Population-based multidimensional assessment of older people in UK general practice: a cluster-randomised factorial trial.

BACKGROUND: The benefit of multidimensional assessment and management of older people remains controversial. Most trials have been too small to produce adequate evidence to inform policy. We aimed to measure the effects of different approaches to assessment and management of older people. METHODS: We undertook a cluster-randomised factorial trial in 106 general practices (43219 eligible patients aged 75 years and older, 78% participation), comparing (1) universal versus targeted assessment and (2) subsequent management by hospital outpatient geriatric team versus the primary-care team. All participants received a brief multidimensional assessment followed by a nurse-led in-depth assessment in the universal group, whereas in the targeted group the in-depth assessment was offered only to those with problems established at the brief assessment. Referrals to the randomised team (geriatric management or primary care), other medical or social services, health-care workers, or agencies, and emergency referrals to the general practitioner were based on a standard protocol at the in-depth assessment. The primary endpoints were mortality, admissions to hospital and institution, and quality of life. Analysis was by intention to treat and per protocol. This trial has been assigned the International Standardised Randomised Controlled Trial Number ISRCTN23494848. FINDINGS: Mortality and hospital or institutional admissions did not differ between groups. During 3 years' follow-up, significant improvements in quality of life resulted from universal versus targeted assessment in terms of homecare, and from management by geriatric team versus primary-care team, in terms of mobility, social interaction, and morale. However, only the result for social interaction was consistent with a small but important effect. INTERPRETATION: The different forms of multidimensional assessment offered almost no differences in patient outcome.

Prevalence of cognitive impairment: results from the MRC trial of assessment and management of older people in the community.

BACKGROUND: cognitive impairment is an important part of the diagnostic criteria for dementia. The Mini-Mental State Examination (MMSE) is recommended to test for cognitive impairment and to monitor medication response. OBJECTIVES: we examined the prevalence of cognitive impairment in the UK and assessed associations with cognitive impairment. DESIGN: cross-sectional survey as part of a cluster randomised trial. SUBJECTS: representative sample of people aged 75 years and over. METHODS: all subjects had a detailed baseline health assessment including the MMSE. RESULTS: a total of 15,051 subjects completed the assessment (71.9%). Almost two-thirds of subjects were female (61.5%) and almost half were aged between 75 and 79 years (47.0%). The prevalence of cognitive impairment was 18.3% (95% confidence intervals (CI) = 16.0-20.9) at a cut-off of 23/24, and 3.3% (95% CI = 2.8-4.0) at 17/18. Those with impairment (MMSE 23/24) were significantly more likely to have hearing (odds ratio (OR) 1.7), vision (OR 1.7) and urinary incontinence problems (OR 1.3), have two or more falls in the previous 6 months (OR 1.4), and report poorer health (OR 1.9). Almost half the participants lived alone (n = 7,073; 47.0%) and of these almost one-fifth were impaired (MMSE 23/24; 19.4%). CONCLUSIONS: there was a high prevalence of cognitive impairment. This representative sample demonstrates the potential burden of disease and service demands. It supports the need for a broader assessment of functioning as recommended by the National Service Framework for Older People, particularly in people with cognitive impairment.