Interventions to prevent, delay or reverse frailty in older people: a journey towards clinical guidelines.

BACKGROUND: Age-related frailty is a multidimensional dynamic condition associated with adverse patient outcomes and high costs for health systems. Several interventions have been proposed to tackle frailty. This correspondence article describes the journey through the development of evidence- and consensus-based guidelines on interventions aimed at preventing, delaying or reversing frailty in the context of the FOCUS (Frailty Management Optimisation through EIP-AHA Commitments and Utilisation of Stakeholders Input) project (664367-FOCUS-HP-PJ-2014). The rationale, framework, processes and content of the guidelines are described. MAIN TEXT: The guidelines were framed into four questions - one general and three on specific groups of interventions - all including frailty as the primary outcome of interest. Quantitative and qualitative studies and reviews conducted in the context of the FOCUS project represented the evidence base. We followed the GRADE Evidence-to-Decision frameworks based on assessment of whether the problem is a priority, the magnitude of the desirable and undesirable effects, the certainty of the evidence, stakeholders' values, the balance between desirable and undesirable effects, the resource use, and other factors like acceptability and feasibility. Experts in the FOCUS consortium acted as panellists in the consensus process. Overall, we eventually recommended interventions intended to affect frailty as well as its course and related outcomes. Specifically, we recommended (1) physical activity programmes or nutritional interventions or a combination of both; (2) interventions based on tailored care and/or geriatric evaluation and management; and (3) interventions based on cognitive training (alone or in combination with exercise and nutritional supplementation). The panel did not support interventions based on hormone treatments or problem-solving therapy. However, all our recommendations were weak (provisional) due to the limited available evidence and based on heterogeneous studies of limited quality. Furthermore, they are conditional to the consideration of participant-, organisational- and contextual/cultural-related facilitators or barriers. There is insufficient evidence in favour of or against other types of interventions. CONCLUSIONS: We provided guidelines based on quantitative and qualitative evidence, adopting methodological standards, and integrating relevant stakeholders' inputs and perspectives. We identified the need for further studies of a higher methodological quality to explore interventions with the potential to affect frailty.

Reliability and Validity of the Geriatric Depression Scale in a Sample of Portuguese Older Adults with Mild-to-Moderate Cognitive Impairment.

Although the Geriatric Depression Scale (GDS) is a well-established instrument for the assessment of depressive symptoms in older adults, this has not been validated specifically for Portuguese older adults with cognitive impairment. The objective of this study was to analyze the psychometric properties of two Portuguese versions of the GDS (GDS-27 and GDS-15) in a sample of Portuguese older adults with mild-to-moderate cognitive impairment. Clinicians assessed for major depressive disorder and cognitive functioning in 117 participants with mild-to-moderate cognitive decline (76.9% female, Mage = 83.66 years). The internal consistency of GDS-27 and GDS-15 were 0.874 and 0.812, respectively. There was a significant correlation between GDS-27 and GDS-15 with the Beck Depression Inventory-II (GDS-27: rho = 0.738, p < 0.001; GDS-15: rho = 0.760, p < 0.001), suggesting good validity. A cutoff point of 15/16 in GDS-27 and 8/9 in GDS-15 resulted in the identification of persons with depression (GDS-27: sensitivity 100%, specificity 63%; GDS-15: sensitivity 90%, specificity 62%). Overall, the GDS-27 and GDS-15 are reliable and valid instruments for the assessment of depression in Portuguese-speaking older adults with cognitive impairment.

Effectiveness of Caregiver-Provided Individual Cognitive Interventions in Older Adults with Dementia.

