Psychometric evaluation of the Decision Support Tool for Functional Independence in community-dwelling older people.

Background: The aging population is increasingly faced with daily life limitations, threatening their Functional Independence (FI). These limitations extend different life domains and require a broad range of community-care professionals to be addressed. The Decision Support Tool for Functional Independence (DST-FI) facilitates community-care professionals in providing uncontradictory recommendations regarding the maintenance of FI in community-dwelling older people. The current study aims to determine the validity and reliability of the DST-FI. Methods: Sixty community-care professionals completed a twofold assessment. To assess construct validity, participants were asked to assign predefined recommendations to fifty cases of older people to maintain their level of FI. Hypotheses were tested regarding the expected recommendations per case. Content validity was assessed by questions on relevance, comprehensiveness, and comprehensibility of the current set of recommendations. Twelve participants repeated the assessment after two weeks to enable both within- and between rater reliability properties, expressed by an Intraclass Correlation Coefficient. Results: Seven out of eight predefined hypotheses confirmed expectations, indicating high construct validity. As the recommendations were indicated 'relevant' and 'complete', content validity was high as well. Agreement between raters was poor to moderate while agreement within raters was moderate to excellent, resulting in moderate overall reliability. CONCLUSION: The DST-FI suggests high validity and moderate reliability properties when used in a population of community-dwelling older people. The tool could facilitate community-care professionals in their task to preserve FI in older people. Future research should focus on psychometric properties like feasibility, acceptability, and developing and piloting strategies for implementation in community-care.

The Ambassador Project: Evaluating a Five-Year Nationwide Leadership Program to Bridge the gap Between Policy and District Nursing Practice.

District nurses have a crucial position in healthcare provision and are expected to use leadership practices to ensure optimal quality patient care. To better equip them, a leadership program named the ambassador project was developed to support the development of a liaison role between policy and district nursing practice. This research aims to evaluate from different perspectives the impact of this nationwide, five-year leadership program for district nurses at the organizational, regional, and societal levels. A mixed-methods study was conducted using two focus groups based on peer-to-peer shadowing (n = 14), semistructured interviews (n = 13), and an online questionnaire (n = 45). The analysis shows that the impact of a nationwide leadership program for district nurses was perceived as predominantly positive, and nurses experienced an increase in courage, assertiveness, professional pride, and leadership skills. They obtained confidence in representing the group of district nurses at the organizational, regional, and societal levels when speaking with various key stakeholders from the healthcare system. They were able to bridge the gaps among daily practice, policymaking, and politics by using translations and shaping actions and information into terms suiting the needs of those involved.

Exploring Associations between Oral Health and Frailty in Community-Dwelling Older People.

BACKGROUND: In frail older people with natural teeth factors like polypharmacy, reduced salivary flow, a decrease of oral self-care, general healthcare issues, and a decrease in dental care utilization contribute to an increased risk for oral complications. On the other hand, oral morbidity may have a negative impact on frailty. OBJECTIVE: This study explored associations between oral health and two frailty measures in community-dwelling older people. DESIGN: A cross-sectional study. SETTING: The study was carried out in a Primary Healthcare Center (PHC) in The Netherlands. PARTICIPANTS: Of the 5,816 persons registered in the PHC, 1,814 persons were eligible for participation at the start of the study. MEASUREMENTS: Two frailty measures were used: 1. Being at risk for frailty, using Electronical Medical Record (EMR) data, and: 2. Survey-based frailty using 'The Groningen Frailty Indicator' (GFI). For oral health measures, dental-record data (dental care utilization, dental status, and oral health information) and self-reported oral problems were recorded. Univariate regression analyses were applied to determine the association between oral health and frailty, followed by age- and sex-adjusted multivariate logistic regressions. RESULTS: In total 1,202 community-dwelling older people were included in the study, 45% were male and the mean age was 73 years (SD=8). Of all participants, 53% was at risk for frailty (638/1,202), and 19% was frail based on the GFI (222/1,202). A dental emergency visit (Odds Ratio (OR)= 2.0, 95% Confidence Interval (CI)=1.33;3.02 and OR=1.58, 95% CI=1.00;2.49), experiencing oral problems (OR=2.07, 95% CI=1.52;2.81 and OR=2.87, 95% CI= 2.07;3.99), and making dietary adaptations (OR=2.66, 95% CI=1.31;5.41 and OR=5.49, 95% CI= 3.01;10.01) were associated with being at risk for frailty and survey-based frailty respectively. CONCLUSIONS: A dental emergency visit and self-reported oral health problems are associated with frailty irrespective of the approach to its measurement. Healthcare professionals should be aware of the associations of oral health and frailty in daily practice.

Evidence-based interventions and nurse-sensitive outcomes in district nursing care: A systematic review.

