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OBJECTIVE: Intrinsic capacity (IC) and frailty are complementary constructs that encapsulate functional capacities of older adults. Although earlier studies suggest the utility of composite IC scores in predicting risk of frailty, key gaps remain with the lack of direct comparative studies between different IC scales and lack of a composite score based on the World Health Organization Integrated Care for Older People (ICOPE) tool. We aimed to compare different IC scales, including an ICOPE-based scale, in their predictive ability for risk of frailty at 2 years in healthy community-dwelling older adults. DESIGN: Cohort study. SETTING AND PARTICIPANTS: A total of 230 participants (age: 67.2 ± 7.4 years) from the GeriLABS-2 cohort study. METHODS: We derived composite scores by summing 4 IC domains (locomotion, cognition, vitality, and psychological). We compared composite scores of 4 scales: IC1-Chew 2021, range: 0-8; IC2-Liu 2021, range: 0-4; IC3-ICOPE, range: 0-4; IC4-modified ICOPE, range: 0-8. The primary outcome was risk of frailty using the modified Fried Frailty Phenotype. We performed logistic regression to examine the association of baseline composite IC with risk of frailty. We also examined the impact of individual domains and number of impaired domains on risk of frailty. RESULTS: Among 193 (83.9%) older adults who completed 2-year follow-up, 20 (10.4%) met criteria for risk of frailty. When adjusted for covariates, 2-point per domain scales (IC1/IC4) predicted increased risk of frailty (OR, 4.31; 95% CI, 1.55-11.96; OR, 5.00; 95% CI, 1.75-14.26). When further adjusted for baseline frailty, only IC4 remained significant (OR, 4.28; 95% CI, 1.45-12.60). Among the domains, impaired locomotion and vitality were associated with risk of frailty. Greater number of impaired domains predicted increased risk of frailty (IC1/IC2: ß = 0.18-0.19, P < .05). CONCLUSIONS AND IMPLICATIONS: Baseline composite IC score using 2-point per domain scales better predicted risk of frailty at 2 years, predicated on impaired locomotion/vitality and greater number of impaired domains. For early identification of healthy older adults at risk of frailty, an ICOPE-based scale should be considered, as it is effective and accessible.
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BACKGROUND: Potentially inappropriate prescribing is common among older adults with multimorbidity due to various reasons, from concurrent application of multiple single-disease clinical guidelines to fragmentation of care. Interventions such as medication review have been implemented worldwide to reduce inappropriate prescribing for older adults. However, the implementability of such interventions are underexplored in the outpatient clinics in Singapore's public hospitals. Hence, the Pro-M study aims to assess the feasibility of implementing a physician-pharmacist collaborative care intervention in geriatric medicine outpatient clinics to facilitate appropriate prescribing for older adults in Singapore. METHODS: This is a single-arm, non-randomised feasibility study using a pre-post evaluation design. This study consists of two parts: (1) implementation phase of the intervention (6 months) and an (2) evaluation phase (3 months). Eligible patients will be recruited from geriatric medicine outpatient clinics at two public hospitals in Singapore through convenience sampling. The main components of the Pro-M intervention are: (1) pharmacist-facilitated medication reviews with feedback on any medication issues and potential recommendations to physicians, and (2) physicians communicating changes to other relevant prescribers. The evaluation phase will involve surveying and interviewing physicians and pharmacists involved in the implementation of the intervention. A mixed-method approach will be employed for data collection and analysis. The quantitative and qualitative findings will be triangulated and reported using Proctor's implementation outcomes: appropriateness, penetration, acceptability, fidelity, feasibility, and sustainability. A basic cost analysis will be conducted alongside the study. DISCUSSION: This is a phase 2 study to test the feasibility of implementing an intervention that was co-created with stakeholders during phase 1 development of an intervention to optimise prescribing for older adults with multimorbidity. The implementation will be assessed using Proctor's implementation outcomes to provide insights on the process and the feasibility of implementing medication reviews for older adults with multimorbidity as a routine practice in outpatient clinics. Data collected from this study will inform a subsequent scale-up study. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT05756478. Registered on 06 March 2023.