Background: In a society increasingly committed to promoting an active life in the community, new resources are needed to respond to the needs of citizens with Alzheimer's disease and other forms of dementia. The potential of several individual cognitive interventions to be provided by caregivers has been explored in the literature. Objective: To synthesize the best available evidence on the effectiveness of caregiver-provided individual cognitive interventions in older adults with dementia. Methods: Systematic review of experimental studies on individual cognitive interventions for older adults with dementia. An initial search of MEDLINE and CINAHL was undertaken. Another search for published and unpublished studies was performed on major healthcare-related online databases in March 2018 and updated in August 2022. This review considered studies that included older adults with dementia, aged 60 years and over. All studies that met the inclusion criteria were assessed for methodological quality using a JBI standardized critical appraisal checklist. Data were extracted using a JBI data extraction form for experimental studies. Results: Eleven studies were included: eight randomized controlled trials and three quasi-experimental studies. Caregiver-provided individual cognitive interventions had several beneficial effects in cognitive domains, including memory, verbal fluency, attention, problem-solving, and autonomy in activities of daily living. Conclusion: These interventions were associated with moderate improvements in cognitive performance and benefits in activities of daily living. The findings highlight the potential of caregiver-provided individual cognitive interventions for older adults with dementia.

Effectiveness of Reminiscence Therapy versus Cognitive Stimulation Therapy in Older Adults with Cognitive Decline: A Quasi-Experimental Pilot Study.

Cognitive impairment can represent a predecessor to neuro-degenerative processes; however, evidence suggests that non-pharmacologic interventions such as reminiscence therapy (RT) and cognitive stimulation therapy (CST) can potentially stabilize or reverse this trend. Community-based settings are widely regarded as the key area of intervention by healthcare professionals in this field. Thus, this study aimed to assess the effects of an RT and a CST program in the cognition, depressive symptomatology, and quality of life (QoL) of older adults with cognitive decline who attend community support structures (CSS) in central Portugal. A quasi-experimental study with two arms (RT and CST program) was conducted for seven weeks. Participants were allocated to each arm based on the CSS they attended. Of the 109 older adults initially screened, 76 completed the intervention (50 in the RT program and 26 in the CST program). A pre- and post-intervention analysis showed statistically significant differences in older adults' cognition, especially in their delayed recall ability, in both groups. Older adults in the RT program evidence improved QoL scores post-intervention. Both the RT and CST programs implemented throughout the study are beneficial to older adults' cognitive performance, although results are more pronounced in the earlier stages of cognitive decline. Participation in the RT program was associated with improvements in older adults' QoL scores.

What Is the Relationship between Lifestyle and Frailty Status? Data from the Portuguese Multicentre Descriptive Study.

This observational and descriptive study attempted, within the scope of the ModulEn Research Project, to determine associations between lifestyle-related variables and frailty involving 160 community-dwelling older adults aged between 65 and 80 years living in the Central Region of Portugal. Forty-three percent of the study participants were pre-frail and 18% were frail. More than 50% of the frail people had slight cognitive decline, and the frailty condition was more frequently observed in women. As the literature highlights, there is potential for greater reversibility in the pre-frailty condition. To contribute to this reversibility, it is necessary to resort to interventions that promote physical activity and cognitive stimulation, apply adequate eating habits, and/or encourage the adoption of an active and socially integrated lifestyle. A healthy lifestyle implies good sleep and eating habits, and correct metabolic control that allows for effective surveillance of dyslipidemia, diabetes, and blood pressure.

Validation and Screening Capacity of the European Portuguese Version of the SUNFRAIL Tool for Community-Dwelling Older Adults.

Early detection of frailty may prevent or delay adverse health outcomes in community-dwelling older adults. In Portugal, there are currently no valid multidimensional frailty screening tools. SUNFRAIL is a user-friendly multidimensional tool for frailty screening that can be used in primary care. AIMS: (i) to determine the validity and reliability of the European Portuguese version of the SUNFRAIL tool for use in community-dwelling older adults; (ii) to assess the screening capacity of this version of SUNFRAIL using Fried's phenotypic model criteria for frailty as a reference test. METHODS: Cross-sectional pilot study in a convenience sample of 128 community-dwelling older adults. Objective and subjective data were collected. Internal consistency, concurrent validity, sensitivity, and specificity (ROC curve analysis) were examined. RESULTS: Internal consistency was low. Significant moderate to strong correlations were found between different domains and the total score. The differences between robust, pre-frail, and frail older adults were significant. SUNFRAIL was also correlated with multimorbidity. Sensitivity and specificity were satisfactory. CONCLUSIONS: The European Portuguese version of the SUNFRAIL tool is a promising frailty screening tool for community-dwelling older adults to be routinely used in clinical practice. However, more consistent results on its validity and reliability are needed to be used nationwide.

