collaborative medication review for preventing medication-associated frailty.

Redistributing medical resources for a bypass strategy for large vessel occlusion: a community-based study.

BACKGROUND: A bypass strategy for large vessel occlusion (LVO) benefits patients receiving endovascular thrombectomy (EVT), but may delay some patients from receiving IV thrombolysis. However, patient centralization has been shown to improve outcomes. OBJECTIVE: To understand the current coverage of medical services for patients with stroke, and to identify the best coverage under different medical resource redistribution to help balance medical equality and patient centralization. METHODS: This 6-year geographic study of 7679 on-scene patients with suspected stroke with a positive Cincinnati Prehospital Stroke Scale (CPSS) score identified 4037 patients with all three CPSS items who were suspected as having an LVO. Geographic, population, and patient coverage rates for hospitals providing IV thrombolysis and those providing EVT were identified according to hospital service areas, defined as geographic districts with access to a hospital within a ≤15 min off-peak driving time estimated using Google Maps. Moreover, we estimated the effects on resource redistribution when implementing a bypass strategy. RESULTS: Geographic coverage rates for hospitals providing IV thrombolysis and those providing EVT were 64.75% and 56.62%, respectively, and population coverage rates were 97.30% and 92.72%, respectively. The service areas of hospitals providing IV thrombolysis covered 93.77% of patients with suspected stroke, and those of hospitals providing EVT covered 87.89% of patients with suspected LVO. The number of hospitals providing IV thrombolysis and those providing EVT could be reduced to six and two hospitals, respectively, without affecting hospital arrival time when implementing a bypass strategy. CONCLUSION: Hospitals providing IV thrombolysis and EVT could be reduced without reducing medical equality.

Psychometric Validation of the Brief Alcohol Social Density Assessment in an Adult Community Sample.

BACKGROUND: Individuals' social networks exert a strong influence on alcohol use, but valid assessment of network drinking behavior is typically lengthy and high in participant burden. The aim of this study was to validate the Brief Alcohol Social Density Assessment (BASDA), an efficient measure of perceived alcohol use within a person's social network, in a sample of adult drinkers from the general community. Specifically, the convergent, criterion-related, incremental validity and internal validity were investigated by examining the BASDA in relation to other established measures of drinking motives, weekly drinking level, and severity of involvement. METHODS: Participants were 903 (56% female) adults who reported drinking in the last year and who completed the BASDA, the Drinking Motives Questionnaire, the Daily Drinking Questionnaire, and the Alcohol Use Disorders Identification Test (AUDIT). RESULTS: Significant positive correlations were found between the BASDA and drinking motives, drinking quantity, and the AUDIT (rs = 0.21 to 0.51, ps < 0.001), providing support for convergent validity. There was a significantly higher BASDA score for those scoring at or above an AUDIT cutoff for hazardous drinking (p < 0.001), providing support for criterion-related validity. Finally, beyond motives and covariates, the BASDA was significantly associated with total AUDIT score (ΔR2  = 0.09, p < 0.001), indicating its additive contribution and providing support for incremental validity. Confirmatory factor analysis revealed excellent fit, and all items significantly loaded onto a single factor (p < 0.0001), providing evidence of internal validity. The resulting alcohol social density latent variable was significantly and robustly associated with drinks per week and AUDIT total score. CONCLUSIONS: These findings provide further support for the BASDA as a valid and efficient measure of social network alcohol density for understanding social influences on alcohol misuse.

Fall-related emergency department visits and hospitalizations among community-dwelling older adults: examination of health problems and injury characteristics.

