RESUMO
BACKGROUND: Exercise interventions are highly effective at preventing falls in older people living in the community. In residential aged care facilities (RACFs), however, the evidence for effectiveness is highly variable, warranting exploration of drivers of successful trials. This study aims to identify the conditions of randomised controlled trials (RCTs) that are associated with reducing falls in RACFs and test whether it can explain the variability. METHODS: RCTs testing exercise interventions in RACFs compared to usual care, reporting rate or risk of falls from the 2018 Cochrane Collaboration review and a search update to December 2022 were included. Two authors independently extracted and coded trial conditions and outcomes according to a theory developed from prior Intervention Component Analysis. Trial outcomes were coded as successful or unsuccessful based on point estimates for the rate or risk ratio for falls, or p value. Qualitative Comparative Analysis (QCA), utilising Boolean minimisation theory, was conducted to determine the key conditions driving trial success. A subgroup meta-analysis and the GRADE approach was applied to the final theory. RESULTS: Eighteen trials undertaken in 11 countries with 2,287 residents were included. Participants were predominately ambulant females aged 70 to 80 with cognitive impairment. Most interventions were fully supervised or supervised at the start of the intervention. QCA identified two configurations as drivers of successful exercise falls prevention programs: (i) group exercise that is moderate or low intensity, or (ii) for independent ambulatory residents, exercise for more than 1 h per week. The combination of configuration (i) and (ii) had consistency and total coverage scores of 1, indicating all trials were explained. This combination was associated with a reduction in falls (rate ratio 0.45, 95%CI 0.34 to 0.59; risk ratio 0.66, 95%CI 0.53 to 0.82; low certainty evidence). CONCLUSION: To successfully reduce falls in RACFs, exercise programs should provide continuous supervised moderate-intensity group exercise. For programs that mostly include independent ambulatory residents, exercise for at least 80 min per week should be provided. As many current residents are frail, tailored exercise is likely necessary and an individualised dose may be required. Future trials should test exercise interventions for less mobile residents.
Assuntos
Acidentes por Quedas , Terapia por Exercício , Instituição de Longa Permanência para Idosos , Ensaios Clínicos Controlados Aleatórios como Assunto , Acidentes por Quedas/prevenção & controle , Humanos , Idoso , Terapia por Exercício/métodos , Ensaios Clínicos Controlados Aleatórios como Assunto/métodos , Idoso de 80 Anos ou mais , Feminino , MasculinoRESUMO
OBJECTIVE: The effect of fall prevention exercise programmes in residential aged care (RAC) is uncertain. This paper reports on an intervention component analysis (ICA) of randomised controlled trials (RCTs), from an update of a Cochrane review, to develop a theory of features of successful fall prevention exercise in RAC. METHODS: Trial characteristics were extracted from RCTs testing exercise interventions in RAC identified from an update of a Cochrane review to December 2022 (n=32). Eligible trials included RCTs or cluster RCTs in RAC, focusing on participants aged 65 or older, assessing fall outcomes with stand-alone exercise interventions. ICA was conducted on trials with >30 participants per treatment arm compared with control (n=17). Two authors coded trialists' perceptions on intervention features that may have contributed to the observed effect on falls. Inductive thematic analysis was used to identify the key differences between the trials which might account for positive and negative outcomes. RESULTS: 32 RCTs involving 3960 residents including people with cognitive (57%) and mobility (41%) impairments were included. ICA on the 17 eligible RCTs informed the development of a theory that (1) effective fall prevention exercise delivers the right exercise by specifically targeting balance and strength, tailored to the individual and delivered simply at a moderate intensity and (2) successful implementation needs to be sufficiently resourced to deliver structured and supervised exercise at an adequate dose. CONCLUSIONS: This analysis suggests that delivering the right exercise, sufficiently resourced, is important for preventing falls in RAC. This clinical guidance requires confirmation in larger trials.
Assuntos
Acidentes por Quedas , Terapia por Exercício , Equilíbrio Postural , Ensaios Clínicos Controlados Aleatórios como Assunto , Acidentes por Quedas/prevenção & controle , Humanos , Terapia por Exercício/métodos , Idoso , Equilíbrio Postural/fisiologia , Instituição de Longa Permanência para IdososRESUMO
BACKGROUND: Multifactorial fall prevention trials providing interventions based on individual risk factors have variable success in aged care facilities. To determine configurations of trial features that reduce falls, intervention component analysis (ICA) and qualitative comparative analysis (QCA) were undertaken. METHODS: Randomised controlled trials (RCTs) from a Cochrane Collaboration review (Cameron, 2018) with meta-analysis data, plus trials identified in a systematic search update to December 2021 were included. Meta-analyses were updated. A theory developed through ICA of English publications of trialist's perspectives was assessed through QCA and a subgroup meta-analysis. RESULTS: Pooled effectiveness of multifactorial interventions indicated a falls rate ratio of 0.85 (95% confidence interval, CI, 0.65-1.10; I2 = 85%; 11 trials). All tested interventions targeted both environmental and personal risk factors by including assessment of environmental hazards, a medical or medication review and exercise intervention. ICA emphasised the importance of co-design involving facility staff and managers and tailored intervention delivery to resident's intrinsic factors for successful outcomes. QCA of facility engagement plus tailored delivery was consistent with greater reduction in falls, supported by high consistency (0.91) and coverage (0.85). An associated subgroup meta-analysis demonstrated strong falls reduction without heterogeneity (rate ratio 0.61, 95%CI 0.54-0.69, I2 = 0%; 7 trials). CONCLUSION: Multifactorial falls prevention interventions should engage aged care staff and managers to implement strategies which include tailored intervention delivery according to each resident's intrinsic factors. Such approaches are consistently associated with a successful reduction in falls, as demonstrated by QCA and subgroup meta-analyses. Co-design approaches may also enhance intervention success.