A Home-Based Individual Cognitive Stimulation Program for Older Adults With Cognitive Impairment: A Randomized Controlled Trial.

Objective: This study aims to assess the feasibility and meaningfulness of a home-based individual cognitive stimulation (iCS) program delivered by caregivers to persons with cognitive impairment (PwCIs). It also aims to assess whether the older adults receiving this program improved their cognitive, neuropsychiatric, and depressive symptoms and quality of life and whether their caregivers improved their mental and physical health. Methods: A randomized controlled trial (RCT) was conducted with PwCI-caregiver dyads recruited from the community. Participants were allocated to two groups: intervention (n = 28) and control (n = 24). The intervention group received the European Portuguese version of the Individual Cognitive Stimulation Program-Making a Difference 3 (MD3-P). The control group received usual care. The iCS therapy program was implemented three times a week for 12 weeks. Caregivers were supported by the researchers to deliver the sessions at home. Participants were assessed at baseline and at the end of the intervention (week 13). Feasibility and meaningfulness were assessed through the attrition rate, adherence, and degree of satisfaction with the sessions. Four interviews were conducted (after week 13) to understand participants' experiences. Results: The attrition rate was 23.1%. The dyads reported that they did not have high expectations about the iCS program before starting the study. Nevertheless, as the program evolved, caregivers noted that their family members had improved some areas of functioning. Intention-to-treat analysis based on group differences revealed a significant improvement in PwCIs' cognition, specifically in their orientation and ability to follow commands. The intervention had no impact on other variables such as caregivers' physical and mental health. Conclusion: The iCS program implemented by caregivers showed promising results in improving PwCIs' cognition. The participants who completed the intervention attributed a positive meaning to the MD3-P, confirming it as a valid non-pharmacological therapeutic approach to reducing frailty in PwCIs in community settings. Clinical Trial Registration: www.ClinicalTrials.gov, identifier [NCT03514095].

The Quality of Carer-Patient Relationship Scale: Adaptation and Validation into Portuguese.

BACKGROUND: This study aimed to translate and adapt the Quality of the Carer-Patient Relationship (QCPR) scale into Portuguese and analyse both its psychometric properties and correlation with sociodemographic and clinical variables. METHODS: Phase (1) Translate and culturally adapt the scale. Phase (2) Assess the scale's confirmatory factorial analysis, internal consistency, construct validity, and correlations. RESULTS: The experts classified the overall quality of the translation as adequate. A total of 53 dyads (cared-for person and carer) were assessed. In both versions, measures of central tendency and symmetry were also adequate, and the two factors under investigation had appropriate reliability, although in the conflict/critical factor, this was more fragile. Cronbach's alpha values were 0.89 for the cared-for person version and 0.91 for the carer version. CONCLUSIONS: The QCPR scale showed satisfactory to good values of reliability. The assessment is essential to guarantee structured interventions by health professionals, since the quality of the dyads' relationship seems to influence both older adults' quality of life and carers' health status. This study is a significant contribution to the introduction of the QCPR scale in the Portuguese clinical and scientific culture but also an opportunity to increase its use internationally.

The Effectiveness of an Evidence-Based Practice (EBP) Educational Program on Undergraduate Nursing Students' EBP Knowledge and Skills: A Cluster Randomized Control Trial.