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BACKGROUND: Patients living with multimorbidity may require frequent visits to multiple healthcare institutions and to follow diverse medical regimens and advice. Older adults with multimorbidity could face additional challenges because of declining cognitive capability, frailty, increased complexity of diseases, as well as limited social and economic resources. Research on how this population navigates the healthcare system in Singapore also remains unknown. This study investigates the challenges older adults with multimorbidity face in navigating healthcare in Singapore. METHODS: Twenty older adults with multimorbidity from a public primary care setting were purposively sampled. Interviews conducted inquired into their experiences of navigating the healthcare system with multiple conditions. Inductive thematic analysis was performed by independent coders who resolved differences through discussion. RESULTS: Older adults with multimorbidity form a population with specific characteristics and challenges. Their ability to navigate the healthcare system well was influenced by these themes including patient-related factors (autonomy and physical mobility, literacy and technological literacy, social support network), healthcare system-related factors (communication and personal rapport, fragmented system, healthcare staff as advocate) and strategies for navigation (fitting in, asking for help, negotiating to achieve goals, managing the logistics of multimorbidity). DISCUSSION: Older adults with multimorbidity should not be treated as a homogenous group but can be stratified according to those with less serious or disruptive conditions (less burden of illness and burden of treatment) and those with more severe conditions (more burden of illness and burden of treatment). Among the latter, some became navigational experts while others struggled to obtain the resources needed. The variations of navigational experiences of the healthcare system show the need for further study of the differential needs of older adults with multimorbidity. To be truly patient-centred, healthcare providers should consider factors such as the existence of family support networks, literacy, technological literacy and the age-related challenges older adults face as they interact with the healthcare system, as well as finding ways to improve healthcare systems through personal rapport and strategies for reducing unnecessary burden of treatment for patients with multimorbidity.
Subject(s)
Delivery of Health Care , Multimorbidity , Humans , Aged , Singapore/epidemiology , Health FacilitiesABSTRACT
BACKGROUND AND OBJECTIVES: This article discusses the development process of an intervention to facilitate appropriate prescribing for older adults with multimorbidity at geriatric medicine outpatient clinics. Both effectiveness and implementability were key aims, which were achieved by a systematic combination of different approaches guided by published guidance. METHODS: Various frameworks and tools were used to guide the intervention development. They include The Medical Research Council Framework for complex health interventions as the overarching framework, supplemented by the Framework of Actions for Intervention Development and a taxonomy of intervention development approaches. RESULTS: A combination of theory and evidence-based-, implementation-based and partnership approaches were used to develop the intervention. The Behaviour Change Wheel and Theoretical Domains Framework were used for intervention design. Three scoping reviews and two modified Delphi studies were conducted to build an evidence base on prescribing-related barriers and existing interventions. The findings were synthesised, assessed for implementability, and culminated in a co-creation exercise with physicians and pharmacists. The final intervention aims to facilitate collaboration between physicians and pharmacists and to improve communication and documentation of prescribing decisions. CONCLUSIONS: Multiple approaches may be required when developing interventions that are effective and implementable. The study team's experiences in using published guidance, integrating different approaches, and co-creating the intervention with healthcare professionals provide a useful case study with lessons and insights for developers of complex interventions. Furthermore, systematic reporting of such research-based efforts would contribute to advancement of intervention development in healthcare and reducing research waste.
Subject(s)
Multimorbidity , Physicians , Humans , Aged , Pharmacists , PolypharmacyABSTRACT
ABSTRACT: This review examined and compared the effects of exercise interventions using portable exercise equipment on muscle strength, balance, and ability to perform activities of daily living in the oldest-old and frail. We also examined the differences in the intervention characteristics between these two groups. The CINAHL, MEDLINE, and Cochrane databases were searched using specific text words and MeSH for randomized controlled trials published from 2000 to 2021, which involved exercise interventions for either oldest-old (≥75 yrs) or physically frail (reduced muscular strength, endurance, and physiological function) older adults. A total of 76 articles were included in this review, in which 61 studies involved oldest-old adults and 15 studies examined frail adults. Subgroup reviews of community dwelling and institutionalized adults were performed. The empirical evidence suggests that single-component and multicomponent exercise interventions produced positive effects for both older adult groups on muscle strength and balance, respectively. The effects of multicomponent interventions on muscular strength could be dependent on the number of exercise components per session. The effects of exercises on activities of daily living enhancement were less clear. We advocate for single intervention resistance training in all oldest-old and frail seniors to improve strength, if compliance to exercise duration is an issue.