Assuntos
Acidentes por Quedas , Idoso , Humanos , Acidentes por Quedas/prevenção & controle , Instituição de Longa Permanência para Idosos , Ensaios Clínicos Controlados Aleatórios como AssuntoRESUMO
BACKGROUND: There is strong evidence that exercise reduces falls in older people living in the community, but its effectiveness in residential aged care is less clear. This systematic review examines the effectiveness of exercise for falls prevention in residential aged care, meta-analysing outcomes measured immediately after exercise or after post-intervention follow-up. METHODS: Systematic review and meta-analysis, including randomised controlled trials from a Cochrane review and additional trials, published to December 2022. Trials of exercise as a single intervention compared to usual care, reporting data suitable for meta-analysis of rate or risk of falls, were included. Meta-analyses were conducted according to Cochrane Collaboration methods and quality of evidence rated using the Grading of Recommendations Assessment, Development and Evaluation approach. RESULTS: 12 trials from the Cochrane review plus 7 new trials were included. At the end of the intervention period, exercise probably reduces the number of falls (13 trials, rate ratio [RaR] = 0.68, 95% confidence interval [CI] = 0.49-0.95), but after post-intervention follow-up exercise had little or no effect (8 trials, RaR = 1.01, 95% CI = 0.80-1.28). The effect on the risk of falling was similar (end of intervention risk ratio (RR) = 0.84, 95% CI = 0.72-0.98, 12 trials; post-intervention follow-up RR = 1.05, 95% CI = 0.92-1.20, 8 trials). There were no significant subgroup differences according to cognitive impairment. CONCLUSIONS: Exercise is recommended as a fall prevention strategy for older people living in aged care who are willing and able to participate (moderate certainty evidence), but exercise has little or no lasting effect on falls after the end of a programme (high certainty evidence).
Assuntos
Acidentes por Quedas , Exercício Físico , Idoso , Humanos , Acidentes por Quedas/prevenção & controleRESUMO
BACKGROUND: Adaptation of existing guidelines can be an efficient way to develop contextualized recommendations. Transparent reporting of the adaptation approach can support the transparency and usability of the adapted guidelines. OBJECTIVE: To develop an extension of the RIGHT (Reporting Items for practice Guidelines in HealThcare) statement for the reporting of adapted guidelines (including recommendations that have been adopted, adapted, or developed de novo), the RIGHT-Ad@pt checklist. DESIGN: A multistep process was followed to develop the checklist: establishing a working group, generating an initial checklist, optimizing the checklist (through an initial assessment of adapted guidelines, semistructured interviews, a Delphi consensus survey, an external review, and a final assessment of adapted guidelines), and approval of the final checklist by the working group. SETTING: International collaboration. PARTICIPANTS: A total of 119 professionals participated in the development process. MEASUREMENTS: Participants' consensus on items in the checklist. RESULTS: The RIGHT-Ad@pt checklist contains 34 items grouped in 7 sections: basic information (7 items); scope (6 items); rigor of development (10 items); recommendations (4 items); external review and quality assurance (2 items); funding, declaration, and management of interest (2 items); and other information (3 items). A user guide with explanations and real-world examples for each item was developed to provide a better user experience. LIMITATION: The RIGHT-Ad@pt checklist requires further validation in real-life use. CONCLUSION: The RIGHT-Ad@pt checklist has been developed to improve the reporting of adapted guidelines, focusing on the standardization, rigor, and transparency of the process and the clarity and explicitness of adapted recommendations. PRIMARY FUNDING SOURCE: None.
Assuntos
Lista de Checagem , Atenção à Saúde , HumanosRESUMO
BACKGROUND: falls and fall-related injuries are common in older adults, have negative effects on functional independence and quality of life and are associated with increased morbidity, mortality and health related costs. Current guidelines are inconsistent, with no up-to-date, globally applicable ones present. OBJECTIVES: to create a set of evidence- and expert consensus-based falls prevention and management recommendations applicable to older adults for use by healthcare and other professionals that consider: (i) a person-centred approach that includes the perspectives of older adults with lived experience, caregivers and other stakeholders; (ii) gaps in previous guidelines; (iii) recent developments in e-health and (iv) implementation across locations with limited access to resources such as low- and middle-income countries. METHODS: a steering committee and a worldwide multidisciplinary group of experts and stakeholders, including older adults, were assembled. Geriatrics and gerontological societies were represented. Using a modified Delphi process, recommendations from 11 topic-specific working groups (WGs), 10 ad-hoc WGs and a WG dealing with the perspectives of older adults were reviewed and refined. The final recommendations were determined by voting. RECOMMENDATIONS: all older adults should be advised on falls prevention and physical activity. Opportunistic case finding for falls risk is recommended for community-dwelling older adults. Those considered at high risk should be offered a comprehensive multifactorial falls risk assessment with a view to co-design and implement personalised multidomain interventions. Other recommendations cover details of assessment and intervention components and combinations, and recommendations for specific settings and populations. CONCLUSIONS: the core set of recommendations provided will require flexible implementation strategies that consider both local context and resources.