Background: Measuring nursing interventions and nurse-sensitive outcomes in a standardized manner is essential because it provides insight into the quality of delivered care. However, there is currently no systematic overview of the interventions conducted by district nurses, the evidence for the effects of these interventions, or what nurse-sensitive outcomes should be measured. Objective: 1) To provide an overview of interventions for community-living older people evaluated in district nursing care and evidence for the effects of these interventions and 2) to identify the nurse-sensitive outcomes that are used to evaluate these district nursing care interventions, how these outcomes are measured, and in which patient groups they are applied. Design: A systematic review of the literature. Setting: District nursing care. Data sources: MEDLINE, CINAHL, PsycInfo, and EMBASE. Methods: Only experimental studies evaluating district nursing care interventions for communkity-living older people were included. A data extraction form was developed to extract the study characteristics and evaluate interventions and nurse-sensitive outcomes. The methodological quality of the included studies was reviewed using the 13-item critical appraisal tool for randomized controlled trials by the Joanna Briggs Institute. Results: A total of 22 studies were included. The methodological quality of the studies varied, with scores ranging from 6 to 11 on a scale of 0-13. The 22 interventions identified were heterogeneous with respect to intervention components, intervention delivery, and target population. The 44 outcomes identified were grouped into categories following the Nursing Outcome Classification and were measured in various ways and at various times. Conclusion: This is the first systematic review summarizing the evidence for the effectiveness of nurse-led interventions conducted by district nurses on community-living older people. It is unclear what interventions are effective and what outcomes should be used to substantiate district nursing care effectiveness. Because only studies with experimental designs were included, this analysis may provide an incomplete assessment of the effectiveness of interventions in district nursing care. Therefore, it is highly necessary to produce methodologically strong evidence through research programs focusing on district nursing care.

The Effectiveness of a PRoactive Multicomponent Intervention Program on Disability in Independently Living Older People: A Randomized Controlled Trial.

BACKGROUND: There is an increase in functional limitations and a decline in physical and mental well-being with age. Very few effective lifestyle interventions are available to prevent adverse outcomes such as disability in (pre-) frail older people. The effectiveness of an interdisciplinary multicomponent intervention program to prevent disability in older people in the community was tested. METHOD: A randomized controlled trial (RCT) with a one-year follow-up was conducted in the Netherlands. Community-dwelling pre-frail older people aged 65 years and over were invited to participate. Frailty was measured with the Groningen Frailty Indicator (GFI) and categorized into non-frail (GFI=0), pre-frail (GFI = 1-3) and frail (GFI ≥ 4). The intervention program consisted of four components: a medication review, physical fitness, social skills, and nutrition. OUTCOMES: The primary outcome was activity of daily living (ADL) measured with the Katz-6. Secondary outcomes were quality of life (SF-12) and healthcare consumption such as hospital admission, nursing home admission and primary care visits. Additional outcomes measured in the intervention group were physical fitness, Instrumental Activities of Daily Living (IADL), muscle strength, walking speed, functional capacity, mobility, feelings of depression and loneliness and nutritional status. The data were collected at baseline, after each intervention component and at a 12-month follow-up. An intention to treat analysis was used. RESULTS: In total, there were 290 participants, and 217 (74.8%) completed the study. The mean age was 74 (SD: 7.2), most were pre-frail (59.9%), the majority were female (55.2%), and the individuals were not living alone (61.4%). After the 12-month follow-up, the median Katz-6 score did not change significantly between the two groups; adjusted Odds Ratio (OR) = 0.96 (95% Confidence Interval (CI): 0.39-2.35, p-value 0.92). No statistically significant differences were observed between the groups for quality of life and healthcare consumption. Among the participants in the intervention group, IADL (Friedman's test p <=0.04, X2 =6.50), walking speed (Friedman's test p <0.001, X2 =19.09) and functional capacity (Friedman's test p <0.001, X2 =33.29) improved significantly after the one-year follow-up. Right-hand grip strength improved immediately after completion of the intervention (Wilcoxon signed-rank test p=0.00, z= -3.39) but not after the 12-month follow-up. CONCLUSION: The intervention program did not significantly improve daily functioning, quality of life and healthcare consumption among (pre) frail community-dwelling older persons at the one-year follow-up. Participants in the intervention group experienced improvements in walking speed, functional capacity and instrumental activities of daily living. More research is needed to better understand why may benefit and how to identify the target population.

Disability in the Individual ADL, IADL, and Mobility among Older Adults: A Prospective Cohort Study.