Subject(s)
Activities of Daily Living , Frail Elderly , Humans , Aged, 80 and over , Aged , Exercise/physiology , Exercise Therapy , Muscle Strength/physiology , Physical Functional PerformanceABSTRACT
BACKGROUND: Challenges in prognosticating patients diagnosed with advanced dementia (AD) hinders timely referrals to palliative care. We aim to develop and validate a prognostic model to predict one-year all-cause mortality (ACM) in patients with AD presenting at an acute care hospital. METHODS: This retrospective cohort study utilised administrative and clinical data from Tan Tock Seng Hospital (TTSH). Patients admitted to TTSH between 1st July 2016 and 31st October 2017 and identified to have AD were included. The primary outcome was ACM within one-year of AD diagnosis. Multivariable logistic regression was used. The PROgnostic Model for Advanced Dementia (PRO-MADE) was internally validated using a bootstrap resampling of 1000 replications and externally validated on a more recent cohort of AD patients. The model was evaluated for overall predictive accuracy (Nagelkerke's R2 and Brier score), discriminative [area-under-the-curve (AUC)], and calibration [calibration slope and calibration-in-the-large (CITL)] properties. RESULTS: A total of 1,077 patients with a mean age of 85 (SD: 7.7) years old were included, and 318 (29.5%) patients died within one-year of AD diagnosis. Predictors of one-year ACM were age > 85 years (OR:1.87; 95%CI:1.36 to 2.56), male gender (OR:1.62; 95%CI:1.18 to 2.22), presence of pneumonia (OR:1.75; 95%CI:1.25 to 2.45), pressure ulcers (OR:2.60; 95%CI:1.57 to 4.31), dysphagia (OR:1.53; 95%CI:1.11 to 2.11), Charlson Comorbidity Index ≥ 8 (OR:1.39; 95%CI:1.01 to 1.90), functional dependency in ≥ 4 activities of daily living (OR: 1.82; 95%CI:1.32 to 2.53), abnormal urea (OR:2.16; 95%CI:1.58 to 2.95) and abnormal albumin (OR:3.68; 95%CI:2.07 to 6.54) values. Internal validation results for optimism-adjusted Nagelkerke's R2, Brier score, AUC, calibration slope and CITL were 0.25 (95%CI:0.25 to 0.26), 0.17 (95%CI:0.17 to 0.17), 0.76 (95%CI:0.76 to 0.76), 0.95 (95% CI:0.95 to 0.96) and 0 (95%CI:-0.0001 to 0.001) respectively. When externally validated, the model demonstrated an AUC of 0.70 (95%CI:0.69 to 0.71), calibration slope of 0.64 (95%CI:0.63 to 0.66) and CITL of -0.27 (95%CI:-0.28 to -0.26). CONCLUSION: The PRO-MADE attained good discrimination and calibration properties. Used synergistically with a clinician's judgement, this model can identify AD patients who are at high-risk of one-year ACM to facilitate timely referrals to palliative care.
Subject(s)
Activities of Daily Living , Dementia , Humans , Male , Aged, 80 and over , Prognosis , Retrospective Studies , Hospitals , Dementia/diagnosis , Dementia/epidemiology , Dementia/therapyABSTRACT
BACKGROUND: Although recommended by the Asian Working Group for Sarcopenia 2019 consensus (AWGS'19) as a screening tool for sarcopenia, there remains no consensus regarding the position (sitting, standing) or laterality (right, left) for the measurement of calf circumference (CC). This study aimed to determine the agreement between CC measurements, correlations with muscle mass and function, and diagnostic performance for sarcopenia screening. METHODS: We studied 176 healthy community-dwelling older adults (mean age, 66.8±7.1 years) from the GERILABS-2 study. CC was measured using non-elastic tape in four ways: left and right sides in the sitting and standing positions. Sarcopenia was diagnosed using the AWGS'19 criteria. We produced Bland-Altman plots to assess the agreement, partial correlations for muscle mass and function to compare convergent validity, and area under the receiver operating characteristic curve (AUC) to compare diagnostic performance. RESULTS: The prevalence rate of sarcopenia was 17.4%. Sitting CC was larger than standing regardless of laterality (right 35.31±2.95 cm vs. 34.61±2.74 cm; left 35.37±2.96 cm vs. 34.70±2.83 cm; both p<0.001), consistent with the systematic bias on Bland-Altman plots showing the overestimation of sitting over standing measurements (right bias=0.70 cm; 95% confidence interval [CI], -0.48-1.88; left bias=0.67 cm, 95% CI, -0.35-1.68). After adjusting for age and sex, CC was significantly correlated with appendicular skeletal mass, hand grip strength, knee extension, gait speed, chair stand, and short physical performance battery. Although right-sided CC measurements had better diagnostic performance (AUC=0.817), the difference was not statistically significant compared to the other positions (p>0.05). The optimal cutoff was <34 cm for all measurements, except for the left standing position (cutoff <35 cm). CONCLUSION: Standing CC measurements are recommended for sarcopenia screening in community-dwelling older adults because of their good agreement without systematic bias, convergent validity, and diagnostic performance.