BACKGROUND: Fall injuries and related healthcare use among older adults are increasing in the United States. This study examined chronic illnesses, sensory and memory problems, and injury characteristics that were associated with ED visits and hospitalizations among older adults who received medical attention for fall injuries within a 91-day reference period. METHODS: Data were from the publicly available 2013-2017 US National Health Interview Survey files (unweighted N = 1840 respondents aged > 60 years with fall injuries). We first described socioeconomic, health/mental health, healthcare utilization, and injury characteristics among three groups: those who neither visited an ED nor were hospitalized for their fall injury, those who visited an ED only, and those who were hospitalized. Then, using multinomial logistic regression analysis, we examined associations of healthcare utilization (ED visit only and hospitalization vs. no ED visit/hospitalization) with chronic illnesses, other health problems, and injury characteristics, controlling for socioeconomic factors. RESULTS: Of older adults who received medical attention for fall injuries, a little more than one-third had an ED visit only and a little less than a fifth had an overnight hospital stay. Multivariable analysis showed that lung disease and memory problems were associated with higher risk of ED visit only; hip and head injuries, facial injuries, and broken bones/fractures (from any type of injury) were more likely to result in hospitalization than other injuries. Fall injuries sustained inside the home, falls from loss of balance/dizziness, and living alone were also more likely to result in hospitalization. CONCLUSIONS: These healthcare utilization findings indicate the significant toll that fall injuries exact on older adults and healthcare systems. Fall prevention should target risk factors that are specific to serious injuries requiring costly care. Strategies for implementing scalable, adaptable, and measurable fall prevention models by primary care and emergency medical service providers and ED staff are needed.

Age group differences in association between IADL decline and depressive symptoms in community-dwelling elderly.

BACKGROUND: Instrumental Activities of Daily Living (IADL) is an indicator of whether a community-dwelling elderly can live independently. IADL decline was reported to be associated with aging and depression. The present study aimed to investigate whether the association between IADL decline and depressive symptoms differs with aging, using two age groups of community-dwelling Japanese elderly in their 70s and 80s. METHODS: We conducted longitudinal analysis among participants in their 70s and 80s at the baseline from Septuagenarians, Octogenarians, Nonagenarians Investigation with Centenarians (SONIC) study. IADL was assessed by The Tokyo Metropolitan Institute of Gerontology (TMIG) index of competence. As a main predictor, depressive symptoms were measured by the five-item version of the Geriatrics Depression Scale (GDS-5). As possible confounders, we considered cognitive function, body mass index, solitary living, education, economic status, medical history of stroke and heart disease, hypertension, dyslipidemia, diabetes, and sex. We obtained odds ratios (ORs) of IADL decline for having depressive symptoms in each age group (70s/80s) and tested interactions between depressive symptoms and age groups in relation to IADL decline in 3 years by logistic regression. Additionally, to confirm age group differences, we conducted multiple group analysis. RESULTS: There were 559 participants in their 70s and 519 in their 80s. Compared to participants without depressive symptoms, those with depressive symptoms had higher OR of IADL decline in 70s (OR [95% CI] = 2.33 [1.13, 4.78]), but not in 80s (OR [95% CI] = 0.85 [0.46, 1.53]). There were significant interactions between depressive symptoms and age groups in relation to IADL decline (p-value = 0.03). Multiple group analyses showed differences between the age groups by Akaike information criterion (AIC), and ORs (95%CI) decline for depressive symptoms was 2.33 (1.14, 4.77) in 70s and 0.85 (0.47, 1.54) in 80s. CONCLUSION: The association of depressive symptoms and IADL decline during the 3 years was significantly different between the 70s and 80s age groups, and significant association was found only in people in their 70s. Detecting depressive symptoms may be a key for preventing IADL decline in people in their 70s and not for those in their 80s.

Objective and perceived food environment and household economic resources related to food insecurity in older adults living alone in rural areas.