Assuntos
Vida Independente , Qualidade de Vida , Idoso , Cuidadores , Humanos , Medição de RiscoRESUMO
BACKGROUND: The demand for residential aged care is increasing due to the ageing population. Optimising the design or adapting the physical environment of residential aged care facilities has the potential to influence quality of life, mood and function. OBJECTIVES: To assess the effects of changes to the physical environment, which include alternative models of residential aged care such as a 'home-like' model of care (where residents live in small living units) on quality of life, behaviour, mood and depression and function in older people living in residential aged care. SEARCH METHODS: CENTRAL, MEDLINE, Embase, six other databases and two trial registries were searched on 11 February 2021. Reference lists and grey literature sources were also searched. SELECTION CRITERIA: Non-randomised trials, repeated measures or interrupted time series studies and controlled before-after studies with a comparison group were included. Interventions which had modified the physical design of a care home or built a care home with an alternative model of residential aged care (including design alterations) in order to enhance the environment to promote independence and well-being were included. Studies which examined quality of life or outcomes related to quality of life were included. Two reviewers independently assessed the abstracts identified in the search and the full texts of all retrieved studies. DATA COLLECTION AND ANALYSIS: Two reviewers independently extracted data, assessed the risk of bias in each included study and evaluated the certainty of evidence according to GRADE criteria. Where possible, data were represented in forest plots and pooled. MAIN RESULTS: Twenty studies were included with 77,265 participants, although one large study included the majority of participants (n = 74,449). The main comparison was home-like models of care incorporating changes to the scale of the building which limit the capacity of the living units to smaller numbers of residents and encourage the participation of residents with domestic activities and a person-centred care approach, compared to traditional designs which may include larger-scale buildings with a larger number of residents, hospital-like features such as nurses' stations, traditional hierarchical organisational structures and design which prioritises safety. Six controlled before-after studies compared the home-like model and the traditional environment (75,074 participants), but one controlled before-after study included 74,449 of the participants (estimated on weighting). It is uncertain whether home-like models improve health-related quality of life, behaviour, mood and depression, function or serious adverse effects compared to traditional designs because the certainty of the evidence is very low. The certainty of the evidence was downgraded from low-certainty to very low-certainty for all outcomes due to very serious concerns due to risk of bias, and also serious concerns due to imprecision for outcomes with more than 400 participants. One controlled before-after study examined the effect of home-like models on quality of life. The author stated "No statistically significant differences were observed between the intervention and control groups." Three studies reported on global behaviour (N = 257). One study found little or no difference in global behaviour change at six months using the Neuropsychiatric Inventory where lower scores indicate fewer behavioural symptoms (mean difference (MD) -0.04 (95% confidence interval (CI) -0.13 to 0.04, n = 164)), and two additional studies (N = 93) examined global behaviour, but these were unsuitable for determining a summary effect estimate. Two controlled before-after studies examined the effect of home-like models of care compared to traditional design on depression. After 18 months, one study (n = 242) reported an increase in the rate of depressive symptoms (rate ratio 1.15 (95% CI 1.02 to 1.29)), but the effect of home-like models of care on the probability of no depressive symptoms was uncertain (odds ratio 0.36 (95% CI 0.12 to 1.07)). One study (n = 164) reported little or no difference in depressive symptoms at six months using the Revised Memory and Behaviour Problems Checklist where lower scores indicate fewer depressive symptoms (MD 0.01 (95% CI -0.12 to 0.14)). Four controlled before-after studies examined function. One study (n = 242) reported little or no difference in function over 18 months using the Activities of Daily Living long-form scale where lower scores indicate better function (MD -0.09 (95% CI -0.46 to 0.28)), and one study (n = 164) reported better function scores at six months using the Interview for the Deterioration of Daily Living activities in Dementia where lower scores indicate better function (MD -4.37 (95% CI -7.06 to -1.69)). Two additional studies measured function but could not be included in the quantitative analysis. One study examined serious adverse effects (physical restraints), and reported a slight reduction in the important outcome of physical restraint use in a home-like model of care compared to a traditional design (MD between the home-like model of care and traditional design -0.3% (95% CI -0.5% to -0.1%), estimate weighted n = 74,449 participants at enrolment). The remaining studies examined smaller design interventions including refurbishment without changes to the scale of the building, special care units for people with dementia, group living corridors compared to a non-corridor design, lighting interventions, dining area redesign and a garden vignette. AUTHORS' CONCLUSIONS: There is currently insufficient evidence on which to draw conclusions about the impact of physical environment design changes for older people living in residential aged care. Outcomes directly associated with the design of the built environment in a supported setting are difficult to isolate from other influences such as health changes of the residents, changes to care practices over time or different staff providing care across shifts. Cluster-randomised trials may be feasible for studies of refurbishment or specific design components within residential aged care. Studies which use a non-randomised design or cluster-randomised trials should consider approaches to reduce risk of bias to improve the certainty of evidence.