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BACKGROUND: Frailty is increasing in prevalence internationally with population ageing. Frailty can be managed or even reversed through community-based interventions delivered by a multi-disciplinary team of professionals, but to varying degrees of success. However, many of these care models' implementation insights are contextual and may not be applicable in different cultural contexts. The Geriatric Service Hub (GSH) is a novel frailty care model in Singapore that focuses on identifying and managing frailty in the community. It includes key components of frailty care such as comprehensive geriatric assessments, care coordination and the assembly of a multi-disciplinary team. This study aims to gain insights into the factors influencing the development and implementation of the GSH. We also aim to determine the programme's effectiveness through patient-reported health-related outcomes. Finally, we will conduct a healthcare utilisation and cost analysis using a propensity score-matched comparator group. METHODS: We will adopt a mixed-methods approach that includes a qualitative evaluation among key stakeholders and participants in the programme, through in-depth interviews and focus group discussions. The main topics covered include factors that affected the development and implementation of each programme, operations and other contextual factors that influenced implementation outcomes. The quantitative evaluation monitors each programme's care process through quality indicators. It also includes a multiple-time point survey study to compare programme participants' pre- and post- outcomes on patient engagement, healthcare services experiences, health status and quality of life, caregiver burden and societal costs. A retrospective cohort study will compare healthcare and cost utilisation between participants of the programme and a propensity score-matched comparator group. DISCUSSION: The GSH sites share a common goal to increase the accessibility of essential services to frail older adults and provide comprehensive care. This evaluation study will provide invaluable insights into both the process and outcomes of the GSH and inform the design of similar programmes targeting frail older adults. TRIAL REGISTRATION: ClinicalTrials.gov Identifier NCT04866316 . Date of Registration April 26, 2021. Retrospectively registered.
Subject(s)
Frailty , Aged , Frail Elderly , Frailty/diagnosis , Frailty/epidemiology , Frailty/therapy , Geriatric Assessment , Humans , Quality of Life , Retrospective StudiesABSTRACT
BACKGROUND: Comprehensive geriatric assessment (CGA) addresses the bio-psycho-social needs of older adults through multidimensional assessments and management. Synthesising evidence on quantitative health outcomes and implementation barriers and facilitators would inform practice and policy on CGA for community-dwelling older adults. METHODS: We systematically searched four medical and social sciences electronic databases for quantitative, qualitative, and mixed methods studies published from 1 January 2000 to 31 October 2020. Due to heterogeneity of articles, we narratively reviewed the synthesis of evidence on health outcomes and implementation barriers and facilitators. RESULTS: We screened 14,151 titles and abstracts and 203 full text articles, and included 43 selected articles. Study designs included controlled intervention studies (n = 31), pre-post studies without controls (n = 4), case-control (n = 1), qualitative methods (n = 3), and mixed methods (n = 4). A majority of articles studied populations aged ≥75 years (n = 18, 42%). CGAs were most frequently conducted in the home (n = 25, 58%) and primary care settings (n = 8, 19%). CGAs were conducted by nurses in most studies (n = 22, 51%). There was evidence of improved functional status (5 of 19 RCTs, 2 of 3 pre-post), frailty and fall outcomes (3 of 6 RCTs, 1 of 1 pre-post), mental health outcomes (3 of 6 RCTs, 2 of 2 pre-post), self-rated health (1 of 6 RCTs, 1 of 1 pre-post), and quality of life (4 of 17 RCTs, 3 of 3 pre-post). Barriers to implementation of CGAs involved a lack of partnership alignment and feedback, poor acceptance of preventive work, and challenges faced by providers in operationalising and optimising CGAs. The perceived benefits of CGA that served to facilitate its implementation included the use of highly skilled staff to provide holistic assessments and patient education, and the resultant improvements in care coordination and convenience to the patients, particularly where home-based assessments and management were performed. CONCLUSION: There is mixed evidence on the quantitative health outcomes of CGA on community-dwelling older adults. While there is perceived positive value from CGA when carried out by highly skilled staff, barriers such as bringing providers into a partnership, greater acceptance of preventive care, and operational issues could impede its implementation.