BACKGROUND: Limited attention has been paid to an association between food environment and household economic resources related to food expenditure in food-insecure seniors. The aim of the study was to investigate the relationship between factors of economic resource, food environment, and food insecurity in single seniors residing in rural areas of South Korea. METHODS: A cross-sectional study was conducted in 170 single senior households aged 65 years or over residing in rural areas. Face-to-face interviews were performed to collect data on demographic characteristics, household economic resources/expenditure, food environmental factors, and food insecurity. RESULTS: Among economic resources, generally limited food expenditures due to housing fees and heating costs during the winter were positively related to food insecurity. Among food environmental factors, food accessibility at community level such as food stores located far from home and inconvenient bus routes was related to food insecurity. The most explainable economic and food environment factors related to food insecurity by stepwise logistic regression analysis were the percentage of total expenditure on housing fee (OR = 1.021, 95% CI: 1.008-1.034), foods purchasing at super supermarket (OR = 0.398, 95% CI: 0.166-0.951), having difficulties in food purchasing due to food stores being located far from home (OR = 14.487, 95% CI: 5.139-40.842) and inconvenient bus routes (OR = 0.083, 95% CI: 0.015-0.460). CONCLUSION: Inadequate community food environment as well as limited household food resources were an important risk factor for food insecurity in Korean single rural seniors. Findings of this study could help us better understand how characteristics of household food resources and community food environment can serve as barriers or facilitators of food security among single older adults residing in rural areas.

Community-dwelling older adults' needs and acceptance regarding the use of robot technology to assist with daily living performance.

BACKGROUND: The rate of aging in Korea is extremely fast compared to major countries. We examined the key demands of community-dwelling older adults with regard to Connected Active Space technology, which provides tailored assistance with daily living performance through robotic services. METHODS: This study is based on a mixed-method design, through a quantitative survey (n = 234) first phase, followed by a qualitative study with focus group interviews (n = 23) to explore the needs and acceptance of community-dwelling aged people concerning the application of robot technology in their daily lives. RESULTS: The scores concerning the need for and acceptance of robot services to assist daily living performance were high, at 7.2 and 7.9 out of 10 points, respectively. Further, for both needs and acceptance, timely reaction to emergency situations, early detection of emergency situations, help to locate objects, assistance with mobility, and assistance in memory recall were prioritized (in that order). In a thematic analysis of qualitative data from three focus-group interviews, a 'mismatch between desires and functional capacity' was the core characteristic of living as an older person and 'being a friend and helper' was the most desired trait of a robot service. CONCLUSION: Although most of the participants lived independently, they regularly experienced difficulties regarding buying products, transportation, using phones, and preparing meals. If appropriate assistance technology is developed, this population can maintain its independence. Thus, it is necessary to address main needs, including detecting and addressing emergency situations, locating objects, assisting mobility and memory recall, and assisting with daily living performance. New robot services that can be tailored to the functions or abilities of the elderly must be developed based on individually collected information.

A parsimonious approach for screening moderate-to-profound hearing loss in a community-dwelling geriatric population based on a decision tree analysis.

BACKGROUND: Hearing loss is one of the most common modifiable factors associated with cognitive and functional decline in geriatric populations. An accurate, easy-to-apply, and inexpensive hearing screening method is needed to detect hearing loss in community-dwelling elderly people, intervene early and reduce the negative consequences and burden of untreated hearing loss on individuals, families and society. However, available hearing screening tools do not adequately meet the need for large-scale geriatric hearing detection due to several barriers, including time, personnel training and equipment costs. This study aimed to propose an efficient method that could potentially satisfy this need. METHODS: In total, 1793 participants (≥60 years) were recruited to undertake a standard audiometric air conduction pure tone test at 4 frequencies (0.5-4 kHz). Audiometric data from one community were used to train the decision tree model and generate a pure tone screening rule to classify people with or without moderate or more serious hearing impairment. Audiometric data from another community were used to validate the tree model. RESULTS: In the decision tree analysis, 2 kHz and 0.5 kHz were found to be the most important frequencies for hearing severity classification. The tree model suggested a simple two-step screening procedure in which a 42 dB HL tone at 2 kHz is presented first, followed by a 47 dB HL tone at 0.5 kHz, depending on the individual's response to the first tone. This approach achieved an accuracy of 91.20% (91.92%), a sensitivity of 95.35% (93.50%) and a specificity of 86.85% (90.56%) in the training dataset (testing dataset). CONCLUSIONS: A simple two-step screening procedure using the two tones (2 kHz and 0.5 kHz) selected by the decision tree analysis can be applied to screen moderate-to-profound hearing loss in a community-based geriatric population in Shanghai. The decision tree analysis is useful in determining the optimal hearing screening criteria for local elderly populations. Implanting the pair of tones into a well-calibrated sound generator may create a simple, practical and time-efficient screening tool with high accuracy that is readily available at healthcare centers of all levels, thereby facilitating the initiation of extensive nationwide hearing screening in older adults.