Evidence-based practice (EBP) prevents unsafe/inefficient practices and improves healthcare quality, but its implementation is challenging due to research and practice gaps. A focused educational program can assist future nurses to minimize these gaps. This study aims to assess the effectiveness of an EBP educational program on undergraduate nursing students' EBP knowledge and skills. A cluster randomized controlled trial was undertaken. Six optional courses in the Bachelor of Nursing final year were randomly assigned to the experimental (EBP educational program) or control group. Nursing students' EBP knowledge and skills were measured at baseline and post-intervention. A qualitative analysis of 18 students' final written work was also performed. Results show a statistically significant interaction between the intervention and time on EBP knowledge and skills (p = 0.002). From pre- to post-intervention, students' knowledge and skills on EBP improved in both groups (intervention group: p < 0.001; control group: p < 0.001). At the post-intervention, there was a statistically significant difference in EBP knowledge and skills between intervention and control groups (p = 0.011). Students in the intervention group presented monographs with clearer review questions, inclusion/exclusion criteria, and methodology compared to students in the control group. The EBP educational program showed a potential to promote the EBP knowledge and skills of future nurses.

Effects of caregiver-provided individual cognitive interventions on cognition, social functioning and quality of life in older adults with major neurocognitive disorders: a systematic review.

OBJECTIVE: The objective of this review was to investigate the effectiveness of caregiver-provided individual cognitive interventions for improving cognition, social functioning and quality of life in older adults with major neurocognitive disorders. INTRODUCTION: A large number of people with major neurocognitive disorders live in their homes, requiring ongoing community care. Different individual cognitive intervention programs have been explored as a potential approach for implementation by caregivers on a one-to-one basis. These programs have the advantage of being implemented in a home setting and in the real-life context of the older adult, in a society that is increasingly aging and where aging in place is being fostered. INCLUSION CRITERIA: This review considered experimental studies that included older adults aged 60 years and over with major neurocognitive disorders who were receiving individual cognitive interventions (e.g. cognitive stimulation, cognitive training or cognitive rehabilitation) provided by their caregivers. The comparator was usual care, wait-list control or alternative therapeutic intervention. The primary outcomes of interest included cognition, social functioning and quality of life. Additionally, behavior, mood and activities of daily living were considered. METHODS: A comprehensive search strategy was used to identify relevant published and unpublished studies from January 1995 to March 2018, written in English, Spanish and Portuguese. Studies meeting the inclusion criteria were retrieved and their methodological quality was assessed by two independent reviewers using the JBI critical appraisal checklists for randomized controlled trials and quasi-experimental studies. Quantitative data were extracted using the standardized data extraction tool from the JBI System for the Unified Management, Assessment and Review of Information. Due to the clinical and methodological heterogeneity in the included studies, statistical pooling was not possible. Therefore, findings are presented in a narrative format. RESULTS: Eight randomized controlled trials and two quasi-experimental studies were included, with a total sample of 844 dyads (older adults and caregivers). The number of dyads included in the studies ranged from 16 to 356. Beneficial effects of the caregiver-provided individual cognitive interventions were observed in various cognitive domains, including memory, attention, verbal fluency and problem-solving. Two studies additionally reported the positive impact of the intervention of interest on general cognitive functioning. None of the reviewed studies revealed significant changes in quality of life. Social functioning was not analyzed in any of the included studies. Beneficial effects were also reported in relation to behavior and activities of daily living, despite the low level of evidence. CONCLUSIONS: This review responds to a gap in current international literature on the synthesis of evidence on the use of caregiver-provided individual cognitive interventions. The intervention of interest is associated with improvement in cognitive performance, revealing some benefits for the stabilization of neuropsychiatric symptoms and an increase in autonomy in activities of daily living. Further research on the impact of sociodemographic and clinical factors on the intervention effects is needed, as these factors seem to interfere with successful intervention implementation. To reinforce current evidence, the methodological quality of future studies should be improved.

Feasibility, appropriateness and meaningfulness analysis of the Sunfrail Tool to the European Portuguese population during cross-cultural adaptation process.