Subject(s)
Geriatric Assessment , Quality of Life , Accidental Falls/prevention & control , Aged , Humans , Independent Living , Outcome Assessment, Health CareABSTRACT
The World Health Organization (WHO) recently published guidelines on the implementation of a new Integrated Care for Older People (ICOPE) framework in 2017-2019. It is an integrated care framework for the screening, assessment, and management of intrinsic capacity (IC) declines. We aimed to examine where the early adopters of ICOPE are across the world, how these study teams and sites plan to apply the framework or have applied it, and the lessons learnt for future adopters. We systematically searched electronic medical and social sciences databases and grey literature published between 31 October 2017 and 31 March 2022. Records were systematically selected using precise inclusion criteria. There were 18 ICOPE study teams and sites across the 29 selected records. Of the 18 study teams and sites, seven were in the development stage, seven conducted feasibility studies, and four have commenced implementation of interventions that applied the ICOPE framework. Future ICOPE adopters may need to make certain decisions. These include whether to adopt ICOPE in the community setting or other settings, whether to adopt only Step 1 on IC screening or additional ICOPE Steps, whether the ICOPE IC screening tool requires modifications, and whether to use digital health technology. We propose the key factors needed to make these decisions and future research needed.
Subject(s)
Delivery of Health Care, Integrated , Learning , Humans , Aged , World Health OrganizationABSTRACT
PURPOSE: Potentially inappropriate prescribing among older adults is a rising concern, attributed mainly by polypharmacy and multimorbidity. We aimed to identify key components and strategies for construction of a context-relevant intervention to facilitate appropriate prescribing in outpatient clinics in Singapore. METHODS: The modified Delphi study was conducted in two rounds with 20 geriatricians from seven public hospitals in Singapore. Round one survey presented 69 statements formulated from a scoping review, while round two presented 23 statements with some modifications based on round one comments. The statements were rated against a 7-point Likert scale on their importance and impact on prescribing for older adults with multimorbidty. RESULTS: Consensus were achieved for 90% of the statements. Seven intervention elements were identified as being important: medication review, training, medication therapy management, shared decision making, patient interview, medication reconciliation, comprehensive geriatric assessment. In addition, some commonly identified behavior change techniques included goal setting (behavior), goal setting (outcome) and problem solving. CONCLUSIONS: This study identified important intervention elements and their potential strategies that could be adopted in an intervention to optimize appropriate prescribing for older adults with multimorbidity.
Subject(s)
Multimorbidity , Polypharmacy , Aged , Behavior Therapy , Delphi Technique , Humans , Singapore/epidemiologyABSTRACT
INTRODUCTION: The rising prevalence of multiple chronic diseases is an important public health issue as it is associated with increased healthcare utilisation. This paper aimed to explore the annual per capita healthcare cost in primary care for patients with multiple chronic diseases (multimorbidity). METHODS: This was a retrospective cohort study conducted in a cluster of public primary care clinics in Singapore. De-identified data from electronic medical records were extracted from July 2015 to June 2017. Only patients with at least 1 chronic disease were included in the study. Basic demographic data and healthcare cost were extracted. A list of 20 chronic diseases was considered for multimorbidity. RESULTS: There were 254,377 patients in our study population, of whom 52.8% were female. The prevalence of multimorbidity was 62.4%. The median annual healthcare cost per capita for patients with multimorbidity was about twice the amount compared to those without multimorbidity (SGD683 versus SGD344). The greatest percentage increment in cost was when the number of chronic diseases increased from 2 to 3 (43.0%). CONCLUSION: Multimorbidity is associated with higher healthcare cost in primary care. Since evidence for the optimal management of multimorbidity is still elusive, prevention or delay in the onset of multimorbidity in the general population is paramount.