Impact of drug burden index on adverse health outcomes in Irish community-dwelling older people: a cohort study.

BACKGROUND: The Drug Burden Index (DBI) quantifies exposure to medications with anticholinergic and/or sedative effects. A consensus list of DBI medications available in Ireland was recently developed for use as a DBI tool. The aim of this study was to validate this DBI tool by examining the association of DBI score with important health outcomes in Irish community-dwelling older people. METHODS: This was a cohort study using data from The Irish Longitudinal Study on Ageing (TILDA) with linked pharmacy claims data. Individuals aged ≥65 years participating in TILDA and enrolled in the General Medical Services scheme were eligible for inclusion. DBI score was determined by applying the DBI tool to participants' medication dispensing data in the year prior to outcome assessment. DBI score was recoded into a categorical variable [none (0), low (> 0 and < 1), and high (≥1)]. Outcome measures included any Activities of Daily Living (ADL) impairment, any Instrumental Activities of Daily Living (IADL) impairment, any self-reported fall in the previous 12 months, any frailty criterion met (Fried Phenotype measure), quality of life (QoL) score (CASP-19 [Control Autonomy Self-realisation Pleasure] measure), and healthcare utilisation (any hospital admission and any emergency department (ED) visit) in the previous 12 months. Statistical analyses included multivariate logistic and linear regression models controlling for potential confounders. RESULTS: 61.3% (n = 1946) of participants received at least one DBI prescription in the year before their outcome assessment. High DBI exposure (DBI score ≥ 1) vs none was significantly associated with impaired function (ADL impairment adjusted OR 1.89, 95% CI 1.25, 2.88; IADL impairment adjusted OR 2.97, 95% CI 1.91, 4.61), self-reported falls (adjusted OR 1.50, 95%CI 1.03, 2.18), frailty (adjusted OR 1.74, 95% CI 1.14, 2.67), and reduced QoL (ß = - 1.84, 95%CI -3.14, - 0.54). There was no significant association between DBI exposure and healthcare utilisation. CONCLUSIONS: The findings validate the use of the DBI tool for predicting risk of functional impairment, falls, frailty and reduced QoL in older people in Ireland, and may be extended to other European countries. Integration of this tool into routine practice may be an appropriate step forward to improve outcomes in older people.

Prevalence of and factors associated with expressed and unmet service needs reported by persons with spinal cord injury living in the community.

STUDY DESIGN: Observational study. OBJECTIVES: To determine the prevalence, predictors, and consequences of self-reported service needs among community-dwelling persons with SCI. SETTING: Community-based, Switzerland. METHODS: Participants were 490 people who took part in the health services module of the Swiss Spinal Cord Injury Cohort Study (SwiSCI) 2012 community survey. We determined the prevalence of 20 service needs and the extent to which they were unmet. Predictors and consequences of service needs were examined with multiple regression analyses. RESULTS: High-prevalence needs (e.g., general health care, accessible housing) exhibited a high level of fulfillment. Conversely, less prevalent service needs (e.g., peer support, support for family caregivers) showed lower levels of fulfillment. Across three specific service domains (peer support, support for family caregivers, sports activities), lower household income predicted most consistently a higher likelihood of unmet needs. The total number of expressed needs was higher in non-Swiss nationals, persons with complete para- or tetraplegia and lower income individuals. Being female, French language region and lower household income predicted more total unmet needs. Increased expressed and unmet service needs were associated with lower life satisfaction. CONCLUSIONS: Service needs with a high prevalence seem to be adequately met by the current service provision system. However, rehabilitation professionals should remain alert to clients' specific and cumulative unmet needs, in particular with respect to less common ones, and their impact on successful community reintegration and life satisfaction.