Assuntos
Atividades Cotidianas , Qualidade de Vida , Idoso , Viés , Estudos Controlados Antes e Depois , Humanos , Análise de Séries Temporais InterrompidaRESUMO
BACKGROUND: Improving mobility outcomes after hip fracture is key to recovery. Possible strategies include gait training, exercise and muscle stimulation. This is an update of a Cochrane Review last published in 2011. OBJECTIVES: To evaluate the effects (benefits and harms) of interventions aimed at improving mobility and physical functioning after hip fracture surgery in adults. SEARCH METHODS: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, CINAHL, trial registers and reference lists, to March 2021. SELECTION CRITERIA: All randomised or quasi-randomised trials assessing mobility strategies after hip fracture surgery. Eligible strategies aimed to improve mobility and included care programmes, exercise (gait, balance and functional training, resistance/strength training, endurance, flexibility, three-dimensional (3D) exercise and general physical activity) or muscle stimulation. Intervention was compared with usual care (in-hospital) or with usual care, no intervention, sham exercise or social visit (post-hospital). DATA COLLECTION AND ANALYSIS: Members of the review author team independently selected trials for inclusion, assessed risk of bias and extracted data. We used standard methodological procedures expected by Cochrane. We used the assessment time point closest to four months for in-hospital studies, and the time point closest to the end of the intervention for post-hospital studies. Critical outcomes were mobility, walking speed, functioning, health-related quality of life, mortality, adverse effects and return to living at pre-fracture residence. MAIN RESULTS: We included 40 randomised controlled trials (RCTs) with 4059 participants from 17 countries. On average, participants were 80 years old and 80% were women. The median number of study participants was 81 and all trials had unclear or high risk of bias for one or more domains. Most trials excluded people with cognitive impairment (70%), immobility and/or medical conditions affecting mobility (72%). In-hospital setting, mobility strategy versus control Eighteen trials (1433 participants) compared mobility strategies with control (usual care) in hospitals. Overall, such strategies may lead to a moderate, clinically-meaningful increase in mobility (standardised mean difference (SMD) 0.53, 95% confidence interval (CI) 0.10 to 0.96; 7 studies, 507 participants; low-certainty evidence) and a small, clinically meaningful improvement in walking speed (CI crosses zero so does not rule out a lack of effect (SMD 0.16, 95% CI -0.05 to 0.37; 6 studies, 360 participants; moderate-certainty evidence). Mobility strategies may make little or no difference to short-term (risk ratio (RR) 1.06, 95% CI 0.48 to 2.30; 6 studies, 489 participants; low-certainty evidence) or long-term mortality (RR 1.22, 95% CI 0.48 to 3.12; 2 studies, 133 participants; low-certainty evidence), adverse events measured by hospital re-admission (RR 0.70, 95% CI 0.44 to 1.11; 4 studies, 322 participants; low-certainty evidence), or return to pre-fracture residence (RR 1.07, 95% CI 0.73 to 1.56; 2 studies, 240 participants; low-certainty evidence). We are uncertain whether mobility strategies improve functioning or health-related quality of life as the certainty of evidence was very low. Gait, balance and functional training probably causes a moderate improvement in mobility (SMD 0.57, 95% CI 0.07 to 1.06; 6 studies, 463 participants; moderate-certainty evidence). There was little or no difference in effects on mobility for resistance training. No studies of other types of exercise or electrical stimulation reported mobility outcomes. Post-hospital setting, mobility strategy versus control Twenty-two trials (2626 participants) compared mobility strategies with control (usual care, no intervention, sham exercise or social visit) in the post-hospital setting. Mobility strategies lead to a small, clinically meaningful increase in mobility (SMD 0.32, 95% CI 0.11 to 0.54; 7 studies, 761 participants; high-certainty evidence) and a small, clinically meaningful improvement in walking speed compared to control (SMD 0.16, 95% CI 0.04 to 0.29; 14 studies, 1067 participants; high-certainty evidence). Mobility strategies lead to a small, non-clinically meaningful increase in functioning (SMD 0.23, 95% CI 0.10 to 0.36; 9 studies, 936 participants; high-certainty evidence), and probably lead to a slight increase in quality of life that may not be clinically meaningful (SMD 0.14, 95% CI -0.00 to 0.29; 10 studies, 785 participants; moderate-certainty evidence). Mobility strategies probably make little or no difference to short-term mortality (RR 1.01, 95% CI 0.49 to 2.06; 8 studies, 737 participants; moderate-certainty evidence). Mobility strategies may make little or no difference to long-term mortality (RR 0.73, 95% CI 0.39 to 1.37; 4 studies, 588 participants; low-certainty evidence) or adverse events measured by hospital re-admission (95% CI includes a large reduction and large increase, RR 0.86, 95% CI 0.52 to 1.42; 2 studies, 206 participants; low-certainty evidence). Training involving gait, balance and functional exercise leads to a small, clinically meaningful increase in mobility (SMD 0.20, 95% CI 0.05 to 0.36; 5 studies, 621 participants; high-certainty evidence), while training classified as being primarily resistance or strength exercise may lead to a clinically meaningful increase in mobility measured using distance walked in six minutes (mean difference (MD) 55.65, 95% CI 28.58 to 82.72; 3 studies, 198 participants; low-certainty evidence). Training involving multiple intervention components probably leads to a substantial, clinically meaningful increase in mobility (SMD 0.94, 95% CI 0.53 to 1.34; 2 studies, 104 participants; moderate-certainty evidence). We are uncertain of the effect of aerobic training on mobility (very low-certainty evidence). No studies of other types of exercise or electrical stimulation reported mobility outcomes. AUTHORS' CONCLUSIONS: Interventions targeting improvement in mobility after hip fracture may cause clinically meaningful improvement in mobility and walking speed in hospital and post-hospital settings, compared with conventional care. Interventions that include training of gait, balance and functional tasks are particularly effective. There was little or no between-group difference in the number of adverse events reported. Future trials should include long-term follow-up and economic outcomes, determine the relative impact of different types of exercise and establish effectiveness in emerging economies.