Frailty is an age-related condition characterized by increased vulnerability to negative outcomes. To enable informed decision-making and implementation of individually tailored practices for frailty management, it is necessary to develop screening tools that cover different domains of individual functioning, reliably predict future adverse outcomes and are generalizable to healthcare settings other than primary care. The Sunfrail Tool, an easy-to-use nine-item instrument, seems to meet all these requirements. The current study aimed to perform a cross-cultural adaptation of the Sunfrail Tool for the European Portuguese population and to perform the feasibility, appropriateness and meaningfulness analyses of the Sunfrail Tool Portuguese version. METHODS: The process of cross-cultural adaptation was conducted in four-phases (translation, synthesis, back translation and creation of consensual version). To reinforce the content validity, the additional analysis on feasibility, appropriateness and meaningfulness were conducted with end-users (older adults, informal caregivers and health and social care professionals). RESULTS: The frailty concept was considered suitable for the European Portuguese population. A consensus version was reached by an expert panel after considering the results of two forward and two back-translations. This prefinal version was endorsed to the first author of the original version of the instrument, as recommended by international guidelines. The content validation performed by healthcare professionals (n = 7), patients (n = 18) and informal caregivers (n = 3) showed that the Sunfrail Tool was moderately comprehensible and ambiguous. Five items required changes for cultural adaptation. CONCLUSION: The Sunfrail Tool seems to be a promising instrument for the early identification of frailty to be used in the European Portuguese context to inform clinical decisions on preventive responses. However, to enable identification of frail and nonfrail individuals with this tool and ensure effectiveness on pathways activation for frailty management, there is a need to define cut-off points. Guidelines supporting the interview process are also desirable.

Schizophrenia and Progressive Muscle Relaxation - A systematic review of effectiveness.

OBJECTIVE: We perform a systematically search, appraise and synthesize of the best available evidence on the effectiveness of Progressive Muscle Relaxation (PMR) in the adults with schizophrenia, in any setting, regarding anxiety, personal and social functioning, cognition, and well-being. METHOD: Major databases were searched to find both published and unpublished studies from inception until April 2017, using Schizophren* AND Relax* as keywords, and studies published in Portuguese, English, Spanish, Italian, French were considered for inclusion in this review. Methodological quality was assessed by two independent reviewers using the Critical Appraisal Checklist for Randomized Controlled Trials from the Joanna Briggs Institute. RESULTS: From a total of 1172 studies, five studies, involving 216 adults with schizophrenia, met the inclusion criteria for this systematic review after assessment of their methodological quality. These studies reported benefits in experimental group participants after PMR intervention on anxiety (assessed with State anxiety inventory, Beck Anxiety Inventory and Spielberger Trait Anxiety Inventory), well-being (assessed with Subjective Exercise Experiences Scale) and personal and social functioning (assessed with Sheehan Disability Scale and Therapist Rating Scale). CONCLUSIONS: Evidence suggests that PMR was effective in adults diagnosed with schizophrenia, except in one study where was only effective when combined with education. Thus, PMR may be useful to decrease state anxiety, improve well-being and social functioning in adults diagnosed with schizophrenia. However, due to the diversity of clinical intervention designs of PMR (different number and length of sessions) and outcome assessment scales, no strong evidence was found in this systematic review.

Effectiveness of a Combined Intervention on Psychological and Physical Capacities of Frail Older Adults: A Cluster Randomized Controlled Trial.