Deprescribing interventions and their impact on medication adherence in community-dwelling older adults with polypharmacy: a systematic review.

BACKGROUND: Polypharmacy, and the associated adverse drug events such as non-adherence to prescriptions, is a common problem for elderly people living with multiple comorbidities. Deprescribing, i.e. the gradual withdrawal from medications with supervision by a healthcare professional, is regarded as a means of reducing adverse effects of multiple medications including non-adherence. This systematic review examines the evidence of deprescribing as an effective strategy for improving medication adherence amongst older, community dwelling adults. METHODS: A mixed methods review was undertaken. Eight bibliographic database and two clinical trials registers were searched between May and December 2017. Results were double screened in accordance with pre-defined inclusion/exclusion criteria related to polypharmacy, deprescribing and adherence in older, community dwelling populations. The Mixed Methods Appraisal Tool (MMAT) was used for quality appraisal and an a priori data collection instrument was used. For the quantitative studies, a narrative synthesis approach was taken. The qualitative data was analysed using framework analysis. Findings were integrated using a mixed methods technique. The review was performed in accordance with the PRISMA reporting statement. RESULTS: A total of 22 original studies were included, of which 12 were RCTs. Deprescribing with adherence as an outcome measure was identified in randomised controlled trials (RCTs), observational and cohort studies from 13 countries between 1996 and 2017. There were 17 pharmacy-led interventions; others were led by General Practitioners (GP) and nurses. Four studies demonstrated an overall reduction in medications of which all studies corresponded with improved adherence. A total of thirteen studies reported improved adherence of which 5 were RCTs. Adherence was reported as a secondary outcome in all but one study. CONCLUSIONS: There is insufficient evidence to show that deprescribing improves medication adherence. Only 13 studies (of 22) reported adherence of which only 5 were randomised controlled trials. Older people are particularly susceptible to non-adherence due to multi-morbidity associated with polypharmacy. Bio-psycho-social factors including health literacy and multi-disciplinary team interventions influence adherence. The authors recommend further study into the efficacy and outcomes of medicines management interventions. A consensus on priority outcome measurements for prescribed medications is indicated. TRIAL REGISTRATION: PROSPERO number CRD42017075315.

Trends in ageing and ageing-in-place and the future market for institutional care: scenarios and policy implications.

In several OECD countries the percentage of elderly in long-term care institutions has been declining as a result of ageing-in-place. However, due to the rapid ageing of population in the next decades future demand for institutional care is likely to increase. In this paper we perform a scenario analysis to examine the potential impact of these two opposite trends on the demand for institutional elderly care in the Netherlands. We find that the demand for institutional care first declines as a result of the expected increase in the number of low-need elderly that age-in-place. This effect is strong at first but then peters out. After this first period the effect of the demographic trend takes over, resulting in an increase in demand for institutional care. We argue that the observed trends are likely to result in a growing mismatch between demand and supply of institutional care. Whereas the current stock of institutional care is primarily focussed on low-need (residential) care, future demand will increasingly consist of high-need (nursing home) care for people with cognitive as well as somatic disabilities. We discuss several policy options to reduce the expected mismatch between supply and demand for institutional care.

Evaluating the social fitness Programme for older people with cognitive problems and their caregivers: lessons learned from a failed trial.

