[From comprehensive geriatric assessment to an integrated multidimensional assessment system : interRAI tools and their applications]. / De l'évaluation gériatrique standardisée à un système intégré d'évaluation multidimensionnelle : les outils interRAI et leurs applications.

The multidimensional assessment carried out with interRAI tools constitutes an operationalization of the International Classification of Functioning, Disability and Health (ICF) and is adapted to the specificities of each place of care. From a single assessment, the interRAI approach makes it possible to conduct a multidimensional assessment of functional autonomy and to produce a series of indicators (health, areas of intervention, quality of care and consumption of resources). It helps to identify clinical needs to be the subject of a personalized care plan and the strengths and weaknesses of health organizations to modify the professional practices. Compared to standardized geriatric assessment, interRAI tools consider the person's expectations and resources, offer a universal common language, produce a multidimensional synthesis and facilitate the construction of an integrated information system. The basis for their development is scientificity based on evidence.

The Association of Anticholinergic Drugs and Delirium in Nursing Home Patients With Dementia: Results From the SHELTER Study.

OBJECTIVES: Drugs with anticholinergic properties are associated with an increased prevalence of delirium, especially in older persons. The aim of this study was to evaluate the association between the use of this class of drugs in nursing home (NH) patients and prevalence of delirium, particularly in people with dementia. DESIGN: Cross-sectional multicenter study. SETTING AND PARTICIPANTS: 3924 nursing home patients of 57 nursing homes in 7 European countries participating in the Services and Health for Elderly in Long TERmcare (SHELTER) project. METHODS: Descriptive statistics, calculation of percentage, and multivariable logistic analysis were applied to describe the relationship between anticholinergic drug use and prevalence of delirium in NH patients. The Anticholinergic Risk Scale (ARS) and the Anticholinergic Burden Scale (ACB) were used to calculate the anticholinergic load. RESULTS: 54% of patients with dementia and 60% without dementia received at least 1 anticholinergic drug according to the ACB. The prevalence of delirium was higher in the dementia group (21%) compared with the nondementia group (11%). Overall, anticholinergic burden according to the ACB and ARS was associated with delirium both in patients with and without dementia, with odds ratios ranging from 1.07 [95% confidence interval (CI) 0.94-1.21] to 1.26 (95% CI 1.11-1.44). These associations reached statistical significance only in the group of patients with dementia. Among patients with dementia, delirium prevalence increased only modestly with increasing anticholinergic burden according to the ACB, from 20% (with none or minimal anticholinergic burden) to 25% (with moderate burden) and 27% delirium (with strong burden scores). CONCLUSIONS AND IMPLICATIONS: The ACB scale is relatively capable to detect anticholinergic side effects, which are positively associated with prevalence of delirium in NH patients. Given the modest nature of this association, strong recommendations are currently not warranted, and more longitudinal studies are needed.

Predictors of Societal Costs of Older Care-Dependent Adults Living in the Community in 11 European Countries.

BACKGROUND: The objective was to identify predictors of societal costs covering formal and informal care utilization by older home care clients in 11 European countries. METHODS: Societal costs of 1907 older clients receiving home care for 12 months from the Aged in Home care (AdHoc) study were estimated using the InterRAI Minimum Data Set for Home Care's (MDS-HC) resource use items. Predictors (medical, functional, and psychosocial domains) of societal costs were identified by performing univariate and multivariate generalized linear model analyses. RESULTS: Mean societal costs per participant were €36 442, ranging from €14 865 in Denmark to €78 836 in the United Kingdom. In the final multivariate model, country, being married, activities of daily living (ADL) dependency, cognitive impairment, limitations of going out, oral conditions, number of medications, arthritis, and cerebro vascular accident (CVA) were significantly associated with societal costs. CONCLUSIONS: Of the predictors, ADL dependency and limitations of going out may be modifiable. Developing interventions targeted at improving these conditions may create opportunities to curtail societal costs.

Implementation of a Standardized Comprehensive Assessment Tool in France: A Case Using the InterRAI Instruments.