BACKGROUND: Older adults experience physical and psychological declines affecting independency. Adapted and structured combined interventions composed of cognitive stimulation and physical exercise contribute to comorbidities' reduction. Methods: Multicenter single-blinded two-arm cluster randomized controlled trial conducted to assess effectiveness of a combined intervention (CI), composed of a cognitive stimulation program (CSP) and a physical exercise program (PEP), on psychological and physical capacities of frail older adults as to on their activities of daily living. Were recruited 50 subjects from two elderly end-user organizations. Of these, 44 (65.9% females, mean age of 80.5 ± 8.47 years) were considered eligible, being randomly allocated in experimental (EG) or control group (CG). Data collected at baseline and post-intervention. EG received CI three times a week during 12 weeks. CG received standard care. Non-parametric measures were considered. Results: At baseline, groups were equivalent for study outcomes. The comparison of pre- and post-intervention data revealed that subjects receiving CI reduced depressive symptomatology and risk of fall based on gait and balance, and improved gait speed. Simultaneously, in the CG a significant decline on activities of daily living was observed. Significant results were found among biomechanical parameters of gait (BPG). EG' effect size revealed to be small (0.2 ≤ r < 0.5). CG' effect size was also small; but for activities of daily living there was an evident decrease. Conclusion: The CI is effective on managing older adults' psychological and physical capacities.

Correction: Stakeholders' views and experiences of care and interventions for addressing frailty and pre-frailty: A meta-synthesis of qualitative evidence.

[This corrects the article DOI: 10.1371/journal.pone.0180127.].

A realist review to understand the efficacy and outcomes of interventions designed to minimise, reverse or prevent the progression of frailty.

Interventions to minimise, reverse or prevent the progression of frailty in older adults represent a potentially viable route to improving quality of life and care needs in older adults. Intervention methods used across European Innovation Partnership on Active and Healthy Ageing collaborators were analysed, along with findings from literature reviews to determine 'what works for whom in what circumstances'. A realist review of FOCUS study literature reviews, 'real-world' studies and grey literature was conducted according to RAMESES (Realist and Meta-narrative Evidence Synthesis: Evolving Standards), and used to populate a framework analysis of theories of why frailty interventions worked, and theories of why frailty interventions did not work. Factors were distilled into mechanisms deriving from theories of causes of frailty, management of frailty and those based on the intervention process. We found that studies based on resolution of a deficiency in an older adult were only successful when there was indeed a deficiency. Client-centred interventions worked well when they had a theoretical grounding in health psychology and offered choice over intervention elements. Healthcare organisational interventions were found to have an impact on success when they were sufficiently different from usual care. Compelling evidence for the reduction of frailty came from physical exercise, or multicomponent (exercise, cognitive, nutrition, social) interventions in group settings. The group context appears to improve participants' commitment and adherence to the programme. Suggested mechanisms included commitment to co-participants, enjoyment and social interaction. In conclusion, initial frailty levels, presence or absence of specific deficits, and full person and organisational contexts should be included as components of intervention design. Strategies to enhance social and psychological aspects should be included even in physically focused interventions.

Effectiveness of interventions to prevent pre-frailty and frailty progression in older adults: a systematic review.