Subject(s)
Health Care Costs , Primary Health Care , Chronic Disease , Comorbidity , Cross-Sectional Studies , Female , Humans , Prevalence , Retrospective Studies , Singapore/epidemiologyABSTRACT
OBJECTIVE: Inappropriate polypharmacy occurs when multiple medications are prescribed without clear indications or where harms outweigh their benefits. The aims of this scoping review are to (1) identify prescribing guidelines that are available for older adults with multimorbidity and (2) to identify cross-cutting themes used in these guidelines. DESIGN: Scoping review. DATA SOURCES: PubMed, Embase, Web of Science, the Cochrane Library databases, Cumulative Index to Nursing and Allied Health Literature, grey literature sources, six key geriatrics journals, and reference lists of identified review papers. The search was conducted in November 2018 and updated in September 2019. STUDY SELECTION: General prescribing guidelines tailored to or for adults including older adults with multimorbidity. DATA EXTRACTION: Data for publication description, guideline characteristics, information for users and criteria were extracted. The synthesis contains summarised qualitative descriptions of the studies and guideline characteristics as well as identified cross-cutting themes. RESULTS: Our search strategy yielded 10 427 unique citations, of which 70 fulfilled the inclusion criteria for synthesis. Among these, there were 61 unique guidelines and tools which used implicit, explicit, mixed or other approaches in the prescriber decision-making process. There are 11 cross-cutting themes identified in the guidelines. Prescriber-related themes are: conduct a comprehensive assessment before prescribing, identify patients' needs, goals and priorities, adopt shared decision-making, consider evidence-based recommendations, use clinical prescribing tools, incorporate multidisciplinary inputs and embrace technology-enabled prescribing. Wider organisation-related and system-related themes related to education, training and the work environment are also identified. CONCLUSIONS: From guidelines and tools identified, eleven cross-cutting themes provide a usable knowledge base when seeking to optimise prescribing among older adults with multimorbidity. Incorporating these themes in an approach that uses mixed criteria and implementation information could facilitate greater uptake of published prescribing recommendations.
Subject(s)
Multimorbidity , Polypharmacy , Aged , Humans , Inappropriate PrescribingABSTRACT
BACKGROUND: Prior literature suggests that psychosocial factors adversely impact health and health care utilization outcomes. However, psychosocial factors are typically not captured by the structured data in electronic medical records (EMRs) but are rather recorded as free text in different types of clinical notes. OBJECTIVE: We here propose a text-mining approach to analyze EMRs to identify older adults with key psychosocial factors that predict adverse health care utilization outcomes, measured by 30-day readmission. The psychological factors were appended to the LACE (Length of stay, Acuity of the admission, Comorbidity of the patient, and Emergency department use) Index for Readmission to improve the prediction of readmission risk. METHODS: We performed a retrospective analysis using EMR notes of 43,216 hospitalization encounters in a hospital from January 1, 2017 to February 28, 2019. The mean age of the cohort was 67.51 years (SD 15.87), the mean length of stay was 5.57 days (SD 10.41), and the mean intensive care unit stay was 5% (SD 22%). We employed text-mining techniques to extract psychosocial topics that are representative of these patients and tested the utility of these topics in predicting 30-day hospital readmission beyond the predictive value of the LACE Index for Readmission. RESULTS: The added text-mined factors improved the area under the receiver operating characteristic curve of the readmission prediction by 8.46% for geriatric patients, 6.99% for the general hospital population, and 6.64% for frequent admitters. Medical social workers and case managers captured more of the psychosocial text topics than physicians. CONCLUSIONS: The results of this study demonstrate the feasibility of extracting psychosocial factors from EMR clinical notes and the value of these notes in improving readmission risk prediction. Psychosocial profiles of patients can be curated and quantified from text mining clinical notes and these profiles can be successfully applied to artificial intelligence models to improve readmission risk prediction.