Assuntos
Fraturas do Quadril , Treinamento Resistido , Idoso de 80 Anos ou mais , Exercício Físico , Terapia por Exercício , Feminino , Fraturas do Quadril/cirurgia , Humanos , Masculino , Ensaios Clínicos Controlados Aleatórios como Assunto , CaminhadaRESUMO
BACKGROUND: Greater continuity of care has been associated with lower hospital admissions and patient mortality. This systematic review aims to examine the impact of relational continuity between primary care professionals and older people receiving aged care services, in residential or home care settings, on health care resource use and person-centred outcomes. METHODS: Systematic review of five databases, four trial registries and three grey literature sources to October 2020. Included studies (a) aimed to increase relational continuity with a primary care professional, (b) focused on older people receiving aged care services (c) included a comparator and (d) reported outcomes of health care resource use, quality of life, activities of daily living, mortality, falls or satisfaction. Cochrane Collaboration or Joanna Briggs Institute criteria were used to assess risk of bias and GRADE criteria to rate confidence in evidence and conclusions. RESULTS: Heterogeneity in study cohorts, settings and outcome measurement in the five included studies (one randomised) precluded meta-analysis. None examined relational continuity exclusively with non-physician providers. Higher relational continuity with a primary care physician probably reduces hospital admissions (moderate certainty evidence; high versus low continuity hazard ratio (HR) 0.94; 95% confidence interval (CI) 0.92-0.96, n = 178,686; incidence rate ratio (IRR) 0.99, 95%CI 0.76-1.27, n = 246) and emergency department (ED) presentations (moderate certainty evidence; high versus low continuity HR 0.90, 95%CI 0.89-0.92, n = 178,686; IRR 0.91, 95%CI 0.72-1.15, n = 246) for older community-dwelling aged care recipients. The benefit of providing on-site primary care for relational continuity in residential settings is uncertain (low certainty evidence, 2 studies, n = 2,468 plus 15 care homes); whilst there are probably lower hospitalisations and may be fewer ED presentations, there may also be an increase in reported mortality and falls. The benefit of general practitioners' visits during hospital admission is uncertain (very low certainty evidence, 1 study, n = 335). CONCLUSION: Greater relational continuity with a primary care physician probably reduces hospitalisations and ED presentations for community-dwelling aged care recipients, thus policy initiatives that increase continuity may have cost offsets. Further studies of approaches to increase relational continuity of primary care within aged care, particularly in residential settings, are needed. REVIEW REGISTRATION: CRD42021215698.
Assuntos
Atividades Cotidianas , Qualidade de Vida , Idoso , Hospitalização , Humanos , Vida Independente , Atenção Primária à SaúdeRESUMO
In an Australian nursing home population, associations between cognitive function and 12-month hospitalizations and costs were examined. Participants with dementia had 57% fewer hospitalizations compared to those without dementia, with 41% lower mean hospitalization costs; poorer cognition scores were also associated with fewer hospitalizations. The cost per admission for those with dementia was 33% greater due to longer hospital stays (5.5 days versus 3.1 days for no dementia, p = .05). People with dementia were most frequently hospitalized for fractures. These findings have policy implications for increasing investment in accurate and timely diagnosis of dementia and fall and fracture prevention strategies to further reduce associated hospitalization costs.
Assuntos
Hospitalização , Casas de Saúde , Austrália/epidemiologia , Cognição , Estudos Transversais , HumanosRESUMO
OBJECTIVE: To compare consumer rated quality of care among individuals living long-term in homelike clustered domestic and standard models of residential care in Australia. DESIGN: Cross-sectional study. SETTING: Seventeen residential aged care facilities in four Australian states providing alternative models of care. STUDY PARTICIPANTS: A sample of individuals with high prevalence of cognitive impairment living in residential care for 12 months or longer, not immediately in palliative care and having a proxy available to provide consent and assist with data collection. Of 901 eligible participants, 541 consented and participated in the study. MAIN OUTCOME MEASURE: Consumer rated quality of care was measured using the Consumer Choice Index-6 Dimension instrument (CCI-6D) providing a preference weighted summary score ranging from 0 to 1. The six dimensions of care time, shared-spaces, own-room, outside and gardens, meaningful activities and care flexibility were individually evaluated. RESULTS: Overall consumer rated quality of care (Mean ∆: 0.138, 95% CI 0.073-0.203 P < 0.001) was higher in clustered domestic models after adjusting for potential confounders. Individually, the dimensions of access to outside and gardens (P < 0.001) and flexibility of care (P < 0.001) were rated significantly better compared to those living in standard model of care. CONCLUSIONS: Homelike, clustered domestic models of care are associated with better consumer rated quality of care, specifically the domains of access to outdoors and care flexibility, in a sample of individuals with cognitive impairment. Including consumer views on quality of care is feasible and should be standard in future evaluations of residential care.