OBJECTIVE: To summarize the best available evidence regarding the effectiveness of interventions for preventing frailty progression in older adults. INTRODUCTION: Frailty is an age-related state of decreased physiological reserves characterized by an increased risk of poor clinical outcomes. Evidence supporting the malleability of frailty, its prevention and treatment, has been presented. INCLUSION CRITERIA: The review considered studies on older adults aged 65 and over, explicitly identified as pre-frail or frail, who had been undergoing interventions focusing on the prevention of frailty progression. Participants selected on the basis of specific illness or with a terminal diagnosis were excluded. The comparator was usual care, alternative therapeutic interventions or no intervention. The primary outcome was frailty. Secondary outcomes included: (i) cognition, quality of life, activities of daily living, caregiver burden, functional capacity, depression and other mental health-related outcomes, self-perceived health and social engagement; (ii) drugs and prescriptions, analytical parameters, adverse outcomes and comorbidities; (iii) costs, and/or costs relative to benefits and/or savings associated with implementing the interventions for frailty. Experimental study designs, cost effectiveness, cost benefit, cost minimization and cost utility studies were considered for inclusion. METHODS: Databases for published and unpublished studies, available in English, Portuguese, Spanish, Italian and Dutch, from January 2001 to November 2015, were searched. Critical appraisal was conducted using standardized instruments from the Joanna Briggs Institute. Data was extracted using the standardized tools designed for quantitative and economic studies. Data was presented in a narrative form due to the heterogeneity of included studies. RESULTS: Twenty-one studies, all randomized controlled trials, with a total of 5275 older adults and describing 33 interventions, met the criteria for inclusion. Economic analyses were conducted in two studies. Physical exercise programs were shown to be generally effective for reducing or postponing frailty but only when conducted in groups. Favorable effects on frailty indicators were also observed after the interventions, based on physical exercise with supplementation, supplementation alone, cognitive training and combined treatment. Group meetings and home visits were not found to be universally effective. Lack of efficacy was evidenced for physical exercise performed individually or delivered one-to-one, hormone supplementation and problem solving therapy. Individually tailored management programs for clinical conditions had inconsistent effects on frailty prevalence. Economic studies demonstrated that this type of intervention, as compared to usual care, provided better value for money, particularly for very frail community-dwelling participants, and had favorable effects in some of the frailty-related outcomes in inpatient and outpatient management, without increasing costs. CONCLUSIONS: This review found mixed results regarding the effectiveness of frailty interventions. However, there is clear evidence on the usefulness of such interventions in carefully chosen evidence-based circumstances, both for frailty itself and for secondary outcomes, supporting clinical investment of resources in frailty intervention. Further research is required to reinforce current evidence and examine the impact of the initial level of frailty on the benefits of different interventions. There is also a need for economic evaluation of frailty interventions.

Stakeholders' views and experiences of care and interventions for addressing frailty and pre-frailty: A meta-synthesis of qualitative evidence.

Frailty is a common condition in older age and is a public health concern which requires integrated care and involves different stakeholders. This meta-synthesis focuses on experiences, understanding, and attitudes towards screening, care, intervention and prevention for frailty across frail and healthy older persons, caregivers, health and social care practitioners. Studies published since 2001 were identified through search of electronic databases; 81 eligible papers were identified and read in full, and 45 papers were finally included and synthesized. The synthesis was conducted with a meta-ethnographic approach. We identified four key themes: Uncertainty about malleability of frailty; Strategies to prevent or to respond to frailty; Capacity to care and person and family-centred service provision; Power and choice. A bottom-up approach which emphasises and works in synchrony with frail older people's and their families' values, goals, resources and optimisation strategies is necessary. A greater employment of psychological skills, enhancing communication abilities and tools to overcome disempowering attitudes should inform care organisation, resulting in more efficient and satisfactory use of services. Public health communication about prevention and management of frailty should be founded on a paradigm of resilience, balanced acceptance, and coping. Addressing stakeholders' views about the preventability of frailty was seen as a salient need.

Predicting risk and outcomes for frail older adults: an umbrella review of frailty screening tools.