OBJECTIVES: To examine the risk of disability in 15 individual ADL, IADL, and mobility in older adults by age; and to assess the association of multimorbidity, gender, and education with disability. DESIGN AND SETTING: A prospective cohort study. The sample included 805 community-dwelling older people aged 60+ living in the Netherlands. MEASUREMENTS: Disability was assessed using the Katz-15 Index of Independence in Basic Activities of Daily Living (ADL), Instrumental Activities of Daily Living (IADL) and one mobility item. Disability in any of these activities was defined as the inability to perform the activity without assistance. The risk of disability by age for each individual ADL, IADL, and for mobility was assessed using Generalized mixed models. RESULTS: Disability in activities as household tasks, traveling, shopping, and continence had the highest risk and increased rapidly with age. The risk traveling disability among people aged 65 with two comorbidities increase from 9% to 37% at age 85. Disability in using the telephone, managing medications, finances, transferring, and toileting, had a very low risk and hardly increased with age. Compared to those without chronic conditions, those with ≥ 3 chronic conditions had a 3 to 5 times higher risk of developing disability. Males had a higher risk of disability in managing medication (P=0.005), and preparing meals (P=0.019), whereas females had a higher risk of disability with traveling (P=0.001). No association between education and disability on the individual ADL, IADL, and mobility was observed. CONCLUSIONS: Older adults were mostly disabled in physical related activities, whereas disability in more cognitive related activities was less often experienced. The impact of multimorbidity on disability in each activity was substantial, while education was not.

Validity and reliability of the Katz-15 scale to measure unfavorable health outcomes in community-dwelling older people.

OBJECTIVES: To predict the risk of future unfavourable health outcomes in older people it is common to assess the level of both basic and instrumental activities of daily living. To accomplish this, the commonly used Katz-6 and the Lawton IADL questionnaires can be combined to form the 'Modified Katz ADL' scale, also known as the Katz-15 scale. So far, the validity and reliability of the Katz-15 scale is unknown. The objective of the current study is to investigate how well the Katz-15 is able to predict future unfavorable health outcomes and how this is related to the existing Katz-6 scale. DESIGN: We performed a follow-up study using data from a group of 60 year and older participants from a large Dutch clinical trial. PARTICIPANTS: We included 2321 participants in the analysis. The average age of the study population was 74 years and 44% was male. MEASUREMENTS: We studied the relation between the Katz-15 scale and a number of unfavourable health outcomes, such as hospitalization, admission to a nursing home, admission to a home for the aged and death within one year of follow-up. RESULTS: We found the Katz-15 to be both internally consistent and strongly associated with quality of life measures. We observed moderate to strong associations between the Katz-15 and the unfavourable health outcomes All associations studied were stronger for the Katz-15 scale as compared to the Katz-6 scale. CONCLUSION: The results of our study indicate that the Katz-15 scale is able to reliably and validly predict future unfavorable health outcomes. This makes the scale a valuable measure in determining both basic and instrumental activities of daily living.

Associations between Frailty, Complex Care Needs and Quality of Life in Multi-Morbid Older People.

BACKGROUND: Little is known regarding the complex care needs, level of frailty or quality of life of multi-morbid older patients. OBJECTIVES: The objective of this study was to determine the relationship between frailty, complexity of care and quality of life in multi-morbid older people. DESIGN: Cross-sectional study. SETTING: Thirteen primary care practices in the Netherlands. PARTICIPANTS: 1,150 multi-morbid older people living in the community. MEASUREMENTS: The level of frailty was assessed with the Groningen Frailty Indicator. Complexity of care needs was measured with the Intermed for the Elderly Self-Assessment. Quality of life (QoL) was measured with two items of the RAND-36. RESULTS: In total, 758 out of 1,150 (65.9%) patients were frail, 8.3% had complex care needs, and the mean QoL score was 7.1 (standard deviation 1.2). Correlations between frailty and complexity, frailty and QoL, and complexity of care and QoL were 0.67, -0.51 and -0.52 (all p<0.001) respectively. All patients with complex care needs were frail, but, only 12.5% of the frail patients had complex care needs. Problems at climbing up stairs was associated with higher levels of frailty and complexity of care but with a lower QoL. CONCLUSIONS: Higher levels of frailty and complexity of care are associated with a lower QoL in multi-morbid older people. The results of this study contribute to a better understanding these concepts and are valuable for the development of tailored interventions for older persons in the future.

[Proactive and structured care for the elderly in primary care]. / Proactieve en gestructureerde zorg voor kwetsbare oudere patiënten in de eerstelijn: Achtergrond, opzet en uitvoering van een screenings- en zorgprogramma.

BACKGROUND: Currently, primary care for the older, vulnerable patient is reactive, fragmented and does not meet patients needs. Given the expected increase of home-dwelling frail elderly people a transition is needed to proactive and integrated care. METHODS: In the described study, we explore two innovative interventions in primary care. First we describe a newly developed screening and monitoring program for frail elderly patients based on routine care information in general practice. Second, we describe a multidisciplinary intervention program by trained nurses for frail elderly patients in general practice. The effectiveness of the interventions is examined in a three-armed, cluster randomized trial, taking place in 58 primary care practices in Utrecht, the Bilt and Maarsenbroek. RESULTS: Three thousand eight patients are included. Primary outcome measure is the impact of the interventions on the daily activities, measured with the Katz questionnaire. Secondary outcomes measures are the quality of life, mortality, recording in a care or nursing home, visit to an emergency room or outpatient unit, recording in the hospital and volunteer caregivers tax.