Study protocol of a randomised controlled trial to examine the impact of a complex intervention in pre-frail older adults.

BACKGROUND: Frailty is a multidimensional geriatric syndrome associated with functional loss. The Senior Chef (SC, nutrition) and SAYGO (strength and balance exercise) programmes are well accepted among older adults but the impact of each, or a combination of both, on the frailty syndrome in pre-frail older adults is unknown. AIMS: To determine the effectiveness and cost-effectiveness of a complex intervention consisting of the SC and/or SAYGO programmes to prevent progression of frailty in pre-frail older adults. METHODS: A multi-centre randomised controlled assessor-blinded study. The four intervention groups are SC, an 8-week nutrition education and cooking class; SAYGO, a 10-week strength and balance exercise class; SC plus SAYGO, and a social group (Control). Community-dwelling adults aged 75+ (60 + Maori and Pasifika) in New Zealand are recruited through health providers. Participants are not terminally ill or with advanced dementia, and have a score of 1 or 2 on the FRAIL questionnaire. Baseline assessments are completed using standardised questionnaires prior to randomisation. Four follow-up assessments are completed: immediately after intervention, 6, 12 and 24 months post-intervention. The primary outcome is frailty score, secondary outcomes are falls, physical function, quality of life, food intake, physical activity, and sustainability of the strategy. Study outcomes will be analysed using intention-to-treat approach. Cost analyses will be completed to determine if interventions are cost effective relative to the control group. DISCUSSION: This trial is designed to be a real world rigorous assessment of whether the two intervention strategies can prevent progression of frailty in older people. If successful, this will generate valuable information about effectiveness of this nutrition and exercise strategy, and provide insights for their implementation. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry number-ACTRN12614000827639.

Progress towards predicting 1-year mortality in older people living in residential long-term care.

BACKGROUND: frail older people living in residential long-term care (LTC) have limited life expectancy. Identifying those with poor prognosis may improve management and facilitate transition to a palliative approach to care. OBJECTIVE: to develop methods for predicting mortality in LTC. DESIGN: a population-based cohort study. SETTING: LTC facilities, Auckland, New Zealand. SUBJECTS: five hundred randomly selected older people in a census-type survey of those living in LTC in 2008. METHODS: mortality data were obtained from New Zealand Ministry of Health. Two methods for assessing mortality risk were developed using demographic, functional and health service information: (i) two geriatricians blinded to identifying data and to mortality, independently reviewed survey, medications and pre-survey hospitalisations data, and grouped residents according to perceived risk of death within 12 months; (ii) multivariate logistic regression model used the same survey and medication items as the geriatricians. RESULTS: for the geriatricians' assessment, each quintile of perceived risk was associated with a significant increase in mortality (P < 0.001). Area under the curve (AUC) for both physicians was 0.64. The logistic regression model included age, gender, assistance with feeding and requiring night attention, all variables which are easily available from LTC records. AUC for the model was 0.70, but when validated against the entire OPAL cohort, it was 0.65. When either or both geriatrician and the model together predicted high risk of death, 1-year mortality was >50%. CONCLUSION: two methods with the potential to identify older people with limited prognosis are described. Use of these methods allowed identification of over half of those who died within 12 months.

Readmissions to hospital in a frail older cohort receiving a community-based transitional care service.

AIMS: To investigate frequency of and reasons for hospital readmission in a frail older cohort receiving a community-based, multidisciplinary, transitional care service. METHODS: A prospective cohort study with descriptive analysis of reasons for readmission in a cohort of frail older people discharged from hospital with the service. Measures of frailty, comorbidity, cognition, quality of life and function were recorded at discharge. Readmissions were recorded within three months after index discharge. Discharge summaries were reviewed and reasons for readmission categorised. Outcomes following readmission were recorded. RESULTS: Readmission rates were high (42%) in our cohort, despite the intervention. People readmitted had worse functional ability and a greater burden of comorbidities. Half of the readmissions were classified as being new, acute medical problems requiring inpatient treatment, and a quarter as exacerbations of chronic medical problems. Eighty-six percent of those readmitted were able to return home following their readmission. CONCLUSIONS: Our study showed high readmission rates despite the community supports. This high readmission rate does not imply failure of the intervention as the majority of these were with new or acute medical problems requiring inpatient treatment which were not preventable. Most were able to recover and return to their own homes.

Telephone discharge support for frail, vulnerable older people discharged from hospital: Impact on readmission rates - Participant and general practitioner feedback.