Subject(s)
Artificial Intelligence , Patient Readmission , Aged , Data Mining , Humans , Length of Stay , Retrospective Studies , Risk FactorsABSTRACT
OBJECTIVE/BACKGROUND: Access to oral health care among older adults is a key issue in society, which has been exacerbated by social distancing measures and lockdowns during the COVID-19 pandemic. Older adults would greatly benefit from teledentistry, yet little information exists on the enablers and challenges of adopting this technology for use with this group. The aim of this scoping review is to summarise the applications and key factors associated with the adoption of teledentistry among older adults. MATERIALS AND METHODS: This scoping review was developed in accordance with Arksey and O'Malley's five-stage framework and the Joanna Briggs Institute scoping review protocol guidelines. Publications on teledentistry involving direct clinical services for older adults aged 60 and above were included. Publications that focused solely on teleeducation were excluded. A systematic search was carried out on major electronic databases until 25 August 2020. Out of 1084 articles screened, 25 articles were included. Facilitators and barriers were categorised using the socio-ecological model. RESULTS/DISCUSSION: Teleconsultation and telediagnosis were the most reported applications of teledentistry among older adults. Reported policy-level factors were data privacy issues (n = 7) and regulations (n = 17). Community-level facilitators and barriers included the availability of resources (n = 15) and support (n = 3). Familiar care settings (n = 2) and effective administration (n = 20) were key organisational-level factors. Staff attitudes and education (n = 23) and individual patient knowledge, attitudes and practices (n = 10) can influence teledentistry adoption while complex medical conditions (n = 8) may pose a challenge. CONCLUSION: Key factors in the uptake of teledentistry among older adults span across policy, community, organisational, interpersonal and individual factors. Commonly reported barriers included technical issues, lack of funding, consent issues and cognitive impairments.
Subject(s)
COVID-19 , Telemedicine , Aged , Communicable Disease Control , Humans , Pandemics , SARS-CoV-2ABSTRACT
OBJECTIVES: We aimed to understand the barriers experienced by physicians when prescribing for older adults with multimorbidity in specialist outpatient clinics in Singapore. METHODS: A modified Delphi study was conducted via email with 20 panel experts in the field of geriatric medicine. Barriers identified from an earlier scoping review were presented as statements to the panel. RESULTS: Eleven barrier statements reached consensus with high importance according to the Delphi panel. Of these statements, seven (64%) belong to the domain of Environmental context and resources in the Theoretical Domains Framework (TDF), while the remaining barriers belong to the domains of skills, knowledge, intentions, and professional/social role and identity. The barriers are further linked to intervention functions in the Behaviour Change Wheel (BCW). CONCLUSION: Linking the TDF domains to intervention functions revealed strategic directions for the development of an intervention to address the barriers and optimize prescribing.
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BACKGROUND: While sarcopenia and frailty independently contribute to functional impairment and disability, the combined impact resulting from their interplay is unclear. We investigated if functional, physical, cognitive, and nutritional measures were more adversely affected in community-dwelling older adults who were screened positive for both frailty and sarcopenia. METHODS: Using the FRAIL (≥1) and SARC-F (Strength, Assistance with walking, Rising from a chair, Climbing stairs, and Falls) (≥1) scales for screening, we categorized 200 participants (age, 67.9±7.9 years) as combined (both positive, 12.5%), intermediate (either positive, 25.5%), or robust (both negative, 62%). RESULTS: Comparisons of the three groups showed that the combined group had significantly worse functional ability (Frenchay Activities Index and Modified Barthel Index), physical performance (knee extension, gait speed, and Short Physical Performance Battery score), cognition/mood (Chinese Mini-Mental State Examination [CMMSE] score and Geriatric Depression Scale), and nutrition (Mini Nutritional Assessment [MNA] score) (p<0.05, one-way analysis of variance). Post-hoc comparisons revealed similar findings between the combined and robust groups, except for knee extension and CMMSE scores. Only MNA scores were significantly lower between the intermediate and robust groups. CONCLUSION: Functional ability, physical performance, and nutrition were more adversely affected in our study population of community-dwelling older adults who screened positive for both frailty and sarcopenia than in those who screened positive for either or neither, supporting the use of community screening for early detection and intervention for both frailty and sarcopenia as opposed to either alone.
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OBJECTIVES: To identify the types of factors included in research examining mortality in patients with dementia, and to stratify the identified factors by care settings. DESIGN: We systematically searched PubMed, Embase, PsycINFO and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases, and identified grey literature from the Networked Digital Library of Theses and Dissertations, Open Grey and Grey Literature Report. Two authors independently screened for eligibility of studies. Independent reviewers extracted relevant study information. We conducted a narrative synthesis of the data. RESULTS: We identified 8254 articles, of which 94 met the inclusion criteria. More than half (n=53) were published between 2009 and 2018 with half from Europe. Studies were conducted across hospices/nursing homes (n=25), hospital (n=23), outpatient clinics (n=21), mixed settings (n=15) and in the community (n=10). Nearly 60% adopted a prospective cohort study design with 87% performing multivariable analysis. Overall, 239 variables were identified and classified into six themes-individual factors, health status, functional ability, cognition and mental health, treatments and health system factors. Although a general set of factors were common across all studies, when stratified by care settings, variations were seen in the specific variables included. CONCLUSION: Identifying prognostic variables relevant to the dementia population in each setting is key to facilitate appropriate care plans and to ensure timely access to palliative care options. Future research should also focus on ensuring the replicability of prognostic models and to generate a better understanding of the direct and interacting influence of the identified factors on mortality.