Assuntos
Instituição de Longa Permanência para Idosos/organização & administração , Casas de Saúde/organização & administração , Satisfação do Paciente , Qualidade da Assistência à Saúde , Idoso , Idoso de 80 Anos ou mais , Austrália , Disfunção Cognitiva , Estudos Transversais , Atenção à Saúde/organização & administração , Demência , Feminino , Instituição de Longa Permanência para Idosos/normas , Humanos , Masculino , Casas de Saúde/normasRESUMO
OBJECTIVE: To compare the outcomes and costs of clustered domestic and standard Australian models of residential aged care. DESIGN: Cross-sectional retrospective analysis of linked health service data, January 2015 - February 2016. SETTING: 17 aged care facilities in four Australian states providing clustered (four) or standard Australian (13) models of residential aged care. PARTICIPANTS: People with or without cognitive impairment residing in a residential aged care facility (RACF) for at least 12 months, not in palliative care, with a family member willing to participate on their behalf if required. 901 residents were eligible; 541 consented to participation (24% self-consent, 76% proxy consent). MAIN OUTCOME MEASURES: Quality of life (measured with EQ-5D-5L); medical service use; health and residential care costs. RESULTS: After adjusting for patient- and facility-level factors, individuals residing in clustered models of care had better quality of life (adjusted mean EQ-5D-5L score difference, 0.107; 95% CI, 0.028-0.186; P = 0.008), lower hospitalisation rates (adjusted rate ratio, 0.32; 95% CI, 0.13-0.79; P = 0.010), and lower emergency department presentation rates (adjusted rate ratio, 0.27; 95% CI, 0.14-0.53; P < 0.001) than residents of standard care facilities. Unadjusted facility running costs were similar for the two models, but, after adjusting for resident- and facility-related factors, it was estimated that overall there is a saving of $12 962 (2016 values; 95% CI, $11 092-14 831) per person per year in residential care costs. CONCLUSIONS: Clustered domestic models of residential care are associated with better quality of life and fewer hospitalisations for residents, without increasing whole of system costs.
Assuntos
Serviços de Saúde para Idosos , Instituição de Longa Permanência para Idosos , Hospitalização/estatística & dados numéricos , Qualidade de Vida , Idoso , Idoso de 80 Anos ou mais , Austrália , Estudos Transversais , Feminino , Serviços de Saúde para Idosos/economia , Serviços de Saúde para Idosos/organização & administração , Serviços de Saúde para Idosos/estatística & dados numéricos , Instituição de Longa Permanência para Idosos/economia , Instituição de Longa Permanência para Idosos/organização & administração , Instituição de Longa Permanência para Idosos/estatística & dados numéricos , Humanos , Masculino , Estudos RetrospectivosRESUMO
OBJECTIVES: This analysis estimates the whole-of-system direct costs for people living with dementia in residential care by using a broad health and social care provision perspective and compares it to people without dementia living in residential care. METHODS: Data were collected from 541 individuals living permanently in 17 care facilities across Australia. The annual cost of health and residential care was determined by using individual resource use data and reported by the dementia status of the individuals. RESULTS: The average annual whole-of-system cost for people living with dementia in residential care was approximately AU$88 000 (US$ 67 100) per person in 2016. The cost of residential care constituted 93% of the total costs. The direct health care costs were comprised mainly of hospital admissions (48%), pharmaceuticals (31%) and out-of-hospital attendances (15%). While total costs were not significantly different between those with and without dementia, the cost of residential care was significantly higher and the cost of health care was significantly lower for people living with dementia. CONCLUSION: This study provides the first estimate of the whole-of-system costs of providing health and residential care for people living with dementia in residential aged care in Australia using individual level health and social care data. This predominantly bottom-up cost estimate indicates the high cost associated with caring for people with dementia living permanently in residential care, which is underestimated when limited cost perspectives or top-down, population costing approaches are taken.
Assuntos
Atenção à Saúde/economia , Demência/economia , Custos de Cuidados de Saúde/estatística & dados numéricos , Serviços de Saúde para Idosos/economia , Instituições Residenciais/economia , Idoso , Idoso de 80 Anos ou mais , Austrália , Feminino , Hospitalização/economia , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
BACKGROUND: Falls in care facilities and hospitals are common events that cause considerable morbidity and mortality for older people. This is an update of a review first published in 2010 and updated in 2012. OBJECTIVES: To assess the effects of interventions designed to reduce the incidence of falls in older people in care facilities and hospitals. SEARCH METHODS: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (August 2017); Cochrane Central Register of Controlled Trials (2017, Issue 8); and MEDLINE, Embase, CINAHL and trial registers to August 2017. SELECTION CRITERIA: Randomised controlled trials of interventions for preventing falls in older people in residential or nursing care facilities, or hospitals. DATA COLLECTION AND ANALYSIS: One review author screened abstracts; two review authors screened full-text articles for inclusion. Two review authors independently performed study selection, 'Risk of bias' assessment and data extraction. We calculated rate ratios (RaR) with 95% confidence intervals (CIs) for rate of falls and risk ratios (RRs) and 95% CIs for outcomes such as risk of falling (number of people falling). We pooled results where appropriate. We used GRADE to assess the quality of evidence. MAIN RESULTS: Thirty-five new trials (77,869 participants) were included in this update. Overall, we included 95 trials (138,164 participants), 71 (40,374 participants; mean age 84 years; 75% women) in care facilities and 24 (97,790 participants; mean age 78 years; 52% women) in hospitals. The majority of trials were at high risk of bias