OBJECTIVE: To assess the use and acceptability to older participants and general practitioners (GPs) of telephone support postdischarge to reduce readmissions. METHODS: A prospective cohort study of older people after discharge from a specialist geriatric unit, and comparison with a previous cohort. Telephone follow-up calls were made fortnightly for three months. Structured questionnaires were used to obtain feedback from participants and GPs. RESULTS: Readmission rates were high, 40%, despite the intervention. This rate had significantly increased since the earlier cohort. Almost one-fifth of the sample (19%) were readmitted before the first telephone call. Subsequent readmissions were not related to whether participants had reported deteriorating health during the preceding telephone call. Feedback on the intervention from both participants and GPs was supportive. CONCLUSIONS: Telephone follow-up as we used it did not reduce readmission rates. However, it was well received and appreciated by participants. It is possible the telephone calls were not made early enough or frequently enough to achieve the desired outcome.

Medication use and potentially inappropriate medications in those with limited prognosis living in residential aged care.

AIM: To compare the prevalence in residential aged care (RAC) of preventative and potentially inappropriate medications (PIMs) in those who died within 12 months versus those alive after 12 months. METHODS: Firstly, a cross-sectional survey of 6196 people living in RAC in Auckland. Secondly, a research physician searched electronic hospital records in one District Health Board for a sub-sample (n = 222) of these residents. Classes of medications and dates of death were obtained from the Ministry of Health databases. Those who died versus those alive at 12 months were compared. RESULTS: Over half of the 6196 participants received antihypertensives and/or antiplatelet agents. Cardiovascular preventative medications were significantly more common in those who died within 12 months. Seventy percent in high-level care received psychotropics. PIMs were commonly used. CONCLUSIONS: Use of preventative medications is common in RAC, especially during the last year of life. Psychotropics are very commonly used, despite being potentially inappropriate.

Perceived factors which shape decision-making around the time of residential care admission in older adults: a qualitative study.

AIM: To understand the perceived factors that shape decision-making around the time of residential care admission in older people. METHOD: Two qualitative methods (telephone interviews at intervals post discharge from geriatric inpatient care and face-to-face interviews with older people and their family carers) were used as part of a multiphase mixed methods study of a cohort of 144 older people discharged from medical wards in a subacute assessment, treatment and rehabilitation facility. RESULTS: Key topics and themes were derived from interviews: the role of the informal carer and other community supports, attitudes to decision-making and loneliness were key aspects of social context. Physical health, the experience of repeated hospital admissions and health professionals' attitudes to repeated admissions were also seen as important. CONCLUSIONS: Social context as an essential component of older people's decisions to enter aged residential care is highlighted in this qualitative study.

Impacts of the emergency mass evacuation of the elderly from residential care facilities after the 2011 Christchurch earthquake.

OBJECTIVE: The 2011 earthquake that devastated Christchurch, New Zealand, led to the closure and evacuation of 7 residential care facilities and the partial evacuation of 2 more. Altogether, 516 elderly persons were evacuated. The emergent nature of the disaster was unexpected and largely unplanned for. This study explored the evacuees' experiences and identified lessons learned for future disaster planning. METHODS: This qualitative study used a general inductive method. Semistructured interviews with evacuees were held in 4 centers throughout New Zealand. Their informal caregivers were also identified and interviewed. Answers were coded and grouped for key themes to provide lessons learned for future disaster planning. RESULTS: We conducted 50 interviews with older people and 34 with informal caregivers. Key themes that emerged were resilience and factors that promoted resilience, including personal attitudes, life experiences, enhanced family support, and social supports. Areas of concern were (1) the mental health of evacuees: 36% reported some symptoms of anxiety, while 32.4% of caregivers reported some cognitive decline; and (2) communication difficulties during the evacuations. CONCLUSIONS: Older people were remarkably resilient to the difficult events, and resilience was promoted by family and community support. Anxiety was reported by older people, while informal caregivers reported cognitive issues. Communication difficulties were a major concern.

Frailty: dominos or deliberation?

Frailty is a common, but under-described, condition in older people, that is now better understood thus aiding better identification and treatment. It is characterised by multisystem deterioration and loss of physiological reserve to cope with insults. The traditional physical phenotype of frailty comprises 5 key findings: weakness, sarcopaenia, weight loss, physical inactivity, and slowness (which are also modulated by psychosocial factors). Several inflammatory, endocrine and nutritional markers have been proposed as contributory, although cause-and-effect is not clear. Predisposing factors are early childhood development and lifestyle, followed by physical inactivity, chronic disease, and anorexia/ malnutrition in later adulthood. These may form a cycle of deterioration. Frailty predisposes to marked decline in physical and mental function resulting from even apparently small insults. This commonly manifests as a "domino" effect, with a small initial insult leading to a cascade of adverse events. Several interventions have been shown to be helpful for frail older adults including exercise programs, nutritional support, maximising function prior to a planned interventions such as surgery, and early intervention when an acute insult threatens independence. Specialist geriatric assessment and management identifies and treats unstable medical conditions, reviews polypharmacy, facilitates early mobilisation, offers nutritional support, and assesses social circumstances. Frail older people in whom function has been compromised may be labelled as "unable to cope" but in fact many benefit from early comprehensive geriatric assessment to enable them to regain lost function.