BACKGROUND: The improvement of quality of care requires a standardized and comprehensive assessment tool but implementation is challenging. PURPOSE: We have reported on the development of the interRAI instruments in France from the onset to the mandatory use at the national level. We also have identified in the literature and in practices, incentives and barriers for the implementation of this integrated clinical information system in long term care. RESULTS: Three periods in the interRAI instruments development were identified over the last twenty years. The first one was a research approach about improving quality of long term care. The second one was an experimental clinical use into an integrated care model with case management. The third one was a call for tenders issued by a French national agency, and the choice to use the interRAI-HC (Home Care) for all case managers. The main incentives and barriers that were identified include the national context, the target population, the providers involved and the impact on their practice, the interRAI instrument characteristics, training and leadership. CONCLUSION: This historical overview of the development of interRAI instruments in France gives health care organizations pertinent information to guide the implementation of a standardized and comprehensive assessment tool.

Updating the Cognitive Performance Scale.

This study presents the first update of the Cognitive Performance Scale (CPS) in 20 years. Its goals are 3-fold: extend category options; characterize how the new scale variant tracks with the Mini-Mental State Examination; and present a series of associative findings. Secondary analysis of data from 3733 older adults from 8 countries was completed. Examination of scale dimensions using older and new items was completed using a forward-entry stepwise regression. The revised scale was validated by examining the scale's distribution with a self-reported dementia diagnosis, functional problems, living status, and distress measures. Cognitive Performance Scale 2 extends the measurement metric from a range of 0 to 6 for the original CPS, to 0 to 8. Relating CPS2 to other measures of function, living status, and distress showed that changes in these external measures correspond with increased challenges in cognitive performance. Cognitive Performance Scale 2 enables repeated assessments, sensitive to detect changes particularly in early levels of cognitive decline.

Dual Sensory Impairment and Cognitive Decline: The Results From the Shelter Study.

OBJECTIVES: To examine whether nursing home residents with concurrent vision and hearing impairment, dual sensory impairment (DSI), have a greater cognitive decline over time than do those without sensory impairment and whether social engagement modifies this association. METHODS: Based on the Services and Health for Elderly in Long TERm Care study, 1,989 nursing home residents who were assessed using the interRAI LTCF at 6-month intervals over 1 year were included. Multivariate linear regression models with time-variant exposure variables of sensory impairment and social engagement using generalized estimating equations were performed to predict cognitive function measured by the Cognitive Performance Scale (range 0-6). RESULTS: Residents with DSI had a greater cognitive decline [changes in Cognitive Performance Scale over 1 year = 1.12 (95% confidence interval = 0.81:1.42)] compared to those with either vision or hearing impairment [0.67 (0.53:0.64)] and those without sensory impairment [0.56 (0.48:0.64)]. A lower level of social engagement was also associated with a greater cognitive decline. The combined exposure variable of sensory impairment and social engagement revealed the greatest cognitive decline for socially disengaged residents with DSI [1.87 (1.24:2.51)] and the potential effect modification of social engagement on the association between DSI and cognitive decline; DSI was not associated with a greater cognitive decline among socially engaged residents, while it was associated among socially disengaged residents DISCUSSION: Cognitive function declines faster in nursing home residents with DSI only when residents were not socially engaged. Therefore, residents with DSI might cognitively benefit from interventions to improve involvement in social life at nursing homes.

Insomnia in long-term care facilities: a comparison of seven European countries and Israel: the Services and Health for Elderly in Long TERm care study.

OBJECTIVES: To assess insomnia and its correlates as part of the Services and Health for Elderly in Long TERm care (SHELTER) study, funded by the 7th Framework Programme of the European Union. DESIGN: Cross-cultural investigation. SETTING: Long-term care facilities (LTCFs) in eight European countries (Czech Republic, France, Finland, Germany, England, the Netherlands, Italy) and one non-European country (Israel). PARTICIPANTS: Elderly residents (N = 4,156) of 57 LTCFs. MEASUREMENTS: Information on insomnia, age, sex, activities of daily living (ADLs), cognitive status, depression, major stressful life events, physical activity, fatigue, pain, and sleep medication use was extracted from the International Resident Assessment Instrument (interRAI)LTCF instrument. Rates of insomnia and its correlates were analyzed. Multivariate logistic regression was used to assess factors associated with insomnia, controlling for demographic variables. RESULTS: The prevalence of insomnia was 24% (range 13-30%), with significant differences between countries (P < .001). More insomnia complaints were reported in older than younger residents (P < .001). Higher rates of insomnia were associated with hypnosedatives and depression in all countries (P < .001) and with stressful life events, fatigue, and pain in most countries (P < .001). No associations were found between insomnia and ADLs, physical activity, or cognitive status. Age, depression, stressful life events, fatigue, pain and hypnosedatives were independent significant predictors of insomnia, controlling for all other variables and for country. CONCLUSION: Hypnosedatives and depression were strong predictors of insomnia beyond cultural differences. Overall, psychosocial variables were more strongly related to insomnia than functional and mental capacities.