Subject(s)
Dementia , Nursing Homes , Dementia/epidemiology , Humans , Palliative Care , Prognosis , Prospective StudiesABSTRACT
BACKGROUND: As the population ages, potentially inappropriate prescribing (PIP) in the older adults may become increasingly prevalent. This undermines patient safety and creates a potential source of major morbidity and mortality. Understanding the factors that influence prescribing behaviour may allow development of interventions to reduce PIP. The aim of this study is to apply the Theoretical Domains Framework (TDF) to explore barriers to effective prescribing for older adults in the ambulatory setting. METHODS: A scoping review was performed based on the five-stage methodological framework developed by Arksey and O'Malley. From 30 Aug 2018 to 5 Sep 2018, we conducted our search on PubMed, CINAHL, EMBASE, the Cochrane Database of Systematic Reviews, and Web of Science. We also searched five electronic journals, Google and Google Scholar to identify additional sources and grey literature. Two reviewers applied eligibility criteria to the title and abstract screening, followed by full text screening, before systematically charting the data. RESULTS: A total of 5731 articles were screened. Twenty-nine studies met the selection criteria for qualitative analysis. We mapped our results using the 14-domain TDF, eventually identifying 10 domains of interest for barriers to effective prescribing. Of these, significant domains include physician-related factors such as "Knowledge", "Skills", and "Social/Professional Role and Identity"; issues with "Environmental Context and Resources"; and the impact of "Social Influences" and "Emotion" on prescribing behaviour. CONCLUSION: The TDF elicited multiple domains which both independently and collectively lead to barriers to effective prescribing for older adults in the ambulatory setting. Changing the prescribing climate will thus require interventions targeting multiple stakeholders, including physicians, patients and hospital/clinic systems. Further work is needed to explore individual domains and guide development of frameworks to aid guide prescribing for older adults in the ambulatory setting.
Subject(s)
Inappropriate Prescribing , Professional Role , Aged , Humans , Patient SafetyABSTRACT
BACKGROUND: Multimorbidity, the coexistence of multiple chronic conditions in an individual, is a growing public health challenge. Amidst the COVID-19 pandemic, physical distancing remains an indispensable measure to limit the spread of the virus. This pertains especially to those belonging to high-risk groups, namely older adults with multimorbidity. In-person visits are discouraged for this cohort; hence, there is a need for an alternative form of consultation such as video consultations to continue the provision of care. OBJECTIVE: The potential of video consultations has been explored in several studies. However, the emergence of COVID-19 presents us with an unprecedented opportunity to explore the use of this technological innovation in a time when physical distancing is imperative. This study will evaluate the sustainability of video consultations on a micro-, meso-, and macro-level by assessing the views of patients, physicians, and organizational and national policymakers, respectively. METHODS: The NASSS (nonadoption, abandonment, scale-up, spread, and sustainability) framework was designed as a guide for the development of health care technologies. In this study, the implementation of and experiences related to video consultations will be studied using the NASSS framework. Individual in-depth interviews or focus group discussions will be conducted with participants using the Zoom platform. Data will be analyzed by at least two investigators trained in qualitative methodology, organized thematically, and coded in two phases-an initial phase and a focused selective phase. All disagreements will be resolved by consulting the larger research team until consensus is reached. RESULTS: This study was approved for funding from the Geriatric Education and Research Institute. Ethics approval was obtained from the National Healthcare Group Domain Specific Review Board (reference #2020/00760). Study recruitment commenced in July 2020. The results of the data analysis are expected to be available by the end of the year. CONCLUSIONS: This study aims to evaluate the adoption and sustainability of video consultations for older adults with multimorbidity during the pandemic as well as post COVID-19. The study will yield knowledge that will challenge the current paradigm on how care is being delivered for community-dwelling older adults with multimorbidity. Findings will be shared with administrators in the health care sector in order to enhance the safety and quality of these video consultations to improve patient care for this group of population. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/22679.