in one or more domains, mostly relating to lack of blinding. With few exceptions, the quality of evidence for individual interventions in either setting was generally rated as low or very low. Risk of fracture and adverse events were generally poorly reported and, where reported, the evidence was very low-quality, which means that we are uncertain of the estimates. Only the falls outcomes for the main comparisons are reported here.Care facilitiesSeventeen trials compared exercise with control (typically usual care alone). We are uncertain of the effect of exercise on rate of falls (RaR 0.93, 95% CI 0.72 to 1.20; 2002 participants, 10 studies; I² = 76%; very low-quality evidence). Exercise may make little or no difference to the risk of falling (RR 1.02, 95% CI 0.88 to 1.18; 2090 participants, 10 studies; I² = 23%; low-quality evidence).There is low-quality evidence that general medication review (tested in 12 trials) may make little or no difference to the rate of falls (RaR 0.93, 95% CI 0.64 to 1.35; 2409 participants, 6 studies; I² = 93%) or the risk of falling (RR 0.93, 95% CI 0.80 to 1.09; 5139 participants, 6 studies; I² = 48%).There is moderate-quality evidence that vitamin D supplementation (4512 participants, 4 studies) probably reduces the rate of falls (RaR 0.72, 95% CI 0.55 to 0.95; I² = 62%), but probably makes little or no difference to the risk of falling (RR 0.92, 95% CI 0.76 to 1.12; I² = 42%). The population included in these studies had low vitamin D levels.Multifactorial interventions were tested in 13 trials. We are uncertain of the effect of multifactorial interventions on the rate of falls (RaR 0.88, 95% CI 0.66 to 1.18; 3439 participants, 10 studies; I² = 84%; very low-quality evidence). They may make little or no difference to the risk of falling (RR 0.92, 95% CI 0.81 to 1.05; 3153 participants, 9 studies; I² = 42%; low-quality evidence).HospitalsThree trials tested the effect of additional physiotherapy (supervised exercises) in rehabilitation wards (subacute setting). The very low-quality evidence means we are uncertain of the effect of additional physiotherapy on the rate of falls (RaR 0.59, 95% CI 0.26 to 1.34; 215 participants, 2 studies; I² = 0%), or whether it reduces the risk of falling (RR 0.36, 95% CI 0.14 to 0.93; 83 participants, 2 studies; I² = 0%).We are uncertain of the effects of bed and chair sensor alarms in hospitals, tested in two trials (28,649 participants) on rate of falls (RaR 0.60, 95% CI 0.27 to 1.34; I² = 0%; very low-quality evidence) or risk of falling (RR 0.93, 95% CI 0.38 to 2.24; I² = 0%; very low-quality evidence).Multifactorial interventions in hospitals may reduce rate of falls in hospitals (RaR 0.80, 95% CI 0.64 to 1.01; 44,664 participants, 5 studies; I² = 52%). A subgroup analysis by setting suggests the reduction may be more likely in a subacute setting (RaR 0.67, 95% CI 0.54 to 0.83; 3747 participants, 2 studies; I² = 0%; low-quality evidence). We are uncertain of the effect of multifactorial interventions on the risk of falling (RR 0.82, 95% CI 0.62 to 1.09; 39,889 participants; 3 studies; I² = 0%; very low-quality evidence). AUTHORS' CONCLUSIONS: In care facilities: we are uncertain of the effect of exercise on rate of falls and it may make little or no difference to the risk of falling. General medication review may make little or no difference to the rate of falls or risk of falling. Vitamin D supplementation probably reduces the rate of falls but not risk of falling. We are uncertain of the effect of multifactorial interventions on the rate of falls; they may make little or no difference to the risk of falling.In hospitals: we are uncertain of the effect of additional physiotherapy on the rate of falls or whether it reduces the risk of falling. We are uncertain of the effect of providing bed sensor alarms on the rate of falls or risk of falling. Multifactorial interventions may reduce rate of falls, although subgroup analysis suggests this may apply mostly to a subacute setting; we are uncertain of the effect of these interventions on risk of falling.
Assuntos
Acidentes por Quedas/prevenção & controle , Hospitais , Casas de Saúde , Acidentes por Quedas/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Cálcio da Dieta/administração & dosagem , Exercício Físico , Feminino , Hospitais/estatística & dados numéricos , Humanos , Masculino , Casas de Saúde/estatística & dados numéricos , Ensaios Clínicos Controlados Aleatórios como Assunto , Gestão da Segurança , Vitamina D/administração & dosagem , Vitaminas/administração & dosagemRESUMO
ABSTRACTBackground:This systematic overview reports findings from systematic reviews of randomized controlled trials of pharmacological and non-pharmacological interventions for behavioural and psychological symptoms of dementia (BPSD). METHODS: The Cochrane Database of Systematic Reviews, DARE, Medline, EMBASE, and PsycINFO were searched to September 2015. RESULTS: Fifteen systematic reviews of eighteen different interventions were included. A significant improvement in BPSD was seen with: functional analysis-based interventions (GRADE quality of evidence moderate; standardized mean difference (SMD) -0.10, 95%CI -0.20 to 0.00), music therapy (low; SMD -0.49, 95%CI -0.82 to -0.17), analgesics (low; SMD -0.24, 95%CI -0.47 to -0.01), donepezil (high; SMD -0.15 95% CI -0.29 to -0.01), galantamine (high; SMD -0.15, 95%CI -0.28 to -0.03), and antipsychotics (high; SMD -0.13, 95%CI -0.21 to -0.06). The estimate of effect size for most interventions was small. CONCLUSIONS: Although some pharmacological interventions had a slightly larger effect size, current evidence suggests functional analysis-based interventions should be used as first line management of BPSD whenever possible due to the lack of associated adverse events. Music therapy may also be beneficial, but further research is required as the quality of evidence to support its use is low. Cholinesterase inhibitors donepezil and galantamine should be trialled for the management of BPSD where non-pharmacological treatments have failed. Low-quality evidence suggests that assessment of pain should be conducted and a stepped analgesic approach trialled when appropriate. Antipsychotics have proven effectiveness but should be avoided where possible due to the high risk of serious adverse events and availability of safer alternatives.