Use of antipsychotic drugs among residents with dementia in European long-term care facilities: results from the SHELTER study.

BACKGROUND: Behavioral and psychological symptoms of dementia (BPSD) are common reasons for use of antipsychotic drugs among older individuals with dementia. These drugs are not approved for such use and both the Food and Drug Administration and European Medicines Agency have issued warnings to limit such use. OBJECTIVES: This study aimed to describe patterns of antipsychotic drug use in a sample of nursing home residents with dementia in 7 European countries and Israel. DESIGN: This cross-sectional, retrospective cohort study used data from the SHELTER study that collected comprehensive resident data using the interRAI Long-Term Care Facility instrument. METHODS: Fifty-seven long-term care facilities participated from 8 countries, and the sample included 4156 long-term care residents from these settings. Individuals with dementia, both Alzheimer and non-Alzheimer types, were identified. Potential correlates of any antipsychotic and atypical versus conventional antipsychotic drug use among residents with dementia were identified using generalized estimation equation modeling. RESULTS: A total of 2091 individuals with dementia were identified. Antipsychotic drug use among these individuals varied by country, with overall prevalence of use being 32.8% (n = 662). Among antipsychotic users, 7 in 10 were receiving atypical agents. Generalized estimation equation analysis revealed that the strongest correlate of any antipsychotic drug use was severe behavioral symptoms, which increased the likelihood by 2.84. Correlates of atypical versus conventional antipsychotic drug use included psychiatric services, more than 10 medications, moderate behavioral symptoms, and female gender. CONCLUSION: Despite recommendations to avoid the use of antipsychotic drugs in patients with dementia, a large proportion of residents in European long-term care facilities continue to receive such agents. Future work should not only establish the appropriateness of such use through outcomes studies, but explore withdrawal strategies as well as alternative treatment modalities.

[Single entry point in a gerontological network for addressing the needs of older people]. / Un guichet unique dans un réseau gérontologique pour i'orientation des personnes âgées.

INTRODUCTION: A single entry point for the elderly is important for the integration of services and for standardizing needs assessment processes. The role of a single entry point role is to refer older persons to the appropriate social and/or health services. The purpose of this paper is to describe the relationships between institutional partners and their use of the single entry point in a gerontological network. METHODS: The gerontological network "Ancrage" is one of the first integrated care models with a single entry point to be implemented in France. The contact assessment tool known as CHIP (Community Hospital Intake Profile) is used to assess the needs of elderly people living at home and to make referrals. The data collected included all the requests made by partners at the single entry point over the course of one year (2008). RESULTS: A total of 303 requests were submitted to the single entry point by all partners (i.e. health and social professionals). These requests came from primary care professionals (68.3%), notably family physicians (29.3%). The needs of elderly people varied according to the type of requester. Most of those involved were directed toward the gerontological network (59.2%) and had more complex needs (no support from an informal caregiver and more difficulties in performing daily activities). CONCLUSION: A single entry point is designed to involve all institutional partners and to meet the needs of the elderly. The level of involvement among physicians is high, and elderly people directed toward the gerontological network have the most complex clinical needs.

The calculation of quality indicators for long term care facilities in 8 countries (SHELTER project).

BACKGROUND: Performance indicators in the long term care sector are important to evaluate the efficiency and quality of care delivery. We are, however, still far from being able to refer to a common set of indicators at the European level.We therefore demonstrate the calculation of Long Term Care Facility Quality Indicators (LTCFQIs) from data of the European Services and Health for Elderly in Long TERm Care (SHELTER) project. We explain how risk factors are taken into account and show how LTC facilities at facility and country level can be compared on quality of care using thresholds and a Quality Indicator sum measure. METHODS: The indicators of Long Term Care Facility quality of care are calculated based on methods that have been developed in the US. The values of these Quality Indicators (QIs) are risk adjusted on the basis of covariates resulting from logistic regression analysis on each of the QIs. To enhance the comparison of QIs between facilities and countries we have used the method of percentile thresholds and developed a QI sum measure based on percentile outcomes. RESULTS: In SHELTER data have been collected with the interRAI Long Term Care Facility instrument (interRAI-LTCF). The data came from LTC facilities in 7 European countries and Israel. The unadjusted values of the LTCF Quality Indicators differ considerably between facilities in the 8 countries. After risk adjustment the differences are less, but still considerable. Our QI sum measure facilitates the overall comparison of quality of care between facilities and countries. CONCLUSIONS: With quality indicators based on assessments with the interRAI LTCF instrument quality of care between LTC facilities in and across nations can be adequately compared.