BACKGROUND: A scoping search identified systematic reviews on diagnostic accuracy and predictive ability of frailty measures in older adults. In most cases, research was confined to specific assessment measures related to a specific clinical model. OBJECTIVES: To summarize the best available evidence from systematic reviews in relation to reliability, validity, diagnostic accuracy and predictive ability of frailty measures in older adults. INCLUSION CRITERIA POPULATION: Older adults aged 60 years or older recruited from community, primary care, long-term residential care and hospitals. INDEX TEST: Available frailty measures in older adults. REFERENCE TEST: Cardiovascular Health Study phenotype model, the Canadian Study of Health and Aging cumulative deficit model, Comprehensive Geriatric Assessment or other reference tests. DIAGNOSIS OF INTEREST: Frailty defined as an age-related state of decreased physiological reserves characterized by an increased risk of poor clinical outcomes. TYPES OF STUDIES: Quantitative systematic reviews. SEARCH STRATEGY: A three-step search strategy was utilized to find systematic reviews, available in English, published between January 2001 and October 2015. METHODOLOGICAL QUALITY: Assessed by two independent reviewers using the Joanna Briggs Institute critical appraisal checklist for systematic reviews and research synthesis. DATA EXTRACTION: Two independent reviewers extracted data using the standardized data extraction tool designed for umbrella reviews. DATA SYNTHESIS: Data were only presented in a narrative form due to the heterogeneity of included reviews. RESULTS: Five reviews with a total of 227,381 participants were included in this umbrella review. Two reviews focused on reliability, validity and diagnostic accuracy; two examined predictive ability for adverse health outcomes; and one investigated validity, diagnostic accuracy and predictive ability. In total, 26 questionnaires and brief assessments and eight frailty indicators were analyzed, most of which were applied to community-dwelling older people. The Frailty Index was examined in almost all these dimensions, with the exception of reliability, and its diagnostic and predictive characteristics were shown to be satisfactory. Gait speed showed high sensitivity, but only moderate specificity, and excellent predictive ability for future disability in activities of daily living. The Tilburg Frailty Indicator was shown to be a reliable and valid measure for frailty screening, but its diagnostic accuracy was not evaluated. Screening Letter, Timed-up-and-go test and PRISMA 7 (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) demonstrated high sensitivity and moderate specificity for identifying frailty. In general, low physical activity, variously measured, was one of the most powerful predictors of future decline in activities of daily living. CONCLUSION: Only a few frailty measures seem to be demonstrably valid, reliable and diagnostically accurate, and have good predictive ability. Among them, the Frailty Index and gait speed emerged as the most useful in routine care and community settings. However, none of the included systematic reviews provided responses that met all of our research questions on their own and there is a need for studies that could fill this gap, covering all these issues within the same study. Nevertheless, it was clear that no suitable tool for assessing frailty appropriately in emergency departments was identified.

The effectiveness of non-pharmacological interventions in older adults with depressive disorders: A systematic review.

BACKGROUND: It is widely acknowledged that mental health disorders are common in older adults and that depression is one of the most serious threats to the mental health of older adults. Although best practice guidelines point out that moderate to severe depression should be approached with pharmacotherapy together with complementary therapies, the use of antidepressant drugs in older adults has various disadvantages, such as long response time, side effects, potential risk of dependency and tolerance, poor compliance rates and high probability of drug interactions. In addition, qualitative studies of depressed people with a chronic illness have indicated that both patients and healthcare professionals prefer a psychosocial treatment for depression over a pharmacological one. OBJECTIVE: This review aimed to identify and synthesize the best available evidence related to the effectiveness of non-pharmacological interventions for older adults with depressive disorders. DESIGN: Systematic review of studies with any experimental design considering non-pharmacological interventions for older adults with depressive disorders. DATA SOURCES: An initial search of MEDLINE and CINAHL was undertaken, followed by a second search for published and unpublished studies, from January 2000 to March 2012, of major healthcare-related electronic databases. Studies in English, Spanish and Portuguese were included in the review. REVIEW METHODS: This review considered studies that included adult patients, aged over 65 years with any type of depressive disorder, regardless of comorbidities and any previous treatments, but excluded those with manic or psychotic episodes/symptoms. All studies that met the inclusion criteria were assessed for methodological quality by two independent reviewers using a standardized critical appraisal checklist for randomized and quasi-randomized controlled studies from the Joanna Briggs Institute. Data extraction was also conducted by two independent reviewers based on the Joanna Briggs Institute data extraction form for experimental studies. RESULTS: Twenty-three studies met the inclusion criteria. Of those, seventeen were excluded after critical appraisal of methodological quality and six were included in this review. These studies included 520 participants and described cognitive behavior therapy, competitive memory training, reminiscence group therapy, problem-adaptation therapy, and problem-solving therapy in home care. Evidence suggests that all these interventions reduce depressive symptoms. CONCLUSIONS: According to evidence, non-pharmacological interventions had positive effects on improving patients' depression and may be useful in practice. However, due to the diversity of interventions and the low number of studies per intervention included in this systematic review, evidence is not strong enough to produce a best practice guideline.