Assuntos
Antipsicóticos/uso terapêutico , Sintomas Comportamentais/terapia , Inibidores da Colinesterase/uso terapêutico , Demência/terapia , Transtornos Mentais/tratamento farmacológico , Musicoterapia , Sintomas Comportamentais/complicações , Terapias Complementares , Demência/psicologia , Humanos , Transtornos Mentais/complicações , Ensaios Clínicos Controlados Aleatórios como AssuntoRESUMO
Evidence-based profiling of obesity and overweight in Indigenous Australian children has been poor. This study systematically reviewed evidence of the prevalence and patterns of obesity/overweight, with respect to gender, age, remoteness, and birth weight, in Indigenous Australian children, 0-18 years (PROSPERO CRD42014007626). Study quality and risk of bias were assessed. Twenty-five publications (21 studies) met inclusion criteria, with large variations in prevalence for obesity or overweight (11 to 54%) reported. A high degree of heterogeneity in study design was observed, few studies (6/21) were representative of the target population, and few appropriately recruited Indigenous children (8/21). Variability in study design, conduct, and small sample sizes mean that it is not possible to derive a single estimate for prevalence although two high-quality studies indicate at least one in four Indigenous Australian children are overweight or obese. Four of six studies reporting on gender, found overweight/obesity higher in girls and eight studies reporting on overweight/obesity by age suggest prevalence increases with age with one high quality large national study reporting total overweight/obesity as 22.4% of children aged 2-4 years, 27.5% of those aged 5-9, 38.5% aged 10-14, and 36.3% aged 15-17. Three of four studies, reporting obesity/overweight by region, found lower rates for children living in more remote areas than urban areas.
Assuntos
Havaiano Nativo ou Outro Ilhéu do Pacífico , Obesidade/etnologia , Sobrepeso/etnologia , Adolescente , Austrália/epidemiologia , Índice de Massa Corporal , Criança , Pré-Escolar , Bases de Dados Factuais , Feminino , Humanos , Masculino , Grupos Populacionais , PrevalênciaRESUMO
OBJECTIVES: The objective of this study was to conduct a systematic review of evidence for the accuracy of the Kimberley Indigenous Cognitive Assessment (KICA) tool in supporting the diagnosis of dementia in Indigenous Australian populations. METHODS: Cross-sectional diagnostic accuracy studies of the KICA with an appropriate reference standard published to November 2015 were included. Comparison to an alternative cognitive assessment tool was required in non-remote populations. Case control analyses were excluded. RESULTS: Four studies were included: one of the KICA-Cog and KICA-Carer, one of the KICA Screen, and two of the modified-KICA. All tools developed for remote populations had a sensitivity of ≥76% and a specificity of ≥71% for the diagnosis of dementia. The KICA-Cog and KICA-Carer conducted in series had the highest sensitivity and specificity (91% and 94% respectively). In an urban and regional population, the mKICA had similar accuracy to the Mini-Mental State Examination (MMSE) (AUC 0.93, 95% CI 0.88-0.99 vs 0.94, 95% CI 0.89-0.99). Key risk of bias limitations related to lack of pre-determined cut-points and population selection methods. CONCLUSION: The use of the KICA in remote Indigenous Australians may assist in timely diagnosis of dementia in this population. Using the KICA-Cog and KICA-Carer in series may maximise specificity, decreasing false positive results without compromising sensitivity.
Assuntos
Demência/diagnóstico , Demência/etnologia , Havaiano Nativo ou Outro Ilhéu do Pacífico/etnologia , Testes Neuropsicológicos/normas , Austrália/etnologia , Humanos , Sensibilidade e EspecificidadeRESUMO
BACKGROUND/AIM: The first evidence-based Clinical Practice Guidelines and Principles of Care for People with Dementia in Australia have been released. The Guidelines detail a number of important evidence-based recommendations for occupational therapists. The aim of this paper is (1) to provide an overview of Guideline development, and (2) to describe the evidence supporting a recommendation for occupational therapy. Common characteristics of effective occupational therapy programmes for people with dementia are described. METHODS: Guideline development involved adaptation of existing high-quality guidelines developed overseas and 17 systematic reviews to ensure that the most recent high-quality evidence was included. One of the systematic reviews involved examining the evidence for interventions to promote independence in people with dementia. Specifically, we looked at the evidence for occupational therapy and its effect on activities of daily living, quality of life and carer impact. RESULTS: A total of 109 recommendations are included in the Guidelines. Occupational therapy was found to significantly increase independence in activities of daily living and improve quality of life. Effective occupational therapy programmes involve: environmental assessment, problem solving strategies, carer education and interactive carer skills training. CONCLUSION: Occupational therapists working with people with dementia in community settings should ensure that their time is spent on those aspects of intervention that are shown to be effective.
Assuntos
Cuidadores , Demência/reabilitação , Prática Clínica Baseada em Evidências/organização & administração , Família , Terapia Ocupacional/organização & administração , Atividades Cotidianas , Prática Clínica Baseada em Evidências/normas , Humanos , Terapia Ocupacional/normas , Educação de Pacientes como Assunto , Guias de Prática Clínica como Assunto , Qualidade da Assistência à Saúde , Qualidade de VidaAssuntos
Instituição de Longa Permanência para Idosos , Casas de Saúde , Idoso , Austrália , HumanosRESUMO
About 9% of Australians aged 65 years and over have a diagnosis of dementia. Clinical practice guidelines aim to enhance research translation by synthesising recent evidence for health and aged care professionals. New clinical practice guidelines and principles of care for people with dementia detail the optimal diagnosis and management in community, residential and hospital settings. The guidelines have been approved by the National Health and Medical Research Council. The guidelines emphasise timely diagnosis; living well with dementia and delaying functional decline; managing symptoms through training staff in how to provide person-centred care and using non-pharmacological approaches in the first instance; and training and supporting families and carers to provide care.