Assessment of nursing home residents in Europe: the Services and Health for Elderly in Long TERm care (SHELTER) study.

BACKGROUND: Aims of the present study are the following: 1. to describe the rationale and methodology of the Services and Health for Elderly in Long TERm care (SHELTER) study, a project funded by the European Union, aimed at implementing the interRAI instrument for Long Term Care Facilities (interRAI LTCF) as a tool to assess and gather uniform information about nursing home (NH) residents across different health systems in European countries; 2. to present the results about the test-retest and inter-rater reliability of the interRAI LTCF instrument translated into the languages of participating countries; 3 to illustrate the characteristics of NH residents at study entry. METHODS: A 12 months prospective cohort study was conducted in 57 NH in 7 EU countries (Czech Republic, England, Finland, France, Germany, Italy, The Netherlands) and 1 non EU country (Israel). Weighted kappa coefficients were used to evaluate the reliability of interRAI LTCF items. RESULTS: Mean age of 4156 residents entering the study was 83.4 ± 9.4 years, 73% were female. ADL disability and cognitive impairment was observed in 81.3% and 68.0% of residents, respectively. Clinical complexity of residents was confirmed by a high prevalence of behavioral symptoms (27.5% of residents), falls (18.6%), pressure ulcers (10.4%), pain (36.0%) and urinary incontinence (73.5%). Overall, 197 of the 198 the items tested met or exceeded standard cut-offs for acceptable test-retest and inter-rater reliability after translation into the target languages. CONCLUSION: The interRAI LTCF appears to be a reliable instrument. It enables the creation of databases that can be used to govern the provision of long-term care across different health systems in Europe, to answer relevant research and policy questions and to compare characteristics of NH residents across countries, languages and cultures.

Diagnostic study, design and implementation of an integrated model of care in France: a bottom-up process with continuous leadership.

BACKGROUND: Sustaining integrated care is difficult, in large part because of problems encountered securing the participation of health care and social service professionals and, in particular, general practitioners (GPs). PURPOSE: To present an innovative bottom-up and pragmatic strategy used to implement a new integrated care model in France for community-dwelling elderly people with complex needs. RESULTS: In the first step, a diagnostic study was conducted with face-to-face interviews to gather data on current practices from a sample of health and social stakeholders working with elderly people. In the second step, an integrated care model called Coordination Personnes Agées (COPA) was designed by the same major stakeholders in order to define its detailed characteristics based on the local context. In the third step, the model was implemented in two phases: adoption and maintenance. This strategy was carried out by a continuous and flexible leadership throughout the process, initially with a mixed leadership (clinician and researcher) followed by a double one (clinician and managers of services) in the implementation phase. CONCLUSION: The implementation of this bottom-up and pragmatic strategy relied on establishing a collaborative dynamic among health and social stakeholders. This enhanced their involvement throughout the implementation phase, particularly among the GPs, and allowed them to support the change practices and services arrangements.

Sharing clinical information across care settings: the birth of an integrated assessment system.

BACKGROUND: Population ageing, the emergence of chronic illness, and the shift away from institutional care challenge conventional approaches to assessment systems which traditionally are problem and setting specific. METHODS: From 2002, the interRAI research collaborative undertook development of a suite of assessment tools to support assessment and care planning of persons with chronic illness, frailty, disability, or mental health problems across care settings. The suite constitutes an early example of a "third generation" assessment system. RESULTS: The rationale and development strategy for the suite is described, together with a description of potential applications. To date, ten instruments comprise the suite, each comprising "core" items shared among the majority of instruments and "optional" items that are specific to particular care settings or situations. CONCLUSION: This comprehensive suite offers the opportunity for integrated multi-domain assessment, enabling electronic clinical records, data transfer, ease of interpretation and streamlined training.