BACKGROUND: This process evaluation article describes the lessons learned from a failed trial which aimed to assess effectiveness of the tailor-made, multidisciplinary Social Fitness Programme to improve social participation of community-dwelling older people with cognitive problems (clients) and their caregivers (couples). METHODS: A process evaluation was performed to get insight in 1) the implementation of the intervention, 2) the context of intervention delivery from professionals' point of view, and 3) the potential impact of intervention delivery from participants' perspectives. Data was gathered using mixed-methods: questionnaires, focus group discussions, interviews, medical records. RESULTS: 1) Implementation. High study decline (65,3%) was mainly caused by a lack of internal motivation to increase social participation expressed by clients. 17 couples participated, however, intervention delivery was insufficient. 2) Context. Barriers during intervention delivery were most often related to client (changing needs), caregiver (increased burden) and health professional factors (delivery of integrated care lacked routine). 3) Impact Qualitative analyses revealed participants to be satisfied with intervention delivery, we were unable to capture these results through our primary outcome measure. CONCLUSIONS: This process evaluation revealed the Social Fitness study did not fit in three ways. First, framing the intervention on social participation promotion was as threatening to clients. The feeling of being unable to adequately contribute to social interactions seemed to be causing embarrassment. Second, the intervention seemed to be too complex to implement in the way it was designed. Third, there is a tension between the offering of a personalised tailor-made intervention and evaluation through a fixed study design. TRIAL REGISTRATION: The trial which is evaluated in this article (the Social Fitness study) is registered with the Dutch Trial Register (NTR), clinical trial number NTR4347 .

Interventions for frail community-dwelling older adults have no significant effect on adverse outcomes: a systematic review and meta-analysis.

BACKGROUND: According to some studies, interventions can prevent or delay frailty, but their effect in preventing adverse outcomes in frail community-dwelling older people is unclear. The aim is to investigate the effect of an intervention on adverse outcomes in frail older adults. METHODS: A systematic review and meta-analysis of Medline, Embase, the Cochrane Library, and Social Sciences Citation Index. Randomized controlled studies that aimed to treat frail community-dwelling older adults, were included. The outcomes were mortality, hospitalization, formal health costs, accidental falls, and institutionalization. Several sub-analyses were performed (duration of intervention, average age, dimension, recruitment). RESULTS: Twenty-five articles (16 original studies) were included. Six types of interventions were found. The pooled odds ratios (OR) for mortality when allocated in the experimental group were 0.99 [95% CI: 0.79, 1.25] for case management and 0.78 [95% CI: 0.41, 1.45] for provision information intervention. For institutionalization, the pooled OR with case management was 0.92 [95% CI: 0.63, 1.32], and the pooled OR for information provision intervention was 1.53 [95% CI: 0.64, 3.65]. The pooled OR for hospitalization when allocated in the experimental group was 1.13 [95% CI: 0.95, 1.35] for case management. Further sub-analyses did not yield any significant findings. CONCLUSION: This systematic review and meta-analysis does not provide sufficient scientific evidence that interventions by frail older adults can be protective against the included adverse outcomes. A sub-analysis for some variables yielded no significant effects, although some findings suggested a decrease in adverse outcomes. TRIAL REGISTRATION: Prospero registration CRD42016035429 .

Identifying and understanding the health and social care needs of older adults with multiple chronic conditions and their caregivers: a scoping review.

BACKGROUND: As the population is aging, the number of persons living with multiple chronic conditions (MCC) is expected to increase. This review seeks to answer two research questions from the perspectives of older adults with MCC, their caregivers and their health care providers (HCPs): 1) What are the health and social care needs of community-dwelling older adults with MCC and their caregivers? and 2) How do social and structural determinants of health impact these health and social care needs? METHODS: We conducted a scoping review guided by a refinement of the Arksey & O'Malley framework. Articles were included if participants were 55 years or older and have at least two chronic conditions. We searched 7 electronic databases. The data were summarized using thematic analysis. RESULTS: Thirty-six studies were included in this review: 28 studies included participants with MCC; 12 studies included HCPs; 5 studies included caregivers. The quality of the studies ranged from moderate to good. Five main areas of needs were identified: need for information; coordination of services and supports; preventive, maintenance and restorative strategies; training for older adults, caregivers and HCPs to help manage the older adults' complex conditions; and the need for person-centred approaches. Structural and social determinants of health such as socioeconomic status, education and access influenced the needs of older adults with MCC. CONCLUSION: The review highlights that most of the needs of older adults with MCC focus on lack of access to information and coordination of care. The main structural and social determinants that influenced older adults' needs were their level of education/health literacy and their socioeconomic status.